mHealth interventions in the management of heart failure, ischaemic heart disease and hypertension: a systematic review and meta-analysis of randomised controlled trials

Introduction

Cardiovascular disease (CVD) remains the leading cause of death in the world. Mobile phones have become ubiquitous in most developed societies. Smartphone applications, telemonitoring and clinician-driven short message service (SMS) allow for novel methods in managing chronic cardiovascular conditions such as ischaemic heart disease, heart failure and hypertension.

Purpose

To evaluate the impact of mobile phone-based interventions (MPIs) on mortality, hospitalisations and blood pressure and body mass index (BMI) in patients diagnosed with either acute coronary syndrome, heart failure or hypertension.

Methods

A systematic review was conducted using seven electronic databases, identifying all randomised control trials (RCTs) featuring an MPI in the management of these conditions. Meta-analysis was performed by using standard analytical techniques. The odds ratio (OR) was used as a summary statistic.

Results

Twenty-six RCTs including 6,713 patients were identified. Of these 26 studies, 13 examined text messaging intereventions, 10 studied telemonitoring interventions and three described smartphone applications with other functions. Twelve studies were included for meta-analysis. In patients with heart failure (n=1683), MPIs were associated with a significantly lower rate of all-cause hospital admissions at six months (31% vs. 36%, OR 0.77, 95% CI 0.62–0.97, p=0.03, I2 = 0). A significant difference was also demonstrated for heart-failure admissions (14.0% vs. 18.5%, OR 0.69, 95% CI 0.48 to 0.98, p=0.04, I2 = 26%). There was no difference in mortality (10.4% vs. 11.6% p=0.45). In patients with hypertension, the difference in systolic BP was 4.3mmHg less in the intervention group (95% CI: −7.8 to −0.78 mmHg, p=0.02). Four studies examined medication compliance as an endpoint in patients with ischaemic heart disease, and all four demonstrated a significant difference favouring the MPI group (see table 1). However, due to variable quantification of compliance, meta-analysis was not possible. There was no significant difference in the change in BMI from four studies after six or more months (mean difference −0.46, 95% CI: −1.44 to 0.52, P=0.36).

Conclusions

The available data suggests MPIs may have a role as valuable adjuncts in the management of chronic CVD.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Health and Medical Research Council (NHMRC)

Electrically injected 1.64µm emitting In0.65Ga0.35As 3-QW laser diodes grown on mismatched substrates by MOVPE

We report the characteristics of the strained In_0.65Ga_0.35As triple quantum well (QW) diode lasers grown by metalorganic vapor phase epitaxy (MOVPE) on lattice-mismatched substrates such as GaAs or Si, by utilizing InP metamorphic buffer layers (MBLs) in conjunction with InAs nanostructure-based dislocation filters. As the lattice-mismatch between the substrate and InP MBL increases, higher threshold current densities and lower slope efficiencies were observed, together with higher temperature sensitivities for the threshold current and slope efficiency. Structural analysis performed by both high-resolution X-ray diffraction (HR-XRD) and transmission electron microscopy indicates graded and/or rougher QW interfaces within the active region grown on the mismatched substrate, which accounts for the observed devices characteristics.

Inertial wearables as pragmatic tools in dementia

Dementia is a critically important issue due to its wide impact on health services as well as its personal and societal costs. Limitations exist for current dementia protocols, and there are calls to introduce modern technology that facilitates the addition of digital biomarkers to routine clinical practice. Wearable technology (wearables) are nearly ubiquitous in everyday life, gathering discrete and continuous digital data on habitual activities, but their utility in modern medicine remains low. Due to advances in data analytics, wearables are now commonly discussed as pragmatic tools to aid the diagnosis and treatment of a range of neurological disorders. Inertial sensor-based wearables are one such technology; they offer a low-cost approach to quantify routine movements that are fundamental to normal activities of daily living, most notably postural control and gait. Here, we provide a narrative review of how wearables are providing useful postural control and gait data to facilitate the capture of digital markers to aid dementia research. We outline the history of wearables, from their humble beginnings to their current use beyond the clinic, and explore their integration into modern systems, as well as the ongoing standardisation and regulatory efforts to integrate their use in clinical trials.

