1
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Wilkinson TM, de Bock M. Analysis of "Hybrid Closed Loop Using a Do-It-Yourself Artificial Pancreas System in Adults With Type 1 Diabetes". J Diabetes Sci Technol 2024; 18:897-898. [PMID: 37850586 DOI: 10.1177/19322968231208216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
In an article in Journal of Diabetes Science and Technology, Nanayakkara and colleagues assessed the glycemic efficacy and safety of AndroidAPS, an open-source automated delivery (AID) system, in a crossover randomized controlled trial. Although the trial included only 20 participants during a relatively short 4-week intervention period, glycemic outcomes attained were similar to commercial AID systems and there were no safety concerns. Validation of open-source AID systems in studies such as this should help address clinician hesitancy regarding these systems, and affirms the role of patient-centered innovation and self-management in diabetes care.
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Affiliation(s)
- Tom M Wilkinson
- Department of Paediatrics, University of Otago, Christchurch, Christchurch, New Zealand
| | - Martin de Bock
- Department of Paediatrics, University of Otago, Christchurch, Christchurch, New Zealand
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2
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Samuel P, Khan N, Klein G, Skobkarev S, Mammon B, Fournier M, Hawke K, Weissinger A, Elliott T. Open-source Artificial Pancreas Systems Are Safe and Effective When Supported In-clinic: Outcomes in 248 Consecutive Type 1 Diabetes Clients. Can J Diabetes 2024; 48:59-65.e1. [PMID: 37802366 DOI: 10.1016/j.jcjd.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 10/10/2023]
Abstract
OBJECTIVE Our aim in this study was to determine the safety, glycemia, and quality of life (QoL) associated with in-clinic installation and management of supported open-source artificial pancreas systems (SOSAPS) in type 1 diabetes (T1D). METHODS This investigation is a retrospective cohort study of consecutive SOSAPS users at a Canadian diabetes centre. SOSAPS were offered to all moderately tech-savvy T1D clients on sensor-augmented multiple daily injection or pump, able to pay for hardware, and willing to sign a consent and waiver document. SOSAPS were installed and maintained by clinic staff at no cost to clients. iPhone users were assigned to either Loop (n=108) or iPhone artificial pancreas systems (iAPS; n=114) and Android users to Android-type APS (n=24). Outcomes included severe hypoglycemia and diabetic ketoacidosis (DKA), time in range (TIR) 4.0 to 10.0 mmol/L, time below range (TBR) <4 mmol/L, glucose management indicator (GMI), mean sensor glucose (MSG), change in glycated hemoglobin (A1C), and QoL. RESULTS Two hundred forty-eight subjects (131 males, 117 females), with a mean age of 36 years and diabetes duration of 21 years, experienced 3 episodes of severe hypoglycemia and no DKA over a follow-up of 17 months. TIR rose by 16%, from 64% to 80% (p<0.0001); TBR fell by 1.0%, from 3.5% to 2.5% (p=0.001); MSG fell from 9.0 to 8.1 mmol/L (p<0.001); GMI fell from 7.3% to 6.7% (p<0.001); and A1C fell from 7.2% to 6.7% (p<0.0001). QoL scores were healthy before and improved after SOSAPS. CONCLUSIONS Clients with T1D using SOSAPS and supported with no-cost care to the client (software, technology, and physician/physician assistant) safely achieved improved TIR, GMI, A1C, and QoL.
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Affiliation(s)
| | - Nabeel Khan
- BCDiabetes, Vancouver, British Columbia, Canada
| | - Gerri Klein
- BCDiabetes, Vancouver, British Columbia, Canada
| | | | | | | | - Kate Hawke
- BCDiabetes, Vancouver, British Columbia, Canada; Logan Endocrinology and Diabetes Service (LEADS), Logan Hospital, Meadowbrook, Queensland, Australia
| | | | - Tom Elliott
- BCDiabetes, Vancouver, British Columbia, Canada; Division of Endocrinology, University of British Columbia, Gordon and Leslie Diamond Centre, Vancouver, British Columbia, Canada.
