Measuring health status and symptom burden using a web-based mHealth application in patients with heart failure.

BACKGROUND: Symptoms of heart failure markedly impair a patient's health status. The aim of this study was to identify predictors of health status in a sample of racially and ethnically diverse patients with heart failure using a web-based mobile health application, mi.Symptoms. METHODS: We conducted a cross-sectional study at an urban academic medical center. Patients with heart failure self-reported symptoms using validated symptom instruments (e.g. patient-reported outcome measurement information system) by way of the mobile health application, mi.Symptoms. The primary study outcome was health status, measured with the Kansas City cardiomyopathy questionnaire clinical summary score. Data were analyzed using descriptive statistics and multiple linear regression. RESULTS: The mean age of the sample ( n=168) was 58.7 (±12.5) years, 37% were women, 36% were Black, 36% identified as Hispanic/Latino, 48% were classified as New York Heart Association class III, and 44% reported not having enough income to make ends meet. Predictors of better health status in heart failure included higher physical function ( ß=0.89, p=0.001) and ability to participate in social roles and activities ( ß=0.58, p=0.002), and predictors of poorer health status were New York Heart Association class IV ( ß=-11.68, p=0.006) and dyspnea ( ß=-0.77, p<0.001). The predictors accounted for 73% of the variance in health status. CONCLUSION: Patient-centered interventions should focus on modifiable risk factors that reduce dyspnea, improve functional status, and enhance engagement in social roles to improve the health status of patients with heart failure.

A Nurse-led Approach to Improving Cardiac Lifestyle Modification in an Atrial Fibrillation Population.

Atrial fibrillation (AF) is a major public health problem and the most common cardiac arrhythmia encountered in clinical practice at this time. AF is associated with numerous symptoms such as palpitations, shortness of breath, and fatigue, which can significantly reduce health-related quality of life and result in serious adverse cardiac outcomes. In light of this, the aim of the present pilot study was to test the feasibility of implementing a mobile health (mHealth) lifestyle intervention titled "Atrial Fibrillation and Cardiac Health: Targeting Improving Outcomes via a Nurse-Led Intervention (ACTION)," with the goal of improving cardiac health measures, AF symptom recognition, and self-management. As part of this study, participants self-identified cardiac health goals at enrollment. The nurse used web-based resources from the American Heart Association (Dallas, TX, USA), which included the Life's Simple 7® My Life Check® assessment, to quantify current lifestyle behavior change needs. Furthermore, on the My AFib Experience™ website (American Heart Association, Dallas, TX, USA), the patient used a symptom tracker tool to capture the date, time, frequency, and type of AF symptoms, and these data were subsequently reviewed by the cardiac nurse. Throughout the six-month intervention period, the cardiac nurse used a motivational interviewing approach to support participants' cardiac health goals. Ultimately, the ACTION intervention was tested in 53 individuals with AF (mean age: 59 ± 11 years; 76% male). Participants were predominantly overweight/obese (79%), had a history of hypertension (62%) or hyperlipidemia (61%), and reported being physically inactive/not preforming any type of regular exercise (52%). The majority (88%) of the participants had one or more Life's Simple 7® measures that could be improved. Most of the participants (98%) liked having a dedicated nurse to work with them on a biweekly basis via the mHealth portal. The most commonly self-reported symptoms were palpitations, fatigue/exercise intolerance, and dyspnea. Seventy percent of the participants had an improvement in their weight and blood pressure as documented within the electronic health record as well as a corresponding improvement in their Life's Simple 7® score at six months. On average, there was a three-pound (1.36-kg) decrease in weight and a 5-mmHg decrease in systolic blood pressure between baseline and at six months. In conclusion, this pilot work provides initial evidence regarding the feasibility of implementing the ACTION intervention and supports testing the ACTION intervention in a larger cohort of AF patients to inform existing AF guidelines and build an evidence base for reducing AF burden through lifestyle modification.

Factors Influencing Sustained Engagement with ECG Self-Monitoring: Perspectives from Patients and Health Care Providers.

