Patient engagement with a mobile web-based telemonitoring system for heart failure self-management: a pilot study

[Development and Effectiveness Evaluation of Comprehensive Mobile-Based, Breastfeeding Promotion Program for Mothers with Gestational Diabetes]

PURPOSE

This study aimed to evaluate the effects of a mobile-based breastfeeding promotion program (M-BFGDM) that helps mothers with gestational diabetes.

METHODS

Forty-seven mothers participated in the study, of whom 22 were in the experimental group and 25 in the control group. To verify the effects, a lag design before and after the non-equivalence control group was used. The data collection for the experimental group was done before and after the intervention.

RESULTS

In the results, breastfeeding knowledge showed a significant difference in the interaction between measurement period and group (χ² = 8.14, p = .017), whereas breastfeeding intention did not show a significant difference in the interaction (χ² = 4.73, p = .094). There was no difference in self-efficacy interaction (F = 0.13, p = .856). The breastfeeding method showed no difference in interaction (F = 0.04, p = .952), whereas cross-analysis showed a significant difference in breastfeeding practice rate between the experimental group and the control group at 1 month postpartum (χ² = 7.59, p = .006).

CONCLUSION

A mobile-based breastfeeding promotion program was developed and applied for gestational diabetic mothers, resulting in an increase in breastfeeding knowledge and an improvement in breastfeeding practice rate one month after childbirth. In addition, M-BFGDM managed to create a breastfeeding practice environment with fewer time and place restrictions. A program study that complements motivation is needed to improve breastfeeding in pregnant diabetic mothers in the future.

Characterising consumer engagement in virtual models of care: A systematic review and narrative synthesis

BACKGROUND

Widespread adoption of digital tools and technologies now support the delivery of virtual healthcare. Although, consumer engagement is central to care processes in virtual care models, there is paucity of evidence regarding the nature and outcomes of consumer engagement. This study aimed to determine the nature of consumer engagement used in virtual models of care, and its impact on quality and safety of care.

METHODS

A systematic review was undertaken with a narrative synthesis, with a search strategy applied to five electronic databases (CINAHL, EMBASE, MEDLINE, PsycINFO and Web of Science) RESULTS: Fifty-eight studies were included in the review that utilised a variety of virtual models of care across care services. Consumer engagement, such as patients' active involvement in monitoring, capturing and reporting their health data, was a common feature of the identified virtual models.

CONCLUSION

Increasing use of virtual models of care requires consideration of the role of patients and their support persons in the use of technology and in wider care processes that occur at a distance from health professionals. Ensuring consumers are equipped with necessary support to effectively engage in virtual care is important to ensure equity in access to, and outcomes of, virtual care models.

Patients' Experiences Using a Mobile Health App for Self-Care of Heart Failure in a Real-World Setting: Qualitative Analysis

BACKGROUND

Publicly available patient-focused mobile health (mHealth) apps are being increasingly integrated into routine heart failure (HF)-related self-care. However, there is a dearth of research on patients' experiences using mHealth apps for self-care in real-world settings.

OBJECTIVE

The purpose of this study was to explore patients' experiences using a commercially available mHealth app, OnTrack to Health, for HF self-care in a real-world setting.

METHODS

Patient satisfaction, measured with a 5-point Likert scale, and an open-ended survey were used to gather data from 23 patients with HF who were provided the OnTrack to Health app as a part of routine HF management. A content analysis of patients' responses was conducted with the qualitative software Atlas.ti (version 8; ATLAS.ti Scientific Software Development GmbH).

RESULTS

Patients (median age 64, IQR 57-71 years; 17/23, 74% male) used OnTrack to Health for a median 164 (IQR 51-640) days before the survey. All patients reported excellent experiences related to app use and would recommend the app to other patients with HF. Five themes emerged from the responses to the open-ended questions: (1) features that enhanced self-care of HF (medication tracker, graphic performance feedback and automated alerts, secured messaging features, and HF self-care education); (2) perceived benefits (provided assurance of safety, improved HF self-care, and decreased hospitalization rates); (3) challenges with using apps for self-care (giving up previous self-care strategies); (4) facilitators (perceived ease of use and availability of technical support); and (5) suggested improvements (streamlining data entry, integration of apps with an electronic medical record, and personalization of app features).

CONCLUSIONS

Patients were satisfied with using OnTrack to Health for self-care. They perceived the features of the app as valuable tools for improving self-care ability and decreasing hospitalization rates. The development of apps in collaboration with end users is essential to ensure high-quality patient experiences related to app use for self-care.

Examining standardized tools used for the evaluation of mobile health applications for cardiovascular disease

Cardiovascular disease is one of the leading causes of death worldwide. Scarce resources and rising costs are pushing healthcare systems to their limits. There is an urgency to develop, optimize and evaluate technologies that provide more effective care for patients. Modern technologies, such as mobile health (mHealth) applications, can provide relief as a key strategy. To integrate digital interventions into care structures, a detailed impact assessment of all professional mHealth applications is needed. The aim of this study is to analyze the standardized tools used in the field of cardiovascular disease. The results show that questionnaires, usage logs, and key indicators are predominantly used. Although the identified mHealth interventions are specific to cardiovascular disease and thus require particular questions to evaluate apps, the user readiness, usability, or quality of life criteria are non-specific. Therefore, the results contribute to understanding how different mHealth interventions can be assessed, categorized, evaluated, and accepted.

The effectiveness of self-care management in treating heart failure: A scoping review

Introduction: Heart failure is a common chronic disease associated with increased mortality and rehospitalization rates. Self-care management provided in various ways is one approach to avoiding the need for rehospitalization by lowering recurrence rates. Therefore, this study aims to determine the most effective self-care management interventions for heart failure patients. Design and Methods: The databases Science Direct, Google Scholar, and PubMed were used to conduct literature reviews over ten years. In September 2021, a full-text article search was conducted using the keywords "Self-Care," "Self-Management," "Intervention," "Heart Failure Patients," and "Randomized Control Trial" in PubMed ScienceDirect and Google Scholar databases. The inclusion and exclusion criteria were determined using the PICOS technique. After the screening, 39 articles met the criteria. Results: Self-care management is provided through education programs, training programs, and the utilization of apps and websites to improve its self-care abilities. Conclusions: Therefore, one way to provide self-care management during the COVID-19 pandemic was through the program's website, which is viewed "remotely" and used to track patient progress.  

Promoting patient self-management following cardiac rehabilitation using a web-based application: A pilot study

Background

The use of health-related mobile apps has become an important component of healthcare. Patients can use a range of tools to strengthen their health literacy and promote disease management. The aim of the project was to develop a web-based application for use on smartphones, tablets and computers for patients with cardiovascular diseases (cardio-app).

Methods

A semi-standardized written survey was conducted among rehabilitation patients with cardiovascular diseases (n = 158). The usability of the cardio-app was assessed using the System Usability Scale (SUS). The usage behaviour was conducted with a self-developed questionnaire.

Results

The study enrolled 158 eligible rehabilitation patients. The SUS of the cardio-app determined was 74.4 (SD ± 17.4). For 86%, the menu navigation was self-explanatory and logical. The visual presentation appealed to 92% of respondents. The content of the texts used in the app was understandable for 95%, and 93% found the technical terms used in the glossary well explained. For 57%, the app was helpful in planning their physical activities. 83% of the rehabilitation patients would recommend the app to others. The main criticisms of the app were the lack of synchronization options with other apps. Of those who did not use the app, the following reasons for non-use were most frequently cited: too much effort (43%), lack of time (29%) and pandemic-related reasons (29%).

Conclusions

The cardio-app revealed high agreement values. Whether the use of the app is associated with improved clinical state and outcome would have to be verified in further studies.

Supporting patients with heart failure with digital therapeutics-A pilot study in Germany

Objective

Continuous monitoring and targeted behavioral interventions have been shown to improve health status and quality of life for heart failure patients. Digital therapeutics offer the possibility to make more frequent monitoring and targeted behavioral interventions available for more people.

Methods

We conduct a pilot study with 71 patients who were given a smartphone app and wearables for a 3-month period. Clinical indicators as well as patient-reported outcomes were collected at entry and exit examinations.

Results

The New York Heart Association class remained stable or improved. Most quantitative outcome measures improved (6-minute walk test distance + 21 m, Kansas City Cardiomyopathy Questionnaire summary score + 6.0 points, European Heard Failure Self-care Behavior Scale summary score + 6.6 points, correct answers in the Atlanta Heart Failure Knowledge Test + 2.1), although the changes were mainly not significantly different from zero. There was no change in EQ-5D weight and 9-item Shared Decision-Making Questionnaire summary score.

Conclusions

This before-after comparison shows that an app-based intervention can work as a digital therapeutic for heart failure patients.

