Needs and Requirements in the Designing of Mobile Interventions for Patients With Peripheral Arterial Disease: Questionnaire Study

Optimization of the Care4Today Digital Health Platform to Enhance Self-Reporting of Medication Adherence and Health Experiences in Patients With Coronary or Peripheral Artery Disease: Mixed Methods Study

BACKGROUND

Care4Today is a digital health platform developed by Johnson & Johnson comprising a patient mobile app (Care4Today Connect), a health care provider (HCP) portal, and an educational website. It aims to improve medication adherence; enable self-reporting of health experiences; provide patient education; enhance connection with HCPs; and facilitate data and analytics learning across disease areas, including cardiovascular disease.

OBJECTIVE

This study aimed to gather patient feedback on Care4Today Connect, specifically the coronary artery disease (CAD) and peripheral artery disease (PAD) module, and to cocreate and validate features with patients to optimize the app experience for those with CAD, PAD, or both.

METHODS

We conducted 3 research engagements between November 2022 and May 2023. Participants were US-based adults recruited and consented through the sponsor's Patient Engagement Research Council program. Participants self-reported a diagnosis of cardiovascular disease, and in some cases, specifically, CAD, PAD, or both. Part 1, internet survey, posed quantitative questions with Likert-scale answer options about existing app features. Part 2, virtual focus group, and part 3, virtual individual interviews, both used semistructured qualitative discussion to cocreate and validate new app enhancements. The quantitative data from part 1 was evaluated descriptively to categorize mobile health app use, confidence in the ability to use the app, and motivations for app use. The qualitative discussions from parts 2 and 3 were synthesized to understand participants' app needs and preferences to inform an optimal app experience.

RESULTS

The response rate for part 1, internet survey, was 67% (37/55). Most participants felt at least somewhat confident using the app after seeing the newly added app tutorial (33/37, 89%), and at least somewhat confident in their ability to earn points for completing activities using app instructions (33/37, 89%). In part 2, virtual focus group (n=3), and part 3, virtual individual interviews (n=8), participants collectively preferred to enhance the app with (1) the ability to automatically add medication data for tracking and (2) the ability to receive relevant care team feedback on their self-reported health experiences. Participants would be willing to spend 10-15 minutes a day tracking 4-5 health experiences, especially those requested by their HCP.

CONCLUSIONS

Participants prefer apps that can reduce user burden and provide information relevant to them. Care4Today Connect can optimize the user experience for patients with CAD, PAD, or both with the automatic addition of medication data for tracking and in-app care team feedback on patient self-reported health experiences.

Adherence, acceptability, and usability of a smartphone app to promote physical exercise in patients with peripheral arterial disease and intermittent claudication

This study presents the development and assessment of a mobile application - the WalkingPAD app - aimed at promoting adherence to physical exercise among patients with Peripheral Arterial Disease (PAD). The assessment of adherence, acceptability, and usability was performed using mixed methods. Thirty-eight patients participated in the study with a mean age of 63.4 years (SD = 6.8). Thirty patients used the application for three months, responded to a semi-structured interview, and completed a task test and the System Usability Scale (SUS, ranging from 0 to 100). The application's adherence rate was 73%. When patients were asked about their reasons for using the app, the main themes that emerged were motivation, self-monitoring, and support in fulfilling a commitment. The average SUS score was 82.82 (SD = 18.4), indicating high usability. An upcoming version of the WalkingPAD app is expected to redesign both tasks - opening the app and looking up the walking history - which were rated as the most difficult tasks to accomplish. The new version of the WalkingPAD app will incorporate participants' comments and suggestions to enhance usability for this population.

Inconsistent Benefits From Mobile Information Communication Technology in Adults With Peripheral Arterial Disease

INTRODUCTION

Quality of evidence regarding telemedicine in adults with peripheral arterial disease has not been systematically appraised.

OBJECTIVES

To explore benefits and harms from mobile information communication technology devices and applications in peripheral arterial disease.

METHODS

Systematic rapid evidence review and appraisal with the grading of recommendations assessment, development, and evaluation working group approach.

RESULTS

Sixteen randomized controlled clinical trials (RCT) examined various self-monitoring devices, telemedicine platforms, and individualized telephone counseling. Low-quality evidence suggested that the odds of treatment failure (pooled Peto odds ratio 0.8; 95% CI, 0.4-1.7; 5 RCTs), adverse effects (pooled Peto odds ratio 0.9; 95% CI, 0.5-1.5; 2 RCTs), and physical performance (standardized mean difference in 6-minute walking test 0.2; 95% CI, -0.3-0.7; 4 RCTs) did not differ between mobile interventions and usual care. Single RCTs suggested large but inconsistent improvement in the quality of life: EuroQol5D standardized mean difference = 5.0 (95% CI, 4.4-5.7; 1 RCT) after telehealth program for promoting patient self-management and standardized mean difference = 1.4 (95% CI, 0.4-2.3; 1 RCT) after structured rehabilitation with mobile self-monitoring. Inconsistent reporting of patient-centered outcomes and small sample sizes hampered the quality of evidence.

