Development of an interactive, Web-delivered system to increase provider-patient engagement in smoking cessation

Strategies to improve smoking cessation rates in primary care

BACKGROUND

Primary care is an important setting in which to treat tobacco addiction. However, the rates at which providers address smoking cessation and the success of that support vary. Strategies can be implemented to improve and increase the delivery of smoking cessation support (e.g. through provider training), and to increase the amount and breadth of support given to people who smoke (e.g. through additional counseling or tailored printed materials).

OBJECTIVES

To assess the effectiveness of strategies intended to increase the success of smoking cessation interventions in primary care settings. To assess whether any effect that these interventions have on smoking cessation may be due to increased implementation by healthcare providers.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and trial registries to 10 September 2020.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and cluster-RCTs (cRCTs) carried out in primary care, including non-pregnant adults. Studies investigated a strategy or strategies to improve the implementation or success of smoking cessation treatment in primary care. These strategies could include interventions designed to increase or enhance the quality of existing support, or smoking cessation interventions offered in addition to standard care (adjunctive interventions). Intervention strategies had to be tested in addition to and in comparison with standard care, or in addition to other active intervention strategies if the effect of an individual strategy could be isolated. Standard care typically incorporates physician-delivered brief behavioral support, and an offer of smoking cessation medication, but differs across studies. Studies had to measure smoking abstinence at six months' follow-up or longer.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Our primary outcome - smoking abstinence - was measured using the most rigorous intention-to-treat definition available. We also extracted outcome data for quit attempts, and the following markers of healthcare provider performance: asking about smoking status; advising on cessation; assessment of participant readiness to quit; assisting with cessation; arranging follow-up for smoking participants. Where more than one study investigated the same strategy or set of strategies, and measured the same outcome, we conducted meta-analyses using Mantel-Haenszel random-effects methods to generate pooled risk ratios (RRs) and 95% confidence intervals (CIs).

MAIN RESULTS

We included 81 RCTs and cRCTs, involving 112,159 participants. Fourteen were rated at low risk of bias, 44 at high risk, and the remainder at unclear risk. We identified moderate-certainty evidence, limited by inconsistency, that the provision of adjunctive counseling by a health professional other than the physician (RR 1.31, 95% CI 1.10 to 1.55; I2 = 44%; 22 studies, 18,150 participants), and provision of cost-free medications (RR 1.36, 95% CI 1.05 to 1.76; I2 = 63%; 10 studies,7560 participants) increased smoking quit rates in primary care. There was also moderate-certainty evidence, limited by risk of bias, that the addition of tailored print materials to standard smoking cessation treatment increased the number of people who had successfully stopped smoking at six months' follow-up or more (RR 1.29, 95% CI 1.04 to 1.59; I2 = 37%; 6 studies, 15,978 participants). There was no clear evidence that providing participants who smoked with biomedical risk feedback increased their likelihood of quitting (RR 1.07, 95% CI 0.81 to 1.41; I2 = 40%; 7 studies, 3491 participants), or that provider smoking cessation training (RR 1.10, 95% CI 0.85 to 1.41; I2 = 66%; 7 studies, 13,685 participants) or provider incentives (RR 1.14, 95% CI 0.97 to 1.34; I2 = 0%; 2 studies, 2454 participants) increased smoking abstinence rates. However, in assessing the former two strategies we judged the evidence to be of low certainty and in assessing the latter strategies it was of very low certainty. We downgraded the evidence due to imprecision, inconsistency and risk of bias across these comparisons. There was some indication that provider training increased the delivery of smoking cessation support, along with the provision of adjunctive counseling and cost-free medications. However, our secondary outcomes were not measured consistently, and in many cases analyses were subject to substantial statistical heterogeneity, imprecision, or both, making it difficult to draw conclusions. Thirty-four studies investigated multicomponent interventions to improve smoking cessation rates. There was substantial variation in the combinations of strategies tested, and the resulting individual study effect estimates, precluding meta-analyses in most cases. Meta-analyses provided some evidence that adjunctive counseling combined with either cost-free medications or provider training enhanced quit rates when compared with standard care alone. However, analyses were limited by small numbers of events, high statistical heterogeneity, and studies at high risk of bias. Analyses looking at the effects of combining provider training with flow sheets to aid physician decision-making, and with outreach facilitation, found no clear evidence that these combinations increased quit rates; however, analyses were limited by imprecision, and there was some indication that these approaches did improve some forms of provider implementation.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that providing adjunctive counseling by an allied health professional, cost-free smoking cessation medications, and tailored printed materials as part of smoking cessation support in primary care can increase the number of people who achieve smoking cessation. There is no clear evidence that providing participants with biomedical risk feedback, or primary care providers with training or incentives to provide smoking cessation support enhance quit rates. However, we rated this evidence as of low or very low certainty, and so conclusions are likely to change as further evidence becomes available. Most of the studies in this review evaluated smoking cessation interventions that had already been extensively tested in the general population. Further studies should assess strategies designed to optimize the delivery of those interventions already known to be effective within the primary care setting. Such studies should be cluster-randomized to account for the implications of implementation in this particular setting. Due to substantial variation between studies in this review, identifying optimal characteristics of multicomponent interventions to improve the delivery of smoking cessation treatment was challenging. Future research could use component network meta-analysis to investigate this further.

Development of a Secure Website to Facilitate Information Sharing in Families at High Risk of Bowel Cancer-The Familyweb Study

Simple Summary

Families with an inherited high risk of bowel cancer may struggle to share information about their diagnosis. This means that relatives are not always aware of their increased risk of cancer or able to access screening for the early detection of cancer. Through this study, we aimed to help such families by creating a website where patients could share confidential information with their relatives securely online. Following a survey and telephone interviews with affected individuals, the content of the website was developed to suit the needs of families. Website function was tested with patients to check feasibility and acceptability. Most participants wanted more information to support their adaptation to the diagnosis and help inform their relatives. This study demonstrates how health professionals can improve access to genetic testing and cancer screening in families at high risk of cancer, thus reducing morbidity and mortality.

