Effectiveness of an electronic patient-centred self-management tool for gout sufferers: A cluster randomised controlled trail protocol

© © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted. Introduction Gout is increasing despite effective therapies to lower serum urate concentrations to 0.36 mmol/L or less, which, if sustained, significantly reduces acute attacks of gout. Adherence to urate-lowering therapy (ULT) is poor, with rates of less than 50% 1 year after initiation of ULT. Attempts to increase adherence in gout patients have been disappointing. We aim to evaluate the effectiveness of use of a personal, self-management, a'smartphone' application (app) to achieve target serum urate concentrations in people with gout. We hypothesise that personalised feedback of serum urate concentrations will improve adherence to ULT. Methods and analysisSetting and design Primary care. A prospective, cluster randomised (by general practitioner (GP) practices), controlled trial. Participants GP practices will be randomised to either intervention or control clusters with their patients allocated to the same cluster. Intervention The intervention group will have access to the Healthy.me app tailored for the self-management of gout. The control group patients will have access to the same app modified to remove all functions except the Gout Attack Diary. Primary and secondary outcomes The proportion of patients whose serum urate concentrations are less than or equal to 0.36 mmol/L after 6 months. Secondary outcomes will be proportions of patients achieving target urate concentrations at 12 months, ULT adherence rates, serum urate concentrations at 6 and 12 months, rates of attacks of gout, quality of life estimations and process and economic evaluations. The study is designed to detect a ≥30% improvement in the intervention group above the expected 50% achievement of target serum urate at 6 months in the control group: power 0.80, significance level 0.05, assumed a'dropout' rate 20%. Ethics and dissemination This study has been approved by the University of New South Wales Human Research Ethics Committee. Study findings will be disseminated in international conferences and peer-reviewed journal. Trial registration number ACTRN12616000455460

Review on the possible interactions of pests, diseases & weeds in cereals grown in organic and conventional agriculture

Background The demand for organically produced food is outstripping the ability of UK farmers to supply it and the majority is imported. Furthermore, there is a major shortfall in home-produced organic cereals and cereal products, including straw. In response to this need, the consequences of increasing the area of organically produced cereal crops on pests, diseases and weeds require evaluation. Furthermore, as the area of organic cereals increases, crops may be grown more in the major cereal production regions. This could have consequences for both the organic producer and farmers growing cereals conventionally. Objectives (i) review the current state of knowledge on the status and distribution of pests, diseases and weeds in organic and conventionally grown cereals, (ii) assess the likely rate of expansion of organic cereal production and the areas where this is most likely to occur, together with any likely or consequent change in the distribution of conventionally grown cereals, (iii) assess the distribution of specific cereal cultivars and species in organic and non-organic production in relation to their impact on disease, pest and weed distribution. A specific sub-objective will be to assess the likely impact of the increased use of organically produced seed on seed-borne diseases, (iv) try to forecast whether or not the changes in cereal production will affect the current status and distribution of pests, diseases and weeds, and, if so, in which major directions, (v) make recommendations for future research, both to ensure that the forecast under paragraph (iii) is correct and that any negative trends are highlighted and, if possible, dealt with. Methods A literature review was undertaken to identify potential risks to conventional and organic production cereals on an extension of the organic area on risks of pests, diseases and weeds. See main report for results. Future work Monitoring of the more important pests and diseases in organic production would be prudent. Any problems for non-organic cereal producers are unlikely to arise for several years because of the small scale and slow increase of organic cereal production, but this should be regarded as a ‘grace’ period to allow for development of appropriate solutions before any potential problems become important in practice. Problems for organic producers may emerge more quickly; these need to be monitored so that cultivar and other recommendations can be developed. It is likely that the best spectrum of cultivars for non-organic and organic production will differ, which would help in restricting disease interactions between the two production systems. Any constraints on production of seed for organic cereal growing should be removed so far as possible. Development of the system of bi-cropping, both for organic and non-organic production, should be continued since there are good indications that this can restrict problems due to slugs, aphids and BYDV, septoria leaf and glume blotch, and probably take all. The importance of using disease resistant cultivars needs to be still further stressed for both organic and non-organic production. The influence of sowing date on disease development, particularly in the autumn, needs more attention. Renewed efforts to develop and introduce production of cultivar mixtures, particularly for organic cereal production, would help to restrict disease development. Fundamental studies on the biology of the major perennial weeds are still needed. Although seed spread can be minimised by frequent cutting, the effects of this on the spread of roots and rhizomes is poorly understood. It is important to maintain a regular watch or survey for indications of any increase in the key seed-borne diseases that may occur in organic cereal production and to determine the reasons for any such increase. Technology transfer The report will be suitable for wider dissemination among researchers and the agriculture industry. All contributing organisations have means by which this information can be made available through press briefings, Web-sites and at farming events

