@Article{info:doi/10.2196/10771,
author="Bashi, Nazli
and Fatehi, Farhad
and Fallah, Mina
and Walters, Darren
and Karunanithi, Mohanraj",
title="Self-Management Education Through mHealth: Review of Strategies and Structures",
journal="JMIR Mhealth Uhealth",
year="2018",
month="Oct",
day="19",
volume="6",
number="10",
pages="e10771",
keywords="health education",
keywords="mHealth",
keywords="mobile apps",
keywords="mobile phone",
keywords="patient education",
keywords="self-management education",
abstract="Background: Despite the plethora of evidence on mHealth interventions for patient education, there is a lack of information regarding their structures and delivery strategies. Objective: This review aimed to investigate the structures and strategies of patient education programs delivered through smartphone apps for people with diverse conditions and illnesses. We also examined the aim of educational interventions in terms of health promotion, disease prevention, and illness management. Methods: We searched PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, and PsycINFO for peer-reviewed papers that reported patient educational interventions using mobile apps and published from 2006 to 2016. We explored various determinants of educational interventions, including the content, mode of delivery, interactivity with health care providers, theoretical basis, duration, and follow-up. The reporting quality of studies was evaluated according to the mHealth evidence and reporting assessment criteria. Results: In this study, 15 papers met the inclusion criteria and were reviewed. The studies mainly focused on the use of mHealth educational interventions for chronic disease management, and the main format for delivering interventions was text. Of the 15 studies, 6 were randomized controlled trials (RCTs), which have shown statistically significant effects on patients' health outcomes, including patients' engagement level, hemoglobin A1c, weight loss, and depression. Although the results of RCTs were mostly positive, we were unable to identify any specific effective structure and strategy for mHealth educational interventions owing to the poor reporting quality and heterogeneity of the interventions. Conclusions: Evidence on mHealth interventions for patient education published in peer-reviewed journals demonstrates that current reporting on essential mHealth criteria is insufficient for assessing, understanding, and replicating mHealth interventions. There is a lack of theory or conceptual framework for the development of mHealth interventions for patient education. Therefore, further research is required to determine the optimal structure, strategies, and delivery methods of mHealth educational interventions. ",
doi="10.2196/10771",
url="https://mhealth.jmir.org/2018/10/e10771/"
}


@Article{info:doi/10.2196/10302,
author="Lundgren, Johan
and Johansson, Peter
and Jaarsma, Tiny
and Andersson, Gerhard
and K{\"a}rner K{\"o}hler, Anita",
title="Patient Experiences of Web-Based Cognitive Behavioral Therapy for Heart Failure and Depression: Qualitative Study",
journal="J Med Internet Res",
year="2018",
month="Sep",
day="05",
volume="20",
number="9",
pages="e10302",
keywords="cognitive therapy",
keywords="content analysis",
keywords="depression",
keywords="heart failure",
keywords="internet",
keywords="patient experience",
keywords="telehealth",
abstract="Background: Web-based cognitive behavioral therapy (wCBT) has been proposed as a possible treatment for patients with heart failure and depressive symptoms. Depressive symptoms are common in patients with heart failure and such symptoms are known to significantly worsen their health. Although there are promising results on the effect of wCBT, there is a knowledge gap regarding how persons with chronic heart failure and depressive symptoms experience wCBT. Objective: The aim of this study was to explore and describe the experiences of participating and receiving health care through a wCBT intervention among persons with heart failure and depressive symptoms. Methods: In this qualitative, inductive, exploratory, and descriptive study, participants with experiences of a wCBT program were interviewed. The participants were included through purposeful sampling among participants previously included in a quantitative study on wCBT. Overall, 13 participants consented to take part in this study and were interviewed via telephone using an interview guide. Verbatim transcripts from the interviews were qualitatively analyzed following the recommendations discussed by Patton in Qualitative Research \& Evaluation Methods: Integrating Theory and Practice. After coding each interview, codes were formed into categories. Results: Overall, six categories were identified during the analysis process. They were as follows: ``Something other than usual health care,'' ``Relevance and recognition,'' ``Flexible, understandable, and safe,'' ``Technical problems,'' ``Improvements by real-time contact,'' and ``Managing my life better.'' One central and common pattern in the findings was that participants experienced the wCBT program as something they did themselves and many participants described the program as a form of self-care. Conclusions: Persons with heart failure and depressive symptoms described wCBT as challenging. This was due to participants balancing the urge for real-time contact with perceived anonymity and not postponing the work with the program. wCBT appears to be a valuable tool for managing depressive symptoms. ",
doi="10.2196/10302",
url="http://www.jmir.org/2018/9/e10302/",
url="http://www.ncbi.nlm.nih.gov/pubmed/30185405"
}


