What makes digital health intrusive? Qualitative findings from an international study on diabetes

Background

Remote digital monitoring (RDM, i.e., using digital devices to monitor patients' health and behavior) is a novel care model that can improve health outcomes for people with chronic conditions. However, it could be intrusive to patients' lives. We sought to understand which aspects of RDM make it intrusive to patients and why.

Methods

We performed content analysis of qualitative data collected by using open-ended questions in an international, online survey with a convenience sample of adults with type 1 or 2 diabetes (February-July 2019). Participants were first shown scenarios describing possible RDM features (i.e. different RDM tools [for glucose or food monitoring], feedback loops [receiving feedback in consultation, or remotely by a physician, or by artificial intelligence], and data handling options [by the public or private sector]).

Results

We analyzed data from 709 participants from 24 countries (38% men, median age 38, 54% type 1). Participants found RDM burdensome (n = 468). Burden arose from RDM features that caused disruption in daily life (e.g., alerts), features that may invite undesirable attention in public (e.g., visible wearable sensors may invite questions about one's health), or from having to adapt one's life to fit in RDM (e.g., adapt one's mealtime routine around food monitoring). Participants wanted control, particularly over sharing food-monitoring data with health care professionals in real-time to receive feedback (n = 440). They felt RDM could expose a delicate topic to 'surveillance' by authority figures (i.e., their data may 'reveal' poor dietary habits, leading to criticism by physicians). Intrusion could take the form of RDM eroding the patient-physician relationship (n = 34), or fear of data misuse (n = 206), which was associated with private-sector financial interests.

Conclusions

Our findings offer directions for minimally intrusive RDM design and show that digital health may cause concerns about stigma and treatment burden.

Key messages

Remote digital monitoring is intrusive when it increases treatment burden and limits patients’ control over their own health. “Minimally intrusive” digital health design could increase patient acceptability and, ultimately, foster scalability.

Comparative efficacy of parathyroidectomy and active surveillance in patients with mild primary hyperparathyroidism: a systematic review and meta-analysis

Counseling for patients with primary hyperparathyroidism (PHPT) and mild hypercalcemia without indications for surgical intervention requires accurate estimates of the potential benefits of parathyroidectomy. We aim to summarize the available evidence regarding the benefits of parathyroidectomy that patients with mild PHPT without indications for surgery experience compared to observation. We searched multiple databases from inception to August 2015. We included randomized controlled trials (RCT) and observational studies that evaluated changes in bone health, quality of life or neuropsychiatric symptoms, or in the risk of nephrolithiasis, cardiovascular events, or death between patients undergoing parathyroidectomy or active surveillance. Eight studies were eligible. Risk differences were not significant, in part due to lack of events (fractures, nephrolithiasis, cardiovascular events, or deaths). No significant differences were observed across measures of bone health, quality of life, and neuropsychiatric symptoms. A single RCT evaluating bone mineral density (BMD) changes at 5 years found a small statistically significant effect favoring parathyroidectomy. Patients with mild PHPT without indications for surgery experience a limited number of adverse consequences during short-term follow-up limiting our ability to estimate the benefit of surgery during this timeframe. This information is helpful as these patients consider surgery versus active surveillance. Long-term data is warranted to determine who benefits in the long run from surgical intervention and the extent to which this benefit affects outcomes that matter to patients.

Omega-3 polyunsaturated fatty acids (PUFA) for type 2 diabetes mellitus

BACKGROUND

People with type 2 diabetes mellitus are at increased risk from cardiovascular disease. Dietary omega-3 polyunsaturated fatty acids (PUFAs) are known to reduce triglyceride levels, but their impact on cholesterol levels, glycemic control and vascular outcomes are not well known.

OBJECTIVES

To determine the effects of omega-3 PUFA supplementation on cardiovascular outcomes, cholesterol levels and glycemic control in people with type 2 diabetes mellitus.

SEARCH STRATEGY

We carried out a comprehensive search of The Cochrane Library, MEDLINE, EMBASE, bibliographies of relevant papers and contacted experts for identifying additional trials.

SELECTION CRITERIA

All randomised controlled trials were included where omega-3 PUFA supplementation or dietary intake was randomly allocated and unconfounded in people with type 2 diabetes. Authors of large trials were contacted for missing information.

DATA COLLECTION AND ANALYSIS

Trials were assessed for inclusion. Authors were contacted for missing information. Data was extracted and quality assessed independently in duplicate. Fixed-effect meta-analysis was carried out.

MAIN RESULTS

Twenty three randomised controlled trials (1075 participants) were included with a mean treatment duration of 8.9 weeks. The mean dose of omega-3 PUFA used in the trials was 3.5 g/d. No trials with vascular events or mortality endpoints were identified. Among those taking omega-3 PUFA triglyceride levels were significantly lowered by 0.45 mmol/L (95% confidence interval (CI) -0.58 to -0.32, P < 0.00001) and VLDL cholesterol lowered by -0.07 mmol/L (95% CI -0.13 to 0.00, P = 0.04). LDL cholesterol levels were raised by 0.11 mmol/L (95% CI 0.00 to 0.22, P = 0.05). No significant change in or total or HDL cholesterol, HbA1c, fasting glucose, fasting insulin or body weight was observed. The increase in VLDL remained significant only in trials of longer duration and in hypertriglyceridemic patients. The elevation in LDL cholesterol was non-significant in subgroup analyses. No adverse effects of the intervention were reported.