Postoperative patient-centered multimedia education in head and neck cancer patients: A pilot study

Objective

It is hypothesized that patients who are actively provided with more treatment-related education may report increased satisfaction and have improved overall outcomes. The aim of this study was to demonstrate the feasibility of an audiovisual education platform in patients undergoing head and neck surgery and to investigate whether patients using this module reported increased satisfaction.

Methods

This was a prospective pilot study of patients undergoing major head and neck reconstructive surgery who were randomized to either (1) control group or (2) intervention (i.e., in-patient audiovisual educational module). Both study groups then completed a discharge survey.

Results

Total 35 patients were recruited into the study (N = 16 Intervention; N = 19 Control). Patients in the intervention group reported an increased satisfaction with their overall outcome. Exactly 87.5% (14 of 16) found the intervention to be "Extremely useful," "Quite useful," or "Sometimes useful." Exactly 68.8% (11 of 16) would recommend similar patients to receive the same educational intervention. However, there was no significant difference in patients' perceived level of involvement amongst the two groups. For future improvements to the intervention, patients requested further information such as how to look after themselves, postoperative radiation, course in hospital, and nutrition.

Conclusion

This pilot study demonstrated the feasibility of an audiovisual education platform in the postoperative setting for patients undergoing major head and neck reconstructive surgery. Although most patients found the module useful, future steps will incorporate patient feedback to further improve the educational platform and confirm the current preliminary impressions in prospective studies.

Level of Evidence

1b.

Quality of Life in Heart Patients Receiving Telerehabilitation: An Overview with Meta-Analyses

Background

This overview is conducted to evaluate the effect of telerehabilitation on Health-Related Quality of Life (HRQOL) in patients with cardiovascular diseases (CVDs).

Methods

A comprehensive search was performed through the [MeSH] keywords (heart diseases, coronary disease, coronary artery disease, myocardial infarction, coronary artery bypass, heart failure, cardiac rehabilitation and telemedicine) until January 20, 2021 in databases of Science Direct, Medline/PubMed, Web of Science, Scopus, ProQuest, Google Scholar and Cochrane library. Finally, 20 reviews were entered into the analysis.

Results

The results of meta-analyses showed that receiving telerehabilitation program by telemedicine method has a positive effect on the physical dimension and changing the mental status of patients following this intervention depends on age so that the use of these technologies in heart patients with younger ages promotes mental status. On the other hand, increasing the duration of the intervention 18 months or more affects the physical dimension and 12 months or more affects promoting overall HRQOL. Among the various types of Telemedicine methods, telephone support has a greater effect on promoting the physical dimension.

Conclusion

The ability to use virtual technology is less at older ages, so age conditions of patients should be considered in choosing this type of intervention. The living place of the people and the level of access to advanced care, seem to play an important role in changing outcomes and choosing this type of intervention because the main purpose of telerehabilitation is to provide treatment care in areas with low access levels.

Digital health and modern technologies applied in patients with heart failure: Can we support patients’ psychosocial well-being?

Despite advances in the treatment of heart failure (HF), the physical symptoms and stress of the disease continue to negatively impact patients’ health outcomes. Technology now offers promising ways to integrate personalized support from health care professionals via a variety of platforms. Digital health technology solutions using mobile devices or those that allow remote patient monitoring are potentially more cost effective and may replace in-person interaction. Notably, digital health methods may not only improve clinical outcomes but may also improve the psycho-social status of HF patients. Using digital health to address biopsychosocial variables, including elements of the person and their context is valuable when considering chronic illness and HF in particular, given the multiple, cross-level factors affecting chronic illness clinical management needed for HF self-care.

Optimal effectiveness of heart failure management - an umbrella review of meta-analyses examining the effectiveness of interventions to reduce (re)hospitalizations in heart failure

Heart failure (HF) is a major health concern, which accounts for 1-2% of all hospital admissions. Nevertheless, there remains a knowledge gap concerning which interventions contribute to effective prevention of HF (re)hospitalization. Therefore, this umbrella review aims to systematically review meta-analyses that examined the effectiveness of interventions in reducing HF-related (re)hospitalization in HFrEF patients. An electronic literature search was performed in PubMed, Web of Science, PsycInfo, Cochrane Reviews, CINAHL, and Medline to identify eligible studies published in the English language in the past 10 years. Primarily, to synthesize the meta-analyzed data, a best-evidence synthesis was used in which meta-analyses were classified based on level of validity. Secondarily, all unique RCTS were extracted from the meta-analyses and examined. A total of 44 meta-analyses were included which encompassed 186 unique RCTs. Strong or moderate evidence suggested that catheter ablation, cardiac resynchronization therapy, cardiac rehabilitation, telemonitoring, and RAAS inhibitors could reduce (re)hospitalization. Additionally, limited evidence suggested that multidisciplinary clinic or self-management promotion programs, beta-blockers, statins, and mitral valve therapy could reduce HF hospitalization. No, or conflicting evidence was found for the effects of cell therapy or anticoagulation. This umbrella review highlights different levels of evidence regarding the effectiveness of several interventions in reducing HF-related (re)hospitalization in HFrEF patients. It could guide future guideline development in optimizing care pathways for heart failure patients.

Measures of Engagement With mHealth Interventions in Patients With Heart Failure: Scoping Review

Background

Despite the potential of mobile health (mHealth) interventions to facilitate the early detection of signs of heart failure (HF) decompensation and provide personalized management of symptoms, the outcomes of such interventions in patients with HF have been inconsistent. As engagement with mHealth is required for interventions to be effective, poor patient engagement with mHealth interventions may be associated with mixed evidence. It is crucial to understand how engagement with mHealth interventions is measured in patients with HF, and the effects of engagement on HF outcomes.

Objective

In this review, we aimed to describe measures of patient engagement with mHealth interventions and the effects of engagement on HF outcomes.

Methods

We conducted a systematic literature search in 7 databases for relevant studies published in the English language from 2009 to September 2021 and reported the descriptive characteristics of the studies. We used content analysis to identify themes that described patient engagement with mHealth interventions in the qualitative studies included in the review.

Results

We synthesized 32 studies that operationalized engagement with mHealth interventions in 4771 patients with HF (3239/4771, 67.88%, male), ranging from a sample of 7 to 1571 (median 53.3) patients, followed for a median duration of 90 (IQR 45-180) days. Patient engagement with mHealth interventions was measured only quantitatively based on system usage data in 72% (23/32) of the studies, only qualitatively based on data from semistructured interviews and focus groups in 6% (2/32) of studies, and by a combination of both quantitative and qualitative data in 22% (7/32) of studies. System usage data were evaluated using 6 metrics of engagement: number of physiological parameters transmitted (19/30, 63% studies), number of HF questionnaires completed (2/30, 7% studies), number of log-ins (4/30, 13% studies), number of SMS text message responses (1/30, 3% studies), time spent (5/30, 17% studies), and the number of features accessed and screen viewed (4/30, 13% studies). There was a lack of consistency in how the system usage metrics were reported across studies. In total, 80% of the studies reported only descriptive characteristics of system usage data. The emotional, cognitive, and behavioral domains of patient engagement were identified through qualitative studies. Patient engagement levels ranged from 45% to 100% and decreased over time. The effects of engagement on HF knowledge, self-care, exercise adherence, and HF hospitalization were inconclusive.

Conclusions

The measures of patient engagement with mHealth interventions in patients with HF are underreported and lack consistency. The application of inferential analytical methods to engagement data is extremely limited. There is a need for a working group on mHealth that may consolidate the previous operational definitions of patient engagement into an optimal and standardized measure.

An eHealth self-management intervention for adults with chronic kidney disease, My Kidneys My Health: a mixed-methods study

BACKGROUND

There is limited research of electronic tools for self-management for patients with chronic kidney disease (CKD). We sought to evaluate participant engagement, perceived self-efficacy and website usage in a preliminary evaluation of My Kidneys My Health, a patient-facing eHealth tool in Canada.

METHODS

We conducted an explanatory sequential mixed-methods study of adults with CKD who were not on kidney replacement therapy and who had access to My Kidneys My Health for 8 weeks. Outcomes included acceptance (measured by the Technology Acceptance Model), self-efficacy (measured by the Chronic Disease Self-Efficacy Scale [CDSES]) and website usage patterns (captured using Google Analytics). We analyzed participant interviews using qualitative content analysis.