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3
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Dahlberg M, Lek M, Malmqvist Castillo M, Bylund A, Hasson H, Riggare S, Reinius M, Wannheden C. Objectives and outcomes of patient-driven innovations published in peer-reviewed journals: a qualitative analysis of publications included in a scoping review. BMJ Open 2023; 13:e071363. [PMID: 37263703 PMCID: PMC10255190 DOI: 10.1136/bmjopen-2022-071363] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 05/20/2023] [Indexed: 06/03/2023] Open
Abstract
OBJECTIVES The aim of this study was to gain a deeper understanding of the objectives and outcomes of patient-driven innovations that have been published in the scientific literature, focusing on (A) the unmet needs that patient-driven innovations address and (B) the outcomes for patients and healthcare that have been reported. METHODS We performed an inductive qualitative content analysis of scientific publications that were included in a scoping review of patient-driven innovations, previously published by our research group. The review was limited to English language publications in peer-reviewed journals, published in the years 2008-2020. RESULTS In total, 83 publications covering 21 patient-driven innovations were included in the analysis. Most of the innovations were developed for use on an individual or community level without healthcare involvement. We created three categories of unmet needs that were addressed by these innovations: access to self-care support tools, open sharing of information and knowledge, and patient agency in self-care and healthcare decisions. Eighteen (22%) publications reported outcomes of patient-driven innovations. We created two categories of outcomes: impact on self-care, and impact on peer interaction and healthcare collaboration. CONCLUSIONS The patient-driven innovations illustrated a diversity of innovative approaches to facilitate patients' and informal caregivers' daily lives, interactions with peers and collaborations with healthcare. As our findings indicate, patients and informal caregivers are central stakeholders in driving healthcare development and research forward to meet the needs that matter to patients and informal caregivers. However, only few studies reported on outcomes of patient-driven innovations. To support wider implementation, more evaluation studies are needed, as well as research into regulatory approval processes, dissemination and governance of patient-driven innovations.
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Affiliation(s)
- Marie Dahlberg
- Department of Learning, Informatics, Management and Ethics, Karolinska Institute, Stockholm, Sweden
| | - Madelen Lek
- Department of Learning, Informatics, Management and Ethics, Karolinska Institute, Stockholm, Sweden
| | - Moa Malmqvist Castillo
- Department of Learning, Informatics, Management and Ethics, Karolinska Institute, Stockholm, Sweden
| | - Ami Bylund
- Department of Learning, Informatics, Management and Ethics, Karolinska Institute, Stockholm, Sweden
| | - Henna Hasson
- Department of Learning, Informatics, Management and Ethics, Karolinska Institute, Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine, Region Stockholm, Stockholms Lans Landsting, Stockholm, Sweden
| | - Sara Riggare
- Participatory eHealth and Health Data, Department of Women's and Children's Health, Uppsala Universitet, Uppsala, Sweden
| | - Maria Reinius
- Department of Learning, Informatics, Management and Ethics, Karolinska Institute, Stockholm, Sweden
| | - Carolina Wannheden
- Department of Learning, Informatics, Management and Ethics, Karolinska Institute, Stockholm, Sweden
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4
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Sherr JL, Heinemann L, Fleming GA, Bergenstal RM, Bruttomesso D, Hanaire H, Holl RW, Petrie JR, Peters AL, Evans M. Automated insulin delivery: benefits, challenges, and recommendations. A Consensus Report of the Joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association. Diabetologia 2023; 66:3-22. [PMID: 36198829 PMCID: PMC9534591 DOI: 10.1007/s00125-022-05744-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/07/2022] [Indexed: 01/15/2023]
Abstract
A technological solution for the management of diabetes in people who require intensive insulin therapy has been sought for decades. The last 10 years have seen substantial growth in devices that can be integrated into clinical care. Driven by the availability of reliable systems for continuous glucose monitoring, we have entered an era in which insulin delivery through insulin pumps can be modulated based on sensor glucose data. Over the past few years, regulatory approval of the first automated insulin delivery (AID) systems has been granted, and these systems have been adopted into clinical care. Additionally, a community of people living with type 1 diabetes has created its own systems using a do-it-yourself approach by using products commercialised for independent use. With several AID systems in development, some of which are anticipated to be granted regulatory approval in the near future, the joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association has created this consensus report. We provide a review of the current landscape of AID systems, with a particular focus on their safety. We conclude with a series of recommended targeted actions. This is the fourth in a series of reports issued by this working group. The working group was jointly commissioned by the executives of both organisations to write the first statement on insulin pumps, which was published in 2015. The original authoring group was comprised by three nominated members of the American Diabetes Association and three nominated members of the European Association for the Study of Diabetes. Additional authors have been added to the group to increase diversity and range of expertise. Each organisation has provided a similar internal review process for each manuscript prior to submission for editorial review by the two journals. Harmonisation of editorial and substantial modifications has occurred at both levels. The members of the group have selected the subject of each statement and submitted the selection to both organisations for confirmation.