@Article{info:doi/10.2196/resprot.9911,
author="Ware, Patrick
and Ross, J. Heather
and Cafazzo, A. Joseph
and Laporte, Audrey
and Seto, Emily",
title="Implementation and Evaluation of a Smartphone-Based Telemonitoring Program for Patients With Heart Failure: Mixed-Methods Study Protocol",
journal="JMIR Res Protoc",
year="2018",
month="May",
day="03",
volume="7",
number="5",
pages="e121",
keywords="heart failure",
keywords="telemedicine",
keywords="self-management",
keywords="health services research",
keywords="costs and cost analysis",
abstract="Background: Meta-analyses of telemonitoring for patients with heart failure conclude that it can lower the utilization of health services and improve health outcomes compared with the standard of care. A smartphone-based telemonitoring program is being implemented as part of the standard of care at a specialty care clinic for patients with heart failure in Toronto, Canada. Objective: The objectives of this study are to (1) evaluate the impact of the telemonitoring program on health service utilization, patient health outcomes, and their ability to self-care; (2) identify the contextual barriers and facilitators of implementation at the physician, clinic, and institutional level; (3) describe patient usage patterns to determine adherence and other behaviors in the telemonitoring program; and (4) evaluate the costs associated with implementation of the telemonitoring program from the perspective of the health care system (ie, public payer), hospital, and patient. Methods: The evaluation will use a mixed-methods approach. The quantitative component will include a pragmatic pre- and posttest study design for the impact and cost analyses, which will make use of clinical data and questionnaires administered to at least 108 patients at baseline and 6 months. Furthermore, outcome data will be collected at 1, 12, and 24 months to explore the longitudinal impact of the program. In addition, quantitative data related to implementation outcomes and patient usage patterns of the telemonitoring system will be reported. The qualitative component involves an embedded single case study design to identify the contextual factors that influenced the implementation. The implementation evaluation will be completed using semistructured interviews with clinicians, and other program staff at baseline, 4 months, and 12 months after the program start date. Interviews conducted with patients will be triangulated with usage data to explain usage patterns and adherence to the system. Results: The telemonitoring program was launched in August 2016 and patient enrollment is ongoing. Conclusions: The methods described provide an example for conducting comprehensive evaluations of telemonitoring programs. The combination of impact, implementation, and cost evaluations will inform the quality improvement of the existing program and will yield insights into the sustainability of smartphone-based telemonitoring programs for patients with heart failure within a specialty care setting. ",
doi="10.2196/resprot.9911",
url="http://www.researchprotocols.org/2018/5/e121/",
url="http://www.ncbi.nlm.nih.gov/pubmed/29724704"
}


@Article{info:doi/10.2196/10057,
author="Athilingam, Ponrathi
and Jenkins, Bradlee",
title="Mobile Phone Apps to Support Heart Failure Self-Care Management: Integrative Review",
journal="JMIR Cardio",
year="2018",
month="May",
day="02",
volume="2",
number="1",
pages="e10057",
keywords="heart failure",
keywords="self-care management",
keywords="mobile health",
abstract="Background: With an explosive growth in mobile health, an estimated 500 million patients are potentially using mHealth apps for supporting health and self-care of chronic diseases. Therefore, this review focused on mHealth apps for use among patients with heart failure. Objective: The aim of this integrative review was to identify and assess the functionalities of mHealth apps that provided usability and efficacy data and apps that are commercially available without supporting data, all of which are to support heart failure self-care management and thus impact heart failure outcomes. Methods: A search of published, peer-reviewed literature was conducted for studies of technology-based interventions that used mHealth apps specific for heart failure. The initial database search yielded 8597 citations. After filters for English language and heart failure, the final 487 abstracts was reviewed. After removing duplicates, a total of 18 articles that tested usability and efficacy of mobile apps for heart failure self-management were included for review. Google Play and Apple App Store were searched with specified criteria to identify mHealth apps for heart failure. A total of 26 commercially available apps specific for heart failure were identified and rated using the validated Mobile Application Rating Scale. Results: The review included studies with low-quality design and sample sizes ranging from 7 to 165 with a total sample size of 847 participants from all 18 studies. Nine studies assessed usability of the newly developed mobile health system. Six of the studies included are randomized controlled trials, and 4 studies are pilot randomized controlled trials with sample sizes of fewer than 40. There were inconsistencies in the self-care components tested, increasing bias. Thus, risk of bias was assessed using the Cochrane Collaboration's tool for risk of selection, performance, detection, attrition, and reporting biases. Most studies included in this review are underpowered and had high risk of bias across all categories. Three studies failed to provide enough information to allow for a complete assessment of bias, and thus had unknown or unclear risk of bias. This review on the commercially available apps demonstrated many incomplete apps, many apps with bugs, and several apps with low quality. Conclusions: The heterogeneity of study design, sample size, intervention components, and outcomes measured precluded the performance of a systematic review or meta-analysis, thus introducing bias of this review. Although the heart failure--related outcomes reported in this review vary, they demonstrated trends toward making an impact and offer a potentially cost-effective solution with 24/7 access to symptom monitoring as a point of care solution, promoting patient engagement in their own home care. ",
doi="10.2196/10057",
url="http://cardio.jmir.org/2018/1/e10057/"
}