RESULTS

Twenty-nine participants with CKD completed baseline questionnaires, of whom 22 completed end-of-study questionnaires; data saturation was achieved with 15 telephone interviews. Acceptance was high, with more than 70% of participants agreeing or strongly agreeing that the website was easy to use and useful. Of the 22 who completed end-of-study questionnaires, 18 (82%) indicated they would recommend its use to others and 16 (73%) stated they would use the website in the future. Average scores for website satisfaction and look and feel were 7.7 (standard deviation [SD] 2.0) and 8.2 (SD 2.0) out of 10, respectively. The CDSES indicated that participants gained an increase in CKD information. Interviewed participants reported that the website offered valuable information and interactive tools for patients with early or newly diagnosed CKD, or for those experiencing changes in health status. Popular website pages and interactive features included Food and Diet, What is CKD, My Question List and the Depression Screener.

INTERPRETATION

Participants indicated that the My Kidneys My Health website provided accessible content and tools that may improve self-efficacy and support in CKD self-management. Further evaluation of the website's effectiveness in supporting self-management among a larger, more heterogenous population is warranted.

The feasibility of telehealth in the monitoring of head and neck cancer patients: a systematic review on remote technology, user adherence, user satisfaction, and quality of life

OBJECTIVES

This systematic review aimed to analyze the use of telehealth in monitoring patients with head and neck cancer regarding the application used, user adherence to technology, user satisfaction, and user quality of life.

MATERIALS AND METHODS

A search strategy was developed using the PICO acronym and the terms "Head and Neck Cancer," "Telehealth," "Mobile Application," and "Supportive Care." A broad literature search was performed on PubMed, Cochrane Library, Scopus, Web of Science, Lilacs, and Embase databases and on grey literature through Open Grey, Google Scholar, and Jstor, for studies comparing the monitoring of head and neck cancer patients with telehealth apps to the monitoring performed in a traditional way at health units. No study design, publication status, publication time, or language restrictions were applied. Pairs of reviewers worked independently for study selection and risk of bias assessment. The protocol was registered in PROSPERO and the PRISMA checklist used for reporting the review.

RESULTS

We found 393 references in the databases, 325 after duplicate removal; 19 met the criteria for full-text reading; 08 studies were included for qualitative synthesis. Although there was heterogeneity regarding the technology used, the studies included showed that remote monitoring and/or self-management of symptoms through mobile applications was feasible for most patients, with satisfactory degrees of acceptability, satisfaction, usability, and adherence. The health-related quality of life improved with the use of remote technologies for telehealth, associated with low to moderate self-efficacy, higher personal control, and higher knowledge of health with clinically acceptable levels of accuracy compared to traditional clinical evaluation. Even when the data presented were not statistically significant, patients reported improvement in health-related quality of life after the intervention.

CONCLUSIONS

Telehealth monitoring through the use of remote technologies presents itself as an alternative way of educating and supporting patients during the treatment of Head and Neck Cancer (HNC). There is the need for a more user-friendly interface, adequate user experience assessment, and the concrete applicability of telehealth technologies for monitoring patients with HNC in order to legitimize the cost-effectiveness of developing long-term multicenter longitudinal studies term.

The willingness to use mobile health and its influencing factors among elderly patients with chronic heart failure in Shanghai, China

OBJECTIVE

The purpose of this study was to explore the willingness of elderly patients with chronic heart failure to use mobile health for health management in Shanghai and analyze influencing factors.

METHODS

The study was conducted from August 2020 to July 2021. A convenience sample of 181 elderly patients with chronic heart failure recruited from three tertiary hospitals and one health service center in Shanghai completed self-developed structured questionnaires. The data collected included demographic information, health status, knowing about mobile health, usage of mobile health, willingness to use mobile health for health management, and beliefs about mobile health. SPSS20.0 software was used for analyzing data.

RESULTS

Eighty-four patients (46.4%) expressed their willingness to use mobile health. Logistic regression analyses showed that knowing about mobile health (OR = 16.30, p < 0.001), usage of mobile health (OR = 15.36, p < 0.001), self-rated health (good vs. poor: OR = 15.03, p = 0.003; neutral vs. poor: OR = 3.00, p = 0.006), perceived ease of use (OR = 3.86, p = 0.002), perceived usefulness (OR = 1.90, p < 0.001), and self-efficacy (OR = 1.43, p < 0.001) were important factors influencing the willingness to use mobile health.

CONCLUSIONS

There is a need for developing user-friendly and useful mobile health for elderly patients with chronic heart failure. The participatory approach could be used to develop mobile health intervention. In addition, mobile health should be promoted, publicized, and trained among this group of population.

Methods Used to Evaluate mHealth Applications for Cardiovascular Disease: A Quasi-Systematic Scoping Review

In the face of demographic change and constantly increasing health care costs, health care system decision-makers face ever greater challenges. Mobile health applications (mHealth apps) have the potential to combat this trend. However, in order to integrate mHealth apps into care structures, an evaluation of such apps is needed. In this paper, we focus on the criteria and methods of evaluating mHealth apps for cardiovascular disease and the implications for developing a widely applicable evaluation framework for mHealth interventions. Our aim is to derive substantiated patterns and starting points for future research by conducting a quasi-systematic scoping review of relevant peer-reviewed literature published in English or German between 2000 and 2021. We screened 4066 articles and identified n = 38 studies that met our inclusion criteria. The results of the data derived from these studies show that usability, motivation, and user experience were evaluated primarily using standardized questionnaires. Usage protocols and clinical outcomes were assessed primarily via laboratory diagnostics and quality-of-life questionnaires, and cost effectiveness was tested primarily based on economic measures. Based on these findings, we propose important considerations and elements for the development of a common evaluation framework for professional mHealth apps, including study designs, data collection tools, and perspectives.

Can manipulation of gut microbiota really be transformed into an intervention strategy for cardiovascular disease management?

Recent advancement in manipulation techniques of gut microbiota either ex vivo or in situ has broadened its plausible applicability for treating various diseases including cardiovascular disease. Several reports suggested that altering gut microbiota composition is an effective way to deal with issues associated with managing cardiovascular diseases. However, actual translation of gut microbiota manipulation-based techniques into cardiovascular-therapeutic approach is still questionable. This review summarized the evidence on challenges, opportunities, recent development, and future prospects of gut microbiota manipulation for targeting cardiovascular diseases. Initially, issues associated with current cardiovascular diseases treatment strategy, association of gut microbiota with cardiovascular disease, and its influence on cardiovascular drugs were discussed, followed by applicability of gut microbiota manipulation as a cardiovascular disease intervention strategy along with its challenges and future prospects. Despite the fact that the gut microbiota is rugged, interventions like probiotics, prebiotics, synbiotics, fecal microbiota transplantation, fecal virome transplantation, antibiotics, diet changes, and exercises could manipulate it. Advanced techniques like administration of engineered bacteriophages and bacteria could also be employed. Intensive exploration revealed that if sufficiently controlled approach and proper monitoring were applied, gut microbiota could provide a compelling answer for cardiovascular therapy.

The Effect of Noninvasive Telemonitoring for Chronic Heart Failure on Health Care Utilization: Systematic Review

Background

Chronic heart failure accounts for approximately 1%-2% of health care expenditures in most developed countries. These costs are primarily driven by hospitalizations and comorbidities. Telemonitoring has been proposed to reduce the number of hospitalizations and decrease the cost of treatment for patients with heart failure. However, the effects of telemonitoring on health care utilization remain unclear.

Objective

This systematic review aims to study the effect of telemonitoring programs on health care utilization and costs in patients with chronic heart failure. We assess the effect of telemonitoring on hospitalizations, emergency department visits, length of stay, hospital days, nonemergency department visits, and health care costs.

Methods

We searched PubMed, Embase, and Web of Science for randomized controlled trials and nonrandomized studies on noninvasive telemonitoring and health care utilization. We included studies published between January 2010 and August 2020. For each study, we extracted the reported data on the effect of telemonitoring on health care utilization. We used P<.05 and CIs not including 1.00 to determine whether the effect was statistically significant.

Results

We included 16 randomized controlled trials and 13 nonrandomized studies. Inclusion criteria, population characteristics, and outcome measures differed among the included studies. Most studies showed no effect of telemonitoring on health care utilization. The number of hospitalizations was significantly reduced in 38% (9/24) of studies, whereas emergency department visits were reduced in 13% (1/8) of studies. An increase in nonemergency department visits (6/9, 67% of studies) was reported. Health care costs showed ambiguous results, with 3 studies reporting an increase in health care costs, 3 studies reporting a reduction, and 4 studies reporting no significant differences. Health care cost reductions were realized through a reduction in hospitalizations, whereas increases were caused by the high costs of the telemonitoring program or increased health care utilization.

Conclusions

Most telemonitoring programs do not show clear effects on health care utilization measures, except for an increase in nonemergency outpatient department visits. This may be an unwarranted side effect rather than a prerequisite for effective telemonitoring. The consequences of telemonitoring on nonemergency outpatient visits should receive more attention from regulators, payers, and providers. This review further demonstrates the high clinical and methodological heterogeneity of telemonitoring programs. This should be taken into account in future meta-analyses aimed at identifying the effective components of telemonitoring programs.