Best Practices for Virtual Care: A Consensus Statement From the Canadian Rheumatology Association

Objective. To develop best practice statements for the provision of virtual care in adult and pediatric rheumatology for the Canadian Rheumatology Association\u27s (CRA) Telehealth Working Group (TWG). Methods. Four members of the TWG representing adult, pediatric, university-based, and community rheumatology practices defined the scope of the project. A rapid literature review of existing systematic reviews, policy documents, and published literature and abstracts on the topic was conducted between April and May 2021. The review informed a candidate set of 7 statements and a supporting document. The statements were submitted to a 3-round (R) modified Delphi process with 22 panelists recruited through the CRA and patient advocacy organizations. Panelists rated the importance and feasibility of the statements on a Likert scale of 1-9. Statements with final median ratings between 7-9 with no disagreement were retained in the final set. Results. Twenty-one (95%) panelists participated in R1, 15 (71%) in R2, and 18 (82%) in R3. All but 1 statement met inclusion criteria during R1. Revisions were made to 5/7 statements following R2 and an additional statement was added. All statements met inclusion criteria following R3. The statements addressed the following themes in the provision of virtual care: adherence to existing standards and regulations, appropriateness, consent, physical examination, patient-reported outcomes, use in addition to in-person visits, and complex comanagement of disease. Conclusion. The best practice statements represent a starting point for advancing virtual care in rheumatology. Future educational efforts to help implement these best practices and research to address identified knowledge gaps are planned

Technical and Behavioral Interventions for Medication Adherence through Mobile Health

In this research, we present a novel intervention, Carrot and Stick, to improve the outcome of one of the self-management tasks, medication adherence (MA), among patients with chronic disease(s). Our design incorporates the growing importance of mobile health (m-health) in Health Information Technology (HIT) with the users’ dependency on mobile phones to facilitate valuable behavioral changes. Drawing on Social Cognitive Theory, Social Exchange Theory, Goal-setting Theory, and people’s dependence on smartphones, we develop the functionalities in our intervention, including positive and negative reinforcement, goal-setting, and social connections. The iterative process of our development follows the Design Science Approach. In the evaluation and validation of our intervention, we not only examine the intervention’s impacts on patients through analytical models and simulation but also demonstrate the possible active support of the intervention from healthcare providers based on the current pay-for-performance (P4P) scheme. Our results suggest that (1) with the help of electronic medication container, appropriate reminder design can reduce the patients’ chances of forgetting doses, overdosing, and intaking doses at the wrong time, (2) positive reinforcement can help increase the probability of the patient achieving expected MA, while negative reinforcement has a further impact that is added to the increment, (3) our intervention can assist the patient in saving more than $600 per year, and (4) under the current P4P scheme, physicians with the exceptional performance or with bad performance are likely to invest in the intervention to change their patients’ behaviors, while physicians with good performance are less likely to participate. Our research is the first to utilize negative reinforcement in intervention design to enhance MA; it is also the first to provide corresponding interventional solutions that are customized according to elements derived from theories. Besides, the focus and understanding of healthcare providers’ involvement in the incentive program can facilitate the adoption, prescription, and implementation of the proposed intervention

Scoping review and bibliometric analysis of Big Data applications for Medication adherence: An explorative methodological study to enhance consistency in literature

Background: Medication adherence has been studied in different settings, with different approaches, and applying different methodologies. Nevertheless, our knowledge and efficacy are quite limited in terms of measuring and evaluating all the variables and components that affect the management of medication adherence regimes as a complex phenomenon. The study aim is mapping the state-of-the-art of medication adherence measurement and assessment methods applied in chronic conditions. Specifically, we are interested in what methods and assessment procedures are currently used to tackle medication adherence. We explore whether Big Data techniques are adopted to improve decision-making procedures regarding patients' adherence, and the possible role of digital technologies in supporting interventions for improving patient adherence and avoiding waste or harm. Methods: A scoping literature review and bibliometric analysis were used. Arksey and O'Malley's framework was adopted to scope the review process, and a bibliometric analysis was applied to observe the evolution of the scientific literature and identify specific characteristics of the related knowledge domain. Results: A total of 533 articles were retrieved from the Scopus academic database and selected for the bibliometric analysis. Sixty-one studies were identified and included in the final analysis. The Morisky medication adherence scale (36%) was the most frequently adopted baseline measurement tool, and cardiovascular/hypertension disease, the most investigated illness (38%). Heterogeneous findings emerged from the types of study design and the statistical methodologies used to assess and compare the results. Conclusions: Our findings reveal a lack of Big Data applications currently deployed to address or measure medication adherence in chronic conditions. Our study proposes a general framework to select the methods, measurements and the corpus of variables in which the treatment regime can be analyzed