BACKGROUND: Patient-generated health data (PGHD) collected digitally with mobile health (mHealth) technology has garnered recent excitement for its potential to improve precision management of chronic conditions such as atrial fibrillation (AF), a common cardiac arrhythmia. However, sustained engagement is a major barrier to collection of PGHD. Little is known about barriers to sustained engagement or strategies to intervene upon engagement through application design. OBJECTIVE: This article investigates individual patient differences in sustained engagement among individuals with a history of AF who are self-monitoring using mHealth technology. METHODS: This qualitative study involved patients, health care providers, and research coordinators previously involved in a randomized, controlled trial involving electrocardiogram (ECG) self-monitoring of AF. Patients were adults with a history of AF randomized to the intervention arm of this trial who self-monitored using ECG mHealth technology for 6 months. Semistructured interviews and focus groups were conducted separately with health care providers and research coordinators, engaged patients, and unengaged patients. A validated model of sustained engagement, an adapted unified theory of acceptance and use of technology (UTAUT), guided data collection, and analysis through directed content analysis. RESULTS: We interviewed 13 patients (7 engaged, 6 unengaged), 6 providers, and 2 research coordinators. In addition to finding differences between engaged and unengaged patients within each predictor in the adapted UTAUT model (perceived ease of use, perceived usefulness, facilitating conditions), four additional factors were identified as being related to sustained engagement in this population. These are: (1) internal motivation to manage health, (2) relationship with health care provider, (3) supportive environments, and (4) feedback and guidance. CONCLUSION: Although it required some modification, the adapted UTAUT model was useful in understanding of the parameters of sustained engagement. The findings of this study provide initial requirement specifications for the design of applications that engage patients in this unique population of adults with AF.

Low health literacy: Implications for managing cardiac patients in practice.

There are limited data on racial and ethnic disparities related to quality of life (QoL) and health literacy in adults with multiple cardiac conditions. This article evaluates the relationship between health literacy and QoL among patients with cardiac conditions in a multiethnic community in New York City.

Converging and diverging needs between patients and providers who are collecting and using patient-generated health data: an integrative review.

Objective: This integrative review identifies convergent and divergent areas of need for collecting and using patient-generated health data (PGHD) identified by patients and providers (i.e., physicians, nurses, advanced practice nurses, physician assistants, and dietitians). Methods: A systematic search of 9 scholarly databases targeted peer-reviewed studies published after 2010 that reported patients' and/or providers' needs for incorporating PGHD in clinical care. The studies were assessed for quality and bias with the Mixed-Methods Appraisal Tool. The results section of each article was coded to themes inductively developed to categorize patient and provider needs. Distinct claims were extracted and areas of convergence and divergence identified. Results: Eleven studies met inclusion criteria. All had moderate to low risk of bias. Three themes (clinical, logistic, and technological needs), and 13 subthemes emerged. Forty-eight claims were extracted. Four were divergent and twenty were convergent. The remainder was discussed by only patients or only providers. Conclusion: As momentum gains for integrating PGHD into clinical care, this analysis of primary source data is critical to understanding the requirements of the 2 groups directly involved in collection and use of PGHD.

Detection and management of atrial fibrillation using remote monitoring.

Atrial fibrillation (AF) is the most common dysrhythmia encountered in the United States. Symptoms may be similar to those of other cardiac conditions, which can delay the timely detection, diagnosis, and management of AF. This article provides an overview of AF and modalities used in remote monitoring.

Review and Analysis of Existing Mobile Phone Apps to Support Heart Failure Symptom Monitoring and Self-Care Management Using the Mobile Application Rating Scale (MARS).

BACKGROUND: Heart failure is the most common cause of hospital readmissions among Medicare beneficiaries and these hospitalizations are often driven by exacerbations in common heart failure symptoms. Patient collaboration with health care providers and decision making is a core component of increasing symptom monitoring and decreasing hospital use. Mobile phone apps offer a potentially cost-effective solution for symptom monitoring and self-care management at the point of need. OBJECTIVE: The purpose of this review of commercially available apps was to identify and assess the functionalities of patient-facing mobile health apps targeted toward supporting heart failure symptom monitoring and self-care management. METHODS: We searched 3 Web-based mobile app stores using multiple terms and combinations (eg, "heart failure," "cardiology," "heart failure and self-management"). Apps meeting inclusion criteria were evaluated using the Mobile Application Rating Scale (MARS), IMS Institute for Healthcare Informatics functionality scores, and Heart Failure Society of America (HFSA) guidelines for nonpharmacologic management. Apps were downloaded and assessed independently by 2-4 reviewers, interclass correlations between reviewers were calculated, and consensus was met by discussion. RESULTS: Of 3636 potentially relevant apps searched, 34 met inclusion criteria. Most apps were excluded because they were unrelated to heart failure, not in English or Spanish, or were games. Interrater reliability between reviewers was high. AskMD app had the highest average MARS total (4.9/5). More than half of the apps (23/34, 68%) had acceptable MARS scores (>3.0). Heart Failure Health Storylines (4.6) and AskMD (4.5) had the highest scores for behavior change. Factoring MARS, functionality, and HFSA guideline scores, the highest performing apps included Heart Failure Health Storylines, Symple, ContinuousCare Health App, WebMD, and AskMD. Peer-reviewed publications were identified for only 3 of the 34 apps. CONCLUSIONS: This review suggests that few apps meet prespecified criteria for quality, content, or functionality, highlighting the need for further refinement and mapping to evidence-based guidelines and room for overall quality improvement in heart failure symptom monitoring and self-care related apps.