Patient Portal Use by Adults With Heart Failure: An Integrative Review

Heart failure is a chronic condition affecting many with an emphasis on self-management to improve outcomes and decrease the cost of care. A potential strategy to improve the self-management of heart failure includes the use of a patient portal. The purpose of this integrative review is to synthesize what is known about patient portal use by adults with heart failure to identify contributing factors for use and areas for future research. Within the three zones of the Health Information Technology Acceptance Model, predominant themes contributing to patient portal use were identified. Within the health zone, the predominant themes were physical and mental health, quality of life, and social interaction. Within the information zone, the predominant themes included knowledge about heart failure and self-care, information sharing, and communication. Within the technology zone, the predominant themes include the barriers and facilitators of patient portal use and overall usability. Overall, the patient perceptions of the patient portal can lead to the acceptance and use of the technology that can enhance self-management. Healthcare providers should partner with adults with heart failure to maximize the features of the patient portal to support self-management.

Effects of self-management interventions on heart failure: Systematic review and meta-analysis of randomized controlled trials - Reprint

BACKGROUND

Self-management intervention is an important component of disease management in patients with heart failure. It can improve heart failure knowledge, quality of life, and heart failure-related hospitalizations of heart failure patients. However, studies on the effect of two self-management interventions tasks have reported conflicting results.

OBJECTIVE

This study conducted an up-to-date systematic review of the literature to evaluate the effects of self-management interventions on heart failure knowledge, quality of life, and heart failure-related hospitalizations in patients with heart failure.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

We searched PubMed, Embase, Web of Science, Cochrane Library, and the references of articles in 14th December 2019.

METHODS

The study characteristics included: authors, year, country, sample size, mean age of patients with heart failure, duration of intervention, recruitment and intervention delivery, interventions based on self-efficacy theory, cognitive behavioral therapy, disease management, self-care education. The risk of bias for each study was assessed independently by two investigators based on the Cochrane Handbook. This study used Revman to analyze different research outcomes. The fixed-effect model was used in the absence of significant heterogeneity or low heterogeneity, and if the heterogeneity was high, the random effect model was used.

RESULTS

A total of 4977 publications were retrieved in this study. After eliminating duplicates and screening for titles and abstracts, 209 articles were retrieved for full-text evaluation. Finally, a total sample size analyzed across 15 randomized controlled trials was 2630 participants. This study showed that self-management interventions significantly improved heart failure knowledge (0.61, 95% confidence interval (CI) 0.27-0.95, p = 0.0004), quality of life (0.20, 95% CI 0.02-0.38, p = 0.03), and heart failure-related hospitalization (OR 0.40, 95% CI 0.29 to 0.55, p<0.00001) in patients with heart failure.

CONCLUSIONS

This study reveals the beneficial effects of self-management interventions on heart failure knowledge, quality of life, and heart failure-related hospitalization in patients with heart failure. Therefore, high quality randomized controlled designs are needed to explore the optimal self-management interventions for patients with heart failure. Tweetable abstract: This study reveals self-management interventions can improve heart failure knowledge, quality of life, and reduced heart failure-related hospitalization.

Digital Health Applications in Heart Failure: a Critical Appraisal of Literature

Purpose of the review

Despite advancements in the diagnostic and therapeutic armamentarium, heart failure (HF) remains a major public health concern in the USA and worldwide. Digital health applications hold promise to bridge this gap and improve HF care. This review will provide the reader with a concise overview of the current digital health applications in HF, the main challenges to its use, and discuss the future of digital health for promoting care for HF patients.

Recent findings

Emerging evidence continues to support the potential role of digital health across the continuum of HF disease process including primary prevention, early detection, disease management, and reducing associated morbidity. There is also increasing emphasis on the need to pursue rigorous investigations to validate these promising claims, with some successful stories that have changed clinical practices.

Summary

Digital health technologies have emerged as potentially useful tools to complement HF care in both research and clinical realms. As digital technologies continue to play an increasing role in transforming healthcare delivery, creating the framework for its effective use would be necessary to ensure that digital health applications consistently improve outcomes and enhance care for HF patients.

Feasibility of Incorporating Voice Technology and Virtual Assistants in Cardiovascular Care and Clinical Trials

PURPOSE OF REVIEW

With the rising cost of cardiovascular clinical trials, there is interest in determining whether new technologies can increase cost effectiveness. This review focuses on current and potential uses of voice-based technologies, including virtual assistants, in cardiovascular clinical trials.

RECENT FINDINGS

Numerous potential uses for voice-based technologies have begun to emerge within cardiovascular medicine. Voice biomarkers, subtle changes in speech parameters, have emerged as a potential tool to diagnose and monitor many cardiovascular conditions, including heart failure, coronary artery disease, and pulmonary hypertension. With the increasing use of virtual assistants, numerous pilot studies have examined whether these devices can supplement initiatives to promote transitional care, physical activity, smoking cessation, and medication adherence with promising initial results. Additionally, these devices have demonstrated the ability to streamline data collection by administering questionnaires accurately and reliably. With the use of these technologies, there are several challenges that must be addressed before wider implementation including respecting patient privacy, maintaining regulatory standards, acceptance by patients and healthcare providers, determining the validity of voice-based biomarkers and endpoints, and increased accessibility.

SUMMARY

Voice technology represents a novel and promising tool for cardiovascular clinical trials; however, research is still required to understand how it can be best harnessed.

Integrating remote monitoring into heart failure patients' care regimen: A pilot study

Background

Around 50% of hospital readmissions due to heart failure are preventable, with lack of adherence to prescribed self-care as a driving factor. Remote tracking and reminders issued by mobile health devices could help to promote self-care, which could potentially reduce these readmissions.

Objective

We sought to investigate two factors: (1) feasibility of enrolling heart failure patients in a remote monitoring regimen that uses wireless sensors and patient-reported outcome measures; and (2) their adherence to using the study devices and completing patient-reported outcome measures.

Methods

Twenty heart failure patients participated in piloting a remote monitoring regimen. Data collection included: (1) physical activity using wrist-worn activity trackers; (2) body weight using bathroom scales; (3) medication adherence using smart pill bottles; and (4) patient -reported outcomes using patient-reported outcome measures.

Results

We evaluated 150 hospitalized heart failure patients and enrolled 20 individuals. Two factors contributed to 50% (65/130) being excluded from the study: smartphone ownership and patient discharge. Over the course of the study, 60.0% of the subjects wore the activity tracker for at least 70% of the hours, and 45.0% used the scale for more than 70% of the days. The pill bottle was used less than 10% of the days by 55.0% of the subjects.

Conclusions

Our method of recruiting heart failure patients prior to hospital discharge may not be feasible as the enrollment rate was low. Once enrolled, the majority of subjects maintained a high adherence to wearing the activity tracker but low adherence to using the pill bottle and completing the follow-up surveys. Scale usage was fair, but it received positive reviews from most subjects. Given the observed usage and feedback, we suggest mobile health-driven interventions consider including an activity tracker and bathroom scale. We also recommend administering a shorter survey more regularly and through an easier interface.

Digital Health and the Care of the Patient With Arrhythmia

The field of cardiac electrophysiology has been on the cutting edge of advanced digital technologies for many years. More recently, medical device development through traditional clinical trials has been supplemented by direct to consumer products with advancement of wearables and health care apps. The rapid growth of innovation along with the mega-data generated has created challenges and opportunities. This review summarizes the regulatory landscape, applications to clinical practice, opportunities for virtual clinical trials, the use of artificial intelligence to streamline and interpret data, and integration into the electronic medical records and medical practice. Preparation of the new generation of physicians, guidance and promotion by professional societies, and advancement of research in the interpretation and application of big data and the impact of digital technologies on health outcomes will help to advance the adoption and the future of digital health care.

The nephrology crystal ball: the medium-term future

In January 2019, the ERA-EDTA surveyed nephrologists with questions on kidney care and kidney research designed to explore comprehension of the impact of alterations to organization of renal care and of advancements in technology and knowledge of kidney disease. Eight hundred and twenty-five ERA-EDTA members, ∼13% of the whole ERA-EDTA membership, replied to an ad hoc questionnaire. More than half of the respondents argued that kidney centres will be increasingly owned by large dialysis providers, nearly a quarter of respondents felt that many medical aspects of dialysis will be increasingly overseen by non-nephrologists and a quarter (24%) also believed that the care and long-term follow-up of kidney transplant patients will be increasingly under the responsibility of transplant physicians caring for patients with any organ transplant. Nearly half of the participants (45%, n = 367) use fully electronic clinical files integrating the clinical ward, the outpatient clinics, the haemodialysis and peritoneal dialysis units, as well as transplantation. Smartphone-based self-management programmes for the care of chronic kidney disease (CKD) patients are scarcely applied (only 11% of surveyed nephrologists), but a substantial proportion of respondents (74%) are eager to know more about the potential usefulness of these apps. Finally, European nephrologists expressed a cautious optimism about the application of omic sciences to nephrology and on wearable and implantable kidneys, but their expectations for the medium term are limited.

