Email for clinical communication between healthcare professionals

Background Email is a popular and commonly-used method of communication, but its use in healthcare is not routine. Where email communication has been utilised in health care, its purposes have included use for clinical communication between healthcare professionals, but the effects of using email in this way are not known. This review assesses the use of email for two-way clinical communication between healthcare professionals. Objectives To assess the effects of healthcare professionals using email to communicate clinical information, on healthcare professional outcomes, patient outcomes, health service performance, and service efficiency and acceptability, when compared to other forms of communicating clinical information. Search methods We searched: the Cochrane Consumers and Communication Review Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1 2010), MEDLINE (OvidSP) (1950 to January 2010), EMBASE (OvidSP) (1980 to January 2010), PsycINFO (1967 to January 2010), CINAHL (EbscoHOST) (1982 to February 2010), and ERIC (CSA) (1965 to January 2010). We searched grey literature: theses/dissertation repositories, trials registers and Google Scholar (searched July 2010). We used additional search methods: examining reference lists, contacting authors. Selection criteria Randomised controlled trials, quasi-randomised trials, controlled before and after studies and interrupted time series studies examining interventions in which healthcare professionals used email for communicating clinical information, and that took the form of 1) unsecured email 2) secure email or 3) web messaging. All healthcare professionals, patients and caregivers in all settings were considered. Data collection and analysis Two authors independently assessed studies for inclusion, assessed the included studies' risk of bias, and extracted data. We contacted study authors for additional information. We report all measures as per the study report. Main results We included one randomised controlled trial involving 327 patients and 159 healthcare providers at baseline. It compared an email to physicians containing patient-specific osteoporosis risk information and guidelines for evaluation and treatment with usual care (no email). This study was at high risk of bias for the allocation concealment and blinding domains. The email reminder changed health professional actions significantly, with professionals more likely to provide guideline-recommended osteoporosis treatment (bone density measurement and/or osteoporosis medication) when compared with usual care. The evidence for its impact on patient behaviours/actions was inconclusive. One measure found that the electronic medical reminder message impacted patient behaviour positively: patients had a higher calcium intake, and two found no difference between the two groups. The study did not assess primary health service outcomes or harms. Authors' conclusions As only one study was identified for inclusion, the results are inadequate to inform clinical practice in regard to the use of email for clinical communication between healthcare professionals. Future research needs to use high-quality study designs that take advantage of the most recent developments in information technology, with consideration of the complexity of email as an intervention, and costs

The cost and cost-effectiveness of a text-messaging based intervention to support management of hypertension in South Africa

This project assessed the cost and cost-effectiveness of hypertension management in South Africa within the context of a text messaging-based intervention (StAR* study) conducted in an urban public-sector clinic in Cape Town. The StAR* study is a community randomized trial that investigated the effect of adherence support via short messaging service (SMS) on treatment adherence and patient outcomes for the management of hypertension at Vanguard CHC in Cape Town (Bobrow et al. 2016). Patients received behavioral text messages as reminders for them to collect and take their medication on time. The StAR* study, consisted of three arms that ran in parallel: participants in the control arm received unrelated messages; patients in the information-only arm received one-way information messages twice a week; and patients in the interactive arm received interactive SMS-texts at the same frequency as those in the information only arm (Bobrow et al. 2016). Patients in the interactive arm could respond to the messages and trigger a response from the healthcare provider. The text messaging based intervention was shown to improve hypertension outcomes over a 12-month period in hypertension patients by improving adherence and retention in care. The study showed, in the one-way intervention arm an improvement in adherence (measured by medication refill rates) and a small reduction in systolic blood pressure (2.2mm Hg reduction over 12months) (Bobrow et al. 2016). In this study, we assessed the cost and cost effectiveness of the StAR* intervention under routine care management at Vanguard CHC. We also assessed the cost of hypertension management from the health system perspective and the cost of accessing hypertension care from the patient perspective. A combination of the ingredients approach and step-down costing was used to cost hypertension care from a health system perspective while a questionnaire was administered to 250 patients to estimate patient costs. The primary outcomes were the average cost of hypertension care and the incremental cost of the text message-based adherence intervention (StAR* intervention), compared to usual care, per millimetre of mercury (mmHg) reduction in systolic blood pressure. Results of the study show that the average health system cost for hypertension management is R262 per visit and the patient cost of accessing hypertension care is R172 per visit. The text messaging based intervention was found to have low implementation costs in this pilot phase. The monthly incremental cost of the text messaging based intervention cost was R4 per person. The incremental cost-effectiveness ratio of the intervention was R22 per mm Hg reduction. This study provides the first contemporary assessment of hypertension management costs and the cost-effectiveness of mobile-based hypertension adherence support in South Africa. Future work will seek to estimate the long-term cost-effectiveness of this intervention and the cost of scaling it to the provincial and national levels

