EMPOWER-support of patient empowerment by an intelligent self-management pathway for patients: study protocol

Construction and Validation of a Protocol Targeting Patients on Oral Anticoagulation with Warfarin

BACKGROUND

Warfarin is an oral anticoagulant that is very useful in preventing thromboembolism, though it is considered a drug with a high risk of causing adverse events. Considering the practical challenges in controlling oral anticoagulation, the patients on warfarin could benefit from educational strategies aimed at behavioral changes, active participation in self-care, and adherence to drug therapy.

OBJECTIVE

The aim was to construct and validate the EmpoderACO protocol for behavioral changes in warfarin patients.

METHODS

The methodological steps were: definition of concepts and domains of self-care, identification of objectives, construction and selection of items, assessment of content validity, and pre-test in the target population.

RESULTS

Relevance, adequacy, clarity, and internal reliability of the instrument's items were assessed by a multidisciplinary judges committee (JC) through the E-surv web platform, obtaining an average agreement of ≥0.91. The understanding of the instrument measured by the target population revealed adequate clarity with a coefficient average of 0.96.

CONCLUSION

EmpoderACO can aid in qualifying the communication process between medical professionals and patients, as well as in improving adherence to both treatment and clinical outcomes, and can be replicated in healthcare settings.

Empowerment-oriented strategies to identify behavior change in patients with chronic diseases: An integrative review of the literature

BACKGROUND

Chronic diseases in the Americas account for about 80 % (5.2 million) of all deaths. Instruments are needed to enhance knowledge, skills, behavior change and self-care attitudes drawing on patient autonomy.

OBJECTIVE

To identify empowerment-oriented strategies focused on behavioral change in patients with chronic diseases.

PATIENT INVOLVEMENT

None.

METHODS

This is an integrative review of articles published from any period until June 2020 by journals indexed in the following databases: National Library of Medicine National Institutes of Health (PubMed), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Biblioteca Virtual em Saúde (BVS).

RESULTS

Out of 1,287 articles, 25 met our selection criteria. Reported health interventions were based on self-management and behavior change, shared decisions and a personalized collaborative process, peer support and self-confidence, as well as strategies involving educational media and health literacy.

DISCUSSION

Over 80 % of health interventions were patient-centered and focused on patient knowledge and skill development towards personal goal setting, including effective problem-solving strategy development. Behavior change is not only an outcome of education, but also implicates revisiting values, attitudes, and experiences. Knowledge is important to facilitate decision-making leading to positive outcomes in chronic disease management.

PRACTICAL VALUE

Empowerment-oriented strategies are important tools for providing trust and motivation to people with chronic diseases. Healthcare professionals should support and encourage patient empowerment as a strategy for behavior change and able to offer qualified care for shared decision making. Thus, patients will be able to participate more actively in their own health condition management and to make decisions to promote self-care.

Differential influences of social support on app use for diabetes self-management - a mixed methods approach

Background

Recent studies increasingly examine social support for diabetes self-management delivered via mHealth. In contrast to previous studies examining social support as an outcome of technology use, or technology as a means for delivering social support, this paper argues that social support has an impact on the use of diabetes mHealth apps. Specifically, we postulate differences between the impact of healthcare professional versus non-professional (family/friends) support on mobile app use for diabetes self-management.

Methods

This research employed a triangulation of methods including exploratory semi-structured face-to-face interviews (N = 21, Study 1) and an online survey (N = 65, Study 2) with adult type 1 and type 2 diabetes patients. Thematic analysis (Study 1) was used to explore the relevance of social support (by professionals versus non-professionals) for diabetes app use. Binary logistic regression (Study 2) was applied to compare healthcare decision-making, healthcare-patient communication, and the support by the personal patient network as predictors of diabetes app use, complemented by other predictors from self-management and technology adoption theory.

Results

The interviews (Study 1) demonstrated that (technology-supported) shared decision-making and supportive communication by healthcare professionals depended on their medical specialty. The personal patient network was perceived as either facilitating or hindering the use of mHealth for self-management. Binary logistic regression (Study 2) showed that the physician specialty significantly predicted the use of diabetes apps, with supervision by diabetes specialists increasing the likelihood of app use (as opposed to general practitioners). Additionally, specialist care positively related to a higher chance of shared decision-making and better physician-patient communication. The support by the personal patient network predicted diabetes app use in the opposite direction, with less family/friend support increasing the likelihood of app use.

Conclusion

The results emphasize the relevance of support by healthcare professionals and by the patient network for diabetes app use and disclose differences from the existing literature. In particular, the use of diabetes apps may increase in the absence of social support by family or friends (e.g., compensation for lack of support), and may decrease when such support is high (e.g., no perceived need to use technology).

