The QardioArm App in the Assessment of Blood Pressure and Heart Rate: Reliability and Validity Study

Evaluation of Cost-Effectiveness of a Virtual Multidisciplinary Stroke Care Clinic for Community-Dwelling Survivors of Stroke

BACKGROUND

A technologically integrated, multidisciplinary approach to stroke rehabilitation service was delivered and embedded into conventional health care practice. This article reports an evaluation of cost-effectiveness analysis of a new Virtual Multidisciplinary Stroke Care Clinic (VMSCC) service for community-dwelling survivors of stroke.

METHODS AND RESULTS

A randomized controlled trial was conducted. Adults with a first/recurrent ischemic/hemorrhagic stroke were recruited from 10 hospitals. Eligible participants were randomly assigned to receive the VMSCC service (individual virtual consultations with a registered nurse, home blood pressure telemonitoring, and unlimited access to an online resource platform) plus usual care or usual care alone. Cost-effectiveness analyses were performed based on incremental cost-effectiveness ratios expressed as incremental cost per emergency admission reduced, and day of hospitalization reduced over the study period. A total of 256 participants (intervention group n=141 versus control group n=115) with complete cost and health care use data were included in the cost-effectiveness analyses. The VMSCC service, on average, resulted in a greater reduction in the number of emergency admission (-0.06 [95% bootstrapped CI, -0.14 to 0.01]) and fewer days of hospitalization (-0.08, [95% bootstrapped CI -0.40 to 0.24]) but incurred a higher total cost of HK$375 (95% bootstrapped CI, -2103 to 2743) compared with the usual care. The incremental cost-effectiveness ratios of the VMSCC service compared with the usual care were HK$6070 and HK$4826 per an emergency admission and a day of hospital stay reduced respectively.

CONCLUSIONS

The study provides preliminary but not confirmative evidence that the VMSCC service could be more effective but more costly than usual care in reducing health service use.

REGISTRATION

URL: https://www.chictr.org.cn. Unique identifier: ChiCTR1800016101.

Emotion Regulation Strategies Relate to Ambulatory Cardiovascular Activity in an American Indian Community

OBJECTIVE

Poor emotion regulation is associated with risk for cardiovascular disease. However, much of this research is conducted in primarily White samples, thus limiting our understanding of this relationship in other racial/ethnic groups. American Indians (AIs) are uniquely and disproportionately at risk for cardiovascular disease. As such, the present study aimed to examine the relationships between emotion regulation strategies and ambulatory cardiovascular activity in an entirely AI sample.

METHODS

The sample consisted of 100 AI adults living on a tribal reservation. Emotion regulation strategies (expressive suppression, cognitive reappraisal) were assessed via the Emotion Regulation Questionnaire. Using ecological momentary assessment, daily measurements of psychological stress and ambulatory cardiovascular activity were taken during a 7-day monitoring period. Statistical analyses included bivariate correlations, hierarchical linear regression models, and mediation models.

RESULTS

Expressive suppression was associated with higher systolic and diastolic blood pressure, as well as higher pulse rate. In contrast, cognitive reappraisal was associated with lower systolic and diastolic blood pressure, lower pulse rate, and lower average daily psychological stress. These results remained statistically significant after adjusting for age, sex, body mass index, anxiety, depression, and early life trauma. In addition, psychological stress mediated the associations between blood pressure and cognitive reappraisal, but not expressive suppression.

CONCLUSIONS

These results provide preliminary evidence for divergent associations of two emotion regulation strategies with cardiovascular activity and psychological stress in an AI community. Modifying health interventions to include training in effective emotion regulation may be beneficial.

Continuous cuffless monitoring of arterial blood pressure via graphene bioimpedance tattoos

Continuous monitoring of arterial blood pressure (BP) in non-clinical (ambulatory) settings is essential for understanding numerous health conditions, including cardiovascular diseases. Besides their importance in medical diagnosis, ambulatory BP monitoring platforms can advance disease correlation with individual behaviour, daily habits and lifestyle, potentially enabling analysis of root causes, prognosis and disease prevention. Although conventional ambulatory BP devices exist, they are uncomfortable, bulky and intrusive. Here we introduce a wearable continuous BP monitoring platform that is based on electrical bioimpedance and leverages atomically thin, self-adhesive, lightweight and unobtrusive graphene electronic tattoos as human bioelectronic interfaces. The graphene electronic tattoos are used to monitor arterial BP for >300 min, a period tenfold longer than reported in previous studies. The BP is recorded continuously and non-invasively, with an accuracy of 0.2 ± 4.5 mm Hg for diastolic pressures and 0.2 ± 5.8 mm Hg for systolic pressures, a performance equivalent to Grade A classification.

