Implementation and Evaluation of a Smartphone-Based Telemonitoring Program for Patients With Heart Failure: Mixed-Methods Study Protocol

Textile-based Wearable to Monitor Heart Activity in Paediatric Population: A Pilot Study

Background

Cardiac monitoring for children with heart disease still employs common clinical techniques that require visits to hospital either in an ambulatory or inpatient setting. Frequent cardiac monitoring, such as heart rate monitoring, can limit children's physical activity and quality of life. The main objective of this study is to evaluate the performance of a textile-based device (SKIIN) in measuring heart rate (HR) in different tasks: lying down, sitting, standing, exercising, and cooling down.

Methods

Twenty participants including healthy children and children with heart disease were included in this study. The difference between the HRs recorded by the SKIIN was compared with a reference electrocardiogram collection by normalized root mean squared error. Participants completed a questionnaire on their experience wearing the textile device with additional parental feedback on the textile device collected.

Results

Participants had the median age of 14 years (range: 10-17 years), with body mass index 23.1 ± 3.8 kg/m2 and body surface area 1.70 ± 0.25 m2. The HR recorded by SKIIN and reference system significantly changes between tasks (P < 0.001), while not significantly different from each other (P > 0.05). The normalized root mean squared error was 3.8% ± 3.0% and 3.6% ± 3.7% for healthy and the heart disease groups, respectively. All participants found the textile device non-irritating and easy to wear.

Conclusions

This study provides proof of concept that HR can be robustly and conveniently monitored by smart textiles, with similar accuracy to standard-of-care devices.

A Voice App Design for Heart Failure Self-management: Proof-of-Concept Implementation Study

BACKGROUND

Voice user interfaces are becoming more prevalent in health care and are commonly being used for patient engagement. There is a growing interest in identifying the potential this form of interface has on patient engagement with digital therapeutics (DTx) in chronic disease management. Making DTx accessible through an alternative interaction model also has the potential to better meet the needs of some patients, such as older adults and those with physical and cognitive impairments, based on existing research.

OBJECTIVE

This study aimed to evaluate how participants with heart failure interacted with a voice app version of a DTx, Medly, through a proof-of-concept implementation study design. The objective was to understand whether the voice app would enable the participants to successfully interact with the DTx, with a focus on acceptability and feasibility.

METHODS

A mixed methods concurrent triangulation design was used to better understand the acceptability and feasibility of the use of the Medly voice app with the study participants (N=20) over a 4-week period. Quantitative data included engagement levels, accuracy rates, and questionnaires, which were analyzed using descriptive statistics. Qualitative data included semistructured interviews and were analyzed using a qualitative descriptive approach.

RESULTS

The overall average engagement level was 73% (SD 9.5%), with a 14% decline between results of weeks 1 and 4. The biggest difference was between the average engagement levels of the oldest and youngest demographics, 84% and 43%, respectively, but these results were not significant-Kruskal-Wallis test, H(2)=3.8 (P=.14). The Medly voice app had an overall accuracy rate of 97.8% and was successful in sending data to the clinic. From an acceptability perspective, the voice app was ranked in the 80th percentile, and overall, the users felt that the voice app was not a lot of work (average of 2.1 on a 7-point Likert scale). However, the overall average score for whether users would use it in the future declined by 13%. Thematic analysis revealed the following: the theme feasibility of clinical integration had 2 subthemes, namely users adapted to the voice app's conversational style and device unreliability, and the theme voice app acceptability had 3 subthemes, namely the device integrated well within household and users' lives, users blamed themselves when problems arose with the voice app, and voice app was missing specific, desirable user features.

CONCLUSIONS

In conclusion, participants were largely successful in using the Medly voice app despite some of the barriers faced, proving that an app such as this could be feasible to be deployed in the clinic. Our data begin to piece together the patient profile this technology may be most suitable for, namely those who are older, have flexible schedules, are confident in using technology, and are experiencing other medical conditions.

