Randomized, controlled trial of home telemanagement in patients with ulcerative colitis (UC HAT)

Predictors of successful acceptance of home telemanagement in veterans with Multiple Sclerosis

Modern telehealth technologies may be instrumental in overcoming the barriers of optimal care delivery for patients with MS. However, the significant potential of telemedicine approaches in improving MS care has not yet been fully explored. The Multiple Sclerosis Centers of Excellence of the Department of Veterans Affairs (VA) has been actively promoting the use of telemedicine in helping veterans with MS. Particular attention was given to the development of cost-effective care coordination solutions which can be easily delivered directly to each veteran home via internet and accessed via a regular computer or a mobile device. In this article, the design of the MS HAT system is introduced and results of the initial feasibility evaluation are presented. The feasibility of the MS HAT system was assessed by (1) analyzing attitudinal surveys of veterans with MS who used the MS HAT system at home for over a month; (2) identifying factors affecting acceptance of the MS HAT system; (3) reviewing adherence of MS HAT users to self-testing regimen; (4) analyzing veteran feedback on MS HAT functionality using semi-structured qualitative interviews.

Comparing the efficacy of a web-assisted calprotectin-based treatment algorithm (IBD-live) with usual practices in teenagers with inflammatory bowel disease: study protocol for a randomized controlled trial

Background

To prevent clinical relapse in teenagers with inflammatory bowel disease (IBD) there is a need to monitor disease activity continuously. Timely optimisation of medical treatment may nip a preclinical relapse in the bud and change the natural course of IBD. Traditionally, disease monitoring is done during scheduled visits, but this is when most teenagers report full control. IBD care could be more efficient if patients were seen at times of clinical need. This study aims to examine the effectiveness of a web-assisted calprotectin-based treatment algorithm (IBD-live) compared with usual practices in teenagers with IBD.

Methods/design

A randomized trial of web-based disease monitoring versus usual care is conducted at 10 Dutch IBD care centers. We plan to recruit 180 patients between 10- and 19-years old with quiescent IBD at baseline. Teenagers assigned to IBD-live will use the flarometer -an automatic cumulation of disease activity and fecal calprotectin measurements- to estimate probability of relapse. In case the flarometer indicates high risk the patient requires treatment intensification in accordance with national guidelines; low risk means that maintenance therapy is unchanged; and intermediate risk requires optimisation of drug adherence. Patients assigned to usual practice get the best accepted medical care with regular health checks. Primary outcome is the frequency of relapse at 52 weeks of follow-up. The diagnosis of relapse is based on a clinical activity index score >10 points necessitating remission induction therapy. Secondary outcomes include quality of life and cost-effectiveness.

Discussion

Web-assisted monitoring of disease activity with rapid access for those with acute relapse may allow teenagers to develop skills that are required of adult patients (including communication and self-determination). Similar monitoring systems have been introduced for teenagers with asthma and diabetes, with a positive effect on disease control, but the intervention has not been evaluated in teenagers with IBD. A randomized trial in adult patients with ulcerative colitis showed that a web-assisted treatment algorithm is feasible, safe and cost-effective. Results of the current trial are expected to have important implications for teenagers with IBD that incurs substantial health burdens and economic costs.

Trial registration

Dutch Trial Register identifier: NTR3759 (registered 29 December 2012)

Web-based interventions for ulcerative colitis and Crohn's disease: systematic review and future directions

Behavioral intervention technologies (BITs), the application of psychological and behavioral interventions through the use of technology, provide the opportunity for clinicians to deliver care through a means that overcomes a number of treatment barriers. Web-based interventions are a subset of BITs developing as promising alternatives to face-to-face delivery of treatments and monitoring for patients with ulcerative colitis (UC) and Crohn’s disease (CD). A systematic review of literature resulted in five empirical studies of web-based interventions for UC and CD. Additionally, an informal search of a popular search engine yielded limited, currently available, web-based interventions for patients with UC and CD. Despite being an ideal population for the development and dissemination of online interventions, patients with UC and CD have far less treatment options compared to other behavioral health concerns. However, given the growing body of research involving web-based interventions for other conditions, researchers and clinicians targeting UC and CD management and treatment have the benefit of being able to utilize the BIT model, an existing conceptual framework for the development of web-based interventions for both conditions. The BIT model is presented and applied to the treatment of UC and CD, as well as a technology development program, Purple, and usability guidelines to guide clinical researchers in the future development, evaluation, and dissemination of BITs for patients with UC and CD.