CONCLUSIONS

Improved quality of life after specific mobile applications should be confirmed in powered RCTs and large postmarketing studies.

Needs and demands for mHealth cardiac health promotion among individuals with cardiac diseases: a patient-centred design approach

Aims

Cardiovascular diseases are one of the main contributors to disability and mortality worldwide. Meanwhile, risk factors can be modified by lifestyle changes. mHealth is an innovative and effective way to deliver cardiac health promotion. This study aims to examine the needs and demands regarding the design and contents of an mHealth intervention for cardiac health promotion among individuals with cardiac diseases. Different clusters were determined and analysed in terms of the intention to use an mHealth intervention.

Methods and results

A cross-sectional study was conducted via a web-based survey. Three hundred and four individuals with coronary artery diseases (CADs) and/or congestive heart failure (CHF) were included in the data analysis. Descriptive statistics were applied to evaluate needs and demands regarding an mHealth intervention. A k-medoids cluster analysis was performed. Individuals with CAD and CHF favoured an mHealth intervention that supports its users permanently and is easily integrated into everyday life. Handheld devices and content formats that involve active user participation and regular updates were preferred. Three clusters were observed and labelled high, moderate, and low burden, according to their psychometric properties. The high burden cluster indicated higher behavioural intention towards use of an mHealth intervention than the other clusters.

Conclusion

The results of the study are a valuable foundation for the development of an mHealth intervention for cardiac health promotion following a user-centred design approach. Individuals with cardiac diseases report positive attitudes in the form of high usage intention regarding mHealth. Highly burdened individuals report a high intention to use such interventions.

A Systematic Review on Smartphone Use for Activity Monitoring During Exercise Therapy in Intermittent Claudication

OBJECTIVE

Supervised exercise therapy (SET) is recommended as first line in the management of intermittent claudication (IC). Its use is often limited by accessibility, compliance and cost. Home-based exercise therapy (HBET) programs emerged as an alternative solution, but have shown inferior results. Employment of structured monitoring with the use of external wearable activity monitors (WAM) has been shown to improve outcomes. Mobile applications can make use of built-in accelerometers of modern smartphones and become an alternative solution for monitoring patients during HBET, potentially providing wider accessibility. This review aims to assess current use of smartphone technology (i.e., mobile apps) for monitoring or tracking patients' activity in exercise therapy for peripheral arterial disease (PAD).

METHODS

The PubMed database was searched from January 2011 to September 2021. Eligible articles had to include a population of patients with PAD, conduct a mobile-health (m-health) exercise intervention and use smartphone technology for monitoring or tracking patients' activity. Randomized control trials (RCTs), prospective studies, and study protocols were included.

RESULTS

A total of seven articles met the selection criteria. These described six different studies and five different mobile applications. Three were fitness apps (FitBit, Nike+ FuelBand and Garmin Connect) that synchronized with commercially available WAMs to provide users with feedback. Two were PAD-specific apps (TrackPAD and Movn) developed specifically to assess patients' activity during exercise therapy. PAD-specific apps also incorporated coaching and educational elements such as weekly goal setting, claudication reminders, messaging, gamification, training advice and PAD education.

CONCLUSION

Current HBET programs use smartphone applications mainly via commercially available fitness apps that synchronize with WAM devices to register and access data. PAD-specific apps are scarce but show promising features that can be used to monitor, train, coach, and educate patients during HBET programs. Larger studies combining these elements into HBET programs should provide future direction.

Supervised Exercise Therapy Using Mobile Health Technology in Patients With Peripheral Arterial Disease: Pilot Randomized Controlled Trial

Background

Mobile health interventions are intended to support complex health care needs in chronic diseases digitally, but they are mainly targeted at general health improvement and neglect disease-specific requirements. Therefore, we designed TrackPAD, a smartphone app to support supervised exercise training in patients with peripheral arterial disease.

Objective

This pilot study aimed to evaluate changes in the 6-minute walking distance (meters) as a primary outcome measure. The secondary outcome measures included changes in physical activity and assessing the patients’ peripheral arterial disease–related quality of life.