How Do Smart Device Apps for Diabetes Self-Management Correspond with Theoretical Indicators of Empowerment? An Analysis of App Features

OBJECTIVES

Smart device apps for diabetes have the potential to support patients in their daily disease management. However, uncertainty exists regarding their suitability for empowering patients to improve self-management behaviors. This paper addresses a general research gap regarding theoretically based examinations of empowerment in diabetes research, by examining how diabetes app features correspond with conceptual indicators of empowerment.

METHODS

We examined features of 121 apps for diabetes self-management available in Singapore, with the second highest proportion of diabetes among developed nations, for psychological empowerment (feeling of empowerment) and for behavioral empowerment (social support).

RESULTS

Diabetes apps studied offered a narrow range of features, with limited feature-sets corresponding to indicators of empowerment. Customization as a strategy to improve perceived relevance of diabetes self-management as an indicator of psychological empowerment was especially limited. Moreover, there was a lack of features supporting patients' communication with healthcare professionals and within their private social networks.

CONCLUSIONS

Mobile apps for diabetes self-management failed to provide relevant features for empowering patients. Specific practical recommendations target improved adoption, sustained usage, and effectiveness of diabetes self-management apps.

Mobile health ethics and the expanding role of autonomy

Mhealth technology is mushrooming world-wide and, in a variety of forms, reaches increasing numbers of users in ever-widening contexts and virtually independent from standard medical evidence assessment. Yet, debate on the broader societal impact including in particular mapping and classification of ethical issues raised has been limited. This article, as part of an ongoing empirically informed ethical research project, provides an overview of ethical issues of mhealth applications with a specific focus on implications on autonomy as a key notion in the debate. A multi-stage model of references to the potential of mhealth use for strengthening some or other form of self-determination will be proposed as a descriptive tool. It illustrates an assumed continuum of enhanced autonomy via mhealth broadly conceived: from patient to user autonomy, to improved health literacy, and finally to the vision of supra-individual empowerment and democratised, participatory health and medicine as a whole. On closer examination, however, these references are frequently ambivalent or vague, perpetuating the at times uncritical use of established autonomy concepts in medical ethics. The article suggests zooming in on the range of autonomy-related aspects against the backdrop of digital innovation and datafied health more generally, and on this basis add to existing frameworks for the ethical evaluation of mhealth more specifically.

Translation and cross-cultural adaptation of the Behavior Change Protocol for educational practices in Diabetes Mellitus

Objective

to translate and cross-culturally adapt the Behavior Change Protocol for educational practices in Diabetes Mellitus.

Method

methodological study aimed at cross-cultural adaptation, comprising the steps of translation, back-translation, assessment by an expert committee and pre-testing of the instrument on a sample of 30 healthcare service users with type 2 Diabetes Mellitus.

Results

the instrument was assessed based on criteria pertaining semantic, idiomatic, conceptual and cultural equivalence between the original instrument and the translated version, its mean Content Validity Index being 0.85.

Conclusion

results showed content validity indicating the instrument’s successful cross-cultural adaptation to the Brazilian culture for use in educational practices targeting self-care in type 2 DM.

Shared decision-making using personal health record technology: a scoping review at the crossroads

Objective

This scoping review aims to determine the size and scope of the published literature on shared decision-making (SDM) using personal health record (PHR) technology and to map the literature in terms of system design and outcomes.

Materials and Methods

Literature from Medline, Google Scholar, Cumulative Index to Nursing and Allied Health Literature, Engineering Village, and Web of Science (2005-2015) using the search terms "personal health records," "shared decision making," "patient-provider communication," "decision aid," and "decision support" was included. Articles ( n  = 38) addressed the efficacy or effectiveness of PHRs for SDM in engaging patients in self-care and decision-making or ways patients can be supported in SDM via PHR.

Results

Analysis resulted in an integrated SDM-PHR conceptual framework. An increased interest in SDM via PHR is apparent, with 55% of articles published within last 3 years. Sixty percent of the literature originates from the United States. Twenty-six articles address a particular clinical condition, with 10 focused on diabetes, and one-third offer empirical evidence of patient outcomes. The tethered and standalone PHR architectural types were most studied, while the interconnected PHR type was the focus of more recently published methodological approaches and discussion articles.

Discussion

The study reveals a scarcity of rigorous research on SDM via PHR. Research has focused on one or a few of the SDM elements and not on the intended complete process.

Conclusion

Just as PHR technology designed on an interconnected architecture has the potential to facilitate SDM, integrating the SDM process into PHR technology has the potential to drive PHR value.