Coordination and trade-offs among hydraulic safety, efficiency and drought avoidance traits in Amazonian rainforest canopy tree species

Predicting responses of tropical forests to climate change-type drought is challenging because of high species diversity. Detailed characterization of tropical tree hydraulic physiology is necessary to evaluate community drought vulnerability and improve model parameterization. Here, we measured xylem hydraulic conductivity (hydraulic efficiency), xylem vulnerability curves (hydraulic safety), sapwood pressure-volume curves (drought avoidance) and wood density on emergent branches of 14 common species of Eastern Amazonian canopy trees in Paracou, French Guiana across species with the densest and lightest wood in the plot. Our objectives were to evaluate relationships among hydraulic traits to identify strategies and test the ability of easy-to-measure traits as proxies for hard-to-measure hydraulic traits. Xylem efficiency was related to capacitance, sapwood water content and turgor loss point, and other drought avoidance traits, but not to xylem safety (P₅₀ ). Wood density was correlated (r = -0.57 to -0.97) with sapwood pressure-volume traits, forming an axis of hydraulic strategy variation. In contrast to drier sites where hydraulic safety plays a greater role, tropical trees in this humid tropical site varied along an axis with low wood density, high xylem efficiency and high capacitance at one end of the spectrum, and high wood density and low turgor loss point at the other.

ACTIVE IMMUNIZATION AGAINST POLIOMYELITIS

1. A single intracutaneous inoculation with a subinfective dose of the virus of poliomyelitis produces considerable immunity. 2. Virus-serum combinations produce an appreciable immunity, providing just sufficient serum is used to protect the animal from paralysis. If there is an excess of serum, the degree of immunity is considerably reduced.

ACTIVE IMMUNIZATION AGAINST POLIOMYELITIS IN MONKEYS

1. A combination of poliomyelitis virus and specific human serum is effective for the production of active immunity. 2. For each gram of active virus given intradermally as an emulsion, 6 cc. of human immune serum, injected subcutaneously, was required in our experiments to protect a monkey from paralysis. Some degree of active immunity was induced. 3. Immunity, without symptom of the disease, was secured when the serum was given at the time of inoculation, or within 3 days preceding or following inoculation of the virus. 4. For the production of immunity, virus, preceded by serum administration, is probably less effective than when it is given simultaneously with, or before, the injection of serum. 5. The virus neutralization test is more sensitive than the direct intracerebral test for determining the production of immunity.

A COMPARISON BETWEEN CONVALESCENT SERUM AND NON-CONVALESCENT SERUM IN POLIOMYELITIS

1. Of twenty-nine so called normal urban adults tested, seven had less than two-fifths, three had two-fifths, two had three-fifths, eight had four-fifths and nine had a neutralizing power at least equal to the average of five batches of pooled convalescent serum. 2. Known contacts and avowed non-contacts were equally represented in the serums of low potency, but in the serums of higher potency, the known contacts predominated. 3. The pooled serums of known contacts and of non-contacts were respectively a little above and a little below half the strength of the average obtained for pooled convalescent serum. 4. Two series of early cases of poliomyelitis, the one treated with normal serum of proved protective power, the other with convalescent serum, showed no advantage of one type of serum over the other.

Americans' views on the use and regulation of dietary supplements

This article presents the views of Americans on what the government's future role should be in regulating or overseeing the growing sales of dietary supplements for health purposes. Based on results of multiple national opinion surveys, including the views of both users and nonusers of supplements, we found that a substantial percentage of Americans surveyed reported that they regularly take dietary supplements as a part of their routine health regimen. However, they reported that they do not discuss the use of dietary supplements with their physicians because they believe that the physicians know little or nothing about these products and may be biased against them. Many users felt so strongly about the potential health benefits of some of these products that they reported that they would continue to take them even if they were shown to be ineffective in scientifically conducted clinical studies. However, there also was broad public support for increased government regulation of these products. We found that a majority of Americans surveyed supported the following: to require that the Food and Drug Administration review the safety of new dietary supplements prior to their sale; to provide increased authority to remove from sale those products shown to be unsafe; and to increase government regulation to ensure that advertising claims about the health benefits of dietary supplements are true.