@Article{info:doi/10.2196/resprot.8865,
author="Woessner, N. Mary
and Levinger, Itamar
and Neil, Christopher
and Smith, Cassandra
and Allen, D. Jason",
title="Effects of Dietary Inorganic Nitrate Supplementation on Exercise Performance in Patients With Heart Failure: Protocol for a Randomized, Placebo-Controlled, Cross-Over Trial",
journal="JMIR Res Protoc",
year="2018",
month="Apr",
day="06",
volume="7",
number="4",
pages="e86",
keywords="cardiovascular disease",
keywords="nitric oxide",
keywords="exercise tolerance",
abstract="Background: Chronic heart failure is characterized by an inability of the heart to pump enough blood to meet the demands of the body, resulting in the hallmark symptom of exercise intolerance. Chronic underperfusion of the peripheral tissues and impaired nitric oxide bioavailability have been implicated as contributors to the decrease in exercise capacity in these patients. nitric oxide bioavailability has been identified as an important mediator of exercise tolerance in healthy individuals, but there are limited studies examining the effects in patients with chronic heart failure. Objective: The proposed trial is designed to determine the effects of chronic inorganic nitrate supplementation on exercise tolerance in both patients with heart failure preserved ejection fraction (HFpEF) and heart failure reduced ejection fraction (HFrEF) and to determine whether there are any differential responses between the 2 cohorts. A secondary objective is to provide mechanistic insights into the 2 heart failure groups' exercise responses to the nitrate supplementation. Methods: Patients with chronic heart failure (15=HFpEF and 15=HFrEF) aged 40 to 85 years will be recruited. Following an initial screen cardiopulmonary exercise test, participants will be randomly allocated in a double-blind fashion to consume either a nitrate-rich beetroot juice (16 mmol nitrate/day) or a nitrate-depleted placebo (for 5 days). Participants will continue daily dosing until the completion of the 4 testing visits (maximal cardiopulmonary exercise test, submaximal exercise test with echocardiography, vascular function assessment, and vastus lateralis muscle biopsy). There will then be a 2-week washout period after which the participants will cross over to the other treatment and complete the same 4 testing visits. Results: This study is funded by National Heart Foundation of Australia and Victoria University. Enrolment has commenced and the data collection is expected to be completed in mid 2018. The initial results are expected to be submitted for publication by the end of 2018. Conclusions: If inorganic nitrate supplementation can improve exercise tolerance in patients with chronic heart failure, it has the potential to aid in further refining the treatment of patients in this population. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12615000906550; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368912 (Archived by WebCite at http://www.webcitation.org/6xymLMiFK) ",
doi="10.2196/resprot.8865",
url="http://www.researchprotocols.org/2018/4/e86/",
url="http://www.ncbi.nlm.nih.gov/pubmed/29625952"
}


@Article{info:doi/10.2196/cardio.9153,
author="Smeets, JP Christophe
and Storms, Valerie
and Vandervoort, M. Pieter
and Dreesen, Pauline
and Vranken, Julie
and Houbrechts, Marita
and Goris, Hanne
and Grieten, Lars
and Dendale, Paul",
title="A Novel Intelligent Two-Way Communication System for Remote Heart Failure Medication Uptitration (the CardioCoach Study): Randomized Controlled Feasibility Trial",
journal="JMIR Cardio",
year="2018",
month="Apr",
day="04",
volume="2",
number="1",
pages="e8",
keywords="heart failure",
keywords="telemedicine",
keywords="clinical decision support",
keywords="drug monitoring",
keywords="drug utilization",
keywords="call centers",
abstract="Background: European Society of Cardiology guidelines for the treatment of heart failure (HF) prescribe uptitration of angiotensin-converting enzyme inhibitors (ACE-I) and $\beta$-blockers to the maximum-tolerated, evidence-based dose. Although HF prognosis can drastically improve when correctly implementing these guidelines, studies have shown that they are insufficiently implemented in clinical practice. Objective: The aim of this study was to verify whether supplementing the usual care with the CardioCoach follow-up tool is feasible and safe, and whether the tool is more efficient in implementing the guideline recommendations for $\beta$-blocker and ACE-I. Methods: A total of 25 HF patients were randomly assigned to either the usual care control group (n=10) or CardioCoach intervention group (n=15), and observed for 6 months. The CardioCoach follow-up tool is a two-way communication platform with decision support algorithms for semiautomatic remote medication uptitration. Remote monitoring sensors automatically transmit patient's blood pressure, heart rate, and weight on a daily basis. Results: Patients' satisfaction and adherence for medication intake (10,018/10,825, 92.55\%) and vital sign measurements (4504/4758, 94.66\%) were excellent. However, the number of technical issues that arose was large, with 831 phone contacts (median 41, IQR 32-65) in total. The semiautomatic remote uptitration was safe, as there were no adverse events and no false positive uptitration proposals. Although no significant differences were found between both groups, a higher number of patients were on guideline-recommended medication dose in both groups compared with previous reports. Conclusions: The CardioCoach follow-up tool for remote uptitration is feasible and safe and was found to be efficient in facilitating information exchange between care providers, with high patient satisfaction and adherence. Trial Registration: ClinicalTrials.gov NCT03294811; https://clinicaltrials.gov/ct2/show/NCT03294811 (Archived by WebCite at http://www.webcitation.org/6xLiWVsgM) ",
doi="10.2196/cardio.9153",
url="http://cardio.jmir.org/2018/1/e8/"
}