Application of Mobile Health Services to Support Patient Self-Management of Chronic Conditions

Background: Chronic conditions are the leading cause of ill-health, disability and premature death, adding huge health and socioeconomic burden to the healthcare system. Although mobile health (mHealth) services have the potential to provide patients with a timely, ubiquitous, and cost-effective means to access healthcare services, to date, much remains to be revealed for their application in chronic condition management. Aim: This doctoral project aims to comprehensively understand the application of mHealth services to support patient self-management of chronic conditions. This aim is achieved through four objectives: (1) to synthesise research evidence about health outcomes of applying mHealth services to support patient self-management of chronic conditions and the essential components to achieve these outcomes, (2) to determine the mechanism for applying mHealth services to support patient self-management of chronic conditions, (3) to explore critical factors and how these factors influence patients\u27 intention to continuously use mHealth services, and (4) to apply the above findings to guide the design of a prototype mHealth service. Methods: To increase the generalisability of the findings, three chronic conditions that could benefit from mHealth services were purposively studied to address the research objectives within the feasibility of available study sites and resources at different stages of the project. First, two literature review studies were conducted to achieve Objective 1. One was a systematic review to investigate health outcomes of mHealth services to support patient self-management of one chronic condition, unhealthy alcohol use, and the essential components to achieve these outcomes. The other was a rapid review on using behavioural theory to guide the design of mHealth services that support patient self-management of another chronic condition, hypertension. Second, two field studies were conducted to achieve Objectives 2 and 3, respectively. One was an interview study that explored patients\u27 perceptions of a mHealth service to support their self-management of hypertension in China. The other was a questionnaire survey study conducted on the same site that explored critical factors influencing patients\u27 intention to continuously use the mHealth service. Third, a clinician-led, experience-based co-design approach was implemented to apply the above-mentioned learning experience to the development practice of a mHealth service that supports patient self-management of obesity before elective surgery in Australia, achieving Objective 4. Results: Literature reviews identify five structural components - context, theory, content, delivery mode, and implementation procedure - which are essential for mHealth services to achieve three health outcomes - behavioural, physiological, and cognitive outcomes. Inductive synthesis of the interview findings lead to a 6A framework that summarises the mechanisms for mHealth services: access, assessment, assistance, awareness, ability, and activation. Mobile health services provide patients with easy access to health assessment and healthcare assistance to increase their self-management awareness and ability, thereby activating their self-management behaviours. Questionnaire survey study finds that patients\u27 intention to continuously use mHealth services can be influenced by the information quality, system quality and service quality by influencing their perceived usefulness and satisfaction with the mHealth services. Guided by Social Cognitive Theory, the developed prototype mHealth service provide patients with functions of automatic push notifications, online resources, goal setting and monitoring, and interactive health-related exchanges that encourage their physical activity, healthy eating, psychological preparation, and a positive outlook for elective surgery. The patients\u27 requirements in two focus group discussions enabled the research team to improve the mHealth service design. Conclusion: Mobile health services guided by behavioural theories can provide patients with easy access to health assessment and healthcare assistance to increase their self-management awareness and ability, thereby activating their self-management behaviours. The effort for designing mHealth services needs to be placed on crafting content (to improve information quality), developing useful functions and selecting a proper delivery mode (to improve system quality), and establishing effective implementation procedures (to improve service quality). These will ensure patients\u27 perceived usefulness and satisfaction with mHealth services, increase their intention to continuously use such services, thus supporting long-term patient self-management of chronic conditions. As demonstrated by the design case, the findings of this PhD project can be generalised to guide the design of other mHealth services that aim to support patient self-management of chronic conditions

