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Dang TH, Wickramasinghe N, Forkan ARM, Jayaraman PP, Burbury K, O'Callaghan C, Whitechurch A, Schofield P. Co-Design, Development, and Evaluation of a Mobile Solution to Improve Medication Adherence in Cancer: Design Science Research Approach. JMIR Cancer 2024; 10:e46979. [PMID: 38569178 PMCID: PMC11024750 DOI: 10.2196/46979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 01/27/2024] [Accepted: 02/14/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Medication nonadherence negatively impacts the health outcomes of people with cancer as well as health care costs. Digital technologies present opportunities to address this health issue. However, there is limited evidence on how to develop digital interventions that meet the needs of people with cancer, are perceived as useful, and are potentially effective in improving medication adherence. OBJECTIVE The objective of this study was to co-design, develop, and preliminarily evaluate an innovative mobile health solution called Safety and Adherence to Medication and Self-Care Advice in Oncology (SAMSON) to improve medication adherence among people with cancer. METHODS Using the 4 cycles and 6 processes of design science research methodology, we co-designed and developed a medication adherence solution for people with cancer. First, we conducted a literature review on medication adherence in cancer and a systematic review of current interventions to address this issue. Behavioral science research was used to conceptualize the design features of SAMSON. Second, we conducted 2 design phases: prototype design and final feature design. Last, we conducted a mixed methods study on patients with hematological cancer over 6 weeks to evaluate the mobile solution. RESULTS The developed mobile solution, consisting of a mobile app, a web portal, and a cloud-based database, includes 5 modules: medication reminder and acknowledgment, symptom assessment and management, reinforcement, patient profile, and reporting. The quantitative study (n=30) showed that SAMSON was easy to use (21/27, 78%). The app was engaging (18/27, 67%), informative, increased user interactions, and well organized (19/27, 70%). Most of the participants (21/27, 78%) commented that SAMSON's activities could help to improve their adherence to cancer treatments, and more than half of them (17/27, 63%) would recommend the app to their peers. The qualitative study (n=25) revealed that SAMSON was perceived as helpful in terms of reminding, supporting, and informing patients. Possible barriers to using SAMSON include the app glitches and users' technical inexperience. Further needs to refine the solution were also identified. Technical improvements and design enhancements will be incorporated into the subsequent iteration. CONCLUSIONS This study demonstrates the successful application of behavioral science research and design science research methodology to design and develop a mobile solution for patients with cancer to be more adherent. The study also highlights the importance of applying rigorous methodologies in developing effective and patient-centered digital intervention solutions.
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Affiliation(s)
- Thu Ha Dang
- Department of Psychological Sciences, School of Health Sciences, Swinburne University of Technology, Melbourne, Australia
- Digital Cancer Care Innovation, Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, Australia
- Digital Health Cooperative Research Centre, Sydney, Australia
| | - Nilmini Wickramasinghe
- Department of Health and Bio Statistics, School of Health Sciences, Swinburne University of Technology, Melbourne, Australia
- Epworth Healthcare, Melbourne, Australia
- Optus Chair Digital Health, La Trobe University, Melbourne, Australia
- Iverson Health Innovation Research Institute, Swinburne University of Technology, Melbourne, Australia
| | - Abdur Rahim Mohammad Forkan
- Digital Innovation Lab, Department of Computer Science and Software Engineering, School Software and Electrical Engineering, Swinburne University of Technology, Hawthorn, Australia
| | - Prem Prakash Jayaraman
- Factory of the Future and Digital Innovation Lab, School of Science, Computing and Engineering Technologies, Swinburne University of Technology, Melbourne, Australia
| | - Kate Burbury
- Digital and Healthcare Innovation, Peter McCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
| | - Clare O'Callaghan
- Caritas Christi and Psychosocial Cancer Care, St Vincent's Hospital, Melbourne, Australia
- Department of Medicine, St Vincent's Hospital, The University of Melbourne, Melbourne, Australia
| | - Ashley Whitechurch
- Department of Clinical Haematology, Peter MacCallum Cancer Centre & Royal Melbourne Hospital, Melbourne, Australia
| | - Penelope Schofield
- Department of Psychological Sciences, School of Health Sciences, Swinburne University of Technology, Melbourne, Australia
- Digital Cancer Care Innovation, Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, Australia
- Iverson Health Innovation Research Institute, Swinburne University of Technology, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
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Santamaria A, Antón Maldonado C, Sánchez-Quiñones B, Ibarra Vega N, Ayo González M, Gonzalez Cabezas P, Carrasco Moreno R. Implementing Telemedicine in Clinical Practice in the First Digital Hematology Unit: Feasibility Study. JMIR Form Res 2023; 7:e48987. [PMID: 38048143 PMCID: PMC10728787 DOI: 10.2196/48987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 09/17/2023] [Accepted: 10/25/2023] [Indexed: 12/05/2023] Open
Abstract
BACKGROUND Currently, there are no telemedicine models that fully integrate all areas of hematology into daily practice. OBJECTIVE The objectives of this feasibility study were to assess the practicality of implementing telemedicine into our clinical practice in the first Digital Hematology Unit and propose an innovative integrative design for clinical practice. METHODS We designed the Digital Hematology Unit, which is a specific physical space dedicated to carrying out telemedicine and monitoring patients in a holistic way. Also, a satisfaction questionnaire was performed and health care indicators were measured. RESULTS In 2021, there were 1331 first visits and 7534 follow-up visits. Of the first visits, 12.2% (n=163) were face-to-face and 87.8% (n=1168) were telematic. For follow-up visits, 29.9% (n=2251) were face-to-face and 70.1% (n=5283) were telematic. The health care management indicators showed that we had a waiting time of less than 4 days and took less than 4 hours to answer interconsultations among specialists. Moreover, patients reported a high level of satisfaction with the services provided. CONCLUSIONS Our Digital Hematology Unit, as a case of success, serves as an example of how innovative digital solutions can contribute to the quality of care and excellence in health care achieved through a digital transformation process led by hematologists.
