Problems and Barriers Related to the Use of mHealth Apps From the Perspective of Patients: Focus Group and Interview Study

BACKGROUND

Since fall 2020, mobile health (mHealth) apps have become an integral part of the German health care system. The belief that mHealth apps have the potential to make the health care system more efficient, close gaps in care, and improve the economic outcomes related to health is unwavering and already partially confirmed. Nevertheless, problems and barriers in the context of mHealth apps usually remain unconsidered.

OBJECTIVE

The focus groups and interviews conducted in this study aim to shed light on problems and barriers in the context of mHealth apps from the perspective of patients.

METHODS

Guided focus groups and individual interviews were conducted with patients with a disease for which an approved mHealth app was available at the time of the interviews. Participants were recruited via self-help groups. The interviews were recorded, transcribed, and subjected to a qualitative content analysis. The content analysis was based on 10 problem categories ("validity," "usability," "technology," "use and adherence," "data privacy and security," "patient-physician relationship," "knowledge and skills," "individuality," "implementation," and "costs") identified in a previously conducted scoping review. Participants were asked to fill out an additional questionnaire about their sociodemographic data and about their use of technology.

RESULTS

A total of 38 patients were interviewed in 5 focus groups (3 onsite and 2 web-based) and 5 individual web-based interviews. The additional questionnaire was completed by 32 of the participants. Patients presented with a variety of different diseases, such as arthrosis, tinnitus, depression, or lung cancer. Overall, 16% (5/32) of the participants had already been prescribed an app. During the interviews, all 10 problem categories were discussed and considered important by patients. A myriad of problem manifestations could be identified for each category. This study shows that there are relevant problems and barriers in the context of mHealth apps from the perspective of patients, which warrant further attention.

CONCLUSIONS

There are essentially 3 different areas of problems in the context of mHealth apps that could be addressed to improve care: quality of the respective mHealth app, its integration into health care, and the expandable digital literacy of patients.

Problems and Barriers related to the Use of Digital Health Applications: A scoping review (Preprint)

BACKGROUND

The digitization of health care led to a steady increase in the adoption and use of mobile health (mHealth) apps. Germany is the first country in the world to cover the costs of mHealth apps through statutory health insurance. Although the benefits of mHealth apps are discussed in detail, aspects of problems and barriers are rarely studied.

OBJECTIVE

This scoping review aimed to map and categorize the evidence on problems and barriers related to the use of mHealth apps.

METHODS

Systematic searches were conducted in the MEDLINE, Embase, and PsycINFO databases. Additional searches were conducted on JMIR Publications and on websites of relevant international organizations. The inclusion criteria were publications dealing with apps similar to those approved in the German health care system, publications addressing problems and barriers related to the use of mHealth apps, and articles published between January 1, 2015, and June 8, 2021. Study selection was performed by 2 reviewers. The manuscript was drafted according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist. The analysis of the included publications and categorization of problems and hurdles were performed using MAXQDA (VERBI Software GmbH).

RESULTS

The database search identified 1479 publications. Of the 1479 publications, 21 (1.42%) met the inclusion criteria. A further 8 publications were included from citation searching and searching in JMIR Publications. The identified publications were analyzed for problems and barriers. Problems and barriers were classified into 10 categories ("validity," "usability," "technology," "use and adherence," "data privacy and security," "patient-physician relationship," "knowledge and skills," "individuality," "implementation," and "costs"). The most frequently mentioned categories were use and adherence (eg, incorporating the app into daily life or dropouts from use; n=22) and usability (eg, ease of use and design; n=19).

CONCLUSIONS

The search identified various problems and barriers in the context of mHealth apps. Although problems at the app level (such as usability) are studied frequently, problems at the system level are addressed rather vaguely. To ensure optimal use of and care with mHealth apps, it is essential to consider all types of problems and barriers. Therefore, researchers and policy makers should have a special focus on this issue to identify the needs for quality assurance.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/32702.