Patients' Experiences and Perspectives of Telehealth Coaching with a Dietitian to Improve Diet Quality in Chronic Kidney Disease: A Qualitative Interview Study

Background: Dietary behavior change interventions for the self-management of chronic kidney disease (CKD) have the potential to slow disease progression and reduce metabolic complications. Telehealth-delivered dietary interventions may assist in the self-management of CKD, although their acceptability by patients is unknown. Objective: This study aims to describe the acceptability and experiences of a telehealth coaching intervention that utilized telephone calls and tailored text messages to improve diet quality in patients with stage 3 to 4 CKD. Design: Semistructured interview study of adults with CKD. Participants/setting: Adults with stage 3 to 4 CKD (n=21) aged 28 to 78 (mean 62) years, who completed a 12-week telehealth-delivered dietary intervention in Queensland, Australia, were interviewed from March to July 2017. Data analysis: Interviews were transcribed verbatim and analyzed thematically. Results: Five themes were identified: valuing relationships (receiving tangible and perceptible support, building trust and rapport remotely, motivated by accountability, readily responding to a personalized approach, reassured by health professional expertise); appreciating convenience (integrating easily into lifestyle, talking comfortably in a familiar environment, minimizing travel and wait time burden); empowered with actionable knowledge (comprehending diet-disease mechanisms, practical problem solving for sustainable dietary behavior); increasing diet consciousness (learning from recurrent feedback, prompted by reiteration of messages); making sense of complexity (contextualizing and prioritizing comorbidities, gaining confidence to make dietary decisions, setting and achieving realistic goals). Conclusions: Among adults with stage 3 to 4 CKD, individualized telehealth coaching for improving diet quality was convenient for patients, and they felt supported and empowered to navigate recommendations and prioritize dietary behavior changes. Telehealth-delivered dietary interventions appear to be well accepted by patients as a way of providing regular, tailored contact with a health professional to support dietary management in CKD

Design and Prototype Evaluation of a Mini Program for Diet Management Focusing on Patients with Chronic Kidney Disease

