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Kumar SS, Hartner AM, Chandran A, Gaythorpe KAM, Li X. Evaluating effective measles vaccine coverage in the Malaysian population accounting for between-dose correlation and vaccine efficacy. BMC Public Health 2023; 23:2351. [PMID: 38017415 PMCID: PMC10683193 DOI: 10.1186/s12889-023-17082-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/27/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Malaysia introduced the two dose measles-mumps-rubella (MMR) vaccine in 2004 as part of its measles elimination strategy. However, despite high historical coverage of MCV1 and MCV2, Malaysia continues to report high measles incidence. This study suggests a novel indicator for investigating population immunity against measles in the Malaysian population. METHODS We define effective vaccine coverage (EVC) of measles as the proportion of a population vaccinated with measles-containing vaccine (MCV) and effectively protected against measles infection. A quantitative evaluation of EVC throughout the life course of Malaysian birth cohorts was conducted accounting for both vaccine efficacy (VE) and between-dose correlation (BdC). Measles vaccination coverage was sourced from WHO-UNICEF estimates of Malaysia's routine immunisation coverage and supplementary immunisation activities (SIAs). United Nations World population estimates and projections (UNWPP) provided birth cohort sizes stratified by age and year. A step wise joint Bernoulli distribution was used to proportionate the Malaysian population born between 1982, the first year of Malaysia's measles vaccination programme, and 2021, into individuals who received zero dose, one dose and multiple doses of MCV. VE estimates by age and doses received are then adopted to derive EVC. A sensitivity analysis was conducted using 1000 random combinations of BdC and VE parameters. RESULTS This study suggests that no birth cohort in the Malaysian population has achieved > 95% population immunity (EVC) conferred through measles vaccination since the measles immunisation programme began in Malaysia. CONCLUSION The persistence of measles in Malaysia is due to pockets of insufficient vaccination coverage against measles in the population. Monitoring BdC through immunisation surveillance systems may allow for the identification of susceptible subpopulations (primarily zero-dose MCV individuals) and increase the coverage of individuals who are vaccinated with multiple doses of MCV. This study provides a tool for assessment of national-level population immunity of measles conferred through vaccination and does not consider subnational heterogeneity or vaccine waning. This tool can be readily applied to other regions and vaccine-preventable diseases.
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Affiliation(s)
- Shurendar Selva Kumar
- MRC Centre for Global Infectious Disease Analysis, Jameel Institute, School of Public Health, Imperial College London, London, W2 1NY, UK.
| | - Anna-Maria Hartner
- MRC Centre for Global Infectious Disease Analysis, Jameel Institute, School of Public Health, Imperial College London, London, W2 1NY, UK
- Centre for Artificial Intelligence in Public Health Research, Robert Koch Institute, Wildau, Germany
| | | | - Katy A M Gaythorpe
- MRC Centre for Global Infectious Disease Analysis, Jameel Institute, School of Public Health, Imperial College London, London, W2 1NY, UK
| | - Xiang Li
- MRC Centre for Global Infectious Disease Analysis, Jameel Institute, School of Public Health, Imperial College London, London, W2 1NY, UK.
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Groene N, Schneck L. Covering digital health applications in the public insurance system: how to foster innovation in patient care while mitigating financial risks-evidence from Germany. Front Digit Health 2023; 5:1217479. [PMID: 37886669 PMCID: PMC10598733 DOI: 10.3389/fdgth.2023.1217479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 09/12/2023] [Indexed: 10/28/2023] Open
Abstract
Context Digital health applications that support patients in managing their condition can have a positive impact on patients' health and improve the overall care process. In late 2019, as the first country worldwide, Germany included digital health applications in the benefit basket of the statutory health insurance (SHI) system to enable fast, broad-scale patient access and encourage innovation in the digital health industry. While the policy is widely recognized as a pioneering step toward improving patient care through digital technologies, there are concerns regarding the mechanics of the policy and the resulting financial risks for the SHI system. Goals The primary objective of this article is to provide a comprehensive and balanced overview of the German policy by evaluating its success in achieving its goals and by reviewing challenges that have emerged. The secondary objective is to delineate prospective policy options and areas warranting future research. Approach The article analyzes publicly available data of the Federal Institute for Drugs and Medical Devices collected between February 1st and July 17th, 2023, and complements it with empirical findings published by academic institutions and sickness funds. It discusses policy options and related areas of future research to overcome the identified challenges without jeopardizing the purpose of the legislation to encourage innovation in the digital health industry to improve patient care. Conclusion In line with the goals of the reimbursement policy, the inclusion of digital health applications in the SHI benefit basked has entailed new digital treatment options for patients across multiple disease areas. However, from a health policy perspective, the policy has several shortcomings, including low prescription rates, the temporary reimbursement of digital health applications that lack proven benefit, and a pricing framework that does not take into account the efficacy and efficiency of a treatment and may lead to a suboptimal allocation of public resources. Rather than the public system covering digital health applications without proven benefit, the authors suggest giving SHI organizations more budget authority to directly incentivize research and development activities and to introduce value-based pricing. More research is needed to determine the details of these mechanisms.
