Factors Influencing Adherence to mHealth Apps for Prevention or Management of Noncommunicable Diseases: Systematic Review.

BACKGROUND: Mobile health (mHealth) apps show vast potential in supporting patients and health care systems with the increasing prevalence and economic costs of noncommunicable diseases (NCDs) worldwide. However, despite the availability of evidence-based mHealth apps, a substantial proportion of users do not adhere to them as intended and may consequently not receive treatment. Therefore, understanding the factors that act as barriers to or facilitators of adherence is a fundamental concern in preventing intervention dropouts and increasing the effectiveness of digital health interventions. OBJECTIVE: This review aimed to help stakeholders develop more effective digital health interventions by identifying factors influencing the continued use of mHealth apps targeting NCDs. We further derived quantified adherence scores for various health domains to validate the qualitative findings and explore adherence benchmarks. METHODS: A comprehensive systematic literature search (January 2007 to December 2020) was conducted on MEDLINE, Embase, Web of Science, Scopus, and ACM Digital Library. Data on intended use, actual use, and factors influencing adherence were extracted. Intervention-related and patient-related factors with a positive or negative influence on adherence are presented separately for the health domains of NCD self-management, mental health, substance use, nutrition, physical activity, weight loss, multicomponent lifestyle interventions, mindfulness, and other NCDs. Quantified adherence measures, calculated as the ratio between the estimated intended use and actual use, were derived for each study and compared with the qualitative findings. RESULTS: The literature search yielded 2862 potentially relevant articles, of which 99 (3.46%) were included as part of the inclusion criteria. A total of 4 intervention-related factors indicated positive effects on adherence across all health domains: personalization or tailoring of the content of mHealth apps to the individual needs of the user, reminders in the form of individualized push notifications, user-friendly and technically stable app design, and personal support complementary to the digital intervention. Social and gamification features were also identified as drivers of app adherence across several health domains. A wide variety of patient-related factors such as user characteristics or recruitment channels further affects adherence. The derived adherence scores of the included mHealth apps averaged 56.0% (SD 24.4%). CONCLUSIONS: This study contributes to the scarce scientific evidence on factors that positively or negatively influence adherence to mHealth apps and is the first to quantitatively compare adherence relative to the intended use of various health domains. As underlying studies mostly have a pilot character with short study durations, research on factors influencing adherence to mHealth apps is still limited. To facilitate future research on mHealth app adherence, researchers should clearly outline and justify the app's intended use; report objective data on actual use relative to the intended use; and, ideally, provide long-term use and retention data.

Assessing the phacoemulsification learning curve using duration of each step.

PURPOSE: To assess the phacoemulsification learning curve for ophthalmology residents using duration for each step. SETTING: Single tertiary, training site hospital. DESIGN: Cross-sectional study. METHODS: Emory ophthalmology postgraduate year (PGY) 3 and PGY-4 residents operating at Grady Memorial Hospital between April 2017 and February 2018 were eligible to participate. Duration in seconds for each step of surgery was calculated for incisions, continuous curvilinear capsulorhexis (CCC), hydrodissection, nucleus disassembly, quadrant removal, cortical cleanup, intraocular lens insertion, and closure, and this outcome was analyzed as a function of different experience levels. RESULTS: A total of 528 surgeries were included of 549 total surgeries recorded. 6 categories of experience levels were established as A to F, increasing by increments of 50. There was an overall downward trend across various steps across the 8 case categories, and several adjacent categories demonstrate statistically significant differences. The 3 most time-intensive steps early in training were nucleus disassembly (336.5 ± 16.5 seconds), quadrant removal (275.1 ± 18.0 seconds), and cortical cleanup (244.2 ± 24.6 seconds). There was a sustained drop in mean duration for all steps through at least category D, with most steps showing a drop through category F. CONCLUSIONS: There is a benefit to a higher caseload, well above the Accreditation Council for Graduate Medical Education-mandated 86 cases. Improvements in efficiency were observed after 250 cases, with nuclear disassembly and CCC demonstrating a significant decrease in operative time.