Personalized Digital Health Beyond the Pandemic

The effectiveness of telehealth and personalized digital health became evident during the coronavirus disease 2019 pandemic. This article defines what personalized digital health is and provides selected examples of the various personalized digital health devices patients may be using. The article also delves into how to implement and incorporate these personalized digital health devices in practice and presents suggestions on political actions that nurse practitioners need to advocate for with regard to telehealth and personalized digital health policy.

A Structured Review of Commercially Available Cardiac Rehabilitation mHealth Applications Using the Mobile Application Rating Scale

PURPOSE

This study systematically evaluated the quality and functionalities of patient-facing, commercially available mobile health (mHealth) apps for cardiac rehabilitation (CR).

METHODS

We performed our search in two of the most widely used commercial mobile app stores: Apple iTunes Appstore and Google Play Store (Android apps). Six search terms were used to query relevant CR apps: "cardiac rehabilitation," "heart disease and remote therapy," "heart failure exercise," "heart therapy and cardiac recovery," "cardiac recovery," and "heart therapy." App quality was evaluated using the Mobile Application Rating Scale (MARS). App functionality was evaluated using the IQVIA functionality scale, and app content was evaluated against the American Heart Association guidelines for CR. Apps meeting our inclusion criteria were downloaded and evaluated by two to three reviewers, and interclass correlations between reviewers were calculated.

RESULTS

We reviewed 3121 apps and nine apps met our inclusion criteria. On average, the apps scored a 3.0 on the MARS (5-point Likert scale) for overall quality. The two top-ranking mHealth apps for CR for all three quality, functionality, and consistency with evidence-based guidelines were My Cardiac Coach and Love My Heart for Women, both of which scored ≥4.0 for behavior change.

CONCLUSION

Overall, the quality and functionality of free apps for mobile CR was high, with two apps performing the best across all three quality categories. High-quality CR apps are available that can expand access to CR for patients with cardiovascular disease.

Historical Loss: Implications for Health of American Indians in the Blackfeet Community

BACKGROUND

Historical loss in American Indians (AIs) is believed to contribute to high incidence of mental health disorders, yet less is known about the associations between historical loss and physical health.

PURPOSE

To investigate whether frequency of thought about historical loss predicts risk factors for chronic physical health conditions in an AI community.

METHODS

Using Community Based Participatory research (CBPR) and Ecological Momentary Assessment (EMA), we measured frequency of thoughts about historical loss in 100 AI adults residing on the Blackfeet reservation. Participants completed a 1-week monitoring period, during which ambulatory blood pressure and daily levels of psychological stress were measured. At the end of the week, we collected a dried blood spot sample for measurement of C-reactive protein (CRP).

RESULTS

In hierarchical linear regression models controlling for demographics and relevant covariates, greater frequency of thoughts about historical loss predicted higher average daily psychological stress (B = .55, t = 6.47, p < .001, ΔR2 = .30) and higher levels of CRP (B = .33, t = 3.93, p < .001, ΔR2 = .10). Using linear mixed modeling with relevant covariates, we found that greater thoughts about historical loss were associated with higher systolic ambulatory blood pressure (B = .32, 95% CI = .22-.42, t = 6.48, p < .001, ΔR2 = .25; Fig. 1c) and greater diastolic ambulatory blood pressure (B = .19, 95% CI = .11-.27, t = 4.73, p < .001, ΔR2 = .19).

CONCLUSIONS

The data suggest that frequency of thought about historical loss may contribute to increased subclinical risk for cardiovascular disease in the Blackfeet community.

Using a Commercially Available App for the Self-Management of Hypertension: Acceptance and Usability Study in Saudi Arabia

BACKGROUND

The use of smartphone apps to assist in the self-management of hypertension is becoming increasingly common, but few commercially available apps have the potential to be effective along with adequate security and privacy measures in place. In a previous study, we identified 5 apps that are potentially effective and safe, and based on the preferences of doctors and patients, one (Cora Health) was selected as the most suitable app for use in a Saudi context. However, there is currently no evidence of its usability and acceptance among potential users. Indeed, there has been little research into the usability and acceptance of hypertension apps in general, and less research considers this in the Gulf Region.

