@Article{info:doi/10.2196/58556,
author="Hewage, Avanthi Sumudu
and Senanayake, Sameera
and Brain, David
and Allen, J. Michelle
and McPhail, M. Steven
and Parsonage, William
and Walters, Tomos
and Kularatna, Sanjeewa",
title="Preferences for Mobile App Features to Support People Living With Chronic Heart Diseases: Discrete Choice Study",
journal="JMIR Mhealth Uhealth",
year="2025",
month="Apr",
day="25",
volume="13",
pages="e58556",
keywords="digital health technologies",
keywords="user preferences",
keywords="latent class model",
keywords="monitoring vital signs",
keywords="adoption rates",
keywords="app",
keywords="chronic heart disease",
keywords="heart disease",
keywords="digital health",
keywords="effectiveness",
keywords="user",
keywords="mobile health app",
keywords="self-navigate",
keywords="health education",
keywords="symptom",
keywords="monitoring",
keywords="adoption",
abstract="Background: Using digital health technologies to aid individuals in managing chronic diseases offers a promising solution to overcome health service barriers such as access and affordability. However, their effectiveness depends on adoption and sustained use, influenced by user preferences. Objectives: This study quantifies the preferences of individuals with chronic heart disease (CHD) for features of a mobile health app to self-navigate their disease condition. Methods: We conducted an unlabeled web-based choice survey among adults older than 18 years with CHD living in Australia, recruited via a web-based survey platform. Four app attributes---ease of navigation, monitoring of blood pressure and heart rhythm, health education, and symptom diary maintenance---were systematically chosen through a multistage process. This process involved a literature review, stakeholder interviews, and expert panel discussions. Participants chose a preferred mobile app out of 3 alternatives: app A, app B, or neither. A D-optimal design was developed using Ngene software, informed by Bayesian priors derived from pilot survey data. Latent class model analysis was conducted using Nlogit software (Econometric Software, Inc). We also estimated attribute importance and anticipated adoption rates for 3 app versions. Results: Our sample included 302 participants with a mean age of 50.5 (SD 18.2) years. Latent class model identified 2 classes. Older respondents with education beyond high school, prior experience with mobile health apps, and a positive perception of app usefulness were more likely to be in class 1 (257/303, 85\%) than in class 2 (45/303, 15\%). Class 1 membership preferred adopting a mobile app (app A: $\beta$ coefficient 0.74, 95\% uncertainty interval (UI) 0.41-1.06; app B: $\beta$ coefficient 0.53, 95\% UI 0.22-0.85). Participants favored apps providing postmonitoring recommendations ($\beta$ coefficient 1.45, 95\% UI 1.26-1.64), tailored health education ($\beta$ coefficient 0.50, 95\% UI 0.36-0.64), and unrestricted symptom diary entry ($\beta$ coefficient 0.58, 95\% UI 0.41-0.76). Class 2 showed no preference for app adoption (app A: $\beta$ coefficient ?1.18, 95\% UI ?2.36 to 0.006; app B: $\beta$ coefficient ?0.78, 95\% UI ?1.99 to 0.42) or any specific attribute levels. Vital sign monitoring was the most influential attribute among the 4. Scenario analysis revealed an 84\% probability of app adoption with basic features, rising to 92\% when app features aligned with respondents' preferences. Conclusions: The study's findings suggest that designing preference-informed mobile health apps could significantly enhance adoption rates and engagement among individuals with CHD, potentially leading to improved clinical outcomes. Adoption rates were notably higher when app attributes included easy navigation, vital sign monitoring, feedback provision, personalized health education, and flexible data entry for symptom diary maintenance. Future research to explore factors influencing app adoption among different groups of patients is warranted. ",
doi="10.2196/58556",
url="https://mhealth.jmir.org/2025/1/e58556"
}


@Article{info:doi/10.2196/60676,
author="Lockwood, G. Kimberly
and Kulkarni, R. Priya
and Branch, H. OraLee
and Graham, A. Sarah",
title="Cardiac Self-Efficacy Improvement in a Digital Heart Health Program: Secondary Analysis From a Feasibility and Acceptability Pilot Study",
journal="JMIR Form Res",
year="2025",
month="Apr",
day="24",
volume="9",
pages="e60676",
keywords="digital health",
keywords="self-efficacy",
keywords="behavior change",
keywords="prevention",
keywords="cardiovascular health",
keywords="digital heart health",
keywords="lifestyle",
keywords="heart health",
keywords="health coaching",
keywords="mobile phone",
abstract="Background: Lifestyle modification programs play a critical role in preventing and managing cardiovascular disease (CVD). A key aim of many programs is improving patients' self-efficacy. In-person lifestyle modification programs can enhance self-efficacy in managing CVD risk, also known as cardiac self-efficacy (CSE). However, such programs are typically staffing and resource intensive. Digital lifestyle modification programs may offer a scalable and accessible way to improve CSE, but this has not been shown in prior research. Objective: This study examined changes in CSE among individuals using a digital lifestyle modification program for cardiovascular health. Evaluation of improvement in CSE was a secondary goal of a feasibility and acceptability pilot study of a digital program for Heart Health. Methods: Participants were individuals with elevated risk for CVD who enrolled in a 90-day pilot study that involved mobile app--based, artificial intelligence--powered health coaching and educational lessons focused on behaviors that promote cardiovascular health. Participants completed the 9-item CSE Scale at baseline and in month 2. Changes in confidence in participants' ability to manage their cardiovascular health were assessed. Results: The sample included 273 (n=207, 61.2\% female; mean age 59.3, SD 10.1 years) participants who submitted a complete CSE Scale at baseline and in month 2. The total CSE Scale score increased by 12.9\% (P<.001) from baseline to month 2. Additionally, there were significant increases in mean score on each of the 9 individual CSE Scale items (all P<.001), with the largest increases in confidence ``in knowing when to call or visit the doctor for your heart disease'' (17\% increase; P<.001), ``in knowing how much physical activity is good for you'' (16.3\% increase; P<.001), and ``that you can get regular aerobic exercise'' (19\% increase; P<.001). Conclusions: The present analyses indicate that participants in a digital lifestyle modification program for cardiovascular health showed significant improvements in CSE within 2 months. This work adds to the growing literature examining ways to improve health-related self-efficacy and scalable access to programs for prevention and management of CVD. ",
doi="10.2196/60676",
url="https://formative.jmir.org/2025/1/e60676"
}


@Article{info:doi/10.2196/57583,
author="Parry, Monica
and Huang, Tony
and Clarke, Hance
and Bj{\o}rnnes, Kristin Ann
and Harvey, Paula
and Parente, Laura
and Norris, Colleen
and Pilote, Louise
and Price, Jennifer
and Stinson, N. Jennifer
and O'Hara, Arland
and Fernando, Madusha
and Watt-Watson, Judy
and Nickerson, Nicole
and Spiteri DeBonis, Vincenza
and Hart, Donna
and Faubert, Christine",
title="Development and Systematic Evaluation of a Progressive Web Application for Women With Cardiac Pain: Usability Study",
journal="JMIR Hum Factors",
year="2025",
month="Apr",
day="17",
volume="12",
pages="e57583",
keywords="digital health",
keywords="chatbot",
keywords="women",
keywords="cardiac pain",
keywords="usability testing",
keywords="self-management",
keywords="artificial intelligence",
keywords="AI",
abstract="Background: Cardiac pain has been widely considered to be the primary indicator of coronary artery disease. The presentation of cardiac pain and associated symptoms vary in women, making it challenging to interpret as cardiac, possibly cardiac, or noncardiac. Women prefer to consult with family and friends instead of seeking immediate medical care. Objective: This study aimed to assess the user performance (ie, ease of use, efficiency, and errors) and user satisfaction (System Usability Scale; SUS) of a progressive web application for women with cardiac pain. Methods: Following ethics approval, a purposive sample of women aged >18 years with cardiac pain or associated symptoms lasting >3 months and able to speak and read English was recruited to participate in 2 iterative usability testing cycles. The first cycle assessed the performance of and satisfaction with at heart using a web application, and the second cycle assessed the performance of and satisfaction with at heart across various Android and iOS devices. In total, 2 investigators recorded user comments and documented problems. At the end of the testing session, the participants completed the SUS and 4 semistructured interview questions. Results: In total, 10 eligible women participated in usability testing from March 31, 2020, to April 17, 2020 (cycle 1), and from November 17, 2020, to November 30, 2020 (cycle 2). Women across usability testing cycles had a mean age of 55.6 (SD 7.3) years, and most (9/10, 90\%) were well educated. In total, 50\% (5/10) were employed full or part time, and 60\% (6/10) earned >CAD \$70,000 (US \$48,881.80) annually. Participants across 2 testing cycles reported the overall usability of the at heart progressive web application as highly acceptable (mean SUS score 81.75, SD 10.41). In total, 90\% (9/10) of participants rated the user-friendliness of at heart as good or excellent. All participants (10/10, 100\%) thought at heart was easy to use and efficient. Only 2 testing errors were noted as high priority; these were low contrast or small font and clarification that the chatbot was not a real person. User satisfaction was assessed using themes that emerged from the debrief and 4 semistructured interview questions; at heart was engaging, comprehensive, understandable, credible, relevant, affirming, personalized, and innovative. Conclusions: This study provides initial support for the at heart progressive web application for women living with cardiac pain and symptoms. Ongoing evaluations in phases 3 and 4 should aim to examine the feasibility and acceptability of and the extent of engagement with the at heart core feature set: Heart Check, Wellness Check, and the library. In addition to assessing effectiveness in the phase-4 effectiveness-implementation hybrid trial (type I), describing and better understanding the context for implementation (eg, race and ethnicity and geography) will be necessary. International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2019-033092 ",
doi="10.2196/57583",
url="https://humanfactors.jmir.org/2025/1/e57583"
}


@Article{info:doi/10.2196/65782,
author="Chauhan, Kumari Gauri
and Vavken, Patrick
and Jacob, Christine",
title="Mobile Apps and Wearable Devices for Cardiovascular Health: Narrative Review",
journal="JMIR Mhealth Uhealth",
year="2025",
month="Apr",
day="4",
volume="13",
pages="e65782",
keywords="eHealth",
keywords="mobile health",
keywords="mHealth",
keywords="digital health",
keywords="technology assessment",
keywords="technology adoption",
keywords="technology implementation",
keywords="cardiovascular diseases",
keywords="cardiovascular health",
keywords="Germany",
keywords="Austria",
keywords="Switzerland",
keywords="wearables",
keywords="apps",
keywords="smartphones",
keywords="Swiss Apple App",
keywords="Google Play Store",
keywords="reviews",
keywords="morbidity",
keywords="mortality",
keywords="well-being",
keywords="care management",
keywords="health technologies",
abstract="Background: Cardiovascular diseases (CVDs) continue to be the leading cause of global morbidity and mortality. Aiming to reduce the risk of CVD development and better manage them, an increasing number of individuals are adopting mobile health (mHealth) apps and wearable devices (wearables). These technologies provide critical insights into heart health and fitness, supporting users to monitor their lifestyle behaviors and adhere to preventative medication. Objective: In this review, we aimed to investigate the current state of mHealth apps and wearables designed for cardiovascular health, with a specific focus on the DACH region (Germany, Austria, and Switzerland). We assessed the benefits these technologies provide to clinicians and patients, particularly in addressing unmet needs like sex-specific symptoms, while also examining their potential integration into the broader health care ecosystem. Methods: To identify heart health apps, a keyword search was performed on both the Swiss Apple App Store and Google Play Stores. A separate search was performed on Google to identify heart health wearables. The identified apps and wearables were evaluated using the foundational and contextual criteria of the sociotechnical framework for assessing patient-facing eHealth tools. Results: After filtering out apps and wearables that did not meet our inclusion criteria, 20 apps and 22 wearables were included in the review. While all the apps were available in the DACH region, only 30\% (6/20) were specifically designed for these countries. Only 25\% (5/20) of the apps included sex-specific information; 40\% (8/20) provided information from evidence-based research, 35\% (7/20) provided general health information without academic and clinical references, and 25\% (5/20) did not include any evidence-based or general health information. While 20\% (4/20) of the included apps had clinical integration features such as clinician dashboards, only 10\% (2/20) had the potential to effectively enhance clinician workflows. Privacy policies were present in 95\% (19/20) of the apps, with 75\% (15/20) adhering to General Data Protection Regulation (GDPR) regulations; 1 app had no data protection policy. Only 20\% (4/20) of the apps were medically certified. For wearables, only 9\% (2/22) were tailored to the DACH region, and 40\% (9/22) addressed women's health. While around 60\% (13/22) offered features to support clinical integration, only 9\% (2/22) had the potential to improve clinical workflows. More than half (12/22) of the wearables were medically certified, and 77\% (17/22) referenced scientific or peer-reviewed research. All wearables included a privacy policy. Conclusions: While many mHealth tools for cardiovascular health are available, only a few provide meaningful value to both patients and clinicians or have the potential to integrate effectively into the health care system. Women's sex-specific needs are often overlooked, and the benefits for clinicians are limited. In addition, mHealth apps largely lack robust evidence, whereas wearables showed comparatively stronger support through evidence-based and medical certification. ",
doi="10.2196/65782",
url="https://mhealth.jmir.org/2025/1/e65782"
}


@Article{info:doi/10.2196/56798,
author="Flaucher, Madeleine
and Berzins, Sabrina
and Jaeger, M. Katharina
and Nissen, Michael
and Rolny, Jana
and Tri{\ss}ler, Patricia
and Eckl, Sebastian
and Eskofier, M. Bjoern
and Leutheuser, Heike",
title="Perception and Evaluation of a Knowledge Transfer Concept in a Digital Health Application for Patients With Heart Failure: Mixed Methods Study",
journal="JMIR Hum Factors",
year="2025",
month="Mar",
day="31",
volume="12",
pages="e56798",
keywords="health literacy",
keywords="digital Literacy",
keywords="user-centered design",
keywords="digital health app",
keywords="heart failure",
keywords="mixed methods study",
keywords="user centered deign",
keywords="usability",
keywords="patient engagement",
keywords="mHealth app",
keywords="development",
abstract="Background: Digital health education can enhance the quality of life of patients with heart failure by providing accessible and tailored information, which is essential for effective self-care and self-management. Objective: This work aims to develop a mobile health knowledge transfer concept for heart failure in a user-centered design process grounded in theoretical frameworks. This approach centers on enhancing the usability, patient engagement, and meaningfulness of mobile health education in the context of heart failure. Methods: A user-centered design process was employed. First, semistructured stakeholder interviews were conducted with patients (n=9) and medical experts (n=5). The results were used to develop a health knowledge transfer concept for a mobile health app for heart failure. This concept was implemented as a digital prototype based on an existing German mobile health app for patients with heart failure. We used this prototype to evaluate our concept with patients with heart failure in a study composed of user testing and semistructured patient interviews (n=7). Results: Stakeholder interviews identified five themes relevant to mobile health education: individualization, content relevance, media diversity, motivation strategies, and trust-building mechanisms. The evaluation of our prototype showed that patients value the adaptation of content to individual interests and prior knowledge. Digital rewards such as badges and push notifications can increase motivation and engagement but should be used with care to avoid overload, irrelevance, and repetition. Conclusions: Our findings emphasize the importance of tailoring mobile health education to the specific needs and preferences of patients with heart failure. At the same time, they also highlight the careful implementation of motivation strategies to promote user engagement effectively. These implications offer guidance for developing more impactful interventions to improve health outcomes for this population. ",
doi="10.2196/56798",
url="https://humanfactors.jmir.org/2025/1/e56798"
}


@Article{info:doi/10.2196/67110,
author="Schweizer, Theresa
and Gilgen-Ammann, Rahel",
title="Wrist-Worn and Arm-Worn Wearables for Monitoring Heart Rate During Sedentary and Light-to-Vigorous Physical Activities: Device Validation Study",
journal="JMIR Cardio",
year="2025",
month="Mar",
day="21",
volume="9",
pages="e67110",
keywords="validity",
keywords="reliability",
keywords="accuracy",
keywords="wearable devices",
keywords="wearing position",
keywords="photoplethysmography",
keywords="heart rate",
abstract="Background: Heart rate (HR) is a vital physiological parameter, serving as an indicator of homeostasis and a key metric for monitoring cardiovascular health and physiological responses. Wearable devices using photoplethysmography (PPG) technology provide noninvasive HR monitoring in real-life settings, but their performance may vary due to factors such as wearing position, blood flow, motion, and device updates. Therefore, ongoing validation of their accuracy and reliability across different activities is essential. Objectives: This study aimed to assess the accuracy and reliability of the HR measurement from the PPG-based Polar Verity Sense and the Polar Vantage V2 devices across a range of physical activities and intensities as well as wearing positions (ie, upper arm, forearm, and both wrists). Methods: Sixteen healthy participants were recruited to participate in this study protocol, which involved 9 activities of varying intensities, ranging from lying down to high-intensity interval training, each repeated twice. The HR measurements from the Verity Sense and Vantage V2 were compared with the criterion measure Polar H10 electrocardiogram (ECG) chest strap. The data were processed to eliminate artifacts and outliers. Accuracy and reliability were assessed using multiple statistical methods, including systematic bias (mean of differences), mean absolute error (MAE) and mean absolute percentage error (MAPE), Pearson product moment correlation coefficient (r), Lin concordance correlation coefficient (CCC), and within-subject coefficient of variation (WSCV). Results: All 16 participants (female=7; male=9; mean 27.4, SD 5.8 years) completed the study. The Verity Sense, worn on the upper arm, demonstrated excellent accuracy across most activities, with a systematic bias of ?0.05 bpm, MAE of 1.43 bpm, MAPE of 1.35\%, r=1.00, and CCC=1.00. It also demonstrated high reliability across all activities with a WSCV of 2.57\% and no significant differences between the 2 sessions. The wrist-worn Vantage V2 demonstrated moderate accuracy with a slight overestimation compared with the ECG and considerable variation in accuracy depending on the activity. For the nondominant wrist, it demonstrated a systematic bias of 2.56 bpm, MAE of 6.41 bpm, MAPE 6.82\%, r=0.93, and CCC=0.92. Reliability varied considerably, ranging from a WSCV of 3.64\% during postexercise sitting to 23.03\% during lying down. Conclusions: The Verity Sense was found to be highly accurate and reliable, outperforming many other wearable HR devices and establishing itself as a strong alternative to ECG-based chest straps, especially when worn on the upper arm. The Vantage V2 was found to have moderate accuracy, with performance highly dependent on activity type and intensity. While it exhibited greater variability and limitations at lower HR, it performed better at higher intensities and outperformed several wrist-worn devices from previous research, particularly during vigorous activities. These findings highlight the importance of device selection and wearing position to ensure the highest possible accuracy in the intended context. ",
doi="10.2196/67110",
url="https://cardio.jmir.org/2025/1/e67110"
}


@Article{info:doi/10.2196/63057,
author="Ullrich, Greta
and B{\"a}uerle, Alexander
and Vogt, Hannah
and Mahabadi, Abbas Amir
and Pald{\'a}n, Katrin
and Messiha, Daniel
and Jahre, Maria Lisa
and Rammos, Christos
and Rassaf, Tienush
and Lortz, Julia",
title="Digital Health Literacy and Attitudes Toward eHealth Technologies Among Patients With Cardiovascular Disease and Their Implications for Secondary Prevention: Survey Study",
journal="JMIR Form Res",
year="2025",
month="Mar",
day="19",
volume="9",
pages="e63057",
keywords="cardiovascular diseases",
keywords="telemedicine",
keywords="eHealth",
keywords="patient-centered approach",
keywords="digital health literacy",
keywords="digital health",
keywords="cardiovascular disease",
keywords="mortality",
keywords="artery disease",
keywords="ischemic",
keywords="heart disease",
keywords="diabetes mellitus",
keywords="obesity",
keywords="patient education",
keywords="eHealth literacy",
keywords="mobile phone",
abstract="Background: Cardiovascular disease is the major cause of death worldwide, leading to a significant socioeconomic burden. Although secondary prevention is a cornerstone in chronic disease management, adherence to guideline recommendations in this regard often falters, leading to suboptimal outcomes. While eHealth technologies are promising for improving treatment adherence, they also represent a new approach to secondary prevention. However, a common critique is that extensive digitalization may not adequately address the needs of older adults with chronic medical conditions. Objective: This study aims to analyze eHealth literacy, digital use patterns, and general attitudes toward digital technologies in a collective of patients with cardiovascular disease to identify potential obstacles in implementing mobile health technologies in secondary preventive therapy. Methods: This survey-based study was a part of the baseline examination of the PreventiPlaque trial. It involved 240 participants with known coronary artery disease. The assessment evaluated their current understanding of the general use of digital devices. The questionnaire covered aspects such as the duration of daily use, personal attitudes, and the perceived burden associated with digital media. eHealth literacy was assessed within the target population and general demographic data were gathered, focusing on cardiovascular comorbidities and risk factors. Results: The analysis revealed an average age of 61.9 (SD 8.9) years, with 59.9\% (n=144) of the participants being male. Overall, 37.3\% (n=90) of the participants had previous knowledge of digital health interventions, while only 17.8\% (n=41) had used them. Despite the generally low practical application within this study population, there was a high level of confidence in handling digital devices, with 61.9\% (n=149) expressing themselves as either rather confident or very confident. Regarding the levels of eHealth literacy among the participants, 71.2\% (n=170) claimed to be familiar with locating health information on the internet, and 64\% (n=153) of participants felt capable of critically evaluating its quality. These levels of digital confidence were consistent across all age groups. Moreover, internet use rates remained high even among the older participants, with 80\% (n=192) of those participants older than 75 years using the internet for 1-3 hours a day. Conclusions: The study unveiled a notable confidence level among participants regarding the use of digital devices, coupled with a favorable attitude toward digital media evident across all age brackets. Remarkably, internet use rates remained high, even among older participants. The actual utilization of digital health interventions was relatively low, potentially stemming from challenges in locating reliable sources. These findings emphasize the prospect of future eHealth interventions customized to the distinct needs and preferences of patients in cardiovascular disease management. Recognizing the incongruity between confidence in device use and the restricted adoption of digital health tools can guide the development of focused interventions to narrow this divide. Trial Registration: ClinicalTrials.gov NCT05096637; https://clinicaltrials.gov/study/NCT05096637 ",
doi="10.2196/63057",
url="https://formative.jmir.org/2025/1/e63057"
}


@Article{info:doi/10.2196/69204,
author="Du, ShanShan
and Zhao, Yining",
title="Enhancing Digital Health Interventions for Medication Adherence: Considerations for Broader Applicability and Long-Term Impact",
journal="J Med Internet Res",
year="2025",
month="Mar",
day="14",
volume="27",
pages="e69204",
keywords="mobile apps",
keywords="digital health",
keywords="atrial fibrillation",
keywords="anticoagulants",
keywords="medication adherence",
keywords="mobile phone",
doi="10.2196/69204",
url="https://www.jmir.org/2025/1/e69204"
}


@Article{info:doi/10.2196/63805,
author="Jin, Xiaorong
and Zhang, Yimei
and Zhou, Min
and Mei, Qian
and Bai, Yangjuan
and Hu, Qiulan
and Wei, Wei
and Zhang, Xiong
and Ma, Fang",
title="An Actor-Partner Interdependence Mediation Model for Assessing the Association Between Health Literacy and mHealth Use Intention in Dyads of Patients With Chronic Heart Failure and Their Caregivers: Cross-Sectional Study",
journal="JMIR Mhealth Uhealth",
year="2025",
month="Mar",
day="6",
volume="13",
pages="e63805",
keywords="chronic heart failure",
keywords="caregivers",
keywords="health literacy",
keywords="mHealth",
keywords="actor-partner interdependence mediation model",
keywords="mobile health",
abstract="Background: Chronic heart failure (CHF) has become a serious threat to the health of the global population. Self-management is the key to treating CHF, and the emergence of mobile health (mHealth) has provided new ideas for the self-management of CHF. Despite the many potential benefits of mHealth, public utilization of mHealth apps is low, and poor health literacy (HL) is a key barrier to mHealth use. However, the mechanism of the influence is unclear. Objective: The aim of this study is to explore the dyadic associations between HL and mHealth usage intentions in dyads of patients with CHF and their caregivers, and the mediating role of mHealth perceived usefulness and perceived ease of use in these associations. Methods: This study had a cross-sectional research design, with a sample of 312 dyads of patients with CHF who had been hospitalized in the cardiology departments of 2 tertiary care hospitals in China from March to October 2023 and their caregivers. A general information questionnaire, the Chinese version of the Heart Failure-Specific Health Literacy Scale, and the mHealth Intention to Use Scale were used to conduct the survey; the data were analyzed using the actor-partner interdependence mediation model. Results: The results of the actor-partner interdependent mediation analysis of HL, perceived usefulness of mHealth, and mHealth use intention among patients with CHF and their caregivers showed that all of the model's actor effects were valid ($\beta$=.26?0.45; P<.001), the partner effects were partially valid ($\beta$=.08?0.20; P<.05), and the mediation effects were valid ($\beta$=.002?0.242, 95\% CI 0.003?0.321; P<.05). Actor-partner interdependent mediation analyses of HL, perceived ease of use of mHealth, and mHealth use intention among patients with CHF and caregivers showed that the model's actor effect partially held ($\beta$=.17?0.71; P<.01), the partner effect partially held ($\beta$=.15; P<.01), and the mediation effect partially held ($\beta$=.355?0.584, 95\% CI 0.234?0.764; P<.001). Conclusions: Our study proposes that the HL of patients with CHF and their caregivers positively contributes to their own intention to use mHealth, suggesting that the use of mHealth by patients with CHF can be promoted by improving the HL of patients and caregivers. Our findings also suggest that the perceived usefulness of patients with CHF and caregivers affects patients' mHealth use intention, and therefore patients with CHF and their caregivers should be involved throughout the mHealth development process to improve the usability of mHealth for both patients and caregivers. This study emphasizes the key role of patients' perception that mHealth is easy to use in facilitating their use of mHealth. Therefore, it is recommended that the development of mHealth should focus on simplifying operational procedures and providing relevant operational training according to the needs of the patients when necessary. ",
doi="10.2196/63805",
url="https://mhealth.jmir.org/2025/1/e63805"
}


@Article{info:doi/10.2196/66464,
author="Abdullayev, Kamilla
and Chico, A. Tim J.
and Canson, Jiana
and Mantelow, Matthew
and Buckley, Oli
and Condell, Joan
and Van Arkel, J. Richard
and Diaz-Zuccarini, Vanessa
and Matcham, Faith",
title="Exploring Stakeholder Perspectives on the Barriers and Facilitators of Implementing Digital Technologies for Heart Disease Diagnosis: Qualitative Study",
journal="JMIR Cardio",
year="2025",
month="Mar",
day="5",
volume="9",
pages="e66464",
keywords="heart disease",
keywords="digital technologies",
keywords="stakeholder perspectives",
keywords="qualitative research",
keywords="digital technology",
keywords="health technology",
keywords="heart",
keywords="cardio",
keywords="cardiology",
keywords="cardiovascular",
keywords="qualitative",
keywords="focused group",
keywords="quality of care",
keywords="efficiency",
keywords="digital health",
keywords="mobile phone",
keywords="artificial intelligence",
keywords="AI",
abstract="Background: Digital technologies are increasingly being implemented in health care to improve the quality and efficiency of care for patients. However, the rapid adoption of health technologies over the last 5 years has failed to adequately consider patient and clinician needs, which results in ineffective implementation. There is also a lack of consideration for the differences between patient and clinician needs, resulting in overgeneralized approaches to the implementation and use of digital health technologies. Objective: This study aimed to explore barriers and facilitators of the implementation of digital technologies in the diagnosis of heart disease for both patients and clinicians, and to provide recommendations to increase the acceptability of novel health technologies. Methods: We recruited 32 participants from across the United Kingdom, including 23 (72\%) individuals with lived experience of heart disease and 9 (28\%) clinicians involved in diagnosing heart disease. Participants with experience of living with heart disease took part in semistructured focused groups, while clinicians contributed to one-to-one semistructured interviews. Inductive thematic analysis using a phenomenological approach was conducted to analyze the resulting qualitative data and to identify themes. Results were discussed with a cardiovascular patient advisory group to enhance the rigor of our interpretation of the data. Results: Emerging themes were separated into facilitators and barriers and categorized into resource-, technology-, and user-related themes. Resource-related barriers and facilitators related to concerns around increased clinician workload, the high cost of digital technologies, and systemic limitations within health care systems such as outdated equipment and limited support. Technology-related barriers and facilitators included themes related to reliability, accuracy, safety parameters, data security, ease of use, and personalization, all of which can impact engagement and trust with digital technologies. Finally, the most prominent themes were the user-related barriers and facilitators, which encompassed user attitudes, individual-level variation in preferences and capabilities, and impact on quality of health care experiences. This theme captured a wide variety of perspectives among the sample and revealed how patient and clinician attitudes and personal experiences substantially impact engagement with digital health technologies across the cardiovascular care pathway. Conclusions: Our findings highlight the importance of considering both patient and clinician needs and preferences when investigating the barriers and facilitators to effective implementation of digital health technologies. Facilitators to technology adoption include the need for cost-effective, accurate, reliable, and easy-to-use systems as well as adequate setup support and personalization to meet individual needs. Positive user attitudes, perceived improvement in care quality, and increased involvement in the care process also enhance engagement. While both clinicians and patients acknowledge the potential benefits of digital technologies, effective implementation hinges on addressing these barriers and leveraging facilitators to ensure that the technologies are perceived as useful, safe, and supportive of health care outcomes. International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2023-072952 ",
doi="10.2196/66464",
url="https://cardio.jmir.org/2025/1/e66464",
url="http://www.ncbi.nlm.nih.gov/pubmed/40053721"
}


@Article{info:doi/10.2196/60115,
author="Li, Guangqi
and Zhou, Xueyan
and Deng, Junyue
and Wang, Jiao
and Ai, Ping
and Zeng, Jingyuan
and Ma, Xuelei
and Liao, Hu",
title="Digital Therapeutics--Based Cardio-Oncology Rehabilitation for Lung Cancer Survivors: Randomized Controlled Trial",
journal="JMIR Mhealth Uhealth",
year="2025",
month="Feb",
day="25",
volume="13",
pages="e60115",
keywords="cardio-oncology rehabilitation",
keywords="digital therapeutics",
keywords="telerehabilitation",
keywords="non-small cell lung cancer",
keywords="exercise prescription",
keywords="cardiology",
keywords="oncology",
keywords="rehabilitation",
keywords="cardiorespiratory fitness",
keywords="cardiopulmonary",
keywords="cancer",
keywords="physical activity",
keywords="digital health",
keywords="digital technology",
keywords="randomized controlled trial",
keywords="wearable",
keywords="app",
keywords="quality of life",
keywords="survivor",
abstract="Background: Lung cancer ranks as the leading cause of cancer-related deaths. For lung cancer survivors, cardiopulmonary fitness is a strong independent predictor of survival, while surgical interventions impact both cardiovascular and pulmonary function. Home-based cardiac telerehabilitation through wearable devices and mobile apps is a substitution for traditional, center-based rehabilitation with equal efficacy and a higher completion rate. However, it has not been widely used in clinical practice. Objective: The objective of this study was to broaden the use of digital health care in the cardiopulmonary rehabilitation of lung cancer survivors and to assess its impact on cardiopulmonary fitness and quality of life (QOL). Methods: Early-stage nonsmall cell lung cancer survivors aged 18-70 years were included. All the participants received surgery 1-2 months before enrollment and did not require further antitumor therapy. Participants were randomly assigned to receive cardiac telerehabilitation or usual care for 5 months. Artificial intelligence--driven exercise prescription with a video guide and real-time heart rate (HR) monitoring was generated based on cardiopulmonary exercise testing. Aerobic exercise combining elastic band--based resistance exercises were recommended with a frequency of 3-5 d/wk and a duration of 90-150 min/wk. The effective exercise duration was recorded when patients' HR reached the target zone (HRresting + [HRmax -- HRresting] {\texttimes} [?40\%-60\%]), representing the duration under the target intensity. The prescription used a gradual progression in duration and action intensity based on the exercise data and feedback. Outcome measurements included cardiopulmonary fitness; lung function; cardiac function; tumor marker; safety; compliance; and scales assessing symptoms, psychology, sleep, fatigue, and QOL. Results: A total of 40 (85\%) out of 47 patients finished the trial. The average prescription compliance rate of patients in the telerehabilitation group reached 101.2\%, with an average exercise duration of 151.4 min/wk and an average effective exercise duration of 92.3 min/wk. The cardiac telerehabilitation was associated with higher improvement of maximal oxygen uptake peak (3.66, SD 3.23 mL/Kg/min vs 1.09, SD 3.23 mL/Kg/min; P=.02) and global health status or QOL (16.25, SD 23.02 vs 1.04, SD 13.90; P=.03) compared with usual care. Better alleviation of affective interference (--0.88, SD 1.50 vs 0.21, SD 1.22; P=.048), fatigue (--8.89, SD 15.96 vs 1.39, SD 12.09; P=.02), anxiety (--0.31, SD 0.44 vs --0.05, SD 0.29; P=.048), and daytime dysfunction (--0.55, SD 0.69 vs 0.00, SD 0.52; P=.02) was also observed in the telerehabilitation group. No exercise-related adverse events were identified during the intervention period. Conclusions: The 5-month, digital therapeutics--based telerehabilitation improved cardiorespiratory fitness in lung cancer survivors with good compliance and safety. Patients receiving telerehabilitation also reported improved QOL with reduced levels of fatigue, anxiety, and daytime dysfunction. Trial Registration: Chinese Clinical Trial Registry ChiCTR2200064000; https://www.chictr.org.cn/showproj.html?proj=180594 ",
doi="10.2196/60115",
url="https://mhealth.jmir.org/2025/1/e60115"
}


@Article{info:doi/10.2196/62719,
author="Smith, Samuel
and Maisrikrod, Shalisa",
title="Wearable Electrocardiogram Technology: Help or Hindrance to the Modern Doctor?",
journal="JMIR Cardio",
year="2025",
month="Feb",
day="10",
volume="9",
pages="e62719",
keywords="mobile applications",
keywords="electrocardiogram",
keywords="wearable monitoring",
keywords="app",
keywords="wearable",
keywords="electrocardiograph",
keywords="ECG",
keywords="electrocardiography",
keywords="mobile app",
keywords="tool",
keywords="ischemic",
keywords="arrhythmia",
keywords="wearable ECG",
keywords="doctor",
keywords="smartwatch",
keywords="atrial fibrillation",
doi="10.2196/62719",
url="https://cardio.jmir.org/2025/1/e62719"
}


@Article{info:doi/10.2196/62964,
author="Maddison, Ralph
and Nourse, Rebecca
and Daryabeygikhotbehsara, Reza
and Tegegne, Kassaw Teketo
and Jansons, Paul
and Rawstorn, Charles Jonathan
and Atherton, John
and Driscoll, Andrea
and Oldenburg, Brian
and Vasa, Rajesh
and Kostakos, Vassilis
and Dingler, Tilman
and Abbott, Gavin
and Scuffham, Paul
and Manski-Nankervis, Elizabeth Jo-Anne
and Kwasnicka, Dominika
and Kensing, Finn
and Islam, Shariful Sheikh Mohammed
and Maeder, Anthony
and Zhang, Yuxin",
title="Digital Home-Based Self-Monitoring System for People with Heart Failure: Protocol for Development of SmartHeart and Evaluation of Feasibility and Acceptability",
journal="JMIR Res Protoc",
year="2025",
month="Jan",
day="28",
volume="14",
pages="e62964",
keywords="smart home",
keywords="health",
keywords="chronic conditions",
keywords="digital health",
keywords="technology",
keywords="behavior change",
keywords="wearables",
keywords="methodological considerations",
abstract="Background: Heart failure (HF) is a chronic, progressive condition where the heart cannot pump enough blood to meet the body's needs. In addition to the daily challenges that HF poses, acute exacerbations can lead to costly hospitalizations and increased mortality. High health care costs and the burden of HF have led to the emerging application of new technologies to support people living with HF to stay well while living in the community. However, many digital solutions have not involved consumers and health care professionals in their design, leading to poor adoption. The SmartHeart project aimed to codevelop a smart health ecosystem to support the early detection of HF deterioration and encourage self-care, potentially preventing hospitalizations. Objective: This study aims to provide an overview of the SmartHeart project by describing our approach to designing the SmartHeart system, outlining its features, and describing the planned pilot study to determine the feasibility of the system. Methods: We used the Integrate, Design, Assess, and Share (IDEAS) framework to guide the development of the SmartHeart system, involving users (people with HF and their caregivers) and stakeholders (health care providers involved in the management of HF) in its design. SmartHeart is a complete remote heart health monitoring and automated feedback delivery system. It includes 2 user interfaces for patients: an Amazon Alexa conversational agent and a smartphone app. The system collects physiological, symptom, and behavioral data through wireless sensors and self-reports from users. These data are processed and analyzed to provide personalized health insights, self-care support, and alerts in case of health deterioration. The system also includes a web-based user interface for health care professionals, allowing them to access data, send messages to users, and receive notifications about potential health deterioration. A single-arm, multicenter pilot trial (N=20) is planned to determine the feasibility and acceptability of SmartHeart before evaluation through a randomized controlled trial. The primary outcome will be a description of the study's feasibility (recruitment, attrition, engagement, and changes in self-care). Results: The SmartHeart study started in January 2021 on procurement of funding. Recruitment for the pilot trial started in August 2024 and will be completed by March 2025. We have currently enrolled 12 participants. Follow-up of all participants will be completed by the end of May 2025. Conclusions: We have co-designed and developed a complete remote heart health monitoring and automated feedback delivery system for the early detection of HF deterioration and prevention of HF-related hospitalizations. The next step is a pilot study, which will provide valuable information on feasibility and preliminary effects to inform a larger evaluation trial. SmartHeart has the potential to augment existing health services and help people with HF stay well while living in the community. International Registered Report Identifier (IRRID): DERR1-10.2196/62964 ",
doi="10.2196/62964",
url="https://www.researchprotocols.org/2025/1/e62964"
}


@Article{info:doi/10.2196/64410,
author="Yu, Tianzhuo
and Parry, Monica
and Yu, Tianyue
and Xu, Linqi
and Wu, Yuejin
and Zeng, Ting
and Leng, Xin
and Tong, Qian
and Li, Feng",
title="Effectiveness of Mobile Health--Based Gamification Interventions for Improving Physical Activity in Individuals With Cardiovascular Diseases: Systematic Review and Meta-Analysis of Randomized Controlled Trials",
journal="JMIR Serious Games",
year="2025",
month="Jan",
day="24",
volume="13",
pages="e64410",
keywords="cardiovascular diseases",
keywords="digital health",
keywords="mobile health",
keywords="gamification",
keywords="exercise",
keywords="physical activity",
keywords="systematic review",
keywords="meta-analysis",
abstract="Background: Gamification refers to using game design elements in nongame contexts. Promoting physical activity (PA) through gamification is a novel and promising avenue for improving lifestyles and mitigating the advancement of cardiovascular diseases (CVDs). However, evidence of its effectiveness remains mixed. Objective: This systematic review and meta-analysis aimed to evaluate the efficacy of gamification interventions in promoting PA during short-term and follow-up periods in individuals with CVDs and to explore the most effective game design elements. Methods: A comprehensive search of 7 electronic databases was conducted for randomized controlled trials published in English from January 1, 2010, to February 3, 2024. Eligible studies used mobile health--based gamification interventions to promote PA or reduce sedentary behavior in individuals with CVDs. In total, 2 independent reviewers screened the retrieved records, extracted data, and evaluated the risk of bias using the RoB 2 tool. Discrepancies were resolved by a third reviewer. Meta-analyses were performed using a random-effects model with the Sidik-Jonkman method adjusted by the Knapp-Hartung method. Sensitivity analysis and influence analysis examined the robustness of results, while prediction intervals indicated heterogeneity. A meta-regression using a multimodel inference approach explored the most important game design elements. Statistical analyses were conducted using R (version 4.3.2; R Foundation for Statistical Computing). Results: In total, 6 randomized controlled trials were included. Meta-analysis of 5 studies revealed a small effect of gamification interventions on short-term PA (after sensitivity analysis: Hedges g=0.32, 95\% CI 0.19-0.45, 95\% prediction interval [PI] 0.02-0.62). Meta-analysis of 3 studies found the maintenance effect (measured with follow-up averaging 2.5 months after the end of the intervention) was small (Hedges g=0.20, 95\% CI 0.12-0.29, 95\% PI --0.01 to 0.41). A meta-analysis of 3 studies found participants taking 696.96 more steps per day than the control group (95\% CI 327.80 to 1066.12, 95\% PI --121.39 to 1515.31). ``Feedback'' was the most important game design element, followed by ``Avatar.'' Conclusions: This meta-analysis demonstrates that gamification interventions effectively promote PA in individuals with CVD, with effects persisting beyond the intervention period, indicating they are not merely novel effects caused by the game nature of gamification. The 95\% PI suggests that implementing gamification interventions in similar populations in the future will lead to actual effects in promoting PA in the vast majority of cases. However, the limited number of included studies underscores the urgent need for more high-quality research in this emerging field. Trial Registration: PROSPERO CRD42024518795; https://www.crd.york.ac.uk/prospero/display\_record.php?RecordID=518795 ",
doi="10.2196/64410",
url="https://games.jmir.org/2025/1/e64410"
}


@Article{info:doi/10.2196/50693,
author="Ehrler, Frederic
and Gschwind, Liliane
and Hagberg, Hamdi
and Meyer, Philippe
and Blondon, Katherine",
title="A Medication Management App (Smart-Meds) for Patients After an Acute Coronary Syndrome: Pilot Pre-Post Mixed Methods Study",
journal="JMIR Cardio",
year="2025",
month="Jan",
day="23",
volume="9",
pages="e50693",
keywords="medication adherence",
keywords="gamified app",
keywords="narration",
keywords="acute coronary syndrome",
keywords="beliefs about medication",
keywords="self-reported adherence",
keywords="pilot study",
keywords="usability evaluation",
keywords="storytelling component",
abstract="Background: Medication nonadherence remains a significant challenge in the management of chronic conditions, often leading to suboptimal treatment outcomes and increased health care costs. Innovative interventions that address the underlying factors contributing to nonadherence are needed. Gamified mobile apps have shown promise in promoting behavior change and engagement. Objective: This pilot study aimed to evaluate the efficacy and usability of a gamified mobile app that used a narrative storytelling approach to enhance medication adherence among patients following acute coronary syndrome (ACS). The study aimed to assess changes in participants' beliefs about medication and self-reported adherence before and after the intervention. Additionally, user feedback regarding the narrative component of the app was gathered. Methods: Overall, 18 patients who recently experienced ACS were recruited for a 1-month intervention using the gamified app. Participants' beliefs about medication and self-reported adherence were assessed using standardized scales pre- and postintervention. The app's usability was also evaluated through a postintervention questionnaire. Statistical analyses were performed to determine the significance of changes in belief and adherence scores. Results: Although 33\% (6/18) of the participants did not use the intervention more than once, the remaining 12 remained engaged during the 30 days of the study. The results did not indicate a significant improvement in participants' beliefs about medication following the intervention. However, self-reported adherence significantly improved (P<.05) after the intervention with a mean score going from 29.1 (SD 6.9) to 32.4 (SD 5.6), with participants demonstrating a greater self-efficacy to their prescribed medication regimen. However, the results did not indicate a significant improvement in participants' beliefs about medication. With a mean average score of 80.6, the usability evaluation indicates a good usability rating for the gamified app. However, the narrative storytelling component of the app was not favored by the participants, as indicated by their feedback. Conclusions: This pilot study suggests that a gamified mobile app using narration may effectively enhance medication self-efficacy and positively influence patients' beliefs about medication following ACS. However, the narrative component of the app did not receive favorable feedback from participants. Future research should focus on exploring alternative methods to engage participants in the app's narrative elements while maintaining the positive impact on adherence and beliefs about medication observed in this study. ",
doi="10.2196/50693",
url="https://cardio.jmir.org/2025/1/e50693"
}


@Article{info:doi/10.2196/64981,
author="Qi, Yihan
and Mohamad, Emma
and Azlan, Anis Arina
and Zhang, Chenglin
and Ma, Yilian
and Wu, Anqi",
title="Digital Health Solutions for Cardiovascular Disease Prevention: Systematic Review",
journal="J Med Internet Res",
year="2025",
month="Jan",
day="23",
volume="27",
pages="e64981",
keywords="cardiovascular disease prevention",
keywords="cardiovascular outcomes",
keywords="digital technologies",
keywords="remote care",
keywords="mobile phone",
abstract="Background: Cardiovascular disease (CVD) is a major global health issue, with approximately 70\% of cases linked to modifiable risk factors. Digital health solutions offer potential for CVD prevention; yet, their effectiveness in covering the full range of prevention strategies is uncertain. Objective: This study aimed to synthesize current literature on digital solutions for CVD prevention, identify the key components of effective digital interventions, and highlight critical research gaps to inform the development of sustainable strategies for CVD prevention. Methods: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we conducted a comprehensive search in Web of Science, Scopus, and PubMed to identify original English-language studies published between January 2000 and May 2024 that examined primary or secondary CVD prevention through digital solutions. The exclusion criteria included: telephone-only interventions, abstract-only publications, methodology-focused studies without primary data, studies without participants or specific groups, and studies with no follow-up period. The literature search used the string with terms like ``digital health,'' ``mHealth,'' ``mobile health,'' ``text message,'' ``short message service,'' ``SMS,'' ``prevention,'' ``prevent,'' ``cardiovascular disease,'' ``CVD,'' etc. Study bias was assessed using the RoB 2 (Cochrane Collaboration) and the ROBINS-I tool (Cochrane Collaboration). Data on prevention components, prevention types, study design, population, intervention, follow-up duration, personnel, and delivery settings were extracted. Results: A total of 2871 studies were identified through the search. After excluding ineligible studies, 30 studies remained, including 24 randomized controlled trials. The reviewed digital solutions for CVD prevention focused on baseline assessment (29/30, 97\%), physical activity counseling (18/30, 60\%), tobacco cessation (14/30, 47\%), blood pressure management (13/30, 43\%), and medication adherence (10/30, 33\%). The technologies used were categorized into 3 types, smartphones and wearables (16/30, 53\%), email and SMS communications (12/30, 40\%), and websites or web portals (3/30, 10\%). The majority of the study outcomes addressed blood pressure (14/30, 47\%), exercise capacity (12/30, 40\%), weight (12/30, 40\%), and lipid profile (11/30, 37\%), while fewer focused on nicotine dependence (9/30, 30\%), medication use (8/30, 27\%), quality of life (7/30, 23\%), dietary habits (5/30, 17\%), intervention adherence (4/30, 13\%), waist circumference (4/30, 13\%), and blood glucose levels (2/30, 7\%). Conclusions: Digital solutions can address challenges in traditional CVD prevention by improving preventive behaviors and monitoring health indicators. However, most evaluated interventions have focused on medication use, quality of life, dietary habits, adherence, and waist circumference. Further studies are needed to assess the long-term impact of more comprehensive interventions on key cardiovascular outcomes. ",
doi="10.2196/64981",
url="https://www.jmir.org/2025/1/e64981",
url="http://www.ncbi.nlm.nih.gov/pubmed/39847411"
}


@Article{info:doi/10.2196/63941,
author="Simioni, Lisa
and Tessitore, Elena
and Hagberg, Hamdi
and Schneider-Paccot, Aur{\'e}lie
and Blondon, Katherine
and Gschwind, Liliane
and Meyer, Philippe
and Ehrler, Frederic",
title="Cardiomeds, an mHealth App for Self-Management to Support Swiss Patients With Heart Failure: 2-Stage Mixed Methods Usability Study",
journal="JMIR Form Res",
year="2025",
month="Jan",
day="15",
volume="9",
pages="e63941",
keywords="usability",
keywords="medication",
keywords="mobile health",
keywords="mHealth",
keywords="Cardiomeds",
keywords="mobile app",
keywords="patient empowerment",
keywords="eHealth",
keywords="smartphone",
keywords="heart failure",
keywords="HF",
keywords="chronic disease",
keywords="interactive",
keywords="self-monitoring",
keywords="usability test",
keywords="mobile phone",
abstract="Background: Mobile health apps have shown promising results in improving self-management of several chronic diseases in patients. We have developed a mobile health app (Cardiomeds) dedicated to patients with heart failure (HF). This app includes an interactive medication list; daily self-monitoring of symptoms, weight, blood pressure, and heart rate; and educational information on HF delivered through various formats. Objective: This study aimed to perform a mixed methods usability study of Cardiomeds. Methods: Smartphone users with HF were recruited from the HF outpatient clinic at the University Hospital of Geneva. The usability test was conducted in 2 stages, with modifications made to the app after the first stage to address major usability issues. Each stage required 10 participants to perform 14 tasks, such as entering vital signs, entering a new medication and time of intake, or finding information about HF. Each task was timed, sessions were recorded, and all data were anonymized. After completing the tasks, patients completed the System Usability Scale 10-item questionnaire and answered 5 open questions about their perceptions of Cardiomeds. Results: Twenty patients with HF, 75\% (15/20) of whom were men, with a mean age of 55 years, were included in this study. The average time to complete all 14 tasks was 18 (SD 5.7) minutes. Manual medication entry was the most time-consuming task, taking an average of 154.40 (SD 68.08) seconds in the first stage, 103.10 (SD 42.76) seconds in the second stage, and 128 (SD 63) seconds overall. The mean overall success rate was 77\% (SD 0.23\%) for the first stage and 94\% (SD 0.07\%) for the second stage. A total of 30\% (3/10) of participants in the first stage completed all tasks without any help compared with 50\% (5/10) of participants during the second stage. The average System Usability Scale score was 80\% (SD 17\%), showing a slight increase from 79\% (SD 16\%) in the first stage to 80\% (SD 28\%) in the second stage, which qualifies the app as ``good'' in terms of usability. Between the 2 stages, part of the app interface was redesigned to address the key issues identified in the first stage. Despite these improvements, problems related to guidance were frequent and comprised 36\% (8/22) of the problems in the first stage and 40\% (6/15) in the second stage. In response to open questions, 85\% (17/20) of the participants responded that they would like to use the app when it became available. Conclusions: The usability test indicated that Cardiomeds is a suitable and user-friendly app for patients with HF. The app will be further tested in a randomized clinical trial (2022-00731) after acute HF hospitalization to assess its impact on patients' knowledge about HF, self-care, and quality of life. ",
doi="10.2196/63941",
url="https://formative.jmir.org/2025/1/e63941",
url="http://www.ncbi.nlm.nih.gov/pubmed/39813081"
}


@Article{info:doi/10.2196/47730,
author="Versluis, Anke
and Penfornis, M. Kristell
and van der Burg, A. Sven
and Scheltinga, L. Bouke
and van Vliet, M. Milon H.
and Albers, Nele
and Meijer, Eline",
title="Targeting Key Risk Factors for Cardiovascular Disease in At-Risk Individuals: Developing a Digital, Personalized, and Real-Time Intervention to Facilitate Smoking Cessation and Physical Activity",
journal="JMIR Cardio",
year="2024",
month="Dec",
day="20",
volume="8",
pages="e47730",
keywords="smoking",
keywords="physical activity",
keywords="virtual coach",
keywords="eHealth",
keywords="development",
keywords="collaboration",
keywords="conversational agent",
keywords="risk factor",
keywords="cardiovascular disease",
keywords="CVD",
keywords="digital",
keywords="smoking cessation",
keywords="intervention",
doi="10.2196/47730",
url="https://cardio.jmir.org/2024/1/e47730"
}


@Article{info:doi/10.2196/52266,
author="Matsumura, Koichiro
and Nakagomi, Atsushi
and Yagi, Eijiro
and Yamada, Nobuhiro
and Funauchi, Yohei
and Kakehi, Kazuyoshi
and Yoshida, Ayano
and Kawamura, Takayuki
and Ueno, Masafumi
and Nakazawa, Gaku
and Tabuchi, Takahiro",
title="Impact of an mHealth App (Kencom) on Patients With Untreated Hypertension Initiating Antihypertensive Medications: Real-World Cohort Study",
journal="JMIR Cardio",
year="2024",
month="Nov",
day="26",
volume="8",
pages="e52266",
keywords="untreated hypertension",
keywords="mobile health app",
keywords="antihypertensive medication",
keywords="cardiovascular disease",
keywords="mHealth",
abstract="Background: To prevent the further development of cardiovascular diseases, it is a growing global priority to detect untreated hypertension in patients and ensure adequate blood pressure control via drug therapy. However, few effective tools that facilitate the initiation of antihypertensive medications among such patients have been identified. Objective: We aimed to determine whether a mobile health (mHealth) app facilitates the initiation of antihypertensive medications among patients with untreated hypertension. Methods: We analyzed a large longitudinal integrated database mainly comprised of data from middle-aged, employed people and their families. The database contained data from health checkups, health insurance claims, and the mHealth app kencom. kencom is used to manage daily life logs (eg, weight, number of steps) and to provide health information tailored to customers. Patients with untreated hypertension were identified using the baseline health checkup data, and follow-up health checkups were conducted to identify the rate of initiation of antihypertensive medications between mHealth app users and nonusers. Antihypertensive medication status was confirmed via a questionnaire administered during the medical checkup as well as a review of the health insurance claims database. We conducted a modified Poisson regression analysis, weighted by inverse probability of treatment weighting, to examine the effect of mHealth app usage on the initiation of antihypertensive medications. Additionally, data from four lifestyle questionnaires from the baseline and follow-up health checkups were collected to evaluate lifestyle modifications that could be attributed to the mHealth app. Results: Data were collected from 50,803 eligible patients (mean age 49, SD 9 years; men n=39,412, 77.6\%; women n=11,391, 22.4\%) with a median follow-up period of 3.0 (IQR 2.3?3.1) years. The rate of initiation of antihypertensive medications was significantly higher in the mHealth app user group than in the nonuser group: 23.4\% (3482/14,879) versus 18.5\% (6646/35,924; P<.001), respectively. The risk ratio of mHealth app usage for initiated antihypertensive medications was 1.28 (95\% CI 1.23?1.33). Among those who did not intend to improve their lifestyle habits such as exercise and diet at baseline, the rate of lifestyle improvement at follow-up was compared between mHealth app users and nonusers, using data from the questionnaires; mHealth app users demonstrated a significantly higher rate of lifestyle changes than nonusers. Conclusions: For patients with untreated hypertension, the use of the mHealth app kencom, which was not dedicated to hypertension treatment, was associated with a higher initiation of antihypertensive medications. ",
doi="10.2196/52266",
url="https://cardio.jmir.org/2024/1/e52266"
}


@Article{info:doi/10.2196/65010,
author="Yoon, Minjae
and Lee, Hyun Ji
and Kim, In-Cheol
and Lee, Ju-Hee
and Kim, Mi-Na
and Kim, Hack-Lyoung
and Lee, Sunki
and Kim, Jai In
and Choi, Seonghoon
and Park, Sung-Ji
and Hur, Taeho
and Hussain, Musarrat
and Lee, Sungyoung
and Choi, Dong-Ju",
title="Smartphone App for Improving Self-Awareness of Adherence to Edoxaban Treatment in Patients With Atrial Fibrillation (ADHERE-App Trial): Randomized Controlled Trial",
journal="J Med Internet Res",
year="2024",
month="Nov",
day="21",
volume="26",
pages="e65010",
keywords="mobile apps",
keywords="digital health",
keywords="atrial fibrillation",
keywords="anticoagulants",
keywords="medication adherence",
keywords="mobile phone",
abstract="Background: Adherence to oral anticoagulant therapy is essential to prevent ischemic stroke in patients with atrial fibrillation (AF). Objective: This study aimed to evaluate whether smartphone app--based interventions improve medication adherence in patients with AF. Methods: This open-label, multicenter randomized controlled trial (ADHERE-App [Self-Awareness of Drug Adherence to Edoxaban Using an Automatic App Feedback System] study) enrolled patients with AF treated with edoxaban for stroke prevention. They were randomly assigned to app-conditioned feedback (intervention; n=248) and conventional treatment (control; n=250) groups. The intervention group received daily alerts via a smartphone app to take edoxaban and measure blood pressure and heart rate at specific times. The control group received only standard, guideline-recommended care. The primary end point was edoxaban adherence, measured by pill count at 3 or 6 months. Medication adherence and the proportion of adequate medication adherence, which was defined as ?95\% of continuous medication adherence, were evaluated. Results: Medication adherence at 3 or 6 months was not significantly different between the intervention and control groups (median 98\%, IQR 95\%-100\% vs median 98\%, IQR 91\%-100\% at 3 months, P=.06; median 98\%, IQR 94.5\%-100\% vs median 97.5\%, IQR 92.8\%-100\% at 6 months, P=.15). However, the proportion of adequate medication adherence (?95\%) was significantly higher in the intervention group at both time points (76.8\% vs 64.7\% at 3 months, P=.01; 73.9\% vs 61\% at 6 months, P=.007). Among patients aged >65 years, the intervention group showed a higher medication adherence value and a higher proportion of adequate medication adherence (?95\%) at 6 months. Conclusions: There was no difference in edoxaban adherence between the groups. However, the proportion of adequate medication adherence was higher in the intervention group, and the benefit of the smartphone app--based intervention on medication adherence was more pronounced among older patients than among younger patients. Given the low adherence to oral anticoagulants, especially among older adults, using a smartphone app may potentially improve medication adherence. Trial Registration: International Clinical Trials Registry Platform KCT0004754; https://cris.nih.go.kr/cris/search/detailSearch.do?seq=28496\&search\_page=L International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2021-048777 ",
doi="10.2196/65010",
url="https://www.jmir.org/2024/1/e65010",
url="http://www.ncbi.nlm.nih.gov/pubmed/39570659"
}