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Affiliation(s)
- Nicole Groene
- Department for Health and Social Sciences, FOM University of Applied Sciences, Munich, Germany
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Olaye IM, Seixas AA. The Gap Between AI and Bedside: Participatory Workshop on the Barriers to the Integration, Translation, and Adoption of Digital Health Care and AI Startup Technology Into Clinical Practice. J Med Internet Res 2023; 25:e32962. [PMID: 37129947 DOI: 10.2196/32962] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 02/02/2022] [Accepted: 10/25/2022] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND Artificial intelligence (AI) and digital health technological innovations from startup companies used in clinical practice can yield better health outcomes, reduce health care costs, and improve patients' experience. However, the integration, translation, and adoption of these technologies into clinical practice are plagued with many challenges and are lagging. Furthermore, explanations of the impediments to clinical translation are largely unknown and have not been systematically studied from the perspective of AI and digital health care startup founders and executives. OBJECTIVE The aim of this paper is to describe the barriers to integrating early-stage technologies in clinical practice and health care systems from the perspectives of digital health and health care AI founders and executives. METHODS A stakeholder focus group workshop was conducted with a sample of 10 early-stage digital health and health care AI founders and executives. Digital health, health care AI, digital health-focused venture capitalists, and physician executives were represented. Using an inductive thematic analysis approach, transcripts were organized, queried, and analyzed for thematic convergence. RESULTS We identified the following four categories of barriers in the integration of early-stage digital health innovations into clinical practice and health care systems: (1) lack of knowledge of health system technology procurement protocols and best practices, (2) demanding regulatory and validation requirements, (3) challenges within the health system technology procurement process, and (4) disadvantages of early-stage digital health companies compared to large technology conglomerates. Recommendations from the study participants were also synthesized to create a road map to mitigate the barriers to integrating early-stage or novel digital health technologies in clinical practice. CONCLUSIONS Early-stage digital health and health care AI entrepreneurs identified numerous barriers to integrating digital health solutions into clinical practice. Mitigation initiatives should create opportunities for early-stage digital health technology companies and health care providers to interact, develop relationships, and use evidence-based research and best practices during health care technology procurement and evaluation processes.
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Affiliation(s)
- Iredia M Olaye
- Department of Medicine, Weill Cornell Medicine, Cornell University, New York, NY, United States
- Covered By Group, Covered By Health, Newark, NJ, United States
| | - Azizi A Seixas
- Media and Innovation Lab, Department of Informatics and Health Data Science, The University of Miami Miller School of Medicine, Miami, FL, United States
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Chakraborty I, Edirippulige S, Vigneswara Ilavarasan P. The role of telehealth startups in healthcare service delivery: A systematic review. Int J Med Inform 2023; 174:105048. [PMID: 36963322 DOI: 10.1016/j.ijmedinf.2023.105048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/08/2023] [Accepted: 03/14/2023] [Indexed: 03/22/2023]
Abstract
OBJECTIVES The role of startups has been growing in healthcare delivery, particularly in telehealth and telemedicine. Yet, little has been published about their role in evolving digital healthcare ecosystem. This study aimed to review the literature on telehealth startups to understand their roles, challenges, business models, and directions for sustainable innovation and commercialization. METHODS Ten databases were screened: PubMed, Scopus, Web of Science, IEEE Xplore, ACM digital library, EBSCOhost, Embase, Medline, Cochrane review, and PsycINFO. The articles were shortlisted based on pre-determined screening criteria, and qualitative synthesis was performed. The quality of included studies was assessed using the Mixed Methods Appraisal Tool. Cohen's K was calculated to ensure the reliability of the authors scoring on the quality appraisal test and qualitative synthesis. RESULTS 26 articles were included in the review. Findings are clubbed under five themes: remote and on-demand healthcare; healthcare data management; digital therapeutics; high-tech driven personalized care; and information integration and exchange. Technical infrastructure, regulation, and revenue generation were identified as major challenges for telehealth start-ups. Osterwalder business canvas was the predominantly used model. Value perspectives were recognized for a sustainable telehealth innovation and its commercialization. CONCLUSION Telehealth startups are evolving to meet digital healthcare needs and playing a significant role in teleconsultations, telemonitoring, and electronic health record solutions. Recently, their focus has shifted towards smartphone-enabled AI-driven personalized care, including digital therapeutics and wearable device innovation. They have significant technical and operational challenges in innovation and commercialization to optimize their role. The review also provides researchers with a new understanding of telehealth startups' sustainable innovation and commercialization through the systematic direction of value proposition, creation, and capture.