Using an Electronic App to Promote Home-Based Self-Care in Older Patients With Heart Failure: Qualitative Study on Patient and Informal Caregiver Challenges

Background

Heart failure (HF) affects many older individuals in North America, with recurrent hospitalizations despite postdischarge strategies to prevent readmission. Proper HF self-care can potentially lead to better clinical outcomes, yet many older patients find self-care challenging. Mobile health (mHealth) apps can provide support to patients with respect to HF self-care. However, many mHealth apps are not designed to consider potential patient barriers, such as literacy, numeracy, and cognitive impairment, leading to challenges for older patients. We previously demonstrated that a paper-based standardized diuretic decision support tool (SDDST) with daily weights and adjustment of diuretic dose led to improved self-care.

Objective

The aim of this study is to better understand the self-care challenges that older patients with HF and their informal care providers (CPs) face on a daily basis, leading to the conversion of the SDDST into a user-centered mHealth app.

Methods

We recruited 14 patients (male: 8/14, 57%) with a confirmed diagnosis of HF, aged ≥60 years, and 7 CPs from the HF clinic and the cardiology ward at the Hamilton General Hospital. Patients were categorized into 3 groups based on the self-care heart failure index: patients with adequate self-care, patients with inadequate self-care without a CP, or patients with inadequate self-care with a CP. We conducted semistructured interviews with patients and their CPs using persona-scenarios. Interviews were transcribed verbatim and analyzed for emerging themes using an inductive approach.

Results

Six themes were identified: usability of technology, communication, app customization, complexity of self-care, usefulness of HF-related information, and long-term use and cost. Many of the challenges patients and CPs reported involved their unfamiliarity with technology and the lack of incentive for its use. However, participants were supportive and more likely to actively use the HF app when informed of the intervention’s inclusion of volunteer and nurse assistance.

Conclusions

Patients with varying self-care adequacy levels were willing to use an mHealth app if it was simple in its functionality and user interface. To promote the adoption and usability of these tools, patients confirmed the need for researchers to engage with end users before developing an app. Findings from this study can be used to help inform the design of an mHealth app to ensure that it is adapted for the needs of older individuals with HF.

Impact of Remote Titration Combined With Telemonitoring on the Optimization of Guideline-Directed Medical Therapy for Patients With Heart Failure: Internal Pilot of a Randomized Controlled Trial

Background

To improve health outcomes in patients with heart failure, guideline-directed medical therapy (GDMT) should be optimized to target doses. However, GDMT remains underutilized, with less than 25% of patients receiving target doses in clinical practice. Telemonitoring could provide reliable and real-time physiological data for clinical decision support to facilitate remote GDMT titration.

Objective

This paper aims to present findings from an internal pilot study regarding the effectiveness of remote titration facilitated by telemonitoring.

Methods

A 2-arm randomized controlled pilot trial comparing remote titration versus standard care in a heart function clinic was conducted. Patients were randomized to undergo remote medication titration facilitated by data from a smartphone-based telemonitoring system or standard titration performed during clinic visits.

Results

A total of 42 patients with new-onset (10/42, 24%) and existing (32/42, 76%) heart failure and a mean age of 55.29 (SD 11.28) years were randomized between January and June 2019. Within 6 months of enrollment, 86% (18/21) of patients in the intervention group achieved optimal doses versus 48% (10/21) of patients in the control group. The median time to dose optimization was 11.0 weeks for the intervention group versus 18.8 weeks for the control group. The number of in-person visits in the intervention group was 54.5% lower than in the control group.

Conclusions

The results of this pilot study suggest that remote titration facilitated by telemonitoring has the potential to increase the proportion of patients who achieve optimal GDMT doses, decrease time to dose optimization, and reduce the number of clinic visits. Remote titration may facilitate optimal and efficient titration of patients with heart failure while reducing the burden for patients to attend in-person clinic visits.

