TY - JOUR AU - Graever, Leonardo AU - Mafra, Cordeiro Priscila AU - Figueira, Klein Vinicius AU - Miler, Navega Vanessa AU - Sobreiro, Lima Júlia dos Santos AU - Silva, da Gabriel Pesce de Castro AU - Issa, Castro Aurora Felice AU - Savassi, Monteiro Leonardo Cançado AU - Dias, Borges Mariana AU - Melo, Machado Marcelo AU - Fonseca, da Viviane Belidio Pinheiro AU - Nóbrega, da Isabel Cristina Pacheco AU - Gomes, Kátia Maria AU - Santos, dos Laís Pimenta Ribeiro AU - Lapa e Silva, Roberto José AU - Froelich, Anne AU - Dominguez, Helena PY - 2025/4/17 TI - Telehealth Support From Cardiologists to Primary Care Physicians in Heart Failure Treatment: Mixed Methods Feasibility Study of the Brazilian Heart Insufficiency With Telemedicine Trial JO - JMIR Cardio SP - e64438 VL - 9 KW - heart failure KW - telemedicine KW - telehealth KW - intersectoral collaboration KW - primary health care KW - low- and middle-income countries KW - family practice N2 - Background: Heart failure is a prevalent condition ideally managed through collaboration between health care sectors. Telehealth between cardiologists and primary care physicians is a strategy to improve the quality of care for patients with heart failure. Still, the effectiveness of this approach on patient-relevant outcomes needs to be determined. Objective: This study aimed to assess the feasibility of telehealth support provided by cardiologists for treating patients with heart failure to primary care physicians from public primary care practices in Rio de Janeiro, Brazil. Methods: We used mixed methods to assess the feasibility of telehealth support. From 2020 to 2022, we tested 2 telehealth approaches: synchronous videoconferences (phase A) and interaction through an asynchronous web platform (phase B). The primary outcome was feasibility. Exploratory outcomes were telehealth acceptability of patients, primary care physicians, and cardiologists; the patients? clinical status; and prescription practices. Qualitative methods comprised content analysis of 3 focus groups and 15 individual interviews with patients, primary care physicians, and cardiologists. Quantitative methods included the baseline assessment of 83 patients; a single-arm, before-and-after assessment of clinical status in 58 patients; and an assessment of guideline-directed medical therapy in 28 patients with reduced ejection fraction measured within 1 year of follow-up. We integrated qualitative and quantitative data using a joint display table and used the A Process for Decision-Making After Pilot and Feasibility Trials framework for feasibility assessment. Results: Telehealth support from cardiologists to primary care physicians was generally well accepted. As barriers, patients expressed concern about reduced direct access to cardiologists, primary care physicians reported work overload and a lack of relative advantage, and cardiologists expressed concern about the sustainability of the intervention. Quantitative analysis revealed an overall poor baseline clinical status of patients with heart failure, with 53% (44/83) decompensated, as expected. Compliance with guideline-directed medical therapy for the treatment of heart failure with reduced ejection fraction after telehealth showed a modest improvement for ?-blockers (17/20, 85% to 18/19, 95%) and renin-angiotensin-aldosterone system inhibitors (14/20, 70% to 15/19, 79%) but a drop in the prescription of spironolactone (16/20, 80% to 15/20, 75%). Neprilysin and sodium-glucose cotransporter 2 inhibitors were introduced in 4 and 1 patient, respectively. Missing record data precluded a more precise analysis. The feasibility assessment was positive, favoring the asynchronous modality. Potential modifications include more effective patient and professional recruitment strategies and educational activities to raise awareness of collaborative support in primary care. Conclusions: Telehealth was feasible to implement. Considering the stakeholders? views and insights on the process is paramount to attaining engagement. Missing data must be anticipated for future research in this setting. Considering the recommended adaptations, the intervention can be studied in a cluster-randomized trial. UR - https://cardio.jmir.org/2025/1/e64438 UR - http://dx.doi.org/10.2196/64438 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/64438 ER - TY - JOUR AU - Abdullah, Nailah Nik AU - Tang, Jia AU - Fetrati, Hemad AU - Kaukiah, Binti Nor Fadhilah AU - Saharudin, Bin Sahrin AU - Yong, Sim Vee AU - Yen, How Chia PY - 2025/4/10 TI - MARIA (Medical Assistance and Rehabilitation Intelligent Agent) for Medication Adherence in Patients With Heart Failure: Empirical Results From a Wizard of Oz Systematic Conversational Agent Design Clinical Protocol JO - JMIR Cardio SP - e55846 VL - 9 KW - heart failure KW - medication adherence KW - self-monitoring KW - chatbot KW - conversational agent KW - Wizard of Oz KW - digital health N2 - Background: Nonadherence to medication is a key factor contributing to high heart failure (HF) rehospitalization rates. A conversational agent (CA) or chatbot is a technology that can enhance medication adherence by helping patients self-manage their medication routines at home. Objective: This study outlines the conception of a design method for developing a CA to support patients in medication adherence, utilizing design thinking as the primary process for gathering requirements, prototyping, and testing. We apply this design method to the ongoing development of Medical Assistance and Rehabilitation Intelligent Agent (MARIA), a rule-based CA. Methods: Following the design thinking process, at the ideation stage, we engaged a multidisciplinary group of stakeholders (patients and pharmacists) to elicit requirements for the early conception of MARIA. In collaboration with pharmacists, we structured MARIA?s dialogue into a workflow based on Adlerian therapy, a psychoeducational theory. At the testing stage, we conducted an observational study using the Wizard of Oz (WoZ) research method to simulate the MARIA prototype with 20 patient participants. This approach validated and refined our application of Adlerian therapy in the CA?s dialogue. We incorporated human-likeness and trust scoring into user satisfaction assessments after each WoZ session to evaluate MARIA?s feasibility and acceptance of medication adherence. Dialogue data collected through WoZ simulations were analyzed using a coding analysis technique. Results: Our design method for the CA revealed gaps in MARIA?s conception, including (1) handling negative responses, (2) appropriate use of emoticons to enhance human-likeness, (3) system feedback mechanisms during turn-taking delays, and (4) defining the extent to which a CA can communicate on behalf of a health care provider regarding medication adherence. Conclusions: The design thinking process provided interactive steps to involve users early in the development of a CA. Notably, the use of WoZ in an observational clinical protocol highlighted the following: (1) coding analysis offered guidelines for modeling CA dialogue with patient safety in mind; (2) incorporating human-likeness and trust in user satisfaction assessments provided insights into attributes that foster patient trust in a CA; and (3) the application of Adlerian therapy demonstrated its effectiveness in motivating patients with HF to adhere to medication within a CA framework. In conclusion, our method is valuable for modeling and validating CA interactions with patients, assessing system reliability, user expectations, and constraints. It can guide designers in leveraging existing CA technologies, such as ChatGPT or AWS Lex, for adaptation in health care settings. UR - https://cardio.jmir.org/2025/1/e55846 UR - http://dx.doi.org/10.2196/55846 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/55846 ER - TY - JOUR AU - Graven, J. Lucinda AU - Abbott, Laurie AU - Hodgkins, V. Josef AU - Ledermann, Thomas AU - Howren, Bryant M. PY - 2025/3/26 TI - Supporting Physical and Mental Health in Rural Veterans Living With Heart Failure: Protocol for a Nurse-Led Telephone Intervention Study JO - JMIR Res Protoc SP - e63498 VL - 14 KW - heart failure KW - veterans KW - problem-solving KW - self-care KW - heart failure symptoms KW - depression KW - anxiety KW - HRQOL KW - health-related quality of life KW - stress KW - resilience KW - coping KW - mental health KW - nurse-led intervention KW - social support KW - telehealth KW - chronic disease management N2 - Background: Heart failure (HF) remains a disease of notable disparity for rural veterans, despite recent advancements in clinical treatment. Managing HF in the home is stressful and complex for rural veterans who experience unique barriers to optimal physical and mental health, necessitating adequate support and problem-solving skills. Objective: This study aims to (1) adapt, to the rural sociocultural context, a culturally sensitive, tailored, telephone support and problem-solving intervention (CARE-HF [Supporting Physical and Mental Health in Rural Veterans With Heart Failure]) using findings from preliminary qualitative research and (2) evaluate the effects of CARE-HF on problem-solving and physical and mental health outcomes among rural veterans with HF. Methods: This study involves a repeated-measures, single-group design. The intervention content was adapted and tailored to the rural sociocultural context using preliminary qualitative data and guided by the Theories of Social Problem-Solving and Stress, Appraisal, and Coping. Veterans are recruited from Veterans Administration home-based cardiac rehabilitation clinics, cardiology clinics that serve veterans, veterans-based community resource centers, and social media campaigns. Veterans with HF (N=100) receive the CARE-HF intervention. This nurse-led intervention comprises 8 telephone sessions that use a five-step, problem-solving process to manage common HF problems in the home: (1) identifying the problem and viewing it in a positive manner, (2) goal setting, (3) generating potential strategies for problem management, (4) choosing and implementing strategies to manage the problem, and (5) evaluating strategy effectiveness. Veterans receive initial problem-solving training during the first session, with follow-up sessions focusing on problem-solving skill reinforcement and assisting veterans in applying these principles to manage self-identified, HF-related problems experienced in the home. Data are collected at baseline and 3, 6, 12, and 18 months from baseline on problem-solving and outcomes of interest (ie, HF self-care; HF symptoms; health care utilization; depressive symptoms; anxiety; HF-specific, health-related quality of life; stress; resilience; and coping). Demographic data will be analyzed using descriptive statistics and multilevel growth curve modeling with restricted maximum likelihood estimation to compare a series of models using Akaike information criteria and Bayesian information criteria fit indices while controlling for covariates. Results: Recruitment started in April 2023. As of December 2024, we have enrolled 56 veterans. Recruitment is anticipated to end in June 2025, with data collection continuing until all enrolled veterans have completed the 18-month follow-up period. Conclusions: Adapting and testing a culturally sensitive, tailored, telephone intervention to aid support and problem-solving in the home has the potential to provide individualized care to rural veterans where they reside, thereby reducing travel burden while also increasing access to evidence-based care programs. If effective, telephone support and problem-solving interventions could be a low-cost, accessible method to improve physical and mental health in rural veterans with HF. Trial Registration: ClinicalTrials.gov NCT05839067; https://clinicaltrials.gov/study/NCT05839067 International Registered Report Identifier (IRRID): DERR1-10.2196/63498 UR - https://www.researchprotocols.org/2025/1/e63498 UR - http://dx.doi.org/10.2196/63498 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/63498 ER - TY - JOUR AU - Dubbala, Keerthi AU - Prizak, Roshan AU - Metzler, Ingrid AU - Rubeis, Giovanni PY - 2025/3/10 TI - Exploring Heart Disease?Related mHealth Apps in India: Systematic Search in App Stores and Metadata Analysis JO - J Med Internet Res SP - e53823 VL - 27 KW - mobile health apps KW - mHealth apps KW - heart disease KW - data collection methods KW - natural language processing KW - metadata analysis KW - Apple App Store KW - Google Play Store KW - mobile phone N2 - Background: Smartphone mobile health (mHealth) apps have the potential to enhance access to health care services and address health care disparities, especially in low-resource settings. However, when developed without attention to equity and inclusivity, mHealth apps can also exacerbate health disparities. Understanding and creating solutions for the disparities caused by mHealth apps is crucial for achieving health equity. There is a noticeable gap in research that comprehensively assesses the entire spectrum of existing health apps and extensively explores apps for specific health priorities from a health care and public health perspective. In this context, with its vast and diverse population, India presents a unique context for studying the landscape of mHealth apps. Objective: This study aimed to create a comprehensive dataset of mHealth apps available in India with an initial focus on heart disease (HD)?related apps. Methods: We collected individual app data from apps in the ?medical? and ?health and fitness? categories from the Google Play Store and the Apple App Store in December 2022 and July 2023, respectively. Using natural language processing techniques, we selected HD apps, performed statistical analysis, and applied latent Dirichlet allocation for clustering and topic modeling to categorize the resulting HD apps. Results: We collected 118,555 health apps from the Apple App Store and 108,945 health apps from the Google Play Store. Within these datasets, we found that approximately 1.7% (1990/118,555) of apps on the Apple App Store and 0.5% (548/108,945) on the Google Play Store included support for Indian languages. Using monograms and bigrams related to HD, we identified 1681 HD apps from the Apple App Store and 588 HD apps from the Google Play Store. HD apps make up only a small fraction of the total number of health apps available in India. About 90% (1496/1681 on Apple App Store and 548/588 on Google Play Store) of the HD apps were free of cost. However, more than 70% (1329/1681, 79.1% on Apple App Store and 423/588, 71.9% on Google Play Store) of HD apps had no reviews and rating-scores, indicating low overall use. Conclusions: Our study proposed a robust method for collecting and analyzing metadata from a wide array of mHealth apps available in India through the Apple App Store and Google Play Store. We revealed the limited representation of India?s linguistic diversity within the health and medical app landscape, evident from the negligible presence of Indian-language apps. We observed a scarcity of mHealth apps dedicated to HD, along with a lower level of user engagement, as indicated by reviews and app ratings. While most HD apps are financially accessible, uptake remains a challenge. Further research should focus on app quality assessment and factors influencing user adoption. UR - https://www.jmir.org/2025/1/e53823 UR - http://dx.doi.org/10.2196/53823 UR - http://www.ncbi.nlm.nih.gov/pubmed/40063078 ID - info:doi/10.2196/53823 ER - TY - JOUR AU - Jin, Xiaorong AU - Zhang, Yimei AU - Zhou, Min AU - Mei, Qian AU - Bai, Yangjuan AU - Hu, Qiulan AU - Wei, Wei AU - Zhang, Xiong AU - Ma, Fang PY - 2025/3/6 TI - 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 JO - JMIR Mhealth Uhealth SP - e63805 VL - 13 KW - chronic heart failure KW - caregivers KW - health literacy KW - mHealth KW - actor-partner interdependence mediation model KW - mobile health N2 - 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 (?=.26?0.45; P<.001), the partner effects were partially valid (?=.08?0.20; P<.05), and the mediation effects were valid (?=.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 (?=.17?0.71; P<.01), the partner effect partially held (?=.15; P<.01), and the mediation effect partially held (?=.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. UR - https://mhealth.jmir.org/2025/1/e63805 UR - http://dx.doi.org/10.2196/63805 ID - info:doi/10.2196/63805 ER - TY - JOUR AU - Maddison, Ralph AU - Nourse, Rebecca AU - Daryabeygikhotbehsara, Reza AU - Tegegne, Kassaw Teketo AU - Jansons, Paul AU - Rawstorn, Charles Jonathan AU - Atherton, John AU - Driscoll, Andrea AU - Oldenburg, Brian AU - Vasa, Rajesh AU - Kostakos, Vassilis AU - Dingler, Tilman AU - Abbott, Gavin AU - Scuffham, Paul AU - Manski-Nankervis, Elizabeth Jo-Anne AU - Kwasnicka, Dominika AU - Kensing, Finn AU - Islam, Shariful Sheikh Mohammed AU - Maeder, Anthony AU - Zhang, Yuxin PY - 2025/1/28 TI - Digital Home-Based Self-Monitoring System for People with Heart Failure: Protocol for Development of SmartHeart and Evaluation of Feasibility and Acceptability JO - JMIR Res Protoc SP - e62964 VL - 14 KW - smart home KW - health KW - chronic conditions KW - digital health KW - technology KW - behavior change KW - wearables KW - methodological considerations N2 - 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 UR - https://www.researchprotocols.org/2025/1/e62964 UR - http://dx.doi.org/10.2196/62964 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/62964 ER - TY - JOUR AU - Kitsiou, Spyros AU - Gerber, S. Ben AU - Buchholz, W. Susan AU - Kansal, M. Mayank AU - Sun, Jiehuan AU - Pressler, J. Susan PY - 2025/1/15 TI - Patient-Centered mHealth Intervention to Improve Self-Care in Patients With Chronic Heart Failure: Phase 1 Randomized Controlled Trial JO - J Med Internet Res SP - e55586 VL - 27 KW - mHealth KW - app KW - digital health KW - telehealth KW - text messaging KW - smartphone KW - wearable electronic devices KW - heart failure KW - self-care KW - self-management KW - randomized controlled trial KW - cardiology KW - SMS N2 - Background: Heart failure (HF) is one of the most common causes of hospital readmission in the United States. These hospitalizations are often driven by insufficient self-care. Commercial mobile health (mHealth) technologies, such as consumer-grade apps and wearable devices, offer opportunities for improving HF self-care, but their efficacy remains largely underexplored. Objective: The objective of this study was to examine the feasibility, acceptability, safety, and preliminary efficacy of a patient-centered mHealth intervention (iCardia4HF) that integrates 3 consumer mHealth apps and devices (Heart Failure Health Storylines, Fitbit, and Withings) with a program of individually tailored SMS text messages to improve HF self-care. Methods: We conducted a phase 1 randomized controlled trial. Eligible patients had stage C HF, were aged ?40 years, and had New York Heart Association (NYHA) class I, II, or III HF. Patients were randomly assigned to either iCardia4HF plus usual care or to usual care only and were observed for 8 weeks. Key feasibility measures were recruitment and retention rates. The primary efficacy outcome was change in HF self-care subscale scores (maintenance, symptom perception, and self-care management) at 8 weeks, assessed with the Self-Care Heart Failure Index (SCHFI; version 7.2). Key secondary outcomes were modifiable behaviors targeted by the intervention (health beliefs, self-efficacy, and HF knowledge), health status, and adherence to daily self-monitoring of 2 core vital signs (body weight and blood pressure). Results: A total of 27 patients were enrolled in the study and randomly assigned to iCardia4HF (n=13, 48%) or usual care (n=14, 52%). Of these 27 patients, 11 (41%) in the intervention group (iCardia4HF) and 14 (52%) in the usual care group started their assigned care and were included in the full analysis. Patients? mean age was 56 (SD 8.3) years, 44% (11/25) were female, 92% (23/25) self-reported race as Black, 76% (19/25) had NYHA class II or III HF, and 60% (15/25) had HF with reduced left ventricular ejection fraction. Participant retention, completion of study visits, and adherence to using the mHealth apps and devices for daily self-monitoring were high (>80%). At 8 weeks, the mean group differences in changes in the SCHFI subscale scores favored the intervention over the control group: maintenance (Cohen d=0.19, 95% CI ?0.65 to 1.02), symptom perception (Cohen d=0.33, 95% CI ?0.51 to 1.17), and self-care management (Cohen d=0.25, 95% CI ?0.55 to 1.04). The greatest improvements in terms of effect size were observed in self-efficacy (Cohen d=0.68) and health beliefs about medication adherence (Cohen d=0.63) and self-monitoring adherence (Cohen d=0.94). There were no adverse events due to the intervention. Conclusions: iCardia4HF was found to be feasible, acceptable, and safe. A larger trial with a longer follow-up duration is warranted to examine its efficacy among patients with HF. Trial Registration: ClinicalTrials.gov NCT03642275; https://clinicaltrials.gov/study/NCT03642275 UR - https://www.jmir.org/2025/1/e55586 UR - http://dx.doi.org/10.2196/55586 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/55586 ER - TY - JOUR AU - Simioni, Lisa AU - Tessitore, Elena AU - Hagberg, Hamdi AU - Schneider-Paccot, Aurélie AU - Blondon, Katherine AU - Gschwind, Liliane AU - Meyer, Philippe AU - Ehrler, Frederic PY - 2025/1/15 TI - Cardiomeds, an mHealth App for Self-Management to Support Swiss Patients With Heart Failure: 2-Stage Mixed Methods Usability Study JO - JMIR Form Res SP - e63941 VL - 9 KW - usability KW - medication KW - mobile health KW - mHealth KW - Cardiomeds KW - mobile app KW - patient empowerment KW - eHealth KW - smartphone KW - heart failure KW - HF KW - chronic disease KW - interactive KW - self-monitoring KW - usability test KW - mobile phone N2 - 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. UR - https://formative.jmir.org/2025/1/e63941 UR - http://dx.doi.org/10.2196/63941 UR - http://www.ncbi.nlm.nih.gov/pubmed/39813081 ID - info:doi/10.2196/63941 ER - TY - JOUR AU - Deka, Pallav AU - Salahshurian, Erin AU - Ng, Teresa AU - Buchholz, W. Susan AU - Klompstra, Leonie AU - Alonso, Windy PY - 2025/1/9 TI - Use of mHealth Technology for Improving Exercise Adherence in Patients With Heart Failure: Systematic Review JO - J Med Internet Res SP - e54524 VL - 27 KW - adherence KW - activity monitors KW - exercise KW - heart failure KW - mHealth KW - mobile health KW - smartphone KW - videoconferencing KW - heart KW - mHealth technology KW - exercise programs KW - age KW - sex KW - race KW - telehealth technology KW - software apps KW - feasibility KW - mobile phone N2 - Background: The known and established benefits of exercise in patients with heart failure (HF) are often hampered by low exercise adherence. Mobile health (mHealth) technology provides opportunities to overcome barriers to exercise adherence in this population. Objective: This systematic review builds on prior research to (1) describe study characteristics of mHealth interventions for exercise adherence in HF including details of sample demographics, sample sizes, exercise programs, and theoretical frameworks; (2) summarize types of mHealth technology used to improve exercise adherence in patients with HF; (3) highlight how the term ?adherence? was defined and how it was measured across mHealth studies and adherence achieved; and (4) highlight the effect of age, sex, race, New York Heart Association (NYHA) functional classification, and HF etiology (systolic vs diastolic) on exercise adherence. Methods: We searched for papers in PubMed, MEDLINE, and CINAHL databases and included studies published between January 1, 2015, and June 30, 2022. The risk of bias was analyzed. Results: In total, 8 studies (4 randomized controlled trials and 4 quasi-experimental trials) met our inclusion and exclusion criteria. A moderate to high risk of bias was noted in the studies. All studies included patients with HF in NYHA classification I-III, with sample sizes ranging from 12 to 81 and study durations lasting 4 to 26 weeks. Six studies had an equal distribution of male and female participants whose ages ranged between 53 and 73 years. Videoconferencing was used in 4 studies, while 4 studies used smartphone apps. Three studies using videoconferencing included an intervention that engaged participants in a group setting. A total of 1 study used a yoga program, 1 study used a walking program, 1 study combined jogging with walking, 1 study used a cycle ergometer, 2 studies combined walking with cycle ergometry, and 1 study used a stepper. Two studies incorporated resistance exercises in their program. Exercise programs varied, ranging between 3 and 5 days of exercise per week, with exercise sessions ranging from 30 to 60 minutes. The Borg rating of perceived exertion scale was mostly used to regulate exercise intensity, with 3 studies using heart rate monitoring using a Fitbit. Only 1 study implicitly mentions developing their intervention using a theoretical framework. Adherence was reported to the investigator-developed exercise programs. All studies were mostly feasibility or pilot studies, and the effect of age, sex, race, and NYHA classification on exercise adherence with the use of mHealth was not reported. Conclusions: The results show some preliminary evidence of the feasibility of using mHealth technology for building exercise adherence in patients with HF; however, theoretically sound and fully powered studies, including studies on minoritized communities, are lacking. In addition, the sustainability of adherence beyond the intervention period is unknown. UR - https://www.jmir.org/2025/1/e54524 UR - http://dx.doi.org/10.2196/54524 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/54524 ER - TY - JOUR AU - Blomqvist, Andreas AU - Bäck, Maria AU - Klompstra, Leonie AU - Strömberg, Anna AU - Jaarsma, Tiny PY - 2025/1/8 TI - Testing the Recruitment Frequency, Implementation Fidelity, and Feasibility of Outcomes of the Heart Failure Activity Coach Study (HEALTHY): Pilot Randomized Controlled Trial JO - JMIR Form Res SP - e62910 VL - 9 KW - heart failure KW - disease management KW - physical activity KW - sedentary KW - older adults KW - aging KW - mobile health KW - mHealth KW - feasibility KW - quality of life KW - digital health KW - smartphone N2 - Background: Heart failure (HF) is a common and deadly disease, precipitated by physical inactivity and sedentary behavior. Although the 1-year survival rate after the first diagnosis is high, physical inactivity and sedentary behavior are associated with increased mortality and negatively impact the health-related quality of life (HR-QoL). Objective: We tested the recruitment frequency, implementation fidelity, and feasibility of outcomes of the Activity Coach app that was developed using an existing mobile health (mHealth) tool, Optilogg, to support older adults with HF to be more physically active and less sedentary. Methods: In this pilot clinical randomized controlled trial (RCT), patients with HF who were already using Optilogg to enhance self-care behavior were recruited from 5 primary care health centers in Sweden. Participants were randomized to either have their mHealth tool updated with the Activity Coach app (intervention group) or a sham version (control group). The intervention duration was 12 weeks, and in weeks 1 and 12, the participants wore an accelerometer daily to objectively measure their physical activity. The HR-QoL was measured with the Kansas City Cardiomyopathy Questionnaire (KCCQ), and subjective goal attainment was assessed using goal attainment scaling. Baseline data were collected from the participants? electronic health records (EHRs). Results: We found 67 eligible people using the mHealth tool, of which 30 (45%) initially agreed to participate, with 20 (30%) successfully enrolled and randomized to the control and intervention groups in a ratio of 1:1. The participants? daily adherence to registering physical activity in the Activity Coach app was 69% (range 24%-97%), and their weekly adherence was 88% (range 58%-100%). The mean goal attainment score was ?1.0 (SD 1.1) for the control group versus 0.6 (SD 0.6) for the intervention group (P=.001). The mean change in the overall HR-QoL summary score was ?9 (SD 10) for the control group versus 3 (SD 13) in the intervention group (P=.027). There was a significant difference in the physical limitation scores between the control (mean 45, SD 27) and intervention (mean 71, SD 20) groups (P=.04). The average length of sedentary bouts increased by 27 minutes to 458 (SD 84) in the control group minutes and decreased by 0.70 minutes to 391 (SD 117) in the intervention group (P=.22). There was a nonsignificant increase in the mean light physical activity (LPA): 146 (SD 46) versus 207 (SD 80) minutes in the control and intervention groups, respectively (P=.07). Conclusions: The recruitment rate was lower than anticipated. An active recruitment process is advised if a future efficacy study is to be conducted. Adherence to the Activity Coach app was high, and it may be able to support older adults with HF in being physically active. Trial Registration: ClinicalTrials.gov NCT05235763; https://clinicaltrials.gov/study/NCT05235763 UR - https://formative.jmir.org/2025/1/e62910 UR - http://dx.doi.org/10.2196/62910 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/62910 ER - TY - JOUR AU - Jiang, Xiangkui AU - Wang, Bingquan PY - 2024/12/31 TI - Enhancing Clinical Decision Making by Predicting Readmission Risk in Patients With Heart Failure Using Machine Learning: Predictive Model Development Study JO - JMIR Med Inform SP - e58812 VL - 12 KW - prediction model KW - heart failure KW - hospital readmission KW - machine learning KW - cardiology KW - admissions KW - hospitalization N2 - Background: Patients with heart failure frequently face the possibility of rehospitalization following an initial hospital stay, placing a significant burden on both patients and health care systems. Accurate predictive tools are crucial for guiding clinical decision-making and optimizing patient care. However, the effectiveness of existing models tailored specifically to the Chinese population is still limited. Objective: This study aimed to formulate a predictive model for assessing the likelihood of readmission among patients diagnosed with heart failure. Methods: In this study, we analyzed data from 1948 patients with heart failure in a hospital in Sichuan Province between 2016 and 2019. By applying 3 variable selection strategies, 29 relevant variables were identified. Subsequently, we constructed 6 predictive models using different algorithms: logistic regression, support vector machine, gradient boosting machine, Extreme Gradient Boosting, multilayer perception, and graph convolutional networks. Results: The graph convolutional network model showed the highest prediction accuracy with an area under the receiver operating characteristic curve of 0.831, accuracy of 75%, sensitivity of 52.12%, and specificity of 90.25%. Conclusions: The model crafted in this study proves its effectiveness in forecasting the likelihood of readmission among patients with heart failure, thus serving as a crucial reference for clinical decision-making. UR - https://medinform.jmir.org/2024/1/e58812 UR - http://dx.doi.org/10.2196/58812 ID - info:doi/10.2196/58812 ER - TY - JOUR AU - Malhotra, Chetna AU - Yee, Alethea AU - Ramakrishnan, Chandrika AU - Kaurani, Naraindas Sanam AU - Chua, Ivy AU - Lakin, R. Joshua AU - Sim, David AU - Balakrishnan, Iswaree AU - Ling, Jin Vera Goh AU - Weiliang, Huang AU - Ling, Fong Lee AU - Pollak, I. Kathryn PY - 2024/12/18 TI - Development and Usability of an Advance Care Planning Website (My Voice) to Empower Patients With Heart Failure and Their Caregivers: Mixed Methods Study JO - JMIR Aging SP - e60117 VL - 7 KW - advance care planning KW - decision aid KW - heart KW - website KW - heart failure KW - care plan KW - caregiver KW - usability KW - acceptability N2 - Background: Web-based advance care planning (ACP) interventions offer a promising solution to improve ACP engagement, but none are specifically designed to meet the needs of patients with heart failure and their caregivers. Objective: We aimed to develop and assess the usability and acceptability of a web-based ACP decision aid called ?My Voice,? which is tailored for patients with heart failure and their caregivers. Methods: This study?s team and advisory board codeveloped the content for both patient and caregiver modules in ?My Voice.? Using a mixed methods approach, we iteratively tested usability and acceptability, incorporating feedback from patients, caregivers, and health care professionals (HCPs). Results: We interviewed 30 participants (11 patients, 9 caregivers, and 10 HCPs). Participants found the website easy to navigate, with simple and clear content facilitating communication of patients? values and goals. They also appreciated that it allowed them to revisit their care goals periodically. The average System Usability Scale score was 74 (SD 14.8; range: 42.5-95), indicating good usability. Over 80% (8/11) of patients and 87% (7/8) of caregivers rated the website?s acceptability as good or excellent. Additionally, 70% (7/10) of HCPs strongly agreed or agreed with 11 of the 15 items testing the website?s acceptability. Conclusions: ?My Voice? shows promise as a tool for patients with heart failure to initiate and revisit ACP conversations with HCPs and caregivers. We will evaluate its efficacy in improving patient and caregiver outcomes in a randomized controlled trial. Trial Registration: ClinicalTrials.gov NCT06090734; https://clinicaltrials.gov/study/NCT06090734 UR - https://aging.jmir.org/2024/1/e60117 UR - http://dx.doi.org/10.2196/60117 ID - info:doi/10.2196/60117 ER - TY - JOUR AU - Bretschneider, Pia Maxi AU - Mayer-Berger, Wolfgang AU - Weine, Jens AU - Roth, Lena AU - Schwarz, H. Peter E. AU - Petermann, Franz PY - 2024/12/11 TI - Results of a Digital Multimodal Motivational and Educational Program as Follow-Up Care for Former Cardiac Rehabilitation Patients: Randomized Controlled Trial JO - JMIR Cardio SP - e57960 VL - 8 KW - mHealth KW - apps KW - digital technology KW - digital interventions KW - coronary heart disease KW - lifestyle intervention KW - cardiac rehabilitation KW - quality of life KW - cardiac care N2 - Background: Digital interventions are promising additions for both usual care and rehabilitation. Evidence and studies for the latter, however, are still rare. Objective: The aim of the study was to examine the app/web-based patient education program called ?mebix? (previously called ?Vision 2 ? Gesundes Herz?) regarding its effectiveness in relation to the parameters of disease-specific quality of life (HeartQoL), cardiovascular risk profile (Cardiovascular Risk Management [CARRISMA]), and prognostic estimation of early retirement (Screening instrument work and occupation [SIBAR]) in 190 participants from a cardiological rehabilitation clinic. Methods: To evaluate mebix, 354 patients from the Roderbirken Clinic of the German Pension Insurance Rhineland (Germany) with a coronary heart diesase were recruited and randomized either to the intervention group (using mebix postrehabiliation for up to 12 months) or the control group (receiving standard care). The data collection took place at the end of inpatient rehabilitation (t0), as well as 6 months (t1) and 12 months (t2) after the end of rehabilitation. Analyses of variance are used to assess the overall significance of difference in outcome parameters between groups and over time. Results: The primary endpoint of disease-related quality of life shows a significant improvement of 7.35 points over the course of the intervention that is also more pronounced in the intervention group. Similarly, the 10-year risk of cardiovascular death and myocardial infarction showed significant improvements in the cardiovascular risk profile over time and between groups, indicating better results in the intervention group (ie, a reduction of ?1.59 and ?5.03, respectively). Positive effects on secondary outcomes like body weight, blood pressure, and number of smokers only showed time effects, indicating no difference between the groups. In addition, the SIBAR was significantly lower/better at the end of the observation period than at the beginning of the observation for both groups. Conclusions: Overall, the digital training program represents an effective follow-up offer after rehabilitation that could be incorporated into standard care to further improve disease-related quality of life and cardiovascular risk profiles. Trial Registration: German Clinical Trials Register DRKS00007569; https://drks.de/search/en/trial/DRKS00007569 UR - https://cardio.jmir.org/2024/1/e57960 UR - http://dx.doi.org/10.2196/57960 ID - info:doi/10.2196/57960 ER - TY - JOUR AU - Zheng, Yaguang AU - Adhikari, Samrachana AU - Li, Xiyue AU - Zhao, Yunan AU - Mukhopadhyay, Amrita AU - Hamo, E. Carine AU - Stokes, Tyrel AU - Blecker, Saul PY - 2024/12/5 TI - Association Between Video-Based Telemedicine Visits and Medication Adherence Among Patients With Heart Failure: Retrospective Cross-Sectional Study JO - JMIR Cardio SP - e56763 VL - 8 KW - telemedicine KW - medication adherence KW - heart failure KW - systolic dysfunction KW - medical therapy KW - telehealth KW - remote monitoring KW - self-management N2 - Background: Despite the exponential growth in telemedicine visits in clinical practice due to the COVID-19 pandemic, it remains unknown if telemedicine visits achieved similar adherence to prescribed medications as in-person office visits for patients with heart failure. Objective: Our study examined the association between telemedicine visits (vs in-person visits) and medication adherence in patients with heart failure. Methods: This was a retrospective cross-sectional study of adult patients with a diagnosis of heart failure or an ejection fraction of ?40% using data between April 1 and October 1, 2020. This period was used because New York University approved telemedicine visits for both established and new patients by April 1, 2020. The time zero window was between April 1 and October 1, 2020, then each identified patient was monitored for up to 180 days. Medication adherence was measured by the mean proportion of days covered (PDC) within 180 days, and categorized as adherent if the PDC was ?0.8. Patients were included in the telemedicine exposure group or in-person group if all encounters were video visits or in-person office visits, respectively. Poisson regression and logistic regression models were used for the analyses. Results: A total of 9521 individuals were included in this analysis (telemedicine visits only: n=830 in-person office visits only: n=8691). Overall, the mean age was 76.7 (SD 12.4) years. Most of the patients were White (n=6996, 73.5%), followed by Black (n=1060, 11.1%) and Asian (n=290, 3%). Over half of the patients were male (n=5383, 56.5%) and over half were married or living with partners (n=4914, 51.6%). Most patients? health insurance was covered by Medicare (n=7163, 75.2%), followed by commercial insurance (n=1687, 17.7%) and Medicaid (n=639, 6.7%). Overall, the average PDC was 0.81 (SD 0.286) and 71.3% (6793/9521) of patients had a PDC?0.8. There was no significant difference in mean PDC between the telemedicine and in-person office groups (mean 0.794, SD 0.294 vs mean 0.812, SD 0.285) with a rate ratio of 0.99 (95% CI 0.96-1.02; P=.09). Similarly, there was no significant difference in adherence rates between the telemedicine and in-person office groups (573/830, 69% vs 6220/8691, 71.6%), with an odds ratio of 0.94 (95% CI 0.81-1.11; P=.12). The conclusion remained the same after adjusting for covariates (eg, age, sex, race, marriage, language, and insurance). Conclusions: We found similar rates of medication adherence among patients with heart failure who were being seen via telemedicine or in-person visits. Our findings are important for clinical practice because we provide real-world evidence that telemedicine can be an approach for outpatient visits for patients with heart failure. As telemedicine is more convenient and avoids transportation issues, it may be an alternative way to maintain the same medication adherence as in-person visits for patients with heart failure. UR - https://cardio.jmir.org/2024/1/e56763 UR - http://dx.doi.org/10.2196/56763 ID - info:doi/10.2196/56763 ER - TY - JOUR AU - Spethmann, Sebastian AU - Hindricks, Gerhard AU - Koehler, Kerstin AU - Stoerk, Stefan AU - Angermann, E. Christiane AU - Böhm, Michael AU - Assmus, Birgit AU - Winkler, Sebastian AU - Möckel, Martin AU - Mittermaier, Mirja AU - Lelgemann, Monika AU - Reuter, Daniel AU - Bosch, Ralph AU - Albrecht, Alexander AU - von Haehling, Stephan AU - Helms, M. Thomas AU - Sack, Stefan AU - Bekfani, Tarek AU - Gröschel, Wolfgang Jan AU - Koehler, Magdalena AU - Melzer, Christoph AU - Wintrich, Jan AU - Zippel-Schultz, Bettina AU - Ertl, Georg AU - Vogelmeier, Claus AU - Dagres, Nikolaos AU - Zernikow, Jasmin AU - Koehler, Friedrich PY - 2024/12/4 TI - Telemonitoring for Chronic Heart Failure: Narrative Review of the 20-Year Journey From Concept to Standard Care in Germany JO - J Med Internet Res SP - e63391 VL - 26 KW - telemedicine KW - e-counseling KW - heart decompensation KW - Europe KW - patient care management N2 - Background: Chronic heart failure (CHF) is a major cause of morbidity and mortality worldwide, placing a significant burden on health care systems. The concept of telemedicine for CHF was first introduced in the late 1990s, and since 2010, studies have demonstrated its potential to improve patient outcomes and reduce health care costs. Over the following decade, technological advancements and changes in health care policy led to the development of more sophisticated telemedicine solutions for CHF, including remote patient management through invasive or noninvasive telemonitoring devices, mobile apps, and virtual consultations. Years of public funding in Germany have generated evidence that remote patient management improves outcomes for patients with CHF, such as quality of life, and reduces hospital admissions. Based on these data, the Federal Joint Committee (Gemeinsamer Bundesausschuss; G-BA) decided, independently of the current European Society of Cardiology recommendations, to incorporate telemedicine as a standard digital intervention for high-risk patients with reduced left ventricular ejection fraction in Germany in 2020. Objective: This review aims to illustrate the journey from the initial concept through pioneering studies that led to telemedicine?s integration into standard care, and to share current experiences that have positioned Germany as a leader in cardiovascular telemedicine. Methods: We review and discuss existing literature and evidence on the development and implementation of telemonitoring for CHF in Germany over the past 20 years. Relevant studies, reports, and guidelines were identified through a comprehensive search of electronic databases, including PubMed, Google Scholar, and specialized journals focused on CHF telemonitoring. Results: Pioneering studies, such as the TIM-HF2 (Telemedical Interventional Management in Heart Failure II) and IN-TIME (Influence of Home Monitoring on Mortality and Morbidity in Heart Failure Patients with Impaired Left Ventricular Function) trials, demonstrated the effectiveness of remote patient management applications for patients with CHF in Germany and their applicability to current practices involving both invasive and noninvasive methods. Collaborations between researchers and technology developers overcame barriers, leading to sustainable improvements in patient care. Ongoing research on artificial intelligence applications for prioritizing and interpreting individual health data will continue to transform digital health care. Conclusions: The establishment of telemedical care for patients with HF across Europe is likely to benefit from experiences in Germany, where significant improvements have been achieved in the care of patients with HF. UR - https://www.jmir.org/2024/1/e63391 UR - http://dx.doi.org/10.2196/63391 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/63391 ER - TY - JOUR AU - Craig, William AU - Ohlmann, Suzanne PY - 2024/11/26 TI - The Benefits of Using Active Remote Patient Management for Enhanced Heart Failure Outcomes in Rural Cardiology Practice: Single-Site Retrospective Cohort Study JO - J Med Internet Res SP - e49710 VL - 26 KW - rural KW - remote patient monitoring KW - heart failure KW - heart failure hospitalizations KW - office visits KW - rural health inequalities KW - telehealth N2 - Background: Rural populations have a disproportionate burden of heart failure (HF) morbidity and mortality, associated with socioeconomic and racial inequities. Multiple randomized controlled trials of remote patient monitoring (RPM) using both direct patient contact and device-based monitoring have been conducted to assess improvement in HF outcomes, with mixed results. Objective: We aimed to assess whether a novel digital health care platform designed to proactively assess and manage patients with HF improved patient outcomes by preventing HF re-exacerbations, thus reducing emergency room visits and HF hospitalizations. Methods: This was a single-site, retrospective cohort study using electronic medical record (EMR) data gathered from 2 years prior to RPM initiation and 2 years afterward. In January 2017, this single center began enrolling New York Heart Association (NYHA) class II and class III patients with HF prone to HF exacerbation into an RPM program using the Cordella HF system. By July 2022, 93 total patients had been enrolled in RPM. Of these patients, 87% lived in rural areas. This retrospective review included 40 of the 93 patients enrolled in RPM. These 40 were selected because they had 2 years of established EMR data prior to initiation of RPM and 2 years of post-RPM data; each consented to this Sterling IRB?approved study. Results: We included 40 patients with at least 4 years of follow-up, including 2 years prior to RPM initiation and 2 years after RPM initiation. In the 2 years after RPM initiation, check-up calls increased 519%, medication change calls increased 519%, and total calls increased by 519%. Emergency room visits for HF fell 93%, heart failure hospitalizations fell 83%, and all other cardiovascular hospitalizations fell 50%. Additionally, the total number of office visits declined by 15% after RPM, and unscheduled or urgent office visits declined by 73%. Conclusions: Daily monitoring of trends in vital sign data between engaged patients and a collaborative team of clinicians, incorporated into daily clinical workflow, enhanced patient interactions and allowed timely response or intervention when HF decompensation occurred, resulting in a reduction of outpatient and inpatient clinical use over more than 2 years of follow-up. UR - https://www.jmir.org/2024/1/e49710 UR - http://dx.doi.org/10.2196/49710 UR - http://www.ncbi.nlm.nih.gov/pubmed/39589775 ID - info:doi/10.2196/49710 ER - TY - JOUR AU - Yu, Bin AU - Kravchenko, Julia AU - Yashkin, Arseniy AU - Akushevich, Igor PY - 2024/11/20 TI - Decomposition of Heart Failure Prevalence and Mortality Among Older Adults in the United States: Medicare-Based Partitioning Analysis JO - JMIR Public Health Surveill SP - e51989 VL - 10 KW - heart failure KW - prevalence KW - mortality KW - partitioning KW - time trends KW - epidemiologic determinants N2 - Background: Heart failure (HF) is a challenging clinical and public health problem characterized by high prevalence and mortality among US older adults, along with a recent decline in HF prevalence and increase in mortality. The changes of prevalence can be decomposed into pre-existing disease prevalence, disease incidence, and respective survival, while the changes of mortality can be decomposed into mortality in the general population independent from HF, pre-existing HF prevalence, incidence, and respective survival. These epidemiological components may contribute differently to the changes in prevalence and mortality. Objective: We aimed to investigate and compare the relative contributions of epidemiologic determinants in HF prevalence and mortality trends. Methods: This study was a secondary data analysis of 5% of Medicare claims data for 1992?2017 in the United States. Medicare is a federal health insurance program for older adults aged 65+ years as well as people with specific disabilities and end-stage renal disease. Age-adjusted prevalence and incidence-based mortality (IBM; all-cause mortality that occurred in patients with HF) were partitioned into their respective epidemiologic determinants using the partitioning analysis approach. Results: The age-adjusted HF prevalence (1/100 person-years) increased from 11 in 1994 to 14.6 in 2005, followed by a decline to 12.6 in 2017, and the age-adjusted HF IBM (1/100,000) increased from 2220.8 in 1994 to 2563.7 in 2000, then declined to 2075.9 in 2016, followed by an increase to 2094.7 in 2017. The HF incidence (1/1000 person-years) declined from 29.4 in 1992 to 19.9 in 2017. The 1-, 3-, and 5-year survival trend showed declines in recent years. Partitioning of HF prevalence showed three phases: (1) decelerated increasing prevalence (1994?2006), (2) accelerated declining prevalence (2007?2014), and (3) decelerated declining prevalence (2015?2017). During the whole period, the decreasing HF incidence contributed to the declines in prevalence, overpowering prevalence increases contributed from survival. Likewise, partitioning of HF IBM showed three phases: (1) decelerated increasing mortality (1994?2001), (2) accelerated declining mortality (2002?2012), and (3) decelerated declining mortality (2013?2017). The decreasing HF incidence in 1994?2017 and increasing survival in 2002?2006 contributed to the declines in mortality, while the decreasing survival in 2007?2017 contributed to the mortality increase. Conclusions: Decade-long declines in HF prevalence and mortality mainly reflected decreasing incidence, while the most recent increase of mortality was predominantly due to the declining survival. If current trends persist, HF prevalence and mortality are forecasted to grow substantially in the next decade. Prevention strategies should continue the prevention of HF risk factors as well as improvement of treatment and management of HF after diagnosis. UR - https://publichealth.jmir.org/2024/1/e51989 UR - http://dx.doi.org/10.2196/51989 ID - info:doi/10.2196/51989 ER - TY - JOUR AU - Malinovská, Jana AU - Michalec, Juraj AU - Bro?, Jan PY - 2024/11/12 TI - Considerations for Future Research and Methodological Clarifications on Smoking Behavior Change and Heart Failure Risk in Patients With Type 2 Diabetes JO - JMIR Public Health Surveill SP - e60713 VL - 10 KW - type 2 diabetes KW - smoking KW - heart failure KW - cardiovascular disease KW - smoking cessation UR - https://publichealth.jmir.org/2024/1/e60713 UR - http://dx.doi.org/10.2196/60713 ID - info:doi/10.2196/60713 ER - TY - JOUR AU - Ferguson, Caleb AU - William, Scott AU - Allida, M. Sabine AU - Fulcher, Jordan AU - Jenkins, J. Alicia AU - Lattimore, Jo-Dee AU - Loch, L-J AU - Keech, Anthony PY - 2024/11/7 TI - The Development of Heart Failure Electronic-Message Driven Tips to Support Self-Management: Co-Design Case Study JO - JMIR Cardio SP - e57328 VL - 8 KW - heart failure KW - co-design KW - smartphone KW - app design KW - patient education KW - e-TIPS KW - electronic-message driven tips N2 - Background: Heart failure (HF) is a complex syndrome associated with high morbidity and mortality and increased health care use. Patient education is key to improving health outcomes, achieved by promoting self-management to optimize medical management. Newer digital tools like SMS text messaging and smartphone apps provide novel patient education approaches. Objective: This study aimed to partner with clinicians and people with lived experience of HF to identify the priority educational topic areas to inform the development and delivery of a bank of electronic-message driven tips (e-TIPS) to