Patient adherence to scheduled vital sign measurements during home telemonitoring: Analysis of the intervention arm in a before and after trial

© Branko Celler, Ahmadreza Argha, Marlien Varnfield, Rajiv Jayasena. Background: In a home telemonitoring trial, patient adherence with scheduled vital signs measurements is an important aspect that has not been thoroughly studied and for which data in the literature are limited. Levels of adherence have been reported as varying from approximately 40% to 90%, and in most cases, the adherence rate usually dropped off steadily over time. This drop is more evident in the first few weeks or months after the start. Higher adherence rates have been reported for simple types of monitoring and for shorter periods of intervention. If patients do not follow the intended procedure, poorer results than expected may be achieved. Hence, analyzing factors that can influence patient adherence is of great importance. Objective: The goal of the research was to present findings on patient adherence with scheduled vital signs measurements in the recently completed Commonwealth Scientific and Industrial Research Organisation (CSIRO) national trial of home telemonitoring of patients (mean age 70.5 years, SD 9.3 years) with chronic conditions (chronic obstructive pulmonary disease, coronary artery disease, hypertensive diseases, congestive heart failure, diabetes, or asthma) carried out at 5 locations along the east coast of Australia. We investigated the ability of chronically ill patients to carry out a daily schedule of vital signs measurements as part of a chronic disease management care plan over periods exceeding 6 months (302 days, SD 135 days) and explored different levels of adherence for different measurements as a function of age, gender, and supervisory models. Methods: In this study, 113 patients forming the test arm of a Before and After Control Intervention (BACI) home telemonitoring trial were analyzed. Patients were required to monitor on a daily basis a range of vital signs determined by their chronic condition and comorbidities. Vital signs included noninvasive blood pressure, pulse oximetry, spirometry, electrocardiogram (ECG), blood glucose level, body temperature, and body weight. Adherence was calculated as the number of days during which at least 1 measurement was taken over all days where measurements were scheduled. Different levels of adherence for different measurements, as a function of age, gender, and supervisory models, were analyzed using linear regression and analysis of covariance for a period of 1 year after the intervention. Results: Patients were monitored on average for 302 (SD 135) days, although some continued beyond 12 months. The overall adherence rate for all measurements was 64.1% (range 59.4% to 68.8%). The adherence rates of patients monitored in hospital settings relative to those monitored in community settings were significantly higher for spirometry (69.3%, range 60.4% to 78.2%, versus 41.0%, range 33.1% to 49.0%, P<.001), body weight (64.5%, range 55.7% to 73.2%, versus 40.5%, range 32.3% to 48.7%, P<.001), and body temperature (66.8%, range 59.7% to 73.9%, versus 55.2%, range 48.4% to 61.9%, P=.03). Adherence with blood glucose measurements (58.1%, range 46.7% to 69.5%, versus 50.2%, range 42.8% to 57.6%, P=.24) was not significantly different overall. Adherence rates for blood pressure (68.5%, range 62.7% to 74.2%, versus 59.7%, range 52.1% to 67.3%, P=.04), ECG (65.6%, range 59.7% to 71.5%, versus 56.5%, range 48.7% to 64.4%, P=.047), and pulse oximetry (67.0%, range 61.4% to 72.7%, versus 56.4%, range 48.6% to 64.1%, P=.02) were significantly higher in males relative to female subjects. No statistical differences were observed between rates of adherence for the younger patient group (70 years and younger) and older patient group (older than 70 years). Conclusions: Patients with chronic conditions enrolled in the home telemonitoring trial were able to record their vital signs at home at least once every 2 days over prolonged periods of time. Male patients maintained a higher adherence than female patients over time, and patients supervised by hospital-based care coordinators reported higher levels of adherence with their measurement schedule relative to patients supervised in community settings. This was most noticeable for spirometry

Supporting the Delivery of Total Knee Replacements Care for Both Patients and Their Clinicians With a Mobile App and Web-Based Tool: Randomized Controlled Trial Protocol

Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 01.03.2017. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on http://www.researchprotocols.org, as well as this copyright and license information must be included.Background: Total knee replacement (TKR) surgeries have increased in recent years. Exercise programs and other interventions following surgery can facilitate the recovery process. With limited clinician contact time, patients with TKR have a substantial burden of self-management and limited communication with their care team, thus often fail to implement an effective rehabilitation plan. Objective: We have developed a digital orthopedic rehabilitation platform that comprises a mobile phone app, wearable activity tracker, and clinical Web portal in order to engage patients with self-management tasks for surgical preparation and recovery, thus addressing the challenges of adherence to and completion of TKR rehabilitation. The study will determine the efficacy of the TKR platform in delivering information and assistance to patients in their preparation and recovery from TKR surgery and a Web portal for clinician care teams (ie, surgeons and physiotherapists) to remotely support and monitor patient progress. Methods: The study will evaluate the TKR platform through a randomized controlled trial conducted at multiple sites (N=5) in a number of states in Australia with 320 patients undergoing TKR surgery; the trial will run for 13 months for each patient. Participants will be randomized to either a control group or an intervention group, both receiving usual care as provided by their hospital. The intervention group will receive the app and wearable activity tracker. Participants will be assessed at 4 different time points: 4 weeks before surgery, immediately before surgery, 12 weeks after surgery, and 52 weeks after surgery. The primary outcome measure is the Oxford Knee Score. Secondary outcome measures include quality of life (Short-Form Health Survey); depression, anxiety, and stress (Depression, Anxiety, and Stress Scales); self-motivation; self-determination; self-efficacy; and the level of satisfaction with the knee surgery and care delivery. The study will also collect quantitative usage data related to all components (app, activity tracker, and Web portal) of the TKR platform and qualitative data on the perceptions of the platform as a tool for patients, carers, and clinicians. Finally, an economic evaluation of the impact of the platform will be conducted. Results: Development of the TKR platform has been completed and deployed for trial. The research protocol is approved by 2 human research ethics committees in Australia. A total of 5 hospitals in Australia (2 in New South Wales, 2 in Queensland, and 1 in South Australia) are expected to participate in the trial. Conclusions: The TKR platform is designed to provide flexibility in care delivery and increased engagement with rehabilitation services. This trial will investigate the clinical and behavioral efficacy of the app and impact of the TKR platform in terms of service satisfaction, acceptance, and economic benefits of the provision of digital services