TELEmedicine for Patients with Inflammatory Bowel Disease (TELE-IBD): Design and implementation of randomized clinical trial

BACKGROUND

Inflammatory bowel diseases (IBD), comprised of ulcerative colitis and Crohn's disease, are chronic disorders characterized by worsening of symptoms followed by symptom-free periods. Symptoms have a profound negative impact on quality of life and are associated with increased health care utilization. Despite effective treatments, outcomes are suboptimal secondary to nonadherence, medication intolerance, inconsistent monitoring, poor patient knowledge and limited access to care.

OBJECTIVES

Compare disease activity and quality of life over 1 year in a randomized trial of IBD patients receiving standard care versus telemedicine.

METHODS

Patients evaluated at 3 IBD referral centers with worsening symptoms within the last 2 years are eligible for randomization to one of two interventions or standard care. The interventions consist of either every other week or weekly assessment of symptoms, side effects, weight and delivery of medication prompts and education via texts to the participant's mobile phone. Individualized alerts and action plans are created on a secure portal. Participants in the standard care group undergo routine and urgent follow-up visits and telephone calls. The primary outcomes group comparisons of changes in disease activity and quality of life scores from baseline to 6 and 12 months.

CONCLUSIONS

Methods such as telemedicine are needed to improve monitoring, adherence, self-efficacy, and patient knowledge in IBD. If effective, telemedicine should decrease symptoms, improve quality of life, and decrease health care utilization. The burden associated with use of telemedicine for patients and providers needs to be assessed. The trial is ongoing and will be completed in July 2016.

Telemedicine in inflammatory bowel disease: opportunities and approaches

This review article summarizes the evidence about telemedicine applications (e.g., telemonitoring, teleconsulting, and tele-education) in the management of patients with inflammatory bowel disease (IBD), and we aim to give an overview of the acceptance and impact of these interventions on health outcomes. Based on the literature search on "inflammatory bowel disease," "Crohn's disease" and "ulcerative colitis" in combination with "e-health," "telemedicine," and "telemanagement," we selected 58 titles and abstracts published up to June 2014 and searched in PubMed, EMBASE, MEDLINE, Cochrane Database, Web of Science and Conference Proceedings. Titles and abstracts were screened for a set of inclusion criteria: e-health intervention, IBD as the main disease, and a primary study performed. Finally, 16 were included for full reading, data extraction, and critical appraisal of the evaluation. Most studies use telemonitoring (home telemanagement system or web portal) and telecare (real-time telephone and image) as telemedicine applications and assessed the feasibility and acceptance of these systems, adherence to treatment, quality of life, and patient knowledge, particularly in patients with ulcerative colitis. Furthermore, some of these studies evaluated the patients' empowerment, health care costs, and safety of telemonitoring in IBD. In conclusion, the health outcomes of telemedicine applications in IBD suggest that these could be implemented in clinical practice because they are safe and feasible applications that are well accepted by the patient and improve adherence, quality of life, and disease knowledge. Further studies with large sample sizes and complex diseases are needed to confirm these results.

Don't Forget the Doctor: Gastroenterologists' Preferences on the Development of mHealth Tools for Inflammatory Bowel Disease

Background

Inflammatory bowel disease (IBD) encompasses a number of disorders of the gastrointestinal tract. Treatment for IBD is lifelong and complex, and the majority of IBD patients seek information on the Internet. However, research has found existing digital resources to be of questionable quality and that patients find content lacking. Gastroenterologists are frontline sources of information for North American IBD patients, but their opinions and preferences for digital content, design, and utility have not been investigated. The purpose of this study is to systematically explore gastroenterologists’ perceptions of, and design preferences for, mHealth tools.

Objective

Our goal was to critically assess these issues and elicit expert feedback by seeking consensus with Canadian gastroenterologists.

Methods

Using a qualitative approach, a closed meeting with 7 gastroenterologists was audio recorded and field notes taken. To synthesize results, an anonymous questionnaire was collected at the end of the session. Participant-led discussion themes included methodological approaches to non-adherence, concordance, patient-centricity, and attributes of digital tools that would be actively supported and promoted.

Results

Survey results indicated that 4 of the 7 gastroenterologists had experienced patients bringing digital resources to a visit, but 5 found digital patient resources to be inaccurate or irrelevant. All participants agreed that digital tools were of increasing importance and could be leveraged to aid in consultations and save time. When asked to assess digital attributes that they would be confident to refer patients to, all seven indicated that the inclusion of evidence-based facts were of greatest importance. Patient peer-support networks were deemed an asset but only if closely monitored by experts. When asked about interventions, nearly all (6/7) preferred tools that addressed a mix of compliance and concordance, and only one supported the development of tools that focused on compliance. Participants confirmed that they would actively refer patients and other physicians to digital resources. However, while a number of digital IBD tools exist, gastroenterologists would be reluctant to endorse them.

