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Xiao YZ, Chen XJ, Sun XL, Chen H, Luo YX, Chen Y, Liang YM. Effect of Implementing an Informatization Case Management Model on the Management of Chronic Respiratory Diseases in a General Hospital: Retrospective Controlled Study. JMIR Med Inform 2024; 12:e49978. [PMID: 38904478 PMCID: PMC11199924 DOI: 10.2196/49978] [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: 06/15/2023] [Revised: 04/14/2024] [Accepted: 04/17/2024] [Indexed: 06/22/2024] Open
Abstract
Background The use of chronic disease information systems in hospitals and communities plays a significant role in disease prevention, control, and monitoring. However, there are several limitations to these systems, including that the platforms are generally isolated, the patient health information and medical resources are not effectively integrated, and the "Internet Plus Healthcare" technology model is not implemented throughout the patient consultation process. Objective The aim of this study was to evaluate the efficiency of the application of a hospital case management information system in a general hospital in the context of chronic respiratory diseases as a model case. Methods A chronic disease management information system was developed for use in general hospitals based on internet technology, a chronic disease case management model, and an overall quality management model. Using this system, the case managers provided sophisticated inpatient, outpatient, and home medical services for patients with chronic respiratory diseases. Chronic respiratory disease case management quality indicators (number of managed cases, number of patients accepting routine follow-up services, follow-up visit rate, pulmonary function test rate, admission rate for acute exacerbations, chronic respiratory diseases knowledge awareness rate, and patient satisfaction) were evaluated before (2019-2020) and after (2021-2022) implementation of the chronic disease management information system. Results Before implementation of the chronic disease management information system, 1808 cases were managed in the general hospital, and an average of 603 (SD 137) people were provided with routine follow-up services. After use of the information system, 5868 cases were managed and 2056 (SD 211) patients were routinely followed-up, representing a significant increase of 3.2 and 3.4 times the respective values before use (U=342.779; P<.001). With respect to the quality of case management, compared to the indicators measured before use, the achievement rate of follow-up examination increased by 50.2%, the achievement rate of the pulmonary function test increased by 26.2%, the awareness rate of chronic respiratory disease knowledge increased by 20.1%, the retention rate increased by 16.3%, and the patient satisfaction rate increased by 9.6% (all P<.001), while the admission rate of acute exacerbation decreased by 42.4% (P<.001) after use of the chronic disease management information system. Conclusions Use of a chronic disease management information system improves the quality of chronic respiratory disease case management and reduces the admission rate of patients owing to acute exacerbations of their diseases.
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Affiliation(s)
- Yi-Zhen Xiao
- Department of Pulmonary and Critical Care Medicine, Yulin First People’s Hospital, Yulin, China
| | - Xiao-Jia Chen
- Department of Pulmonary and Critical Care Medicine, Yulin First People’s Hospital, Yulin, China
| | - Xiao-Ling Sun
- Department of Pulmonary and Critical Care Medicine, Yulin First People’s Hospital, Yulin, China
| | - Huan Chen
- Department of Pulmonary and Critical Care Medicine, Yulin First People’s Hospital, Yulin, China
| | - Yu-Xia Luo
- Department of Pulmonary and Critical Care Medicine, Yulin First People’s Hospital, Yulin, China
| | - Yuan Chen
- Department of Pulmonary and Critical Care Medicine, Yulin First People’s Hospital, Yulin, China
| | - Ye-Mei Liang
- Department of Nursing, Yulin First People’s Hospital, Yulin, China
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Tomlinson OW, Barker AR, Denford S, Williams CA. Adapting, restarting, and terminating a randomised control trial for people with cystic fibrosis: Reflections on the impact of the COVID-19 pandemic upon research in a clinical population. Contemp Clin Trials Commun 2024; 39:101294. [PMID: 38577655 PMCID: PMC10992694 DOI: 10.1016/j.conctc.2024.101294] [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: 10/17/2023] [Revised: 02/26/2024] [Accepted: 03/27/2024] [Indexed: 04/06/2024] Open
Abstract
Background Habitual physical activity (PA) and exercise form a cornerstone of the management of cystic fibrosis (CF), a genetically inherited pulmonary and digestive condition - whereby telehealth platforms have been proposed as a mechanism to engage remotely people with CF in PA and exercise. Methods To test this, in early 2020, the 'ActivOnline: Physical Activity in Cystic Fibrosis Trial' (ActiOn PACT) randomised control trial was established to examine whether an online intervention was effective at increasing PA in adolescents and adults with CF. Results The emergence of the COVID-19 pandemic in 2020 forced this trial to be paused and modified, with the adoption of online recruitment and remote assessment of outcome measures. Despite such adaptations in accord with frameworks developed by the National Institute for Health Research, this trial failed to recruit and was subsequently terminated. Conclusions This article details the authors reflections upon the proposed reasons for lack of recruitment, including improved technology and medications for people with CF, and contextualises this finding in relation to the wider issue of non-reporting of trial results in clinical research.