@Article{info:doi/10.2196/jmir.7873,
author="Farnia, Troskah
and Jaulent, Marie-Christine
and Steichen, Olivier",
title="Evaluation Criteria of Noninvasive Telemonitoring for Patients With Heart Failure: Systematic Review",
journal="J Med Internet Res",
year="2018",
month="Jan",
day="16",
volume="20",
number="1",
pages="e16",
keywords="telemedicine",
keywords="outcome and process assessment (health care)",
keywords="program evaluation",
keywords="heart failure",
abstract="Background: Telemonitoring can improve heart failure (HF) management, but there is no standardized evaluation framework to comprehensively evaluate its impact. Objective: Our objectives were to list the criteria used in published evaluations of noninvasive HF telemonitoring projects, describe how they are used in the evaluation studies, and organize them into a consistent scheme. Methods: Articles published from January 1990 to August 2015 were obtained through MEDLINE, Web of Science, and EMBASE. Articles were eligible if they were original reports of a noninvasive HF telemonitoring evaluation study in the English language. Studies of implantable telemonitoring devices were excluded. Each selected article was screened to extract the description of the telemonitoring project and the evaluation process and criteria. A qualitative synthesis was performed. Results: We identified and reviewed 128 articles leading to 52 evaluation criteria classified into 6 dimensions: clinical, economic, user perspective, educational, organizational, and technical. The clinical and economic impacts were evaluated in more than 70\% of studies, whereas the educational, organizational, and technical impacts were studied in fewer than 15\%. User perspective was the most frequently covered dimension in the development phase of telemonitoring projects, whereas clinical and economic impacts were the focus of later phases. Conclusions: Telemonitoring evaluation frameworks should cover all 6 dimensions appropriately distributed along the telemonitoring project lifecycle. Our next goal is to build such a comprehensive evaluation framework for telemonitoring and test it on an ongoing noninvasive HF telemonitoring project. ",
doi="10.2196/jmir.7873",
url="http://www.jmir.org/2018/1/e16/",
url="http://www.ncbi.nlm.nih.gov/pubmed/29339348"
}


@Article{info:doi/10.2196/cardio.8301,
author="Moayedi, Yasbanoo
and Abdulmajeed, Raghad
and Duero Posada, Juan
and Foroutan, Farid
and Alba, Carolina Ana
and Cafazzo, Joseph
and Ross, Joan Heather",
title="Assessing the Use of Wrist-Worn Devices in Patients With Heart Failure: Feasibility Study",
journal="JMIR Cardio",
year="2017",
month="Dec",
day="19",
volume="1",
number="2",
pages="e8",
keywords="MeSH: exercise physiology",
keywords="heart rate tracker",
keywords="wrist worn devices",
keywords="Fitbit",
keywords="Apple watch",
keywords="heart failure",
keywords="steps",
abstract="Background: Exercise capacity and raised heart rate (HR) are important prognostic markers in patients with heart failure (HF). There has been significant interest in wrist-worn devices that track activity and HR. Objective: We aimed to assess the feasibility and accuracy of HR and activity tracking of the Fitbit and Apple Watch. Methods: We conducted a two-phase study assessing the accuracy of HR by Apple Watch and Fitbit in healthy participants. In Phase 1, 10 healthy individuals wore a Fitbit, an Apple Watch, and a GE SEER Light 5-electrode Holter monitor while exercising on a cycle ergometer with a 10-watt step ramp protocol from 0-100 watts. In Phase 2, 10 patients with HF and New York Heart Association (NYHA) Class II-III symptoms wore wrist devices for 14 days to capture overall step count/exercise levels. Results: Recorded HR by both wrist-worn devices had the best agreement with Holter readings at a workload of 60-100 watts when the rate of change of HR is less dynamic. Fitbit recorded a mean 8866 steps/day for NYHA II patients versus 4845 steps/day for NYHA III patients (P=.04). In contrast, Apple Watch recorded a mean 7027 steps/day for NYHA II patients and 4187 steps/day for NYHA III patients (P=.08). Conclusions: Both wrist-based devices are best suited for static HR rate measurements. In an outpatient setting, these devices may be adequate for average HR in patients with HF. When assessing exercise capacity, the Fitbit better differentiated patients with NYHA II versus NYHA III by the total number of steps recorded. This exploratory study indicates that these wrist-worn devices show promise in prognostication of HF in the continuous monitoring of outpatients. ",
doi="10.2196/cardio.8301",
url="http://cardio.jmir.org/2017/2/e8/"
}


@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/"
}


@Article{info:doi/10.2196/jmir.6931,
author="Hargreaves, Sarah
and Hawley, S. Mark
and Haywood, Annette
and Enderby, M. Pamela",
title="Informing the Design of ``Lifestyle Monitoring'' Technology for the Detection of Health Deterioration in Long-Term Conditions: A Qualitative Study of People Living With Heart Failure",
journal="J Med Internet Res",
year="2017",
month="Jun",
day="28",
volume="19",
number="6",
pages="e231",
keywords="independent living",
keywords="human activities",
keywords="heart failure",
keywords="biomedical technology",
abstract="Background: Health technologies are being developed to help people living at home manage long-term conditions. One such technology is ``lifestyle monitoring'' (LM), a telecare technology based on the idea that home activities may be monitored unobtrusively via sensors to give an indication of changes in health-state. However, questions remain about LM technology: how home activities change when participants experience differing health-states; and how sensors might capture clinically important changes to inform timely interventions. Objective: The objective of this paper was to report the findings of a study aimed at identifying changes in activity indicative of important changes in health in people with long-term conditions, particularly changes indicative of exacerbation, by exploring the relationship between home activities and health among people with heart failure (HF). We aimed to add to the knowledge base informing the development of home monitoring technologies designed to detect health deterioration in order to facilitate early intervention and avoid hospital admissions. Methods: This qualitative study utilized semistructured interviews to explore everyday activities undertaken during the three health-states of HF: normal days, bad days, and exacerbations. Potential recruits were identified by specialist nurses and attendees at an HF support group. The sample was purposively selected to include a range of experience of living with HF. Results: The sample comprised a total of 20 people with HF aged 50 years and above, and 11 spouses or partners of the individuals with HF. All resided in Northern England. Participant accounts revealed that home activities are in part shaped by the degree of intrusion from HF symptoms. During an exacerbation, participants undertook activities specifically to ease symptoms, and detailed activity changes were identified. Everyday activity was also influenced by a range of factors other than health. Conclusions: The study highlights the importance of careful development of LM technology to identify changes in activities that occur during clinically important changes in health. These detailed activity changes need to be considered by developers of LM sensors, platforms, and algorithms intended to detect early signs of deterioration. Results suggest that for LM to move forward, sensor set-up should be personalized to individual circumstances and targeted at individual health conditions. LM needs to take account of the uncertainties that arise from placing technology within the home, in order to inform sensor set-up and data interpretation. This targeted approach is likely to yield more clinically meaningful data and address some of the ethical issues of remote monitoring. ",
doi="10.2196/jmir.6931",
url="http://www.jmir.org/2017/6/e231/",
url="http://www.ncbi.nlm.nih.gov/pubmed/28659253"
}