@Article{info:doi/10.2196/57289,
author="B{\'a}ez Guti{\'e}rrez, Nerea
and Rodr{\'i}guez Ramallo, H{\'e}ctor
and Mendoza-Zambrano, Mar{\'i}a Elva
and Brown Arreola, Berenice
and Santos Ramos, Bernardo
and Abdel-kader Mart{\'i}n, Laila
and Otero Candelera, Remedios",
title="Smartphone Apps for Pulmonary Hypertension: Systematic Search and Content Evaluation",
journal="JMIR Mhealth Uhealth",
year="2024",
month="Oct",
day="30",
volume="12",
pages="e57289",
keywords="pulmonary hypertension",
keywords="mobile apps",
keywords="smartphone",
keywords="eHealth",
keywords="mHealth",
keywords="app",
keywords="hypertension",
keywords="chronic condition",
keywords="mobile health app",
keywords="monitoring",
keywords="systematic search",
keywords="app development",
keywords="clinical validation",
keywords="evaluation",
keywords="pulmonary",
abstract="Background: Pulmonary hypertension (PH) is a chronic and complex condition, requiring consistent management and education. The widespread use of smartphones has opened possibilities for mobile health apps to support both patients and health care professionals in monitoring and managing PH more effectively. Objective: This study aimed to identify and assess the quality of free smartphone apps for PH targeted at either patients or health care professionals. Methods: A systematic search was conducted on freely available apps for patients with PH and health care professionals, accessed from a Spanish IP address, on Android (Google Play) and iOS (App Store) platforms. Searches were performed in October 2022 and 2023. Apps were independently analyzed by two reviewers, focusing on general characteristics. Quality assessment was based on the Mobile Application Rating Scale (MARS) framework, and Mann-Whitney U tests compared mean MARS scores against specific variables. Results: In the overall study, 21 apps were identified. In the 2022 search, 19 apps were listed (9 iOS, 7 Android, 3 available on both platforms). In the subsequent 2023 search, 16 apps were identified (6 Android, 7 iOS, 3 available on both platforms). Of those identified in 2022, 14 remained available in 2023, with only 7 updated since 2022. In addition, 12 apps targeted patients or the general population, while 9 targeted health care professionals; none involved patients in the development or design. Conversely, 13 apps involving health care professionals were identified. There were 10 apps that received pharmaceutical industry funding. The primary goal for 81\% (17/21) of the apps was to disseminate general information about PH. The overall mean MARS quality was acceptable in 2022 and 2023, with mean ratings of 3.1 (SD 0.6) and 3.3 (SD 0.5), respectively. The functionality category achieved the highest scores in both years, indicating ease of use and intuitive navigation. In contrast, the subjective quality domain consistently received the lowest ratings in the MARS assessment across both years. None of the apps underwent clinical testing themselves; however, 2 incorporated tools or algorithms derived from trials. The overall quality of iOS apps statistically outperformed that of Android apps in both years (P<.05). Furthermore, the involvement of health care professionals in app development was associated with enhanced quality, a trend observed in both years (P=.003 for both years). Conclusions: This review of mobile health apps for PH reveals their emergent development stage, with generally acceptable quality but lacking refinement. It highlights the critical role of health care professionals in app development, as they contribute significantly to quality and reliability. Despite this, a notable stagnation in app quality and functionality improvement over 2 years points to a need for continuous innovation and clinical validation for effective clinical integration. This research advocates for future app developers to actively engage with health care professionals, integrate patient insights, and mandate rigorous clinical validation for PH management. ",
doi="10.2196/57289",
url="https://mhealth.jmir.org/2024/1/e57289"
}


@Article{info:doi/10.2196/63707,
author="Gibson, Irene
and Neubeck, Lis
and Corcoran, Marissa
and Morland, Chris
and Donovan, Steve
and Jones, Jennifer
and Costello, Caroline
and Hynes, Lisa
and Harris, Aisling
and Harrahill, Mary
and Lillis, Mary
and Atrey, Alison
and Ski, F. Chantal
and Savickas, Vilius
and Byrne, Molly
and Murphy, W. Andrew
and McEvoy, William John
and Wood, David
and Jennings, Catriona",
title="Development of a Digital Health Intervention for the Secondary Prevention of Cardiovascular Disease (INTERCEPT): Co-Design and Usability Testing Study",
journal="JMIR Hum Factors",
year="2024",
month="Oct",
day="23",
volume="11",
pages="e63707",
keywords="cardiovascular disease",
keywords="secondary prevention",
keywords="digital health",
keywords="intervention development",
keywords="co-design",
keywords="usability testing",
keywords="mobile health",
keywords="usability",
keywords="design",
keywords="conline workshop",
keywords="social support",
keywords="behavioral change",
keywords="self-monitoring",
abstract="Background: Secondary prevention is an important strategy to reduce the burden of cardiovascular disease (CVD), a leading cause of death worldwide. Despite the growing evidence for the effectiveness of digital health interventions (DHIs) for the secondary prevention of CVD, the majority are designed with minimal input from target end users, resulting in poor uptake and usage. Objective: This study aimed to optimize the acceptance and effectiveness of a DHI for the secondary prevention of CVD through co-design, integrating end users' perspectives throughout. Methods: A theory-driven, person-based approach using co-design was adopted for the development of the DHI, known as INTERCEPT. This involved a 4-phase iterative process using online workshops. In phase 1, a stakeholder team of health care professionals, software developers, and public and patient involvement members was established. Phase 2 involved identification of the guiding principles, content, and design features of the DHI. In phase 3, DHI prototypes were reviewed for clarity of language, ease of navigation, and functionality. To anticipate and interpret DHI usage, phase 4 involved usability testing with participants who had a recent cardiac event (<2 years). To assess the potential impact of usability testing, the System Usability Scale was administered before and after testing. The GUIDED (Guidance for Reporting Intervention Development Studies in Health Research) checklist was used to report the development process. Results: Five key design principles were identified: simplicity and ease of use, behavioral change through goal setting and self-monitoring, personalization, system credibility, and social support. Usability testing resulted in 64 recommendations for the app, of which 51 were implemented. Improvements in System Usability Scale scores were observed when comparing the results before and after implementing the recommendations (61 vs 83; P=.02). Conclusions: Combining behavior change theory with a person-based, co-design approach facilitated the development of a DHI for the secondary prevention of CVD that optimized responsiveness to end users' needs and preferences, thereby potentially improving future engagement. ",
doi="10.2196/63707",
url="https://humanfactors.jmir.org/2024/1/e63707",
url="http://www.ncbi.nlm.nih.gov/pubmed/39441626"
}


@Article{info:doi/10.2196/54405,
author="Suresh Kumar, Sagar
and Connolly, Patricia
and Maier, Anja",
title="Considering User Experience and Behavioral Approaches in the Design of mHealth Interventions for Atrial Fibrillation: Systematic Review",
journal="J Med Internet Res",
year="2024",
month="Oct",
day="4",
volume="26",
pages="e54405",
keywords="atrial fibrillation",
keywords="wearable devices",
keywords="lifestyle modification",
keywords="user experience",
keywords="design for behavior change",
keywords="systems thinking",
keywords="cardiac disease",
keywords="stroke",
keywords="heart disease",
keywords="complication",
keywords="mobile health",
keywords="systematic review",
keywords="usability",
keywords="mHealth",
keywords="intervention",
abstract="Background: Atrial fibrillation (AF) is a leading chronic cardiac disease associated with an increased risk of stroke, cardiac complications, and general mortality. Mobile health (mHealth) interventions, including wearable devices and apps, can aid in the detection, screening, and management of AF to improve patient outcomes. The inclusion of approaches that consider user experiences and behavior in the design of health care interventions can increase the usability of mHealth interventions, and hence, hopefully, yield an increase in positive outcomes in the lives of users. Objective: This study aims to show how research has considered user experiences and behavioral approaches in designing mHealth interventions for AF detection, screening, and management; the phases of designing complex interventions from the UK Medical Research Council (MRC) were referenced: namely, identification, development, feasibility, evaluation, and implementation. Methods: Studies published until September 7, 2022, that examined user experiences and behavioral approaches associated with mHealth interventions in the context of AF were extracted from multiple databases. The PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines were used. Results: A total of 2219 records were extracted, with only 55 records reporting on usability, user experiences, or behavioral approaches more widely for designing mHealth interventions in the context of AF. When mapping the studies onto the phases of the UK MRC's guidance for developing and evaluating complex interventions, the following was found: in the identification phase, there were significant differences between the needs of patients and health care workers. In the development phase, user perspectives guided the iterative development of apps, interfaces, and intervention protocols in 4 studies. Most studies (43/55, 78\%) assessed the usability of interventions in the feasibility phase as an outcome, although the data collection tools were not designed together with users and stakeholders. Studies that examined the evaluation and implementation phase entailed reporting on challenges in user participation, acceptance, and workflows that could not be captured by studies in the previous phases. To realize the envisaged human behavior intended through treatment, review results highlight the scant inclusion of behavior change approaches for mHealth interventions across multiple levels of sociotechnical health care systems. While interventions at the level of the individual (micro) and the level of communities (meso) were found in the studies reviewed, no studies were found intervening at societal levels (macro). Studies also failed to consider the temporal variation of user goals and feedback in the design of long-term behavioral interventions. Conclusions: In this systematic review, we proposed 2 contributions: first, mapping studies to different phases of the MRC framework for developing and evaluating complex interventions, and second, mapping behavioral approaches to different levels of health care systems. Finally, we discuss the wider implications of our results in guiding future mHealth research. ",
doi="10.2196/54405",
url="https://www.jmir.org/2024/1/e54405"
}


@Article{info:doi/10.2196/59243,
author="Kalinowski, Jolaade
and Bhusal, Sandesh
and Pagoto, L. Sherry
and Newton Jr, Robert
and Waring, E. Molly",
title="Smart Device Ownership and Use of Social Media, Wearable Trackers, and Health Apps Among Black Women With Hypertension in the United States: National Survey Study",
journal="JMIR Cardio",
year="2024",
month="Sep",
day="9",
volume="8",
pages="e59243",
keywords="Black women",
keywords="Black",
keywords="women",
keywords="tracker",
keywords="trackers",
keywords="wearable",
keywords="wearables",
keywords="hypertension",
keywords="hypertensive",
keywords="cardiology",
keywords="cardiovascular",
keywords="blood pressure",
keywords="social media",
keywords="technology",
keywords="usage",
keywords="digital health",
keywords="eHealth",
keywords="tablet",
keywords="mHealth",
keywords="mobile health",
keywords="app",
keywords="apps",
keywords="applications",
keywords="survey",
keywords="surveys",
keywords="questionnaire",
keywords="questionnaires",
keywords="Health Information National Trends Survey",
keywords="HINTS",
doi="10.2196/59243",
url="https://cardio.jmir.org/2024/1/e59243"
}


@Article{info:doi/10.2196/55506,
author="Mir, Hassan
and Cullen, J. Katelyn
and Mosleh, Karen
and Setrak, Rafi
and Jolly, Sanjit
and Tsang, Michael
and Rutledge, Gregory
and Ibrahim, Quazi
and Welsford, Michelle
and Mercuri, Mathew
and Schwalm, JD
and Natarajan, K. Madhu",
title="Smartphone App for Prehospital ECG Transmission in ST-Elevation Myocardial Infarction Activation: Protocol for a Mixed Methods Study",
journal="JMIR Res Protoc",
year="2024",
month="Sep",
day="6",
volume="13",
pages="e55506",
keywords="ST-elevation myocardial infarction",
keywords="m-health",
keywords="cardiac systems of care",
keywords="knowledge mobilization",
keywords="digital health",
keywords="smartphone technology",
keywords="technology",
keywords="STEMI",
keywords="Canada",
keywords="implementation",
keywords="mobile phone",
abstract="Background: Timely diagnosis and treatment for ST-elevation myocardial infarction (STEMI) requires a coordinated response from multiple providers. Rapid intervention is key to reducing mortality and morbidity. Activation of the cardiac catheterization laboratory may occur through verbal communication and may also involve the secure sharing of electrocardiographic images between frontline health care providers and interventional cardiologists. To improve this response, we developed a quick, easy-to-use, privacy-compliant smartphone app, that is SMART AMI-ACS (Strategic Management of Acute Reperfusion and Therapies in Acute Myocardial Infarction Acute Coronary Syndromes), for real-time verbal communication and sharing of electrocardiographic images among health care providers in Ontario, Canada. The app further provides information about diagnosis, management, and risk calculators for patients presenting with acute coronary syndrome. Objective: This study aims to integrate the app into workflow processes to improve communication for STEMI activation, resulting in decreased treatment times, improved patient outcomes, and reduced unnecessary catheterization laboratory activation and transfer. Methods: Implementation of the app will be guided by the Reach, Effectiveness, Acceptability, Implementation, and Maintenance (RE-AIM) framework to measure impact. The study will use quantitative registry data already being collected through the SMART AMI project (STEMI registry), the use of the SMART AMI app, and quantitative and qualitative survey data from physicians. Survey questions will be based on the Consolidated Framework for Implementation Research. Descriptive quantitative analysis and thematic qualitative analysis of survey results will be conducted. Continuous variables will be described using either mean and SD or median and IQR values at pre- and postintervention periods by the study sites. Categorical variables, such as false activation, will be described as frequencies (percentages). For each outcome, an interrupted time series regression model will be fitted to evaluate the impact of the app. Results: The primary outcomes of this study include the usability, acceptability, and functionality of the app for physicians. This will be measured using electronic surveys to identify barriers and facilitators to app use. Other key outcomes will measure the implementation of the app by reviewing the timing-of-care intervals, false ``avoidable'' catheterization laboratory activation rates, and uptake and use of the app by physicians. Prospective evaluation will be conducted between April 1, 2022, and March 31, 2023. However, for the timing- and accuracy-of-care outcomes, registry data will be compared from January 1, 2019, to March 31, 2023. Data analysis is expected to be completed in Fall 2024, with the completion of a paper for publication anticipated by the end of 2024. Conclusions: Smartphone technology is well integrated into clinical practice and widely accessible. The proposed solution being tested is secure and leverages the accessibility of smartphones. Emergency medicine physicians can use this app to quickly, securely, and accurately transmit information ensuring faster and more appropriate decision-making for STEMI activation. Trial Registration: ClinicalTrials.gov NCT05290389; https://clinicaltrials.gov/study/NCT05290389 International Registered Report Identifier (IRRID): DERR1-10.2196/55506 ",
doi="10.2196/55506",
url="https://www.researchprotocols.org/2024/1/e55506",
url="http://www.ncbi.nlm.nih.gov/pubmed/39240681"
}


@Article{info:doi/10.2196/54509,
author="Ho, Ngan Dang Khanh
and Chiu, Wan-Chun
and Kao, Jing-Wen
and Tseng, Hsiang-Tung
and Lin, Cheng-Yu
and Huang, Pin-Hsiang
and Fang, Yu-Ren
and Chen, Kuei-Hung
and Su, Ting-Ying
and Yang, Chia-Hui
and Yao, Chih-Yuan
and Su, Hsiu-Yueh
and Wei, Pin-Hui
and Chang, Jung-Su",
title="Reliability Issues of Mobile Nutrition Apps for Cardiovascular Disease Prevention: Comparative Study",
journal="JMIR Mhealth Uhealth",
year="2024",
month="Sep",
day="4",
volume="12",
pages="e54509",
keywords="mobile apps",
keywords="mHealth",
keywords="dietary assessment",
keywords="validity",
keywords="cardiovascular disease prevention",
keywords="app",
keywords="apps",
keywords="applications",
keywords="application",
keywords="nutrition",
keywords="cardiovascular",
keywords="nutrients",
keywords="fitness",
keywords="diet",
keywords="mobile health",
abstract="Background: Controlling saturated fat and cholesterol intake is important for the prevention of cardiovascular diseases. Although the use of mobile diet-tracking apps has been increasing, the reliability of nutrition apps in tracking saturated fats and cholesterol across different nations remains underexplored. Objective: This study aimed to examine the reliability and consistency of nutrition apps focusing on saturated fat and cholesterol intake across different national contexts. The study focused on 3 key concerns: data omission, inconsistency (variability) of saturated fat and cholesterol values within an app, and the reliability of commercial apps across different national contexts. Methods: Nutrient data from 4 consumer-grade apps (COFIT, MyFitnessPal-Chinese, MyFitnessPal-English, and LoseIt!) and an academic app (Formosa FoodApp) were compared against 2 national reference databases (US Department of Agriculture [USDA]--Food and Nutrient Database for Dietary Studies [FNDDS] and Taiwan Food Composition Database [FCD]). Percentages of missing nutrients were recorded, and coefficients of variation were used to compute data inconsistencies. One-way ANOVAs were used to examine differences among apps, and paired 2-tailed t tests were used to compare the apps to national reference data. The reliability across different national contexts was investigated by comparing the Chinese and English versions of MyFitnessPal with the USDA-FNDDS and Taiwan FCD. Results: Across the 5 apps, 836 food codes from 42 items were analyzed. Four apps, including COFIT, MyFitnessPal-Chinese, MyFitnessPal-English, and LoseIt!, significantly underestimated saturated fats, with errors ranging from ?13.8\% to ?40.3\% (all P<.05). All apps underestimated cholesterol, with errors ranging from ?26.3\% to ?60.3\% (all P<.05). COFIT omitted 47\% of saturated fat data, and MyFitnessPal-Chinese missed 62\% of cholesterol data. The coefficients of variation of beef, chicken, and seafood ranged from 78\% to 145\%, from 74\% to 112\%, and from 97\% to 124\% across MyFitnessPal-Chinese, MyFitnessPal-English, and LoseIt!, respectively, indicating a high variability in saturated fats across different food groups. Similarly, cholesterol variability was consistently high in dairy (71\%-118\%) and prepackaged foods (84\%-118\%) across all selected apps. When examining the reliability of MyFitnessPal across different national contexts, errors in MyFitnessPal were consistent across different national FCDs (USDA-FNDSS and Taiwan FCD). Regardless of the FCDs used as a reference, these errors persisted to be statistically significant, indicating that the app's core database is the source of the problems rather than just mismatches or variances in external FCDs. Conclusions: The findings reveal substantial inaccuracies and inconsistencies in diet-tracking apps' reporting of saturated fats and cholesterol. These issues raise concerns for the effectiveness of using consumer-grade nutrition apps in cardiovascular disease prevention across different national contexts and within the apps themselves. ",
doi="10.2196/54509",
url="https://mhealth.jmir.org/2024/1/e54509"
}


@Article{info:doi/10.2196/60773,
author="He, Yunfan
and Chen, Han
and Xiang, Peng
and Zhao, Min
and Li, Yingjun
and Liu, Yongcheng
and Wang, Tong
and Liang, Jun
and Lei, Jianbo",
title="Establishing an Evaluation Indicator System for User Satisfaction With Hypertension Management Apps: Combining User-Generated Content and Analytic Hierarchy Process",
journal="J Med Internet Res",
year="2024",
month="Sep",
day="3",
volume="26",
pages="e60773",
keywords="hypertension management",
keywords="mobile health",
keywords="user satisfaction",
keywords="evaluation indicator system",
keywords="analytic hierarchy process",
abstract="Background: Hypertension management apps (HMAs) can be effective in controlling blood pressure, but their actual impact is often suboptimal. Establishing a user satisfaction evaluation indicator system for HMAs can assist app developers in enhancing app design and functionality, while also helping users identify apps that best meet their needs. This approach aims to improve the overall effectiveness of app usage. Objective: This study aims to systematically collect data on HMAs and their user reviews in the United States and China. It analyzes app usage patterns and functional characteristics, identifies factors influencing user satisfaction from existing research, and develops a satisfaction evaluation indicator system to provide more accurate recommendations for improving user satisfaction. Methods: We conducted a descriptive statistical analysis to assess the development status of HMAs in both countries and applied the task-technology fit model to evaluate whether the app functionalities align with business needs. We separately summarized the factors influencing user satisfaction in both countries from previous research, utilized the analytic hierarchy process to develop an evaluation indicator system for HMA user satisfaction, and calculated satisfaction levels. Based on these findings, we propose improvements to enhance app functionality and user satisfaction. Results: In terms of current development status, there were fewer HMAs and user reviews in China compared with the United States. Regarding app functional availability, fewer than 5\% (4/91) of the apps achieved a demand fulfillment rate exceeding 80\% (8/10). Overall, user satisfaction in both countries was low. Conclusions: In the United States, user satisfaction was lowest for advertising distribution, data synchronization, and reliability. By contrast, Chinese apps need improvements in cost efficiency and compatibility. ",
doi="10.2196/60773",
url="https://www.jmir.org/2024/1/e60773",
url="http://www.ncbi.nlm.nih.gov/pubmed/39226103"
}


@Article{info:doi/10.2196/54511,
author="Niyomyart, Atsadaporn
and Ruksakulpiwat, Suebsarn
and Benjasirisan, Chitchanok
and Phianhasin, Lalipat
and Nigussie, Kabtamu
and Thorngthip, Sutthinee
and Shamita, Gazi
and Thampakkul, Jai
and Begashaw, Lidya",
title="Current Status of Barriers to mHealth Access Among Patients With Stroke and Steps Toward the Digital Health Era: Systematic Review",
journal="JMIR Mhealth Uhealth",
year="2024",
month="Aug",
day="22",
volume="12",
pages="e54511",
keywords="digital health",
keywords="mHealth",
keywords="barrier",
keywords="stroke",
keywords="systematic review",
keywords="mobile phones",
abstract="Background: Mobile health (mHealth) offers significant benefits for patients with stroke, facilitating remote monitoring and personalized health care solutions beyond traditional settings. However, there is a dearth of comprehensive data, particularly qualitative insights, on the barriers to mHealth access. Understanding these barriers is crucial for devising strategies to enhance mHealth use among patients with stroke. Objective: This study aims to examine the recent literature focusing on barriers to mHealth access among patients with stroke. Methods: A systematic search of PubMed, MEDLINE, Web of Science, and CINAHL Plus Full Text was conducted for literature published between 2017 and 2023. Abstracts and full texts were independently screened based on predetermined inclusion and exclusion criteria. Data synthesis was performed using the convergent integrated analysis framework recommended by the Joanna Briggs Institute. Results: A total of 12 studies met the inclusion criteria. The majority were qualitative studies (about 42\%), followed by mixed methods (25\%), pilot studies (about 17\%), nonrandomized controlled trials (about 8\%), and observational studies (about 8\%). Participants included patients with stroke, caregivers, and various health care professionals. The most common mHealth practices were home-based telerehabilitation (30\%) and poststroke mHealth and telecare services (20\%). Identified barriers were categorized into two primary themes: (1) at the patient level and (2) at the health provider-patient-device interaction level. The first theme includes 2 subthemes: health-related issues and patient acceptability. The second theme encompassed 3 subthemes: infrastructure challenges (including software, networking, and hardware), support system deficiencies, and time constraints. Conclusions: This systematic review underscores significant barriers to mHealth adoption among patients with stroke. Addressing these barriers in future research is imperative to ensure that mHealth solutions effectively meet patients' needs. ",
doi="10.2196/54511",
url="https://mhealth.jmir.org/2024/1/e54511"
}


@Article{info:doi/10.2196/50066,
author="Berglund, Aseel
and Klompstra, Leonie
and Or{\"a}dd, Helena
and Fallstr{\"o}m, Johan
and Str{\"o}mberg, Anna
and Jaarsma, Tiny
and Berglund, Erik",
title="The Rationale Behind the Design Decisions in an Augmented Reality Mobile eHealth Exergame to Increase Physical Activity for Inactive Older People With Heart Failure",
journal="JMIR Serious Games",
year="2024",
month="Aug",
day="21",
volume="12",
pages="e50066",
keywords="sedentary",
keywords="exercise",
keywords="exertion",
keywords="exergames",
keywords="technology",
keywords="training",
keywords="inactivity",
keywords="eHealth application",
keywords="heart disease",
keywords="physical activity",
doi="10.2196/50066",
url="https://games.jmir.org/2024/1/e50066"
}


@Article{info:doi/10.2196/56921,
author="Klassen, A. Stephen
and Jabbar, Jesica
and Osborne, Jenna
and Iannarelli, J. Nathaniel
and Kirby, S. Emerson
and O'Leary, D. Deborah
and Locke, Sean",
title="Examining the Light Heart Mobile Device App for Assessing Human Pulse Interval and Heart Rate Variability: Validation Study",
journal="JMIR Form Res",
year="2024",
month="Aug",
day="20",
volume="8",
pages="e56921",
keywords="pulse interval",
keywords="mobile app",
keywords="validation",
keywords="mHealth",
keywords="mHealth app",
keywords="app mobile device",
keywords="mobile device app",
keywords="pulse",
keywords="heart",
keywords="heart rate",
keywords="validation study",
keywords="biomarker",
keywords="psychological",
keywords="physiological",
keywords="pulse rate",
keywords="young adults",
keywords="youth",
keywords="linear correlation",
keywords="heart rate variability",
keywords="examining",
keywords="examine",
keywords="validity",
keywords="psychological health",
keywords="physiological health",
keywords="interval data",
keywords="mobile phone",
abstract="Background: Pulse interval is a biomarker of psychological and physiological health. Pulse interval can now be assessed using mobile phone apps, which expands researchers' ability to assess pulse interval in the real world. Prior to implementation, measurement accuracy should be established. Objective: This investigation evaluated the validity of the Light Heart mobile app to measure pulse interval and pulse rate variability in healthy young adults. Methods: Validity was assessed by comparing the pulse interval and SD of normal pulse intervals obtained by Light Heart to the gold standard, electrocardiogram (ECG), in 14 young healthy individuals (mean age 24, SD 5 years; n=9, 64\% female) in a seated posture. Results: Mean pulse interval (Light Heart: 859, SD 113 ms; ECG: 857, SD 112 ms) demonstrated a strong positive linear correlation (r=0.99; P<.001) and strong agreement (intraclass correlation coefficient=1.00, 95\% CI 0.99-1.00) between techniques. The Bland-Altman plot demonstrated good agreement for the mean pulse interval measured with Light Heart and ECG with evidence of fixed bias (--1.56, SD 1.86; 95\% CI --5.2 to 2.1 ms), suggesting that Light Heart overestimates pulse interval by a small margin. When Bland-Altman plots were constructed for each participant's beat-by-beat pulse interval data, all participants demonstrated strong agreement between Light Heart and ECG with no evidence of fixed bias between measures. Heart rate variability, assessed by SD of normal pulse intervals, demonstrated strong agreement between techniques (Light Heart: mean 73, SD 23 ms; ECG: mean 73, SD 22 ms; r=0.99; P<.001; intraclass correlation coefficient=0.99, 95\% CI 0.97-1.00). Conclusions: This study provides evidence to suggest that the Light Heart mobile app provides valid measures of pulse interval and heart rate variability in healthy young adults. ",
doi="10.2196/56921",
url="https://formative.jmir.org/2024/1/e56921"
}


@Article{info:doi/10.2196/59948,
author="Carter, Carter Jocelyn A.
and Swack, Natalia
and Isselbacher, Eric
and Donelan, Karen
and Thorndike, Anne",
title="Feasibility, Acceptability, and Preliminary Effectiveness of a Combined Digital Platform and Community Health Worker Intervention for Patients With Heart Failure: Pilot Randomized Controlled Trial",
journal="JMIR Cardio",
year="2024",
month="Aug",
day="8",
volume="8",
pages="e59948",
keywords="heart failure",
keywords="heart",
keywords="cardiology",
keywords="failure",
keywords="clinical pilot trial",
keywords="digital platform",
keywords="home",
keywords="digital health",
keywords="remote monitoring",
keywords="monitoring",
keywords="home-based care",
keywords="community health workers",
keywords="social needs care",
keywords="randomized controlled trial",
keywords="controlled trials",
keywords="feasibility",
keywords="usability",
keywords="acceptability",
keywords="social needs",
abstract="Background: Heart failure (HF) is a burdensome condition and a leading cause of 30-day hospital readmissions in the United States. Clinical and social factors are key drivers of hospitalization. These 2 strategies, digital platforms and home-based social needs care, have shown preliminary effectiveness in improving adherence to clinical care plans and reducing acute care use in HF. Few studies, if any, have tested combining these 2 strategies in a single intervention. Objective: This study aims to perform a pilot randomized controlled trial assessing the acceptability, feasibility, and preliminary effectiveness of a 30-day digitally-enabled community health worker (CHW) intervention in HF. Methods: Adults hospitalized with a diagnosis of HF at an academic hospital were randomly assigned to receive digitally-enabled CHW care (intervention; digital platform +CHW) or CHW-enhanced usual care (control; CHW only) for 30 days after hospital discharge. Primary outcomes were feasibility (use of the platform) and acceptability (willingness to use the platform in the future). Secondary outcomes assessed preliminary effectiveness (30-day readmissions, emergency department visits, and missed clinic appointments). Results: A total of 56 participants were randomized (control: n=31; intervention: n=25) and 47 participants (control: n=28; intervention: n=19) completed all trial activities. Intervention participants who completed trial activities wore the digital sensor on 78\% of study days with mean use of 11.4 (SD 4.6) hours/day, completed symptom questionnaires on 75\% of study days, used the blood pressure monitor 1.1 (SD 0.19) times/day, and used the digital weight scale 1 (SD 0.13) time/day. Of intervention participants, 100\% responded very or somewhat true to the statement ``If I have access to the [platform] moving forward, I will use it.'' Some (n=9, 47\%) intervention participants indicated they required support to use the digital platform. A total of 19 (100\%) intervention participants and 25 (89\%) control participants had ?5 CHW interactions during the 30-day study period. All intervention (n=19, 100\%) and control (n=26, 93\%) participants who completed trial activities indicated their CHW interactions were ``very satisfying.'' In the full sample (N=56), fewer participants in the intervention group were readmitted 30 days after hospital discharge compared to the control group (n=3, 12\% vs n=8, 26\%; P=.12). Both arms had similar rates of missed clinic appointments and emergency department visits. Conclusions: This pilot trial of a digitally-enabled CHW intervention for HF demonstrated feasibility, acceptability, and a clinically relevant reduction in 30-day readmissions among participants who received the intervention. Additional investigation is needed in a larger trial to determine the effect of this intervention on HF home management and clinical outcomes. Trial Registration: Clinicaltrials.gov NCT05130008; https://clinicaltrials.gov/study/NCT05130008 International Registered Report Identifier (IRRID): RR2-10.2196/55687 ",
doi="10.2196/59948",
url="https://cardio.jmir.org/2024/1/e59948",
url="http://www.ncbi.nlm.nih.gov/pubmed/38959294"
}


@Article{info:doi/10.2196/52973,
author="Kashyap, Nick
and Sebastian, Tresa Ann
and Lynch, Chris
and Jansons, Paul
and Maddison, Ralph
and Dingler, Tilman
and Oldenburg, Brian",
title="Engagement With Conversational Agent--Enabled Interventions in Cardiometabolic Disease Management: Protocol for a Systematic Review",
journal="JMIR Res Protoc",
year="2024",
month="Aug",
day="7",
volume="13",
pages="e52973",
keywords="cardiometabolic disease",
keywords="cardiovascular disease",
keywords="diabetes",
keywords="chronic disease",
keywords="chatbot",
keywords="acceptability",
keywords="technology acceptance model",
keywords="design",
keywords="natural language processing",
keywords="adult",
keywords="heart failure",
keywords="digital health intervention",
keywords="Australia",
keywords="systematic review",
keywords="meta-analysis",
keywords="digital health",
keywords="conversational agent--enabled",
keywords="health informatics",
keywords="management",
abstract="Background: Cardiometabolic diseases (CMDs) are a group of interrelated conditions, including heart failure and diabetes, that increase the risk of cardiovascular and metabolic complications. The rising number of Australians with CMDs has necessitated new strategies for those managing these conditions, such as digital health interventions. The effectiveness of digital health interventions in supporting people with CMDs is dependent on the extent to which users engage with the tools. Augmenting digital health interventions with conversational agents, technologies that interact with people using natural language, may enhance engagement because of their human-like attributes. To date, no systematic review has compiled evidence on how design features influence the engagement of conversational agent--enabled interventions supporting people with CMDs. This review seeks to address this gap, thereby guiding developers in creating more engaging and effective tools for CMD management. Objective: The aim of this systematic review is to synthesize evidence pertaining to conversational agent--enabled intervention design features and their impacts on the engagement of people managing CMD. Methods: The review is conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions and reported in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Searches will be conducted in the Ovid (Medline), Web of Science, and Scopus databases, which will be run again prior to manuscript submission. Inclusion criteria will consist of primary research studies reporting on conversational agent--enabled interventions, including measures of engagement, in adults with CMD. Data extraction will seek to capture the perspectives of people with CMD on the use of conversational agent--enabled interventions. Joanna Briggs Institute critical appraisal tools will be used to evaluate the overall quality of evidence collected. Results: This review was initiated in May 2023 and was registered with the International Prospective Register of Systematic Reviews (PROSPERO) in June 2023, prior to title and abstract screening. Full-text screening of articles was completed in July 2023 and data extraction began August 2023. Final searches were conducted in April 2024 prior to finalizing the review and the manuscript was submitted for peer review in July 2024. Conclusions: This review will synthesize diverse observations pertaining to conversational agent--enabled intervention design features and their impacts on engagement among people with CMDs. These observations can be used to guide the development of more engaging conversational agent--enabled interventions, thereby increasing the likelihood of regular intervention use and improved CMD health outcomes. Additionally, this review will identify gaps in the literature in terms of how engagement is reported, thereby highlighting areas for future exploration and supporting researchers in advancing the understanding of conversational agent--enabled interventions. Trial Registration: PROSPERO CRD42023431579; https://tinyurl.com/55cxkm26 International Registered Report Identifier (IRRID): DERR1-10.2196/52973 ",
doi="10.2196/52973",
url="https://www.researchprotocols.org/2024/1/e52973",
url="http://www.ncbi.nlm.nih.gov/pubmed/39110504"
}


@Article{info:doi/10.2196/57241,
author="Kapoor, Melissa
and Holman, Blair
and Cohen, Carolyn",
title="Contactless and Calibration-Free Blood Pressure and Pulse Rate Monitor for Screening and Monitoring of Hypertension: Cross-Sectional Validation Study",
journal="JMIR Cardio",
year="2024",
month="Aug",
day="5",
volume="8",
pages="e57241",
keywords="remote photoplethysmography",
keywords="vital signs",
keywords="calibration-free blood pressure monitor",
keywords="medical device",
keywords="hypertension screening",
keywords="home blood pressure monitoring",
keywords="vital",
keywords="vitals",
keywords="device",
keywords="devices",
keywords="hypertension",
keywords="hypertensive",
keywords="cardiovascular",
keywords="cardiology",
keywords="heart",
keywords="blood pressure",
keywords="monitoring",
keywords="monitor",
keywords="mHealth",
keywords="mobile health",
keywords="validation",
abstract="Background: The key to reducing the immense morbidity and mortality burdens of cardiovascular diseases is to help people keep their blood pressure (BP) at safe levels. This requires that more people with hypertension be identified, diagnosed, and given tools to lower their BP. BP monitors are critical to hypertension diagnosis and management. However, there are characteristics of conventional BP monitors (oscillometric cuff sphygmomanometers) that hinder rapid and effective hypertension diagnosis and management. Calibration-free, software-only BP monitors that operate on ubiquitous mobile devices can enable on-demand BP monitoring, overcoming the hardware barriers of conventional BP monitors. Objective: This study aims to investigate the accuracy of a contactless BP monitor software app for classifying the full range of clinically relevant BPs as hypertensive or nonhypertensive and to evaluate its accuracy for measuring the pulse rate (PR) and BP of people with BPs relevant to stage-1 hypertension. Methods: The software app, known commercially as Lifelight, was investigated following the data collection and data analysis methodology outlined in International Organization for Standardization (ISO) 81060-2:2018/AMD 1:2020 ``Non-invasive Sphygmomanometers---Part 2: Clinical investigation of automated measurement type.'' This validation study was conducted by the independent laboratory Element Materials Technology Boulder (formerly Clinimark). The study generated data from 85 people aged 18-85 years with a wide-ranging distribution of BPs specified in ISO 81060-2:2018/AMD 1:2020. At least 20\% were required to have Fitzpatrick scale skin tones of 5 or 6 (ie, dark skin tones). The accuracy of the app's BP measurements was assessed by comparing its BP measurements with measurements made by dual-observer manual auscultation using the same-arm sequential method specified in ISO 81060-2:2018/AMD 1:2020. The accuracy of the app's PR measurements was assessed by comparing its measurements with concurrent electroencephalography-derived heart rate values. Results: The app measured PR with an accuracy root-mean-square of 1.3 beats per minute and mean absolute error of 1.1 (SD 0.8) beats per minute. The sensitivity and specificity with which it determined that BPs exceeded the in-clinic systolic threshold for hypertension diagnosis were 70.1\% and 71.7\%, respectively. These rates are consistent with those reported for conventional BP monitors in a literature review by The National Institute for Health and Care Excellence. The app's mean error for measuring BP in the range of normotension and stage-1 hypertension (ie, 65/85, 76\% of participants) was 6.5 (SD 12.9) mm Hg for systolic BP and 0.4 (SD 10.6) mm Hg for diastolic BP. Mean absolute error was 11.3 (SD 10.0) mm Hg and 8.6 (SD 6.8) mm Hg, respectively. Conclusions: A calibration-free, software-only medical device was independently tested against ISO 81060-2:2018/AMD 1:2020. The safety and performance demonstrated in this study suggest that this technique could be a potential solution for rapid and scalable screening and management of hypertension. ",
doi="10.2196/57241",
url="https://cardio.jmir.org/2024/1/e57241",
url="http://www.ncbi.nlm.nih.gov/pubmed/39102277"
}


@Article{info:doi/10.2196/46319,
author="Chen, Wenfei
and Chen, Jiana
and Jiang, Shaojun
and Wang, Chunhua
and Zhang, Jinhua",
title="Web-Based Warfarin Management (Alfalfa App) Versus Traditional Warfarin Management: Multicenter Prospective Cohort Study",
journal="J Med Internet Res",
year="2024",
month="Jul",
day="29",
volume="26",
pages="e46319",
keywords="warfarin",
keywords="telemedicine",
keywords="smart phone application",
keywords="anti-coagulation management",
keywords="management",
keywords="cohort study",
keywords="application",
keywords="chronic disease",
keywords="support",
keywords="effectiveness",
keywords="online model",
keywords="patient management",
abstract="Background: Poor anticoagulation management of warfarin may lead to patient admission, prolonged hospital stays, and even death due to anticoagulation-related adverse events. Traditional non--web-based outpatient clinics struggle to provide ideal anticoagulation management services for patients, and there is a need to explore a safer, more effective, and more convenient mode of warfarin management. Objective: This study aimed to compare differences in the quality of anticoagulation management and clinical adverse events between a web-based management model (via a smartphone app) and the conventional non--web-based outpatient management model. Methods: This study is a prospective cohort research that includes multiple national centers. Patients meeting the nadir criteria were split into a web-based management group using the Alfalfa app or a non--web-based management group with traditional outpatient management, and they were then monitored for a 6-month follow-up period to collect coagulation test results and clinical events. The effectiveness and safety of the 2 management models were assessed by the following indicators: time in therapeutic range (TTR), bleeding events, thromboembolic events, all-cause mortality events, cumulative event rates, and the distribution of the international normalized ratio (INR). Results: This national multicenter cohort study enrolled 522 patients between June 2019 and May 2021, with 519 (99\%) patients reaching the follow-up end point, including 260 (50\%) in the non--web-based management group and 259 (50\%) in the web-based management group. There were no observable differences in baseline characteristics between the 2 patient groups. The web-based management group had a significantly higher TTR than the non--web-based management group (82.4\% vs 71.6\%, P<.001), and a higher proportion of patients received effective anticoagulation management (81.2\% vs 63.5\%, P<.001). The incidence of minor bleeding events in the non--web-based management group was significantly higher than that in the web-based management group (12.1\% vs 6.6\%, P=.048). Between the 2 groups, there was no statistically significant difference in the incidence of severe bleeding and thromboembolic and all-cause death events. In addition, compared with the non--web-based management group, the web-based management group had a lower proportion of INR in the extreme subtreatment range (17.6\% vs 21.3\%) and severe supertreatment range (0\% vs 0.8\%) and a higher proportion in the treatment range (50.4\% vs 43.1\%), with statistical significance. Conclusions: Compared with traditional non--web-based outpatient management, web-based management via the Alfalfa app may be more beneficial because it can enhance patient anticoagulation management quality, lower the frequency of small bleeding events, and improve INR distribution. ",
doi="10.2196/46319",
url="https://www.jmir.org/2024/1/e46319",
url="http://www.ncbi.nlm.nih.gov/pubmed/39073869"
}


@Article{info:doi/10.2196/57111,
author="Huecker, Martin
and Schutzman, Craig
and French, Joshua
and El-Kersh, Karim
and Ghafghazi, Shahab
and Desai, Ravi
and Frick, Daniel
and Thomas, Jeremy Jarred",
title="Accurate Modeling of Ejection Fraction and Stroke Volume With Mobile Phone Auscultation: Prospective Case-Control Study",
journal="JMIR Cardio",
year="2024",
month="Jun",
day="26",
volume="8",
pages="e57111",
keywords="ejection fraction",
keywords="stroke volume",
keywords="auscultation",
keywords="digital health",
keywords="telehealth",
keywords="acoustic recording",
keywords="acoustic recordings",
keywords="acoustic",
keywords="mHealth",
keywords="mobile health",
keywords="mobile phone",
keywords="mobile phones",
keywords="heart failure",
keywords="heart",
keywords="cardiac",
keywords="cardiology",
keywords="health care costs",
keywords="audio",
keywords="echocardiographic",
keywords="echocardiogram",
keywords="ultrasonography",
keywords="echocardiography",
keywords="accuracy",
keywords="monitoring",
keywords="telemonitoring",
keywords="recording",
keywords="recordings",
keywords="ejection",
keywords="machine learning",
keywords="algorithm",
keywords="algorithms",
abstract="Background: Heart failure (HF) contributes greatly to morbidity, mortality, and health care costs worldwide. Hospital readmission rates are tracked closely and determine federal reimbursement dollars. No current modality or technology allows for accurate measurement of relevant HF parameters in ambulatory, rural, or underserved settings. This limits the use of telehealth to diagnose or monitor HF in ambulatory patients. Objective: This study describes a novel HF diagnostic technology using audio recordings from a standard mobile phone. Methods: This prospective study of acoustic microphone recordings enrolled convenience samples of patients from 2 different clinical sites in 2 separate areas of the United States. Recordings were obtained at the aortic (second intercostal) site with the patient sitting upright. The team used recordings to create predictive algorithms using physics-based (not neural networks) models. The analysis matched mobile phone acoustic data to ejection fraction (EF) and stroke volume (SV) as evaluated by echocardiograms. Using the physics-based approach to determine features eliminates the need for neural networks and overfitting strategies entirely, potentially offering advantages in data efficiency, model stability, regulatory visibility, and physical insightfulness. Results: Recordings were obtained from 113 participants. No recordings were excluded due to background noise or for any other reason. Participants had diverse racial backgrounds and body surface areas. Reliable echocardiogram data were available for EF from 113 patients and for SV from 65 patients. The mean age of the EF cohort was 66.3 (SD 13.3) years, with female patients comprising 38.3\% (43/113) of the group. Using an EF cutoff of ?40\% versus >40\%, the model (using 4 features) had an area under the receiver operating curve (AUROC) of 0.955, sensitivity of 0.952, specificity of 0.958, and accuracy of 0.956. The mean age of the SV cohort was 65.5 (SD 12.7) years, with female patients comprising 34\% (38/65) of the group. Using a clinically relevant SV cutoff of <50 mL versus >50 mL, the model (using 3 features) had an AUROC of 0.922, sensitivity of 1.000, specificity of 0.844, and accuracy of 0.923. Acoustics frequencies associated with SV were observed to be higher than those associated with EF and, therefore, were less likely to pass through the tissue without distortion. Conclusions: This work describes the use of mobile phone auscultation recordings obtained with unaltered cellular microphones. The analysis reproduced the estimates of EF and SV with impressive accuracy. This technology will be further developed into a mobile app that could bring screening and monitoring of HF to several clinical settings, such as home or telehealth, rural, remote, and underserved areas across the globe. This would bring high-quality diagnostic methods to patients with HF using equipment they already own and in situations where no other diagnostic and monitoring options exist. ",
doi="10.2196/57111",
url="https://cardio.jmir.org/2024/1/e57111"
}


@Article{info:doi/10.2196/55552,
author="Hirten, P. Robert
and Danieletto, Matteo
and Landell, Kyle
and Zweig, Micol
and Golden, Eddye
and Pyzik, Renata
and Kaur, Sparshdeep
and Chang, Helena
and Helmus, Drew
and Sands, E. Bruce
and Charney, Dennis
and Nadkarni, Girish
and Bagiella, Emilia
and Keefer, Laurie
and Fayad, A. Zahi",
title="Remote Short Sessions of Heart Rate Variability Biofeedback Monitored With Wearable Technology: Open-Label Prospective Feasibility Study",
journal="JMIR Ment Health",
year="2024",
month="Apr",
day="25",
volume="11",
pages="e55552",
keywords="biofeedback",
keywords="digital health",
keywords="digital technology",
keywords="health care worker",
keywords="HCW",
keywords="heart rate variability",
keywords="mHealth",
keywords="mobile health",
keywords="mobile phone",
keywords="remote monitoring",
keywords="smartphone",
keywords="wearable devices",
abstract="Background: Heart rate variability (HRV) biofeedback is often performed with structured education, laboratory-based assessments, and practice sessions. It has been shown to improve psychological and physiological function across populations. However, a means to remotely use and monitor this approach would allow for wider use of this technique. Advancements in wearable and digital technology present an opportunity for the widespread application of this approach. Objective: The primary aim of the study was to determine the feasibility of fully remote, self-administered short sessions of HRV-directed biofeedback in a diverse population of health care workers (HCWs). The secondary aim was to determine whether a fully remote, HRV-directed biofeedback intervention significantly alters longitudinal HRV over the intervention period, as monitored by wearable devices. The tertiary aim was to estimate the impact of this intervention on metrics of psychological well-being. Methods: To determine whether remotely implemented short sessions of HRV biofeedback can improve autonomic metrics and psychological well-being, we enrolled HCWs across 7 hospitals in New York City in the United States. They downloaded our study app, watched brief educational videos about HRV biofeedback, and used a well-studied HRV biofeedback program remotely through their smartphone. HRV biofeedback sessions were used for 5 minutes per day for 5 weeks. HCWs were then followed for 12 weeks after the intervention period. Psychological measures were obtained over the study period, and they wore an Apple Watch for at least 7 weeks to monitor the circadian features of HRV. Results: In total, 127 HCWs were enrolled in the study. Overall, only 21 (16.5\%) were at least 50\% compliant with the HRV biofeedback intervention, representing a small portion of the total sample. This demonstrates that this study design does not feasibly result in adequate rates of compliance with the intervention. Numerical improvement in psychological metrics was observed over the 17-week study period, although it did not reach statistical significance (all P>.05). Using a mixed effect cosinor model, the mean midline-estimating statistic of rhythm (MESOR) of the circadian pattern of the SD of the interbeat interval of normal sinus beats (SDNN), an HRV metric, was observed to increase over the first 4 weeks of the biofeedback intervention in HCWs who were at least 50\% compliant. Conclusions: In conclusion, we found that using brief remote HRV biofeedback sessions and monitoring its physiological effect using wearable devices, in the manner that the study was conducted, was not feasible. This is considering the low compliance rates with the study intervention. We found that remote short sessions of HRV biofeedback demonstrate potential promise in improving autonomic nervous function and warrant further study. Wearable devices can monitor the physiological effects of psychological interventions. ",
doi="10.2196/55552",
url="https://mental.jmir.org/2024/1/e55552",
url="http://www.ncbi.nlm.nih.gov/pubmed/38663011"
}


@Article{info:doi/10.2196/33868,
author="C{\'a}ceres Rivera, Isabel Diana
and Rojas, Jaimes Luz Mileyde
and Rojas, Z. Lyda
and Gomez, Canon Diana
and Castro Ruiz, Andr{\'e}s David
and L{\'o}pez Romero, Alberto Luis",
title="Using Principles of Digital Development for a Smartphone App to Support Data Collection in Patients With Acute Myocardial Infarction and Physical Activity Intolerance: Case Study",
journal="JMIR Form Res",
year="2024",
month="Mar",
day="18",
volume="8",
pages="e33868",
keywords="app",
keywords="applications of medical informatics",
keywords="coronary disease",
keywords="data collection",
keywords="development",
keywords="health care reform",
keywords="health data",
keywords="medical informatics",
keywords="medical informatics apps",
keywords="mobile app",
keywords="mobile applications",
keywords="nursing diagnosis",
keywords="nursing research",
keywords="research data",
keywords="software",
keywords="validation",
abstract="Background: Advances in health have highlighted the need to implement technologies as a fundamental part of the diagnosis, treatment, and recovery of patients at risk of or with health alterations. For this purpose, digital platforms have demonstrated their applicability in the identification of care needs. Nursing is a fundamental component in the care of patients with cardiovascular disorders and plays a crucial role in diagnosing human responses to these health conditions. Consequently, the validation of nursing diagnoses through ongoing research processes has become a necessity that can significantly impact both patients and health care professionals. Objective: We aimed to describe the process of developing a mobile app to validate the nursing diagnosis ``intolerance to physical activity'' in patients with acute myocardial infarction. Methods: We describe the development and pilot-testing of a mobile system to support data collection for validating the nursing diagnosis of activity intolerance. This was a descriptive study conducted with 11 adults (aged ?18 years) who attended a health institution for highly complex needs with a suspected diagnosis of coronary syndrome between August and September 2019 in Floridablanca, Colombia. An app for the clinical validation of activity intolerance (North American Nursing Diagnosis Association [NANDA] code 00092) in patients with acute coronary syndrome was developed in two steps: (1) operationalization of the nursing diagnosis and (2) the app development process, which included an evaluation of the initial requirements, development and digitization of the forms, and a pilot test. The agreement level between the 2 evaluating nurses was evaluated with the $\kappa$ index. Results: We developed a form that included sociodemographic data, hospital admission data, medical history, current pharmacological treatment, and thrombolysis in myocardial infarction risk score (TIMI-RS) and GRACE (Global Registry of Acute Coronary Events) scores. To identify the defining characteristics, we included official guidelines, physiological measurements, and scales such as the Piper fatigue scale and Borg scale. Participants in the pilot test (n=11) had an average age of 63.2 (SD 4.0) years and were 82\% (9/11) men; 18\% (2/11) had incomplete primary schooling. The agreement between the evaluators was approximately 80\% for most of the defining characteristics. The most prevalent characteristics were exercise discomfort (10/11, 91\%), weakness (7/11, 64\%), dyspnea (3/11, 27\%), abnormal heart rate in response to exercise (2/10, 20\%), electrocardiogram abnormalities (1/10, 9\%), and abnormal blood pressure in response to activity (1/10, 10\%). Conclusions: We developed a mobile app for validating the diagnosis of ``activity intolerance.'' Its use will guarantee not only optimal data collection, minimizing errors to perform validation, but will also allow the identification of individual care needs. ",
doi="10.2196/33868",
url="https://formative.jmir.org/2024/1/e33868",
url="http://www.ncbi.nlm.nih.gov/pubmed/38498019"
}


@Article{info:doi/10.2196/50813,
author="Starnecker, Fabian
and Reimer, Marie Lara
and Nissen, Leon
and Jovanovi{\'c}, Marko
and Kapsecker, Maximilian
and Rospleszcz, Susanne
and von Scheidt, Moritz
and Krefting, Johannes
and Kr{\"u}ger, Nils
and Perl, Benedikt
and Wiehler, Jens
and Sun, Ruoyu
and Jonas, Stephan
and Schunkert, Heribert",
title="Guideline-Based Cardiovascular Risk Assessment Delivered by an mHealth App: Development Study",
journal="JMIR Cardio",
year="2023",
month="Dec",
day="8",
volume="7",
pages="e50813",
keywords="cardiovascular disease",
keywords="cardiovascular risk assessment",
keywords="HerzFit",
keywords="mobile health app",
keywords="mHealth app",
keywords="public information campaigns",
keywords="prevention",
keywords="risk calculator",
keywords="mobile phone",
abstract="Background: Identifying high-risk individuals is crucial for preventing cardiovascular diseases (CVDs). Currently, risk assessment is mostly performed by physicians. Mobile health apps could help decouple the determination of risk from medical resources by allowing unrestricted self-assessment. The respective test results need to be interpretable for laypersons. Objective: Together with a patient organization, we aimed to design a digital risk calculator that allows people to individually assess and optimize their CVD risk. The risk calculator was integrated into the mobile health app HerzFit, which provides the respective background information. Methods: To cover a broad spectrum of individuals for both primary and secondary prevention, we integrated the respective scores (Framingham 10-year CVD, Systematic Coronary Risk Evaluation 2, Systematic Coronary Risk Evaluation 2 in Older Persons, and Secondary Manifestations Of Arterial Disease) into a single risk calculator that was recalibrated for the German population. In primary prevention, an individual's heart age is estimated, which gives the user an easy-to-understand metric for assessing cardiac health. For secondary prevention, the risk of recurrence was assessed. In addition, a comparison of expected to mean and optimal risk levels was determined. The risk calculator is available free of charge. Data safety is ensured by processing the data locally on the users' smartphones. Results: Offering a risk calculator to the general population requires the use of multiple instruments, as each provides only a limited spectrum in terms of age and risk distribution. The integration of 4 internationally recommended scores allows risk calculation in individuals aged 30 to 90 years with and without CVD. Such integration requires recalibration and harmonization to provide consistent and plausible estimates. In the first 14 months after the launch, the HerzFit calculator was downloaded more than 96,000 times, indicating great demand. Public information campaigns proved effective in publicizing the risk calculator and contributed significantly to download numbers. Conclusions: The HerzFit calculator provides CVD risk assessment for the general population. The public demonstrated great demand for such a risk calculator as it was downloaded up to 10,000 times per month, depending on campaigns creating awareness for the instrument. ",
doi="10.2196/50813",
url="https://cardio.jmir.org/2023/1/e50813",
url="http://www.ncbi.nlm.nih.gov/pubmed/38064248"
}


@Article{info:doi/10.2196/50701,
author="Klier, Kristina
and Koch, Lucas
and Graf, Lisa
and Schink{\"o}the, Timo
and Schmidt, Annette",
title="Diagnostic Accuracy of Single-Lead Electrocardiograms Using the Kardia Mobile App and the Apple Watch 4: Validation Study",
journal="JMIR Cardio",
year="2023",
month="Nov",
day="23",
volume="7",
pages="e50701",
keywords="accuracy",
keywords="electrocardiography",
keywords="eHealth",
keywords="mHealth",
keywords="mobile health",
keywords="app",
keywords="applications",
keywords="mobile monitoring",
keywords="electrocardiogram",
keywords="ECG",
keywords="telemedicine",
keywords="diagnostic",
keywords="diagnosis",
keywords="monitoring",
keywords="heart",
keywords="cardiology",
keywords="mobile phone",
abstract="Background: To date, the 12-lead electrocardiogram (ECG) is the gold standard for cardiological diagnosis in clinical settings. With the advancements in technology, a growing number of smartphone apps and gadgets for recording, visualizing, and evaluating physical performance as well as health data is available. Although this new smart technology is innovative and time- and cost-efficient, less is known about its diagnostic accuracy and reliability. Objective: This study aimed to examine the agreement between the mobile single-lead ECG measurements of the Kardia Mobile App and the Apple Watch 4 compared to the 12-lead gold standard ECG in healthy adults under laboratory conditions. Furthermore, it assessed whether the measurement error of the devices increases with an increasing heart rate. Methods: This study was designed as a prospective quasi-experimental 1-sample measurement, in which no randomization of the sampling was carried out. In total, ECGs at rest from 81 participants (average age 24.89, SD?8.58 years; n=58, 72\% male) were recorded and statistically analyzed. Bland-Altman plots were created to graphically illustrate measurement differences. To analyze the agreement between the single-lead ECGs and the 12-lead ECG, Pearson correlation coefficient (r) and Lin concordance correlation coefficient (CCCLin) were calculated. Results: The results showed a higher agreement for the Apple Watch (mean deviation QT: 6.85\%; QT interval corrected for heart rate using Fridericia formula [QTcF]: 7.43\%) than Kardia Mobile (mean deviation QT: 9.53\%; QTcF: 9.78\%) even if both tend to underestimate QT and QTcF intervals. For Kardia Mobile, the QT and QTcF intervals correlated significantly with the gold standard (rQT=0.857 and rQTcF=0.727; P<.001). CCCLin corresponded to an almost complete heuristic agreement for the QT interval (0.835), whereas the QTcF interval was in the range of strong agreement (0.682). Further, for the Apple Watch, Pearson correlations were highly significant and in the range of a large effect (rQT=0.793 and rQTcF=0.649; P<.001). CCCLin corresponded to a strong heuristic agreement for both the QT (0.779) and QTcF (0.615) intervals. A small negative correlation between the measurement error and increasing heart rate could be found of each the devices and the reference. Conclusions: Smart technology seems to be a promising and reliable approach for nonclinical health monitoring. Further research is needed to broaden the evidence regarding its validity and usability in different target groups. ",
doi="10.2196/50701",
url="https://cardio.jmir.org/2023/1/e50701",
url="http://www.ncbi.nlm.nih.gov/pubmed/37995111"
}