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Affiliation(s)
- Owen W. Tomlinson
- Children's Health and Exercise Research Centre, Department of Public Health and Sports Sciences, University of Exeter, Exeter, United Kingdom
- Academic Department of Respiratory Medicine, Royal Devon University Healthcare NHS Foundation Trust, Exeter, United Kingdom
- Department of Clinical and Biomedical Science, University of Exeter, Exeter, United Kingdom
| | - Alan R. Barker
- Children's Health and Exercise Research Centre, Department of Public Health and Sports Sciences, University of Exeter, Exeter, United Kingdom
| | - Sarah Denford
- Children's Health and Exercise Research Centre, Department of Public Health and Sports Sciences, University of Exeter, Exeter, United Kingdom
- Health Protection Research Unit in Behavioural Science and Evaluation, University of Bristol, Bristol, United Kingdom
| | - Craig A. Williams
- Children's Health and Exercise Research Centre, Department of Public Health and Sports Sciences, University of Exeter, Exeter, United Kingdom
- Academic Department of Respiratory Medicine, Royal Devon University Healthcare NHS Foundation Trust, Exeter, United Kingdom
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Zhang W, Ji H, Wu Y, Xu Z, Li J, Sun Q, Wang C, Zhao F. Patients' needs and experiences of telerehabilitation after total hip and knee arthroplasty: A qualitative systematic review and meta-synthesis. Digit Health 2024; 10:20552076241256756. [PMID: 38846364 PMCID: PMC11155359 DOI: 10.1177/20552076241256756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 05/07/2024] [Indexed: 06/09/2024] Open
Abstract
Background The number of patients undergoing joint replacement procedures is continuously increasing. Tele-equipment is progressively being employed for postrehabilitation of total hip and knee replacements. Gaining a comprehensive understanding of the experiences and requirements of patients undergoing total hip and knee arthroplasty who participate in telerehabilitation can contribute to the enhancement of telerehabilitation programs and the overall rehabilitation and care provided to this specific population. Objective To explore the needs and experiences of total hip and knee arthroplasty patients with telerehabilitation. Design Systematic review and qualitative synthesis. Methods Electronic databases PubMed, Web of Science, The Cochrane Library, Embase, CINAHL, Scopus, ProQuest, CNKI, Wanfang Data, VIP, and SinoMed were systematically searched for information on the needs and experiences of telerehabilitation for patients with total hip arthroplasty and total knee arthroplasty in qualitative studies. The search period was from the creation of the database to March 2024. Literature quality was assessed using the 2016 edition of the Australian Joanna Briggs Institute Centre for Evidence-Based Health Care Quality Assessment Criteria for Qualitative Research. A pooled integration approach was used to integrate the findings inductively. Results A total of 11 studies were included and 4 themes were identified: the desire to communicate and the need to acquire knowledge; accessible, high-quality rehabilitation services; positive psychological experiences; the dilemmas of participating in telerehabilitation. Conclusions This study's findings emphasize that the practical needs and challenges of total hip and knee arthroplasty patients' participation in telerehabilitation should be continuously focused on, and the advantages of telerehabilitation should be continuously strengthened to guarantee the continuity of patients' postoperative rehabilitation and to promote their postoperative recovery.