Evaluating the Effects of a Mobile Health App on Reducing Patient Care Needs and Improving Quality of Life After Oral Cancer Surgery: Quasiexperimental Study

BACKGROUND

Intervention with a mobile Health (mHealth) app can improve the efficacy of early detection of oral cancer and the outcomes for patients taking oral anticancer medications. The quality of life of oral cancer patients is significantly reduced within three months after surgery; also, their needs for nursing care and health information increase, mainly due to side effects and associated psychological problems.

OBJECTIVE

This study aimed to evaluate changes in the care needs and quality of life of patients with oral cancer after receiving the intervention of a newly developed mHealth app.

METHODS

After surgery, oral cancer patients were divided into an experimental group (n=50) who received the mHealth app intervention and a control group (n=50) who received routine health care and instruction. After 3 months of intervention, survey questionnaires were used to assess the patients' quality of life, nursing care needs, and acceptance of the mHealth app.

RESULTS

The physiological care needs were significantly decreased in the experimental group compared with the control group (P<.05). Although the differences were not statistically significant, the psychological needs, communication needs, and care support needs all improved after the mHealth app intervention. The overall improvement in quality of life was higher in the experimental group than in the control group (-7.24 vs -4.36). In terms of intention to use, perceived usefulness, and perceived ease of use, the acceptability scores of the mHealth app were significantly increased after 3 months of intervention (P<.05).

CONCLUSIONS

Compared with routine health care and instruction, for patients after surgery, the education/information intervention using the mHealth app significantly reduced their nursing care needs, improved their quality of life, and increased their acceptance of using an mHealth app on a mobile device. These findings can provide a theoretical basis for future health care app design and improvement. This study suggests that an mHealth app should be incorporated into the routine care of oral cancer patients to provide medical information quickly and improve their self-management abilities, thereby reducing the patients' need for physiological care and improving their quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04049968; https://www.clinicaltrials.gov/ct2/show/NCT04049968.

mHealth and Engagement Concerning Persons With Chronic Somatic Health Conditions: Integrative Literature Review

Background

Chronic somatic health conditions are a global public health challenge. Being engaged in one’s own health management for such conditions is important, and mobile health (mHealth) solutions are often suggested as key to promoting engagement.

Objective

The aim of this study was to review, critically appraise, and synthesize the available research regarding engagement through mHealth for persons with chronic somatic health conditions.

Methods

An integrative literature review was conducted. The PubMed, CINAHL, and Inspec databases were used for literature searches. Quality assessment was done with the guidance of Critical Appraisal Skills Programme (CASP) checklists. We used a self-designed study protocol comprising 4 engagement aspects—cognitive, behavioral and emotional, interactional, and the usage of mHealth—as part of the synthesis and analysis.

Results

A total of 44 articles met the inclusion criteria and were included in the analysis. mHealth usage was the most commonly occurring engagement aspect, behavioral and emotional aspects the second, cognitive aspects the third, and interactional aspects of engagement the least common aspect in the included articles. The results showed that there is a mix of enablers and barriers to engagement in relation to the 4 engagement aspects. The perceived meaningfulness and need for the solution and its content were important to create and maintain engagement. When perceived as meaningful, suitable, and usable, mHealth can support knowledge gain and learning, facilitate emotional and behavioral aspects such as a sense of confidence, and improve interactions and communications with health care professionals.

Conclusions

mHealth solutions have the potential to support health care engagement for persons with chronic somatic conditions. More research is needed to further understand how, by which means, when, and among whom mHealth could further improve engagement for this population.

Extending Enhanced Recovery after Surgery Protocols to the Post-Discharge Setting: A Phone Call Intervention to Support Patients after Expedited Discharge after Pancreaticoduodenectomy

The goal of this pilot study was to track patient outcomes after an expedited discharge after enhanced recovery after surgery (ERAS) pathway for pancreaticoduodenectomy (PD). A quantitative content analysis approach was used. All PD patients in a single academic medical center between February 2017 and June 2018 were called twice by specialized physician extenders after discharge. A semi-structured interview approach was used to identify patient's symptoms or concerns, proactively educate them, and provide outpatient management when indicated. A detailed narrative of the conversation was documented. Ninety patients (mean age 66.3; 58.1% males) were included in the study. Of all, 88.9 per cent of the patients received follow-up phone calls in accordance with our PD ERAS protocol. Among the 80 patients called, 71 (88.8%) reported at least one symptom, issue, or self-care need. The most common issues involved bowel movements and nutrition. A total of 147 interventions were performed to address patient needs including medication management, local care coordination, and outpatient referral to a healthcare provider. The intervention led to the identification of 15 patients for earlier evaluation. This identification was associated with the total number of reported symptoms ( X2 = 15.6, P = 0.004). Most patients require additional care after discharge after traditional ERAS pathways. ERAS transitional care protocols uncovered an unmet need for additional patient support after PD.

Effects of self-management interventions on heart failure: Systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Self-management intervention is an important component of disease management in patients with heart failure. It can improve heart failure knowledge, quality of life, and heart failure-related hospitalizations of heart failure patients. However, studies on the effect of two self-management interventions tasks have reported conflicting results.

OBJECTIVE

This study conducted an up-to-date systematic review of the literature to evaluate the effects of self-management interventions on heart failure knowledge, quality of life, and heart failure-related hospitalizations in patients with heart failure.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

We searched PubMed, Embase, Web of Science, Cochrane Library, and the references of articles in 14th December 2019.

METHODS

The study characteristics included: authors, year, country, sample size, mean age of patients with heart failure, duration of intervention, recruitment and intervention delivery, interventions based on self-efficacy theory, cognitive behavioral therapy, disease management, self-care education. The risk of bias for each study was assessed independently by two investigators based on the Cochrane Handbook. This study used Revman to analyze different research outcomes. The fixed-effect model was used in the absence of significant heterogeneity or low heterogeneity, and if the heterogeneity was high, the random effect model was used.

RESULTS

A total of 4977 publications were retrieved in this study. After eliminating duplicates and screening for titles and abstracts, 209 articles were retrieved for full-text evaluation. Finally, a total sample size analyzed across 15 randomized controlled trials was 2630 participants. This study showed that self-management interventions significantly improved heart failure knowledge (0.61, 95% confidence interval (CI) 0.27-0.95, p = 0.0004), quality of life (0.20, 95% CI 0.02-0.38, p = 0.03), and heart failure-related hospitalization (OR 0.40, 95% CI 0.29 to 0.55, p<0.00001) in patients with heart failure.

CONCLUSIONS

This study reveals the beneficial effects of self-management interventions on heart failure knowledge, quality of life, and heart failure-related hospitalization in patients with heart failure. Therefore, high quality randomized controlled designs are needed to explore the optimal self-management interventions for patients with heart failure. Tweetable abstract: This study reveals self-management interventions can improve heart failure knowledge, quality of life, and reduced heart failure-related hospitalization.

Technology-based health promotion: Current state and perspectives in emerging gig economy

It has been a decade since smartphone application stores started allowing developers to post their own applications. This paper presents a narrative review on the state-of-the-art and the future of technology used by researchers in the field of mobile health promotion. Researchers build high cost, complex systems with the purpose of promoting health and collecting data. These systems promote health by using a feedback component that "educates" the subject. Other researchers instead use platforms which provide them with data collected by others, which allows for no communication with subjects, but may be cheaper than building a system to collect the data. This second type of systems cannot be used directly for health promotion. However, both types of systems are relevant to the field of health promotion, because they are precursors to a third type of systems that are emerging, the gig economy systems for mobile health data collection, which are low cost, globally available, and provide limited communication with subjects. If such systems evolve to include more channels for communication with the data-generating subjects, and also bring developers into the economy, they may eventually revolutionize the field of mobile health promotion and data collection by giving researchers new capabilities, such as the ability to replicate existing health promotion campaigns with the click of a button and the appropriate licenses. In this paper we present a review of state-of-the-art systems for mobile health promotion and data collection and a model for what these systems may look like in the future.

