Sustainability of mHealth Effects on Cardiometabolic Risk Factors: Five-Year Results of a Randomized Clinical Trial

Epidemiology of cardiometabolic health in Latin America and strategies to address disparities

In Latin America and the Caribbean (LAC), sociodemographic context, socioeconomic disparities and the high level of urbanization provide a unique entry point to reflect on the burden of cardiometabolic disease in the region. Cardiovascular diseases are the main cause of death in LAC, precipitated by population growth and ageing together with a rapid increase in the prevalence of cardiometabolic risk factors, predominantly obesity and diabetes mellitus, over the past four decades. Strategies to address this growing cardiometabolic burden include both population-wide and individual-based initiatives tailored to the specific challenges faced by different LAC countries, which are heterogeneous. The implementation of public policies to reduce smoking and health system approaches to control hypertension are examples of scalable strategies. The challenges faced by LAC are also opportunities to foster innovative approaches to combat the high burden of cardiometabolic diseases such as implementing digital health interventions and team-based initiatives. This Review provides a summary of trends in the epidemiology of cardiometabolic diseases and their risk factors in LAC as well as context-specific disease determinants and potential solutions to improve cardiometabolic health in the region.

Multimorbidity

Multimorbidity (two or more coexisting conditions in an individual) is a growing global challenge with substantial effects on individuals, carers and society. Multimorbidity occurs a decade earlier in socioeconomically deprived communities and is associated with premature death, poorer function and quality of life and increased health-care utilization. Mechanisms underlying the development of multimorbidity are complex, interrelated and multilevel, but are related to ageing and underlying biological mechanisms and broader determinants of health such as socioeconomic deprivation. Little is known about prevention of multimorbidity, but focusing on psychosocial and behavioural factors, particularly population level interventions and structural changes, is likely to be beneficial. Most clinical practice guidelines and health-care training and delivery focus on single diseases, leading to care that is sometimes inadequate and potentially harmful. Multimorbidity requires person-centred care, prioritizing what matters most to the individual and the individual's carers, ensuring care that is effectively coordinated and minimally disruptive, and aligns with the patient's values. Interventions are likely to be complex and multifaceted. Although an increasing number of studies have examined multimorbidity interventions, there is still limited evidence to support any approach. Greater investment in multimorbidity research and training along with reconfiguration of health care supporting the management of multimorbidity is urgently needed.

Effect of Telehealth Interventions on Blood Pressure Control: A Meta-analysis

The aim of this study was to find out the effects of telehealth interventions on blood pressure control by conducting a meta-analysis. Six databases were used. The literature review covered the period between December 1, 2020, and January 26, 2021. The meta-analysis was conducted by comprehensive Meta-Analysis Software version 2.2. Categorical variables were analyzed by odds ratios at a confidence interval of 95%. In data formatting and analysis, independent groups (sample size, P value); independent groups (mean, SD); Cohen's d, SE; and paired groups (N, P value) were used. The bias risk was assessed based on the Revised Cochrane Risk-of-Bias Tool for Randomized Trials. Total sample size including 22 studies was 11 120. It was determined that interventions performed through telehealth applications had a significant effect on blood pressure control (odds ratio = -0.14; 95% confidence interval = -0.20 to -0.08; P < .001). In telehealth applications, blood pressure values decreased more when the application was performed through a Web site (-0.31; 95% confidence interval = -0.49 to -0.13), duration of the intervention was 12 months or shorter (-0.18; 95% confidence interval = -0.28 to -0.010), stroke developed in case of hypertension (-0.31, 95% confidence interval = -0.76 to 0.12), and the study was conducted in the Far East countries (-0.24; 95% confidence interval = 0.40 to -0.07). Interventions with telehealth applications are effective in blood pressure management. PROSPERO ID: CRD42021228536.