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Affiliation(s)
- Imon Chakraborty
- Centre for Online Health, The University of Queensland, Brisbane, Australia; UQ-IIT Delhi Academy of Research, Indian Institute of Technology Delhi, New Delhi, India.
| | - Sisira Edirippulige
- Centre for Online Health, The University of Queensland, Brisbane, Australia.
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Alami H, Shaw SE, Fortin JP, Savoldelli M, Fleet R, Têtu B. The 'wrong pocket' problem as a barrier to the integration of telehealth in health organisations and systems. Digit Health 2023; 9:20552076231169835. [PMID: 37089458 PMCID: PMC10116005 DOI: 10.1177/20552076231169835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 03/29/2023] [Indexed: 04/25/2023] Open
Abstract
The COVID-19 pandemic has accelerated the deployment of telehealth services in many countries around the world. It also revealed many barriers and challenges to the use of digital health technologies in health organisations and systems that have persisted for decades. One of these barriers is what is known as the 'wrong pocket' problem - where an organisation or sector makes expenditures and investments to address a given problem, but the benefits (return on investment) are captured by another organisation or sector (the wrong pocket). This problem is the origin of many difficulties in public policies and programmes (e.g. education, environment, justice and public health), especially in terms of sustainability and scaling-up of technology and innovation. In this essay/perspective, we address the wrong pocket problem in the context of a major telehealth project in Canada. We show how the problem of sharing investments and expenses, as well as the redistribution of economies among the different stakeholders involved, may have threatened the sustainability and scaling-up of this project, even though it has demonstrated the clinical utility and contributed to improving the health of populations. In conclusion, the wrong pocket problem may be decisive in the reduced take-up, and potential failure, of certain telehealth programmes and policies. It is not enough for a telehealth service to be clinically relevant and 'efficient', it must also be mutually beneficial to the various stakeholders involved, particularly in terms of the equitable sharing of costs and benefits (return on investment) associated with the implementation of this new service model. Finally, the wrong pocket concept offers a helpful lens for studying the success, sustainability, and scale-up of digital transformations in health organisations and systems. This needs to be considered in future research and evaluations in the field.
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Affiliation(s)
- Hassane Alami
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Hassane Alami, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Sara E Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jean-Paul Fortin
- Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Quebec, Canada
| | | | - Richard Fleet
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Laval University, Quebec, Canada
| | - Bernard Têtu
- Faculty of Medicine, Laval University, Quebec, Canada
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Kroon D, van Dulmen SA, Westert GP, Jeurissen PPT, Kool RB. Development of the SPREAD framework to support the scaling of de-implementation strategies: a mixed-methods study. BMJ Open 2022; 12:e062902. [PMID: 36343997 PMCID: PMC9644331 DOI: 10.1136/bmjopen-2022-062902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE We aimed to increase the understanding of the scaling of de-implementation strategies by identifying the determinants of the process and developing a determinant framework. DESIGN AND METHODS This study has a mixed-methods design. First, we performed an integrative review to build a literature-based framework describing the determinants of the scaling of healthcare innovations and interventions. PubMed and EMBASE were searched for relevant studies from 1995 to December 2020. We systematically extracted the determinants of the scaling of interventions and developed a literature-based framework. Subsequently, this framework was discussed in four focus groups with national and international de-implementation experts. The literature-based framework was complemented by the findings of the focus group meetings and adapted for the scaling of de-implementation strategies. RESULTS The literature search resulted in 42 articles that discussed the determinants of the scaling of innovations and interventions. No articles described determinants specifically for de-implementation strategies. During the focus groups, all participants agreed on the relevance of the extracted determinants for the scaling of de-implementation strategies. The experts emphasised that while the determinants are relevant for various countries, the implications differ due to different contexts, cultures and histories. The analyses of the focus groups resulted in additional topics and determinants, namely, medical training, professional networks, interests of stakeholders, clinical guidelines and patients' perspectives. The results of the focus group meetings were combined with the literature framework, which together formed the supporting the scaling of de-implementation strategies (SPREAD) framework. The SPREAD framework includes determinants from four domains: (1) scaling plan, (2) external context, (3) de-implementation strategy and (4) adopters. CONCLUSIONS The SPREAD framework describes the determinants of the scaling of de-implementation strategies. These determinants are potential targets for various parties to facilitate the scaling of de-implementation strategies. Future research should validate these determinants of the scaling of de-implementation strategies.