support HF self-management. Methods: We conducted 3 focus groups with cardiovascular clinicians, people with lived experience of HF, and their caregivers, which consisted of 2 stages: stage 1 (an exploratory qualitative study to identify the unmet educational needs of people living with HF; previously reported) and stage 2 (a co-design feedback session to identify educational topic areas and inform the delivery of e-TIPS). This paper reports the findings of the co-design feedback session. Results: We identified 5 key considerations in delivering e-TIPS and 5 relevant HF educational topics for their content. Key considerations in e-TIP delivery included (1) timing of the e-TIPS; (2) clear and concise e-TIPS; (3) embedding a feedback mechanism; (4) distinguishing actionable and nonactionable e-TIPS; and (5) frequency of e-TIP delivery. Relevant educational topic areas included the following: (1) cardiovascular risk reduction, (2) self-management, (3) food and nutrition, (4) sleep hygiene, and (5) mental health. Conclusions: The findings from this co-design case study have provided a foundation for developing a bank of e-TIPS. These will now be evaluated for usability in the BANDAIDS e-TIPS, a single-group, quasi-experimental study of a 24-week e-TIP program (personalized educational messages) delivered via SMS text messaging (ACTRN12623000644662). UR - https://cardio.jmir.org/2024/1/e57328 UR - http://dx.doi.org/10.2196/57328 ID - info:doi/10.2196/57328 ER - TY - JOUR AU - Marier-Tétrault, Emmanuel AU - Bebawi, Emmanuel AU - Béchard, Stéphanie AU - Brouillard, Philippe AU - Zuchinali, Priccila AU - Remillard, Emilie AU - Carrier, Zoé AU - Jean-Charles, Loyda AU - Nguyen, Kha John Nam AU - Lehoux, Pascale AU - Pomey, Marie-Pascale AU - Ribeiro, B. Paula A. AU - Tournoux, François PY - 2024/11/6 TI - Remote Patient Monitoring and Digital Therapeutics Enhancing the Continuum of Care in Heart Failure: Nonrandomized Pilot Study JO - JMIR Form Res SP - e53444 VL - 8 KW - heart failure KW - remote patient management KW - telemonitoring KW - digital therapeutics KW - digital health KW - heart KW - therapeutics KW - pilot study KW - patient care KW - medical therapy KW - vitals KW - weight KW - symptoms KW - quality of life KW - medication optimization KW - mobile phone N2 - Background: Heart failure (HF) is the primary cause of hospitalization among Canadian patients aged ?65 years. Care for HF requires regular clinical follow-ups to prevent readmissions and facilitate medical therapy optimization. Multiple barriers lead to therapeutic medical inertia including limited human resources and regional inequities. Remote patient monitoring (RPM) and digital therapeutics (DTx) solutions have been developed to improve HF management, but their adoption remains limited and underexplored. The Continuum project emerged as a collaborative initiative involving a health care center, a software start-up, and an industrial partner. Objective: We aimed to develop and test the feasibility of the Continuum intervention that seamlessly combined an RPM system with a DTx solution for HF within the same software. Methods: A 3-month pre-post pilot study was conducted from October 2020 to June 2021. Patients with HF who owned a smartphone or tablet (having remote patient monitoring [RPM+]), had (1) access to a self-care app where they could enter their vital signs, weight, and HF symptoms and view educational content; (2) daily monitoring of their data by a nurse; and (3) a DTx module with automated HF medication suggestions based on national guidelines, made available to their treating medical team. Bluetooth devices were offered to facilitate data recording. Nurses on RPM monitoring could call patients and arrange appointments with their medical team. Patients without a mobile device or unable to use the app were followed in another group (without remote patient monitoring [RPM?]). Results: In total, 52 patients were enrolled in this study (32 RPM+ and 20 RPM?). Among patients owning a mobile device, only 14% (5/37) could not use the app. In the RPM+ group, 47% (15/32) of the patients used the app for more than 80% (67 days) of the 12-week study period. The use of our digital solution was integrated into the regular nursing workday and only 34 calls had to be made by the nurse during the study period. Only 6% (2/32) of the patients in the RPM+ group experienced at least 1 all-cause hospitalization versus 35% (7/20) of the RPM? ones during the follow-up (6%, 2/32 vs 25%, 5/20 for HF hospitalization) and patients were more likely to have their HF therapy optimized if the DTx solution was available. Quality of life improved in patients compliant with the use of the mobile app (mean score variation +10.6, SD 14.7). Conclusions: This pilot study demonstrated the feasibility of implementing our digital solution, within the specific context of HF. The seamless integration of Continuum into nursing workflow, mobile app accessibility, and adoption by patients, were the 3 main key learning points of this study. Further investigation is required to assess the potential impacts on hospitalizations, drug optimization, and quality of life. Trial Registration: ClinicalTrials.gov NCT05377190; https://clinicaltrials.gov/study/NCT05377190 (pilot study #21.403) UR - https://formative.jmir.org/2024/1/e53444 UR - http://dx.doi.org/10.2196/53444 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/53444 ER - TY - JOUR AU - Jin, Xiaorong AU - Zhang, Yimei AU - Zhou, Min AU - Zhang, Xiong AU - Mei, Qian AU - Bai, Yangjuan AU - Wei, Wei AU - Ma, Fang PY - 2024/10/31 TI - Experiences With mHealth Use Among Patient-Caregiver Dyads With Chronic Heart Failure: Qualitative Study JO - J Med Internet Res SP - e57115 VL - 26 KW - chronic heart failure KW - informal caregiver KW - mHealth KW - experience KW - dyad N2 - Background: Chronic heart failure has become a serious threat to the health of the global population, and self-management is key to treating chronic heart failure. The emergence of mobile health (mHealth) provides new ideas for the self-management of chronic heart failure in which the informal caregiver plays an important role. Current research has mainly studied the experiences with using mHealth among patients with chronic heart failure from the perspective of individual patients, and there is a lack of research from the dichotomous perspective. Objective: The aim of this study was to explore the experiences with mHealth use among patients with chronic heart failure and their informal caregivers from a dichotomous perspective. Methods: This descriptive phenomenological study from a post-positivist perspective used a dyadic interview method, and face-to-face semistructured interviews were conducted with patients with chronic heart failure and their informal caregivers. Data were collected and managed using NVivo 12 software, and data analysis used thematic analysis to identify and interpret participants? experiences and perspectives. The thematic analysis included familiarizing ourselves with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report. Results: A total of 14 dyads of patients with chronic heart failure and their informal caregivers (13 men and 15 women) participated in this study, including 3 couples and 11 parent-child pairs. We constructed 4 key themes and their subthemes related to the experiences with mHealth use: (1) opposing experiences with mHealth as human interaction or trauma (great experience with mHealth use; trauma), (2) supplement instead of replacement (it is useful but better as a reference; offline is unavoidable sometimes), (3) both agreement and disagreement over who should be the adopter of mHealth (achieving consensus regarding who should adopt mHealth; conflict occurs when considering patients as the adopter of mHealth), (4) for better mHealth (applying mHealth with caution; suggestions for improved mHealth). Conclusions: This study reported that the experiences with mHealth use among patients with chronic heart failure and their informal caregivers were mixed, and it highlighted the human touch of mHealth and the importance of network security. These results featured mHealth as a complement to offline hospitals rather than a replacement. In the context of modern or changing Chinese culture, we encourage patients to use mHealth by themselves and their informal caregivers to provide help when necessary. In addition, we need to use mHealth carefully, and future mHealth designs should focus more on ease of use and be oriented more toward older adults. UR - https://www.jmir.org/2024/1/e57115 UR - http://dx.doi.org/10.2196/57115 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/57115 ER - TY - JOUR AU - Erdt, Mojisola AU - Yusof, Binte Sakinah AU - Chai, Liquan AU - Md Salleh, Umairah Siti AU - Liu, Zhengyuan AU - Sarim, Binte Halimah AU - Lim, Choo Geok AU - Lim, Hazel AU - Suhaimi, Ain Nur Farah AU - Yulong, Lin AU - Guo, Yang AU - Ng, Angela AU - Ong, Sharon AU - Choo, Peide Bryan AU - Lee, Sheldon AU - Weiliang, Huang AU - Oh, Choon Hong AU - Wolters, Klara Maria AU - Chen, F. Nancy AU - Krishnaswamy, Pavitra PY - 2024/10/30 TI - Characterization of Telecare Conversations on Lifestyle Management and Their Relation to Health Care Utilization for Patients with Heart Failure: Mixed Methods Study JO - J Med Internet Res SP - e46983 VL - 26 KW - telehealth KW - telecare KW - heart failure KW - chronic disease KW - self-management KW - lifestyle management KW - behavior KW - health care utilization KW - conversation KW - dialogue KW - medical informatics N2 - Background: Telehealth interventions where providers offer support and coaching to patients with chronic conditions such as heart failure (HF) and type 2 diabetes mellitus (T2DM) are effective in improving health outcomes. However, the understanding of the content and structure of these interactions and how they relate to health care utilization remains incomplete. Objective: This study aimed to characterize the content and structure of telecare conversations on lifestyle management for patients with HF and investigate how these conversations relate to health care utilization. Methods: We leveraged real-world data from 50 patients with HF enrolled in a postdischarge telehealth program, with the primary intervention comprising a series of telephone calls from nurse telecarers over a 12-month period. For the full cohort, we transcribed 729 English-language calls and annotated conversation topics. For a subcohort (25 patients with both HF and T2DM), we annotated lifestyle management content with fine-grained dialogue acts describing typical conversational structures. For each patient, we identified calls with unusually high ratios of utterances on lifestyle management as lifestyle-focused calls. We further extracted structured data for inpatient admissions from 6 months before to 6 months after the intervention period. First, to understand conversational structures and content of lifestyle-focused calls, we compared the number of utterances, dialogue acts, and symptom attributes in lifestyle-focused calls to those in calls containing but not focused on lifestyle management. Second, to understand the perspectives of nurse telecarers on these calls, we conducted an expert evaluation where 2 nurse telecarers judged levels of concern and follow-up actions for lifestyle-focused and other calls (not focused on lifestyle management content). Finally, we assessed how the number of lifestyle-focused calls relates to the number of admissions, and to the average length of stay per admission. Results: In comparative analyses, lifestyle-focused calls had significantly fewer utterances (P=.01) and more dialogue acts (Padj=.005) than calls containing but not focused on lifestyle management. Lifestyle-focused calls did not contain deeper discussions on clinical symptoms. These findings indicate that lifestyle-focused calls entail short, intense discussions with greater emphasis on understanding patient experience and coaching than on clinical content. In the expert evaluation, nurse telecarers identified 24.2% (29/120) of calls assessed as concerning enough for follow-up. For these 29 calls, nurse telecarers were more attuned to concerns about symptoms and vitals (19/29, 65.5%) than lifestyle management concerns (4/29, 13.8%). The number of lifestyle-focused calls a patient had was modestly (but not significantly) associated with a lower average length of stay for inpatient admissions (Spearman ?=-0.30; Padj=.06), but not with the number of admissions (Spearman ?=-0.03; Padj=.84). Conclusions: Our approach and findings offer novel perspectives on the content, structure, and clinical associations of telehealth conversations on lifestyle management for patients with HF. Hence, our study could inform ways to enhance telehealth programs for self-care management in chronic conditions. UR - https://www.jmir.org/2024/1/e46983 UR - http://dx.doi.org/10.2196/46983 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/46983 ER - TY - JOUR AU - Kashiwakura, Daisaku AU - Hiyama, Akiko AU - Muramatsu, Masumi AU - Hinotsu, Atsuko AU - Takeda, Michiko AU - Suzuki, Norio AU - Akiyama, Sachie AU - Kurihara, Sayuri AU - Kida, Keisuke PY - 2024/10/18 TI - A Self-Administered Eating Behavior Scale for Patients With Heart Failure Living at Home: Protocol for a Mixed Methods Scale Development Study JO - JMIR Res Protoc SP - e60719 VL - 13 KW - heart failure KW - eating behavior KW - self-care KW - patient-reported outcome measures KW - International Classification of Functioning, Disability, and Health (ICF) N2 - Background: The prevalence of heart failure (HF) is increasing worldwide, with the associated mortality rates rising consistently. Preventing HF progression requires adherence to restricted sodium intake alongside sufficient and balanced nutritional consumption. For patients at home, preparing nutritionally balanced meals is essential, either self-assisted or with the aid of close individuals. Patients with HF frequently experience decreased exercise tolerance, depression, anxiety, and social isolation, which interfere with eating behaviors, leading to inadequate dietary habits. However, measures focusing on the determinants of eating behavior among patients with HF are currently lacking. Objective: This study aims to develop a self-administered scale to assess the eating behaviors of patients with HF living at home (Self-Administered Eating Behaviors Scale for Heart Failure [SEBS-HF]). Methods: This study encompasses 3 phases. Phase 1 involves identifying factors influencing eating behaviors in patients with HF. First, a literature review will be conducted using PubMed and CINAHL databases. The specified literature will be analyzed qualitatively and inductively. Additionally, verbatim transcripts obtained from semistructured interviews of patients with HF and medical experts will be qualitatively analyzed. Based on the Phase 1 results, a preliminary scale will be constructed. In Phase 2, cognitive interviews will be conducted with patients with HF and experts; the preliminary scale will be used to qualitatively evaluate its content validity. After validation, the scale will be used in Phase 3 to conduct a cross-sectional study involving patients with HF. In Phase 3, data will be collected from clinical records and self-administered questionnaires or scales. After conducting a preliminary survey, the main survey will be conducted. The reliability and validity of the scale will be assessed using statistical methods. Results: The first phase of this study commenced in September 2023, and by May 2, 2024, a total of 7 patients with HF and 6 expert professionals were enrolled as study participants. The draft creation of the scale will be completed in 2024, and the content validity evaluation of the draft scale is expected to be finished by early 2025. The third phase will begin its investigation in mid-2025 and is expected to be completed by late 2025, after which the SEBS-HF will be published. Conclusions: The development and use of this scale will enable a more comprehensive evaluation of the factors influencing eating behaviors in patients with HF. Thus, medical and welfare professionals should provide appropriate support tailored to the specific needs of patients with HF. International Registered Report Identifier (IRRID): DERR1-10.2196/60719 UR - https://www.researchprotocols.org/2024/1/e60719 UR - http://dx.doi.org/10.2196/60719 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/60719 ER - TY - JOUR AU - Ikuta, Kasumi AU - Aishima, Miya AU - Noguchi-Watanabe, Maiko AU - Fukui, Sakiko PY - 2024/10/8 TI - Feasibility of Monitoring Heart and Respiratory Rates Using Nonwearable Devices and Consistency of the Measured Parameters: Pilot Feasibility Study JO - JMIR Hum Factors SP - e56547 VL - 11 KW - heart rate KW - older adults KW - respiratory rate KW - nonwearable devices KW - vital signs N2 - Background: As Japan is the world?s fastest-aging society with a declining population, it is challenging to secure human resources for care providers. Therefore, the Japanese government is promoting digital transformation and the use of nursing care equipment, including nonwearable devices that monitor heart and respiratory rates. However, the feasibility of monitoring heart and respiratory rates with nonwearable devices and the consistency of the rates measured have not been reported. Objective: In this study, we focused on a sheet-type nonwearable device (Safety Sheep Sensor) introduced in many nursing homes. We evaluated the feasibility of monitoring heart rate (HR) and respiratory rate (RR) continuously using nonwearable devices and the consistency of the HR and RR measured. Methods: A sheet-type nonwearable device that measured HR and RR every minute through body vibrations was placed under the mattress of each participant. The participants in study 1 were healthy individuals aged 20?60 years (n=21), while those in study 2 were older adults living in multidwelling houses and required nursing care (n=20). The HR was measured using standard methods by the nurse and using the wearable device (Silmee Bar-type Lite sensor), and RR was measured by the nurse. The primary outcome was the mean difference in HR and RR between nonwearable devices and standard methods. Results: The mean difference in HR was ?0.32 (SD 3.12) in study 1 and 0.04 (SD: 3.98) in study 2; both the differences were within the predefined accepted discrepancies (<5 beats/min). The mean difference in RR was ?0.98 (SD 3.01) in study 1 and ?0.49 (SD 2.40) in study 2; both the differences were within the predefined accepted discrepancies (3 breaths/min). Conclusions: HR and RR measurements obtained using the nonwearable devices and the standard method were similar. Continuous monitoring of vital signs using nonwearable devices can aid in the early detection of abnormal conditions in older people. UR - https://humanfactors.jmir.org/2024/1/e56547 UR - http://dx.doi.org/10.2196/56547 ID - info:doi/10.2196/56547 ER - TY - JOUR AU - Melnikov, Semyon AU - Klein, Stav AU - Shahar, Moni AU - Guy, David PY - 2024/8/13 TI - Using Topic Modeling to Understand Patients? and Caregivers? Perspectives About Left Ventricular Assist Device: Thematic Analysis JO - J Med Internet Res SP - e50009 VL - 26 KW - left ventricular assist device KW - LVAD KW - topic modeling KW - health care forum KW - heart disease KW - cardiovascular condition KW - medical devices KW - devices for heart KW - latent Dirichlet allocation KW - cardiovascular KW - device KW - visualization tool KW - tool KW - heart KW - caregiver KW - monitoring KW - management KW - care KW - users KW - communication KW - heart failure N2 - Background: Heart failure (HF) is a significant global clinical and public health challenge, impacting 64.3 million individuals worldwide. To address the scarcity of donor organs, left ventricular assist device (LVAD) implantation has become a crucial intervention for managing end-stage HF, serving as a bridge to heart transplantation or as a destination therapy. Web-based health forums, such as MyLVAD.com, play a vital role as trusted sources of information for individuals with HF symptoms and their caregivers. Objective: We aim to uncover the latent topics within the posts shared by users on the MyLVAD.com website. Methods: Using the latent Dirichlet allocation algorithm and a visualization tool, our objective was to uncover latent topics within the posts shared on the MyLVAD.com website. Through the application of topic modeling techniques, we analyzed 459 posts authored by recipients of LVAD and their family members from 2015 to 2023. Results: This study unveiled 5 prominent themes of concern among patients with LVAD and their family members. These themes included family support (39.5% weight value), encompassing subthemes such as family caregiving roles and emotional or practical support; clothing (23.9% weight value), with subthemes related to comfort, normalcy, and functionality; infection (18.2% weight value), covering driveline infections, prevention, and care; power (12% weight value), involving challenges associated with power dependency; and self-care maintenance, monitoring, and management (6.3% weight value), which included subthemes such as blood tests, monitoring, alarms, and device management. Conclusions: These findings contribute to a better understanding of the experiences and needs of patients implanted with LVAD, providing valuable insights for health care professionals to offer tailored support and care. By using latent Dirichlet allocation to analyze posts from the MyLVAD.com forum, this study sheds light on key topics discussed by users, facilitating improved patient care and enhanced patient-provider communication. UR - https://www.jmir.org/2024/1/e50009 UR - http://dx.doi.org/10.2196/50009 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/50009 ER - TY - JOUR AU - Urien, Marie Jean AU - Berthelot, Emmanuelle AU - Raphael, Pierre AU - Moine, Thomas AU - Lopes, Emilie Marie AU - Assayag, Patrick AU - Jourdain, Patrick PY - 2024/8/13 TI - Evaluation of a New Telemedicine System for Early Detection of Cardiac Instability in Patients With Chronic Heart Failure: Real-Life Out-of-Hospital Study JO - JMIR Cardio SP - e52648 VL - 8 KW - telemedicine system KW - follow-up KW - detection KW - heart failure KW - chronic heart failure KW - CHF KW - heart disease KW - ambulatory patient KW - ambulatory patients KW - home-based KW - TwoCan Pulse KW - telecardiology KW - cardiology KW - e-device KW - mHealth KW - mobile health KW - app KW - apps KW - application KW - applications KW - effectiveness KW - real-life setting KW - remote monitoring KW - virtual monitoring KW - France KW - men KW - gerontology KW - geriatric KW - geriatrics KW - older adult KW - older adults KW - elder KW - elderly KW - older man KW - ageing KW - aging N2 - Background: For a decade, despite results from many studies, telemedicine systems have suffered from a lack of recommendations for chronic heart failure (CHF) care because of variable study results. Another limitation is the hospital-based architecture of most telemedicine systems. Some systems use an algorithm based on daily weight, transcutaneous oxygen measurement, and heart rate to detect and treat acute heart failure (AHF) in patients with CHF as early on as possible. Objective: The aim of this study is to determine the efficacy of a telemonitoring system in detecting clinical destabilization in real-life settings (out-of-hospital management) without generating too many false positive alerts. Methods: All patients self-monitoring at home using the system after a congestive AHF event treated at a cardiology clinic in France between March 2020 and March 2021 with at least 75% compliance on daily measurements were included retrospectively. New-onset AHF was defined by the presence of at least 1 of the following criteria: transcutaneous oxygen saturation loss, defined as a transcutaneous oxygen measurement under 90%; rise of cardiac frequency above 110 beats per minute; weight gain of at least 2 kg; and symptoms of congestive AHF, described over the phone. An AHF alert was generated when the criteria reached our definition of new-onset acute congestive heart failure (HF). Results: A total of 111 consecutive patients (n=70 men) with a median age of 76.60 (IQR 69.5-83.4) years receiving the telemonitoring system were included. Thirty-nine patients (35.1%) reached the HF warning level, and 28 patients (25%) had confirmed HF destabilization during follow-up. No patient had AHF without being detected by the telemonitoring system. Among incorrect AHF alerts (n=11), 5 patients (45%) had taken inaccurate measurements, 3 patients (27%) had supraventricular arrhythmia, 1 patient (9%) had a pulmonary bacterial infection, and 1 patient (9%) contracted COVID-19. A weight gain of at least 2 kg within 4 days was significantly associated with a correct AHF alert (P=.004), and a heart rate of more than 110 beats per minute was more significantly associated with an incorrect AHF alert (P=.007). Conclusions: This single-center study highlighted the efficacy of the telemedicine system in detecting and quickly treating cardiac instability complicating the course of CHF by detecting new-onset AHF as well as supraventricular arrhythmia, thus helping cardiologists provide better follow-up to ambulatory patients. UR - https://cardio.jmir.org/2024/1/e52648 UR - http://dx.doi.org/10.2196/52648 UR - http://www.ncbi.nlm.nih.gov/pubmed/39137030 ID - info:doi/10.2196/52648 ER - TY - JOUR AU - Carter, Carter Jocelyn A. AU - Swack, Natalia AU - Isselbacher, Eric AU - Donelan, Karen AU - Thorndike, Anne PY - 2024/8/8 TI - Feasibility, Acceptability, and Preliminary Effectiveness of a Combined Digital Platform and Community Health Worker Intervention for Patients With Heart Failure: Pilot Randomized Controlled Trial JO - JMIR Cardio SP - e59948 VL - 8 KW - heart failure KW - heart KW - cardiology KW - failure KW - clinical pilot trial KW - digital platform KW - home KW - digital health KW - remote monitoring KW - monitoring KW - home-based care KW - community health workers KW - social needs care KW - randomized controlled trial KW - controlled trials KW - feasibility KW - usability KW - acceptability KW - social needs N2 - 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 UR - https://cardio.jmir.org/2024/1/e59948 UR - http://dx.doi.org/10.2196/59948 UR - http://www.ncbi.nlm.nih.gov/pubmed/38959294 ID - info:doi/10.2196/59948 ER - TY - JOUR AU - Levinson, T. Rebecca AU - Paul, Cinara AU - Meid, D. Andreas AU - Schultz, Jobst-Hendrik AU - Wild, Beate PY - 2024/7/23 TI - Identifying Predictors of Heart Failure Readmission in Patients From a Statutory Health Insurance Database: Retrospective Machine Learning Study JO - JMIR Cardio SP - e54994 VL - 8 KW - statutory health insurance KW - readmission KW - machine learning KW - heart failure KW - heart KW - cardiology KW - cardiac KW - hospitalization KW - insurance KW - predict KW - predictive KW - prediction KW - predictions KW - predictor KW - predictors KW - all cause N2 - Background: Patients with heart failure (HF) are the most commonly readmitted group of adult patients in Germany. Most patients with HF are readmitted for noncardiovascular reasons. Understanding the relevance of HF management outside the hospital setting is critical to understanding HF and factors that lead to readmission. Application of machine learning (ML) on data from statutory health insurance (SHI) allows the evaluation of large longitudinal data sets representative of the general population to support clinical decision-making. Objective: This study aims to evaluate the ability of ML methods to predict 1-year all-cause and HF-specific readmission after initial HF-related admission of patients with HF in outpatient SHI data and identify important predictors. Methods: We identified individuals with HF using outpatient data from 2012 to 2018 from the AOK Baden-Württemberg SHI in Germany. We then trained and applied regression and ML algorithms to predict the first all-cause and HF-specific readmission in the year after the first admission for HF. We fitted a random forest, an elastic net, a stepwise regression, and a logistic regression to predict readmission by using diagnosis codes, drug exposures, demographics (age, sex, nationality, and type of coverage within SHI), degree of rurality for residence, and participation in disease management programs for common chronic conditions (diabetes mellitus type 1 and 2, breast cancer, chronic obstructive pulmonary disease, and coronary heart disease). We then evaluated the predictors of HF readmission according to their importance and direction to predict readmission. Results: Our final data set consisted of 97,529 individuals with HF, and 78,044 (80%) were readmitted within the observation period. Of the tested modeling approaches, the random forest approach best predicted 1-year all-cause and HF-specific readmission with a C-statistic of 0.68 and 0.69, respectively. Important predictors for 1-year all-cause readmission included prescription of pantoprazole, chronic obstructive pulmonary disease, atherosclerosis, sex, rurality, and participation in disease management programs for type 2 diabetes mellitus and coronary heart disease. Relevant features for HF-specific readmission included a large number of canonical HF comorbidities. Conclusions: While many of the predictors we identified were known to be relevant comorbidities for HF, we also uncovered several novel associations. Disease management programs have widely been shown to be effective at managing chronic disease; however, our results indicate that in the short term they may be useful for targeting patients with HF with comorbidity at increased risk of readmission. Our results also show that living in a more rural location increases the risk of readmission. Overall, factors beyond comorbid disease were relevant for risk of HF readmission. This finding may impact how outpatient physicians identify and monitor patients at risk of HF readmission. UR - https://cardio.jmir.org/2024/1/e54994 UR - http://dx.doi.org/10.2196/54994 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/54994 ER - TY - JOUR AU - Huecker, Martin AU - Schutzman, Craig AU - French, Joshua AU - El-Kersh, Karim AU - Ghafghazi, Shahab AU - Desai, Ravi AU - Frick, Daniel AU - Thomas, Jeremy Jarred PY - 2024/6/26 TI - Accurate Modeling of Ejection Fraction and Stroke Volume With Mobile Phone Auscultation: Prospective Case-Control Study JO - JMIR Cardio SP - e57111 VL - 8 KW - ejection fraction KW - stroke volume KW - auscultation KW - digital health KW - telehealth KW - acoustic recording KW - acoustic recordings KW - acoustic KW - mHealth KW - mobile health KW - mobile phone KW - mobile phones KW - heart failure KW - heart KW - cardiac KW - cardiology KW - health care costs KW - audio KW - echocardiographic KW - echocardiogram KW - ultrasonography KW - echocardiography KW - accuracy KW - monitoring KW - telemonitoring KW - recording KW - recordings KW - ejection KW - machine learning KW - algorithm KW - algorithms N2 - 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. UR - https://cardio.jmir.org/2024/1/e57111 UR - http://dx.doi.org/10.2196/57111 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/57111 ER - TY - JOUR AU - Vögeli, Benjamin AU - Arenja, Nisha AU - Schütz, Narayan AU - Nef, Tobias AU - Buluschek, Philipp AU - Saner, Hugo PY - 2024/5/31 TI - Evaluation of Ambient Sensor Systems for the Early Detection of Heart Failure Decompensation in Older Patients Living at Home Alone: Protocol for a Prospective Cohort Study JO - JMIR Res Protoc SP - e55953 VL - 13 KW - heart failure KW - home telemonitoring KW - digital health KW - biomarker KW - ambient sensor system N2 - Background: The results of telemedicine intervention studies in patients with heart failure (HF) to reduce rehospitalization rate and mortality by early detection of HF decompensation are encouraging. However, the benefits are lower than expected. A possible reason for this could be the fact that vital signs, including blood pressure, heart rate, heart rhythm, and weight changes, may not be ideal indicators of the early stages of HF decompensation but are more sensitive for acute events triggered by ischemic episodes or rhythm disturbances. Preliminary results indicate a potential role of ambient sensor?derived digital biomarkers in this setting. Objective: The aim of this study is to identify changes in ambient sensor system?derived digital biomarkers with a high potential for early detection of HF decompensation. Methods: This is a prospective interventional cohort study. A total of 24 consecutive patients with HF aged 70 years and older, living alone, and hospitalized for HF decompensation will be included. Physical activity in the apartment and toilet visits are quantified using a commercially available, passive, infrared motion sensing system (DomoHealth SA). Heart rate, respiration rate, and toss-and-turns in bed are recorded by using a commercially available Emfit QS device (Emfit Ltd), which is a contact-free piezoelectric sensor placed under the participant?s mattress. Sensor data are visualized on a dedicated dashboard for easy monitoring by health professionals. Digital biomarkers are evaluated for predefined signs of HF decompensation, including particularly decreased physical activity; time spent in bed; increasing numbers of toilet visits at night; and increasing heart rate, respiration rate, and motion in bed at night. When predefined changes in digital biomarkers occur, patients will be called in for clinical evaluation, and N-terminal pro b-type natriuretic peptide measurement (an increase of >30% considered as significant) will be performed. The sensitivity and specificity of the different biomarkers and their combinations for the detection of HF decompensation will be calculated. Results: The study is in the data collection phase. Study recruitment started in February 2024. Data analysis is scheduled to start after all data are collected. As of manuscript submission, 5 patients have been recruited. Results are expected to be published by the end of 2025. Conclusions: The results of this study will add to the current knowledge about opportunities for telemedicine to monitor older patients with HF living at home alone by evaluating the potential of ambient sensor systems for this purpose. Timely recognition of HF decompensation could enable proactive management, potentially reducing health care costs associated with preventable emergency presentations or hospitalizations. Trial Registration: ClinicalTrials.gov NCT06126848; https://clinicaltrials.gov/study/NCT06126848 International Registered Report Identifier (IRRID): PRR1-10.2196/55953 UR - https://www.researchprotocols.org/2024/1/e55953 UR - http://dx.doi.org/10.2196/55953 UR - http://www.ncbi.nlm.nih.gov/pubmed/38820577 ID - info:doi/10.2196/55953 ER - TY - JOUR AU - Zakiyah, Neily AU - Marulin, Dita AU - Alfaqeeh, Mohammed AU - Puspitasari, Melyani Irma AU - Lestari, Keri AU - Lim, Keat Ka AU - Fox-Rushby, Julia PY - 2024/4/30 TI - Economic Evaluations of Digital Health Interventions for Patients With Heart Failure: Systematic Review JO - J Med Internet Res SP - e53500 VL - 26 KW - digital health KW - telemonitoring KW - telehealth KW - heart failure KW - cost-effectiveness KW - systematic review KW - mobile phone N2 - Background: Digital health interventions (DHIs) have shown promising results in enhancing the management of heart failure (HF). Although health care interventions are increasingly being delivered digitally, with growing evidence on the potential cost-effectiveness of adopting them, there has been little effort to collate and synthesize the findings. Objective: This study?s objective was to systematically review the economic evaluations that assess the adoption of DHIs in the management and treatment of HF. Methods: A systematic review was conducted using 3 electronic databases: PubMed, EBSCOhost, and Scopus. Articles reporting full economic evaluations of DHIs for patients with HF published up to July 2023 were eligible for inclusion. Study characteristics, design (both trial based and model based), input parameters, and main results were extracted from full-text articles. Data synthesis was conducted based on the technologies used for delivering DHIs in the management of patients with HF, and the findings were analyzed narratively. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed for this systematic review. The reporting quality of the included studies was evaluated using the CHEERS (Consolidated Health Economic Evaluation Reporting Standards) guidelines. Results: Overall, 27 economic evaluations were included in the review. The economic evaluations were based on models (13/27, 48%), trials (13/27, 48%), or a combination approach (1/27, 4%). The devices evaluated included noninvasive remote monitoring devices (eg, home telemonitoring using digital tablets or specific medical devices that enable transmission of physiological data), telephone support, mobile apps and wearables, remote monitoring follow-up in patients with implantable medical devices, and videoconferencing systems. Most of the studies (24/27, 89%) used cost-utility analysis. The majority of the studies (25/27, 93%) were conducted in high-income countries, particularly European countries (16/27, 59%) such as the United Kingdom and the Netherlands. Mobile apps and wearables, remote monitoring follow-up in patients with implantable medical devices, and videoconferencing systems yielded cost-effective results or even emerged as dominant strategies. However, conflicting results were observed, particularly in noninvasive remote monitoring devices and telephone support. In 15% (4/27) of the studies, these DHIs were found to be less costly and more effective than the comparators (ie, dominant), while 33% (9/27) reported them to be more costly but more effective with incremental cost-effectiveness ratios below the respective willingness-to-pay thresholds (ie, cost-effective). Furthermore, in 11% (3/27) of the studies, noninvasive remote monitoring devices and telephone support were either above the willingness-to-pay thresholds or more costly than, yet as effective as, the comparators (ie, not cost-effective). In terms of reporting quality, the studies were classified as good (20/27, 74%), moderate (6/27, 22%), or excellent (1/27, 4%). Conclusions: Despite the conflicting results, the main findings indicated that, overall, DHIs were more cost-effective than non-DHI alternatives. Trial Registration: PROSPERO CRD42023388241; https://tinyurl.com/2p9axpmc UR - https://www.jmir.org/2024/1/e53500 UR - http://dx.doi.org/10.2196/53500 UR - http://www.ncbi.nlm.nih.gov/pubmed/38687991 ID - info:doi/10.2196/53500 ER - TY - JOUR AU - Yoon, Minjae AU - Lee, Seonhwa AU - Choi, Yeon Jah AU - Jung, Mi-Hyang AU - Youn, Jong-Chan AU - Shim, Young Chi AU - Choi, Jin-Oh AU - Kim, Ju Eung AU - Kim, Hyungseop AU - Yoo, Byung-Su AU - Son, Joo Yeon AU - Choi, Dong-Ju PY - 2024/4/29 TI - Effectiveness of a Smartphone App?Based Intervention With Bluetooth-Connected Monitoring Devices and a Feedback System in Heart Failure (SMART-HF Trial): Randomized Controlled Trial JO - J Med Internet Res SP - e52075 VL - 26 KW - heart failure KW - mobile applications KW - mobile health KW - self-care KW - vital sign monitoring KW - mobile phone N2 - Background: Current heart failure (HF) guidelines recommend a multidisciplinary approach, discharge education, and self-management for HF. However, the recommendations are challenging to implement in real-world clinical settings. Objective: We developed a mobile health (mHealth) platform for HF self-care to evaluate whether a smartphone app?based intervention with Bluetooth-connected monitoring devices and a feedback system can help improve HF symptoms. Methods: In this prospective, randomized, multicenter study, we enrolled patients 20 years of age and older, hospitalized for acute HF, and who could use a smartphone from 7 tertiary hospitals in South Korea. In the intervention group (n=39), the apps were automatically paired with Bluetooth-connected monitoring devices. The patients could enter information on vital signs, HF symptoms, diet, medications, and exercise regimen into the app daily and receive feedback or alerts on their input. In the control group (n=38), patients could only enter their blood pressure, heart rate, and weight using conventional, non-Bluetooth devices and could not receive any feedback or alerts from the app. The primary end point was the change in dyspnea symptom scores from baseline to 4 weeks, assessed using a questionnaire. Results: At 4 weeks, the change in dyspnea symptom score from baseline was significantly greater in the intervention group than in the control group (mean ?1.3, SD 2.1 vs mean ?0.3, SD 2.3; P=.048). A significant reduction was found in body water composition from baseline to the final measurement in the intervention group (baseline level mean 7.4, SD 2.5 vs final level mean 6.6, SD 2.5; P=.003). App adherence, which was assessed based on log-in or the percentage of days when symptoms were first observed, was higher in the intervention group than in the control group. Composite end points, including death, rehospitalization, and urgent HF visits, were not significantly different between the 2 groups. Conclusions: The mobile-based health platform with Bluetooth-connected monitoring devices and a feedback system demonstrated improvement in dyspnea symptoms in patients with HF. This study provides evidence and rationale for implementing mobile app?based self-care strategies and feedback for patients with HF. Trial Registration: ClinicalTrials.gov NCT05668000; https://clinicaltrials.gov/study/NCT05668000 UR - https://www.jmir.org/2024/1/e52075 UR - http://dx.doi.org/10.2196/52075 UR - http://www.ncbi.nlm.nih.gov/pubmed/38683665 ID - info:doi/10.2196/52075 ER - TY - JOUR AU - Keogh, Alison AU - Brennan, Carol AU - Johnston, William AU - Dickson, Jane AU - Leslie, J. Stephen AU - Burke, David AU - Megyesi, Peter AU - Caulfield, Brian PY - 2024/3/1 TI - Six-Month Pilot Testing of a Digital Health Tool to Support Effective Self-Care in People With Heart Failure: Mixed Methods Study JO - JMIR Form Res SP - e52442 VL - 8 KW - digital health KW - heart failure KW - cardiology KW - self-care KW - behavior change KW - eHealth KW - mHealth KW - mobile health KW - mobile app KW - mobile phone KW - elderly KW - self-management KW - digital tools KW - digital tool KW - human-centered design KW - app KW - apps KW - applications KW - wearables KW - wearable KW - Fitbit KW - usability KW - adherence KW - feasibility KW - congestive heart failure KW - cardiac failure KW - myocardial failure KW - heart decompensation N2 - Background: Digital tools may support people to self-manage their heart failure (HF). Having previously outlined the human-centered design development of a digital tool to support self-care of HF, the next step was to pilot the tool over a period of time to establish people?s acceptance of it in practice. Objective: This study aims to conduct an observational pilot study to examine the usability, adherence, and feasibility of a digital health tool for HF within the Irish health care system. Methods: A total of 19 participants with HF were provided with a digital tool comprising a mobile app and the Fitbit Charge 4 and Aria Air smart scales for a period of 6 months. Changes to their self-care were assessed before and after the study with the 9-item European HF Self-care Behavior Scale (EHFScBS) and the Minnesota Living with HF Questionnaire (MLwHFQ) using a Wilcoxon signed rank test. After the study, 3 usability questionnaires were implemented and descriptively analyzed: the System Usability Scale (SUS), Wearable Technology Motivation Scale (WTMS), and Comfort Rating Scale (CRS). Participants also undertook a semistructured interview regarding their experiences with the digital tool. Interviews were analyzed deductively using the Theoretical Domains Framework. Results: Participants wore their devices for an average of 86.2% of the days in the 6-month testing period ranging from 40.6% to 98%. Although improvements in the EHFScBS and MLwHFQ were seen, these changes were not significant (P=.10 and P=.70, respectively, where P>.03, after a Bonferroni correction). SUS results suggest that the usability of this system was not acceptable with a median score of 58.8 (IQR 55.0-60.0; range 45.0-67.5). Participants demonstrated a strong motivation to use the system according to the WTMS (median 6.0, IQR 5.0-7.0; range 1.0-7.0), whereas the Fitbit was considered very comfortable as demonstrated by the low CRS results (median 0.0, IQR 0.0-0.0; range 0.0-2.0). According to participant interviews, the digital tool supported self-management through increased knowledge, improved awareness, decision-making, and confidence in their own data, and improving their social support through a feeling of comfort in being watched. Conclusions: The digital health tool demonstrated high levels of adherence and acceptance among participants. Although the SUS results suggest low usability, this may be explained by participants uncertainty that they were using it fully, rather than it being unusable, especially given the experiences documented in their interviews. The digital tool targeted key self-management behaviors and feelings of social support. However, a number of changes to the tool, and the health service, are required before it can be implemented at scale. A full-scale feasibility trial conducted at a wider level is required to fully determine its potential effectiveness and wider implementation needs. UR - https://formative.jmir.org/2024/1/e52442 UR - http://dx.doi.org/10.2196/52442 UR - http://www.ncbi.nlm.nih.gov/pubmed/38427410 ID - info:doi/10.2196/52442 ER - TY - JOUR AU - Tegegne, Kassaw Teketo AU - Tran, Ly-Duyen AU - Nourse, Rebecca AU - Gurrin, Cathal AU - Maddison, Ralph PY - 2024/2/21 TI - Daily Activity Lifelogs of People With Heart Failure: Observational Study JO - JMIR Form Res SP - e51248 VL - 8 KW - heart failure KW - self-management KW - lifelogs KW - daily activity KW - wearable camera KW - E-Myscéal KW - activities of daily living KW - ADL KW - intervention KW - self-report method KW - wearable KW - chronic condition N2 - Background: Globally, heart failure (HF) affects more than 64 million people, and attempts to reduce its social and economic burden are a public health priority. Interventions to support people with HF to self-manage have been shown to reduce hospitalizations, improve quality of life, and reduce mortality rates. Understanding how people self-manage is imperative to improve future interventions; however, most approaches to date, have used self-report methods to achieve this. Wearable cameras provide a unique tool to understand the lived experiences of people with HF and the daily activities they undertake, which could lead to more effective interventions. However, their potential for understanding chronic conditions such as HF is unclear. Objective: This study aimed to determine the potential utility of wearable cameras to better understand the activities of daily living in people living with HF. Methods: The ?Seeing is Believing (SIB)? study involved 30 patients with HF who wore wearable cameras for a maximum of 30 days. We used the E-Myscéal web-based lifelog retrieval system to process and analyze the wearable camera image data set. Search terms for 7 daily activities (physical activity, gardening, shopping, screen time, drinking, eating, and medication intake) were developed and used for image retrieval. Sensitivity analysis was conducted to compare the number of images retrieved using different search terms. Temporal patterns in daily activities were examined, and differences before and after hospitalization were assessed. Results: E-Myscéal exhibited sensitivity to specific search terms, leading to significant variations in the number of images retrieved for each activity. The highest number of images returned were related to eating and drinking, with fewer images for physical activity, screen time, and taking medication. The majority of captured activities occurred before midday. Notably, temporal differences in daily activity patterns were observed for participants hospitalized during this study. The number of medication images increased after hospital discharge, while screen time images decreased. Conclusions: Wearable cameras offer valuable insights into daily activities and self-management in people living with HF. E-Myscéal efficiently retrieves relevant images, but search term sensitivity underscores the need for careful selection. UR - https://formative.jmir.org/2024/1/e51248 UR - http://dx.doi.org/10.2196/51248 UR - http://www.ncbi.nlm.nih.gov/pubmed/38381484 ID - info:doi/10.2196/51248 ER - TY - JOUR AU - Chai, R. Peter AU - Kaithamattam, J. Jenson AU - Chung, Michelle AU - Tom, J. Jeremiah AU - Goodman, R. Georgia AU - Hasdianda, Adrian Mohammad AU - Carnes, Christopher Tony AU - Vaduganathan, Muthiah AU - Scirica, M. Benjamin AU - Schnipper, L. Jeffrey PY - 2024/2/15 TI - Formative Perceptions of a Digital Pill System to Measure Adherence to Heart Failure Pharmacotherapy: Mixed Methods Study JO - JMIR Cardio SP - e48971 VL - 8 KW - behavioral interventions KW - cardiac treatment KW - digital pill system KW - heart failure medication KW - heart failure KW - ingestible sensors KW - medication adherence N2 - Background: Heart failure (HF) affects 6.2 million Americans and is a leading cause of hospitalization. The mainstay of the management of HF is adherence to pharmacotherapy. Despite the effectiveness of HF pharmacotherapy, effectiveness is closely linked to adherence. Measuring adherence to HF pharmacotherapy is difficult; most clinical measures use indirect strategies such as calculating pharmacy refill data or using self-report. While helpful in guiding treatment adjustments, indirect measures of adherence may miss the detection of suboptimal adherence and co-occurring structural barriers associated with nonadherence. Digital pill systems (DPSs), which use an ingestible radiofrequency emitter to directly measure medication ingestions in real-time, represent a strategy for measuring and responding to nonadherence in the context of HF pharmacotherapy. Previous work has demonstrated the feasibility of using DPSs to measure adherence in other chronic diseases, but this strategy has yet to be leveraged for individuals with HF. Objective: We aim to explore through qualitative interviews the facilitators and barriers to using DPS technology to monitor pharmacotherapy adherence among patients with HF. Methods: We conducted individual, semistructured qualitative interviews and quantitative assessments between April and August 2022. A total of 20 patients with HF who were admitted to the general medical or cardiology service at an urban quaternary care hospital participated in this study. Participants completed a qualitative interview exploring the overall acceptability of and willingness to use DPS technology for adherence monitoring and perceived barriers to DPS use. Quantitative assessments evaluated HF history, existing medication adherence strategies, and attitudes toward technology. We analyzed qualitative data using applied thematic analysis and NVivo software (QSR International). Results: Most participants (12/20, 60%) in qualitative interviews reported a willingness to use the DPS to measure HF medication adherence. Overall, the DPS was viewed as useful for increasing accountability and reinforcing adherence behaviors. Perceived barriers included technological issues, a lack of need, additional costs, and privacy concerns. Most were open to sharing adherence data with providers to bolster clinical care and decision-making. Reminder messages following detected nonadherence were perceived as a key feature, and customization was desired. Suggested improvements are primarily related to the design and usability of the Reader (a wearable device). Conclusions: Overall, individuals with HF perceived the DPS to be an acceptable and useful tool for measuring medication adherence. Accurate, real-time ingestion data can guide adherence counseling to optimize adherence management and inform tailored behavioral