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Affiliation(s)
- Amparo Santamaria
- Hematology Department, University Hospital Vinalopó, Alicante, Spain
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3
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Báez Gutiérrez N, Rodríguez Ramallo H, Fernández González M, Abdel-Kader Martín L. Smartphone Apps for Patients With Hematologic Malignancies: Systematic Review and Evaluation of Content. JMIR Mhealth Uhealth 2022; 10:e35851. [PMID: 36125860 PMCID: PMC9533204 DOI: 10.2196/35851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 06/21/2022] [Accepted: 09/02/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Hematological malignancies (HMs) are a heterogeneous group of cancers representing a significant cause of morbidity and mortality. The chronification of HMs and the increasing use of smartphones may lead patients to seek their current unmet needs through mobile health apps. OBJECTIVE The goal of this review was to identify and assess the quality of smartphone apps aimed at patients diagnosed with HMs. METHODS A systematic search of apps that were aimed at patients diagnosed with HMs, accessed from a Spain IP address, and were available on the iOS (App Store) and Android (Google Play) platforms was conducted in November 2021. The search terms used were "hematology," "blood cancer," "leukemia," "lymphoma," and "myeloma" apps in English, Spanish, or both languages. The identified apps were downloaded and analyzed independently by 2 reviewers. Information about general app characteristics was collected. The Mobile Application Rating Scale (MARS) was used to assess quality. The resulting parameter of the analyses, the mean score of the apps, was compared by Student t test. RESULTS Overall, 18 apps were identified; 7 were available on Android, 5 were available on iOS, and 6 were available on both platforms. All included apps were free; 3 were published in 2021, and among the apps published before 2021, only 6 were updated in 2021. Most (16/18, 89%) of the apps were aimed at patients with leukemia or lymphoma (16). The primary purposes of the apps were to provide general information about the condition (16/18, 89%) and monitor symptoms and clinical parameters (11/18, 61%). Health care professionals contributed to the development of 50% (9/18) of apps; 6 were owned and supported by scientific societies, and 3 were developed with the participation of health care professionals. The mean MARS score for the overall quality of the apps was 3.1 (SD 1.0). The engagement and aesthetics subscales were the lowest rated subscales, with only 44% (8/18) and 67% (12/18), respectively, of the apps obtaining acceptable scores. None of the included apps proved clinical efficacy through clinical trials in patients with HMs. Statistically significant differences were found in the MARS scores between operating systems (+1.0, P=.003) in favor of iOS apps. The participation of health care professionals in the development of the apps did not have a statistically significant impact on the MARS scores. CONCLUSIONS This systematic search and evaluation identified few acceptable quality mobile apps for patients with HMs. Current and future apps for patients with HMs should provide evidence-based valuable information, improve user engagement, incorporate functions according to patient preferences, and generate evidence regarding the efficacy of app use by patients with HMs.
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Khadam S, Chu T, Deekes N, FitzGerald D, Preston A, Duncan N. An investigation of the use of app technology to support clinical management of patients with chronic myeloid leukaemia (CML). J Oncol Pharm Pract 2022:10781552221090904. [DOI: 10.1177/10781552221090904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction The availability of healthcare apps to support patient self-management of various medical conditions, including cancer, has increased considerably in the past decade. However, there are limited published data on the role of apps in the management of chronic myeloid leukaemia (CML). The primary aim of this study was to investigate the current and future role of apps as a means of supporting patients with CML. Methods A 31-item questionnaire was developed and distributed to patients via three on-line CML support groups. Results Responses were received from 286 patients. There was an approximate 2:1 female: male split and the majority (54%, n = 155) resided in the United Kingdom. 91% (n = 260) of respondents were currently receiving drug treatment for their CML. 23.4% (n = 67) of respondents were aware that apps were available to support their CML management and 11.5% (n = 33) had experience of using such an app. 94.1% (n = 238) of those who had not used a patient support app in the past stated that they would consider using an app in the future to help manage their disease. App awareness was significantly higher amongst male patients (30.3% vs. 19.9%). Likelihood of being a current or previous app user was higher amongst younger patients (16.3% for <55 years old vs. 5.6% for ≥55 years old) whilst younger patients and those with a more recent diagnosis of CML were both more likely to be interested in using an app in the future. When asked about potential app functionality, a drug interaction checker was the feature of greatest interest to respondents. Conclusions We have identified both a lack of awareness of and a low uptake of patient support apps amongst CML patients. Importantly, we have demonstrated a clear interest in CML-specific apps amongst this population. Based on the functionality that study participants were most interested in, we will work with health care professionals, app developers and patients to develop a new app to deliver holistic support to CML patients.