Background Chronic kidney disease (CKD) is a global public health problem and has become a common chronic non-communicable disease threatening human well-being. There is no effective cure for CKD, and once it progresses to end-stage renal disease, only renal replacement therapy can be performed, which brings a heavy medical burden to families and the country. Dietetic-nutritional management is closely related to delaying the progression of CKD and improving health outcomes and is essential in the treatment of CKD. However, dietary compliance of patients is currently a major challenge in clinical work. With the integration of mobile Internet and healthcare, mobile health, represented by smartphones, has become an important tool for healthcare services. Previous studies have shown that information tools can motivate users to make positive eating behavior changes and improve their confidence in achieving their dietary goals. In recent years, diet management tools for CKD patients have gradually increased in China, but most patients still face difficulties in self-managing their diet at home. Aims Given that the advantages of WeChat Mini Program in China and the cost limitation of the study, the purpose of this study is to follow the concept of human-centred design to design an open accessible WeChat Mini Program for home diet management, and with CKD patients and caregivers as the target users, to ultimately improve the patient's experience of diet management and improve their dietary compliance to obtain the optimal benefits of medical nutrition therapy. To understand the usability and design flaws of this Mini Program through the prototype development and evaluation, to further improve the design and provide a reference for future development. Methods This study was divided into three stages. The first stage was the requirements analysis of diet management Mini Program: stakeholders, i.e., CKD patients and caregivers, renal dietitians, nephrologists, and specialist nurses, were interviewed through a qualitative study to explore their functional needs and suggestions for the Mini Program. The second stage was the design and expert evaluation of the Mini Program for CKD patients: based on literature review and stakeholders' requirements analysis and drawing on the features of the existing applications on the market, the first draft of the written design of this Mini Program was completed and then the written design and technical feasibility of the Mini Program were evaluated by multidisciplinary experts, including renal dietitians, nephrologists and specialist nurses, as well as WeChat Mini Program development technicians, to further revise and finalize the written design of this Mini Program. The third stage was prototype development and evaluation of the Mini Program: using Mocking Bot to develop the prototype and then was a mixed study, 15 testers were recruited to evaluate the prototype by convenience sampling. mHealth App Usability Questionnaire (MAUQ) (patient version) was used to collect quantitative usability scores, and qualitative interviews were conducted to explore their experience and suggestions for improvement of the Mini Program. Results 1. Requirements analysis of diet management Mini Program: 22 stakeholders were interviewed, including 9 CKD patients, 4 caregivers, and 9 clinical professionals. Three themes are extracted, which are attitudes towards the Mini Program (overall, highly expected the Mini Program for diet management), functional requirements of the Mini Program (including provide comprehensive diet management information, diet decision support, professional diet self-management skills, and emotional support channels), and performance requirements of the Mini Program (easy to use and learn, with simple interface). There are 12 specific functional requirements, which is expected to provide reliable dietary knowledge, food nutrient query, individualized dietary advice, dietary nutrition monitoring, customize individual recipes, recommend disease-specific foods, diet record and analysis, nutrition consultation, promote family participation, communication among patients, user feedback, and intelligent reminder. 2. Design and expert evaluation of the Mini Program: After two rounds of evaluation and feedback from multidisciplinary experts, the final version of the written design of the Mini Program was formed, including 4 modules, namely, Home Page, Interactive Community, Health Record, Personal Centre; and 19 functions, including Site Search, Diet Management, Popular Science Articles, and News (Home Page), Circle of Patients, My Doctors, Doctor's Lectures, My Family (Interactive Community), BP Record, BG Record, Wt. Record, Exercise Record (Health Record), and Basic Information Setting, Health Report, My equipment, My favourites, My Posts, Product Introduction, Feedback and Help (Personal Centre). 3. Prototype development and evaluation of the Mini Program: the prototype developed in this study was high-fidelity and interactive. Quantitative result: the mean value of the overall scoring of MAUQ was 1.39, with a standard deviation of 0.29, indicating that patients and caregivers recognize the Mini Program as usable. Qualitative result: clinical professionals, CKD patients, and caregivers who participated in the testing have a high acceptance of the Mini Program. Clinical professionals consider the Mini Program to be comprehensive, helpful for patients' diet management, and to reduce the burden of clinical diet education; patients and caregivers consider the Mini Program to be a comprehensive, easy-to-use, and practical tool that facilitates access to professional knowledge, improves their confidence in diet management and social support, and they have a positive attitude towards using it and express their great expectations. The main shortcomings of the Mini Program are the need to adjust the colour scheme and optimize the layout of the user interface and to highlight the main functions of diet management, and to realize the function of voice use if the development technology is feasible. Conclusion The Mini Program designed in this study meet the needs and demands of home diet management for CKD patients and may positively affect their diet self-management. In the future, we consider further collaboration with information technology companies and clinical usability assessment and effectiveness evaluation would be necessary, to determine the clinical effect and economic cost-effectiveness of interventions for CKD patients based on such a WeChat Mini Program, and to promote the close integration of mHealth and clinical practice

Innovative, Scalable and Affordable Interventions for the Treatment of Low Back Pain

The overall aim of the thesis was to investigate innovative, scalable and affordable interventions for the management of low back pain. Chapter Two shows an increasing online public interest in musculoskeletal conditions from 2008, with low back and neck pain being the ones with the highest annual increase (nearly 7%). Chapter Three reviews the use of text messages in the management of musculoskeletal pain. Text messages improved medication adherence compared to usual care and pain, function, quality of life and treatment adherence when added to comprehensive interventions and compared to control. Chapter Four describes the development process of the TEXT4myBACK intervention, which is a self-management text message intervention for people with low back pain. Chapter Five presents the protocol of the randomised controlled trial assessing the effect of the TEXT4myBACK intervention on function of people with low back pain compared to control. Chapter Six explores participants’ experience with the TEXT4myBACK intervention, including its acceptance, usefulness and behaviour-change ability. Chapter Seven proposes a methodology to aid the interpretation of the clinical significance of the TEXT4myBACK trial’s findings. It shows that people need to improve at least 9.4 points on a 0-30 function scale to consider self-management worthwhile. As pain management is complex and influenced by several factors including families, Chapter Eight reviews the effects of family-based interventions on health outcomes of people with musculoskeletal pain. It found that family-based interventions improve pain and disability compared to individual-focused interventions and pain compared to usual care. Chapter Nine explores the feasibility of a telephone health coaching intervention with or without an exercise buddy for people with low back pain compared to usual care and data collection approaches through a pilot and feasibility study. The thesis findings may be used to 1) guide the development of educational and text message interventions for musculoskeletal pain; 2) aid the interpretation of the clinical relevance of the TEXT4myBACK intervention’s effects through a responder analysis; 3) optimise the approaches of future randomised controlled trials including family members or exercise buddies for low back pain