OBJECTIVE

This study aims to evaluate the acceptance and usability of the selected app in the Saudi context.

METHODS

This study used a mixed methods approach with 2 studies: a usability test involving patients in a controlled setting performing predefined tasks and a real-world usability study where patients used the app for 4 weeks. In the usability test, participants were asked to think aloud while performing the tasks, and an observer recorded the number of tasks they completed. At the end of the real-world pilot study, participants were interviewed, and the mHealth App Usability Questionnaire was completed. Descriptive statistics were used to analyze quantitative data, and thematic analysis was used to analyze qualitative data.

RESULTS

In total, 10 patients completed study 1. The study found that app usability was moderate and that participants needed some familiarization time before they could use the app proficiently. Some usability issues were revealed, related to app accessibility and navigation, and a few tasks remained uncompleted by most people. A total of 20 patients completed study 2, with a mean age of 51.6 (SD 11.7) years. Study 2 found that the app was generally acceptable and easy to use, with some similar usability issues identified. Participants stressed the importance of practice and training to use it more easily and proficiently. Participants had a good engagement level with 48% retention at the end of study 2, with most participants' engagement being classed as meaningful. The most recorded data were blood pressure, followed by stress and medication, and the most accessed feature was viewing graphs of data trends.

CONCLUSIONS

This study shows that a commercially available app can be usable and acceptable in the self-management of hypertension but also found a considerable number of possibilities for improvement, which needs to be considered in future app development. The results show that there is potential for a commercially available app to be used in large-scale studies of hypertension self-management if suggestions for improvements are addressed.

Validation of the Multidimensional Fatigue Inventory with Coronary Artery Disease Patients

BACKGROUND

Fatigue is a common distressing symptom in patients with coronary artery disease (CAD). The Multidimensional Fatigue Inventory (MFI) is used for measuring fatigue in various clinical settings. Nevertheless, its multidimensional structure has not been consistent across studies. Thus, we aimed to psychometrically evaluate the MFI in patients with CAD.

METHODS

In sum, 1162 CAD patients completed questionnaires assessing their subjective fatigue level (MFI-20), mental distress symptoms (HADS, STAI), and health-related quality of life (SF-36). Participants also completed exercise capacity (EC) testing.

RESULTS

Confirmatory factor analysis of the four-factor model, showed acceptable fit (CFI = 0.905; GFI = 0.895; NFI = 0.893, RMSEA = 0.077). After eliminating four items, confirmatory factor analysis testing showed improvement in the four-factor model of the MFI-16 (CFI = 0.910; GFI = 0.909; NFI = 0.898, RMSEA = 0.077). Internal consistency values were adequate for the total score and four MFI-16 subscales: General fatigue, physical fatigue, reduced activity, and mental fatigue with Cronbach's α range: 0.60-0.82. The inadequate value (Cronbach's α = 0.43) was received for the subscale of reduced motivation in both MFI-20 and MFI-16. Correlations between the MFI-16 and HADS, STAI, SF-36, and EC measures were statistically significant (all p's < 0.001).

CONCLUSIONS

The Lithuanian version of the modified MFI of 16 items showed good factorial structure and satisfactory psychometric characteristics, except for reduced motivation subscale.

Using Smart Bracelets to Assess Heart Rate Among Students During Physical Education Lessons: Feasibility, Reliability, and Validity Study

Background

An increasing number of wrist-worn wearables are being examined in the context of health care. However, studies of their use during physical education (PE) lessons remain scarce.

Objective

We aim to examine the reliability and validity of the Fizzo Smart Bracelet (Fizzo) in measuring heart rate (HR) in the laboratory and during PE lessons.