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Affiliation(s)
| | | | | | - Richard M Bergenstal
- International Diabetes Center and HealthPartners Institute, Minneapolis, MN, USA
| | - Daniela Bruttomesso
- Unit of Metabolic Diseases, Department of Medicine, University of Padova, Padova, Italy
| | - Hélène Hanaire
- Department of Diabetology, University Hospital of Toulouse, University of Toulouse, Toulouse, France
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, Central Institute of Biomedical Engineering (ZIBMT), University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - John R Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Anne L Peters
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Mark Evans
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK.
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5
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Sherr JL, Heinemann L, Fleming GA, Bergenstal RM, Bruttomesso D, Hanaire H, Holl RW, Petrie JR, Peters AL, Evans M. Automated Insulin Delivery: Benefits, Challenges, and Recommendations. A Consensus Report of the Joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association. Diabetes Care 2022; 45:3058-3074. [PMID: 36202061 DOI: 10.2337/dci22-0018] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/07/2022] [Indexed: 02/03/2023]
Abstract
A technological solution for the management of diabetes in people who require intensive insulin therapy has been sought for decades. The last 10 years have seen substantial growth in devices that can be integrated into clinical care. Driven by the availability of reliable systems for continuous glucose monitoring, we have entered an era in which insulin delivery through insulin pumps can be modulated based on sensor glucose data. Over the past few years, regulatory approval of the first automated insulin delivery (AID) systems has been granted, and these systems have been adopted into clinical care. Additionally, a community of people living with type 1 diabetes has created its own systems using a do-it-yourself approach by using products commercialized for independent use. With several AID systems in development, some of which are anticipated to be granted regulatory approval in the near future, the joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association has created this consensus report. We provide a review of the current landscape of AID systems, with a particular focus on their safety. We conclude with a series of recommended targeted actions. This is the fourth in a series of reports issued by this working group. The working group was jointly commissioned by the executives of both organizations to write the first statement on insulin pumps, which was published in 2015. The original authoring group was comprised by three nominated members of the American Diabetes Association and three nominated members of the European Association for the Study of Diabetes. Additional authors have been added to the group to increase diversity and range of expertise. Each organization has provided a similar internal review process for each manuscript prior to submission for editorial review by the two journals. Harmonization of editorial and substantial modifications has occurred at both levels. The members of the group have selected the subject of each statement and submitted the selection to both organizations for confirmation.