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Affiliation(s)
- Wenzhong Zhang
- Shandong University of Traditional Chinese Medicine, School of Nursing, Jinan, China
- Nursing Department, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Hong Ji
- Nursing Department, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Yan Wu
- Nursing Department, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Zhenzhen Xu
- Shandong University of Traditional Chinese Medicine, School of Nursing, Jinan, China
| | - Jing Li
- Shandong University of Traditional Chinese Medicine, School of Nursing, Jinan, China
| | - Qingxiang Sun
- Shandong University of Traditional Chinese Medicine, School of Nursing, Jinan, China
| | - Chunlei Wang
- Shandong University of Traditional Chinese Medicine, School of Nursing, Jinan, China
| | - Fengyi Zhao
- Shandong University of Traditional Chinese Medicine, School of Nursing, Jinan, China
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Jha S, Chandi D. Recent Advances in the Devices for the Treatment of Chronic Obstructive Pulmonary Disease: A Review. Cureus 2023; 15:e49371. [PMID: 38146553 PMCID: PMC10749692 DOI: 10.7759/cureus.49371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 11/24/2023] [Indexed: 12/27/2023] Open
Abstract
Chronic obstructive pulmonary disease or COPD has been known to adversely affect people's quality of life. It influences a great number of individuals overall and is a main source of horribleness and mortality. It is associated with major healthcare and socioeconomic burdens. So, it is important to cure such types of diseases. This review article deals with the proper understanding of the newly developed devices and various advances taking place in the treatment of COPD. There are many new methods and procedures being developed recently for the cure or treatment of COPD, of which some are mentioned in the following review article. The articles also deal with the beneficial effects as well as the challenges faced during the use of those newly developed methods during the treatment of the disease. Various types of management of COPD are also mentioned in the article. This article also deals with the various new advances that are currently taking place in devices used in the therapy of COPD.
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Affiliation(s)
- Shivangi Jha
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Dhurba Chandi
- Microbiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Scheckel B, Schmidt K, Stock S, Redaèlli M. Patient Portals as Facilitators of Engagement in Patients With Diabetes and Chronic Heart Disease: Scoping Review of Usage and Usability. J Med Internet Res 2023; 25:e38447. [PMID: 37624629 PMCID: PMC10492174 DOI: 10.2196/38447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 02/08/2023] [Accepted: 06/28/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Patient portals have the potential to improve care for chronically ill patients by engaging them in their treatment. These platforms can work, for example, as a standalone self-management intervention or a tethered link to treatment providers in routine care. Many different types of portals are available for different patient groups, providing various features. OBJECTIVE This scoping review aims to summarize the current literature on patient portals for patients with diabetes mellitus and chronic heart disease regarding usage behavior and usability. METHODS We conducted this review according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement for scoping reviews. We performed database searches using PubMed, PsycInfo, and CINAHL, as well as additional searches in reviews and reference lists. We restricted our search to 2010. Qualitative and quantitative studies, and studies using both approaches that analyzed usage behavior or usability of patient portals were eligible. We mapped portal features according to broad thematic categories and summarized the results of the included studies separately according to outcome and research design. RESULTS After screening, we finally included 85 studies. Most studies were about patients with diabetes, included patients younger than 65 years, and were conducted in the United States. Portal features were categorized into educational/general information, reminder, monitoring, interactivity, personal health information, electronic/personal health record, and communication. Portals mostly provided educational, monitoring, and communication-related features. Studies reported on usage behavior including associated variables, usability dimensions, and suggestions for improvement. Various ways of reporting usage frequency were identified. A noticeable decline in portal usage over time was reported frequently. Age was most frequently studied in association with portal use, followed by gender, education, and eHealth literacy. Younger age and higher education were often associated with higher portal use. In two-thirds of studies reporting on portal usability, the portals were rated as user friendly and comprehensible, although measurement and reporting were heterogeneous. Portals were considered helpful for self-management through positive influences on motivation, health awareness, and behavioral changes. Helpful features for self-management were educational/general information and monitoring. Barriers to portal use were general (eg, aspects of design or general usability), related to specific situations during portal use (eg, login procedure), or not portal specific (eg, user skills and preferences). Frequent themes were aspects of design, usability, and technology. Suggestions for improvement were mainly related to technical issues and need for support. CONCLUSIONS The current state of research emphasizes the importance of involving patients in the development and evaluation of patient portals. The consideration of various research designs in a scoping review is helpful for a deeper understanding of usage behavior and usability. Future research should focus on the role of disease burden, and usage behavior and usability among older patients.
