Implementation of a Web-Based Tool for Patient Medication Self-Management: The Medication Self-titration Evaluation Programme (Med-STEP) for Blood Pressure Control
Grant RW, Pandiscio JC, Pajolek H, Woulfe A, Pelletier A, Kvedar J, Park ER. Implementation of a web-based tool for patient medication self-management: the Medication Self-titration Evaluation Programme (Med-STEP) for blood pressure control. Inform Prim Care. 2012;20(1):57-67. PubMed PMID: 23336836.Read More...
Informatics tools may help support hypertension management.
To design, implement and evaluate a web-based system for patient anti-hypertensive medication self-titration.
Study stages included: six focus groups (50 patients) to identify barriers/facilitators to patient medication self-titration, software design informed by qualitative analysis of focus group responses and a six-month single-arm pilot study (20 patients) to assess implementation feasibility.
Focus groups emphasised patient need to feel confident that their own primary care providers were directly involved and approved of the titration protocol. Physicians required 3.3 ± 2.8 minutes/patient to create individualised six-step medication pathways for once-monthly blood pressure evaluations. Pilot participants (mean age of 51.5 ± 11 years, 45% women, mean baseline blood pressure 139/84 ± 12.2/7.5 mmHg) had five medication increases, two non-adherence self-reports, 52 months not requiring medication changes, 24 skipped months and 17 months with no evaluations due to technical issues. Four pilot patients dropped out before study completion. From baseline to study completion, blood pressure decreased among the 16 patients remaining in the study (8.0/4.7 mmHg, p = 0.03 for both systolic and diastolic pressures).
Lessons learned included the benefit of qualitative patient analysis prior to system development and the feasibility of physicians designing individual treatment pathways. Any potential clinical benefits were offset by technical problems, the tendency for patients to skip their monthly self-evaluations and drop outs. To be more widely adopted such systems must effectively generalise to a wider range of patients and be integrated into clinical workflow.
Diabetes Connect: An Evaluation of Patient Adoption and Engagement in a Web-Based Remote Glucose Monitoring Program
Jethwani K, Ling E, Mohammed M, Myint-U K, Pelletier A, Kvedar JC. Diabetes connect: an evaluation of patient adoption and engagement in a web-based remote glucose monitoring program. J Diabetes Sci Technol. 2012 Nov 1;6(6):1328-36. PubMed PMID: 23294777.Read More...
We determine whether Diabetes Connect (DC), a Web-based diabetes self-management program, can help patients effectively manage their diabetes and improve clinical outcomes.
Diabetes Connect is a 12-month program that allows patients with type 2 diabetes mellitus to upload their blood glucose readings to a database, monitor trends, and share their data with their providers. To examine the impact of the program, we analyzed patient utilization and engagement data, clinical outcomes, as well as qualitative feedback from current and potential users through focus groups.
We analyzed 75 out of 166 patients. Mean age was 61 years (range 27-87). Patients engaged in DC had an average hemoglobin A1c (HbA1c) change of 1.5%, while nonengaged patients had a HbA1c change of 0.4% (p = .05). Patients with the best outcomes (HbAlc decline of at least 0.8%) typically took less than 10 days to upload, while patients with the worst outcomes (a rise in HbAlc) took an average of 65 days to upload. Patients with more engaged providers had a better HbA1c change (1.39% versus 0.87%) for practices with an average of 74 versus 30 logins/providers.
Patient engagement in the program has a positive impact on the outcomes of this collaborative Web-based diabetes self-management tool. Patients who engage early and remain active have better clinical outcomes than unengaged patients. Provider engagement, too, was found critical in engaging patients in DC.
Evaluating a Web-Based Self-Management Program for Employees with Hypertension and Prehypertension: A Randomized Clinical Trial
Watson AJ, Singh K, Myint-U K, Grant RW, Jethwani K, Murachver E, Harris K, Lee TH, Kvedar JC. Evaluating a web-based self-management program for employees with hypertension and prehypertension: a randomized clinical trial. Am Heart J. 2012 Oct;164(4):625-31. doi: 10.1016/j.ahj.2012.06.013. PubMed PMID: 23067923.Read More...
Web-based self-management programs offer a novel approach for self-insured employers seeking to improve and maintain employee health.