@Article{info:doi/10.2196/resprot.7110,
author="Pedersen, S. Susanne
and Schmidt, Thomas
and Skovbakke, Jensen S{\o}ren
and Wiil, Kock Uffe
and Egstrup, Kenneth
and Smolderen, G. Kim
and Spertus, A. John",
title="A Personalized and Interactive Web-Based Health Care Innovation to Advance the Quality of Life and Care of Patients With Heart Failure (ACQUIRE-HF): A Mixed Methods Feasibility Study",
journal="JMIR Res Protoc",
year="2017",
month="May",
day="23",
volume="6",
number="5",
pages="e96",
keywords="feasibility",
keywords="heart failure",
keywords="patient-centered tools",
keywords="mixed methods",
keywords="Internet",
abstract="Background: Heart failure (HF) is a progressive, debilitating, and complex disease, and due to an increasing incidence and prevalence, it represents a global health and economic problem. Hence, there is an urgent need to evaluate alternative care modalities to current practice to safeguard a high level of care for this growing population. Objective: Our goal was to examine the feasibility of engaging patients to use patient-centered and personalized tools coupled with a Web-based, shared care and interactive platform in order to empower and enable them to live a better life with their disease. Methods: We used a mixed methods, single-center, pre-post design. Patients with HF and reduced left ventricular ejection fraction (n=26) were recruited from the outpatient HF clinic at Odense University Hospital (Svendborg Hospital), Denmark, between October 2015 and March 2016. Patients were asked to monitor their health status via the platform using the standardized, disease-specific measure, the Kansas City Cardiomyopathy Questionnaire (KCCQ), and to register their weight. A subset of patients and nursing staff were interviewed after 3-month follow-up about their experiences with the platform. Results: Overall, patients experienced improvement in patient-reported health status but deterioration in self-care behavior between baseline and 3-month follow-up. The mean score reflecting patient expectations toward use prior to start of the study was lower (16 [SD 5]) than their actual experiences with use of the platform (21 [SD 5]) after 3-month follow-up. Of all patients, 19 completed both a baseline and follow-up KCCQ. A total of 9 experienced deterioration in their health status (range from 3-34 points), while 10 experienced an improvement (range from 1-23 points). The qualitative data indicated that the majority of patients found the registration and monitoring on the platform useful. Both nursing staff and patients indicated that such monitoring could be a useful tool to engage and empower patients, in particular when patients are just diagnosed with HF. Conclusions: The use of patient tracking and monitoring of health status in HF using a standardized and validated measure seems feasible and may lead to insights that will help educate, empower, and engage patients more in their own disease management, although it is not suitable for all patients. Nursing staff found the patient-centered tool beneficial as a communication tool with patients but were more reticent with respect to using it as a replacement for the personal contact in the outpatient clinic. ",
doi="10.2196/resprot.7110",
url="http://www.researchprotocols.org/2017/5/e96/",
url="http://www.ncbi.nlm.nih.gov/pubmed/28536092"
}