interventions to support adherence among patients with HF. UR - https://cardio.jmir.org/2024/1/e48971 UR - http://dx.doi.org/10.2196/48971 UR - http://www.ncbi.nlm.nih.gov/pubmed/38358783 ID - info:doi/10.2196/48971 ER - TY - JOUR AU - Carter, Jocelyn AU - Swack, Natalia AU - Isselbacher, Eric AU - Donelan, Karen AU - Thorndike, Anne PY - 2024/2/6 TI - Feasibility, Acceptability, and Preliminary Effectiveness of a Combined Digital Platform and Community Health Worker Intervention for Patients With Heart Failure: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e55687 VL - 13 KW - heart failure KW - digital platform KW - remote monitoring KW - home-based care KW - health worker KW - social needs care KW - community health worker N2 - Background: Interventions focused on remote monitoring and social needs care have shown promise in improving clinical outcomes for patients with heart failure (HF). However, patient willingness to use technology as well as concerns about access in underresourced settings have limited digital platform implementation and adoption. There is little research in HF populations examining the effect of a combined digital and social needs care intervention that could enhance patient engagement in digital platform use while closing gaps in care related to social determinants of health. Here, we describe the protocol for a clinical trial of a digitally enabled community health worker intervention designed for patients with HF. Objective: This study aims to describe the protocol for a randomized controlled trial assessing the acceptability, feasibility, and preliminary effectiveness of an intervention that combines remote monitoring with a digital platform and community health worker (CHW) social needs care for patients with HF who are transitioning from hospital to home. Given the elevated morbidity and mortality, identifying comprehensive and patient-centered interventions at the time of hospital care transitions that can improve clinical outcomes, impact cost, and augment the quality of care for this cohort is a priority. Methods: This trial randomized adult inpatient participants (n=50) with a diagnosis of HF receiving care at a single academic health care institution to the 30-day intervention (digital platform+CHW pairing+usual care) or the 30-day control (CHW pairing+usual care) arms. All study participants completed baseline questionnaires and 30-day exit interviews and questionnaires. The primary outcomes will be acceptability, feasibility, and preliminary effectiveness. Results: This clinical trial opened for enrollment in September 2022 and was completed in June 2023. Initial results are expected to be published in the spring of 2024, and analysis is currently underway. Feasibility outcome measures will include the use rates of the biometric sensor (average hours per day), the digital blood pressure monitor (average times per day), the weight scale (average times per day), and the completion of the symptoms questionnaire (average times per day). The acceptability outcome will be measured by the patients? response to the truthfulness of the statement that they would be willing to use the digital platform in the future (response options: very true, somewhat true, or not true). Preliminary effectiveness will be measured by tracking 30-day clinical outcomes (hospital readmissions, emergency room visits, and missed primary care and cardiology appointments). Conclusions: The results of this investigation are expected to contribute to our understanding of the use of digital interventions and the implementation of supportive home-based social needs care to enhance engagement and the potential effectiveness of clinically focused digital platforms. These results may inform the construction of a future multi-institutional trial designed to test the true effectiveness of this intervention in HF. Trial Registration: ClinicalTrials.gov NCT05130008; https://clinicaltrials.gov/study/NCT05130008 International Registered Report Identifier (IRRID): DERR1-10.2196/55687 UR - https://www.researchprotocols.org/2024/1/e55687 UR - http://dx.doi.org/10.2196/55687 UR - http://www.ncbi.nlm.nih.gov/pubmed/38216543 ID - info:doi/10.2196/55687 ER - TY - JOUR AU - Yoo, Eun Jung AU - Jeong, Su-Min AU - Lee, Na Kyu AU - Lee, Heesun AU - Yoon, Won Ji AU - Han, Kyungdo AU - Shin, Wook Dong PY - 2024/1/10 TI - Smoking Behavior Change and the Risk of Heart Failure in Patients With Type 2 Diabetes: Nationwide Retrospective Cohort Study JO - JMIR Public Health Surveill SP - e46450 VL - 10 KW - smoking KW - change in smoking behavior KW - cessation KW - heart failure KW - type 2 diabetes KW - diabetes KW - cardiovascular disease KW - smoking cessation KW - smoker KW - risk factor N2 - Background: Heart failure (HF) is one of the most common initial manifestations of cardiovascular disease in patients with type 2 diabetes. Although smoking is an independent risk factor for HF, there is a lack of data for the incidence of HF according to changes in smoking behaviors in patients with type 2 diabetes. Objective: We aimed to examine the association between interval changes in smoking behavior and the risk of HF among patients with type 2 diabetes. Methods: We conducted a retrospective cohort study using the National Health Insurance Service database. We identified 365,352 current smokers with type 2 diabetes who had 2 consecutive health screenings (2009-2012) and followed them until December 31, 2018, for the incident HF. Based on smoking behavior changes between 2 consecutive health screenings, participants were categorized into quitter, reducer I (?50% reduction) and II (<50% reduction), sustainer (reference group), and increaser groups. Results: During a median follow-up of 5.1 (IQR 4.0-6.1) years, there were 13,879 HF cases (7.8 per 1000 person-years). Compared to sustainers, smoking cessation was associated with lower risks of HF (adjusted hazard ratio [aHR] 0.90, 95% CI0.86-0.95), whereas increasers showed higher risks of HF than sustainers; heavy smokers who increased their level of smoking had a higher risk of HF (aHR 1.13, 95% CI 1.04-1.24). In the case of reducers, the risk of HF was not reduced but rather increased slightly (reducer I: aHR 1.14, 95% CI 1.08-1.21; reducer II: aHR 1.03, 95% CI 0.98-1.09). Consistent results were noted for subgroup analyses including type 2 diabetes severity, age, and sex. Conclusions: Smoking cessation was associated with a lower risk of HF among patients with type 2 diabetes, while increasing smoking amount was associated with a higher risk for HF than in those sustaining their smoking amount. There was no benefit from reduction in smoking amount. UR - https://publichealth.jmir.org/2024/1/e46450 UR - http://dx.doi.org/10.2196/46450 UR - http://www.ncbi.nlm.nih.gov/pubmed/38198206 ID - info:doi/10.2196/46450 ER - TY - JOUR AU - Auener, L. Stefan AU - van Dulmen, A. Simone AU - Atsma, Femke AU - van der Galiën, Onno AU - Bellersen, Louise AU - van Kimmenade, Roland AU - Westert, P. Gert AU - Jeurissen, T. Patrick P. PY - 2023/10/18 TI - Characteristics Associated With Telemonitoring Use Among Patients With Chronic Heart Failure: Retrospective Cohort Study JO - J Med Internet Res SP - e43038 VL - 25 KW - heart failure KW - telemonitoring KW - remote monitoring KW - eHealth KW - chronic heart failure KW - heart KW - disease KW - patient KW - self-management KW - prevention KW - utilization KW - Netherlands KW - hospital KW - treatment N2 - Background: Chronic heart failure (HF) is a chronic disease affecting more than 64 million people worldwide, with an increasing prevalence and a high burden on individual patients and society. Telemonitoring may be able to mitigate some of this burden by increasing self-management and preventing use of the health care system. However, it is unknown to what degree telemonitoring has been adopted by hospitals and if the use of telemonitoring is associated with certain patient characteristics. Insight into the dissemination of this technology among hospitals and patients may inform strategies for further adoption. Objective: We aimed to explore the use of telemonitoring among hospitals in the Netherlands and to identify patient characteristics associated with the use of telemonitoring for HF. Methods: We performed a retrospective cohort study based on routinely collected health care claim data in the Netherlands. Descriptive analyses were used to gain insight in the adoption of telemonitoring for HF among hospitals in 2019. We used logistic multiple regression analyses to explore the associations between patient characteristics and telemonitoring use. Results: Less than half (31/84, 37%) of all included hospitals had claims for telemonitoring, and 20% (17/84) of hospitals had more than 10 patients with telemonitoring claims. Within these 17 hospitals, a total of 7040 patients were treated for HF in 2019, of whom 5.8% (409/7040) incurred a telemonitoring claim. Odds ratios (ORs) for using telemonitoring were higher for male patients (adjusted OR 1.90, 95% CI 1.50-2.41) and patients with previous hospital treatment for HF (adjusted OR 1.76, 95% CI 1.39-2.24). ORs were lower for higher age categories and were lowest for the highest age category, that is, patients older than 80 years (OR 0.30, 95% CI 0.21-0.44) compared to the reference age category (18-59 years). Socioeconomic status, degree of multimorbidity, and excessive polypharmacy were not associated with the use of telemonitoring. Conclusions: The use of reimbursed telemonitoring for HF was limited up to 2019, and our results suggest that large variation exists among hospitals. A lack of adoption is therefore not only due to a lack of diffusion among hospitals but also due to a lack of scaling up within hospitals that already deploy telemonitoring. Future studies should therefore focus on both kinds of adoption and how to facilitate these processes. Older patients, female patients, and patients with no previous hospital treatment for HF were less likely to use telemonitoring for HF. This shows that some patient groups are not served as much by telemonitoring as other patient groups. The underlying mechanism of the reported associations should be identified in order to gain a deeper understanding of telemonitoring use among different patient groups. UR - https://www.jmir.org/2023/1/e43038 UR - http://dx.doi.org/10.2196/43038 UR - http://www.ncbi.nlm.nih.gov/pubmed/37851505 ID - info:doi/10.2196/43038 ER - TY - JOUR AU - Carter, Jocelyn AU - Swack, Natalia AU - Isselbacher, Eric AU - Donelan, Karen AU - Thorndike, N. Anne PY - 2023/10/2 TI - Feasibility and Acceptability of a Combined Digital Platform and Community Health Worker Intervention for Patients With Heart Failure: Single-Arm Pilot Study JO - JMIR Cardio SP - e47818 VL - 7 KW - heart failure KW - digital platform KW - remote monitoring KW - home-based care KW - community health worker KW - social needs care KW - community health work KW - care KW - monitoring KW - pilot study KW - heart KW - feasibility KW - acceptability KW - community KW - heart rate KW - oxygenation KW - willingness KW - mobile phone N2 - Background: Heart failure (HF) is one of the leading causes of hospital admissions. Clinical (eg, complex comorbidities and low ejection fraction) and social needs factors (eg, access to transportation, food security, and housing security) have both contributed to hospitalizations, emphasizing the importance of increased clinical and social needs support at home. Digital platforms designed for remote monitoring of HF can improve clinical outcomes, but their effectiveness has been limited by patient barriers such as lack of familiarity with technology and unmet social care needs. To address these barriers, this study explored combining a digital platform with community health worker (CHW) social needs care for patients with HF. Objective: We aim to determine the feasibility and acceptability of an intervention combining digital platform use and CHW social needs care for patients with HF. Methods: Adults (aged ?18 years) with HF receiving care at a single health care institution and with a history of hospital admission in the previous 12 months were enrolled in a single-arm pilot study from July to November 2021 (N=14). The 30-day intervention used a digital platform within a mobile app that included symptom questionnaire and educational videos connected to a biometric sensor (tracking heart rate, oxygenation, and steps taken), a digital weight scale, and a digital blood pressure monitor. All patients were paired with a CHW who had access to the digital platform data. A CHW provided routine phone calls to patients throughout the study period to discuss their biometric data and to address barriers to any social needs. Feasibility outcomes were patient use of the platform and engagement with the CHW. The acceptability outcome was patient willingness to use the intervention again. Results: Participants (N=14) were 67.7 (SD 11.7) years old; 8 (57.1%) were women, and 7 (50%) were insured by Medicare. Participants wore the sensor for 82.2% (n=24.66) of study days with an average of 13.5 (SD 2.1) hours per day. Participants used the digital blood pressure monitor and digital weight scale for an average of 1.2 (SD 0.17) times per day and 1.1 (SD 0.12) times per day, respectively. All participants completed the symptom questionnaire on at least 71% (n=21.3) of study days; 11 (78.6%) participants had ?3 CHW interactions, and 11 (78.6%) indicated that if given the opportunity, they would use the platform again in the future. Exit interviews found that despite some platform ?glitches,? participants generally found the remote monitoring platform to be ?helpful? and ?motivating.? Conclusions: A novel intervention combining a digital platform with CHW social needs care for patients with HF was feasible and acceptable. The majority of participants were engaged throughout the study and indicated their willingness to use the intervention again. A future clinical trial is needed to determine the effectiveness of this intervention. UR - https://cardio.jmir.org/2023/1/e47818 UR - http://dx.doi.org/10.2196/47818 UR - http://www.ncbi.nlm.nih.gov/pubmed/37698975 ID - info:doi/10.2196/47818 ER - TY - JOUR AU - Madujibeya, Ifeanyi AU - Lennie, A. Terry AU - Pelzel, Jamie AU - Moser, K. Debra PY - 2023/8/15 TI - Patients? Experiences Using a Mobile Health App for Self-Care of Heart Failure in a Real-World Setting: Qualitative Analysis JO - JMIR Form Res SP - e39525 VL - 7 KW - heart failure KW - patients? experiences KW - experience KW - satisfaction KW - facilitator KW - mobile health apps KW - mobile app KW - health app KW - app feature KW - mobile health KW - cardiology KW - cardiovascular KW - patient care KW - self-management KW - patient KW - heart KW - mHealth KW - self-care KW - medication KW - performance KW - feedback KW - personalized N2 - Background: Publicly available patient-focused mobile health (mHealth) apps are being increasingly integrated into routine heart failure (HF)?related self-care. However, there is a dearth of research on patients? experiences using mHealth apps for self-care in real-world settings. Objective: The purpose of this study was to explore patients? experiences using a commercially available mHealth app, OnTrack to Health, for HF self-care in a real-world setting. Methods: Patient satisfaction, measured with a 5-point Likert scale, and an open-ended survey were used to gather data from 23 patients with HF who were provided the OnTrack to Health app as a part of routine HF management. A content analysis of patients? responses was conducted with the qualitative software Atlas.ti (version 8; ATLAS.ti Scientific Software Development GmbH). Results: Patients (median age 64, IQR 57-71 years; 17/23, 74% male) used OnTrack to Health for a median 164 (IQR 51-640) days before the survey. All patients reported excellent experiences related to app use and would recommend the app to other patients with HF. Five themes emerged from the responses to the open-ended questions: (1) features that enhanced self-care of HF (medication tracker, graphic performance feedback and automated alerts, secured messaging features, and HF self-care education); (2) perceived benefits (provided assurance of safety, improved HF self-care, and decreased hospitalization rates); (3) challenges with using apps for self-care (giving up previous self-care strategies); (4) facilitators (perceived ease of use and availability of technical support); and (5) suggested improvements (streamlining data entry, integration of apps with an electronic medical record, and personalization of app features). Conclusions: Patients were satisfied with using OnTrack to Health for self-care. They perceived the features of the app as valuable tools for improving self-care ability and decreasing hospitalization rates. The development of apps in collaboration with end users is essential to ensure high-quality patient experiences related to app use for self-care. UR - https://formative.jmir.org/2023/1/e39525 UR - http://dx.doi.org/10.2196/39525 UR - http://www.ncbi.nlm.nih.gov/pubmed/37581912 ID - info:doi/10.2196/39525 ER - TY - JOUR AU - Zaman, Sameer AU - Padayachee, Yorissa AU - Shah, Moulesh AU - Samways, Jack AU - Auton, Alice AU - Quaife, M. Nicholas AU - Sweeney, Mark AU - Howard, P. James AU - Tenorio, Indira AU - Bachtiger, Patrik AU - Kamalati, Tahereh AU - Pabari, A. Punam AU - Linton, F. Nick W. AU - Mayet, Jamil AU - Peters, S. Nicholas AU - Barton, Carys AU - Cole, D. Graham AU - Plymen, M. Carla PY - 2023/6/23 TI - Smartphone-Based Remote Monitoring in Heart Failure With Reduced Ejection Fraction: Retrospective Cohort Study of Secondary Care Use and Costs JO - JMIR Cardio SP - e45611 VL - 7 KW - heart failure KW - remote monitoring KW - smartphone care KW - telemonitoring KW - self-management KW - admission prevention KW - cohort study KW - hospitalization KW - noninvasive KW - smartphone KW - vital signs KW - diagnosis N2 - Background: Despite effective therapies, the economic burden of heart failure with reduced ejection fraction (HFrEF) is driven by frequent hospitalizations. Treatment optimization and admission avoidance rely on frequent symptom reviews and monitoring of vital signs. Remote monitoring (RM) aims to prevent admissions by facilitating early intervention, but the impact of noninvasive, smartphone-based RM of vital signs on secondary health care use and costs in the months after a new diagnosis of HFrEF is unknown. Objective: The purpose of this study is to conduct a secondary care health use and health-economic evaluation for patients with HFrEF using smartphone-based noninvasive RM and compare it with matched controls receiving usual care without RM. Methods: We conducted a retrospective study of 2 cohorts of newly diagnosed HFrEF patients, matched 1:1 for demographics, socioeconomic status, comorbidities, and HFrEF severity. They are (1) the RM group, with patients using the RM platform for >3 months and (2) the control group, with patients referred before RM was available who received usual heart failure care without RM. Emergency department (ED) attendance, hospital admissions, outpatient use, and the associated costs of this secondary care activity were extracted from the Discover data set for a 3-month period after diagnosis. Platform costs were added for the RM group. Secondary health care use and costs were analyzed using Kaplan-Meier event analysis and Cox proportional hazards modeling. Results: A total of 146 patients (mean age 63 years; 42/146, 29% female) were included (73 in each group). The groups were well-matched for all baseline characteristics except hypertension (P=.03). RM was associated with a lower hazard of ED attendance (hazard ratio [HR] 0.43; P=.02) and unplanned admissions (HR 0.26; P=.02). There were no differences in elective admissions (HR 1.03, P=.96) or outpatient use (HR 1.40; P=.18) between the 2 groups. These differences were sustained by a univariate model controlling for hypertension. Over a 3-month period, secondary health care costs were approximately 4-fold lower in the RM group than the control group, despite the additional cost of RM itself (mean cost per patient GBP £465, US $581 vs GBP £1850, US $2313, respectively; P=.04). Conclusions: This retrospective cohort study shows that smartphone-based RM of vital signs is feasible for HFrEF. This type of RM was associated with an approximately 2-fold reduction in ED attendance and a 4-fold reduction in emergency admissions over just 3 months after a new diagnosis with HFrEF. Costs were significantly lower in the RM group without increasing outpatient demand. This type of RM could be adjunctive to standard care to reduce admissions, enabling other resources to help patients unable to use RM. UR - https://cardio.jmir.org/2023/1/e45611 UR - http://dx.doi.org/10.2196/45611 UR - http://www.ncbi.nlm.nih.gov/pubmed/37351921 ID - info:doi/10.2196/45611 ER - TY - JOUR AU - Auton, Alice AU - Zaman, Sameer AU - Padayachee, Yorissa AU - Samways, W. Jack AU - Quaife, M. Nicholas AU - Sweeney, Mark AU - Tenorio, Indira AU - Linton, F. Nick W. AU - Cole, D. Graham AU - Peters, S. Nicholas AU - Mayet, Jamil AU - Barton, Carys AU - Plymen, Carla PY - 2023/6/6 TI - Smartphone-Based Remote Monitoring for Chronic Heart Failure: Mixed Methods Analysis of User Experience From Patient and Nurse Perspectives JO - JMIR Nursing SP - e44630 VL - 6 KW - heart failure KW - health-related quality of life KW - mHealth KW - nurse specialist KW - patient engagement KW - self-management KW - self-care N2 - Background: Community-based management by heart failure specialist nurses (HFSNs) is key to improving self-care in heart failure with reduced ejection fraction. Remote monitoring (RM) can aid nurse-led management, but in the literature, user feedback evaluation is skewed in favor of the patient rather than nursing user experience. Furthermore, the ways in which different groups use the same RM platform at the same time are rarely directly compared in the literature. We present a balanced semantic analysis of user feedback from patient and nurse perspectives of Luscii, a smartphone-based RM strategy combining self-measurement of vital signs, instant messaging, and e-learning. Objective: This study aims to (1) evaluate how patients and nurses use this type of RM (usage type), (2) evaluate patients? and nurses? user feedback on this type of RM (user experience), and (3) directly compare the usage type and user experience of patients and nurses using the same type of RM platform at the same time. Methods: We performed a retrospective usage type and user experience evaluation of the RM platform from the perspective of both patients with heart failure with reduced ejection fraction and the HFSNs using the platform to manage them. We conducted semantic analysis of written patient feedback provided via the platform and a focus group of 6 HFSNs. Additionally, as an indirect measure of tablet adherence, self-measured vital signs (blood pressure, heart rate, and body mass) were extracted from the RM platform at onboarding and 3 months later. Paired 2-tailed t tests were used to evaluate differences between mean scores across the 2 timepoints. Results: A total of 79 patients (mean age 62 years; 35%, 28/79 female) were included. Semantic analysis of usage type revealed extensive, bidirectional information exchange between patients and HFSNs using the platform. Semantic analysis of user experience demonstrates a range of positive and negative perspectives. Positive impacts included increased patient engagement, convenience for both user groups, and continuity of care. Negative impacts included information overload for patients and increased workload for nurses. After the patients used the platform for 3 months, they showed significant reductions in heart rate (P=.004) and blood pressure (P=.008) but not body mass (P=.97) compared with onboarding. Conclusions: Smartphone-based RM with messaging and e-learning facilitates bilateral information sharing between patients and nurses on a range of topics. Patient and nurse user experience is largely positive and symmetrical, but there are possible negative impacts on patient attention and nurse workload. We recommend RM providers involve patient and nurse users in platform development, including recognition of RM usage in nursing job plans. UR - https://nursing.jmir.org/2023/1/e44630 UR - http://dx.doi.org/10.2196/44630 UR - http://www.ncbi.nlm.nih.gov/pubmed/37279054 ID - info:doi/10.2196/44630 ER - TY - JOUR AU - Radhakrishnan, Kavita AU - Julien, Christine AU - O'Hair, Matthew AU - Tunis, Rachel AU - Lee, Grace AU - Rangel, Angelica AU - Custer, James AU - Baranowski, Tom AU - Rathouz, J. Paul AU - Kim, T. Miyong PY - 2023/5/10 TI - Sensor-Controlled Digital Game for Heart Failure Self-management: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e45801 VL - 12 KW - heart failure KW - digital game KW - self-management KW - mobile phone KW - older adults N2 - Background: Heart failure (HF) is the leading cause of hospitalization among older adults in the United States. There are substantial racial and geographic disparities in HF outcomes, with patients living in southern US states having a mortality rate 69% higher than the national average. Self-management behaviors, particularly daily weight monitoring and physical activity, are extremely important in improving HF outcomes; however, patients typically have particularly low adherence to these behaviors. With the rise of digital technologies to improve health outcomes and motivate health behaviors, sensor-controlled digital games (SCDGs) have become a promising approach. SCDGs, which leverage sensor-connected technologies, offer the benefits of being portable and scalable and allowing for continuous observation and motivation of health behaviors in their real-world contexts. They are also becoming increasingly popular among older adults and offer an immersive and accessible way to measure self-management behaviors and improve adherence. No SCDGs have been designed for older adults or evaluated to test their outcomes. Objective: This randomized clinical trial aims to assess the efficacy of a SCDG in integrating the behavioral data of participants with HF from weight scale and activity tracker sensors to activate game progress, rewards, and feedback and, ultimately, to improve adherence to important self-management behaviors. Methods: A total of 200 participants with HF, aged ?45 years, will be recruited and randomized into 2 groups: the SCDG playing group (intervention group) and sensor-only group (control group). Both groups will receive a weight scale, physical activity tracker, and accompanying app, whereas only the intervention group will play the SCDG. This design, thereby, assesses the contributions of the game. All participants will complete a baseline survey as well as posttests at 6 and 12 weeks to assess the immediate effect of the intervention. They will also complete a third posttest at 24 weeks to assess the maintenance of behavioral changes. Efficacy and benefits will be assessed by measuring improvements in HF-related proximal outcomes (self-management behaviors of daily weight monitoring and physical activity) and distal outcomes (HF hospitalization, quality of life, and functional status) between baseline and weeks 6, 12, and 24. The primary outcome measured will be days with weight monitoring, for which this design provides at least 80% power to detect differences between the 2 groups. Results: Recruitment began in the fall of 2022, and the first patient was enrolled in the study on November 7, 2022. Recruitment of the last participant is expected in quarter 1 of 2025. Publication of complete results and data from this study is expected in 2026. Conclusions: This project will generate insight and guidance for scalable and easy-to-use digital gaming solutions to motivate persistent adherence to HF self-management behaviors and improve health outcomes among individuals with HF. Trial Registration: ClinicalTrials.gov NCT05056129; https://clinicaltrials.gov/ct2/show/NCT05056129 International Registered Report Identifier (IRRID): DERR1-10.2196/45801 UR - https://www.researchprotocols.org/2023/1/e45801 UR - http://dx.doi.org/10.2196/45801 UR - http://www.ncbi.nlm.nih.gov/pubmed/37163342 ID - info:doi/10.2196/45801 ER - TY - JOUR AU - Ru, Boshu AU - Tan, Xi AU - Liu, Yu AU - Kannapur, Kartik AU - Ramanan, Dheepan AU - Kessler, Garin AU - Lautsch, Dominik AU - Fonarow, Gregg PY - 2023/4/17 TI - Comparison of Machine Learning Algorithms for Predicting Hospital Readmissions and Worsening Heart Failure Events in Patients With Heart Failure With Reduced Ejection Fraction: Modeling Study JO - JMIR Form Res SP - e41775 VL - 7 KW - deep learning KW - machine learning KW - hospital readmission KW - heart failure KW - heart failure with reduced ejection fraction KW - worsening heart failure event KW - Bidirectional Encoder Representations From Transformers KW - BERT KW - clinical registry KW - medical claims KW - real-world data N2 - Background: Heart failure (HF) is highly prevalent in the United States. Approximately one-third to one-half of HF cases are categorized as HF with reduced ejection fraction (HFrEF). Patients with HFrEF are at risk of worsening HF, have a high risk of adverse outcomes, and experience higher health care use and costs. Therefore, it is crucial to identify patients with HFrEF who are at high risk of subsequent events after HF hospitalization. Objective: Machine learning (ML) has been used to predict HF-related outcomes. The objective of this study was to compare different ML prediction models and feature construction methods to predict 30-, 90-, and 365-day hospital readmissions and worsening HF events (WHFEs). Methods: We used the Veradigm PINNACLE outpatient registry linked to Symphony Health?s Integrated Dataverse data from July 1, 2013, to September 30, 2017. Adults with a confirmed diagnosis of HFrEF and HF-related hospitalization were included. WHFEs were defined as HF-related hospitalizations or outpatient intravenous diuretic use within 1 year of the first HF hospitalization. We used different approaches to construct ML features from clinical codes, including frequencies of clinical classification software (CCS) categories, Bidirectional Encoder Representations From Transformers (BERT) trained with CCS sequences (BERT + CCS), BERT trained on raw clinical codes (BERT + raw), and prespecified features based on clinical knowledge. A multilayer perceptron neural network, extreme gradient boosting (XGBoost), random forest, and logistic regression prediction models were applied and compared. Results: A total of 30,687 adult patients with HFrEF were included in the analysis; 11.41% (3184/27,917) of adults experienced a hospital readmission within 30 days of their first HF hospitalization, and nearly half (9231/21,562, 42.81%) of the patients experienced at least 1 WHFE within 1 year after HF hospitalization. The prediction models and feature combinations with the best area under the receiver operating characteristic curve (AUC) for each outcome were XGBoost with CCS frequency (AUC=0.595) for 30-day readmission, random forest with CCS frequency (AUC=0.630) for 90-day readmission, XGBoost with CCS frequency (AUC=0.649) for 365-day readmission, and XGBoost with CCS frequency (AUC=0.640) for WHFEs. Our ML models could discriminate between readmission and WHFE among patients with HFrEF. Our model performance was mediocre, especially for the 30-day readmission events, most likely owing to limitations of the data, including an imbalance between positive and negative cases and high missing rates of many clinical variables and outcome definitions. Conclusions: We predicted readmissions and WHFEs after HF hospitalizations in patients with HFrEF. Features identified by data-driven approaches may be comparable with those identified by clinical domain knowledge. Future work may be warranted to validate and improve the models using more longitudinal electronic health records that are complete, are comprehensive, and have a longer follow-up time. UR - https://formative.jmir.org/2023/1/e41775 UR - http://dx.doi.org/10.2196/41775 UR - http://www.ncbi.nlm.nih.gov/pubmed/37067873 ID - info:doi/10.2196/41775 ER - TY - JOUR AU - Dellafiore, Federica AU - Ghizzardi, Greta AU - Vellone, Ercole AU - Magon, Arianna AU - Conte, Gianluca AU - Baroni, Irene AU - De Angeli, Giada AU - Vangone, Ida AU - Russo, Sara AU - Arrigoni, Cristina AU - Caruso, Rosario PY - 2023/3/28 TI - Motivational Interviewing for Enhancing Self-care in Patients With Heart Failure: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e44629 VL - 12 KW - cardiology KW - cardiovascular KW - clinical trial KW - heart failure KW - motivational interviewing KW - randomized KW - heart KW - self-care KW - randomized controlled trial N2 - Background: Heart failure (HF) is characterized by an increasing prevalence, representing a public health problem and a significant cause of morbidity and mortality. Self-care is a cornerstone approach for optimizing therapy for patients with HF. Patients play a crucial role in managing their condition, given that several adverse health outcomes might be avoided with adequate self-care. In this regard, the literature describes motivational interviewing (MI) as highly favorable for treating chronic diseases, with promising results supporting its efficacy in enhancing self-care. Moreover, caregivers? availability constitutes a fundamental supporting factor among the strategies to improve self-care behaviors in people with HF. Objective: The primary study aim is to test the efficacy of a structured program, including scheduled MI interventions, in improving self-care maintenance in the 3-month follow-up from the enrollment. Secondary aims comprehend the assessment of the effectiveness of the above intervention on secondary outcomes (eg, self-care monitoring, quality of life, sleep disturbance) and the corroboration of the superiority of caregivers? participation to the intervention over the program administrated only to individual patients in enhancing self-care behaviors and other outcomes at 3, 6, 9, and 12 months from the enrollment. Methods: This study protocol designed a prospective, parallel-arm, open-label, 3-arm, controlled trial. The MI intervention will be administered by nurses trained in HF self-care and MI; the education program will be provided to nurses by an expert psychologist. Analyses will be performed within the framework of intention-to-treat analysis. Comparisons between groups will be based on an alpha of 5% and 2-tailed null hypotheses. In the case of missingness, analyzing the extent of the missingness and identifying underlying mechanisms and patterns will guide imputation methods. Results: The data collection was started in May 2017. We completed the data collection with the last follow-up in May 2021. We plan to perform data analysis by December 2022. We plan to publish the study results within March 2023. Conclusions: MI enhances potential self-care practices in patients with HF and their caregivers. Although MI is effectively largely employed either alone or combined with other treatments and is administered in different settings and ways, face-to-face interventions seem to be more effective. Dyads with higher shared HF knowledge are more efficient in promoting self-care adherence behaviors. Moreover, patients and caregivers may perceive proximity with health care professionals, resulting in a better ability to follow the received health professionals? directions. The scheduled in-person meetings with patients and caregivers will be exploited to administer MI, respecting all the safety regulations for infection containment. The conduction of this study may support changes in clinical practice to include MI to improve self-care for patients with HF. Trial Registration: ClinicalTrials.gov NCT05595655; https://clinicaltrials.gov/ct2/show/NCT05595655 International Registered Report Identifier (IRRID): DERR1-10.2196/44629 UR - https://www.researchprotocols.org/2023/1/e44629 UR - http://dx.doi.org/10.2196/44629 UR - http://www.ncbi.nlm.nih.gov/pubmed/36976630 ID - info:doi/10.2196/44629 ER - TY - JOUR AU - Davat, Ambre AU - Martin-Juchat, Fabienne PY - 2023/1/23 TI - Patients? Information Needs Related to a Monitoring Implant for Heart Failure: Co-designed Study Based on Affect Stories JO - JMIR Hum Factors SP - e38096 VL - 10 KW - co-design KW - affect stories KW - mixed methods study KW - heart failure KW - medical implantable device KW - mobile health KW - mHealth KW - remote monitoring KW - quantified self KW - telehealth N2 - Background: RealWorld4Clinic is a European consortium that is currently developing an implantable monitoring device for acute heart failure prevention. Objective: This study aimed to identify the main issues and information needs related to this new cardiac implant from the patients? perspective. Methods: A total of 3 patient collaborators were recruited to help us design the study. During 4 remotely held meetings (each lasting for 2 hours), we defined the main questions and hypotheses together. Next, 26 additional interviews were conducted remotely to test these hypotheses. During both phases, we used affect stories, which are life narratives focusing on affect and the relationship between patients and the care ecosystem, to highlight the main social issues that should be addressed by the research according to the patients. Results: Context of diagnosis, age, and severity of illness strongly influence patient experience. However, these variables do not seem to influence the choice regarding being implanted, which relies mostly on the individual patient?s trust in their physicians. It seems that the major cause of anxiety for the patient is not the implant but the disease itself, although some people may initially be concerned over the idea of becoming a cyborg. Remote monitoring of cardiac implants should draw on existing remote disease management programs focusing on a long-term relationship between the patient and their medical team. Conclusions: Co-design with affect stories is a useful method for quickly identifying the main social issues related to information about a new health technology. UR - https://humanfactors.jmir.org/2023/1/e38096 UR - http://dx.doi.org/10.2196/38096 UR - http://www.ncbi.nlm.nih.gov/pubmed/36689266 ID - info:doi/10.2196/38096 ER - TY - JOUR AU - Barbaric, Antonia AU - Munteanu, Cosmin AU - Ross, Heather AU - Cafazzo, A. Joseph PY - 2022/12/21 TI - A Voice App Design for Heart Failure Self-management: Proof-of-Concept Implementation Study JO - JMIR Form Res SP - e40021 VL - 6 IS - 12 KW - heart failure KW - self-management KW - digital therapeutics KW - voice-activated technology KW - smart speaker KW - formative evaluation KW - mobile phone N2 - Background: Voice user interfaces are becoming more prevalent in health care and are commonly being used for patient engagement. There is a growing interest in identifying the potential this form of interface has on patient engagement with digital therapeutics (DTx) in chronic disease management. Making DTx accessible through an alternative interaction model also has the potential to better meet the needs of some patients, such as older adults and those with physical and cognitive impairments, based on existing research. Objective: This study aimed to evaluate how participants with heart failure interacted with a voice app version of a DTx, Medly, through a proof-of-concept implementation study design. The objective was to understand whether the voice app would enable the participants to successfully interact with the DTx, with a focus on acceptability and feasibility. Methods: A mixed methods concurrent triangulation design was used to better understand the acceptability and feasibility of the use of the Medly voice app with the study participants (N=20) over a 4-week period. Quantitative data included engagement levels, accuracy rates, and questionnaires, which were analyzed using descriptive statistics. Qualitative data included semistructured interviews and were analyzed using a qualitative descriptive approach. Results: The overall average engagement level was 73% (SD 9.5%), with a 14% decline between results of weeks 1 and 4. The biggest difference was between the average engagement levels of the oldest and youngest demographics, 84% and 43%, respectively, but these results were not significant?Kruskal-Wallis test, H(2)=3.8 (P=.14). The Medly voice app had an overall accuracy rate of 97.8% and was successful in sending data to the clinic. From an acceptability perspective, the voice app was ranked in the 80th percentile, and overall, the users felt that the voice app was not a lot of work (average of 2.1 on a 7-point Likert scale). However, the overall average score for whether users would use it in the future declined by 13%. Thematic analysis revealed the following: the theme feasibility of clinical integration had 2 subthemes, namely users adapted to the voice app?s conversational style and device unreliability, and the theme voice app acceptability had 3 subthemes, namely the device integrated well within household and users? lives, users blamed themselves when problems arose with the voice app, and voice app was missing specific, desirable user features. Conclusions: In conclusion, participants were largely successful in using the Medly voice app despite some of the barriers faced, proving that an app such as this could be feasible to be deployed in the clinic. Our data begin to piece together the patient profile this technology may be most suitable for, namely those who are older, have flexible schedules, are confident in using technology, and are experiencing other medical conditions. UR - https://formative.jmir.org/2022/12/e40021 UR - http://dx.doi.org/10.2196/40021 UR - http://www.ncbi.nlm.nih.gov/pubmed/36542435 ID - info:doi/10.2196/40021 ER - TY - JOUR AU - Foster, Marva AU - Xiong, Wei AU - Quintiliani, Lisa AU - Hartmann, W. Christine AU - Gaehde, Stephan PY - 2022/12/20 TI - Preferences of Older Adult Veterans With Heart Failure for Engaging With Mobile Health Technology to Support Self-care: Qualitative Interview Study Among Patients With Heart Failure and Content Analysis JO - JMIR Form Res SP - e41317 VL - 6 IS - 12 KW - qualitative research KW - heart failure KW - self-care KW - mobile health KW - mobile health technology KW - older adults KW - elderly KW - perceptions KW - mhealth intervention KW - veteran health KW - mHealth technology KW - elderly health care KW - elderly self-care N2 - Background: Heart failure (HF) affects approximately 6.5 million adults in the United States, disproportionately afflicting older adults. Mobile health (mHealth) has emerged as a promising tool to empower older adults in HF self-care. However, little is known about the use of this approach among older adult veterans. Objective: The goal of this study was to explore which features of an app were prioritized for older adult veterans with HF. Methods: Between January and July 2021, we conducted semistructured interviews with patients with heart failure aged 65 years and older at a single facility in an integrated health care system (the Veterans Health Administration). We performed content analysis and derived themes based on the middle-range theory of chronic illness, generating findings both deductively and inductively. The qualitative questions captured data on the 3 key themes of the theory: self-care maintenance, self-care monitoring, and self-care management. Qualitative responses were analyzed using a qualitative data management platform, and descriptive statistics were used to analyze demographic data. Results: Among patients interviewed (n=9), most agreed that a smartphone app for supporting HF self-care was desirable. In addition to 3 a priori themes, we identified 7 subthemes: education on daily HF care, how often to get education on HF, support of medication adherence, dietary restriction support, goal setting for exercises, stress reduction strategies, and prompts of when to call a provider. In addition, we identified 3 inductive themes related to veteran preferences for app components: simplicity, ability to share data with caregivers, and positive framing of HF language. Conclusions: We identified educational and tracking app features that can guide the development of HF self-care for an older adult veteran population. Future research needs to be done to extend these findings and assess the feasibility of and test an app with these features. UR - https://formative.jmir.org/2022/12/e41317 UR - http://dx.doi.org/10.2196/41317 UR - http://www.ncbi.nlm.nih.gov/pubmed/36538348 ID - info:doi/10.2196/41317 ER - TY - JOUR AU - Barbaric, Antonia AU - Munteanu, Cosmin AU - Ross, Heather AU - Cafazzo, A. Joseph PY - 2022/12/6 TI - Design of a Patient Voice App Experience for Heart Failure Management: Usability Study JO - JMIR Form Res SP - e41628 VL - 6 IS - 12 KW - heart failure KW - self-management KW - digital therapeutics KW - voice-activated technology KW - smart speaker KW - usability study KW - formative evaluation KW - mobile phone KW - smartphone N2 - Background: The use of digital therapeutics (DTx) in the prevention and management of medical conditions has increased through the years, with an estimated 44 million people using one as part of their treatment plan in 2021, nearly double the number from the previous year. DTx are commonly accessed through smartphone apps, but offering these treatments through additional platforms can improve the accessibility of these interventions. Voice apps are an emerging technology in the digital health field; not only do they have the potential to improve DTx adherence, but they can also create a better user experience for some user groups. Objective: This research aimed to identify the acceptability and feasibility of offering a voice app for a chronic disease self-management program. The objective of this project was to design, develop, and evaluate a voice app of an already-existing smartphone-based heart failure self-management program, Medly, to be used as a case study. Methods: A voice app version of Medly was designed and developed through a user-centered design process. We conducted a usability study and semistructured interviews with patients with heart failure (N=8) at the Peter Munk Cardiac Clinic in Toronto General Hospital to better understand the user experience. A Medly voice app prototype was built using a software development kit in tandem with a cloud computing platform and was verified and validated before the usability study. Data collection and analysis were guided by a mixed methods triangulation convergence design. Results: Common themes were identified in the results of the usability study, which involved 8 participants with heart failure. Almost all participants (7/8, 88%) were satisfied with the voice app and felt confident using it, although half of the participants (4/8, 50%) were unsure about using it in the future. Six main themes were identified: changes in physical behavior, preference between voice app and smartphone, importance of music during voice app interaction, lack of privacy concerns, desired reassurances during voice app interaction, and helpful aids during voice app interaction. These findings were triangulated with the quantitative data, and it concluded that the main area for improvement was related to the ease of use; design changes were then implemented to better improve the user experience. Conclusions: This work offered preliminary insight into the acceptability and feasibility of a Medly voice app. Given the recent emergence of voice apps in health care, we believe that this research offered invaluable insight into successfully deploying DTx for chronic disease self-management using this technology. UR - https://formative.jmir.org/2022/12/e41628 UR - http://dx.doi.org/10.2196/41628 UR - http://www.ncbi.nlm.nih.gov/pubmed/36472895 ID - info:doi/10.2196/41628 ER - TY - JOUR AU - Nourse, Rebecca AU - Lobo, Elton AU - McVicar, Jenna AU - Kensing, Finn AU - Islam, Shariful Sheikh Mohammed AU - Kayser, Lars AU - Maddison, Ralph PY - 2022/11/2 TI - Characteristics of Smart Health Ecosystems That Support Self-care Among People With Heart Failure: Scoping Review JO - JMIR Cardio SP - e36773 VL - 6 IS - 2 KW - digital health KW - review KW - chronic diseases KW - cardiovascular disease KW - information technology KW - digital technology KW - mobile phone KW - self-management N2 - Background: The management of heart failure is complex. Innovative solutions are required to support health care providers and people with heart failure with decision-making and self-care behaviors. In recent years, more sophisticated technologies have enabled new health care models, such as smart health ecosystems. Smart health ecosystems use data collection, intelligent data processing, and communication to support the diagnosis, management, and primary and secondary prevention of chronic conditions. Currently, there is little information on the characteristics of smart health ecosystems for people with heart failure. Objective: We aimed to identify and describe the characteristics of smart health ecosystems that support heart failure self-care. Methods: We conducted a scoping review using the Joanna Briggs Institute methodology. The MEDLINE, Embase, CINAHL, PsycINFO, IEEE Xplore, and ACM Digital Library databases were searched from January 2008 to September 2021. The search strategy focused on identifying articles describing smart health ecosystems that support heart failure self-care. A total of 2 reviewers screened the articles and extracted relevant data from the included full texts. Results: After removing duplicates, 1543 articles were screened, and 34 articles representing 13 interventions were included in this review. To support self-care, the interventions used sensors and questionnaires to collect data and used tailoring methods to provide personalized support. The interventions used a total of 34 behavior change techniques, which were facilitated by a combination of 8 features for people with heart failure: automated feedback, monitoring (integrated and manual input), presentation of data, education, reminders, communication with a health care provider, and psychological support. Furthermore, features to support health care providers included data presentation, alarms, alerts, communication tools, remote care plan modification, and health record integration. Conclusions: This scoping review identified that there are few reports of smart health ecosystems that support heart failure self-care, and those that have been reported do not provide comprehensive support across all domains of self-care. This review describes the technical and behavioral components of the identified interventions, providing information that can be used as a starting point for designing and testing future smart health ecosystems. UR - https://cardio.jmir.org/2022/2/e36773 UR - http://dx.doi.org/10.2196/36773 UR - http://www.ncbi.nlm.nih.gov/pubmed/36322112 ID - info:doi/10.2196/36773 ER - TY - JOUR AU - Sivakumar, Bridve AU - Lemonde, Manon AU - Stein, Matthew AU - Goldstein, Sarah AU - Mak, Susanna AU - Arcand, JoAnne PY - 2022/10/26 TI - Evaluating Health Care Provider Perspectives on the Use of Mobile Apps to Support Patients With Heart Failure Management: Qualitative Descriptive Study JO - JMIR Cardio SP - e40546 VL - 6 IS - 2 KW - heart failure KW - mobile health KW - mHealth KW - eHealth KW - mobile apps KW - adherence KW - self-management KW - mobile phone N2 - 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. UR - https://cardio.jmir.org/2022/2/e40546 UR - http://dx.doi.org/10.2196/40546 UR - http://www.ncbi.nlm.nih.gov/pubmed/36287588 ID - info:doi/10.2196/40546 ER - TY - JOUR AU - Villalobos, Paola Jennifer AU - Bull, Salyers Sheana AU - Portz, Dickman Jennifer PY - 2022/10/6 TI - Usability and Acceptability of a Palliative Care Mobile Intervention for Older Adults With Heart Failure and Caregivers: Observational Study JO - JMIR Aging SP - e35592 VL - 5 IS - 4 KW - mHealth KW - older adult KW - symptom KW - heart failure KW - palliative care KW - app KW - digital health KW - cardiology KW - heart KW - Convoy-Pal KW - mobile KW - tablet KW - smartwatch KW - adult KW - aging N2 - Background: Heart failure is a leading cause of death among older adults. Digital health can increase access to and awareness of palliative care for patients with advanced heart failure and their caregivers. However, few palliative care digital interventions target heart failure or patients? caregivers, family, and friends, termed here as the social convoy. To address this need, the Social Convoy Palliative Care (Convoy-Pal) mobile intervention was developed to deliver self-management tools and palliative care resources to older adults with advanced heart failure and their social convoys. Objective: The goal of the research was to test the acceptability and usability of Convoy-Pal among older adults with advanced heart failure and their social convoys. Methods: Convoy-Pal includes tablet-based and smartwatch tools facilitating self-management and access to palliative care resources. Older adults and social convoy caregivers completed an acceptability and usability interview via Zoom, including open-ended questions and the Mobile Application Rating Scale: User Version (uMARS). Descriptive analysis was conducted to summarize the results of open-ended feedback and self-reported acceptability and usability. Results: A total of 26 participants (16 older adults and 10 social convoy caregivers) participated in the interview. Overall, the feedback from users was good (uMARS mean 3.96/5 [SD 0.81]). Both older adults and social convoy caregivers scored information provided by Convoy-Pal the highest (mean 4.22 [SD 0.75] and mean 4.21 [SD 0.64], respectively). Aesthetics, functionality, and engagement were also perceived as acceptable (mean >3.5). Open-ended feedback resulted in 5 themes including improvements to goal setting, monitoring tools, daily check-in call feature, portal and mobile app, and convoy assessment. Conclusions: Convoy-Pal was perceived as acceptable with good usability among older adults with heart failure and their social convoy caregivers. With good acceptability, Convoy-Pal may ultimately lead to increased access to palliative care resources and facilitate self-management among older adults with heart failure and their social convoy caregivers. UR - https://aging.jmir.org/2022/4/e35592 UR - http://dx.doi.org/10.2196/35592 UR - http://www.ncbi.nlm.nih.gov/pubmed/36201402 ID - info:doi/10.2196/35592 ER - TY - JOUR AU - Liu, Siru AU - Li, Jili AU - Wan, Ding-yuan AU - Li, Runyi AU - Qu, Zhan AU - Hu, Yundi AU - Liu, Jialin PY - 2022/9/26 TI - Effectiveness of eHealth Self-management Interventions in Patients With Heart Failure: Systematic Review and Meta-analysis JO - J Med Internet Res SP - e38697 VL - 24 IS - 9 KW - heart failure KW - eHealth KW - self-management KW - systematic review KW - cardiology KW - cardiovascular KW - morbidity N2 - Background: Heart failure (HF) is a common clinical syndrome associated with substantial morbidity, a heavy economic burden, and high risk of readmission. eHealth self-management interventions may be an effective way to improve HF clinical outcomes. Objective: The aim of this study was to systematically review the evidence for the effectiveness of eHealth self-management in patients with HF. Methods: This study included only randomized controlled trials (RCTs) that compared the effects of eHealth interventions with usual care in adult patients with HF using searches of the EMBASE, PubMed, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL databases from January 1, 2011, to July 12, 2022. The Cochrane Risk of Bias tool (RoB 2) was used to assess the risk of bias for each study. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria were used to rate the certainty of the evidence for each outcome of interest. Meta-analyses were performed using Review Manager (RevMan v.5.4) and R (v.4.1.0 x64) software. Results: In total, 24 RCTs with 9634 participants met the inclusion criteria. Compared with the usual-care group, eHealth self-management interventions could significantly reduce all-cause mortality (odds ratio [OR] 0.83, 95% CI 0.71-0.98, P=.03; GRADE: low quality) and cardiovascular mortality (OR 0.74, 95% CI 0.59-0.92, P=.008; GRADE: moderate quality), as well as all-cause readmissions (OR 0.82, 95% CI 0.73-0.93, P=.002; GRADE: low quality) and HF-related readmissions (OR 0.77, 95% CI 0.66-0.90, P<.001; GRADE: moderate quality). The meta-analyses also showed that eHealth interventions could increase patients? knowledge of HF and improve their quality of life, but there were no statistically significant effects. However, eHealth interventions could significantly increase medication adherence (OR 1.82, 95% CI 1.42-2.34, P<.001; GRADE: low quality) and improve self-care behaviors (standardized mean difference ?1.34, 95% CI ?2.46 to ?0.22, P=.02; GRADE: very low quality). A subgroup analysis of primary outcomes regarding the enrolled population setting found that eHealth interventions were more effective in patients with HF after discharge compared with those in the ambulatory clinic setting. Conclusions: eHealth self-management interventions could benefit the health of patients with HF in various ways. However, the clinical effects of eHealth interventions in patients with HF are affected by multiple aspects, and more high-quality studies are needed to demonstrate effectiveness. UR - https://www.jmir.org/2022/9/e38697 UR - http://dx.doi.org/10.2196/38697 UR - http://www.ncbi.nlm.nih.gov/pubmed/36155484 ID - info:doi/10.2196/38697 ER - TY - JOUR AU - El-Dassouki, Noor AU - Pfisterer, Kaylen AU - Benmessaoud, Camila AU - Young, Karen AU - Ge, Kelly AU - Lohani, Raima AU - Saragadam, Ashish AU - Pham, Quynh PY - 2022/9/7 TI - The Value of Technology to Support Dyadic Caregiving for Individuals Living With Heart Failure: Qualitative Descriptive Study JO - J Med Internet Res SP - e40108 VL - 24 IS - 9 KW - heart failure KW - digital therapeutics KW - remote patient management KW - caregiving KW - dyadic management N2 - Background: The demand for health services to meet the chronic health needs of the aging population is significant and remains unmet because of the limited supply of clinical resources. Specifically, in managing heart failure (HF), digital health sought to address this gap during the COVID-19 pandemic but highlighted an access issue for those who could not use technology-mediated health care services without the support of their informal caregivers (ICs). The complexity of managing HF symptoms and recurrent exacerbations requires many patients to comanage their illness with their ICs in a care dyad, working together to optimize patient outcomes and health-related quality of life. However, most HF programs have missed the opportunity to consider the dyadic perspective despite interdependencies on HF outcomes. Objective: This study aims to characterize the value of technology in supporting caregiving for individuals living with HF. Methods: Motivated by an observed unique pattern of engagement in patients enrolled in our Medly HF management program at the Peter Munk Cardiac Centre in Toronto, Canada, we conducted 20 semistructured interviews with a convenience sample of ICs. All interviews were analyzed using the iterative refinement of a codeveloped codebook. The team maintained reflexivity journals to reflect the impact of their positionality on their coding. Themes were first derived deductively using HF typologies (patient-oriented dyads, caregiver-oriented dyads, and collaboratively oriented dyads) and then inductively refined and recategorized based on concepts from the van Houtven et al framework. Results: We believe that there is a need to formally and intentionally expand HF technologies to include dyadic needs and goals. We suggest defining 3 opportunities in which value can be added to technological design. First, identify how technology may be leveraged to increase psychological bandwidth by reducing uncertainty and providing peace of mind. We found that actionable feedback was highly desired by both partners. Second, develop technology that can serve as a member of the dyad?s support system. In our experience, automated prompts for patients to take measurements can mimic the support typically provided by ICs and ease their workload. Third, consider how technology can mitigate the dyad?s clinical knowledge requirements and learning curve. Our approach includes real-time actionable feedback paired with a human-in-the-loop, nurse-led model of care. Conclusions: Our findings identified a need to focus on improving the dyadic experience as a whole by building IC functionality into digital health self-management interventions. Through a shared model of care that supports the role of the patient in their own HF management, includes ICs to expand and enhance the patient?s capacity to care, and acknowledges the need of ICs to care for themselves, we anticipate improved outcomes for both partners. UR - https://www.jmir.org/2022/9/e40108 UR - http://dx.doi.org/10.2196/40108 UR - http://www.ncbi.nlm.nih.gov/pubmed/36069782 ID - info:doi/10.2196/40108 ER - TY - JOUR AU - Lewinski, A. Allison AU - Walsh, Conor AU - Rushton, Sharron AU - Soliman, Diana AU - Carlson, M. Scott AU - Luedke, W. Matthew AU - Halpern, J. David AU - Crowley, J. Matthew AU - Shaw, J. Ryan AU - Sharpe, A. Jason AU - Alexopoulos, Anastasia-Stefania AU - Tabriz, Alishahi Amir AU - Dietch, R. Jessica AU - Uthappa, M. Diya AU - Hwang, Soohyun AU - Ball Ricks, A. Katharine AU - Cantrell, Sarah AU - Kosinski, S. Andrzej AU - Ear, Belinda AU - Gordon, M. Adelaide AU - Gierisch, M. Jennifer AU - Williams Jr, W. John AU - Goldstein, M. Karen PY - 2022/8/26 TI - Telehealth for the Longitudinal Management of Chronic Conditions: Systematic Review JO - J Med Internet Res SP - e37100 VL - 24 IS - 8 KW - telemedicine KW - diabetes mellitus, type 2 KW - heart failure KW - pulmonary disease KW - chronic obstructive KW - veterans KW - delivery of health care KW - systematic review N2 - Background: Extensive literature support telehealth as a supplement or adjunct to in-person care for the management of chronic conditions such as congestive heart failure (CHF) and type 2 diabetes mellitus (T2DM). Evidence is needed to support the use of telehealth as an equivalent and equitable replacement for in-person care and to assess potential adverse effects. Objective: We conducted a systematic review to address the following question: among adults, what is the effect of synchronous telehealth (real-time response among individuals via phone or phone and video) compared with in-person care (or compared with phone, if synchronous video care) for chronic management of CHF, chronic obstructive pulmonary disease, and T2DM on key disease-specific clinical outcomes and health care use? Methods: We followed systematic review methodologies and searched two databases (MEDLINE and Embase). We included randomized or quasi-experimental studies that evaluated the effect of synchronously delivered telehealth for relevant chronic conditions that occurred over ?2 encounters and in which some or all in-person care was supplanted by care delivered via phone or video. We assessed the bias using the Cochrane Effective Practice and Organization of Care risk of bias (ROB) tool and the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation. We described the findings narratively and did not conduct meta-analysis owing to the small number of studies and the conceptual heterogeneity of the identified interventions. Results: We identified 8662 studies, and 129 (1.49%) were reviewed at the full-text stage. In total, 3.9% (5/129) of the articles were retained for data extraction, all of which (5/5, 100%) were randomized controlled trials. The CHF study (1/5, 20%) was found to have high ROB and randomized patients (n=210) to receive quarterly automated asynchronous web-based review and follow-up of telemetry data versus synchronous personal follow-up (in-person vs phone-based) for 1 year. A 3-way comparison across study arms found no significant differences in clinical outcomes. Overall, 80% (4/5) of the studies (n=466) evaluated synchronous care for patients with T2DM (ROB was judged to be low for 2, 50% of studies and high for 2, 50% of studies). In total, 20% (1/5) of the studies were adequately powered to assess the difference in glycosylated hemoglobin level between groups; however, no significant difference was found. Intervention design varied greatly from remote monitoring of blood glucose combined with video versus in-person visits to an endocrinology clinic to a brief, 3-week remote intervention to stabilize uncontrolled diabetes. No articles were identified for chronic obstructive pulmonary disease. Conclusions: This review found few studies with a variety of designs and interventions that used telehealth as a replacement for in-person care. Future research should consider including observational studies and studies on additional highly prevalent chronic diseases. UR - https://www.jmir.org/2022/8/e37100 UR - http://dx.doi.org/10.2196/37100 UR - http://www.ncbi.nlm.nih.gov/pubmed/36018711 ID - info:doi/10.2196/37100 ER - TY - JOUR AU - Madujibeya, Ifeanyi AU - Lennie, Terry AU - Aroh, Adaeze AU - Chung, L. Misook AU - Moser, Debra PY - 2022/8/22 TI - Measures of Engagement With mHealth Interventions in Patients With Heart Failure: Scoping Review JO - JMIR Mhealth Uhealth SP - e35657 VL - 10 IS - 8 KW - heart failure KW - mobile health interventions KW - mHealth interventions KW - patient engagement KW - system usage data KW - heart failure outcomes KW - mobile phone N2 - Background: Despite the potential of mobile health (mHealth) interventions to facilitate the early detection of signs of heart failure (HF) decompensation and provide personalized management of symptoms, the outcomes of such interventions in patients with HF have been inconsistent. As engagement with mHealth is required for interventions to be effective, poor patient engagement with mHealth interventions may be associated with mixed evidence. It is crucial to understand how engagement with mHealth interventions is measured in patients with HF, and the effects of engagement on HF outcomes. Objective: In this review, we aimed to describe measures of patient engagement with mHealth interventions and the effects of engagement on HF outcomes. Methods: We conducted a systematic literature search in 7 databases for relevant studies published in the English language from 2009 to September 2021 and reported the descriptive characteristics of the studies. We used content analysis to identify themes that described patient engagement with mHealth interventions in the qualitative studies included in the review. Results: We synthesized 32 studies that operationalized engagement with mHealth interventions in 4771 patients with HF (3239/4771, 67.88%, male), ranging from a sample of 7 to 1571 (median 53.3) patients, followed for a median duration of 90 (IQR 45-180) days. Patient engagement with mHealth interventions was measured only quantitatively based on system usage data in 72% (23/32) of the studies, only qualitatively based on data from semistructured interviews and focus groups in 6% (2/32) of studies, and by a combination of both quantitative and qualitative data in 22% (7/32) of studies. System usage data were evaluated using 6 metrics of engagement: number of physiological parameters transmitted (19/30, 63% studies), number of HF questionnaires completed (2/30, 7% studies), number of log-ins (4/30, 13% studies), number of SMS text message responses (1/30, 3% studies), time spent (5/30, 17% studies), and the number of features accessed and screen viewed (4/30, 13% studies). There was a lack of consistency in how the system usage metrics were reported across studies. In total, 80% of the studies reported only descriptive characteristics of system usage data. The emotional, cognitive, and behavioral domains of patient engagement were identified through qualitative studies. Patient engagement levels ranged from 45% to 100% and decreased over time. The effects of engagement on HF knowledge, self-care, exercise adherence, and HF hospitalization were inconclusive. Conclusions: The measures of patient engagement with mHealth interventions in patients with HF are underreported and lack consistency. The application of inferential analytical methods to engagement data is extremely limited. There is a need for a working group on mHealth that may consolidate the previous operational definitions of patient engagement into an optimal and standardized measure. UR - https://mhealth.jmir.org/2022/8/e35657 UR - http://dx.doi.org/10.2196/35657 UR - http://www.ncbi.nlm.nih.gov/pubmed/35994345 ID - info:doi/10.2196/35657 ER - TY - JOUR AU - Li, Jili AU - Liu, Siru AU - Hu, Yundi AU - Zhu, Lingfeng AU - Mao, Yujia AU - Liu, Jialin PY - 2022/8/9 TI - Predicting Mortality in Intensive Care Unit Patients With Heart Failure Using an Interpretable Machine Learning Model: Retrospective Cohort Study JO - J Med Internet Res SP - e38082 VL - 24 IS - 8 KW - heart failure KW - mortality KW - intensive care unit KW - prediction KW - XGBoost KW - SHAP KW - SHapley Additive exPlanation N2 - Background: Heart failure (HF) is a common disease and a major public health problem. HF mortality prediction is critical for developing individualized prevention and treatment plans. However, due to their lack of interpretability, most HF mortality prediction models have not yet reached clinical practice. Objective: We aimed to develop an interpretable model to predict the mortality risk for patients with HF in intensive care units (ICUs) and used the SHapley Additive exPlanation (SHAP) method to explain the extreme gradient boosting (XGBoost) model and explore prognostic factors for HF. Methods: In this retrospective cohort study, we achieved model development and performance comparison on the eICU Collaborative Research Database (eICU-CRD). We extracted data during the first 24 hours of each ICU admission, and the data set was randomly divided, with 70% used for model training and 30% used for model validation. The prediction performance of the XGBoost model was compared with three other machine learning models by the area under the curve. We used the SHAP method to explain the XGBoost model. Results: A total of 2798 eligible patients with HF were included in the final cohort for this study. The observed in-hospital mortality of patients with HF was 9.97%. Comparatively, the XGBoost model had the highest predictive performance among four models with an area under the curve (AUC) of 0.824 (95% CI 0.7766-0.8708), whereas support vector machine had the poorest generalization ability (AUC=0.701, 95% CI 0.6433-0.7582). The decision curve showed that the net benefit of the XGBoost model surpassed those of other machine learning models at 10%~28% threshold probabilities. The SHAP method reveals the top 20 predictors of HF according to the importance ranking, and the average of the blood urea nitrogen was recognized as the most important predictor variable. Conclusions: The interpretable predictive model helps physicians more accurately predict the mortality risk in ICU patients with HF, and therefore, provides better treatment plans and optimal resource allocation for their patients. In addition, the interpretable framework can increase the transparency of the model and facilitate understanding the reliability of the predictive model for the physicians. UR - https://www.jmir.org/2022/8/e38082 UR - http://dx.doi.org/10.2196/38082 UR - http://www.ncbi.nlm.nih.gov/pubmed/35943767 ID - info:doi/10.2196/38082 ER - TY - JOUR AU - Chu, Cherry AU - Stamenova, Vess AU - Fang, Jiming AU - Shakeri, Ahmad AU - Tadrous, Mina AU - Bhatia, Sacha R. PY - 2022/8/4 TI - The Association Between Telemedicine Use and Changes in Health Care Usage and Outcomes in Patients With Congestive Heart Failure: Retrospective Cohort Study JO - JMIR Cardio SP - e36442 VL - 6 IS - 2 KW - telemedicine KW - telehealth KW - eHealth KW - digital health KW - population KW - outcomes KW - health service KW - health system KW - utilization KW - congestive heart failure KW - cardiology KW - health outcome KW - clinical outcome KW - patient outcome KW - heart KW - cardiac KW - ambulatory KW - COVID-19 N2 - Background: Telemedicine use has become widespread owing to the COVID-19 pandemic, but its impact on patient outcomes remains unclear. Objective: We sought to investigate the effect of telemedicine use on changes in health care usage and clinical outcomes in patients diagnosed with congestive heart failure (CHF). Methods: We conducted a population-based retrospective cohort study using administrative data in Ontario, Canada. Patients were included if they had at least one ambulatory visit between March 14 and September 30, 2020, and a heart failure diagnosis any time prior to March 14, 2020. Telemedicine users were propensity score?matched with unexposed users based on several baseline characteristics. Monthly use of various health care services was compared between the 2 groups during 12 months before to 3 months after their index in-person or telemedicine ambulatory visit after March 14, 2020, using generalized estimating equations. Results: A total of 11,131 pairs of telemedicine and unexposed patients were identified after matching (49% male; mean age 78.9, SD 12.0 years). All patients showed significant reductions in health service usage from pre- to postindex visit. There was a greater decline across time in the unexposed group than in the telemedicine group for CHF admissions (ratio of slopes for high- vs low-frequency users 1.02, 95% CI 1.02-1.03), cardiovascular admissions (1.03, 95% CI 1.02-1.04), any-cause admissions (1.03, 95% CI 1.02-1.04), any-cause ED visits (1.03, 95% CI 1.03-1.04), visits with any cardiologist (1.01, 95% CI 1.01-1.02), laboratory tests (1.02, 95% CI 1.02-1.03), diagnostic tests (1.04, 95% CI 1.03-1.05), and new prescriptions (1.02, 95% CI 1.01-1.03). However, the decline in primary care visit rates was steeper among telemedicine patients than among unexposed patients (ratio of slopes 0.99, 95% CI 0.99-1.00). Conclusions: Overall health care usage over time appeared higher among telemedicine users than among low-frequency users or nonusers, suggesting that telemedicine was used by patients with the greatest need or that it allowed patients to have better access or continuity of care among those who received it. UR - https://cardio.jmir.org/2022/2/e36442 UR - http://dx.doi.org/10.2196/36442 UR - http://www.ncbi.nlm.nih.gov/pubmed/35881831 ID - info:doi/10.2196/36442 ER - TY - JOUR AU - Albuquerque de Almeida, Fernando AU - Corro Ramos, Isaac AU - Al, Maiwenn AU - Rutten-van Mölken, Maureen PY - 2022/8/4 TI - Home Telemonitoring and a Diagnostic Algorithm in the Management of Heart Failure in the Netherlands: Cost-effectiveness Analysis JO - JMIR Cardio SP - e31302 VL - 6 IS - 2 KW - discrete event simulation KW - cost-effectiveness KW - early warning systems KW - home telemonitoring KW - diagnostic algorithm KW - heart failure N2 - 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 ?27,712 (currency conversion rate in purchasing power parity at the time of study: ?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 ?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. UR - https://cardio.jmir.org/2022/2/e31302 UR - http://dx.doi.org/10.2196/31302 UR - http://www.ncbi.nlm.nih.gov/pubmed/35925670 ID - info:doi/10.2196/31302 ER - TY - JOUR AU - Buhr, Lorina AU - Kaufmann, Martiana Pauline Lucie AU - Jörß, Katharina PY - 2022/8/3 TI - Attitudes of Patients With Chronic Heart Failure Toward Digital Device Data for Self-documentation and Research in Germany: Cross-sectional Survey Study JO - JMIR Cardio SP - e34959 VL - 6 IS - 2 KW - mobile health KW - mHealth KW - digital devices KW - wearables KW - heart failure KW - data sharing KW - consent KW - mobile phone N2 - 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. UR - https://cardio.jmir.org/2022/2/e34959 UR - http://dx.doi.org/10.2196/34959 UR - http://www.ncbi.nlm.nih.gov/pubmed/35921134 ID - info:doi/10.2196/34959 ER - TY - JOUR AU - Apantaku, Glory AU - Mitton, Craig AU - Wong, Hubert AU - Ho, Kendall PY - 2022/6/2 TI - Home Telemonitoring Technology for Patients With Heart Failure: Cost-Consequence Analysis of a Pilot Study JO - JMIR Form Res SP - e32147 VL - 6 IS - 6 KW - cost-consequence analysis KW - feasibility study KW - pilot study KW - heart failure KW - cardiology KW - cardiovascular disease KW - economic analysis KW - telehealth KW - health care cost KW - home monitoring KW - digital monitor KW - health monitor N2 - Background: Heart failure (HF) is a costly health condition and a major public health problem. It is estimated that 2%-3% of the population in developed countries has HF, and the prevalence increases to 8% among patients aged ?75 years. Home telemonitoring is a form of noninvasive, remote patient monitoring that aims to improve the care and management of patients with chronic HF. Telehealth for Emergency-Community Continuity of Care Connectivity via Home-Telemonitoring (TEC4Home) is a project that implements and evaluates a comprehensive home monitoring protocol designed to support patients with HF as they transition from the emergency department to home. Objective: The aim of this study is to assess the cost of using the home monitoring platform (TEC4Home) relative to usual care for patients with HF. Methods: This study is a cost-consequence analysis of the TEC4Home pilot study. The analysis was conducted from a partial societal perspective, including direct and indirect health care costs. The aim is to assess the costs of the home monitoring platform relative to usual care and track costs related to health care utilization during the 90-day postdischarge period. Results: Economic analysis of the TEC4Home pilot study showed a positive trend in cost savings for patients using TEC4Home. From both the health system perspective (Pre TEC4Home cost per patient: CAD $2924 vs post TEC4Home cost per patient: CAD $1293; P=.01) and partial societal perspective (Pre TEC4Home cost per patient: CAD $2411 vs post TEC4Home cost per patient: CAD $1108; P=.01), we observed a statistically significant cost saving per patient. Conclusions: In line with the advantages of conducting an economic analysis alongside a feasibility study, the economic analysis of the TEC4Home pilot study facilitated the piloting of patient questionnaires and informed the methodology for a full clinical trial. UR - https://formative.jmir.org/2022/6/e32147 UR - http://dx.doi.org/10.2196/32147 UR - http://www.ncbi.nlm.nih.gov/pubmed/35653179 ID - info:doi/10.2196/32147 ER - TY - JOUR AU - Johnston, William AU - Keogh, Alison AU - Dickson, Jane AU - Leslie, J. Stephen AU - Megyesi, Peter AU - Connolly, Rachelle AU - Burke, David AU - Caulfield, Brian PY - 2022/5/10 TI - Human-Centered Design of a Digital Health Tool to Promote Effective Self-care in Patients With Heart Failure: Mixed Methods Study JO - JMIR Form Res SP - e34257 VL - 6 IS - 5 KW - digital health KW - heart failure KW - cardiology KW - self-care KW - behavior change KW - eHealth KW - mHealth KW - mobile health KW - mobile app KW - mobile phone N2 - Background: Effective self-care is an important factor in the successful management of patients with heart failure (HF). Despite the importance of self-care, most patients with HF are not adequately taught the wide range of skills required to become proficient in self-care. Digital health technology (DHT) may provide a novel solution to support patients at home in effective self-care, with the view to enhancing the quality of life and ultimately improving patient outcomes. However, many of the solutions developed to date have failed to consider users? perspectives at the point of design, resulting in poor effectiveness. Leveraging a human-centered design (HCD) approach to the development of DHTs may lead to the successful promotion of self-care behaviors in patients with HF. Objective: This study aimed to outline the HCD, development, and evaluation process of a DHT designed to promote effective self-care in patients with HF. Methods: A design thinking approach within the HCD framework was undertaken, as described in the International Organization for Standardization 9241-210:2019 regulations, using a 5-step process: empathize, ideate, design, develop, and test. Patients with HF were involved throughout the design and evaluation of the system. The designed system was grounded in behavior change theory using the Theoretical Domains Framework and included behavior change techniques. Mixed methods were used to evaluate the DHT during the testing phase. Results: Steps 1 to 3 of the process resulted in a set of evidence- and user-informed design requirements that were carried forward into the iterative development of a version 1 system. A cross-platform (iOS and Android) mobile app integrated with Fitbit activity trackers and smart scales was developed. A 2-week user testing phase highlighted the ease of use of the system, with patients demonstrating excellent adherence. Qualitative analysis of semistructured interviews identified the early potential for the system to positively influence self-care. Specifically, users perceived that the system increased their confidence and motivation to engage in key self-care behaviors, provided them with skills and knowledge that made them more aware of the importance of self-care behaviors, and might facilitate timely help seeking. Conclusions: The use of an HCD methodology in this research has resulted in the development of a DHT that may engage patients with HF and potentially affect their self-care behaviors. This comprehensive work lays the groundwork for further development and evaluation of this solution before its implementation in health care systems. A detailed description of the HCD process used in this research will help guide the development and evaluation of future DHTs across a range of disease use cases. UR - https://formative.jmir.org/2022/5/e34257 UR - http://dx.doi.org/10.2196/34257 UR - http://www.ncbi.nlm.nih.gov/pubmed/35536632 ID - info:doi/10.2196/34257 ER - TY - JOUR AU - Bas-Sarmiento, Pilar AU - Fernández-Gutiérrez, Martina AU - Poza-Méndez, Miriam AU - Marín-Paz, Jesús Antonio AU - Paloma-Castro, Olga AU - Romero-Sánchez, Manuel José AU - PY - 2022/4/29 TI - 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 JO - JMIR Res Protoc SP - e35945 VL - 11 IS - 4 KW - complex health needs KW - health literacy KW - heart failure KW - mHealth KW - multimorbidity N2 - 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 UR - https://www.researchprotocols.org/2022/4/e35945 UR - http://dx.doi.org/10.2196/35945 UR - http://www.ncbi.nlm.nih.gov/pubmed/35486437 ID - info:doi/10.2196/35945 ER - TY - JOUR AU - Bezerra Giordan, Leticia AU - Ronto, Rimante AU - Chau, Josephine AU - Chow, Clara AU - Laranjo, Liliana PY - 2022/4/20 TI - Use of Mobile Apps in Heart Failure Self-management: Qualitative Study Exploring the Patient and Primary Care Clinician Perspective JO - JMIR Cardio SP - e33992 VL - 6 IS - 1 KW - mobile app KW - mHealth KW - heart failure KW - self-management KW - eHealth KW - telehealth N2 - 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. UR - https://cardio.jmir.org/2022/1/e33992 UR - http://dx.doi.org/10.2196/33992 UR - http://www.ncbi.nlm.nih.gov/pubmed/35442205 ID - info:doi/10.2196/33992 ER - TY - JOUR AU - Brasca, Angelo Francesco Maria AU - Casale, Carla Maria AU - Canevese, Lorenzo Fabio AU - Tortora, Giovanni AU - Pagano, Giulia AU - Botto, Luca Giovanni PY - 2022/4/19 TI - Physical Activity in Patients With Heart Failure During and After COVID-19 Lockdown: Single-Center Observational Retrospective Study JO - JMIR Cardio SP - e30661 VL - 6 IS - 1 KW - heart failure KW - physical activity KW - COVID-19 KW - remote monitoring KW - implantable cardiac device KW - monitoring KW - exercise KW - surveillance KW - lockdown KW - cardiovascular KW - heart KW - retrospective KW - burden N2 - 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. UR - https://cardio.jmir.org/2022/1/e30661 UR - http://dx.doi.org/10.2196/30661 UR - http://www.ncbi.nlm.nih.gov/pubmed/35103602 ID - info:doi/10.2196/30661 ER - TY - JOUR AU - Bezerra Giordan, Leticia AU - Tong, Ly Huong AU - Atherton, J. John AU - Ronto, Rimante AU - Chau, Josephine AU - Kaye, David AU - Shaw, Tim AU - Chow, Clara AU - Laranjo, Liliana PY - 2022/3/31 TI - The Use of Mobile Apps for Heart Failure Self-management: Systematic Review of Experimental and Qualitative Studies JO - JMIR Cardio SP - e33839 VL - 6 IS - 1 KW - heart failure KW - self-management KW - mobile health KW - mobile app KW - secondary prevention KW - mobile phone N2 - 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. UR - https://cardio.jmir.org/2022/1/e33839 UR - http://dx.doi.org/10.2196/33839 UR - http://www.ncbi.nlm.nih.gov/pubmed/35357311 ID - info:doi/10.2196/33839 ER - TY - JOUR AU - Johnson, E. Amber AU - Routh, Shuvodra AU - Taylor, N. Christy AU - Leopold, Meagan AU - Beatty, Kathryn AU - McNamara, M. Dennis AU - Davis, M. Esa PY - 2022/3/21 TI - Developing and Implementing an mHealth Heart Failure Self-care Program to Reduce Readmissions: Randomized Controlled Trial JO - JMIR Cardio SP - e33286 VL - 6 IS - 1 KW - mHealth KW - heart failure KW - self-care KW - remote monitoring KW - telehealth KW - cardiology KW - hospital readmission KW - self-management KW - mobile health KW - patient-centered N2 - 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 UR - https://cardio.jmir.org/2022/1/e33286 UR - http://dx.doi.org/10.2196/33286 UR - http://www.ncbi.nlm.nih.gov/pubmed/35311679 ID - info:doi/10.2196/33286 ER - TY - JOUR AU - ten Klooster, Iris AU - Wentzel, Jobke AU - Sieverink, Floor AU - Linssen, Gerard AU - Wesselink, Robin AU - van Gemert-Pijnen, Lisette PY - 2022/3/15 TI - Personas for Better Targeted eHealth Technologies: User-Centered Design Approach JO - JMIR Hum Factors SP - e24172 VL - 9 IS - 1 KW - personas KW - clustering KW - heart failure KW - eHealth KW - user-centered design N2 - Background: The full potential of eHealth technologies to support self-management and disease management for patients with chronic diseases is not being reached. A possible explanation for these lacking results is that during the development process, insufficient attention is paid to the needs, wishes, and context of the prospective end users. To overcome such issues, the user-centered design practice of creating personas is widely accepted to ensure the fit between a technology and the target group or end users throughout all phases of development. Objective: In this study, we integrate several approaches to persona development into the Persona Approach Twente to attain a more holistic and structured approach that aligns with the iterative process of eHealth development. Methods: In 3 steps, a secondary analysis was carried out on different parts of the data set using the Partitioning Around Medoids clustering method. First, we used health-related electronic patient record data only. Second, we added person-related data that were gathered through interviews and questionnaires. Third, we added log data. Results: In the first step, 2 clusters were found, with average silhouette widths of 0.12 and 0.27. In the second step, again 2 clusters were found, with average silhouette widths of 0.08 and 0.12. In the third step, 3 clusters were identified, with average silhouette widths of 0.09, 0.12, and 0.04. Conclusions: The Persona Approach Twente is applicable for mixed types of data and allows alignment of this user-centered design method to the iterative approach of eHealth development. A variety of characteristics can be used that stretches beyond (standardized) medical and demographic measurements. Challenges lie in data quality and fitness for (quantitative) clustering. UR - https://humanfactors.jmir.org/2022/1/e24172 UR - http://dx.doi.org/10.2196/24172 UR - http://www.ncbi.nlm.nih.gov/pubmed/35289759 ID - info:doi/10.2196/24172 ER - TY - JOUR AU - Morken, Margreta Ingvild AU - Storm, Marianne AU - Søreide, Arne Jon AU - Urstad, Hjorthaug Kristin AU - Karlsen, Bjørg AU - Husebø, Lunde Anne Marie PY - 2022/2/15 TI - Posthospitalization Follow-Up of Patients With Heart Failure Using eHealth Solutions: Restricted Systematic Review JO - J Med Internet Res SP - e32946 VL - 24 IS - 2 KW - adherence KW - eHealth KW - heart failure KW - posthospitalization follow-up KW - patient outcome KW - review N2 - Background: Heart failure (HF) is a clinical syndrome with high incidence rates, a substantial symptom and treatment burden, and a significant risk of readmission within 30 days after hospitalization. The COVID-19 pandemic has revealed the significance of using eHealth interventions to follow up on the care needs of patients with HF to support self-care, increase quality of life (QoL), and reduce readmission rates during the transition between hospital and home. Objective: The aims of this review are to summarize research on the content and delivery modes of HF posthospitalization eHealth interventions, explore patient adherence to the interventions, and examine the effects on the patient outcomes of self-care, QoL, and readmissions. Methods: A restricted systematic review study design was used. Literature searches and reviews followed the (PRISMA-S) Preferred Reporting Items for Systematic Reviews and Meta-Analyses literature search extension checklist, and the CINAHL, MEDLINE, Embase, and Cochrane Library databases were searched for studies published between 2015 and 2020. The review process involved 3 groups of researchers working in pairs. The Mixed Methods Appraisal Tool was used to assess the included studies? methodological quality. A thematic analysis method was used to analyze data extracted from the studies. Results: A total of 18 studies were examined in this review. The studies were published between 2015 and 2019, with 56% (10/18) of them published in the United States. Of the 18 studies, 16 (89%) were randomized controlled trials, and 14 (78%) recruited patients upon hospital discharge to eHealth interventions lasting from 14 days to 12 months. The studies involved structured telephone calls, interactive voice response, and telemonitoring and included elements of patient education, counseling, social and emotional support, and self-monitoring of symptoms and vital signs. Of the 18 studies, 11 (61%) provided information on patient adherence, and the adherence levels were 72%-99%. When used for posthospitalization follow-up of patients with HF, eHealth interventions can positively affect QoL, whereas its impact is less evident for self-care and readmissions. Conclusions: This review suggests that patients with HF should receive prompt follow-up after hospitalization and eHealth interventions have the potential to improve these patients? QoL. Patient adherence in eHealth follow-up trials shows promise for successful future interventions and adherence research. Further studies are warranted to examine the effects of eHealth interventions on self-care and readmissions among patients with HF. UR - https://www.jmir.org/2022/2/e32946 UR - http://dx.doi.org/10.2196/32946 UR - http://www.ncbi.nlm.nih.gov/pubmed/35166680 ID - info:doi/10.2196/32946 ER - TY - JOUR AU - Leigh, W. Jonathan AU - Gerber, S. Ben AU - Gans, P. Christopher AU - Kansal, M. Mayank AU - Kitsiou, Spyros PY - 2022/1/14 TI - Smartphone Ownership and Interest in Mobile Health Technologies for Self-care Among Patients With Chronic Heart Failure: Cross-sectional Survey Study JO - JMIR Cardio SP - e31982 VL - 6 IS - 1 KW - mHealth KW - smartphone KW - mobile phone KW - heart failure KW - self-care KW - self-management N2 - 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 (Cramér V [?C]=0.35; P<.001), education (?C=0.29; P=.001), and employment status (?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. UR - https://cardio.jmir.org/2022/1/e31982 UR - http://dx.doi.org/10.2196/31982 UR - http://www.ncbi.nlm.nih.gov/pubmed/35029533 ID - info:doi/10.2196/31982 ER - TY - JOUR AU - Cornelius, Judith AU - Whitaker-Brown, Charlene AU - Smoot, Jaleesa AU - Hart, Sonia AU - Lewis, Zandria AU - Smith, Olivia PY - 2022/1/7 TI - A Text Messaging?Enhanced Intervention for African American Patients With Heart Failure, Depression, and Anxiety (TXT COPE-HF): Protocol for a Pilot Feasibility Study JO - JMIR Res Protoc SP - e32550 VL - 11 IS - 1 KW - African American KW - heart failure KW - depression KW - anxiety KW - assessment KW - decision KW - administration KW - production KW - topical expert KW - integration KW - training and testing model KW - text messaging KW - SMS KW - minorities KW - behavior therapy N2 - Background: African Americans have a higher incidence rate of heart failure (HF) and an earlier age of HF onset compared to those of other racial and ethnic groups. Scientific literature suggests that by 2030, African Americans will have a 30% increased prevalence rate of HF coupled with depression. In addition to depression, anxiety is a predictor of worsening functional capacity, decreased quality of life, and increased hospital readmission rates. There is no consensus on the best way to treat patients with HF, depression, and anxiety. One promising type of treatment?cognitive behavioral therapy (CBT)?has been shown to significantly improve patients? quality of life and treatment compliance, but CBT has not been used with SMS text messaging reminders to enhance the effect of reducing symptoms of depression and anxiety in racial and ethnic minority patients with HF. Objective: The objectives of our study are to (1) adapt and modify the Creating Opportunities for Personal Empowerment (COPE) curriculum for delivery to patients with HF by using an SMS text messaging component to improve depression and anxiety symptoms, (2) administer the adapted intervention to 10 patients to examine the feasibility and acceptability of the approach and modify it as needed, and (3) examine trends in depression and anxiety symptoms postintervention. We hypothesize that patients will show an improvement in depression scores and anxiety symptoms postintervention. Methods: The study will comprise a mixed methods approach. We will use the eight steps of the ADAPT-ITT (assessment, decision, administration, production, topical expert, integration, training, and testing) model to adapt the intervention. The first step in this feasibility study will involve assembling individuals from the target population (n=10) to discuss questions on a specific topic. In phase 2, we will examine the feasibility and acceptability of the enhanced SMS text messaging intervention (TXT COPE-HF [Texting With COPE for Patients With HF]) and its preliminary effects with 10 participants. The Beck Depression Inventory will be used to assess depression, the State-Trait Anxiety Inventory will be used to assess anxiety, and the Healthy Beliefs and Lifestyle Behavior surveys will be used to assess participants? lifestyle beliefs and behavior changes. Changes will be compared from baseline to end point by using paired 2-tailed t tests. An exit focus group (n=10) will be held to examine facilitators and barriers to the SMS text messaging protocol. Results: The pilot feasibility study was funded by the Academy for Clinical Research and Scholarship. Institutional review board approval was obtained in April 2021. Data collection and analysis are expected to conclude by November 2021 and April 2022, respectively. Conclusions: The study results will add to the literature on the effectiveness of an SMS text messaging CBT-enhanced intervention in reducing depression and anxiety among African American patients with HF. International Registered Report Identifier (IRRID): PRR1-10.2196/32550 UR - https://www.researchprotocols.org/2022/1/e32550 UR - http://dx.doi.org/10.2196/32550 UR - http://www.ncbi.nlm.nih.gov/pubmed/34994709 ID - info:doi/10.2196/32550 ER - TY - JOUR AU - Ali, Lilas AU - Wallström, Sara AU - Fors, Andreas AU - Barenfeld, Emmelie AU - Fredholm, Eva AU - Fu, Michael AU - Goudarzi, Mahboubeh AU - Gyllensten, Hanna AU - Lindström Kjellberg, Irma AU - Swedberg, Karl AU - Vanfleteren, W. Lowie E. G. AU - Ekman, Inger PY - 2021/12/13 TI - Effects of Person-Centered Care Using a Digital Platform and Structured Telephone Support for People With Chronic Obstructive Pulmonary Disease and Chronic Heart Failure: Randomized Controlled Trial JO - J Med Internet Res SP - e26794 VL - 23 IS - 12 KW - chronic heart failure KW - chronic obstructive pulmonary disease KW - digital platform KW - eHealth KW - patient-centered care KW - person-centered care KW - randomized controlled trial KW - telehealth N2 - Background: Chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) are characterized by severe symptom burden and common acute worsening episodes that often require hospitalization and affect prognosis. Although many studies have shown that person-centered care (PCC) increases self-efficacy in patients with chronic conditions, studies on patients with COPD and CHF treated in primary care and the effects of PCC on the risk of hospitalization in these patients are scarce. Objective: The aim of this study is to evaluate the effects of PCC through a combined digital platform and telephone support for people with COPD and CHF. Methods: A multicenter randomized trial was conducted from 2018 to 2020. A total of 222 patients were recruited from 9 primary care centers. Patients diagnosed with COPD, CHF, or both and with internet access were eligible. Participants were randomized into either usual care (112/222, 50.5%) or PCC combined with usual care (110/222, 49.5%). The intervention?s main component was a personal health plan cocreated by the participants and assigned health care professionals. The health care professionals called the participants in the intervention group and encouraged narration to establish a partnership using PCC communication skills. A digital platform was used as a communication tool. The primary end point, divided into 2 categories (improved and deteriorated or unchanged), was a composite score of change in general self-efficacy and hospitalization or death 6 months after randomization. Data from the intention-to-treat group at 3- and 6-month follow-ups were analyzed. In addition, a per-protocol analysis was conducted on the participants who used the intervention. Results: No significant differences were found in composite scores between the groups at the 3- and 6-month follow-ups. However, the per-protocol analysis of the 3-month follow-up revealed a significant difference in composite scores between the study groups (P=.047), although it was not maintained until the end of the 6-month follow-up (P=.24). This effect was driven by a change in general self-efficacy from baseline. Conclusions: PCC using a combined digital platform and structured telephone support seems to be an option to increase the short-term self-efficacy of people with COPD and CHF. This study adds to the knowledge of conceptual innovations in primary care to support patients with COPD and CHF. Trial Registration: ClinicalTrials.gov NCT03183817; http://clinicaltrials.gov/ct2/show/NCT03183817 UR - https://www.jmir.org/2021/12/e26794 UR - http://dx.doi.org/10.2196/26794 UR - http://www.ncbi.nlm.nih.gov/pubmed/34898447 ID - info:doi/10.2196/26794 ER - TY - JOUR AU - Dorsch, P. Michael AU - Farris, B. Karen AU - Rowell, E. Brigid AU - Hummel, L. Scott AU - Koelling, M. Todd PY - 2021/12/7 TI - The Effects of the ManageHF4Life Mobile App on Patients With Chronic Heart Failure: Randomized Controlled Trial JO - JMIR Mhealth Uhealth SP - e26185 VL - 9 IS - 12 KW - mHealth KW - remote monitoring KW - self-management KW - self-care KW - heart failure KW - medical therapy KW - mobile app N2 - 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 UR - https://mhealth.jmir.org/2021/12/e26185 UR - http://dx.doi.org/10.2196/26185 UR - http://www.ncbi.nlm.nih.gov/pubmed/34878990 ID - info:doi/10.2196/26185 ER - TY - JOUR AU - Artanian, Veronica AU - Ware, Patrick AU - Rac, E. Valeria AU - Ross, J. Heather AU - Seto, Emily PY - 2021/11/25 TI - Experiences and Perceptions of Patients and Providers Participating in Remote Titration of Heart Failure Medication Facilitated by Telemonitoring: Qualitative Study JO - JMIR Cardio SP - e28259 VL - 5 IS - 2 KW - telemonitoring KW - remote KW - titration KW - monitoring KW - mHealth KW - heart failure KW - qualitative KW - mobile phone N2 - Background: Guideline-directed medical therapy (GDMT), optimized to target doses, improves health outcomes in patients with heart failure. However, GDMT remains underused, with <25% of patients receiving target doses in clinical practice. A randomized controlled trial was conducted at the Peter Munk Cardiac Centre in Toronto to compare a remote GDMT titration intervention with standard in-office titration. This randomized controlled trial found that remote titration increased the proportion of patients who achieved optimal GDMT doses, decreased the time to dose optimization, and reduced the number of essential clinic visits. This paper presents findings from the qualitative component of the mixed methods study, which evaluated the implementation of the remote titration intervention. Objective: The objective of the qualitative component is to assess the perceptions and experiences of clinicians and patients with heart failure who participated in the remote titration intervention to identify factors that affected the implementation of the intervention. Methods: We conducted semistructured interviews with clinicians (n=5) and patients (n=11) who participated in the remote titration intervention. Questions probed the experiences of the participants to identify factors that can serve as barriers and facilitators to its implementation. Conventional content analysis was first used to analyze the interviews and gain direct information based on the participants? unique perspectives. Subsequently, the generated themes were delineated and mapped following a multilevel framework. Results: Patients and clinicians indicated that the intervention was easy to use, integrated well into their routines, and removed practical barriers to titration. Key implementation facilitators from the patients? perspective included the reduction in clinic visits and daily monitoring of their condition, whereas clinicians emphasized the benefits of rapid drug titration and efficient patient management. Key implementation barriers included the resources necessary to support the intervention and lack of physician remuneration. Conclusions: This study presents results from a real-world implementation assessment of remote titration facilitated by telemonitoring. It is among the first to provide insight into the perception of the remote titration process by clinicians and patients. Our findings indicate that the relative advantages that remote titration presents over standard care strongly appeal to both clinicians and patients. However, to ensure uptake and adherence, it is important to ensure that suitable patients are enrolled and the impact on the physicians? workload is minimized. The implementation of remote titration is now more critical than ever, as it can help provide access to care for patients during times when physical distancing is required. Trial Registration: ClinicalTrials.gov NCT04205513; https://clinicaltrials.gov/ct2/show/NCT04205513 International Registered Report Identifier (IRRID): RR2-10.2196/19705 UR - https://cardio.jmir.org/2021/2/e28259 UR - http://dx.doi.org/10.2196/28259 UR - http://www.ncbi.nlm.nih.gov/pubmed/34842546 ID - info:doi/10.2196/28259 ER - TY - JOUR AU - Radhakrishnan, Kavita AU - Julien, Christine AU - Baranowski, Tom AU - O'Hair, Matthew AU - Lee, Grace AU - Sagna De Main, Atami AU - Allen, Catherine AU - Viswanathan, Bindu AU - Thomaz, Edison AU - Kim, Miyong PY - 2021/11/8 TI - Feasibility of a Sensor-Controlled Digital Game for Heart Failure Self-management: Randomized Controlled Trial JO - JMIR Serious Games SP - e29044 VL - 9 IS - 4 KW - heart failure KW - digital game KW - sensor KW - self-management KW - older adults KW - weight monitoring KW - physical activity KW - behaviors KW - mobile phone N2 - 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 UR - https://games.jmir.org/2021/4/e29044 UR - http://dx.doi.org/10.2196/29044 UR - http://www.ncbi.nlm.nih.gov/pubmed/34747701 ID - info:doi/10.2196/29044 ER - TY - JOUR AU - ter Stal, Silke AU - Sloots, Joanne AU - Ramlal, Aniel AU - op den Akker, Harm AU - Lenferink, Anke AU - Tabak, Monique PY - 2021/11/4 TI - An Embodied Conversational Agent in an eHealth Self-management Intervention for Chronic Obstructive Pulmonary Disease and Chronic Heart Failure: Exploratory Study in a Real-life Setting JO - JMIR Hum Factors SP - e24110 VL - 8 IS - 4 KW - embodied conversational agent KW - eHealth KW - self-management KW - design KW - daily life evaluation N2 - Background: Embodied conversational agents (ECAs) have the potential to stimulate actual use of eHealth apps. An ECA?s design influences the user?s perception during short interactions, but daily life evaluations of ECAs in health care are scarce. Objective: This is an exploratory, long-term study on the design of ECAs for eHealth. The study investigates how patients perceive the design of the ECA over time with regard to the ECA?s characteristics (friendliness, trustworthiness, involvement, expertise, and authority), small talk interaction, and likeliness of following the agent?s advice. Methods: We developed an ECA within an eHealth self-management intervention for patients with both chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF), which we offered for 4 months. Patients rated 5 agent characteristics and likeliness of following the agent?s advice before use and after 3 and 9 weeks of use. The amount of patients? small talk interaction was assessed by log data. Lastly, individual semistructured interviews were used to triangulate results. Results: Eleven patients (7 male and 4 female) with COPD and CHF participated (median age 70 years). Patients? perceptions of the agent characteristics did not change over time (P>.05 for all characteristics) and only 1 participant finished all small talk dialogues. After 3 weeks of use, the patients were less likely to follow the agent?s advice (P=.01). The agent?s messages were perceived as nonpersonalized and the feedback as inappropriate, affecting the agent?s perceived reliability. Conclusions: This exploratory study provides first insights into ECA design for eHealth. The first impression of an ECA?s design seems to remain during long-term use. To investigate future added value of ECAs in eHealth, perceived reliability should be improved by managing users? expectations of the ECA?s capabilities and creating ECA designs fitting individual needs. Trial Registration: Netherlands Trial Register NL6480; https://www.trialregister.nl/trial/6480 UR - https://humanfactors.jmir.org/2021/4/e24110 UR - http://dx.doi.org/10.2196/24110 UR - http://www.ncbi.nlm.nih.gov/pubmed/34734824 ID - info:doi/10.2196/24110 ER - TY - JOUR AU - Diaz-Skeete, Maria Yohanca AU - McQuaid, David AU - Akinosun, Samuel Adewale AU - Ekerete, Idongesit AU - Carragher, Natacha AU - Carragher, Lucia PY - 2021/11/2 TI - Analysis of Apps With a Medication List Functionality for Older Adults With Heart Failure Using the Mobile App Rating Scale and the IMS Institute for Healthcare Informatics Functionality Score: Evaluation Study JO - JMIR Mhealth Uhealth SP - e30674 VL - 9 IS - 11 KW - mobile app KW - mHealth KW - medication app KW - heart failure KW - Mobile App Rating Scale N2 - Background: Managing the care of older adults with heart failure (HF) largely centers on medication management. Because of frequent medication or dosing changes, an app that supports these older adults in keeping an up-to-date list of medications could be advantageous. During the COVID-19 pandemic, HF outpatient consultations are taking place virtually or by telephone. An app with the capability to share a patient?s medication list with health care professionals before consultation could support clinical efficiency, for example, by reducing consultation time. However, the influence of apps on maintaining an up-to-date medication history for older adults with HF in Ireland remains largely unexplored. Objective: The aims of this review are twofold: to review apps with a medication list functionality and to assess the quality of the apps included in the review using the Mobile App Rating Scale (MARS) and the IMS Institute for Healthcare Informatics functionality scale. Methods: A systematic search of apps was conducted in June 2019 using the Google Play Store and iTunes App Store. The MARS was used independently by 4 researchers to assess the quality of the apps using an Android phone and an iPad. Apps were also evaluated using the IMS Institute for Healthcare Informatics functionality score. Results: Google Play and iTunes App store searches identified 483 potential apps (292 from Google Play and 191 from iTunes App stores). A total of 6 apps (3 across both stores) met the inclusion criteria. Of the 6 apps, 4 achieved an acceptable MARS score (3/5). The Medisafe app had the highest overall MARS score (4/5), and the Medication List & Medical Records app had the lowest overall score (2.5/5). On average, the apps had 8 functions based on the IMS functionality criteria (range 5-11). A total of 2 apps achieved the maximum score for number of features (11 features) according to the IMS Institute for Healthcare Informatics functionality score, and 2 scored the lowest (5 features). Peer-reviewed publications were identified for 3 of the apps. Conclusions: The quality of current apps with medication list functionality varies according to their technical aspects. Most of the apps reviewed have an acceptable MARS objective quality (ie, the overall quality of an app). However, subjective quality (ie, satisfaction with the apps) was poor. Only 3 apps are based on scientific evidence and have been tested previously. A total of 2 apps featured all the IMS Institute for Healthcare Informatics functionalities, and half did not provide clear instructions on how to enter medication data, did not display vital parameter data in an easy-to-understand format, and did not guide users on how or when to take their medication. UR - https://mhealth.jmir.org/2021/11/e30674 UR - http://dx.doi.org/10.2196/30674 UR - http://www.ncbi.nlm.nih.gov/pubmed/34726613 ID - info:doi/10.2196/30674 ER - TY - JOUR AU - Skov Schacksen, Cathrine AU - Henneberg, Celina Nanna AU - Muthulingam, Anajan Janusiya AU - Morimoto, Yuh AU - Sawa, Ryuichi AU - Saitoh, Masakazu AU - Morisawa, Tomoyuki AU - Kagiyama, Nobuyuki AU - Takahashi, Tetsuya AU - Kasai, Takatoshi AU - Daida, Hiroyuki AU - Refsgaard, Jens AU - Hollingdal, Malene AU - Dinesen, Birthe PY - 2021/11/1 TI - Effects of Telerehabilitation Interventions on Heart Failure Management (2015-2020): Scoping Review JO - JMIR Rehabil Assist Technol SP - e29714 VL - 8 IS - 4 KW - heart failure KW - telerehabilitation KW - quality of life KW - physical capacity KW - depression KW - anxiety KW - telehealth KW - rehabilitation KW - cardiac rehabilitation KW - cardiovascular disease KW - CVD KW - mental health KW - adherence N2 - Background: Heart failure is one of the world?s most frequently diagnosed cardiovascular diseases. An important element of heart failure management is cardiac rehabilitation, the goal of which is to improve patients? recovery, functional capacity, psychosocial well-being, and health-related quality of life. Patients in cardiac rehabilitation may lack sufficient motivation or may feel that the rehabilitation process does not meet their individual needs. One solution to these challenges is the use of telerehabilitation. Although telerehabilitation has been available for several years, it has only recently begun to be utilized in heart failure studies. Especially within the past 5 years, we now have several studies focusing on the effectiveness of telerehabilitation for heart failure management, all with varying results. Based on a review of these studies, this paper offers an assessment of the effectiveness of telerehabilitation as applied to heart failure management. Objective: The aim of this scoping review was to assess the effects of telerehabilitation in the management of heart failure by systematically reviewing the available scientific literature within the period from January 1, 2015, to December 31, 2020. Methods: The literature search was carried out using PubMed and EMBASE. After duplicates were removed, 77 articles were screened and 12 articles were subsequently reviewed. The review followed the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses for scoping reviews) guidelines. As measures of the effectiveness of telerehabilitation, the following outcomes were used: patients? quality of life, physical capacity, depression or anxiety, and adherence to the intervention. Results: A total of 12 articles were included in this review. In reviewing the effects of telerehabilitation for patients with heart failure, it was found that 4 out of 6 randomized controlled trials (RCTs), a single prospective study, and 4 out of 5 reviews reported increased quality of life for patients. For physical capacity, 4 RCTs and 3 systematic reviews revealed increased physical capacity. Depression or depressive symptoms were reported as being reduced in 1 of the 6 RCTs and in 2 of the 5 reviews. Anxiety or anxiety-related symptoms were reported as reduced in only 1 review. High adherence to the telerehabilitation program was reported in 4 RCTs and 4 reviews. It should be mentioned that some of the reviewed articles described the same studies although they employed different outcome measures. Conclusions: It was found that there is a tendency toward improvement in patients? quality of life and physical capacity when telerehabilitation was used in heart failure management. The outcome measures of depression, anxiety, and adherence to the intervention were found to be positive. Additional research is needed to determine more precise and robust effects of telerehabilitation. UR - https://rehab.jmir.org/2021/4/e29714 UR - http://dx.doi.org/10.2196/29714 UR - http://www.ncbi.nlm.nih.gov/pubmed/34723827 ID - info:doi/10.2196/29714 ER - TY - JOUR AU - Auener, L. Stefan AU - Remers, P. Toine E. AU - van Dulmen, A. Simone AU - Westert, P. Gert AU - Kool, B. Rudolf AU - Jeurissen, T. Patrick P. PY - 2021/9/29 TI - The Effect of Noninvasive Telemonitoring for Chronic Heart Failure on Health Care Utilization: Systematic Review JO - J Med Internet Res SP - e26744 VL - 23 IS - 9 KW - heart failure KW - telemonitoring KW - remote monitoring KW - health care utilization KW - eHealth N2 - Background: Chronic heart failure accounts for approximately 1%-2% of health care expenditures in most developed countries. These costs are primarily driven by hospitalizations and comorbidities. Telemonitoring has been proposed to reduce the number of hospitalizations and decrease the cost of treatment for patients with heart failure. However, the effects of telemonitoring on health care utilization remain unclear. Objective: This systematic review aims to study the effect of telemonitoring programs on health care utilization and costs in patients with chronic heart failure. We assess the effect of telemonitoring on hospitalizations, emergency department visits, length of stay, hospital days, nonemergency department visits, and health care costs. Methods: We searched PubMed, Embase, and Web of Science for randomized controlled trials and nonrandomized studies on noninvasive telemonitoring and health care utilization. We included studies published between January 2010 and August 2020. For each study, we extracted the reported data on the effect of telemonitoring on health care utilization. We used P<.05 and CIs not including 1.00 to determine whether the effect was statistically significant. Results: We included 16 randomized controlled trials and 13 nonrandomized studies. Inclusion criteria, population characteristics, and outcome measures differed among the included studies. Most studies showed no effect of telemonitoring on health care utilization. The number of hospitalizations was significantly reduced in 38% (9/24) of studies, whereas emergency department visits were reduced in 13% (1/8) of studies. An increase in nonemergency department visits (6/9, 67% of studies) was reported. Health care costs showed ambiguous results, with 3 studies reporting an increase in health care costs, 3 studies reporting a reduction, and 4 studies reporting no significant differences. Health care cost reductions were realized through a reduction in hospitalizations, whereas increases were caused by the high costs of the telemonitoring program or increased health care utilization. Conclusions: Most telemonitoring programs do not show clear effects on health care utilization measures, except for an increase in nonemergency outpatient department visits. This may be an unwarranted side effect rather than a prerequisite for effective telemonitoring. The consequences of telemonitoring on nonemergency outpatient visits should receive more attention from regulators, payers, and providers. This review further demonstrates the high clinical and methodological heterogeneity of telemonitoring programs. This should be taken into account in future meta-analyses aimed at identifying the effective components of telemonitoring programs. UR - https://www.jmir.org/2021/9/e26744 UR - http://dx.doi.org/10.2196/26744 UR - http://www.ncbi.nlm.nih.gov/pubmed/34586072 ID - info:doi/10.2196/26744 ER - TY - JOUR AU - Schmaderer, Myra AU - Miller, N. Jennifer AU - Mollard, Elizabeth PY - 2021/8/9 TI - Experiences of Using a Self-management Mobile App Among Individuals With Heart Failure: Qualitative Study JO - JMIR Nursing SP - e28139 VL - 4 IS - 3 KW - mHealth KW - eHealth KW - mobile applications KW - patient experiences KW - patient perceptions KW - self-management KW - self-care KW - heart failure KW - congestive heart failure KW - heart decompensation N2 - 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. UR - https://nursing.jmir.org/2021/3/e28139 UR - http://dx.doi.org/10.2196/28139 UR - http://www.ncbi.nlm.nih.gov/pubmed/34406966 ID - info:doi/10.2196/28139 ER - TY - JOUR AU - Aerts, Hannelore AU - Kalra, Dipak AU - Sáez, Carlos AU - Ramírez-Anguita, Manuel Juan AU - Mayer, Miguel-Angel AU - Garcia-Gomez, M. Juan AU - Durà-Hernández, Marta AU - Thienpont, Geert AU - Coorevits, Pascal PY - 2021/8/4 TI - Quality of Hospital Electronic Health Record (EHR) Data Based on the International Consortium for Health Outcomes Measurement (ICHOM) in Heart Failure: Pilot Data Quality Assessment Study JO - JMIR Med Inform SP - e27842 VL - 9 IS - 8 KW - data quality KW - electronic health records KW - heart failure KW - value-based health insurance KW - patient outcome assessment N2 - Background: There is increasing recognition that health care providers need to focus attention, and be judged against, the impact they have on the health outcomes experienced by patients. The measurement of health outcomes as a routine part of clinical documentation is probably the only scalable way of collecting outcomes evidence, since secondary data collection is expensive and error-prone. However, there is uncertainty about whether routinely collected clinical data within electronic health record (EHR) systems includes the data most relevant to measuring and comparing outcomes and if those items are collected to a good enough data quality to be relied upon for outcomes assessment, since several studies have pointed out significant issues regarding EHR data availability and quality. Objective: In this paper, we first describe a practical approach to data quality assessment of health outcomes, based on a literature review of existing frameworks for quality assessment of health data and multistakeholder consultation. Adopting this approach, we performed a pilot study on a subset of 21 International Consortium for Health Outcomes Measurement (ICHOM) outcomes data items from patients with congestive heart failure. Methods: All available registries compatible with the diagnosis of heart failure within an EHR data repository of a general hospital (142,345 visits and 12,503 patients) were extracted and mapped to the ICHOM format. We focused our pilot assessment on 5 commonly used data quality dimensions: completeness, correctness, consistency, uniqueness, and temporal stability. Results: We found high scores (>95%) for the consistency, completeness, and uniqueness dimensions. Temporal stability analyses showed some changes over time in the reported use of medication to treat heart failure, as well as in the recording of past medical conditions. Finally, the investigation of data correctness suggested several issues concerning the characterization of missing data values. Many of these issues appear to be introduced while mapping the IMASIS-2 relational database contents to the ICHOM format, as the latter requires a level of detail that is not explicitly available in the coded data of an EHR. Conclusions: Overall, results of this pilot study revealed good data quality for the subset of heart failure outcomes collected at the Hospital del Mar. Nevertheless, some important data errors were identified that were caused by fundamentally different data collection practices in routine clinical care versus research, for which the ICHOM standard set was originally developed. To truly examine to what extent hospitals today are able to routinely collect the evidence of their success in achieving good health outcomes, future research would benefit from performing more extensive data quality assessments, including all data items from the ICHOM standards set and across multiple hospitals. UR - https://medinform.jmir.org/2021/8/e27842 UR - http://dx.doi.org/10.2196/27842 UR - http://www.ncbi.nlm.nih.gov/pubmed/34346902 ID - info:doi/10.2196/27842 ER - TY - JOUR AU - Skov Schacksen, Cathrine AU - Dyrvig, Anne-Kirstine AU - Henneberg, Celina Nanna AU - Dam Gade, Josefine AU - Spindler, Helle AU - Refsgaard, Jens AU - Hollingdal, Malene AU - Dittman, Lars AU - Dremstrup, Kim AU - Dinesen, Birthe PY - 2021/7/2 TI - Patient-Reported Outcomes From Patients With Heart Failure Participating in the Future Patient Telerehabilitation Program: Data From the Intervention Arm of a Randomized Controlled Trial JO - JMIR Cardio SP - e26544 VL - 5 IS - 2 KW - adherence KW - cardiology KW - cardiomyopathy KW - compliance KW - heart failure KW - heart KW - Kansas City Cardiomyopathy Questionnaire KW - monitoring KW - patient-reported outcome KW - patients KW - quality of life KW - rehabilitation KW - self-reporting KW - telehealth KW - telemonitoring N2 - Background: More than 37 million people worldwide have been diagnosed with heart failure, which is a growing burden on the health sector. Cardiac rehabilitation aims to improve patients? recovery, functional capacity, psychosocial well-being, and health-related quality of life. However, cardiac rehabilitation programs have poor compliance and adherence. Telerehabilitation may be a solution to overcome some of these challenges to cardiac rehabilitation by making it more individualized. As part of the Future Patient Telerehabilitation program, a digital toolbox aimed at enabling patients with heart failure to monitor and evaluate their own current status has been developed and tested using data from a patient-reported outcome questionnaire that the patient filled in every alternate week for 1 year. Objective: The aim of this study is to evaluate the changes in quality of life and well-being among patients with heart failure, who are participants in the Future Patient Telerehabilitation program over the course of 1 year. Methods: In total, 140 patients were enrolled in the Future Patient Telerehabilitation program and randomized into either the telerehabilitation group (n=70) or the control group (n=70). Of the 70 patients in the telerehabilitation group, 56 (80.0%) answered the patient-reported outcome questionnaire and completed the program, and these 56 patients comprised the study population. The patient-reported outcomes consisted of three components: (1) questions regarding the patients? sleep patterns assessed using the Spiegel Sleep Questionnaire; (2) measurements of physical limitations, symptoms, self-efficacy, social interaction, and quality of life assessed using the Kansas City Cardiomyopathy Questionnaire in 10 dimensions; and (3) 5 additional questions regarding psychological well-being that were developed by the research group. Results: The changes in scores during 1 year of the study were examined using 1-sample Wilcoxon signed-rank tests. There were significant differences in the scores for most of the slopes of the scores from the dimensions of the Kansas City Cardiomyopathy Questionnaire (P<.05). Conclusions: There was a significant increase in clinical and social well-being and quality of life during the 1-year period of participating in a telerehabilitation program. These results suggest that patient-reported outcome questionnaires may be used as a tool for patients in a telerehabilitation program that can both monitor and guide patients in mastering their own symptoms. Trial Registration: ClinicalTrials.gov NCT03388918; https://clinicaltrials.gov/ct2/show/NCT03388918 UR - https://cardio.jmir.org/2021/2/e26544 UR - http://dx.doi.org/10.2196/26544 UR - http://www.ncbi.nlm.nih.gov/pubmed/34255642 ID - info:doi/10.2196/26544 ER - TY - JOUR AU - Ho, Kendall AU - Novak Lauscher, Helen AU - Cordeiro, Jennifer AU - Hawkins, Nathaniel AU - Scheuermeyer, Frank AU - Mitton, Craig AU - Wong, Hubert AU - McGavin, Colleen AU - Ross, Dianne AU - Apantaku, Glory AU - Karim, Ehsan Mohammad AU - Bhullar, Amrit AU - Abu-Laban, Riyad AU - Nixon, Suzanne AU - Smith, Tyler PY - 2021/6/3 TI - Testing the Feasibility of Sensor-Based Home Health Monitoring (TEC4Home) to Support the Convalescence of Patients With Heart Failure: Pre?Post Study JO - JMIR Form Res SP - e24509 VL - 5 IS - 6 KW - telemonitoring KW - heart failure KW - home health monitoring KW - technology KW - telehealth KW - emergency care KW - community care KW - emergency department KW - quality of life KW - self-efficacy N2 - Background: Patients with heart failure (HF) can be affected by disabling symptoms and low quality of life. Furthermore, they may frequently need to visit the emergency department or be hospitalized due to their condition deteriorating. Home telemonitoring can play a role in tracking symptoms, reducing hospital visits, and improving quality of life. Objective: Our objective was to conduct a feasibility study of a home health monitoring (HHM) solution for patients with HF in British Columbia, Canada, to prepare for conducting a randomized controlled trial. Methods: Patients with HF were recruited from 3 urban hospitals and provided with HHM technology for 60 days of monitoring postdischarge. Participants were asked to monitor their weight, blood pressure, and heart rate and to answer symptomology questions via Bluetooth sensors and a tablet computer each day. A monitoring nurse received this data and monitored the patient?s condition. In our evaluation, the primary outcome was the combination of unscheduled emergency department revisits of discharged participants or death within 90 days. Secondary outcomes included 90-day hospital readmissions, patient quality of life (as measured by Veterans Rand 12-Item Health Survey and Kansas City Cardiomyopathy Scale), self-efficacy (as measured by European Heart Failure Self-Care Behaviour Scale 9), end-user experience, and health system cost-effectiveness including cost reduction and hospital bed capacity. In this feasibility study, we also tested the recruitment strategy, clinical protocols, evaluation framework, and data collection methods. Results: Seventy participants were enrolled into this trial. Participant engagement to monitoring was measured at 94% (N=70; ie, data submitted 56/60 days on average). Our evaluation framework allowed us to collect sound data, which also showed encouraging trends: a 79% reduction of emergency department revisits post monitoring, an 87% reduction in hospital readmissions, and a 60% reduction in the median hospital length of stay (n=36). Cost of hospitalization for participants decreased by 71%, and emergency department visit costs decreased by 58% (n=30). Overall health system costs for our participants showed a 56% reduction post monitoring (n=30). HF-specific quality of life (Kansas City Cardiomyopathy Scale) scores showed a significant increase of 101% (n=35) post monitoring (P<.001). General quality of life (Veterans Rand 12-Item Health Survey) improved by 19% (n=35) on the mental component score (P<.001) and 19% (n=35) on the physical component score (P=.02). Self-efficacy improved by 6% (n=35). Interviews with participants revealed that they were satisfied overall with the monitoring program and its usability, and participants reported being more engaged, educated, and involved in their self-management. Conclusions: Results from this small-sample feasibility study suggested that our HHM intervention can be beneficial in supporting patients post discharge. Additionally, key insights from the trial allowed us to refine our methods and procedures, such as shifting our recruitment methods to in-patient wards and increasing our scope of data collection. Although these findings are promising, a more rigorous trial design is required to test the true efficacy of the intervention. The results from this feasibility trial will inform our next step as we proceed with a randomized controlled trial across British Columbia. Trial Registration: ClinicalTrials.gov NCT03439384; https://clinicaltrials.gov/ct2/show/NCT03439384 UR - https://formative.jmir.org/2021/6/e24509 UR - http://dx.doi.org/10.2196/24509 UR - http://www.ncbi.nlm.nih.gov/pubmed/34081015 ID - info:doi/10.2196/24509 ER - TY - JOUR AU - Friedman, M. Daniel AU - Goldberg, M. Jana AU - Molinsky, L. Rebecca AU - Hanson, A. Mark AU - Castaño, Adam AU - Raza, Syed-Samar AU - Janas, Nodar AU - Celano, Peter AU - Kapoor, Karen AU - Telaraja, Jina AU - Torres, L. Maria AU - Jain, Nayan AU - Wessler, D. Jeffrey PY - 2021/6/1 TI - A Virtual Cardiovascular Care Program for Prevention of Heart Failure Readmissions in a Skilled Nursing Facility Population: Retrospective Analysis JO - JMIR Cardio SP - e29101 VL - 5 IS - 1 KW - heart failure KW - readmissions KW - skilled nursing facilities KW - posthospitalization KW - cardiovascular KW - cardiology KW - outcome KW - cost KW - virtual care KW - telehealth KW - telemedicine KW - mobile health KW - mHealth KW - digital health N2 - Background: Patients with heart failure (HF) in skilled nursing facilities (SNFs) have 30-day hospital readmission rates as high as 43%. A virtual cardiovascular care program, consisting of patient selection, initial televisit, postconsultation care planning, and follow-up televisits, was developed and delivered by Heartbeat Health, Inc., a cardiovascular digital health company, to 11 SNFs (3510 beds) in New York. The impact of this program on the expected SNF 30-day HF readmission rate is unknown, particularly in the COVID-19 era. Objective: The aim of the study was to assess whether a virtual cardiovascular care program could reduce the 30-day hospital readmission rate for patients with HF discharged to SNF relative to the expected rate for this population. Methods: We performed a retrospective case review of SNF patients who received a virtual cardiology consultation between August 2020 and February 2021. Virtual cardiologists conducted 1 or more telemedicine visit via smartphone, tablet, or laptop for cardiac patients identified by a SNF care team. Postconsult care plans were communicated to SNF clinical staff. Patients included in this analysis had a preceding index admission for HF. Results: We observed lower hospital readmission among patients who received 1 or more virtual consultations compared with the expected readmission rate for both cardiac (3% vs 10%, respectively) and all-cause etiologies (18% vs 27%, respectively) in a population of 3510 patients admitted to SNF. A total of 185/3510 patients (5.27%) received virtual cardiovascular care via the Heartbeat Health program, and 40 patients met study inclusion criteria and were analyzed, with 26 (65%) requiring 1 televisit and 14 (35%) requiring more than 1. Cost savings associated with this reduction in readmissions are estimated to be as high as US $860 per patient. Conclusions: The investigation provides initial evidence for the potential effectiveness and efficiency of virtual and digitally enabled virtual cardiovascular care on 30-day hospital readmissions. Further research is warranted to optimize the use of novel virtual care programs to transform delivery of cardiovascular care to high-risk populations. UR - https://cardio.jmir.org/2021/1/e29101 UR - http://dx.doi.org/10.2196/29101 UR - http://www.ncbi.nlm.nih.gov/pubmed/34061037 ID - info:doi/10.2196/29101 ER - TY - JOUR AU - Suutari, Anne-Marie AU - Thor, Johan AU - Nordin, M. Annika M. AU - Kjellström, Sofia AU - Areskoug Josefsson, Kristina PY - 2021/5/11 TI - Improving Health for People Living With Heart Failure: Focus Group Study of Preconditions for Co-Production of Health and Care JO - J Particip Med SP - e27125 VL - 13 IS - 2 KW - co-production of health and care KW - capability KW - motivation KW - opportunity KW - Capability, Opportunity, and Motivation Behavior model KW - focus groups KW - heart failure KW - Sweden KW - primary care KW - cardiology KW - co-production N2 - Background: Co-production of health and care involving patients, families of patients, and professionals in care processes can create joint learning about how to meet patients? needs. Although barriers and facilitators to co-production have been examined previously in various health care contexts, the preconditions in Swedish chronic cardiac care contexts are yet to be explored. This study is set in the health system of the Swedish region of Jönköping County and is part of system-wide efforts to promote better health for persons with heart failure (HF). Objective: The objective of this study was to test the usefulness of the Capability, Opportunity, and Motivation Behavior (COM-B) model when assessing the barriers to and facilitators of co-production of health and care perceived by patients with HF, family members of patients with HF, and professionals in a Swedish chronic cardiac care context as a guide for subsequent initiatives. Methods: Data collection involved 1 focus group interview (FGI) with patients with HF (n=5), 1 FGI with family members of patients with HF (n=5), 1 FGI with professionals in primary care (n=7), and 1 FGI with professionals in cardiac care (n=4). In addition, patients with HF kept diaries of their thoughts regarding co-production. Using a deductive approach to content analysis, underpinned by the COM-B model, barriers and facilitators were categorized into capabilities, opportunities, and motivations to co-produce health and care. Results: The participants showed limited understanding of co-production as a practice. They appeared to view it as a privilege to be offered to patients on top of traditional care and rarely as an approach for improving health care processes. The interviews revealed the limited health literacy among patients and the struggle of professionals to convey health information to these patients. Co-production was considered to be more resource-intensive than traditional care. Different expectations of stakeholders? roles were revealed: professionals expected older patients not to want to co-produce health and care, and all participants expected professionals to be in charge of health care services. The family members? position involved trying to balance their desire to support their relatives with understanding when, how, and with whom to co-produce. Presumed benefits motivated stakeholders: co-production was recognized to motivate patients to improve self-care. However, the participants recognized that motivation to get involved in health and care decisions varies over time among stakeholders. Conclusions: Co-production can be facilitated by the stakeholders? motivation. However, varying levels of understanding of co-production, patients? limited health literacy, unease with power sharing between patients and professionals, and resource constraints are barriers that need to be managed to promote co-produced care and better health for persons living with HF. Further research is warranted to explore how to co-produce health care services with patients with HF and how leaders can facilitate the inevitable cultural change it requires and represents. UR - https://jopm.jmir.org/2021/2/e27125 UR - http://dx.doi.org/10.2196/27125 UR - http://www.ncbi.nlm.nih.gov/pubmed/33973859 ID - info:doi/10.2196/27125 ER - TY - JOUR AU - Krzesinski, Pawel AU - Sobotnicki, Aleksander AU - Gacek, Adam AU - Siebert, Janusz AU - Walczak, Andrzej AU - Murawski, Piotr AU - Gielerak, Grzegorz PY - 2021/5/5 TI - Noninvasive Bioimpedance Methods From the Viewpoint of Remote Monitoring in Heart Failure JO - JMIR Mhealth Uhealth SP - e25937 VL - 9 IS - 5 KW - heart failure KW - impedance cardiography KW - remote monitoring KW - overhydration KW - hemodynamics KW - heart KW - cardiac function KW - cardiac KW - monitor UR - https://mhealth.jmir.org/2021/5/e25937 UR - http://dx.doi.org/10.2196/25937 UR - http://www.ncbi.nlm.nih.gov/pubmed/33949964 ID - info:doi/10.2196/25937 ER - TY - JOUR AU - Litrownik, Daniel AU - Gilliam, A. Elizabeth AU - Wayne, M. Peter AU - Richardson, R. Caroline AU - Kadri, Reema AU - Rist, M. Pamela AU - Moy, L. Marilyn AU - Yeh, Y. Gloria PY - 2021/4/29 TI - Development of a Novel Intervention (Mindful Steps) to Promote Long-Term Walking Behavior in Chronic Cardiopulmonary Disease: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e27826 VL - 10 IS - 4 KW - mind?body exercise KW - internet-mediated intervention KW - behavior change KW - physical activity KW - COPD KW - heart failure N2 - Background: Despite current rehabilitation programs, long-term engagement in physical activity remains a significant challenge for patients with chronic obstructive pulmonary disease (COPD) and heart failure (HF). Novel strategies to promote physical activity in these populations are greatly needed. Emerging literature on the benefits of both mind?body interventions and web-based interventions provide the rationale for the development of the Mindful Steps intervention for increasing walking behavior. Objective: This study aims to develop a novel multimodal mind?body exercise intervention through adaptation of an existing web-based physical activity intervention and incorporation of mind?body exercise, and to pilot test the delivery of the new intervention, Mindful Steps, in a randomized controlled feasibility trial in older adults with COPD and/or HF. Methods: In phase 1, guided by a theoretical conceptual model and review of the literature on facilitators and barriers of physical activity in COPD and HF, we convened an expert panel of researchers, mind?body practitioners, and clinicians to inform development of the novel, multimodal intervention. In phase 2, we are conducting a pilot randomized controlled feasibility trial of the Mindful Steps intervention that includes in-person mind?body exercise classes, an educational website, online mind?body videos, and a pedometer with step-count feedback and goals to increase walking behavior in patients with COPD and/or HF. Outcomes include feasibility measures as well as patient-centered measures. Results: The study is currently ongoing. Phase 1 intervention development was completed in March 2019, and phase 2 data collection began in April 2019. Conclusions: Through the integration of components from a web-based physical activity intervention and mind?body exercise, we created a novel, multimodal program to impact long-term physical activity engagement for individuals with COPD and HF. This developmental work and pilot study will provide valuable information needed to design a future clinical trial assessing efficacy of this multimodal approach. Trial Registration: ClinicalTrials.gov NCT03003780; https://clinicaltrials.gov/ct2/show/NCT03003780 International Registered Report Identifier (IRRID): DERR1-10.2196/27826 UR - https://www.researchprotocols.org/2021/4/e27826 UR - http://dx.doi.org/10.2196/27826 UR - http://www.ncbi.nlm.nih.gov/pubmed/33913819 ID - info:doi/10.2196/27826 ER - TY - JOUR AU - Jiang, Ying AU - Koh, Ling Karen Wei AU - Ramachandran, Joann Hadassah AU - Tay, Kian Yee AU - Wu, Xi Vivien AU - Shorey, Shefaly AU - Wang, Wenru PY - 2021/4/27 TI - Patients? Experiences of a Nurse-Led, Home-Based Heart Failure Self-management Program: Findings From a Qualitative Process Evaluation JO - J Med Internet Res SP - e28216 VL - 23 IS - 4 KW - self-care KW - psychosocial educational KW - nurse-led KW - mHealth KW - self-management KW - heart failure KW - process evaluation KW - nursing KW - mobile phone N2 - Background: Heart failure (HF) is a major public health problem that places a significant disease burden on society. Self-care is important in the management of HF because it averts disease progression and reduces the number of hospitalizations. Effective nursing interventions promote HF self-care. Objective: This study aims to explore participants? perspectives on a nurse-led, home-based heart failure self-management program (HOM-HEMP) in a randomized controlled trial conducted in Singapore to gain insight into the effectiveness of the study intervention. Methods: A descriptive, qualitative approach was used. English- or Chinese-speaking participants from the intervention arms were recruited through a purposive sampling method from January 2019 to July 2019. Individual, face-to-face, semistructured interviews were conducted with 11 participants. All interviews were audio recorded and transcribed verbatim, with the participant identifiers omitted to ensure confidentiality. The thematic analysis approach was used to identify, analyze, and report patterns (themes) within the data. Results: A total of six themes emerged from the process evaluation interviews and were categorized according to the Donabedian structure-process-outcome framework as intervention structure, intervention process, and intervention outcome. These six themes were manageability of the intervention, areas for improvement, benefits of visiting, personal accountability in self-care, empowered with knowledge and skills in self-care after the intervention, and increased self-efficacy in cardiac care. Conclusions: The findings of the process evaluation provided additional information on participants? perceptions and experiences with the HOM-HEMP intervention. Although a home visit may be perceived as resource intensive, it remains to be the preferred way of engagement for most patients. Nurses play an important role in promoting HF self-care. The process of interaction with the patient can be an important process for empowering self-care behavior changes. UR - https://www.jmir.org/2021/4/e28216 UR - http://dx.doi.org/10.2196/28216 UR - http://www.ncbi.nlm.nih.gov/pubmed/33904823 ID - info:doi/10.2196/28216 ER - TY - JOUR AU - D´Ancona, Giuseppe AU - Murero, Monica AU - Feickert, Sebastian AU - Kaplan, Hilmi AU - Öner, Alper AU - Ortak, Jasmin AU - Ince, Hueseyin PY - 2021/4/21 TI - Implantation of an Innovative Intracardiac Microcomputer System for Web-Based Real-Time Monitoring of Heart Failure: Usability and Patients? Attitudes JO - JMIR Cardio SP - e21055 VL - 5 IS - 1 KW - heart KW - failure KW - left atrial KW - pressure KW - intracardiac KW - device KW - monitoring KW - implantable KW - wireless KW - transmission KW - web-based N2 - 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 UR - https://cardio.jmir.org/2021/1/e21055 UR - http://dx.doi.org/10.2196/21055 UR - http://www.ncbi.nlm.nih.gov/pubmed/33881400 ID - info:doi/10.2196/21055 ER - TY - JOUR AU - Bakogiannis, Constantinos AU - Tsarouchas, Anastasios AU - Mouselimis, Dimitrios AU - Lazaridis, Charalampos AU - Theofillogianakos, K. Efstratios AU - Billis, Antonios AU - Tzikas, Stergios AU - Fragakis, Nikolaos AU - Bamidis, D. Panagiotis AU - Papadopoulos, E. Christodoulos AU - Vassilikos, P. Vassilios PY - 2021/4/13 TI - A Patient-Oriented App (ThessHF) to Improve Self-Care Quality in Heart Failure: From Evidence-Based Design to Pilot Study JO - JMIR Mhealth Uhealth SP - e24271 VL - 9 IS - 4 KW - mHealth KW - heart failure KW - smartphone app KW - self-care KW - COVID-19 KW - patients KW - caregivers N2 - Background: Heart failure (HF) remains a major public health challenge, while HF self-care is particularly challenging. Mobile health (mHealth)?based interventions taking advantage of smartphone technology have shown particular promise in increasing the quality of self-care among these patients, and in turn improving the outcomes of their disease. Objective: The objective of this study was to co-develop with physicians, patients with HF, and their caregivers a patient-oriented mHealth app, perform usability assessment, and investigate its effect on the quality of life of patients with HF and rate of hospitalizations in a pilot study. Methods: The development of an mHealth app (The Hellenic Educational Self-care and Support Heart Failure app [ThessHF app]) was evidence based, including features based on previous clinically tested mHealth interventions and selected by a panel of HF expert physicians and discussed with patients with HF. At the end of alpha development, the app was rated by mHealth experts with the Mobile Application Rating Scale (MARS). The beta version was tested by patients with HF, who rated its design and content by means of the Post-Study System Usability Questionnaire (PSSUQ). Subsequently, a prospective pilot study (THESS-HF [THe Effect of a Specialized Smartphone app on Heart Failure patients? quality of self-care, quality of life and hospitalization rate]) was performed to investigate the effect of app use on patients with HF over a 3-month follow-up period. The primary endpoint was patients? quality of life, which was measured with the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the 5-level EQ-5D version (EQ-5D-5L). The secondary endpoints were the European Heart Failure Self-care Behavior Scale (EHFScBS) score and the hospitalization rate. Results: A systematic review of mHealth-based HF interventions and expert panel suggestions yielded 18 separate app features, most of which were incorporated into the ThessHF app. A total of 14 patients and 5 mHealth experts evaluated the app. The results demonstrated a very good user experience (overall PSSUQ score 2.37 [SD 0.63], where 1 is the best, and a median MARS score of 4.55/5). Finally, 30 patients (male: n=26, 87%) participated in the THESS-HF pilot study (mean age 68.7 [SD 12.4] years). A significant increase in the quality of self-care was noted according to the EHFScBS, which increased by 4.4% (SD 7.2%) (P=.002). The mean quality of life increased nonsignificantly after 3 months according to both KCCQ (mean increase 5.8 [SD 15] points, P=.054) and EQ-5D-5L (mean increase 5.6% [SD 15.6%], P=.06) scores. The hospitalization rate for the follow-up duration was 3%. Conclusions: The need for telehealth services and remote self-care management in HF is of vital importance, especially in periods such as the COVID-19 pandemic. We developed a user-friendly mHealth app to promote remote self-care support in HF. In this pilot study, the use of the ThessHF app was associated with an increase in the quality of self-care. A future multicenter study will investigate the effect of the app use on long-term outcomes in patients with HF. UR - https://mhealth.jmir.org/2021/4/e24271 UR - http://dx.doi.org/10.2196/24271 UR - http://www.ncbi.nlm.nih.gov/pubmed/33847599 ID - info:doi/10.2196/24271 ER - TY - JOUR AU - Apergi, Anna Lida AU - Bjarnadottir, V. Margret AU - Baras, S. John AU - Golden, L. Bruce AU - Anderson, M. Kelley AU - Chou, Jiling AU - Shara, Nawar PY - 2021/4/1 TI - Voice Interface Technology Adoption by Patients With Heart Failure: Pilot Comparison Study JO - JMIR Mhealth Uhealth SP - e24646 VL - 9 IS - 4 KW - heart failure KW - telehealth KW - voice interface KW - conversational agent KW - artificial intelligence KW - wireless technology KW - social determinants of health KW - mobile phone N2 - Background: Heart failure (HF) is associated with high mortality rates and high costs, and self-care is crucial in the management of the condition. Telehealth can promote patients? self-care while providing frequent feedback to their health care providers about the patient?s compliance and symptoms. A number of technologies have been considered in the literature to facilitate telehealth in patients with HF. An important factor in the adoption of these technologies is their ease of use. Conversational agent technologies using a voice interface can be a good option because they use speech recognition to communicate with patients. Objective: The aim of this paper is to study the engagement of patients with HF with voice interface technology. In particular, we investigate which patient characteristics are linked to increased technology use. Methods: We used data from two separate HF patient groups that used different telehealth technologies over a 90-day period. Each group used a different type of voice interface; however, the scripts followed by the two technologies were identical. One technology was based on Amazon?s Alexa (Alexa+), and in the other technology, patients used a tablet to interact with a visually animated and voice-enabled avatar (Avatar). Patient engagement was measured as the number of days on which the patients used the technology during the study period. We used multiple linear regression to model engagement with the technology based on patients? demographic and clinical characteristics and past technology use. Results: In both populations, the patients were predominantly male and Black, had an average age of 55 years, and had HF for an average of 7 years. The only patient characteristic that was statistically different (P=.008) between the two populations was the number of medications they took to manage HF, with a mean of 8.7 (SD 4.0) for Alexa+ and 5.8 (SD 3.4) for Avatar patients. The regression model on the combined population shows that older patients used the technology more frequently (an additional 1.19 days of use for each additional year of age; P=.004). The number of medications to manage HF was negatively associated with use (?5.49; P=.005), and Black patients used the technology less frequently than other patients with similar characteristics (?15.96; P=.08). Conclusions: Older patients? higher engagement with telehealth is consistent with findings from previous studies, confirming the acceptability of technology in this subset of patients with HF. However, we also found that a higher number of HF medications, which may be correlated with a higher disease burden, is negatively associated with telehealth use. Finally, the lower engagement of Black patients highlights the need for further study to identify the reasons behind this lower engagement, including the possible role of social determinants of health, and potentially create technologies that are better tailored for this population. UR - https://mhealth.jmir.org/2021/4/e24646 UR - http://dx.doi.org/10.2196/24646 UR - http://www.ncbi.nlm.nih.gov/pubmed/33792556 ID - info:doi/10.2196/24646 ER - TY - JOUR AU - Lu?trek, Mitja AU - Bohanec, Marko AU - Cavero Barca, Carlos AU - Ciancarelli, Costanza Maria AU - Clays, Els AU - Dawodu, Adeyemo Amos AU - Derboven, Jan AU - De Smedt, Delphine AU - Dovgan, Erik AU - Lampe, Jure AU - Marino, Flavia AU - Mlakar, Miha AU - Pioggia, Giovanni AU - Puddu, Emilio Paolo AU - Rodríguez, Mario Juan AU - Schiariti, Michele AU - Slapni?ar, Ga?per AU - Slegers, Karin AU - Tartarisco, Gennaro AU - Vali?, Jakob AU - Vodopija, Aljo?a PY - 2021/3/5 TI - A Personal Health System for Self-Management of Congestive Heart Failure (HeartMan): Development, Technical Evaluation, and Proof-of-Concept Randomized Controlled Trial JO - JMIR Med Inform SP - e24501 VL - 9 IS - 3 KW - congestive heart failure KW - personal health system KW - mobile application KW - mobile phone KW - wearable electronic devices KW - decision support techniques KW - psychological support KW - human centered design N2 - 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 UR - https://medinform.jmir.org/2021/3/e24501 UR - http://dx.doi.org/10.2196/24501 UR - http://www.ncbi.nlm.nih.gov/pubmed/33666562 ID - info:doi/10.2196/24501 ER - TY - JOUR AU - Jiang, Xinchan AU - Yao, Jiaqi AU - You, Hoi-Sze Joyce PY - 2021/3/3 TI - Cost-effectiveness of a Telemonitoring Program for Patients With Heart Failure During the COVID-19 Pandemic in Hong Kong: Model Development and Data Analysis JO - J Med Internet Res SP - e26516 VL - 23 IS - 3 KW - telemonitoring KW - mobile health KW - smartphone KW - heart failure KW - COVID-19 KW - health care avoidance KW - cost-effectiveness N2 - Background: The COVID-19 pandemic has caused patients to avoid seeking medical care. Provision of telemonitoring programs in addition to usual care has demonstrated improved effectiveness in managing patients with heart failure (HF). Objective: We aimed to examine the potential clinical and health economic outcomes of a telemonitoring program for management of patients with HF during the COVID-19 pandemic from the perspective of health care providers in Hong Kong. Methods: A Markov model was designed to compare the outcomes of a care under COVID-19 (CUC) group and a telemonitoring plus CUC group (telemonitoring group) in a hypothetical cohort of older patients with HF in Hong Kong. The model outcome measures were direct medical cost, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio. Sensitivity analyses were performed to examine the model assumptions and the robustness of the base-case results. Results: In the base-case analysis, the telemonitoring group showed a higher QALY gain (1.9007) at a higher cost (US $15,888) compared to the CUC group (1.8345 QALYs at US $15,603). Adopting US $48,937/QALY (1 × the gross domestic product per capita of Hong Kong) as the willingness-to-pay threshold, telemonitoring was accepted as a highly cost-effective strategy, with an incremental cost-effective ratio of US $4292/QALY. No threshold value was identified in the deterministic sensitivity analysis. In the probabilistic sensitivity analysis, telemonitoring was accepted as cost-effective in 99.22% of 10,000 Monte Carlo simulations. Conclusions: Compared to the current outpatient care alone under the COVID-19 pandemic, the addition of telemonitoring-mediated management to the current care for patients with HF appears to be a highly cost-effective strategy from the perspective of health care providers in Hong Kong. UR - https://www.jmir.org/2021/3/e26516 UR - http://dx.doi.org/10.2196/26516 UR - http://www.ncbi.nlm.nih.gov/pubmed/33656440 ID - info:doi/10.2196/26516 ER - TY - JOUR AU - Wei, S. Kevin AU - Ibrahim, E. Nasrien AU - Kumar, A. Ashok AU - Jena, Sidhant AU - Chew, Veronica AU - Depa, Michal AU - Mayanil, Namrata AU - Kvedar, C. Joseph AU - Gaggin, K. Hanna PY - 2021/1/20 TI - Habits Heart App for Patient Engagement in Heart Failure Management: Pilot Feasibility Randomized Trial JO - JMIR Mhealth Uhealth SP - e19465 VL - 9 IS - 1 KW - heart failure KW - smartphone application KW - heart failure management N2 - 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; ?=0.59, P=.04) and quality of life (Kansas City Cardiomyopathy Questionnaire score; ?=0.63, P=.03). The correlation between app use and weight change was ?=?