@Article{info:doi/10.2196/47475,
author="Avram, Robert
and Byrne, Julia
and So, Derek
and Iturriaga, Erin
and Lennon, Ryan
and Murthy, Vishakantha
and Geller, Nancy
and Goodman, Shaun
and Rihal, Charanjit
and Rosenberg, Yves
and Bailey, Kent
and Farkouh, Michael
and Bell, Malcolm
and Cagin, Charles
and Chavez, Ivan
and El-Hajjar, Mohammad
and Ginete, Wilson
and Lerman, Amir
and Levisay, Justin
and Marzo, Kevin
and Nazif, Tamim
and Tanguay, Jean-Francois
and Pletcher, Mark
and Marcus, M. Gregory
and Pereira, L. Naveen
and Olgin, Jeffrey",
title="Digital Tool-Assisted Hospitalization Detection in the Tailored Antiplatelet Initiation to Lessen Outcomes due to Decreased Clopidogrel Response After Percutaneous Coronary Intervention Study Compared to Traditional Site-Coordinator Ascertainment: Intervention Study",
journal="J Med Internet Res",
year="2023",
month="Nov",
day="10",
volume="25",
pages="e47475",
keywords="web-based digital study",
keywords="randomized clinical trial",
keywords="study app",
keywords="clinical tracking cardiovascular hospitalizations",
keywords="detection",
keywords="digital tools",
keywords="tool",
keywords="clinical trial",
keywords="research application",
keywords="application",
keywords="smartphone application",
keywords="mobile phone survey",
keywords="survey",
keywords="hospital",
keywords="accuracy",
keywords="geofencing",
keywords="cardiovascular",
keywords="algorithm",
keywords="hospital visit",
keywords="mobile phone",
abstract="Background: Accurate, timely ascertainment of clinical end points, particularly hospitalizations, is crucial for clinical trials. The Tailored Antiplatelet Initiation to Lessen Outcomes Due to Decreased Clopidogrel Response after Percutaneous Coronary Intervention (TAILOR-PCI) Digital Study extended the main TAILOR-PCI trial's follow-up to 2 years, using a smartphone-based research app featuring geofencing-triggered surveys and routine monthly mobile phone surveys to detect cardiovascular (CV) hospitalizations. This pilot study compared these digital tools to conventional site-coordinator ascertainment of CV hospitalizations. Objective: The objectives were to evaluate geofencing-triggered notifications and routine monthly mobile phone surveys' performance in detecting CV hospitalizations compared to telephone visits and health record reviews by study coordinators at each site. Methods: US and Canadian participants from the TAILOR-PCI Digital Follow-Up Study were invited to download the Eureka Research Platform mobile app, opting in for location tracking using geofencing, triggering a smartphone-based survey if near a hospital for ?4 hours. Participants were sent monthly notifications for CV hospitalization surveys. Results: From 85 participants who consented to the Digital Study, downloaded the mobile app, and had not previously completed their final follow-up visit, 73 (85.8\%) initially opted in and consented to geofencing. There were 9 CV hospitalizations ascertained by study coordinators among 5 patients, whereas 8 out of 9 (88.9\%) were detected by routine monthly hospitalization surveys. One CV hospitalization went undetected by the survey as it occurred within two weeks of the previous event, and the survey only allowed reporting of a single hospitalization. Among these, 3 were also detected by the geofencing algorithm, but 6 out of 9 (66.7\%) were missed by geofencing: 1 occurred in a participant who never consented to geofencing, while 5 hospitalizations occurred among participants who had subsequently turned off geofencing prior to their hospitalization. Geofencing-detected hospitalizations were ascertained within a median of 2 (IQR 1-3) days, monthly surveys within 11 (IQR 6.5-25) days, and site coordinator methods within 38 (IQR 9-105) days. The geofencing algorithm triggered 245 notifications among 39 participants, with 128 (52.2\%) from true hospital presence and 117 (47.8\%) from nonhospital health care facility visits. Additional geofencing iterative improvements to reduce hospital misidentification were made to the algorithm at months 7 and 12, elevating the rate of true alerts from 35.4\% (55 true alerts/155 total alerts before month 7) to 78.7\% (59 true alerts/75 total alerts in months 7-12) and ultimately to 93.3\% (14 true alerts/5 total alerts in months 13-21), respectively. Conclusions: The monthly digital survey detected most CV hospitalizations, while the geofencing survey enabled earlier detection but did not offer incremental value beyond traditional tools. Digital tools could potentially reduce the burden on study coordinators in ascertaining CV hospitalizations. The advantages of timely reporting via geofencing should be weighed against the issue of false notifications, which can be mitigated through algorithmic refinements. ",
doi="10.2196/47475",
url="https://www.jmir.org/2023/1/e47475",
url="http://www.ncbi.nlm.nih.gov/pubmed/37948098"
}


@Article{info:doi/10.2196/48454,
author="Nakrys, Marius
and Valinskas, Sarunas
and Aleknavicius, Kasparas
and Jonusas, Justinas",
title="Pilot Investigation of Blood Pressure Control Using a Mobile App (Cardi.Health): Retrospective Chart Review Study",
journal="JMIR Cardio",
year="2023",
month="Oct",
day="17",
volume="7",
pages="e48454",
keywords="mobile app",
keywords="Cardi.Health",
keywords="blood pressure",
keywords="engagement",
keywords="app",
keywords="pilot study",
keywords="hypertension",
keywords="effective",
keywords="blood pressure control",
keywords="self-monitoring",
keywords="medication",
keywords="management",
keywords="users",
keywords="use",
abstract="Background: The high prevalence of hypertension necessitates effective, scalable interventions for blood pressure (BP) control. Self-monitoring has shown improved adherence to medication and better BP management. Mobile apps offer a promising approach with their increasing popularity and potential for large-scale implementation. Studies have demonstrated associations between mobile app interventions and lowered BP, yet real-world data on app effectiveness and engagement remain limited. Objective: In this study, we analyzed real-world user data from the Cardi.Health mobile app, which is aimed at helping its users monitor and control their BP. Our goal was to find out whether there is an association between the use of the mobile app and a decrease in BP. Additionally, the study explored how engagement with the app may influence this outcome. Methods: This was a retrospective chart review study. The initial study population comprised 4407 Cardi.Health users who began using the app between January 2022 and April 2022. After applying inclusion criteria, the final study cohort comprised 339 users with elevated BP at the baseline. The sample consisted of 108 (31.9\%) men and 231 (68.1\%) women (P=.04). This retrospective chart review study obtained permission from the Biomedical Research Alliance of New York Institutional Review Board (June 2022, registration ID 22-08-503-939). Results: The study's main findings were that there is a possible relationship between use of the Cardi.Health mobile app and a decrease in systolic BP. Additionally, there was a significant association between active use of the app and systolic BP decrease ($\chi$21=5.311; P=.02). Finally, active users had an almost 2 times greater chance of reducing systolic BP by 5 mm Hg or more over 4 weeks (odds ratio 1.932, 95\% CI 1.074-3.528; P=.03). Conclusions: This study shows a possible relationship between Cardi.Health mobile app use and decreased BP. Additionally, engagement with the app may be related to better results---active use was associated with an almost 2-fold increase in the odds of reducing BP by 5 or more mm Hg. ",
doi="10.2196/48454",
url="https://cardio.jmir.org/2023/1/e48454",
url="http://www.ncbi.nlm.nih.gov/pubmed/37847544"
}


@Article{info:doi/10.2196/43889,
author="Kazi, Samia
and Truesdale, Chloe
and Ryan, Pauline
and Wiesner, Glen
and Jennings, Garry
and Chow, Clara",
title="Initial Implementation of the My Heart, My Life Program by the National Heart Foundation of Australia: Pilot Mixed Methods Evaluation Study",
journal="JMIR Cardio",
year="2023",
month="Oct",
day="5",
volume="7",
pages="e43889",
keywords="cardiology",
keywords="prevention",
keywords="digital health",
keywords="heart",
keywords="text message",
keywords="text messaging",
keywords="SMS",
keywords="health communication",
keywords="demographic",
keywords="preventative",
keywords="cardio",
abstract="Background: Coronary heart disease (CHD) remains the leading cause of death in Australia, with a high residual risk of repeat events in survivors. Secondary prevention therapy is crucial for reducing the risk of both death and other major adverse cardiac events. The National Heart Foundation of Australia has developed a consumer-facing support program called My Heart, My Life (MHML) to address the gap in the secondary prevention of CHD in Australia. The MHML pilot program supplies advice and support for both patients and their caregivers, and it was conducted over 8 months from November 2019 to June 2020. Objective: This study aims to describe and examine the implementation of a novel multimodality secondary CHD prevention pilot program called MHML, which was delivered through booklets, text messages, emails, and telephone calls. Methods: This pilot study consists of a mixed methods evaluation involving surveys of participants (patients and caregivers) and health professionals, in-depth interviews, and digital communication (SMS text message, electronic direct mail, and call record analytics). This study was performed in people older than 18 years with acute coronary syndrome or angina and their caregivers in 38 Australian hospitals from November 2019 to June 2020 through the National Heart Foundation of Australia web page. The main outcome measures were reach, accessibility, feasibility, barriers, and enablers to implementation of this program. Results: Of the 1004 participants (838 patients and 164 caregivers; 2 missing), 60.9\% (608/1001) were males, 50.7\% (491/967) were aged between 45 and 64 years, 27.4\% (276/1004) were from disadvantaged areas, 2.5\% (24/946) were from Aboriginal or Torres Strait Islander background, and 16.9\% (170/1004) reported English as their second language. The participants (patients and their caregivers) and health professionals reported high satisfaction with the MHML program (55/62, 88.7\% and 33/38, 87\%, respectively). Of the 62 participants who took the survey, 88\% (55/62) used the text messaging service and reported a very high level of satisfaction. Approximately 94\% (58/62) and 89\% (55/62) of the participants were satisfied with the quick guide booklets 1 and 2, respectively; 79\% (49/62) were satisfied with the monthly email journey and 71\% (44/62) were satisfied with the helpline calls. Most participants reported that the MHML program improved preventive behaviors, that is, 73\% (45/62) of them reported that they maintained increased physical activity and 84\% (52/62) reported that they maintained a healthy diet even after the MHML program. Conclusions: The findings of our pilot study suggest that a multimodal support program, including digital, print, phone, and web-based media, for the secondary prevention of CHD is useful and could be a potential means of providing customized at-scale secondary prevention support for survivors of acute coronary syndrome. ",
doi="10.2196/43889",
url="https://cardio.jmir.org/2023/1/e43889",
url="http://www.ncbi.nlm.nih.gov/pubmed/37796544"
}


@Article{info:doi/10.2196/46082,
author="Mitra, Sayan
and Kroeger, M. Cynthia
and Xu, Jing
and Avery, Leah
and Masedunskas, Andrius
and Cassidy, Sophie
and Wang, Tian
and Hunyor, Imre
and Wilcox, Ian
and Huang, Robin
and Chakraborty, Bibhas
and Fontana, Luigi",
title="Testing the Effects of App-Based Motivational Messages on Physical Activity and Resting Heart Rate Through Smartphone App Compliance in Patients With Vulnerable Coronary Artery Plaques: Protocol for a Microrandomized Trial",
journal="JMIR Res Protoc",
year="2023",
month="Oct",
day="2",
volume="12",
pages="e46082",
keywords="adherence",
keywords="coronary artery disease",
keywords="coronary heart disease",
keywords="digital health",
keywords="health behavior",
keywords="heart rate",
keywords="messages",
keywords="mhealth",
keywords="microrandomized trial",
keywords="mobile app",
keywords="physical activity",
keywords="smartphone",
keywords="telehealth",
keywords="user motivation",
abstract="Background: Achieving the weekly physical activity recommendations of at least 150-300 minutes of moderate-intensity or 75-150 minutes of vigorous-intensity aerobic exercise is important for reducing cardiometabolic risk, but evidence shows that most people struggle to meet these goals, particularly in the mid to long term. Objective: The Messages Improving Resting Heart Health (MIRTH) study aims to determine if (1) sending daily motivational messages through a research app is effective in improving motivation and in promoting adherence to physical activity recommendations in men and women with coronary heart disease randomized to a 12-month intensive lifestyle intervention, and (2) the time of the day when the message is delivered impacts compliance with exercise training. Methods: We will conduct a single-center, microrandomized trial. Participants will be randomized daily to either receive or not receive motivational messages over two 90-day periods at the beginning (phase 1: months 4-6) and at the end (phase 2: months 10-12) of the Lifestyle Vulnerable Plaque Study. Wrist-worn devices (Fitbit Inspire 2) and Bluetooth pairing with smartphones will be used to passively collect data for proximal (ie, physical activity duration, steps walked, and heart rate within 180 minutes of receiving messages) and distal (ie, change values for resting heart rate and total steps walked within and across both phases 1 and 2 of the trial) outcomes. Participants will be recruited from a large academic cardiology office practice (Central Sydney Cardiology) and the Royal Prince Alfred Hospital Departments of Cardiology and Radiology. All clinical investigations will be undertaken at the Charles Perkins Centre Royal Prince Alfred clinic. Individuals aged 18-80 years (n=58) with stable coronary heart disease who have low attenuation plaques based on a coronary computed tomography angiography within the past 3 months and have been randomized to an intensive lifestyle intervention program will be included in MIRTH. Results: The Lifestyle Vulnerable Plaque Study was funded in 2020 and started enrolling participants in February 2022. Recruitment for MIRTH commenced in November 2022. As of September 2023, 2 participants were enrolled in the MIRTH study and provided baseline data. Conclusions: This MIRTH microrandomized trial will represent the single most detailed and integrated analysis of the effects of a comprehensive lifestyle intervention delivered through a customized mobile health app on smart devices on time-based motivational messaging for patients with coronary heart disease. This study will also help inform future studies optimizing for just-in-time adaptive interventions. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12622000731796; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=382861 International Registered Report Identifier (IRRID): DERR1-10.2196/46082 ",
doi="10.2196/46082",
url="https://www.researchprotocols.org/2023/1/e46082",
url="http://www.ncbi.nlm.nih.gov/pubmed/37782531"
}


@Article{info:doi/10.2196/48096,
author="Klier, Kristina
and Patel, J. Yash
and Schink{\"o}the, Timo
and Harbeck, Nadia
and Schmidt, Annette",
title="Corrected QT Interval (QTc) Diagnostic App for the Oncological Routine: Development Study",
journal="JMIR Cardio",
year="2023",
month="Sep",
day="11",
volume="7",
pages="e48096",
keywords="telemedicine",
keywords="mobile health",
keywords="mHealth",
keywords="eHealth",
keywords="tele-cardiology",
keywords="cardiology",
keywords="long QT syndrome",
keywords="prolonged QT interval",
keywords="electrocardiography",
keywords="ECG",
keywords="telehealth",
keywords="app",
keywords="application",
keywords="oncology",
keywords="cancer",
keywords="diagnosis",
keywords="diagnostic",
keywords="heart",
keywords="arrhythmia",
keywords="cardiotoxic",
keywords="side effects",
keywords="adverse effects",
abstract="Background: Numerous antineoplastic drugs such as chemotherapeutics have cardiotoxic side effects and can lead to long QT syndrome (LQTS). When diagnosed and treated in time, the potentially fatal outcomes of LQTS can be prevented. Therefore, regular electrocardiogram (ECG) assessments are critical to ensure patient safety. However, these assessments are associated with patient discomfort and require timely support of the attending oncologist by a cardiologist. Objective: This study aimed to examine whether this approach can be made more efficient and comfortable by a smartphone app (QTc Tracker), supporting single-lead ECG records on site and transferring to a tele-cardiologist for an immediate diagnosis. Methods: To evaluate the QTc Tracker, it was implemented in 54 cancer centers in Germany. In total, 266 corrected QT interval (QTc) diagnoses of 122 patients were recorded. Moreover, a questionnaire on routine ECG workflow, turnaround time, and satisfaction (1=best, 6=worst) was answered by the centers before and after the implementation of the QTc Tracker. Results: Compared to the routine ECG workflow, the QTc Tracker enabled a substantial turnaround time reduction of 98\% (mean 2.67, 95\% CI 1.72-2.67 h) and even further time efficiency in combination with a cardiologic on-call service (mean 12.10, 95\% CI 5.67-18.67 min). Additionally, nurses and patients reported higher satisfaction when using the QTc Tracker. In particular, patients' satisfaction sharply improved from 2.59 (95\% CI 2.41-2.88) for the routine ECG workflow to 1.25 (95\% CI 0.99-1.51) for the QTc Tracker workflow. Conclusions: These results reveal a significant improvement regarding reduced turnaround time and increased user satisfaction. Best patient care might be guaranteed as the exposure of patients with an uncontrolled risk of QTc prolongations can be avoided by using the fast and easy QTc Tracker. In particular, as regular side-effect monitoring, the QTc Tracker app promises more convenience for patients and their physicians. Finally, future studies are needed to empirically test the usability and validity of such mobile ECG assessment methods. Trial Registration: ClinicalTrials.gov NCT04055493; https://classic.clinicaltrials.gov/ct2/show/NCT04055493 ",
doi="10.2196/48096",
url="https://cardio.jmir.org/2023/1/e48096",
url="http://www.ncbi.nlm.nih.gov/pubmed/37695655"
}


@Article{info:doi/10.2196/48812,
author="Kuo, Ming-Hao
and Lin, You-Jin
and Huang, Wun-Wei
and Chiang, Kwo-Tsao
and Tu, Min-Yu
and Chu, Chi-Ming
and Lai, Chung-Yu",
title="G Tolerance Prediction Model Using Mobile Device--Measured Cardiac Force Index for Military Aircrew: Observational Study",
journal="JMIR Mhealth Uhealth",
year="2023",
month="Jul",
day="26",
volume="11",
pages="e48812",
keywords="G force",
keywords="baroreflex",
keywords="anti-G straining maneuver",
keywords="G tolerance",
keywords="cardiac force index",
keywords="anti-G suit",
keywords="relaxed G tolerance",
keywords="straining G tolerance",
keywords="cardiac force ratio",
abstract="Background: During flight, G force compels blood to stay in leg muscles and reduces blood flow to the heart. Cardiovascular responses activated by the autonomic nerve system and strengthened by anti-G straining maneuvers can alleviate the challenges faced during G loading. To our knowledge, no definite cardiac information measured using a mobile health device exists for analyzing G tolerance. However, our previous study developed the cardiac force index (CFI) for analyzing the G tolerance of military aircrew. Objective: This study used the CFI to verify participants' cardiac performance when walking and obtained a formula for predicting an individual's G tolerance during centrifuge training. Methods: Participants from an air force aircrew undertook high-G training from January 2020 to December 2022. Their heart rate (HR) in beats per minute and activity level per second were recorded using the wearable BioHarness 3.0 device. The CFI was computed using the following formula: weight {\texttimes} activity / HR during resting or walking. Relaxed G tolerance (RGT) and straining G tolerance (SGT) were assessed at a slowly increasing rate of G loading (0.1 G/s) during training. Other demographic factors were included in the multivariate regression to generate a model for predicting G tolerance from the CFI. Results: A total of 213 eligible trainees from a military aircrew were recruited. The average age was 25.61 (SD 3.66) years, and 13.1\% (28/213) of the participants were women. The mean resting CFI and walking CFI (WCFI) were 0.016 (SD 0.001) and 0.141 (SD 0.037) kg {\texttimes} G/beats per minute, respectively. The models for predicting RGT and SGT were as follows: RGT = 0.066 {\texttimes} age + 0.043 {\texttimes} (WCFI {\texttimes} 100) -- 0.037 {\texttimes} height + 0.015 {\texttimes} systolic blood pressure -- 0.010 {\texttimes} HR + 7.724 and SGT = 0.103 {\texttimes} (WCFI {\texttimes} 100) ? 0.069 {\texttimes} height + 0.018 {\texttimes} systolic blood pressure + 15.899. Thus, the WCFI is a positive factor for predicting the RGT and SGT before centrifuge training. Conclusions: The WCFI is a vital component of the formula for estimating G tolerance prior to training. The WCFI can be used to monitor physiological conditions against G stress. ",
doi="10.2196/48812",
url="https://mhealth.jmir.org/2023/1/e48812",
url="http://www.ncbi.nlm.nih.gov/pubmed/37494088"
}


@Article{info:doi/10.2196/43940,
author="Shibuta, Tomomi
and Waki, Kayo
and Miyake, Kana
and Igarashi, Ayumi
and Yamamoto-Mitani, Noriko
and Sankoda, Akiko
and Takeuchi, Yoshinori
and Sumitani, Masahiko
and Yamauchi, Toshimasa
and Nangaku, Masaomi
and Ohe, Kazuhiko",
title="Preliminary Efficacy, Feasibility, and Perceived Usefulness of a Smartphone-Based Self-Management System With Personalized Goal Setting and Feedback to Increase Step Count Among Workers With High Blood Pressure: Before-and-After Study",
journal="JMIR Cardio",
year="2023",
month="Jul",
day="21",
volume="7",
pages="e43940",
keywords="behavior change",
keywords="blood pressure",
keywords="feasibility studies",
keywords="goal setting",
keywords="mobile health",
keywords="mHealth",
keywords="self-control",
keywords="self-efficacy",
keywords="self-regulation",
keywords="smartphone",
keywords="step count",
keywords="walking",
keywords="workplace",
keywords="mobile phone",
abstract="Background: High blood pressure (BP) and physical inactivity are the major risk factors for cardiovascular diseases. Mobile health is expected to support patients' self-management for improving cardiovascular health; the development of fully automated systems is necessary to minimize the workloads of health care providers. Objective: The objective of our study was to evaluate the preliminary efficacy, feasibility, and perceived usefulness of an intervention using a novel smartphone-based self-management system (DialBetes Step) in increasing steps per day among workers with high BP. Methods: On the basis of the Social Cognitive Theory, we developed personalized goal-setting and feedback functions and information delivery functions for increasing step count. Personalized goal setting and feedback consist of 4 components to support users' self-regulation and enhance their self-efficacy: goal setting for daily steps, positive feedback, action planning, and barrier identification and problem-solving. In the goal-setting component, users set their own step goals weekly in gradual increments based on the system's suggestion. We added these fully automated functions to an extant system with the function of self-monitoring daily step count, BP, body weight, blood glucose, exercise, and diet. We conducted a single-arm before-and-after study of workers with high BP who were willing to increase their physical activity. After an educational group session, participants used only the self-monitoring function for 2 weeks (baseline) and all functions of DialBetes Step for 24 weeks. We evaluated changes in steps per day, self-reported frequencies of self-regulation and self-management behavior, self-efficacy, and biomedical characteristics (home BP, BMI, visceral fat area, and glucose and lipid parameters) around week 6 (P1) of using the new functions and at the end of the intervention (P2). Participants rated the usefulness of the system using a paper-based questionnaire. Results: We analyzed 30 participants (n=19, 63\% male; mean age 52.9, SD 5.3 years); 1 (3\%) participant dropped out of the intervention. The median percentage of step measurement was 97\%. Compared with baseline (median 10,084 steps per day), steps per day significantly increased at P1 (median +1493 steps per day; P<.001), but the increase attenuated at P2 (median +1056 steps per day; P=.04). Frequencies of self-regulation and self-management behavior increased at P1 and P2. Goal-related self-efficacy tended to increase at P2 (median +5\%; P=.05). Home BP substantially decreased only at P2. Of the other biomedical characteristics, BMI decreased significantly at P1 (P<.001) and P2 (P=.001), and high-density lipoprotein cholesterol increased significantly only at P1 (P<.001). DialBetes Step was rated as useful or moderately useful by 97\% (28/29) of the participants. Conclusions: DialBetes Step intervention might be a feasible and useful way of increasing workers' step count for a short period and, consequently, improving their BP and BMI; self-efficacy--enhancing techniques of the system should be improved. ",
doi="10.2196/43940",
url="https://cardio.jmir.org/2023/1/e43940",
url="http://www.ncbi.nlm.nih.gov/pubmed/37477976"
}


@Article{info:doi/10.2196/35876,
author="Alnooh, Ghadah
and Alessa, Tourkiah
and Hawley, Mark
and de Witte, Luc",
title="The Use of Dietary Approaches to Stop Hypertension (DASH) Mobile Apps for Supporting a Healthy Diet and Controlling Hypertension in Adults: Systematic Review",
journal="JMIR Cardio",
year="2022",
month="Nov",
day="2",
volume="6",
number="2",
pages="e35876",
keywords="DASH diet",
keywords="Dietary Approaches to Stop Hypertension",
keywords="smartphone app",
keywords="mobile app",
keywords="blood pressure",
abstract="Background: Uncontrolled hypertension is a public health issue, with increasing prevalence worldwide. The Dietary Approaches to Stop Hypertension (DASH) diet is one of the most effective dietary approaches for lowering blood pressure (BP). Dietary mobile apps have gained popularity and are being used to support DASH diet self-management, aiming to improve DASH diet adherence and thus lower BP. Objective: This systematic review aimed to assess the effectiveness of smartphone apps that support self-management to improve DASH diet adherence and consequently reduce BP. A secondary aim was to assess engagement, satisfaction, acceptance, and usability related to DASH mobile app use. Methods: The Embase (OVID), Cochrane Library, CINAHL, Web of Science, Scopus, and Google Scholar electronic databases were used to conduct systematic searches for studies conducted between 2008 and 2021 that used DASH smartphone apps to support self-management. The reference lists of the included articles were also checked. Studies were eligible if they (1) were randomized controlled trials (RCTs) or pre-post studies of app-based interventions for adults (aged 18 years or above) with prehypertension or hypertension, without consideration of gender or sociodemographic characteristics; (2) used mobile phone apps alone or combined with another component, such as communication with others; (3) used or did not use any comparator; and (4) had the primary outcome measures of BP level and adherence to the DASH diet. For eligible studies, data were extracted and outcomes were organized into logical categories, including clinical outcomes (eg, systolic BP, diastolic BP, and weight loss), DASH diet adherence, app usability and acceptability, and user engagement and satisfaction. The quality of the studies was evaluated using the Cochrane Collaboration's Risk of Bias tool for RCTs, and nonrandomized quantitative studies were evaluated using a tool provided by the US National Institutes of Health. Results: A total of 5 studies (3 RCTs and 2 pre-post studies) including 334 participants examined DASH mobile apps. All studies found a positive trend related to the use of DASH smartphone apps, but the 3 RCTs had a high risk of bias. One pre-post study had a high risk of bias, while the other had a low risk. As a consequence, no firm conclusions could be drawn regarding the effectiveness of DASH smartphone apps for increasing DASH diet adherence and lowering BP. All the apps appeared to be acceptable and easy to use. Conclusions: There is weak emerging evidence of a positive effect of using DASH smartphone apps for supporting self-management to improve DASH diet adherence and consequently lower BP. Further research is needed to provide high-quality evidence that can determine the effectiveness of DASH smartphone apps. ",
doi="10.2196/35876",
url="https://cardio.jmir.org/2022/2/e35876",
url="http://www.ncbi.nlm.nih.gov/pubmed/36322108"
}


@Article{info:doi/10.2196/40546,
author="Sivakumar, Bridve
and Lemonde, Manon
and Stein, Matthew
and Goldstein, Sarah
and Mak, Susanna
and Arcand, JoAnne",
title="Evaluating Health Care Provider Perspectives on the Use of Mobile Apps to Support Patients With Heart Failure Management: Qualitative Descriptive Study",
journal="JMIR Cardio",
year="2022",
month="Oct",
day="26",
volume="6",
number="2",
pages="e40546",
keywords="heart failure",
keywords="mobile health",
keywords="mHealth",
keywords="eHealth",
keywords="mobile apps",
keywords="adherence",
keywords="self-management",
keywords="mobile phone",
abstract="Background: Nonadherence to diet and medical therapies in heart failure (HF) contributes to poor HF outcomes. Mobile apps may be a promising way to improve adherence because they increase knowledge and behavior change via education and monitoring. Well-designed apps with input from health care providers (HCPs) can lead to successful adoption of such apps in practice. However, little is known about HCPs' perspectives on the use of mobile apps to support HF management. Objective: The aim of this study is to determine HCPs' perspectives (needs, motivations, and challenges) on the use of mobile apps to support patients with HF management. Methods: A qualitative descriptive study using one-on-one semistructured interviews, informed by the diffusion of innovation theory, was conducted among HF HCPs, including cardiologists, nurses, and nurse practitioners. Transcripts were independently coded by 2 researchers and analyzed using content analysis. Results: The 21 HCPs (cardiologists: n=8, 38\%; nurses: n=6, 29\%; and nurse practitioners: n=7, 33\%) identified challenges and opportunities for app adoption across 5 themes: participant-perceived factors that affect app adoption---these include patient age, technology savviness, technology access, and ease of use; improved delivery of care---apps can support remote care; collect, share, and assess health information; identify adverse events; prevent hospitalizations; and limit clinic visits; facilitating patient engagement in care---apps can provide feedback and reinforcement, facilitate connection and communication between patients and their HCPs, support monitoring, and track self-care; providing patient support through education---apps can provide HF-related information (ie, diet and medications); and participant views on app features for their patients---HCPs felt that useful apps would have reminders and alarms and participative elements (gamification, food scanner, and quizzes). Conclusions: HCPs had positive views on the use of mobile apps to support patients with HF management. These findings can inform effective development and implementation strategies of HF management apps in clinical practice. ",
doi="10.2196/40546",
url="https://cardio.jmir.org/2022/2/e40546",
url="http://www.ncbi.nlm.nih.gov/pubmed/36287588"
}


@Article{info:doi/10.2196/35796,
author="Rissanen, E. Antti-Pekka
and Rottensteiner, Mirva
and Kujala, M. Urho
and Kurkela, O. Jari L.
and Wikgren, Jan
and Laukkanen, A. Jari",
title="Cardiorespiratory Fitness Estimation Based on Heart Rate and Body Acceleration in Adults With Cardiovascular Risk Factors: Validation Study",
journal="JMIR Cardio",
year="2022",
month="Oct",
day="25",
volume="6",
number="2",
pages="e35796",
keywords="cardiopulmonary exercise test",
keywords="cardiorespiratory fitness",
keywords="heart rate variability",
keywords="hypertension",
keywords="type 2 diabetes",
keywords="wearable technology",
abstract="Background: Cardiorespiratory fitness (CRF) is an independent risk factor for cardiovascular morbidity and mortality. Adding CRF to conventional risk factors (eg, smoking, hypertension, impaired glucose metabolism, and dyslipidemia) improves the prediction of an individual's risk for adverse health outcomes such as those related to cardiovascular disease. Consequently, it is recommended to determine CRF as part of individualized risk prediction. However, CRF is not determined routinely in everyday clinical practice. Wearable technologies provide a potential strategy to estimate CRF on a daily basis, and such technologies, which provide CRF estimates based on heart rate and body acceleration, have been developed. However, the validity of such technologies in estimating individual CRF in clinically relevant populations is poorly known. Objective: The objective of this study is to evaluate the validity of a wearable technology, which provides estimated CRF based on heart rate and body acceleration, in working-aged adults with cardiovascular risk factors. Methods: In total, 74 adults (age range 35-64 years; n=56, 76\% were women; mean BMI 28.7, SD 4.6 kg/m2) with frequent cardiovascular risk factors (eg, n=64, 86\% hypertension; n=18, 24\% prediabetes; n=14, 19\% type 2 diabetes; and n=51, 69\% metabolic syndrome) performed a 30-minute self-paced walk on an indoor track and a cardiopulmonary exercise test on a treadmill. CRF, quantified as peak O2 uptake, was both estimated (self-paced walk: a wearable single-lead electrocardiogram device worn to record continuous beat-to-beat R-R intervals and triaxial body acceleration) and measured (cardiopulmonary exercise test: ventilatory gas analysis). The accuracy of the estimated CRF was evaluated against that of the measured CRF. Results: Measured CRF averaged 30.6 (SD 6.3; range 20.1-49.6) mL/kg/min. In all participants (74/74, 100\%), mean difference between estimated and measured CRF was ?0.1 mL/kg/min (P=.90), mean absolute error was 3.1 mL/kg/min (95\% CI 2.6-3.7), mean absolute percentage error was 10.4\% (95\% CI 8.5-12.5), and intraclass correlation coefficient was 0.88 (95\% CI 0.80-0.92). Similar accuracy was observed in various subgroups (sexes, age, BMI categories, hypertension, prediabetes, and metabolic syndrome). However, mean absolute error was 4.2 mL/kg/min (95\% CI 2.6-6.1) and mean absolute percentage error was 16.5\% (95\% CI 8.6-24.4) in the subgroup of patients with type 2 diabetes (14/74, 19\%). Conclusions: The error of the CRF estimate, provided by the wearable technology, was likely below or at least very close to the clinically significant level of 3.5 mL/kg/min in working-aged adults with cardiovascular risk factors, but not in the relatively small subgroup of patients with type 2 diabetes. From a large-scale clinical perspective, the findings suggest that wearable technologies have the potential to estimate individual CRF with acceptable accuracy in clinically relevant populations. ",
doi="10.2196/35796",
url="https://cardio.jmir.org/2022/2/e35796",
url="http://www.ncbi.nlm.nih.gov/pubmed/36282560"
}


@Article{info:doi/10.2196/37343,
author="Buss, Helen Vera
and Varnfield, Marlien
and Harris, Mark
and Barr, Margo",
title="Mobile Health Use by Older Individuals at Risk of Cardiovascular Disease and Type 2 Diabetes Mellitus in an Australian Cohort: Cross-sectional Survey Study",
journal="JMIR Mhealth Uhealth",
year="2022",
month="Sep",
day="7",
volume="10",
number="9",
pages="e37343",
keywords="cardiovascular diseases",
keywords="diabetes mellitus type 2",
keywords="cohort studies",
keywords="telemedicine",
keywords="mobile applications",
keywords="mHealth",
keywords="mobile health",
keywords="mobile app",
keywords="aging",
keywords="digital health",
keywords="cardiovascular",
keywords="diabetes",
abstract="Background: The digital transformation has the potential to change health care toward more consumers' involvement, for example, in the form of health-related apps which are already widely available through app stores. These could be useful in helping people understand their risk of chronic conditions and helping them to live more healthily. Objective: With this study, we assessed mobile health app use among older Australians in general and among those who were at risk of cardiovascular disease or type 2 diabetes mellitus. Methods: In this cross-sectional analysis, we used data from the second follow-up wave of the 45 and Up Study. It is a cohort study from New South Wales, Australia, with 267,153 participants aged 45 years and older that is based on a random sample from the Services Australia (formerly the Australian Government Department of Human Services) Medicare enrollment database. The 2019 follow-up questionnaire contained questions about technology and mobile health use. We further used data on prescribed drugs and hospitalizations to identify participants who already had cardiovascular disease or diabetes or who were at risk of these conditions. Our primary outcome measure was mobile health use, defined as having used a mobile health app before. We used descriptive statistics and multivariate logistic regression to answer the research questions. Results: Overall, 31,946 individuals with a median age of 69 (IQR 63-76) years had completed the follow-up questionnaire in 2019. We classified half (16,422/31,946, 51.41\%) of these as being at risk of cardiovascular disease or type 2 diabetes mellitus and 38.04\% (12,152/31,946) as having cardiovascular disease or type 1 or type 2 diabetes mellitus. The proportion of mobile health app users among the at-risk group was 31.46\% (5166/16,422) compared to 29.16\% (9314/31,946) in the total sample. Those who used mobile health apps were more likely to be female, younger, without physical disability, and with a higher income. People at risk of cardiovascular disease or type 2 diabetes mellitus were not statistically significantly more likely to use mobile health than were people without risk (odds ratio 1.06, 95\% CI 0.97-1.16; P=.18; adjusted for age, sex, income, and physical disability). Conclusions: People at risk of cardiovascular disease or type 2 diabetes mellitus were not more likely to use mobile health apps than were people without risk. Those who used mobile health apps were less likely to be male, older, with a physical disability, and with a lower income. From the results, we concluded that aspects of equity must be considered when implementing a mobile health intervention to reach all those that can potentially benefit from it. ",
doi="10.2196/37343",
url="https://mhealth.jmir.org/2022/9/e37343",
url="http://www.ncbi.nlm.nih.gov/pubmed/36069764"
}


@Article{info:doi/10.2196/36972,
author="Cakmak, S. Ayse
and Perez Alday, A. Erick
and Densen, Samuel
and Najarro, Gabriel
and Rout, Pratik
and Rozell, J. Christopher
and Inan, T. Omer
and Shah, J. Amit
and Clifford, D. Gari",
title="Passively Captured Interpersonal Social Interactions and Motion From Smartphones for Predicting Decompensation in Heart Failure: Observational Cohort Study",
journal="JMIR Form Res",
year="2022",
month="Aug",
day="24",
volume="6",
number="8",
pages="e36972",
keywords="heart failure",
keywords="mobile device",
keywords="social interaction",
keywords="heart disease",
keywords="mobile health",
keywords="hospitalization",
abstract="Background: Heart failure (HF) is a major cause of frequent hospitalization and death. Early detection of HF symptoms using smartphone-based monitoring may reduce adverse events in a low-cost, scalable way. Objective: We examined the relationship of HF decompensation events with smartphone-based features derived from passively and actively acquired data. Methods: This was a prospective cohort study in which we monitored HF participants' social and movement activities using a smartphone app and followed them for clinical events via phone and chart review and classified the encounters as compensated or decompensated by reviewing the provider notes in detail. We extracted motion, location, and social interaction passive features and self-reported quality of life weekly (active) with the short Kansas City Cardiomyopathy Questionnaire (KCCQ-12) survey. We developed and validated an algorithm for classifying decompensated versus compensated clinical encounters (hospitalizations or clinic visits). We evaluated models based on single modality as well as early and late fusion approaches combining patient-reported outcomes and passive smartphone data. We used Shapley additive explanation values to quantify the contribution and impact of each feature to the model. Results: We evaluated 28 participants with a mean age of 67 years (SD 8), among whom 11\% (3/28) were female and 46\% (13/28) were Black. We identified 62 compensated and 48 decompensated clinical events from 24 and 22 participants, respectively. The highest area under the precision-recall curve (AUCPr) for classifying decompensation was with a late fusion approach combining KCCQ-12, motion, and social contact features using leave-one-subject-out cross-validation for a 2-day prediction window. It had an AUCPr of 0.80, with an area under the receiver operator curve (AUC) of 0.83, a positive predictive value (PPV) of 0.73, a sensitivity of 0.77, and a specificity of 0.88 for a 2-day prediction window. Similarly, the 4-day window model had an AUC of 0.82, an AUCPr of 0.69, a PPV of 0.62, a sensitivity of 0.68, and a specificity of 0.87. Passive social data provided some of the most informative features, with fewer calls of longer duration associating with a higher probability of future HF decompensation. Conclusions: Smartphone-based data that includes both passive monitoring and actively collected surveys may provide important behavioral and functional health information on HF status in advance of clinical visits. This proof-of-concept study, although small, offers important insight into the social and behavioral determinants of health and the feasibility of using smartphone-based monitoring in this population. Our strong results are comparable to those of more active and expensive monitoring approaches, and underscore the need for larger studies to understand the clinical significance of this monitoring method. ",
doi="10.2196/36972",
url="https://formative.jmir.org/2022/8/e36972",
url="http://www.ncbi.nlm.nih.gov/pubmed/36001367"
}


@Article{info:doi/10.2196/35599,
author="Matthews, Stacey
and Atkins, Brooke
and Walton, Natalie
and Mitchell, Julie-Anne
and Jennings, Garry
and Buttery, K. Amanda",
title="Development and Use of a Cardiac Clinical Guideline Mobile App in Australia: Acceptability and Multi-Methods Study",
journal="JMIR Form Res",
year="2022",
month="Aug",
day="5",
volume="6",
number="8",
pages="e35599",
keywords="mHealth",
keywords="mobile heath",
keywords="apps",
keywords="app",
keywords="guideline",
keywords="cardiovascular disease",
keywords="atrial fibrillation",
keywords="heart failure",
keywords="heart",
keywords="cardiac",
keywords="cardiovascular",
keywords="acute coronary syndrome",
keywords="smartphone",
keywords="implementation",
keywords="digital health",
keywords="develop",
keywords="evaluate",
keywords="evaluation",
keywords="Australia",
abstract="Background: Implementation of clinical guidelines into routine practice remains highly variable. Strategies to increase guideline uptake include developing digital tools and mobile apps for use in clinical practice. The National Heart Foundation of Australia in collaboration with the Cardiac Society of Australia and New Zealand published 3 key cardiac clinical guidelines, including the Australian clinical guidelines for the (1) prevention and detection of atrial fibrillation, (2) detection and management of heart failure, and (3) management of acute coronary syndromes. To improve access and uptake for health care providers, we developed the Smart Heart Guideline App. Objective: This study aims to evaluate the acceptability, implementation, and usability of an Australian-specific cardiac guidelines mobile app. Methods: We used an iterative multiple methods development and implementation approach. First, we conducted a cross-sectional web-based survey with end users (n=504 health professionals) in 2017 to determine the acceptability of an Australian-specific cardiac clinical guidelines mobile app. Second, the Smart Heart Guidelines app was created using a design, user testing, and revision process. The app includes interactive algorithms and flowcharts to inform diagnosis and management at the point of care. The freely available app was launched in October 2019 on iOS and Android operating systems and promoted and implemented using multiple methods. Third, data from 2 annual national cross-sectional general practitioner (GP) surveys in 2019 and 2020 were evaluated to understand the awareness and use of the clinical guidelines and the app. Fourth, data from the app stores were analyzed between October 1, 2019, and June 30, 2021, to evaluate usage. Results: Most health professionals surveyed (447/504, 89\%) reported accessing resources electronically, and most (318/504, 63\%) reported that they would use an Australian-specific cardiac guidelines app. GPs surveyed in 2019 were aware of the heart failure (159/312, 51\%) and atrial fibrillation (140/312, 45\%) guidelines, and in 2020, a total of 34 of 189 (18\%) reported that they were aware of the app. The app was downloaded 11,313 times (7483, 66\% from the Apple App Store; 3830, 34\% from Google Play) during the first 20-month period. Most downloads (6300/7483, 84\%) were a result of searching for the app in the stores. Monthly download rates varied. App Store data showed that people used the app twice (on average 2.06 times) during the 20 months. Many (3256/3830, 85\%) Android users deleted the app. Conclusions: Health professionals supported the development of the Smart Heart Guidelines app. Although initial downloads were promising, the frequency of using the app was low and deletion rates were high. Further evaluation of users' experience of the most and least useful components of the app is needed. ",
doi="10.2196/35599",
url="https://formative.jmir.org/2022/8/e35599",
url="http://www.ncbi.nlm.nih.gov/pubmed/35930350"
}


@Article{info:doi/10.2196/31302,
author="Albuquerque de Almeida, Fernando
and Corro Ramos, Isaac
and Al, Maiwenn
and Rutten-van M{\"o}lken, Maureen",
title="Home Telemonitoring and a Diagnostic Algorithm in the Management of Heart Failure in the Netherlands: Cost-effectiveness Analysis",
journal="JMIR Cardio",
year="2022",
month="Aug",
day="4",
volume="6",
number="2",
pages="e31302",
keywords="discrete event simulation",
keywords="cost-effectiveness",
keywords="early warning systems",
keywords="home telemonitoring",
keywords="diagnostic algorithm",
keywords="heart failure",
abstract="Background: Heart failure is a major health concern associated with significant morbidity, mortality, and reduced quality of life in patients. Home telemonitoring (HTM) facilitates frequent or continuous assessment of disease signs and symptoms, and it has shown to improve compliance by involving patients in their own care and prevent emergency admissions by facilitating early detection of clinically significant changes. Diagnostic algorithms (DAs) are predictive mathematical relationships that make use of a wide range of collected data for calculating the likelihood of a particular event and use this output for prioritizing patients with regard to their treatment. Objective: This study aims to assess the cost-effectiveness of HTM and a DA in the management of heart failure in the Netherlands. Three interventions were analyzed: usual care, HTM, and HTM plus a DA. Methods: A previously published discrete event simulation model was used. The base-case analysis was performed according to the Dutch guidelines for economic evaluation. Sensitivity, scenario, and value of information analyses were performed. Particular attention was given to the cost-effectiveness of the DA at various levels of diagnostic accuracy of event prediction and to different patient subgroups. Results: HTM plus the DA extendedly dominates HTM alone, and it has a deterministic incremental cost-effectiveness ratio compared with usual care of {\texteuro}27,712 (currency conversion rate in purchasing power parity at the time of study: {\texteuro}1=US \$1.29; further conversions are not applicable in cost-effectiveness terms) per quality-adjusted life year. The model showed robustness in the sensitivity and scenario analyses. HTM plus the DA had a 96.0\% probability of being cost-effective at the appropriate {\texteuro}80,000 per quality-adjusted life year threshold. An optimal point for the threshold value for the alarm of the DA in terms of its cost-effectiveness was estimated. New York Heart Association class IV patients were the subgroup with the worst cost-effectiveness results versus usual care, while HTM plus the DA was found to be the most cost-effective for patients aged <65 years and for patients in New York Heart Association class I. Conclusions: Although the increased costs of adopting HTM plus the DA in the management of heart failure may seemingly be an additional strain on scarce health care resources, the results of this study demonstrate that, by increasing patient life expectancy by 1.28 years and reducing their hospitalization rate by 23\% when compared with usual care, the use of this technology may be seen as an investment, as HTM plus the DA in its current form extendedly dominates HTM alone and is cost-effective compared with usual care at normally accepted thresholds in the Netherlands. ",
doi="10.2196/31302",
url="https://cardio.jmir.org/2022/2/e31302",
url="http://www.ncbi.nlm.nih.gov/pubmed/35925670"
}


@Article{info:doi/10.2196/38570,
author="Helgerud, Jan
and Haglo, H{\aa}vard
and Hoff, Jan",
title="Prediction of VO2max From Submaximal Exercise Using the Smartphone Application Myworkout GO: Validation Study of a Digital Health Method",
journal="JMIR Cardio",
year="2022",
month="Aug",
day="4",
volume="6",
number="2",
pages="e38570",
keywords="high-intensity interval training",
keywords="cardiovascular health",
keywords="physical inactivity",
keywords="endurance training",
keywords="measurement accuracy",
abstract="Background: Physical inactivity remains the largest risk factor for the development of cardiovascular disease worldwide. Wearable devices have become a popular method of measuring activity-based outcomes and facilitating behavior change to increase cardiorespiratory fitness (CRF) or maximal oxygen consumption (VO2max) and reduce weight. However, it is critical to determine their accuracy in measuring these variables. Objective: This study aimed to determine the accuracy of using a smartphone and the application Myworkout GO for submaximal prediction of VO2max. Methods: Participants included 162 healthy volunteers: 58 women and 104 men (17-73 years old). The study consisted of 3 experimental tests randomized to 3 separate days. One-day VO2max was assessed with Metamax II, with the participant walking or running on the treadmill. On the 2 other days, the application Myworkout GO used standardized high aerobic intensity interval training (HIIT) on the treadmill to predict VO2max. Results: There were no significant differences between directly measured VO2max (mean 49, SD 14 mL/kg/min) compared with the VO2max predicted by Myworkout GO (mean 50, SD 14 mL/kg/min). The direct and predicted VO2max values were highly correlated, with an R2 of 0.97 (P<.001) and standard error of the estimate (SEE) of 2.2 mL/kg/min, with no sex differences. Conclusions: Myworkout GO accurately calculated VO2max, with an SEE of 4.5\% in the total group. The submaximal HIIT session (4 x 4 minutes) incorporated in the application was tolerated well by the participants. We present health care providers and their patients with a more accurate and practical version of health risk estimation. This might increase physical activity and improve exercise habits in the general population. ",
doi="10.2196/38570",
url="https://cardio.jmir.org/2022/2/e38570",
url="http://www.ncbi.nlm.nih.gov/pubmed/35925653"
}


@Article{info:doi/10.2196/34959,
author="Buhr, Lorina
and Kaufmann, Martiana Pauline Lucie
and J{\"o}r{\ss}, Katharina",
title="Attitudes of Patients With Chronic Heart Failure Toward Digital Device Data for Self-documentation and Research in Germany: Cross-sectional Survey Study",
journal="JMIR Cardio",
year="2022",
month="Aug",
day="3",
volume="6",
number="2",
pages="e34959",
keywords="mobile health",
keywords="mHealth",
keywords="digital devices",
keywords="wearables",
keywords="heart failure",
keywords="data sharing",
keywords="consent",
keywords="mobile phone",
abstract="Background: In recent years, the use of digital mobile measurement devices (DMMDs) for self-documentation in cardiovascular care in Western industrialized health care systems has increased. For patients with chronic heart failure (cHF), digital self-documentation plays an increasingly important role in self-management. Data from DMMDs can also be integrated into telemonitoring programs or data-intensive medical research to collect and evaluate patient-reported outcome measures through data sharing. However, the implementation of data-intensive devices and data sharing poses several challenges for doctors and patients as well as for the ethical governance of data-driven medical research. Objective: This study aims to explore the potential and challenges of digital device data in cardiology research from patients' perspectives. Leading research questions of the study concerned the attitudes of patients with cHF toward health-related data collected in the use of digital devices for self-documentation as well as sharing these data and consenting to data sharing for research purposes. Methods: A cross-sectional survey of patients of a research in cardiology was conducted at a German university medical center (N=159) in 2020 (March to July). Eligible participants were German-speaking adult patients with cHF at that center. A pen-and-pencil questionnaire was sent by mail. Results: Most participants (77/105, 73.3\%) approved digital documentation, as they expected the device data to help them observe their body and its functions more objectively. Digital device data were believed to provide cognitive support, both for patients' self-assessment and doctors' evaluation of their patients' current health condition. Interestingly, positive attitudes toward DMMD data providing cognitive support were, in particular, voiced by older patients aged >65 years. However, approximately half of the participants (56/105, 53.3\%) also reported difficulty in dealing with self-documented data that lay outside the optimal medical target range. Furthermore, our findings revealed preferences for the self-management of DMMD data disclosed for data-intensive medical research among German patients with cHF, which are best implemented with a dynamic consent model. Conclusions: Our findings provide potentially valuable insights for introducing DMMD in cardiovascular research in the German context. They have several practical implications, such as a high divergence in attitudes among patients with cHF toward different data-receiving organizations as well as a large variance in preferences for the modes of receiving information included in the consenting procedure for data sharing for research. We suggest addressing patients' multiple views on consenting and data sharing in institutional normative governance frameworks for data-intensive medical research. ",
doi="10.2196/34959",
url="https://cardio.jmir.org/2022/2/e34959",
url="http://www.ncbi.nlm.nih.gov/pubmed/35921134"
}


@Article{info:doi/10.2196/38469,
author="Buss, Helen Vera
and Varnfield, Marlien
and Harris, Mark
and Barr, Margo",
title="Remotely Conducted App-Based Intervention for Cardiovascular Disease and Diabetes Risk Awareness and Prevention: Single-Group Feasibility Trial",
journal="JMIR Hum Factors",
year="2022",
month="Jul",
day="1",
volume="9",
number="3",
pages="e38469",
keywords="mobile health",
keywords="feasibility studies",
keywords="primary prevention",
keywords="cardiovascular disease",
keywords="diabetes mellitus, type 2",
keywords="mHealth",
keywords="cardiology",
keywords="heart disease",
keywords="diabetes",
keywords="smartphone",
keywords="participate engagement",
keywords="app-based intervention",
abstract="Background: Cardiovascular disease and type 2 diabetes mellitus are two of the most prevalent chronic conditions worldwide. An unhealthy lifestyle greatly contributes to someone's risk of developing these conditions. Mobile health is an emerging technology that can help deliver health promotion interventions to the population, for example, in the form of health apps. Objective: The aim of this study was to test the feasibility of an app-based intervention for cardiovascular and diabetes risk awareness and prevention by measuring nonusage, dropout, adherence to app use, and usability of the app over 3 months. Methods: Participants were eligible if they were aged 45 years or older, resided in Australia, were free of cardiovascular disease and diabetes, were fluent in English, and owned a smartphone. In the beginning, participants received an email with instructions on how to install the app and a user guide. After 3 months, they received an email with an invitation to an end-of-study survey. The survey included questions about general smartphone use and the user version of the Mobile Application Rating Scale. We analyzed app-generated and survey data by using descriptive and inferential statistics as well as thematic analysis for open-text comments. Results: Recruitment took place between September and October 2021. Of the 46 participants who consented to the study, 20 (44\%) never used the app  and 15 (33\%) dropped out. The median age of the app users at baseline was 62 (IQR 56-67) years. Adherence to app use, that is, using the app at least once a week over 3 months, was 17\% (8/46) of the total sample and 31\% (8/26) of all app users. The mean app quality rating on the user version of the Mobile Application Rating Scale was 3.5 (SD 0.6) of 5 points. The app scored the highest for the information section and the lowest for the engagement section of the scale. Conclusions: Nonusage and dropouts were too high, and the adherence was too low to consider the intervention in its current form feasible. Potential barriers that we identified include the research team not actively engaging with participants early in the study to verify that all participants could install the app, the intervention did not involve direct contact with health care professionals, and the app did not have enough interactive features. ",
doi="10.2196/38469",
url="https://humanfactors.jmir.org/2022/3/e38469",
url="http://www.ncbi.nlm.nih.gov/pubmed/35776504"
}


@Article{info:doi/10.2196/29481,
author="Praus, Friederike
and Krzowski, Bartosz
and Walther, Tabea
and Gratzke, Christian
and Balsam, Pawe?
and Miernik, Arkadiusz
and Pohlmann, Fabian Philippe",
title="Smartphone Apps for Managing Antithrombotic Therapy: Scoping Literature Review",
journal="JMIR Cardio",
year="2022",
month="Jun",
day="21",
volume="6",
number="1",
pages="e29481",
keywords="anticoagulation",
keywords="mobile app",
keywords="telehealth",
keywords="telemedicine",
keywords="mHealth",
keywords="smartphone",
keywords="educational apps",
keywords="digital tools",
keywords="physician support",
abstract="Background: Antithrombotic therapy is complex and requires informed decisions and high therapy adherence. Several mobile phone apps exist to either support physicians in the management of antithrombotic therapies or to educate and support patients. For the majority of these apps, both their medical evidence and their development background are unknown. Objective: This review aims to investigate the available literature describing high-quality apps for managing antithrombotic therapy based on professional scientific information. Methods: Keywords and Medical Subject Heading terms were used to search MEDLINE via PubMed and Ovid between December 2019 and January 2022. Inclusion criteria were the availability of full text and publications in the English language. Apps that solely focused on atrial fibrillation were excluded. Qualitative findings were thematically synthesized and reported narratively. Results: Out of 149 identified records, 32 were classified as eligible. We identified four groups: (1) apps for patients supporting self-management of vitamin K antagonists, (2) apps for patients increasing therapy adherence, (3) educational apps for patients, and (4) apps for physicians in supporting guideline adherence. Conclusions: Throughout the evaluated data, patients from all age groups receiving antithrombotic drugs expressed the desire for a digital tool that could support their therapy management. In addition, physicians using mobile guideline-based apps may have contributed to decreased adverse event rates among their patients. In general, digital apps encompassing both user-friendly designs and scientific backgrounds may enhance the safety of antithrombotic therapies. However, our evaluation did not identify any apps that addressed all antithrombotic drugs in combination with perioperative stratification strategies. Currently, strict regulations for smartphone apps seem to negatively affect the development of new apps. Therefore, new legal policies for medical digital apps are urgently needed. ",
doi="10.2196/29481",
url="https://cardio.jmir.org/2022/1/e29481",
url="http://www.ncbi.nlm.nih.gov/pubmed/35727608"
}


@Article{info:doi/10.2196/36086,
author="Yeung, Kan Andy Wai
and Kulnik, Tino Stefan
and Parvanov, D. Emil
and Fassl, Anna
and Eibensteiner, Fabian
and V{\"o}lkl-Kernstock, Sabine
and Kletecka-Pulker, Maria
and Crutzen, Rik
and Gutenberg, Johanna
and H{\"o}ppchen, Isabel
and Niebauer, Josef
and Smeddinck, David Jan
and Willschke, Harald
and Atanasov, G. Atanas",
title="Research on Digital Technology Use in Cardiology: Bibliometric Analysis",
journal="J Med Internet Res",
year="2022",
month="May",
day="11",
volume="24",
number="5",
pages="e36086",
keywords="cardiovascular",
keywords="heart",
keywords="hypertension",
keywords="atrial fibrillation",
keywords="cardiopulmonary resuscitation",
keywords="electrocardiography",
keywords="photoplethysmography",
keywords="wearable device, digital health, mHealth",
keywords="cardiology",
keywords="cardiac",
keywords="health application",
abstract="Background: Digital technology uses in cardiology have become a popular research focus in recent years. However, there has been no published bibliometric report that analyzed the corresponding academic literature in order to derive key publishing trends and characteristics of this scientific area. Objective: We used a bibliometric approach to identify and analyze the academic literature on digital technology uses in cardiology, and to unveil popular research topics, key authors, institutions, countries, and journals. We further captured the cardiovascular conditions and diagnostic tools most commonly investigated within this field. Methods: The Web of Science electronic database was queried to identify relevant papers on digital technology uses in cardiology. Publication and citation data were acquired directly from the database. Complete bibliographic data were exported to VOSviewer, a dedicated bibliometric software package, and related to the semantic content of titles, abstracts, and keywords. A term map was constructed for findings visualization. Results: The analysis was based on data from 12,529 papers. Of the top 5 most productive institutions, 4 were based in the United States. The United States was the most productive country (4224/12,529, 33.7\%), followed by United Kingdom (1136/12,529, 9.1\%), Germany (1067/12,529, 8.5\%), China (682/12,529, 5.4\%), and Italy (622/12,529, 5.0\%). Cardiovascular diseases that had been frequently investigated included hypertension (152/12,529, 1.2\%), atrial fibrillation (122/12,529, 1.0\%), atherosclerosis (116/12,529, 0.9\%), heart failure (106/12,529, 0.8\%), and arterial stiffness (80/12,529, 0.6\%). Recurring modalities were electrocardiography (170/12,529, 1.4\%), angiography (127/12,529, 1.0\%), echocardiography (127/12,529, 1.0\%), digital subtraction angiography (111/12,529, 0.9\%), and photoplethysmography (80/12,529, 0.6\%). For a literature subset on smartphone apps and wearable devices, the Journal of Medical Internet Research (20/632, 3.2\%) and other JMIR portfolio journals (51/632, 8.0\%) were the major publishing venues. Conclusions: Digital technology uses in cardiology target physicians, patients, and the general public. Their functions range from assisting diagnosis, recording cardiovascular parameters, and patient education, to teaching laypersons about cardiopulmonary resuscitation. This field already has had a great impact in health care, and we anticipate continued growth. ",
doi="10.2196/36086",
url="https://www.jmir.org/2022/5/e36086",
url="http://www.ncbi.nlm.nih.gov/pubmed/35544307"
}


@Article{info:doi/10.2196/35945,
author="Bas-Sarmiento, Pilar
and Fern{\'a}ndez-Guti{\'e}rrez, Martina
and Poza-M{\'e}ndez, Miriam
and Mar{\'i}n-Paz, Jes{\'u}s Antonio
and Paloma-Castro, Olga
and Romero-S{\'a}nchez, Manuel Jos{\'e}
and ",
title="Development and Effectiveness of a Mobile Health Intervention in Improving Health Literacy and Self-management of Patients With Multimorbidity and Heart Failure: Protocol for a Randomized Controlled Trial",
journal="JMIR Res Protoc",
year="2022",
month="Apr",
day="29",
volume="11",
number="4",
pages="e35945",
keywords="complex health needs",
keywords="health literacy",
keywords="heart failure",
keywords="mHealth",
keywords="multimorbidity",
abstract="Background: Patients with multimorbidity and complex health needs are defined as a priority by the World Health Organization (WHO) and the European Union. There is a need to develop appropriate strategies with effective measures to meet the challenge of chronicity, reorienting national health systems. The increasing expansion of mobile health (mHealth) interventions in patient communication, the reduction of health inequalities, improved access to health care resources, adherence to treatment, and self-care of chronic diseases all point to an optimistic outlook. However, only few mobile apps demonstrate their effectiveness in these patients, which is diminished when they are not based on evidence, or when they are not designed by and for users with different levels of health literacy (HL). Objective: This study aims to evaluate the efficacy of an mHealth intervention relative to routine clinical practice in improving HL and self-management in patients with multimorbidity with heart failure (HF) and complex health needs. Methods: This is a randomized, multicenter, blinded clinical trial evaluating 2 groups, namely, a control group (standard clinical practice) and an intervention group (standard clinical practice and an ad hoc designed mHealth intervention previously developed), for 12 months. Results: The contents of the mHealth intervention will address user-perceived needs based on the development of user stories regarding diet, physical exercise, cardiac rehabilitation, therapeutic adherence, warning signs and symptoms, and emotional management. These contents have been validated by expert consensus. The creation and development of the contents of the mHealth intervention (app) took 18 months and was completed during 2021. The mobile app is expected to be developed by the end of 2022, after which it will be applied to the experimental group as an adjunct to standard clinical care during 12 months. Conclusions: The trial will demonstrate whether the mobile app improves HL and self-management in patients with HF and complex health needs, improves therapeutic adherence, and reduces hospital admissions. This study can serve as a starting point for developing other mHealth tools in other pathologies and for their generalization to other contexts. Trial Registration: ClinicalTrials.gov NCT04725526; https://tinyurl.com/bd8va27w International Registered Report Identifier (IRRID): DERR1-10.2196/35945 ",
doi="10.2196/35945",
url="https://www.researchprotocols.org/2022/4/e35945",
url="http://www.ncbi.nlm.nih.gov/pubmed/35486437"
}