Peru - Progress in health and sciences in 200 years of independence

Peru celebrates 200 years of independence in 2021. Over this period of independent life, and despite the turbulent socio-political scenarios, from internal armed conflict to economic crisis to political instability over the last 40 years, Peru has experienced major changes on its epidemiological and population health profile. Major advancements in maternal and child health as well as in communicable diseases have been achieved in recent decades, and today Peru faces an increasing burden of non-communicable diseases including mental health conditions. In terms of the configuration of the public health system, Peru has also strived to secure country-wide optimal health care, struggling in particular to improve primary health care and intercultural services. The science and technology infrastructure has also evolved, although the need for substantial investments remains if advancing science is to be a national priority. Climate change will also bring significant challenges to population health given Peru's geographical and microclimates diversity. Looking back over the 200-years of independence, we present a summary of key advances in selected health-related fields, thus serving as the basis for reflections on pending agendas and future challenges, in order to look forward to ensuring the future health and wellbeing of the Peruvian population.

Resumen translated abstract

El Perú cumple 200 años de independencia en 2021. Durante estos dos siglos de vida independiente, junto con periodos sociales y políticos turbulentos, incluyendo un conflicto armado interno, hiperinflación y la inestabilidad política de los últimos 40 años, el Perú ha experimentado importantes cambios en su perfil epidemiológico con repercusiones directas en la salud de la población. En las últimas décadas, los indicadores de salud materno-infantil y de las enfermedades transmisibles muestran mejoría importante, pero el país se enfrenta de manera simultánea a una carga cada vez mayor de enfermedades no transmisibles y de salud mental. En cuanto a los sistemas de salud pública, se han realizado esfuerzos por aumentar la cobertura y calidad de la atención de salud en todo el país, apostándose en particular por mejorar la atención primaria. La ciencia y tecnología relacionadas con la salud también han mejorado, aunque si se quiere que la ciencia sea una prioridad nacional, son necesarias inversiones sustanciales. El cambio climático traerá importantes desafíos para la salud de la población, dada la diversidad geográfica y de microclimas del país. Para conmemorar los 200 años de vida independiente del Perú, presentamos un resumen de avances clave en diversas áreas y temas relacionados con la salud. Este repaso sirve como base para reflexionar sobre agendas y desafíos pendientes y futuros, con el fin de asegurar la salud y el bienestar de la población peruana en las próximas décadas.

A Smartphone-Based Model of Care to Support Patients With Cardiac Disease Transitioning From Hospital to the Community (TeleClinical Care): Pilot Randomized Controlled Trial

Background

Patients hospitalized with acute coronary syndrome (ACS) or heart failure (HF) are frequently readmitted. This is the first randomized controlled trial of a mobile health intervention that combines telemonitoring and education for inpatients with ACS or HF to prevent readmission.

Objective

This study aims to investigate the feasibility, efficacy, and cost-effectiveness of a smartphone app–based model of care (TeleClinical Care [TCC]) in patients discharged after ACS or HF admission.

Methods

In this pilot, 2-center randomized controlled trial, TCC was applied at discharge along with usual care to intervention arm participants. Control arm participants received usual care alone. Inclusion criteria were current admission with ACS or HF, ownership of a compatible smartphone, age ≥18 years, and provision of informed consent. The primary end point was the incidence of unplanned 30-day readmissions. Secondary end points included all-cause readmissions, cardiac readmissions, cardiac rehabilitation completion, medication adherence, cost-effectiveness, and user satisfaction. Intervention arm participants received the app and Bluetooth-enabled devices for measuring weight, blood pressure, and physical activity daily plus usual care. The devices automatically transmitted recordings to the patients’ smartphones and a central server. Thresholds for blood pressure, heart rate, and weight were determined by the treating cardiologists. Readings outside these thresholds were flagged to a monitoring team, who discussed salient abnormalities with the patients’ usual care providers (cardiologists, general practitioners, or HF outreach nurses), who were responsible for further management. The app also provided educational push notifications. Participants were followed up after 6 months.