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Affiliation(s)
- Saffiya Khadam
- School of Pharmacy, University of Birmingham, Birmingham, UK
| | - Teresa Chu
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | - Andrea Preston
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Nick Duncan
- School of Pharmacy, University of Birmingham, Birmingham, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Skrabal Ross X, Gunn KM, Suppiah V, Patterson P, Boyle T, Carrington C, Tan SL, Ryan M, Joshi R, Olver I. A smartphone program to support adherence to oral chemotherapy in people with cancer: Proof-of-concept trial. Asia Pac J Clin Oncol 2022; 18:e378-e387. [PMID: 35098675 DOI: 10.1111/ajco.13656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 07/25/2021] [Indexed: 11/28/2022]
Abstract
AIM Nonadherence to oral chemotherapy (OC) can lead to health complications, including premature death. Mobile phones are increasingly used to deliver medication adherence interventions. However, there is limited evidence about mobile phone-based interventions to increase adherence to OC, specifically. This study explores the proof-of-concept of a smartphone program to support adherence to OC in people with cancer. METHODS This was a 10-week, nonrandomized, multisite trial. The outcomes assessed were acceptability, satisfaction with the intervention, adherence to OC, knowledge about OC, and side-effects presence and severity. The program consisted of short message service (SMS) reminders to take OC, as well as information about OC, including the management of side-effects. RESULTS Twenty-two participants (17-74 y/o, median age 60 y/o) were recruited at six hospitals. The sample included 10 different cancer diagnoses (predominance of breast cancer) and 11 OC medications. Acceptability of the intervention was high, with 95% of the enrolled participants completing postintervention measures, and 81% reporting high satisfaction with the program. The intervention was found to have no effect on supporting adherence to OC (assessed by self-report and medication event monitoring system) in this sample. An increase in knowledge about OC was observed at postintervention (p = 0.010). CONCLUSIONS This study demonstrated proof-of-concept of the smartphone program and highlighted the need for intervention and trial design-related refinements. Future work should evaluate the effect of the program on adherence to OC with nonadherent patients.
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Affiliation(s)
- Xiomara Skrabal Ross
- Cancer Research Institute, University of South Australia, Adelaide, Australia.,Allied Health and Human Performance, University of South Australia, Adelaide, Australia.,Research, Evaluation & Social Policy Unit, Canteen Australia, Sydney, Australia
| | - Kate M Gunn
- Cancer Research Institute, University of South Australia, Adelaide, Australia.,Department of Rural Health, University of South Australia, Adelaide, Australia
| | - Vijayaprakash Suppiah
- UniSA Clinical and Health Sciences, University of South Australia, Adelaide, Australia.,Australian Centre for Precision Health, University of South Australia, Adelaide, Australia
| | - Pandora Patterson
- Research, Evaluation & Social Policy Unit, Canteen Australia, Sydney, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Terry Boyle
- Allied Health and Human Performance, University of South Australia, Adelaide, Australia.,Australian Centre for Precision Health, University of South Australia, Adelaide, Australia
| | - Christine Carrington
- Department of Pharmacy, Princess Alexandra Hospital, Brisbane, Australia.,School of Pharmacy, University of Queensland, Brisbane, Australia
| | - Shir Ley Tan
- HPS Pharmacies, Calvary North Adelaide Hospital, Adelaide, Australia
| | - Marissa Ryan
- Department of Pharmacy, Princess Alexandra Hospital, Brisbane, Australia.,Centre for Online Health, The University of Queensland, Brisbane, Australia.,Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Rohit Joshi
- Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Ian Olver
- School of Psychology, University of Adelaide, Adelaide, South Australia, Australia
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Gagné M, Lauzier S, Lemay M, Loiselle CG, Provencher L, Simard C, Guillaumie L. Women with breast cancer's perceptions of nurse-led telephone-based motivational interviewing consultations to enhance adherence to adjuvant endocrine therapy: a qualitative study. Support Care Cancer 2022; 30:4759-4768. [PMID: 35133477 PMCID: PMC8825251 DOI: 10.1007/s00520-021-06692-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 11/10/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Daily adjuvant endocrine therapy (AET) for 5 or 10 years is the standard of care for women diagnosed with non-metastatic hormone receptor-positive breast cancer. However, many women experience AET-related issues that may hamper quality of life and adherence. Here, we aimed to describe women's perceptions of motivational interviewing (MI)-guided consultations delivered by a trained nurse navigator over the telephone to enhance AET adherence. METHODS Eighteen women who were first prescribed AET for non-metastatic breast cancer in the last 5 years, who self-reported AET-related issues, and who participated in at least two MI-guided consultations over a year were interviewed about their perceptions of the intervention, using a semi-structured interview guide. Audio recordings were transcribed verbatim and analyzed using a thematic analysis approach. RESULTS Three main themes emerged from the data about women's perceptions on MI-guided consultations. These consultations were described as (1) a person-centred experience, (2) providing key information about AET, and (3) supportive of present and future AET experience, by contributing to AET side-effect management, motivation, adherence, calming negative emotions, improving well-being and self-esteem, and making women to feel empowered. CONCLUSIONS Nurse-led telephone-based MI-guided consultations about AET were found to respond to participants' needs and to enhance participants' perceptions of being informed and being supported in experiencing various facets of AET. Telephone-based consultations for AET are perceived as a promising strategy in an increasing virtual care world.
