Comprehending the Safety Paradox and Privacy Concerns with Medical Device Remote Patient Monitoring

Medical literature identifies a number of technology-driven improvements in disease management such as implantable medical devices (IMDs) that are a standard treatment for candidates with specific diseases. Among patients using implantable cardiac defibrillators (ICD), for example, problems and issues are being discovered faster compared to patients without monitoring, improving safety. What is not known is why patients report not feeling safer, creating a safety paradox, and why patients identify privacy concerns in ICD monitoring. There is a major gap in the literature regarding the factors that contribute to perceived safety and privacy in remote patient monitoring (RPM). To address this gap, the research goal of this study was to provide an interpretive account of the experience of RPM patients. This study investigated two research questions: 1) How did RPM recipients perceive safety concerns?, and 2) How did RPM recipients perceive privacy concerns? To address the research questions, in-depth, semi-structured interviews were conducted with six participants to explore individual perceptions in rich detail using interpretative phenomenological analysis (IPA). Four themes were identified and described based on the analysis of the interviews that include — comfort with perceived risk, control over information, education, and security — emerged from the iterative review and data analysis. Participants expressed comfort with perceived risk, however being scared and anxious were recurrent subordinate themes. The majority of participants expressed negative feelings as a result of an initial traumatic event related to their devices and lived in fear of being shocked in inopportune moments. Most of these concerns stem from lack of information and inadequate education. Uncertainties concerning treatment tends to be common, due to lack of feedback from ICD RPM status. Those who knew others with ICD RPM became worrisome after hearing about incidences of sudden cardiac death (SCD) when the device either failed or did not work adequately to save their friend’s life. Participants also expressed cybersecurity concerns that their ICD might be hacked, maladjusted, manipulated with magnets, or turned off. They believed ICD RPM security was in place but inadequate as well as reported feeling a lack of control over information. Participants expressed wanting the right to be left alone and in most cases wanted to limit others’ access to their information, which in turn, created conflict within families and loved ones. Geolocation was a contentious node in this study, with most of participants reporting they did not want to be tracked under any circumstances. This research was needed because few researchers have explored how people live and interact with these newer and more advanced devices. These findings have implications for practice relating to RPM safety and privacy such as identifying a gap between device companies, practitioners, and participants and provided directions for future research to discover better ways to live with ICD RPM and ICD shock

Enhancing the Diagnosis and Management of Obstructive Sleep Apnoea in Atrial Fibrillation Patients

Background: Atrial fibrillation (AF), is the most common sustained cardiac arrhythmia, and significantly increases the risk of stroke and cardiovascular mortality. It is strongly associated with obstructive sleep apnoea (OSA). Aims: 1. Examine the epidemiology of OSA in a hospital cohort with AF. 2. Compare the diagnostic accuracy of clinical screening tools for OSA in patients with AF. 3. Compare cardiac autonomic function in AF patients with and without OSA. 4. Conduct a pilot study of mandibular advancement splint (MAS) therapy for OSA in AF patients. Methods: 107 AF patients were recruited. The diagnostic accuracy of screening tools including a level 3 (portable) sleep study device as compared to polysomnography in AF patients was assessed. Cardiac autonomic function as a potential mechanistic link between OSA and AF was assessed using Heart Rate Variability (HRV). A pilot study of OSA treatment in AF patients using MAS therapy was conducted. Results: 62.6% of patients were newly diagnosed with OSA. Patients with moderate to severe OSA showed an increased BMI, neck circumference and Mallampati score, but were not significantly different in terms of daytime somnolence. Oxygen desaturation index (ODI) derived from a Level 3 portable sleep study device performed best for the diagnosis of moderate to severe and severe OSA, with excellent diagnostic accuracy (AUC 0.899, 95% CI 0.838 – 0.960 and AUC 0.925, 95% CI 0.859 – 0.991 respectively). We found a chronic increase in parasympathetic nervous activity in paroxysmal AF patients with OSA. MAS therapy showed high rates of acceptance, compliance and efficacy in AF patients. Conclusions: This thesis contributes to our understanding of the association between AF and OSA across a spectrum o

The cardiovascular assessment skills gap in small animal general veterinary practitioners and identification of methods to reduce this