Feasibility of Emergency Department–initiated, Mobile Health Blood Pressure Intervention: An Exploratory, Randomized Clinical Trial

ObjectivesWe aimed to assess the feasibility of a text messaging intervention by determining the proportion of emergency department (ED) patients who responded to prompted home blood pressure (BP) self‐monitoring and had persistent hypertension. We also explored the effect of the intervention on systolic blood pressure (sBP) over time.MethodsWe conducted a randomized, controlled trial of ED patients with expected discharge to home with elevated BP. Participants were identified by automated alerts from the electronic health record. Those who consented received a BP cuff to take home and enrolled in the 3‐week screening phase. Text responders with persistent hypertension were randomized to control or weekly prompted BP self‐monitoring and healthy behavior text messages.ResultsAmong the 104 patients enrolled in the ED, 73 reported at least one home BP over the 3‐week run‐in (screening) period. A total of 55 of 73 reported a home BP of ≥140/90 and were randomized to SMS intervention (n = 28) or control (n = 27). The intervention group had significant sBP reduction over time with a mean drop of 9.1 mm Hg (95% confidence interval = 1.1 to 17.6).ConclusionsThe identification of ED patients with persistent hypertension using home BP self‐monitoring and text messaging was feasible. The intervention was associated with a decrease in sBP likely to be clinically meaningful. Future studies are needed to further refine this approach and determine its efficacy.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/149295/1/acem13691.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149295/2/acem13691_am.pd

Improving Medication Adherence In Hypertensive Patients: A Scoping Review

Nos últimos anos, o interesse na área da adesão terapêutica tem aumentado de forma significativa. O panorama da adesão tem sido estudado particularmente na área do tratamento da hipertensão arterial; de facto, já foram desenvolvidas numerosas intervenções na tentativa de melhorar a adesão terapêutica em doentes hipertensos. No entanto, este tem sido um esforço frequentemente frustrante e desorganizado. O objetivo do presente estudo foi a realização de uma scoping review de intervenções destinadas a melhorar a adesão terapêutica em doentes hipertensos, de forma a fornecer uma visão mais clara e estruturada desta área. Além disso, desenvolveu-se um novo sistema de categorização de intervenções, baseado em evidência. A presente revisão foi realizada de acordo com o PRISMA-ScR statement. As bases de dados utilizadas foram a MEDLINE e a Web of Science, sendo que se incluíram estudos desde a criação das bases de dados até o dia 17 de agosto de 2020. De um número inicial de 2994 estudos não duplicados, 45 artigos foram incluídos após a realização das fases de screening e elegibility. Estes artigos foram analisados de acordo com o seu desenho, características dos participantes e estratégias de gestão de adesão aplicadas. De igual forma, avaliaram-se os seus outcomes relativos a indicadores de adesão terapêutica e pressão arterial, bem como os métodos utilizados para medir adesão. Posteriormente, cada intervenção descrita foi categorizada de acordo com um novo sistema de categorização, baseado em evidência e desenhado de acordo com o framework de conceptual clustering, amplamente utilizado em machine learning. Ao apresentar uma visão geral e organizada desta área de investigação, criando ainda uma nova ferramenta de categorização de intervenções, este trabalho revela-se um marco importante no desenvolvimento informado e eficiente de futuras intervenções em adesão terapêutica. Adicionalmente, para profissionais de saúde esta é uma fonte de informação valiosa sobre adesão terapêutica em doentes hipertensos.In recent years, interest in medication adherence has greatly increased. Adherence has been particularly well studied in the context of arterial hypertension treatment. Numerous interventions have addressed this issue, however, the effort to improve adherence has been often frustrating and frequently disorganized. The aim of present study was to perform a scoping review of medication adherence interventions in hypertensive patients, so that a clear overview was achieved. Moreover, an evidence-based categorization of interventions was developed. The review was performed according to the PRISMA-ScR statement. MEDLINE and Web of Science were searched, and studies published from database inception until August 17, 2020 were included. A total of 2994 non-duplicate studies were retrieved. After screening and eligibility phases, a total of 45 articles were included. Studies were analyzed regarding their design, participant characteristics and management of adherence strategies employed. Furthermore, medication adherence and blood pressure outcomes, as well as adherence measuring tools were evaluated. Each study's intervention was then categorized using a novel evidence-based system of categorization, derived from the conceptual clustering framework used in machine learning. This work is an important step in pushing for better informed and more efficient future research efforts, both by providing an overview of the research field and by creating a new, evidence-based intervention categorization tool. It also provides valuable information to clinicians about medication adherence to antihypertensive therapy