@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/jmir.6688,
author="Hanlon, Peter
and Daines, Luke
and Campbell, Christine
and McKinstry, Brian
and Weller, David
and Pinnock, Hilary",
title="Telehealth Interventions to Support Self-Management of Long-Term Conditions: A Systematic Metareview of Diabetes, Heart Failure, Asthma, Chronic Obstructive Pulmonary Disease, and Cancer",
journal="J Med Internet Res",
year="2017",
month="May",
day="17",
volume="19",
number="5",
pages="e172",
keywords="telehealth",
keywords="telemonitoring",
keywords="self-management",
keywords="chronic disease",
keywords="diabetes",
keywords="heart failure",
keywords="asthma",
keywords="COPD",
keywords="pulmonary disease, chronic obstructive",
keywords="cancer",
abstract="Background: Self-management support is one mechanism by which telehealth interventions have been proposed to facilitate management of long-term conditions. Objective: The objectives of this metareview were to (1) assess the impact of telehealth interventions to support self-management on disease control and health care utilization, and (2) identify components of telehealth support and their impact on disease control and the process of self-management. Our goal was to synthesise evidence for telehealth-supported self-management of diabetes (types 1 and 2), heart failure, asthma, chronic obstructive pulmonary disease (COPD) and cancer to identify components of effective self-management support. Methods: We performed a metareview (a systematic review of systematic reviews) of randomized controlled trials (RCTs) of telehealth interventions to support self-management in 6 exemplar long-term conditions. We searched 7 databases for reviews published from January 2000 to May 2016 and screened identified studies against eligibility criteria. We weighted reviews by quality (revised A Measurement Tool to Assess Systematic Reviews), size, and relevance. We then combined our results in a narrative synthesis and using harvest plots. Results: We included 53 systematic reviews, comprising 232 unique RCTs. Reviews concerned diabetes (type 1: n=6; type 2, n=11; mixed, n=19), heart failure (n=9), asthma (n=8), COPD (n=8), and cancer (n=3). Findings varied between and within disease areas. The highest-weighted reviews showed that blood glucose telemonitoring with feedback and some educational and lifestyle interventions improved glycemic control in type 2, but not type 1, diabetes, and that telemonitoring and telephone interventions reduced mortality and hospital admissions in heart failure, but these findings were not consistent in all reviews. Results for the other conditions were mixed, although no reviews showed evidence of harm. Analysis of the mediating role of self-management, and of components of successful interventions, was limited and inconclusive. More intensive and multifaceted interventions were associated with greater improvements in diabetes, heart failure, and asthma. Conclusions: While telehealth-mediated self-management was not consistently superior to usual care, none of the reviews reported any negative effects, suggesting that telehealth is a safe option for delivery of self-management support, particularly in conditions such as heart failure and type 2 diabetes, where the evidence base is more developed. Larger-scale trials of telehealth-supported self-management, based on explicit self-management theory, are needed before the extent to which telehealth technologies may be harnessed to support self-management can be established. ",
doi="10.2196/jmir.6688",
url="http://www.jmir.org/2017/5/e172/",
url="http://www.ncbi.nlm.nih.gov/pubmed/28526671"
}


@Article{info:doi/10.2196/jmir.6571,
author="Bashi, Nazli
and Karunanithi, Mohanraj
and Fatehi, Farhad
and Ding, Hang
and Walters, Darren",
title="Remote Monitoring of Patients With Heart Failure: An Overview of Systematic Reviews",
journal="J Med Internet Res",
year="2017",
month="Jan",
day="20",
volume="19",
number="1",
pages="e18",
keywords="systematic review",
keywords="patient monitoring",
keywords="mobile phone",
keywords="telemedicine",
keywords="heart failure",
abstract="Background: Many systematic reviews exist on the use of remote patient monitoring (RPM) interventions to improve clinical outcomes and psychological well-being of patients with heart failure. However, research is broadly distributed from simple telephone-based to complex technology-based interventions. The scope and focus of such evidence also vary widely, creating challenges for clinicians who seek information on the effect of RPM interventions. Objective: The aim of this study was to investigate the effects of RPM interventions on the health outcomes of patients with heart failure by synthesizing review-level evidence. Methods: We searched PubMed, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Library from 2005 to 2015. We screened reviews based on relevance to RPM interventions using criteria developed for this overview. Independent authors screened, selected, and extracted information from systematic reviews. AMSTAR (Assessment of Multiple Systematic Reviews) was used to assess the methodological quality of individual reviews. We used standardized language to summarize results across reviews and to provide final statements about intervention effectiveness. Results: A total of 19 systematic reviews met our inclusion criteria. Reviews consisted of RPM with diverse interventions such as telemonitoring, home telehealth, mobile phone--based monitoring, and videoconferencing. All-cause mortality and heart failure mortality were the most frequently reported outcomes, but others such as quality of life, rehospitalization, emergency department visits, and length of stay were also reported. Self-care and knowledge were less commonly identified. Conclusions: Telemonitoring and home telehealth appear generally effective in reducing heart failure rehospitalization and mortality. Other interventions, including the use of mobile phone--based monitoring and videoconferencing, require further investigation. ",
doi="10.2196/jmir.6571",
url="http://www.jmir.org/2017/1/e18/",
url="http://www.ncbi.nlm.nih.gov/pubmed/28108430"
}