Prescription of opioid analgesics for non-cancer pain in Germany: study protocol for a mixed methods analysis

Aim

Long-term therapy with opioid analgesics bears the risk of complications, such as misuse, abuse, and dependence. An evidence-based guideline addresses the long-term use of opioid analgesics for non-cancer pain. Recent studies observed an increase in opioid prescriptions over the past two decades in Germany. However, the exact circumstances of this increase and if long-term therapy adheres to these guidelines in practice remains unknown. Therefore, this study aimed to evaluate the provision of opioid analgesics for adults with non-cancer pain from patients’ and physicians’ perspectives. Based on the results, recommendations for care strategies for the patient groups at risk of misuse, abuse, and dependence were developed.

Methods

Built on a mixed methods approach, this evaluation combines (i) interviews with primary care physicians and specialists, (ii) surveys of patients and physicians, (iii) analyses based on administrative claims data from a German statutory health insurance provider. Proceeding from the analysis of the evaluation results, the development of care strategies included (iv) semi-structured interviews with stakeholders and (v) expert workshops.

Conclusion

To our knowledge, this is the first attempt to analyze opioid prescriptions from the combined perspectives of patients and practitioners in Germany. The results are intended to facilitate the development of target group-specific care strategies and recommendations to establish a general framework for the implementation of care strategies.

Quality Assessment of Digital Health Applications: A Scoping Review Protocol (Preprint)

Background

All over the world, development and usage of mobile health (mHealth) apps is increasing. While apps offer numerous opportunities to improve health care, there are associated problems that differ significantly from those of traditional health care services. Further investigations on the quality of mHealth apps are needed to address these problems.

Objective

This study aims to identify and map research on quality assessment and quality assurance of mHealth apps and their transferability to continuous quality assurance of mHealth apps.

Methods

The scoping review will follow published methodological frameworks for scoping studies as well as Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews criteria. Electronic databases (Medline, EMBASE, and PsycINFO), reference lists of relevant articles, and websites of relevant institutions will be searched. Two reviewers will independently assess eligibility of articles. Therefore, a 2-stage (title and abstract, followed by full text) screening process was conducted. Quality management systems and quality assessment tools will be analyzed and included in our review. Particular focus is placed on quality dimensions.

Results

This scoping review provides an overview of the available evidence and identifies research gaps regarding continuous quality assessment of mHealth apps. Thereby, relevant quality dimensions and criteria can be identified and their eligibility and relevance for the development of a continuous quality assurance system of mHealth apps can be determined. Our results are planned to be submitted to an indexed, peer-reviewed journal in the second half of 2022.

Conclusions

This is the first review in the context of continuous quality assurance of mHealth apps. Our results will be used within the research “Continuous quality assurance of Digital Health Applications” (“QuaSiApps”) project funded by the German Federal Joint Committee.

International Registered Report Identifier (IRRID)

DERR1-10.2196/36974

Problems and Barriers related to the Use of Digital Health Applications: A Scoping Review Protocol (Preprint)

Background

The use of mobile health (mHealth) apps is increasing rapidly worldwide. More and more institutions and organizations develop regulations and guidelines to enable an evidence-based and safe use. In Germany, mHealth apps fulfilling predefined criteria (Digitale Gesundheitsanwendungen [DiGA]) can be prescribed and are reimbursable by the German statutory health insurance scheme. Due to the increasing distribution of DiGA, problems and barriers should receive special attention.

Objective

This study aims to identify the relevant problems and barriers related to the use of mHealth apps fulfilling the criteria of DiGA.

Methods

This scoping review will follow published methodological frameworks and the PRISMA-Scr (Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews) criteria. Electronic databases (MEDLINE, EMBASE, PsycINFO, and JMIR), reference lists of relevant articles, and grey literature sources will be searched. Two reviewers will assess the eligibility of the articles by a two-stage (title and abstract as well as full text) screening process. Only problems and barriers related to mHealth apps fulfilling the criteria of DiGA are included for this research. The identified studies will be categorized and analyzed with MAXQDA.

Results

This scoping review gives an overview of the available evidence and identifies research gaps regarding problems and barriers related to DiGA. The results are planned to be submitted to an indexed, peer-reviewed journal in the first quarter of 2022.