AUTHORS' CONCLUSIONS

Omega-3 PUFA supplementation in type 2 diabetes lowers triglycerides and VLDL cholesterol, but may raise LDL cholesterol (although results were non-significant in subgroups) and has no statistically significant effect on glycemic control or fasting insulin. Trials with vascular events or mortality defined endpoints are needed.

Interventions for smokeless tobacco use cessation

BACKGROUND

Use of smokeless tobacco (ST) can lead to nicotine addiction and long-term use can lead to health problems including periodontal disease and cancer.

OBJECTIVES

To assess the effects of behavioural and pharmacologic interventions for the treatment of ST use.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, Web of Science, PsycINFO, Dissertation Abstracts Online, and Scopus. Date of last search: March, 2007.

SELECTION CRITERIA

Randomized trials of behavioural or pharmacological interventions to help users of ST to quit with follow up of at least six months.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data.

MAIN RESULTS

Two trials of bupropion SR did not detect a benefit of treatment at six months or longer (Odds Ratio (OR) 0.86, 95% Confidence Interval (CI): 0.47 to 1.57). Four trials of nicotine patch did not detect a benefit (OR 1.16, 95% CI: 0.88 to 1.54), nor did two trials of nicotine gum (OR 0.98, 95% CI: 0.59 to 1.63). There was statistical heterogeneity among the results of 12 behavioural interventions included in the meta-analyses. Six trials showed significant benefits of intervention. In post-hoc subgroup analyses, behavioural interventions which include telephone counselling or an oral examination may increase abstinence rates more than interventions without these components.

AUTHORS' CONCLUSIONS

Behavioural interventions should be used to help ST users to quit and telephone counselling or an oral examination may increase abstinence rates. Pharmacotherapies have not been shown to affect long-term abstinence.

Interventions for smokeless tobacco use cessation

BACKGROUND

Use of smokeless tobacco (ST) can lead to nicotine addiction and health problems including periodontal disease and oral cancer

OBJECTIVES

To assess the effects of behavioural and pharmacotherapeutic interventions to treat ST use.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group trials register (February 2004), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2004), MEDLINE (January 1966-February 2004), EMBASE (1988-January 2004), CINAHL (1982-February 2004), PsycINFO (1984-February 2004), Database of Abstract of Reviews of Effectiveness (DARE, The Cochrane Library, Issue 1, 2004).

SELECTION CRITERIA

Randomized trials of behavioural or pharmacological interventions to help users of ST to quit, with follow-up of at least six months.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data.

MAIN RESULTS

One trial of bupropion did not detect a benefit of treatment after six months (Odds Ratio (OR) 1.00, 95% Confidence Interval (CI): 0.23 to 4.37). Three trials of nicotine patch did not detect a benefit (OR 1.16, 95% CI: 0.88 to 1.54), nor did two trials of nicotine gum (OR 0.98, 95% CI: 0.59 to 1.63). There was statistical heterogeneity among the results of eight trials of behavioural interventions included in the meta-analysis. Three trials showed significant benefits of intervention. In a post-hoc analysis the trials of interventions which included an oral examination and feedback about ST-induced mucosal changes had homogeneous results and when pooled showed a significant benefit (OR 2.41 95% CI: 1.79 to 3.24).

REVIEWERS' CONCLUSIONS

Behavioural interventions should be used to help ST users to quit. Pharmacotherapies have not been shown to affect long-term abstinence but larger trials are needed.

Fish oil in people with type 2 diabetes mellitus

BACKGROUND

People with type 2 diabetes mellitus are at increased risk from cardiovascular disease. Dietary fish oils are known to reduce triglyceride levels, but their impact on cholesterol levels, glycemic control and vascular outcomes are not well known.

OBJECTIVES

To determine the effects of fish oil supplementation on cardiovascular outcomes, cholesterol levels and glycemic control in people with type 2 diabetes mellitus.

SEARCH STRATEGY

We carried out a comprehensive search of the Cochrane Controlled Trials Register, Medline, Embase, Lilacs, bibliographies of relevant papers and contacted experts for identifying additional trials. Date of last search: September 2000.

SELECTION CRITERIA

All randomized placebo-controlled trials in which fish oil supplementation was the only intervention in people with type 2 diabetes were included. Authors were contacted for missing information.

DATA COLLECTION AND ANALYSIS

Three investigators performed data extraction and quality scoring independently with discrepancies resolved by consensus.

MAIN RESULTS

Eighteen trials including 823 participants followed for a mean of 12 weeks were included. Doses of fish oil used ranged from 3 to 18 g/day. No trials with vascular event or mortality endpoints were identified. The outcomes studied were glycemic control and lipid levels. Meta-analysis of pooled data demonstrated a statistically significant effect of fish oil in lowering triglycerides by 0.56 mmol/l (95% CI -0.71 to -0.40 mmol/l) and raising LDL cholesterol by 0.21 mmol/l (95% CI 0.02 to 0.41 mmol/l). No statistically significant effect was observed for fasting glucose, HbA1c, total or HDL cholesterol. The triglyceride lowering effect and the elevation in LDL cholesterol were most marked in those trials that recruited people with hypertriglyceridemia and used higher doses of fish oil. No adverse effects of the intervention were reported.

REVIEWER'S CONCLUSIONS

Fish oil supplementation in type 2 diabetes lowers triglycerides, may raise LDL cholesterol (especially in hypertriglyceridemic patients on higher doses of fish oil) and has no statistically significant effect on glycemic control. Trials with vascular event or mortality defined endpoints are needed.