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Affiliation(s)
- Benjamin Scheckel
- Institute of Health Economics and Clinical Epidemiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Katharina Schmidt
- Institute of Health Economics and Clinical Epidemiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Stephanie Stock
- Institute of Health Economics and Clinical Epidemiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Marcus Redaèlli
- Institute of Health Economics and Clinical Epidemiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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Peckham D, Spoletini G. Impact of Digital Technologies on Clinical Care for Adults with Cystic Fibrosis. Semin Respir Crit Care Med 2023; 44:217-224. [PMID: 36535666 DOI: 10.1055/s-0042-1758730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The coronavirus disease 2019 pandemic accelerated the implementation of digital technologies, which have now become embedded as essential tools for the management of chronic disease, including cystic fibrosis (CF). Despite subsequent easing of restrictions and because of improved clinical stability resulting from the introduction of highly effective modulator therapy, digital technologies including video and telephone consultations and remote monitoring are likely to remain integral to the future delivery of CF health care. In this article, we explore some of the key developments in digital technologies, barriers to their adoption, and how the CF community is likely to embrace lessons learned from the recent pandemic to help modernize and reshape the future of CF care.
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Affiliation(s)
- Daniel Peckham
- Leeds Adult Cystic Fibrosis Unit, St James's University Hospital, Leeds, United Kingdom.,Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, United Kingdom
| | - Giulia Spoletini
- Leeds Adult Cystic Fibrosis Unit, St James's University Hospital, Leeds, United Kingdom
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Uche-Okoye D, Ajemba MN, Amy B, Arene EC, Ugo CH, Eze NP, Anyadike IK, Onuorah UM, Chiwenite CM. Is telerehabilitation an effective maintenance strategy for patients with chronic obstructive pulmonary diseases: a systematic review. BULLETIN OF THE NATIONAL RESEARCH CENTRE 2023; 47:13. [PMID: 36743313 PMCID: PMC9890431 DOI: 10.1186/s42269-023-00980-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 01/05/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Pulmonary rehabilitation (PR) has proven to improve the physical and psychosocial function in patients with chronic obstructive pulmonary disease (COPD). However, the gains achieved during pulmonary rehabilitation diminish over time without an effective maintenance strategy. With several factors affecting access to pulmonary rehabilitation, calls for innovative models were made, which saw the emergence of studies exploring telerehabilitation (TR) as an alternative to traditional pulmonary rehabilitation models. Although there are current reviews exploring the effectiveness of telerehabilitation as an alternative for conventional PR, no review has considered telerehabilitation effectiveness in the long term. Hence, this review aims at examining the effectiveness of telerehabilitation following to pulmonary rehabilitation in patients with chronic obstructive pulmonary disease. MAIN BODY A systematic review of the literature using CINAHL, MEDLINE, SCOPUS, Web of science PEDRO, AMED and EMBASE databases was conducted to assess the effectiveness of telerehabilitation following PR in patients with COPD. Health-related quality of life (HRQoL) and exercise capacity was maintained within 6-12 months of a TR maintenance programme. However, there was no significant increase in HRQoL and exercise capacity between the intervention and control groups in 6-12 months. CONCLUSIONS This review suggests that a TR maintenance strategy effectively maintains benefits gained and may improve HRQoL and exercise capacity within 6-12 months for patients with COPD. Nonetheless, it is impossible to extrapolate the findings to the general population due to the paucity of included studies. Further high quality randomised controlled trials examining TR in the long-term is required in the future. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1186/s42269-023-00980-8.