Conclusions

This is the first review to identify the problems and barriers related to the use of mHealth apps fulfilling the German definition of DiGA. Nevertheless, the findings can be applied to other contexts and health care systems as well.

International Registered Report Identifier (IRRID)

DERR1-10.2196/32702

Accuracy of mHealth Devices for Atrial Fibrillation Screening: Systematic Review

BACKGROUND

Mobile health (mHealth) devices can be used for the diagnosis of atrial fibrillation. Early diagnosis allows better treatment and prevention of secondary diseases like stroke. Although there are many different mHealth devices to screen for atrial fibrillation, their accuracy varies due to different technological approaches.

OBJECTIVE

We aimed to systematically review available studies that assessed the accuracy of mHealth devices in screening for atrial fibrillation. The goal of this review was to provide a comprehensive overview of available technologies, specific characteristics, and accuracy of all relevant studies.

METHODS

PubMed and Web of Science databases were searched from January 2014 until January 2019. Our systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses. We restricted the search by year of publication, language, noninvasive methods, and focus on diagnosis of atrial fibrillation. Articles not including information about the accuracy of devices were excluded.

RESULTS

We found 467 relevant studies. After removing duplicates and excluding ineligible records, 22 studies were included. The accuracy of mHealth devices varied among different technologies, their application settings, and study populations. We described and summarized the eligible studies.

CONCLUSIONS

Our systematic review identifies different technologies for screening for atrial fibrillation with mHealth devices. A specific technology's suitability depends on the underlying form of atrial fibrillation to be diagnosed. With the suitable use of mHealth, early diagnosis and treatment of atrial fibrillation are possible. Successful application of mHealth technologies could contribute to significantly reducing the cost of illness of atrial fibrillation.

Prevalence of fecal incontinence: what can be expected?

Fecal incontinence is a serious problem especially for the elderly. The epidemiology of incontinence is not well described in the literature although it is often used as an endpoint for treatment evaluation in clinical trials. Complete continence is often assumed to be the "normal" standard. The goals of this study were to establish detailed prevalence rates for fecal incontinence in a standard population and to identify differences due to age and sex. A questionnaire about fecal incontinence and its consequences with predefined answers was filled out anonymously by 500 volunteers. The study population was selected to meet the respective age and sex distribution of the German adult population. The data indicated that 4.8% of the persons were unable to control solid stools, while 19.6% had problems at least with one type of incontinence (solid, pasty, or lipid stools, winds). Problems with pasty or liquid stools are more frequent in women. The ability to control wind is decreased in elderly persons. The time needed to reach a toilet is shorter for women, and generally decreases in the elderly. Men more often describe soiling the underwear. Persons with signs of incontinence show decreased levels of social activities. A global incontinence rate of 5% fits well with some previously published results. Soiling of the underwear is not well suited for defining incontinence. The increased rate in women may in part be explained by morphological differences. The reduced time to hold stools especially in the elderly in combination with a reduced mobility may result in a higher rate of incontinence, which is correlated with reduced social activities.

[Waiting for the crisis]

AIM OF THE STUDY

Experience in daily routine reveals that most of ICU patients usually go through "crisis" within 14 days of admission. Only few patients need remarkable more time to get to this point and it seems there is hardly anything to be done therapeutically to change the course of it. We therefore examined a large group of ICU patients in order to find reasons for this course or to spot them as an "entity of their own".

METHODS

1,861 ICU patients all being on IPPV for more than three days were included in the study. Every day 18 variables were taken down in a standardised way until the day IPPV was finished. We extracted 170 patients who were artificially ventilated for more than 40 days. For these patients we established mean values for each of the 18 variables during the first and the last 40 days of ventilation. In both groups we compared survivors to non-survivors.

RESULTS

Mortality was almost the same in both groups (IPPV < 40 days vs. IPPV > 40 days). Survivors and non-survivors showed remarkable differences regarding extrapulmonary factors-in terms of total fluid amount and transfusion, state of abdomen, brain, liver and kidney function and circulation problems. Pulmonary factors revealed major differences only towards the end of the observation period.