Abstract

Individuals with pathogenic variants in genes predisposing to bowel cancer are encouraged to share this information within their families. Close relatives at 50% risk can have access to bowel cancer surveillance. However, many relatives remain unaware of their vulnerability or have insufficient information. We investigated the feasibility and acceptability of using a secure website to support information sharing within families at high risk of bowel cancer. Patients (n = 286) answered an anonymous cross-sectional survey, with 14 participating in telephone interviews. They reported that the diagnosis had a profound effect on them and their family relationships, and consequently desired more support from health professionals. Website content was created in response to the preferences of survey and interview participants. Reactions to the website from 12 volunteers were captured through remote usability testing to guide further refinement of the website. Participants welcomed the opportunity to store and share personal information via the website and wanted more information and help informing their relatives about the diagnosis. Important website topics were: healthy lifestyle; genetic testing; and how to talk to children about the diagnosis. A website providing online access to confidential documents was both feasible and acceptable and could translate into increased uptake of cancer surveillance, resulting in lower morbidity and mortality in these families.

A context-adaptive smoking cessation system using videos

Cigarette smoking is the primary preventable cause of death and disease worldwide. Studies reveal that smoking is associated with psychiatric symptoms, sociodemographic characteristics, social stressors, and lack of social support. In general, smokers report poorer mental health and benefit from support to be able to quit smoking (Jorm et al., 1999). In this paper, a tailored smoking cessation system has been developed in which the counseling and support is delivered via video-messaging. The system engages users in adaptive motivating video access. Users can interact with the system and the system selects the best matching video for them by processing their messages using Natural Language Processing (NLP). We have tailored 77 videos for interactive contents that encompass important issues users might face during the process of smoking cessation. A novel application-based data driven approach has been taken for categorizing videos to push to participants. The approach is based on analyzing 750 messages of people in the cessation process. We observed that most of the messages' contents were about smoking health effects, cravings, triggers, relapse, positive mood, low cessation self efficacy, medications, and culturally specific targeting inquiries. Considering these categories, videos are categorized to the corresponding groups by an intelligent approach. The information underlying the data driven categories allows for improving and facilitating smoking status assessment. The system has the potential for improving future smoking cessation decision-making adaptive interventions and health monitoring systems. The goal is to tailor the system to meet the needs of the users in real-time and maximize the potential impact.

An Automated Patient Self-Monitoring System to Reduce Health Care System Burden During the COVID-19 Pandemic in Malaysia: Development and Implementation Study

Background

During the COVID-19 pandemic, there was an urgent need to develop an automated COVID-19 symptom monitoring system to reduce the burden on the health care system and to provide better self-monitoring at home.

Objective

This paper aimed to describe the development process of the COVID-19 Symptom Monitoring System (CoSMoS), which consists of a self-monitoring, algorithm-based Telegram bot and a teleconsultation system. We describe all the essential steps from the clinical perspective and our technical approach in designing, developing, and integrating the system into clinical practice during the COVID-19 pandemic as well as lessons learned from this development process.

Methods

CoSMoS was developed in three phases: (1) requirement formation to identify clinical problems and to draft the clinical algorithm, (2) development testing iteration using the agile software development method, and (3) integration into clinical practice to design an effective clinical workflow using repeated simulations and role-playing.

Results

We completed the development of CoSMoS in 19 days. In Phase 1 (ie, requirement formation), we identified three main functions: a daily automated reminder system for patients to self-check their symptoms, a safe patient risk assessment to guide patients in clinical decision making, and an active telemonitoring system with real-time phone consultations. The system architecture of CoSMoS involved five components: Telegram instant messaging, a clinician dashboard, system administration (ie, back end), a database, and development and operations infrastructure. The integration of CoSMoS into clinical practice involved the consideration of COVID-19 infectivity and patient safety.

Conclusions

This study demonstrated that developing a COVID-19 symptom monitoring system within a short time during a pandemic is feasible using the agile development method. Time factors and communication between the technical and clinical teams were the main challenges in the development process. The development process and lessons learned from this study can guide the future development of digital monitoring systems during the next pandemic, especially in developing countries.

Nurse-Driven mHealth Implementation Using the Technology Inpatient Program for Smokers (TIPS): Mixed Methods Study

Background

Smoking is the leading cause of preventable death and disease, yet implementation of smoking cessation in inpatient settings is inconsistent. The Technology Inpatient Program for Smokers (TIPS) is an implementation program designed to reach smokers with a mobile health (mHealth) intervention using stakeholder-supported strategies.

Objective

The purpose of this study was to determine the impact of the TIPS implementation strategies on smoker-level engagement of the mHealth intervention during care transition.

Methods

We examined varying intensities (passive motivational posters only and posters + active nurse-led facilitation) of TIPS strategies on four hospital units located in two sites. Unit-level and smoker-level adoption was monitored during active implementation (30 weeks) and sustainability follow-up (30 weeks). Process measures reflecting the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework, stakeholder reported adaptations of strategies, and formative evaluation data were collected and analyzed.

Results

For our smoker-level reach, 103 smokers signed up for the mHealth intervention in-hospital, with minimal decline during sustainability follow-up. While posters + nurse facilitation did not lead to higher reach than posters alone during active implementation (27 vs 30 signed up), it did lead to higher engagement of smokers (85.2% vs 73.3% completion of the full 2-week intervention). TIPS strategy adoption and fidelity varied by unit, including adoption of motivational posters (range: weeks 1 and 5), fidelity of posters (0.4% to 16.2% of posters missing per unit weekly) and internal facilitation of nurse training sessions (average of 2 vs 7.5 by site). Variable maintenance costs of the program totaled US $6.63 (US $683.28/103) per smoker reached. Reported family-member facilitation of mHealth sign-up was an observation of unintended behavior.