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Roy AL, Duruflé A, Piette P, Fraudet B, Lofficial V, Gallien P. Telerehabilitation during the COVID-19 pandemic, what are the determinants of satisfaction for chronic diseases? a retrospective study. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:1108087. [PMID: 36776736 PMCID: PMC9909006 DOI: 10.3389/fresc.2023.1108087] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 01/09/2023] [Indexed: 01/27/2023]
Abstract
Background During the Covid-19 health crisis, telerehabilitation provided a solution to ensure the continuity of care. Since then, it has been offered as an alternative to face-to-face rehabilitation in chronic conditions. Data measuring satisfaction are essential to adapt and increase the effectiveness of this type of programme. Aim and scope This research focused on determining the most significant determinants of participant satisfaction in a telerehabilitation programme. Methods We conducted a retrospective study by analysing the satisfaction questionnaire used from the start of the programme. Result Two hundred and ten (210) participants completed the programme; 180 questionnaires were filled in and 175 analyzed of which 70 with chronic low back pain (CLBP), 59 for multiple sclerosis (MS) and 22 with parkinson's disease (PD). Satisfaction was high for all participants (scoring out of 10, mean = 8.22 sd = 1.53), but the determinants reported for the three main conditions involved in the programme differed. Main determinant was "benefice" for CLBP (p = 1.23e-05), "home exercises adapted" for MS (p = 0.000679) and "interest in staying at home" for PD (p = 1.84e-05). Conclusion Depending on the context of the condition/disease, the drivers of satisfaction were not identical. Knowledge of these determinants will allow us to further improve the programme. However, some unresolved questions remain regarding the place of therapists, their role and the skills required for a successful telerehabilitation programme. Further studies are required to understand the impact.
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Ortiz Ortigosa L, Vinolo-Gil MJ, Pastora Bernal JM, Casuso-Holgado MJ, Rodriguez-Huguet M, Martín-Valero R. Telerehabilitation and telemonitoring interventions programs used to improving quality of life in people with cystic fibrosis: A systematic review. Digit Health 2023; 9:20552076231197023. [PMID: 37654722 PMCID: PMC10467216 DOI: 10.1177/20552076231197023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 09/02/2023] Open
Abstract
Background Cystic fibrosis causes mucus to build up in the lungs, digestive tract, and other areas. It is the most common chronic lung disease in children and young adults. It requires daily medical care. Before the COVID-19 pandemic, telerehabilitation and telehealth were used, but it was after this that there was a boom in these types of assistance in order to continue caring for cystic fibrosis patients. Objective The objective is to evaluate the effect of telemedicine programs in people with cystic fibrosis. Methods For the search, the PubMed, Scopus, Web of Science, PEDro, Cochrane, and CINAHL databases were used. Randomized controlled trials, pilot studies, and clinical trials have been included. The exclusion criteria have considered that the population did not have another active disease or that telemedicine was not used as the main intervention. This study follows the PRISMA statement and has been registered in the PROSPERO database (CRD42021257647). Results A total of 11 articles have been included in the systematic review. No improvements have been found in quality of life, forced expiratory volume, and forced vital capacity. Good results have been found in increasing physical activity and early detection of exacerbations. Adherence and satisfaction are very positive and promising. Conclusions Despite not obtaining significant improvements in some of the variables, it should be noted that the adherence and satisfaction of both patients and workers reinforce the use of this type of care. Future studies are recommended in which to continue investigating this topic.
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Affiliation(s)
- Lucía Ortiz Ortigosa
- Department of Physiotherapy, Faculty of Health Science, University of Málaga, CTS-1071 Research Group, Málaga, Spain
| | | | - José-Manuel Pastora Bernal
- Department of Physiotherapy, Faculty of Health Science, University of Málaga, CTS-1071 Research Group, Málaga, Spain
| | - María Jesús Casuso-Holgado
- Department of Physiotherapy, Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, Sevilla, Spain
| | | | - Rocío Martín-Valero
- Department of Physiotherapy, Faculty of Health Science, University of Málaga, CTS-1071 Research Group, Málaga, Spain
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Wannheden C, Åberg-Wennerholm M, Dahlberg M, Revenäs Å, Tolf S, Eftimovska E, Brommels M. Digital Health Technologies Enabling Partnerships in Chronic Care Management: A Scoping Review (Preprint). J Med Internet Res 2022; 24:e38980. [PMID: 35916720 PMCID: PMC9379797 DOI: 10.2196/38980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/02/2022] [Accepted: 06/16/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Carolina Wannheden
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Matilda Åberg-Wennerholm
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Marie Dahlberg
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Åsa Revenäs
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Division of Physiotherapy, School of Health Care and Social Welfare, Mälardalen University, Västerås, Sweden
- Center for Clinical Research, County of Västmanland, Uppsala University, Västerås, Sweden
| | - Sara Tolf
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Elena Eftimovska
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Mats Brommels
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
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