Conclusions

Gastroenterologists appear eager to use digital resources that they believe benefit the physician-patient relationship, but despite the trend of patient-centric tools that focus on concordance (shared decision making and enlightened communication between patients and their health care providers), they would prefer digital tools that highlight compliance (patient following orders). This concordance gap highlights an issue of disparity in digital health: patients may not use tools that physicians promote, and physicians may not endorse tools that patients will use. Further research investigating the concordance gap, and tensions between physician preferences and patient needs, is required.

Utilization and efficacy of internet-based eHealth technology in gastroenterology: a systematic review

OBJECTIVE

While there have been several reviews exploring the outcomes of various eHealth studies, none have been gastroenterology-specific. This paper aims to evaluate the research conducted within gastroenterology which utilizes internet-based eHealth technology to promote physical and psychological well-being.

MATERIAL AND METHODS

A systematic literature review of internet-based eHealth interventions involving gastroenterological cohorts was conducted. Searched databases included: EbSCOhost Medline, CINAHL, and PsycINFO. Inclusion criteria were studies reporting on eHealth interventions (both to manage mental health problems and somatic symptoms) in gastroenterology, with no time restrictions. Exclusion criteria were non-experimental studies, or studies using only email as primary eHealth method, and studies in language other than English.

RESULTS

A total of 17 papers were identified; seven studies evaluated the efficacy of a psychologically oriented intervention (additional two provided follow-up analyses exploring the original published data) and eight studies evaluated disease management programs for patients with either irritable bowel syndrome, inflammatory bowel disease (IBD) or celiac disease. Overall, psychological eHealth interventions were associated with significant reductions in bowel symptoms and improvement in quality of life (QoL) that tended to continue up to 12 months follow up. The eHealth disease management was shown to generally improve QoL, adherence, knowledge about the disease, and reduce healthcare costs in IBD, although the studies were associated with various methodological problems, and thus, this observation should be confirmed in well-designed interventional studies.

CONCLUSIONS

Based on the evidence to date, eHealth internet-based technology is a promising tool that can be utilized to both promote and enhance gastrointestinal disease management and mental health.

Distance management of inflammatory bowel disease: Systematic review and meta-analysis

AIM: To review the effectiveness of distance management methods in the management of adult inflammatory bowel disease (IBD) patients.

METHODS: A systematic review and meta-analysis of randomized controlled trials comparing distance management and standard clinic follow-up in the management of adult IBD patients. Distance management intervention was defined as any remote management method in which there is a patient self-management component whereby the patient interacts remotely via a self-guided management program, electronic interface, or self-directs open access to clinic follow up. The search strategy included electronic databases (Medline, PubMed, CINAHL, The Cochrane Central Register of Controlled Trials, EMBASE, KTPlus, Web of Science, and SCOPUS), conference proceedings, and internet search for web publications. The primary outcome was the mean difference in quality of life, and the secondary outcomes included mean difference in relapse rate, clinic visit rate, and hospital admission rate. Study selection, data extraction, and risk of bias assessment were completed by two independent reviewers.

RESULTS: The search strategy identified a total of 4061 articles, but only 6 randomized controlled trials met the inclusion and exclusion criteria for the systematic review and meta-analysis. Three trials involved telemanagement, and three trials involved directed patient self-management and open access clinics. The total sample size was 1463 patients. There was a trend towards improved quality of life in distance management patients with an end IBDQ quality of life score being 7.28 (95%CI: -3.25-17.81) points higher than standard clinic follow-up. There was a significant decrease in the clinic visit rate among distance management patients mean difference -1.08 (95%CI: -1.60--0.55), but no significant change in relapse rate or hospital admission rate.

CONCLUSION: Distance management of IBD significantly decreases clinic visit utilization, but does not significantly affect relapse rates or hospital admission rates.

Predictive factors of complementary and alternative medicine use for patients with inflammatory bowel disease in Korea

OBJECTIVES

The aim of this study was to assess characteristics and predictive factors of complementary and alternative medicine (CAM) use for patients with inflammatory bowel disease (IBD) in Korea.

DESIGN

Prospective, questionnaire based study for patients with IBD in Korea.

SETTING

Six university hospitals and one primary IBD clinic.