CONCLUSIONS

There seems to be an "entity of ist own", a small population of patients who arrive at the crucial turning point later. Pulmonary complications (pneumonia, ARDS) is not the reason but the expression of cause for prolonged ventilation. The key to the extrapulmonary origin of the crisis remains unknown, the only thing we can do is alleviate its manifestations.

The arterial supply of the ankle joint and its importance for the operative fracture treatment

The operative exposure of a fracture causes disturbances in the blood supply, which may lead to a prolonged healing process or even to bone necrosis, especially when using the complex and complicated methods of osteosynthesis at the ankle. In order to damage the supplying vessels as little as possible, position, direction and penetration of the bone arteries of the talocrural joint were examined by corrosion preparation. The tibial nutrient artery arises from the posterior tibial artery or from the popliteal artery and penetrates constantly from posterior at the level of the proximal third. The fibular nutrient artery, coming from the peroneal artery, penetrates more distally from medial into the middle third of the diaphysis. In one specimen it did not exist at all. Distal tibia and fibula are supplied by the perimalleolar arterial ring, which is connected with the three arteries of the leg. The talus is supplied by numerous very small vessels, which are provided with extraosseous anastomoses and penetrate the whole non-articular surface. Implications for the operation will be explained.

[Sprain of the cervical spine: early functional vs. immobilization treatment]

Neck sprains are very common injuries often treated with immobilisation of different duration. The treatment with collars was tested against physiotherapy in a prospective randomised trial. Endpoints were defined as state of health, pain and costs. Ninety-seven patients with whiplash injuries were splitted by randomisation into two groups. One group was treated with a certain scheme of physiotherapy. Another group was treated with collar immobilisation for 3 weeks. Concerning symptoms at the time of admittance, age and sex distribution the groups were comparable. Fifty healthy persons with the same age and sex distribution served as a control group. Regarding to physical state of health and pain, which were examined by valid questionnaires, significant advantages of physiotherapy after two weeks were found. After 12 weeks the physical state of health corresponds to that of the control group. No influence on psychical state of health was seen. Physiotherapy for treatment of neck sprain is highly recommended. It has clear advantages over the treatment with collars with regard to state of health and pain, and it seems to be economically favourable.

Arterial supply of forearm bones and its importance for the operative treatment of fractures

The operative exposure of a fracture in an osteosynthesis causes disturbances in the blood supply, which often leads to a prolonged process of healing or even to healing problems, a fracture non-union, which is frequently located at the forearm. In order to damage the supplying vessels as little as possible, the position, direction and penetration of the arteries of radius and ulna are demonstrated and systematised in this study. Near the elbow arteries, coming from large adjoining vessels, penetrate the area of the capsular insertion. The nutrient arteries enter both bones in the second proximal quarter of diaphysis, at the radius from anterior to medial, at the ulna from anterior to anteroradial. Small vessels, which penetrate closely proximal to the articular surface in order to supply the distal forearm bones, come from an anastomosis between the radial, the interosseous and the ulnar arteries. In this study access vessels, choice and position of implants will be discussed.

[Patient education: what does the patient know, what does he want to know? Thrombosis and wound infection]

The manners of which preoperative informations are given to a patient depend on several different points. So not only the patient's education, his knowledge of medical items and his intelligence are important, but also the juridical situation and the doctor's ability to explain the situation in a way the patient is able to understand. The aim of this study was to evaluate the patient's previous knowledge about two major complications in surgery--thrombosis and wound infection. Beside this it was looked for the importance of confidence in the doctor and previous information about the operation.

PATIENTS AND METHOD

117 patients aged 16 to 87 years were tested anonymous by a standardised questionnaire.

RESULTS

There is only little knowledge about the time a thrombosis develops, embolism, a wound infection and their consequences. On the other side, more than 50% of the patients were able to explain correctly the symptoms of thrombosis and the time a wound infection occurs. There was a correlation between the statement of knowledge about thrombosis (p < 0.01) and wound infection (p < 0.01) and the ability of correct explanation. Almost 90% of the patients thought that information about the operation is as important as the confidence in their surgeon. More than two third of the patients wanted to be informed about "everything" that possibly could happen. The main sources of information were neighbours, friends, the press, books and at last the doctor.