Methods

In Study 1, 11 healthy subjects (median age 22.0 years, IQR 3.75 years) twice completed a test that involved running on a treadmill at 6 km/h for 12 minutes and 12 km/h for 5 minutes. During the test, participants wore two Fizzo devices, one each on their left and right wrists, to measure their HR. At the same time, the Polar Team2 Pro (Polar), which is worn on the chest, was used as the standard. In Study 2, we went to 10 schools and measured the HR of 24 students (median age 14.0 years, IQR 2.0 years) during PE lessons. During the PE lessons, each student wore a Polar device on their chest and a Fizzo on their right wrist to measure HR data. At the end of the PE lessons, the students and their teachers completed a questionnaire where they assessed the feasibility of Fizzo. The measurements taken by the left wrist Fizzo and the right wrist Fizzo were compared to estimate reliability, while the Fizzo measurements were compared to the Polar measurements to estimate validity. To measure reliability, intraclass correlation coefficients (ICC), mean difference (MD), standard error of measurement (SEM), and mean absolute percentage errors (MAPE) were used. To measure validity, ICC, limits of agreement (LOA), and MAPE were calculated and Bland-Altman plots were constructed. Percentage values were used to estimate the feasibility of Fizzo.

Results

The Fizzo showed excellent reliability and validity in the laboratory and moderate validity in a PE lesson setting. In Study 1, reliability was excellent (ICC>0.97; MD<0.7; SEM<0.56; MAPE<1.45%). The validity as determined by comparing the left wrist Fizzo and right wrist Fizzo was excellent (ICC>0.98; MAPE<1.85%). Bland-Altman plots showed a strong correlation between left wrist Fizzo measurements (bias=0.48, LOA=–3.94 to 4.89 beats per minute) and right wrist Fizzo measurements (bias=0.56, LOA=–4.60 to 5.72 beats per minute). In Study 2, the validity of the Fizzo was lower compared to that found in Study 1 but still moderate (ICC>0.70; MAPE<9.0%). The Fizzo showed broader LOA in the Bland-Altman plots during the PE lessons (bias=–2.60, LOA=–38.89 to 33.69 beats per minute). Most participants considered the Fizzo very comfortable and easy to put on. All teachers thought the Fizzo was helpful.

Conclusions

When participants ran on a treadmill in the laboratory, both left and right wrist Fizzo measurements were accurate. The validity of the Fizzo was lower in PE lessons but still reached a moderate level. The Fizzo is feasible for use during PE lessons.

QardioArm Blood Pressure Monitoring in a Population With Type 2 Diabetes: Validation Study

BACKGROUND

Home blood pressure monitoring has many benefits, even more so, in populations prone to high blood pressure, such as persons with diabetes.

OBJECTIVE

The purpose of this research was to validate the QardioArm mobile device in a sample of individuals with noninsulin-dependent type 2 diabetes in accordance with the guidelines of the second International Protocol of the European Society of Hypertension.

METHODS

The sample consisted of 33 patients with type 2 diabetes. To evaluate the validity of QardioArm by comparing its data with that obtained with a digital sphygmomanometer (Omron M3 Intellisense), two nurses collected diastolic blood pressure, systolic blood pressure, and heart rate with both devices.

RESULTS

The analysis indicated that the test device QardioArm met all the validation requirements using a sample population with type 2 diabetes.

CONCLUSIONS

This paper reports the first validation of QardioArm in a population of individuals with noninsulin-dependent type 2 diabetes. QardioArm for home monitoring of blood pressure and heart rate met the requirements of the second International Protocol of the European Society of Hypertension.

QardioArm Upper Arm Blood Pressure Monitor Against Omron M3 Upper Arm Blood Pressure Monitor in Patients With Chronic Kidney Disease: A Validation Study According to the European Society of Hypertension International Protocol Revision 2010

Background

Hypertension is considered as a main risk factor for chronic kidney disease development and progression. Thus, the control and evaluation of this disease with new software and devices are especially important in patients who suffer from chronic kidney disease.

Objective

This study aimed to validate the QardioArm mobile device, which is used for blood pressure (BP) self-measurement in patients who suffer from chronic kidney disease, by following the European Society of Hypertension International Protocol 2 (ESH-IP2) guidelines.

Methods

A validation study was carried out by following the ESH-IP2 guidelines. A sample of 33 patients with chronic kidney disease self-measured their BP by using the QardioArm and Omron M3 Intellisense devices. Heart rate (HR), diastolic BP, and systolic BP were measured.

Results

The QardioArm fulfilled the ESH-IP2 validation criteria in patients who suffered from chronic kidney disease.

Conclusions

Thus, this study is considered as the first validation using a wireless upper arm oscillometric device connected to an app to measure BP and HR meeting the ESH-IP2 requirements in patients who suffer from chronic kidney disease. New validation studies following the ESH-IP2 guidelines should be carried out using different BP devices in patients with specific diseases.