MAIN OUTCOME MEASURE

Overall characteristics and predictors of CAM use were compared between CAM users and non-users.

RESULTS

During the study period, 366 patients with IBD (ulcerative colitis=228, Crohn's disease=138) completed the full questionnaire; 29.5% (n=108) reported CAM use and 70.5% (n=258) reported no CAM use after diagnosis of IBD. In total, 64.0% were male, the mean patient age was 42.3±15.5 years, and the mean duration of IBD was 5.5±5.8 years. Using logistic regression analysis, university education (p=0.040), higher income levels (p=0.009), and longer duration of IBD (p=0.003) were found to be independent predictors of CAM use. Among CAM users, 65% of CAM was attained within 2 years of IBD diagnosis and only 28.7% discussed CAM use with their physician. Furthermore, 13.9% of CAM users discontinued conventional IBD therapy while using CAM.

CONCLUSIONS

The overall use of CAM in Korea was comparable with those in the West. Physicians should be aware of the high prevalence of CAM use by patients with IBD, especially among those with higher education levels, higher income levels, and longer IBD duration. Furthermore, physicians should ask about CAM use, and help their IBD patients make a more informed choice about CAM use.

An exploration of the follow-up up needs of patients with inflammatory bowel disease

BACKGROUND AND AIMS

The rising incidence of inflammatory bowel disease (IBD) in adults and children has implications for the lifelong burden of disease and the provision of specialist services. Patients with IBD should have access to specialist care which is delivered according to their values and needs. Few studies have examined patients' views of follow-up care. The aim of this qualitative study was to explore patients' needs, preferences and views of follow-up care.

METHODS

IBD patients were selected from a gastroenterology clinic in a UK Hospital and invited to participate in interviews which focused on needs, preferences and role of follow-up, their experience of follow-up, service delivery, and other models of follow-up care.

RESULTS

24 patients were recruited, 18 patients had Crohn's Disease, and 6 ulcerative colitis. Median age was 48.5 years (range was 27-72 years) and median disease duration 11.5 years (range 2-40 years). Four main themes emerged: (1) experiences of current follow-up care; (2) attitudes to new models of care, including self-management, role of general practitioner, patient-initiated consultations and 'virtual' follow-up; (3) the personal value of follow-up care; and (4) the 'ideal' consultation.

CONCLUSION

The main finding was that patients prefer a more flexible follow-up care system. 'Virtual' care as an adjunct to patient-initiated consultations and self-management, was identified as optimal approaches to meet the patients' needs of follow-up care. New models of follow-up care could improve the patients' experience of care, offer potential cost savings with reduction in face-to-face consultations and allow targeted care to those who need it.

Computer-assisted upper extremity training using interactive biking exercise (iBikE) platform

Upper extremity exercise training has been shown to improve clinical outcomes in different chronic health conditions. Arm-operated bicycles are frequently used to facilitate upper extremity training however effective use of these devices at patient homes is hampered by lack of remote connectivity with clinical rehabilitation team, inability to monitor exercise progress in real time using simple graphical representation, and absence of an alert system which would prevent exertion levels exceeding those approved by the clinical rehabilitation team. We developed an interactive biking exercise (iBikE) platform aimed at addressing these limitations. The platform uses a miniature wireless 3-axis accelerometer mounted on a patient wrist that transmits the cycling acceleration data to a laptop. The laptop screen presents an exercise dashboard to the patient in real time allowing easy graphical visualization of exercise progress and presentation of exercise parameters in relation to prescribed targets. The iBikE platform is programmed to alert the patient when exercise intensity exceeds the levels recommended by the patient care provider. The iBikE platform has been tested in 7 healthy volunteers (age range: 26-50 years) and shown to reliably reflect exercise progress and to generate alerts at pre-setup levels. Implementation of remote connectivity with patient rehabilitation team is warranted for future extension and evaluation efforts.

Practical strategies for enhancing adherence to treatment regimen in inflammatory bowel disease

Promoting adherence to treatment among pediatric and adult patients with inflammatory bowel disease (IBD) is a critical yet challenging task for health care providers. Several existing interventions to enhance adherence among individuals with IBD offer useful information about practical strategies to enhance adherence. The current review article has 3 goals. First, the review provides a context for understanding treatment regimen adherence in IBD by reviewing key definitional, measurement, and conceptual challenges in this area. Next, published studies focused on interventions to enhance adherence in IBD are briefly summarized, followed by a synthesis of practical adherence promotion strategies for use in IBD by health care providers. Strategies are distinguished by the level of evidence supporting their utility as well as by age group. Finally, recommendations for future research to facilitate the development and implementation of practical, evidence-based strategies for adherence promotion in IBD are provided. Findings from the literature review suggest that strategies including education, regimen simplification, and use of reminder systems and organizational strategies (e.g., pill boxes) are likely to be best suited for addressing accidental nonadherence. In contrast, addressing motivational issues, teaching problem-solving skills, and addressing problematic patterns of family functioning are more likely to benefit individuals displaying intentional nonadherence.