Trial Registration

ClinicalTrials.gov NCT04205513; https://clinicaltrials.gov/ct2/show/NCT04205513

International Registered Report Identifier (IRRID)

RR2-10.2196/preprints.19705

Exploring perspectives, preferences and needs of a telemonitoring program for women at high risk for preeclampsia in a tertiary health facility of Karachi: a qualitative study protocol

Background

In Pakistan, deaths from preeclampsia/eclampsia (PE/E) represent one-third of maternal deaths reported at tertiary care hospitals. To reduce the morbidity and mortality associated with PE/E, an accessible strategy is to support pregnant women at high risk for preeclampsia (HRPE) by closely monitoring their blood pressures at home (i.e., telemonitoring) for the earliest signs of preeclampsia. This could lead to the earliest possible detection of high blood pressure, resulting in early intervention such as through medications, hospitalization, or delivery of the baby. The study aims to explore the perspectives, preferences and needs of telemonitoring (TM) for pregnant women at HRPE in Karachi, to inform future implementation strategies.

Methods

The study will employ an exploratory qualitative research design. The study will be conducted at the Jinnah Postgraduate Medical Centre (JPMC) hospital and Aga Khan University Hospital (AKUH) in Karachi, Sindh, Pakistan. Data will be collected through key-informant interviews (KIIs) and in-depth patient interviews (IDPIs). IDPIs will be conducted with the pregnant women at HRPE who are visiting the out-patient department/ antenatal clinics of JPMC hospital for antenatal check-ups and immunizations. KIIs will be conducted with the obstetricians, Maternal, neonatal and child health (MNCH) specialists and health care providers at JPMC, as well as TM experts from Karachi. Study data will be analyzed through conventional content analysis. Interviews are anticipated to begin in April 2020 and to be completed during the summer of 2020.

Discussion

This is the first study to explore the use of TM program for pregnant women at HRPE in a tertiary health facility in Karachi. The research will help explore perceived benefits associated with the use of a TM program alongside potential facilitators and barriers that may help inform the future implementation of a TM program for pregnant women at HRPE in Karachi.

Will applications on smartphones allow a generalization of telemedicine?

Background

Telemedicine is one of the healthcare sectors that has developed the most in recent years. Currently, telemedicine is mostly used for patients who have difficulty attending medical consultations because of where they live (teleconsultation) or for specialist referrals when no specialist of a given discipline is locally available (telexpertise). However, the use of specific equipment (with dedicated cameras, screens, and computers) and the need for institutional infrastructure made the deployment and use of these systems expensive and rigid. Although many telemedicine systems have been tested, most have not generally gone beyond local projects.

Our hypothesis is that the use of smartphones will allow health care providers to overcome some of the limitations that we have exposed, thus allowing the generalization of telemedicine.

Main body

This paper addresses the problem of telemedicine applications, the market of which is growing fast. Their development may completely transform the organization of healthcare systems, change the way patients are managed and revolutionize prevention. This new organization should facilitate the lives of both patients and doctors.

In this paper, we examine why telemedicine has failed for years to take its rightful place in many European healthcare systems although there was a real need. By developing the example of France, this article analyses the reasons most commonly put forth: the administrative and legal difficulties, and the lack of funding. We argue that the real reason telemedicine struggled to find its place was because the technology was not close enough to the patient.

Conclusion

Finally, we explain how the development of smartphones and their current ubiquitousness should allow the generalization of telemedicine in France and on a global scale.

Outcomes of a Heart Failure Telemonitoring Program Implemented as the Standard of Care in an Outpatient Heart Function Clinic: Pretest-Posttest Pragmatic Study

Background

Telemonitoring (TM) can improve heart failure (HF) outcomes by facilitating patient self-care and clinical decisions. The Medly program enables patients to use a mobile phone to record daily HF readings and receive personalized self-care messages generated by a clinically validated algorithm. The TM system also generates alerts, which are immediately acted upon by the patients’ existing care team. This program has been operating for 3 years as part of the standard of care in an outpatient heart function clinic in Toronto, Canada.