@Article{info:doi/10.2196/32348,
author="Hammond, M. Michael
and Zhang, Yuankai
and Pathiravasan, H. Chathurangi
and Lin, Honghuang
and Sardana, Mayank
and Trinquart, Ludovic
and Benjamin, J. Emelia
and Borrelli, Belinda
and Manders, S. Emily
and Fusco, Kelsey
and Kornej, Jelena
and Spartano, L. Nicole
and Kheterpal, Vik
and Nowak, Christopher
and McManus, D. David
and Liu, Chunyu
and Murabito, M. Joanne",
title="Relations Between BMI Trajectories and Habitual Physical Activity Measured by a Smartwatch in the Electronic Cohort of the Framingham Heart Study: Cohort Study",
journal="JMIR Cardio",
year="2022",
month="Apr",
day="27",
volume="6",
number="1",
pages="e32348",
keywords="mobile health",
keywords="BMI",
keywords="smartwatch",
keywords="physical activity",
keywords="cardiovascular diseases",
keywords="cardiology",
keywords="digital health",
keywords="mHealth",
keywords="mobile health apps",
abstract="Background: The prevalence of obesity is rising. Most previous studies that examined the relations between BMI and physical activity (PA) measured BMI at a single timepoint. The association between BMI trajectories and habitual PA remains unclear. Objective: This study assesses the relations between BMI trajectories and habitual step-based PA among participants enrolled in the electronic cohort of the Framingham Heart Study (eFHS). Methods: We used a semiparametric group-based modeling to identify BMI trajectories from eFHS participants who attended research examinations at the Framingham Research Center over 14 years. Daily steps were recorded from the smartwatch provided at examination 3. We excluded participants with <30 days or <5 hours of smartwatch wear data. We used generalized linear models to examine the association between BMI trajectories and daily step counts. Results: We identified 3 trajectory groups for the 837 eFHS participants (mean age 53 years; 57.8\% [484/837] female). Group 1 included 292 participants whose BMI was stable (slope 0.005; P=.75), group 2 included 468 participants whose BMI increased slightly (slope 0.123; P<.001), and group 3 included 77 participants whose BMI increased greatly (slope 0.318; P<.001). The median follow-up period for step count was 516 days. Adjusting for age, sex, wear time, and cohort, participants in groups 2 and 3 took 422 (95\% CI --823 to --21) and 1437 (95\% CI --2084 to --790) fewer average daily steps, compared with participants in group 1. After adjusting for metabolic and social risk factors, group 2 took 382 (95\% CI --773 to 10) and group 3 took 1120 (95\% CI --1766 to --475) fewer steps, compared with group 1. Conclusions: In this community-based eFHS, participants whose BMI trajectory increased greatly over time took significantly fewer steps, compared with participants with stable BMI trajectories. Our findings suggest that greater weight gain may correlate with lower levels of step-based physical activity. ",
doi="10.2196/32348",
url="https://cardio.jmir.org/2022/1/e32348",
url="http://www.ncbi.nlm.nih.gov/pubmed/35476038"
}


@Article{info:doi/10.2196/30236,
author="Treskes, Willem Roderick
and van den Akker-van Marle, Elske M.
and van Winden, Louise
and van Keulen, Nicole
and van der Velde, Tjeerd Enno
and Beeres, Saskia
and Atsma, Douwe
and Schalij, Jan Martin",
title="The Box---eHealth in the Outpatient Clinic Follow-up of Patients With Acute Myocardial Infarction: Cost-Utility Analysis",
journal="J Med Internet Res",
year="2022",
month="Apr",
day="25",
volume="24",
number="4",
pages="e30236",
keywords="smart technology",
keywords="myocardial infarction",
keywords="cost-utility",
keywords="outpatients",
keywords="cost-effectiveness",
keywords="eHealth",
keywords="remote monitoring",
keywords="cost of care",
keywords="quality of life",
abstract="Background: Smartphone compatible wearables have been released on the consumers market, enabling remote monitoring. Remote monitoring is often named as a tool to reduce the cost of care. Objective: The primary purpose of this paper is to describe a cost-utility analysis of an eHealth intervention compared to regular follow-up in patients with acute myocardial infarction (AMI). Methods: In this trial, of which clinical results have been published previously, patients with an AMI were randomized in a 1:1 fashion between an eHealth intervention and regular follow-up. The remote monitoring intervention consisted of a blood pressure monitor, weight scale, electrocardiogram device, and step counter. Furthermore, two in-office outpatient clinic visits were replaced by e-visits. The control group received regular care. The differences in mean costs and quality of life per patient between both groups during one-year follow-up were calculated. Results: Mean costs per patient were {\texteuro}2417{\textpm}2043 (US \$2657{\textpm}2246) for the intervention and {\texteuro}2888{\textpm}2961 (US \$3175{\textpm}3255) for the control group. This yielded a cost reduction of {\texteuro}471 (US \$518) per patient. This difference was not statistically significant (95\% CI --{\texteuro}275 to {\texteuro}1217; P=.22, US \$--302 to \$1338). The average quality-adjusted life years in the first year of follow-up was 0.74 for the intervention group and 0.69 for the control (difference --0.05, 95\% CI --0.09 to --0.01; P=.01). Conclusions: eHealth in the outpatient clinic setting for patients who suffered from AMI is likely to be cost-effective compared to regular follow-up. Further research should be done to corroborate these findings in other patient populations and different care settings. Trial Registration: ClinicalTrials.gov NCT02976376; https://clinicaltrials.gov/ct2/show/NCT02976376 International Registered Report Identifier (IRRID): RR2-10.2196/resprot.8038 ",
doi="10.2196/30236",
url="https://www.jmir.org/2022/4/e30236",
url="http://www.ncbi.nlm.nih.gov/pubmed/35468091"
}


@Article{info:doi/10.2196/33992,
author="Bezerra Giordan, Leticia
and Ronto, Rimante
and Chau, Josephine
and Chow, Clara
and Laranjo, Liliana",
title="Use of Mobile Apps in Heart Failure Self-management: Qualitative Study Exploring the Patient and Primary Care Clinician Perspective",
journal="JMIR Cardio",
year="2022",
month="Apr",
day="20",
volume="6",
number="1",
pages="e33992",
keywords="mobile app",
keywords="mHealth",
keywords="heart failure",
keywords="self-management",
keywords="eHealth",
keywords="telehealth",
abstract="Background: Mobile apps have the potential to support patients with heart failure and facilitate disease self-management, but this area of research is recent and rapidly evolving, with inconsistent results for efficacy. So far, most of the published studies evaluated the feasibility of a specific app or assessed the quality of apps available in app stores. Research is needed to explore patients' and clinicians' perspectives to guide app development, evaluation, and implementation into models of care. Objective: This study aims to explore the patient and primary care clinician perspective on the facilitators and barriers to using mobile apps, as well as desired features, to support heart failure self-management. Methods: This is a qualitative phenomenological study involving face-to-face semistructured interviews. Interviews were conducted in a general practice clinic in Sydney, Australia. Eligible participants were adult patients with heart failure and health care professionals who provided care to these patients at the clinic. Patients did not need to have previous experience using heart failure mobile apps to be eligible for this study. The interviews were audio-recorded, transcribed, and analyzed using inductive thematic data analysis in NVivo 12. Results: A total of 12 participants were interviewed: 6 patients (mean age 69 [SD 7.9] years) and 6 clinicians. The interviews lasted from 25 to 45 minutes. The main facilitators to the use of apps to support heart failure self-management were communication ability, personalized feedback and education, and automated self-monitoring. Patients mentioned that chat-like features and ability to share audio-visual information can be helpful for getting support outside of clinical appointments. Clinicians considered helpful to send motivational messages to patients and ask them about signs and symptoms of heart failure decompensation. Overall, participants highlighted the importance of personalization, particularly in terms of feedback and educational content. Automated self-monitoring with wireless devices was seen to alleviate the burden of tracking measures such as weight and blood pressure. Other desired features included tools to monitor patient-reported outcomes and support patients' mental health and well-being. The main barriers identified were the patients' unwillingness to engage in a new strategy to manage their condition using an app, particularly in the case of low digital literacy. However, clinicians mentioned this barrier could potentially be overcome by introducing the app soon after an exacerbation, when patients might be more willing to improve their self-management and avoid rehospitalization. Conclusions: The use of mobile apps to support heart failure self-management may be facilitated by features that increase the usefulness and utility of the app, such as communication ability in-between consultations and personalized feedback. Also important is facilitating ease of use by supporting automated self-monitoring through integration with wireless devices. Future research should consider these features in the co-design and testing of heart failure mobile apps with patients and clinicians. ",
doi="10.2196/33992",
url="https://cardio.jmir.org/2022/1/e33992",
url="http://www.ncbi.nlm.nih.gov/pubmed/35442205"
}


@Article{info:doi/10.2196/29408,
author="Luo, Xueyan
and Xu, Wei
and Ming, Wai-Kit
and Jiang, Xinchan
and Yuan, Quan
and Lai, Han
and Huang, Chunji
and Zhong, Xiaoni",
title="Cost-Effectiveness of Mobile Health--Based Integrated Care for Atrial Fibrillation: Model Development and Data Analysis",
journal="J Med Internet Res",
year="2022",
month="Apr",
day="19",
volume="24",
number="4",
pages="e29408",
keywords="mobile health",
keywords="integrated care",
keywords="ABC pathway",
keywords="atrial fibrillation",
keywords="model-based",
keywords="cost-effectiveness",
keywords="health economic evaluation",
abstract="Background: Mobile health (mHealth) technology is increasingly used in disease management. Using mHealth tools to integrate and streamline care has improved clinical outcomes of patients with atrial fibrillation (AF). Objective: The aim of this study was to investigate the potential clinical and health economic outcomes of mHealth-based integrated care for AF from the perspective of a public health care provider in China. Methods: A Markov model was designed to compare outcomes of mHealth-based care and usual care in a hypothetical cohort of patients with AF in China. The time horizon was 30 years with monthly cycles. Model outcomes measured were direct medical cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER). Sensitivity analyses were performed to examine the robustness of the base-case results. Results: In the base-case analysis, mHealth-based care gained higher QALYs of 0.0730 with an incurred cost of US \$1090. Using US \$33,438 per QALY (three times the gross domestic product) as the willingness-to-pay threshold, mHealth-based care was cost-effective, with an ICER of US \$14,936 per QALY. In one-way sensitivity analysis, no influential factor with a threshold value was identified. In probabilistic sensitivity analysis, mHealth-based care was accepted as cost-effective in 92.33\% of 10,000 iterations. Conclusions: This study assessed the expected cost-effectiveness of applying mHealth-based integrated care for AF according to a model-based health economic evaluation. The exploration suggested the potential cost-effective use of mHealth apps in streamlining and integrating care via the Atrial fibrillation Better Care (ABC) pathway for AF in China. Future economic evaluation alongside randomized clinical trials is highly warranted to verify the suggestion and investigate affecting factors such as geographical variations in patient characteristics, identification of subgroups, and constraints on local implementation. ",
doi="10.2196/29408",
url="https://www.jmir.org/2022/4/e29408",
url="http://www.ncbi.nlm.nih.gov/pubmed/35438646"
}


@Article{info:doi/10.2196/30661,
author="Brasca, Angelo Francesco Maria
and Casale, Carla Maria
and Canevese, Lorenzo Fabio
and Tortora, Giovanni
and Pagano, Giulia
and Botto, Luca Giovanni",
title="Physical Activity in Patients With Heart Failure During and After COVID-19 Lockdown: Single-Center Observational Retrospective Study",
journal="JMIR Cardio",
year="2022",
month="Apr",
day="19",
volume="6",
number="1",
pages="e30661",
keywords="heart failure",
keywords="physical activity",
keywords="COVID-19",
keywords="remote monitoring",
keywords="implantable cardiac device",
keywords="monitoring",
keywords="exercise",
keywords="surveillance",
keywords="lockdown",
keywords="cardiovascular",
keywords="heart",
keywords="retrospective",
keywords="burden",
abstract="Background: The COVID-19 pandemic forced several European governments to impose severe lockdown measures. The reduction of physical activity during the lockdown could have been deleterious. Objective: The aim of this observational, retrospective study was to investigate the effect of the lockdown strategy on the physical activity burden and subsequent reassessment in a group of patients with heart failure who were followed by means of remote monitoring. Methods: We analyzed remote monitoring transmissions during the 3-month period immediately preceding the lockdown, 69 days of lockdown, and 3-month period after the first lockdown in a cohort of patients with heart failure from a general hospital in Lombardy, Italy. We compared variation of daily physical activity measured by cardiac implantable electrical devices with clinical variables collected in a hospital database. Results: We enrolled 41 patients with heart failure that sent 176 transmissions. Physical activity decreased during the lockdown period (mean 3.4, SD 1.9 vs mean 2.9, SD 1.8 hours/day; P<.001) but no significant difference was found when comparing the period preceding and following the lockdown (--0.0007 hours/day; P=.99). We found a significant correlation between physical activity reduction during and after the lockdown (R2=0.45, P<.001). The only significant predictor of exercise variation in the postlockdown period was the lockdown to prelockdown physical activity ratio. Conclusions: An excessive reduction of exercise in patients with heart failure decreased the tolerance to exercise, especially in patients with more comorbidities. Remote monitoring demonstrated exercise reduction, suggesting its potential utility to encourage patients to maintain their usual physical activity levels. ",
doi="10.2196/30661",
url="https://cardio.jmir.org/2022/1/e30661",
url="http://www.ncbi.nlm.nih.gov/pubmed/35103602"
}


@Article{info:doi/10.2196/34142,
author="Bonner, Carissa
and Batcup, Carys
and Ayre, Julie
and Cvejic, Erin
and Trevena, Lyndal
and McCaffery, Kirsten
and Doust, Jenny",
title="The Impact of Health Literacy--Sensitive Design and Heart Age in a Cardiovascular Disease Prevention Decision Aid: Randomized Controlled Trial and End-User Testing",
journal="JMIR Cardio",
year="2022",
month="Apr",
day="15",
volume="6",
number="1",
pages="e34142",
keywords="decision aids",
keywords="shared decision-making",
keywords="risk communication",
keywords="heart age",
keywords="cardiovascular disease prevention",
keywords="behavior change",
keywords="health literacy",
abstract="Background: Shared decision-making is an essential principle for the prevention of cardiovascular disease (CVD), where asymptomatic people consider lifelong medication and lifestyle changes. Objective: This study aims to develop and evaluate the first literacy-sensitive CVD prevention decision aid (DA) developed for people with low health literacy, and investigate the impact of literacy-sensitive design and heart age. Methods: We developed a standard DA based on international standards. The standard DA was based on our existing general practitioner DA. The literacy-sensitive DA included simple language, supporting images, white space, and a lifestyle action plan. The control DA used Heart Foundation materials. A randomized trial included 859 people aged 45-74 years using a 3 (DA: standard, literacy-sensitive, control) {\texttimes}2 (heart age: heart age + percentage risk, percentage risk only) factorial design, with outcomes including prevention intentions and behaviors, gist and verbatim knowledge of risk, credibility, emotional response, and decisional conflict. We iteratively improved the literacy-sensitive version based on end-user testing interviews with 20 people with varying health literacy levels. Results: Immediately after the intervention (n=859), there were no differences in any outcome among the DA groups. The heart age group was less likely to have a positive emotional response, perceived the message as less credible, and had higher gist and verbatim knowledge of heart age risk but not percentage risk. After 4 weeks (n=596), the DA group had better gist knowledge of percentage risk than the control group. The literacy-sensitive DA group had higher fruit consumption, and the standard DA group had better verbatim knowledge of percentage risk. Verbatim knowledge was higher for heart age than for percentage risk among those who received both. Conclusions: The literacy-sensitive DA resulted in increased knowledge of CVD risk and increased fruit consumption in participants with varying health literacy levels and CVD risk results. Adding heart age did not increase lifestyle change intentions or behavior but did affect psychological outcomes, consistent with previous findings. This tool will be integrated with additional resources to improve other lifestyle outcomes. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12620000806965; https://tinyurl.com/226yhk8a ",
doi="10.2196/34142",
url="https://cardio.jmir.org/2022/1/e34142",
url="http://www.ncbi.nlm.nih.gov/pubmed/35436208"
}


@Article{info:doi/10.2196/33839,
author="Bezerra Giordan, Leticia
and Tong, Ly Huong
and Atherton, J. John
and Ronto, Rimante
and Chau, Josephine
and Kaye, David
and Shaw, Tim
and Chow, Clara
and Laranjo, Liliana",
title="The Use of Mobile Apps for Heart Failure Self-management: Systematic Review of Experimental and Qualitative Studies",
journal="JMIR Cardio",
year="2022",
month="Mar",
day="31",
volume="6",
number="1",
pages="e33839",
keywords="heart failure",
keywords="self-management",
keywords="mobile health",
keywords="mobile app",
keywords="secondary prevention",
keywords="mobile phone",
abstract="Background: Heart failure self-management is essential to avoid decompensation and readmissions. Mobile apps seem promising in supporting heart failure self-management, and there has been a rapid growth in publications in this area. However, to date, systematic reviews have mostly focused on remote monitoring interventions using nonapp types of mobile technologies to transmit data to health care providers, rarely focusing on supporting patient self-management of heart failure. Objective: This study aims to systematically review the evidence on the effect of heart failure self-management apps on health outcomes, patient-reported outcomes, and patient experience. Methods: Four databases (PubMed, Embase, CINAHL, and PsycINFO) were searched for studies examining interventions that comprised a mobile app targeting heart failure self-management and reported any health-related outcomes or patient-reported outcomes or perspectives published from 2008 to December 2021. The studies were independently screened. The risk of bias was appraised using Cochrane tools. We performed a narrative synthesis of the results. The protocol was registered on PROSPERO (International Prospective Register of Systematic Reviews; CRD42020158041). Results: A total of 28 articles (randomized controlled trials [RCTs]: n=10, 36\%), assessing 23 apps, and a total of 1397 participants were included. The most common app features were weight monitoring (19/23, 83\%), symptom monitoring (18/23, 78\%), and vital sign monitoring (15/23, 65\%). Only 26\% (6/23) of the apps provided all guideline-defined core components of heart failure self-management programs: education, symptom monitoring, medication support, and physical activity support. RCTs were small, involving altogether 717 participants, had ?6 months of follow-up, and outcomes were predominantly self-reported. Approximately 20\% (2/10) of RCTs reported a significant improvement in their primary outcomes: heart failure knowledge (P=.002) and self-care (P=.004). One of the RCTs found a significant reduction in readmissions (P=.02), and 20\% (2/10) of RCTs reported higher unplanned clinic visits. Other experimental studies also found significant improvements in knowledge, self-care, and readmissions, among others. Less than half of the studies involved patients and clinicians in the design of apps. Engagement with the intervention was poorly reported, with only 11\% (3/28) of studies quantifying app engagement metrics such as frequency of use over the study duration. The most desirable app features were automated self-monitoring and feedback, personalization, communication with clinicians, and data sharing and integration. Conclusions: Mobile apps may improve heart failure self-management; however, more robust evaluation studies are needed to analyze key end points for heart failure. On the basis of the results of this review, we provide a road map for future studies in this area. ",
doi="10.2196/33839",
url="https://cardio.jmir.org/2022/1/e33839",
url="http://www.ncbi.nlm.nih.gov/pubmed/35357311"
}


@Article{info:doi/10.2196/34946,
author="Castela Forte, Jos{\'e}
and Gannamani, Rahul
and Folkertsma, Pytrik
and Kumaraswamy, Sridhar
and Mount, Sarah
and van Dam, Sipko
and Hoogsteen, Jan",
title="Changes in Blood Lipid Levels After a Digitally Enabled Cardiometabolic Preventive Health Program: Pre-Post Study in an Adult Dutch General Population Cohort",
journal="JMIR Cardio",
year="2022",
month="Mar",
day="23",
volume="6",
number="1",
pages="e34946",
keywords="cholesterol",
keywords="lifestyle intervention",
keywords="prevention",
keywords="hypercholesterolemia",
keywords="digital health",
abstract="Background: Despite widespread education, many individuals fail to follow basic health behaviors such as consuming a healthy diet and exercising. Positive changes in lifestyle habits are associated with improvements in multiple cardiometabolic health risk factors, including lipid levels. Digital lifestyle interventions have been suggested as a viable complement or potential alternative to conventional health behavior change strategies. However, the benefit of digital preventive interventions for lipid levels in a preventive health context remains unclear. Objective: This observational study aimed to determine how the levels of lipids, namely total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, non-HDL cholesterol, and triglycerides, changed over time in a Dutch general population cohort undergoing a digital preventive health program. Moreover, we looked to establish associations between lifestyle factors at baseline and lipid levels. Methods: We included 348 adults from the Dutch general population who underwent a digitally enabled preventive health program at Ancora Health between January 2020 and October 2021. Upon enrollment, participants underwent a baseline assessment involving a comprehensive lifestyle questionnaire, a blood biochemistry panel, physical measurements, and cardiopulmonary fitness measurements. Thereafter, users underwent a lifestyle coaching program and could access the digital application to register and track health behaviors, weight, and anthropometric data at any time. Lipid levels were categorized as normal, elevated, high, and clinical dyslipidemia according to accepted international standards. If at least one lipid marker was high or HDL was low, participants received specific coaching and advice for cardiometabolic health. We retrospectively analyzed the mean and percentage changes in lipid markers in users who were remeasured after a cardiometabolic health--focused intervention, and studied the association between baseline user lifestyle characteristics and having normal lipid levels. Results: In our cohort, 199 (57.2\%) participants had dyslipidemia at baseline, of which 104 participants were advised to follow a cardiometabolic health--focused intervention. Eating more amounts of favorable food groups and being more active were associated with normal lipid profiles. Among the participants who underwent remeasurement 9 months after intervention completion, 57\% (17/30), 61\% (19/31), 56\% (15/27), 82\% (9/11), and 100\% (8/8) showed improvements at remeasurement for total, LDL, HDL, and non-HDL cholesterol, and triglycerides, respectively. Moreover, between 35.3\% and 77.8\% showed a return to normal levels. In those with high lipid levels at baseline, total cholesterol decreased by 0.5 mmol/L (7.5\%), LDL cholesterol decreased by 0.39 mmol/L (10.0\%), non-HDL cholesterol decreased by 0.44 mmol/L (8.3\%), triglycerides decreased by 0.97 mmol/L (32.0\%), and HDL increased by 0.17 mmol/L (15.6\%), after the intervention. Conclusions: A cardiometabolic screening program in a general population cohort identified a significant portion of individuals with subclinical and clinical lipid levels. Individuals who, after screening, actively engaged in a cardiometabolic health--focused lifestyle program improved their lipid levels. ",
doi="10.2196/34946",
url="https://cardio.jmir.org/2022/1/e34946",
url="http://www.ncbi.nlm.nih.gov/pubmed/35319473"
}


@Article{info:doi/10.2196/34294,
author="Lunde, Pernille
and Bye, Asta
and Bruusgaard, Anette Kari
and Hellem, Elisabet
and Nilsson, Blakstad Birgitta",
title="Patients' Experiences of Using a Smartphone App After Cardiac Rehabilitation: Qualitative Study",
journal="JMIR Hum Factors",
year="2022",
month="Mar",
day="23",
volume="9",
number="1",
pages="e34294",
keywords="mHealth",
keywords="mobile health",
keywords="cardiac rehabilitation",
keywords="mobile phone app",
keywords="smartphone",
keywords="lifestyle",
abstract="Background: Exercise-based cardiac rehabilitation (CR) is a crucial part of the treatment of patients with cardiac diseases, and adherence to healthy behavior is a prerequisite to improve long-term prognosis. Unfortunately, adherence to healthy behavior adapted in CR is challenging for many cardiac patients in the long term. Recently, we demonstrated that follow-up conducted via an app for 1 year significantly improved adherence to healthy behavior after CR. To increase the knowledge and understanding of mobile Health (mHealth) interventions that can promote acceptance and adherence, qualitative research investigating patients' experiences with these interventions is warranted. Objective: The aim was to investigate patient experiences with individualized long-term follow-up conducted via an app for 1 year and their thoughts about what features promoted adherence to healthy behavior after CR. The purpose was to increase the understanding of significant findings previously reported and to guide future development of similar interventions in the field of adherence. Methods: A qualitative study with individual interviews was conducted from November 2018 to May 2019. A thematic interview guide was used when conducting the semistructured in-depth interviews. The interviews were audio recorded and transcribed successively during the period in which the interviews were conducted. Texts were managed and systematized by NVivo. Interviews were analyzed by qualitative content analysis. Codes and themes were inductively developed. Results: Ten patients who had participated in a randomized controlled trial evaluating the effect of follow-up conducted via an app on adherence to healthy behavior after CR were included. The median patient age was 65 years (range 46-72 years), and both genders were represented. The analysis resulted in the following 4 themes describing the patients' experiences: (1) The person behind the app is crucial for motivation and adherence; (2) The app as a commitment; (3) The app as a path to independence; and (4) Suggestions for improvements. Features experienced as beneficial to promote adherence were individualized feedback and the use of goal setting. The significance of the person behind the app (the supervisor) who provided individualized feedback was a consistent finding. This person seemed to promote motivation in general and to enable other known behavioral change techniques. Conclusions: The person behind the app (the supervisor) seems to be one of the most significant success factors in promoting adherence to healthy behavior after CR. This indicates that a health care provider must actively participate in a patient's process of adherence to healthy behavior, even when using interventions, including an app. Future development of interventions in the field of adherence should strive to create tools that enable an ongoing collaborative relationship between the patient and the health care provider. The follow-up should be based on the patient's own goals, and individualized feedback should be provided. ",
doi="10.2196/34294",
url="https://humanfactors.jmir.org/2022/1/e34294",
url="http://www.ncbi.nlm.nih.gov/pubmed/35319476"
}


@Article{info:doi/10.2196/33286,
author="Johnson, E. Amber
and Routh, Shuvodra
and Taylor, N. Christy
and Leopold, Meagan
and Beatty, Kathryn
and McNamara, M. Dennis
and Davis, M. Esa",
title="Developing and Implementing an mHealth Heart Failure Self-care Program to Reduce Readmissions: Randomized Controlled Trial",
journal="JMIR Cardio",
year="2022",
month="Mar",
day="21",
volume="6",
number="1",
pages="e33286",
keywords="mHealth",
keywords="heart failure",
keywords="self-care",
keywords="remote monitoring",
keywords="telehealth",
keywords="cardiology",
keywords="hospital readmission",
keywords="self-management",
keywords="mobile health",
keywords="patient-centered",
abstract="Background: Patients admitted with decompensated heart failure (HF) are at risk for hospital readmission and poor quality of life during the discharge period. Lifestyle behavior modifications that promote the self-management of chronic cardiac diseases have been associated with an improved quality of life. However, whether a mobile health (mHealth) program can assist patients in the self-management of HF during the acute posthospital discharge period is unknown. Objective: We aimed to develop an mHealth program designed to enhance patients' self-management of HF by increasing knowledge, self-efficacy, and symptom detection. We hypothesized that patients hospitalized with HF would be willing to use a feasibly deployed mHealth program after their hospital discharge. Methods: We employed a patient-centered outcomes research methodology to design a stakeholder-informed mHealth program. Adult patients with HF admitted to a large academic hospital were enrolled and randomized to receive the mHealth intervention versus usual care. Our feasibility outcomes included ease of program deployment, use of the clinical escalation process, duration of participant recruitment, and participant attrition. Surveys assessing the demographics and clinical characteristics of HF were measured at baseline and at 30 and 90 days after discharge. Results: The study period was between July 1, 2019, and April 7, 2020. The mean cohort (N=31) age was 60.4 (range 22-85) years. Over half of the participants were men (n=18, 58\%) and 77\% (n=24) were White. There were no significant differences in baseline measures. We determined that an educational mHealth program tailored for patients with HF is feasibly deployed and acceptable by patients. Though not significant, we found notable trends including a higher mean quality of life at 30 days posthospitalization among program users and a longer duration before rehospitalization, which are suggestive of better HF prognosis. Conclusions: Our mHealth tool should be further assessed in a larger comparative effectiveness trial. Our pilot intervention offers promise as an innovative means to help HF patients lead healthy, independent lives. These preliminary data suggest that patient-centered mHealth tools can enable high-risk patients to play a role in the management of their HF after discharge. Trial Registration: ClinicalTrials.gov NCT03982017; https://clinicaltrials.gov/ct2/show/NCT03982017 ",
doi="10.2196/33286",
url="https://cardio.jmir.org/2022/1/e33286",
url="http://www.ncbi.nlm.nih.gov/pubmed/35311679"
}


@Article{info:doi/10.2196/35503,
author="Bakre, Shivani
and Shea, Benjamin
and Langheier, Jason
and Hu, A. Emily",
title="Blood Pressure Control in Individuals With Hypertension Who Used a Digital, Personalized Nutrition Platform: Longitudinal Study",
journal="JMIR Form Res",
year="2022",
month="Mar",
day="17",
volume="6",
number="3",
pages="e35503",
keywords="blood pressure",
keywords="hypertension",
keywords="systolic",
keywords="diastolic",
keywords="digital",
keywords="nutrition",
keywords="meal planning",
keywords="food environment",
keywords="food ordering",
keywords="food purchasing",
keywords="cardiology",
keywords="digital health",
keywords="digital platform",
keywords="health technology",
keywords="platform usability",
abstract="Background: While there is a strong association between adhering to a healthy dietary pattern and reductions in blood pressure, adherence remains low. New technologies aimed to help facilitate behavior change may have an effect on reducing blood pressure among individuals with hypertension. Objective: This study aims to evaluate characteristics of participants with stage 2 hypertension who used Foodsmart and to assess changes in systolic blood pressure (SBP) and diastolic blood pressure (DBP). Methods: We analyzed demographic, dietary, and clinical characteristics collected from 11,934 adults with at least two blood pressure readings who used the Foodsmart platform. Stage 2 hypertension was defined as SBP ?140 mmHg or DBP ?90 mmHg. We calculated mean changes in blood pressure among participants with stage 2 hypertension and stratified by length of follow-up and the covariates associated with achieving blood pressure levels below stage 2 hypertension. We compared changes in diet quality and weight between participants with stage 2 hypertension at baseline who achieved stage 1 hypertension or below and those who did not. Results: We found that 10.63\% (1269/11,934) of participants had stage 2 hypertension at baseline. Among Foodsmart participants with stage 2 hypertension at baseline, SBP and DBP decreased, on average, by 5.7 and 4.0 mmHg, respectively; 33.02\% (419/1269) of participants with stage 2 hypertension at baseline achieved blood pressure levels below stage 2 hypertension (SBP <140 mmHg and DBP <90 mmHg). Using a multivariable ordinal logistic regression model, changes in Nutriscore (P=.001) and weight (P=.04) were statistically significantly associated with changes in blood pressure categories for users with stage 2 hypertension at baseline. Using a multivariable logistic regression model, we found that baseline Nutriscore, change in Nutriscore, and change in weight were associated with greater likelihood of users with stage 2 hypertension at baseline achieving a lower blood pressure category. Conclusions: This study evaluated changes in SBP and DBP among users (with hypertension) of the Foodsmart platform and found that those with stage 2 hypertension, on average, improved their blood pressure levels over time. ",
doi="10.2196/35503",
url="https://formative.jmir.org/2022/3/e35503",
url="http://www.ncbi.nlm.nih.gov/pubmed/35297775"
}


@Article{info:doi/10.2196/31501,
author="Larsen, Hoejkjaer Lisbeth
and Lauritzen, Hedegaard Maja
and Sinkjaer, Mikkel
and Kjaer, W. Troels",
title="The Effect of Wearable Tracking Devices on Cardiorespiratory Fitness Among Inactive Adults: Crossover Study",
journal="JMIR Cardio",
year="2022",
month="Mar",
day="15",
volume="6",
number="1",
pages="e31501",
keywords="activity tracking",
keywords="cardiorespiratory fitness",
keywords="mHealth",
keywords="mobile health",
keywords="motivation",
keywords="physical activity",
keywords="self-monitoring",
keywords="wearable",
keywords="cardio",
keywords="fitness",
keywords="cardiorespiratory",
keywords="behavior change",
abstract="Background: Modern lifestyle is associated with a high prevalence of physical inactivity. Objective: This study aims to investigate the effect of a wearable tracking device on cardiorespiratory fitness among inactive adults and to explore if personal characteristics and health outcomes can predict adoption of the device. Methods: In total, 62 inactive adults were recruited for this study. A control period (4 weeks) was followed by an intervention period (8 weeks) where participants were instructed to register and follow their physical activity (PA) behavior on a wrist-worn tracking device. Data collected included estimated cardiorespiratory fitness, body composition, blood pressure, perceived stress levels, and self-reported adoption of using the tracking device. Results: In total, 50 participants completed the study (mean age 48, SD 13 years, 84\% women). Relative to the control period, participants increased cardiorespiratory fitness by 1.52 mL/kg/minute (95\% CI 0.82-2.22; P<.001), self-reported PA by 140 minutes per week (95\% CI 93.3-187.1; P<.001), daily step count by 982 (95\% CI 492-1471; P<.001), and participants' fat percentage decreased by 0.48\% (95\% CI --0.84 to --0.13; P=.009). No difference was observed in blood pressure (systolic: 95\% CI --2.16 to 3.57, P=.63; diastolic: 95\% CI --0.70 to 2.55; P=.27) or perceived stress (95\% CI --0.86 to 1.78; P=.49). No associations were found between adoption of the wearable tracking device and age, gender, personality, or education. However, participants with a low perceived stress at baseline were more likely to rate the use of a wearable tracking device highly motivating. Conclusions: Tracking health behavior using a wearable tracking device increases PA resulting in an improved cardiorespiratory fitness among inactive adults. ",
doi="10.2196/31501",
url="https://cardio.jmir.org/2022/1/e31501",
url="http://www.ncbi.nlm.nih.gov/pubmed/35289763"
}


@Article{info:doi/10.2196/27202,
author="Ni, Zhao
and Wu, Bei
and Yang, Qing
and Yan, L. Lijing
and Liu, Changqing
and Shaw, J. Ryan",
title="An mHealth Intervention to Improve Medication Adherence and Health Outcomes Among Patients With Coronary Heart Disease: Randomized Controlled Trial",
journal="J Med Internet Res",
year="2022",
month="Mar",
day="9",
volume="24",
number="3",
pages="e27202",
keywords="mHealth",
keywords="medication adherence",
keywords="coronary disease",
keywords="blood pressure",
keywords="China",
keywords="randomized controlled trial",
abstract="Background: The treatment of many chronic illnesses involves long-term pharmaceutical therapy, but it is an ongoing challenge to find effective ways to improve medication adherence to promote good health outcomes. Cardioprotective medications can prevent the enlargement of harmful clots, cardiovascular symptoms, and poor therapeutic outcomes, such as uncontrolled high blood pressure and hyperlipidemia, for patients with coronary heart disease. Poor adherence to cardioprotective medications, however, has been reported as a global health concern among patients with coronary heart disease, and it is particularly a concern in China. Objective: This study aimed to evaluate the efficacy of a mobile health (mHealth) intervention using 2 mobile apps to improve medication adherence and health outcomes. Methods: A randomized, placebo-controlled, 2-arm parallel study was conducted in a major university-affiliated medical center located in Chengdu, China. Participants were recruited by flyers and health care provider referrals. Each participant was observed for 90 days, including a 60-day period of mHealth intervention and a 30-day period of nonintervention follow-up. The study coordinator used WeChat and Message Express to send educational materials and reminders to take medication, respectively. Participants used WeChat to receive both the educational materials and reminders. Participants in the control group only received educational materials. This study received ethics approval from the Duke Health Institutional Review Board (Pro00073395) on May 5, 2018, and was approved by West China Hospital (20170331180037). Recruitment began on May 20, 2018. The pilot phase of this study was registered on June 8, 2016, and the current, larger-scale study was retrospectively registered on January 11, 2021 (ClinicalTrials.gov). Results: We recruited 230 patients with coronary heart disease. Of these patients, 196 completed the baseline survey and received the intervention. The majority of participants were married (181/196, 92.4\%), male (157/196, 80.1\%), and lived in urban China (161/196, 82.1\%). Participants' average age was 61 years, and half were retired (103/191, 53.9\%). More than half the participants (121/196, 61.7\%) were prescribed at least 5 medications. The mean decrease in medication nonadherence score was statistically significant at both 60 days (t179=2.04, P=.04) and 90 days (t155=3.48, P<.001). Systolic blood pressure and diastolic blood pressure decreased in the experimental group but increased in the control group. The mean decrease in diastolic blood pressure was statistically significant at both 60 days (t160=2.07, P=.04) and 90 days (t164=2.21, P=.03). The mean decrease in systolic blood pressure was significantly different in the groups at 90 days (t165=3.12, P=.002). Conclusions: The proposed mHealth intervention can improve medication adherence and health outcomes, including systolic blood pressure and diastolic blood pressure. Trial Registration: ClinicalTrials.gov NCT02793830; https://clinicaltrials.gov/ct2/show/NCT02793830 and ClinicalTrials.gov NCT04703439; https://clinicaltrials.gov/ct2/show/NCT04703439 ",
doi="10.2196/27202",
url="https://www.jmir.org/2022/3/e27202",
url="http://www.ncbi.nlm.nih.gov/pubmed/35262490"
}


@Article{info:doi/10.2196/34452,
author="Chen, Jinying
and Wijesundara, G. Jessica
and Enyim, E. Gabrielle
and Lombardini, M. Lisa
and Gerber, S. Ben
and Houston, K. Thomas
and Sadasivam, S. Rajani",
title="Understanding Patients' Intention to Use Digital Health Apps That Support Postdischarge Symptom Monitoring by Providers Among Patients With Acute Coronary Syndrome: Survey Study",
journal="JMIR Hum Factors",
year="2022",
month="Mar",
day="7",
volume="9",
number="1",
pages="e34452",
keywords="coronary",
keywords="monitor",
keywords="elder",
keywords="health app",
keywords="symptom",
keywords="eHealth",
keywords="mobile health",
keywords="intention",
keywords="barrier",
keywords="facilitator",
abstract="Background: After hospital discharge, patients with acute coronary syndrome (ACS) often experience symptoms that prompt them to seek acute medical attention. Early evaluation of postdischarge symptoms by health care providers may reduce unnecessary acute care utilization. However, hospital-initiated follow-up encounters are insufficient for timely detection and assessment of symptoms. While digital health tools can help address this issue, little is known about the intention to use such tools in ACS patients. Objective: This study aimed to assess ACS patients' intention to use digital health apps that support postdischarge symptom monitoring by health care providers and identify patient-perceived facilitators and barriers to app use. Methods: Using email invitations or phone calls, we recruited ACS patients discharged from a central Massachusetts health care system between December 2020 and April 2021, to participate in the study. Surveys were delivered online or via phone to individual participants. Demographics and access to technology were assessed. The intention to use a symptom monitoring app was assessed using 5-point Likert-type (from strongly agree to strongly disagree) items, such as ``If this app were available to me, I would use it.'' Responses were compared across demographic subgroups and survey delivery methods. Two open-ended questions assessed perceived facilitators and barriers to app use, with responses analyzed using qualitative content analysis. Results: Among 100 respondents (response rate 8.1\%), 45 (45\%) completed the survey by phone. The respondents were on average 68 years old (SD 13 years), with 90\% (90/100) White, 39\% (39/100) women, and 88\% (88/100) having access to the internet or a mobile phone. Most participants (65/100, 65\%) agreed or strongly agreed that they would use the app, among which 53 (82\%) would use the app as often as possible. The percentage of participants with the intention to use the app was 75\% among those aged 65-74 years and dropped to 44\% among those older than 75 years. The intention to use was higher in online survey respondents (vs phone survey respondents; odds ratio 3.07, 95\% CI 1.20-7.88) after adjusting for age and access to technology. The analysis of open-ended questions identified the following 4 main facilitators (motivations): (1) easily reaching providers, (2) accessing or providing information, (3) quickly reaching providers, and (4) consulting providers for symptoms, and the following 4 main barriers: (1) privacy/security concerns, (2) uncomfortable using technology, (3) user-unfriendly app interface, and (4) preference for in-person/phone care. Conclusions: There was a strong intention to use a symptom monitoring app postdischarge among ACS patients. However, this intent decreased in patients older than 75 years. The survey identified barriers related to technology use, privacy/security, and the care delivery mode. Further research is warranted to determine if such intent translates into app use, and better symptom management and health care quality. ",
doi="10.2196/34452",
url="https://humanfactors.jmir.org/2022/1/e34452",
url="http://www.ncbi.nlm.nih.gov/pubmed/35254269"
}


@Article{info:doi/10.2196/32163,
author="Dodson, A. John
and Schoenthaler, Antoinette
and Sweeney, Greg
and Fonceva, Ana
and Pierre, Alicia
and Whiteson, Jonathan
and George, Barbara
and Marzo, Kevin
and Drewes, Wendy
and Rerisi, Elizabeth
and Mathew, Reena
and Aljayyousi, Haneen
and Chaudhry, I. Sarwat
and Hajduk, M. Alexandra
and Gill, M. Thomas
and Estrin, Deborah
and Kovell, Lara
and Jennings, A. Lee
and Adhikari, Samrachana",
title="Rehabilitation Using Mobile Health for Older Adults With Ischemic Heart Disease in the Home Setting (RESILIENT): Protocol for a Randomized Controlled Trial",
journal="JMIR Res Protoc",
year="2022",
month="Mar",
day="3",
volume="11",
number="3",
pages="e32163",
keywords="mobile health",
keywords="cardiac rehabilitation",
keywords="clinical trial",
keywords="rehabilitation",
keywords="cardiology",
keywords="heart disease",
keywords="ambulatory care",
keywords="mHealth",
keywords="health outcomes",
keywords="older adults",
abstract="Background: Participation in ambulatory cardiac rehabilitation remains low, especially among older adults. Although mobile health cardiac rehabilitation (mHealth-CR) provides a novel opportunity to deliver care, age-specific impairments may limit older adults' uptake, and efficacy data are currently lacking. Objective: This study aims to describe the design of the rehabilitation using mobile health for older adults with ischemic heart disease in the home setting (RESILIENT) trial. Methods: RESILIENT is a multicenter randomized clinical trial that is enrolling patients aged ?65 years with ischemic heart disease in a 3:1 ratio to either an intervention (mHealth-CR) or control (usual care) arm, with a target sample size of 400 participants. mHealth-CR consists of a commercially available mobile health software platform coupled with weekly exercise therapist sessions to review progress and set new activity goals. The primary outcome is a change in functional mobility (6-minute walk distance), which is measured at baseline and 3 months. Secondary outcomes are health status, goal attainment, hospital readmission, and mortality. Among intervention participants, engagement with the mHealth-CR platform will be analyzed to understand the characteristics that determine different patterns of use (eg, persistent high engagement and declining engagement). Results: As of December 2021, the RESILIENT trial had enrolled 116 participants. Enrollment is projected to continue until October 2023. The trial results are expected to be reported in 2024. Conclusions: The RESILIENT trial will generate important evidence about the efficacy of mHealth-CR among older adults in multiple domains and characteristics that determine the sustained use of mHealth-CR. These findings will help design future precision medicine approaches to mobile health implementation in older adults. This knowledge is especially important in light of the COVID-19 pandemic that has shifted much of health care to a remote, internet-based setting. Trial Registration: ClinicalTrials.gov NCT03978130; https://clinicaltrials.gov/ct2/show/NCT03978130 International Registered Report Identifier (IRRID): DERR1-10.2196/32163 ",
doi="10.2196/32163",
url="https://www.researchprotocols.org/2022/3/e32163",
url="http://www.ncbi.nlm.nih.gov/pubmed/35238793"
}


@Article{info:doi/10.2196/35399,
author="Siebert, N. Johan
and Gosetto, La{\"e}titia
and Sauvage, Manon
and Bloudeau, Laurie
and Suppan, Laurent
and Rodieux, Fr{\'e}d{\'e}rique
and Haddad, Kevin
and Hugon, Florence
and Gervaix, Alain
and Lovis, Christian
and Combescure, Christophe
and Manzano, Sergio
and Ehrler, Frederic
and ",
title="Usability Testing and Technology Acceptance of an mHealth App at the Point of Care During Simulated Pediatric In- and Out-of-Hospital Cardiopulmonary Resuscitations: Study Nested Within 2 Multicenter Randomized Controlled Trials",
journal="JMIR Hum Factors",
year="2022",
month="Mar",
day="1",
volume="9",
number="1",
pages="e35399",
keywords="cardiopulmonary resuscitation",
keywords="drugs",
keywords="emergency medical services",
keywords="medication errors",
keywords="mobile health",
keywords="mobile apps",
keywords="out-of-hospital cardiac arrest",
keywords="paramedics",
keywords="pediatrics",
keywords="System Usability Scale",
keywords="Unified Theory of Acceptance and Use of Technology",
keywords="smartphone",
keywords="mobile phone",
abstract="Background: Mobile apps are increasingly being used in various domains of medicine. Few are evidence-based, and their benefits can only be achieved if end users intend to adopt and use them. To date, only a small fraction of mobile apps have published data on their field usability and end user acceptance results, especially in emergency medicine. Objective: This study aims to determine the usability and acceptance of an evidence-based mobile app while safely preparing emergency drugs at the point of care during pediatric in- and out-of-hospital cardiopulmonary resuscitations by frontline caregivers. Methods: In 2 multicenter randomized controlled parent trials conducted at 6 pediatric emergency departments from March 1 to December 31, 2017, and 14 emergency medical services from September 3, 2019, to January 21, 2020, the usability and technology acceptance of the PedAMINES (Pediatric Accurate Medication in Emergency Situations) app were evaluated among skilled pediatric emergency nurses and advanced paramedics when preparing continuous infusions of vasoactive drugs and direct intravenous emergency drugs at pediatric dosages during standardized, simulation-based, pediatric in- and out-of-hospital cardiac arrest scenarios, respectively. Usability was measured using the 10-item System Usability Scale. A 26-item technology acceptance self-administered survey (5-point Likert-type scales), adapted from the Unified Theory of Acceptance and Use of Technology model, was used to measure app acceptance and intention to use. Results: All 100\% (128/128) of nurses (crossover trial) and 49.3\% (74/150) of paramedics (parallel trial) were assigned to the mobile app. Mean total scores on the System Usability Scale were excellent and reached 89.5 (SD 8.8; 95\% CI 88.0-91.1) for nurses and 89.7 (SD 8.7; 95\% CI 87.7-91.7) for paramedics. Acceptance of the technology was very good and rated on average >4.5/5 for 5 of the 8 independent constructs evaluated. Only the image construct scored between 3.2 and 3.5 by both participant populations. Conclusions: The results provide evidence that dedicated mobile apps can be easy to use and highly accepted at the point of care during in- and out-of-hospital cardiopulmonary resuscitations by frontline emergency caregivers. These findings can contribute to the implementation and valorization of studies aimed at evaluating the usability and acceptance of mobile apps in the field by caregivers, even in critical situations. Trial Registration: ClinicalTrials.gov NCT03021122; https://clinicaltrials.gov/ct2/show/NCT03021122. ClinicalTrials.gov NCT03921346; https://clinicaltrials.gov/ct2/show/NCT03921346 International Registered Report Identifier (IRRID): RR2-10.1186/s13063-019-3726-4 ",
doi="10.2196/35399",
url="https://humanfactors.jmir.org/2022/1/e35399",
url="http://www.ncbi.nlm.nih.gov/pubmed/35230243"
}


@Article{info:doi/10.2196/32554,
author="Indraratna, Praveen
and Biswas, Uzzal
and McVeigh, James
and Mamo, Andrew
and Magdy, Joseph
and Vickers, Dominic
and Watkins, Elaine
and Ziegl, Andreas
and Liu, Hueiming
and Cholerton, Nicholas
and Li, Joan
and Holgate, Katie
and Fildes, Jennifer
and Gallagher, Robyn
and Ferry, Cate
and Jan, Stephen
and Briggs, Nancy
and Schreier, Guenter
and Redmond, J. Stephen
and Loh, Eugene
and Yu, Jennifer
and Lovell, H. Nigel
and Ooi, Sze-Yuan",
title="A Smartphone-Based Model of Care to Support Patients With Cardiac Disease Transitioning From Hospital to the Community (TeleClinical Care): Pilot Randomized Controlled Trial",
journal="JMIR Mhealth Uhealth",
year="2022",
month="Feb",
day="28",
volume="10",
number="2",
pages="e32554",
keywords="digital health",
keywords="telemedicine",
keywords="mHealth",
keywords="heart failure",
keywords="ischemic heart disease",
keywords="mobile phone",
abstract="Background: Patients hospitalized with acute coronary syndrome (ACS) or heart failure (HF) are frequently readmitted. This is the first randomized controlled trial of a mobile health intervention that combines telemonitoring and education for inpatients with ACS or HF to prevent readmission. Objective: This study aims to investigate the feasibility, efficacy, and cost-effectiveness of a smartphone app--based model of care (TeleClinical Care [TCC]) in patients discharged after ACS or HF admission. Methods: In this pilot, 2-center randomized controlled trial, TCC was applied at discharge along with usual care to intervention arm participants. Control arm participants received usual care alone. Inclusion criteria were current admission with ACS or HF, ownership of a compatible smartphone, age ?18 years, and provision of informed consent. The primary end point was the incidence of unplanned 30-day readmissions. Secondary end points included all-cause readmissions, cardiac readmissions, cardiac rehabilitation completion, medication adherence, cost-effectiveness, and user satisfaction. Intervention arm participants received the app and Bluetooth-enabled devices for measuring weight, blood pressure, and physical activity daily plus usual care. The devices automatically transmitted recordings to the patients' smartphones and a central server. Thresholds for blood pressure, heart rate, and weight were determined by the treating cardiologists. Readings outside these thresholds were flagged to a monitoring team, who discussed salient abnormalities with the patients' usual care providers (cardiologists, general practitioners, or HF outreach nurses), who were responsible for further management. The app also provided educational push notifications. Participants were followed up after 6 months. Results: Overall, 164 inpatients were randomized (TCC: 81/164, 49.4\%; control: 83/164, 50.6\%; mean age 61.5, SD 12.3 years; 130/164, 79.3\% men; 128/164, 78\% admitted with ACS). There were 11 unplanned 30-day readmissions in both groups (P=.97). Over a mean follow-up of 193 days, the intervention was associated with a significant reduction in unplanned hospital readmissions (21 in TCC vs 41 in the control arm; P=.02), including cardiac readmissions (11 in TCC vs 25 in the control arm; P=.03), and higher rates of cardiac rehabilitation completion (20/51, 39\% vs 9/49, 18\%; P=.03) and medication adherence (57/76, 75\% vs 37/74, 50\%; P=.002). The average usability rating for the app was 4.5/5. The intervention cost Aus \$6028 (US \$4342.26) per cardiac readmission saved. When modeled in a mainstream clinical setting, enrollment of 237 patients was projected to have the same expenditure compared with usual care, and enrollment of 500 patients was projected to save approximately Aus \$100,000 (approximately US \$70,000) annually. Conclusions: TCC was feasible and safe for inpatients with either ACS or HF. The incidence of 30-day readmissions was similar; however, long-term benefits were demonstrated, including fewer readmissions over 6 months, improved medication adherence, and improved cardiac rehabilitation completion. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12618001547235; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375945 ",
doi="10.2196/32554",
url="https://mhealth.jmir.org/2022/2/e32554",
url="http://www.ncbi.nlm.nih.gov/pubmed/35225819"
}


@Article{info:doi/10.2196/30410,
author="Eastman, A. Jennifer
and Kaup, R. Allison
and Bahorik, L. Amber
and Butcher, Xochitl
and Attarha, Mouna
and Marcus, M. Gregory
and Pletcher, J. Mark
and Olgin, E. Jeffrey
and Barnes, E. Deborah
and Yaffe, Kristine",
title="Remote Assessment of Cardiovascular Risk Factors and Cognition in Middle-Aged and Older Adults: Proof-of-Concept Study",
journal="JMIR Form Res",
year="2022",
month="Feb",
day="2",
volume="6",
number="2",
pages="e30410",
keywords="mHealth",
keywords="internet",
keywords="mobile health",
keywords="digital health",
keywords="eHealth",
keywords="cardiovascular",
keywords="risk factors",
keywords="cognition",
keywords="cognitive impairment",
keywords="remote cognitive assessment",
keywords="aging",
abstract="Background: Adults with cardiovascular disease risk factors (CVRFs) are also at increased risk of developing cognitive decline and dementia. However, it is often difficult to study the relationships between CVRFs and cognitive function because cognitive assessment typically requires time-consuming in-person neuropsychological evaluations that may not be feasible for real-world situations. Objective: We conducted a proof-of-concept study to determine if the association between CVRFs and cognitive function could be detected using web-based, self-administered cognitive tasks and CVRF assessment. Methods: We recruited 239 participants aged ?50 years (mean age 62.7 years, SD 8.8; 42.7\% [n=102] female, 88.7\% [n=212] White) who were enrolled in the Health eHeart Study, a web-based platform focused on cardiac disease. The participants self-reported CVRFs (hypertension, high cholesterol, diabetes, and atrial fibrillation) using web-based health surveys between August 2016 and July 2018. After an average of 3 years of follow-up, we remotely evaluated episodic memory, working memory, and executive function via the web-based Posit Science platform, BrainHQ. Raw data were normalized and averaged into 3 domain scores. We used linear regression models to examine the association between CVRFs and cognitive function. Results: CVRF prevalence was 62.8\% (n=150) for high cholesterol, 45.2\% (n=108) for hypertension, 10.9\% (n=26) for atrial fibrillation, and 7.5\% (n=18) for diabetes. In multivariable models, atrial fibrillation was associated with worse working memory ($\beta$=-.51, 95\% CI -0.91 to -0.11) and worse episodic memory ($\beta$=-.31, 95\% CI -0.59 to -0.04); hypertension was associated with worse episodic memory ($\beta$=-.27, 95\% CI -0.44 to -0.11). Diabetes and high cholesterol were not associated with cognitive performance. Conclusions: Self-administered web-based tools can be used to detect both CVRFs and cognitive health. We observed that atrial fibrillation and hypertension were associated with worse cognitive function even in those in their 60s and 70s. The potential of mobile assessments to detect risk factors for cognitive aging merits further investigation. ",
doi="10.2196/30410",
url="https://formative.jmir.org/2022/2/e30410",
url="http://www.ncbi.nlm.nih.gov/pubmed/35107430"
}


@Article{info:doi/10.2196/25384,
author="Agher, Dahbia
and Sedki, Karima
and Despres, Sylvie
and Albinet, Jean-Pierre
and Jaulent, Marie-Christine
and Tsopra, Rosy",
title="Encouraging Behavior Changes and Preventing Cardiovascular Diseases Using the Prevent Connect Mobile Health App: Conception and Evaluation of App Quality",
journal="J Med Internet Res",
year="2022",
month="Jan",
day="20",
volume="24",
number="1",
pages="e25384",
keywords="digital health",
keywords="mHealth, mobile application",
keywords="IT",
keywords="technology",
keywords="prevention",
keywords="cardiovascular risk factor",
keywords="behavior change",
keywords="primary care",
abstract="Background: Cardiovascular diseases are a major cause of death worldwide. Mobile health apps could help in preventing cardiovascular diseases by improving modifiable risk factors such as eating habits, physical activity levels, and alcohol or tobacco consumption. Objective: The aim of this study was to design a mobile health app, Prevent Connect, and to assess its quality for (1) assessing patient behavior for 4 cardiovascular risk factors (unhealthy eating, sedentary lifestyle, alcohol, and tobacco consumption) and (2) suggesting personalized recommendations and mobile health interventions for risky behaviors. Methods: The knowledge base of the app is based on French national recommendations for healthy eating, physical activity, and limiting alcohol and tobacco consumption. It contains a list of patient behaviors and related personalized recommendations and digital health interventions. The interface was designed according to usability principles. Its quality was assessed by a panel of 52 users in a 5-step process: completion of the demographic form, visualization of a short presentation of the app, testing of the app, completion of the user version of the Mobile App Rating Scale (uMARS), and an open group discussion. Results: This app assesses patient behaviors through specific questionnaires about 4 risk factors (unhealthy eating, sedentary lifestyle, alcohol, and tobacco consumption) and suggests personalized recommendations and digital health interventions for improving behavior. The app was deemed to be of good quality, with a mean uMARS quality score of 4 on a 5-point Likert scale. The functionality and information content of the app were particularly appreciated, with a mean uMARS score above 4. Almost all the study participants appreciated the navigation system and found the app easy to use. More than three-quarters of the study participants found the app content relevant, concise, and comprehensive. The aesthetics and the engagement of the app were also appreciated (uMARS score, 3.7). Overall, 80\% (42/52) of the study participants declared that the app helped them to become aware of the importance of addressing health behavior, and 65\% (34/52) said that the app helped motivate them to change lifestyle habits. Conclusions: The app assessed the risky behaviors of the patients and delivered personalized recommendations and digital health interventions for multiple risk factors. The quality of the app was considered to be good, but the impact of the app on behavior changes is yet to be demonstrated and will be assessed in further studies. ",
doi="10.2196/25384",
url="https://www.jmir.org/2022/1/e25384",
url="http://www.ncbi.nlm.nih.gov/pubmed/35049508"
}