Telehealth methods to deliver multifactorial dietary interventions in adults with chronic disease: A systematic review protocol

Background: The long-term management of chronic diseases requires adoption of complex dietary recommendations, which can be facilitated by regular coaching to support sustained behaviour change. Telehealth interventions can overcome patient-centred barriers to accessing face-to-face programs and provide feasible delivery methods, ubiquitous and accessible regardless of geographic location. The protocol for this systematic review explains the methods that will be utilised to answer the review question of whether telehealth interventions are effective at promoting change in dietary intake and improving diet quality in people with chronic disease. Methods/design: A structured search of Medline, EMBASE, CINAHL, and PsychINFO, from their inception, will be conducted. We will consider randomised controlled trials which evaluate complex dietary interventions in adults with chronic disease. Studies must provide diet education in an intervention longer than 4 weeks in duration, and at least half of the intervention contact must be delivered via telehealth. Comparisons will be made against usual care or a non-telehealth intervention. The primary outcome of interest is dietary change with secondary outcomes relating to clinical markers pre-specified in the methodology. The process for selecting studies, extracting data, and resolving conflicts will follow a set protocol. Two authors will independently appraise the studies and extract the data, using specified methods. Meta-analyses will be conducted where appropriate, with parameters for determining statistical heterogeneity pre-specified. The GRADE tool will be used for determining the quality of evidence for analysed outcomes. Discussion: To date, there has been a considerable variability in the strategies used to deliver dietary education, and the overall effectiveness of telehealth dietary interventions for facilitating dietary change has not been reviewed systematically in adults with chronic disease. A systematic synthesis of telehealth strategies will inform the development of evidence-based telehealth programs that can be tailored to deliver dietary interventions specific to chronic disease conditions. Systematic review registration: PROSPERO CRD42015026398

A realist evaluation of a clinic based lay health worker intervention to improve the management of Hypertension in rural South Africa

