@Article{info:doi/10.2196/17957,
author="Subedi, Narayan
and Rawstorn, C. Jonathan
and Gao, Lan
and Koorts, Harriet
and Maddison, Ralph",
title="Implementation of Telerehabilitation Interventions for the Self-Management of Cardiovascular Disease: Systematic Review",
journal="JMIR Mhealth Uhealth",
year="2020",
month="Nov",
day="27",
volume="8",
number="11",
pages="e17957",
keywords="heart diseases",
keywords="cardiac rehabilitation",
keywords="telerehabilitation",
keywords="implementation science",
keywords="smartphone",
keywords="systematic review",
abstract="Background: Coronary heart disease (CHD) is a leading cause of disability and deaths worldwide. Secondary prevention, including cardiac rehabilitation (CR), is crucial to improve risk factors and to reduce disease burden and disability. Accessibility barriers contribute to underutilization of traditional center-based CR programs; therefore, alternative delivery models, including cardiac telerehabilitation (ie, delivery via mobile, smartphone, and/or web-based apps), have been tested. Experimental studies have shown cardiac telerehabilitation to be effective and cost-effective, but there is inadequate evidence about how to translate this research into routine clinical practice. Objective: This systematic review aimed to synthesize research evaluating the effectiveness of implementing cardiac telerehabilitation interventions at scale in routine clinical practice, including factors underlying successful implementation processes, and experimental research evaluating implementation-related outcomes. Methods: MEDLINE, Embase, PsycINFO, and Global Health databases were searched from 1990 through November 9, 2018, for studies evaluating the implementation of telerehabilitation for the self-management of CHD. Reference lists of included studies and relevant systematic reviews were hand searched to identify additional studies. Implementation outcomes of interest included acceptability, appropriateness, adoption, feasibility, fidelity, implementation cost, penetration, and sustainability. A narrative synthesis of results was carried out. Results: No included studies evaluated the implementation of cardiac telerehabilitation in routine clinical practice. A total of 10 studies of 2250 participants evaluated implementation outcomes, including acceptability (8/10, 80\%), appropriateness (9/10, 90\%), adoption (6/10, 60\%), feasibility (6/10, 60\%), fidelity (7/10, 70\%), and implementation cost (4/10, 40\%), predominantly from the participant perspective. Cardiac telerehabilitation interventions had high acceptance among the majority of participants, but technical challenges such as reliable broadband internet connectivity can impact acceptability and feasibility. Many participants considered telerehabilitation to be an appropriate alternative CR delivery model, as it was convenient, flexible, and easy to access. Participants valued interactive intervention components, such as real-time exercise monitoring and feedback as well as individualized support. The penetration and sustainability of cardiac telerehabilitation, as well as the perspectives of CR practitioners and health care organizations, have received little attention in existing cardiac telerehabilitation research. Conclusions: Experimental trials suggest that participants perceive cardiac telerehabilitation to be an acceptable and appropriate approach to improve the reach and utilization of CR, but pragmatic implementation studies are needed to understand how interventions can be sustainably translated from research into clinical practice. Addressing this gap could help realize the potential impact of telerehabilitation on CR accessibility and participation as well as person-centered, health, and economic outcomes. Trial Registration: International Prospective Register of Systematic Reviews (PROSPERO) CRD42019124254; https://www.crd.york.ac.uk/prospero/display\_record.php?RecordID=124254 ",
doi="10.2196/17957",
url="http://mhealth.jmir.org/2020/11/e17957/",
url="http://www.ncbi.nlm.nih.gov/pubmed/33245286"
}


@Article{info:doi/10.2196/15320,
author="Waring, E. Molly
and Hills, T. Mellanie
and Lessard, M. Darleen
and Saczynski, S. Jane
and Libby, A. Brooke
and Holovatska, M. Marta
and Kapoor, Alok
and Kiefe, I. Catarina
and McManus, D. David",
title="Characteristics Associated With Facebook Use and Interest in Digital Disease Support Among Older Adults With Atrial Fibrillation: Cross-Sectional Analysis of Baseline Data From the Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF) Cohort",