@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/jmir.4417,
author="Agboola, Stephen
and Jethwani, Kamal
and Khateeb, Kholoud
and Moore, Stephanie
and Kvedar, Joseph",
title="Heart Failure Remote Monitoring: Evidence From the Retrospective Evaluation of a Real-World Remote Monitoring Program",
journal="J Med Internet Res",
year="2015",
month="Apr",
day="22",
volume="17",
number="4",
pages="e101",
keywords="heart failure",
keywords="telemonitoring",
keywords="remote monitoring",
keywords="self-management",
keywords="hospitalizations",
keywords="mortality",
abstract="Background: Given the magnitude of increasing heart failure mortality, multidisciplinary approaches, in the form of disease management programs and other integrative models of care, are recommended to optimize treatment outcomes. Remote monitoring, either as structured telephone support or telemonitoring or a combination of both, is fast becoming an integral part of many disease management programs. However, studies reporting on the evaluation of real-world heart failure remote monitoring programs are scarce. Objective: This study aims to evaluate the effect of a heart failure telemonitoring program, Connected Cardiac Care Program (CCCP), on hospitalization and mortality in a retrospective database review of medical records of patients with heart failure receiving care at the Massachusetts General Hospital. Methods: Patients enrolled in the CCCP heart failure monitoring program at the Massachusetts General Hospital were matched 1:1 with usual care patients. Control patients received care from similar clinical settings as CCCP patients and were identified from a large clinical data registry. The primary endpoint was all-cause mortality and hospitalizations assessed during the 4-month program duration. Secondary outcomes included hospitalization and mortality rates (obtained by following up on patients over an additional 8 months after program completion for a total duration of 1 year), risk for multiple hospitalizations and length of stay. The Cox proportional hazard model, stratified on the matched pairs, was used to assess primary outcomes. Results: A total of 348 patients were included in the time-to-event analyses. The baseline rates of hospitalizations prior to program enrollment did not differ significantly by group. Compared with controls, hospitalization rates decreased within the first 30 days of program enrollment: hazard ratio (HR)=0.52, 95\% CI 0.31-0.86, P=.01). The differential effect on hospitalization rates remained consistent until the end of the 4-month program (HR=0.74, 95\% CI 0.54-1.02, P=.06). The program was also associated with lower mortality rates at the end of the 4-month program: relative risk (RR)=0.33, 95\% 0.11-0.97, P=.04). Additional 8-months follow-up following program completion did not show residual beneficial effects of the CCCP program on mortality (HR=0.64, 95\% 0.34-1.21, P=.17) or hospitalizations (HR=1.12, 95\% 0.90-1.41, P=.31). Conclusions: CCCP was associated with significantly lower hospitalization rates up to 90 days and significantly lower mortality rates over 120 days of the program. However, these effects did not persist beyond the 120-day program duration. ",
doi="10.2196/jmir.4417",
url="http://www.jmir.org/2015/4/e101/",
url="http://www.ncbi.nlm.nih.gov/pubmed/25903278"
}


@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/resprot.3411,
author="Stut, Wim
and Deighan, Carolyn
and Armitage, Wendy
and Clark, Michelle
and Cleland, G. John
and Jaarsma, Tiny",
title="Design and Usage of the HeartCycle Education and Coaching Program for Patients With Heart Failure",
journal="JMIR Res Protoc",
year="2014",
month="Dec",
day="11",
volume="3",
number="4",
pages="e72",
keywords="e-counseling",
keywords="heart failure",
keywords="lifestyle",
keywords="patient adherence",
keywords="self-care",
keywords="telehealth",
abstract="Background: Heart failure (HF) is common, and it is associated with high rates of hospital readmission and mortality. It is generally assumed that appropriate self-care can improve outcomes in patients with HF, but patient adherence to many self-care behaviors is poor. Objective: The objective of our study was to develop and test an intervention to increase self-care in patients with HF using a novel, online, automated education and coaching program. Methods: The online automated program was developed using a well-established, face-to-face, home-based cardiac rehabilitation approach. Education is tailored to the behaviors and knowledge of the individual patient, and the system supports patients in adopting self-care behaviors. Patients are guided through a goal-setting process that they conduct at their own pace through the support of the system, and they record their progress in an electronic diary such that the system can provide appropriate feedback. Only in challenging situations do HF nurses intervene to offer help. The program was evaluated in the HeartCycle study, a multicenter, observational trial with randomized components in which researchers investigated the ability of a third-generation telehealth system to enhance the management of patients with HF who had a recent (<60 days) admission to the hospital for symptoms or signs of HF (either new onset or recurrent) or were outpatients with persistent New York Heart Association (NYHA) functional class III/IV symptoms despite treatment with diuretic agents. The patients were enrolled from January 2012 through February 2013 at 3 hospital sites within the United Kingdom, Germany, and Spain. Results: Of 123 patients enrolled (mean age 66 years (SD 12), 66\% NYHA III, 79\% men), 50 patients (41\%) reported that they were not physically active, 56 patients (46\%) did not follow a low-salt diet, 6 patients (5\%) did not restrict their fluid intake, and 6 patients (5\%) did not take their medication as prescribed. About 80\% of the patients who started the coaching program for physical activity and low-salt diet became adherent by achieving their personal goals for 2 consecutive weeks. After becoming adherent, 61\% continued physical activity coaching, but only 36\% continued low-salt diet coaching. Conclusions: The HeartCycle education and coaching program helped most nonadherent patients with HF to adopt recommended self-care behaviors. Automated coaching worked well for most patients who started the coaching program, and many patients who achieved their goals continued to use the program. For many patients who did not engage in the automated coaching program, their choice was appropriate rather than a failure of the program. ",
doi="10.2196/resprot.3411",
url="http://www.researchprotocols.org/2014/4/e72/",
url="http://www.ncbi.nlm.nih.gov/pubmed/25499976"
}