Objective

This study aimed to evaluate the 6-month impact of this TM program on health service utilization, clinical outcomes, quality of life (QoL), and patient self-care.

Methods

This pragmatic quality improvement study employed a pretest-posttest design to compare 6-month outcome measures with those at program enrollment. The primary outcome was the number of HF-related hospitalizations. Secondary outcomes included all-cause hospitalizations, emergency department visits (HF related and all cause), length of stay (HF related and all cause), and visits to the outpatient clinic. Clinical outcomes included bloodwork (B-type natriuretic peptide [BNP], creatinine, and sodium), left ventricular ejection fraction, and predicted survival score using the Seattle Heart Failure Model. QoL was measured using the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and the 5-level EuroQol 5-dimensional questionnaire. Self-care was measured using the Self-Care of Heart Failure Index (SCHFI). The difference in outcome scores was analyzed using negative binomial distribution and Poisson regressions for the health service utilization outcomes and linear regressions for all other outcomes to control for key demographic and clinical variables.

Results

Available data for 315 patients enrolled in the TM program between August 2016 and January 2019 were analyzed. A 50% decrease in HF-related hospitalizations (incidence rate ratio [IRR]=0.50; P<.001) and a 24% decrease in the number of all-cause hospitalizations (IRR=0.76; P=.02) were found when comparing the number of events 6 months after program enrollment with the number of events 6 months before enrollment. With regard to clinical outcomes at 6 months, a 59% decrease in BNP values was found after adjusting for control variables. Moreover, 6-month MLHFQ total scores were 9.8 points lower than baseline scores (P<.001), representing a clinically meaningful improvement in HF-related QoL. Similarly, the MLHFQ physical and emotional subscales showed a decrease of 5.4 points (P<.001) and 1.5 points (P=.04), respectively. Finally, patient self-care after 6 months improved as demonstrated by a 7.8-point (P<.001) and 8.5-point (P=.01) increase in the SCHFI maintenance and management scores, respectively. No significant changes were observed in the remaining secondary outcomes.

Conclusions

This study suggests that an HF TM program, which provides patients with self-care support and active monitoring by their existing care team, can reduce health service utilization and improve clinical, QoL, and patient self-care outcomes.

A Mobile Phone-Based Telemonitoring Program for Heart Failure Patients After an Incidence of Acute Decompensation (Medly-AID): Protocol for a Randomized Controlled Trial

BACKGROUND

Patients with heart failure (HF) are at the highest risk for hospital readmissions during the first few weeks after discharge when patients are transitioning from hospital to home. Telemonitoring (TM) for HF management has been found to reduce mortality risk and hospital readmissions if implemented appropriately; however, the impact of TM targeted for patients recently discharged from hospital, for whom TM might have the biggest benefit, is still unknown. Medly, a mobile phone-based TM system that is currently being used as a standard of care for HF at a large Canadian hospital, may be an effective tool for the management of HF in patients recently discharged from hospital.

OBJECTIVE

The objective of the Medly-After an Incidence of acute Decompensation (Medly-AID) trial is to determine the effect of Medly on the self-care and quality of life of patients with HF who have been recently discharged from hospital after an HF-related decompensation.

METHODS

A multisite multimethod randomized controlled trial (RCT) will be conducted at 2 academic hospitals and at least one community hospital to evaluate the impact of Medly-enabled HF management on the outcomes of patients with HF who had been hospitalized for HF-related decompensation and discharged during the 2 weeks before recruitment. The trial will include 144 participants with HF (74 in each control and intervention groups). Control patients will receive standard of care, whereas patients in the intervention group will receive standard of care and Medly. Specifically, patients in the intervention group will record daily weight, blood pressure, and heart rate and answer symptom-related questions via the Medly app. Medly will generate automated patient self-care messages such as to adjust diuretic medications, based on the rules-based algorithm personalized to the individual patient, and send real-time alerts to their health care providers as necessary. All patients will be followed for 3 months. Primary outcome measures are self-care and quality of life as measured through the validated questionnaires Self-Care of Heart Failure Index, EQ-5D-5L, and the Kansas City Cardiomyopathy Questionnaire-12. Secondary outcome measures for this study include cost of health care services used and health outcomes.