A thesis submitted for the degree: Doctor of Philosophy School of Public Health Faculty of Health Sciences University of the Witwatersrand, Johannesburg. 30 October 2017.1. Background Hypertension prevalence is high in Africa and is one of the commonest cardiovascular ailments. A cluster randomized control trial (RCT) was run in the Bushbuckridge sub-district, Mpumalanga, in South Africa, to test whether lay health workers (LHW), working alongside nurses in rural clinics can improve management of hypertension. The trial’s programme theory was thus management of hypertension would improve since LHWs would free up nurses by taking up some of their tasks. Nurses would then focus on clinical management of the patients. In this area, nearly half of adults are hypertensive, but only 9% have the blood pressure well controlled. In my PhD, I have used realist evaluation approach to understand the impact of the LHWs and explain “what worked for whom, under what conditions and how”. I have also discussed the practicality of combining realist evaluations and RCTs, contributing to an ongoing debate. 2. Aims To understand under what context and through what mechanisms a clinic based lay health worker intervention will enhance integrated chronic care for hypertensive patients and will modify patient outcomes in a cluster randomized trial in primary health care clinics. 3. Methods This study was a theory driven realist evaluation. It was based in realism approach which focused on explaining “why” and “how” improvements happened (or not). I used Medical Research Council’s (MRC) framework for process evaluation of complex interventions to understand and present how the different constituents of the intervention, implementation, context, mechanisms and outcomes are interconnected. My programme theory was adapted from Pawson and Tilley’s realist approach that considered outcomes from the intervention, as a configuration of the context and the mechanisms through which the intervention was implemented (context + mechanisms = outcomes). I also used other theories that describe factors for ideal chronic care (Wagner model) and effects of complexity in organizations (theory of complex adaptive system). I used a case study approach to compare and contrast experiences in the eight case clinics. The intervention and operation of the clinics were explored over time during the pre-trial period, during the preparation and development phase of the intervention, mid-way through the implementation of the intervention and towards the closure of the trial. Data collected was largely qualitative using detailed, observation of clinic activities and patient pathway, focus group discussions with community health workers and community members, semi-structured interviews Clinic Managers, Clinic Supervisors and sub-District Manager, in-depth interviews with LHWs and the Implementation Manager, semi-structured interviews with three cohorts of purposively selected hypertensive patients in their homes, patient exit structured interviews, and Implementation Manager’s and researcher diaries. Qualitative data was analyzed using Nvivo and data extraction sheets that pulled together data from different sources. Quantitative data from patient exit structured interviews was analyzed descriptively using simple statistical tests. 4. Findings At the time of the study, implementation of a government initiative called Integrated Chronic Disease Management (ICDM) model was underway in all clinics. There was rapidly increasing demand for chronic disease care as HIV management and management of stable chronic patients was referred down from hospitals to clinics. The trial clinics were swamped by HIV and hypertensive patients with 53% of the clinic visits by patients with chronic diseases done by HIV patients and 47% done by hypertensive patients. More support is available for HIV patients as compared with hypertensive patients such as tracing of patients that default treatment, counselling and testing by lay counsellors and data capturing. Clinics were affected by constant break down of BP machines and cuffs that were torn. There was limited maintenance of equipment and supply of materials i.e. patient files and packs for prepacking medication. Supply of hypertension drugs increasingly became erratic in all clinics. There was perceived shortage of nurses with some clinics being better off than others. Limited space and dilapidated Infrastructure affected chronic pathways in some clinics. Clinic management differed from clinic to clinic which affected relations among staff, relationship between staff and patients, and day to day operation of the clinic. Performance and motivation among LHWs varied across clinics and largely depended on support from other clinic staff. LHWs had background in community health work, were residents of villages served by respective clinics and had attained grade 12 (Matric). LHWs supported the nurses with appointment booking, pre-retrieval of files and filing back, measuring blood pressure, health education and prepacking of medication. They also reminded hypertensive patients prior to their appointment and followed up with those that missed appointment. The LHWs were supervised by an Implementation Manager who was a Professional Nurse by training. During the intervention, LHWs played an important role of identifying and following up with acute and other chronic patients with raised blood pressure. I placed the clinics into well, medium and poor functioning categories, although there was no clear cut difference between well and medium functioning clinics, and between medium and poor functioning clinics. However, my analysis showed that clinics require at least one of the following: strong management, teamwork, or a committed chronic care nurse, to get reasonable outcomes. If none of these exist, clinics perform poorly. 5. Discussion and conclusion The LHW programme theory partially worked as expected. The intervention was not successful in improving population levels of BP but successfully changed the functioning of clinics and delivery of care to patients with chronic diseases. The success in improving functioning of clinics varied across the intervention clinics. The LHW programme theory has explained the causal pathways that led to these differences in the programme outcomes and effects. These were mainly as a result of differences in context, mechanisms and implementation process. Using the MRC framework for process evaluation of complex interventions, the following configuration of intervention, context and mechanisms explains the study: Clinics with observed better contextual factors i.e. infrastructure, equipment, good clinic management, nurse levels, low patient loads; were clinics with positive effects in the work of the LHWs i.e. appointment booking, reminding and following up with patients, prepacking medication and filing. These were also clinics where staff related well among themselves and with patients, supported the work of LHWs and had motivated and skilled LHWs. Such clinics had positive clinic level proximal outcomes (collected through clinic link) that included patients adhering to their appointment dates and identifying patient with raised BP. Use of theories in this study has helped me to understand that health care facilities are complex organizations and are always evolving and changing. A complex mix of different factors i.e. relations, management, resources, resulted in no linear path of implementation and outcomes. Chronic care depends on positive interaction between the health system, the providers and the users. When carrying out health care interventions, implementers should consider the unique nature of facilities and strengthen the interactions between the health system, the providers and the users. I support the notion that realist evaluations can be used with RCTs and can be used to explain and strengthen findings from the trial. Trials should routinely include a process evaluation which should describe the context in detail and review how the contexts of the trial affect the implementation and outcomes, while understanding the mechanisms by which the intervention works. LHWs provided useful support to nurses in providing integrated care for chronic patients compared to usual clinics. However, the effectiveness of LHWs was affected by limited resources, increasing patient load and poor clinic management. The realist evaluation has reflected on policy and practice implications for effective chronic disease management. Such issues include, (a) lay persons can take up socially and medically oriented tasks of nurses with proper selection, training and supervision, (b) measuring vital signs for every patient that comes to the clinic has left the BP machines overwhelmed and often broken down, (c) despite introduction of integrated chronic disease management, programmes are still implemented vertically at clinic level with special attention given to HIV. The innovative methodological contribution in this PhD has been this additional level of information about the causal pathway in implementing the LHW intervention which otherwise could not have been identified just with a randomized controlled trial.LG201