Conclusions

TIPS is a feasible and low-cost implementation program that successfully engages smokers in an mHealth intervention and sustains engagement after discharge. Further testing of nurse facilitation and expanding reach to patient family and friends as an implementation strategy is needed.

A Multicomponent eHealth Intervention for Family Carers for People Affected by Psychosis: A Coproduced Design and Build Study

Background

Psychosis, including schizophrenia, is the most common severe mental illness affecting 1% of the population worldwide. A large number of people provide long-term support and care for a relative with psychosis. Although psychoeducational interventions, especially those delivered through a face-to-face group format, have an established evidence base for improving the caregiving experience, well-being, and health outcomes, large-scale implementation and access remain limited. There is a demand for such provision to be made through the internet for greater flexibility and wider access.

Objective

This study aimed to integrate participatory research methodologies by the public, patients, and carers into the eHealth (electronic health) intervention design and build process to improve the product’s usability and acceptability.

Methods

We adapted a structured eHealth intervention build method to include participatory research activities involving key stakeholders and end users to co-design and coproduce our intervention. An expert advisory group (EAG) comprising public involvement members led the formative design and build work using an agile build process. Carers independent from the study were consulted on the evolving drafts of the intervention prototype through focus group meetings. These results were fed back into the intervention build work continuously to ensure end users’ input inform every stage of the process.

Results

An EAG comprising individuals with lived experience of psychosis, carers, health care professionals, researchers, voluntary organization workers, and eLearning experts (n=14) was established. A total of 4 coproduction workshops were held over 1 year during which the alpha and beta prototypes were designed and built through the participatory research work. Alongside this, 2 rounds of focus group study with carers (n=24, in 4 groups) were conducted to seek consultation on end users’ views and ideas to optimize the intervention design and usability. Finally, the EAG carried out a Web-based walk-through exercise on the intervention prototype and further refined it to make it ready for an online usability test. The final product contains multiple sections providing information on psychosis and related caregiving topics and interactive discussion forums with experts and peers for psychosocial support. It provides psychoeducation and psychosocial support for carers through the internet, promoting flexible access and individualized choices of information and support.

Conclusions

The participatory research work led to the coproduction of a eHealth intervention called COPe-support (Carers fOr People with Psychosis e-support). We believe the study methodology, results, and output have optimized the intervention design and usability, fitting the end users’ needs and usage pattern. COPe-support is currently being tested for its effectiveness in promoting carers’ health outcome through an online randomized controlled trial.

Trial Registration

ISRCTN Registry ISRCTN89563420; http://www.isrctn.com/ISRCTN89563420

Gamification to Motivate the Unmotivated Smoker: The "Take a Break" Digital Health Intervention

Objective: Digital health technologies most often reach only those more motivated to engage, particularly when preventive health is targeted. To test whether gamification could be used to engage low-motivation smokers, we conceptualized "Take a Break"-a 3-week technology-assisted challenge for smokers to compete in setting and achieving brief abstinence goals. Materials and Methods: In the feasibility study of the multi-technology Take a Break challenge, low-motivation smokers were given (1) daily motivational messages, (2) brief "challenge quizzes" related to smoking behaviors, (3) a telehealth call to personalize their abstinence goal for the challenge, (4) "coping minigames" to help manage cravings while attempting to achieve their brief abstinence goals, and (5) a leaderboard "webApp," providing comparative feedback on smokers' participation, and allowing for competition. Heterogeneity of engagement was tracked. Results: All 41 smokers initially reported that they were not actively quitting. Over half were employed less than full time (51%), completed less than a 4-year college education (76%), and experienced financial stress (54%). No smokers opted out of the motivational messages, and mean proportion of response to the challenge quizzes was 0.88 (SD = 0.19). Half of the smokers reported using the "coping minigames." Almost all set abstinence goals (78%), with over half lasting 1-2 days (51%); median = 1 day (IQR 1-7). Leaderboard points ranged widely. Conclusions: Rates of smoking in the developed world have declined, and those who remain smokers are complex and have lower motivation to quit. Using a game-inspired challenge, we achieved high levels of engagement from low-motivation smokers.

The development of a self-help intervention to build social confidence in people living with visible skin conditions or scars: a think-aloud study

INTRODUCTION

People with a visible difference, such as scarring or a skin condition, can experience anxiety and intrusive reactions from others when in social situations. The use of products to conceal marks on the skin is provided in a number of different hospital services and by charities. However, there are relatively few psychosocial interventions available for these individuals.

OBJECTIVES

To examine the views of skin camouflage users and practitioners on the acceptability, usability and need for a specifically developed cognitive behavioural therapy (CBT) self-help booklet.

METHODS

A think-aloud protocol and descriptive form of thematic analysis were used to ascertain participants' views of this novel psychosocial intervention. Nine participants took part in think-aloud interviews that were analysed using thematic analysis. Six skin camouflage users and three skin camouflage practitioners participated in the study.

RESULTS

Support for the relevance, acceptability and usability of the booklet was found from both participants who used camouflage and those who provided it. However, some participants reported that they would envisage that some people would need additional support so as to be able to use the techniques described within the booklet.

CONCLUSIONS

This study represents an important step towards developing a brief self-help intervention for people with living with visible skin conditions or scars and demonstrates the importance of seeking feedback from experts by experience on theoretically informed psychological interventions for this patient group.