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 UR - http://mhealth.jmir.org/2021/1/e19465/ UR - http://dx.doi.org/10.2196/19465 UR - http://www.ncbi.nlm.nih.gov/pubmed/33470941 ID - info:doi/10.2196/19465 ER - TY - JOUR AU - Cartledge, Susie AU - Maddison, Ralph AU - Vogrin, Sara AU - Falls, Roman AU - Tumur, Odgerel AU - Hopper, Ingrid AU - Neil, Christopher PY - 2020/12/22 TI - The Utility of Predicting Hospitalizations Among Patients With Heart Failure Using mHealth: Observational Study JO - JMIR Mhealth Uhealth SP - e18496 VL - 8 IS - 12 KW - cardiac failure KW - heart failure KW - readmission KW - hospitalization KW - risk prediction KW - mHealth N2 - Background: Heart failure decompensation is a major driver of hospitalizations and represents a significant burden to the health care system. Identifying those at greatest risk of admission can allow for targeted interventions to reduce this risk. Objective: This paper aims to compare the predictive value of objective and subjective heart failure respiratory symptoms on imminent heart failure decompensation and subsequent hospitalization within a 30-day period. Methods: A prospective observational pilot study was conducted. People living at home with heart failure were recruited from a single-center heart failure outpatient clinic. Objective (blood pressure, heart rate, weight, B-type natriuretic peptide) and subjective (4 heart failure respiratory symptoms scored for severity on a 5-point Likert scale) data were collected twice weekly for a 30-day period. Results: A total of 29 participants (median age 79 years; 18/29, 62% men) completed the study. During the study period, 10 of the 29 participants (34%) were hospitalized as a result of heart failure. For objective data, only heart rate exhibited a between-group difference. However, it was nonsignificant for variability (P=.71). Subjective symptom scores provided better prediction. Specifically, the highest precision of heart failure hospitalization was observed when patients with heart failure experienced severe dyspnea, orthopnea, and bendopnea on any given day (area under the curve of 0.77; sensitivity of 83%; specificity of 73%). Conclusions: The use of subjective respiratory symptom reporting on a 5-point Likert scale may facilitate a simple and low-cost method of predicting heart failure decompensation and imminent hospitalization. Serial collection of symptom data could be augmented using ecological momentary assessment of self-reported symptoms within a mobile health monitoring strategy for patients at high risk for heart failure decompensation. UR - http://mhealth.jmir.org/2020/12/e18496/ UR - http://dx.doi.org/10.2196/18496 UR - http://www.ncbi.nlm.nih.gov/pubmed/33350962 ID - info:doi/10.2196/18496 ER - TY - JOUR AU - Gade, Dam Josefine AU - Spindler, Helle AU - Hollingdal, Malene AU - Refsgaard, Jens AU - Dittmann, Lars AU - Frost, Lars AU - Mahboubi, Kiomars AU - Dinesen, Birthe PY - 2020/11/30 TI - Predictors of Walking Activity in Patients With Systolic Heart Failure Equipped With a Step Counter: Randomized Controlled Trial JO - JMIR Biomed Eng SP - e20776 VL - 5 IS - 1 KW - heart failure KW - cardiovascular rehabilitation KW - step counters KW - physical activity KW - telerehabilitation N2 - 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 UR - http://biomedeng.jmir.org/2020/1/e20776/ UR - http://dx.doi.org/10.2196/20776 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/20776 ER - TY - JOUR AU - Herkert, Cyrille AU - Kraal, Johannes Jos AU - Spee, Ferdinand Rudolph AU - Serier, Anouk AU - Graat-Verboom, Lidwien AU - Kemps, Clemens Hareld Marijn PY - 2020/11/19 TI - Quality Assessment of an Integrated Care Pathway Using Telemonitoring in Patients with Chronic Heart Failure and Chronic Obstructive Pulmonary Disease: Protocol for a Quasi-Experimental Study JO - JMIR Res Protoc SP - e20571 VL - 9 IS - 11 KW - chronic heart failure KW - chronic obstructive pulmonary disease KW - integrated care pathway KW - telemonitoring N2 - Background: Chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) often coexist and are associated with a high morbidity and reduced quality of life (QoL). Although these diseases share similarities in symptoms and clinical course, and exacerbations of both diseases often overlap, care pathways for both conditions are usually not integrated. This results in frequent outpatient consultations and suboptimal treatment during exacerbations, leading to frequent hospital admissions. Therefore, we propose an integrated care pathway for both diseases, using telemonitoring to detect deterioration at an early stage and a single case manager for both diseases. Objective: This study aims to investigate whether an integrated care pathway using telemonitoring in patients with combined CHF and COPD results in a higher general health-related QoL (HRQoL) as compared with the traditional care pathways. Secondary end points include disease-specific HRQoL, level of self-management, patient satisfaction, compliance to the program, and cost-effectiveness. Methods: This is a monocenter, prospective study using a quasi-experimental interrupted time series design. Thirty patients with combined CHF and COPD are included. The study period of 2.5 years per patient is divided into a preintervention phase (6 months) and a postintervention phase (2 years) in which end points are assessed. The intervention consists of an on-demand treatment strategy based on monitoring symptoms related to CHF/COPD and vital parameters (weight, blood pressure, heart rate, oxygen saturation, temperature), which are uploaded on a digital platform. The monitoring frequency and the limit values of the measurements to detect abnormalities are determined individually. Monitoring is performed by a case manager, who has the opportunity for a daily multidisciplinary meeting with both the cardiologist and the pulmonologist. Routine appointments at the outpatient clinic are cancelled and replaced by telemonitoring-guided treatment. Results: Following ethical approval of the study protocol, the first patient was included in May 2018. Inclusion is expected to be complete in May 2021. Conclusions: This study is the first to evaluate the effects of a novel integrated care pathway using telemonitoring for patients with combined CHF and COPD. Unique to this study is the concept of remote on-demand disease management by a single case manager for both diseases, combined with multidisciplinary meetings. Moreover, modern telemonitoring technology is used instead of, rather than as an addition to, regular care. Trial Registration: Netherlands Trial Register NL6741; https://www.trialregister.nl/trial/6741 International Registered Report Identifier (IRRID): DERR1-10.2196/20571 UR - https://www.researchprotocols.org/2020/11/e20571 UR - http://dx.doi.org/10.2196/20571 UR - http://www.ncbi.nlm.nih.gov/pubmed/33211017 ID - info:doi/10.2196/20571 ER - TY - JOUR AU - Ding, Hang AU - Chen, Huey Sheau AU - Edwards, Iain AU - Jayasena, Rajiv AU - Doecke, James AU - Layland, Jamie AU - Yang, A. Ian AU - Maiorana, Andrew PY - 2020/11/13 TI - Effects of Different Telemonitoring Strategies on Chronic Heart Failure Care: Systematic Review and Subgroup Meta-Analysis JO - J Med Internet Res SP - e20032 VL - 22 IS - 11 KW - telehealth KW - telemonitoring KW - mobile health KW - chronic heart failure KW - systematic review KW - meta-analysis N2 - Background: Telemonitoring studies in chronic heart failure are characterized by mixed mortality and hospitalization outcomes, which have deterred the uptake of telemonitoring in clinical practice. These mixed outcomes may reflect the diverse range of patient management strategies incorporated in telemonitoring. To address this, we compared the effects of different telemonitoring strategies on clinical outcomes. Objective: The aim of this systematic review and subgroup meta-analysis was to identify noninvasive telemonitoring strategies attributing to improvements in all-cause mortality or hospitalization outcomes for patients with chronic heart failure. Methods: We reviewed and analyzed telemonitoring strategies from randomized controlled trials (RCTs) comparing telemonitoring intervention with usual care. For each strategy, we examined whether RCTs that applied the strategy in the telemonitoring intervention (subgroup 1) resulted in a significantly lower risk ratio (RR) of all-cause mortality or incidence rate ratio (IRR) of all-cause hospitalization compared with RCTs that did not apply this strategy (subgroup 2). Results: We included 26 RCTs (N=11,450) incorporating 18 different telemonitoring strategies. RCTs that provided medication support were found to be associated with a significantly lower IRR value than RCTs that did not provide this type of support (P=.01; subgroup 1 IRR=0.83, 95% CI 0.72-0.95 vs subgroup 2 IRR=1.02, 95% CI 0.93-1.12). RCTs that applied mobile health were associated with a significantly lower IRR (P=.03; IRR=0.79, 95% CI 0.64-0.96 vs IRR=1.00, 95% CI 0.94-1.06) and RR (P=.01; RR=0.67, 95% CI 0.53-0.85 vs RR=0.95, 95% CI 0.84-1.07). Conclusions: Telemonitoring strategies involving medication support and mobile health were associated with improvements in all-cause mortality or hospitalization outcomes. These strategies should be prioritized in telemonitoring interventions for the management of patients with chronic heart failure. UR - http://www.jmir.org/2020/11/e20032/ UR - http://dx.doi.org/10.2196/20032 UR - http://www.ncbi.nlm.nih.gov/pubmed/33185554 ID - info:doi/10.2196/20032 ER - TY - JOUR AU - Wali, Sahr AU - Keshavjee, Karim AU - Nguyen, Linda AU - Mbuagbaw, Lawrence AU - Demers, Catherine PY - 2020/11/9 TI - Using an Electronic App to Promote Home-Based Self-Care in Older Patients With Heart Failure: Qualitative Study on Patient and Informal Caregiver Challenges JO - JMIR Cardio SP - e15885 VL - 4 IS - 1 KW - mobile health KW - mobile apps KW - heart failure KW - self-care KW - mobile phone N2 - Background: Heart failure (HF) affects many older individuals in North America, with recurrent hospitalizations despite postdischarge strategies to prevent readmission. Proper HF self-care can potentially lead to better clinical outcomes, yet many older patients find self-care challenging. Mobile health (mHealth) apps can provide support to patients with respect to HF self-care. However, many mHealth apps are not designed to consider potential patient barriers, such as literacy, numeracy, and cognitive impairment, leading to challenges for older patients. We previously demonstrated that a paper-based standardized diuretic decision support tool (SDDST) with daily weights and adjustment of diuretic dose led to improved self-care. Objective: The aim of this study is to better understand the self-care challenges that older patients with HF and their informal care providers (CPs) face on a daily basis, leading to the conversion of the SDDST into a user-centered mHealth app. Methods: We recruited 14 patients (male: 8/14, 57%) with a confirmed diagnosis of HF, aged ?60 years, and 7 CPs from the HF clinic and the cardiology ward at the Hamilton General Hospital. Patients were categorized into 3 groups based on the self-care heart failure index: patients with adequate self-care, patients with inadequate self-care without a CP, or patients with inadequate self-care with a CP. We conducted semistructured interviews with patients and their CPs using persona-scenarios. Interviews were transcribed verbatim and analyzed for emerging themes using an inductive approach. Results: Six themes were identified: usability of technology, communication, app customization, complexity of self-care, usefulness of HF-related information, and long-term use and cost. Many of the challenges patients and CPs reported involved their unfamiliarity with technology and the lack of incentive for its use. However, participants were supportive and more likely to actively use the HF app when informed of the intervention?s inclusion of volunteer and nurse assistance. Conclusions: Patients with varying self-care adequacy levels were willing to use an mHealth app if it was simple in its functionality and user interface. To promote the adoption and usability of these tools, patients confirmed the need for researchers to engage with end users before developing an app. Findings from this study can be used to help inform the design of an mHealth app to ensure that it is adapted for the needs of older individuals with HF. UR - http://cardio.jmir.org/2020/1/e15885/ UR - http://dx.doi.org/10.2196/15885 UR - http://www.ncbi.nlm.nih.gov/pubmed/33164901 ID - info:doi/10.2196/15885 ER - TY - JOUR AU - Artanian, Veronica AU - Ross, J. Heather AU - Rac, E. Valeria AU - O'Sullivan, Mary AU - Brahmbhatt, H. Darshan AU - Seto, Emily PY - 2020/11/3 TI - Impact of Remote Titration Combined With Telemonitoring on the Optimization of Guideline-Directed Medical Therapy for Patients With Heart Failure: Internal Pilot of a Randomized Controlled Trial JO - JMIR Cardio SP - e21962 VL - 4 IS - 1 KW - telemonitoring KW - remote KW - titration KW - monitoring KW - mHealth KW - heart failure N2 - Background: To improve health outcomes in patients with heart failure, guideline-directed medical therapy (GDMT) should be optimized to target doses. However, GDMT remains underutilized, with less than?25% of patients receiving target doses in clinical practice. Telemonitoring could provide reliable and real-time physiological data for clinical decision support to facilitate remote GDMT titration. Objective: This paper aims to present findings from an internal pilot study regarding the effectiveness of remote titration facilitated by telemonitoring. Methods: A 2-arm randomized controlled pilot trial comparing remote titration versus standard care in a heart function clinic was conducted. Patients were randomized to undergo remote medication titration facilitated by data from a smartphone-based telemonitoring system or standard titration performed during clinic visits. Results: A total of 42 patients with new-onset (10/42, 24%) and existing (32/42, 76%) heart failure and a mean age of 55.29 (SD 11.28) years were randomized between January and June 2019. Within 6 months of enrollment, 86% (18/21) of patients in the intervention group achieved optimal doses versus 48% (10/21) of patients in the control group. The median time to dose optimization was 11.0 weeks for the intervention group versus 18.8 weeks for the control group. The number of in-person visits in the intervention group was 54.5% lower than in the control group. Conclusions: The results of this pilot study suggest that remote titration facilitated by telemonitoring has the potential to increase the proportion of patients who achieve optimal GDMT doses, decrease time to dose optimization, and reduce the number of clinic visits. Remote titration may facilitate optimal and efficient titration of patients with heart failure while reducing the burden for patients to attend in-person clinic visits. Trial Registration: ClinicalTrials.gov NCT04205513; https://clinicaltrials.gov/ct2/show/NCT04205513 International Registered Report Identifier (IRRID): RR2-10.2196/preprints.19705 UR - http://cardio.jmir.org/2020/1/e21962/ UR - http://dx.doi.org/10.2196/21962 UR - http://www.ncbi.nlm.nih.gov/pubmed/33141094 ID - info:doi/10.2196/21962 ER - TY - JOUR AU - Davoudi, Mahboube AU - Najafi Ghezeljeh, Tahereh AU - Vakilian Aghouee, Farveh PY - 2020/11/2 TI - Effect of a Smartphone-Based App on the Quality of Life of Patients With Heart Failure: Randomized Controlled Trial JO - JMIR Nursing SP - e20747 VL - 3 IS - 1 KW - heart failure KW - mobile app KW - quality of life KW - mobile phone N2 - Background: Patients with heart failure have low quality of life because of physical impairments and advanced clinical symptoms. One of the main goals of caring for patients with heart failure is to improve their quality of life. Objective: The aim of this study was to investigate the effect of the use of a smartphone-based app on the quality of life of patients with heart failure. Methods: This randomized controlled clinical trial with a control group was conducted from June to October 2018 in an urban hospital. In this study, 120 patients with heart failure hospitalized in cardiac care units were randomly allocated to control and intervention groups. Besides routine care, patients in the intervention group received a smartphone-based app and used it every day for 3 months. Both the groups completed the Minnesota Living with Heart Failure Questionnaire before entering the study and at 3 months after entering the study. Data were analyzed using the SPSS software V.16. Results: The groups showed statistically significant differences in the mean scores of quality of life and its dimensions after the intervention, thereby indicating a better quality of life in the intervention group (P<.001). The effect size of the intervention on the quality of life was 1.85 (95% CI 1.41-2.3). Moreover, the groups showed statistically significant differences in the changes in the quality of life scores and its dimensions (P<.001). Conclusions: Use of a smartphone-based app can improve the quality of life in patients with heart failure. The results of our study recommend that digital apps be used for improving the management of patients with heart failure. Trial Registration: Iranian Registry of Clinical Trials IRCT2017061934647N1; https://www.irct.ir/trial/26434 UR - https://nursing.jmir.org/2020/1/e20747 UR - http://dx.doi.org/10.2196/20747 UR - http://www.ncbi.nlm.nih.gov/pubmed/34406971 ID - info:doi/10.2196/20747 ER - TY - JOUR AU - Artanian, Veronica AU - Rac, E. Valeria AU - Ross, J. Heather AU - Seto, Emily PY - 2020/10/13 TI - Impact of Remote Titration Combined With Telemonitoring on the Optimization of Guideline-Directed Medical Therapy for Patients With Heart Failure: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e19705 VL - 9 IS - 10 KW - telemonitoring KW - telemedicine KW - remote titration KW - mHealth KW - heart failure N2 - Background: Guideline-directed medical therapy (GDMT), optimized to maximum tolerated doses, has been shown to improve clinical outcomes in patients with heart failure (HF). Timely use and optimization of GDMT can improve HF symptoms, reduce the burden of hospitalization, and increase survival rates, whereas GDMT deferral may worsen the progression of HF, decrease survival rates, and predispose patients to poor outcomes. However, studies indicate that GDMT remains underused, with less than?25% of patients receiving target doses in clinical practice. Telemonitoring is a potential component in the management of HF that can provide reliable and real-time physiological data for clinical decision support and facilitate remote titration of medication. Objective: The primary objective of this study is to evaluate the impact of remote titration facilitated by telemonitoring on health care outcomes, with a primary outcome measure being the proportion of patients achieving target doses. The secondary objective is to identify the barriers and facilitators that can affect the implementation and effectiveness of the intervention. Methods: A mixed methods study of a smartphone-based telemonitoring system is being conducted at the Peter Munk Cardiac Centre (PMCC), University Health Network, Toronto. The study is based on an effectiveness-implementation hybrid design and incorporates process evaluations alongside the assessment of clinical outcomes. The effectiveness research component is assessed by a two-arm randomized controlled trial (RCT) aiming to enroll 108 patients. The RCT compares a remote titration strategy that uses data from a smartphone-based telemonitoring system with a standard titration program consisting of in-office visits. The implementation research component consists of a qualitative study based on semistructured interviews with a purposive sample of clinicians and patients. Results: Patient recruitment began in January 2019 at PMCC, with a total of 76 participants recruited by February 24, 2020 (39 in the intervention group and 37 in the control group). The final analysis is expected to be completed by the winter of 2021. Conclusions: This study will be among the first to provide evidence on the implementation of remote titration facilitated by telemonitoring and its impact on patient health outcomes. The successful use of telemonitoring for this purpose has the potential to alter the existing approach to titration of HF medication and support the development of a care delivery model that combines clinic visits with virtual follow-ups. Trial Registration: ClinicalTrials.gov NCT04205513; https://clinicaltrials.gov/ct2/show/NCT04205513 International Registered Report Identifier (IRRID): DERR1-10.2196/19705 UR - https://www.researchprotocols.org/2020/10/e19705 UR - http://dx.doi.org/10.2196/19705 UR - http://www.ncbi.nlm.nih.gov/pubmed/33048057 ID - info:doi/10.2196/19705 ER - TY - JOUR AU - Boodoo, Chris AU - Zhang, Qi AU - Ross, J. Heather AU - Alba, Carolina Ana AU - Laporte, Audrey AU - Seto, Emily PY - 2020/10/6 TI - Evaluation of a Heart Failure Telemonitoring Program Through a Microsimulation Model: Cost-Utility Analysis JO - J Med Internet Res SP - e18917 VL - 22 IS - 10 KW - cost utility analysis KW - cost effectiveness KW - telemedicine KW - heart failure KW - microsimulation KW - mobile phone N2 - Background: Heart failure (HF) is a major public health issue in Canada that is associated with high prevalence, morbidity, and mortality rates and high financial and social burdens. Telemonitoring (TM) has been shown to improve all-cause mortality and hospitalization rates in patients with HF. The Medly program is a TM intervention integrated as standard of care at a large Canadian academic hospital for ambulatory patients with HF that has been found to improve patient outcomes. However, the cost-effectiveness of the Medly program is yet to be determined. Objective: This study aims to conduct a cost-utility analysis of the Medly program compared with the standard of care for HF in Ontario, Canada, from the perspective of the public health care payer. Methods: Using a microsimulation model, individual patient data were simulated over a 25-year time horizon to compare the costs and quality-adjusted life years (QALYs) between the Medly program and standard care for patients with HF treated in the ambulatory care setting. Data were sourced from a Medly Program Evaluation study and literature to inform model parameters, such as Medly?s effectiveness in reducing mortality and hospitalizations, health care and intervention costs, and model transition probabilities. Scenario analyses were conducted in relation to HF severity and TM deployment models. One-way deterministic effectiveness analysis and probabilistic sensitivity analysis were performed to explore the impact on the results of uncertainty in model parameters. Results: The Medly program was associated with an average total cost of Can $102,508 (US $77,626) per patient and total QALYs of 5.51 per patient compared with the average cost of Can $97,497 (US $73,831) and QALYs of 4.95 per patient in the Standard Care Group. This led to an incremental cost of Can $5011 (US $3794) and incremental QALY of 0.566, resulting in an incremental cost-effectiveness ratio of Can $8850 (US $6701)/QALY. Cost-effectiveness improved in relation to patients with advanced HF and with deployment models in which patients used their own equipment. Baseline and alternative scenarios consistently showed probabilities of cost-effectiveness greater than 85% at a willingness-to-pay threshold of Can $50,000 (US $37,718). Although the results showed some sensitivity to assumptions about effectiveness parameters, the intervention was found to remain cost-effective. Conclusions: The Medly program for patients with HF is cost-effective compared with standard care using commonly reported willingness-to-pay thresholds. This study provides evidence for decision makers on the use of TM for HF, supports the use of a nurse-led model of TM that embeds clinically validated algorithms, and informs the use of economic modeling for future evaluations of early-stage health informatics technology. UR - https://www.jmir.org/2020/10/e18917 UR - http://dx.doi.org/10.2196/18917 UR - http://www.ncbi.nlm.nih.gov/pubmed/33021485 ID - info:doi/10.2196/18917 ER - TY - JOUR AU - Gordon, Kayleigh AU - Dainty, N. Katie AU - Steele Gray, Carolyn AU - DeLacy, Jane AU - Shah, Amika AU - Resnick, Myles AU - Seto, Emily PY - 2020/9/29 TI - Experiences of Complex Patients With Telemonitoring in a Nurse-Led Model of Care: Multimethod Feasibility Study JO - JMIR Nursing SP - e22118 VL - 3 IS - 1 KW - telemonitoring KW - adherence KW - patient experience KW - complex patients KW - normalization process theory KW - implementation KW - mobile phone N2 - Background: Telemonitoring (TM) interventions have been designed to support care delivery and engage patients in their care at home, but little research exists on TM of complex chronic conditions (CCCs). Given the growing prevalence of complex patients, an evaluation of multi-condition TM is needed to expand TM interventions and tailor opportunities to manage complex chronic care needs. Objective: This study aims to evaluate the feasibility and patients? perceived usefulness of a multi-condition TM platform in a nurse-led model of care. Methods: A pragmatic, multimethod feasibility study was conducted with patients with heart failure (HF), hypertension (HTN), and/or diabetes. Patients were asked to take physiological readings at home via a smartphone-based TM app for 6 months. The recommended frequency of taking readings was dependent on the condition, and adherence data were obtained through the TM system database. Patient questionnaires were administered, and patient interviews were conducted at the end of the study. An inductive analysis was performed, and codes were then mapped to the normalization process theory and Implementation Outcomes constructs by Proctor. Results: In total, 26 participants were recruited, 17 of whom used the TM app for 6 months. Qualitative interviews were conducted with 14 patients, and 8 patients were interviewed with their informal caregiver present. Patient adherence was high, with patients with HF taking readings on average 76.6% (141/184) of the days they were asked to use the system and patients with diabetes taking readings on average 72% (19/26) of the days. The HTN adherence rate was 55% (29/52) of the days they were asked to use the system. The qualitative findings of the patient experience can be grouped into 4 main themes and 13 subthemes. The main themes were (1) making sense of the purpose of TM, (2) engaging and investing in TM, (3) implementing and adopting TM, and (4) perceived usefulness and the perceived benefits of TM in CCCs. Conclusions: Multi-condition TM in nurse-led care was found to be feasible and was perceived as useful. Patients accepted and adopted the technology by demonstrating a moderate to high level of adherence across conditions. These results demonstrate how TM can address the needs of patients with CCCs through virtual TM assessments in a nurse-led care model by supporting patient self-care and keeping patients connected to their clinical team. UR - https://nursing.jmir.org/2020/1/e22118/ UR - http://dx.doi.org/10.2196/22118 UR - http://www.ncbi.nlm.nih.gov/pubmed/34406972 ID - info:doi/10.2196/22118 ER - TY - JOUR AU - Li, Rui AU - Yin, Changchang AU - Yang, Samuel AU - Qian, Buyue AU - Zhang, Ping PY - 2020/9/28 TI - Marrying Medical Domain Knowledge With Deep Learning on Electronic Health Records: A Deep Visual Analytics Approach JO - J Med Internet Res SP - e20645 VL - 22 IS - 9 KW - electronic health records KW - interpretable deep learning KW - knowledge graph KW - visual analytics N2 - Background: Deep learning models have attracted significant interest from health care researchers during the last few decades. There have been many studies that apply deep learning to medical applications and achieve promising results. However, there are three limitations to the existing models: (1) most clinicians are unable to interpret the results from the existing models, (2) existing models cannot incorporate complicated medical domain knowledge (eg, a disease causes another disease), and (3) most existing models lack visual exploration and interaction. Both the electronic health record (EHR) data set and the deep model results are complex and abstract, which impedes clinicians from exploring and communicating with the model directly. Objective: The objective of this study is to develop an interpretable and accurate risk prediction model as well as an interactive clinical prediction system to support EHR data exploration, knowledge graph demonstration, and model interpretation. Methods: A domain-knowledge?guided recurrent neural network (DG-RNN) model is proposed to predict clinical risks. The model takes medical event sequences as input and incorporates medical domain knowledge by attending to a subgraph of the whole medical knowledge graph. A global pooling operation and a fully connected layer are used to output the clinical outcomes. The middle results and the parameters of the fully connected layer are helpful in identifying which medical events cause clinical risks. DG-Viz is also designed to support EHR data exploration, knowledge graph demonstration, and model interpretation. Results: We conducted both risk prediction experiments and a case study on a real-world data set. A total of 554 patients with heart failure and 1662 control patients without heart failure were selected from the data set. The experimental results show that the proposed DG-RNN outperforms the state-of-the-art approaches by approximately 1.5%. The case study demonstrates how our medical physician collaborator can effectively explore the data and interpret the prediction results using DG-Viz. Conclusions: In this study, we present DG-Viz, an interactive clinical prediction system, which brings together the power of deep learning (ie, a DG-RNN?based model) and visual analytics to predict clinical risks and visually interpret the EHR prediction results. Experimental results and a case study on heart failure risk prediction tasks demonstrate the effectiveness and usefulness of the DG-Viz system. This study will pave the way for interactive, interpretable, and accurate clinical risk predictions. UR - http://www.jmir.org/2020/9/e20645/ UR - http://dx.doi.org/10.2196/20645 UR - http://www.ncbi.nlm.nih.gov/pubmed/32985996 ID - info:doi/10.2196/20645 ER - TY - JOUR AU - Portz, Dickman Jennifer AU - Ford, Lynett Kelsey AU - Elsbernd, Kira AU - Knoepke, E. Christopher AU - Flint, Kelsey AU - Bekelman, B. David AU - Boxer, S. Rebecca AU - Bull, Sheana PY - 2020/9/4 TI - ?I Like the Idea of It?But Probably Wouldn?t Use It? - Health Care Provider Perspectives on Heart Failure mHealth: Qualitative Study JO - JMIR Cardio SP - e18101 VL - 4 IS - 1 KW - heart failure KW - information technology KW - informatics KW - telemedicine KW - mHealth N2 - Background: Many mobile health (mHealth) technologies exist for patients with heart failure (HF). However, HF mhealth lacks evidence of efficacy, caregiver involvement, and clinically useful real-time data. Objective: We aim to capture health care providers? perceived value of HF mHealth, particularly for pairing patient?caregiver-generated data with clinical intervention to inform the design of future HF mHealth. Methods: This study is a subanalysis of a larger qualitative study based on interviewing patients with HF, their caregivers, and health care providers. This analysis included interviews with health care providers (N=20), focusing on their perceived usefulness of HF mHealth tools and interventions. Results: A total of 5 themes emerged: (1) bio-psychosocial-spiritual monitoring, (2) use of sensors, (3) interoperability, (4) data sharing, and (5) usefulness of patient-reported outcomes in practice. Providers remain interested in mHealth technologies for HF patients and their caregivers. However, providers report being unconvinced of the clinical usefulness of robust real-time patient-reported outcomes. Conclusions: The use of assessments, sensors, and real-time data collection could provide value in patient care. Future research must continually explore how to maximize the utility of mHealth for HF patients, their caregivers, and health care providers. UR - http://cardio.jmir.org/2020/1/e18101/ UR - http://dx.doi.org/10.2196/18101 UR - http://www.ncbi.nlm.nih.gov/pubmed/32885785 ID - info:doi/10.2196/18101 ER - TY - JOUR AU - Essay, Patrick AU - Balkan, Baran AU - Subbian, Vignesh PY - 2020/8/7 TI - Decompensation in Critical Care: Early Prediction of Acute Heart Failure Onset JO - JMIR Med Inform SP - e19892 VL - 8 IS - 8 KW - critical care KW - heart failure KW - intensive care units KW - machine learning KW - time series KW - heart KW - cardiology KW - prediction KW - chronic disease KW - ICU KW - intensive care unit N2 - Background: Heart failure is a leading cause of mortality and morbidity worldwide. Acute heart failure, broadly defined as rapid onset of new or worsening signs and symptoms of heart failure, often requires hospitalization and admission to the intensive care unit (ICU). This acute condition is highly heterogeneous and less well-understood as compared to chronic heart failure. The ICU, through detailed and continuously monitored patient data, provides an opportunity to retrospectively analyze decompensation and heart failure to evaluate physiological states and patient outcomes. Objective: The goal of this study is to examine the prevalence of cardiovascular risk factors among those admitted to ICUs and to evaluate combinations of clinical features that are predictive of decompensation events, such as the onset of acute heart failure, using machine learning techniques. To accomplish this objective, we leveraged tele-ICU data from over 200 hospitals across the United States. Methods: We evaluated the feasibility of predicting decompensation soon after ICU admission for 26,534 patients admitted without a history of heart failure with specific heart failure risk factors (ie, coronary artery disease, hypertension, and myocardial infarction) and 96,350 patients admitted without risk factors using remotely monitored laboratory, vital signs, and discrete physiological measurements. Multivariate logistic regression and random forest models were applied to predict decompensation and highlight important features from combinations of model inputs from dissimilar data. Results: The most prevalent risk factor in our data set was hypertension, although most patients diagnosed with heart failure were admitted to the ICU without a risk factor. The highest heart failure prediction accuracy was 0.951, and the highest area under the receiver operating characteristic curve was 0.9503 with random forest and combined vital signs, laboratory values, and discrete physiological measurements. Random forest feature importance also highlighted combinations of several discrete physiological features and laboratory measures as most indicative of decompensation. Timeline analysis of aggregate vital signs revealed a point of diminishing returns where additional vital signs data did not continue to improve results. Conclusions: Heart failure risk factors are common in tele-ICU data, although most patients that are diagnosed with heart failure later in an ICU stay presented without risk factors making a prediction of decompensation critical. Decompensation was predicted with reasonable accuracy using tele-ICU data, and optimal data extraction for time series vital signs data was identified near a 200-minute window size. Overall, results suggest combinations of laboratory measurements and vital signs are viable for early and continuous prediction of patient decompensation. UR - http://medinform.jmir.org/2020/8/e19892/ UR - http://dx.doi.org/10.2196/19892 UR - http://www.ncbi.nlm.nih.gov/pubmed/32663162 ID - info:doi/10.2196/19892 ER - TY - JOUR AU - Cornet, Philip Victor AU - Toscos, Tammy AU - Bolchini, Davide AU - Rohani Ghahari, Romisa AU - Ahmed, Ryan AU - Daley, Carly AU - Mirro, J. Michael AU - Holden, J. Richard PY - 2020/7/21 TI - 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 JO - JMIR Mhealth Uhealth SP - e17703 VL - 8 IS - 7 KW - user-centered design KW - research methods KW - mobile health KW - digital health KW - mobile apps KW - usability KW - technology KW - evaluation KW - human-computer interaction KW - mobile phone N2 - 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. UR - http://mhealth.jmir.org/2020/7/e17703/ UR - http://dx.doi.org/10.2196/17703 UR - http://www.ncbi.nlm.nih.gov/pubmed/32706745 ID - info:doi/10.2196/17703 ER - TY - JOUR AU - Ding, Hang AU - Jayasena, Rajiv AU - Chen, Huey Sheau AU - Maiorana, Andrew AU - Dowling, Alison AU - Layland, Jamie AU - Good, Norm AU - Karunanithi, Mohanraj AU - Edwards, Iain PY - 2020/7/8 TI - The Effects of Telemonitoring on Patient Compliance With Self-Management Recommendations and Outcomes of the Innovative Telemonitoring Enhanced Care Program for Chronic Heart Failure: Randomized Controlled Trial JO - J Med Internet Res SP - e17559 VL - 22 IS - 7 KW - heart failure KW - digital health KW - telemonitoring KW - remote monitoring KW - patient compliance KW - randomized controlled trial N2 - Background: Telemonitoring enables care providers to remotely support outpatients in self-managing chronic heart failure (CHF), but the objective assessment of patient compliance with self-management recommendations has seldom been studied. Objective: This study aimed to evaluate patient compliance with self-management recommendations of an innovative telemonitoring enhanced care program for CHF (ITEC-CHF). Methods: We conducted a multicenter randomized controlled trial with a 6-month follow-up. The ITEC-CHF program comprised the provision of Bluetooth-enabled scales linked to a call center and nurse care services to assist participants with weight monitoring compliance. Compliance was defined a priori as weighing at least 4 days per week, analyzed objectively from weight recordings on the scales. The intention-to-treat principle was used to perform the analysis. Results: A total of 184 participants (141/184, 76.6% male), with a mean age of 70.1 (SD 12.3) years, were randomized to receive either ITEC-CHF (n=91) or usual care (control; n=93), of which 67 ITEC-CHF and 81 control participants completed the intervention. For the compliance criterion of weighing at least 4 days per week, the proportion of compliant participants in the ITEC-CHF group was not significantly higher than that in the control group (ITEC-CHF: 67/91, 74% vs control: 56/91, 60%; P=.06). However, the proportion of ITEC-CHF participants achieving the stricter compliance standard of at least 6 days a week was significantly higher than that in the control group (ITEC-CHF: 41/91, 45% vs control: 23/93, 25%; P=.005). Conclusions: ITEC-CHF improved participant compliance with weight monitoring, although the withdrawal rate was high. Telemonitoring is a promising method for supporting both patients and clinicians in the management of CHF. However, further refinements are required to optimize this model of care. Trial Registration: Australian New Zealand Clinical Trial Registry ACTRN12614000916640; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366691 UR - https://www.jmir.org/2020/7/e17559 UR - http://dx.doi.org/10.2196/17559 UR - http://www.ncbi.nlm.nih.gov/pubmed/32673222 ID - info:doi/10.2196/17559 ER - TY - JOUR AU - Jiang, Xinchan AU - Yao, Jiaqi AU - You, HS Joyce PY - 2020/7/6 TI - Telemonitoring Versus Usual Care for Elderly Patients With Heart Failure Discharged From the Hospital in the United States: Cost-Effectiveness Analysis JO - JMIR Mhealth Uhealth SP - e17846 VL - 8 IS - 7 KW - telemedicine KW - heart failure KW - hospitalization KW - cost KW - quality-adjusted life year KW - cost-effectiveness analysis N2 - Background: Telemonitoring-guided interventional management reduces the need for hospitalization and mortality of patients with chronic heart failure (CHF). Objective: This study aimed to analyze the cost-effectiveness of usual care with and without telemonitoring-guided management in patients with CHF discharged from the hospital, from the perspective of US health care providers. Methods: A lifelong Markov model was designed to estimate outcomes of (1) usual care alone for all postdischarge patients with CHF (New York Heart Association [NYHA] class I-IV), (2) usual care and telemonitoring for all postdischarge patients with CHF, (3) usual care for all postdischarge patients with CHF and telemonitoring for patients with NYHA class III to IV, and (4) usual care for all postdischarge patients with CHF plus telemonitoring for patients with NYHA class II to IV. Model inputs were derived from the literature and public data. Sensitivity analyses were conducted to assess the robustness of model. The primary outcomes were total direct medical cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER). Results: In the base case analysis, universal telemonitoring group gained the highest QALYs (6.2967 QALYs), followed by the telemonitoring for NYHA class II to IV group (6.2960 QALYs), the telemonitoring for NYHA class III to IV group (6.2450 QALYs), and the universal usual care group (6.1530 QALYs). ICERs of the telemonitoring for NYHA class III to IV group (US $35,393 per QALY) and the telemonitoring for NYHA class II to IV group (US $38,261 per QALY) were lower than the ICER of the universal telemonitoring group (US $100,458 per QALY). One-way sensitivity analysis identified five critical parameters: odds ratio of hospitalization for telemonitoring versus usual care, hazard ratio of all-cause mortality for telemonitoring versus usual care, CHF hospitalization cost and monthly outpatient costs for NYHA class I, and CHF hospitalization cost for NYHA class II. In probabilistic sensitivity analysis, probabilities of the universal telemonitoring, telemonitoring for NYHA class II to IV, telemonitoring for NYHA class III to IV, and universal usual care groups to be accepted as cost-effective at US $50,000 per QALY were 2.76%, 76.31%, 18.6%, and 2.33%, respectively. Conclusions: Usual care for all discharged patients with CHF plus telemonitoring-guided management for NYHA class II to IV patients appears to be the preferred cost-effective strategy. UR - https://mhealth.jmir.org/2020/7/e17846 UR - http://dx.doi.org/10.2196/17846 UR - http://www.ncbi.nlm.nih.gov/pubmed/32407288 ID - info:doi/10.2196/17846 ER - TY - JOUR AU - Indraratna, Praveen AU - Tardo, Daniel AU - Yu, Jennifer AU - Delbaere, Kim AU - Brodie, Matthew AU - Lovell, Nigel AU - Ooi, Sze-Yuan PY - 2020/7/6 TI - Mobile Phone Technologies in the Management of Ischemic Heart Disease, Heart Failure, and Hypertension: Systematic Review and Meta-Analysis JO - JMIR Mhealth Uhealth SP - e16695 VL - 8 IS - 7 KW - mobile phone KW - text messaging KW - telemedicine KW - myocardial ischemia KW - heart failure KW - hypertension N2 - 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. UR - https://mhealth.jmir.org/2020/7/e16695 UR - http://dx.doi.org/10.2196/16695 UR - http://www.ncbi.nlm.nih.gov/pubmed/32628615 ID - info:doi/10.2196/16695 ER - TY - JOUR AU - Shaw, E. Sara AU - Seuren, Martinus Lucas AU - Wherton, Joseph AU - Cameron, Deborah AU - A'Court, Christine AU - Vijayaraghavan, Shanti AU - Morris, Joanne AU - Bhattacharya, Satyajit AU - Greenhalgh, Trisha PY - 2020/5/11 TI - Video Consultations Between Patients and Clinicians in Diabetes, Cancer, and Heart Failure Services: Linguistic Ethnographic Study of Video-Mediated Interaction JO - J Med Internet Res SP - e18378 VL - 22 IS - 5 KW - delivery of health care KW - physical examination KW - remote consultation KW - telemedicine KW - health communication KW - language KW - nonverbal communication KW - mobile phone N2 - Background: Video-mediated clinical consultations offer potential benefits over conventional face-to-face in terms of access, convenience, and sometimes cost. The improved technical quality and dependability of video-mediated consultations has opened up the possibility for more widespread use. However, questions remain regarding clinical quality and safety. Video-mediated consultations are sometimes criticized for being not as good as face-to-face, but there has been little previous in-depth research on their interactional dynamics, and no agreement on what a good video consultation looks like. Objective: Using conversation analysis, this study aimed to identify and analyze the communication strategies through which video-mediated consultations are accomplished and to produce recommendations for patients and clinicians to improve the communicative quality of such consultations. Methods: We conducted an in-depth analysis of the clinician-patient interaction in a sample of video-mediated consultations and a comparison sample of face-to-face consultations drawn from 4 clinical settings across 2 trusts (1 community and 1 acute care) in the UK National Health Service. The video dataset consisted of 37 recordings of video-mediated consultations (with diabetes, antenatal diabetes, cancer, and heart failure patients), 28 matched audio recordings of face-to-face consultations, and fieldnotes from before and after each consultation. We also conducted 37 interviews with staff and 26 interviews with patients. Using linguistic ethnography (combining analysis of communication with an appreciation of the context in which it takes place), we examined in detail how video interaction was mediated by 2 software platforms (Skype and FaceTime). Results: Patients had been selected by their clinician as appropriate for video-mediated consultation. Most consultations in our sample were technically and clinically unproblematic. However, we identified 3 interactional challenges: (1) opening the video consultation, (2) dealing with disruption to conversational flow (eg, technical issues with audio and/or video), and (3) conducting an examination. Operational and technological issues were the exception rather than the norm. In all but 1 case, both clinicians and patients (deliberately or intuitively) used established communication strategies to successfully negotiate these challenges. Remote physical examinations required the patient (and, in some cases, a relative) to simultaneously follow instructions and manipulate technology (eg, camera) to make it possible for the clinician to see and hear adequately. Conclusions: A remote video link alters how patients and clinicians interact and may adversely affect the flow of conversation. However, our data suggest that when such problems occur, clinicians and patients can work collaboratively to find ways to overcome them. There is potential for a limited physical examination to be undertaken remotely with some patients and in some conditions, but this appears to need complex interactional work by the patient and/or their relatives. We offer preliminary guidance for patients and clinicians on what is and is not feasible when consulting via a video link. International Registered Report Identifier (IRRID): RR2-10.2196/10913 UR - http://www.jmir.org/2020/5/e18378/ UR - http://dx.doi.org/10.2196/18378 UR - http://www.ncbi.nlm.nih.gov/pubmed/32391799 ID - info:doi/10.2196/18378 ER - TY - JOUR AU - Heiney, P. Sue AU - Donevant, B. Sara AU - Arp Adams, Swann AU - Parker, D. Pearman AU - Chen, Hongtu AU - Levkoff, Sue PY - 2020/4/3 TI - A Smartphone App for Self-Management of Heart Failure in Older African Americans: Feasibility and Usability Study JO - JMIR Aging SP - e17142 VL - 3 IS - 1 KW - heart failure KW - mobile health app KW - self-management N2 - Background: Mobile health (mHealth) apps are dramatically changing how patients and providers manage and monitor chronic health conditions, especially in the area of self-monitoring. African Americans have higher mortality rates from heart failure than other racial groups in the United States. Therefore, self-management of heart failure may improve health outcomes for African American patients. Objective: The aim of the present study was to determine the feasibility of using an mHealth app, and explore the outcomes of quality of life, including self-care maintenance, management, and confidence, among African American patients managing their condition after discharge with a diagnosis of heart failure. Methods: Prior to development of the app, we conducted qualitative interviews with 7 African American patients diagnosed with heart failure, 3 African American patients diagnosed with cardiovascular disease, and 6 health care providers (cardiologists, nurse practitioners, and a geriatrician) who worked with heart failure patients. In addition, we asked 6 hospital chaplains to provide positive spiritual messages for the patients, since spirituality is an important coping method for many African Americans. These formative data were then used for creating a prototype of the app, named Healthy Heart. Specifically, the Healthy Heart app incorporated the following evidence-based features to promote self-management: one-way messages, journaling (ie, weight and symptoms), graphical display of data, and customized feedback (ie, clinical decision support) based on daily or weekly weight. The educational messages about heart failure self-management were derived from the teaching materials provided to the patients diagnosed with heart failure, and included information on diet, sleep, stress, and medication adherence. The information was condensed and simplified to be appropriate for text messages and to meet health literacy standards. Other messages were derived from interviews conducted during the formative stage of app development, including interviews with African American chaplains. Usability testing was conducted over a series of meetings between nurses, social workers, and computer engineers. A pilot one-group pretest-posttest design was employed with participants using the mHealth app for 4 weeks. Descriptive statistics were computed for each of the demographic variables, overall and subscales for Health Related Quality of Life Scale 14 (HQOL14) and subscales for the Self-Care of Heart Failure Index (SCHFI) Version 6 using frequencies for categorical measures and means with standard deviations for continuous measures. Baseline and postintervention comparisons were computed using the Fisher exact test for overall health and paired t tests for HQOL14 and SCHFI questionnaire subscales. Results: A total of 12 African American participants (7 men, 5 women; aged 51-69 years) diagnosed with heart failure were recruited for the study. There was no significant increase in quality of life (P=.15), but clinically relevant changes in self-care maintenance, management, and confidence were observed. Conclusions: An mHealth app to assist with the self-management of heart failure is feasible in patients with low literacy, low health literacy, and limited smartphone experience. Based on the clinically relevant changes observed in this feasibility study of the Healthy Heart app, further research should explore effectiveness in this vulnerable population. UR - http://aging.jmir.org/2020/1/e17142/ UR - http://dx.doi.org/10.2196/17142 UR - http://www.ncbi.nlm.nih.gov/pubmed/32242822 ID - info:doi/10.2196/17142 ER - TY - JOUR AU - Smeets, P. Christophe J. AU - Lee, Seulki AU - Groenendaal, Willemijn AU - Squillace, Gabriel AU - Vranken, Julie AU - De Cannière, Hélène AU - Van Hoof, Chris AU - Grieten, Lars AU - Mullens, Wilfried AU - Nijst, Petra AU - Vandervoort, M. Pieter PY - 2020/3/18 TI - The Added Value of In-Hospital Tracking of the Efficacy of Decongestion Therapy and Prognostic Value of a Wearable Thoracic Impedance Sensor in Acutely Decompensated Heart Failure With Volume Overload: Prospective Cohort Study JO - JMIR Cardio SP - e12141 VL - 4 IS - 1 KW - congestive heart failure KW - electric impedance KW - prognosis N2 - Background: Incomplete relief of congestion in acute decompensated heart failure (HF) is related to poor outcomes. However, congestion can be difficult to evaluate, stressing the urgent need for new objective approaches. Due to its inverse correlation with tissue hydration, continuous bioimpedance monitoring might be an effective method for serial fluid status assessments. Objective: This study aimed to determine whether in-hospital bioimpedance monitoring can be used to track fluid changes (ie, the efficacy of decongestion therapy) and the relationships between bioimpedance changes and HF hospitalization and all-cause mortality. Methods: A wearable bioimpedance monitoring device was used for thoracic impedance measurements. Thirty-six patients with signs of acute decompensated HF and volume overload were included. Changes in the resistance at 80 kHz (R80kHz) were analyzed, with fluid balance (fluid in/out) used as a reference. Patients were divided into two groups depending on the change in R80kHz during hospitalization: increase in R80kHz or decrease in R80kHz. Clinical outcomes in terms of HF rehospitalization and