Race, ethnicity, and the health care system: public perceptions and experiences

To assess the public's perceptions and attitudes about racial and ethnic differences in health care, the Kaiser Family Foundation surveyed a nationally representative sample of 3,884 whites, African Americans, and Latinos in 1999. The survey found that the majority of Americans are uninformed about health care disparities--many were unaware that blacks fare worse than whites on measures such as infant mortality and life expectancy, and that Latinos are less likely than whites to have health insurance. Views on whether the health system treats people equally were strikingly different by race. For example, most minority Americans perceive that they get lower quality care than whites, but most whites think otherwise. Nonetheless, more minority Americans were concerned about the cost of care than racial barriers. Efforts to eliminate disparities will need to improve public awareness of the problems as well as address racial and financial barriers to care.

Health information, the Internet, and the digital divide

Through an analysis of recent data on adults' and children's computer use and experiences, this DataWatch shows that use of computers and the Internet is widespread and that significant percentages of the public are already using the Internet to get health information. The surveys also show that the Internet is already a useful vehicle for reaching large numbers of lower-income, less-educated, and minority Americans. However, a substantial digital divide continues to characterize computer and Internet use, with lower-income blacks especially affected. Implications for the future of health communication on the Internet also are explored.

Tiagabine in the treatment of epilepsy--a clinical review with a guide for the prescribing physician

Tiagabine is currently recommended mainly as add-on therapy in adults and children above 12 years with partial epilepsy not satisfactorily controlled with other antiepileptic drugs. Based on available evidence and our clinical experience, tiagabine should be used preferably in patients sharing one or more of the following additional features, (i) a history of drug-induced cutaneous adverse events; (ii) mild to moderate epilepsy allowing for a slow titration and gradual onset of anticonvulsant action over a few weeks; (iii) patients for whom it is particularly important to avoid a deterioration in cognitive performance; and, (iv) patients who failed to respond to previous treatment with sodium channel blocker agents as they may particularly benefit from the introduction of tiagabine, due to its GABAergic mechanism of action. Tiagabine can also be used successfully in other patients with refractory partial epilepsy. Tiagabine is not indicated for patients with generalized or unclassified epilepsies and for patients with severely impaired liver function.

Health care in the upcoming 2000 election

Health care will be one of the top issues in the year 2000 election, but voters' interest in health care is not as great as it was in 1992. There is no single unifying theme to the health care issue. Rather, there are multiple concerns: making Medicare financially sound, providing coverage for prescription medicines for seniors, covering the uninsured, and addressing patients' rights. Voters favor an incremental approach to expanding health insurance coverage rather than a major program. They express about equal levels of support for plans similar in concept to those proposed by presidential candidates Al Gore and George W. Bush.

Does dissatisfaction with health plans stem from having no choices?

Data from a 1997 nationwide telephone survey are used to assess the relationship between choice and public opinion about managed care. We found that only a minority of the working-age population effectively control what health plan they get. Persons without choice were markedly more dissatisfied with their health plan, especially when enrolled in managed care. In multivariate analysis, how respondents rated their health plan depended as much on whether they lacked choice as on whether they were enrolled in managed care. Persons without choice also had more negative opinions about managed care in general. The results suggest that the managed care "backlash" may persist so long as consumers have little control over health insurance decisions.

Understanding the managed care backlash

This paper examines the depth and breadth of the public backlash against managed care and the reasons for it. We conclude that the backlash is real and influenced by at least two principal factors: (1) A significant proportion of Americans report problems with managed care plans; and (2) the public perceives threatening and dramatic events in managed care that have been experienced by just a few. In addition, public concern is driven by fear that regardless of how well their plans perform today, care might not be available or paid for when they are very sick.

Media coverage of managed care: is there a negative bias?

We conducted content analysis of media coverage (both print and broadcast) of managed care over the period 1 January 1990 to 30 June 1997, examining in detail more than 2,100 randomly selected stories. Coverage changed noticeably over the seven and a half-year period, with early years focused on managed care as a business story, and later years focused more on patient care and concerns about backlash. Coverage differed substantially depending on media source. The large majority of all media coverage of managed care was neutral in tone. However, the tone of coverage has become more critical over time and differs dramatically by source of media. The most visible media sources--television and newspaper special series--conveyed negative stories in more than half of their coverage and most often used anecdotes in telling their stories.

Understanding the quality challenge for health consumers: the Kaiser/AHCPR Survey

BACKGROUND AND PURPOSE

"Americans as Health Care Consumers: The Role of Quality Information," a nationally representative telephone survey of 2,006 adults, designed by the Henry J. Kaiser Family Foundation (Kaiser) and the Agency for Health Care Policy and Research (AHCPR) of the U.S. Department of Health and Human Services, was presented at the Kaiser/AHCPR conference "Value and Choice: Providing Consumers with Information on the Quality of Care" in Arlington, Virginia, October 29-30, 1996. The survey was conducted by Princeton Survey Research Associates between July 16 and September 5, 1996, and has a margin of error of plus or minus 3 percentage points.