Online Decision Support Tool for Personalized Cancer Symptom Checking in the Community (REACT): Acceptability, Feasibility, and Usability Study

Background

Improving cancer survival in the UK, despite recent significant gains, remains a huge challenge. This can be attributed to, at least in part, patient and diagnostic delays, when patients are unaware they are suffering from a cancerous symptom and therefore do not visit a general practitioner promptly and/or when general practitioners fail to investigate the symptom or refer promptly. To raise awareness of symptoms that may potentially be indicative of underlying cancer among members of the public a symptom-based risk assessment model (developed for medical practitioner use and currently only used by some UK general practitioners) was utilized to develop a risk assessment tool to be offered to the public in community settings. Such a tool could help individuals recognize a symptom, which may potentially indicate cancer, faster and reduce the time taken to visit to their general practitioner. In this paper we report results about the design and development of the REACT (Risk Estimation for Additional Cancer Testing) website, a tool to be used in a community setting allowing users to complete an online questionnaire and obtain personalized cancer symptom-based risk estimation.

Objective

The objectives of this study are to evaluate (1) the acceptability of REACT among the public and health care practitioners, (2) the usability of the REACT website, (3) the presentation of personalized cancer risk on the website, and (4) potential approaches to adopt REACT into community health care services in the UK.

Methods

Our research consisted of multiple stages involving members of the public (n=39) and health care practitioners (n=20) in the UK. Data were collected between June 2017 and January 2018. User views were collected by (1) the “think-aloud” approach when participants using the website were asked to talk about their perceptions and feelings in relation to the website, and (2) self-reporting of website experiences through open-ended questionnaires. Data collection and data analysis continued simultaneously, allowing for website iterations between different points of data collection.

Results

The results demonstrate the need for such a tool. Participants suggest the best way to offer REACT is through a guided approach, with a health care practitioner (eg, pharmacist or National Health Service Health Check nurse) present during the process of risk evaluation. User feedback, which was generally consistent across members of public and health care practitioners, has been used to inform the development of the website. The most important aspects were: simplicity, ability to evaluate multiple cancers, content emphasizing an inviting community “feel,” use (when possible) of layperson language in the symptom screening questionnaire, and a robust and positive approach to cancer communication relying on visual risk representation both with affected individuals and the entire population at risk.

Conclusions

This study illustrates the benefits of involving public and stakeholders in developing and implementing a simple cancer symptom check tool within community. It also offers insights and design suggestions for user-friendly interfaces of similar health care Web-based services, especially those involving personalized risk estimation.

Exploring Online Asynchronous Counseling With Tobacco Treatment Specialists in the QUIT-PRIMO and National Dental PBRN HI-QUIT Studies: Who Uses It and What Do They Say?

PURPOSE

To describe the content of messages sent by smokers through asynchronous counseling within a Web-based smoking cessation intervention.

DESIGN

Qualitative.

SETTING

National community-based setting of patients who had been engaged by the medical or dental practices at which they attended or via Google advertisements.

PARTICIPANTS

Adults older than 19 years who were current smokers and interested in quitting. Participants throughout the United States referred to a Web-based cessation intervention by their medical or dental provider or by clicking on a Google advertisement.

METHODS

We conducted a qualitative review of 742 asynchronous counseling messages sent by 270 Web site users. Messages were reviewed, analyzed, and organized into qualitative themes by the investigative team.

RESULTS

The asynchronous counseling feature of the intervention was used most frequently by smokers who were white (87%), female (67%), aged 45 to 54 (32%), and who had at least some college-level education (70%). Qualitative analysis yielded 7 basic themes-Talk about the Process of Quitting, Barriers to Quitting, Reasons to Quit, Quit History, Support and Strategies for Quitting, Quitting with Medication, and Quit Progress. The most common theme was Support and Strategies for Quitting with 255 references among all messages.

CONCLUSION

We found rich communication across the spectrum of the quit process, from persons preparing to quit to those who had successfully quit. Asynchronous smoking cessation counseling provides a promising means of social support for smokers during the quit process.

An m-Health system for education and motivation in cardiac rehabilitation: the experience of HeartCycle guided exercise

Introduction

Home-based programmes for cardiac rehabilitation play a key role in the recovery of patients with coronary artery disease. However, their necessary educational and motivational components have been rarely implemented with the help of modern mobile technologies. We developed a mobile health system designed for motivating patients to adhere to their rehabilitation programme by providing exercise monitoring, guidance, motivational feedback, and educational content.

Methods

Our multi-disciplinary approach is based on mapping “desired behaviours” into specific system’s specifications, borrowing concepts from Fogg’s Persuasive Systems Design principles. A randomised controlled trial was conducted to compare mobile-based rehabilitation (55 patients) versus standard care (63 patients).

Results

Some technical issues related to connectivity, usability and exercise sessions interrupted by safety algorithms affected the trial. For those who completed the rehabilitation (19 of 55), results show high levels of both user acceptance and perceived usefulness. Adherence in terms of started exercise sessions was high, but not in terms of total time of performed exercise or drop-outs. Educational level about heart-related health improved more in the intervention group than the control. Exercise habits at 6 months follow-up also improved, although without statistical significance.

Discussion

Results indicate that the adopted design methodology is promising for creating applications that help improve education and foster better exercise habits, but further studies would be needed to confirm these indications.

Virtual Patient Technology: Engaging Primary Care in Quality Improvement Innovations

BACKGROUND

Engaging health care staff in new quality improvement programs is challenging.

OBJECTIVE

We developed 2 virtual patient (VP) avatars in the context of a clinic-level quality improvement program. We sought to determine differences in preferences for VPs and the perceived influence of interacting with the VP on clinical staff engagement with the quality improvement program.

METHODS

Using a participatory design approach, we developed an older male smoker VP and a younger female smoker VP. The older male smoker was described as a patient with cardiovascular disease and was ethnically ambiguous. The female patient was younger and was worried about the impact of smoking on her pregnancy. Clinical staff were allowed to choose the VP they preferred, and the more they engaged with the VP, the more likely the VP was to quit smoking and become healthier. We deployed the VP within the context of a quality improvement program designed to encourage clinical staff to refer their patients who smoke to a patient-centered Web-assisted tobacco intervention. To evaluate the VPs, we used quantitative analyses using multivariate models of provider and practice characteristics and VP characteristic preference and analyses of a brief survey of positive deviants (clinical staff in practices with high rates of encouraging patients to use the quit smoking innovation).