A Machine Learning Approach to Classifying Self-Reported Health Status in a Cohort of Patients With Heart Disease Using Activity Tracker Data

Constructing statistical models using personal sensor data could allow for tracking health status over time, thereby enabling the possibility of early intervention. The goal of this study was to use machine learning algorithms to classify patient-reported outcomes (PROs) using activity tracker data in a cohort of patients with stable ischemic heart disease (SIHD). A population of 182 patients with SIHD were monitored over a period of 12 weeks. Each subject received a Fitbit Charge 2 device to record daily activity data, and each subject completed eight Patient-Reported Outcomes Measurement Information Systems short form at the end of each week as a self-assessment of their health status. Two models were built to classify PRO scores using activity tracker data. The first model treated each week independently, whereas the second used a hidden Markov model (HMM) to take advantage of correlations between successive weeks. Retrospective analysis compared the classification accuracy of the two models and the importance of each feature. In the independent model, a random forest classifier achieved a mean area under curve (AUC) of 0.76 for classifying the physical function PRO. The HMM model achieved significantly better AUCs for all PROs (p < 0.05) other than Fatigue and Sleep Disturbance, with a highest mean AUC of 0.79 for the physical function-short form 10a. Our study demonstrates the ability of activity tracker data to classify health status over time. These results suggest that patient outcomes can be monitored in real time using activity trackers.

Extending Enhanced Recovery after Surgery Protocols to the Post-Discharge Setting: A Phone Call Intervention to Support Patients after Expedited Discharge after Pancreaticoduodenectomy

The goal of this pilot study was to track patient outcomes after an expedited discharge after enhanced recovery after surgery (ERAS) pathway for pancreaticoduodenectomy (PD). A quantitative content analysis approach was used. All PD patients in a single academic medical center between February 2017 and June 2018 were called twice by specialized physician extenders after discharge. A semi-structured interview approach was used to identify patient's symptoms or concerns, proactively educate them, and provide outpatient management when indicated. A detailed narrative of the conversation was documented. Ninety patients (mean age 66.3; 58.1% males) were included in the study. Of all, 88.9 per cent of the patients received follow-up phone calls in accordance with our PD ERAS protocol. Among the 80 patients called, 71 (88.8%) reported at least one symptom, issue, or self-care need. The most common issues involved bowel movements and nutrition. A total of 147 interventions were performed to address patient needs including medication management, local care coordination, and outpatient referral to a healthcare provider. The intervention led to the identification of 15 patients for earlier evaluation. This identification was associated with the total number of reported symptoms (X² = 15.6, P = 0.004). Most patients require additional care after discharge after traditional ERAS pathways. ERAS transitional care protocols uncovered an unmet need for additional patient support after PD.

Call to Action: Urgent Challenges in Cardiovascular Disease: A Presidential Advisory From the American Heart Association

Although advances in care have spurred improvements in cardiovascular outcomes, cardiovascular disease remains the leading cause of death in the United States and around the world. Previous declines in cardiovascular disease mortality have slowed and even reversed for certain demographics. Further concerns exist with regard to cardiovascular drug innovation, quality of care, and healthcare costs. The Value in Healthcare Initiative-Transforming Cardiovascular Care, a collaboration of the American Heart Association and Duke University, Robert J. Margolis, MD, Center for Health Policy, aims to increase access to and affordability of cardiovascular treatment and to decrease barriers to care. The following Call to Action describes trends in cardiovascular care, identifies gaps in areas of cardiovascular disease prevention and treatment, highlights challenges with medical product innovation, and finally, outlines a series of learning collaboratives that will aid in the development of road maps for transforming cardiovascular care.

Home-Based e-Health Platform for Multidimensional Telemonitoring of Symptoms, Body Weight, Sleep, and Circadian Activity: Relevance for Chronomodulated Administration of Irinotecan, Fluorouracil-Leucovorin, and Oxaliplatin at Home-Results From a Pilot Study

PURPOSE

To assess the impact of chronomodulated irinotecan fluorouracil-leucovorin and oxaliplatin (chronoIFLO4) delivered at home on the daily life of patients with cancer in real time using a home-based e-Health multifunction and multiuser platform. This involved multidimensional telemonitoring of circadian rest-activity rhythm (CircAct), sleep, patient-reported outcome measures, and body weight changes (BWCs).

PATIENTS AND METHODS

Patients received chronoIFLO4 fortnightly at home. Patients completed the 19-item MD Anderson Symptom Inventory on an interactive electronic screen, weighed themselves on a dedicated scale, and continuously wore a wrist accelerometer for CircAct and sleep monitoring. Daily data were securely teletransmitted to a specific server accessible by the hospital team. The clinically relevant CircAct parameter dichotomy index I < O and sleep efficiency (SE) were calculated. The dynamic patterns over time of patient-reported outcome measures, BWC, I < O, and SE informed the oncology team on tolerance in real time.

RESULTS

The platform was installed in the home of 11 patients (48 to 72 years of age; 45% men; 27% with performance status = 0), who were instructed on its use on site. They received 26 cycles and provided 5,891 data points of 8,736 expected (67.4%). The most severe MD Anderson Symptom Inventory scores were: interference with work (mean: 5.1 of 10) or general activity (4.9), fatigue (4.9), distress (4.2), and appetite loss (3.6). Mean BWC was -0.9%, and mean SE remained > 82%. CircAct disruption (I < O ≤ 97.5%) was observed in four (15%) cycles before chronoIFLO4 start and in five (19%) cycles at day 14.

CONCLUSION

The patient-centered multidimensional telemonitoring solution implemented here was well accepted by patients receiving multidrug chemotherapy at home. Moreover, it demonstrated that chronoIFLO4 was a safe therapeutic option. Such integrated technology allows the design of innovative management approaches, ultimately improving patients' experience with chemotherapy, wellbeing, and outcomes.

A Patient-Centered Mobile Phone App (iHeartU) With a Virtual Human Assistant for Self-Management of Heart Failure: Protocol for a Usability Assessment Study

Background

Heart failure (HF) causes significant economic and humanistic burden for patients and their families, especially those with a low income, partly due to high hospital readmission rates. Optimal self-care is considered an important nonpharmacological aspect of HF management that can improve health outcomes. Emerging evidence suggests that self-management assisted by smartphone apps may reduce rehospitalization rates and improve the quality of life of patients. We developed a virtual human–assisted, patient-centered mobile health app (iHeartU) for patients with HF to enhance their engagement in self-management and improve their communication with health care providers and family caregivers. iHeartU may help patients with HF in self-management to reduce the technical knowledge and usability barrier while maintaining a low cost and natural, effective social interaction with the user.

Objective

With a standardized systematic usability assessment, this study had two objectives: (1) to determine the obstacles to effective and efficient use of iHeartU in patients with HF and (2) to evaluate of HF patients’ adoption, satisfaction, and engagement with regard to the of iHeartU app.

Methods

The basic methodology to develop iHeartU systems consists of a user-centric design, development, and mixed methods formative evaluation. The iterative design and evaluation are based on the guidelines of the American College of Cardiology Foundation and American Heart Association for the management of heart failure and the validated “Information, Motivation, and Behavioral skills” behavior change model. Our hypothesis is that this method of a user-centric design will generate a more usable, useful, and easy-to-use mobile health system for patients, caregivers, and practitioners.

Results

The prototype of iHeartU has been developed. It is currently undergoing usability testing. As of September 2018, the first round of usability testing data have been collected. The final data collection and analysis are expected to be completed by the end of 2019.

Conclusions

The main contribution of this project is the development of a patient-centered self-management system, which may support HF patients’ self-care at home and aid in the communication between patients and their health care providers in a more effective and efficient way. Widely available mobile phones serve as care coordination and “no-cost” continuum of care. For low-income patients with HF, a mobile self-management tool will expand their accessibility to care and reduce the cost incurred due to emergency visits or readmissions. The user-centered design will improve the level of engagement of patients and ultimately lead to better health outcomes. Developing and testing a novel mobile system for patients with HF that incorporates chronic disease management is critical for advancing research and clinical practice of care for them. This research fills in the gap in user-centric design and lays the groundwork for a large-scale population study in the next phase.

International Registered Report Identifier (IRRID)

DERR1-10.2196/13502

Designing meaningful outcome parameters using mobile technology: a new mobile application for telemonitoring of patients with heart failure

Aims

Health data captured by commercially available smart devices may represent meaningful patient‐reported outcome measures (PROMs) in heart failure (HF) patients. The purpose of this study was to test this hypothesis by evaluating the feasibility of a new telemonitoring concept for patients following initial HF hospitalization.