journal="JMIR Cardio",
year="2019",
month="Nov",
day="14",
volume="3",
number="2",
pages="e15320",
keywords="atrial fibrillation",
keywords="social media",
keywords="information seeking behavior",
abstract="Background: Online support groups for atrial fibrillation (AF) and apps to detect and manage AF exist, but the scientific literature does not describe which patients are interested in digital disease support. Objective: The objective of this study was to describe characteristics associated with Facebook use and interest in digital disease support among older patients with AF who used the internet. Methods: We used baseline data from the Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF), a prospective cohort of older adults (?65 years) with AF at high stroke risk. Participants self-reported demographics, clinical characteristics, and Facebook and technology use. Online patients (internet use in the past 4 weeks) were asked whether they would be interested in participating in an online support AF community. Mobile users (owns smartphone and/or tablet) were asked about interest in communicating with their health care team about their AF-related health using a secure app. Logistic regression models identified crude and multivariable predictors of Facebook use and interest in digital disease support. Results: Online patients (N=816) were aged 74.2 (SD 6.6) years, 47.8\% (390/816) were female, and 91.1\% (743/816) were non-Hispanic white. Roughly half (52.5\%; 428/816) used Facebook. Facebook use was more common among women (adjusted odds ratio [aOR] 2.21, 95\% CI 1.66-2.95) and patients with mild to severe depressive symptoms (aOR 1.50, 95\% CI 1.08-2.10) and less common among patients aged ?85 years (aOR 0.27, 95\% CI 0.15-0.48). Forty percent (40.4\%; 330/816) reported interest in an online AF patient community. Interest in an online AF patient community was more common among online patients with some college/trade school or Bachelors/graduate school (aOR 1.70, 95\% CI 1.10-2.61 and aOR 1.82, 95\% CI 1.13-2.92, respectively), obesity (aOR 1.65, 95\% CI 1.08-2.52), online health information seeking at most weekly or multiple times per week (aOR 1.84, 95\% CI 1.32-2.56 and aOR 2.78, 95\% CI 1.86-4.16, respectively), and daily Facebook use (aOR 1.76, 95\% CI 1.26-2.46). Among mobile users, 51.8\% (324/626) reported interest in communicating with their health care team via a mobile app. Interest in app-mediated communication was less likely among women (aOR 0.48, 95\% CI 0.34-0.68) and more common among online patients who had completed trade school/some college versus high school/General Educational Development (aOR 1.95, 95\% CI 1.17-3.22), sought online health information at most weekly or multiple times per week (aOR 1.86, 95\% CI 1.27-2.74 and aOR 2.24, 95\% CI 1.39-3.62, respectively), and had health-related apps (aOR 3.92, 95\% CI 2.62-5.86). Conclusions: Among older adults with AF who use the internet, technology use and demographics are associated with interest in digital disease support. Clinics and health care providers may wish to encourage patients to join an existing online support community for AF and explore opportunities for app-mediated patient-provider communication. ",
doi="10.2196/15320",
url="http://cardio.jmir.org/2019/2/e15320/",
url="http://www.ncbi.nlm.nih.gov/pubmed/31758791"
}


@Article{info:doi/10.2196/humanfactors.8820,
author="Tanaka, Rika
and Banerjee, Anita
and Surikova, Jelena
and Tracey, Jacqueline
and Payne, Ada
and Ross, Heather
and Nolan, Robert",
title="A Moderated e-Forum for Adults With Cardiovascular Disease: Usability Study",
journal="JMIR Hum Factors",
year="2018",
month="May",
day="18",
volume="5",
number="2",
pages="e20",
keywords="support groups",
keywords="cardiovascular disease",
keywords="qualitative research",
abstract="Background: Self-care behaviors are commonly prescribed to manage both cardiovascular disease and hypertension to reduce modifiable risk factors and improve quality of life. Nevertheless, long-term adherence to self-care recommendations for cardiac patients has been problematic. In cardiac patients, moderated online forums have been found to be particularly useful in supporting maintenance of heart-healthy diet and fewer hospital visits. As such, we developed the e-Forum, a Web-based moderated forum designed to promote continued user engagement and long-term self-care adherence. Objective: The objective of this study was to assess the usability of the user interface for the newly designed e-Forum. In addition to overall user