Using the Medical Research Council framework for development and evaluation of complex interventions in a low resource setting to develop a theory-based treatment support intervention delivered via SMS text message to improve blood pressure control

Several frameworks now exist to guide intervention development but there remains only limited evidence of their application to health interventions based around use of mobile phones or devices, particularly in a low-resource setting. We aimed to describe our experience of using the Medical Research Council (MRC) Framework on complex interventions to develop and evaluate an adherence support intervention for high blood pressure delivered by SMS text message. We further aimed to describe the developed intervention in line with reporting guidelines for a structured and systematic description

A Team-Based Approach to Increase Initiation of Self-Management Goals in Adult Patients Diagnosed with Hypertension With the Use of a Self-Management Goal Toolkit

Due to the high risk of cardiovascular disease and other negative complications, it is imperative that patients in the primary care clinic diagnosed with hypertension control blood pressure levels. The purpose of this scholarly project was to increase the initiation of self-management goals (SMGs) among adult males and females age 30 to 60 diagnosed with hypertension. These patients were active duty military, reservists, and dependent beneficiaries who receive care at the Navy Medicine Readiness Training Unit–Memphis. The practice change took the onus of introduction and education about SMGs off the provider and added key responsibilities to support staff, who provided handouts and education to patients via a SMG toolkit. The goal was to minimize time needed for providers to focus on SMGs and to increase the initiation of SMGs through the utilization of support staff. Through patient education about SMGs and lifestyle goal setting, the hope was to improve clinical outcomes and improve the participating patients’ health. Navy Medicine Readiness Training Unit–Memphis did not have a SMG process, and had not been in compliance with Joint Commission mandates for the initiation and documentation of SMGs for patients with chronic conditions. Through staff education, training, delivery of proper educational materials via a SMG toolkit, and the attainment of information from the electronic medical record Genesis, initiation and documentation of SMGs among adult patients diagnosed with hypertension improved to 62.5% from the current baseline