Methods and results

We designed a cardio patient monitoring platform (CPMP) that comprised mobile iOS‐based applications for patients' smartphone/smartwatch and the equivalent application on a physicians' tablet. It allowed for safe and continuous data transmission of self‐measured physiological parameters, activity data, and patient‐reported symptoms. In a prospective feasibility trial with 692 patient days from 10 patients hospitalized for newly diagnosed HF with reduced ejection fraction (mean left ventricular ejection fraction (LVEF) 26.5 ± 9.8%), we examined the CPMP during the first 2 months following discharge (69 ± 15 observation days per patient). The mean daily step count recorded by the mobile devices emerged as a promising new PROM. Its 14 day average increased over the study period (3612 ± 3311 steps/day at study inclusion and 7069 ± 5006 steps/day at end of study; P < 0.0001). It is unique for continuously reflecting real‐life activity and correlated significantly with traditional surrogate parameters of cardiac performance including LVEF (r = 0.44; 95% CI 0.07–0.71; P = 0.0232), 6 min walk test (r = 0.67; 95% CI 0.38–0.84; P = 0.0002), and scores in health‐related quality of life questionnaires.

Conclusions

We provide the first patient monitoring platform for HF patients that relies on commercially available iOS/watchOS‐based devices. Our study suggests it is ready for implementation as a tool for recording meaningful PROMs in future HF trials and telemonitoring.

Evaluating the Use of Mobile Health Technology in Older Adults With Heart Failure: Mixed-Methods Study

BACKGROUND

Heart failure (HF) is associated with high rates of hospitalizations, morbidity, mortality, and costs. Remote patient monitoring (mobile health, mHealth) shows promise in improving self-care and HF management, thus increasing quality of care while reducing hospitalizations and costs; however, limited information exists regarding perceptions of older adults with HF about mHealth use.

OBJECTIVE

This study aimed to compare perspectives of older adults with HF who were randomized to either (1) mHealth equipment connected to a 24-hour call center, (2) digital home equipment, or (3) standard care, with regard to ease and satisfaction with equipment, provider communication and engagement, and ability to self-monitor and manage their disease.

METHODS

We performed a pilot study using a mixed-methods descriptive design with pre- and postsurveys, following participants for 12 weeks. We augmented these data with semistructured qualitative interviews to learn more about feasibility, satisfaction, communication, and self-management.

RESULTS

We enrolled 28 patients with HF aged 55 years and above, with 57% (16/28) male, 79% (22/28) non-Hispanic white, and with multiple comorbid conditions. At baseline, 50% (14/28) rated their health fair or poor and 36% (10/28) and 25% (7/28) were very often/always frustrated and discouraged by their health. At baseline, 46% (13/28) did not monitor their weight, 29% (8/28) did not monitor their blood pressure, and 68% (19/28) did not monitor for symptoms. Post intervention, 100% of the equipment groups home monitored daily. For technology anxiety, 36% (10/28) indicated technology made them nervous, and 32% (9/28) reported fear of technology, without significant changes post intervention. Technology usability post intervention scored high (91/100), reflecting ease of use. A majority indicated that a health care provider should be managing their health, and 71% reported that one should trust and not question the provider. Moreover, 57% (16/28) believed it was better to seek professional help than caring for oneself. Post intervention, mHealth users relied more on themselves, which was not mirrored in the home equipment or standard care groups. Participants were satisfied with communication and engagement with providers, yet many described access problems. Distressing symptoms were unpredictable and prevailed over the 12 weeks with 79 provider visits and 7 visits to emergency departments. The nurse call center received 872 readings, and we completed 289 telephone calls with participants. Narrative data revealed the following main themes: (1) traditional communication and engagement with providers prevailed, delaying access to care; (2) home monitoring with technology was described as useful, and mHealth users felt secure knowing that someone was observing them; (3) equipment groups felt more confident in self-monitoring and managing; and finally, (4) uncertainty and frustration with persistent health problems.

CONCLUSIONS

mHealth equipment is feasible with potential to improve patient-centered outcomes and increase self-management in older adults with HF.

HF app to support self-care among community dwelling adults with HF: A feasibility study

BACKGROUND

The prevalence of Heart Failure (HF) is expected to increase by 46% from 2012 to 2030, which will result in over 8 million adults with HF. The development and testing of interventions that can support HF self-care behaviors is critical.

AIM

Determine the: 1) feasibility of using the HF App in middle to older adult community dwelling patients with HF; and 2) acceptability of using the HF App mobile health application.

METHODS

A convenience sample of community dwelling HF participants daily used the HF App to enter physiologic data, answer questions about symptoms, reviewed HF education within the application and received reminders over a two-week period. Feasibility and acceptability measures were assessed using data extracted from the principal investigator's qualitative diary. In addition, two acceptability questionnaires were utilized.

RESULTS

All participants enrolled (N = 10) completed the two-week period. Participant mean age was 64.5 years. The mean scores on the acceptability of the HF App 19 (SD 2.87) indicated increased perceived benefit of using the app while the mean scores of acceptability of the education offered in the app 12.4 (SD 2.84) indicated that participants positively benefited from viewing the education. Qualitative results indicated that participants were more aware of their symptoms and the need to self-monitor.

CONCLUSIONS

This feasibility study points to the incorporation of mobile applications to support self-care as promising research that can be useful to aid middle to older individuals in performing effective HF self-care but further studies with a larger randomized sample is needed.

Evaluating utility and compliance in a patient-based eHealth study using continuous-time heart rate and activity trackers

Telemedicine has been used to remotely diagnose and treat patients, yet previously applied telemonitoring approaches have been fraught with adherence issues. The primary goal of this study was to evaluate the adherence rates using a consumer-grade continuous-time heart rate and activity tracker in a mid-risk cardiovascular patient population. As a secondary analysis, we show the ability to utilize the information provided by this device to identify information about a patient's state by correlating tracker information with patient-reported outcome survey scores. We showed that using continuous-time activity trackers with heart rate monitors can be effective in a telemonitoring application, as patients had a high level of adherence (90.0% median usage) and low attrition (0.09% decrease per day) over a 90-day period. Furthermore, data collected correlated significantly with clinically relevant patient surveys (r2=0.15 for PROMIS global health scores, p < .00001), and therefore might provide an effective signal for identifying patients in need of intervention.

The Digital Outcome Measure

Improving clinical outcomes remains the gold standard in advancing healthcare. Focusing on outcomes holds the potential to unite all clinical stakeholders including payers, industry, providers, and patients. Yet, the dominant ways in which outcomes are captured, provider-collected or patient-reported, have significant limitations. The emerging field of biosensors and wearables, which aims to capture many types of health data, holds promise to specifically capture outcomes while complementing existing outcome collection methods. A digital outcome measure, unlike a traditional provider-collected or patient-reported outcome measure, depends less on active patient or provider participation. Thus, digital outcome measures may be more amenable to standardization as well as greater collection consistency, frequency, and accuracy.

Mobile health applications in cardiovascular research

Cardiovascular disease is the leading cause of mortality and morbidity globally. With widespread and growing use of smart phones and mobile devices, the use of mobile health (mHealth) in transmission of physiologic parameters and patient-referred symptoms to healthcare providers and researchers, as well as reminders and care plan applications from providers to patients, has potential to revolutionize both clinical care and the conduct of clinical trials with improved designs, data capture, and potentially lower costs. In randomized early phase proof-of-concept studies, focusing on lifestyle intervention, there is evidence that mHealth technology can improve outcomes. By contrast, results from small randomized controlled trials that tested mHealth interventions in heart failure patients were disappointing with inconsistent findings. These inconclusive results could be partially attributed to a lack of methodological rigor (insufficient sample size, quasi-experimental design, inadequate mHealth equipment). Therefore, there is an urgent need to develop systematic evidence-based guidelines and parameters for mHealth to be effectively utilized in cardiovascular clinical trials.

Mobile Phone Apps to Support Heart Failure Self-Care Management: Integrative Review

Background

With an explosive growth in mobile health, an estimated 500 million patients are potentially using mHealth apps for supporting health and self-care of chronic diseases. Therefore, this review focused on mHealth apps for use among patients with heart failure.

Objective

The aim of this integrative review was to identify and assess the functionalities of mHealth apps that provided usability and efficacy data and apps that are commercially available without supporting data, all of which are to support heart failure self-care management and thus impact heart failure outcomes.

Methods

A search of published, peer-reviewed literature was conducted for studies of technology-based interventions that used mHealth apps specific for heart failure. The initial database search yielded 8597 citations. After filters for English language and heart failure, the final 487 abstracts was reviewed. After removing duplicates, a total of 18 articles that tested usability and efficacy of mobile apps for heart failure self-management were included for review. Google Play and Apple App Store were searched with specified criteria to identify mHealth apps for heart failure. A total of 26 commercially available apps specific for heart failure were identified and rated using the validated Mobile Application Rating Scale.