Smartphone Apps to Support Self-Management of Hypertension: Review and Content Analysis

Background

Hypertension is a widespread chronic disease, and its effective treatment requires self-management by patients. Health-related apps provide an effective way of supporting hypertension self-management. However, the increasing range and variety of hypertension apps available on the market, owing to the global growth in apps, creates the need for patients and health care professionals to be informed about the effectiveness of these apps and the levels of privacy and security that they provide.

Objective

This study aimed to describe and assess all available apps supporting hypertension self-management in the most popular app stores and investigate their functionalities.

Methods

In January 2018, the UK Apple and Google Play stores were scanned for all free and paid apps supporting hypertension self-management. Apps were included if they were in English, had functionality supporting hypertension self-management, and targeted adult users with hypertension. The included apps were downloaded and their functionalities were investigated. Behavior change techniques (BCTs) linked with the theoretical domain framework (TDF) underpinning potentially effective apps were independently coded by two reviewers. The data privacy and security of the apps were also independently assessed.

Results

A total of 186 hypertension apps that met the inclusion criteria were included in this review. The majority of these apps had only one functionality (n=108), while the remainder offered different combinations of functionalities. A small number of apps had comprehensive functionalities (n=30) that are likely to be more effective in supporting hypertension self-management. Most apps lacked a clear theoretical basis, and 24 BCTs identified in these 30 apps were mapped to 10 TDF mechanisms of actions. On an average, 18.4 BCTs were mapped to 6 TDF mechanisms of actions that may support hypertension self-management behaviors. There was a concerning absence of evidence related to the effectiveness and usability of all 186 apps, and involvement of health care professionals in the app development process was minimal. Most apps did not meet the current standards of data security and privacy.

Conclusions

Despite the widespread accessibility and availability of smartphone apps with a range of combinations of functionalities that can support the self-management of hypertension, only a small number of apps are likely to be effective. Many apps lack security measures as well as a clear theoretical basis and do not provide any evidence concerning their effectiveness and usability. This raises a serious issue, as health professionals and those with hypertension have insufficient information to make decisions on which apps are safe and effective.

The QardioArm Blood Pressure App for Self-Measurement in an Obese Population: Validation Study Using the European Society of Hypertension International Protocol Revision 2010

Background

Obesity and high blood pressure (HBP) pose high cardiovascular risks, and they are frequent causes of cardiovascular disease.

Objective

The aim of this study was to validate the mobile app QardioArm for high blood pressure monitoring in obese subjects (body mass index ≥30 kg/m²) according to guidelines in the European Society of Hypertension-International Protocol 2 (ESH-IP2).

Methods

We recruited 33 obese subjects and measured their blood pressure using QardioArm (test device) and Omron M3 Intellisense (Omron Healthcare, Kyoto, Japan; standard device). We compared systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) according to the ESH-IP2.

Results

A total of 95 of 99 differences for SBP and 91 of 99 for DBP displayed absolute differences within 10 mm Hg. A total of 98 of 99 differences for SBP and 98 of 99 for DBP exhibited absolute differences within 15 mm Hg. This result satisfied requirements for part 1 of the ESH-IP2. A total of 27 out of 33 individuals for SBP and 30 out of 33 individuals for DBP had a minimum of 2 of 3 comparisons within 5 mm Hg difference. None of the subjects had 3 differences outside 5 mm Hg for SBP and DBP, satisfying part 2 of the ESH-IP2. For HR measurements, a total of 90 of 99 differences had absolute differences within 3 beats per minute (bpm), and a total of 94 or 99 differences had absolute differences within 5 bpm. A total of 98 of 99 differences had absolute differences within 8 bpm. Therefore, the test device satisfied part 1 of ESH-IP2 criteria for HR. For part 2 of ESH-IP2, 31 of 33 individuals had a minimum of 2 of 3 comparisons within 3 bpm difference for HR. Only 1 of 33 subjects had 3 differences outside 3 bpm.

Conclusions

To the best of our knowledge, this was the first study to show that an app that measures blood pressure and HR meets the requirements of the ESH-IP2 in an obese population. We believe the ESH-IP2 should publish explicit criteria for validation of blood pressure devices in specific populations.