SMARTphone-based, early cardiac REHABilitation in patients with acute coronary syndromes [SMART-REHAB Trial]: A randomized controlled trial protocol

© 2016 The Author(s). Background: There are well-documented treatment gaps in secondary prevention of coronary heart disease and no clear guidelines to assist early physical activity after acute coronary syndromes (ACS). Smartphone technology may provide an innovative platform to close these gaps. This paper describes the study design of a randomized controlled trial assessing whether a smartphone-based secondary prevention program can facilitate early physical activity and improve cardiovascular health in patients with ACS. Methods: We have developed a multi-faceted, patient-centred smartphone-based secondary prevention program emphasizing early physical activity with a graduated walking program initiated on discharge from ACS admission. The program incorporates; physical activity tracking through the smartphone's accelerometer with interactive feedback and goal setting; a dynamic dashboard to review and optimize cardiovascular risk factors; educational messages delivered twice weekly; a photographic food diary; pharmacotherapy review; and support through a short message service. The primary endpoint of the trial is change in exercise capacity, as measured by the change in six-minute walk test distance at 8-weeks when compared to baseline. Secondary endpoints include improvements in cardiovascular risk factor status, psychological well-being and quality of life, medication adherence, uptake of cardiac rehabilitation and re-hospitalizations. Discussion: This randomized controlled trial will use a smartphone-phone based secondary prevention program to emphasize early physical activity post-ACS. It will provide evidence regarding the feasibility and utility of this innovative platform in closing the treatment gaps in secondary prevention. Trial registration: The trial was retrospectively registered in the Australian New Zealand Clinical Trials Registry (ANZCTR) on April 4, 2016. The registration number is ACTRN12616000426482

Promoting patient utilization of outpatient cardiac rehabilitation: A joint International Council and Canadian Association of Cardiovascular Prevention and Rehabilitation position statement

Background: Cardiac Rehabilitation (CR) is a recommendation in international clinical practice guidelines given its’ benefits, however use is suboptimal. The purpose of this position statement was to translate evidence on interventions that increase CR enrolment and adherence into implementable recommendations. Methods: The writing panel was constituted by representatives of societies internationally concerned with preventive cardiology, and included disciplines that would be implementing the recommendations. Patient partners served, as well as policy-makers. The statement was developed in accordance with AGREE II, among other guideline checklists. Recommendations were based on our update of the Cochrane review on interventions to promote patient utilization of CR. These were circulated to panel members, who were asked to rate each on a 7-point Likert scale in terms of scientific acceptability, actionability, and feasibility of assessment. A web call was convened to achieve consensus and confirm strength of the recommendations (based on GRADE). The draft underwent external review and public comment. Results: The 3 drafted recommendations were that to increase enrolment, healthcare providers, particularly nurses (strong), should promote CR to patients face-to-face (strong), and that to increase adherence part of CR could be delivered remotely (weak). Ratings for the 3 recommendations were 5.95±0.69 (mean ± standard deviation), 5.33±1.12 and 5.64±1.08, respectively. Conclusions: Interventions can significantly increase utilization of CR, and hence should be widely applied. We call upon cardiac care institutions to implement these strategies to augment CR utilization, and to ensure CR programs are adequately resourced to serve enrolling patients and support them to complete programs

Information and communication technology-based cardiac rehabilitation homecare programs

Marlien Varnfield, Mohanraj KarunanithiAustralian eHealth Research Centre, Commonwealth Scientific and Industrial Research Organization, Royal Brisbane and Women&#39;s Hospital, Brisbane, AustraliaAbstract: Cardiac rehabilitation (CR) has, for many years, been a highly recommended approach to secondary prevention for patients recovering after a heart attack or heart surgery. These programs are traditionally delivered from a hospital outpatient center. Despite demonstrated benefits and guideline recommendations, CR utilization has been poor, particularly in women, older patients, and ethnic minority groups. To overcome some of the barriers to the traditional delivery of CR, different delivery platforms and approaches have been developed in recent years. In general, Telehealth solutions which have been used to address the delivery of CR services remotely include: 1) patient&ndash;provider contact delivered by telephone systems; 2) the Internet, with the majority of patient&ndash;provider contact for risk factor management taking place online; and 3) interventions using Smartphones as tools to deliver CR through (independently or in combination with) short message service messaging, journaling applications, connected measurement devices, and remote coaching. These solutions have been shown to overcome some of the barriers in CR participation and show potential as alternative or complementary options for individuals that find traditional center-based CR programs difficult to commit to. The major benefits of remote platforms for CR delivery are the ability to deliver these interventions without ongoing face-to-face contact, which provides an opportunity to reach large numbers of people, and the convenience of selecting the timing of cardiovascular disease management sessions. Furthermore, technologies have the potential to deliver long-term follow-up, which programs delivered by health professionals cannot afford to do due to staff shortages and budget restrictions. However, change in the existing CR services is not without challenges. There is a need to identify development issues that can hamper the implementation of the interventions outside controlled trial settings systems, which may require new computing infrastructures, specific clinical responsibilities, time for training, and development and openness to new ways of doing things.Keywords: cardiovascular disease, Telehealth, telephone, Internet, mobile phone