Results

The review included studies with low-quality design and sample sizes ranging from 7 to 165 with a total sample size of 847 participants from all 18 studies. Nine studies assessed usability of the newly developed mobile health system. Six of the studies included are randomized controlled trials, and 4 studies are pilot randomized controlled trials with sample sizes of fewer than 40. There were inconsistencies in the self-care components tested, increasing bias. Thus, risk of bias was assessed using the Cochrane Collaboration’s tool for risk of selection, performance, detection, attrition, and reporting biases. Most studies included in this review are underpowered and had high risk of bias across all categories. Three studies failed to provide enough information to allow for a complete assessment of bias, and thus had unknown or unclear risk of bias. This review on the commercially available apps demonstrated many incomplete apps, many apps with bugs, and several apps with low quality.

Conclusions

The heterogeneity of study design, sample size, intervention components, and outcomes measured precluded the performance of a systematic review or meta-analysis, thus introducing bias of this review. Although the heart failure–related outcomes reported in this review vary, they demonstrated trends toward making an impact and offer a potentially cost-effective solution with 24/7 access to symptom monitoring as a point of care solution, promoting patient engagement in their own home care.

Mobile Technologies for Managing Heart Failure: A Systematic Review and Meta-analysis

BACKGROUND

Randomized clinical trials (RCTs) conducted among heart failure (HF) patients have reported that mobile technologies can improve HF-related outcomes. Our aim was to conduct a meta-analysis to evaluate m-Health's impact on healthcare services utilization, mortality, and cost.

METHODS

We searched MEDLINE, Cochrane, CINAHL, and EMBASE for studies published between 1966 and May-2017. We included studies that compared the use of m-Health in HF patients to usual care. m-Health is defined as the use of mobile computing and communication technologies to record and transmit data. The outcomes were HF-related and all-cause hospital days, cost, admissions, and mortality.

RESULTS

Our search strategy resulted in 1,494 articles. We included 10 RCTs and 1 quasi-experimental study, which represented 3,109 patients in North America and Europe. Patient average age range was 53-80 years, New York Heart Association (NYHA) class III, and Left Ventricular Ejection Fraction <50%. Patients were mostly monitored daily and followed for an average of 6 months. A reduction was seen in HF-related hospital days. Nonsignificant reductions were seen in HF-related cost, admissions, and mortality and total mortality. We found no significant differences for all-cause hospital days and admissions, and an increase in total cost.

CONCLUSIONS

m-Health reduced HF-related hospital days, showed reduction trends in total mortality and HF-related admissions, mortality and cost, and increased total costs related to more clinic visits and implementation of new technologies. More studies reporting consistent quality outcomes are warranted to give conclusive information about the effectiveness and cost-effectiveness of m-Health interventions for HF.

Addition of Blood Pressure and Weight Transmissions to Standard Remote Monitoring of Implantable Defibrillators and its Association with Mortality and Rehospitalization

BACKGROUND

Among patients with implantable defibrillators (ICD), use of remote patient monitoring (RPM) is associated with lower risk of death and rehospitalization. Standard ICD RPM can be supplemented with weight and blood pressure data. It is not known whether standard RPM plus routine weight and blood pressure transmission (RPM+) is associated with better outcomes.

METHODS AND RESULTS

RPM+ patients (n=4106) were compared with patients who only transmitted standard ICD RPM data (n=14 183). Logistic regression models identified patient, physician, and hospital characteristics associated with RPM+ utilization. Mortality and rehospitalization were examined using landmark analyses at 180 days after ICD implant in Medicare fee-for-service patients. In these analyses, we examined the independent association between RPM+ utilization and times to events up to 3 years after device implantation with Cox regression models. We further examined whether the association between RPM+ and outcomes varied by frequency or type of transmissions. Determinants of RPM+ utilization included impaired ejection fraction, cardiac resynchronization therapy, and institutional practice. The risk of mortality of RPM+ patients was similar to standard ICD RPM patients (hazard ratio, 1.06; 95% confidence interval, 0.94-1.19; P=0.34). RPM+ patients also had similar risks of all-cause hospitalization (subdistribution hazard ratio, 1.03; 95% confidence interval, 0.94-1.14; P=0.52), cardiovascular hospitalization (subdistribution hazard ratio, 0.92; 95% confidence interval, 0.83-1.02; P=0.15), or heart failure hospitalizations (subdistribution hazard ratio, 0.90; 95% confidence interval, 0.78-1.05; P=0.18). RPM+ transmission frequency was not associated with outcomes.

CONCLUSIONS

In patients using standard ICD RPM, the added transmission of weight and blood pressure data was not associated with improved outcomes.

Check and Report Ebola (CARE) Hotline: The User Perspective of an Innovative Tool for Postarrival Monitoring of Ebola in the United States

Background

The response to the 2014-2016 Ebola epidemic included an unprecedented effort from federal, state, and local public health authorities to monitor the health of travelers entering the United States from countries with Ebola outbreaks. The Check and Report Ebola (CARE) Hotline, a novel approach to monitoring, was designed to enable travelers to report their health status daily to an interactive voice recognition (IVR) system. The system was tested with 70 Centers for Disease Control and Prevention (CDC) federal employees returning from deployments in outbreak countries.

Objective

The objective of this study was to describe the development of the CARE Hotline as a tool for postarrival monitoring and examine the usage characteristics and user experience of the tool during a public health emergency.

Methods

Data were obtained from two sources. First, the CARE Hotline system produced a call log which summarized the usage characteristics of all 70 users’ daily health reports. Second, we surveyed federal employees (n=70) who used the CARE Hotline to engage in monitoring. A total of 21 (21/70, 30%) respondents were included in the survey analytic sample.

Results

While the CARE Hotline was used for monitoring, 70 users completed a total of 1313 calls. We found that 94.06% (1235/1313) of calls were successful, and the average call time significantly decreased from the beginning of the monitoring period to the end by 32 seconds (Z score=−6.52, P<.001). CARE Hotline call log data were confirmed by user feedback; survey results indicated that users became more familiar with the system and found the system easier to use, from the beginning to the end of their monitoring period. The majority of the users were highly satisfied (90%, 19/21) with the system, indicating ease of use and convenience as primary reasons, and would recommend it for future monitoring efforts (90%, 19/21).

Conclusions

The CARE Hotline garnered high user satisfaction, required minimal reporting time from users, and was an easily learned tool for monitoring. This phone-based technology can be modified for future public health emergencies.

Recruitment and Ongoing Engagement in a UK Smartphone Study Examining the Association Between Weather and Pain: Cohort Study

BACKGROUND

The huge increase in smartphone use heralds an enormous opportunity for epidemiology research, but there is limited evidence regarding long-term engagement and attrition in mobile health (mHealth) studies.

OBJECTIVE

The objective of this study was to examine how representative the Cloudy with a Chance of Pain study population is of wider chronic-pain populations and to explore patterns of engagement among participants during the first 6 months of the study.

METHODS

Participants in the United Kingdom who had chronic pain (≥3 months) and enrolled between January 20, 2016 and January 29, 2016 were eligible if they were aged ≥17 years and used the study app to report any of 10 pain-related symptoms during the study period. Participant characteristics were compared with data from the Health Survey for England (HSE) 2011. Distinct clusters of engagement over time were determined using first-order hidden Markov models, and participant characteristics were compared between the clusters.

RESULTS

Compared with the data from the HSE, our sample comprised a higher proportion of women (80.51%, 5129/6370 vs 55.61%, 4782/8599) and fewer persons at the extremes of age (16-34 and 75+). Four clusters of engagement were identified: high (13.60%, 865/6370), moderate (21.76%, 1384/6370), low (39.35%, 2503/6370), and tourists (25.44%, 1618/6370), between which median days of data entry ranged from 1 (interquartile range; IQR: 1-1; tourist) to 149 (124-163; high). Those in the high-engagement cluster were typically older, whereas those in the tourist cluster were mostly male. Few other differences distinguished the clusters.

CONCLUSIONS

Cloudy with a Chance of Pain demonstrates a rapid and successful recruitment of a large, representative, and engaged sample of people with chronic pain and provides strong evidence to suggest that smartphones could provide a viable alternative to traditional data collection methods.

Interventions to Improve Management of Chronic Conditions Among Racial and Ethnic Minorities

Digital and mhealth interventions can be effective in improving health outcomes among minority patients with diabetes, congestive heart failure, and chronic respiratory diseases. A number of electronic and digital approaches to individual and population-level interventions involving telephones, internet and web-based resources, and mobile platforms have been deployed to improve chronic disease outcomes. This paper summarizes the evidence supporting the efficacy of various behavioral and digital interventions targeting intermediate outcomes and hospitalizations with particular emphasis on studies examining the effects of these interventions on racial and ethnic minority population.