@Article{info:doi/10.2196/29434,
author="Naseri Jahfari, Arman
and Tax, David
and Reinders, Marcel
and van der Bilt, Ivo",
title="Machine Learning for Cardiovascular Outcomes From Wearable Data: Systematic Review From a Technology Readiness Level Point of View",
journal="JMIR Med Inform",
year="2022",
month="Jan",
day="19",
volume="10",
number="1",
pages="e29434",
keywords="mHealth",
keywords="wearable",
keywords="machine learning",
keywords="cardiovascular disease",
keywords="digital health",
keywords="review",
keywords="mobile phone",
abstract="Background: Wearable technology has the potential to improve cardiovascular health monitoring by using machine learning. Such technology enables remote health monitoring and allows for the diagnosis and prevention of cardiovascular diseases. In addition to the detection of cardiovascular disease, it can exclude this diagnosis in symptomatic patients, thereby preventing unnecessary hospital visits. In addition, early warning systems can aid cardiologists in timely treatment and prevention. Objective: This study aims to systematically assess the literature on detecting and predicting outcomes of patients with cardiovascular diseases by using machine learning with data obtained from wearables to gain insights into the current state, challenges, and limitations of this technology. Methods: We searched PubMed, Scopus, and IEEE Xplore on September 26, 2020, with no restrictions on the publication date and by using keywords such as ``wearables,'' ``machine learning,'' and ``cardiovascular disease.'' Methodologies were categorized and analyzed according to machine learning--based technology readiness levels (TRLs), which score studies on their potential to be deployed in an operational setting from 1 to 9 (most ready). Results: After the removal of duplicates, application of exclusion criteria, and full-text screening, 55 eligible studies were included in the analysis, covering a variety of cardiovascular diseases. We assessed the quality of the included studies and found that none of the studies were integrated into a health care system (TRL<6), prospective phase 2 and phase 3 trials were absent (TRL<7 and 8), and group cross-validation was rarely used. These issues limited these studies' ability to demonstrate the effectiveness of their methodologies. Furthermore, there seemed to be no agreement on the sample size needed to train these studies' models, the size of the observation window used to make predictions, how long participants should be observed, and the type of machine learning model that is suitable for predicting cardiovascular outcomes. Conclusions: Although current studies show the potential of wearables to monitor cardiovascular events, their deployment as a diagnostic or prognostic cardiovascular clinical tool is hampered by the lack of a realistic data set and proper systematic and prospective evaluation. ",
doi="10.2196/29434",
url="https://medinform.jmir.org/2022/1/e29434",
url="http://www.ncbi.nlm.nih.gov/pubmed/35044316"
}


@Article{info:doi/10.2196/31982,
author="Leigh, W. Jonathan
and Gerber, S. Ben
and Gans, P. Christopher
and Kansal, M. Mayank
and Kitsiou, Spyros",
title="Smartphone Ownership and Interest in Mobile Health Technologies for Self-care Among Patients With Chronic Heart Failure: Cross-sectional Survey Study",
journal="JMIR Cardio",
year="2022",
month="Jan",
day="14",
volume="6",
number="1",
pages="e31982",
keywords="mHealth",
keywords="smartphone",
keywords="mobile phone",
keywords="heart failure",
keywords="self-care",
keywords="self-management",
abstract="Background: Heart failure (HF) is a highly prevalent chronic condition that places a substantial burden on patients, families, and health care systems worldwide. Recent advances in mobile health (mHealth) technologies offer great opportunities for supporting many aspects of HF self-care. There is a need to better understand patients' adoption of and interest in using mHealth for self-monitoring and management of HF symptoms. Objective: The purpose of this study is to assess smartphone ownership and patient attitudes toward using mHealth technologies for HF self-care in a predominantly minority population in an urban clinical setting. Methods: We conducted a cross-sectional survey of adult outpatients (aged ?18 years) at an academic outpatient HF clinic in the Midwest. The survey comprised 34 questions assessing patient demographics, ownership of smartphones and other mHealth devices, frequently used smartphone features, use of mHealth apps, and interest in using mHealth technologies for vital sign and HF symptom self-monitoring and management. Results: A total of 144 patients were approached, of which 100 (69.4\%) participated in the study (63/100, 63\% women). The participants had a mean age of 61.3 (SD 12.25) years and were predominantly Black or African American (61/100, 61\%) and Hispanic or Latino (18/100, 18\%). Almost all participants (93/100, 93\%) owned a cell phone. The share of patients who owned a smartphone was 68\% (68/100). Racial and ethnic minorities that identified as Black or African American or Hispanic or Latino reported higher smartphone ownership rates compared with White patients with HF (45/61, 74\% Black or African American and 11/18, 61\% Hispanic or Latino vs 9/17, 53\% White). There was a moderate and statistically significant association between smartphone ownership and age (Cram{\'e}r V [$\Phi$C]=0.35; P<.001), education ($\Phi$C=0.29; P=.001), and employment status ($\Phi$C=0.3; P=.01). The most common smartphone features used by the participants were SMS text messaging (51/68, 75\%), internet browsing (43/68, 63\%), and mobile apps (41/68, 60\%). The use of mHealth apps and wearable activity trackers (eg, Fitbits) for self-monitoring of HF-related parameters was low (15/68, 22\% and 15/100, 15\%, respectively). The most popular HF-related self-care measures participants would like to monitor using mHealth technologies were physical activity (46/68, 68\%), blood pressure (44/68, 65\%), and medication use (40/68, 59\%). Conclusions: Most patients with HF have smartphones and are interested in using commercial mHealth apps and connected health devices to self-monitor their condition. Thus, there is a great opportunity to capitalize on the high smartphone ownership among racial and ethnic minority patients to increase reach and enhance HF self-management through mHealth interventions. ",
doi="10.2196/31982",
url="https://cardio.jmir.org/2022/1/e31982",
url="http://www.ncbi.nlm.nih.gov/pubmed/35029533"
}


@Article{info:doi/10.2196/30807,
author="Senoo, Keitaro
and Miki, Tomonori
and Ohkura, Takashi
and Iwakoshi, Hibiki
and Nishimura, Tetsuro
and Shiraishi, Hirokazu
and Teramukai, Satoshi
and Matoba, Satoaki",
title="A Smartphone App to Improve Oral Anticoagulation Adherence in Patients With Atrial Fibrillation: Prospective Observational Study",
journal="JMIR Mhealth Uhealth",
year="2022",
month="Jan",
day="7",
volume="10",
number="1",
pages="e30807",
keywords="atrial fibrillation",
keywords="smartphone app",
keywords="anticoagulants",
keywords="drug adherence",
keywords="education",
keywords="patient involvement",
abstract="Background: Poor adherence to oral anticoagulation in elderly patients with atrial fibrillation (AF) has been shown to negatively impact health care costs, morbidity, and mortality. Although various methods such as automated reminders, counseling, telephone support, and patient education have been effective in improving medication adherence, the burden on health care providers has been considerable. Recently, an attempt has been made to improve medication adherence without burdening health care providers by using smartphone apps; however, the use of the app for elderly patients with AF is still limited. Objective: The purpose of this study was to determine whether the newly developed smartphone app for patients with AF (the Smart AF), which integrates education, automatic reminder, and patient engagement strategies with a simple user interface, can improve medication adherence in elderly patients with AF. Methods: Patient enrollment was carried out by obtaining informed consent from patients with AF attending Kyoto Prefectural University of Medicine hospital between May 2019 and September 2020. Follow-up was planned at 1, 3, and 6 months after enrollment, and questionnaire reminders were automatically sent to patient apps at designated follow-up time points. A questionnaire-based survey of medication adherence was performed electronically using the self-reported 8-item Morisky Medication Adherence Scale (MMAS-8) as the survey tool. Results: A total of 136 patients with AF were enrolled in this study. During the follow-up period, 112 (82\%) patients underwent follow-up at 1 month, 107 (79\%) at 3 months, and 96 (71\%) at 6 months. The mean age of the enrolled patients was 64.3 years (SD 9.6), and male participants accounted for 79.4\% (108/136) of the study population. The mean CHADS2 (congestive heart failure, hypertension, age, diabetes, previous stroke, or transient ischemic attack) score was 1.2, with hypertension being the most common comorbidity. At the time of enrollment, 126 (93\%) and 10 (7\%) patients were taking direct oral anticoagulants and warfarin, respectively. For medication adherence as measured according to the MMAS-8, MMAS scores at 1 month, 3 months, and 6 months were significantly improved compared with baseline MMAS scores (all P values less than .01). The overall improvement in medication adherence achieved by the 6-month intervention was as follows: 77.8\% (14/18) of the patients in the high adherence group (score=8) at baseline remained in the same state, 45.3\% (24/53) of the patients in the medium adherence group (score=6 to <8) at baseline moved to the high adherence group, and 72\% (18/25) of the patients in the low adherence group (score <6) moved to either the medium or high adherence group. Conclusions: The Smart AF app improved medication adherence among elderly patients with AF. In the realm of medication management, an approach using a mobile health technology that emphasizes education, automatic reminder, and patient engagement may be helpful. ",
doi="10.2196/30807",
url="https://mhealth.jmir.org/2022/1/e30807",
url="http://www.ncbi.nlm.nih.gov/pubmed/34894626"
}


@Article{info:doi/10.2196/31617,
author="Breil, Bernhard
and Salewski, Christel
and Apolin{\'a}rio-Hagen, Jennifer",
title="Comparing the Acceptance of Mobile Hypertension Apps for Disease Management Among Patients Versus Clinical Use Among Physicians: Cross-sectional Survey",
journal="JMIR Cardio",
year="2022",
month="Jan",
day="6",
volume="6",
number="1",
pages="e31617",
keywords="patient acceptance of health care",
keywords="mobile apps",
keywords="blood pressure",
keywords="mobile health",
keywords="health applications",
keywords="technology acceptance",
keywords="patients",
keywords="physicians",
keywords="digital health",
abstract="Background: High blood pressure or hypertension is a vastly prevalent chronic condition among adults that can, if not appropriately treated, contribute to several life-threatening secondary diseases and events, such as stroke. In addition to first-line medication, self-management in daily life is crucial for tertiary prevention and can be supported by mobile health apps, including medication reminders. However, the prescription of medical apps is a relatively novel approach. There is limited information regarding the determinants of acceptance of such mobile health (mHealth) apps among patients as potential users and physicians as impending prescribers in direct comparison. Objective: The present study aims to investigate the determinants of the acceptance of health apps (in terms of intention to use) among patients for personal use and physicians for clinical use in German-speaking countries. Moreover, we assessed patients' preferences regarding different delivery modes for self-care service (face-to-face services, apps, etc). Methods: Based on an extended model of the unified theory of acceptance and use of technology (UTAUT2), we performed a web-based cross-sectional survey to explore the acceptance of mHealth apps for self-management of hypertension among patients and physicians in Germany. In addition to UTAUT2 variables, we measured self-reported self-efficacy, eHealth literacy, previous experiences with health apps, perceived threat to privacy, and protection motivation as additional determinants of mHealth acceptance. Data from 163 patients and 46 physicians were analyzed using hierarchical regression and mediation analyses. Results: As expected, a significant influence of the unified theory of acceptance and use of technology (UTAUT) predictors on intentions to use hypertension apps was confirmed, especially for performance expectancy. Intention to use was moderate in patients (mean 3.5; SD 1.1; range 1-5) and physicians (mean 3.4, SD 0.9), and did not differ between both groups. Among patients, a higher degree of self-reported self-efficacy and protection motivation contributed to an increased explained variance in acceptance with R2=0.09, whereas eHealth literacy was identified as exerting a positive influence on physicians (increased R2=0.10). Furthermore, our findings indicated mediating effects of performance expectancy on the acceptance among patients but not among physicians. Conclusions: In summary, this study has identified performance expectancy as the most important determinant of the acceptance of mHealth apps for self-management of hypertension among patients and physicians. Concerning patients, we also identified mediating effects of performance expectancy on the relationships between effort expectancy and social influence and the acceptance of apps. Self-efficacy and protection motivation also contributed to an increase in the explained variance in app acceptance among patients, whereas eHealth literacy was a predictor in physicians. Our findings on additional determinants of the acceptance of health apps may help tailor educational material and self-management interventions to the needs and preferences of prospective users of hypertension apps in future research. ",
doi="10.2196/31617",
url="https://cardio.jmir.org/2022/1/e31617",
url="http://www.ncbi.nlm.nih.gov/pubmed/34989683"
}


@Article{info:doi/10.2196/26439,
author="Chen, Yuling
and Ji, Meihua
and Wu, Ying
and Wang, Qingyu
and Deng, Ying
and Liu, Yong
and Wu, Fangqin
and Liu, Mingxuan
and Guo, Yiqiang
and Fu, Ziyuan
and Zheng, Xiaoying",
title="An Intelligent Individualized Cardiovascular App for Risk Elimination (iCARE) for Individuals With Coronary Heart Disease: Development and Usability Testing Analysis",
journal="JMIR Mhealth Uhealth",
year="2021",
month="Dec",
day="13",
volume="9",
number="12",
pages="e26439",
keywords="mobile health",
keywords="health behavior",
keywords="system",
keywords="development",
keywords="usability",
keywords="coronary heart disease",
abstract="Background: Death and disability from coronary heart disease (CHD) can be largely reduced by improving risk factor management. However, adhering to evidence-based recommendations is challenging and requires interventions at the level of the patient, provider, and health system. Objective: The aim of this study was to develop an Intelligent Individualized Cardiovascular App for Risk Elimination (iCARE) to facilitate adherence to health behaviors and preventive medications, and to test the usability of iCARE. Methods: We developed iCARE based on a user-centered design approach, which included 4 phases: (1) function design, (2) iterative design, (3) expert inspections and walkthroughs of the prototypes, and (4) usability testing with end users. The usability testing of iCARE included 2 stages: stage I, which included a task analysis and a usability evaluation (January to March 2019) of the iCARE patient app using the modified Health Information Technology Usability Survey (Health-ITUES); and stage II (June 2020), which used the Health-ITUES among end users who used the app for 6 months. The end users were individuals with a confirmed diagnosis of CHD from 2 university-affiliated hospitals in Beijing, China. Results: iCARE consists of a patient app, a care provider app, and a cloud platform. It has a set of algorithms that trigger tailored feedback and can send individualized interventions based on data from initial assessment and health monitoring via manual entry or wearable devices. For stage I usability testing, 88 hospitalized patients (72\% [63/88] male; mean age 60 [SD 9.9] years) with CHD were included in the study. The mean score of the usability testing was 90.1 (interquartile range 83.3-99.0). Among enrolled participants, 90\% (79/88) were satisfied with iCARE; 94\% (83/88) and 82\% (72/88) reported that iCARE was useful and easy to use, respectively. For stage II usability testing, 61 individuals with CHD (85\% [52/61] male; mean age 53 [SD 8.2] years) who were from an intervention arm and used iCARE for at least six months were included. The mean total score on usability testing based on the questionnaire was 89.0 (interquartile distance: 77.0-99.5). Among enrolled participants, 89\% (54/61) were satisfied with the use of iCARE, 93\% (57/61) perceived it as useful, and 70\% (43/61) as easy to use. Conclusions: This study developed an intelligent, individualized, evidence-based, and theory-driven app (iCARE) to improve patients' adherence to health behaviors and medication management. iCARE was identified to be highly acceptable, useful, and easy to use among individuals with a diagnosis of CHD. Trial Registration: Chinese Clinical Trial Registry ChiCTR-INR-16010242; https://tinyurl.com/2p8bkrew ",
doi="10.2196/26439",
url="https://mhealth.jmir.org/2021/12/e26439",
url="http://www.ncbi.nlm.nih.gov/pubmed/34898449"
}


@Article{info:doi/10.2196/22557,
author="Ghorbani, Banafsheh
and Jackson, C. Alun
and Noorchenarboo, Mohammad
and Mandegar, H. Mohammad
and Sharifi, Farshad
and Mirmoghtadaie, Zohrehsadat
and Bahramnezhad, Fatemeh",
title="Comparing the Effects of Gamification and Teach-Back Training Methods on Adherence to a Therapeutic Regimen in Patients After Coronary Artery Bypass Graft Surgery: Randomized Clinical Trial",
journal="J Med Internet Res",
year="2021",
month="Dec",
day="10",
volume="23",
number="12",
pages="e22557",
keywords="teach back",
keywords="gamification",
keywords="treatment regimen",
keywords="coronary artery bypass graft",
keywords="patient training",
abstract="Background: Patients undergoing coronary artery bypass graft surgery (CABGS) may fail to adhere to their treatment regimen for many reasons. Among these, one of the most important reasons for nonadherence is the inadequate training of such patients or training using inappropriate methods. Objective: This study aimed to compare the effect of gamification and teach-back training methods on adherence to a therapeutic regimen in patients after CABGS. Methods: This randomized clinical trial was conducted on 123 patients undergoing CABGS in Tehran, Iran, in 2019. Training was provided to the teach-back group individually. In the gamification group, an app developed for the purpose was installed on each patient's smartphone, with training given via this device. The control group received usual care, or routine training. Adherence to the therapeutic regimen was assessed using a questionnaire on adherence to a therapeutic regimen (physical activity and dietary regimen) and an adherence scale as a pretest and a 1-month posttest. Results: One-way analysis of variance (ANOVA) for comparing the mean scores of teach-back and gamification training methods showed that the mean normalized scores for the dietary regimen (P<.001, F=71.80), movement regimen (P<.001, F=124.53), and medication regimen (P<.001, F=9.66) before and after intervention were significantly different between the teach-back, gamification, and control groups. In addition, the results of the Dunnett test showed that the teach-back and gamification groups were significantly different from the control group in all three treatment regimen methods. There was no statistically significant difference in adherence to the therapeutic regimen between the teach-back and control groups. Conclusions: Based on the results of this study, the use of teach-back and gamification training approaches may be suggested for patients after CABGS to facilitate adherence to the therapeutic regimen. Trial Registration: Iranian Registry of Clinical Trials IRCT20111203008286N8; https://en.irct.ir/trial/41507 ",
doi="10.2196/22557",
url="https://www.jmir.org/2021/12/e22557",
url="http://www.ncbi.nlm.nih.gov/pubmed/34890346"
}


@Article{info:doi/10.2196/23285,
author="Choi, Yeon Jah
and Kim, Bak Ji
and Lee, Sunki
and Lee, Seo-Joon
and Shin, Eon Seung
and Park, Hyun Se
and Park, Jin Eun
and Kim, Woohyeun
and Na, Oh Jin
and Choi, Ung Cheol
and Rha, Seung-Woon
and Park, Gyu Chang
and Seo, Seog Hong
and Ahn, Jeonghoon
and Jeong, Hyun-Ghang
and Kim, Ju Eung",
title="A Smartphone App (AnSim) With Various Types and Forms of Messages Using the Transtheoretical Model for Cardiac Rehabilitation in Patients With Coronary Artery Disease: Development and Usability Study",
journal="JMIR Med Inform",
year="2021",
month="Dec",
day="7",
volume="9",
number="12",
pages="e23285",
keywords="cardiac rehabilitation",
keywords="smartphone app",
keywords="coronary heart disease",
abstract="Background: Despite strong evidence of clinical benefit, cardiac rehabilitation (CR) programs are currently underutilized and smartphone-based CR strategies are thought to address this unmet need. However, data regarding the detailed process of development are scarce. Objective: This study focused on the development of a smartphone-based, patient-specific, messaging app for patients who have undergone percutaneous coronary intervention (PCI). Methods: The AnSim app was developed in collaboration with a multidisciplinary team that included cardiologists, psychiatrists, nurses, pharmacists, nutritionists, and rehabilitation doctors and therapists. First, a focus group interview was conducted, and the narratives of the patients were analyzed to identify their needs and preferences. Based on the results, health care experts and clinicians drafted messages into 5 categories: (1) general information regarding cardiovascular health and medications, (2) nutrition, (3) physical activity, (4) destressing, and (5) smoking cessation. In each category, 90 messages were developed according to 3 simplified steps of the transtheoretical model of behavioral change: (1) precontemplation, (2) contemplation and preparation, and (3) action and maintenance. After an internal review and feedback from potential users, a bank of 450 messages was developed. Results: The focus interview was conducted with 8 patients with PCI within 1 year, and 450 messages, including various forms of multimedia, were developed based on the transtheoretical model of behavioral change in each category. Positive feedback was obtained from the potential users (n=458). The mean Likert scale score was 3.95 (SD 0.39) and 3.91 (SD 0.39) for readability and usefulness, respectively, and several messages were refined based on the feedback. Finally, the patient-specific message delivery system was developed according to the baseline characteristics and stages of behavioral change in each participant. Conclusions: We developed an app (AnSim), which includes a bank of 450 patient-specific messages, that provides various medical information and CR programs regarding coronary heart disease. The detailed process of multidisciplinary collaboration over the course of the study provides a scientific basis for various medical professionals planning smartphone-based clinical research. ",
doi="10.2196/23285",
url="https://medinform.jmir.org/2021/12/e23285",
url="http://www.ncbi.nlm.nih.gov/pubmed/34878987"
}


@Article{info:doi/10.2196/26185,
author="Dorsch, P. Michael
and Farris, B. Karen
and Rowell, E. Brigid
and Hummel, L. Scott
and Koelling, M. Todd",
title="The Effects of the ManageHF4Life Mobile App on Patients With Chronic Heart Failure: Randomized Controlled Trial",
journal="JMIR Mhealth Uhealth",
year="2021",
month="Dec",
day="7",
volume="9",
number="12",
pages="e26185",
keywords="mHealth",
keywords="remote monitoring",
keywords="self-management",
keywords="self-care",
keywords="heart failure",
keywords="medical therapy",
keywords="mobile app",
abstract="Background: The successful management of heart failure (HF) involves guideline-based medical therapy as well as self-management behavior. As a result, the management of HF is moving toward a proactive real-time technological model of assisting patients with monitoring and self-management. Objective: The aim of this paper was to evaluate the efficacy of enhanced self-management via a mobile app intervention on health-related quality of life, self-management, and HF readmissions. Methods: A single-center randomized controlled trial was performed. Participants older than 45 years and admitted for acute decompensated HF or recently discharged in the past 4 weeks were included. The intervention group (``app group'') used a mobile app, and the intervention prompted daily self-monitoring and promoted self-management. The control group (``no-app group'') received usual care. The primary outcome was the change in Minnesota Living with Heart Failure Questionnaire (MLHFQ) score from baseline to 6 and 12 weeks. Secondary outcomes were the Self-Care Heart Failure Index (SCHFI) questionnaire score and recurrent HF admissions. Results: A total of 83 participants were enrolled and completed all baseline assessments. Baseline characteristics were similar between the groups except for the prevalence of ischemic HF. The app group had a reduced MLHFQ at 6 weeks (mean 37.5, SD 3.5 vs mean 48.2, SD 3.7; P=.04) but not at 12 weeks (mean 44.2, SD 4 vs mean 45.9, SD 4; P=.78), compared to the no-app group. There was no effect of the app on the SCHFI at 6 or 12 weeks. The time to first HF readmission was not statistically different between the app group and the no-app group (app group 11/42, 26\% vs no-app group 12/41, 29\%; hazard ratio 0.89, 95\% CI 0.39-2.02; P=.78) over 12 weeks. Conclusions: The adaptive mobile app intervention, which focused on promoting self-monitoring and self-management, improved the MLHFQ at 6 weeks but did not sustain its effects at 12 weeks. No effect was seen on HF self-management measured by self-report. Further research is needed to enhance engagement in the app for a longer period and to determine if the app can reduce HF readmissions in a larger study. Trial Registration: ClinicalTrials.gov NCT03149510; https://clinicaltrials.gov/ct2/show/NCT03149510 ",
doi="10.2196/26185",
url="https://mhealth.jmir.org/2021/12/e26185",
url="http://www.ncbi.nlm.nih.gov/pubmed/34878990"
}


@Article{info:doi/10.2196/26597,
author="Chudyk, M. Anna
and Ragheb, Sandra
and Kent, David
and Duhamel, A. Todd
and Hyra, Carole
and Dave, G. Mudra
and Arora, C. Rakesh
and Schultz, SH Annette",
title="Patient Engagement in the Design of a Mobile Health App That Supports Enhanced Recovery Protocols for Cardiac Surgery: Development Study",
journal="JMIR Perioper Med",
year="2021",
month="Nov",
day="30",
volume="4",
number="2",
pages="e26597",
keywords="cardiac surgery",
keywords="perioperative care",
keywords="enhanced recovery protocols",
keywords="mobile app",
keywords="smartphone app",
keywords="mHealth",
keywords="development",
keywords="patient and public involvement",
keywords="patient engagement in research",
abstract="Background: Despite the importance of their perspectives, end users (eg, patients, caregivers) are not typically engaged by academic researchers in the development of mobile health (mHealth) apps for perioperative cardiac surgery settings. Objective: The aim of this study was to describe a process for and the impact of patient engagement in the development of an mHealth app that supports patient and caregiver involvement with enhanced recovery protocols during the perioperative period of cardiac surgery. Methods: Engagement occurred at the level of consultation and took the form of an advisory panel. Patients who underwent cardiac surgery (2017-2018) at St. Boniface Hospital (Winnipeg, Manitoba) and their caregivers were approached for participation. A qualitative exploration determined the impact of patient engagement on the development (ie, design and content) of the mHealth app. This included a description of (1) the key messages generated by the advisory panel, (2) how key messages were incorporated into the development of the mHealth app, and (3) feedback from the developers of the mHealth app about the key messages generated by the advisory panel. Results: The advisory panel (N=10) generated 23 key messages to guide the development of the mHealth app. Key design-specific messages (n=7) centered around access, tracking, synchronization, and reminders. Key content-specific messages (n=16) centered around medical terms, professional roles, cardiac surgery procedures and recovery, educational videos, travel, nutrition, medications, resources, and physical activity. This information was directly incorporated into the design of the mHealth app as long as it was supported by the existing functionalities of the underlying platform. For example, the platform did not support the scheduling of reminders by users, identifying drug interactions, or synchronizing with other devices. The developers of the mHealth app noted that key messages resulted in the integration of a vast range and volume of information and resources instead of ones primarily focused on surgical information, content geared toward expectations management, and an expanded focus to include caregivers and other family members, so that these stakeholders may be directly included in the provision of information, allowing them to be better informed, prepare along with the patient, and be involved in recovery planning. Conclusions: Patient engagement may facilitate the development of a detail-oriented and patient-centered mHealth app whose design and content are driven by the lived experiences of end users. ",
doi="10.2196/26597",
url="https://periop.jmir.org/2021/2/e26597",
url="http://www.ncbi.nlm.nih.gov/pubmed/34851299"
}


@Article{info:doi/10.2196/32351,
author="Montgomery, M. Robert
and Boucher, M. Eliane
and Honomichl, D. Ryan
and Powell, A. Tyler
and Guyton, L. Sharelle
and Bernecker, L. Samantha
and Stoeckl, Elizabeth Sarah
and Parks, C. Acacia",
title="The Effects of a Digital Mental Health Intervention in Adults With Cardiovascular Disease Risk Factors: Analysis of Real-World User Data",
journal="JMIR Cardio",
year="2021",
month="Nov",
day="19",
volume="5",
number="2",
pages="e32351",
keywords="digital mental health",
keywords="digital health",
keywords="mobile apps",
keywords="mobile health",
keywords="internet-based intervention",
keywords="happiness",
keywords="subjective well-being",
keywords="anxiety",
keywords="cardiovascular health",
keywords="high blood pressure",
keywords="high cholesterol",
keywords="diabetes",
keywords="cardiovascular disease risk",
keywords="real-world data",
abstract="Background: The American Heart Association has identified poor mental health as a key barrier to healthy behavior change for those with cardiovascular disease (CVD) risk factors such as high blood pressure, high cholesterol, and diabetes. Digital mental health interventions, like those delivered via the internet to computers or smartphones, may provide a scalable solution to improving the mental and physical health of this population. Happify is one such intervention and has demonstrated evidence of efficacy for improving aspects of mental health in both the general population and in users with chronic conditions. Objective: The objectives of this analysis of real-world data from Happify users with self-reported CVD risk factors, including high blood pressure and cholesterol, diabetes, and heart disease, were to examine whether these users would report improvements in subjective well-being and anxiety over time (H1) and use of Happify as recommended would be associated with significantly greater improvement in subjective well-being and anxiety over time compared to less-than-recommended usage (H2). Methods: Data were obtained from existing Happify users who reported the aforementioned CVD risk factors. The sample included 1803 users receiving at least 6 weeks' exposure to Happify (ranging from 42 days to 182 days) who completed at least one activity and two assessments within the app during that time. Subjective well-being was assessed with the Happify Scale, a 9-item measure of positive emotionality and life satisfaction, and anxiety was assessed with the Generalized Anxiety Disorder 2 (GAD-2). To evaluate H1, changes over time in both outcomes were assessed using mixed effects linear regression models, controlling for demographics and usage. For H2, an interaction term was added to the models to assess whether usage as recommended was associated with greater improvement over time. Results: Both hypotheses were supported. For both the Happify scale and GAD-2, the initial multivariable model without an interaction demonstrated an effect for time from baseline, and the addition of the interaction term between time and recommended use was significant as well. Conclusions: This analysis of real-world data provides preliminary evidence that Happify users with self-reported CVD risk factors including high blood pressure or cholesterol, diabetes, and heart disease experienced improved well-being and anxiety over time and that those who used Happify as recommended experienced greater improvements in these aspects of mental health than those who completed fewer activities. These findings extend previous research, which demonstrated that engagement with Happify as recommended was associated with improved well-being among physically healthy users and in those with chronic conditions, to a new population for whom mental health is especially critical: those at risk of developing CVD. ",
doi="10.2196/32351",
url="https://cardio.jmir.org/2021/2/e32351",
url="http://www.ncbi.nlm.nih.gov/pubmed/34806986"
}


@Article{info:doi/10.2196/27016,
author="Kapoor, Alok
and Hayes, Anna
and Patel, Jay
and Patel, Harshal
and Andrade, Andreza
and Mazor, Kathleen
and Possidente, Carl
and Nolen, Kimberly
and Hegeman-Dingle, Rozelle
and McManus, David",
title="Usability and Perceived Usefulness of the AFib 2gether Mobile App in a Clinical Setting: Single-Arm Intervention Study",
journal="JMIR Cardio",
year="2021",
month="Nov",
day="19",
volume="5",
number="2",
pages="e27016",
keywords="shared decision-making",
keywords="mobile health",
keywords="stroke risk",
keywords="anticoagulation risk",
keywords="anticoagulation",
keywords="atrial fibrillation",
keywords="anticoagulation therapy",
keywords="atrial flutter",
keywords="mobile phone",
abstract="Background: Although the American Heart Association and other professional societies have recommended shared decision-making as a way for patients with atrial fibrillation (AF) or atrial flutter to make informed decisions about using anticoagulation (AC), the best method for facilitating shared decision-making remains uncertain. Objective: The aim of this study is to assess the AFib 2gether mobile app for usability, perceived usefulness, and the extent and nature of shared decision-making that occurred for clinical encounters between patients with AF and their cardiology providers in which the app was used. Methods: We identified patients visiting a cardiology provider between October 2019 and May 2020. We measured usability from patients and providers using the Mobile App Rating Scale. From the 8 items of the Mobile App Rating Scale, we reported the average score (out of 5) for domains of functionality, esthetics, and overall quality. We administered a 3-item questionnaire to patients relating to their perceived usefulness of the app and a separate 3-item questionnaire to providers to measure their perceived usefulness of the app. We performed a chart review to track the occurrence of AC within 6 months of the index visit. We also audio recorded a subset of the encounters to identify evidence of shared decision-making. Results: We facilitated shared decision-making visits for 37 patients visiting 13 providers. In terms of usability, patients' average ratings of functionality, esthetics, and overall quality were 4.51 (SD 0.61), 4.26 (SD 0.51), and 4.24 (SD 0.89), respectively. In terms of usefulness, 41\% (15/37) of patients agreed that the app improved their knowledge regarding AC, and 62\% (23/37) agreed that the app helped clarify to their provider their preferences regarding AC. Among providers, 79\% (27/34) agreed that the app helped clarify their patients' preferences, 82\% (28/34) agreed that the app saved them time, and 59\% (20/34) agreed that the app helped their patients make decisions about AC. In addition, 32\% (12/37) of patients started AC after their shared decision-making visits. We audio recorded 25 encounters. Of these, 84\% (21/25) included the mention of AC for AF, 44\% (11/25) included the discussion of multiple options for AC, 72\% (18/25) included a provider recommendation for AC, and 48\% (12/25) included the evidence of patient involvement in the discussion. Conclusions: Patients and providers rated the app with high usability and perceived usefulness. Moreover, one-third of the patients began AC, and approximately 50\% (12/25) of the encounters showed evidence of patient involvement in decision-making. In the future, we plan to study the effect of the app on a larger sample and with a controlled study design. Trial Registration: ClinicalTrials.gov NCT04118270; https://clinicaltrials.gov/ct2/show/NCT04118270 International Registered Report Identifier (IRRID): RR2-21986 ",
doi="10.2196/27016",
url="https://cardio.jmir.org/2021/2/e27016",
url="http://www.ncbi.nlm.nih.gov/pubmed/34806997"
}


@Article{info:doi/10.2196/29207,
author="Alessa, Tourkiah
and Hawley, Mark
and de Witte, Luc",
title="Identification of the Most Suitable App to Support the Self-Management of Hypertension: Systematic Selection Approach and Qualitative Study",
journal="JMIR Mhealth Uhealth",
year="2021",
month="Nov",
day="17",
volume="9",
number="11",
pages="e29207",
keywords="app",
keywords="hypertension",
keywords="self-management",
keywords="mHealth",
keywords="blood pressure",
keywords="support",
keywords="Saudi Arabia",
keywords="cardiology",
keywords="heart",
keywords="effective",
keywords="security",
abstract="Background: Smartphone apps are increasingly being used to aid in hypertension self-management, and a large and ever-growing number of self-management apps have been commercially released. However, very few of these are potentially effective and secure, and researchers have yet to establish the suitability of specific hypertension apps to particular contexts. Objective: The aim of this study is to identify the most suitable hypertension app in the context of Saudi Arabia and its health system. Methods: This study used a 2-stage approach to selecting the most suitable app for hypertension self-management. First, a systematic selection approach was followed to identify a shortlist of the most suitable apps according to the criteria of potential effectiveness, theoretical underpinning, and privacy and security. Second, an exploratory qualitative study was conducted to select the most suitable from the shortlist: 12 doctors were interviewed, and 22 patients participated in 4 focus groups. These explored participants' attitudes towards self-management apps in general, and their views towards the apps identified via the systematic selection process. The qualitative data were analyzed using framework analysis. Results: In the first stage, only 5 apps were found to be potentially effective while also having a theoretical underpinning and protecting users' data. In the second stage, both doctors and patients were generally interested in using hypertension apps, but most had no experience with these apps due to a lack of awareness of their availability and suitability. Patients and doctors liked apps that combine intuitive interfaces with a pleasant and clear visual design, in-depth features (eg, color-coded feedback accompanied with textual explanations), activity-specific reminders, and educational content regarding hypertension and potential complications. When the pros and cons of the 5 apps were discussed, 3 apps were identified as being more suitable, with Cora Health rated the highest by the participants. Conclusions: Only 5 apps were deemed potentially effective and secure. Patients' and doctors' discussions of the pros and cons of these 5 apps revealed that 3 out of the 5 are clearly more suitable, with the Cora Health app being judged most suitable overall. ",
doi="10.2196/29207",
url="https://mhealth.jmir.org/2021/11/e29207",
url="http://www.ncbi.nlm.nih.gov/pubmed/34787586"
}


@Article{info:doi/10.2196/25192,
author="Amin, Shiraz
and Gupta, Vedant
and Du, Gaixin
and McMullen, Colleen
and Sirrine, Matthew
and Williams, V. Mark
and Smyth, S. Susan
and Chadha, Romil
and Stearley, Seth
and Li, Jing",
title="Developing and Demonstrating the Viability and Availability of the Multilevel Implementation Strategy for Syncope Optimal Care Through Engagement (MISSION) Syncope App: Evidence-Based Clinical Decision Support Tool",
journal="J Med Internet Res",
year="2021",
month="Nov",
day="16",
volume="23",
number="11",
pages="e25192",
keywords="cardiology",
keywords="medical diagnosis",
keywords="medicine",
keywords="mobile applications",
keywords="prognostics and health",
keywords="syncope",
abstract="Background: Syncope evaluation and management is associated with testing overuse and unnecessary hospitalizations. The 2017 American College of Cardiology/American Heart Association (ACC/AHA) Syncope Guideline aims to standardize clinical practice and reduce unnecessary services. The use of clinical decision support (CDS) tools offers the potential to successfully implement evidence-based clinical guidelines. However, CDS tools that provide an evidence-based differential diagnosis (DDx) of syncope at the point of care are currently lacking. Objective: With input from diverse health systems, we developed and demonstrated the viability of a mobile app, the Multilevel Implementation Strategy for Syncope optImal care thrOugh eNgagement (MISSION) Syncope, as a CDS tool for syncope diagnosis and prognosis. Methods: Development of the app had three main goals: (1) reliable generation of an accurate DDx, (2) incorporation of an evidence-based clinical risk tool for prognosis, and (3) user-based design and technical development. To generate a DDx that incorporated assessment recommendations, we reviewed guidelines and the literature to determine clinical assessment questions (variables) and likelihood ratios (LHRs) for each variable in predicting etiology. The creation and validation of the app diagnosis occurred through an iterative clinician review and application to actual clinical cases. The review of available risk score calculators focused on identifying an easily applied and valid evidence-based clinical risk stratification tool. The review and decision-making factors included characteristics of the original study, clinical variables, and validation studies. App design and development relied on user-centered design principles. We used observations of the emergency department workflow, storyboard demonstration, multiple mock review sessions, and beta-testing to optimize functionality and usability. Results: The MISSION Syncope app is consistent with guideline recommendations on evidence-based practice (EBP), and its user interface (UI) reflects steps in a real-world patient evaluation: assessment, DDx, risk stratification, and recommendations. The app provides flexible clinical decision making, while emphasizing a care continuum; it generates recommendations for diagnosis and prognosis based on user input. The DDx in the app is deemed a pragmatic model that more closely aligns with real-world clinical practice and was validated using actual clinical cases. The beta-testing of the app demonstrated well-accepted functionality and usability of this syncope CDS tool. Conclusions: The MISSION Syncope app development integrated the current literature and clinical expertise to provide an evidence-based DDx, a prognosis using a validated scoring system, and recommendations based on clinical guidelines. This app demonstrates the importance of using research literature in the development of a CDS tool and applying clinical experience to fill the gaps in available research. It is essential for a successful app to be deliberate in pursuing a practical clinical model instead of striving for a perfect mathematical model, given available published evidence. This hybrid methodology can be applied to similar CDS tool development. ",
doi="10.2196/25192",
url="https://www.jmir.org/2021/11/e25192",
url="http://www.ncbi.nlm.nih.gov/pubmed/34783669"
}


@Article{info:doi/10.2196/29044,
author="Radhakrishnan, Kavita
and Julien, Christine
and Baranowski, Tom
and O'Hair, Matthew
and Lee, Grace
and Sagna De Main, Atami
and Allen, Catherine
and Viswanathan, Bindu
and Thomaz, Edison
and Kim, Miyong",
title="Feasibility of a Sensor-Controlled Digital Game for Heart Failure Self-management: Randomized Controlled Trial",
journal="JMIR Serious Games",
year="2021",
month="Nov",
day="8",
volume="9",
number="4",
pages="e29044",
keywords="heart failure",
keywords="digital game",
keywords="sensor",
keywords="self-management",
keywords="older adults",
keywords="weight monitoring",
keywords="physical activity",
keywords="behaviors",
keywords="mobile phone",
abstract="Background: Poor self-management of heart failure (HF) contributes to devastating health consequences. Our innovative sensor-controlled digital game (SCDG) integrates data from sensors to trigger game rewards, progress, and feedback based on the real-time behaviors of individuals with HF. Objective: The aim of this study is to compare daily weight monitoring and physical activity behavior adherence by older adults using an SCDG intervention versus a sensors-only intervention in a feasibility randomized controlled trial. Methods: English-speaking adults with HF aged 55 years or older who owned a smartphone and could walk unassisted were recruited from Texas and Oklahoma from November 2019 to August 2020. Both groups were given activity trackers and smart weighing scales to track behaviors for 12 weeks. The feasibility outcomes of recruitment, retention, intervention engagement, and satisfaction were assessed. In addition to daily weight monitoring and physical activity adherence, the participants' knowledge, functional status, quality of life, self-reported HF behaviors, motivation to engage in behaviors, and HF-related hospitalization were also compared between the groups at baseline and at 6, 12, and 24 weeks. Results: A total of 38 participants with HF---intervention group (IG; 19/38, 50\%) and control group (CG; 19/38, 50\%)---were enrolled in the study. Of the 38 participants, 18 (47\%) were women, 18 (47\%) were aged 65 years or older, 21 (55\%) had been hospitalized with HF in the past 6 months, and 29 (76\%) were White. Furthermore, of these 38 participants, 31 (82\%)---IG (15/19, 79\%) and CG (16/19, 84\%)---had both weight monitoring and physical activity data at the end of 12 weeks, and 27 (71\%)---IG (14/19, 74\%) and CG (13/19, 68\%)---participated in follow-up assessments at 24 weeks. For the IG participants who installed the SCDG app (15/19, 79\%), the number of days each player opened the game app was strongly associated with the number of days the player engaged in weight monitoring (r=0.72; P=.04) and the number of days with physical activity step data (r=0.9; P<.001). The IG participants who completed the satisfaction survey (13/19, 68\%) reported that the SCDG was easy to use. Trends of improvement in daily weight monitoring and physical activity in the IG, as well as within-group improvements in HF functional status, quality of life, knowledge, self-efficacy, and HF hospitalization in both groups, were observed in this feasibility trial. Conclusions: Playing an SCDG on smartphones was feasible and acceptable for older adults with HF for motivating daily weight monitoring and physical activity. A larger efficacy trial of the SCDG intervention will be needed to validate trends of improvement in daily weight monitoring and physical activity behaviors. Trial Registration: ClinicalTrials.gov NCT03947983; https://clinicaltrials.gov/ct2/show/NCT03947983 ",
doi="10.2196/29044",
url="https://games.jmir.org/2021/4/e29044",
url="http://www.ncbi.nlm.nih.gov/pubmed/34747701"
}


@Article{info:doi/10.2196/21906,
author="Tuttle, Katherine
and Kelemen, Arpad
and Liang, Yulan",
title="Use of Smartphone Apps for Improving Physical Function Capacity in Cardiac Patient Rehabilitation: Systematic Review",
journal="JMIRx Med",
year="2021",
month="Sep",
day="17",
volume="2",
number="3",
pages="e21906",
keywords="cardiac rehabilitation",
keywords="physical capacity",
keywords="exercise",
keywords="smartphone apps",
abstract="Background: Cardiac rehabilitation (CR) is an evidence-based approach for preventing secondary cardiac events. Smartphone apps are starting to be used in CR to give patients real-time feedback on their health, connect them remotely with their medical team, and allow them to perform their rehabilitation at home. The use of smartphone apps is becoming omnipresent and has real potential in impacting patients in need of CR. Objective: This paper provides critical examinations and summaries of existing research studies with an in-depth analysis of not only the individual studies but also the larger patterns that have emerged with smartphone apps in CR as well as their significance for practice change. Methods: A systematic review was conducted through broad database searches that focused on evaluating randomized controlled trials, in compliance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) expectations. A total of 43 articles were evaluated, and 6 were chosen for this review. The dates of the articles ranged from 2014-2020, and the studies focused on the population of cardiac outpatients who needed CR after suffering a cardiac event, with interventions using a smartphone that incorporated the CR standards of the American Heart Association. The outcomes measured were directed at focusing on improved exercise function capacity, valued at a significance level of P<.05, for improved 6-minute walk test (6MWT) and peak oxygen uptake (PVO2) results. Results: In the evaluated articles, the results were inconsistent for significant positive effects of CR smartphone apps on cardiac patients' physical function capacity in terms of the 6MWT and PVO2 when using a smartphone app to aid in CR. Conclusions: Because evidence in the literature suggests nonhomogeneous results for successful use of smartphone apps in CR, it is crucial to investigate the potential reasons for this inconsistency. An important observation from this systematic review is that smartphone apps used in CR have better clinical outcomes related to physical function capacity if the app automatically records information or provides real-time feedback to participants about their progress, compared to apps that only educate and encourage use while requiring the participant to manually log their CR activities. Additional factors to consider during these studies include the starting health of the patients, the sample sizes, and the specific components of CR that the smartphone apps are using. Overall, more clinical trials are needed that implement smartphone apps with these factors in mind, while placing stronger emphasis on using biosensing capabilities that can automatically log results and send them to providers on a real-time dashboard. ",
doi="10.2196/21906",
url="https://med.jmirx.org/2021/3/e21906",
url="http://www.ncbi.nlm.nih.gov/pubmed/37725554"
}


@Article{info:doi/10.2196/23425,
author="Ksi??czyk, Marcin
and D?bska-Koz?owska, Agnieszka
and Warcho?, Izabela
and Lubi?ski, Andrzej",
title="Enhancing Healthcare Access--Smartphone Apps in Arrhythmia Screening: Viewpoint",
journal="JMIR Mhealth Uhealth",
year="2021",
month="Aug",
day="27",
volume="9",
number="8",
pages="e23425",
keywords="arrhythmia screening",
keywords="atrial fibrillation",
keywords="mobile electrocardiography",
keywords="mobile health",
keywords="phonocardiography",
keywords="photoplethysmography",
keywords="seismocardiography",
keywords="stroke prevention",
doi="10.2196/23425",
url="https://mhealth.jmir.org/2021/8/e23425",
url="http://www.ncbi.nlm.nih.gov/pubmed/34448723"
}


@Article{info:doi/10.2196/23464,
author="de Castro, Paul Kim
and Chiu, Henrison Harold
and De Leon-Yao, Cheska Ronna
and Almelor-Sembrana, Lorraine
and Dans, Miguel Antonio",
title="A Patient Decision Aid for Anticoagulation Therapy in Patients With Nonvalvular Atrial Fibrillation: Development and Pilot Study",
journal="JMIR Cardio",
year="2021",
month="Aug",
day="12",
volume="5",
number="2",
pages="e23464",
keywords="shared decision-making",
keywords="patient decision aid",
keywords="atrial fibrillation",
keywords="anticoagulation",
keywords="stroke prevention",
keywords="mHealth",
keywords="mobile health",
abstract="Background: Atrial fibrillation (AF) is one of the most common predisposing factors for ischemic stroke worldwide. Because of this, patients with AF are prescribed anticoagulant medications to decrease the risk. The availability of different options for oral anticoagulation makes it difficult for some patients to decide a preferred choice of medication. Clinical guidelines often recommend enhancing the decision-making process of patients by increasing their involvement in health decisions. In particular, the use of patient decision aids (PDAs) in patients with AF was associated with increased knowledge and increased likelihood of making a choice. However, the majority of available PDAs are from Western countries. Objective: We aimed to develop and pilot test a PDA to help patients with nonvalvular AF choose an oral anticoagulant for stroke prevention in the local setting. Outcomes were (1) reduction in patient decisional conflict, (2) improvement in patient knowledge, and (3) patient and physician acceptability. Methods: We followed the International Patient Decision Aid Standards (IPDAS) to develop a mobile app--based PDA for anticoagulation therapy in patients with nonvalvular AF. Focus group discussions identified decisional needs, which were subsequently incorporated into the PDA to compare choices for anticoagulation. Based on recommendations, the prototype PDA was rendered by at least 30 patients and 30 physicians. Decisional conflict and patient knowledge were tested before and after the PDA was implemented. Patient acceptability and physician acceptability were measured after each encounter. Results: Anticoagulant options were compared by the PDA using three factors that were identified (impact on stroke and bleeding risk, and price). The comparisons were presented as tables and graphs. The prototype PDA was rendered by 30 doctors and 37 patients for pilot testing. The mean duration of the encounters was 15 minutes. The decisional conflict score reduced by 35 points (100-point scale; P<.001). The AF knowledge score improved from 10 to 15 (P<.001). The PDA was acceptable for both patients and doctors. Conclusions: Our study showed that an app-based PDA for anticoagulation therapy in patients with nonvalvular AF (1) reduced patient decisional conflict, (2) improved patient knowledge, and (3) was acceptable to patients and physicians. A PDA is potentially acceptable and useful in our setting. A randomized controlled trial is warranted to test its effectiveness compared to usual care. PDAs for other conditions should also be developed. ",
doi="10.2196/23464",
url="https://cardio.jmir.org/2021/2/e23464",
url="http://www.ncbi.nlm.nih.gov/pubmed/34385138"
}


@Article{info:doi/10.2196/28139,
author="Schmaderer, Myra
and Miller, N. Jennifer
and Mollard, Elizabeth",
title="Experiences of Using a Self-management Mobile App Among Individuals With Heart Failure: Qualitative Study",
journal="JMIR Nursing",
year="2021",
month="Aug",
day="9",
volume="4",
number="3",
pages="e28139",
keywords="mHealth",
keywords="eHealth",
keywords="mobile applications",
keywords="patient experiences",
keywords="patient perceptions",
keywords="self-management",
keywords="self-care",
keywords="heart failure",
keywords="congestive heart failure",
keywords="heart decompensation",
abstract="Background: Interventions that focus on the self-management of heart failure are vital to promoting health in patients with heart failure. Mobile health (mHealth) apps are becoming more integrated into practice to promote self-management strategies for chronic diseases, optimize care delivery, and reduce health disparities. Objective: The purpose of this study was to explore the experience of using a self-management mHealth intervention in individuals with heart failure to inform a future mHealth intervention study. Methods: This study used a qualitative descriptive design. Participants were enrolled in the intervention groups of a larger parent study using a mobile app related to self-management of heart failure. The purposive, convenient, criterion-based sample for this qualitative analysis comprised 10 patients who responded to phone calls and were willing to be interviewed. Inclusion criteria for the parent study were adults who were hospitalized at Nebraska Medical Center with a primary diagnosis and an episode of acute decompensated heart failure; discharged to home without services such as home health care; had access to a mobile phone; and were able to speak, hear, and understand English. Results: Study participants were middle-aged (mean age 55.8, SD 12 years; range 36-73 years). They had completed a mean of 13.5 (SD 2.2) years (range 11-17 years) of education. Of the 10 participants, 6 (60\%) were male. Half of them (5/10, 50\%) were New York Heart Association Classification Class III patients and the other half were Class IV patients. The intervention revealed four self-management themes, including (1) I didn't realize, and now I know; (2) It feels good to focus on my health; (3) I am the leader of my health care team; and (4) My health is improving. Conclusions: Participants who used a self-management mHealth app intervention for heart failure reported an overall positive experience. Their statements were organized into four major themes. The education provided during the study increased self-awareness and promoted self-management of their heart failure. The mHealth app supported patient empowerment, resulting in better heart failure management and improved quality of life. Participants advocated for themselves by becoming the leader of their health, especially when communicating with their health care team. Finally, the mHealth app was used by the participants as a self-management tool to assist in symptom management and improve their overall health. Future research should study symptom evaluation, medication tracking, and possibly serve as a health provider communication platform to empower individuals to be leaders in their chronic disease management. ",
doi="10.2196/28139",
url="https://nursing.jmir.org/2021/3/e28139",
url="http://www.ncbi.nlm.nih.gov/pubmed/34406966"
}


@Article{info:doi/10.2196/25437,
author="Fija{\v c}ko, Nino
and Masterson Creber, Ruth
and Gosak, Lucija
and {\vS}tiglic, Gregor
and Egan, Dominic
and Chaka, Brian
and Debeljak, Nika
and Strnad, Matej
and Skok, Pavel",
title="Evaluating Quality, Usability, Evidence-Based Content, and Gamification Features in Mobile Learning Apps Designed to Teach Children Basic Life Support: Systematic Search in App Stores and Content Analysis",
journal="JMIR Mhealth Uhealth",
year="2021",
month="Jul",
day="20",
volume="9",
number="7",
pages="e25437",
keywords="cardiopulmonary resuscitation",
keywords="basic life support",
keywords="mobile learning",
keywords="mobile phone",
keywords="gamification",
keywords="schoolchildren",
abstract="Background: Globally, 3.7 million people die of sudden cardiac death annually. Following the World Health Organization endorsement of the Kids Save Lives statements, initiatives to train school-age children in basic life support (BLS) have been widespread. Mobile phone apps, combined with gamification, represent an opportunity for including mobile learning (m-learning) in teaching schoolchildren BLS as an additional teaching method; however, the quality of these apps is questionable. Objective: This study aims to systematically evaluate the quality, usability, evidence-based content, and gamification features (GFs) of commercially available m-learning apps for teaching guideline-directed BLS knowledge and skills to school-aged children. Methods: We searched the Google Play Store and Apple iOS App Store using multiple terms (eg, cardiopulmonary resuscitation [CPR] or BLS). Apps meeting the inclusion criteria were evaluated by 15 emergency health care professionals using the user version of the Mobile Application Rating Scale and System Usability Scale. We modified a five-finger mnemonic for teaching schoolchildren BLS and reviewed the apps' BLS content using standardized criteria based on three CPR guidelines. GFs in the apps were evaluated using a gamification taxonomy. Results: Of the 1207 potentially relevant apps, only 6 (0.49\%) met the inclusion criteria. Most apps were excluded because the content was not related to teaching schoolchildren BLS. The mean total scores for the user version of the Mobile Application Rating Scale and System Usability Scale score were 3.2/5 points (95\% CI 3.0-3.4) and 47.1/100 points (95\% CI 42.1-52.1), respectively. Half of the apps taught hands-only CPR, whereas the other half also included ventilation. All the apps indicated when to start chest compressions, and only 1 app taught BLS using an automated external defibrillator. Gamification was well integrated into the m-learning apps for teaching schoolchildren BLS, whereas the personal and fictional, educational, and performance gamification groups represented most GFs. Conclusions: Improving the quality and usability of BLS content in apps and combining them with GFs can offer educators novel m-learning tools to teach schoolchildren BLS skills. ",
doi="10.2196/25437",
url="https://mhealth.jmir.org/2021/7/e25437",
url="http://www.ncbi.nlm.nih.gov/pubmed/34283034"
}


@Article{info:doi/10.2196/25522,
author="Song, Ting
and Liu, Fang
and Deng, Ning
and Qian, Siyu
and Cui, Tingru
and Guan, Yingping
and Arnolda, Leonard
and Zhang, Zhenyu
and Yu, Ping",
title="A Comprehensive 6A Framework for Improving Patient Self-Management of Hypertension Using mHealth Services: Qualitative Thematic Analysis",
journal="J Med Internet Res",
year="2021",
month="Jun",
day="21",
volume="23",
number="6",
pages="e25522",
keywords="patient experience",
keywords="mHealth",
keywords="mobile phone",
keywords="mobile app",
keywords="intervention",
keywords="self-management",
keywords="high blood pressure",
keywords="chronic disease management",
keywords="qualitative research",
abstract="Background: Hypertension affects over 15\% of the world's population and is a significant global public health and socioeconomic challenge. Mobile health (mHealth) services have been increasingly introduced to support hypertensive patients to improve their self-management behaviors, such as adherence to pharmacotherapy and lifestyle modifications. Objective: This study aims to explore patients' perceptions of mHealth services and the mechanisms by which the services support them to self-manage their hypertension. Methods: A semistructured, in-depth interview study was conducted with 22 outpatients of the General Hospital of Ningxia Medical University from March to May 2019. In 2015, the hospital introduced an mHealth service to support community-dwelling outpatients with self-management of hypertension. Content analysis was conducted by following a grounded theory approach for inductive thematic extraction. Constant comparison and categorization classified the first-level codes with similar meanings into higher-level themes. Results: The patient-perceived mechanisms by which the mHealth service supported their self-management of hypertension were summarized as 6A: access, assessment, assistance, awareness, ability, and activation. With the portability of mobile phones and digitization of information, the mHealth service provided outpatients with easy access to assess their vital signs and self-management behaviors. The assessment results gave the patients real-time awareness of their health conditions and self-management performance, which activated their self-management behaviors. The mHealth service also gave outpatients access to assistance, which included health education and self-management reminders. Both types of assistance could also be activated by abnormal assessment results, that is, uncontrolled or deteriorating blood pressure values, discomfort symptoms, or not using the service for a long period. With its scalable use to handle any possible information and services, the mHealth service provided outpatients with educational materials to learn at their own pace. This led to an improvement in self-management awareness and ability, again activating their self-management behaviors. The patients would like to see further improvements in the service to provide more useful, personalized information and reliable services. Conclusions: The mHealth service extended the traditional hypertension care model beyond the hospital and clinician's office. It provided outpatients with easy access to otherwise inaccessible hypertension management services. This led to process improvement for outpatients to access health assessment and health care assistance and improved their awareness and self-management ability, which activated their hypertension self-management behaviors. Future studies can apply the 6A framework to guide the design, implementation, and evaluation of mHealth services for outpatients to self-manage chronic conditions. ",
doi="10.2196/25522",
url="https://www.jmir.org/2021/6/e25522",
url="http://www.ncbi.nlm.nih.gov/pubmed/34152272"
}