We conducted a 6-month prospective, cluster-randomized controlled trial designed to evaluate whether worksite access to an automated, web-based, self-management program resulted in better blood pressure control. The trial was conducted at 6 EMC Corporation worksites in Massachusetts, each of which had at least 600 employees; 404 EMC employees with pre-hypertension or hypertension participated. Participants at 3 worksites received a home blood pressure cuff that uploaded readings to a Web site where they could view trends and read automated rules-based messages. Participants at 3 worksites received access to an onsite blood pressure cuff. Primary outcome measure was change in systolic blood pressure. Secondary outcome measures were change in diastolic blood pressure, proportion of participants achieving significant changes in systolic and diastolic blood pressure, and subject satisfaction.
Although the mean change in systolic blood pressure was not significantly different between intervention and control groups (-1.69 vs. -0.86 mm HG, respectively, P = .49) the change in diastolic blood pressure between groups was significant. (-1.08 vs. = 1.47 mm HG, respectively, P < .001). Significantly more intervention participants experienced a >10-mm Hg decrease in systolic blood pressure or >5-mm Hg decrease in diastolic blood pressure compared to controls (22% vs 17%, P = .02 and 29% vs 16%, P = .03, respectively). Intervention participants were twice as likely to report starting a new medication (P = .02) and more likely to report improved communication with their doctor (P = .02).
Participation in an automated online self-management program resulted in improved blood pressure among employees with prehypertension or hypertension.
Feasibility of a Clearing House for Improved Cooperation Between Telemedicine Networks Delivering Humanitarian Services: Acceptability to Network Coordinators
Wootton R, Bonnardot L, Geissbuhler A, Jethwani K, Kovarik C, McGoey S, Person DA, Vladzymyrskyy A, Zolfo M. Feasibility of a clearing house for improved cooperation between telemedicine networks delivering humanitarian services: acceptability to network coordinators. Glob Health Action. 2012 Oct 9;5:18713. doi: 10.3402/gha.v5i0.18713. PubMed PMID: 23058274.Read More...
Telemedicine networks, which deliver humanitarian services, sometimes need to share expertise to find particular experts in other networks. It has been suggested that a mechanism for sharing expertise between networks (a 'clearing house') might be useful.
To propose a mechanism for implementing the clearing house concept for sharing expertise, and to confirm its feasibility in terms of acceptability to the relevant networks.
We conducted a needs analysis among eight telemedicine networks delivering humanitarian services. A small proportion of consultations (5-10%) suggested that networks may experience difficulties in finding the right specialists from within their own resources. With the assistance of key stakeholders, many of whom were network coordinators, various methods of implementing a clearing house were considered. One simple solution is to establish a central database holding information about consultants who have agreed to provide help to other networks; this database could be made available to network coordinators who need a specialist when none was available in their own network.
The proposed solution was examined in a desktop simulation exercise, which confirmed its feasibility and probable value.
This analysis informs full-scale implementation of a clearing house, and an associated examination of its costs and benefits.
Comparative Performance of Seven Long-Running Telemedicine Networks Delivering Humanitarian Services
Wootton R, Geissbuhler A, Jethwani K, Kovarik C, Person DA, Vladzymyrskyy A, Zanaboni P, Zolfo M. Comparative performance of seven long-running telemedicine networks delivering humanitarian services. J Telemed Telecare. 2012 Sep;18(6):305-11. doi: 10.1258/jtt.2012.120315. Epub 2012 Aug 6. PubMed PMID: 22869822.Read More...
Seven long-running telemedicine networks were surveyed. The networks provided humanitarian services (clinical and educational) in developing countries, and had been in operation for periods of 5-15 years. The number of experts serving each network ranged from 15 to 513. The smallest network had a total of 10 requesters and the largest one had more than 500 requesters. The networks operated in nearly 60 countries. The seven networks managed a total of 1857 cases in 2011, i.e. an average of 265 cases per year per network. There was a significant growth in total activity, amounting to 100.3 cases per year during the 15 year study period. In 2011, network activity was 50-700 teleconsultations per network. There were clear differences in the patterns of activity, with some networks managing an increasing caseload, and others managing a slowly reducing caseload. The seven networks had published a total of 44 papers listed in Medline which summarized the evidence resulting from the delivery of services by telemedicine. There was a dearth of information about clinical and cost-effectiveness. Nevertheless, the services were widely appreciated by referring doctors, considered to be clinically useful, and there were indications that clinical outcomes for telemedicine patients were often improved. Despite a lack of formal evidence, the present study suggests that telemedicine can provide clinically useful services in developing countries.
Prevention of Weight Gain Following a Worksite Nutrition and Exercise Program: A Randomized Controlled Trial
Thorndike AN, Sonnenberg L, Healey E, Myint-U K, Kvedar JC, Regan S. Prevention of weight gain following a worksite nutrition and exercise program: a randomized controlled trial. Am J Prev Med. 2012 Jul;43(1):27-33. doi: 10.1016/j.amepre.2012.02.029. PubMed PMID: 22704742.Read More...