Remotely controlled cycling exercise system for home-based telerehabilitation

Limited research has been conducted in utilizing telemedicine to promote upper and lower limb rehabilitation using remotely controlled home-based ergometers. The goal of this study was to develop and assess a telerehabilitation system supporting internet-controlled home-based cycling exercise. We designed an interface to control cycling speed of an ergometer from a remote server via Internet. The evaluation of the interface included consecutive transmission of 7 different cycling speed levels, each level of 2-minute duration. Overall, the mean difference between remotely setup and actual cycling speed was 0.002 ± 0.03 miles/hour. Our evaluation demonstrated high fidelity of the proposed system and reliability of controlling individualized exercise prescription for home-based cycling equipment via Internet.

eHealth: individualisation of infliximab treatment and disease course via a self-managed web-based solution in Crohn’s disease

BACKGROUND

Infliximab (IFX) maintenance therapy for Crohn's disease (CD) is administered every 8 weeks, but inter-patient variation in optimal treatment intervals may exist.

AIM

To assess, in a prospective pilot study, the efficacy, safety and quality of life (QoL) of IFX maintenance treatment scheduled through web-based self-monitoring of disease activity.

METHODS

Twenty-seven CD patients in IFX maintenance therapy were enrolled and received a standardised disease education and web-training. Using the http://www.cd.constant-care.dk concept, patients recorded their disease activity and faecal calprotectin weekly. From this, the inflammatory burden (IB) score was calculated, placing patients in the green, yellow or red zones of a ‘traffic light’ system. If placed in the yellow or red zones, the computer directed these patients to consult their physician for IFX infusion.

RESULTS

Seventeen patients (63%) completed 52 weeks of follow-up, 6 (22%) completed 26 weeks and 4 (15%) were excluded due to loss of response, patient decision or non-adherence. In total, 121 IFX infusions were given with a median interval of 9 (range: 4–18) weeks. Only 10% of infusions were given at 8-week intervals, whereas 39% were administered with shorter and 50% with longer intervals respectively. The mean IB and the QoL remained stable during the web-treatment. One mild infusion reaction and one case of folliculitis were observed, while three patients underwent surgery.

CONCLUSIONS

The program http://www.cd.constant-care.dk appears to be a practical and safe concept for the individualised scheduling of maintenance treatment with IFX in patients with Crohn's disease. Larger studies are awaited to confirm this preliminary outcome.

Characterisation of complementary and alternative medicine use and its impact on medication adherence in inflammatory bowel disease

BACKGROUND

Complementary and alternative medicine (CAM) use among inflammatory bowel disease (IBD) patients is common. We characterised CAM utilisation and assessed its impact on medical adherence in the IBD population.

AIM

To characterise CAM utilisation and assess its impact on medical adherence in the IBD population.

METHODS

Inflammatory bowel disease patients recruited from an out-patient clinic at a tertiary centre were asked to complete a questionnaire on CAM utilisation, conventional IBD therapy, demographics and communication with their gastroenterologist. Adherence was measured using the self-reported Morisky scale. Demographics, clinical characteristics and self-reported adherence among CAM and non-CAM users were compared.

RESULTS

We recruited prospectively 380 IBD subjects (57% Crohn's disease; 35% ulcerative colitis, and 8% indeterminate colitis). The prevalence of CAM use was 56% and did not significantly vary by type of IBD. The most common reason cited for using CAM was ineffectiveness of conventional IBD therapy (40%). The most popular form of CAM was probiotics (53%). CAM users were younger than non-CAM users at diagnosis (21.2 vs. 26.2, P < 0.0001) and more likely than non-CAM users to have a University-level education or higher (75% vs. 62% P = 0.006). There was no overall difference in adherence between CAM and non-CAM users (Morisky score: 1.0 vs. 0.9, P = 0.26).

CONCLUSIONS

The use of complementary and alternative medicine is widely prevalent among IBD patients, and is more frequent among those with experience of adverse effects of conventional medications. From this cross-sectional analysis, complementary and alternative medicine use does not appear to be associated with reduced overall adherence to medical therapy.