Administration of pimobendan to dogs with preclinical myxomatous mitral valve disease (MMVD) with cardiomegaly (stage B2 mitral valve disease, Atkins et al., 2009) has been shown to extend the asymptomatic period by an average of 15 months, and dogs receiving the drug live significantly longer than those receiving a placebo (Boswood et al., 2016). The identification in general veterinary practice of patients with MMVD who could benefit from this medication relies heavily on the accurate identification of a heart murmur on a physical examination and identification of cardiomegaly, including left atriomegaly, on thoracic radiographs. Little is known about the ability of general practitioners to identify these patients accurately. To investigate this in more detail, practitioner record keeping in relation to cardiovascular parameters, practitioner accuracy in interpretation of cardiac murmurs (Chapter 1) and practitioner accuracy in identification of cardiomegaly and left atriomegaly on thoracic radiographs (Chapter 2) was assessed. To identify methods that might aid the detection of cardiovascular disease in general practice, the value of focused echocardiography was assessed. Record keeping by general veterinary practitioners for important cardiovascular parameters was markedly limited in standard. General practitioners, compared with a referral clinician consensus opinion, agreed substantially on murmur grade (K = 0.7), agreed perfectly on murmur timing (K = 1.0) and moderately on the site of maximum intensity of murmurs (K = 0.5). These findings would suggest that practitioners are able to accurately grade a heart murmur and therefore could potentially correctly select patients who would benefit from further investigation, confirming the cause of the murmur as MMVD and therefore potentially benefit from medication. However due to poor record keeping, the loss of information may prevent the identification of patients in early stages of heart disease or patients who might benefit from further cardiovascular investigation. When assessing thoracic radiographs for changes associated with MMVD (Chapter II), general practitioners were found to have a high level of accuracy in the detection of patients with marked generalised cardiomegaly (median number of images correctly identified was 100%) and patients with no left atrial enlargement (median number of images correctly identified was 80%) using subjective methods of assessment. However, their accuracy was lower in detection of those with mild changes (median number of images correctly identified with mild cardiomegaly and mild left atrial enlargement was 66.67%). Whilst practitioners were accurate in their ability to measure a vertebral heart score (VHS), the lack of a clear upper limit for VHS meant that VHS added no significant value in aiding correct diagnosis. Patients in stage B2 MMVD (Atkins et al., 2009) have mild changes on thoracic radiographs, therefore this research suggests that in general practice patients in the early stages of cardiac remodelling, and those who might benefit greatly from medication, may go undiagnosed. This highlights that radiographic examination may not be sufficiently reliable in the evaluation of mild cardiomegaly and emphasizes the need for echocardiography to assist in the detection of patients with B2 MMVD. The introduction of the novel tool of focused echocardiography (Chapter 3) significantly improved general practitioner’s ability to correctly identify cardiac anatomy on echocardiography, detect left atrial enlargement, detect reduced systolic function and detect pericardial effusion (p<0.0001), practically obtain the views required to make these assessments, and improved their confidence in both image interpretation and practical acquisition. In relation to detection of MMVD, following the training course in focussed echocardiography, the mean accuracy of identification of normal left atrial size, a mildly enlarged left atrium and severely enlarged left atrium was 88%. Post training, 95% of practitioners were able to correctly identify a severely enlarged left atrium. These results suggest that the addition of the focused echocardiogram to general practice could aid earlier detection of patients in stage B2 MMVD or greater by detection of left atrial enlargement. These patients could then benefit from an echocardiogram and potentially benefit from the positive effects of pimobendan

Accessibility of Health Data Representations for Older Adults: Challenges and Opportunities for Design

Health data of consumer off-the-shelf wearable devices is often conveyed to users through visual data representations and analyses. However, this is not always accessible to people with disabilities or older people due to low vision, cognitive impairments or literacy issues. Due to trade-offs between aesthetics predominance or information overload, real-time user feedback may not be conveyed easily from sensor devices through visual cues like graphs and texts. These difficulties may hinder critical data understanding. Additional auditory and tactile feedback can also provide immediate and accessible cues from these wearable devices, but it is necessary to understand existing data representation limitations initially. To avoid higher cognitive and visual overload, auditory and haptic cues can be designed to complement, replace or reinforce visual cues. In this paper, we outline the challenges in existing data representation and the necessary evidence to enhance the accessibility of health information from personal sensing devices used to monitor health parameters such as blood pressure, sleep, activity, heart rate and more. By creating innovative and inclusive user feedback, users will likely want to engage and interact with new devices and their own data