A Narrative Review of Strategies to Increase Patient Safety Event Reporting by Residents.

BACKGROUND: Because residents are often on the frontlines of patient care and are likely to witness adverse events firsthand, it is critical they report patient safety events. They may, however, be underreporting. OBJECTIVE: We examined the current literature to identify strategies to increase patient safety event reporting by residents. METHODS: We used CINAHL (EBSCO Information Services, Ipswich, MA), EMBASE (Elsevier, Amsterdam, the Netherlands), PsycINFO (APA Publishing, Washington, DC), and PubMed (National Center for Biotechnology Information, Bethesda, MD) databases. The search was limited to English-language articles published in peer-reviewed journals through March 2020. Key terms included "residents, trainees, fellows, interns, graduate medical education, house staff, event reporting, patient safety reporting, incident reporting, adverse event, and medical error." To organize findings, we adapted a published framework of strategies for encouraging self-protective behavior. RESULTS: We identified 68 articles that described strategies used to increase event reporting. The most sustainable interventions used a combination of 3 of the 5 strategies: behavior modeling, surveys and messaging, and required limited financial support. The survey creates awareness; the behavior modeling is critical for educational purposes, and the reminders help to reinforce the new behavior and embed it into routine patient care activities. We noted a dearth of studies involving trainees in root cause analysis following submission of event reports. CONCLUSIONS: The most successful sustainable interventions were those that combined strategies that minimized time for busy physicians, incorporated accessible event reporting in already existing medical records, and became part of a normal workflow in patient care.

Using the CLER Pathways to Excellence to Evaluate the Learning Environments at a Multi-Site Institution.

BACKGROUND: The Accreditation Council for Graduate Medical Education Clinical Learning Environment Review (CLER) program visits 1 participating site per sponsoring institution. While valuable, feedback on that site does not necessarily generalize to all learning environments where trainees and faculty provide clinical care, and institutions may be missing significant insight and feedback on other clinical learning sites. OBJECTIVE: We explored how the Emory Learning Environment Evaluation process-modeled after CLER-could be used to improve the learning environments at 5 major clinical training sites. METHODS: Participants were recruited via e-mail. Sites hosted separate 60-minute sessions for medical students, residents and fellows, and faculty. We used the CLER Pathways to Excellence to develop a combination of fixed choice and opened-ended questions deployed via an audience response system and verbal queries. Data were analyzed primarily through descriptive statistics and graphs. RESULTS: Across sites, per session, medical student participants ranged from 9-16, residents and fellows ranged 21-30, and faculty ranged 15-29. Learners agreed that sites: (1) provided a supportive culture for requesting supervision (students 100%; residents and fellows 70%-100%), and (2) provided a supportive culture for reporting patient safety events (students 94%-100%; residents and fellows 91%-95%). Only a minority of residents and fellows and faculty agreed that they were educated on how to provide effective supervision (residents and fellows 21%-52%; faculty 45%-64%). CONCLUSIONS: Data from this process have helped standardize improvement efforts across multiple clinical learning environments within our sponsoring institution.

Hyperbaric oxygen therapy and optic neuritis: case report and literature review.

A history of optic neuritis has long been considered a relative contraindication to hyperbaric oxygen therapy. However, the published medical literature regarding the use of hyperbaric oxygen therapy in patients with previous optic neuritis is very limited, and patients who might benefit from hyperbaric oxygen therapy may be denied its benefit without adequate consideration of the risk-benefit ratio. We present a case report of a patient with a history of optic neuritis who underwent comprehensive ophthalmologic evaluation before and after 40 treatments with hyperbaric oxygen therapy, with no detectable ophthalmologic deficit.

Evaluation of the virtual mentor cataract training program.