RESULTS

The survey found that Americans value quality but that the use of quality indicators is likely to be only one factor in their decision making, given their reliance on and preference for quality information from their physicians, friends, and family. A plurality (42%) chose having high quality of care as their most important concern, but only 39% reported seeing information comparing health plans, and only about one-third of that group said they used this information themselves to make decisions. The following are possible explanations for why consumers don't use information on quality in making health care decisions: They trust friends, families, and physicians about all other sources for advice; They do not (at the time of the survey) have many health plan choices to make; or They lack familiarity with comparative health care quality information.

Americans' political participation in the 1993-94 national health care reform debate

The health politics and policy communities are still struggling with the question of "what went wrong" in the 1993-94 health care reform effort. Here I identify which Americans were politically active and inactive during the health care reform debate to explore the role political participation may have had in determining the outcome of the debate. Using data from a national and California random-sample telephone surveys, and controlling for other demographic attributes, I found that those who engaged in political activity specifically related to health care reform were disproportionately more likely to be self-identified conservatives, less likely to favor an employer mandate plan, more likely to be fifty to sixty-four years old, more likely to be men, and more likely to have greater interest in and knowledge of the health care issue. Even in California, where a single-payer proposal was on the November ballot, self-identified liberals were no more likely to engage in political activity on health care reform than were moderates or conservatives. I consider implications for the reform outcome given that liberals, the elderly, and those favoring the employer mandate proposal were all disproportionately "silent" during this debate, and finally I discuss the potential for mobilization during future debates.

The public and the welfare reform debate

OBJECTIVES

To identify the core beliefs and policy preferences of the American public toward changing the welfare system and providing support for low-income families.

DESIGN

Results are presented from 19 telephone and in-person surveys of adults nationwide between 1937 and February 1995.

SETTING

At-home interviews with adults.

PARTICIPANTS

Seventeen surveys; each survey involved 1000 to 2000 adults nationwide.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The results showed that the public supports strong welfare reform measures (eg, time limits and work requirements), but it is reluctant simply to cut off welfare benefits to people and leave them without some means of basic support. The surveys identified five underlying beliefs that shape the public's policy preferences: (1) welfare causes more harm than good because it discourages work and causes families to break up; (2) welfare should be a temporary transition to work, not a long-term subsidy for low-income families; (3) the country spends too much on welfare programs; (4) lack of economic opportunity as well as personal responsibility is the reason people need welfare; and (5) both government and people themselves have a shared responsibility for ensuring that people have a minimum standard of living.

CONCLUSIONS

The outcome of the welfare reform debate will have a substantial impact on the 21% of the nation's children who now live in poverty. The jury is still out on what the public will support in the welfare reform debate. The Medicaid program is caught in the middle of the welfare reform debate, and its ultimate fate may rely on state rather than federal decision making.

What happened to Americans' support for the Clinton health plan?

Within a twelve-month period public support for the Clinton plan fell from 71 percent to 43 percent. The administration lost substantial support among two politically important groups--the elderly and Democrats. This outcome was brought on by a series of key strategic and substantive misjudgments by the administration in the choices that it made in the development of its plan. These particular decisions inadvertently reinforced the public's deeply held cynicism that although health care reform was needed, the government in Washington would not do it right and would ultimately leave the middle class worse off than it was before.

Americans compare managed care, Medicare, and fee-for-service

Are all health plans created equal? A recent survey of 1,000 adults queried Americans about their experiences with managed care, the Medicare program, and traditional fee-for-service medicine. Most Americans said they generally are content with their arrangements, but Medicare patients reported the highest level of satisfaction. Managed care consumers said they are generally pleased with their care, but they reported some problems with their specialist care. Overall most Americans are not looking for a completely new health care system.

How much does the public know about health reform?

With federal action on major health reform set to take place in 1994, a recent survey of 1,200 adults found major gaps in Americans' understanding of what the problems are or how major legislative proposals would address them. While the public is primarily concerned about how health reform will affect them personally, their current lack of knowledge heightens the impact that political advertising, media coverage, and public education campaigns will have.