@Article{info:doi/10.2196/24190,
author="Al-Arkee, Shahd
and Mason, Julie
and Lane, A. Deirdre
and Fabritz, Larissa
and Chua, Winnie
and Haque, Sayeed M.
and Jalal, Zahraa",
title="Mobile Apps to Improve Medication Adherence in Cardiovascular Disease: Systematic Review and Meta-analysis",
journal="J Med Internet Res",
year="2021",
month="May",
day="25",
volume="23",
number="5",
pages="e24190",
keywords="mobile health care applications",
keywords="medication adherence",
keywords="cardiovascular disease",
keywords="systematic review",
keywords="mobile phone",
abstract="Background: Adherence rates of preventative medication for cardiovascular disease (CVD) have been reported as 57\%, and approximately 9\% of all CVD events in Europe are attributable to poor medication adherence. Mobile health technologies, particularly mobile apps, have the potential to improve medication adherence and clinical outcomes. Objective: The objective of this study is to assess the effects of mobile health care apps on medication adherence and health-related outcomes in patients with CVD. This study also evaluates apps' functionality and usability and the involvement of health care professionals in their use. Methods: Electronic databases (MEDLINE [Ovid], PubMed Central, Cochrane Library, CINAHL Plus, PsycINFO [Ovid], Embase [Ovid], and Google Scholar) were searched for randomized controlled trials (RCTs) to investigate app-based interventions aimed at improving medication adherence in patients with CVD. RCTs published in English from inception to January 2020 were reviewed. The Cochrane risk of bias tool was used to assess the included studies. Meta-analysis was performed for clinical outcomes and medication adherence, with meta-regression analysis used to evaluate the impact of app intervention duration on medication adherence. Results: This study included 16 RCTs published within the last 6 years. In total, 12 RCTs reported medication adherence as the primary outcome, which is the most commonly self-reported adherence. The duration of the interventions ranged from 1 to 12 months, and sample sizes ranged from 24 to 412. Medication adherence rates showed statistically significant improvements in 9 RCTs when compared with the control, and meta-analysis of the 6 RCTs reporting continuous data showed a significant overall effect in favor of the app intervention (mean difference 0.90, 95\% CI 0.03-1.78) with a high statistical heterogeneity (I2=93.32\%). Moreover, 9 RCTs assessed clinical outcomes and reported an improvement in systolic blood pressure, diastolic blood pressure, total cholesterol, and low-density lipoprotein cholesterol levels in the intervention arm. Meta-analysis of these clinical outcomes from 6 RCTs favored app interventions, but none were significant. In the 7 trials evaluating app usability, all were found to be acceptable. There was a great variation in the app characteristics. A total of 10 RCTs involved health care professionals, mainly physicians and nurses, in the app-based interventions. The apps had mixed functionality: 2 used education, 7 delivered reminders, and 7 provided reminders in combination with educational support. Conclusions: Apps tended to increase medication adherence, but interventions varied widely in design, content, and delivery. Apps have an acceptable degree of usability; yet the app characteristics conferring usability and effectiveness are ill-defined. Future large-scale studies should focus on identifying the essential active components of successful apps. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42019121385; https://www.crd.york.ac.uk/prospero/display\_record.php?RecordID=121385 ",
doi="10.2196/24190",
url="https://www.jmir.org/2021/5/e24190",
url="http://www.ncbi.nlm.nih.gov/pubmed/34032583"
}


@Article{info:doi/10.2196/21055,
author="D{\textasciiacute}Ancona, Giuseppe
and Murero, Monica
and Feickert, Sebastian
and Kaplan, Hilmi
and {\"O}ner, Alper
and Ortak, Jasmin
and Ince, Hueseyin",
title="Implantation of an Innovative Intracardiac Microcomputer System for Web-Based Real-Time Monitoring of Heart Failure: Usability and Patients' Attitudes",
journal="JMIR Cardio",
year="2021",
month="Apr",
day="21",
volume="5",
number="1",
pages="e21055",
keywords="heart",
keywords="failure",
keywords="left atrial",
keywords="pressure",
keywords="intracardiac",
keywords="device",
keywords="monitoring",
keywords="implantable",
keywords="wireless",
keywords="transmission",
keywords="web-based",
abstract="Background: Heart failure (HF) management guided by the measurement of intracardiac and pulmonary pressure values obtained through innovative permanent intracardiac microsensors has been recently proposed as a valid strategy to individualize treatment and anticipate hemodynamic destabilization. These sensors have potential to reduce patient hospitalization rates and optimize quality of life. Objective: The aim of this study was to evaluate the usability and patients' attitudes toward a new permanent intracardiac device implanted to remotely monitor left intra-atrial pressures (V-LAP, Vectorious Medical Technologies, Tel Aviv, Israel) in patients with chronic HF. Methods: The V-LAP system is a miniaturized sensor implanted percutaneously across the interatrial septum. The system communicates wirelessly with a ``companion device'' (a wearable belt) that is placed on the patient's chest at the time of acquisition/transmission of left heart pressure measurements. At first follow-up after implantation, the patients and health care providers were asked to fill out a questionnaire on the usability of the system, ease in performing the various required tasks (data acquisition and transmission), and overall satisfaction. Replies to the questions were mainly given using a 5-point Likert scale (1: very poor, 2: poor, 3: average, 4: good, 5: excellent). Further patient follow-ups were performed at 3, 6, and 12 months. Results: Use and acceptance of the first 14 patients receiving the V-LAP technology worldwide and related health care providers have been analyzed to date. No periprocedural morbidity/mortality was observed. Before discharge, a tailored educational session was performed after device implantation with the patients and their health care providers. At the first follow-up, the mean score for overall comfort in technology use was 3.7 (SD 1.2) with 93\% (13/14) of patients succeeding in applying and operating the system independently. For health care providers, the mean score for overall ease and comfort in use of the technology was 4.2  (SD 0.8). No significant differences were found between the patients' and health care providers' replies to the questionnaires. There was a general trend for higher scores in patients' usability reports at later follow-ups, in which the score related to overall comfort with using the technology increased from 3.0 (SD 1.4) to 4.0 (SD 0.7) (P=.40) and comfort with wearing and adjusting the measuring thoracic belt increased from 2.8 (SD 1.0) to 4.2 (SD 0.4) (P=.02). Conclusions: Despite the gravity of their HF pathology and the complexity of their comorbid profile, patients are comfortable in using the V-LAP technology and, in the majority of cases, they can correctly and consistently acquire and transmit hemodynamic data. Although the overall patient/care provider satisfaction with the V-LAP system seems to be acceptable, improvements can be achieved after ameliorating the design of the measuring tools. Trial Registration: ClincalTrials.gov NCT03775161; https://clinicaltrials.gov/ct2/show/NCT03775161 ",
doi="10.2196/21055",
url="https://cardio.jmir.org/2021/1/e21055",
url="http://www.ncbi.nlm.nih.gov/pubmed/33881400"
}


@Article{info:doi/10.2196/26167,
author="Yang, Yun Tien
and Huang, Li
and Malwade, Shwetambara
and Hsu, Chien-Yi
and Chen, Ching Yang",
title="Diagnostic Accuracy of Ambulatory Devices in Detecting Atrial Fibrillation: Systematic Review and Meta-analysis",
journal="JMIR Mhealth Uhealth",
year="2021",
month="Apr",
day="9",
volume="9",
number="4",
pages="e26167",
keywords="atrial fibrillation",
keywords="ambulatory devices",
keywords="electrocardiogram",
keywords="photoplethysmography",
keywords="diagnostic accuracy",
keywords="ubiquitous health",
keywords="mobile health",
keywords="technology",
keywords="ambulatory device",
abstract="Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide. Early diagnosis of AF is crucial for preventing AF-related morbidity, mortality, and economic burden, yet the detection of the disease remains challenging. The 12-lead electrocardiogram (ECG) is the gold standard for the diagnosis of AF. Because of technological advances, ambulatory devices may serve as convenient screening tools for AF. Objective: The objective of this review was to investigate the diagnostic accuracy of 2 relatively new technologies used in ambulatory devices, non-12-lead ECG and photoplethysmography (PPG), in detecting AF. We performed a meta-analysis to evaluate the diagnostic accuracy of non-12-lead ECG and PPG compared to the reference standard, 12-lead ECG. We also conducted a subgroup analysis to assess the impact of study design and participant recruitment on diagnostic accuracy. Methods: This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. MEDLINE and EMBASE were systematically searched for articles published from January 1, 2015 to January 23, 2021. A bivariate model was used to pool estimates of sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and area under the summary receiver operating curve (SROC) as the main diagnostic measures. Study quality was evaluated using the quality assessment of diagnostic accuracy studies (QUADAS-2) tool. Results: Our search resulted in 16 studies using either non-12-lead ECG or PPG for detecting AF, comprising 3217 participants and 7623 assessments. The pooled estimates of sensitivity, specificity, PLR, NLR, and diagnostic odds ratio for the detection of AF were 89.7\% (95\% CI 83.2\%-93.9\%), 95.7\% (95\% CI 92.0\%-97.7\%), 20.64 (95\% CI 10.10-42.15), 0.11 (95\% CI 0.06-0.19), and 224.75 (95\% CI 70.10-720.56), respectively, for the automatic interpretation of non-12-lead ECG measurements and 94.7\% (95\% CI 93.3\%-95.8\%), 97.6\% (95\% CI 94.5\%-99.0\%), 35.51 (95\% CI 18.19-69.31), 0.05 (95\% CI 0.04-0.07), and 730.79 (95\% CI 309.33-1726.49), respectively, for the automatic interpretation of PPG measurements. Conclusions: Both non-12-lead ECG and PPG offered high diagnostic accuracies for AF. Detection employing automatic analysis techniques may serve as a useful preliminary screening tool before administering a gold standard test, which generally requires competent physician analyses. Subgroup analysis indicated variations of sensitivity and specificity between studies that recruited low-risk and high-risk populations, warranting future validity tests in the general population. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42020179937; https://www.crd.york.ac.uk/prospero/display\_record.php?RecordID=179937 ",
doi="10.2196/26167",
url="https://mhealth.jmir.org/2021/4/e26167",
url="http://www.ncbi.nlm.nih.gov/pubmed/33835039"
}


@Article{info:doi/10.2196/24461,
author="Beerten, Gabri{\"e}l Simon
and Proesmans, Tine
and Vaes, Bert",
title="A Heart Rate Monitoring App (FibriCheck) for Atrial Fibrillation in General Practice: Pilot Usability Study",
journal="JMIR Form Res",
year="2021",
month="Apr",
day="7",
volume="5",
number="4",
pages="e24461",
keywords="atrial fibrillation",
keywords="smartphone app",
keywords="FibriCheck",
keywords="primary care",
abstract="Background: Atrial fibrillation (AF) is a major risk factor for stroke. The current opportunistic screening procedure consists of pulse palpation and an electrocardiogram when an irregular rhythm is found. Smartphone apps that measure heart rhythm could be useful in increasing the detection of AF in a primary care setting. Objective: We conducted a pilot study with the smartphone app FibriCheck to assess whether the introduction of such an app is feasible. Methods: Four general practices across Flanders provided patient data for the study. Inclusion criteria for participants were aged 65 or older and a CHARGE-AF score of at least 10\%. We excluded patients with known AF or a pacemaker. Participants were asked to measure at least twice a day with FibriCheck (for at least 14 days). They were provided the 36-Item Short Form Survey (SF-36) questionnaire both before and after the study, as well as different surveys concerning their user experience and general perception of technology. Results: There were 92 participants (36 women and 56 men). The study population was relatively homogenous concerning risk factors and medication use at baseline. During the study period, 5/86 (6\%) participants were found to have AF (6 dropouts). The average study period was 23 days and the average number of measurements per day was 2.1. Patient compliance was variable, but high. On the whole, there were no appreciable changes in quality of life. The overall user experience and satisfaction were very high. Conclusions: FibriCheck is a relatively easy-to-use smartphone app to complement AF screening in primary care. Its implementation in this setting is certainly achievable, and one can expect high rates of patient compliance. Based on these results, a planned cluster randomized trial will be going ahead. Trial Registration: ClinicalTrials.gov NCT03509493; https://clinicaltrials.gov/ct2/show/NCT03509493 ",
doi="10.2196/24461",
url="https://formative.jmir.org/2021/4/e24461",
url="http://www.ncbi.nlm.nih.gov/pubmed/33825692"
}


@Article{info:doi/10.2196/25313,
author="Muggeridge, Joseph David
and Hickson, Kirsty
and Davies, Victoria Aimie
and Giggins, M. Oonagh
and Megson, L. Ian
and Gorely, Trish
and Crabtree, R. Daniel",
title="Measurement of Heart Rate Using the Polar OH1 and Fitbit Charge 3 Wearable Devices in Healthy Adults During Light, Moderate, Vigorous, and Sprint-Based Exercise: Validation Study",
journal="JMIR Mhealth Uhealth",
year="2021",
month="Mar",
day="25",
volume="9",
number="3",
pages="e25313",
keywords="heart rate",
keywords="photoplethysmography",
keywords="wearable electronic devices",
keywords="validation study",
keywords="exercise",
keywords="mobile phone",
abstract="Background: Accurate, continuous heart rate measurements are important for health assessment, physical activity, and sporting performance, and the integration of heart rate measurements into wearable devices has extended its accessibility. Although the use of photoplethysmography technology is not new, the available data relating to the validity of measurement are limited, and the range of activities being performed is often restricted to one exercise domain and/or limited intensities. Objective: The primary objective of this study was to assess the validity of the Polar OH1 and Fitbit Charge 3 devices for measuring heart rate during rest, light, moderate, vigorous, and sprint-type exercise. Methods: A total of 20 healthy adults (9 female; height: mean 1.73 [SD 0.1] m; body mass: mean 71.6 [SD 11.0] kg; and age: mean 40 [SD 10] years) volunteered and provided written informed consent to participate in the study consisting of 2 trials. Trial 1 was split into 3 components: 15-minute sedentary activities, 10-minute cycling on a bicycle ergometer, and incremental exercise test to exhaustion on a motorized treadmill (18-42 minutes). Trial 2 was split into 2 components: 4 {\texttimes} 15-second maximal sprints on a cycle ergometer and 4 {\texttimes} 30- to 50-m sprints on a nonmotorized resistance treadmill. Data from the 3 devices were time-aligned, and the validity of Polar OH1 and Fitbit Charge 3 was assessed against Polar H10 (criterion device). Validity was evaluated using the Bland and Altman analysis, Pearson moment correlation coefficient, and mean absolute percentage error. Results: Overall, there was a very good correlation between the Polar OH1 and Polar H10 devices (r=0.95), with a mean bias of ?1 beats{\textperiodcentered}min-1 and limits of agreement of ?20 to 19 beats{\textperiodcentered}min-1. The Fitbit Charge 3 device underestimated heart rate by 7 beats{\textperiodcentered}min-1 compared with Polar H10, with a limit of agreement of ?46 to 33 beats{\textperiodcentered}min-1 and poor correlation (r=0.8). The mean absolute percentage error for both devices was deemed acceptable (<5\%). Polar OH1 performed well across each phase of trial 1; however, validity was worse for trial 2 activities. Fitbit Charge 3 performed well only during rest and nonsprint-based treadmill activities. Conclusions: Compared with our criterion device, Polar OH1 was accurate at assessing heart rate, but the accuracy of Fitbit Charge 3 was generally poor. Polar OH1 performed worse during trial 2 compared with the activities in trial 1, and the validity of the Fitbit Charge 3 device was particularly poor during our cycling exercises. ",
doi="10.2196/25313",
url="https://mhealth.jmir.org/2021/3/e25313",
url="http://www.ncbi.nlm.nih.gov/pubmed/33764310"
}


@Article{info:doi/10.2196/24501,
author="Lu{\vs}trek, Mitja
and Bohanec, Marko
and Cavero Barca, Carlos
and Ciancarelli, Costanza Maria
and Clays, Els
and Dawodu, Adeyemo Amos
and Derboven, Jan
and De Smedt, Delphine
and Dovgan, Erik
and Lampe, Jure
and Marino, Flavia
and Mlakar, Miha
and Pioggia, Giovanni
and Puddu, Emilio Paolo
and Rodr{\'i}guez, Mario Juan
and Schiariti, Michele
and Slapni{\v c}ar, Ga{\vs}per
and Slegers, Karin
and Tartarisco, Gennaro
and Vali{\v c}, Jakob
and Vodopija, Aljo{\vs}a",
title="A Personal Health System for Self-Management of Congestive Heart Failure (HeartMan): Development, Technical Evaluation, and Proof-of-Concept Randomized Controlled Trial",
journal="JMIR Med Inform",
year="2021",
month="Mar",
day="5",
volume="9",
number="3",
pages="e24501",
keywords="congestive heart failure",
keywords="personal health system",
keywords="mobile application",
keywords="mobile phone",
keywords="wearable electronic devices",
keywords="decision support techniques",
keywords="psychological support",
keywords="human centered design",
abstract="Background: Congestive heart failure (CHF) is a disease that requires complex management involving multiple medications, exercise, and lifestyle changes. It mainly affects older patients with depression and anxiety, who commonly find management difficult. Existing mobile apps supporting the self-management of CHF have limited features and are inadequately validated. Objective: The HeartMan project aims to develop a personal health system that would comprehensively address CHF self-management by using sensing devices and artificial intelligence methods. This paper presents the design of the system and reports on the accuracy of its patient-monitoring methods, overall effectiveness, and patient perceptions. Methods: A mobile app was developed as the core of the HeartMan system, and the app was connected to a custom wristband and cloud services. The system features machine learning methods for patient monitoring: continuous blood pressure (BP) estimation, physical activity monitoring, and psychological profile recognition. These methods feed a decision support system that provides recommendations on physical health and psychological support. The system was designed using a human-centered methodology involving the patients throughout development. It was evaluated in a proof-of-concept trial with 56 patients. Results: Fairly high accuracy of the patient-monitoring methods was observed. The mean absolute error of BP estimation was 9.0 mm Hg for systolic BP and 7.0 mm Hg for diastolic BP. The accuracy of psychological profile detection was 88.6\%. The F-measure for physical activity recognition was 71\%. The proof-of-concept clinical trial in 56 patients showed that the HeartMan system significantly improved self-care behavior (P=.02), whereas depression and anxiety rates were significantly reduced (P<.001), as were perceived sexual problems (P=.01). According to the Unified Theory of Acceptance and Use of Technology questionnaire, a positive attitude toward HeartMan was seen among end users, resulting in increased awareness, self-monitoring, and empowerment. Conclusions: The HeartMan project combined a range of advanced technologies with human-centered design to develop a complex system that was shown to help patients with CHF. More psychological than physical benefits were observed. Trial Registration: ClinicalTrials.gov NCT03497871; https://clinicaltrials.gov/ct2/history/NCT03497871. International Registered Report Identifier (IRRID): RR2-10.1186/s12872-018-0921-2 ",
doi="10.2196/24501",
url="https://medinform.jmir.org/2021/3/e24501",
url="http://www.ncbi.nlm.nih.gov/pubmed/33666562"
}


@Article{info:doi/10.2196/21986,
author="Kapoor, Alok
and Andrade, Andreza
and Hayes, Anna
and Mazor, Kathleen
and Possidente, Carl
and Nolen, Kim
and Hegeman-Dingle, Rozelle
and McManus, David",
title="Usability, Perceived Usefulness, and Shared Decision-Making Features of the AFib 2gether Mobile App: Protocol for a Single-Arm Intervention Study",
journal="JMIR Res Protoc",
year="2021",
month="Feb",
day="24",
volume="10",
number="2",
pages="e21986",
keywords="shared decision making",
keywords="mobile health",
keywords="stroke risk",
keywords="anticoagulation risk",
keywords="anticoagulation education",
keywords="atrial fibrillation",
keywords="anticoagulation therapy",
keywords="anticoagulation",
keywords="atrial flutter",
keywords="mobile phone",
abstract="Background: The Centers for Disease Control and Prevention has estimated that atrial fibrillation (AF) affects between 2.7 million and 6.1 million people in the United States. Those who have AF tend to have a much higher stroke risk than others. Although most individuals with AF benefit from anticoagulation (AC) therapy, a significant majority are hesitant to start it. To add, providers often struggle in helping patients negotiate the decision to start AC therapy. To assist in the communication between patients and providers regarding preferences and knowledge about AC therapy, different strategies are being used to try and solve this problem. In this research study, we will have patients and providers utilize the AFib 2gether app with hopes that it will create a platform for shared decision making regarding the prevention of stroke in patients with AF receiving AC therapy. Objective: The aim of our study is to measure several outcomes related to encounters between patients and their cardiology providers where AFib 2gether is used. These outcomes include usability and perceived usefulness of the app from the perspective of patients and providers. In addition, we will assess the extent and nature of shared decision making. Methods: Eligible patients and providers will evaluate the AFib 2gether mobile app for usability and perceived usefulness in facilitating shared decision making regarding understanding the patient's risk of stroke and whether or not to start AC therapy. Both patients and providers will review the app and complete multiple questionnaires about the usability and perceived usefulness of the mobile app in a clinical setting. We will also audio-record a subset of encounters to assess for evidence of shared decision making. Results: Enrollment in the AFib 2gether shared decision-making study is still ongoing for both patients and providers. The first participant enrolled on November 22, 2019. Analysis and publishing of results are expected to be completed in spring 2021. Conclusions: The AFib 2gether app emerged from a desire to increase the ability of patients and providers to engage in shared decision making around understanding the risk of stroke and AC therapy. We anticipate that the AFib 2gether mobile app will facilitate patient discussion with their cardiologist and other providers. Additionally, we hope the study will help us identify barriers that providers face when placing patients on AC therapy. We aim to demonstrate the usability and perceived usefulness of the app with a future goal of testing the value of our approach in a larger sample of patients and providers at multiple medical centers across the country. Trial Registration: ClinicalTrials.gov NCT04118270;  https://clinicaltrials.gov/ct2/show/NCT04118270 International Registered Report Identifier (IRRID): DERR1-10.2196/21986 ",
doi="10.2196/21986",
url="https://www.researchprotocols.org/2021/2/e21986",
url="http://www.ncbi.nlm.nih.gov/pubmed/33625361"
}


@Article{info:doi/10.2196/18834,
author="Spaulding, M. Erin
and Marvel, A. Francoise
and Piasecki, J. Rebecca
and Martin, S. Seth
and Allen, K. Jerilyn",
title="User Engagement With Smartphone Apps and Cardiovascular Disease Risk Factor Outcomes: Systematic Review",
journal="JMIR Cardio",
year="2021",
month="Feb",
day="3",
volume="5",
number="1",
pages="e18834",
keywords="mHealth",
keywords="smartphone",
keywords="mobile phone",
keywords="engagement",
keywords="cardiovascular disease",
keywords="health behaviors",
keywords="risk factors",
abstract="Background: The use of mobile health (mHealth) interventions, including smartphone apps, for the prevention of cardiovascular disease (CVD) has demonstrated mixed results for obesity, hypercholesterolemia, diabetes, and hypertension management. A major factor attributing to the variation in mHealth study results may be mHealth user engagement. Objective: This systematic review aims to determine if user engagement with smartphone apps for the prevention and management of CVD is associated with improved CVD health behavior change and risk factor outcomes. Methods: We conducted a comprehensive search of PubMed, CINAHL, and Embase databases from 2007 to 2020. Studies were eligible if they assessed whether user engagement with a smartphone app used by an individual to manage his or her CVD risk factors was associated with the CVD health behavior change or risk factor outcomes. For eligible studies, data were extracted on study and sample characteristics, intervention description, app user engagement measures, and the relationship between app user engagement and the CVD risk factor outcomes. App user engagement was operationalized as general usage (eg, number of log-ins or usage days per week) or self-monitoring within the app (eg, total number of entries made in the app). The quality of the studies was assessed. Results: Of the 24 included studies, 17 used a randomized controlled trial design, 4 used a retrospective analysis, and 3 used a single-arm pre- and posttest design. Sample sizes ranged from 55 to 324,649 adults, with 19 studies recruiting participants from a community setting. Most of the studies assessed weight loss interventions, with 6 addressing additional CVD risk factors, including diabetes, sleep, stress, and alcohol consumption. Most of the studies that assessed the relationship between user engagement and reduction in weight (9/13, 69\%), BMI (3/4, 75\%), body fat percentage (1/2, 50\%), waist circumference (2/3, 67\%), and hemoglobin A1c (3/5, 60\%) found statistically significant results, indicating that greater app user engagement was associated with better outcomes. Of 5 studies, 3 (60\%) found a statistically significant relationship between higher user engagement and an increase in objectively measured physical activity. The studies assessing the relationship between user engagement and dietary and diabetes self-care behaviors, blood pressure, and lipid panel components did not find statistically significant results. Conclusions: Increased app user engagement for prevention and management of CVD may be associated with improved weight and BMI; however, only a few studies assessed other outcomes, limiting the evidence beyond this. Additional studies are needed to assess user engagement with smartphone apps targeting other important CVD risk factors, including dietary behaviors, hypercholesterolemia, diabetes, and hypertension. Further research is needed to assess mHealth user engagement in both inpatient and outpatient settings to determine the effect of integrating mHealth interventions into the existing clinical workflow and on CVD outcomes. ",
doi="10.2196/18834",
url="http://cardio.jmir.org/2021/1/e18834/",
url="http://www.ncbi.nlm.nih.gov/pubmed/33533730"
}


@Article{info:doi/10.2196/26155,
author="Lokker, Cynthia
and Jezrawi, Rita
and Gabizon, Itzhak
and Varughese, Jobin
and Brown, Michael
and Trottier, Dan
and Alvarez, Elizabeth
and Schwalm, Jon-David
and McGillion, Michael
and Ma, Jinhui
and Bhagirath, Vinai",
title="Feasibility of a Web-Based Platform (Trial My App) to Efficiently Conduct Randomized Controlled Trials of mHealth Apps For Patients With Cardiovascular Risk Factors: Protocol For Evaluating an mHealth App for Hypertension",
journal="JMIR Res Protoc",
year="2021",
month="Feb",
day="1",
volume="10",
number="2",
pages="e26155",
keywords="mHealth",
keywords="mobile health",
keywords="hypertension",
keywords="app",
keywords="patient-oriented",
keywords="feasibility",
keywords="cardiovascular disease",
keywords="internet-administered",
keywords="randomized controlled trial",
abstract="Background: Mobile health (mHealth) interventions can improve health by improving cardiovascular risk factors, but their adoption in care by physicians and patients is untapped. Few mHealth apps have been evaluated in clinical trials, and due to the fast pace of technological development, those previously evaluated are often outdated by the time trial results are available. Given the rapid pace of change in this field, it is not feasible to rigorously evaluate mHealth apps with current methodologies. Objective: The overall aim of this pilot study was to test the feasibility of using a web research platform called Trial My App to conduct efficient and rigorous web-based randomized controlled trials (RCTs) of mHealth apps relevant to patients with cardiovascular risk factors by evaluating an app that targets hypertension. Methods: For this study, 200 participants with suboptimally controlled hypertension will be recruited through advertisements in newsletters, media, and the internet, as well as through referrals from their health care providers. Screening, consent, randomization, and collection of patient-important health confidence and self-management ability outcomes will be conducted online through the Trial My App research platform. Participants will be randomized into 2 groups: 100 that will use an mHealth app for tracking hypertension and 100 that will be considered as an educational control. All participants will complete questionnaires at 0, 1, 3 and 6 months after enrolment. A substudy to validate the method of blood pressure readings and the consistency of data entered through Trial My App will be conducted with 40 participants. Results: The development of the Trial My App web platform has been completed. The creation of survey instruments has been completed in collaboration with our patient partners and advisory board. Recruitment is expected to begin in the first quarter of 2021; data collection and analysis are expected to be completed approximately 1 year after study commencement. Results will be disseminated through conferences and publications. The primary outcomes of this study include the feasibility of conducting an RCT using the Trial My App platform by reporting recruitment, retention, and completion statistics. We will validate app-entered data with a standard 7-day home blood pressure measurement method. Lastly, the pilot, nonblinded RCT will assess the effectiveness of the mHealth app in improving the control of hypertension compared with the control of hypertension in the educational control group. Conclusions: This study will determine if it is feasible to use the Trial My App web-based platform to evaluate the effectiveness of mHealth apps for patients with cardiovascular risk factors. As more mHealth apps are evaluated in RCTs, patients will be able to select apps that meet their needs and physicians will be able to make evidence-based recommendations to their patients for apps aimed at improving cardiovascular health. Trial Registration: ClinicalTrials.gov NCT04528654; https://clinicaltrials.gov/ct2/show/NCT04528654 International Registered Report Identifier (IRRID): PRR1-10.2196/26155 ",
doi="10.2196/26155",
url="https://www.researchprotocols.org/2021/2/e26155",
url="http://www.ncbi.nlm.nih.gov/pubmed/33522978"
}


@Article{info:doi/10.2196/25424,
author="Lakshminarayan, Kamakshi
and Murray, A. Thomas
and Westberg, M. Sarah
and Connett, John
and Overton, Val
and Nyman, A. John
and Culhane-Pera, A. Kathleen
and Pergament, L. Shannon
and Drawz, Paul
and Vollbrecht, Emily
and Xiong, Txia
and Everson-Rose, A. Susan",
title="Mobile Health Intervention to Close the Guidelines-To-Practice Gap in Hypertension Treatment: Protocol for the mGlide Randomized Controlled Trial",
journal="JMIR Res Protoc",
year="2021",
month="Jan",
day="25",
volume="10",
number="1",
pages="e25424",
keywords="hypertension",
keywords="mobile health technology",
keywords="health disparities",
keywords="randomized controlled trial",
abstract="Background: Suboptimal treatment of hypertension remains a widespread problem, particularly among minorities and socioeconomically disadvantaged groups. We present a health system--based intervention with diverse patient populations using readily available smartphone technology. This intervention is designed to empower patients and create partnerships between patients and their provider team to promote hypertension control. Objective: The mGlide randomized controlled trial is a National Institutes of Health--funded study, evaluating whether a mobile health (mHealth)-based intervention that is an active partnership between interprofessional health care teams and patients results in better hypertension control rates than a state-of-clinical care comparison. Methods: We are recruiting 450 participants including stroke survivors and primary care patients with elevated cardiovascular disease risk from diverse health systems. These systems include an acute stroke service (n=100), an academic medical center (n=150), and community medical centers including Federally Qualified Health Centers serving low-income and minority (Latino, Hmong, African American, Somali) patients (n=200). The primary aim tests the clinical effectiveness of the 6-month mHealth intervention versus standard of care. Secondary aims evaluate sustained hypertension control rates at 12 months; describe provider experiences of system usability and satisfaction; examine patient experiences, including medication adherence and medication use self-efficacy, self-rated health and quality of life, and adverse event rates; and complete a cost-effectiveness analysis. Results: To date, we have randomized 107 participants (54 intervention, 53 control). Conclusions: This study will provide evidence for whether a readily available mHealth care model is better than state-of-clinical care for bridging the guideline-to-practice gap in hypertension treatment in health systems serving diverse patient populations. Trial Registration: Clinicaltrials.gov NCT03612271; https://clinicaltrials.gov/ct2/show/NCT03612271 International Registered Report Identifier (IRRID): DERR1-10.2196/25424 ",
doi="10.2196/25424",
url="http://www.researchprotocols.org/2021/1/e25424/",
url="http://www.ncbi.nlm.nih.gov/pubmed/33492231"
}


@Article{info:doi/10.2196/19465,
author="Wei, S. Kevin
and Ibrahim, E. Nasrien
and Kumar, A. Ashok
and Jena, Sidhant
and Chew, Veronica
and Depa, Michal
and Mayanil, Namrata
and Kvedar, C. Joseph
and Gaggin, K. Hanna",
title="Habits Heart App for Patient Engagement in Heart Failure Management: Pilot Feasibility Randomized Trial",
journal="JMIR Mhealth Uhealth",
year="2021",
month="Jan",
day="20",
volume="9",
number="1",
pages="e19465",
keywords="heart failure",
keywords="smartphone application",
keywords="heart failure management",
abstract="Background: Due to the complexity and chronicity of heart failure, engaging yet simple patient self-management tools are needed. Objective: This study aimed to assess the feasibility and patient engagement with a smartphone app designed for heart failure. Methods: Patients with heart failure were randomized to intervention (smartphone with the Habits Heart App installed and Bluetooth-linked scale) or control (paper education material) groups. All intervention group patients were interviewed and monitored closely for app feasibility while receiving standard of care heart failure management by cardiologists. The Atlanta Heart Failure Knowledge Test, a quality of life survey (Kansas City Cardiomyopathy Questionnaire), and weight were assessed at baseline and final visits. Results: Patients (N=28 patients; intervention: n=15; control: n=13) with heart failure (with reduced ejection fraction: 15/28, 54\%; male: 20/28, 71\%, female: 8/28, 29\%; median age 63 years) were enrolled, and 82\% of patients (N=23; intervention: 12/15, 80\%; control: 11/13, 85\%) completed both baseline and final visits (median follow up 60 days). In the intervention group, 2 out of the 12 patients who completed the study did not use the app after study onboarding due to illnesses and hospitalizations. Of the remaining 10 patients who used the app, 5 patients logged ?1 interaction with the app per day on average, and 2 patients logged an interaction with the app every other day on average. The intervention group averaged 403 screen views (per patient) in 56 distinct sessions, 5-minute session durations, and 22 weight entries per patient. There was a direct correlation between duration of app use and improvement in heart failure knowledge (Atlanta Heart Failure Knowledge Test score; $\rho$=0.59, P=.04) and quality of life (Kansas City Cardiomyopathy Questionnaire score; $\rho$=0.63, P=.03). The correlation between app use and weight change was $\rho$=--0.40 (P=.19). Only 1 out of 11 patients in the control group retained education material by the follow-up visit. Conclusions: The Habits Heart App with a Bluetooth-linked scale is a feasible way to engage patients in heart failure management, and barriers to app engagement were identified. A larger multicenter study may be warranted to evaluate the effectiveness of the app. Trial Registration: ClinicalTrials.gov NCT03238729; http://clinicaltrials.gov/ct2/show/NCT03238729 ",
doi="10.2196/19465",
url="http://mhealth.jmir.org/2021/1/e19465/",
url="http://www.ncbi.nlm.nih.gov/pubmed/33470941"
}


@Article{info:doi/10.2196/16114,
author="M{\"u}ller, Dueholm Sune
and Lauridsen, Glerup Kasper
and Palic, Hadrovic Amra
and Frederiksen, Nygaard Lotte
and Mathiasen, Morten
and L{\o}fgren, Bo",
title="Mobile App Support for Cardiopulmonary Resuscitation: Development and Usability Study",
journal="JMIR Mhealth Uhealth",
year="2021",
month="Jan",
day="5",
volume="9",
number="1",
pages="e16114",
keywords="the Kano model",
keywords="cardiopulmonary resuscitation",
keywords="healthcare",
keywords="smartphone apps",
keywords="public health",
keywords="ALS CPR algorithm",
keywords="app evaluation",
keywords="mobile phone",
abstract="Background: The user requirements for in-hospital cardiopulmonary resuscitation (CPR) support apps are understudied. To study usability, functionality, and design based on user requirements, we applied a mixed methods research design using interviews, observations, and a Kano questionnaire to survey perspectives of both physicians and nurses. Objective: This study aims to identify what an in-hospital CPR support app should include to meet the requirements and expectations of health care professionals by evaluating the CprPrototype app. Methods: We used a mixed methods research design. The qualitative methods consisted of semistructured interviews and observations from an advanced life support (ALS) course; both provided input to the subsequent questionnaire development. The quantitative method is a questionnaire based on the Kano model classifying user requirements as must-be, one-dimensional (attributes causing satisfaction when present and dissatisfaction when absent), attractive, indifferent, and reverse (attributes causing dissatisfaction when present and satisfaction when absent). The questionnaire was supplemented with comment fields. All respondents were physicians and nurses providing ALS at hospitals in the Central Denmark Region. Results: A total of 83 physicians and nurses responded to the questionnaire, 15 physicians and nurses were observed during ALS training, and 5 physicians were interviewed. On the basis of the Kano questionnaire, 53\% (9/17) of requirements were classified as indifferent, 29\% (5/17) as attractive, and 18\% (3/17) as one-dimensional. The comments revealed 7 different categories of user requirements with noticeable differences between those of physicians and nurses: technological challenges, keep track of time, documentation and history, disturbing element, improvement areas: functions, improvement areas: design, and better guidance. Conclusions: The study provides recommendations to developers on the user requirements that need to be addressed when developing CPR support apps. Three features (one-dimensional attributes) must be incorporated in an in-hospital CPR support app: reminder of rhythm check, reminder of resuscitation drugs, and differentiate between adults and children. In addition, 5 features (attractive attributes) would result in higher user satisfaction: all functions on one side, access to the patient journal in the app, automatic time recording when cardiac arrest is called, sound to guide the chest compression rate (metronome), and send CPR history to the DANARREST(Danish in-hospital cardiac arrest registry) database. ",
doi="10.2196/16114",
url="https://mhealth.jmir.org/2021/1/e16114",
url="http://www.ncbi.nlm.nih.gov/pubmed/33399539"
}


@Article{info:doi/10.2196/20776,
author="Gade, Dam Josefine
and Spindler, Helle
and Hollingdal, Malene
and Refsgaard, Jens
and Dittmann, Lars
and Frost, Lars
and Mahboubi, Kiomars
and Dinesen, Birthe",
title="Predictors of Walking Activity in Patients With Systolic Heart Failure Equipped With a Step Counter: Randomized Controlled Trial",
journal="JMIR Biomed Eng",
year="2020",
month="Nov",
day="30",
volume="5",
number="1",
pages="e20776",
keywords="heart failure",
keywords="cardiovascular rehabilitation",
keywords="step counters",
keywords="physical activity",
keywords="telerehabilitation",
abstract="Background: Physical activity has been shown to decrease cardiovascular mortality and morbidity. Walking, a simple physical activity which is an integral part of daily life, is a feasible and safe activity for patients with heart failure (HF). A step counter, measuring daily walking activity, might be a motivational factor for increased activity. Objective: The aim of this study was to examine the association between walking activity and demographical and clinical data of patients with HF, and whether these associations could be used as predictors of walking activity. Methods: A total of 65 patients with HF from the Future Patient Telerehabilitation (FPT) program were included in this study. The patients monitored their daily activity using a Fitbit step counter for 1 year. This monitoring allowed for continuous and safe data transmission of self-monitored activity data. Results: A higher walking activity was associated with younger age, lower New York Heart Association (NYHA) classification, and higher ejection fraction (EF). There was a statistically significant correlation between the number of daily steps and NYHA classification at baseline (P=.01), between the increase in daily steps and EF at baseline (P<.001), and between the increase in daily steps and improvement in EF (P=.005). The patients' demographic, clinical, and activity data could predict 81\% of the variation in daily steps. Conclusions: This study demonstrated an association between demographic, clinical, and activity data for patients with HF that could predict daily steps. A step counter can thus be a useful tool to help patients monitor their own physical activity. Trial Registration: ClinicalTrials.gov NCT03388918; https://clinicaltrials.gov/ct2/show/NCT03388918 International Registered Report Identifier (IRRID): RR2-10.2196/14517 ",
doi="10.2196/20776",
url="http://biomedeng.jmir.org/2020/1/e20776/"
}


@Article{info:doi/10.2196/19065,
author="Gomis-Pastor, Mar
and Mirabet, Sonia
and Roig, Eulalia
and Lopez, Laura
and Brossa, Vicens
and Galvez-Tugas, Elisabeth
and Rodriguez-Murphy, Esther
and Feliu, Anna
and Ontiveros, Gerardo
and Garcia-Cuy{\`a}s, Francesc
and Salazar, Albert
and Mangues, Antonia M.",
title="Interdisciplinary Mobile Health Model to Improve Clinical Care After Heart Transplantation: Implementation Strategy Study",
journal="JMIR Cardio",
year="2020",
month="Nov",
day="24",
volume="4",
number="1",
pages="e19065",
keywords="cardiology",
keywords="heart transplantation",
keywords="implementation strategy",
keywords="health care model",
keywords="integrated health care systems",
keywords="interdisciplinary health team",
keywords="medication therapy management",
keywords="health care technology",
keywords="mHealth",
keywords="eHealth",
abstract="Background: Solid organ transplantation could be the only life-saving treatment for end-stage heart failure. Nevertheless, multimorbidity and polypharmacy remain major problems after heart transplant. A technology-based behavioral intervention model was established to improve clinical practice in a heart transplant outpatient setting. To support the new strategy, the mHeart app, a mobile health (mHealth) tool, was developed for use by patients and providers. Objective: The primary objective of this study was to describe the implementation of the mHeart model and to outline the main facilitators identified when conceiving an mHealth approach. The secondary objectives were to evaluate the barriers, benefits, and willingness to use mHealth services reported by heart transplant recipients and cardiology providers. Methods: This was an implementation strategy study directed by a multidisciplinary cardiology team conducted in four stages: design of the model and the software, development of the mHeart tool, interoperability among systems, and quality and security requirements. A mixed methods study design was applied combining a literature review, several surveys, interviews, and focus groups. The approach involved merging engineering and behavioral theory science. Participants were chronic-stage heart transplant recipients, patient associations, health providers, stakeholders, and diverse experts from the legal, data protection, and interoperability fields. Results: An interdisciplinary and patient-centered process was applied to obtain a comprehensive care model. The heart transplant recipients (N=135) included in the study confirmed they had access to smartphones (132/135, 97.7\%) and were willing to use the mHeart system (132/135, 97.7\%). Based on stakeholder agreement (>75\%, N=26), the major priorities identified of the mHealth approach were to improve therapy management, patient empowerment, and patient-provider interactions. Stakeholder agreement on the barriers to implementing the system was weak (<75\%). Establishing the new model posed several challenges to the multidisciplinary team in charge. The main factors that needed to be overcome were ensuring data confidentiality, reducing workload, minimizing the digital divide, and increasing interoperability. Experts from various fields, scientific societies, and patient associations were essential to meet the quality requirements and the model scalability. Conclusions: The mHeart model will be applicable in distinct clinical and research contexts, and may inspire other cardiology health providers to create innovative ways to deal with therapeutic complexity and multimorbidity through health care systems. Professionals and patients are willing to use such innovative mHealth programs. The facilitators and key strategies described were needed for success in the implementation of the new holistic theory--based mHealth strategy. ",
doi="10.2196/19065",
url="http://cardio.jmir.org/2020/1/e19065/",
url="http://www.ncbi.nlm.nih.gov/pubmed/33231557"
}


@Article{info:doi/10.2196/19070,
author="Corazza, Francesco
and Snijders, Deborah
and Arpone, Marta
and Stritoni, Valentina
and Martinolli, Francesco
and Daverio, Marco
and Losi, Giulia Maria
and Soldi, Luca
and Tesauri, Francesco
and Da Dalt, Liviana
and Bressan, Silvia",
title="Development and Usability of a Novel Interactive Tablet App (PediAppRREST) to Support the Management of Pediatric Cardiac Arrest: Pilot High-Fidelity Simulation-Based Study",
journal="JMIR Mhealth Uhealth",
year="2020",
month="Oct",
day="1",
volume="8",
number="10",
pages="e19070",
keywords="cardiac arrest",
keywords="resuscitation",
keywords="mobile app",
keywords="high-fidelity simulation training",
keywords="cognitive aid",
keywords="pediatrics",
keywords="emergency medicine",
abstract="Background: Pediatric cardiac arrest (PCA), although rare, is associated with high mortality. Deviations from international management guidelines are frequent and associated with poorer outcomes. Different strategies/devices have been developed to improve the management of cardiac arrest, including cognitive aids. However, there is very limited experience on the usefulness of interactive cognitive aids in the format of an app in PCA. No app has so far been tested for its usability and effectiveness in guiding the management of PCA. Objective: To develop a new audiovisual interactive app for tablets, named PediAppRREST, to support the management of PCA and to test its usability in a high-fidelity simulation-based setting. Methods: A research team at the University of Padova (Italy) and human--machine interface designers, as well as app developers, from an Italian company (RE:Lab S.r.l.) developed the app between March and October 2019, by applying an iterative design approach (ie, design--prototyping--evaluation iterative loops). In October--November 2019, a single-center nonrandomized controlled simulation--based pilot study was conducted including 48 pediatric residents divided into teams of 3. The same nonshockable PCA scenario was managed by 11 teams with and 5 without the app. The app user's experience and interaction patterns were documented through video recording of scenarios, debriefing sessions, and questionnaires. App usability was evaluated with the User Experience Questionnaire (UEQ) (scores range from --3 to +3 for each scale) and open-ended questions, whereas participants' workload was measured using the NASA Raw-Task Load Index (NASA RTLX). Results: Users' difficulties in interacting with the app during the simulations were identified using a structured framework. The app usability, in terms of mean UEQ scores, was as follows: attractiveness 1.71 (SD 1.43), perspicuity 1.75 (SD 0.88), efficiency 1.93 (SD 0.93), dependability 1.57 (SD 1.10), stimulation 1.60 (SD 1.33), and novelty 2.21 (SD 0.74). Team leaders' perceived workload was comparable (P=.57) between the 2 groups; median NASA RTLX score was 67.5 (interquartile range [IQR] 65.0-81.7) for the control group and 66.7 (IQR 54.2-76.7) for the intervention group. A preliminary evaluation of the effectiveness of the app in reducing deviations from guidelines showed that median time to epinephrine administration was significantly longer in the group that used the app compared with the control group (254 seconds versus 165 seconds; P=.015). Conclusions: The PediAppRREST app received a good usability evaluation and did not appear to increase team leaders' workload. Based on the feedback collected from the participants and the preliminary results of the evaluation of its effects on the management of the simulated scenario, the app has been further refined. The effectiveness of the new version of the app in reducing deviations from guidelines recommendations in the management of PCA and its impact on time to critical actions will be evaluated in an upcoming multicenter simulation-based randomized controlled trial. ",
doi="10.2196/19070",
url="https://mhealth.jmir.org/2020/10/e19070",
url="http://www.ncbi.nlm.nih.gov/pubmed/32788142"
}


@Article{info:doi/10.2196/17703,
author="Cornet, Philip Victor
and Toscos, Tammy
and Bolchini, Davide
and Rohani Ghahari, Romisa
and Ahmed, Ryan
and Daley, Carly
and Mirro, J. Michael
and Holden, J. Richard",
title="Untold Stories in User-Centered Design of Mobile Health: Practical Challenges and Strategies Learned From the Design and Evaluation of an App for Older Adults With Heart Failure",
journal="JMIR Mhealth Uhealth",
year="2020",
month="Jul",
day="21",
volume="8",
number="7",
pages="e17703",
keywords="user-centered design",
keywords="research methods",
keywords="mobile health",
keywords="digital health",
keywords="mobile apps",
keywords="usability",
keywords="technology",
keywords="evaluation",
keywords="human-computer interaction",
keywords="mobile phone",
abstract="Background: User-centered design (UCD) is a powerful framework for creating useful, easy-to-use, and satisfying mobile health (mHealth) apps. However, the literature seldom reports the practical challenges of implementing UCD, particularly in the field of mHealth. Objective: This study aims to characterize the practical challenges encountered and propose strategies when implementing UCD for mHealth. Methods: Our multidisciplinary team implemented a UCD process to design and evaluate a mobile app for older adults with heart failure. During and after this process, we documented the challenges the team encountered and the strategies they used or considered using to address those challenges. Results: We identified 12 challenges, 3 about UCD as a whole and 9 across the UCD stages of formative research, design, and evaluation. Challenges included the timing of stakeholder involvement, overcoming designers' assumptions, adapting methods to end users, and managing heterogeneity among stakeholders. To address these challenges, practical recommendations are provided to UCD researchers and practitioners. Conclusions: UCD is a gold standard approach that is increasingly adopted for mHealth projects. Although UCD methods are well-described and easily accessible, practical challenges and strategies for implementing them are underreported. To improve the implementation of UCD for mHealth, we must tell and learn from these traditionally untold stories. ",
doi="10.2196/17703",
url="http://mhealth.jmir.org/2020/7/e17703/",
url="http://www.ncbi.nlm.nih.gov/pubmed/32706745"
}


@Article{info:doi/10.2196/16695,
author="Indraratna, Praveen
and Tardo, Daniel
and Yu, Jennifer
and Delbaere, Kim
and Brodie, Matthew
and Lovell, Nigel
and Ooi, Sze-Yuan",
title="Mobile Phone Technologies in the Management of Ischemic Heart Disease, Heart Failure, and Hypertension: Systematic Review and Meta-Analysis",
journal="JMIR Mhealth Uhealth",
year="2020",
month="Jul",
day="6",
volume="8",
number="7",
pages="e16695",
keywords="mobile phone",
keywords="text messaging",
keywords="telemedicine",
keywords="myocardial ischemia",
keywords="heart failure",
keywords="hypertension",
abstract="Background: Cardiovascular disease (CVD) remains the leading cause of death worldwide. Mobile phones have become ubiquitous in most developed societies. Smartphone apps, telemonitoring, and clinician-driven SMS allow for novel opportunities and methods in managing chronic CVD, such as ischemic heart disease, heart failure, and hypertension, and in the conduct and support of cardiac rehabilitation. Objective: A systematic review was conducted using seven electronic databases, identifying all relevant randomized control trials (RCTs) featuring a mobile phone intervention (MPI) used in the management of chronic CVD. Outcomes assessed included mortality, hospitalizations, blood pressure (BP), and BMI. Methods: Electronic data searches were performed using seven databases from January 2000 to June 2019. Relevant articles were reviewed and analyzed. Meta-analysis was performed using standard techniques. The odds ratio (OR) was used as a summary statistic for dichotomous variables. A random effect model was used. Results: A total of 26 RCTs including 6713 patients were identified and are described in this review, and 12 RCTs were included in the meta-analysis. In patients with heart failure, MPIs were associated with a significantly lower rate of hospitalizations (244/792, 30.8\% vs 287/803, 35.7\%; n=1595; OR 0.77, 95\% CI 0.62 to 0.97; P=.03; I2=0\%). In patients with hypertension, patients exposed to MPIs had a significantly lower systolic BP (mean difference 4.3 mm Hg; 95\% CI ?7.8 to ?0.78 mm Hg; n=2023; P=.02). Conclusions: The available data suggest that MPIs may have a role as a valuable adjunct in the management of chronic CVD. ",
doi="10.2196/16695",
url="https://mhealth.jmir.org/2020/7/e16695",
url="http://www.ncbi.nlm.nih.gov/pubmed/32628615"
}


@Article{info:doi/10.2196/13756,
author="Salvi, Dario
and Poffley, Emma
and Orchard, Elizabeth
and Tarassenko, Lionel",
title="The Mobile-Based 6-Minute Walk Test: Usability Study and Algorithm Development and Validation",
journal="JMIR Mhealth Uhealth",
year="2020",
month="Jan",
day="3",
volume="8",
number="1",
pages="e13756",
keywords="cardiology",
keywords="exercise test",
keywords="pulmonary hypertension",
keywords="mobile apps",
keywords="digital signal processing",
keywords="global positioning system",
abstract="Background: The 6-min walk test (6MWT) is a convenient method for assessing functional capacity in patients with cardiopulmonary conditions. It is usually performed in the context of a hospital clinic and thus requires the involvement of hospital staff and facilities, with their associated costs. Objective: This study aimed to develop a mobile phone--based system that allows patients to perform the 6MWT in the community. Methods: We developed 2 algorithms to compute the distance walked during a 6MWT using sensors embedded in a mobile phone. One algorithm makes use of the global positioning system to track the location of the phone when outdoors and hence computes the distance travelled. The other algorithm is meant to be used indoors and exploits the inertial sensors built into the phone to detect U-turns when patients walk back and forth along a corridor of fixed length. We included these algorithms in a mobile phone app, integrated with wireless pulse oximeters and a back-end server. We performed Bland-Altman analysis of the difference between the distances estimated by the phone and by a reference trundle wheel on 49 indoor tests and 30 outdoor tests, with 11 different mobile phones (both Apple iOS and Google Android operating systems). We also assessed usability aspects related to the app in a discussion group with patients and clinicians using a technology acceptance model to guide discussion. Results: The mean difference between the mobile phone-estimated distances and the reference values was ?2.013 m (SD 7.84 m) for the indoor algorithm and ?0.80 m (SD 18.56 m) for the outdoor algorithm. The absolute maximum difference was, in both cases, below the clinically significant threshold. A total of 2 pulmonary hypertension patients, 1 cardiologist, 2 physiologists, and 1 nurse took part in the discussion group, where issues arising from the use of the 6MWT in hospital were identified. The app was demonstrated to be usable, and the 2 patients were keen to use it in the long term. Conclusions: The system described in this paper allows patients to perform the 6MWT at a place of their convenience. In addition, the use of pulse oximetry allows more information to be generated about the patient's health status and, possibly, be more relevant to the real-life impact of their condition. Preliminary assessment has shown that the developed 6MWT app is highly accurate and well accepted by its users. Further tests are needed to assess its clinical value. ",
doi="10.2196/13756",
url="https://mhealth.jmir.org/2020/1/e13756",
url="http://www.ncbi.nlm.nih.gov/pubmed/31899457"
}


@Article{info:doi/10.2196/14909,
author="Zhang, Hui
and Zhang, Jie
and Li, Hong-Bao
and Chen, Yi-Xin
and Yang, Bin
and Guo, Yu-Tao
and Chen, Yun-Dai",
title="Validation of Single Centre Pre-Mobile Atrial Fibrillation Apps for Continuous Monitoring of Atrial Fibrillation in a Real-World Setting: Pilot Cohort Study",
journal="J Med Internet Res",
year="2019",
month="Dec",
day="3",
volume="21",
number="12",
pages="e14909",
keywords="atrial fibrillation",
keywords="photoplethysmography",
keywords="continuous detection",
keywords="accuracy",
keywords="smartphone",
keywords="smart band",
keywords="algorithm",
abstract="Background: Atrial fibrillation is the most common recurrent arrhythmia in clinical practice, with most clinical events occurring outside the hospital. Low detection and nonadherence to guidelines are the primary obstacles to atrial fibrillation management. Photoplethysmography is a novel technology developed for atrial fibrillation screening. However, there has been limited validation of photoplethysmography-based smart devices for the detection of atrial fibrillation and its underlying clinical factors impacting detection. Objective: This study aimed to explore the feasibility of photoplethysmography-based smart devices for the detection of atrial fibrillation in real-world settings. Methods: Subjects aged ?18 years (n=361) were recruited from September 14 to October 16, 2018, for screening of atrial fibrillation with active measurement, initiated by the users, using photoplethysmography-based smart wearable devices (ie, a smart band or smart watches). Of these, 200 subjects were also automatically and periodically monitored for 14 days with a smart band. The baseline diagnosis of ``suspected'' atrial fibrillation was confirmed by electrocardiogram and physical examination. The sensitivity and accuracy of photoplethysmography-based smart devices for monitoring atrial fibrillation were evaluated. Results: A total of 2353 active measurement signals and 23,864 periodic measurement signals were recorded. Eleven subjects were confirmed to have persistent atrial fibrillation, and 20 were confirmed to have paroxysmal atrial fibrillation. Smart devices demonstrated >91\% predictive ability for atrial fibrillation. The sensitivity and specificity of devices in detecting atrial fibrillation among active recording of the 361 subjects were 100\% and about 99\%, respectively. For subjects with persistent atrial fibrillation, 127 (97.0\%) active measurements and 2240 (99.2\%) periodic measurements were identified as atrial fibrillation by the algorithm. For subjects with paroxysmal atrial fibrillation, 36 (17\%) active measurements and 717 (19.8\%) periodic measurements were identified as atrial fibrillation by the algorithm. All persistent atrial fibrillation cases could be detected as ``atrial fibrillation episodes'' by the photoplethysmography algorithm on the first monitoring day, while 14 (70\%) patients with paroxysmal atrial fibrillation demonstrated ``atrial fibrillation episodes'' within the first 6 days. The average time to detect paroxysmal atrial fibrillation was 2 days (interquartile range: 1.25-5.75) by active measurement and 1 day (interquartile range: 1.00-2.00) by periodic measurement (P=.10). The first detection time of atrial fibrillation burden of <50\% per 24 hours was 4 days by active measurement and 2 days by periodic measurementThe first detection time of atrial fibrillation burden of >50\% per 24 hours was 1 day for both active and periodic measurements (active measurement: P=.02, periodic measurement: P=.03). Conclusions: Photoplethysmography-based smart devices demonstrated good atrial fibrillation predictive ability in both active and periodic measurements. However, atrial fibrillation type could impact detection, resulting in increased monitoring time. Trial Registration: Chinese Clinical Trial Registry of the International Clinical Trials Registry Platform of the World Health Organization ChiCTR-OOC-17014138; http://www.chictr.org.cn/showprojen.aspx?proj=24191. ",
doi="10.2196/14909",
url="https://www.jmir.org/2019/12/e14909",
url="http://www.ncbi.nlm.nih.gov/pubmed/31793887"
}


@Article{info:doi/10.2196/13173,
author="Wali, Sahr
and Demers, Catherine
and Shah, Hiba
and Wali, Huda
and Lim, Delphine
and Naik, Nirav
and Ghany, Ahmad
and Vispute, Ayushi
and Wali, Maya
and Keshavjee, Karim",
title="Evaluation of Heart Failure Apps to Promote Self-Care: Systematic App Search",
journal="JMIR Mhealth Uhealth",
year="2019",
month="Nov",
day="11",
volume="7",
number="11",
pages="e13173",
keywords="mHealth",
keywords="heart failure",
keywords="self-care",
keywords="mobile phone",
abstract="Background: Heart failure (HF) is a chronic disease that affects over 1\% of Canadians and at least 26 million people worldwide. With the continued rise in disease prevalence and an aging population, HF-related costs are expected to create a significant economic burden. Many mobile health (mHealth) apps have been developed to help support patients' self-care in the home setting, but it is unclear if they are suited to the needs or capabilities of older adults. Objective: This study aimed to identify HF apps and evaluate whether they met the criteria for optimal HF self-care. Methods: We conducted a systematic search of all apps available exclusively for HF self-care across Google Play and the App Store. We then evaluated the apps according to a list of 25 major functions pivotal to promoting HF self-care for older adults. Results: A total of 74 apps for HF self-care were identified, but only 21 apps were listed as being both HF and self-care specific. None of the apps had all 25 of the listed features for an adequate HF self-care app, and only 41\% (31/74) apps had the key weight management feature present. HF Storylines received the highest functionality score (18/25, 72\%). Conclusions: Our findings suggest that currently available apps are not adequate for use by older adults with HF. This highlights the need for mHealth apps to refine their development process so that user needs and capabilities are identified during the design stage to ensure the usability of the app. ",
doi="10.2196/13173",
url="https://mhealth.jmir.org/2019/11/e13173",
url="http://www.ncbi.nlm.nih.gov/pubmed/31710298"
}