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Affiliation(s)
| | | | | | | | - Rudolf B Kool
- IQ Healthcare, Radboudumc, Nijmegen, The Netherlands
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Challenges and opportunities in implementing clinical decision support systems (CDSS) at scale: Interviews with Australian policymakers. HEALTH POLICY AND TECHNOLOGY 2022. [DOI: 10.1016/j.hlpt.2022.100652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Lee J, Oh Y, Kim M, Cho B, Shin J. Willingness to Use and Pay for Digital Healthcare Services According to Four Scenarios: Results from a National Survey (Preprint). JMIR Mhealth Uhealth 2022; 11:e40834. [PMID: 36989025 PMCID: PMC10131682 DOI: 10.2196/40834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 02/01/2023] [Accepted: 03/06/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND Smartphones and their associated technology have evolved to an extent where these devices can be used to provide digital health interventions. However, few studies have been conducted on the willingness to use (WTU) and willingness to pay (WTP) for digital health interventions. OBJECTIVE The purpose of this study was to investigate how previous service experience, the content of the services, and individuals' health status affect WTU and WTP. METHODS We conducted a nationwide web-based survey in 3 groups: nonusers (n=506), public service users (n=368), and private service users (n=266). Participants read scenarios about an imagined health status (such as having a chronic illness) and the use of digital health intervention models (self-management, expert management, and medical management). They were then asked to respond to questions on WTU and WTP. RESULTS Public service users had a greater intention to use digital health intervention services than nonusers and private service users: scenario A (health-risk situation and self-management), nonusers=odd ratio [OR] .239 (SE .076; P<.001) and private service users=OR .138 (SE .044; P<.001); scenario B (health-risk situation and expert management), nonusers=OR .175 (SE .040; P<.001) and private service users=OR .219 (SE .053; P<.001); scenario C (chronic disease situation and expert management), nonusers=OR .413 (SE .094; P<.001) and private service users=OR .401 (SE .098; P<.001); and scenario D (chronic disease situation and medical management), nonusers=OR .480 (SE .120; P=.003) and private service users=OR .345 (SE .089; P<.001). In terms of WTP, in scenarios A and B, those who used the public and private services had a higher WTP than those who did not (scenario A: β=-.397, SE .091; P<.001; scenario B: β=-.486, SE .098; P<.001). In scenario C, private service users had greater WTP than public service users (β=.264, SE .114; P=.02), whereas public service users had greater WTP than nonusers (β=-.336, SE .096; P<.001). In scenario D, private service users were more WTP for the service than nonusers (β=-.286, SE .092; P=.002). CONCLUSIONS We confirmed that the WTU and WTP for digital health interventions differed based on individuals' prior experience with health care services, health status, and demographics. Recently, many discussions have been made to expand digital health care beyond the early adapters and fully into people's daily lives. Thus, more understanding of people's awareness and acceptance of digital health care is needed.