RESULTS

Patient recruitment began in November 2018 at the Sunnybrook Health Sciences Centre, with a total of 35 participants recruited by July 30, 2019 (17 in the intervention group and 18 in the control group). The final analysis is expected to occur in the fall of 2020.

CONCLUSIONS

This RCT will be the first to assess the effectiveness of the Medly TM system for use following discharge from hospital after a HF-related decompensation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03358303; https://clinicaltrials.gov/ct2/show/NCT03358303.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/15753.

Patient Adherence to a Mobile Phone-Based Heart Failure Telemonitoring Program: A Longitudinal Mixed-Methods Study

BACKGROUND

Telemonitoring (TM) can improve heart failure (HF) outcomes by facilitating patient self-care and clinical decision support. However, these outcomes are only possible if patients consistently adhere to taking prescribed home readings.

OBJECTIVE

The objectives of this study were to (1) quantify the degree to which patients adhered to taking prescribed home readings in the context of a mobile phone-based TM program and (2) explain longitudinal adherence rates based on the duration of program enrollment, patient characteristics, and patient perceptions of the TM program.

METHODS

A mixed-methods explanatory sequential design was used to meet the 2 research objectives, and all explanatory methods were guided by the unified theory of acceptance and use of technology 2 (UTAUT2). Overall adherence rates were calculated as the proportion of days patients took weight, blood pressure, heart rate, and symptom readings over the total number of days they were enrolled in the program up to 1 year. Monthly adherence rates were also calculated as the proportion of days patients took the same 4 readings over each 30-day period following program enrollment. Next, simple and multivariate regressions were performed to determine the influence of time, age, sex, and disease severity on adherence rates. Additional explanatory methods included questionnaires at 6 and 12 months probing patients on the perceived benefits and ease of use of the TM program, an analysis of reasons for patients leaving the program, and semistructured interviews conducted with a purposeful sampling of patients (n=24) with a range of adherence rates and demographics.

RESULTS

Overall average adherence was 73.6% (SD 25.0) with average adherence rates declining over time at a rate of 1.4% per month (P<.001). The multivariate regressions found no significant effect of sex and disease severity on adherence rates. When grouping patients' ages by decade, age was a significant predictor (P=.04) whereby older patients had higher adherence rates over time. Adherence rates were further explained by patients' perceptions with regard to the themes of (1) performance expectancy (improvements in HF management and peace of mind), (2) effort expectancy (ease of use and technical issues), (3) facilitating conditions (availability of technical support and automated adherence calls), (4) social influence (support from family, friends, and trusted clinicians), and (5) habit (degree to which taking readings became automatic).

CONCLUSIONS

The decline in adherence rates over time is consistent with findings from other studies. However, this study also found adherence to be the highest and most consistent over time in older age groups and progressively lower over time for younger age groups. These findings can inform the design and implementation of TM interventions that maximize patient adherence, which will enable a more accurate evaluation of impact and optimization of resources.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/resprot.9911.

User-Centered Adaptation of an Existing Heart Failure Telemonitoring Program to Ensure Sustainability and Scalability: Qualitative Study

BACKGROUND

Telemonitoring interventions for the management of heart failure have seen limited adoption in Canadian health systems, but isolated examples of telemonitoring programs do exist. An example of such a program was launched in a specialty heart failure clinic in Toronto, Canada, and a recent implementation evaluation concluded that reducing the cost of delivering the program is necessary to ensure its sustainability and scalability.