satisfaction, we obtained feedback from our target users on the key features of this newly developed interface. Methods: An iterative design tested the usability of the e-Forum. On the basis of the user feedback, adjustments were made to the design of our e-Forum, and these changes were then tested in the succeeding group. Participants were recruited from the Heart Function Clinic at the Peter Munk Cardiac Center, University Health Network. After consenting to participate in our study, patients were asked to complete a set of goal-oriented tasks and a feedback interview for the e-Forum. A content analysis of the transcripts from the set of goal-oriented tasks and feedback interviews identified several themes, including general feedback and comments regarding 3 key areas of the e-Forum: layout, navigation, and content. Results: Overall, 13 cardiac patients (aged 32-81 years) participated in 3 rounds of testing. Participants across all 3 rounds were highly satisfied with our e-Forum and indicated that they would find such a forum useful in managing their health. Expressions of overall satisfaction with the e-Forum and positive comments regarding layout increased between the initial and the final round. As improvements were made to the e-Forum based on participant feedback, potential barriers, negative comments related to the content, and the number of navigation errors decreased between rounds 1 and 3. Conclusions: We found evidence to support the usability of the user interface for our e-Forum. These results indicate that the e-Forum will likely be a successful tool to support an online community of cardiac patients in their efforts to sustain long-term lifestyle behavior change. ",
doi="10.2196/humanfactors.8820",
url="http://humanfactors.jmir.org/2018/2/e20/",
url="http://www.ncbi.nlm.nih.gov/pubmed/29776901"
}


@Article{info:doi/10.2196/cardio.9000,
author="Baek, Hyunyoung
and Suh, Jung-Won
and Kang, Si-Hyuck
and Kang, Seungjin
and Lim, Ho Tae
and Hwang, Hee
and Yoo, Sooyoung",
title="Enhancing User Experience Through User Study: Design of an mHealth Tool for Self-Management and Care Engagement of Cardiovascular Disease Patients",
journal="JMIR Cardio",
year="2018",
month="Feb",
day="09",
volume="2",
number="1",
pages="e3",
keywords="cardiovascular disease",
keywords="mHealth",
keywords="mobile application",
keywords="app",
keywords="user-centered design",
abstract="Background: As patient communication, engagement, personal health data tracking, and up-to-date information became more efficient through mobile health (mHealth), cardiovascular diseases (CVD) and other diseases that require behavioral improvements in daily life are now capable of being managed and prevented more effectively. However, to increase patient engagement through mHealth, it is important for the initial design to consider functionality and usability factors and accurately assess user demands during the developmental process so that the app can be used continuously. Objective: The purpose of the study was to provide insightful information for developing mHealth service for patients with CVD based on user research to help enhance communication between patients and doctors. Methods: To drive the mobile functions and services needed to manage diseases in CVD patients, user research was conducted on patients and doctors at a tertiary general university hospital located in the Seoul metropolitan area of South Korea. Interviews and a survey were performed on patients (35 participants) and a focus group interview was conducted with doctors (5 participants). A mock-up mobile app was developed based on the user survey results, and a usability test was then conducted (8 participants) to identify factors that should be considered to improve usability. Results: The majority of patients showed a positive response in terms of their interest or intent to use an app for managing CVD. Functional features, such as communication with doctors, self-risk assessment, exercise, tailored education, blood pressure management, and health status recording had a score of 4.0 or higher on a 5-point Likert scale, showing that these functions were perceived to be useful to patients. The results of the mock-up usability test showed that inputting and visualizing blood pressure and other health conditions was required to be easier. The doctors requested a function that offered a comprehensive view of the patient's daily health status by linking the mHealth app data with the hospital's electronic health record system. Conclusions: Insights derived from a user study for developing an mHealth tool for CVD management, such as self-assessment and a communication channel between patients and doctors, may be helpful to improve patient engagement in care. ",