RESULTS

A total of 146 clinical staff from 76 primary care practices interacted with the VPs. Clinic staff included medical providers (35/146, 24.0%), nurse professionals (19/146, 13.0%), primary care technicians (5/146, 3.4%), managerial staff (67/146, 45.9%), and receptionists (20/146, 13.7%). Medical staff were mostly male, and other roles were mostly female. Medical providers (OR 0.031; CI 0.003-0.281; P=.002) and younger staff (OR 0.411; CI 0.177-0.952; P=.038) were less likely to choose the younger, female VP when controlling for all other characteristics. VP preference did not influence online patient referrals by staff. In high-performing practices that referred 20 or more smokers to the ePortal (13/76), the majority of clinic staff were motivated by or liked the virtual patient (20/26, 77%).

CONCLUSIONS

Medical providers are more likely motivated by VPs that are similar to their patient population, while nurses and other staff may prefer avatars that are more similar to them.

Development of a Web-Accessible Population Pharmacokinetic Service-Hemophilia (WAPPS-Hemo): Study Protocol

BACKGROUND

Individual pharmacokinetic assessment is a critical component of tailored prophylaxis for hemophilia patients. Population pharmacokinetics allows using individual sparse data, thus simplifying individual pharmacokinetic studies. Implementing population pharmacokinetics capacity for the hemophilia community is beyond individual reach and requires a system effort.

OBJECTIVE

The Web-Accessible Population Pharmacokinetic Service-Hemophilia (WAPPS-Hemo) project aims to assemble a database of patient pharmacokinetic data for all existing factor concentrates, develop and validate population pharmacokinetics models, and integrate these models within a Web-based calculator for individualized pharmacokinetic estimation in patients at participating treatment centers.

METHODS

Individual pharmacokinetic studies on factor VIII and IX concentrates will be sourced from pharmaceutical companies and independent investigators. All factor concentrate manufacturers, hemophilia treatment centers (HTCs), and independent investigators (identified via a systematic review of the literature) having on file pharmacokinetic data and willing to contribute full or sparse pharmacokinetic data will be eligible for participation. Multicompartmental modeling will be performed using a mixed-model approach for derivation and Bayesian forecasting for estimation of individual sparse data. NONMEM (ICON Development Solutions) will be used as modeling software.

RESULTS

The WAPPS-Hemo research network has been launched and is currently joined by 30 HTCs from across the world. We have gathered dense individual pharmacokinetic data on 878 subjects, including several replicates, on 21 different molecules from 17 different sources. We have collected sparse individual pharmacokinetic data on 289 subjects from the participating centers through the testing phase of the WAPPS-Hemo Web interface. We have developed prototypal population pharmacokinetics models for 11 molecules. The WAPPS-Hemo website (available at www.wapps-hemo.org, version 2.4), with core functionalities allowing hemophilia treaters to obtain individual pharmacokinetic estimates on sparse data points after 1 or more infusions of a factor concentrate, was launched for use within the research network in July 2015.

CONCLUSIONS

The WAPPS-Hemo project and research network aims to make it easier to perform individual pharmacokinetic assessments on a reduced number of plasma samples by adoption of a population pharmacokinetics approach. The project will also gather data to substantially enhance the current knowledge about factor concentrate pharmacokinetics and sources of its variability in target populations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02061072; https://clinicaltrials.gov/ct2/show/NCT02061072 (Archived by WebCite at http://www.webcitation.org/6mRK9bKP6).

Online tobacco websites and online communities-who uses them and do users quit smoking? The quit-primo and national dental practice-based research network Hi-Quit studies

Online tobacco cessation communities are beneficial but underused. Our study examined whether, among smokers participating in a web-assisted tobacco intervention (Decide2quit.org), specific characteristics were associated with navigating to BecomeAnEx.org, an online cessation community, and with subsequent quit rates. Among smokers (N = 759) registered with Decide2quit.org, we identified visitors to BecomeAnEx.org, examining associations between smoker characteristics and likelihood of visiting. We then tested for associations between visits and 6-month cessation (point prevalence). We also tested for an interaction between use of other online support-seeking (Decide2quit.org tobacco cessation coaches), visiting, and 6-month cessation. One quarter (26.0 %; n = 197) of the smokers visited BecomeAnEx.org; less than one tenth (7.5 %; n = 57) registered to participate in the online forum. Visitors were more likely to be female (73.0 vs. 62.6 % of non-visitors, P < 0.01) to have visited a cessation website before (33.0 vs. 17.4 %, P < 0.01) and to report quit attempts in the previous year (62.0 vs. 53.0 %, P = 0.03). In analyses of all participants, BecomeAnEx.org visiting was not associated with 6-month quit completion. Among participants who communicated with a coach, BecomeAnEx.org visiting also lacked a significant association with 6 month quit completion, although a non-significant trend toward quit completion in visitors was noted (OR 2.21, 95 % CI 0.81-3.1). Online cessation communities attract smokers with previous cessation website experience and recent quit attempts. Community visiting was not associated with quit rates in our study, but low use may have limited our power to detect differences. Further research should explore whether an additive effect can be achieved by offering community visitors support via online coaches.

The promise and the reality: a mental health workforce perspective on technology-enhanced youth mental health service delivery

BACKGROUND

Digital technologies show promise for reversing poor engagement of youth (16-24 years) with mental health services. In particular, mobile and internet based applications with communication capabilities can augment face-to-face mental health service provision. The literature in this field, however, fails to adequately capture the perspectives of the youth mental health workforce regarding utility and acceptability of technology for this purpose.