OBJECTIVE: Evaluate the effectiveness of an interactive cognitive computer simulation for teaching the hydrodissection portion of cataract surgery compared with standard teaching and to assess the attitudes of residents about the teaching tools and their perceived confidence in the knowledge gained after using the tools. DESIGN: Case-control study. PARTICIPANTS AND CONTROLS: Residents at academic institutions. METHODS: Prospective, multicenter, single-masked, controlled trial was performed in 7 academic departments of ophthalmology (Harvard Medical School/Massachusetts Eye and Ear Infirmary, University of Iowa, Emory University, University of Cincinnati, University of Pennsylvania/Scheie Eye Institute, Jefferson Medical College of Thomas Jefferson University/Wills Eye Institute, and the Aravind Eye Institute). All residents from these centers were asked to participate and were randomized into 2 groups. Group A (n = 30) served as the control and received traditional teaching materials; group B (n = 38) received a digital video disc of the Virtual Mentor program. This program is an interactive cognitive simulation, specifically designed to separate cognitive aspects (such as decision making and error recognition) from the motor aspects. Both groups took online anonymous pretests (n = 68) and posttests (n = 58), and answered satisfaction questionnaires (n = 53). Wilcoxon tests were completed to compare pretest and posttest scores between groups. Analysis of variance was performed to assess differences in mean scores between groups. MAIN OUTCOME MEASURES: Scores on pretests, posttests, and satisfaction questionnaires. RESULTS: There was no difference in the pretest scores between the 2 groups (P = 0.62). However, group B (Virtual Mentor [VM]) scored significantly higher on the posttest (P = 0.01). Mean difference between pretest and posttest scores were significantly better in the VM group than in the traditional learning group (P = 0.04). Questionnaire revealed that the VM program was "more fun" to use (24.1% vs 4.2%) and residents were more likely to use this type of program again compared with the likelihood of using the traditional tools (58.6% vs 4.2%). CONCLUSIONS: The VM, a cognitive computer simulation, augmented teaching of the hydrodissection step of phacoemulsification surgery compared with traditional teaching alone. The program was more enjoyable and more likely to be used repetitively by ophthalmology residents.

Phacoemulsification with topical anesthesia performed by resident surgeons.

PURPOSE: To evaluate and compare the outcomes in phacoemulsification cases performed by resident surgeons using topical anesthesia or retrobulbar anesthesia. SETTING: Department of Ophthalmology, Emory University, Atlanta, and Department of Veterans Affairs Medical Center, Decatur, Georgia, USA. METHODS: This was a retrospective review of phacoemulsification cases performed by resident surgeons during 1 academic year. Variables analyzed included patient age and sex, preexisting conditions limiting final acuity, and type of anesthesia used. Outcomes measured included intraoperative and postoperative complications and final visual acuity. RESULTS: Of the 291 cases analyzed, 119 (40.9%) were retrobulbar and 172 (59.1%) were topical. Residents began using topical anesthesia after a brief introductory period with retrobulbar anesthesia. Vitreous loss occurred in 15 cases (5.1%), 8 retrobulbar (6.7%) and 7 topical (4.1%) (P =.42). Postoperative complications occurred in 30 cases (10.3%), 17 topical (9.9%) and 13 retrobulbar (10.9%) (P =.85). Overall, 245 cases (84.2%) achieved a final best corrected visual acuity (BCVA) of 20/40 or better. When cases with preexisting conditions limiting final acuity were eliminated, 92.1% achieved a final BCVA of 20/40 or better. More topical cases (112, 65.1%) than retrobulbar cases (64, 53.8%) achieved a final BCVA of 20/25 or better (P =.06), and more topical cases (149, 86.6%) than retrobulbar cases (96, 80.7%) achieved a final BCVA of 20/40 or better (P =.19). CONCLUSION: Topical anesthesia is safe and efficacious for phacoemulsification performed by resident surgeons early in training after a brief introduction to phacoemulsification using retrobulbar anesthesia.