CONCLUSION

There wasn't any influence of former surgeries, the awareness of complications or education on the active knowledge of the patients. Therefore we think that the way of giving explanation to a patient should help reducing fear of an uncomfortable situation and take account to the patients need for information. Thus, the patient will be able to make a real decision.

[Violation of patient education responsibility. Implications and outlook]

In both jurisdiction and medical science, given conditions require appropriate intervention, which may in turn result in norms being created. Norms, however, counteract individuality. An essential prerequisite for free decision--making is an absolute awareness of all possibilities available. Therefore the physician/surgeon too, is obliged to impart all relevant information to the patient prior to an operation to enable the patient to reach a decision, either to agree to or refuse the operation. This process of information transfer may sometimes fail on one or both sides. Treatment errors are usually classified according to scientific medical practice. In the case of "breach to duty in information patient" the final decision is the judges. As judicial decisions are not foreseeable, the communication between patient and surgeon thus becomes standardized and doctors tend to become defensive, resulting in the information becoming even more extensive covering all possible situations. There is no guarantee of success in surgery. Selective perception on the part of the patient is unavoidable and confidence in the relationship between patient and surgeon is beneficial to the patient's rehabilitation. Therefore, we should strive to decriminalize the preoperative talk held between surgeon and patient.

Ileal pouch-anal anastomosis for ulcerative colitis and polyposis coli: is the risk of carcinoma formation conclusively averted?

We took biopsies from the ileal pouch mucosa of 26 patients (13 with ulcerative colitis, 13 with polyposis coli) at least 1 year after the newly formed pouch was finally linked to the faecal flow. Histochemical mucin differentiation was carried out in addition to the ordinary stains. All patients underwent colonization of pouch mucosa with goblet cell multiplication, reduction or loss of villi, and formation of crypts. Only 19 patients could be classified morphologically as bearing large bowel mucosa in the ilea] pouch. Patients with one incidence of ulcerative colitis developed one criterion, those with two incidences two criteria, and those with seven incidences three criteria of the original colitic disease. Patients with two incidences of colitis and those with 10 incidences of polyposis coli developed an excess of sialomucine formation, which is known as an obligate pre-cancerosis. These findings prove, that in ileal pouches, even when affected by systemic diseases with extraintestinal manifestations, a new kind of mucosa develops, which is also prediposed to carcinoma formation. Papers reporting adenocarcinoma arising in ileostomy areas as well as in ileoanal anastomosis, and ileal reservoirs, confirm this presumption. Assuming this conclusion, restorative proctocolectomy cannot hinder malignant transformation of intestinal mucosa, but only delay the onset of cancer, thereby making lifelong follow-ups necessary.

Elastofibroma and pre-elastofibroma--a biopsy and autopsy study

Two biopsy cases of elastofibroma--one unilateral and one bilateral--are described. A study of 100 autopsies revealed 13 elderly patients with elastofibroma. Males (n = 10; 16.9%) were more affected than females (n = 3; 7.3%). Pre-elastofibroma-like morphological changes (e.g. few or many degenerated elastic fibres) were observed in 81% of the autopsies. Minor pre-elastofibroma-like changes were seen in males and major changes predominantly in females. In addition to physiological ageing as yet unknown factors, rather than abnormal elastogenesis or degeneration, seem to be involved in this pseudotumour.

[Possibilities and limits of scores. Theoretical considerations about scores]

Scores are intended to facilitate an accurate appreciation of the overall situation from a few characteristic, reasonably weighted parameters. This definite result in the form of a score means a reduction of reality. For the individual it cannot reasonably be applied in practice. Despite a long list of problems and limitations, a score can describe a collective and thus make it comparable to some extent. Because of the different compositions of the collectives, the value of scores for quality control is limited. The more physiological variables a score contains the more difficult it is to distinguish between the effect of therapy and the clinical course. Therefore, repeated measurement of scores is not useful to verify a therapeutic effect, but it can indicate a trend regarding the endpoint.

