RESUMO
BACKGROUND: The uptake of digital health technology (DHT) has been surprisingly low in clinical practice. Despite showing great promise to improve patient outcomes and disease management, there is limited information on the factors that contribute to the limited adoption of DHT, particularly for hypertension management. OBJECTIVE: This scoping review provides a comprehensive summary of barriers to and facilitators of DHT adoption for hypertension management reported in the published literature with a focus on provider- and patient-related barriers and facilitators. METHODS: This review followed the methodological framework developed by Arskey and O'Malley. Systematic literature searches were conducted on PubMed or Medical Literature Analysis and Retrieval System Online, Cumulative Index to Nursing and Allied Health Literature, and Excerpta Medica database. Articles that reported on barriers to and/or facilitators of digital health adoption for hypertension management published in English between 2008 and 2017 were eligible. Studies not reporting on barriers or facilitators to DHT adoption for management of hypertension were excluded. A total of 2299 articles were identified based on the above criteria after removing duplicates, and they were assessed for eligibility. Of these, 2165 references did not meet the inclusion criteria. After assessing 134 studies in full text, 98 studies were excluded (full texts were either unavailable or studies did not fulfill the inclusion criteria), resulting in a final set of 32 articles. In addition, 4 handpicked articles were also included in the review, making it a total of 36 studies. RESULTS: A total of 36 studies were selected for data extraction after abstract and full-text screening by 2 independent reviewers. All conflicts were resolved by a third reviewer. Thematic analysis was conducted to identify major themes pertaining to barriers and facilitators of DHT from both provider and patient perspectives. The key facilitators of DHT adoption by physicians that were identified include ease of integration with clinical workflow, improvement in patient outcomes, and technology usability and technical support. Technology usability and timely technical support improved self-management and patient experience, and positive impact on patient-provider communication were most frequently reported facilitators for patients. Barriers to use of DHTs reported by physicians include lack of integration with clinical workflow, lack of validation of technology, and lack of technology usability and technical support. Finally, lack of technology usability and technical support, interference with patient-provider relationship, and lack of validation of technology were the most commonly reported barriers by patients. CONCLUSIONS: Findings suggest the settings and context in which DHTs are implemented and individuals involved in implementation influence adoption. Finally, to fully realize the potential of digitally enabled hypertension management, there is a greater need to validate these technologies to provide patients and providers with reliable and accurate information on both clinical outcomes and cost effectiveness.
RESUMO
BACKGROUND: Soaring health care costs and a rapidly aging population, with multiple comorbidities, necessitates the development of innovative strategies to deliver high-quality, value-based care. OBJECTIVE: The goal of this study is to evaluate the impact of a risk assessment system (CareSage) and targeted interventions on health care utilization. METHODS: This is a two-arm randomized controlled trial recruiting 370 participants from a pool of high-risk patients receiving care at a home health agency. CareSage is a risk assessment system that utilizes both real-time data collected via a Personal Emergency Response Service and historical patient data collected from the electronic medical records. All patients will first be observed for 3 months (observation period) to allow the CareSage algorithm to calibrate based on patient data. During the next 6 months (intervention period), CareSage will use a predictive algorithm to classify patients in the intervention group as "high" or "low" risk for emergency transport every 30 days. All patients flagged as "high risk" by CareSage will receive nurse triage calls to assess their needs and personalized interventions including patient education, home visits, and tele-monitoring. The primary outcome is the number of 180-day emergency department visits. Secondary outcomes include the number of 90-day emergency department visits, total medical expenses, 180-day mortality rates, time to first readmission, total number of readmissions and avoidable readmissions, 30-, 90-, and 180-day readmission rates, as well as cost of intervention per patient. The two study groups will be compared using the Student t test (two-tailed) for normally distributed and Mann Whitney U test for skewed continuous variables, respectively. The chi-square test will be used for categorical variables. Time to event (readmission) and 180-day mortality between the two study groups will be compared by using the Kaplan-Meier survival plots and the log-rank test. Cox proportional hazard regression will be used to compute hazard ratio and compare outcomes between the two groups. RESULTS: We are actively enrolling participants and the study is expected to be completed by end of 2018; results are expected to be published in early 2019. CONCLUSIONS: Innovative solutions for identifying high-risk patients and personalizing interventions based on individual risk and needs may help facilitate the delivery of value-based care, improve long-term patient health outcomes and decrease health care costs. TRIAL REGISTRATION: ClinicalTrials.gov NCT03126565; https://clinicaltrials.gov/ct2/show/NCT03126565 (Archived by WebCite at http://www.webcitation.org/6ymDuAwQA).
RESUMO
BACKGROUND: Physical inactivity is one of the leading risk factors contributing to the rising rates of chronic diseases and has been associated with deleterious health outcomes in patients with chronic disease conditions. We developed a mobile phone app, FeatForward, to increase the level of physical activity in patients with cardiometabolic risk (CMR) factors. This intervention is expected to result in an overall improvement in patient health outcomes. OBJECTIVE: The objective of this study is to evaluate the effect of a mobile phone-based app, FeatForward, on physical activity levels and other CMR factors in patients with chronic conditions. METHODS: The study will be implemented as a 2-arm randomized controlled trial with 300 adult patients with chronic conditions over a 6-month follow-up period. Participants will be assigned to either the intervention group receiving the FeatForward app and standard care versus a control group who will receive only usual care. The difference in physical activity levels between the control group and intervention group will be measured as the primary outcome. We will also evaluate the effect of this intervention on secondary measures including clinical outcome changes in global CMR factors (glycated hemoglobin, fasting blood glucose, blood pressure, waist circumference, Serum lipids, C-reactive protein), health-related quality of life, health care usage, including attendance of scheduled clinic visits and hospitalizations, usability, and satisfaction, participant engagement with the FeatForward app, physician engagement with physician portal, and willingness to engage in physical activity. Instruments that will be used in evaluating secondary outcomes include the Short-Form (SF)-12, app usability and satisfaction questionnaires, physician satisfaction questionnaire. The intention-to-treat approach will be used to evaluate outcomes. All outcomes will be measured longitudinally at baseline, midpoint (3 months), and 6 months. Our primary outcome, physical activity, will be assessed by mixed-model analysis of variance with intervention assignment as between-group factor and time as within-subject factor. A similar approach will be used to analyze continuous secondary outcomes while categorical outcomes will be analyzed by chi-square test. RESULTS: The study is still in progress and we hope to have the results by the end of 2016. CONCLUSIONS: The mobile phone-based app, FeatForward, could lead to significant improvements in physical activity and other CMR factors in patients.