Psychological interventions for diabetes-related distress in adults with type 2 diabetes mellitus

BACKGROUND

Many adults with type 2 diabetes mellitus (T2DM) experience a psychosocial burden and mental health problems associated with the disease. Diabetes-related distress (DRD) has distinct effects on self-care behaviours and disease control. Improving DRD in adults with T2DM could enhance psychological well-being, health-related quality of life, self-care abilities and disease control, also reducing depressive symptoms.

OBJECTIVES

To assess the effects of psychological interventions for diabetes-related distress in adults with T2DM.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, Embase, PsycINFO, CINAHL, BASE, WHO ICTRP Search Portal and ClinicalTrials.gov. The date of the last search was December 2014 for BASE and 21 September 2016 for all other databases.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) on the effects of psychological interventions for DRD in adults (18 years and older) with T2DM. We included trials if they compared different psychological interventions or compared a psychological intervention with usual care. Primary outcomes were DRD, health-related quality of life (HRQoL) and adverse events. Secondary outcomes were self-efficacy, glycosylated haemoglobin A1c (HbA1c), blood pressure, diabetes-related complications, all-cause mortality and socioeconomic effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified publications for inclusion and extracted data. We classified interventions according to their focus on emotion, cognition or emotion-cognition. We performed random-effects meta-analyses to compute overall estimates.

MAIN RESULTS

We identified 30 RCTs with 9177 participants. Sixteen trials were parallel two-arm RCTs, and seven were three-arm parallel trials. There were also seven cluster-randomised trials: two had four arms, and the remaining five had two arms. The median duration of the intervention was six months (range 1 week to 24 months), and the median follow-up period was 12 months (range 0 to 12 months). The trials included a wide spectrum of interventions and were both individual- and group-based.A meta-analysis of all psychological interventions combined versus usual care showed no firm effect on DRD (standardised mean difference (SMD) -0.07; 95% CI -0.16 to 0.03; P = 0.17; 3315 participants; 12 trials; low-quality evidence), HRQoL (SMD 0.01; 95% CI -0.09 to 0.11; P = 0.87; 1932 participants; 5 trials; low-quality evidence), all-cause mortality (11 per 1000 versus 11 per 1000; risk ratio (RR) 1.01; 95% CI 0.17 to 6.03; P = 0.99; 1376 participants; 3 trials; low-quality evidence) or adverse events (17 per 1000 versus 41 per 1000; RR 2.40; 95% CI 0.78 to 7.39; P = 0.13; 438 participants; 3 trials; low-quality evidence). We saw small beneficial effects on self-efficacy and HbA1c at medium-term follow-up (6 to 12 months): on self-efficacy the SMD was 0.15 (95% CI 0.00 to 0.30; P = 0.05; 2675 participants; 6 trials; low-quality evidence) in favour of psychological interventions; on HbA1c there was a mean difference (MD) of -0.14% (95% CI -0.27 to 0.00; P = 0.05; 3165 participants; 11 trials; low-quality evidence) in favour of psychological interventions. Our included trials did not report diabetes-related complications or socioeconomic effects.Many trials were small and were at high risk of bias for incomplete outcome data as well as possible performance and detection biases in the subjective questionnaire-based outcomes assessment, and some appeared to be at risk of selective reporting. There are four trials awaiting further classification. These are parallel RCTs with cognition-focused and emotion-cognition focused interventions. There are another 18 ongoing trials, likely focusing on emotion-cognition or cognition, assessing interventions such as diabetes self-management support, telephone-based cognitive behavioural therapy, stress management and a web application for problem solving in diabetes management. Most of these trials have a community setting and are based in the USA.

AUTHORS' CONCLUSIONS

Low-quality evidence showed that none of the psychological interventions would improve DRD more than usual care. Low-quality evidence is available for improved self-efficacy and HbA1c after psychological interventions. This means that we are uncertain about the effects of psychological interventions on these outcomes. However, psychological interventions probably have no substantial adverse events compared to usual care. More high-quality research with emotion-focused programmes, in non-US and non-European settings and in low- and middle-income countries, is needed.