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Affiliation(s)
- Myriam Gagné
- grid.17063.330000 0001 2157 2938Unity Health Toronto (St. Michael’s Hospital), affiliated with the University of Toronto, Toronto, ON Canada
| | - Sophie Lauzier
- grid.411081.d0000 0000 9471 1794Population Health and Optimal Health Practices Research Axis, CHU de Québec Research Center−Université Laval, Québec City, QC Canada ,grid.23856.3a0000 0004 1936 8390Faculty of Pharmacy, Université Laval, Québec City, QC Canada ,grid.498721.1Équipe de recherche Michel-Sarrazin en oncologie psychosociale et soins palliatifs (ERMOS), Québec City, QC Canada
| | - Martine Lemay
- grid.411081.d0000 0000 9471 1794Centre des maladies du sein, CHU de Québec-Université-Laval, Québec City, QC Canada
| | - Carmen G. Loiselle
- grid.14709.3b0000 0004 1936 8649Department of Oncology and Ingram School of Nursing, McGill University, Montreal, QC Canada
| | - Louise Provencher
- grid.23856.3a0000 0004 1936 8390Cancer Research Centre, Université Laval, Québec City, QC Canada
| | - Chantale Simard
- grid.265696.80000 0001 2162 9981Université du Québec à Chicoutimi, Chicoutimi, QC Canada
| | - Laurence Guillaumie
- grid.411081.d0000 0000 9471 1794Population Health and Optimal Health Practices Research Axis, CHU de Québec Research Center−Université Laval, Québec City, QC Canada ,grid.23856.3a0000 0004 1936 8390Faculty of Nursing, Université Laval, Québec City, QC Canada ,grid.23856.3a0000 0004 1936 8390Faculté des Sciences Infirmières, Université Laval Pavillon Ferdinand-Vandry, Local 3443, Québec, Québec G1V 0A6 Canada
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Dang TH, Forkan ARM, Wickramasinghe N, Jayaraman PP, Alexander M, Burbury K, Schofield P. Investigation of intervention solutions to enhance adherence to oral anti-cancer medicines in adults: an overview of reviews (Preprint). JMIR Cancer 2021; 8:e34833. [PMID: 35475978 PMCID: PMC9096640 DOI: 10.2196/34833] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/26/2022] [Accepted: 03/15/2022] [Indexed: 11/23/2022] Open
Abstract
Background Adherence to anticancer medicines is critical for the success of cancer treatments; however, nonadherence remains challenging, and there is limited evidence of interventions to improve adherence to medicines in patients with cancer. Objective This overview of reviews aimed to identify and summarize available reviews of interventions to improve adherence to oral anticancer medicines in adult cancer survivors. Methods A comprehensive search of 7 electronic databases was conducted by 2 reviewers who independently conducted the study selection, quality assessment using the A Measurement Tool to Assess Systematic Reviews 2, and data extraction. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 checklist was adapted to report the results. Results A total of 29 reviews were included in the narrative synthesis. The overall quality of the systematic reviews was low. The 4 main strategies to promote adherence were focused on education, reminders, behavior and monitoring, and multicomponent approaches. Digital technology–based interventions were reported in most reviews (27/29, 93%). A few interventions applied theories (10/29, 34%), design frameworks (2/29, 7%), or engaged stakeholders (1/29, 3%) in the development processes. The effectiveness of interventions was inconsistent between and within reviews. However, interventions using multiple strategies to promote adherence were more likely to be effective than single-strategy interventions (12/29, 41% reviews). Unidirectional communication (7/29, 24% reviews) and technology alone (11/29, 38% reviews) were not sufficient to demonstrate improvement in adherence outcomes. Nurses and pharmacists played a critical role in promoting patient adherence to oral cancer therapies, especially with the support of digital technologies (7/29, 24% reviews). Conclusions Multicomponent interventions are potentially effective in promoting patient adherence to oral anticancer medicines. The seamless integration of digital solutions with direct clinical contacts is likely to be effective in promoting adherence. Future research for developing comprehensive digital adherence interventions should be evidence-based, theory-based, and rigorously evaluated.
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Affiliation(s)
- Thu Ha Dang
- Department of Psychology, School of Health Sciences, Swinburne University of Technology, Melbourne, Australia
- Behavioural Sciences Unit, Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, Australia
- Digital Health Cooperative Research Centre, Sydney, Australia
| | - Abdur Rahim Mohammad Forkan
- Digital Innovation Lab, School of Science, Computing and Engineering Technologies, Swinburne University of Technology, Melbourne, Australia
| | - Nilmini Wickramasinghe
- Department Health and Bio Statistics, School of Health Sciences and Iverson Health Innovation Research Institute, Swinburne University of Technology, Melbourne, Australia
- Epworth Healthcare, Melbourne, Australia
| | - Prem Prakash Jayaraman
- Digital Innovation Lab, School of Science, Computing and Engineering Technologies, Swinburne University of Technology, Melbourne, Australia
| | - Marliese Alexander
- Pharmacy Department, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
| | - Kate Burbury
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
- Digital and Healthcare Innovation, Peter McCallum Cancer Centre, Melbourne, Australia
| | - Penelope Schofield
- Behavioural Sciences Unit, Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
- Department of Psychology, and Iverson Health Innovation Research Institute, Swinburne University of Technology, Melbourne, Australia
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Heiney SP, Sorrell M, Sheng J, Adams SA, Nelson K, Nguyen LA, Edwards A, Wickersham KE. Interventions to Improve Adherence to Tyrosine Kinase Inhibitors in Chronic Myeloid Leukemia: A Systematic Review. Am J Clin Oncol 2021; 44:291-298. [PMID: 33867480 DOI: 10.1097/coc.0000000000000818] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Lack of adherence to tyrosine kinase inhibitors (TKIs) is a significant problem resulting in incomplete cytogenetic response and increased mortality in patients with chronic myeloid leukemia (CML). Few studies have been conducted on interventions to improve adherence. The authors conducted a systematic review to explore studies that examined the impact of strategies to improve TKI adherence among individuals with CML. METHODS The first 2 authors completed a systematic literature review according to the guidelines in Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). Studies (n=2633) conducted between 1980 and 2019 were identified through 3 databases and examined for inclusion/exclusion criteria. RESULTS Fourteen studies were identified which met the eligibility criteria. The studies only examined adherence to imatinib, dasatinib, or nilotinib. Ten of the 14 used large data sets (commercial health insurance plans or Surveillance Epidemiology and End Results [SEER] data) for analysis. The majority of the studies used a cohort design. Adherence was defined and measured in a variety of ways with most studies using 80% or higher as adequate adherence. Strategies not focused on health care costs used a multidisciplinary team approach. CONCLUSION Development of evidence to improve treatment adherence to TKIs for CML have relied on large data sets rather than prospective trials. Current studies lack patient focused interventions.