METHODS

This paper describes results of in-depth qualitative data drawn from various stakeholders involved in provision of youth mental health services in one Australian rural region. Data were obtained using focus groups and semi-structured interviews with regional youth mental health clinicians, youth workers and support/management staff (n = 4 focus groups; n = 8 interviews) and analysed via inductive thematic analysis.

RESULTS

Results question the acceptability of technology to engage clients within youth mental health services. Six main themes were identified: young people in a digital age, personal connection, power and vulnerability, professional identity, individual factors and organisational legitimacy.

CONCLUSIONS

These findings deepen the understanding of risks and challenges faced when adopting new technologies in mental healthcare. Recommendations for technology design and implementation in mental health services are made.

Web-Based Intervention for Transitioning Smokers From Inpatient to Outpatient Care: An RCT

INTRODUCTION

Smoking-cessation follow-up care after hospitalization is known to be effective. Cost-effective and disseminable interventions adoptable by hospitals are needed.

DESIGN

RCT.

SETTING/PARTICIPANTS

Fourteen hundred eighty-eight current smokers recruited during a tertiary care hospital stay were randomly assigned to Usual Care (UC) or Usual Care plus Web-Based Intervention (WI). Data were collected in 2011-2013 and analyzed in 2014-2015.

INTERVENTION

UC provided brief bedside advice to quit, a quit plan template, and quitline contact information. WI included access to a website with asynchronous e-message communication with a tobacco counselor, use of interactive self-assessments, helpful cessation information, and access to additional web resources, as well as automated e-mail messages tailored for health concern and readiness to quit.

MAIN OUTCOME MEASURES

Self-reported 30-day abstinence at 6 months was the primary outcome; a subset was verified by saliva cotinine.

RESULTS

Six-month follow-up was completed by 83% of participants. No difference was found between study arms for self-reported abstinence rates in intent-to-treat (25.4% WI vs 26.8% UC) and complete case (31.3% WI vs 31.4% UC) analyses. Reduced smoking was reported by 45.5% (WI, n=276) and 47% (UC, n=296) of non-abstinent responders (p=0.59). Using a 10-ng/mL cotinine cut off, abstinence was verified in 52.1% of WI and 62.5% of UC (p=0.11). Significant covariates associated with abstinence at 6 months were being male, not smoking during hospitalization, being very confident in quitting, planning to quit/stay quit, smoking fewer days in the past 30 days, fewer years of smoking, and having cerebrovascular or connective tissue rheumatic disease as primary hospital diagnosis.

CONCLUSIONS

Lack of difference between treatment arms suggests a strong effect for UC, WI was not effective, or both. Low intervention engagement may be partially responsible. Self-reported abstinence rates were relatively high in both arms, although the biochemically verified rates indicate over-reporting of abstinence. These findings suggest brief bedside counseling for all hospitalized smokers is beneficial.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT01277250.

The acceptability and feasibility of an anxiety reduction intervention for emergency department patients with non-cardiac chest pain

Despite good physical prognosis, patients who receive a diagnosis of non-cardiac chest pain (NCCP) may experience persistent pain and distress. While cognitive-behavioural interventions have been found to be effective for this group, they are difficult to deliver in busy emergency department (ED) settings. Addressing the acceptability and relevance of self-help interventions is an important initial step in addressing this need. This study sought to examine the acceptability and relevance of an evidence-based self-help intervention for ED patients with persistent NCCP and anxiety. Patient (interviews: N = 11) and specialist chest pain nurse (focus group: N = 4) views on acceptability and feasibility were examined. Data were analysed using thematic analysis. Patients and nurses reported that there was a need for the intervention, as stress and anxiety are common among patients with NCCP, and provision of psychosocial support is currently lacking. Both patients and nurses reported that the intervention was relevant, acceptable, and potentially useful. Some changes to the intervention were suggested. Nurses reported that the intervention could be used within the existing staff resources available in an ED setting. This study represents an important first step towards developing a brief self-help intervention for ED patients with NCCP and anxiety. Further research should seek to determine the efficacy of the intervention in a pilot trial.

Evaluating the QUIT-PRIMO clinical practice ePortal to increase smoker engagement with online cessation interventions: a national hybrid type 2 implementation study

Background

Effective web-assisted tobacco interventions (WATIs) have been underutilized by smokers; moreover, despite practice guideline recommendations, clinical teams do not routinely refer smokers to WATIs. Our goal was to test a clinical practice innovation, an ePortal designed to change practice and patient behavior. Our hypotheses were that the integrated system would result in increased smoker referrals, with an automated follow-up system resulting in more smoker registrations and finally augmentations of the WATI would result in more smokers quitting at 6 months.

Methods

Practice ePortal Implementation Trial: Practices (n = 174) were randomized to an online practice ePortal with an “e-referral tool” to the WATI (e-referred smokers received automated email reminders from the practice) and with practice feedback reports with patient tracking and practice-to-patient secure messaging versus comparison (a paper “referral prescription”). Implementation success was measured by the number of smokers referred and smokers registering.

Clinical Effectiveness Trial: To estimate the effectiveness of the WATI components on 6-month smoking cessation, registered smokers were randomized into three groups: a state-of-the-art tailored WATI control [control], the WATI enhanced with proactive, pushed tailored email motivational messaging (messaging), and the WATI with messaging further enhanced with personal secure messaging with a tobacco treatment specialist and an online support group (personalized).

Results

Practice ePortal Trial results: A total of 4789 smokers were referred. The mean smokers referred per practice was not statistically different by group (ePortal 24.89 (SD 22.29) versus comparison 30.15 (SD 25.45), p = 0.15). The e-referral portal implementation program resulted in nearly triple the rate of smoker registration (31 % of all smokers referred registered online) versus comparison (11 %, p < 0.001).

Clinical Effectiveness Trial results: Active smokers randomized to the personalized group had a 6-month cessation rate of 25.2 %, compared with the messaging group (26.7 %) and the control (17 %). Next, when using an inverse probability weighted selection model to account for attrition, those randomized to the two groups that received motivational messaging (messaging or personalized) were more likely to quit than those in the control (p = 0.04).

