Patients' perspectives of a multifaceted intervention with a focus on technology: a qualitative analysis

Patients' perspectives on digital health tools

Objective

Digital technology has changed the way healthcare is delivered and accessed. However, the focus is mostly on technology and clinical aspects. This review aimed to integrate and critically analyse the available knowledge regarding patients' perspectives on digital health tools and identify facilitators and barriers to their uptake.

Methods

A narrative review was conducted using the Scopus and Google Scholar databases. Information related to facilitators and barriers to uptake was synthesised and interpreted using thematic and content analyses, respectively.

Results

Seventy-one out of 1722 articles identified were eligible for inclusion. Patient empowerment, self-management, and personalisation were identified as the main factors that contributed to patient uptake in using digital health tools. Digital literacy, health literacy, and privacy concerns were identified as barriers to the uptake of digital health technology.

Conclusion

Digital health technologies have changed the way healthcare is experienced by patients. Research highlights the disconnect between the development and implementation of digital health tools and the patients they are created for. This review may serve as the foundation for future research incorporating patients' perspectives to help increase patients' engagement with emerging technologies.

Innovation

Participatory design approaches have the potential to support the creation of patient-centred digital health tools.

SMS-facilitated home blood pressure monitoring: A qualitative analysis of resultant health behavior change

OBJECTIVE

Hypertension is largely asymptomatic and, as a result, patients often fail to sufficiently engage in medication adherence and other health behaviors to control their blood pressure (BP). This study explores the mechanisms by which MyBP, an automated SMS-facilitated home blood pressure monitoring (HBPM) program, helps facilitate healthy behavior changes.

METHODS

A thematic analysis of transcribed audio-recordings from semi-structured post-intervention interviews (n = 40) was conducted.

RESULTS

Three primary themes were identified as contributing most to patients' decision to initiate a behavior change: 1) increased hypertension literacy attributed to educational videos presented at enrollment, 2) increased day-to-day salience of blood pressure levels as a result of consistent HBPM, and 3) use of BP readings as feedback, with high readings triggering motivations to make behavior changes. These themes and most accompanying sub-themes correspond to constructs in the Health Belief Model and Social Cognitive Theory.

CONCLUSION

Patient-centered HBPM interventions such asMyBP appear to promote improvements in hypertension self-management via several mechanisms consistent with recognized models of behavior change.

PRACTICE IMPLICATIONS

SMS-supported HBPM, paired with video-based education, may provide a simple and scalable way of encouraging health behavior adherence in hypertensive patients.

Understanding short-term blood-pressure-variability phenotypes: from concept to clinical practice

Clinic blood pressure (BP) is recognized as the gold standard for the screening, diagnosis, and management of hypertension. However, optimal diagnosis and successful management of hypertension cannot be achieved exclusively by a handful of conventionally acquired BP readings. It is critical to estimate the magnitude of BP variability by estimating and quantifying each individual patient's specific BP variations. Short-term BP variability or exaggerated circadian BP variations that occur within a day are associated with increased cardiovascular events, mortality and target-organ damage. Popular concepts of BP variability, including "white-coat hypertension" and "masked hypertension", are well recognized in clinical practice. However, nocturnal hypertension, morning surge, and morning hypertension are also important phenotypes of short-term BP variability that warrant attention, especially in the primary-care setting. In this review, we try to theorize and explain these phenotypes to ensure they are better understood and recognized in day-to-day clinical practice.

Using digital interventions for self-management of chronic physical health conditions: A meta-ethnography review of published studies

OBJECTIVES

To understand the experiences of patients and healthcare professionals (HCPs) using self-management digital interventions (DIs) for chronic physical health conditions.

METHODS

A systematic search was conducted in 6 electronic databases. Qualitative studies describing users' experiences of self-management DIs were included, and authors' interpretations were synthesised using meta-ethnography.

RESULTS

30 papers met the inclusion criteria, covering a range of DIs and chronic conditions, including hypertension, asthma and heart disease. The review found that patients monitoring their health felt reassured by the insight this provided, and perceived they had more meaningful consultations with the HCP. These benefits were elicited by simple tele-monitoring systems as well as multifaceted DIs. Patients appeared to feel more reliant on HCPs if they received regular feedback from the HCP. HCPs focused mainly on their improved clinical control, and some also appreciated patients' increased understanding of their condition.

CONCLUSIONS

Patients using self-management DIs tend to feel well cared for and perceive that they adopt a more active role in consultations, whilst HCPs focus on the clinical benefits provided by DIs.

PRACTICE IMPLICATIONS

DIs can simultaneously support patient condition management, and HCPs' control of patient health. Tele-monitoring physiological data can promote complex behaviour change amongst patients.