Many employers are now providing wellness programs to help employees make changes in diet and exercise behaviors. Improving health outcomes and reducing costs will depend on whether employees sustain lifestyle changes and maintain a healthy weight over time.
To determine if a 9-month maintenance intervention immediately following a 10-week worksite exercise and nutrition program would prevent regain of the weight lost during the program.
In 2008, a total of 330 employees from 24 teams completed a 10-week exercise and nutrition program at a large hospital worksite and were randomized by team to maintenance or control (usual care) for 9 months.
Internet support with a website for goal-setting and self-monitoring of weight and exercise plus minimal personal support.
MAIN OUTCOME MEASURES:
Weight loss, percentage weight loss, time spent in physical activity, and frequency of consumption of fruits/vegetables, fatty foods, and sugary foods at 1 year compared to baseline. One-year follow-up was completed in 2010, and data were analyzed in 2011.
At 1 year, 238 subjects (72%) completed follow-up assessments. Mean baseline BMI was 27.6 and did not differ between intervention and control. Compared to baseline, both groups lost weight during the 10-week program and maintained 65% of weight loss at 1 year (p<0.001). There was no difference in weight loss between groups at the end of the 10-week program (4.8 lbs vs 4.3 lbs, p=0.53 for group X time interaction) or end of maintenance at 1 year (3.4 lbs vs 2.5 lbs, p=0.40 for group X time interaction). All subjects had improvements in physical activity and nutrition (increased fruits/vegetables and decreased fat and sugar intake) at 1 year but did not differ by group.
An intensive 10-week team-based worksite exercise and nutrition program resulted in moderate weight loss and improvements in diet and exercise behaviors at 1 year, but an Internet-based maintenance program immediately following the 10-week program did not improve these outcomes.
Long-Running Telemedicine Networks Delivering Humanitarian Services: Experience, Performance and Scientific Output
Wootton R, Geissbuhler A, Jethwani K, Kovarik C, Person DA, Vladzymyrskyy A, Zanaboni P, Zolfo M. Long-running telemedicine networks delivering humanitarian services: experience, performance and scientific output. Bull World Health Organ. 2012 May 1;90(5):341-347D. doi: 10.2471/BLT.11.099143. PubMed PMID: 22589567.Read More...
To summarize the experience, performance and scientific output of long-running telemedicine networks delivering humanitarian services.
Nine long-running networks--those operating for five years or more--were identified and seven provided detailed information about their activities, including performance and scientific output. Information was extracted from peer-reviewed papers describing the networks' study design, effectiveness, quality, economics, provision of access to care and sustainability. The strength of the evidence was scored as none, poor, average or good.
The seven networks had been operating for a median of 11 years (range: 5-15). All networks provided clinical tele-consultations for humanitarian purposes using store-and-forward methods and five were also involved in some form of education. The smallest network had 15 experts and the largest had more than 500. The clinical caseload was 50 to 500 cases a year. A total of 59 papers had been published by the networks, and 44 were listed in Medline. Based on study design, the strength of the evidence was generally poor by conventional standards (e.g. 29 papers described non-controlled clinical series). Over half of the papers provided evidence of sustainability and improved access to care. Uncertain funding was a common risk factor.
Improved collaboration between networks could help attenuate the lack of resources reported by some networks and improve sustainability. Although the evidence base is weak, the networks appear to offer sustainable and clinically useful services. These findings may interest decision-makers in developing countries considering starting, supporting or joining similar telemedicine networks.
Mobile Health as the Patient-facing Convergence Platform for Clinical Research and Healthcare
Jethwani K, Havasy R, Mohammed M, Kvedar J. Mobile health as the patient-facing convergence platform for clinical research and healthcare. iHealth Connections, 2012;2(1):10–3.Read More...
Current clinical research practices are impacted by high cost and low recruitment and retention, and limited by how data can be collected. Given the widespread availability and affordability of mobile technology there now exist new opportunities to facilitate the processes underlying clinical research. Mobile Health’s (mHealth) efficacy in changing healthcare delivery has been well established, though further exploration is needed to understand how it can be used as a tool for clinical research. This article explores the opportunities and challenges of using mHealth in clinical research.
The Feasibility and Impact of Delivering a Mind-Body Intervention in a Virtual World
Hoch DB, Watson AJ, Linton DA, Bello HE, Senelly M, Milik MT, Baim MA, Jethwani K, Fricchione GL, Benson H, Kvedar JC. The feasibility and impact of delivering a mind-body intervention in a virtual world. PLoS One. 2012;7(3):e33843. doi: 10.1371/journal.pone.0033843. Epub 2012 Mar 28. PubMed PMID: 22470483.Read More...