all-cause mortality were studied at 30 days and 1 year of follow-up. Results: During hospitalization, R80kHz increased for 24 patients, and decreased for 12 patients. For the total study sample, a moderate negative correlation was found between changes in fluid balance (in/out) and relative changes in R80kHz during hospitalization (rs=-0.51, P<.001). Clinical outcomes at both 30 days and 1 year of follow-up were significantly better for patients with an increase in R80kHz. At 1 year of follow-up, 88% (21/24) of patients with an increase in R80kHz were free from all-cause mortality, compared with 50% (6/12) of patients with a decrease in R80kHz (P=.01); 75% (18/24) and 25% (3/12) were free from all-cause mortality and HF hospitalization, respectively (P=.01). A decrease in R80kHz resulted in a significant hazard ratio of 4.96 (95% CI 1.82-14.37, P=.003) on the composite endpoint. Conclusions: The wearable bioimpedance device was able to track changes in fluid status during hospitalization and is a convenient method to assess the efficacy of decongestion therapy during hospitalization. Patients who do not show an improvement in thoracic impedance tend to have worse clinical outcomes, indicating the potential use of thoracic impedance as a prognostic parameter. UR - https://cardio.jmir.org/2020/1/e12141 UR - http://dx.doi.org/10.2196/12141 UR - http://www.ncbi.nlm.nih.gov/pubmed/32186520 ID - info:doi/10.2196/12141 ER - TY - JOUR AU - Seuren, Martinus Lucas AU - Wherton, Joseph AU - Greenhalgh, Trisha AU - Cameron, Deborah AU - A'Court, Christine AU - Shaw, E. Sara PY - 2020/2/20 TI - Physical Examinations via Video for Patients With Heart Failure: Qualitative Study Using Conversation Analysis JO - J Med Internet Res SP - e16694 VL - 22 IS - 2 KW - remote consultation KW - telemedicine KW - videoconferencing KW - communication KW - language KW - linguistics KW - gestures KW - physical examination N2 - Background: Video consultations are increasingly seen as a possible replacement for face-to-face consultations. Direct physical examination of the patient is impossible; however, a limited examination may be undertaken via video (eg, using visual signals or asking a patient to press their lower legs and assess fluid retention). Little is currently known about what such video examinations involve. Objective: This study aimed to explore the opportunities and challenges of remote physical examination of patients with heart failure using video-mediated communication technology. Methods: We conducted a microanalysis of video examinations using conversation analysis (CA), an established approach for studying the details of communication and interaction. In all, seven video consultations (using FaceTime) between patients with heart failure and their community-based specialist nurses were video recorded with consent. We used CA to identify the challenges of remote physical examination over video and the verbal and nonverbal communication strategies used to address them. Results: Apart from a general visual overview, remote physical examination in patients with heart failure was restricted to assessing fluid retention (by the patient or relative feeling for leg edema), blood pressure with pulse rate and rhythm (using a self-inflating blood pressure monitor incorporating an irregular heartbeat indicator and put on by the patient or relative), and oxygen saturation (using a finger clip device). In all seven cases, one or more of these examinations were accomplished via video, generating accurate biometric data for assessment by the clinician. However, video examinations proved challenging for all involved. Participants (patients, clinicians, and, sometimes, relatives) needed to collaboratively negotiate three recurrent challenges: (1) adequate design of instructions to guide video examinations (with nurses required to explain tasks using lay language and to check instructions were followed), (2) accommodation of the patient?s desire for autonomy (on the part of nurses and relatives) in light of opportunities for involvement in their own physical assessment, and (3) doing the physical examination while simultaneously making it visible to the nurse (with patients and relatives needing adequate technological knowledge to operate a device and make the examination visible to the nurse as well as basic biomedical knowledge to follow nurses? instructions). Nurses remained responsible for making a clinical judgment of the adequacy of the examination and the trustworthiness of the data. In sum, despite significant challenges, selected participants in heart failure consultations managed to successfully complete video examinations. Conclusions: Video examinations are possible in the context of heart failure services. However, they are limited, time consuming, and challenging for all involved. Guidance and training are needed to support rollout of this new service model, along with research to understand if the challenges identified are relevant to different patients and conditions and how they can be successfully negotiated. UR - https://www.jmir.org/2020/2/e16694 UR - http://dx.doi.org/10.2196/16694 UR - http://www.ncbi.nlm.nih.gov/pubmed/32130133 ID - info:doi/10.2196/16694 ER - TY - JOUR AU - Johansson, Marcia AU - Athilingam, Ponrathi PY - 2020/2/10 TI - A Dual-Pronged Approach to Improving Heart Failure Outcomes: A Quality Improvement Project JO - JMIR Aging SP - e13513 VL - 3 IS - 1 KW - heart failure KW - mobile messaging KW - structured telephone support KW - self-care management KW - medication adherence KW - quality improvement N2 - Background: Presently, 6.5 million Americans are living with heart failure (HF). These patients are expected to follow a complex self-management regimen at home. Several demographic and psychosocial factors limit patients with HF in following the prescribed self-management recommendations at home. Poor self-care is associated with increased hospital readmissions. Under the Affordable Care Act, there are financial implications related to hospital readmissions for hospitals and programs such as the Program of All-Inclusive Care for the Elderly (PACE) in Pinellas County, Florida. Previous studies and systematic reviews demonstrated improvement in self-management and quality of life (QoL) in patients with HF with structured telephone support (STS) and SMS text messaging. Objective: This study aimed to evaluate the effects of STS and SMS on self-care, knowledge, medication adherence, and QoL of patients with HF. Methods: A prospective quality improvement project using a pre-post design was implemented. Data were collected at baseline, 30 days, and 3 months from 51 patients with HF who were enrolled in PACE in Pinellas County, Florida. All participants received STS and SMS for 30 days. The feasibility and sustained benefit of using STS and SMS was assessed at a 3-month follow-up. Results: A paired t test was used to compare the mean difference in HF outcomes at the baseline and 30-day follow-up, which demonstrated improved HF self-care maintenance (t49=0.66; P=.01), HF knowledge (t49=0.71; P=.01), medication adherence (t49=0.92; P=.01), and physical and mental health measured using Short-Form-12 (SF-12; t49=0.81; P=.01). The results also demonstrated the sustained benefit with improved HF self-care maintenance, self-care management, self-care confidence, knowledge, medication adherence, and physical and mental health (SF-12) at 3 months with P<.05 for all outcomes. Living status and social support had a strong correlation with HF outcomes. Younger participants (aged less than 65 years) performed extremely well compared with older adults. Conclusions: STS and SMS were feasible to use among PACE participants with sustained benefits at 3 months. Implementing STS and SMS may serve as viable options to improve HF outcomes. Improving outcomes with HF affects hospital systems and the agencies that monitor and provide care for outpatients and those in independent or assisted-living facilities. Investigating viable options and support for implementation will improve outcomes. UR - https://aging.jmir.org/2020/1/e13513 UR - http://dx.doi.org/10.2196/13513 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/13513 ER - TY - JOUR AU - Ware, Patrick AU - Ross, J. Heather AU - Cafazzo, A. Joseph AU - Boodoo, Chris AU - Munnery, Mikayla AU - Seto, Emily PY - 2020/2/6 TI - Outcomes of a Heart Failure Telemonitoring Program Implemented as the Standard of Care in an Outpatient Heart Function Clinic: Pretest-Posttest Pragmatic Study JO - J Med Internet Res SP - e16538 VL - 22 IS - 2 KW - telemonitoring KW - telemedicine KW - virtual care KW - mHealth KW - heart failure N2 - Background: Telemonitoring (TM) can improve heart failure (HF) outcomes by facilitating patient self-care and clinical decisions. The Medly program enables patients to use a mobile phone to record daily HF readings and receive personalized self-care messages generated by a clinically validated algorithm. The TM system also generates alerts, which are immediately acted upon by the patients? existing care team. This program has been operating for 3 years as part of the standard of care in an outpatient heart function clinic in Toronto, Canada. Objective: This study aimed to evaluate the 6-month impact of this TM program on health service utilization, clinical outcomes, quality of life (QoL), and patient self-care. Methods: This pragmatic quality improvement study employed a pretest-posttest design to compare 6-month outcome measures with those at program enrollment. The primary outcome was the number of HF-related hospitalizations. Secondary outcomes included all-cause hospitalizations, emergency department visits (HF related and all cause), length of stay (HF related and all cause), and visits to the outpatient clinic. Clinical outcomes included bloodwork (B-type natriuretic peptide [BNP], creatinine, and sodium), left ventricular ejection fraction, and predicted survival score using the Seattle Heart Failure Model. QoL was measured using the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and the 5-level EuroQol 5-dimensional questionnaire. Self-care was measured using the Self-Care of Heart Failure Index (SCHFI). The difference in outcome scores was analyzed using negative binomial distribution and Poisson regressions for the health service utilization outcomes and linear regressions for all other outcomes to control for key demographic and clinical variables. Results: Available data for 315 patients enrolled in the TM program between August 2016 and January 2019 were analyzed. A 50% decrease in HF-related hospitalizations (incidence rate ratio [IRR]=0.50; P<.001) and a 24% decrease in the number of all-cause hospitalizations (IRR=0.76; P=.02) were found when comparing the number of events 6 months after program enrollment with the number of events 6 months before enrollment. With regard to clinical outcomes at 6 months, a 59% decrease in BNP values was found after adjusting for control variables. Moreover, 6-month MLHFQ total scores were 9.8 points lower than baseline scores (P<.001), representing a clinically meaningful improvement in HF-related QoL. Similarly, the MLHFQ physical and emotional subscales showed a decrease of 5.4 points (P<.001) and 1.5 points (P=.04), respectively. Finally, patient self-care after 6 months improved as demonstrated by a 7.8-point (P<.001) and 8.5-point (P=.01) increase in the SCHFI maintenance and management scores, respectively. No significant changes were observed in the remaining secondary outcomes. Conclusions: This study suggests that an HF TM program, which provides patients with self-care support and active monitoring by their existing care team, can reduce health service utilization and improve clinical, QoL, and patient self-care outcomes. UR - https://www.jmir.org/2020/2/e16538 UR - http://dx.doi.org/10.2196/16538 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/16538 ER - TY - JOUR AU - Aamodt, Thon Ina AU - Lycholip, Edita AU - Celutkiene, Jelena AU - von Lueder, Thomas AU - Atar, Dan AU - Falk, Sørum Ragnhild AU - Hellesø, Ragnhild AU - Jaarsma, Tiny AU - Strömberg, Anna AU - Lie, Irene PY - 2020/1/7 TI - Self-Care Monitoring of Heart Failure Symptoms and Lung Impedance at Home Following Hospital Discharge: Longitudinal Study JO - J Med Internet Res SP - e15445 VL - 22 IS - 1 KW - heart failure KW - telemedicine KW - lung impedance KW - diary KW - self-care KW - prospective study N2 - Background: Self-care is key to the daily management of chronic heart failure (HF). After discharge from hospital, patients may struggle to recognize and respond to worsening HF symptoms. Failure to monitor and respond to HF symptoms may lead to unnecessary hospitalizations. Objective: This study aimed to (1) determine the feasibility of lung impedance measurements and a symptom diary to monitor HF symptoms daily at home for 30 days following hospital discharge and (2) determine daily changes in HF symptoms of pulmonary edema, lung impedance measurements, and if self-care behavior improves over time when patients use these self-care monitoring tools. Methods: This study used a prospective longitudinal design including patients from cardiology wards in 2 university hospitals?one in Norway and one in Lithuania. Data on HF symptoms and pulmonary edema were collected from 10 participants (mean age 64.5 years; 90% (9/10) male) with severe HF (New York Heart Association classes III and IV) who were discharged home after being hospitalized for an HF condition. HF symptoms were self-reported using the Memorial Symptom Assessment Scale for Heart Failure. Pulmonary edema was measured by participants using a noninvasive lung impedance monitor, the CardioSet Edema Guard Monitor. Informal caregivers aided the participants with the noninvasive measurements. Results: The prevalence and burden of shortness of breath varied from participants experiencing them daily to never, whereas lung impedance measurements varied for individual participants and the group participants, as a whole. Self-care behavior score improved significantly (P=.007) from a median of 56 (IQR range 22-75) at discharge to a median of 81 (IQR range 72-98) 30 days later. Conclusions: Noninvasive measurement of lung impedance daily and the use of a symptom diary were feasible at home for 30 days in HF patients. Self-care behavior significantly improved after 30 days of using a symptom diary and measuring lung impedance at home. Further research is needed to determine if daily self-care monitoring of HF signs and symptoms, combined with daily lung impedance measurements, may reduce hospital readmissions. UR - https://www.jmir.org/2020/1/e15445 UR - http://dx.doi.org/10.2196/15445 UR - http://www.ncbi.nlm.nih.gov/pubmed/31909717 ID - info:doi/10.2196/15445 ER - TY - JOUR AU - Herkert, Cyrille AU - Kraal, Johannes Jos AU - van Loon, Agnes Eline Maria AU - van Hooff, Martijn AU - Kemps, Clemens Hareld Marijn PY - 2019/12/19 TI - Usefulness of Modern Activity Trackers for Monitoring Exercise Behavior in Chronic Cardiac Patients: Validation Study JO - JMIR Mhealth Uhealth SP - e15045 VL - 7 IS - 12 KW - cardiac diseases KW - activity trackers KW - energy metabolism KW - physical activity KW - validation studies N2 - Background: Improving physical activity (PA) is a core component of secondary prevention and cardiac (tele)rehabilitation. Commercially available activity trackers are frequently used to monitor and promote PA in cardiac patients. However, studies on the validity of these devices in cardiac patients are scarce. As cardiac patients are being advised and treated based on PA parameters measured by these devices, it is highly important to evaluate the accuracy of these parameters in this specific population. Objective: The aim of this study was to determine the accuracy and responsiveness of 2 wrist-worn activity trackers, Fitbit Charge 2 (FC2) and Mio Slice (MS), for the assessment of energy expenditure (EE) in cardiac patients. Methods: EE assessed by the activity trackers was compared with indirect calorimetry (Oxycon Mobile [OM]) during a laboratory activity protocol. Two groups were assessed: patients with stable coronary artery disease (CAD) with preserved left ventricular ejection fraction (LVEF) and patients with heart failure with reduced ejection fraction (HFrEF). Results: A total of 38 patients were included: 19 with CAD and 19 with HFrEF (LVEF 31.8%, SD 7.6%). The CAD group showed no significant difference in total EE between FC2 and OM (47.5 kcal, SD 112 kcal; P=.09), in contrast to a significant difference between MS and OM (88 kcal, SD 108 kcal; P=.003). The HFrEF group showed significant differences in EE between FC2 and OM (38 kcal, SD 57 kcal; P=.01), as well as between MS and OM (106 kcal, SD 167 kcal; P=.02). Agreement of the activity trackers was low in both groups (CAD: intraclass correlation coefficient [ICC] FC2=0.10, ICC MS=0.12; HFrEF: ICC FC2=0.42, ICC MS=0.11). The responsiveness of FC2 was poor, whereas MS was able to detect changes in cycling loads only. Conclusions: Both activity trackers demonstrated low accuracy in estimating EE in cardiac patients and poor performance to detect within-patient changes in the low-to-moderate exercise intensity domain. Although the use of activity trackers in cardiac patients is promising and could enhance daily exercise behavior, these findings highlight the need for population-specific devices and algorithms. UR - http://mhealth.jmir.org/2019/12/e15045/ UR - http://dx.doi.org/10.2196/15045 UR - http://www.ncbi.nlm.nih.gov/pubmed/31855191 ID - info:doi/10.2196/15045 ER - TY - JOUR AU - Guo, Xiaorong AU - Gu, Xiang AU - Jiang, Jiang AU - Li, Hongxiao AU - Duan, Ruoyu AU - Zhang, Yi AU - Sun, Lei AU - Bao, Zhengyu AU - Shen, Jianhua AU - Chen, Fukun PY - 2019/12/13 TI - A Hospital-Community-Family?Based Telehealth Program for Patients With Chronic Heart Failure: Single-Arm, Prospective Feasibility Study JO - JMIR Mhealth Uhealth SP - e13229 VL - 7 IS - 12 KW - telehealth KW - chronic heart failure KW - feasibility studies KW - precise follow-up KW - self-management N2 - Background: An increasing number of patients with chronic heart failure (CHF) are demanding more convenient and efficient modern health care systems, especially in remote areas away from central cities. Telehealth is receiving increasing attention, which may be useful to patients with CHF. Objective: This study aimed to evaluate the feasibility of a hospital-community-family (HCF)?based telehealth program, which was designed to implement remote hierarchical management in patients with CHF. Methods: This was a single-arm prospective study in which 70 patients with CHF participated in the HCF-based telehealth program for remote intervention for at least 4 months. The participants were recruited from the clinic and educated on the use of smart health tracking devices and mobile apps to collect and manually upload comprehensive data elements related to the risk of CHF self-care management. They were also instructed on how to use the remote platform and mobile app to send text messages, check notifications, and open video channels. The general practitioners viewed the index of each participant on the mobile app and provided primary care periodically, and cardiologists in the regional central hospital offered remote guidance, if necessary. The assessed outcomes included accomplishments of the program, usability and satisfaction, engagement with the intervention, and changes of heart failure?related health behaviors. Results: As of February 2018, a total of 66 individuals, aged 40-79 years, completed the 4-month study. Throughout the study period, 294 electronic medical records were formed on the remote monitoring service platform. In addition, a total of 89 remote consultations and 196 remote ward rounds were conducted. Participants indicated that they were generally satisfied with the intervention for its ease of use and usefulness. More than 91% (21/23) of physicians believed the program was effective, and 87% (20/23) of physicians stated that their professional knowledge could always be refreshed and enhanced through a library hosted on the platform and remote consultation. More than 60% (40/66) of participants showed good adherence to the care plan in the study period, and 79% (52/66) of patients maintained a consistent pattern of reporting and viewing their data over the course of the 4-month follow-up period. The program showed a positive effect on self-management for patients (healthy diet: P=.046, more fruit and vegetable intake: P=.02, weight monitoring: P=.002, blood pressure: P<.001, correct time: P=.049, and daily dosages of medicine taken: P=.006). Conclusions: The HCF-based telehealth program is feasible and provided researchers with evidence of remote hierarchical management for patients with CHF, which can enhance participants? and their families? access and motivation to engage in self-management. Further prospective studies with a larger sample size are necessary to confirm the program?s effectiveness. UR - https://mhealth.jmir.org/2019/12/e13229 UR - http://dx.doi.org/10.2196/13229 UR - http://www.ncbi.nlm.nih.gov/pubmed/31833835 ID - info:doi/10.2196/13229 ER - TY - JOUR AU - Park, Christopher AU - Otobo, Emamuzo AU - Ullman, Jennifer AU - Rogers, Jason AU - Fasihuddin, Farah AU - Garg, Shashank AU - Kakkar, Sarthak AU - Goldstein, Marni AU - Chandrasekhar, Vishudhi Sai AU - Pinney, Sean AU - Atreja, Ashish PY - 2019/11/15 TI - Impact on Readmission Reduction Among Heart Failure Patients Using Digital Health Monitoring: Feasibility and Adoptability Study JO - JMIR Med Inform SP - e13353 VL - 7 IS - 4 KW - heart failure KW - blood pressure KW - body weight KW - mHealth KW - remote consultation KW - patient care management KW - patient readmission KW - cell phone KW - mobile phone KW - blood pressure monitors KW - mobile apps N2 - Background: Heart failure (HF) is a condition that affects approximately 6.2 million people in the United States and has a 5-year mortality rate of approximately 42%. With the prevalence expected to exceed 8 million cases by 2030, projections estimate that total annual HF costs will increase to nearly US $70 billion. Recently, the advent of remote monitoring technology has significantly broadened the scope of the physician?s reach in chronic disease management. Objective: The goal of our program, named the Heart Health Program, was to examine the feasibility of using digital health monitoring in real-world home settings, ascertain patient adoption, and evaluate impact on 30-day readmission rate. Methods: A digital medicine software platform developed at Mount Sinai Health System, called RxUniverse, was used to prescribe a digital care pathway including the HealthPROMISE digital therapeutic and iHealth mobile apps to patients? personal smartphones. Vital sign data, including blood pressure (BP) and weight, were collected through an ambulatory remote monitoring system that comprised a mobile app and complementary consumer-grade Bluetooth-connected smart devices (BP cuff and digital scale) that send data to the provider care teams. Care teams were alerted via a Web-based dashboard of abnormal patient BP and weight change readings, and further action was taken at the clinicians? discretion. We used statistical analyses to determine risk factors associated with 30-day all-cause readmission. Results: Overall, the Heart Health Program included 58 patients admitted to the Mount Sinai Hospital for HF. The 30-day hospital readmission rate was 10% (6/58), compared with the national readmission rates of approximately 25% and the Mount Sinai Hospital?s average of approximately 23%. Single marital status (P=.06) and history of percutaneous coronary intervention (P=.08) were associated with readmission. Readmitted patients were also less likely to have been previously prescribed angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (P=.02). Notably, readmitted patients utilized the BP and weight monitors less than nonreadmitted patients, and patients aged younger than 70 years used the monitors more frequently on average than those aged over 70 years, though these trends did not reach statistical significance. The percentage of the 58 patients using the monitors at least once dropped from 83% (42/58) in the first week after discharge to 46% (23/58) in the fourth week. Conclusions: Given the increasing burden of HF, there is a need for an effective and sustainable remote monitoring system for HF patients following hospital discharge. We identified clinical and social factors as well as remote monitoring usage trends that identify targetable patient populations that could benefit most from integration of daily remote monitoring. In addition, we demonstrated that interventions driven by real-time vital sign data may greatly aid in reducing hospital readmissions and costs while improving patient outcomes. UR - https://medinform.jmir.org/2019/4/e13353 UR - http://dx.doi.org/10.2196/13353 UR - http://www.ncbi.nlm.nih.gov/pubmed/31730039 ID - info:doi/10.2196/13353 ER - TY - JOUR AU - Wali, Sahr AU - Demers, Catherine AU - Shah, Hiba AU - Wali, Huda AU - Lim, Delphine AU - Naik, Nirav AU - Ghany, Ahmad AU - Vispute, Ayushi AU - Wali, Maya AU - Keshavjee, Karim PY - 2019/11/11 TI - Evaluation of Heart Failure Apps to Promote Self-Care: Systematic App Search JO - JMIR Mhealth Uhealth SP - e13173 VL - 7 IS - 11 KW - mHealth KW - heart failure KW - self-care KW - mobile phone N2 - 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. UR - https://mhealth.jmir.org/2019/11/e13173 UR - http://dx.doi.org/10.2196/13173 UR - http://www.ncbi.nlm.nih.gov/pubmed/31710298 ID - info:doi/10.2196/13173 ER - TY - JOUR AU - Sohn, Albert AU - Speier, William AU - Lan, Esther AU - Aoki, Kymberly AU - Fonarow, Gregg AU - Ong, Michael AU - Arnold, Corey PY - 2019/10/29 TI - Assessment of Heart Failure Patients? Interest in Mobile Health Apps for Self-Care: Survey Study JO - JMIR Cardio SP - e14332 VL - 3 IS - 2 KW - mHealth KW - patient-reported outcome KW - heart failure KW - self-care KW - patient monitoring N2 - 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. UR - https://cardio.jmir.org/2019/2/e14332 UR - http://dx.doi.org/10.2196/14332 UR - http://www.ncbi.nlm.nih.gov/pubmed/31758788 ID - info:doi/10.2196/14332 ER - TY - JOUR AU - Woods, Leanna AU - Duff, Jed AU - Roehrer, Erin AU - Walker, Kim AU - Cummings, Elizabeth PY - 2019/9/23 TI - Design of a Consumer Mobile Health App for Heart Failure: Findings From the Nurse-Led Co-Design of Care4myHeart JO - JMIR Nursing SP - e14633 VL - 2 IS - 1 KW - heart failure KW - mobile health (mHealth) KW - mobile apps KW - self-management KW - mobile phone KW - patient involvement N2 - Background: Consumer health care technology shows potential to improve outcomes for community-dwelling persons with chronic conditions, yet health app quality varies considerably. In partnership with patients and family caregivers, hospital clinicians developed Care4myHeart, a mobile health (mHealth) app for heart failure (HF) self-management. Objective: The aim of this paper was to report the outcomes of the nurse-led design process in the form of the features and functions of the developed app, Care4myHeart. Methods: Seven patients, four family caregivers, and seven multidisciplinary hospital clinicians collaborated in a design thinking process of innovation. The co-design process, involving interviews, design workshops, and prototype feedback sessions, incorporated the lived experience of stakeholders and evidence-based literature in a design that would be relevant and developed with rigor. Results: The home screen displays the priority HF self-management components with a reminder summary, general information on the condition, and a settings tab. The health management section allows patients to list health care team member?s contact details, schedule medical appointments, and store documents. The My Plan section contains nine important self-management components with a combination of information and advice pages, graphical representation of patient data, feedback, and more. The greatest strength of the co-design process to achieve the design outcomes was the involvement of local patients, family caregivers, and clinicians. Moreover, incorporating the literature, guidelines, and current practices into the design strengthened the relevance of the app to the health care context. However, the strength of context specificity is also a limitation to portability, and the final design is limited to the stakeholders involved in its development. Conclusions: We recommend health app development teams strategically incorporate relevant stakeholders and literature to design mHealth solutions that are rigorously designed from a solid evidence base and are relevant to those who will use or recommend their use. UR - https://nursing.jmir.org/2019/1/e14633 UR - http://dx.doi.org/10.2196/14633 UR - http://www.ncbi.nlm.nih.gov/pubmed/34345774 ID - info:doi/10.2196/14633 ER - TY - JOUR AU - Dinesen, Birthe AU - Dittmann, Lars AU - Gade, Dam Josefine AU - Jørgensen, Klitgaard Cecilia AU - Hollingdal, Malene AU - Leth, Soeren AU - Melholt, Camilla AU - Spindler, Helle AU - Refsgaard, Jens PY - 2019/09/19 TI - ?Future Patient? Telerehabilitation for Patients With Heart Failure: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e14517 VL - 8 IS - 9 KW - heart failure KW - telerehabilitation KW - research design KW - quality of life KW - patient education KW - user-driven innovation N2 - Background: Cardiovascular disease is the leading cause of mortality worldwide, accounting for 13%-15% of all deaths. Cardiac rehabilitation has poor compliance and adherence. Telerehabilitation has been introduced to increase patients? participation, access, and adherence with the help of digital technologies. The target group is patients with heart failure. A telerehabilitation program called ?Future Patient? has been developed and consists of three phases: (1) titration of medicine (0-3 months), (2) implementation of the telerehabilitation protocols (3 months), and (3) follow-up with rehabilitation in everyday life (6 months). Patients in the Future Patient program measure their blood pressure, pulse, weight, number of steps taken, sleep, and respiration and answer questions online regarding their well-being. All data are transmitted and accessed in the HeartPortal by patients and health care professionals. Objective: The aim of this paper is to describe the research design, outcome measures, and data collection techniques in the clinical test of the Future Patient Telerehabilitation Program for patients with heart failure. Methods: A randomized controlled study will be performed. The intervention group will follow the Future Patient Telerehabilitation program, and the control group will follow the traditional cardiac rehabilitation program. The primary outcome is quality of life measured by the Kansas City Cardiomyopathy Questionnaire. Secondary outcomes are development of clinical data; illness perception; motivation; anxiety and depression; health and electronic health literacy; qualitative exploration of patients?, spouses?, and health care professionals? experiences of participating in the telerehabilitation program; and a health economy evaluation of the program. Outcomes were assessed using questionnaires and through the data generated by digital technologies. Results: Data collection began in December 2016 and will be completed in October 2019. The study results will be published in peer-reviewed journals and presented at international conferences. Results from the Future Patient Telerehabilitation program are expected to be published by the spring of 2020. Conclusions: The expected outcomes are increased quality of life, increased motivation and illness perception, reduced anxiety and depressions, improved electronic health literacy, and health economics benefits. We expect the study to have a clinical impact for future telerehabilitation of patients with heart failure. Trial Registration: ClinicalTrials.gov NCT03388918; https://clinicaltrials.gov/ct2/show/NCT03388918 International Registered Report Identifier (IRRID): DERR1-10.2196/14517 UR - https://www.researchprotocols.org/2019/9/e14517 UR - http://dx.doi.org/10.2196/14517 UR - http://www.ncbi.nlm.nih.gov/pubmed/31538944 ID - info:doi/10.2196/14517 ER - TY - JOUR AU - Meeker, Daniella AU - Goldberg, Jordan AU - Kim, K. Katherine AU - Peneva, Desi AU - Campos, Oliveira Hugo De AU - Maclean, Ross AU - Selby, Van AU - Doctor, N. Jason PY - 2019/08/06 TI - Patient Commitment to Health (PACT-Health) in the Heart Failure Population: A Focus Group Study of an Active Communication Framework for Patient-Centered Health Behavior Change JO - J Med Internet Res SP - e12483 VL - 21 IS - 8 KW - heart failure KW - behavioral economics KW - motivational interviewing N2 - Background: Over 6 million Americans have heart failure, and 1 in 8 deaths included heart failure as a contributing cause in 2016. Lifestyle changes and adherence to diet and exercise regimens are important in limiting disease progression. Health coaching and public commitment are two interactive communication strategies that may improve self-management of heart failure. Objective: This study aimed to conduct patient focus groups to gain insight into how best to implement health coaching and public commitment strategies within the heart failure population. Methods: Focus groups were conducted in two locations. We studied 2 patients in Oakland, California, and 5 patients in Los Angeles, California. Patients were referred by local cardiologists and had to have a diagnosis of chronic heart failure. We used a semistructured interview tool to explore several patient-centered themes including medication adherence, exercise habits, dietary habits, goals, accountability, and rewards. We coded focus group data using the a priori coding criteria for these domains. Results: Medication adherence barriers included regimen complexity, forgetfulness, and difficulty coping with side effects. Participants reported that they receive little instruction from care providers on appropriate exercise and dietary habits. They also reported personal and social obstacles to achieving these objectives. Participants were in favor of structured goal setting, use of online social networks, and financial rewards as a means of promoting health lifestyles. Peers were viewed as better motivating agents than family members. Conclusions: An active communication framework involving dissemination of diet- and exercise-related health information, structured goal setting, peer accountability, and financial rewards appears promising in the management of heart failure. UR - http://www.jmir.org/2019/8/e12483/ UR - http://dx.doi.org/10.2196/12483 UR - http://www.ncbi.nlm.nih.gov/pubmed/31389339 ID - info:doi/10.2196/12483 ER - TY - JOUR AU - Bogyi, Peter AU - Vamos, Mate AU - Bari, Zsolt AU - Polgar, Balazs AU - Muk, Balazs AU - Nyolczas, Noemi AU - Kiss, Gabor Robert AU - Duray, Zoltan Gabor PY - 2019/07/26 TI - Association of Remote Monitoring With Survival in Heart Failure Patients Undergoing Cardiac Resynchronization Therapy: Retrospective Observational Study JO - J Med Internet Res SP - e14142 VL - 21 IS - 7 KW - survival KW - CRT-D KW - remote monitoring KW - telemedicine KW - heart failure N2 - Background: Remote monitoring is an established, guideline-recommended technology with unequivocal clinical benefits; however, its ability to improve survival is contradictory. Objective: The aim of our study was to investigate the effects of remote monitoring on mortality in an optimally treated heart failure patient population undergoing cardiac resynchronization defibrillator therapy (CRT-D) implantation in a large-volume tertiary referral center. Methods: The population of this single-center, retrospective, observational study included 231 consecutive patients receiving CRT-D devices in the Medical Centre of the Hungarian Defence Forces (Budapest, Hungary) from January 2011 to June 2016. Clinical outcomes were compared between patients on remote monitoring and conventional follow-up. Results: The mean follow-up time was 28.4 (SD 18.1) months. Patients on remote monitoring were more likely to have atrial fibrillation, received heart failure management at our dedicated heart failure outpatient clinic more often, and have a slightly lower functional capacity. Crude all-cause mortality of remote-monitored patients was significantly lower compared with patients followed conventionally (hazard ratio [HR] 0.368, 95% CI 0.186-0.727, P=.004). The survival benefit remained statistically significant after adjustment for important baseline parameters (adjusted HR 0.361, 95% CI 0.181-0.722, P=.004). Conclusions: In this single-center, retrospective study of optimally treated heart failure patients undergoing CRT-D implantation, the use of remote monitoring systems was associated with a significantly better survival rate. UR - http://www.jmir.org/2019/7/e14142/ UR - http://dx.doi.org/10.2196/14142 UR - http://www.ncbi.nlm.nih.gov/pubmed/31350836 ID - info:doi/10.2196/14142 ER - TY - JOUR AU - Seto, Emily AU - Morita, Pelegrini Plinio AU - Tomkun, Jonathan AU - Lee, M. Theresa AU - Ross, Heather AU - Reid-Haughian, Cheryl AU - Kaboff, Andrew AU - Mulholland, Deb AU - Cafazzo, A. Joseph PY - 2019/07/26 TI - Implementation of a Heart Failure Telemonitoring System in Home Care Nursing: Feasibility Study JO - JMIR Med Inform SP - e11722 VL - 7 IS - 3 KW - patient monitoring KW - home care services KW - heart failure KW - mobile phone KW - feasibility studies N2 - Background: Telemonitoring (TM) of heart failure (HF) patients in a clinic setting has been shown to be effective if properly implemented, but little is known about the feasibility and impact of implementing TM through a home care nursing agency. Objective: This study aimed to determine the feasibility of implementing a mobile phone?based TM system through a home care nursing agency and to explore the feasibility of conducting a future effectiveness trial. Methods: A feasibility study was conducted by recruiting, through community cardiologists and family physicians, 10 to 15 HF patients who would use the TM system for 4 months by taking daily measurements of weight and blood pressure and recording symptoms. Home care nurses responded to alerts generated by the TM system through either a phone call and/or a home visit. Patients and their clinicians were interviewed poststudy to determine their perceptions and experiences of using the TM system. Results: Only one community cardiologist was recruited who was willing to refer patients to this study, even after multiple attempts were made to recruit further physicians, including family physicians. The cardiologist referred only 6 patients over a 6-month period, and half of the patients dropped out of the study. The identified barriers to implementing the TM system in home care nursing were numerous and led to the small recruitment in patients and clinicians and large dropout rate. These barriers included challenges in nurses contacting patients and physicians, issues related to retention, and challenges related to integrating the TM system into a complex home care nursing workflow. However, some potential benefits of TM through a home care nursing agency were indicated, including improved patient education, providing nurses with a better understanding of the patient?s health status, and reductions in home visits. Conclusions: Lessons learned included the need to incentivize physicians, to ensure streamlined processes for recruitment and communication, to target appropriate patient populations, and to create a core clinical group. Barriers encountered in this feasibility trial should be considered to determine their applicability when deploying innovations into different service delivery models. UR - http://medinform.jmir.org/2019/3/e11722/ UR - http://dx.doi.org/10.2196/11722 UR - http://www.ncbi.nlm.nih.gov/pubmed/31350841 ID - info:doi/10.2196/11722 ER - TY - JOUR AU - Shariatpanahi, Shabnam AU - Ashghali Farahani, Mansoureh AU - Rafii, Forough AU - Rassouli, Maryam AU - Kavousi, Amir PY - 2019/07/26 TI - Designing and Testing a Treatment Adherence Model Based on the Roy Adaptation Model in Patients With Heart Failure: Protocol for a Mixed Methods Study JO - JMIR Res Protoc SP - e13317 VL - 8 IS - 7 KW - adaptation KW - treatment adherence and compliance KW - heart failure N2 - Background: Adherence to treatment is an important factor to decrease repeated and costly hospitalization owing to heart failure (HF). The explanation and prediction of medication adherence and other lifestyle recommendations in chronic diseases, including HF, are complex. Theories lead to a better understanding of complex situations as well as the process of changing behavior and explain the reasons for the existence of a problem. Objective: The aim of this study is to report a protocol for a mixed methods study setting out to investigate the empirical validity of the Roy Adaptation Model as a conceptual framework for explaining and predicting adherence to treatment in patients with HF in Iran. Methods: This mixed methods study consists of an exploratory sequential design to be conducted in 2 phases. The first phase involves identifying the factors associated with treatment adherence in patients with HF through content analysis of the literature and elucidating the perception of participants in the context of Iranian health care where the model of adherence to treatment is designed based on the Roy Adaptation Model. The second phase addresses the interrelationships among variables in the model through a descriptive study using structural equation modeling. Finally, following the summarization and separate interpretation of the qualitative findings and quantitative results, a decision is made about the extent to and ways in which the results of the quantitative stage can be generalized or tested for the qualitative findings. Results: Content analysis of the literature in part 1 of the first phase was completed in 2017. Collection and analysis of qualitative data in part 2 of the first phase will be completed soon. The results are expected to be submitted for publication in 2019. Then, the second phase?the quantitative study?will be conducted. Conclusions: The results of this study will provide valuable information about the empirical validity of the Roy Adaptation Model as a conceptual framework for explaining and predicting adherence to treatment in patients with HF, which, to date, have received little attention. The results can be used as a guide for nursing practice and care provision to patients with HF and also to design and implement effective interventions to improve treatment adherence in these patients. International Registered Report Identifier (IRRID): DERR1-10.2196/13317 UR - https://www.researchprotocols.org/2019/7/e13317/ UR - http://dx.doi.org/10.2196/13317 UR - http://www.ncbi.nlm.nih.gov/pubmed/31350842 ID - info:doi/10.2196/13317 ER - TY - JOUR AU - Allemann, Hanna AU - Thylén, Ingela AU - Ågren, Susanna AU - Liljeroos, Maria AU - Strömberg, Anna PY - 2019/07/16 TI - Perceptions of Information and Communication Technology as Support for Family Members of Persons With Heart Failure: Qualitative Study JO - J Med Internet Res SP - e13521 VL - 21 IS - 7 KW - family KW - caregivers KW - telemedicine KW - perception KW - heart failure KW - social support KW - focus groups KW - qualitative research N2 - Background: Heart failure (HF) affects not only the person diagnosed with the syndrome but also family members, who often have the role of informal carers. The needs of these carers are not always met, and information and communications technology (ICT) could have the potential to support them in their everyday life. However, knowledge is lacking about how family members perceive ICT and see opportunities for this technology to support them. Objective: The aim of this study was to explore the perceptions of ICT solutions as supportive aids among family members of persons with HF. Methods: A qualitative design was applied. A total of 8 focus groups, comprising 23 family members of persons affected by HF, were conducted between March 2015 and January 2017. Participants were recruited from 1 hospital in Sweden. A purposeful sampling strategy was used to find family members of persons with symptomatic HF from diverse backgrounds. Data were analyzed using qualitative content analysis. Results: The analysis revealed 4 categories and 9 subcategories. The first category, about how ICT could provide relevant support, included descriptions of how ICT could be used for communication with health care personnel, for information and communication retrieval, plus opportunities to interact with persons in similar life situations and to share support with peers and extended family. The second category, about how ICT could provide access, entailed how ICT could offer solutions not bound by time or place and how it could be both timely and adaptable to different life situations. ICT could also provide an arena for family members to which they might not otherwise have had access. The third category concerned how ICT could be too impersonal and how it could entail limited personal interaction and individualization, which could lead to concerns about usability. It was emphasized that ICT could not replace physical meetings. The fourth category considered how ICT could be out of scope, reflecting the fact that some family members were generally uninterested in ICT and had difficulties envisioning how it could be used for support. It was also discussed as more of a solution for the future. Conclusions: Family members described multiple uses for ICT and agreed that ICT could provide access to relevant sources of information from which family members could potentially exchange support. ICT was also considered to have its limitations and was out of scope for some but with expected use in the future. Even though some family members seemed hesitant about ICT solutions in general, this might not mean they are unreceptive to suggestions about their usage in, for example, health care. Thus, a variety of factors should be considered to facilitate future implementations of ICT tools in clinical practice. UR - http://www.jmir.org/2019/7/e13521/ UR - http://dx.doi.org/10.2196/13521 UR - http://www.ncbi.nlm.nih.gov/pubmed/31313662 ID - info:doi/10.2196/13521 ER - TY - JOUR AU - Jiang, Xinchan AU - Ming, Wai-Kit AU - You, HS Joyce PY - 2019/06/17 TI - The Cost-Effectiveness of Digital Health Interventions on the Management of Cardiovascular Diseases: Systematic Review JO - J Med Internet Res SP - e13166 VL - 21 IS - 6 KW - telemedicine KW - cardiovascular diseases KW - stroke KW - heart failure KW - myocardial infarction KW - heart attack KW - cost-effectiveness KW - medical economics KW - decision modeling KW - systematic review N2 - Background: With the advancement in information technology and mobile internet, digital health interventions (DHIs) are improving the care of cardiovascular diseases (CVDs). The impact of DHIs on cost-effective management of CVDs has been examined using the decision analytic model?based health technology assessment approach. Objective: The aim of this study was to perform a systematic review of the decision analytic model?based studies evaluating the cost-effectiveness of DHIs on the management of CVDs. Methods: A literature review was conducted in Medline, Embase, Cumulative Index to Nursing and Allied Health Literature Complete, PsycINFO, Scopus, Web of Science, Center for Review and Dissemination, and Institute for IEEE Xplore between 2001 and 2018. Studies were included if the following criteria were met: (1) English articles, (2) DHIs that promoted or delivered clinical interventions and had an impact on patients? cardiovascular conditions, (3) studies that were modeling works with health economic outcomes of DHIs for CVDs, (4) studies that had a comparative group for assessment, and (5) full economic evaluations including a cost-effectiveness analysis, cost-utility analysis, cost-benefit analysis, and cost-consequence analysis. The primary outcome collected was the cost-effectiveness of the DHIs, presented by incremental cost per additional quality-adjusted life year (QALY). The quality of each included study was evaluated using the Consolidated Health Economic Evaluation Reporting Standards. Results: A total of 14 studies met the defined criteria and were included in the review. Among the included studies, heart failure (7/14, 50%) and stroke (4/14, 29%) were two of the most frequent CVDs that were managed by DHIs. A total of 9 (64%) studies were published between 2015 and 2018 and 5 (36%) published between 2011 and 2014. The time horizon was ?1 year in 3 studies (21%), >1 year in 10 studies (71%), and 1 study (7%) did not declare the time frame. The types of devices or technologies used to deliver the health interventions were short message service (1/14, 7%), telephone support (1/14, 7%), mobile app (1/14, 7%), video conferencing system (5/14, 36%), digital transmission of physiologic data (telemonitoring; 5/14, 36%), and wearable medical device (1/14, 7%). The DHIs gained higher QALYs with cost saving in 43% (6/14) of studies and gained QALYs at a higher cost at acceptable incremental cost-effectiveness ratio (ICER) in 57% (8/14) of studies. The studies were classified as excellent (0/14, 0%), good (9/14, 64%), moderate (4/14, 29%), and low (1/14, 7%) quality. Conclusions: This study is the first systematic review of decision analytic model?based cost-effectiveness analyses of DHIs in the management of CVDs. Most of the identified studies were published recently, and the majority of the studies were good quality cost-effectiveness analyses with an adequate duration of time frame. All the included studies found the DHIs to be cost-effective. UR - http://www.jmir.org/2019/6/e13166/ UR - http://dx.doi.org/10.2196/13166 UR - http://www.ncbi.nlm.nih.gov/pubmed/31210136 ID - info:doi/10.2196/13166 ER - TY - JOUR AU - Zhang, Lingling AU - Babu, V. Sabarish AU - Jindal, Meenu AU - Williams, E. Joel AU - Gimbel, W. Ronald PY - 2019/05/23 TI - A Patient-Centered Mobile Phone App (iHeartU) With a Virtual Human Assistant for Self-Management of Heart Failure: Protocol for a Usability Assessment Study JO - JMIR Res Protoc SP - e13502 VL - 8 IS - 5 KW - heart failure KW - mobile health KW - self-management KW - patient engagement KW - virtual human N2 - Background: Heart failure (HF) causes significant economic and humanistic burden for patients and their families, especially those with a low income, partly due to high hospital readmission rates. Optimal self-care is considered an important nonpharmacological aspect of HF management that can improve health outcomes. Emerging evidence suggests that self-management assisted by smartphone apps may reduce rehospitalization rates and improve the quality of life of patients. We developed a virtual human?assisted, patient-centered mobile health app (iHeartU) for patients with HF to enhance their engagement in self-management and improve their communication with health care providers and family caregivers. iHeartU may help patients with HF in self-management to reduce the technical knowledge and usability barrier while maintaining a low cost and natural, effective social interaction with the user. Objective: With a standardized systematic usability assessment, this study had two objectives: (1) to determine the obstacles to effective and efficient use of iHeartU in patients with HF and (2) to evaluate of HF patients? adoption, satisfaction, and engagement with regard to the of iHeartU app. Methods: The basic methodology to develop iHeartU systems consists of a user-centric design, development, and mixed methods formative evaluation. The iterative design and evaluation are based on the guidelines of the American College of Cardiology Foundation and American Heart Association for the management of heart failure and the validated ?Information, Motivation, and Behavioral skills? behavior change model. Our hypothesis is that this method of a user-centric design will generate a more usable, useful, and easy-to-use mobile health system for patients, caregivers, and practitioners. Results: The prototype of iHeartU