doi="10.2196/cardio.9000",
url="http://cardio.jmir.org/2018/1/e3/",
url="http://www.ncbi.nlm.nih.gov/pubmed/31758783"
}


@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/cardio.7342,
author="Cossette, Sylvie
and C{\^o}t{\'e}, Jos{\'e}
and Rouleau, Genevi{\`e}ve
and Robitaille, Marie
and Heppell, Sonia
and Mailhot, Tanya
and Fontaine, Guillaume
and Cournoyer, Catherine
and Gagnon, Marie-Pierre
and Gallani, Maria-Cecilia
and Tanguay, Jean-Francois
and Dupuis, Jocelyn
and Nigam, Anil
and Guertin, Marie-Claude",
title="A Web-Based Tailored Intervention to Support Illness Management in Patients With an Acute Coronary Syndrome: Pilot Study",
journal="JMIR Cardio",
year="2017",
month="Sep",
day="06",
volume="1",
number="2",
pages="e4",
keywords="nursing informatics",
keywords="health behavior",
keywords="self-care",
keywords="acute coronary syndrome",
keywords="pilot study",
abstract="Background: Illness management after an acute coronary syndrome (ACS) is crucial to prevent cardiac complications, to foster participation in a cardiac rehabilitation (CR) program, and to optimize recovery. Web-based tailored interventions have the potential to provide individualized information and counseling to optimize patient's illness management after hospital discharge. Objective: We aimed to assess the feasibility and acceptability of a Web-based tailored intervention (TAVIE@COEUR) designed to improve illness management in patients hospitalized for an ACS. Illness management outcomes were operationalized by self-care, medication adherence, anxiety management, cardiac risk factors reduction, and enrollment in a CR program. Methods: This posttest pilot study was conducted with one group (N=30) of patients hospitalized for an ACS on the coronary care unit of a tertiary cardiology center. TAVIE@COEUR comprises three Web-based sessions, with a duration ranging from 10 to 45 min and is structured around an algorithm to allow the tailoring of the intervention to different pathways according to patients' responses to questions. TAVIE@COEUR includes 90 pages, 85 videos, and 47 PDF documents divided across session 1 (S1), session 2 (S2), and session 3 (S3). These sessions concern self-care and self-observation skills related to medication-taking (S1), emotional control and problem-solving skills (S2), and social skills and interacting with health professionals (S3). Throughout the videos, a virtual nurse (providing the intervention virtually) guides the participants in the acquisition of self-care skills. Patients completed S1 of TAVIE@COEUR before hospital discharge and were asked to complete S2 and S3 within 2 weeks after discharge. Feasibility indicators were extracted from the TAVIE@COEUR system. Data regarding acceptability (satisfaction and appreciation of the platform) and preliminary effect (self-care, medication adherence, anxiety management, risk factor reduction, and CR enrollment) were assessed through questionnaires at 1 month following discharge. Preliminary effect was assessed by comparing baseline and 1-month illness management variables. Results: Of the 30 participants, 20 completed S1, 10 completed S2, and 5 completed S3. Good acceptability scores were observed for ease of navigation (mean=3.58, standard deviation [SD]=0.70; scale=0-4), ease of understanding (mean=3.46, SD=0.63; scale=0-4), and applicability (mean=3.55, SD=0.74; scale=0-4). The lowest acceptability scores were observed for information tailoring (mean=2.93, SD=0.68; scale=0-4) and individual relevance (mean=2.56, SD=0.96; scale=0-4). With regard to preliminary effect, we observed an overall self-care at 1 month following discharge score higher than at baseline (mean at 1 month=54.07, SD=3.99 vs mean at baseline=49.09, SD=6.92; scale-0-60). Conclusions: Although participants reported general satisfaction and appreciation of TAVIE@COEUR, acceptability and feasibility results show the need for further development of the Web-based intervention to enhance its tailoring before undertaking a full-fledged randomized controlled trial. This may be accomplished by optimizing the adaptability of TAVIE@COEUR to patients' knowledge, needs, interests, individual capabilities, and emotional and cognitive responses during session completion. ",
doi="10.2196/cardio.7342",
url="http://cardio.jmir.org/2017/2/e4/",
url="http://www.ncbi.nlm.nih.gov/pubmed/31758758"
}