Results

Overall, 164 inpatients were randomized (TCC: 81/164, 49.4%; control: 83/164, 50.6%; mean age 61.5, SD 12.3 years; 130/164, 79.3% men; 128/164, 78% admitted with ACS). There were 11 unplanned 30-day readmissions in both groups (P=.97). Over a mean follow-up of 193 days, the intervention was associated with a significant reduction in unplanned hospital readmissions (21 in TCC vs 41 in the control arm; P=.02), including cardiac readmissions (11 in TCC vs 25 in the control arm; P=.03), and higher rates of cardiac rehabilitation completion (20/51, 39% vs 9/49, 18%; P=.03) and medication adherence (57/76, 75% vs 37/74, 50%; P=.002). The average usability rating for the app was 4.5/5. The intervention cost Aus $6028 (US $4342.26) per cardiac readmission saved. When modeled in a mainstream clinical setting, enrollment of 237 patients was projected to have the same expenditure compared with usual care, and enrollment of 500 patients was projected to save approximately Aus $100,000 (approximately US $70,000) annually.

Conclusions

TCC was feasible and safe for inpatients with either ACS or HF. The incidence of 30-day readmissions was similar; however, long-term benefits were demonstrated, including fewer readmissions over 6 months, improved medication adherence, and improved cardiac rehabilitation completion.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12618001547235; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375945

Facilitators and Barriers to the Adoption of Telemedicine During the First Year of COVID-19: Systematic Review

BACKGROUND

The virulent and unpredictable nature of COVID-19 combined with a change in reimbursement mechanisms both forced and enabled the rapid adoption of telemedicine around the world. Thus, it is important to now assess the effects of this rapid adoption and to determine whether the barriers to such adoption are the same today as they were under prepandemic conditions.

OBJECTIVE

The objective of this systematic literature review was to examine the research literature published during the COVID-19 pandemic to identify facilitators, barriers, and associated medical outcomes as a result of adopting telemedicine, and to determine if changes have occurred in the industry during this time.

METHODS

The systematic review was performed in accordance with the Kruse protocol and the results are reported in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We analyzed 46 research articles from five continents published during the first year of the COVID-19 pandemic that were retrieved from searches in four research databases: PubMed (MEDLINE), CINAHL, Science Direct, and Web of Science.

RESULTS

Reviewers identified 25 facilitator themes and observations, 12 barrier themes and observations, and 14 results (compared to a control group) themes and observations. Overall, 22% of the articles analyzed reported strong satisfaction or satisfaction (zero reported a decline in satisfaction), 27% reported an improvement in administrative or efficiency results (as compared with a control group), 14% reported no statistically significant difference from the control group, and 40% and 10% reported an improvement or no statistically significant difference in medical outcomes using the telemedicine modality over the control group, respectively.

CONCLUSIONS

The pandemic encouraged rapid adoption of telemedicine, which also encouraged practices to adopt the modality regardless of the challenges identified in previous research. Several barriers remain for health policymakers to address; however, health care administrators can feel confident in the modality as the evidence largely shows that it is safe, effective, and widely accepted.

The effectiveness of text message delivered interventions for weight loss in developing countries: A systematic review and meta-analysis

Recent advances in mobile technologies have provided an opportunity to disseminate health information on a variety of health conditions. Randomized controlled trials (RCTs) have shown that text messaging helps people to lose weight, but the effectiveness of interventions varies between studies. Thus, this review aimed to (1) identify RCTs that used text messages for overweight management, (2) identify components of the interventions, and (3) test their effectiveness. PubMed, Web of Science, ProQuest, and Scopus databases were searched to identify relevant studies. Quality scores for selected articles were assessed using the Joanna Briggs Institute (JBI) critical appraisal tools for interventional studies. The effectiveness of the interventions was tested using random effect models. Twelve studies that met inclusion criteria were included in this review. Ten of the included studies reported that text message interventions had a significant effect on weight loss. The pooled mean difference in body mass index (BMI) change after the intervention was -0.43 kg/m² (95% confidence interval, - 0.63 to - 0.23 kg/m² ). Synthesis of the included studies provides evidence that (1) regular text messages; (2) interventions targeting weight monitoring, diet habit, and physical activity; and (3) the use of behavior change techniques led to significant weight loss.