Methods

This was a pilot two-arm, single-blinded, randomized controlled trial. Patients with symptomatic PAD (Fontaine stage IIa/b) and access to smartphones were eligible. Eligible participants were randomly assigned to the study, with the control group stratified by the distance covered in the 6-minute walking test using the TENALEA software. Participants randomized to the intervention group received usual care and the mobile intervention (TrackPAD) for the follow-up period of 3 months, whereas participants randomized to the control group received routine care only. TrackPAD records the frequency and duration of training sessions and pain levels using manual user input. Clinical outcome data were collected at the baseline and after 3 months via validated tools (the 6-minute walk test and self-reported quality of life). The usability and quality of the app were determined using the Mobile Application Rating Scale user version.

Results

The intervention group (n=19) increased their mean 6-minute walking distance (83 meters, SD 72.2), while the control group (n=20) decreased their mean distance after 3 months of follow-up (–38.8 meters, SD 53.7; P=.01). The peripheral arterial disease–related quality of life increased significantly in terms of “symptom perception” and “limitations in physical functioning.” Users’ feedback showed increased motivation and a changed attitude toward performing supervised exercise training.

Conclusions

Besides the rating providing a valuable support tool for the user group, the mobile intervention TrackPAD was linked to a change in prognosis-relevant outcome measures combined with enhanced coping with the disease. The influence of mobile interventions on long-term prognosis must be evaluated in the future.

Trial Registration

ClinicalTrials.gov NCT04947228; https://clinicaltrials.gov/ct2/show/NCT04947228

Mobile applications in peripheral arterial disease (PAD): a review and introduction of a new innovative telemonitoring application: JBZetje

Introduction:Peripheral arterial disease (PAD) is an occlusive vascular disease of the lower extremities with increasing incidence and prevalence numbers and therefore rising health care costs. Mobile applications have great potential to improve health system efficiency and can assist in overcoming the increasing health care costs. In this review all available mobile applications developed for PAD are summarized and a new innovative application is introduced.Areas covered:Available applications for PAD are scarce and currently aim at prevention, teleconsultation and telemonitoring via questionnaires and activity tracking. Integration in the daily workflow of the physician is an overlooked aspect of these applications. JBZetje is an innovative mobile application that provides remote care, information services and self-service tools, and enables connection with the electronic health record (EHR).Expert opinion:Connection of the application with the EHR generates a complete overview of a patient's current health status. This will reinforce the tendency toward personalized medicine and will probably lead to reduced health care costs and increase the quality of care. Future feasibility studies should answer the question whether the use of mobile applications is feasible in the PAD population.

An Updated Systematic Review and Meta-Analysis of Home-based Exercise Programmes for Individuals with Intermittent Claudication

OBJECTIVES

Supervised exercise programmes (SEP) are effective for improving walking distance in patients with intermittent claudication (IC) but provision and uptake rates are sub-optimal. Access to such programmes has also been halted by the Coronavirus pandemic. The aim of this review is to provide a comprehensive overview of the evidence for home-based exercise programmes (HEP).

DATA SOURCES

Medline, EMBASE, CINAHL, PEDro and Cochrane CENTRAL were searched for terms relating to HEP and IC.

REVIEW METHODS

This review was conducted in according with the published protocol and PRISMA guidance. Randomised and non-randomised trials that compared a HEP to SEP, basic exercise advice or no exercise controls for IC were included. A narrative synthesis was provided for all studies and meta-analyses conducted using data from randomised trials. The primary outcome was maximal walking distance. Sub-group analyses were performed to consider the effect of monitoring. Risk of bias was assessed using the Cochrane tool and quality of evidence via GRADE.

RESULTS

23 studies with 1907 participants were included. Considering the narrative review, HEPs were inferior to SEPs which was reflected in the meta-analysis (MD 139m, 95% CI 45 to 232m, p = .004, very-low-quality evidence). Monitoring was an important component, as HEPs adopting this were equivalent to SEPs (MD: 8m, 95% CI -81 to 97, p = .86; moderate-quality evidence). For HEPs versus basic exercise advice, narrative review suggested HEPs can be superior, though not always significantly so. For HEPs versus no exercise controls, narrative review and meta-analysis suggested HEPs were potentially superior (MD: 136m, -2-273m p = .05, very-low-quality evidence). Monitoring was also a key element in these comparisons.Other elements such as appropriate frequency (≥3x a week), intensity (to moderate-maximum pain), duration (20 progressing to 60 minutes) and type (walking) of exercise were important, as was education, self-regulation, goal setting, feedback and action planning.

CONCLUSION

When SEPs are unavailable, HEPs are recommended. However, to elicit maximum benefit they should be structured, incorporating all elements of our evidence-based recommendations.

PROSPERO REGISTRATION NUMBER

CRD42018091248.