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MESH Headings
- Health Care Costs
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/economics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/enzymology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/psychology
- Medication Adherence/psychology
- Medication Adherence/statistics & numerical data
- Prognosis
- Protein Kinase Inhibitors/economics
- Protein Kinase Inhibitors/therapeutic use
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Affiliation(s)
| | - McKenzie Sorrell
- Prisma Health-Midlands/USC School of Medicine Columbia, Internal Medicine Residency Program
- Medical University of South Carolina, Charleston, SC
| | | | - Swann A Adams
- College of Nursing
- Department of Epidemiology & Biostatistics, Arnold School of Public Health
| | | | | | - Amy Edwards
- Thomas Cooper Library, University of South Carolina
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Karim JL, Talhouk A. Person-Generated Health Data in Women's Health: Protocol for a Scoping Review. JMIR Res Protoc 2021; 10:e26110. [PMID: 34047708 PMCID: PMC8196349 DOI: 10.2196/26110] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 03/25/2021] [Accepted: 04/04/2021] [Indexed: 12/25/2022] Open
Abstract
Background Due to their ability to collect person-generated health data, digital tools and connected health devices may hold great utility in disease prevention, chronic disease self-monitoring and self-tracking, as well as in tailoring information and educational content to fit individual needs. Facilitators and barriers to the use of digital health technologies vary across demographics, including sex. The “femtech” market is growing rapidly, and women are some of the largest adopters of digital health technologies. Objective This paper aims to provide the background and methods for conducting a scoping review on the use of person-generated health data from connected devices in women’s health. The objectives of the scoping review are to identify the various contexts of digital technologies in women’s health and to consolidate women’s views on the usability and acceptability of the devices. Methods Searches were conducted in the following databases: Medline, Embase, APA PsycInfo, CINAHL Complete, and Web of Science Core Collection. We included articles from January 2015 to February 2020. Screening of articles was done independently by at least two authors in two stages. Data charting is being conducted in duplicate. Results will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist. Results Our search identified 9102 articles after deduplication. As of November 2020, the full-text screening stage is almost complete and data charting is in progress. The scoping review is expected to be completed by Fall 2021. Conclusions This scoping review will broadly map the literature regarding the contexts and acceptability of digital health tools for women. The results from this review will be useful in guiding future digital health and women’s health research. International Registered Report Identifier (IRRID) DERR1-10.2196/26110
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Affiliation(s)
- Jalisa Lynn Karim
- Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, ON, Canada.,Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
| | - Aline Talhouk
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
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10
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The effect of a mobile application on treatment adherence and symptom management in patients using oral anticancer agents: A randomized controlled trial. Eur J Oncol Nurs 2021; 52:101969. [PMID: 33991868 DOI: 10.1016/j.ejon.2021.101969] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 03/23/2021] [Accepted: 04/18/2021] [Indexed: 11/23/2022]
Abstract
PURPOSE The use of mobile health technologies in the management of oral anticancer agents (OAA) can be beneficial in terms of treatment adherence and symptom management. This study was conducted to investigate the effect of a mobile application developed for patients using OAA on treatment adherence and symptom management. METHOD The study was conducted using a randomized controlled trial design, and it was carried out on 77 patients. Data were collected from the Oral Chemotherapy Adherence Scale (OCAS), and the Memorial Symptom Assessment Scale (MSAS). Data were collected at the beginning of the research, and face-to-face interviews were conducted after one, three, and six months. Patients in the intervention group were followed up for six months using the mobile application. RESULTS It was found that there was no difference between the intervention and control groups in the baseline OCAS mean scores (p > 0.05), and the mean score of the intervention group increased over the first, third- and sixth-month measurements (p < 0.05). It was found that there was no difference between the intervention and control groups in the MSAS mean scores (p > .05), and there was a decrease in the mean MSAS score of the intervention group between the third- and sixth-month follow-up (p < .05). CONCLUSION The present study results showed that the mobile application is effective in managing symptoms and increasing treatment adherence. A well-designed mobile health application that increases treatment adherence, decreases symptom severity, and supports patients' self-management could be beneficial for patients using OAA. CLINICALTRIALS. GOV IDENTIFIER NCT04626830.