Self-monitoring blood pressure in hypertension, patient and provider perspectives: A systematic review and thematic synthesis

OBJECTIVE

To systematically review the qualitative evidence for patient and clinician perspectives on self-measurement of blood pressure (SMBP) in the management of hypertension focussing on: how SMBP was discussed in consultations; the motivation for patients to start self-monitoring; how both patients and clinicians used SMBP to promote behaviour change; perceived barriers and facilitators to SMBP use by patients and clinicians.

METHODS

Medline, Embase, PsycINFO, Cinahl, Web of Science, SocAbs were searched for empirical qualitative studies that met the review objectives. Reporting of included studies was assessed using the COREQ framework. All relevant data from results/findings sections of included reports were extracted, coded inductively using thematic analysis, and overarching themes across studies were abstracted.

RESULTS

Twelve studies were included in the synthesis involving 358 patients and 91 clinicians. Three major themes are presented: interpretation, attribution and action; convenience and reassurance v anxiety and uncertainty; and patient autonomy and empowerment improve patient-clinician alliance.

CONCLUSIONS

SMBP was successful facilitating the interaction in consultations about hypertension, bridging a potential gap in the traditional patient-clinician relationship.

PRACTICE IMPLICATIONS

Uncertainty could be reduced by providing information specifically about how to interpret SMBP, what variation is acceptable, adjustment for home-clinic difference, and for patients what they should be concerned about and how to act.

Clinical significance of home blood pressure measurements for the prevention and management of high blood pressure

1. Ambulatory blood pressure (ABP) monitoring (M) provides BP information at many points on any particular day during unrestricted routine daily activities, whereas home blood pressure (HBP) monitoring provides a lot of BP information obtained under fixed times and conditions over a long period of time, thus mean values of HBP provide high reproducibility, and thus an overall superiority compared with ABP.  2. HBP is at least equally or better able than ABP to predict hypertensive target organ damage and prognosis of cardiovascular disease.  3. HBPM allows for ongoing disease monitoring by patients, improves adherence to antihypertensive treatment, and can provide health-care providers with timely clinical data and direct and immediate feedback regarding diagnosis and treatment of hypertension.  4. HBPM provides BP information in relation to time; that is, BP in the morning, in the evening and at night during sleep, and it is an essential tool for the diagnosis of white-coat and masked hypertension.  5. HBPM yields minimal alerting affects and no or minimal placebo effect, and can therefore distinguish small, but significant, serial changes in BP. It is thus the most practical method for monitoring BP in the day-to-day management of hypertension. 6. The superiority of HBPM over ABPM and clinic BPM is apparent from almost all practical and clinical research perspectives.

A pharmacist-led follow-up program for patients with coronary heart disease in North Norway--a qualitative study exploring patient experiences

BACKGROUND

Coronary heart disease (CHD) is one of the leading causes of death worldwide. Scientific literature shows that prevention of CHD is inadequate. The clinical pharmacist's role in patient-centred care has been shown favourable in a large amount of studies, also in relation to reduction of risk factors related to CHD. We developed and piloted a pharmacist-led follow-up program for patients with established CHD after hospital discharge from a hospital in North Norway. The aim of the present study was to explore how participants in the follow-up program experienced the program with regard to four main topics; medication knowledge, feeling of safety and comfort with medications, the functionality of the program and the clinical pharmacist's role in the interdisciplinary team.

METHODS

We performed semi-structured thematic interviews with four patients included in the program. After verbatim transcribing, we analysed the interviews using "qualitative content analyses" by Graneheim and Lundman. Trial registration http://www.clinicaltrials.gov: NCT01131715.

RESULTS

All participants appreciated the follow-up program because their medication knowledge had increased, participation had made them feel safe, they were reassured about the appropriateness of their medications, and they had become more involved in their own medication. The participants reported that the program was well structured and the clinical pharmacist was said to be an important caretaker in the health-care system. The importance of collaboration between pharmacists and physicians, both in hospital and primary care, was emphasized.

CONCLUSION

Our results indicate that the follow-up program was highly appreciated among the four participants included in this study. The results must be interpreted in the context of the health care system in Norway today. Here, few pharmacists are working in hospitals or in close relation to the general practitioners. In addition, physicians are short of time in order to supply appropriate medication information, both in hospital and primary care. Involving pharmacists in follow-up of patients with CHD seems to be highly appreciated among patients and may be a step towards improving patient care. The study is limited by the low number of participants.

Experiences of patients and professionals participating in the HITS home blood pressure telemonitoring trial: a qualitative study

OBJECTIVES

To explore the experiences of patients and professionals taking part in a randomised controlled trial (RCT) of remote blood pressure (BP) telemonitoring supported by primary care. To identify factors facilitating or hindering the effectiveness of the intervention and those likely to influence its potential translation to routine practice.