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Affiliation(s)
| | | | | | | | - Daniela Bruttomesso
- Unit of Metabolic Diseases, Department of Medicine, University of Padova, Padova, Italy
| | - Hélène Hanaire
- Department of Diabetology, University Hospital of Toulouse, University of Toulouse, Toulouse, France
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, Central Institute of Biomedical Engineering (ZIBMT), University of Ulm, Ulm, Germany.,German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - John R Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, U.K
| | - Anne L Peters
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Mark Evans
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, U.K
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6
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Lou S, Dahlen HG, Gefke Hansen S, Ørneborg Rodkjær L, Maimburg RD. Why freebirth in a maternity system with free midwifery care? A qualitative study of Danish women's motivations and preparations for freebirth. SEXUAL & REPRODUCTIVE HEALTHCARE 2022; 34:100789. [PMID: 36332498 DOI: 10.1016/j.srhc.2022.100789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 09/12/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Even in maternity care systems with free midwifery care, some women intentionally choose to birth unattended by any health professional (freebirth). Women who choose freebirth represent an enigma for many, and a provocation to some. However, people who do not conform to dominant medical practices are a source of valuable insights that can reveal shortcomings in the mainstream health care system. Thus, the aim of this study was to explore and understand women's motivations and preparations for freebirth. METHODS The study was informed by the theoretical lens of the 'undisciplined patient'. Qualitative, in-depth interviews were performed with ten Danish women, who for their most recent birth had planned to freebirth. Data were analysed using reflexive thematic analysis. RESULTS Four themes were identified. "The standard system is not for me" describes negative experiences during previous births and the desire for more individualised support. "Re-establishing trust in myself" describes the women's quest for recognizing their own needs and re-building autonomy and inner strength. "I do my research" describes how the women sought new ways of knowing and prioritised experiential knowledge. And finally, "I create my safe space" describes the women's efforts to create the best possible physical and emotional space for themselves and their babies in order to have a safe and autonomous birth experience. CONCLUSION Freebirth is not undertaken lightly or without preparation by women. Improved continuity of care as well as greater flexibility in hospital guidelines could accommodate some of these women's demand for autonomy in birth.
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Affiliation(s)
- Stina Lou
- Defactum - Public health & Health Services Research, Central Denmark Region, Aarhus, Denmark; Center for Fetal Diagnostics, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark.
| | - Hannah G Dahlen
- School of Nursing and Midwifery, Western Sydney University, Penrith, NSW, Australia
| | - Sofie Gefke Hansen
- Defactum - Public health & Health Services Research, Central Denmark Region, Aarhus, Denmark
| | - Lotte Ørneborg Rodkjær
- Research Centre for Patient Involvement (ResCenPI), Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark; Department of Public Health, Health, Aarhus University, Aarhus, Denmark
| | - Rikke Damkjær Maimburg
- Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark; School of Nursing and Midwifery, Western Sydney University, Penrith, NSW, Australia; Department of Obstetrics & Gynecology, Aarhus University Hospital, Aarhus, Denmark; Department of Midwifery, University College of Northern Denmark, Aalborg, Denmark
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7
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Walsh L, Hyett N, Juniper N, Li C, Hill S. The Experiences of Stakeholders Using Social Media as a Tool for Health Service Design and Quality Improvement: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192214851. [PMID: 36429570 PMCID: PMC9690250 DOI: 10.3390/ijerph192214851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/08/2022] [Accepted: 11/08/2022] [Indexed: 05/12/2023]
Abstract
BACKGROUND Health organisations and stakeholders use social media for a range of functions, including engaging stakeholders in the design and quality improvement (QI) of services. Social media may help overcome some of the limitations of traditional stakeholder engagement methods. This scoping review explores the benefits, risks, barriers and enablers for using social media as a tool for stakeholder engagement in health service design and QI. METHODS The searches were conducted on 16 August 2022. Inclusion criteria were: studies of any health service stakeholders, in any health setting, where social media was used as a tool for service design or QI. Data was analysed using deductive content analysis. A committee of stakeholders provided input on research questions, data analysis and key findings. RESULTS 61 studies were included. Benefits included improved organisational communication and relationship building. Risks/limitations included low quality of engagement and harms to users. Limited access and familiarity with social media were frequently reported barriers. Making discussions safe and facilitating access were common enablers. CONCLUSION The benefits, risks, barriers and enablers identified highlight the complexity of social media as an engagement tool for health service design and QI. Understanding these experiences may help implementers design more effective social media-based engagement activities.