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Affiliation(s)
- Junbok Lee
- Health-IT Center, Yonsei University Health System, Seoul, Republic of Korea
- Department of Human Systems Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yumi Oh
- Korea Health Promotion Institute, Seoul, Republic of Korea
| | - Meelim Kim
- Health-IT Center, Yonsei University Health System, Seoul, Republic of Korea
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, San Diego, CA, United States
| | - Belong Cho
- Department of Human Systems Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Family Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jaeyong Shin
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
- Institute for Innovation in Digital Healthcare, Yonsei University, Seoul, Republic of Korea
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Pei J. Approaches Toward Building the Digital Enterprise and Sustainable Economic Development: The Moderating Role of Sustainability. Front Psychol 2022; 13:835602. [PMID: 35360590 PMCID: PMC8964085 DOI: 10.3389/fpsyg.2022.835602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/24/2022] [Indexed: 11/13/2022] Open
Abstract
Achieving enduring economic development is the biggest challenge of today's humanity. However, at present, there is a consensus that the digital economy plays a significant role in achieving sustainable economic development. The advancement of the digital enterprise is critical for obtaining socioeconomic stability and growth. In explanation, this study focuses on gaining economic progression through deploying the modern concept of digitalization. The study analyzes the mediating relationship of digital enterprise among e-commerce, digitalization, and digital marketing and their effect on China's economic development while considering sustainability as a moderating variable. The study has used primary data collection techniques, and the study sample size is 400 respondents. The research has used SmartPLS software to measure the relationship through bootstrapping and algorithms. The study has found significant positive mediation of digital enterprise and moderation of sustainability between digital enterprise and economic development. This study suggests the theoretical and practical implications toward political stability, policymakers, and researcher perspective.
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Affiliation(s)
- Jianhua Pei
- School of Law and Economics, Changzhi University, Changzhi, China
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Shah N, Costello K, Mehta A, Kumar D. Applications of Digital Health Technologies in Knee Osteoarthritis: A Narrative Review (Preprint). JMIR Rehabil Assist Technol 2021; 9:e33489. [PMID: 35675102 PMCID: PMC9218886 DOI: 10.2196/33489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 01/12/2022] [Accepted: 05/06/2022] [Indexed: 12/23/2022] Open
Abstract
Background With the increasing adoption of high-speed internet and mobile technologies by older adults, digital health is a promising modality to enhance clinical care for people with knee osteoarthritis (KOA), including those with knee replacement (KR). Objective This study aimed to summarize the current use, cost-effectiveness, and patient and clinician perspectives of digital health for intervention delivery in KOA and KR. Methods In this narrative review, search terms such as mobile health, smartphone, mobile application, mobile technology, ehealth, text message, internet, knee osteoarthritis, total knee arthroplasty, and knee replacement were used in the PubMed and Embase databases between October 2018 and February 2021. The search was limited to original articles published in the English language within the past 10 years. In total, 91 studies were included. Results Digital health technologies such as websites, mobile apps, telephone calls, SMS text messaging, social media, videoconferencing, and custom multi-technology systems have been used to deliver interventions in KOA and KR populations. Overall, there was significant heterogeneity in the types and applications of digital health used in these populations. Digital patient education improved disease-related knowledge, especially when used as an adjunct to traditional methods of patient education for both KOA and KR. Digital health that incorporated person-specific motivational messages, biofeedback, or patient monitoring was more successful at improving physical activity than self-directed digital interventions for both KOA and KR. Many digital exercise interventions were found to be as effective as in-person physical therapy for people with KOA. Many digital exercise interventions for KR incorporated both in-person and web-based treatments (blended format), communication with clinicians, and multi-technology systems and were successful in improving knee range of motion and self-reported symptoms and reducing the length of hospital stays. All digital interventions that incorporated cognitive behavioral therapy or similar psychological interventions showed significant improvements in knee pain, function, and psychological health when compared with no treatment or traditional treatments for both KOA and KR. Although limited in number, studies have indicated that digital health may be cost-effective for these populations, especially when travel costs are considered. Finally, although patients with KOA and KR and clinicians had positive views on digital health, concerns related to privacy and security and concerns related to logistics and training were raised by patients and clinicians, respectively. Conclusions For people with KOA and KR, many studies found digital health to be as effective as traditional treatments for patient education, physical activity, and exercise interventions. All digital interventions that incorporated cognitive behavioral therapy or similar psychological treatments were reported to result in significant improvements in patients with KOA and KR when compared with no treatment or traditional treatments. Overall, technologies that were blended and incorporated communication with clinicians, as well as biofeedback or patient monitoring, showed favorable outcomes.
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Affiliation(s)
- Nirali Shah
- Department of Physical Therapy and Athletic Training, Boston University, Boston, MA, United States
| | - Kerry Costello
- Department of Physical Therapy and Athletic Training, Boston University, Boston, MA, United States
| | - Akshat Mehta
- Department of Physical Therapy and Athletic Training, Boston University, Boston, MA, United States
| | - Deepak Kumar
- Department of Physical Therapy and Athletic Training, Boston University, Boston, MA, United States
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