DESIGN

Qualitative study adopting a qualitative descriptive approach.

PARTICIPANTS

25 patients, 11 nurses and 9 doctors who were participating in an RCT of BP telemonitoring. A maximum variation sample of patients from within the trial based on age, sex and deprivation status of the practice was sought.

SETTING

6 primary care practices in Scotland.

METHOD

Data were collected via taped semistructured interviews. Initial thematic analysis was inductive. Multiple strategies were employed to ensure that the analysis was credible and trustworthy.

RESULTS

Prior to the trial, both patients and professionals were reluctant to increase the medication based on single BP measurements taken in the surgery. BP measurements based on multiple electronic readings were perceived as more accurate as a basis for action. Patients using telemonitoring became more engaged in the clinical management of their condition. Professionals reported that telemonitoring challenged existing roles and work practices and increased workload. Lack of integration of telemonitoring data with the electronic health record was perceived as a drawback.

CONCLUSIONS

BP telemonitoring in a usual care setting can provide a trusted basis for medication management and improved BP control. It increases patients' engagement in the management of their condition, but supporting telemetry and greater patient engagement can increase professional workloads and demand changes in service organisation. Successful service design in practice would have to take account of how additional roles and responsibilities could be realigned with existing work and data management practices. The embedded qualitative study was included in the protocol for the HITS trial registered with ISRCTN no. 72614272.

The impact of using mobile-enabled devices on patient engagement in remote monitoring programs

BACKGROUND

Different types of data transmission technologies are used in remote monitoring (RM) programs. This study reports on a retrospective analysis of how participants engage, based on the type of data transfer technology used in a blood pressure (BP) RM program, and its potential impact on RM program design and outcomes.

METHODS

Thirty patients, aged 23-84 years (62 ± 14 years), who had completed at least 2 months in the program and were not participating in any other clinical trial were identified from the Remote Monitoring Data Repository. Half of these patients used wireless-based data transfer devices [wireless-based device (WBD)] while the other half used telephone modem-based data transfer devices [modem-based device (MBD)]. Participants were matched by practice and age. Engagement indices, which include frequency of BP measurements, frequency of data uploads, time to first BP measurement, and time to first data upload, were compared in both groups using the Wilcoxon-Mann-Whitney two-sample rank-sum test. Help desk call data were analyzed by Chi square test.

RESULTS

The frequency of BP measurements and data uploads was significantly higher in the WBD group versus the MBD group [median = 0.66 versus 0.2 measurements/day (p = .01) and 0.46 versus 0.01 uploads/day (p < .001), respectively]. Time to first upload was significantly lower in the WBD group (median = 4 versus 7 days; p = .02), but time to first BP measurement did not differ between the two groups (median = 2 versus 1 day; p = .98).

CONCLUSION

Wireless transmission ensures instantaneous transmission of readings, providing clinicians timely data to intervene on. Our findings suggest that mobile-enabled wireless technologies can positively impact patient engagement, outcomes, and operational workflow in RM programs.

Patient perspectives on participation in the ENABLE II randomized controlled trial of a concurrent oncology palliative care intervention: benefits and burdens

BACKGROUND

ENABLE (Educate, Nurture, Advise Before Life Ends) II was one of the first randomized controlled trials (RCTs) examining the effects of a concurrent oncology palliative care intervention on quality of life, mood, and symptom control for advanced cancer patients and their caregivers. However, little is known about how participants experience early palliative care and the benefits and burdens of participating in a palliative care clinical trial.

AIM

To gain a deeper understanding of participants' perspectives of the intervention and palliative care trial participation.

DESIGN

A qualitative descriptive study using thematic analysis to determine benefits and burdens of a new palliative care intervention and trial participation.

SETTING/PARTICIPANTS

Of the 72 participants who were alive when the study commenced, 53 agreed to complete an in-depth, semi-structured interview regarding the ENABLE II intervention and clinical trial participation.

RESULTS

Participants' perceptions of intervention benefits were represented by four themes: enhanced problem-solving skills, better coping, feeling empowered, and feeling supported or reassured. Three themes related to trial participation: helping future patients and contributing to science, gaining insight through completion of questionnaires, and trial/intervention aspects to improve.

CONCLUSIONS

The benefits of the intervention and the positive aspects of trial participation outweighed trial "burdens". This study raises additional important questions relevant to future trial design and intervention development: when should a palliative care intervention be initiated and what aspects of self-care and healthy living should be offered in addition to palliative content for advanced cancer patients when they are feeling well?