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Affiliation(s)
- Louisa Walsh
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Melbourne, VIC 3083, Australia
- Correspondence: ; Tel.: +61-3-9479-1578
| | - Nerida Hyett
- La Trobe Rural Health School, La Trobe University, Bendigo, VIC 3550, Australia
| | | | - Chi Li
- Albury Wodonga Health, Wodonga, VIC 3690, Australia
| | - Sophie Hill
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Melbourne, VIC 3083, Australia
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Morrison AE, Chong K, Senior PA, Lam A. A scoping review of Do-It-Yourself Automated Insulin Delivery system (DIY AID) use in people with type 1 diabetes. PLoS One 2022; 17:e0271096. [PMID: 35951597 PMCID: PMC9371307 DOI: 10.1371/journal.pone.0271096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/23/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction User designed Automated Insulin Delivery systems (AID), termed Do-It-Yourself (DIY) AID include; AndroidAPS, OpenAPS and Loop. These unregulated systems provide challenges for healthcare providers worldwide, with potential legal and ethical barriers to supporting their use. We performed a scoping review of the currently available literature surrounding DIY AID systems, specifically to highlight the evidence available to facilitate healthcare providers to support persons with diabetes who may benefit from DIY AID. Methods Studies relating to DIY AID systems were searched in Embase, Medline, Web of Science, Scopus, Proquest and Cochrane library until 31st December 2021. Publications were screened through title and abstract to identify study type and AID system type described. A thematic synthesis methodology was used for analysis of studies of DIY AID use due to the heterogeneity in study designs (case reports, qualitative, cross-sectional and cohort studies), with similarity in outcome themes. Results Following implementation of the search strategy, 38 relevant full texts were identified; comprising 12 case reports, 9 qualitative studies and 17 cohort studies, and data was also available from 24 relevant conference abstracts. No randomized studies were identified. Common themes were identified in the outcomes across the studies; glycemic variability, safety, quality of life, healthcare provider attitudes and social media. Conclusion There is extensive real-world data, but a lack of randomized control trial evidence supporting DIY AID system use, due to the user-driven, unregulated nature of these systems. Healthcare providers report a lack of understanding surrounding, and confidence in supporting, DIY AID despite impressive observational and user self-reported improvements in glycemic variability, without any reported safety compromises.
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Affiliation(s)
- Amy E. Morrison
- Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Edmonton, AB, Canada
- * E-mail:
| | - Kimberley Chong
- Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Peter A. Senior
- Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Edmonton, AB, Canada
- Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
| | - Anna Lam
- Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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Reinius M, Mazzocato P, Riggare S, Bylund A, Jansson H, Øvretveit J, Savage C, Wannheden C, Hasson H. Patient-driven innovations reported in peer-reviewed journals: a scoping review. BMJ Open 2022; 12:e053735. [PMID: 35074818 PMCID: PMC8788234 DOI: 10.1136/bmjopen-2021-053735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 12/03/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Awareness of patients' innovative capabilities is increasing, but there is limited knowledge regarding the extent and nature of patient-driven innovations in the peer-reviewed literature. OBJECTIVES The objective of the review was to answer the question: what is the nature and extent of patient-driven innovations published in peer-reviewed scientific journals? ELIGIBILITY CRITERIA We used a broad definition of innovation to allow for a comprehensive review of different types of innovations and a narrow definition of 'patient driven' to focus on the role of patients and/or family caregivers. The search was limited to years 2008-2020. SOURCES OF EVIDENCE Four electronic databases (Medline (Ovid), Web of Science Core Collection, PsycINFO (Ovid) and Cinahl (Ebsco)) were searched in December 2020 for publications describing patient-driven innovations and complemented with snowball strategies. CHARTING METHODS Data from the included articles were extracted and categorised inductively. RESULTS A total of 96 articles on 20 patient-driven innovations were included. The number of publications increased over time, with 69% of the articles published between 2016 and 2020. Author affiliations were exclusively in high income countries with 56% of first authors in North America and 36% in European countries. Among the 20 innovations reported, 'Do-It-Yourself Artificial Pancreas System' and the online health network 'PatientsLikeMe', were the subject of half of the articles. CONCLUSIONS Peer-reviewed publications on patient-driven innovations are increasing and we see an important opportunity for researchers and clinicians to support patient innovators' research while being mindful of taking over the work of the innovators themselves.
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Affiliation(s)
- Maria Reinius
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | - Pamela Mazzocato
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | - Sara Riggare
- Department of Women's and Children's Health, Healthcare Sciences and E-Health, Uppsala University, Uppsala, Sweden
| | - Ami Bylund
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | - Hanna Jansson
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | - John Øvretveit
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
- Department of Research Development and Education, Region Stockholm, Stockholm, Sweden
| | - Carl Savage
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | - Carolina Wannheden
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | - Henna Hasson
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine, Region Stockholm, Stockholm, Sweden
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