Histochemical and metabolic changes in functioning ileal pouches after proctocolectomy for familial adenomatous polyposis and ulcerative colitis

Ulcerative colitis and familial adenomatous polyposis may be treated by proctocolectomy with ileal pouch reconstruction, anastomosing the pouch to the anus. We studied 24 patients who underwent this procedure, of whom 12 had ulcerative colitis and 12 had familial adenomatous polyposis. Ileal absorption was investigated and pouch histology assessed more than one year after closure of the protective defunctioning loop ileostomy. The results showed a reduction in bile acid reabsorption and vitamin B12 absorption. These observations were associated with a morphologic transformation in the small bowel mucosa to large bowel mucosa. In 10 of the 12 colitis patients one or more of the histological features of the original disease (such as active inflammation, increased regeneration, atypia) were evident. Histological examination of the biopsies taken from the polyposis patients showed areas with an excess of sialomucins.

Arthroscopic repair of traumatic longitudinal meniscal tears. A 3 to 5-year follow-up

The healing potential of the meniscal tissue has been known for a century but has only been broadly introduced into surgical treatment during the last years. Open surgical suture of the meniscus has increasingly been replaced by arthroscopic refixation. We report 34 meniscal refixations with a minimal follow-up of at least 3 years and a mean of 4 years. Using our own simple and economic surgical technique, 34 refixations were performed in 32 patients from January 1987 to December 1988. All patients had traumatic meniscal tears close to the capsule. Frequently the injury was associated with a fresh or old rupture of the anterior cruciate ligament. Without additional trauma, one meniscus had to be partially resected after 4 months; a second one was partially resected in an unstable knee. Both the clinical examination and the satisfaction of the patient demonstrate that meniscal refixation is feasible and appropriate with a correct indication.

[Osteosynthesis procedures in microsurgery]

In microsurgery the indications and techniques of osteosynthesis are often different from normal orthopaedic surgery. Simple methods which do not require much time or metal and which guarantee sufficient stability and minimal soft-tissue trauma are preferable. The external fixator has a good indication in the tibia and the plate osteosynthesis in the upper extremity and in the femur. Kirschner wires are useful in peripheral osteosyntheses.

[Treatment of osteomyelitis using free myocutaneous flap in the lower leg]

The primary indication for free muscle transfer to the lower leg is post-traumatic osteomyelitis with soft tissue and bony defects. The intention is to provide sufficient soft tissue covering and a new blood supply. Our experience with 24 free muscle transfers to infected areas on the lower leg is presented. The longest bone infection was 25 years. The indications were early bone infections, infected pseudoarthrosis and chronic osteomyelitis. The indications, contra-indications, method and results are reported. Economic and social advantages of the procedure are also discussed.

[Variants in the management of decubitus ulcers]

Decubitus ulcers of the fourth or fifth degree often tend to heal only after years. The result is a bad scar which is unstable and likely to breakdown. It is still surgically correctable, however. The ulcer should be cleaned and after tamponage one should perform excision without opening into the ulcer. Cover can be achieved with either a rotation flap with accompanying muscular padding or a myocutaneous flap. To protect against recurrence, the bone debridement has to be carried out aggressively.

[Measuring the sensitivity before and following breast reduction-plasty in 2 competitive surgical procedures]

All non-operated breasts have an irregular pattern of sensibility. The areola is distinctly more sensitive than its periphery; the nipple has a very low grade of sensitivity. The postoperative sensitivity increases for about 2 years without reaching the former level. The loss of sensitivity is unrelated to the method of operation (Strömberg, Pitanguy). The loss of sensitivity is proportional to the reduction of tissue. Most important is to keep the ability for breast-feeding (sympathetic innervation by the arterior branch of the 4th ramus cutaneous lateralis).

[Surgical therapy of malignant melanoma]

148 patients with malignant melanoma are presented. Localization, prognosis and clinical stadium are summarized. The surgical procedure is still three-dimensional excision. The latitude of defects asks for a specialists surgeon.