has been developed. It is currently undergoing usability testing. As of September 2018, the first round of usability testing data have been collected. The final data collection and analysis are expected to be completed by the end of 2019. Conclusions: The main contribution of this project is the development of a patient-centered self-management system, which may support HF patients? self-care at home and aid in the communication between patients and their health care providers in a more effective and efficient way. Widely available mobile phones serve as care coordination and ?no-cost? continuum of care. For low-income patients with HF, a mobile self-management tool will expand their accessibility to care and reduce the cost incurred due to emergency visits or readmissions. The user-centered design will improve the level of engagement of patients and ultimately lead to better health outcomes. Developing and testing a novel mobile system for patients with HF that incorporates chronic disease management is critical for advancing research and clinical practice of care for them. This research fills in the gap in user-centric design and lays the groundwork for a large-scale population study in the next phase. International Registered Report Identifier (IRRID): DERR1-10.2196/13502 UR - http://www.researchprotocols.org/2019/5/e13502/ UR - http://dx.doi.org/10.2196/13502 UR - http://www.ncbi.nlm.nih.gov/pubmed/31124472 ID - info:doi/10.2196/13502 ER - TY - JOUR AU - Baril, Jonathan-F AU - Bromberg, Simon AU - Moayedi, Yasbanoo AU - Taati, Babak AU - Manlhiot, Cedric AU - Ross, Joan Heather AU - Cafazzo, Joseph PY - 2019/05/17 TI - Use of Free-Living Step Count Monitoring for Heart Failure Functional Classification: Validation Study JO - JMIR Cardio SP - e12122 VL - 3 IS - 1 KW - exercise physiology KW - heart rate tracker KW - wrist worn devices KW - Fitbit KW - heart failure KW - steps KW - cardiopulmonary exercise test KW - ambulatory monitoring N2 - Background: The New York Heart Association (NYHA) functional classification system has poor inter-rater reproducibility. A previously published pilot study showed a statistically significant difference between the daily step counts of heart failure (with reduced ejection fraction) patients classified as NYHA functional class II and III as measured by wrist-worn activity monitors. However, the study?s small sample size severely limits scientific confidence in the generalizability of this finding to a larger heart failure (HF) population. Objective: This study aimed to validate the pilot study on a larger sample of patients with HF with reduced ejection fraction (HFrEF) and attempt to characterize the step count distribution to gain insight into a more objective method of assessing NYHA functional class. Methods: We repeated the analysis performed during the pilot study on an independently recorded dataset comprising a total of 50 patients with HFrEF (35 NYHA II and 15 NYHA III) patients. Participants were monitored for step count with a Fitbit Flex for a period of 2 weeks in a free-living environment. Results: Comparing group medians, patients exhibiting NYHA class III symptoms had significantly lower recorded 2-week mean daily total step count (3541 vs 5729 [steps], P=.04), lower 2-week maximum daily total step count (10,792 vs 5904 [steps], P=.03), lower 2-week recorded mean daily mean step count (4.0 vs 2.5 [steps/minute], P=.04,), and lower 2-week mean and 2-week maximum daily per minute step count maximums (88.1 vs 96.1 and 111.0 vs 123.0 [steps/minute]; P=.02 and .004, respectively). Conclusions: Patients with NYHA II and III symptoms differed significantly by various aggregate measures of free-living step count including the (1) mean and (2) maximum daily total step count as well as by the (3) mean of daily mean step count and by the (4) mean and (5) maximum of the daily per minute step count maximum. These findings affirm that the degree of exercise intolerance of NYHA II and III patients as a group is quantifiable in a replicable manner. This is a novel and promising finding that suggests the existence of a possible, completely objective measure of assessing HF functional class, something which would be a great boon in the continuing quest to improve patient outcomes for this burdensome and costly disease. UR - http://cardio.jmir.org/2019/1/e12122/ UR - http://dx.doi.org/10.2196/12122 UR - http://www.ncbi.nlm.nih.gov/pubmed/31758777 ID - info:doi/10.2196/12122 ER - TY - JOUR AU - Woods, Sarah Leanna AU - Duff, Jed AU - Roehrer, Erin AU - Walker, Kim AU - Cummings, Elizabeth PY - 2019/05/02 TI - Patients? Experiences of Using a Consumer mHealth App for Self-Management of Heart Failure: Mixed-Methods Study JO - JMIR Hum Factors SP - e13009 VL - 6 IS - 2 KW - heart failure KW - mobile health (mHealth) KW - mobile apps KW - usability study KW - Mobile Application Rating Scale KW - patient experience KW - self-management KW - mobile phone N2 - Background: To support the self-management of heart failure, a team of hospital clinicians, patients, and family caregivers have co-designed the consumer mobile health app, Care4myHeart. Objective: This research aimed to determine patient experiences of using the app to self-manage heart failure. Methods: Patients with heart failure used the app for 14 days on their own smart device in a home setting, following which a mixed-methods evaluation was performed. Eight patients were recruited, of whom six completed the Mobile Application Rating Scale and attended an interview. Results: The overall app quality score was ?acceptable? with 3.53 of 5 points, with the aesthetics (3.83/5) and information (3.78/5) subscales scoring the highest. The lowest mean score was in the app-specific subscale representing the perceived impact on health behavior change (2.53/5). Frequently used features were weight and fluid restriction tracking, with graphical representation of data particularly beneficial for improved self-awareness and ongoing learning. The use of technology for self-management will fundamentally differ from current practices and require a change in daily routines. However, app use was correlated with potential utility for daily management of illness with benefits of accurate recording and review of personal health data and as a communication tool for doctors to assist with care planning, as all medical information is available in one place. Technical considerations included participants? attitudes toward technology, functionality and data entry issues, and relatively minor suggested changes. Conclusions: The findings from this usability study suggest that a significant barrier to adoption is the lack of integration of technology into everyday life in the context of already established disease self-management routines. Future studies should explore the barriers to adoption and sustainability of consumer mobile health interventions for chronic conditions, particularly whether introducing such apps is more beneficial at the commencement of a self-management regimen. UR - http://humanfactors.jmir.org/2019/2/e13009/ UR - http://dx.doi.org/10.2196/13009 UR - http://www.ncbi.nlm.nih.gov/pubmed/31045504 ID - info:doi/10.2196/13009 ER - TY - JOUR AU - Athilingam, Ponrathi AU - Jenkins, Bradlee AU - Redding, A. Barbara PY - 2019/04/25 TI - Reading Level and Suitability of Congestive Heart Failure (CHF) Education in a Mobile App (CHF Info App): Descriptive Design Study JO - JMIR Aging SP - e12134 VL - 2 IS - 1 KW - health literacy KW - reading level KW - patient education KW - heart failure KW - mobile app N2 - 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. UR - http://aging.jmir.org/2019/1/e12134/ UR - http://dx.doi.org/10.2196/12134 UR - http://www.ncbi.nlm.nih.gov/pubmed/31518265 ID - info:doi/10.2196/12134 ER - TY - JOUR AU - Treskes, Willem Roderick AU - Maan, C. Arie AU - Verwey, Florence Harriette AU - Schot, Robert AU - Beeres, Anna Saskia Lambertha Maria AU - Tops, F. Laurens AU - Van Der Velde, Tjeerd Enno AU - Schalij, Jan Martin AU - Slats, Margaretha Annelies PY - 2019/03/19 TI - Mobile Health for Central Sleep Apnea Screening Among Patients With Stable Heart Failure: Single-Cohort, Open, Prospective Trial JO - JMIR Cardio SP - e9894 VL - 3 IS - 1 KW - mobile health KW - central sleep apnea KW - heart failure KW - prevention KW - screening KW - mobile phone N2 - Background: Polysomnography is the gold standard for detection of central sleep apnea in patients with stable heart failure. However, this procedure is costly, time consuming, and a burden to the patient and therefore unsuitable as a screening method. An electronic health (eHealth) app to measure overnight oximetry may be an acceptable screening alternative, as it can be automatically analyzed and is less burdensome to patients. Objective: This study aimed to assess whether overnight pulse oximetry using a smartphone-compatible oximeter can be used to detect central sleep apnea in a population with stable heart failure. Methods: A total of 26 patients with stable heart failure underwent one night of both a polygraph examination and overnight saturation using a smartphone-compatible oximeter. The primary endpoint was agreement between the oxygen desaturation index (ODI) above or below 15 on the smartphone-compatible oximeter and the diagnosis of the polygraph. Results: The median age of patients was 66.4 (interquartile range, 62-71) years and 92% were men. The median body mass index was 27.1 (interquartile range, 24.4-30.8) kg/m2. Two patients were excluded due to incomplete data, and two other patients were excluded because they could not use a smartphone. Seven patients had central sleep apnea, and 6 patients had obstructive sleep apnea. Of the 7 (of 22, 32%) patients with central sleep apnea that were included in the analysis, 3 (13%) had an ODI?15. Of all patients without central sleep apnea, 8 (36%) had an ODI<15. The McNemar test yielded a P value of .55. Conclusions: Oxygen desaturation measured by this smartphone-compatible oximeter is a weak predictor of central sleep apnea in patients with stable heart failure. UR - http://cardio.jmir.org/2019/1/e9894/ UR - http://dx.doi.org/10.2196/cardio.9894 UR - http://www.ncbi.nlm.nih.gov/pubmed/31758786 ID - info:doi/10.2196/cardio.9894 ER - TY - JOUR AU - Ware, Patrick AU - Dorai, Mala AU - Ross, J. Heather AU - Cafazzo, A. Joseph AU - Laporte, Audrey AU - Boodoo, Chris AU - Seto, Emily PY - 2019/02/26 TI - Patient Adherence to a Mobile Phone?Based Heart Failure Telemonitoring Program: A Longitudinal Mixed-Methods Study JO - JMIR Mhealth Uhealth SP - e13259 VL - 7 IS - 2 KW - telemonitoring KW - mHealth KW - adherence KW - heart failure N2 - Background: Telemonitoring (TM) can improve heart failure (HF) outcomes by facilitating patient self-care and clinical decision support. However, these outcomes are only possible if patients consistently adhere to taking prescribed home readings. Objective: The objectives of this study were to (1) quantify the degree to which patients adhered to taking prescribed home readings in the context of a mobile phone?based TM program and (2) explain longitudinal adherence rates based on the duration of program enrollment, patient characteristics, and patient perceptions of the TM program. Methods: A mixed-methods explanatory sequential design was used to meet the 2 research objectives, and all explanatory methods were guided by the unified theory of acceptance and use of technology 2 (UTAUT2). Overall adherence rates were calculated as the proportion of days patients took weight, blood pressure, heart rate, and symptom readings over the total number of days they were enrolled in the program up to 1 year. Monthly adherence rates were also calculated as the proportion of days patients took the same 4 readings over each 30-day period following program enrollment. Next, simple and multivariate regressions were performed to determine the influence of time, age, sex, and disease severity on adherence rates. Additional explanatory methods included questionnaires at 6 and 12 months probing patients on the perceived benefits and ease of use of the TM program, an analysis of reasons for patients leaving the program, and semistructured interviews conducted with a purposeful sampling of patients (n=24) with a range of adherence rates and demographics. Results: Overall average adherence was 73.6% (SD 25.0) with average adherence rates declining over time at a rate of 1.4% per month (P<.001). The multivariate regressions found no significant effect of sex and disease severity on adherence rates. When grouping patients? ages by decade, age was a significant predictor (P=.04) whereby older patients had higher adherence rates over time. Adherence rates were further explained by patients? perceptions with regard to the themes of (1) performance expectancy (improvements in HF management and peace of mind), (2) effort expectancy (ease of use and technical issues), (3) facilitating conditions (availability of technical support and automated adherence calls), (4) social influence (support from family, friends, and trusted clinicians), and (5) habit (degree to which taking readings became automatic). Conclusions: The decline in adherence rates over time is consistent with findings from other studies. However, this study also found adherence to be the highest and most consistent over time in older age groups and progressively lower over time for younger age groups. These findings can inform the design and implementation of TM interventions that maximize patient adherence, which will enable a more accurate evaluation of impact and optimization of resources. International Registered Report Identifier (IRRID): RR2-10.2196/resprot.9911 UR - http://mhealth.jmir.org/2019/2/e13259/ UR - http://dx.doi.org/10.2196/13259 UR - http://www.ncbi.nlm.nih.gov/pubmed/30806625 ID - info:doi/10.2196/13259 ER - TY - JOUR AU - Aamodt, Thon Ina AU - Lycholip, Edita AU - Celutkiene, Jelena AU - Strömberg, Anna AU - Atar, Dan AU - Falk, Sørum Ragnhild AU - von Lueder, Thomas AU - Hellesø, Ragnhild AU - Jaarsma, Tiny AU - Lie, Irene PY - 2019/02/06 TI - Health Care Professionals? Perceptions of Home Telemonitoring in Heart Failure Care: Cross-Sectional Survey JO - J Med Internet Res SP - e10362 VL - 21 IS - 2 KW - nurses KW - physicians KW - perception KW - telemedicine KW - heart failure KW - self-care N2 - Background: Noninvasive telemonitoring (TM) can be used in heart failure (HF) patients to perform early detection of decompensation at home, prevent unnecessary health care utilization, and decrease health care costs. However, the evidence is not sufficient to be part of HF guidelines for follow-up care, and we have no knowledge of how TM is used in the Nordic Baltic region. Objective: The aim of this study was to describe health care professionals? (HCPs) perception of and presumed experience with noninvasive TM in daily HF patient care, perspectives of the relevance of and reasons for applying noninvasive TM, and barriers to the use of noninvasive TM. Methods: A cross-sectional survey was performed between September and December 2016 in Norway and Lithuania with physicians and nurses treating HF patients at either a hospital ward or an outpatient clinic. A total of 784 questionnaires were sent nationwide by postal mail to 107 hospitals. The questionnaire consisted of 43 items with close- and open-ended questions. In Norway, the response rate was 68.7% (226/329), with 57 of 60 hospitals participating, whereas the response rate was 68.1% (310/455) in Lithuania, with 41 of 47 hospitals participating. Responses to the closed questions were analyzed using descriptive statistics, and the open-ended questions were analyzed using summative content analysis. Results: This study showed that noninvasive TM is not part of the current daily clinical practice in Norway or Lithuania. A minority of HCPs responded to be familiar with noninvasive TM in HF care in Norway (48/226, 21.2%) and Lithuania (64/310, 20.6%). Approximately half of the HCPs in both countries perceived noninvasive TM to be relevant in follow-up of HF patients in Norway (131/226, 58.0%) and Lithuania (172/310, 55.5%). For physicians in both countries and nurses in Norway, the 3 most mentioned reasons for introducing noninvasive TM were to improve self-care, to reduce hospitalizations, and to provide high-quality care, whereas the Lithuanian nurses described ability to treat more patients and to reduce their workload as reasons for introducing noninvasive TM. The main barriers to implement noninvasive TM were lack of funding from health care authorities or the Territorial Patient Fund. Moreover, HCPs perceive that HF patients themselves could represent barriers because of their physical or mental condition in addition to a lack of internet access. Conclusions: HCPs in Norway and Lithuania are currently nonusers of TM in daily HF care. However, they perceive a future with TM to improve the quality of care for HF patients. Financial barriers and HF patients? condition may have an impact on the use of TM, whereas sufficient funding from health care authorities and improved knowledge may encourage the more widespread use of TM in the Nordic Baltic region and beyond. UR - http://www.jmir.org/2019/2/e10362/ UR - http://dx.doi.org/10.2196/10362 UR - http://www.ncbi.nlm.nih.gov/pubmed/30724744 ID - info:doi/10.2196/10362 ER - TY - JOUR AU - Lang, Michael PY - 2019/01/30 TI - Automatic Near Real-Time Outlier Detection and Correction in Cardiac Interbeat Interval Series for Heart Rate Variability Analysis: Singular Spectrum Analysis-Based Approach JO - JMIR Biomed Eng SP - e10740 VL - 4 IS - 1 KW - change-point detection KW - cumulative sum KW - forecasting KW - heart rate variability KW - R-R series KW - singular spectrum analysis KW - ventricular premature complexes N2 - Background: Heart rate variability (HRV) is derived from the series of R-R intervals extracted from an electrocardiographic (ECG) measurement. Ideally all components of the R-R series are the result of sinoatrial node depolarization. However, the actual R-R series are contaminated by outliers due to heart rhythm disturbances such as ectopic beats, which ought to be detected and corrected appropriately before HRV analysis. Objective: We have introduced a novel, lightweight, and near real-time method to detect and correct anomalies in the R-R series based on the singular spectrum analysis (SSA). This study aimed to assess the performance of the proposed method in terms of (1) detection performance (sensitivity, specificity, and accuracy); (2) root mean square error (RMSE) between the actual N-N series and the approximated outlier-cleaned R-R series; and (3) how it benchmarks against a competitor in terms of the relative RMSE. Methods: A lightweight SSA-based change-point detection procedure, improved through the use of a cumulative sum control chart with adaptive thresholds to reduce detection delays, monitored the series of R-R intervals in real time. Upon detection of an anomaly, the corrupted segment was substituted with the respective outlier-cleaned approximation obtained using recurrent SSA forecasting. Next, N-N intervals from a 5-minute ECG segment were extracted from each of the 18 records in the MIT-BIH Normal Sinus Rhythm Database. Then, for each such series, a number (randomly drawn integer between 1 and 6) of simulated ectopic beats were inserted at random positions within the series and results were averaged over 1000 Monte Carlo runs. Accordingly, 18,000 R-R records corresponding to 5-minute ECG segments were used to assess the detection performance whereas another 180,000 (10,000 for each record) were used to assess the error introduced in the correction step. Overall 198,000 R-R series were used in this study. Results: The proposed SSA-based algorithm reliably detected outliers in the R-R series and achieved an overall sensitivity of 96.6%, specificity of 98.4% and accuracy of 98.4%. Furthermore, it compared favorably in terms of discrepancies of the cleaned R-R series compared with the actual N-N series, outperforming an established correction method on average by almost 30%. Conclusions: The proposed algorithm, which leverages the power and versatility of the SSA to both automatically detect and correct artifacts in the R-R series, provides an effective and efficient complementary method and a potential alternative to the current manual-editing gold standard. Other important characteristics of the proposed method include the ability to operate in near real-time, the almost entirely model-free nature of the framework which does not require historical training data, and its overall low computational complexity. UR - https://biomedeng.jmir.org/2019/1/e10740/ UR - http://dx.doi.org/10.2196/10740 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/10740 ER - TY - JOUR AU - Conn, J. Nicholas AU - Schwarz, Q. Karl AU - Borkholder, A. David PY - 2019/01/18 TI - In-Home Cardiovascular Monitoring System for Heart Failure: Comparative Study JO - JMIR Mhealth Uhealth SP - e12419 VL - 7 IS - 1 KW - ballistocardiogram KW - BCG KW - blood pressure KW - ECG KW - electrocardiogram KW - heart failure KW - Internet of Things KW - IoT KW - photoplethysmogram KW - PPG KW - remote monitoring KW - SpO2 KW - stroke volume N2 - Background: There is a pressing need to reduce the hospitalization rate of heart failure patients to limit rising health care costs and improve outcomes. Tracking physiologic changes to detect early deterioration in the home has the potential to reduce hospitalization rates through early intervention. However, classical approaches to in-home monitoring have had limited success, with patient adherence cited as a major barrier. This work presents a toilet seat?based cardiovascular monitoring system that has the potential to address low patient adherence as it does not require any change in habit or behavior. Objective: The objective of this work was to demonstrate that a toilet seat?based cardiovascular monitoring system with an integrated electrocardiogram, ballistocardiogram, and photoplethysmogram is capable of clinical-grade measurements of systolic and diastolic blood pressure, stroke volume, and peripheral blood oxygenation. Methods: The toilet seat?based estimates of blood pressure and peripheral blood oxygenation were compared to a hospital-grade vital signs monitor for 18 subjects over an 8-week period. The estimated stroke volume was validated on 38 normative subjects and 111 subjects undergoing a standard echocardiogram at a hospital clinic for any underlying condition, including heart failure. Results: Clinical grade accuracy was achieved for all of the seat measurements when compared to their respective gold standards. The accuracy of diastolic blood pressure and systolic blood pressure is 1.2 (SD 6.0) mm Hg (N=112) and ?2.7 (SD 6.6) mm Hg (N=89), respectively. Stroke volume has an accuracy of ?2.5 (SD 15.5) mL (N=149) compared to an echocardiogram gold standard. Peripheral blood oxygenation had an RMS error of 2.3% (N=91). Conclusions: A toilet seat?based cardiovascular monitoring system has been successfully demonstrated with blood pressure, stroke volume, and blood oxygenation accuracy consistent with gold standard measures. This system will be uniquely positioned to capture trend data in the home that has been previously unattainable. Demonstration of the clinical benefit of the technology requires additional algorithm development and future clinical trials, including those targeting a reduction in heart failure hospitalizations. UR - http://mhealth.jmir.org/2019/1/e12419/ UR - http://dx.doi.org/10.2196/12419 UR - http://www.ncbi.nlm.nih.gov/pubmed/30664492 ID - info:doi/10.2196/12419 ER - TY - JOUR AU - Isaranuwatchai, Wanrudee AU - Redwood, Olwen AU - Schauer, Adrian AU - Van Meer, Tim AU - Vallée, Jonathan AU - Clifford, Patrick PY - 2018/12/20 TI - A Remote Patient Monitoring Intervention for Patients With Chronic Obstructive Pulmonary Disease and Chronic Heart Failure: Pre-Post Economic Analysis of the Smart Program JO - JMIR Cardio SP - e10319 VL - 2 IS - 2 KW - chronic heart failure KW - chronic obstructive pulmonary disease KW - costs KW - economic analysis KW - emergency department visits KW - hospitalizations KW - health service utilization KW - remote patient monitoring N2 - Background: Exacerbation of chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) are associated with high health care costs owing to increased emergency room (ER) visits and hospitalizations. Remote patient monitoring (RPM) interventions aim to improve the monitoring of symptoms to detect early deterioration and provide self-management strategies. As a result, RPM aims to reduce health resource utilization. To date, studies have inconsistently reported the benefits of RPM in chronic illnesses. The Smart Program is an RPM intervention that aims to provide clinical benefit to patients and economic benefit to health care payers. Objective: This study aims to economically evaluate the potential benefits of the Smart Program in terms of hospitalizations and ER visits and, thus, associated health care costs from the perspective of the public health care system. Methods: Seventy-four patients diagnosed with COPD or CHF from one hospital site were included in this one-group, pre-post study. The study involved a secondary data analysis of deidentified data collected during the study period ? from 3 months before program initiation (baseline), during the program, to 3 months after program completion (follow-up). Descriptive analysis was conducted for the study population characteristics at baseline, the clinical frailty score at baseline and 3-month follow-up, client satisfaction at 3-month follow-up, and number and costs of ER visits and hospitalizations throughout the study period. Furthermore, the cost of the Smart Program over a 3-month period was calculated from the perspective of the potential implementer. Results: The baseline characteristics of the study population (N=74) showed that the majority of patients had COPD (50/74, 68%), were female (42/74, 57%), and had an average age of 72 (SD 12) years. Using the Wilcoxon signed-rank test, the number of ER visits and hospitalizations, including their associated costs, were significantly reduced between baseline and 3-month follow-up (P<.001). The intervention showed a potential 68% and 35% reduction in ER visits and hospitalizations, respectively, between the 3-month pre- and 3-month postintervention period. The average cost of ER visits reduced from Can $243 at baseline to Can $67 during the 3-month follow-up, and reduced from Can $3842 to Can $1399 for hospitalizations. Conclusions: In this study, the number and cost of ER visits and hospitalizations appeared to be markedly reduced for patients with COPD or CHF when comparing data before and after the Smart Program implementation. Recognizing the limitations of the one-group, pre-post study design, RPM requires an upfront investment, but it has the potential to reduce health care costs to the system over time. This study represents another piece of evidence to support the potential value of RPM among patients with COPD or CHF. UR - http://cardio.jmir.org/2018/2/e10319/ UR - http://dx.doi.org/10.2196/10319 UR - http://www.ncbi.nlm.nih.gov/pubmed/31758770 ID - info:doi/10.2196/10319 ER - TY - JOUR AU - Ware, Patrick AU - Ross, J. Heather AU - Cafazzo, A. Joseph AU - Laporte, Audrey AU - Gordon, Kayleigh AU - Seto, Emily PY - 2018/12/06 TI - User-Centered Adaptation of an Existing Heart Failure Telemonitoring Program to Ensure Sustainability and Scalability: Qualitative Study JO - JMIR Cardio SP - e11466 VL - 2 IS - 2 KW - telemonitoring KW - mHealth KW - diffusion of innovation KW - heart failure N2 - Background: Telemonitoring interventions for the management of heart failure have seen limited adoption in Canadian health systems, but isolated examples of telemonitoring programs do exist. An example of such a program was launched in a specialty heart failure clinic in Toronto, Canada, and a recent implementation evaluation concluded that reducing the cost of delivering the program is necessary to ensure its sustainability and scalability. Objective: The objectives of this study were to (1) understand which components of the telemonitoring program could be modified to reduce costs and adapted to other contexts while maintaining program fidelity and (2) describe the changes made to the telemonitoring program to enable its sustainability within the initial implementation site and scalability to other health organizations. Methods: Semistructured interviews probed the experiences of patients (n=23) and clinicians (n=8) involved in the telemonitoring program to identify opportunities for cost reduction and resource optimization. Ideas for adapting the program were informed by the interview results and prioritized based on (1) potential impact for sustainability and scalability, (2) feasibility, and (3) perceived risks to negatively impacting the program?s ability to yield desired health outcomes. Results: A total of 5 themes representing opportunities for cost reduction were discussed, including (1) Bring Your Own Device (BYOD), (2) technical support, (3) clinician role, (4) duration of enrollment, and (5) intensity of monitoring. The hardware used for the telemonitoring system and the modalities of providing technical support were found to be highly adaptable, which supported the decision to implement a BYOD model, whereby patients used their own smartphone, weight scale, and blood pressure cuff. Changes also included the development of a website aimed at reducing the burden on a technical support telehealth analyst. In addition, the interviews suggested that although it is important to have a clinician who is part of a patient?s circle of care monitoring telemonitoring alerts, the skill level and experience were moderately adaptable. Thus, a registered nurse was determined to be more cost-effective and was hired to replace the existing nurse practitioners in the frontline management of telemonitoring alerts and take over the technical support role from a telehealth analyst. Conclusions: This study provides a user-centered example of how necessary cost-reduction actions can be taken to ensure the sustainability and scalability of telemonitoring programs. In addition, the findings offer insights into what components of a telemonitoring program can be safely adapted to ensure its integration in various clinical settings. UR - http://cardio.jmir.org/2018/2/e11466/ UR - http://dx.doi.org/10.2196/11466 UR - http://www.ncbi.nlm.nih.gov/pubmed/31758774 ID - info:doi/10.2196/11466 ER - TY - JOUR AU - Lefler, L. Leanne AU - Rhoads, J. Sarah AU - Harris, Melodee AU - Funderburg, E. Ashley AU - Lubin, A. Sandra AU - Martel, D. Isis AU - Faulkner, L. Jennifer AU - Rooker, L. Janet AU - Bell, K. Deborah AU - Marshall, Heather AU - Beverly, J. Claudia PY - 2018/12/04 TI - Evaluating the Use of Mobile Health Technology in Older Adults With Heart Failure: Mixed-Methods Study JO - JMIR Aging SP - e12178 VL - 1 IS - 2 KW - heart failure KW - remote monitoring KW - mHealth KW - older adults KW - feasibility KW - self-management N2 - Background: Heart failure (HF) is associated with high rates of hospitalizations, morbidity, mortality, and costs. Remote patient monitoring (mobile health, mHealth) shows promise in improving self-care and HF management, thus increasing quality of care while reducing hospitalizations and costs; however, limited information exists regarding perceptions of older adults with HF about mHealth use. Objective: This study aimed to compare perspectives of older adults with HF who were randomized to either (1) mHealth equipment connected to a 24-hour call center, (2) digital home equipment, or (3) standard care, with regard to ease and satisfaction with equipment, provider communication and engagement, and ability to self-monitor and manage their disease. Methods: We performed a pilot study using a mixed-methods descriptive design with pre- and postsurveys, following participants for 12 weeks. We augmented these data with semistructured qualitative interviews to learn more about feasibility, satisfaction, communication, and self-management. Results: We enrolled 28 patients with HF aged 55 years and above, with 57% (16/28) male, 79% (22/28) non-Hispanic white, and with multiple comorbid conditions. At baseline, 50% (14/28) rated their health fair or poor and 36% (10/28) and 25% (7/28) were very often/always frustrated and discouraged by their health. At baseline, 46% (13/28) did not monitor their weight, 29% (8/28) did not monitor their blood pressure, and 68% (19/28) did not monitor for symptoms. Post intervention, 100% of the equipment groups home monitored daily. For technology anxiety, 36% (10/28) indicated technology made them nervous, and 32% (9/28) reported fear of technology, without significant changes post intervention. Technology usability post intervention scored high (91/100), reflecting ease of use. A majority indicated that a health care provider should be managing their health, and 71% reported that one should trust and not question the provider. Moreover, 57% (16/28) believed it was better to seek professional help than caring for oneself. Post intervention, mHealth users relied more on themselves, which was not mirrored in the home equipment or standard care groups. Participants were satisfied with communication and engagement with providers, yet many described access problems. Distressing symptoms were unpredictable and prevailed over the 12 weeks with 79 provider visits and 7 visits to emergency departments. The nurse call center received 872 readings, and we completed 289 telephone calls with participants. Narrative data revealed the following main themes: (1) traditional communication and engagement with providers prevailed, delaying access to care; (2) home monitoring with technology was described as useful, and mHealth users felt secure knowing that someone was observing them; (3) equipment groups felt more confident in self-monitoring and managing; and finally, (4) uncertainty and frustration with persistent health problems. Conclusions: mHealth equipment is feasible with potential to improve patient-centered outcomes and increase self-management in older adults with HF. UR - http://aging.jmir.org/2018/2/e12178/ UR - http://dx.doi.org/10.2196/12178 UR - http://www.ncbi.nlm.nih.gov/pubmed/31518257 ID - info:doi/10.2196/12178 ER - TY - JOUR AU - Bashi, Nazli AU - Fatehi, Farhad AU - Fallah, Mina AU - Walters, Darren AU - Karunanithi, Mohanraj PY - 2018/10/19 TI - Self-Management Education Through mHealth: Review of Strategies and Structures JO - JMIR Mhealth Uhealth SP - e10771 VL - 6 IS - 10 KW - health education KW - mHealth KW - mobile apps KW - mobile phone KW - patient education KW - self-management education N2 - 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. UR - https://mhealth.jmir.org/2018/10/e10771/ UR - http://dx.doi.org/10.2196/10771 UR - http://www.ncbi.nlm.nih.gov/pubmed/30341042 ID - info:doi/10.2196/10771 ER - TY - JOUR AU - Lundgren, Johan AU - Johansson, Peter AU - Jaarsma, Tiny AU - Andersson, Gerhard AU - Kärner Köhler, Anita PY - 2018/09/05 TI - Patient Experiences of Web-Based Cognitive Behavioral Therapy for Heart Failure and Depression: Qualitative Study JO - J Med Internet Res SP - e10302 VL - 20 IS - 9 KW - cognitive therapy KW - content analysis KW - depression KW - heart failure KW - internet KW - patient experience KW - telehealth N2 - 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. UR - http://www.jmir.org/2018/9/e10302/ UR - http://dx.doi.org/10.2196/10302 UR - http://www.ncbi.nlm.nih.gov/pubmed/30185405 ID - info:doi/10.2196/10302 ER - TY - JOUR AU - Ware, Patrick AU - Ross, J. Heather AU - Cafazzo, A. Joseph AU - Laporte, Audrey AU - Seto, Emily PY - 2018/05/03 TI - Implementation and Evaluation of a Smartphone-Based Telemonitoring Program for Patients With Heart Failure: Mixed-Methods Study Protocol JO - JMIR Res Protoc SP - e121 VL - 7 IS - 5 KW - heart failure KW - telemedicine KW - self-management KW - health services research KW - costs and cost analysis N2 - 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. International Registered Report Identifier (IRRID): RR1-10.2196/resprot.9911 UR - http://www.researchprotocols.org/2018/5/e121/ UR - http://dx.doi.org/10.2196/resprot.9911 UR - http://www.ncbi.nlm.nih.gov/pubmed/29724704 ID - info:doi/10.2196/resprot.9911 ER - TY - JOUR AU - Athilingam, Ponrathi AU - Jenkins, Bradlee PY - 2018/05/02 TI - Mobile Phone Apps to Support Heart Failure Self-Care Management: Integrative Review JO - JMIR Cardio SP - e10057 VL - 2 IS - 1 KW - heart failure KW - self-care management KW - mobile health N2 - 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. UR - http://cardio.jmir.org/2018/1/e10057/ UR - http://dx.doi.org/10.2196/10057 UR - http://www.ncbi.nlm.nih.gov/pubmed/31758762 ID - info:doi/10.2196/10057 ER - TY - JOUR AU - Woessner, N. Mary AU - Levinger, Itamar AU - Neil, Christopher AU - Smith, Cassandra AU - Allen, D. Jason PY - 2018/04/06 TI - Effects of Dietary Inorganic Nitrate Supplementation on Exercise Performance in Patients With Heart Failure: Protocol for a Randomized, Placebo-Controlled, Cross-Over Trial JO - JMIR Res Protoc SP - e86 VL - 7 IS - 4 KW - cardiovascular disease KW - nitric oxide KW - exercise tolerance N2 - 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) UR - http://www.researchprotocols.org/2018/4/e86/ UR - http://dx.doi.org/10.2196/resprot.8865 UR - http://www.ncbi.nlm.nih.gov/pubmed/29625952 ID - info:doi/10.2196/resprot.8865 ER - TY - JOUR AU - Smeets, JP Christophe AU - Storms, Valerie AU - Vandervoort, M. Pieter AU - Dreesen, Pauline AU - Vranken, Julie AU - Houbrechts, Marita AU - Goris, Hanne AU - Grieten, Lars AU - Dendale, Paul PY - 2018/04/04 TI - A Novel Intelligent Two-Way Communication System for Remote Heart Failure Medication Uptitration (the CardioCoach Study): Randomized Controlled Feasibility Trial JO - JMIR Cardio SP - e8 VL - 2 IS - 1 KW - heart failure KW - telemedicine KW - clinical decision support KW - drug monitoring KW - drug utilization KW - call centers N2 - Background: European Society of Cardiology guidelines for the treatment of heart failure (HF) prescribe uptitration of angiotensin-converting enzyme inhibitors (ACE-I) and ?-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 ?-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) UR - http://cardio.jmir.org/2018/1/e8/ UR - http://dx.doi.org/10.2196/cardio.9153 UR - http://www.ncbi.nlm.nih.gov/pubmed/31758773 ID - info:doi/10.2196/cardio.9153 ER - TY - JOUR AU - Farnia, Troskah AU - Jaulent, Marie-Christine AU - Steichen, Olivier PY - 2018/01/16 TI - Evaluation Criteria of Noninvasive Telemonitoring for Patients With Heart Failure: Systematic Review JO - J Med Internet Res SP - e16 VL - 20 IS - 1 KW - telemedicine KW - outcome and process assessment (health care) KW - program evaluation KW - heart failure N2 - 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. UR - http://www.jmir.org/2018/1/e16/ UR - http://dx.doi.org/10.2196/jmir.7873 UR - http://www.ncbi.nlm.nih.gov/pubmed/29339348 ID - info:doi/10.2196/jmir.7873 ER - TY - JOUR AU - Moayedi, Yasbanoo AU - Abdulmajeed, Raghad AU - Duero Posada, Juan AU - Foroutan, Farid AU - Alba, Carolina Ana AU - Cafazzo, Joseph AU - Ross, Joan Heather PY - 2017/12/19 TI - Assessing the Use of Wrist-Worn Devices in Patients With Heart Failure: Feasibility Study JO - JMIR Cardio SP - e8 VL - 1 IS - 2 KW - MeSH: exercise physiology KW - heart rate tracker KW - wrist worn devices KW - Fitbit KW - Apple watch KW - heart failure KW - steps N2 - 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. UR - http://cardio.jmir.org/2017/2/e8/ UR - http://dx.doi.org/10.2196/cardio.8301 UR - http://www.ncbi.nlm.nih.gov/pubmed/31758789 ID - info:doi/10.2196/cardio.8301 ER - TY - JOUR AU - Athilingam, Ponrathi AU - Jenkins, Bradlee AU - Johansson, Marcia AU - Labrador, Miguel PY - 2017/08/11 TI - A Mobile Health Intervention to Improve Self-Care in Patients With Heart Failure: Pilot Randomized Control Trial JO - JMIR Cardio SP - e3 VL - 1 IS - 2 KW - heart failure KW - mobile applications KW - self-care KW - quality of life N2 - 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. UR - http://cardio.jmir.org/2017/2/e3/ UR - http://dx.doi.org/10.2196/cardio.7848 UR - http://www.ncbi.nlm.nih.gov/pubmed/31758759 ID - info:doi/10.2196/cardio.7848 ER - TY - JOUR AU - Hargreaves, Sarah AU - Hawley, S. Mark AU - Haywood, Annette AU - Enderby, M. Pamela PY - 2017/06/28 TI - 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 JO - J Med Internet Res SP - e231 VL - 19 IS - 6 KW - independent living KW - human activities KW - heart failure KW - biomedical technology N2 - 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. UR - http://www.jmir.org/2017/6/e231/ UR - http://dx.doi.org/10.2196/jmir.6931 UR - http://www.ncbi.nlm.nih.gov/pubmed/28659253 ID - info:doi/10.2196/jmir.6931 ER - TY - JOUR AU - Pedersen, S. Susanne AU - Schmidt, Thomas AU - Skovbakke, Jensen Søren AU - Wiil, Kock Uffe AU - Egstrup, Kenneth AU - Smolderen, G. Kim AU - Spertus, A. John PY - 2017/05/23 TI - 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 JO - JMIR Res Protoc SP - e96 VL - 6 IS - 5 KW - feasibility KW - heart failure KW - patient-centered tools KW - mixed methods KW - Internet N2 - 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. UR - http://www.researchprotocols.org/2017/5/e96/ UR - http://dx.doi.org/10.2196/resprot.7110 UR - http://www.ncbi.nlm.nih.gov/pubmed/28536092 ID - info:doi/10.2196/resprot.7110 ER - TY - JOUR AU - Kim, YB Ben AU - Lee, Joon PY - 2017/05/23 TI - Smart Devices for Older Adults Managing Chronic Disease: A Scoping Review JO - JMIR Mhealth Uhealth SP - e69 VL - 5 IS - 5 KW - mobile health KW - mHealth KW - smartphone KW - mobile phone KW - tablet KW - older adults KW - seniors KW - chronic disease KW - chronic disease management KW - scoping review N2 - 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. UR - http://mhealth.jmir.org/2017/5/e69/ UR - http://dx.doi.org/10.2196/mhealth.7141 UR - http://www.ncbi.nlm.nih.gov/pubmed/28536089 ID - info:doi/10.2196/mhealth.7141 ER - TY - JOUR AU - Hanlon, Peter AU - Daines, Luke AU - Campbell, Christine AU - McKinstry, Brian AU - Weller, David AU - Pinnock, Hilary PY - 2017/05/17 TI - Telehealth Interventions to Support Self-Management of Long-Term Conditions: A Systematic Metareview of Diabetes, Heart Failure, Asthma, Chronic Obstructive Pulmonary Disease, and Cancer JO - J Med Internet Res SP - e172 VL - 19 IS - 5 KW - telehealth KW - telemonitoring KW - self-management KW - chronic disease KW - diabetes KW - heart failure KW - asthma KW - COPD KW - pulmonary disease, chronic obstructive KW - cancer N2 - 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. UR - http://www.jmir.org/2017/5/e172/ UR - http://dx.doi.org/10.2196/jmir.6688 UR - http://www.ncbi.nlm.nih.gov/pubmed/28526671 ID - info:doi/10.2196/jmir.6688 ER - TY - JOUR AU - Bashi, Nazli AU - Karunanithi, Mohanraj AU - Fatehi, Farhad AU - Ding, Hang AU - Walters, Darren PY - 2017/01/20 TI - Remote Monitoring of Patients With Heart Failure: An Overview of Systematic Reviews JO - J Med Internet Res SP - e18 VL - 19 IS - 1 KW - systematic review KW - patient monitoring KW - mobile phone KW - telemedicine KW - heart failure N2 - 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. UR - http://www.jmir.org/2017/1/e18/ UR - http://dx.doi.org/10.2196/jmir.6571 UR - http://www.ncbi.nlm.nih.gov/pubmed/28108430 ID - info:doi/10.2196/jmir.6571 ER - TY - JOUR AU - PY - 2016/12/18 TI - Supporting Heart Failure Patient Transitions From Acute to Community Care With Home Telemonitoring Technology: A Protocol for a Provincial Randomized Controlled Trial (TEC4Home) JO - JMIR Res Protoc SP - e198 VL - 5 IS - 4 KW - heart failure KW - telemedicine KW - remote sensing technology KW - emergency service, hospital KW - hospitalization KW - quality of life N2 - Background: Seniors with chronic diseases such as heart failure have complex care needs. They are vulnerable to their condition deteriorating and, without timely intervention, may require multiple emergency department visits and/or repeated hospitalizations. Upon discharge, the transition from the emergency department to home can be a vulnerable time for recovering patients with disruptions in the continuity of care. Remote monitoring of heart failure patients using home telemonitoring, coupled with clear communication protocols between health care professionals, can be effective in increasing the safety and quality of care for seniors with heart failure discharged from the emergency department. Objective: The aim of the Telehealth for Emergency-Community Continuity of Care Connectivity via Home Telemonitoring (TEC4Home) study is to generate evidence through a programmatic evaluation and a clinical trial to determine how home telemonitoring may improve care and increase patient safety during the transition of care and determine how it is best implemented to support patients with heart failure within this context. Methods: This 4-year project consists of 3 studies to comprehensively evaluate the outcomes and effectiveness of TEC4Home. Study 1 is a feasibility study with 90 patients recruited from 2 emergency department sites to test implementation and evaluation procedures. Findings from the feasibility study will be used to refine protocols for the larger trial. Study 2 is a cluster randomized controlled trial that will include 30 emergency department sites and 900 patients across British Columbia. The primary outcome of the randomized controlled trial will be emergency department revisits and hospital readmission rates. Secondary outcomes include health care resource utilization/costs, communication between members of the care team, and patient quality of life. Study 3 will run concurrently to study 2 and test the effectiveness of predictive analytic software to detect patient deterioration sooner. Results: It is hypothesized that TEC4Home will be a cost-effective strategy to decrease 90-day emergency department revisits and hospital admission rates and improve comfort and quality of life for seniors with heart failure. The results from this project will also help establish an innovation pathway for rapid and rigorous introduction of innovation into the health system. Conclusions: While there is some evidence about the effectiveness of home telemonitoring for some patients and conditions, the TEC4Home project will be one of the first protocols that implements and evaluates the technology for patients with heart failure as they transition from the emergency department to home care. The results from this research are expected to inform the full scale and spread of the home monitoring approach throughout British Columbia and Canada and to other chronic diseases. ClinicalTrial: ClinicalTrials.gov NCT02821065; https://clinicaltrials.gov/ct2/show/NCT02821065 (Archived by WebCite at http://www.webcitation.org/6ml2iwKax) UR - http://www.researchprotocols.org/2016/4/e198/ UR - http://dx.doi.org/10.2196/resprot.5856 UR - http://www.ncbi.nlm.nih.gov/pubmed/27977002 ID - info:doi/10.2196/resprot.5856 ER - TY - JOUR AU - Masterson Creber, M. Ruth AU - Maurer, S. Mathew AU - Reading, Meghan AU - Hiraldo, Grenny AU - Hickey, T. Kathleen AU - Iribarren, Sarah PY - 2016/06/14 TI - 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) JO - JMIR Mhealth Uhealth SP - e74 VL - 4 IS - 2 KW - mobile apps KW - mobile health KW - heart failure KW - self-care KW - self-management KW - review KW - symptom assessment KW - nursing informatics N2 - 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. UR - http://mhealth.jmir.org/2016/2/e74/ UR - http://dx.doi.org/10.2196/mhealth.5882 UR - http://www.ncbi.nlm.nih.gov/pubmed/27302310 ID - info:doi/10.2196/mhealth.5882 ER - TY - JOUR AU - Agboola, Stephen AU - Jethwani, Kamal AU - Khateeb, Kholoud AU - Moore, Stephanie AU - Kvedar, Joseph PY - 2015/04/22 TI - Heart Failure Remote Monitoring: Evidence From the Retrospective Evaluation of a Real-World Remote Monitoring Program JO - J Med Internet Res SP - e101 VL - 17 IS - 4 KW - heart failure KW - telemonitoring KW - remote monitoring KW - self-management KW - hospitalizations KW - mortality N2 - 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. UR - http://www.jmir.org/2015/4/e101/ UR - http://dx.doi.org/10.2196/jmir.4417 UR - http://www.ncbi.nlm.nih.gov/pubmed/25903278 ID - info:doi/10.2196/jmir.4417 ER - TY - JOUR AU - Zan, Shiyi AU - Agboola, Stephen AU - Moore, A. Stephanie AU - Parks, A. Kimberly AU - Kvedar, C. Joseph AU - Jethwani, Kamal PY - 2015/04/01 TI - Patient Engagement With a Mobile Web-Based Telemonitoring System for Heart Failure Self-Management: A Pilot Study JO - JMIR mHealth uHealth SP - e33 VL - 3 IS - 2 KW - heart failure KW - disease self-management KW - remote monitoring KW - telemonitoring KW - interactive voice response system KW - mobile health KW - Web portal KW - patient engagement KW - quality of life N2 - 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. UR - http://mhealth.jmir.org/2015/2/e33/ UR - http://dx.doi.org/10.2196/mhealth.3789 UR - http://www.ncbi.nlm.nih.gov/pubmed/25842282 ID - info:doi/10.2196/mhealth.3789 ER - TY - JOUR AU - Stut, Wim AU - Deighan, Carolyn AU - Armitage, Wendy AU - Clark, Michelle AU - Cleland, G. John AU - Jaarsma, Tiny PY - 2014/12/11 TI - Design and Usage of the HeartCycle Education and Coaching Program for Patients With Heart Failure JO - JMIR Res Protoc SP - e72 VL - 3 IS - 4 KW - e-counseling KW - heart failure KW - lifestyle KW - patient adherence KW - self-care KW - telehealth N2 - 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. UR - http://www.researchprotocols.org/2014/4/e72/ UR - http://dx.doi.org/10.2196/resprot.3411 UR - http://www.ncbi.nlm.nih.gov/pubmed/25499976 ID - info:doi/10.2196/resprot.3411 ER - TY - JOUR AU - Vuorinen, Anna-Leena AU - Leppänen, Juha AU - Kaijanranta, Hannu AU - Kulju, Minna AU - Heliö, Tiina AU - van Gils, Mark AU - Lähteenmäki, Jaakko PY - 2014/12/11 TI - Use of Home Telemonitoring to Support Multidisciplinary Care of Heart Failure Patients in Finland: Randomized Controlled Trial JO - J Med Internet Res SP - e282 VL - 16 IS - 12 KW - heart failure KW - telemonitoring KW - hospitalization KW - user experience KW - clinical outcomes KW - EHFSBS KW - health care resources N2 - 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). UR - http://www.jmir.org/2014/12/e282/ UR - http://dx.doi.org/10.2196/jmir.3651 UR - http://www.ncbi.nlm.nih.gov/pubmed/25498992 ID - info:doi/10.2196/jmir.3651 ER - TY - JOUR AU - Zanaboni, Paolo AU - Landolina, Maurizio AU - Marzegalli, Maurizio AU - Lunati, Maurizio AU - Perego, B. Giovanni AU - Guenzati, Giuseppe AU - Curnis, Antonio AU - Valsecchi, Sergio AU - Borghetti, Francesca AU - Borghi, Gabriella AU - Masella, Cristina PY - 2013/05/30 TI - Cost-Utility Analysis of the EVOLVO Study on Remote Monitoring for Heart Failure Patients With Implantable Defibrillators: Randomized Controlled Trial JO - J Med Internet Res SP - e106 VL - 15 IS - 5 KW - telemedicine KW - heart failure KW - implantable defibrillators KW - cost-effectiveness N2 - 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 (?1962.78 versus ?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 (?291.36 versus ?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 ?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). UR - http://www.jmir.org/2013/5/e106/ UR - http://dx.doi.org/10.2196/jmir.2587 UR - http://www.ncbi.nlm.nih.gov/pubmed/23722666 ID - info:doi/10.2196/jmir.2587 ER - TY - JOUR AU - Seto, Emily AU - Leonard, J. Kevin AU - Cafazzo, A. Joseph AU - Barnsley, Jan AU - Masino, Caterina AU - Ross, J. Heather PY - 2012/02/10 TI - Perceptions and Experiences of Heart Failure Patients and Clinicians on the Use of Mobile Phone-Based Telemonitoring JO - J Med Internet Res SP - e25 VL - 14 IS - 1 KW - heart failure KW - telemonitoring KW - mobile phone KW - patient monitoring KW - self-care KW - qualitative research N2 - 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: UR - http://www.jmir.org/2012/1/e25/ UR - http://dx.doi.org/10.2196/jmir.1912 UR - http://www.ncbi.nlm.nih.gov/pubmed/22328237 ID - info:doi/10.2196/jmir.1912 ER -