A Qualitative Study of the Barriers and Opportunities for Adoption of Web-Portals for Doctors and Patients in Russia

The use of Web portals has several benefits. They have been proven to enhance communication between patients and health care professionals, allow patients to play a more active role in their own treatment and self-management, increase self-efficiency. Doctors can access patients' medical data and give recommendations to the patients. Some evidence of positive outcomes has been reported including improved clinical indicators and reduced health service use, as well as enhanced feelings of security and increased satisfaction with health and social care services. However, a number of studies have demonstrated that these types of solutions often fail to be successfully implemented and adopted within routine healthcare. The goal of the study was to analyze attitude of tuberculosis patients and doctors and identify perceived opportunities and barriers to operate a Web portal. The perceptions of 30 tuberculosis patients and 18 doctors (10 general practitioners and 8 phthisiatricians) from Tomsk, Russia were collected through semi-structured interviews. The responses were analyzed using grounded theory and thematic analysis, in order to understand the participants' opinions and attitudes towards accepting tuberculosis web-portal in the treatment and rehabilitation process. We have recognized core topics that represented the participants' responses. These core topics indicated that most respondents mentioned "the potential of tuberculosis web-portal to establish a better communication between doctors and patients" and "the increased health status of the patients" as the most valuable outcomes of adopting the tool. Both doctors and patients also expressed their opinions on the usability of the solutions, with no significant concerns reported about its usability. The main barrier we identified was different expectations of doctors and patients: doctors expected that the portal would decrease the amount of paper work and will help them to quickly react in acute cases, however, the patients were disappointed that the portal did not allow them to be able to reach doctors on the 24/7 basis and have a consultation whenever they felt they needed it. Finally, our findings disclosed that participants appreciated the perceived clinical utility of the portal, which could further have an influence on their intention to use it. The findings from our reported study in the area of tuberculosis treatment and rehabilitation suggested that the participants generally accepted the introduction of web-portal for the purpose of reporting health status and getting recommendation from the doctors as an alternative to the traditional doctor visits.

Open data models for smart health interconnected applications: the example of openEHR

BACKGROUND

Smart Health is known as a concept that enhances networking, intelligent data processing and combining patient data with other parameters. Open data models can play an important role in creating a framework for providing interoperable data services that support the development of innovative Smart Health applications profiting from data fusion and sharing.

METHODS

This article describes a model-driven engineering approach based on standardized clinical information models and explores its application for the development of interoperable electronic health record systems. The following possible model-driven procedures were considered: provision of data schemes for data exchange, automated generation of artefacts for application development and native platforms that directly execute the models. The applicability of the approach in practice was examined using the openEHR framework as an example.

RESULTS

A comprehensive infrastructure for model-driven engineering of electronic health records is presented using the example of the openEHR framework. It is shown that data schema definitions to be used in common practice software development processes can be derived from domain models. The capabilities for automatic creation of implementation artefacts (e.g., data entry forms) are demonstrated. Complementary programming libraries and frameworks that foster the use of open data models are introduced. Several compatible health data platforms are listed. They provide standard based interfaces for interconnecting with further applications.

CONCLUSION

Open data models help build a framework for interoperable data services that support the development of innovative Smart Health applications. Related tools for model-driven application development foster semantic interoperability and interconnected innovative applications.

Electronic health record-based assessment of cardiovascular health: The stroke prevention in healthcare delivery environments (SPHERE) study

< 3% of Americans have ideal cardiovascular health (CVH). The primary care encounter provides a setting in which to conduct patient-provider discussions of CVH. We implemented a CVH risk assessment, visualization, and decision-making tool that automatically populates with electronic health record (EHR) data during the encounter in order to encourage patient-centered CVH discussions among at-risk, yet under-treated, populations. We quantified five of the seven CVH behaviors and factors that were available in The Ohio State University Wexner Medical Center's EHR at baseline (May–July 2013) and compared values to those ascertained at one-year (May–July 2014) among intervention (n = 109) and control (n = 42) patients. The CVH of women in the intervention clinic improved relative to the metrics of body mass index (16% to 21% ideal) and diabetes (62% to 68% ideal), but not for smoking, total cholesterol, or blood pressure. Meanwhile, the CVH of women in the control clinic either held constant or worsened slightly as measured using those same metrics. Providers need easy-to-use tools at the point-of-care to help patients improve CVH. We demonstrated that the EHR could deliver such a tool using an existing American Heart Association framework, and we noted small improvements in CVH in our patient population. Future work is needed to assess how to best harness the potential of such tools in order to have the greatest impact on the CVH of a larger patient population.

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Use and adoption of health information technology advances quality in patient care.

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Healthcare systems need tools to enhance primary prevention at the point-of-care.

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Providers and patients have shared accountability for population health metrics.

Laboratory medicine and mobile health technologies at crossroads: Perspectives for the management of chronic diseases

Management of chronic diseases represents a leading health and economic issue worldwide. Biomarkers are critical for the diagnosis and management of both communicable and non-communicable chronic diseases, and mobile health (mHealth) technologies are about to change the "game" with regard to the management of patients with such chronic diseases. The development of efficient, accurate and interactive solutions that integrate biomarkers and mHealth opens new perspectives for caregivers for the management of chronic illness.