Mind-body medical approaches may ameliorate chronic disease. Stress reduction is particularly helpful, but face-to-face delivery systems cannot reach all those who might benefit. An online, 3-dimensional virtual world may be able to support the rich interpersonal interactions required of this approach. In this pilot study, we explore the feasibility of translating a face-to-face stress reduction program into an online virtual setting and estimate the effect size of the intervention.
METHODS AND FINDINGS:
Domain experts in virtual world technology joined with mind body practitioners to translate an existing 8 week relaxation response-based resiliency program into an 8-week virtual world-based program in Second Life™ (SL). Twenty-four healthy volunteers with at least one month's experience in SL completed the program. Each subject filled out the Perceived Stress Scale (PSS) and the Symptom Checklist 90- Revised (SCL-90-R) before and after taking part. Participants took part in one of 3 groups of about 10 subjects. The participants found the program to be helpful and enjoyable. Many reported that the virtual environment was an excellent substitute for the preferred face-to-face approach. On quantitative measures, there was a general trend toward decreased perceived stress, (15.7 to 15.0), symptoms of depression, (57.6 to 57.0) and anxiety (56.8 to 54.8). There was a significant decrease of 2.8 points on the SCL-90-R Global Severity Index (p<0.05).
This pilot project showed that it is feasible to deliver a typical mind-body medical intervention through a virtual environment and that it is well received. Moreover, the small reduction in psychological distress suggests further research is warranted. Based on the data collected for this project, a randomized trial with less than 50 subjects would be appropriately powered if perceived stress is the primary outcome.
An Internet-Based Virtual Coach to Promote Physical Activity Adherence in Overweight Adults: Randomized Controlled Trial
Watson A, Bickmore T, Cange A, Kulshreshtha A, Kvedar J. An internet-based virtual coach to promote physical activity adherence in overweight adults: randomized controlled trial. J Med Internet Res. 2012 Jan 26;14(1):e1. doi: 10.2196/jmir.1629. PubMed PMID: 22281837.Read More...
Addressing the obesity epidemic requires the development of effective, scalable interventions. Pedometers and Web-based programs are beneficial in increasing activity levels but might be enhanced by the addition of nonhuman coaching.
We hypothesized that a virtual coach would increase activity levels, via step count, in overweight or obese individuals beyond the effect observed using a pedometer and website alone.
We recruited 70 participants with a body mass index (BMI) between 25 and 35 kg/m(2) from the Boston metropolitan area. Participants were assigned to one of two study arms and asked to wear a pedometer and access a website to view step counts. Intervention participants also met with a virtual coach, an automated, animated computer agent that ran on their home computers, set goals, and provided personalized feedback. Data were collected and analyzed in 2008. The primary outcome measure was change in activity level (percentage change in step count) over the 12-week study, split into four 3-week time periods. Major secondary outcomes were change in BMI and participants' satisfaction.
The mean age of participants was 42 years; the majority of participants were female (59/70, 84%), white (53/70, 76%), and college educated (68/70, 97%). Of the initial 70 participants, 62 completed the study. Step counts were maintained in intervention participants but declined in controls. The percentage change in step count between those in the intervention and control arms, from the start to the end, did not reach the threshold for significance (2.9% vs -12.8% respectively, P = .07). However, repeated measures analysis showed a significant difference when comparing percentage changes in step counts between control and intervention participants over all time points (analysis of variance, P = .02). There were no significant changes in secondary outcome measures.
The virtual coach was beneficial in maintaining activity level. The long-term benefits and additional applications of this technology warrant further study.
Text Messaging to Encourage Prenatal Care
Pelletier A, McDermott L, Myint-U K, Kvedar JC. Text messaging to encourage prenatal care. The Female Patient. 2012;37(1):36-39.Read More...
Text messaging presents an opportunity to provide low-cost, multilingual communication that is easily delivered between visits. This small-scale pilot study demonstrates the usefulness of text messaging to improve provider reach and engagement in prenatal care for at-risk women. The obstetric team at Lynn Community Health Center (LCHC) is working hard to promote healthy outcomes by ensuring that women receive the appropriate level of prenatal care. The team strives to deliver culturally sensitive and patient-centered care. Even so, there are barriers to such care, including a wide range of socioeconomic, demographic, physical, or psychological disabilities, which may cause a woman to delay or not enter into care at all.