Conclusions

Among all smokers referred, the e-referral resulted in nearly threefold greater registrants (31 %) than paper (11 %). The practice ePortal smokers received multiple reminders (increasing registration opportunities), and the practices could track patient progress. The result was more smokers registering and, thus, more cessation opportunities. Combining the proactive referral and the WATI resulted in higher rates of smoking cessation.

Trial Registration

Web-delivered Provider Intervention for Tobacco Control (QUIT-PRIMO) - a randomized controlled trial: NCT00797628.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0336-8) contains supplementary material, which is available to authorized users.

Communicating cancer treatment information using the Web: utilizing the patient's perspective in website development

Background

Online cancer information can support patients in making treatment decisions. However, such information may not be adequately tailored to the patient’s perspective, particularly if healthcare professionals do not sufficiently engage patient groups when developing online information. We applied qualitative user testing during the development of a patient information website on stereotactic ablative radiotherapy (SABR), a new guideline-recommended curative treatment for early-stage lung cancer.

Methods

We recruited 27 participants who included patients referred for SABR and their relatives. A qualitative user test of the website was performed in 18 subjects, followed by an additional evaluation by users after website redesign (N = 9). We primarily used the ‘thinking aloud’ approach and semi-structured interviewing. Qualitative data analysis was performed to assess the main findings reported by the participants.

Results

Study participants preferred receiving different information that had been provided initially. Problems identified with the online information related to comprehending medical terminology, understanding the scientific evidence regarding SABR, and appreciating the side-effects associated with SABR. Following redesign of the website, participants reported fewer problems with understanding content, and some additional recommendations for better online information were identified.

Conclusions

Our findings indicate that input from patients and their relatives allows for a more comprehensive and usable website for providing treatment information. Such a website can facilitate improved patient participation in treatment decision-making for cancer.

Smoking-cessation e-referrals: a national dental practice-based research network randomized controlled trial

BACKGROUND

Tobacco use is still the leading preventable cause of death and morbidity in the U.S. Web-assisted tobacco interventions are an effective but underutilized tool in assisting smokers with quitting. The dental visit is an excellent opportunity to assist smokers in quitting by referring them to these tobacco-cessation online programs.

PURPOSE

The study purpose was to test two patient referral methods-paper referrals (information prescriptions) versus paper plus e-referrals-to a web-assisted smoking-cessation induction system.

DESIGN

RCT that used implementation research methods.

PARTICIPANTS/SETTING

A total of 100 community-based dental practices were enrolled and 1814 smokers were referred to the web-assisted tobacco induction system.

INTERVENTION

The study intervention was a proactive e-referral of smokers to a web-assisted tobacco induction system called Decide2Quit.org, and the control group used paper referrals (information prescriptions) to refer smokers to the Decide2Quit.org.

MAIN OUTCOME MEASUREMENTS

The outcome measurements were the referral numbers, Decide2Quit registration numbers, and the smokers' quit rate. Data were collected in 2010-2011 and analyses were completed in 2012.

RESULTS

Although total referrals from intervention practices was lower than control, subsequent proportions of registrations among smokers referred to Decide2Quit.org were nearly fourfold higher (adjusted mean percentages: 29.5% vs 7.6%, p<0.01) in intervention compared with control practices. Subsequent rates of cessation among referred smokers were threefold higher (adjusted mean percentages: 3.0% vs 0.8%, p=0.03) in intervention practices as compared with control.

CONCLUSIONS

Intervention practices using the e-referral system had higher smoker registration numbers and higher quit smoking rates than the control practices. This study finds that e-referrals are effective in getting smokers to the web-assisted smoking-cessation induction system and in assisting with quitting that more than compensates for any additional effort that e-referrals require on the part of the practitioner.

CLINICAL TRIAL REGISTRATION

DPBRN Hygienists Internet Quality Improvement in Tobacco Cessation (HiQuit); NCT01108432.

Implementing point of care "e-referrals" in 137 clinics to increase access to a quit smoking internet system: the Quit-Primo and National Dental PBRN HI-QUIT Studies

Integrating electronic referral systems into clinical practices may increase use of web-accessible tobacco interventions. We report on our feasibility evaluation of using theory-driven implementation science techniques to translate an e-referral system (ReferASmoker.org) into the workflow of 137 community-based medical and dental practices, including system use, patient registration, implementation costs, and lessons learned. After 6 months, 2,376 smokers were e-referred (medical, 1,625; dental, 751). Eighty-six percent of the medical practices [75/87, mean referral = 18.7 (SD = 17.9), range 0-105] and dental practices [43/50, mean referral = 15.0 (SD = 10.5), range 0-38] had e-referred. Of those smokers e-referred, 25.3 registered [mean smoker registration rate-medical 4.9 (SD = 7.6, range 0-59), dental 3.6 (SD = 3.0, range 0-10)]. Estimated mean implementation costs are medical practices, US$429.00 (SD = 85.3); and dental practices, US$238.75 (SD = 13.6). High performing practices reported specific strategies to integrate ReferASmoker.org; low performers reported lack of smokers and patient disinterest in the study. Thus, a majority of practices e-referred and 25.3 % of referred smokers registered demonstrating e-referral feasibility. However, further examination of the identified implementation barriers is important as of the estimated 90,000 to 140,000 smokers seen in the 87 medical practices in 6 months, only 1,625 were e-referred.

Who participates in Web-assisted tobacco interventions? The QUIT-PRIMO and National Dental Practice-Based Research Network Hi-Quit studies

INTRODUCTION

Smoking is the most preventable cause of death. Although effective, Web-assisted tobacco interventions are underutilized and recruitment is challenging. Understanding who participates in Web-assisted tobacco interventions may help in improving recruitment.

