Preserving Continuity of Behavioral Health Clinical Care to Patients Using Mobile Devices.

INTRODUCTION: The current model for treating behavioral health patients requires that providers and patients be in the same location for appointments. However, deploying warfighters present a challenge to this current model. Recent advances in technology make telehealth or virtual visits a viable option to replace the current model. This project leveraged mobile technology to see if performing tele-behavioral health visits presented a viable option to the current in-person model for future deployed warfighters. At the time of this publication, the authors note the current pandemic lends all the more urgency to the need for enhancing our video communication platforms for remote monitoring with the Military Health System. MATERIALS AND METHODS: The research team assessed existing Internet protocol-based desktop teleconferencing solutions, generically known as a Web Real-Time Communications (WebRTC) system, for establishing a secure connection to a Service Members personal mobile device outside of the Department of Defense (DoD) network. Of the five existing WebRTC systems evaluated, only the backbone component to the existing Defense Information Systems Agency Global Video Services (DISA GVS) known as Vidyo, was suitable to meet DoD security requirements and still connect with both major operating systems (OS) on mobile devices. An existing DoD program of record mobile application, mCare, was integrated with Vidyo desktop technologies to form what the research team called "Mobile Connect." RESULTS: Deployment of the Mobile Connect product yielded distinct differences and high levels or variability between the .osd.mil and the army.mil network connections over time. These network differences impacted quality of service solution where Mobile Connect could not be used to provide care between the .mil and patient's personal mobile devices from a osd.mil domain connection. The current DoD WebRTC systems offer potential solutions but presently cannot connect with personal mobile devices in their current configurations. Additionally, any WebRTC system used by the DoD for future connections to personal mobile device must leverage commercial Single Socket Layer certificates (e.g., not DoD issued), or the communications with the mobile device will fail as a result of an authentication error. CONCLUSION: It is technically feasible to provide desktop Video Tele-Conference capabilities from a .mil computer to a personal mobile device without compromising DoD security and information assurance requirements using future WebRTC systems. Approved ports, protocols, and system settings must be configured to accept both inbound and outbound, encrypted traffic to/from personal mobile devices to maintain consistent quality of service with all DoD networks. Of the current DoD WebRTC options, working with the DISA GVS Program Manager to expand services to support commercial mobile devices has the highest probability of future success.

Enhancing Patient Activation and Self-Management Activities in Patients With Type 2 Diabetes Using the US Department of Defense Mobile Health Care Environment: Feasibility Study.

BACKGROUND: Past mobile health (mHealth) efforts to empower type 2 diabetes (T2D) self-management include portals, text messaging, collection of biometric data, electronic coaching, email, and collection of lifestyle information. OBJECTIVE: The primary objective was to enhance patient activation and self-management of T2D using the US Department of Defense's Mobile Health Care Environment (MHCE) in a patient-centered medical home setting. METHODS: A multisite study, including a user-centered design and a controlled trial, was conducted within the US Military Health System. Phase I assessed preferences regarding the enhancement of the enabling technology. Phase II was a single-blinded 12-month feasibility study that randomly assigned 240 patients to either the intervention (n=123, received mHealth technology and behavioral messages tailored to Patient Activation Measure [PAM] level at baseline) or the control group (n=117, received equipment but not messaging. The primary outcome measure was PAM scores. Secondary outcome measures included Summary of Diabetes Self-Care Activities (SDSCA) scores and cardiometabolic outcomes. We used generalized estimating equations to estimate changes in outcomes. RESULTS: The final sample consisted of 229 patients. Participants were 61.6% (141/229) male, had a mean age of 62.9 years, mean glycated hemoglobin (HbA1c) of 7.5%, mean BMI of 32.7, and a mean duration of T2D diagnosis of 9.8 years. At month 12, the control group showed significantly greater improvements compared with the intervention group in PAM scores (control mean 7.49, intervention mean 1.77; P=.007), HbA1c (control mean -0.53, intervention mean -0.11; P=.006), and low-density lipoprotein cholesterol (control mean -7.14, intervention mean 4.38; P=.01). Both groups showed significant improvement in SDSCA, BMI, waist size, and diastolic blood pressure; between-group differences were not statistically significant. Except for patients with the highest level of activation (PAM level 4), intervention group patients exhibited significant improvements in PAM scores. For patients with the lowest level of activation (PAM level 1), the intervention group showed significantly greater improvement compared with the control group in HbA1c (control mean -0.09, intervention mean -0.52; P=.04), BMI (control mean 0.58, intervention mean -1.22; P=.01), and high-density lipoprotein cholesterol levels (control mean -4.86, intervention mean 3.56; P<.001). Significant improvements were seen in AM scores, SDSCA, and waist size for both groups and in diastolic and systolic blood pressure for the control group; the between-group differences were not statistically significant. The percentage of participants who were engaged with MHCE for ≥50% of days period was 60.7% (68/112; months 0-3), 57.4% (62/108; months 3-6), 49.5% (51/103; months 6-9), and 43% (42/98; months 9-12). CONCLUSIONS: Our study produced mixed results with improvement in PAM scores and outcomes in both the intervention and control groups. Structural design issues may have hampered the influence of tailored behavioral messaging within the intervention group. TRIAL REGISTRATION: ClinicalTrials.gov NCT02949037; https://clinicaltrials.gov/ct2/show/NCT02949037. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/resprot.6993.

Factors Associated With Response to Biofeedback Therapy for Dyssynergic Defecation.

BACKGROUND & AIMS: Biofeedback therapy is effective for dyssynergic defecation (DD), but it is not widely available or reimbursed, and is labor intensive. It is therefore important to select the appropriate patients for this treatment. We investigated symptoms and demographic, manometric, and other factors associated with outcomes of biofeedback therapy in patients with DD. METHODS: We performed a post hoc analysis of 2 prospective studies of biofeedback therapy in 127 adult outpatients (18-75 years old, 120 female) with chronic constipation who failed to respond to treatment with dietary fiber or laxatives (>1 year) and were diagnosed with DD based on standard criteria. In each study, patients received 1-hour, biweekly office biofeedback therapy (6 sessions) or home biofeedback therapy with a device. A therapist used visual feedback, postural, and diaphragmatic breathing techniques to teach subjects to improve defecation. Treatment success was defined by a composite of normalization of dyssynergia pattern and increase of 20 mm in baseline bowel satisfaction score. Factors were compared between the treatment success and failure groups. Intention-to-treat analysis was performed. RESULTS: Of the 127 patients enrolled, 77 (61%) had treatment success. Dyssynergia was corrected in 78% of patients and bowel satisfaction improved in 64% of patients. Baseline demographic features, constipation symptoms, manometric and sensory parameters, balloon expulsion time, and colonic transit results were similar between treatment failure and success groups. Patients with lower baseline bowel satisfaction score (P = .008) and patients who used digital maneuvers (P = .04) were more likely to have successful biofeedback therapy. CONCLUSIONS: Biofeedback therapy is successful in more than 60% of patients with DD. Patients who used digital maneuvers and patients with lower baseline levels of bowel satisfaction were more likely to have treatment success, whereas other factors were not associated with success. Biofeedback therapy should be offered to all patients with DD, irrespective of baseline symptoms or anorectal physiology findings.