@Article{info:doi/10.2196/14332,
author="Sohn, Albert
and Speier, William
and Lan, Esther
and Aoki, Kymberly
and Fonarow, Gregg
and Ong, Michael
and Arnold, Corey",
title="Assessment of Heart Failure Patients' Interest in Mobile Health Apps for Self-Care: Survey Study",
journal="JMIR Cardio",
year="2019",
month="Oct",
day="29",
volume="3",
number="2",
pages="e14332",
keywords="mHealth",
keywords="patient-reported outcome",
keywords="heart failure",
keywords="self-care",
keywords="patient monitoring",
abstract="Background: Heart failure is a serious public health concern that afflicts millions of individuals in the United States. Development of behaviors that promote heart failure self-care may be imperative to reduce complications and avoid hospital re-admissions. Mobile health solutions, such as activity trackers and smartphone apps, could potentially help to promote self-care through remote tracking and issuing reminders. Objective: The objective of this study was to ascertain heart failure patients' interest in a smartphone app to assist them in managing their treatment and symptoms and to determine factors that influence their interest in such an app. Methods: In the clinic waiting room on the day of their outpatient clinic appointments, 50 heart failure patients participated in a self-administered survey. The survey comprised 139 questions from previously published, institutional review board--approved questionnaires. The survey measured patients' interest in and experience using technology as well as their function, heart failure symptoms, and heart failure self-care behaviors. The Minnesota Living with Heart Failure Questionnaire (MLHFQ) was among the 11 questionnaires and was used to measure the heart failure patients' health-related quality of life through patient-reported outcomes. Results: Participants were aged 64.5 years on average, 32\% (16/50) of the participants were women, and 91\% (41/45) of the participants were determined to be New York Heart Association Class II or higher. More than 60\% (30/50) of the survey participants expressed interest in several potential features of a smartphone app designed for heart failure patients. Participant age correlated negatively with interest in tracking, tips, and reminders in multivariate regression analysis (P<.05). In contrast, MLHFQ scores (worse health status) produced positive correlations with these interests (P<.05). Conclusions: The majority of heart failure patients showed interest in activity tracking, heart failure symptom management tips, and reminder features of a smartphone app. Desirable features and an understanding of factors that influence patient interest in a smartphone app for heart failure self-care may allow researchers to address common concerns and to develop apps that demonstrate the potential benefits of mobile technology. ",
doi="10.2196/14332",
url="https://cardio.jmir.org/2019/2/e14332",
url="http://www.ncbi.nlm.nih.gov/pubmed/31758788"
}


@Article{info:doi/10.2196/13651,
author="Pald{\'a}n, Katrin
and Simanovski, Jan
and Ullrich, Greta
and Steinmetz, Martin
and Rammos, Christos
and J{\'a}nosi, Alexander Rolf
and Moebus, Susanne
and Rassaf, Tienush
and Lortz, Julia",
title="Feasibility and Clinical Relevance of a Mobile Intervention Using TrackPAD to Support Supervised Exercise Therapy in Patients With Peripheral Arterial Disease: Study Protocol for a Randomized Controlled Pilot Trial",
journal="JMIR Res Protoc",
year="2019",
month="Jun",
day="26",
volume="8",
number="6",
pages="e13651",
keywords="peripheral arterial disease",
keywords="telemedicine",
keywords="patient participation",
keywords="patient compliance",
keywords="primary health care",
abstract="Background: Peripheral arterial disease (PAD) is a common and severe disease with a highly increased cardiovascular morbidity and mortality. Through the circulatory disorder and the linked undersupply of oxygen carriers in the lower limbs, the ongoing decrease of the pain-free walking distance occurs with a significant reduction in patients' quality of life. Studies including activity monitoring for patients with PAD are rare and digital support to increase activity via mobile health technologies is mainly targeted at patients with cardiovascular disease in general. The special requirement of patients with PAD is the need to reach a certain pain level to improve the pain-free walking distance. Unfortunately, both poor adherence and availability of institutional resources are major problems in patient-centered care. Objective: The objective of this trackPAD pilot study is to evaluate the feasibility of a mobile phone--based self tracking app to promote physical activity and supervised exercise therapy (SET) in particular. We also aim for a subsequent patient centered adjustment of the app prototype based on the results of the app evaluation and process evaluation. Methods: This study was designed as a closed user group trial, with assessors blinded, and parallel group study with face-to-face components for assessment with a follow-up of 3 months. Patients with symptomatic PAD (Fontaine stage IIa or IIb) and possession of a mobile phone were eligible. Eligible participants were randomly assigned into study and control group, stratified by their distance covered in the 6-min walk test, using the software TENALEA. Participants randomized to the study group received usual care and the mobile intervention (trackPAD) for the follow-up period of 3 months, whereas participants randomized to the control group received only usual care. TrackPAD records the frequency and duration of training sessions and pain level using manual user input. Clinical outcome data were collected at the baseline and after 3 months via validated tools (6-min walk test, ankle-brachial index, and duplex ultrasound at the lower arteries) and self-reported quality of life. Usability and quality of the app was determined using the user version of the Mobile Application Rating Scale. Results: The study enrolled 45 participants with symptomatic PAD (44\% male). Of these participants, 21 (47\%) were randomized to the study group and 24 (53\%) were randomized to the control group. The distance walked in the 6-min walk test was comparable in both groups at baseline (study group: mean 368.1m [SD 77.6] vs control group: mean 394.6m [SD 100.6]). Conclusions: This is the first trial to test a mobile intervention called trackPAD that was designed especially for patients with PAD. Its results will provide important insights in terms of feasibility, effectiveness, and patient preferences of an app-based mobile intervention supporting SET for the conservative treatment of PAD. International Registered Report Identifier (IRRID): DERR1-10.2196/13651 ",
doi="10.2196/13651",
url="http://www.researchprotocols.org/2019/6/e13651/",
url="http://www.ncbi.nlm.nih.gov/pubmed/31244477"
}


@Article{info:doi/10.2196/12134,
author="Athilingam, Ponrathi
and Jenkins, Bradlee
and Redding, A. Barbara",
title="Reading Level and Suitability of Congestive Heart Failure (CHF) Education in a Mobile App (CHF Info App): Descriptive Design Study",
journal="JMIR Aging",
year="2019",
month="Apr",
day="25",
volume="2",
number="1",
pages="e12134",
keywords="health literacy",
keywords="reading level",
keywords="patient education",
keywords="heart failure",
keywords="mobile app",
abstract="Background: Education at the time of diagnosis or at discharge after an index illness is a vital component of improving outcomes in congestive heart failure (CHF). About 90 million Americans have limited health literacy and have a readability level at or below a 5th-grade level, which could affect their understanding of education provided at the time of diagnosis or discharge from hospital. Objective: The aim of this paper was to assess the suitability and readability level of a mobile phone app, the CHF Info App. Methods: A descriptive design was used to assess the reading level and suitability of patient educational materials included in the CHF Info App. The suitability assessment of patient educational materials included in the CHF Info App was independently assessed by two of the authors using the 26-item Suitability Assessment of Materials (SAM) tool. The reading grade level for each of the 10 CHF educational modules included in the CHF Info App was assessed using the comprehensive online Text Readability Consensus Calculator based on the seven most-common readability formulas: the Flesch Reading Ease Formula, the Gunning Fog Index, the Flesch-Kincaid Grade Level Formula, the Coleman-Liau Index, the Simplified Measure of Gobbledygook Index, the Automated Readability Index, and the Linsear Write Formula. The reading level included the text-scale score, the ease-of-reading score, and the corresponding grade level. Results: The educational materials included in the CHF Info App ranged from a 5th-grade to an 8th-grade reading level, with a mean of a 6th-grade level, which is recommended by the American Medical Association. The SAM tool result demonstrated adequate-to-superior levels in all four components assessed, including content, appearance, visuals, and layout and design, with a total score of 77\%, indicating superior suitability. Conclusions: The authors conclude that the CHF Info App will be suitable and meet the recommended health literacy level for American adult learners. Further testing of the CHF Info App in a longitudinal study is warranted to determine improvement in CHF knowledge. ",
doi="10.2196/12134",
url="http://aging.jmir.org/2019/1/e12134/",
url="http://www.ncbi.nlm.nih.gov/pubmed/31518265"
}


@Article{info:doi/10.2196/10755,
author="Choi, G. Brian
and Dhawan, Tania
and Metzger, Kelli
and Marshall, Lorraine
and Akbar, Awdah
and Jain, Tushina
and Young, A. Heather
and Katz, J. Richard",
title="Image-Based Mobile System for Dietary Management in an American Cardiology Population: Pilot Randomized Controlled Trial to Assess the Efficacy of Dietary Coaching Delivered via a Smartphone App Versus Traditional Counseling",
journal="JMIR Mhealth Uhealth",
year="2019",
month="Apr",
day="23",
volume="7",
number="4",
pages="e10755",
keywords="Mediterranean diet",
keywords="telemedicine",
keywords="cardiovascular disease",
keywords="randomized controlled trial",
abstract="Background: Randomized controlled trials conducted in Mediterranean countries have shown that the Mediterranean diet lowers adverse cardiovascular events. In the American population, diet remains the biggest uncontrolled risk factor for cardiovascular disease. Objective: This study aimed to test the hypothesis that asynchronous dietary counseling supplied through a custom smartphone app results in better adherence to a Mediterranean diet in a non-Mediterranean population than traditional standard-of-care (SOC) counseling. Methods: In total, 100 patients presenting to the cardiology clinic of an academic medical center were randomized to either the SOC or smartphone app-based experimental (EXP) Mediterranean diet intervention after informed consent and 1 hour of individual face-to-face dietary counseling with a registered dietitian. Participants in EXP received a custom smartphone app that reinforced the Mediterranean diet, whereas participants in SOC received 2 additional sessions of in-person dietary counseling with the registered dietitian---30 min at 1 month and 30 min at 3 months. Preexisting knowledge of a Mediterranean diet was measured by the validated Mediterranean Diet Score (MDS) instrument. Baseline height, weight, blood pressure (BP), and laboratory biomarkers were collected. At 1, 3, and 6 months, participants presented for a follow-up appointment to assess compliance to the Mediterranean diet using the MDS as well as a patient satisfaction survey, BP, and weight. Repeat laboratory biomarkers were performed at 3 and 6 months. Results: Enrolled participants had a mean age with SE of 56.6 (SD 1.7) for SOC and 57.2 (SD 1.8) for EXP; 65.3\% of SOC and 56.9\% of EXP were male, and 20.4\% of SOC and 35.3\% of EXP had coronary artery disease. There were no significant differences between EXP and SOC with regard to BP, lipid parameters, hemoglobin A1c, or C-reactive protein (CRP). Participants in EXP achieved a significantly greater weight loss on average of 3.3 pounds versus 3.1 pounds for participants in SOC, P=.04. Adherence to the Mediterranean diet increased significantly over time for both groups (P<.001), but there was no significant difference between groups (P=.69). Similarly, there was no significant difference in diet satisfaction between EXP and SOC, although diet satisfaction increased significantly over time for both groups. The proportion of participants with high Mediterranean diet compliance (defined as the MDS ?9) increased significantly over time (P<.001)---from 18.4\% to 57.1\% for SOC and 27.5\% to 64.7\% for EXP; however, there was no significant difference between the groups. Conclusions: Both traditional SOC counseling and smartphone-based counseling were effective in getting participants to adhere to a Mediterranean diet, and these dietary changes persisted even after counseling had ended. However, neither method was more effective than the other. This pilot study demonstrates that patients can change to and maintain a Mediterranean diet with either traditional or smartphone app-based nutrition counseling. Trial Registration: ClinicalTrials.gov NCT03897426;https://clinicaltrials.gov/ct2/show/NCT03897426 ",
doi="10.2196/10755",
url="https://mhealth.jmir.org/2019/4/e10755/",
url="http://www.ncbi.nlm.nih.gov/pubmed/31012860"
}


@Article{info:doi/10.2196/10809,
author="Leong, Y. Amanda
and Makowsky, J. Mark",
title="Quality of Blood Pressure Tracking Apps for the iPhone: Content Analysis and Evaluation of Adherence With Home Blood Pressure Measurement Best Practices",
journal="JMIR Mhealth Uhealth",
year="2019",
month="Apr",
day="12",
volume="7",
number="4",
pages="e10809",
keywords="hypertension",
keywords="mobile apps",
keywords="self-management",
keywords="blood pressure monitoring, ambulatory",
keywords="cross-sectional studies",
abstract="Background: Blood pressure (BP) tracking apps may aid in hypertension (HTN) self-management, but app quality may be problematic. Objective: This study aimed to develop a content-dependent rating system for BP tracking apps and systematically evaluate BP tracking features, content-independent quality, functional characteristics, and educational comprehensiveness of English language iPhone apps developed with the primary purpose of tracking a consumer's BP measurements. Methods: We created a 28-item checklist reflecting overall app quality and a simplified 2-item checklist to assess adherence with home BP monitoring best practices. Apps with educational information were evaluated for comprehensiveness on a 7-point scale and for consistency with evidence-based guidelines. Higher scores represent better quality and comprehensiveness. We searched the Canadian App Store on June 28, 2016, using the keywords hypertension and blood pressure. A total of 2 reviewers independently assessed apps according to the standardized template. We determined if paid apps, educational apps, or those rated ?4 stars were of higher quality. Results: Of the 948 apps screened, 62 met the inclusion criteria. The mean overall quality score was 12.2 (SD 4.6, out of 28) and 6 apps (10\%, 6/62) met the home BP monitoring best practice criteria. In all, 12 apps contained educational content (mean comprehensiveness 2.4, SD 1.6 out of 14), most commonly, background information on HTN. Apps with educational content (mean 15.1, SD 3.8 vs 11.8, SD 4.8; P=.03) or a ?4 star rating (median 19, interquartile range [IQR] 15-20, vs 12, IQR 9-15; P=.02) had higher overall quality. Conclusions: The BP tracking apps reviewed had variable quality and few met the home BP monitoring best practice criteria. When deciding to recommend a specific BP tracking app, we suggest clinicians should evaluate whether the app allows input of duplicate BP readings in the morning and evening for at least seven days and presents the mean BP value for user-specified dates. Greater attention to home BP measurement best practices is required during app development. ",
doi="10.2196/10809",
url="https://mhealth.jmir.org/2019/4/e10809/",
url="http://www.ncbi.nlm.nih.gov/pubmed/30977739"
}


@Article{info:doi/10.2196/10874,
author="Sankaran, Supraja
and Dendale, Paul
and Coninx, Karin",
title="Evaluating the Impact of the HeartHab App on Motivation, Physical Activity, Quality of Life, and Risk Factors of Coronary Artery Disease Patients: Multidisciplinary Crossover Study",
journal="JMIR Mhealth Uhealth",
year="2019",
month="Apr",
day="04",
volume="7",
number="4",
pages="e10874",
keywords="heart diseases",
keywords="cardiac rehabilitation",
keywords="human factors engineering",
keywords="evaluation studies",
keywords="telerehabilitation",
keywords="mobile app",
keywords="multidisciplinary research",
abstract="Background: Telerehabilitation approaches have been successful in supporting coronary artery disease (CAD) patients to rehabilitate at home after hospital-based rehabilitation. However, on completing a telerehabilitation program, the effects are not sustained beyond the intervention period because of the lack of lifestyle adaptations. Furthermore, decline in patients' motivation lead to recurrence of disease and increased rehospitalization rates. We developed HeartHab, using persuasive design principles and personalization, to enable sustenance of rehabilitation effects beyond the intervention period. HeartHab promotes patients' understanding, motivates them to reach personalized rehabilitation goals, and helps to maintain positive lifestyle adaptations during telerehabilitation. Objective: This study aimed to investigate the impact of the HeartHab app on patients' overall motivation, increasing physical activities, reaching exercise targets, quality of life, and modifiable risk factors in patients with CAD during telerehabilitation. The study also investigated carryover effects to determine the maintenance of effects after the conclusion of the intervention. Methods: A total of 32 CAD patients were randomized on a 1:1 ratio to telerehabilitation or usual care. We conducted a 4-month crossover study with a crossover point at 2 months using a mixed-methods approach for evaluation. We collected qualitative data on users' motivation, user experience, and quality of life using questionnaires, semistructured interviews and context-based sentiment analysis. Quantitative data on health parameters, exercise capacity, and risk factors were gathered from blood tests and ergo-spirometry tests. Data procured during the app usage phase were compared against baseline values to assess the impact of the app on parameters such as motivation, physical activity, quality of life, and risk factors. Carryover effects were used to gather insights on the maintenance of effects. Results: The qualitative data showed that 75\% (21/28) of patients found the HeartHab app motivating and felt encouraged to achieve their rehabilitation targets. 84\% (21/25) of patients either reached or exceeded their prescribed physical activity targets. We found positive significant effects on glycated hemoglobin (P=.01; d=1.03; 95\% CI 0.24-1.82) with a mean decrease of 1.5 mg/dL and high-density lipoprotein (HDL) cholesterol (P=.04; d=0.78; 95\% CI 0.02-1.55) with a mean increase of 0.61 mg/dL after patients used the HeartHab app. We observed significant carryover effects on weight, HDL cholesterol, and maximal oxygen consumption (VO2 max), indicating the maintenance of effects. Conclusions: Persuasive design techniques integrated in HeartHab and tailoring of exercise targets were effective in motivating patients to reach their telerehabilitation targets. This study demonstrated significant effects on glucose and HDL cholesterol and positive carryover effects on weight, HDL cholesterol, and VO2 max. There was also a perceived improvement in quality of life. A longer-term evaluation with more patients could possibly reveal effectiveness on other risk factors and maintenance of the positive health behavior change. Trial Registration: ClinicalTrials.gov NCT03102671; https://clinicaltrials.gov/ct2/show/NCT03102671 (Archived by WebCite at http://www.webcitation.org/76gzI9Pvd) ",
doi="10.2196/10874",
url="https://mhealth.jmir.org/2019/4/e10874/",
url="http://www.ncbi.nlm.nih.gov/pubmed/30946021"
}


@Article{info:doi/10.2196/12191,
author="Ricci-Cabello, Ignacio
and Bobrow, Kirsten
and Islam, Shariful Sheikh Mohammed
and Chow, K. Clara
and Maddison, Ralph
and Whittaker, Robyn
and Farmer, J. Andrew",
title="Examining Development Processes for Text Messaging Interventions to Prevent Cardiovascular Disease: Systematic Literature Review",
journal="JMIR Mhealth Uhealth",
year="2019",
month="Mar",
day="29",
volume="7",
number="3",
pages="e12191",
keywords="systematic review",
keywords="cardiovascular disease",
keywords="telemedicine",
keywords="text messaging",
keywords="methods",
abstract="Background: Interventions delivered by mobile phones have the potential to prevent cardiovascular disease (CVD) by supporting behavior change toward healthier lifestyles and treatment adherence. To allow replication and adaptation of these interventions across settings, it is important to fully understand how they have been developed. However, the development processes of these interventions have not previously been systematically examined. Objective: This study aimed to systematically describe and compare the development process of text messaging interventions identified in the Text2PreventCVD systematic review. Methods: We extracted data about the development process of the 9 interventions identified in the Text2PreventCVD systematic review. Data extraction, which was guided by frameworks for the development of complex interventions, considered the following development stages: intervention planning, design, development, and pretesting. Following data extraction, we invited the developers of the interventions to contribute to our study by reviewing the accuracy of the extracted data and providing additional data not reported in the available publications. Results: A comprehensive description of the development process was available for 5 interventions. Multiple methodologies were used for the development of each intervention. Intervention planning involved gathering information from stakeholder consultations, literature reviews, examination of relevant theory, and preliminary qualitative research. Intervention design involved the use of behavior change theories and behavior change techniques. Intervention development involved (1) generating message content based on clinical guidelines and expert opinions; (2) conducting literature reviews and primary qualitative research to inform decisions about message frequency, timing, and level of tailoring; and (3) gathering end-user feedback concerning message readability, intervention acceptability, and perceived utility. Intervention pretesting involved pilot studies with samples of 10 to 30 participants receiving messages for a period ranging from 1 to 4 weeks. Conclusions: The development process of the text messaging interventions examined was complex and comprehensive, involving multiple studies to guide decisions about the scope, content, and structure of the interventions. Additional research is needed to establish whether effective messaging systems can be adapted from work already done or whether this level of development is needed for application in other conditions and settings. ",
doi="10.2196/12191",
url="http://mhealth.jmir.org/2019/3/e12191/",
url="http://www.ncbi.nlm.nih.gov/pubmed/30924790"
}


@Article{info:doi/10.2196/12179,
author="Ernsting, Clemens
and St{\"u}hmann, Mareike Lena
and Dombrowski, U. Stephan
and Voigt-Antons, Jan-Niklas
and Kuhlmey, Adelheid
and Gellert, Paul",
title="Associations of Health App Use and Perceived Effectiveness in People With Cardiovascular Diseases and Diabetes: Population-Based Survey",
journal="JMIR Mhealth Uhealth",
year="2019",
month="Mar",
day="28",
volume="7",
number="3",
pages="e12179",
keywords="mHealth",
keywords="eHealth",
keywords="smartphone",
keywords="telemedicine",
keywords="health literacy",
keywords="chronic disease",
keywords="comorbidity",
keywords="multimorbidity",
abstract="Background: Mobile health apps can help to change health-related behaviors and manage chronic conditions in patients with cardiovascular diseases (CVDs) and diabetes mellitus, but a certain level of health literacy and electronic health (eHealth) literacy may be needed. Objective: The aim of this study was to identify factors associated with mobile health app use in individuals with CVD or diabetes and detect relations with the perceived effectiveness of health apps among app users. Methods: The study used population-based Web-based survey (N=1500) among Germans, aged 35 years and older, with CVD, diabetes, or both. A total of 3 subgroups were examined: (1) Individuals with CVD (n=1325), (2) Individuals with diabetes (n=681), and (3) Individuals with CVD and diabetes (n=524). Sociodemographics, health behaviors, CVD, diabetes, health and eHealth literacy, characteristics of health app use, and characteristics of apps themselves were assessed by questionnaires. Linear and logistic regression models were applied. Results: Overall, patterns of factors associated with health app use were comparable in individuals with CVD or diabetes or both. Across subgroups, about every fourth patient reported using apps for health-related purposes, with physical activity and weight loss being the most prominent target behaviors. Health app users were younger, more likely to be female (except in those with CVD and diabetes combined), better educated, and reported more physical activity. App users had higher eHealth literacy than nonusers. Those users who perceived the app to have a greater effectiveness on their health behaviors tended to be more health and eHealth literate and rated the app to use more behavior change techniques (BCTs). Conclusions: There are health- and literacy-related disparities in the access to health app use among patients with CVD, diabetes, or both, which are relevant to specific health care professionals such as endocrinologists, dieticians, cardiologists, or general practitioners. Apps containing more BCTs had a higher perceived effect on people's health, and app developers should take the complexity of needs into account. Furthermore, eHealth literacy appears to be a requirement to use health apps successfully, which should be considered in health education strategies to improve health in patients with CVD and diabetes. ",
doi="10.2196/12179",
url="http://mhealth.jmir.org/2019/3/e12179/",
url="http://www.ncbi.nlm.nih.gov/pubmed/30920383"
}


@Article{info:doi/10.2196/11889,
author="Falter, Maarten
and Budts, Werner
and Goetschalckx, Kaatje
and Cornelissen, V{\'e}ronique
and Buys, Roselien",
title="Accuracy of Apple Watch Measurements for Heart Rate and Energy Expenditure in Patients With Cardiovascular Disease: Cross-Sectional Study",
journal="JMIR Mhealth Uhealth",
year="2019",
month="Mar",
day="19",
volume="7",
number="3",
pages="e11889",
keywords="mobile health",
keywords="heart rate",
keywords="energy expenditure",
keywords="validation",
keywords="Apple Watch",
keywords="wrist-worn devices",
keywords="cardiovascular rehabilitation",
abstract="Background: Wrist-worn tracking devices such as the Apple Watch are becoming more integrated in health care. However, validation studies of these consumer devices remain scarce. Objectives: This study aimed to assess if mobile health technology can be used for monitoring home-based exercise in future cardiac rehabilitation programs. The purpose was to determine the accuracy of the Apple Watch in measuring heart rate (HR) and estimating energy expenditure (EE) during a cardiopulmonary exercise test (CPET) in patients with cardiovascular disease. Methods: Forty patients (mean age 61.9 [SD 15.2] yrs, 80\% male) with cardiovascular disease (70\% ischemic, 22.5\% valvular, 7.5\% other) completed a graded maximal CPET on a cycle ergometer while wearing an Apple Watch. A 12-lead electrocardiogram (ECG) was used to measure HR; indirect calorimetry was used for EE. HR was analyzed at three levels of intensity (seated rest, HR1; moderate intensity, HR2; maximal performance, HR3) for 30 seconds. The EE of the entire test was used. Bias or mean difference (MD), standard deviation of difference (SDD), limits of agreement (LoA), mean absolute error (MAE), mean absolute percentage error (MAPE), and intraclass correlation coefficients (ICCs) were calculated. Bland-Altman plots and scatterplots were constructed. Results: SDD for HR1, HR2, and HR3 was 12.4, 16.2, and 12.0 bpm, respectively. Bias and LoA (lower, upper LoA) were 3.61 (--20.74, 27.96) for HR1, 0.91 (--30.82, 32.63) for HR2, and --1.82 (--25.27, 21.63) for HR3. MAE was 6.34 for HR1, 7.55 for HR2, and 6.90 for HR3. MAPE was 10.69\% for HR1, 9.20\% for HR2, and 6.33\% for HR3. ICC was 0.729 (P<.001) for HR1, 0.828 (P<.001) for HR2, and 0.958 (P<.001) for HR3. Bland-Altman plots and scatterplots showed good correlation without systematic error when comparing Apple Watch with ECG measurements. SDD for EE was 17.5 kcal. Bias and LoA were 30.47 (--3.80, 64.74). MAE was 30.77; MAPE was 114.72\%. ICC for EE was 0.797 (P<.001). The Bland-Altman plot and a scatterplot directly comparing Apple Watch and indirect calorimetry showed systematic bias with an overestimation of EE by the Apple Watch. Conclusions: In patients with cardiovascular disease, the Apple Watch measures HR with clinically acceptable accuracy during exercise. If confirmed, it might be considered safe to incorporate the Apple Watch in HR-guided training programs in the setting of cardiac rehabilitation. At this moment, however, it is too early to recommend the Apple Watch for cardiac rehabilitation. Also, the Apple Watch systematically overestimates EE in this group of patients. Caution might therefore be warranted when using the Apple Watch for measuring EE. ",
doi="10.2196/11889",
url="http://mhealth.jmir.org/2019/3/e11889/",
url="http://www.ncbi.nlm.nih.gov/pubmed/30888332"
}


@Article{info:doi/10.2196/11108,
author="Haldane, Victoria
and Tan, Guo Yao
and Teo, Qi Krichelle Wei
and Koh, Kai Joel Jun
and Srivastava, Aastha
and Cheng, Xiang Rui
and Yap, Cheng Yi
and Ong, Pei-Shi
and van Dam, M. Rob
and Foo, Min Jie
and M{\"u}ller-Riemenschneider, Falk
and Koh, Choon-Huat Gerald
and Perel, Pablo
and Legido-Quigley, Helena",
title="Perspectives on Acceptance and Use of a Mobile Health Intervention for the Prevention of Atherosclerotic Cardiovascular Disease in Singapore: Mixed-Methods Study",
journal="JMIR Mhealth Uhealth",
year="2019",
month="Mar",
day="14",
volume="7",
number="3",
pages="e11108",
keywords="atherosclerosis",
keywords="mHealth",
keywords="eHealth",
keywords="patient-centered care",
keywords="patient acceptance of health care",
keywords="medication adherence",
abstract="Background: Cardiovascular disease, including atherosclerotic cardiovascular disease (ASCVD), is a growing public health threat globally and many individuals remain undiagnosed, untreated, and uncontrolled. Simultaneously, mobile health (mHealth) interventions using short messaging service (SMS) have gained popularity globally. There is an opportunity for innovative approaches such as mHealth to encourage and enable adherence to medications for ASCVD and its risk factors. Objective: This study aimed to understand mobile technology acceptance, use, and facilitating conditions among the study population ahead of the design of an mHealth intervention. Methods: Using data from a mixed-methods study conducted in Singapore, we conducted a cross-sectional survey with 100 participants and in-depth, semistructured interviews with 20 patients. All participants were over the age of 40 years with ASCVD or its risk factors. Interviews were conducted in English and Mandarin and if needed translated to English. Nvivo 11 (QSR International) was used for analyses. Results: Participants reported their perspectives on technology use and preferences, including low or sporadic mobile phone use and usability concerns including small screen and text size, among others; the benefit of previous mHealth use in creating a favorable opinion of SMS for health information; trust in both the source of mHealth SMS, as well as in treatment; the formation of habits; and fear of sequelae or death for facilitating intention to use an mHealth intervention and adhere to medication. We also highlighted a case that underscored the importance of the period after diagnosis in habit forming as an opportunity for an mHealth intervention. Conclusions: We explored both technology- and adherence-related factors that influence a patient's intention to use an mHealth intervention for adherence to ASCVD medication in Singapore. We highlighted the importance of identifying the right opportunity to engage with patients and promote an mHealth intervention for adherence, such as immediately following diagnosis when patients are establishing medication-taking habits. ",
doi="10.2196/11108",
url="http://mhealth.jmir.org/2019/3/e11108/",
url="http://www.ncbi.nlm.nih.gov/pubmed/30869651"
}


@Article{info:doi/10.2196/11606,
author="Li, Christien Ka Hou
and White, Anne Francesca
and Tipoe, Timothy
and Liu, Tong
and Wong, CS Martin
and Jesuthasan, Aaron
and Baranchuk, Adrian
and Tse, Gary
and Yan, P. Bryan",
title="The Current State of Mobile Phone Apps for Monitoring Heart Rate, Heart Rate Variability, and Atrial Fibrillation: Narrative Review",
journal="JMIR Mhealth Uhealth",
year="2019",
month="Feb",
day="15",
volume="7",
number="2",
pages="e11606",
keywords="mobile phone apps",
keywords="atrial fibrillation",
keywords="heart rate",
keywords="arrhythmia",
keywords="photoplethysmography",
keywords="electrocardiography",
keywords="mobile health",
abstract="Background: Mobile phone apps capable of monitoring arrhythmias and heart rate (HR) are increasingly used for screening, diagnosis, and monitoring of HR and rhythm disorders such as atrial fibrillation (AF). These apps involve either the use of (1) photoplethysmographic recording or (2) a handheld external electrocardiographic recording device attached to the mobile phone or wristband. Objective: This review seeks to explore the current state of mobile phone apps in cardiac rhythmology while highlighting shortcomings for further research. Methods: We conducted a narrative review of the use of mobile phone devices by searching PubMed and EMBASE from their inception to October 2018. Potentially relevant papers were then compared against a checklist for relevance and reviewed independently for inclusion, with focus on 4 allocated topics of (1) mobile phone monitoring, (2) AF, (3) HR, and (4) HR variability (HRV). Results: The findings of this narrative review suggest that there is a role for mobile phone apps in the diagnosis, monitoring, and screening for arrhythmias and HR. Photoplethysmography and handheld electrocardiograph recorders are the 2 main techniques adopted in monitoring HR, HRV, and AF. Conclusions: A number of studies have demonstrated high accuracy of a number of different mobile devices for the detection of AF. However, further studies are warranted to validate their use for large scale AF screening. ",
doi="10.2196/11606",
url="http://mhealth.jmir.org/2019/2/e11606/",
url="http://www.ncbi.nlm.nih.gov/pubmed/30767904"
}


@Article{info:doi/10.2196/resprot.9017,
author="Woringer, Maria
and Dharmayat, I. Kanika
and Greenfield, Geva
and Bottle, Alex
and Ray, K. Kausik",
title="American Heart Association's Cholesterol CarePlan as a Smartphone-Delivered Web App for Patients Prescribed Cholesterol-Lowering Medication: Protocol for an Observational Feasibility Study",
journal="JMIR Res Protoc",
year="2019",
month="Jan",
day="24",
volume="8",
number="1",
pages="e9017",
keywords="behavioral change",
keywords="cholesterol",
keywords="lifestyle",
keywords="mHealth",
keywords="medication adherence",
abstract="Background: Adoption of healthy lifestyle and compliance with cholesterol-lowering medication reduces the risk of cardiovascular disease (CVD). The use of digital tools and mobile technology may be important for sustaining positive behavioral change. Objective: The primary objective of this study is to evaluate the feasibility and acceptability of administering the Cholesterol CarePlan Web app developed by the American Heart Association aimed at improving lifestyle and medication adherence among patients prescribed cholesterol-lowering medication. The secondary objective is to assess the Web app's efficacy. Methods: A prospective, observational feasibility study will be conducted to demonstrate whether the Web app may be successfully taken up by patients and will be associated with improved clinical and behavioral outcomes. The study will aim to recruit 180 study participants being prescribed cholesterol-lowering medication for at least 30 days across 14 general practices in London, England. Potentially eligible patients will be invited to use the Web app on a smartphone and visit general practice for three 20-minute clinical assessments of blood pressure, height, weight, smoking, and nonfasting cholesterol over 24 weeks. The feasibility of administering the Web app will be judged by recruitment and dropout statistics and the sociodemographic and comorbidity profile of consenting study participants, consenting nonparticipants, and all potentially eligible patients. Acceptability will be assessed using patients' readiness to embrace new technologies, the usability of the Web app, and patient satisfaction. The efficacy of the Web app will be assessed by changes in medication adherence and clinical risk factors by levels of the Web app compliance. Results: This study is currently funded by the American Heart Association. Initial study recruitment will take place between February and July 2018 followed by patient follow-up. Patient level data will be obtained in January 2019. Data analysis will be completed by February 2019. Results will be submitted for publication in March 2019. Conclusions: The potential of an app to improve patients' lifestyle and management of cholesterol may inform the design of a randomized controlled trial and the delivery of more effective CVD prevention programs. International Registered Report Identifier (IRRID): PRR1-10.2196/9017 ",
doi="10.2196/resprot.9017",
url="https://www.researchprotocols.org/2019/1/e9017/",
url="http://www.ncbi.nlm.nih.gov/pubmed/30679150"
}


@Article{info:doi/10.2196/12008,
author="Napa, Sandeep
and Moore, Michael
and Bardyn, Tania",
title="Advancing Cardiac Surgery Case Planning and Case Review Conferences Using Virtual Reality in Medical Libraries: Evaluation of the Usability of Two Virtual Reality Apps",
journal="JMIR Hum Factors",
year="2019",
month="Jan",
day="16",
volume="6",
number="1",
pages="e12008",
keywords="virtual reality",
keywords="cardiac surgery",
keywords="usability study",
keywords="system usability score",
keywords="NASA-Task Load Index",
keywords="medical libraries",
keywords="case planning",
keywords="presurgical planning",
abstract="Background: Care providers and surgeons prepare for cardiac surgery using case conferences to review, discuss, and run through the surgical procedure. Surgeons visualize a patient's anatomy to decide the right surgical approach using magnetic resonance imaging and echocardiograms in a presurgical case planning session. Previous studies have shown that surgical errors can be reduced through the effective use of immersive virtual reality (VR) to visualize patient anatomy. However, inconsistent user interfaces, delegation of view control, and insufficient depth information cause user disorientation and interaction difficulties in using VR apps for case planning. Objective: The objective of the study was to evaluate and compare the usability of 2 commercially available VR apps---Bosc (Pyrus Medical systems) and Medical Holodeck (Nooon Web \& IT GmbH)---using the Vive VR headset (HTC Corporation) to evaluate ease of use, physician attitudes toward VR technology, and viability for presurgical case planning. The role of medical libraries in advancing case planning is also explored. Methods: After screening a convenience sample of surgeons, fellows, and residents, ethnographic interviews were conducted to understand physician attitudes and experience with VR. Gaps in current case planning methods were also examined. We ran a usability study, employing a concurrent think-aloud protocol. To evaluate user satisfaction, we used the system usability scale (SUS) and the National Aeronautics and Space Administration-Task Load Index (NASA-TLX). A poststudy questionnaire was used to evaluate the VR experience and explore the role of medical libraries in advancing presurgical case planning. Semistructured interview data were analyzed using content analysis with feedback categorization. Results: Participants were residents, fellows, and surgeons from the University of Washington with a mean age of 41.5 (SD 11.67) years. A total of 8 surgeons participated in the usability study, 3 of whom had prior exposure to VR. Users found Medical Holodeck easier to use than Bosc. Mean adjusted NASA-TLX score for Medical Holodeck was 62.71 (SD 18.25) versus Bosc's 40.87 (SD 13.90). Neither app passed the mean SUS score of 68 for an app to be considered usable, though Medical Holodeck (66.25 [SD 12.87]) scored a higher mean SUS than Bosc (37.19 [SD 22.41]). One user rated the Bosc usable, whereas 3 users rated Medical Holodeck usable. Conclusions: Interviews highlighted the importance of precise anatomical conceptualization in presurgical case planning and teaching, identifying it as the top reason for modifying a surgical procedure. The importance of standardized user interaction features such as labeling is justified. The study also sheds light on the new roles medical librarians can play in curating VR content and promoting interdisciplinary collaboration. ",
doi="10.2196/12008",
url="http://humanfactors.jmir.org/2019/1/e12008/",
url="http://www.ncbi.nlm.nih.gov/pubmed/30664469"
}


@Article{info:doi/10.2196/11753,
author="Albrecht, Urs-Vito
and Hasenfu{\ss}, Gerd
and von Jan, Ute",
title="Description of Cardiological Apps From the German App Store: Semiautomated Retrospective App Store Analysis",
journal="JMIR Mhealth Uhealth",
year="2018",
month="Nov",
day="20",
volume="6",
number="11",
pages="e11753",
keywords="mHealth",
keywords="mobile health",
keywords="mobile apps",
keywords="retrospective app store analysis",
keywords="cardiology",
abstract="Background: In the app stores of mobile platforms, consumers are confronted with an enormous number of mobile apps. Over the past few years, considerable research has been undertaken into to identifying, characterizing, and evaluating apps, be it in health-related or other contexts. However, many of these projects are restricted to specific areas of application and offer little flexibility in adapting the applied criteria. Objective: This paper presents an adaptable method for selecting and characterizing mobile apps listed in a mobile App Store (the Apple App Store). The method is based on filtering processes using predefined criteria, through a semiautomated retrospective App Store analysis (SARASA). Methods: To illustrate the SARASA process, keyword-based filtering and metadata-based description, review, and ranking steps were applied to a dataset, more specifically, an April 2018 readout of the Medical category of the German App Store, with the aim of obtaining a list of cardiology-related apps. Results: From the original list of 39,427 apps within the ``Medical'' category of the App Store on April 14, 2018, 34,382 apps with store descriptions in languages other than German were removed. For the remaining 5045 apps, keywords related to cardiology were applied to filter the output, obtaining a final total of 335 subject-specific apps for further analysis and description. Conclusions: SARASA provides an easy to use method for applying filtering processes to identify apps matching predefined, formal criteria from app stores. The criteria can be well adapted to the needs of users. Automatic and manual analyses are easily combined when using SARASA. In the future, additional features, such as algorithmic topic analyses, may supplement the process. Although the area of application is currently limited to Apple's App Store, expansion to other stores is planned. The method stands or falls with the transparency of the app store providers and the manufacturers to make relevant meta-information available. It is up to them to liberalize information and restrict censorship to provide clients, customers, and users truly fair circumstances finding their way around the app market. ",
doi="10.2196/11753",
url="http://mhealth.jmir.org/2018/11/e11753/",
url="http://www.ncbi.nlm.nih.gov/pubmed/30459140"
}


@Article{info:doi/10.2196/mhealth.9651,
author="Metelmann, Bibiana
and Metelmann, Camilla
and Schuffert, Louisa
and Hahnenkamp, Klaus
and Brinkrolf, Peter",
title="Medical Correctness and User Friendliness of Available Apps for Cardiopulmonary Resuscitation: Systematic Search Combined With Guideline Adherence and Usability Evaluation",
journal="JMIR Mhealth Uhealth",
year="2018",
month="Nov",
day="06",
volume="6",
number="11",
pages="e190",
keywords="mHealth",
keywords="resuscitation",
keywords="review",
keywords="guidelines",
keywords="mobile phones",
keywords="health care information systems",
keywords="health informatics",
abstract="Background: In case of a cardiac arrest, start of cardiopulmonary resuscitation by a bystander before the arrival of the emergency personnel increases the probability of survival. However, the steps of high-quality resuscitation are not known by every bystander or might be forgotten in this complex and time-critical situation. Mobile phone apps offering real-time step-by-step instructions might be a valuable source of information. Objective: The aim of this study was to examine mobile phone apps offering real-time instructions in German or English in case of a cardiac arrest, to evaluate their adherence to current resuscitation guidelines, and to test their usability. Methods: Our 3-step approach combines a systematic review of currently available apps guiding a medical layperson through a resuscitation situation, an adherence testing to medical guidelines, and a usability evaluation of the determined apps. The systematic review followed an adapted preferred reporting items for systematic reviews and meta-analyses flow diagram, the guideline adherence was tested by applying a conformity checklist, and the usability was evaluated by a group of mobile phone frequent users and emergency physicians with the system usability scale (SUS) tool. Results: The structured search in Google Play Store and Apple App Store resulted in 3890 hits. After removing redundant ones, 2640 hits were checked for fulfilling the inclusion criteria. As a result, 34 apps meeting all inclusion criteria were identified. These included apps were analyzed to determine medical accuracy as defined by the European Resuscitation Council's guidelines. Only 5 out of 34 apps (15\%, 5/34) fulfilled all criteria chosen to determine guideline adherence. All other apps provided no or wrong information on at least one relevant topic. The usability of 3 apps was evaluated by 10 mobile phone frequent users and 9 emergency physicians. Of these 3 apps, solely the app ``HELP Notfall'' (median=87.5) was ranked with an SUS score above the published average of 68. This app was rated significantly superior to ``HAMBURG SCHOCKT'' (median=55; asymptotic Wilcoxon test: z=?3.63, P<.01, n=19) and ``Mein DRK'' (median=32.5; asymptotic Wilcoxon test: z=?3.83, P<.01, n=19). Conclusions: Implementing a systematic quality control for health-related apps should be enforced to ensure that all products provide medically accurate content and sufficient usability in complex situations. This is of exceptional importance for apps dealing with the treatment of life-threatening events such as cardiac arrest. ",
doi="10.2196/mhealth.9651",
url="http://mhealth.jmir.org/2018/11/e190/",
url="http://www.ncbi.nlm.nih.gov/pubmed/30401673"
}


@Article{info:doi/10.2196/10499,
author="Gandhi, Sumeet
and Morillo, A. Carlos
and Schwalm, Jon-David",
title="Implantable Cardioverter Defibrillator mHealth App for Physician Referrals and eHealth Education: ICD-TEACH Pilot Study",
journal="JMIR Cardio",
year="2018",
month="Nov",
day="05",
volume="2",
number="2",
pages="e10499",
keywords="mHealth",
keywords="smartphone app",
keywords="implantable defibrillator cardioverter",
keywords="ICD",
keywords="physician decision",
keywords="eHealth",
keywords="mobile phone",
abstract="Background: Mobile health (mHealth) decision tools for implantable cardioverter defibrillator may increase physician knowledge and overall patient care. Objective: The goals of the ICD-TEACH pilot study were to design a smartphone app or mHealth technology with a novel physician decision support algorithm, implement a direct referral mechanism for device implantation from the app, and assess its overall usability and feasibility with physicians involved in the care of patients with an implantable cardioverter defibrillator. Methods: The initial design and development of the mHealth or smartphone app included strategic collaboration from an information technology company and key stakeholders including arrhythmia specialists (electrophysiologists), general cardiologists, and key members of the hospital administrative team. A convenience sampling method was used to recruit general internists or cardiologists that refer to our local tertiary care center. Physicians were asked to incorporate the mHealth app in daily clinical practice and avail the decision support algorithm and direct referral feature to the arrhythmia clinic. Feasibility assessment, in the form of a physician survey, was conducted after initial mHealth app use (within 3 months) addressing the physicians' overall satisfaction with the app, compliance, and reason for noncompliance; usability assessment of the mHealth app was addressed in the physician survey for technical or hardware problems encountered while using the app and suggestions on improvement. Results: A total of 17 physicians agreed to participate in the pilot study with 100\% poststudy survey response rate. Physicians worked in an academic practice, which included both inpatient and ambulatory care. System Usability Scale was applied with an average score of 77 including the 17 participants (>68 points is above average). Regarding the novel physician decision support algorithm for implantable cardioverter defibrillator referral, 11\% (1/9) strongly agreed and 78\% (7/9) agreed that the algorithm for device eligibility was easy to use. Only 1 patient was referred through the direct referral system via the mHealth app during the pilot study of 3 months. Feasibility assessment showed that 46\% (5/11) strongly agreed and 55\% (6/11) agreed that the mHealth app would be utilized if integrated into an electronic medical record (EMR) where data are automatically sent to the referring arrhythmia clinic. Conclusions: The ICD-TEACH pilot study revealed high usability features of a physician decision support algorithm; however, we received only 1 direct referral through our app despite supportive feedback. A specific reason from our physician survey included the lack of integration into an EMR. Future studies should continue to systematically evaluate smartphone apps in cardiology to assess usability, feasibility, and strategies to integrate into daily workflow. ",
doi="10.2196/10499",
url="http://cardio.jmir.org/2018/2/e10499/",
url="http://www.ncbi.nlm.nih.gov/pubmed/31758779"
}


@Article{info:doi/10.2196/10126,
author="Steijlen, SM Annemarijn
and Jansen, MB Kaspar
and Albayrak, Armagan
and Verschure, O. Derk
and Van Wijk, F. Diederik",
title="A Novel 12-Lead Electrocardiographic System for Home Use: Development and Usability Testing",
journal="JMIR Mhealth Uhealth",
year="2018",
month="Jul",
day="30",
volume="6",
number="7",
pages="e10126",
keywords="12-lead ECG system",
keywords="electrocardiography",
keywords="home use",
keywords="handheld",
keywords="user-centered design",
abstract="Background: Cardiovascular diseases (CVD) are the leading cause of morbidity and mortality worldwide. Early diagnosis is of pivotal importance for patients with cardiac arrhythmias and ischemia to minimize the consequences like strokes and myocardial infarctions. The chance of capturing signals of arrhythmias or ischemia is substantially high when a 12-lead electrocardiogram (ECG) can be recorded at the moment when a patient experiences the symptoms. However, until now, available diagnostic systems (Holter monitors and other wearable ECG sensors) have not enabled patients to record a reliable 12-lead ECG at home. Objective: The objective of this project was to develop a user-friendly system that enables persons with cardiac complaints to record a reliable 12-lead ECG at home to improve the diagnostic process and, consequently, reduce the time between the onset of symptoms and adequate treatment. Methods: Using an iterative design approach, ECGraph was developed. The system consists of an ECG measurement system and a mobile app, which were developed with the help of several concept tests. To evaluate the design, a prototype of the final design was built and a final technical performance test and usability test were executed. Results: The ECG measurement system consists of a belt and 4 limb straps. Ten wet Ag/AgCl electrodes are placed in the belt to optimize skin-electrode contact. The product is controlled via an app on the mobile phone of the user. Once a person experiences symptoms, he or she can put on the belt and record ECGs within a few minutes. Short instructions, supported by visualizations, offer guidance during use. ECGs are sent wirelessly to the caregiver, and the designated expert can quickly interpret the results. Usability tests with the final prototype (n=6) showed that the participants were able to put on the product within 8 minutes during first-time use. However, we expect that the placement of the product can be executed faster when the user becomes more familiar with the product. Areas of improvement focus mainly on confidence during product use. In the technical performance test, a 12-lead ECG was made and reproduced 6 times. Conclusions: We developed a new 12-lead ECG system for home use. The product is expected to be more user-friendly than current hospital ECG systems and is designed to record more reliable data than current ECG systems for home use, which makes it suitable for expert interpretation. The system has great potential to be incorporated into an outpatient practice, so that arrhythmias and ischemia can be diagnosed and treated as early as possible. ",
doi="10.2196/10126",
url="http://mhealth.jmir.org/2018/7/e10126/",
url="http://www.ncbi.nlm.nih.gov/pubmed/30061094"
}


@Article{info:doi/10.2196/10723,
author="Alessa, Tourkiah
and Abdi, Sarah
and Hawley, S. Mark
and de Witte, Luc",
title="Mobile Apps to Support the Self-Management of Hypertension: Systematic Review of Effectiveness, Usability, and User Satisfaction",
journal="JMIR Mhealth Uhealth",
year="2018",
month="Jul",
day="23",
volume="6",
number="7",
pages="e10723",
keywords="mobile phone",
keywords="mobile application",
keywords="mobile app",
keywords="self-management",
keywords="hypertension",
keywords="blood pressure",
abstract="Background: Hypertension is a chronic disease that is considered to be a public health problem and requires efforts by patients to manage themselves. The global growth in the use of mobile phones and tablets has been accompanied by the increased use of health apps. Many of these apps support the self-management of hypertension and, therefore, they have the potential benefits of lowering blood pressure. Despite this, there is currently a lack of evidence for their effectiveness, usability, and patient satisfaction with their use. Objective: A systematic review was conducted to assess the effectiveness of apps in lowering blood pressure, as well as their usability and patients' satisfaction with their use. Methods: We conducted searches in the following databases: MEDLINE (OVID), EMBASE (OVID), PsycINFO (OVID), CINAHL, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), IEEE Xplore ASSIAN, Google Scholar and the main Arabic databases Al Manhal, AskZad, and Mandumah. We looked for studies that used apps in the self-management of hypertension from 2008-2016. We also checked the reference lists of the review papers and all the primary studies for additional references. Results: A total of 21 studies with a total of 3112 participants were included in the review. Of the 14 studies that assessed the effectiveness of the apps in lowering blood pressure, 10 (71.4\%) studies (6 RCTs and 4 nonrandomized studies) reported that using the apps led to significant decreases in blood pressure and seemed to be effective in the self-management of hypertension. Of these 10, only 2 (20\%) RCTs and 3 (30\%) nonrandomized studies had a low--moderate risk of bias. The results of this review are inconclusive regarding which combinations of functionalities would be most effective in lowering blood pressure because of variation in the studies' quality, but the data suggest that apps incorporating more comprehensive functionalities are likely to be more effective. In all the studies that assessed the usability of the apps and users' acceptance of them, all the apps seemed to be accepted and easy to use. Conclusions: Most of the studies reported that apps might be effective in lowering blood pressure and are accepted by users. However, these findings should be interpreted with caution, as most of the studies had a high risk of bias. More well-designed, large-scale studies are required to evaluate the real effect of using apps in lowering blood pressure and to identify the most effective functionality combinations for lowering blood pressure. ",
doi="10.2196/10723",
url="http://mhealth.jmir.org/2018/7/e10723/",
url="http://www.ncbi.nlm.nih.gov/pubmed/30037787"
}


@Article{info:doi/10.2196/jmir.9751,
author="Lunde, Pernille
and Nilsson, Blakstad Birgitta
and Bergland, Astrid
and Kv{\ae}rner, Jorunn Kari
and Bye, Asta",
title="The Effectiveness of Smartphone Apps for Lifestyle Improvement in Noncommunicable Diseases: Systematic Review and Meta-Analyses",
journal="J Med Internet Res",
year="2018",
month="May",
day="04",
volume="20",
number="5",
pages="e162",
keywords="smartphone",
keywords="telemedicine",
keywords="noncommunicable diseases",
keywords="lifestyle",
keywords="diet",
keywords="exercise",
abstract="Background: Noncommunicable diseases (NCDs) account for 70\% of all deaths in a year globally. The four main NCDs are cardiovascular diseases, cancers, chronic pulmonary diseases, and diabetes mellitus. Fifty percent of persons with NCD do not adhere to prescribed treatment; in fact, adherence to lifestyle interventions is especially considered as a major challenge. Smartphone apps permit structured monitoring of health parameters, as well as the opportunity to receive feedback. Objective: The aim of this study was to review and assess the effectiveness of app-based interventions, lasting at least 3 months, to promote lifestyle changes in patients with NCDs. Methods: In February 2017, a literature search in five databases (EMBASE, MEDLINE, CINAHL, Academic Research Premier, and Cochrane Reviews and Trials) was conducted. Inclusion criteria was quantitative study designs including randomized and nonrandomized controlled trials that included patients aged 18 years and older diagnosed with any of the four main NCDs. Lifestyle outcomes were physical activity, physical fitness, modification of dietary habits, and quality of life. All included studies were assessed for risk of bias using the Cochrane Collaboration`s risk of bias tool. Meta-analyses were conducted for one of the outcomes (glycated hemoglobin, HbA1c) by using the estimate of effect of mean post treatment with SD or CI. Heterogeneity was tested using the I2 test. All studies included in the meta-analyses were graded. Results: Of the 1588 records examined, 9 met the predefined criteria. Seven studies included diabetes patients only, one study included heart patients only, and another study included both diabetes and heart patients. Statistical significant effect was shown in HbA1c in 5 of 8 studies, as well in body weight in one of 5 studies and in waist circumference in one of 3 studies evaluating these outcomes. Seven of the included studies were included in the meta-analyses and demonstrated significantly overall effect on HbA1c on a short term (3-6 months; P=.02) with low heterogeneity (I2=41\%). In the long term (10-12 months), the overall effect on HbA1c was statistical significant (P=.009) and without heterogeneity (I2=0\%). The quality of evidence according to Grading of Recommendations Assessment, Development and Evaluation was low for short term and moderate for long term. Conclusions: Our review demonstrated limited research of the use of smartphone apps for NCDs other than diabetes with a follow-up of at least 3 months. For diabetes, the use of apps seems to improve lifestyle factors, especially to decrease HbA1c. More research with long-term follow-up should be performed to assess the effect of smartphone apps for NCDs other than diabetes. ",
doi="10.2196/jmir.9751",
url="http://www.jmir.org/2018/5/e162/",
url="http://www.ncbi.nlm.nih.gov/pubmed/29728346"
}


@Article{info:doi/10.2196/humanfactors.8004,
author="Hirschey, Jaclyn
and Bane, Sunetra
and Mansour, Moussa
and Sperber, Jodi
and Agboola, Stephen
and Kvedar, Joseph
and Jethwani, Kamal",
title="Evaluating the Usability and Usefulness of a Mobile App for Atrial Fibrillation Using Qualitative Methods: Exploratory Pilot Study",
journal="JMIR Hum Factors",
year="2018",
month="Mar",
day="15",
volume="5",
number="1",
pages="e13",
keywords="nonvalvular atrial fibrillation",
keywords="medication adherence",
keywords="patient self-care",
keywords="mobile application",
keywords="exploratory research",
keywords="pilot study",
keywords="usability study",
keywords="acceptability study",
keywords="qualitative methods",
abstract="Background: Atrial fibrillation (AFib) is the most common form of heart arrhythmia and a potent risk factor for stroke. Nonvitamin K antagonist oral anticoagulants (NOACs) are routinely prescribed to manage AFib stroke risk; however, nonadherence to treatment is a concern. Additional tools that support self-care and medication adherence may benefit patients with AFib. Objective: The aim of this study was to evaluate the perceived usability and usefulness of a mobile app designed to support self-care and treatment adherence for AFib patients who are prescribed NOACs. Methods: A mobile app to support AFib patients was previously developed based on early stage interview and usability test data from clinicians and patients. An exploratory pilot study consisting of naturalistic app use, surveys, and semistructured interviews was then conducted to examine patients' perceptions and everyday use of the app. Results: A total of 12 individuals with an existing diagnosis of nonvalvular AFib completed the 4-week study. The average age of participants was 59 years. All participants somewhat or strongly agreed that the app was easy to use, and 92\% (11/12) reported being satisfied or very satisfied with the app. Participant feedback identified changes that may improve app usability and usefulness for patients with AFib. Areas of usability improvement were organized by three themes: app navigation, clarity of app instructions and design intent, and software bugs. Perceptions of app usefulness were grouped by three key variables: core needs of the patient segment, patient workflow while managing AFib, and the app's ability to support the patient's evolving needs. Conclusions: The results of this study suggest that mobile tools that target self-care and treatment adherence may be helpful to AFib patients, particularly those who are newly diagnosed. Additionally, participant feedback provided insight into the varied needs and health experiences of AFib patients, which may improve the design and targeting of the intervention. Pilot studies that qualitatively examine patient perceptions of usability and usefulness are a valuable and often underutilized method for assessing the real-world acceptability of an intervention. Additional research evaluating the AFib Connect mobile app over a longer period, and including a larger, more diverse sample of AFib patients, will be helpful for understanding whether the app is perceived more broadly to be useful and effective in supporting patient self-care and medication adherence. ",
doi="10.2196/humanfactors.8004",
url="http://humanfactors.jmir.org/2018/1/e13/",
url="http://www.ncbi.nlm.nih.gov/pubmed/29549073"
}


@Article{info:doi/10.2196/cardio.8574,
author="Abt, Grant
and Bray, James
and Benson, Clare Amanda",
title="Measuring Moderate-Intensity Exercise with the Apple Watch: Validation Study",
journal="JMIR Cardio",
year="2018",
month="Feb",
day="28",
volume="2",
number="1",
pages="e6",
keywords="smartwatch",
keywords="wearables",
keywords="technology",
keywords="physical activity",
keywords="cardiovascular health, Apple Watch",
abstract="Background: Moderate fitness levels and habitual exercise have a protective effect for cardiovascular disease, stroke, type 2 diabetes, and all-cause mortality. The Apple Watch displays exercise completed at an intensity of a brisk walk or above using a green ``exercise'' ring. However, it is unknown if the exercise ring accurately represents an exercise intensity comparable to that defined as moderate-intensity. In order for health professionals to prescribe exercise intensity with confidence, consumer wearable devices need to be accurate and precise if they are to be used as part of a personalized medicine approach to disease management. Objective: The aim of this study was to examine the validity and reliability of the Apple Watch for measuring moderate-intensity exercise, as defined as 40-59\% oxygen consumption reserve (VO2R). Methods: Twenty recreationally active participants completed resting oxygen consumption (VO2rest) and maximal oxygen consumption (VO2 max) tests prior to a series of 5-minute bouts of treadmill walking at increasing speed while wearing an Apple Watch on both wrists, and with oxygen consumption measured continuously. Five-minute exercise bouts were added until the Apple Watch advanced the green ``exercise'' ring by 5 minutes (defined as the treadmill inflection speed). Validity was examined using a one-sample t-test, with interdevice and intradevice reliability reported as the standardized typical error and intraclass correlation. Results: The mean \%VO2R at the treadmill inflection speed was 30\% (SD 7) for both Apple Watches. There was a large underestimation of moderate-intensity exercise (left hand: mean difference = -10\% [95\% CI -14 to -7], d=-1.4; right hand: mean difference = -10\% [95\% CI -13 to -7], d=-1.5) when compared to the criterion of 40\% VO2R. Standardized typical errors for \%VO2R at the treadmill inflection speed were small to moderate, with intraclass correlations higher within trials compared to between trials. Conclusions: The Apple Watch threshold for moderate-intensity exercise was lower than the criterion, which would lead to an overestimation of moderate-intensity exercise minutes completed throughout the day. ",
doi="10.2196/cardio.8574",
url="http://cardio.jmir.org/2018/1/e6/",
url="http://www.ncbi.nlm.nih.gov/pubmed/31758766"
}