OBJECTIVES

To understand characteristics of smokers participating in a Web-assisted tobacco intervention (Decide2Quit.org).

METHODS

In addition to the typical Google advertisements, we expanded Decide2Quit.org recruitment to include referrals from medical and dental providers. We assessed how the expanded recruitment of smokers changed the users' characteristics, including comparison with a population-based sample of smokers from the national Behavioral Risk Factors Surveillance Survey (BRFSS). Using a negative binomial regression, we compared demographic and smoking characteristics by recruitment source, in particular readiness to quit and association with subsequent Decide2Quit.org use.

RESULTS

The Decide2Quit.org cohort included 605 smokers; the 2010 BRFSS dataset included 69,992. Compared to BRFSS smokers, a higher proportion of Decide2Quit.org smokers were female (65.2% vs 45.7%, P=.001), over age 35 (80.8% vs 67.0%, P=.001), and had some college or were college graduates (65.7% vs 45.9%, P=.001). Demographic and smoking characteristics varied by recruitment; for example, a lower proportion of medical- (22.1%) and dental-referred (18.9%) smokers had set a quit date or had already quit than Google smokers (40.1%, P<.001). Medical- and dental-referred smokers were less likely to use Decide2Quit.org functions; in adjusted analysis, Google smokers (predicted count 17.04, 95% CI 14.97-19.11) had higher predicted counts of Web page visits than medical-referred (predicted count 12.73, 95% CI 11.42-14.04) and dental-referred (predicted count 11.97, 95% CI 10.13-13.82) smokers, and were more likely to contact tobacco treatment specialists.

CONCLUSIONS

Recruitment from clinical practices complimented Google recruitment attracting smokers less motivated to quit and less experienced with Web-assisted tobacco interventions.

Using information technology and social networking for recruitment of research participants: experience from an exploratory study of pediatric Klinefelter syndrome

Background

Recruiting pediatric samples for research may be challenging due to parental mistrust of the research process, privacy concerns, and family time constraints. Recruitment of children with chronic and genetic conditions may further complicate the enrollment process.

Objective

In this paper, we describe the methodological challenges of recruiting children for research and provide an exemplar of how the use of information technology (IT) strategies with social networking may improve access to difficult-to-reach pediatric research participants.

Methods

We conducted a cross-sectional descriptive study of boys between the ages of 8 and 18 years with Klinefelter syndrome. This study presented unique challenges for recruitment of pediatric participants. These challenges are illustrated by the report of recruitment activities developed for the study. We reviewed the literature to explore the issues of recruiting children for research using conventional and IT approaches. Success rates of conventional recruitment approaches, such as brochures, flyers in medical offices, and physician referrals, are compared with IT-based outreach. The IT approaches included teleconferencing via a Klinefelter syndrome support group, services of a Web-based commercial recruitment-matching company, and the development of a university-affiliated research recruitment website with the use of paid advertising on a social networking website (Facebook).

Results

Over a 3-month period, dissemination of over 150 recruitment brochures and flyers placed in a large urban hospital and hospital-affiliated clinical offices, with 850 letters to physicians and patients were not successful. Within the same period, face-to-face recruitment in the clinical setting yielded 4 (9%) participants. Using Web-based and social networking approaches, 39 (91%) agreed to participate in the study. With these approaches, 5 (12%) were recruited from the national Klinefelter syndrome advocacy group, 8 (19%) from local and teleconference support groups, 10 (23%) from a Web-based research recruitment program, and 16 (37%) from the university-affiliated recruitment website. For the initial 6 months, the university website was viewed approximately 2 to 3 times per day on average. An advertisement placed on a social networking site for 1 week increased website viewing to approximately 63 visits per day. Out of 112 families approached using all of these methods, 43 (38%) agreed to participate. Families who declined cited either travel distance to the study site (15, 22%) or unwillingness to disclose the Klinefelter syndrome diagnosis to their sons (54, 78%) as the reasons for nonparticipation.

Conclusions

Use of Web-based technologies enhances the recruitment of difficult-to-reach populations. Of the many approaches employed in this study, the university-affiliated recruitment website supported by a Facebook advertisement appeared to be the most successful. Research grant budgets should include expenses for website registration and maintenance fees as well as online advertisements on social networking websites. Tracking of recruitment referral sources may be helpful in planning future recruitment campaigns.

Randomized controlled trial of feedback on cost of hospital care among gastroenterology inpatients

INTRODUCTION

Spending on hospital inpatients comprises a major proportion of healthcare costs. This study assessed the impact of systematic feedback to gastroenterologists on the cost of care provided to inpatients on a gastrointestinal/hepatology (GIH) hospital service.

METHODS

Patients with a GIH diagnosis were randomly assigned to be cared for by one of two hospital services. Over 3 months, teams were randomized to receive feedback (GIH A) or no feedback (GIH B, control group); feedback consisted of an email sent twice weekly to all physicians on the GIH A service detailing the length of stay (LOS) and real-time cost of care accrued by each inpatient.

RESULTS

Over 3 months, care was provided to 56 (GIH A) and 47 (GIH B) inpatients with a GIH illness. Patient complexity level was similar for both services as demonstrated by mean relative value: 1.11 (GIH A) vs. 1.27 (GIH B), p=0.2. Weighted LOS and weighted cost of care values were calculated to adjust for the respective RV of each patient. Mean weighted LOS (10.8 [GIH A] vs. 13.8 days/pt [GIH B], p=0.02) and mean weighted cost of care (9,904 [GIH A] vs. 12,654 euros/pt [GIH B], p=0.02) were significantly lower in the feedback group. Subsequent hospital readmission rates did not differ among both groups.

CONCLUSION

Systematic feedback on cost of care was associated with lower healthcare costs without compromising quality. Incorporating a running total of patient costs into computer software used to order patient tests may represent one approach to controlling healthcare expenses.