OBJECTIVE

The objectives of this study were to (1) understand which components of the telemonitoring program could be modified to reduce costs and adapted to other contexts while maintaining program fidelity and (2) describe the changes made to the telemonitoring program to enable its sustainability within the initial implementation site and scalability to other health organizations.

METHODS

Semistructured interviews probed the experiences of patients (n=23) and clinicians (n=8) involved in the telemonitoring program to identify opportunities for cost reduction and resource optimization. Ideas for adapting the program were informed by the interview results and prioritized based on (1) potential impact for sustainability and scalability, (2) feasibility, and (3) perceived risks to negatively impacting the program's ability to yield desired health outcomes.

RESULTS

A total of 5 themes representing opportunities for cost reduction were discussed, including (1) Bring Your Own Device (BYOD), (2) technical support, (3) clinician role, (4) duration of enrollment, and (5) intensity of monitoring. The hardware used for the telemonitoring system and the modalities of providing technical support were found to be highly adaptable, which supported the decision to implement a BYOD model, whereby patients used their own smartphone, weight scale, and blood pressure cuff. Changes also included the development of a website aimed at reducing the burden on a technical support telehealth analyst. In addition, the interviews suggested that although it is important to have a clinician who is part of a patient's circle of care monitoring telemonitoring alerts, the skill level and experience were moderately adaptable. Thus, a registered nurse was determined to be more cost-effective and was hired to replace the existing nurse practitioners in the frontline management of telemonitoring alerts and take over the technical support role from a telehealth analyst.

CONCLUSIONS

This study provides a user-centered example of how necessary cost-reduction actions can be taken to ensure the sustainability and scalability of telemonitoring programs. In addition, the findings offer insights into what components of a telemonitoring program can be safely adapted to ensure its integration in various clinical settings.

Evaluating the Implementation of a Mobile Phone-Based Telemonitoring Program: Longitudinal Study Guided by the Consolidated Framework for Implementation Research

BACKGROUND

Telemonitoring has shown promise for alleviating the burden of heart failure on individuals and health systems. However, real-world implementation of sustained programs is rare.

OBJECTIVE

The objective of this study was to evaluate the implementation of a mobile phone-based telemonitoring program, which has been implemented as part of standard care in a specialty heart function clinic by answering two research questions: (1) To what extent was the telemonitoring program successfully implemented? (2) What were the barriers and facilitators to implementing the telemonitoring program?

METHODS

We conducted a longitudinal single case study. The implementation success was evaluated using the following four implementation outcomes: adoption, penetration, feasibility, and fidelity. Semistructured interviews based on the Consolidated Framework for Implementation Research (CFIR) were conducted at 0, 4, and 12 months with 12 program staff members to identify the barriers and facilitators of the implementation.

RESULTS

One year after the implementation, 98 patients and 8 clinicians were enrolled in the program. Despite minor technical issues, the intervention was used as intended. We obtained qualitative data from clinicians (n=8) and implementation staff members (n=4) for 24 CFIR constructs. A total of 12 constructs were facilitators clustered in the CFIR domains of inner setting (culture, tension for change, compatibility, relative priority, learning climate, leadership engagement, and available resources), characteristics of individuals (knowledge and beliefs about the intervention and self-efficacy), and process (engaging and reflecting and evaluating). In addition, we identified other notable facilitators from the characteristics of the intervention domain (relative advantage and adaptability) and the outer setting (patient needs and resources). Four constructs were perceived as minor barriers- the complexity of the intervention, cost, inadequate communication among high-level stakeholders, and the absence of a formal implementation plan. The remaining CFIR constructs had a neutral impact on the overall implementation.

CONCLUSIONS

This is the first comprehensive evaluation of the implementation of a mobile phone-based telemonitoring program. Although the acceptability of the telemonitoring system was high, the strongest facilitators to the implementation success were related to the implementation context. By identifying what works and what does not in a real-world clinical context using a framework-guided approach, this work will inform the design of telemonitoring services and implementation strategies of similar telemonitoring interventions.