@Article{info:doi/10.2196/cardio.8802,
author="De Ridder, Benjamin
and Van Rompaey, Bart
and Kampen, K. Jarl
and Haine, Steven
and Dilles, Tinne",
title="Smartphone Apps Using Photoplethysmography for Heart Rate Monitoring: Meta-Analysis",
journal="JMIR Cardio",
year="2018",
month="Feb",
day="27",
volume="2",
number="1",
pages="e4",
keywords="mobile applications",
keywords="heart rate",
keywords="photoplethysmography",
keywords="electrocardiography",
keywords="oximetry",
keywords="meta-analysis",
abstract="Background: Smartphone ownership is rising at a stunning rate. Moreover, smartphones prove to be suitable for use in health care due to their availability, portability, user-friendliness, relatively low price, wireless connectivity, far-reaching computing capabilities, and comprehensive memory. To measure vital signs, smartphones are often connected to a mobile sensor or a medical device. However, by using the white light-emitting diode as light source and the phone camera as photodetector, a smartphone could be used to perform photoplethysmography (PPG), enabling the assessment of vital signs. Objective: The objective of this meta-analysis was to evaluate the available evidence on the use of smartphone apps to measure heart rate by performing PPG in comparison with a validated method. Methods: PubMed and ISI Web of Knowledge were searched for relevant studies published between January 1, 2009 and December 7, 2016. The reference lists of included studies were hand-searched to find additional eligible studies. Critical Appraisal Skills Programme (CASP) Diagnostic Test Study checklist and some extra items were used for quality assessment. A fixed effects model of the mean difference and a random effects model of Pearson correlation coefficient were applied to pool the outcomes of the studies. Results: In total, 14 studies were included. The pooled result showed no significant difference between heart rate measurements with a smartphone and a validated method (mean difference ?0.32; 99\% CI ?1.24 to 0.60; P=.37). In adults, the Pearson correlation coefficient of the relation between heart rate measurement with a smartphone and a validated method was always ?.90. In children, the results varied depending on measuring point and heart rate. The pooled result showed a strong correlation that was significant (correlation coefficient .951; 95\% CI 0.906-0.975; P<.001). The reported limits of agreement showed good agreement between a smartphone and a validated method. There was a moderately strong significant negative correlation between the year of publication of the included studies and the mean difference (r=?.69; P<.001). Conclusions: Smartphone apps measuring heart rate by performing PPG appear to agree with a validated method in an adult population during resting sinus rhythm. In a pediatric population, the use of these apps is currently not validated. ",
doi="10.2196/cardio.8802",
url="http://cardio.jmir.org/2018/1/e4/",
url="http://www.ncbi.nlm.nih.gov/pubmed/31758768"
}


@Article{info:doi/10.2196/cardio.8710,
author="Kropp, Caley
and Ellis, Jordan
and Nekkanti, Rajasekhar
and Sears, Samuel",
title="Monitoring Patients With Implantable Cardioverter Defibrillators Using Mobile Phone Electrocardiogram: Case Study",
journal="JMIR Cardio",
year="2018",
month="Feb",
day="21",
volume="2",
number="1",
pages="e5",
keywords="atrial fibrillation",
keywords="ICD",
keywords="ECG",
keywords="mobile phone monitoring",
keywords="mobile health",
keywords="electrophysiology",
abstract="Background: Preventable poor health outcomes associated with atrial fibrillation continue to make early detection a priority. A one-lead mobile electrocardiogram (mECG) device given to patients with an implantable cardioverter defibrillator (ICD) allowed users to receive real-time ECG readings in 30 seconds. Objective: Three cases were selected from an institutional review board-approved clinical trial aimed at assessing mECG device usage and satisfaction, patient engagement, quality of life (QoL), and cardiac anxiety. These three specific cases were selected to examine a variety of possible patient presentations and user experiences. Methods: Three ICD patients with mobile phones who were being seen in an adult device clinic were asked to participate. The participants chosen represented individuals with varying degrees of reported education and patient engagement. Participants were instructed to use the mECG device at least once per day for 30 days. Positive ECGs for atrial fibrillation were evaluated in clinic. At follow-up, information was collected regarding their frequency of use of the mECG device and three psychological outcomes in the domains of patient engagement, QoL, and cardiac anxiety. Results: Each patient used the technology approximately daily or every other day as prescribed. At the 30-day follow-up, usage reports indicated an average of 32 readings per month per participant. At 90-day follow-up, usage reports indicated an average of 34 readings per month per participant. Two of the three participants self-reported a significant improvement in their physical QoL from baseline to completion, while simultaneously self-reporting a significant decrease in their mental QoL. All three participants reported high levels of device acceptance and technology satisfaction. Conclusions: This case study demonstrates that ICD patients with varying degrees of education and patient engagement were relatively active in their use of mECGs. All three participants using the mECG technology reported high technology satisfaction and device acceptance. High sensitivity, specificity, and accuracy of mECG technology may allow routine atrial fibrillation screening at lower costs, in addition to improving patient outcomes. ",
doi="10.2196/cardio.8710",
url="http://cardio.jmir.org/2018/1/e5/",
url="http://www.ncbi.nlm.nih.gov/pubmed/31758776"
}


@Article{info:doi/10.2196/cardio.7586,
author="Marvel, Adeline Francoise
and Wang, Jane
and Martin, Shay Seth",
title="Digital Health Innovation: A Toolkit to Navigate From Concept to Clinical Testing",
journal="JMIR Cardio",
year="2018",
month="Jan",
day="18",
volume="2",
number="1",
pages="e2",
keywords="digital health innovation models",
keywords="mHealth",
keywords="innovation framework",
keywords="development of smartphone applications",
keywords="wearable technology",
keywords="healthcare transformation",
doi="10.2196/cardio.7586",
url="http://cardio.jmir.org/2018/1/e2/",
url="http://www.ncbi.nlm.nih.gov/pubmed/31758761"
}


@Article{info:doi/10.2196/mhealth.8873,
author="Marcolino, Soriano Milena
and Oliveira, Queiroz Jo{\~a}o Antonio
and D'Agostino, Marcelo
and Ribeiro, Luiz Antonio
and Alkmim, Moreira Maria Beatriz
and Novillo-Ortiz, David",
title="The Impact of mHealth Interventions: Systematic Review of Systematic Reviews",
journal="JMIR Mhealth Uhealth",
year="2018",
month="Jan",
day="17",
volume="6",
number="1",
pages="e23",
keywords="telemedicine",
keywords="medical informatics",
keywords="mobile phones",
abstract="Background: Mobile phone usage has been rapidly increasing worldwide. mHealth could efficiently deliver high-quality health care, but the evidence supporting its current effectiveness is still mixed. Objective: We performed a systematic review of systematic reviews to assess the impact or effectiveness of mobile health (mHealth) interventions in different health conditions and in the processes of health care service delivery. Methods: We used a common search strategy of five major scientific databases, restricting the search by publication date, language, and parameters in methodology and content. Methodological quality was evaluated using the Measurement Tool to Assess Systematic Reviews (AMSTAR) checklist. Results: The searches resulted in a total of 10,689 articles. Of these, 23 systematic reviews (371 studies; more than 79,665 patients) were included. Seventeen reviews included studies performed in low- and middle-income countries. The studies used diverse mHealth interventions, most frequently text messaging (short message service, SMS) applied to different purposes (reminder, alert, education, motivation, prevention). Ten reviews were rated as low quality (AMSTAR score 0-4), seven were rated as moderate quality (AMSTAR score 5-8), and six were categorized as high quality (AMSTAR score 9-11). A beneficial impact of mHealth was observed in chronic disease management, showing improvement in symptoms and peak flow variability in asthma patients, reducing hospitalizations and improving forced expiratory volume in 1 second; improving chronic pulmonary diseases symptoms; improving heart failure symptoms, reducing deaths and hospitalization; improving glycemic control in diabetes patients; improving blood pressure in hypertensive patients; and reducing weight in overweight and obese patients. Studies also showed a positive impact of SMS reminders in improving attendance rates, with a similar impact to phone call reminders at reduced cost, and improved adherence to tuberculosis and human immunodeficiency virus therapy in some scenarios, with evidence of decrease of viral load. Conclusions: Although mHealth is growing in popularity, the evidence for efficacy is still limited. In general, the methodological quality of the studies included in the systematic reviews is low. For some fields, its impact is not evident, the results are mixed, or no long-term studies exist. Exceptions include the moderate quality evidence of improvement in asthma patients, attendance rates, and increased smoking abstinence rates. Most studies were performed in high-income countries, implying that mHealth is still at an early stage of development in low-income countries. ",
doi="10.2196/mhealth.8873",
url="http://mhealth.jmir.org/2018/1/e23/",
url="http://www.ncbi.nlm.nih.gov/pubmed/29343463"
}


@Article{info:doi/10.2196/humanfactors.8017,
author="Beatty, L. Alexis
and Magnusson, L. Sara
and Fortney, C. John
and Sayre, G. George
and Whooley, A. Mary",
title="VA FitHeart, a Mobile App for Cardiac Rehabilitation: Usability Study",
journal="JMIR Hum Factors",
year="2018",
month="Jan",
day="15",
volume="5",
number="1",
pages="e3",
keywords="cardiac rehabilitation",
keywords="mobile applications",
keywords="exercise therapy",
keywords="exercise",
keywords="rehabilitation research",
keywords="telemedicine",
keywords="habits",
keywords="qualitative research",
abstract="Background: Cardiac rehabilitation (CR) improves outcomes for patients with ischemic heart disease or heart failure but is underused. New strategies to improve access to and engagement in CR are needed. There is considerable interest in technology-facilitated home CR. However, little is known about patient acceptance and use of mobile technology for CR. Objective: The aim of this study was to develop a mobile app for technology-facilitated home CR and seek to determine its usability. Methods: We recruited patients eligible for CR who had access to a mobile phone, tablet, or computer with Internet access. The mobile app includes physical activity goal setting, logs for tracking physical activity and health metrics (eg, weight, blood pressure, and mood), health education, reminders, and feedback. Study staff demonstrated the mobile app to participants in person and then observed participants completing prespecified tasks with the mobile app. Participants completed the System Usability Scale (SUS, 0-100), rated likelihood to use the mobile app (0-100), questionnaires on mobile app use, and participated in a semistructured interview. The Unified Theory of Acceptance and Use of Technology and the Theory of Planned Behavior informed the analysis. On the basis of participant feedback, we made iterative revisions to the mobile app between users. Results: We conducted usability testing in 13 participants. The first version of the mobile app was used by the first 5 participants, and revised versions were used by the final 8 participants. From the first version to revised versions, task completion success rate improved from 44\% (11/25 tasks) to 78\% (31/40 tasks; P=.05), SUS improved from 54 to 76 (P=.04; scale 0-100, with 100 being the best usability), and self-reported likelihood of use remained high at 76 and 87 (P=.30; scale 0-100, with 100 being the highest likelihood). In interviews, patients expressed interest in tracking health measures (``I think it'll be good to track my exercise and to see what I'm doing''), a desire for introductory training (``Initially, training with a technical person, instead of me relying on myself''), and an expectation for sharing data with providers (``It would also be helpful to share with my doctor, it just being a matter of clicking a button and sharing it with my doctor''). Conclusions: With participant feedback and iterative revisions, we significantly improved the usability of a mobile app for CR. Patient expectations for using a mobile app for CR include tracking health metrics, introductory training, and sharing data with providers. Iterative mixed-method evaluation may be useful for improving the usability of health technology. ",
doi="10.2196/humanfactors.8017",
url="http://humanfactors.jmir.org/2018/1/e3/",
url="http://www.ncbi.nlm.nih.gov/pubmed/29335235"
}


@Article{info:doi/10.2196/mhealth.8458,
author="Mazoteras Pardo, Victoria
and Losa Iglesias, E. Marta
and L{\'o}pez Chicharro, Jos{\'e}
and Becerro de Bengoa Vallejo, Ricardo",
title="The QardioArm App in the Assessment of Blood Pressure and Heart Rate: Reliability and Validity Study",
journal="JMIR Mhealth Uhealth",
year="2017",
month="Dec",
day="15",
volume="5",
number="12",
pages="e198",
keywords="blood pressure",
keywords="heart rate",
keywords="reliability",
keywords="validity",
keywords="mobile apps",
abstract="Background: Self-measurement of blood pressure is a priority strategy for managing blood pressure. Objective: The aim of this study was to evaluate the reliability and validity of blood pressure and heart rate following the European Society of Hypertension's international validation protocol, as measured with the QardioArm, a fully automatic, noninvasive wireless blood pressure monitor and mobile app. Methods: A total of 100 healthy volunteers older than 25 years from the general population of Ciudad Real, Spain, participated in a test-retest validation study with two measurement sessions separated by 5 to 7 days. In each measurement session, seven systolic blood pressure, diastolic blood pressure, and heart rate assessments were taken, alternating between the two devices. The test device was the QardioArm and the previously validated criterion device was the Omron M3. Sessions took place at a single study site with an evaluation room that was maintained at an appropriate temperature and kept free from noises and distractions. Results: The QardioArm displayed very consistent readings both within and across sessions (intraclass correlation coefficients=0.80-0.95, standard errors of measurement=2.5-5.4). The QardioArm measurements corresponded closely to those from the criterion device (r>.96) and mean values for the two devices were nearly identical. The QardioArm easily passed all validation standards set by the European Society of Hypertension International Protocol. Conclusions: The QardioArm mobile app has validity and it can be used free of major measurement error. ",
doi="10.2196/mhealth.8458",
url="http://mhealth.jmir.org/2017/12/e198/",
url="http://www.ncbi.nlm.nih.gov/pubmed/29246880"
}


@Article{info:doi/10.2196/mhealth.8549,
author="Xie, Bo
and Su, Zhaohui
and Zhang, Wenhui
and Cai, Run",
title="Chinese Cardiovascular Disease Mobile Apps' Information Types, Information Quality, and Interactive Functions for Self-Management: Systematic Review",
journal="JMIR Mhealth Uhealth",
year="2017",
month="Dec",
day="14",
volume="5",
number="12",
pages="e195",
keywords="mobile health",
keywords="mHealth",
keywords="cardiovascular disease",
keywords="CVD",
keywords="patient preferences",
keywords="information quality",
keywords="self-management",
keywords="mobile applications",
keywords="mobile apps",
keywords="China",
abstract="Background: China has a large population with cardiovascular disease (CVD) that requires extensive self-management. Mobile health (mHealth) apps may be a useful tool for CVD self-management. Little is currently known about the types and quality of health information provided in Chinese CVD mobile apps and whether app functions are conducive to promoting CVD self-management. Objective: We undertook a systematic review to evaluate the types and quality of health information provided in Chinese CVD mobile apps and interactive app functions for promoting CVD self-management. Methods: Mobile apps targeting end users in China with CVD conditions were selected in February 2017 through a multi-stage process. Three frameworks were used to evaluate the selected apps: (1) types of health information offered were assessed using our Health Information Wants framework, which encompasses 7 types of information; (2) quality of information provided in the apps was assessed using the 11 guidelines recommended by the National Library of Medicine of the National Institutes of Health; and (3) types of interactive app functions for CVD self-management were assessed using a 15-item framework adapted from the literature, including our own prior work. Results: Of 578 apps identified, 82 were eligible for final review. Among these, information about self-care (67/82, 82\%) and information specifically regarding CVD (63/82, 77\%) were the most common types of information provided, while information about health care providers (22/82, 27\%) and laboratory tests (5/82, 6\%) were least common. The most common indicators of information quality were the revealing of apps' providers (82/82, 100\%) and purpose (82/82, 100\%), while the least common quality indicators were the revealing of how apps' information was selected (1/82, 1\%) and app sponsorship (0/82, 0\%). The most common interactive functions for CVD self-management were those that enabled user interaction with the app provider (57/82, 70\%) and with health care providers (36/82, 44\%), while the least common interactive functions were those that enabled lifestyle management (13/82, 16\%) and psychological health management (6/82, 7\%). None of the apps covered all 7 types of health information, all 11 indicators of information quality, or all 15 interactive functions for CVD self-management. Conclusions: Chinese CVD apps are insufficient in providing comprehensive health information, high-quality information, and interactive functions to facilitate CVD self-management. End users should exercise caution when using existing apps. Health care professionals and app developers should collaborate to better understand end users' preferences and follow evidence-based guidelines to develop mHealth apps conducive to CVD self-management. ",
doi="10.2196/mhealth.8549",
url="http://mhealth.jmir.org/2017/12/e195/",
url="http://www.ncbi.nlm.nih.gov/pubmed/29242176"
}


@Article{info:doi/10.2196/cardio.8543,
author="Magnani, W. Jared
and Schlusser, L. Courtney
and Kimani, Everlyne
and Rollman, L. Bruce
and Paasche-Orlow, K. Michael
and Bickmore, W. Timothy",
title="The Atrial Fibrillation Health Literacy Information Technology System: Pilot Assessment",
journal="JMIR Cardio",
year="2017",
month="Dec",
day="12",
volume="1",
number="2",
pages="e7",
keywords="atrial fibrillation",
keywords="mHealth",
keywords="health-related quality of life",
keywords="medication adherence",
abstract="Background: Atrial fibrillation (AF) is a highly prevalent heart rhythm condition that has significant associated morbidity and requires chronic treatment. Mobile health (mHealth) technologies have the potential to enhance multiple aspects of AF care, including education, monitoring of symptoms, and encouraging and tracking medication adherence. We have previously implemented and tested relational agents to improve outcomes in chronic disease and sought to develop a smartphone-based relational agent for improving patient-centered outcomes in AF. Objective: The objective of this study was to pilot a smartphone-based relational agent as preparation for a randomized clinical trial, the Atrial Fibrillation Health Literacy Information Technology Trial (AF-LITT). Methods: We developed the relational agent for use by a smartphone consistent with our prior approaches. We programmed the relational agent as a computer-animated agent to simulate a face-to-face conversation and to serve as a health counselor or coach specific to AF. Relational agent's dialogue content, informed by a review of literature, focused on patient-centered domains and qualitative interviews with patients with AF, encompassed AF education, common symptoms, adherence challenges, and patient activation. We established that the content was accessible to individuals with limited health or computer literacy. Relational agent content coordinated with use of the smartphone AliveCor Kardia heart rate and rhythm monitor. Participants (N=31) were recruited as a convenience cohort from ambulatory clinical sites and instructed to use the relational agent and Kardia for 30 days. We collected demographic, social, and clinical characteristics and conducted baseline and 30-day assessments of health-related quality of life (HRQoL) with the Atrial Fibrillation Effect on Quality of life (AFEQT) measure; self-reported medication adherence with the Morisky 8-item Medication Adherence Scale (MMAS-8); and patient activation with the Patient Activation Measure (PAM). Results: Participants (mean age 68 [SD 11]; 39\% [12/31] women) used the relational agent for an average 17.8 (SD 10.0) days. The mean number of independent log-ins was 19.6 (SD 10.7), with a median of 20 times over 30 days. The mean number of Kardia uses was 26.5 (SD 5.9), and participants using Kardia were in AF for 14.3 (SD 11.0) days. AFEQT scores improved significantly from 64.5 (SD 22.9) at baseline to 76.3 (SD 19.4) units at 30 days (P<.01). We observed marginal but statistically significant improvement in self-reported medication adherence (baseline: 7.3 [SD 0.9], 30 days: 7.7 [SD 0.5]; P=.01). Assessments of acceptability identified that most of the participants found the relational agent useful, informative, and trustworthy. Conclusions: We piloted a 30-day smartphone-based intervention that combined a relational agent with dedicated content for AF alongside Kardia heart rate and rhythm monitoring. Pilot participants had favorable improvements in HRQoL and self-reported medication adherence, as well as positive responses to the intervention. These data will guide a larger, enhanced randomized trial implementing the smartphone relational agent and the Kardia monitor system. ",
doi="10.2196/cardio.8543",
url="http://cardio.jmir.org/2017/2/e7/",
url="http://www.ncbi.nlm.nih.gov/pubmed/29473644"
}


@Article{info:doi/10.2196/mhealth.7254,
author="Vandenberk, Thijs
and Stans, Jelle
and Mortelmans, Christophe
and Van Haelst, Ruth
and Van Schelvergem, Gertjan
and Pelckmans, Caroline
and Smeets, JP Christophe
and Lanssens, Dorien
and De Canni{\`e}re, H{\'e}l{\`e}ne
and Storms, Valerie
and Thijs, M. Inge
and Vaes, Bert
and Vandervoort, M. Pieter",
title="Clinical Validation of Heart Rate Apps: Mixed-Methods Evaluation Study",
journal="JMIR Mhealth Uhealth",
year="2017",
month="Aug",
day="25",
volume="5",
number="8",
pages="e129",
keywords="heart rate",
keywords="software validation",
keywords="remote sensing technology",
abstract="Background: Photoplethysmography (PPG) is a proven way to measure heart rate (HR). This technology is already available in smartphones, which allows measuring HR only by using the smartphone. Given the widespread availability of smartphones, this creates a scalable way to enable mobile HR monitoring. An essential precondition is that these technologies are as reliable and accurate as the current clinical (gold) standards. At this moment, there is no consensus on a gold standard method for the validation of HR apps. This results in different validation processes that do not always reflect the veracious outcome of comparison. Objective: The aim of this paper was to investigate and describe the necessary elements in validating and comparing HR apps versus standard technology. Methods: The FibriCheck (Qompium) app was used in two separate prospective nonrandomized studies. In the first study, the HR of the FibriCheck app was consecutively compared with 2 different Food and Drug Administration (FDA)-cleared HR devices: the Nonin oximeter and the AliveCor Mobile ECG. In the second study, a next step in validation was performed by comparing the beat-to-beat intervals of the FibriCheck app to a synchronized ECG recording. Results: In the first study, the HR (BPM, beats per minute) of 88 random subjects consecutively measured with the 3 devices showed a correlation coefficient of .834 between FibriCheck and Nonin, .88 between FibriCheck and AliveCor, and .897 between Nonin and AliveCor. A single way analysis of variance (ANOVA; P=.61 was executed to test the hypothesis that there were no significant differences between the HRs as measured by the 3 devices. In the second study, 20,298 (ms) R-R intervals (RRI)--peak-to-peak intervals (PPI) from 229 subjects were analyzed. This resulted in a positive correlation (rs=.993, root mean square deviation [RMSE]=23.04 ms, and normalized root mean square error [NRMSE]=0.012) between the PPI from FibriCheck and the RRI from the wearable ECG. There was no significant difference (P=.92) between these intervals. Conclusions: Our findings suggest that the most suitable method for the validation of an HR app is a simultaneous measurement of the HR by the smartphone app and an ECG system, compared on the basis of beat-to-beat analysis. This approach could lead to more correct assessments of the accuracy of HR apps. ",
doi="10.2196/mhealth.7254",
url="http://mhealth.jmir.org/2017/8/e129/"
}


@Article{info:doi/10.2196/biomedeng.8179,
author="Lang, Michael",
title="Heart Rate Monitoring Apps: Information for Engineers and Researchers About the New European Medical Devices Regulation 2017/745",
journal="JMIR Biomed Eng",
year="2017",
month="Aug",
day="18",
volume="2",
number="1",
pages="e2",
keywords="European Medical Device Regulation",
keywords="(EU) 2017/745",
keywords="MDR",
keywords="93/42/EEC",
keywords="MDD",
keywords="heart rate monitoring",
keywords="health apps",
keywords="mHealth",
abstract="Background: After years in the making, on April 5, 2017, the European Parliament and Council finally adopted Regulation (EU) 2017/745, the new Medical Devices Regulation (MDR), repealing the existing Medical Device Directive (MDD) 93/42/EEC. Though long anticipated, this shift in policy will have strong and lasting effects in the medical devices industry. Objective: This paper focuses specifically on the classification of software as a potential medical device under MDD and MDR and examines whether or not the regulatory framework for health apps has changed substantially and what, if any, impact is to expected. A particular emphasis will be on the issue of classification uncertainty raised by borderline cases such as heart rate monitoring and well-being apps. The paper primarily targets researchers and engineers unfamiliar with regulatory requirements for medical devices and aims to provide a concise, yet accurate, overview of the European regulatory framework. This is of particular relevance as with the exponential growth of fitness and health-related apps, the lines between toys, lifestyle products, and medical devices have increasingly blurred. Methods: The recently published European Medical Device Regulation is analyzed and compared to the preceding MDD. Results: The previous regulatory framework already provided for the possibility of apps to fall under the definition of medical devices, in which case classification rules for active medical devices applied. However, while applicability of the new regulatory framework still hinges on whether the intended purpose is medical or not, the threshold for classifying as a medical device has been considerably lowered due to a broader interpretation of what constitutes a medical purpose. Conclusions: The adoption of the new European regulation on medical devices entails the risk that manufacturers previously unaffected by the medical devices regulatory framework may now unwillingly and unwittingly find themselves in the arena of medical device manufacturing. ",
doi="10.2196/biomedeng.8179",
url="http://biomedeng.jmir.org/2017/1/e2/"
}


@Article{info:doi/10.2196/cardio.7848,
author="Athilingam, Ponrathi
and Jenkins, Bradlee
and Johansson, Marcia
and Labrador, Miguel",
title="A Mobile Health Intervention to Improve Self-Care in Patients With Heart Failure: Pilot Randomized Control Trial",
journal="JMIR Cardio",
year="2017",
month="Aug",
day="11",
volume="1",
number="2",
pages="e3",
keywords="heart failure",
keywords="mobile applications",
keywords="self-care",
keywords="quality of life",
abstract="Background: Heart failure (HF) is a progressive chronic disease affecting 6.5 million Americans and over 15 million individuals globally. Patients with HF are required to engage in complex self-care behaviors. Although the advancements in medicine have enabled people with HF to live longer, they often have poor health-related quality of life and experience severe and frequent symptoms that limit several aspects of their lives. Mobile phone apps have not only created new and interactive ways of communication between patients and health care providers but also provide a platform to enhance adherence to self-care management. Objective: The aim of this pilot study was to test the feasibility of a newly developed mobile app (HeartMapp) in improving self-care behaviors and quality of life of patients with HF and to calculate effect sizes for sample size calculation for a larger study. Methods: This was a pilot feasibility randomized controlled trial. Participants were enrolled in the hospital before discharge and followed at home for 30 days. The intervention group used HeartMapp (n=9), whereas the control group (n=9) received HF education. These apps were downloaded onto their mobile phones for daily use. Results: A total of 72\% (13/18) participants completed the study; the mean age of the participants was 53 (SD 4.02) years, 56\% (10/18) were females, 61\% (11/18) lived alone, 33\% (6/18) were African Americans, and 61\% (11/18) used mobile phone to get health information. The mean engagement with HeartMapp was 78\%. Results were promising with a trend that participants in the HeartMapp group had a significant mean score change on self-care management (8.7 vs 2.3; t3.38=11, P=.01), self-care confidence (6.7 vs 1.8; t2.53=11, P=.28), and HF knowledge (3 vs ?0.66; t2.37=11, P=.04. Depression improved among both groups, more so in the control group (?1.14 vs ?5.17; t1.97=11, P=.07). Quality of life declined among both groups, more so in the control group (2.14 vs 9.0; t?1.43=11, P=.18). Conclusions: The trends demonstrated in this pilot feasibility study warrant further exploration on the use of HeartMapp to improve HF outcomes. Trial Registration: Pilot study, no funding from National agencies, hence not registered. ",
doi="10.2196/cardio.7848",
url="http://cardio.jmir.org/2017/2/e3/",
url="http://www.ncbi.nlm.nih.gov/pubmed/31758759"
}


@Article{info:doi/10.2196/jmir.7782,
author="Duff, Mairead Orlaith
and Walsh, MJ Deirdre
and Furlong, A. Br{\'o}na
and O'Connor, E. Noel
and Moran, A. Kieran
and Woods, B. Catherine",
title="Behavior Change Techniques in Physical Activity eHealth Interventions for People With Cardiovascular Disease: Systematic Review",
journal="J Med Internet Res",
year="2017",
month="Aug",
day="02",
volume="19",
number="8",
pages="e281",
keywords="systematic review",
keywords="exercise",
keywords="behavior",
keywords="telemedicine",
keywords="cardiovascular disease",
abstract="Background: Cardiovascular disease (CVD) is the leading cause of premature death and disability in Europe, accounting for 4 million deaths per year and costing the European Union economy almost {\texteuro}196 billion annually. There is strong evidence to suggest that exercise-based secondary rehabilitation programs can decrease the mortality risk and improve health among patients with CVD. Theory-informed use of behavior change techniques (BCTs) is important in the design of cardiac rehabilitation programs aimed at changing cardiovascular risk factors. Electronic health (eHealth) is the use of information and communication technologies (ICTs) for health. This emerging area of health care has the ability to enhance self-management of chronic disease by making health care more accessible, affordable, and available to the public. However, evidence-based information on the use of BCTs in eHealth interventions is limited, and particularly so, for individuals living with CVD. Objective: The aim of this systematic review was to assess the application of BCTs in eHealth interventions designed to increase physical activity (PA) in CVD populations. Methods: A total of 7 electronic databases, including EBSCOhost (MEDLINE, PsycINFO, Academic Search Complete, SPORTDiscus with Full Text, and CINAHL Complete), Scopus, and Web of Science (Core Collection) were searched. Two authors independently reviewed references using the software package Covidence (Veritas Health Innovation). The reviewers met to resolve any discrepancies, with a third independent reviewer acting as an arbitrator when required. Following this, data were extracted from the papers that met the inclusion criteria. Bias assessment of the studies was carried out using the Cochrane Collaboration's tool for assessing the risk of bias within Covidence; this was followed by a narrative synthesis. Results: Out of the 987 studies that were identified, 14 were included in the review. An additional 9 studies were added following a hand search of review paper references. The average number of BCTs used across the 23 studies was 7.2 (range 1-19). The top three most frequently used BCTs included information about health consequences (78\%, 18/23), goal setting (behavior; 74\%, 17/23), and joint third, self-monitoring of behavior and social support (practical) were included in 11 studies (48\%, 11/23) each. Conclusions: This systematic review is the first to investigate the use of BCTs in PA eHealth interventions specifically designed for people with CVD. This research will have clear implications for health care policy and research by outlining the BCTs used in eHealth interventions for chronic illnesses, in particular CVD, thereby providing clear foundations for further research and developments in the area. ",
doi="10.2196/jmir.7782",
url="http://www.jmir.org/2017/8/e281/",
url="http://www.ncbi.nlm.nih.gov/pubmed/28768610"
}


@Article{info:doi/10.2196/mhealth.7141,
author="Kim, YB Ben
and Lee, Joon",
title="Smart Devices for Older Adults Managing Chronic Disease: A Scoping Review",
journal="JMIR Mhealth Uhealth",
year="2017",
month="May",
day="23",
volume="5",
number="5",
pages="e69",
keywords="mobile health",
keywords="mHealth",
keywords="smartphone",
keywords="mobile phone",
keywords="tablet",
keywords="older adults",
keywords="seniors",
keywords="chronic disease",
keywords="chronic disease management",
keywords="scoping review",
abstract="Background: The emergence of smartphones and tablets featuring vastly advancing functionalities (eg, sensors, computing power, interactivity) has transformed the way mHealth interventions support chronic disease management for older adults. Baby boomers have begun to widely adopt smart devices and have expressed their desire to incorporate technologies into their chronic care. Although smart devices are actively used in research, little is known about the extent, characteristics, and range of smart device-based interventions. Objective: We conducted a scoping review to (1) understand the nature, extent, and range of smart device-based research activities, (2) identify the limitations of the current research and knowledge gap, and (3) recommend future research directions. Methods: We used the Arksey and O'Malley framework to conduct a scoping review. We identified relevant studies from MEDLINE, Embase, CINAHL, and Web of Science databases using search terms related to mobile health, chronic disease, and older adults. Selected studies used smart devices, sampled older adults, and were published in 2010 or after. The exclusion criteria were sole reliance on text messaging (short message service, SMS) or interactive voice response, validation of an electronic version of a questionnaire, postoperative monitoring, and evaluation of usability. We reviewed references. We charted quantitative data and analyzed qualitative studies using thematic synthesis. To collate and summarize the data, we used the chronic care model. Results: A total of 51 articles met the eligibility criteria. Research activity increased steeply in 2014 (17/51, 33\%) and preexperimental design predominated (16/50, 32\%). Diabetes (16/46, 35\%) and heart failure management (9/46, 20\%) were most frequently studied. We identified diversity and heterogeneity in the collection of biometrics and patient-reported outcome measures within and between chronic diseases. Across studies, we found 8 self-management supporting strategies and 4 distinct communication channels for supporting the decision-making process. In particular, self-monitoring (38/40, 95\%), automated feedback (15/40, 38\%), and patient education (13/40, 38\%) were commonly used as self-management support strategies. Of the 23 studies that implemented decision support strategies, clinical decision making was delegated to patients in 10 studies (43\%). The impact on patient outcomes was consistent with studies that used cellular phones. Patients with heart failure and asthma reported improved quality of life. Qualitative analysis yielded 2 themes of facilitating technology adoption for older adults and 3 themes of barriers. Conclusions: Limitations of current research included a lack of gerontological focus, dominance of preexperimental design, narrow research scope, inadequate support for participants, and insufficient evidence for clinical outcome. Recommendations for future research include generating evidence for smart device-based programs, using patient-generated data for advanced data mining techniques, validating patient decision support systems, and expanding mHealth practice through innovative technologies. ",
doi="10.2196/mhealth.7141",
url="http://mhealth.jmir.org/2017/5/e69/",
url="http://www.ncbi.nlm.nih.gov/pubmed/28536089"
}


@Article{info:doi/10.2196/cardio.6057,
author="Darling, Eric Chad
and Dovancescu, Silviu
and Saczynski, S. Jane
and Riistama, Jarno
and Sert Kuniyoshi, Fatima
and Rock, Joseph
and Meyer, E. Theo
and McManus, D. David",
title="Bioimpedance-Based Heart Failure Deterioration Prediction Using a Prototype Fluid Accumulation Vest-Mobile Phone Dyad: An Observational Study",
journal="JMIR Cardio",
year="2017",
month="Mar",
day="13",
volume="1",
number="1",
pages="e1",
keywords="telemedicine",
keywords="outpatient monitoring",
keywords="heart failure",
keywords="electric impedance",
abstract="Background: Recurrent heart failure (HF) events are common in patients discharged after acute decompensated heart failure (ADHF). New patient-centered technologies are needed to aid in detecting HF decompensation. Transthoracic bioimpedance noninvasively measures pulmonary fluid retention. Objective: The objectives of our study were to (1) determine whether transthoracic bioimpedance can be measured daily with a novel, noninvasive, wearable fluid accumulation vest (FAV) and transmitted using a mobile phone and (2) establish whether an automated algorithm analyzing daily thoracic bioimpedance values would predict recurrent HF events. Methods: We prospectively enrolled patients admitted for ADHF. Participants were trained to use a FAV--mobile phone dyad and asked to transmit bioimpedance measurements for 45 consecutive days. We examined the performance of an algorithm analyzing changes in transthoracic bioimpedance as a predictor of HF events (HF readmission, diuretic uptitration) over a 75-day follow-up. Results: We observed 64 HF events (18 HF readmissions and 46 diuretic uptitrations) in the 106 participants (67 years; 63.2\%, 67/106, male; 48.1\%, 51/106, with prior HF) who completed follow-up. History of HF was the only clinical or laboratory factor related to recurrent HF events (P=.04). Among study participants with sufficient FAV data (n=57), an algorithm analyzing thoracic bioimpedance showed 87\% sensitivity (95\% CI 82-92), 70\% specificity (95\% CI 68-72), and 72\% accuracy (95\% CI 70-74) for identifying recurrent HF events. Conclusions: Patients discharged after ADHF can measure and transmit daily transthoracic bioimpedance using a FAV--mobile phone dyad. Algorithms analyzing thoracic bioimpedance may help identify patients at risk for recurrent HF events after hospital discharge. ",
doi="10.2196/cardio.6057",
url="http://cardio.jmir.org/2017/1/e1/",
url="http://www.ncbi.nlm.nih.gov/pubmed/31758769"
}


@Article{info:doi/10.2196/mhealth.7275,
author="Yan, P. Bryan
and Chan, KY Christy
and Li, KH Christien
and To, TL Olivia
and Lai, HS William
and Tse, Gary
and Poh, C. Yukkee
and Poh, Ming-Zher",
title="Resting and Postexercise Heart Rate Detection From Fingertip and Facial Photoplethysmography Using a Smartphone Camera: A Validation Study",
journal="JMIR Mhealth Uhealth",
year="2017",
month="Mar",
day="13",
volume="5",
number="3",
pages="e33",
keywords="heart rate",
keywords="mobile apps",
keywords="photoplethysmography",
keywords="smartphone",
keywords="mobile phone",
abstract="Background: Modern smartphones allow measurement of heart rate (HR) by detecting pulsatile photoplethysmographic (PPG) signals with built-in cameras from the fingertips or the face, without physical contact, by extracting subtle beat-to-beat variations of skin color. Objective: The objective of our study was to evaluate the accuracy of HR measurements at rest and after exercise using a smartphone-based PPG detection app. Methods: A total of 40 healthy participants (20 men; mean age 24.7, SD 5.2 years; von Luschan skin color range 14-27) underwent treadmill exercise using the Bruce protocol. We recorded simultaneous PPG signals for each participant by having them (1) facing the front camera and (2) placing their index fingertip over an iPhone's back camera. We analyzed the PPG signals from the Cardiio-Heart Rate Monitor + 7 Minute Workout (Cardiio) smartphone app for HR measurements compared with a continuous 12-lead electrocardiogram (ECG) as the reference. Recordings of 20 seconds' duration each were acquired at rest, and immediately after moderate- (50\%-70\% maximum HR) and vigorous- (70\%-85\% maximum HR) intensity exercise, and repeated successively until return to resting HR. We used Bland-Altman plots to examine agreement between ECG and PPG-estimated HR. The accuracy criterion was root mean square error (RMSE) ?5 beats/min or ?10\%, whichever was greater, according to the American National Standards Institute/Association for the Advancement of Medical Instrumentation EC-13 standard. Results: We analyzed a total of 631 fingertip and 626 facial PPG measurements. Fingertip PPG-estimated HRs were strongly correlated with resting ECG HR (r=.997, RMSE=1.03 beats/min or 1.40\%), postmoderate-intensity exercise (r=.994, RMSE=2.15 beats/min or 2.53\%), and postvigorous-intensity exercise HR (r=.995, RMSE=2.01 beats/min or 1.93\%). The correlation of facial PPG-estimated HR was stronger with resting ECG HR (r=.997, RMSE=1.02 beats/min or 1.44\%) than with postmoderate-intensity exercise (r=.982, RMSE=3.68 beats/min or 4.11\%) or with postvigorous-intensity exercise (r=.980, RMSE=3.84 beats/min or 3.73\%). Bland-Altman plots showed better agreement between ECG and fingertip PPG-estimated HR than between ECG and facial PPG-estimated HR. Conclusions: We found that HR detection by the Cardiio smartphone app was accurate at rest and after moderate- and vigorous-intensity exercise in a healthy young adult sample. Contact-free facial PPG detection is more convenient but is less accurate than finger PPG due to body motion after exercise. ",
doi="10.2196/mhealth.7275",
url="http://mhealth.jmir.org/2017/3/e33/",
url="http://www.ncbi.nlm.nih.gov/pubmed/28288955"
}


@Article{info:doi/10.2196/jmir.7005,
author="Siebert, N. Johan
and Ehrler, Frederic
and Combescure, Christophe
and Lacroix, Laurence
and Haddad, Kevin
and Sanchez, Oliver
and Gervaix, Alain
and Lovis, Christian
and Manzano, Sergio",
title="A Mobile Device App to Reduce Time to Drug Delivery and Medication Errors During Simulated Pediatric Cardiopulmonary Resuscitation: A Randomized Controlled Trial",
journal="J Med Internet Res",
year="2017",
month="Feb",
day="01",
volume="19",
number="2",
pages="e31",
keywords="resuscitation",
keywords="medication errors",
keywords="pharmaceutical preparations",
keywords="pediatrics",
keywords="biomedical technology",
abstract="Background: During pediatric cardiopulmonary resuscitation (CPR), vasoactive drug preparation for continuous infusion is both complex and time-consuming, placing children at higher risk than adults for medication errors. Following an evidence-based ergonomic-driven approach, we developed a mobile device app called Pediatric Accurate Medication in Emergency Situations (PedAMINES), intended to guide caregivers step-by-step from preparation to delivery of drugs requiring continuous infusion. Objective: The aim of our study was to determine whether the use of PedAMINES reduces drug preparation time (TDP) and time to delivery (TDD; primary outcome), as well as medication errors (secondary outcomes) when compared with conventional preparation methods. Methods: The study was a randomized controlled crossover trial with 2 parallel groups comparing PedAMINES with a conventional and internationally used drugs infusion rate table in the preparation of continuous drug infusion. We used a simulation-based pediatric CPR cardiac arrest scenario with a high-fidelity manikin in the shock room of a tertiary care pediatric emergency department. After epinephrine-induced return of spontaneous circulation, pediatric emergency nurses were first asked to prepare a continuous infusion of dopamine, using either PedAMINES (intervention group) or the infusion table (control group), and second, a continuous infusion of norepinephrine by crossing the procedure. The primary outcome was the elapsed time in seconds, in each allocation group, from the oral prescription by the physician to TDD by the nurse. TDD included TDP. The secondary outcome was the medication dosage error rate during the sequence from drug preparation to drug injection. Results: A total of 20 nurses were randomized into 2 groups. During the first study period, mean TDP while using PedAMINES and conventional preparation methods was 128.1 s (95\% CI 102-154) and 308.1 s (95\% CI 216-400), respectively (180 s reduction, P=.002). Mean TDD was 214 s (95\% CI 171-256) and 391 s (95\% CI 298-483), respectively (177.3 s reduction, P=.002). Medication errors were reduced from 70\% to 0\% (P<.001) by using PedAMINES when compared with conventional methods. Conclusions: In this simulation-based study, PedAMINES dramatically reduced TDP, to delivery and the rate of medication errors. ",
doi="10.2196/jmir.7005",
url="http://www.jmir.org/2017/2/e31/",
url="http://www.ncbi.nlm.nih.gov/pubmed/28148473"
}


@Article{info:doi/10.2196/mhealth.5882,
author="Masterson Creber, M. Ruth
and Maurer, S. Mathew
and Reading, Meghan
and Hiraldo, Grenny
and Hickey, T. Kathleen
and Iribarren, Sarah",
title="Review and Analysis of Existing Mobile Phone Apps to Support Heart Failure Symptom Monitoring and Self-Care Management Using the Mobile Application Rating Scale (MARS)",
journal="JMIR Mhealth Uhealth",
year="2016",
month="Jun",
day="14",
volume="4",
number="2",
pages="e74",
keywords="mobile apps",
keywords="mobile health",
keywords="heart failure",
keywords="self-care",
keywords="self-management",
keywords="review",
keywords="symptom assessment",
keywords="nursing informatics",
abstract="Background: Heart failure is the most common cause of hospital readmissions among Medicare beneficiaries and these hospitalizations are often driven by exacerbations in common heart failure symptoms. Patient collaboration with health care providers and decision making is a core component of increasing symptom monitoring and decreasing hospital use. Mobile phone apps offer a potentially cost-effective solution for symptom monitoring and self-care management at the point of need. Objective: The purpose of this review of commercially available apps was to identify and assess the functionalities of patient-facing mobile health apps targeted toward supporting heart failure symptom monitoring and self-care management. Methods: We searched 3 Web-based mobile app stores using multiple terms and combinations (eg, ``heart failure,'' ``cardiology,'' ``heart failure and self-management''). Apps meeting inclusion criteria were evaluated using the Mobile Application Rating Scale (MARS), IMS Institute for Healthcare Informatics functionality scores, and Heart Failure Society of America (HFSA) guidelines for nonpharmacologic management. Apps were downloaded and assessed independently by 2-4 reviewers, interclass correlations between reviewers were calculated, and consensus was met by discussion. Results: Of 3636 potentially relevant apps searched, 34 met inclusion criteria. Most apps were excluded because they were unrelated to heart failure, not in English or Spanish, or were games. Interrater reliability between reviewers was high. AskMD app had the highest average MARS total (4.9/5). More than half of the apps (23/34, 68\%) had acceptable MARS scores (>3.0). Heart Failure Health Storylines (4.6) and AskMD (4.5) had the highest scores for behavior change. Factoring MARS, functionality, and HFSA guideline scores, the highest performing apps included Heart Failure Health Storylines, Symple, ContinuousCare Health App, WebMD, and AskMD. Peer-reviewed publications were identified for only 3 of the 34 apps. Conclusions: This review suggests that few apps meet prespecified criteria for quality, content, or functionality, highlighting the need for further refinement and mapping to evidence-based guidelines and room for overall quality improvement in heart failure symptom monitoring and self-care related apps. ",
doi="10.2196/mhealth.5882",
url="http://mhealth.jmir.org/2016/2/e74/",
url="http://www.ncbi.nlm.nih.gov/pubmed/27302310"
}


@Article{info:doi/10.2196/mhealth.3789,
author="Zan, Shiyi
and Agboola, Stephen
and Moore, A. Stephanie
and Parks, A. Kimberly
and Kvedar, C. Joseph
and Jethwani, Kamal",
title="Patient Engagement With a Mobile Web-Based Telemonitoring System for Heart Failure Self-Management: A Pilot Study",
journal="JMIR mHealth uHealth",
year="2015",
month="Apr",
day="01",
volume="3",
number="2",
pages="e33",
keywords="heart failure",
keywords="disease self-management",
keywords="remote monitoring",
keywords="telemonitoring",
keywords="interactive voice response system",
keywords="mobile health",
keywords="Web portal",
keywords="patient engagement",
keywords="quality of life",
abstract="Background: Intensive remote monitoring programs for congestive heart failure have been successful in reducing costly readmissions, but may not be appropriate for all patients. There is an opportunity to leverage the increasing accessibility of mobile technologies and consumer-facing digital devices to empower patients in monitoring their own health outside of the hospital setting. The iGetBetter system, a secure Web- and telephone-based heart failure remote monitoring program, which leverages mobile technology and portable digital devices, offers a creative solution at lower cost. Objective: The objective of this pilot study was to evaluate the feasibility of using the iGetBetter system for disease self-management in patients with heart failure. Methods: This was a single-arm prospective study in which  21 ambulatory, adult heart failure patients used the intervention for heart failure self-management over a 90-day study period. Patients were instructed to take their weight, blood pressure, and heart rate measurements each morning using a WS-30 bluetooth weight scale, a self-inflating blood pressure cuff (Withings LLC, Issy les Moulineaux, France), and an iPad Mini tablet computer (Apple Inc, Cupertino, CA, USA) equipped with cellular Internet connectivity to view their measurements on the Internet. Outcomes assessed included usability and satisfaction, engagement with the intervention, hospital resource utilization, and heart failure-related quality of life. Descriptive statistics were used to summarize data, and matched controls identified from the electronic medical record were used as comparison for evaluating hospitalizations. Results: There were 20 participants (mean age 53 years) that completed the study. Almost all participants (19/20, 95\%) reported feeling more connected to their health care team and more confident in performing care plan activities, and 18/20 (90\%) felt better prepared to start discussions about their health with their doctor. Although heart failure-related quality of life improved from baseline, it was not statistically significant (P=.55). Over half of the participants had greater than 80\% (72/90 days) weekly and overall engagement with the program, and 15\% (3/20) used the interactive voice response telephone system exclusively for managing their care plan. Hospital utilization did not differ in the intervention group compared to the control group (planned hospitalizations P=.23, and unplanned hospitalizations P=.99). Intervention participants recorded shorter average length of hospital stay, but no significant differences were observed between intervention and control groups (P=.30). Conclusions: This pilot study demonstrated the feasibility of a low-intensive remote monitoring program leveraging commonly used mobile and portable consumer devices in augmenting care for a fairly young population of ambulatory patients with heart failure. Further prospective studies with a larger sample size and within more diverse patient populations is necessary to determine the effect of mobile-based remote monitoring programs such as the iGetBetter system on clinical outcomes in heart failure. ",
doi="10.2196/mhealth.3789",
url="http://mhealth.jmir.org/2015/2/e33/",
url="http://www.ncbi.nlm.nih.gov/pubmed/25842282"
}


@Article{info:doi/10.2196/jmir.2951,
author="Kalz, Marco
and Lenssen, Niklas
and Felzen, Marc
and Rossaint, Rolf
and Tabuenca, Bernardo
and Specht, Marcus
and Skorning, Max",
title="Smartphone Apps for Cardiopulmonary Resuscitation Training and Real Incident Support: A Mixed-Methods Evaluation Study",
journal="J Med Internet Res",
year="2014",
month="Mar",
day="19",
volume="16",
number="3",
pages="e89",
keywords="basic life support (BLS)",
keywords="cardiopulmonary resuscitation (CPR)",
keywords="external chest compression (ECC)",
keywords="smartphone apps",
keywords="mobile phone",
keywords="mobile health",
abstract="Background: No systematic evaluation of smartphone/mobile apps for resuscitation training and real incident support is available to date. To provide medical, usability, and additional quality criteria for the development of apps, we conducted a mixed-methods sequential evaluation combining the perspective of medical experts and end-users. Objective: The study aims to assess the quality of current mobile apps for cardiopulmonary resuscitation (CPR) training and real incident support from expert as well as end-user perspective. Methods: Two independent medical experts evaluated the medical content of CPR apps from the Google Play store and the Apple App store. The evaluation was based on pre-defined minimum medical content requirements according to current Basic Life Support (BLS) guidelines. In a second phase, non-medical end-users tested usability and appeal of the apps that had at least met the minimum requirements. Usability was assessed with the System Usability Scale (SUS); appeal was measured with the self-developed ReactionDeck toolkit. Results: Out of 61 apps, 46 were included in the experts' evaluation. A consolidated list of 13 apps resulted for the following layperson evaluation. The interrater reliability was substantial (kappa=.61). Layperson end-users (n=14) had a high interrater reliability (intraclass correlation 1 [ICC1]=.83, P<.001, 95\% CI 0.75-0.882 and ICC2=.79, P<.001, 95\% CI 0.695-0.869). Their evaluation resulted in a list of 5 recommendable apps. Conclusions: Although several apps for resuscitation training and real incident support are available, very few are designed according to current BLS guidelines and offer an acceptable level of usability and hedonic quality for laypersons. The results of this study are intended to optimize the development of CPR mobile apps. The app ranking supports the informed selection of mobile apps for training situations and CPR campaigns as well as for real incident support. ",
doi="10.2196/jmir.2951",
url="http://www.jmir.org/2014/3/e89/",
url="http://www.ncbi.nlm.nih.gov/pubmed/24647361"
}


@Article{info:doi/10.2196/mhealth.2737,
author="Mart{\'i}nez-P{\'e}rez, Borja
and de la Torre-D{\'i}ez, Isabel
and L{\'o}pez-Coronado, Miguel
and Herreros-Gonz{\'a}lez, Jes{\'u}s",
title="Mobile Apps in Cardiology: Review",
journal="JMIR Mhealth Uhealth",
year="2013",
month="Jul",
day="24",
volume="1",
number="2",
pages="e15",
keywords="apps",
keywords="cardiology",
keywords="heart",
keywords="m-health",
keywords="mobile applications",
abstract="Background: Cardiovascular diseases are the deadliest diseases worldwide, with 17.3 million deaths in 2008 alone. Among them, heart-related deaths are of the utmost relevance; a fact easily proven by the 7.25 million deaths caused by ischemic heart disease alone in that year. The latest advances in smartphones and mHealth have been used in the creation of thousands of medical apps related to cardiology, which can help to reduce these mortality rates. Objective: The aim of this paper is to study the literature on mobile systems and applications currently available, as well as the existing apps related to cardiology from the leading app stores and to then classify the results to see what is available and what is missing, focusing particularly on commercial apps. Methods: Two reviews have been developed. One is a literature review of mobile systems and applications, retrieved from several databases and systems such as Scopus, PubMed, IEEE Xplore, and Web of Knowledge. The other is a review of mobile apps in the leading app stores, Google play for Android and Apple's App Store for iOS. Results: Search queries up to May 2013 located 406 papers and 710 apps related to cardiology and heart disease. The most researched section in the literature associated with cardiology is related to mobile heart (and vital signs) monitoring systems and the methods involved in the classification of heart signs in order to detect abnormal functions. Other systems with a significant number of papers are mobile cardiac rehabilitation systems, blood pressure measurement, and systems for the detection of heart failure. The majority of apps for cardiology are heart monitors and medical calculators. Other categories with a high number of apps are those for ECG education and interpretation, cardiology news and journals, blood pressure tracking, heart rate monitoring using an external device, and CPR instruction. There are very few guides on cardiac rehabilitation and apps for the management of the cardiac condition, and there were no apps that assist people who have undergone a heart transplant. Conclusions: The distribution of work in the field of cardiology apps is considerably disproportionate. Whereas some systems have significant research and apps are available, other important systems lack such research and lack apps, even though the contribution they could provide is significant. ",
doi="10.2196/mhealth.2737",
url="http://mhealth.jmir.org/2013/2/e15/",
url="http://www.ncbi.nlm.nih.gov/pubmed/25098320"
}


@Article{info:doi/10.2196/jmir.1909,
author="Seto, Emily
and Leonard, J. Kevin
and Cafazzo, A. Joseph
and Barnsley, Jan
and Masino, Caterina
and Ross, J. Heather",
title="Mobile Phone-Based Telemonitoring for Heart Failure Management:  A Randomized Controlled Trial",
journal="J Med Internet Res",
year="2012",
month="Feb",
day="16",
volume="14",
number="1",
pages="e31",
keywords="heart failure",
keywords="telemedicine",
keywords="mobile phone",
keywords="patient monitoring",
keywords="randomized controlled trial",
abstract="Background: Previous trials of telemonitoring for heart failure management have reported inconsistent results, largely due to diverse intervention and study designs. Mobile phones are becoming ubiquitous and economical, but the feasibility and efficacy of a mobile phone-based telemonitoring system have not been determined. Objective: The objective of this trial was to investigate the effects of a mobile phone-based telemonitoring system on heart failure management and outcomes. Methods: One hundred patients were recruited from a heart function clinic and randomized into telemonitoring and control groups. The telemonitoring group (N = 50) took daily weight and blood pressure readings and weekly single-lead ECGs, and answered daily symptom questions on a mobile phone over 6 months. Readings were automatically transmitted wirelessly to the mobile phone and then to data servers. Instructions were sent to the patients' mobile phones and alerts to a cardiologist's mobile phone as required. Results: Baseline questionnaires were completed and returned by 94 patients, and 84 patients returned post-study questionnaires. About 70\% of telemonitoring patients completed at least 80\% of their possible daily readings. The change in quality of life from baseline to post-study, as measured with the Minnesota Living with Heart Failure Questionnaire, was significantly greater for the telemonitoring group compared to the control group (P = .05). A between-group analysis also found greater post-study self-care maintenance (measured with the Self-Care of Heart Failure Index) for the telemonitoring group (P = .03). Brain natriuretic peptide (BNP) levels, self-care management, and left ventricular ejection fraction (LVEF) improved significantly for both groups from baseline to post-study, but did not show a between-group difference. However, a subgroup within-group analysis using the data from the 63 patients who had attended the heart function clinic for more than 6 months revealed the telemonitoring group had significant improvements from baseline to post-study in BNP (decreased by 150 pg/mL, P = .02), LVEF (increased by 7.4\%, P = .005) and self-care maintenance (increased by 7 points, P = .05) and management (increased by 14 points, P = .03), while the control group did not. No differences were found between the telemonitoring and control groups in terms of hospitalization, mortality, or emergency department visits, but the trial was underpowered to detect differences in these metrics. Conclusions: Our findings provide evidence of improved quality of life through improved self-care and clinical management from a mobile phone-based telemonitoring system. The use of the mobile phone-based system had high adherence and was feasible for patients, including the elderly and those with no experience with mobile phones. Trial Registration: ClinicalTrials.gov NCT00778986 ",
doi="10.2196/jmir.1909",
url="http://www.jmir.org/2012/1/e31/",
url="http://www.ncbi.nlm.nih.gov/pubmed/22356799"
}


@Article{info:doi/10.2196/jmir.1912,
author="Seto, Emily
and Leonard, J. Kevin
and Cafazzo, A. Joseph
and Barnsley, Jan
and Masino, Caterina
and Ross, J. Heather",
title="Perceptions and Experiences of Heart Failure Patients and Clinicians on the Use of Mobile Phone-Based Telemonitoring",
journal="J Med Internet Res",
year="2012",
month="Feb",
day="10",
volume="14",
number="1",
pages="e25",
keywords="heart failure",
keywords="telemonitoring",
keywords="mobile phone",
keywords="patient monitoring",
keywords="self-care",
keywords="qualitative research",
abstract="Background: Previous trials of heart failure telemonitoring systems have produced inconsistent findings, largely due to diverse interventions and study designs. Objectives: The objectives of this study are (1) to provide in-depth insight into the effects of telemonitoring on self-care and clinical management, and (2) to determine the features that enable successful heart failure telemonitoring. Methods: Semi-structured interviews were conducted with 22 heart failure patients attending a heart function clinic who had used a mobile phone-based telemonitoring system for 6 months. The telemonitoring system required the patients to take daily weight and blood pressure readings, weekly single-lead ECGs, and to answer daily symptom questions on a mobile phone. Instructions were sent to the patient's mobile phone based on their physiological values. Alerts were also sent to a cardiologist's mobile phone, as required. All clinicians involved in the study were also interviewed post-trial (N = 5). The interviews were recorded, transcribed, and then analyzed using a conventional content analysis approach. Results: The telemonitoring system improved patient self-care by instructing the patients in real-time how to appropriately modify their lifestyle behaviors. Patients felt more aware of their heart failure condition, less anxiety, and more empowered. Many were willing to partially fund the use of the system. The clinicians were able to manage their patients' heart failure conditions more effectively, because they had physiological data reported to them frequently to help in their decision-making (eg, for medication titration) and were alerted at the earliest sign of decompensation. Essential characteristics of the telemonitoring system that contributed to improved heart failure management included immediate self-care and clinical feedback (ie, teachable moments), how the system was easy and quick to use, and how the patients and clinicians perceived tangible benefits from telemonitoring. Some clinical concerns included ongoing costs of the telemonitoring system and increased clinical workload. A few patients did not want to be watched long-term while some were concerned they might become dependent on the system. Conclusions: The success of a telemonitoring system is highly dependent on its features and design. The essential system characteristics identified in this study should be considered when developing telemonitoring solutions. Key Words: ",
doi="10.2196/jmir.1912",
url="http://www.jmir.org/2012/1/e25/",
url="http://www.ncbi.nlm.nih.gov/pubmed/22328237"
}