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Marshall VK, Given BA. Satisfaction With an Interactive Voice Response System and Symptom Management Toolkit Intervention to Improve Adherence in Patients Prescribed an Oral Anticancer Agent. Oncol Nurs Forum 2020; 47:637-648. [PMID: 33063783 DOI: 10.1188/20.onf.637-648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To describe patient satisfaction with an interactive voice response (IVR) system to assess adherence and symptom management in patients newly prescribed an oral anticancer agent (OAA). SAMPLE & SETTING Patients prescribed a new OAA were recruited from six comprehensive cancer centers in the United States. METHODS & VARIABLES Cross-sectional analysis and descriptive statistics were used to summarize patient demographics and satisfaction with the IVR system and symptom management toolkit. RESULTS Participants had a mean age of 61.82 years, and gastrointestinal cancer was most prevalent. Participants were either "very" or "highly" satisfied with the IVR weekly calling system to assess symptoms, the IVR system daily OAA adherence reminders, and the symptom management toolkit. IMPLICATIONS FOR NURSING Nurses often triage patient-reported issues with OAAs. Nurses are well positioned to lead IVR system symptom management interventions and to be actively involved in the development, implementation, and dissemination of IVR technologies through research and practice.
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Gambalunga F, Iacorossi L, Notarnicola I, Serra V, Piredda M, De Marinis MG. Mobile Health in Adherence to Oral Anticancer Drugs: A Scoping Review. Comput Inform Nurs 2020; 39:17-23. [PMID: 32568900 DOI: 10.1097/cin.0000000000000643] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In oncology, adherence to oral antineoplastic medication is a key element of treatment, on which the success of any therapeutic intervention depends. Given their widespread use in clinical practice, it is important to identify tools that can facilitate the monitoring and self-management of the patient at home, to avoid the consequences of employing ineffective treatment. One of the tools available today to take action on this phenomenon is mobile health technology. The aim of this review is to describe published studies relating to the use of mobile health to promote adherence to oral antineoplastic medication. This scoping review was conducted using the framework proposed by Arksey and O'Malley, adapted according to Levac et al. Of 1320 articles identified, only seven met the eligibility criteria and therefore were included in the review. All seven articles involved the use of digital means to measure adherence to treatment, patient satisfaction, acceptability and feasibility of the digital means used, and presence of symptoms, but not the effectiveness of the digital instrument used. In conclusion, the use of digital means to assist adherence of cancer patients to oral antineoplastic medication is widely recognized, but its effectiveness in clinical practice is poorly supported by the nature of the published studies.
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Affiliation(s)
- Francesca Gambalunga
- Author Affiliations: Department of Health Professions (DAPS), University Hospital "Policlinico Umberto I" (Ms Gambalunga); IRCCS "Regina Elena" National Cancer Institute (Dr Iacorossi and Ms Serra); Centre of Excellence for Nursing Scholarship OPI Rome Italy (Dr Notarnicola); and Research Unit Nursing Science, Campus Bio-Medico of Rome University (Drs Piredda and De Marinis), Rome, Italy
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13
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Rosenberg SM, Petrie KJ, Stanton AL, Ngo L, Finnerty E, Partridge AH. Interventions to Enhance Adherence to Oral Antineoplastic Agents: A Scoping Review. J Natl Cancer Inst 2020; 112:443-465. [PMID: 31899790 PMCID: PMC7225676 DOI: 10.1093/jnci/djz244] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 11/11/2019] [Accepted: 12/23/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND As new targeted oral antineoplastic therapies have emerged in recent years, the development of effective strategies that promote optimal adherence to cancer medication regimens has become an important priority. METHODS We conducted a scoping literature review to search for English language articles published through July 15, 2019, to identify studies that reported the testing and/or evaluation of interventions to improve adherence to oral antineoplastic agents. RESULTS A total of 56 articles were selected for review. Of the studies evaluated, 14 were randomized trials. All interventions except two targeted adult patients. Thirty-three studies enrolled fewer than 100 patients. Most interventions were education- and counseling-based and centered on provision of information about the drug and strategies to manage side effects. Only eight studies used an mHealth tool and/or text messages to target nonadherence. Among studies with a comparison sample, fewer than one-half (44.7%) reported statistically significant improvements in adherence or persistence associated with the intervention; however, some pharmacist-directed programs, particularly those that integrated monitoring or routine follow-up with a provider, did demonstrate efficacy. CONCLUSION Although the development of adherence-promoting interventions for oral antineoplastic therapies has increased recently, few have been rigorously tested. The nascent literature suggests those that are pharmacist directed and use regular monitoring show promise, though additional prospective studies are needed. Study methodology, population selection, and potential challenges that may be encountered in the implementation and dissemination phases should be considered when developing new interventions to address nonadherence to oral antineoplastic treatment.