@Article{info:doi/10.2196/jmir.3651,
author="Vuorinen, Anna-Leena
and Lepp{\"a}nen, Juha
and Kaijanranta, Hannu
and Kulju, Minna
and Heli{\"o}, Tiina
and van Gils, Mark
and L{\"a}hteenm{\"a}ki, Jaakko",
title="Use of Home Telemonitoring to Support Multidisciplinary Care of Heart Failure Patients in Finland: Randomized Controlled Trial",
journal="J Med Internet Res",
year="2014",
month="Dec",
day="11",
volume="16",
number="12",
pages="e282",
keywords="heart failure",
keywords="telemonitoring",
keywords="hospitalization",
keywords="user experience",
keywords="clinical outcomes",
keywords="EHFSBS",
keywords="health care resources",
abstract="Background: Heart failure (HF) patients suffer from frequent and repeated hospitalizations, causing a substantial economic burden on society. Hospitalizations can be reduced considerably by better compliance with self-care. Home telemonitoring has the potential to boost patients' compliance with self-care, although the results are still contradictory. Objective: A randomized controlled trial was conducted in order to study whether the multidisciplinary care of heart failure patients promoted with telemonitoring leads to decreased HF-related hospitalization. Methods: HF patients were eligible whose left ventricular ejection fraction was lower than 35\%, NYHA functional class ?2, and who needed regular follow-up. Patients in the telemonitoring group (n=47) measured their body weight, blood pressure, and pulse and answered symptom-related questions on a weekly basis, reporting their values to the heart failure nurse using a mobile phone app. The heart failure nurse followed the status of patients weekly and if necessary contacted the patient. The primary outcome was the number of HF-related hospital days. Control patients (n=47) received multidisciplinary treatment according to standard practices. Patients' clinical status, use of health care resources, adherence, and user experience from the patients' and the health care professionals' perspective were studied. Results: Adherence, calculated as a proportion of weekly submitted self-measurements, was close to 90\%. No difference was found in the number of HF-related hospital days (incidence rate ratio [IRR]=0.812, P=.351), which was the primary outcome. The intervention group used more health care resources: they paid an increased number of visits to the nurse (IRR=1.73, P<.001), spent more time at the nurse reception (mean difference of 48.7 minutes, P<.001), and there was a greater number of telephone contacts between the nurse and intervention patients (IRR=3.82, P<.001 for nurse-induced contacts and IRR=1.63, P=.049 for patient-induced contacts). There were no statistically significant differences in patients' clinical health status or in their self-care behavior. The technology received excellent feedback from the patient and professional side with a high adherence rate throughout the study. Conclusions: Home telemonitoring did not reduce the number of patients' HF-related hospital days and did not improve the patients' clinical condition. Patients in the telemonitoring group contacted the Cardiology Outpatient Clinic more frequently, and on this way increased the use of health care resources. Trial Registration: Clinicaltrials.gov NCT01759368; http://clinicaltrials.gov/show/NCT01759368 (Archived by WebCite at http://www.webcitation.org/6UFxiCk8Z). ",
doi="10.2196/jmir.3651",
url="http://www.jmir.org/2014/12/e282/",
url="http://www.ncbi.nlm.nih.gov/pubmed/25498992"
}


@Article{info:doi/10.2196/jmir.2587,
author="Zanaboni, Paolo
and Landolina, Maurizio
and Marzegalli, Maurizio
and Lunati, Maurizio
and Perego, B. Giovanni
and Guenzati, Giuseppe
and Curnis, Antonio
and Valsecchi, Sergio
and Borghetti, Francesca
and Borghi, Gabriella
and Masella, Cristina",
title="Cost-Utility Analysis of the EVOLVO Study on Remote Monitoring for Heart Failure Patients With Implantable Defibrillators: Randomized Controlled Trial",
journal="J Med Internet Res",
year="2013",
month="May",
day="30",
volume="15",
number="5",
pages="e106",
keywords="telemedicine",
keywords="heart failure",
keywords="implantable defibrillators",
keywords="cost-effectiveness",
abstract="Background: Heart failure patients with implantable defibrillators place a significant burden on health care systems. Remote monitoring allows assessment of device function and heart failure parameters, and may represent a safe, effective, and cost-saving method compared to conventional in-office follow-up. Objective: We hypothesized that remote device monitoring represents a cost-effective approach. This paper summarizes the economic evaluation of the Evolution of Management Strategies of Heart Failure Patients With Implantable Defibrillators (EVOLVO) study, a multicenter clinical trial aimed at measuring the benefits of remote monitoring for heart failure patients with implantable defibrillators. Methods: Two hundred patients implanted with a wireless transmission--enabled implantable defibrillator were randomized to receive either remote monitoring or the conventional method of in-person evaluations. Patients were followed for 16 months with a protocol of scheduled in-office and remote follow-ups. The economic evaluation of the intervention was conducted from the perspectives of the health care system and the patient. A cost-utility analysis was performed to measure whether the intervention was cost-effective in terms of cost per quality-adjusted life year (QALY) gained. Results: Overall, remote monitoring did not show significant annual cost savings for the health care system ({\texteuro}1962.78 versus {\texteuro}2130.01; P=.80). There was a significant reduction of the annual cost for the patients in the remote arm in comparison to the standard arm ({\texteuro}291.36 versus {\texteuro}381.34; P=.01). Cost-utility analysis was performed for 180 patients for whom QALYs were available. The patients in the remote arm gained 0.065 QALYs more than those in the standard arm over 16 months, with a cost savings of {\texteuro}888.10 per patient. Results from the cost-utility analysis of the EVOLVO study show that remote monitoring is a cost-effective and dominant solution. Conclusions: Remote management of heart failure patients with implantable defibrillators appears to be cost-effective compared to the conventional method of in-person evaluations. Trial Registration: ClinicalTrials.gov NCT00873899; http://clinicaltrials.gov/show/NCT00873899 (Archived by WebCite at http://www.webcitation.org/6H0BOA29f). ",
doi="10.2196/jmir.2587",
url="http://www.jmir.org/2013/5/e106/",
url="http://www.ncbi.nlm.nih.gov/pubmed/23722666"
}


@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"
}