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Affiliation(s)
| | - Keith J Petrie
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
| | - Annette L Stanton
- Jonsson Comprehensive Cancer Center, Department of Psychology, University of California Los Angeles, Los Angeles, CA, USA
- Department of Psychiatry/Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, USA
| | - Lan Ngo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Emma Finnerty
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Ann H Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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14
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Hong YA, Hossain MM, Chou WS. Digital interventions to facilitate patient‐provider communication in cancer care: A systematic review. Psychooncology 2020; 29:591-603. [DOI: 10.1002/pon.5310] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/12/2019] [Accepted: 12/01/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Y. Alicia Hong
- Department of Health Administration and Policy, College of Health and Human ServicesGeorge Mason University Fairfax Virginia
| | - Md Mahbub Hossain
- Department of Health Promotion and Community Health Sciences, School of Public HealthTexas A&M University College Station Texas
| | - Wen‐Ying Sylvia Chou
- Health Communication and Informatics Research Branch, Division of Cancer Control and Population ScienceNational Cancer Institute Bethesda Maryland
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15
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Zackon AY, Ayers AA, Yeager KA, Somma ML, Friedberg JW, Flowers CR, Nastoupil LJ. Maximizing the effectiveness of oral therapies in lymphoid cancers: research gaps and unmet needs. Leuk Lymphoma 2019; 60:2356-2364. [PMID: 31164024 PMCID: PMC6791753 DOI: 10.1080/10428194.2019.1594217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 02/27/2019] [Accepted: 03/05/2019] [Indexed: 12/27/2022]
Abstract
Oral therapies have become a common treatment choice for several lymphoid cancers. While therapeutic efficacy and patient preference for this therapy type have been reported, there is a lack of knowledge about its effectiveness for lymphoma in clinical practice, particularly in regard to the effects of medication nonadherence. While studies of oral medications in other diseases have shown that adherence is a major factor in outcomes and costs, there is scant research investigating adherence specifically in lymphoma patients, who face unique challenges in their diseases and treatments. To address the limited data available, we constructed a conceptual model and highlighted key opportunities for future research to better elucidate oral therapy adherence in lymphoma. This research will hopefully improve understanding and efficacy of oral treatment for lymphoma patients, while also informing other cancers utilizing oral therapies currently and in the future.
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Affiliation(s)
| | - Amy A. Ayers
- Winship Cancer Institute, Emory University, Atlanta, GA, U.S.A
| | | | - Mary L. Somma
- Scientific and Research Programs, Lymphoma Research Foundation, New York, NY, U.S.A
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16
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Russell L, Pascoe MC, Seymour JF, Aranda S, Butow P, Gough K, Schofield P. The trials and tribulations of conducting an m-health pilot randomized controlled trial to improve oral cancer therapy adherence: recommendations for future multisite, non-drug clinical trials. BMC Res Notes 2019; 12:226. [PMID: 30987685 PMCID: PMC6466650 DOI: 10.1186/s13104-019-4264-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 04/06/2019] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE Integrating mobile phone-based health (m-health) interventions into healthcare systems is one solution to improve access to services for the growing number of patients with chronic illness. Practical challenges such as poor recruitment and inadequate resource allocation can hamper the assessment of such interventions with clinical trial methodology. This paper highlights the challenges encountered during a pilot randomized controlled trial of an m-health medication adherence intervention and offers recommendations for future multi-site, non-drug clinical trials. RESULTS Eighteen patients were recruited to the study; eight were randomly allocated to the intervention arm. Intervention participants responded to their daily medication-reminder text messages, indicating that medication had been taken or not, and nurses were able to organize their calls around their workload. The trial closed prematurely primarily due to inadequate numbers of eligible patients; however, other potentially resolvable feasibility issues were identified. These included lack of infrastructure at study sites, poor screening data acquisition and management processes, and inexperience in conducting supportive care trials at participating sites. M-health intervention trials are designed to inform implementation of best supportive care practice. Adequate skills and infrastructure are research prerequisites that require careful consideration and sufficient investment for the successful execution of multi-site supportive care trials. Trial registration Australian and New Zealand Clinical Trials Register: ACTRN12612000635864.
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Affiliation(s)
- Lahiru Russell
- School of Nursing and Midwifery, Faculty of Health, Deakin University, Geelong, VIC Australia
| | - Michaela C. Pascoe
- Institute of Sport, Exercise and Active Living, Victoria University, Footscray, VIC Australia
| | - John F. Seymour
- Peter MacCallum Cancer Centre, Parkville, Melbourne, VIC Australia
- Royal Melbourne Hospital, Parkville, Melbourne, VIC Australia
- University of Melbourne, Melbourne, VIC Australia
| | - Sanchia Aranda
- University of Melbourne, Melbourne, VIC Australia
- Cancer Council Australia, Sydney, Australia
| | - Phyllis Butow
- Department of Psychology, University of Sydney, Sydney, Australia
| | - Karla Gough
- Peter MacCallum Cancer Centre, Parkville, Melbourne, VIC Australia
- University of Melbourne, Melbourne, VIC Australia
| | - Penelope Schofield
- Peter MacCallum Cancer Centre, Parkville, Melbourne, VIC Australia
- University of Melbourne, Melbourne, VIC Australia
- Swinburne University of Technology, Hawthorn, VIC Australia
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Crawford SY, Boyd AD, Nayak AK, Venepalli NK, Cuellar S, Wirth SM, Hsu GIH. Patient-centered design in developing a mobile application for oral anticancer medications. J Am Pharm Assoc (2003) 2019; 59:S86-S95.e1. [PMID: 30745188 DOI: 10.1016/j.japh.2018.12.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 11/28/2018] [Accepted: 12/11/2018] [Indexed: 01/14/2023]
Abstract
OBJECTIVES To develop and test the usability and feasibility of a customizable mobile application (app) designed to help educate patients about their oral anticancer medications (OAMs) and regimens. SETTING Outpatient cancer center and oncology pharmacy for urban, Midwestern academic health system. PRACTICE DESCRIPTION Clinically-supervised educational intervention to support patients learning about OAMs. PRACTICE INNOVATION With input from patient partners, our interdisciplinary team designed the first known tablet-based educational app that can interface with a patient's electronic medical record. The app is based on learning style and adherence theories and is customizable for individually prescribed OAMs. The app can accommodate multiple learning styles through text at 6th-grade reading level, pictures, animations, and audio voiceovers. Functionalities include interactive educational modules on 11 OAMs and case-based patient stories on common barriers to OAM adherence. EVALUATION Early phase testing provided the opportunity to observe the user interface with the app and app functionality. Data were summarized descriptively from observations and comments of patient subjects. RESULTS Thirty patient subjects provided input-19 in phase 1 usability testing and 11 in phase 2 feasibility testing. Comments provided by patient subjects during usability testing were largely positive. Responses included self-identification with patient stories, usefulness of drug information, preferences for text messages, and app limitations (e.g., perceived generational digital divide in technology use and potential patient inability to receive text messages). Using their feedback, modifications were made to the prototype app. Responses in feasibility testing demonstrated the app's usefulness across a wide range of ages. Highest opinion ratings on app usefulness were stated by patients who were newer to OAM therapy. CONCLUSION User feedback suggests the potential benefit of the app as a tool to help patients with cancer, particularly after the first months for those starting new OAM regimens. Processes and lessons learned are transferable to other settings.
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Skrabal Ross X, Gunn KM, Patterson P, Olver I. Mobile-Based Oral Chemotherapy Adherence-Enhancing Interventions: Scoping Review. JMIR Mhealth Uhealth 2018; 6:e11724. [PMID: 30578182 PMCID: PMC6320412 DOI: 10.2196/11724] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 10/03/2018] [Accepted: 10/08/2018] [Indexed: 12/14/2022] Open
Abstract
Background Adherence to oral chemotherapy is crucial to maximize treatment outcomes and avoid health complications in cancer patients. Mobile phones are widely available worldwide, and evidence that this technology can be successfully employed to increase medication adherence for the treatment of other chronic diseases (eg, diabetes) is well established. However, the extent to which there is evidence that mobile phone–based interventions improve adherence to oral chemotherapy is unknown. Objective This scoping review aims to explore what is known about mobile phone–delivered interventions designed to enhance adherence to oral chemotherapy, to examine the reported findings on the utility of these interventions in increasing oral chemotherapy adherence, and to identify opportunities for development of future interventions. Methods This study followed Arksey and O’Malley’s scoping review methodological framework. Results The review search yielded 5 studies reporting on 4 interventions with adults (aged >18 years) diagnosed with diverse cancer types. All interventions were considered acceptable, useful, and feasible. The following themes were evident: text messages and mobile apps were the main methods of delivering these interventions, the 2 most commonly employed oral chemotherapy adherence–enhancing strategies were management and reporting of drug-related symptoms and reminders to take medication, the importance of stakeholders’ engagement in intervention design, and the overall positive perceptions of delivery features. Areas for future research identified by this review include the need for further studies to evaluate the impact of mobile phone–delivered interventions on adherence to oral chemotherapy as well as the relevance for future studies to incorporate design frameworks and economic evaluations and to explore the moderator effect of high anxiety, poor baseline adherence, and longer time taking prescribed drug on adherence to oral chemotherapy. Conclusions Despite the increasing body of evidence on the use of mobile phones to deliver medication adherence–enhancing interventions in chronic diseases, literature on the oral chemotherapy context is lacking. This review showed that existing interventions are highly acceptable and useful to cancer patients. The engagement of stakeholders as well as the use of a design framework are important elements in the development of mobile phone–delivered interventions that can be translated into oncology settings.
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Affiliation(s)
- Xiomara Skrabal Ross
- Cancer Research Institute, University of South Australia, Adelaide, Australia.,School of Health Sciences, University of South Australia, Adelaide, Australia
| | - Kate M Gunn
- Cancer Research Institute, University of South Australia, Adelaide, Australia
| | - Pandora Patterson
- Cancer Nursing Research Unit, University of Sydney, Sydney, Australia.,Research, Evaluation, and Social Policy Team, CanTeen Australia, Sydney, Australia
| | - Ian Olver
- Cancer Research Institute, University of South Australia, Adelaide, Australia
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How should we assess patient-reported outcomes in the onco-hematology clinic? Curr Opin Support Palliat Care 2018; 12:522-529. [DOI: 10.1097/spc.0000000000000386] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Challenges to the design and testing supportive interventions for cancer patients treated with oral oncolytic agents. Support Care Cancer 2018; 26:3975-3977. [PMID: 30136026 DOI: 10.1007/s00520-018-4414-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 08/08/2018] [Indexed: 10/28/2022]
Abstract
Conducting research into supportive care for patients as they initiate treatment with oral oncolytic agents poses numerous new challenges. Some of these medications have very complex dosing schedules and produce symptoms that patients need to manage at home with less reliance on oncology clinicians. We describe lessons learned from a multi-site trial designed to improve adherence to these medications and self-management of symptoms among patients newly prescribed oral oncolytic agents. Identifying these challenges can assist researchers to improve the integrity of their future supportive care trials.
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