Claudia Pagliari

The impact of eHealth on the quality and safety of health care: a systematic overview.

Aziz Sheikh and colleagues report the findings of their systematic overview that assessed the impact of eHealth solutions on the quality and safety of health care.

A randomized controlled trial of Sweet Talk, a text-messaging system to support young people with diabetes.

Aims  To assess Sweet Talk, a text‐messaging support system designed to enhance self‐efficacy, facilitate uptake of intensive insulin therapy and improve glycaemic control in paediatric patients with Type 1 diabetes.

Potential of electronic personal health records

Novel methods for helping patients to access and manage their personal electronic health data are emerging in the UK and internationally. Claudia Pagliari, Don Detmer, and Peter Singleton examine their potential benefits and challenges

Systematic Review of Factors Influencing the Adoption of Information and Communication Technologies by Healthcare Professionals

This systematic review of mixed methods studies focuses on factors that can facilitate or limit the implementation of information and communication technologies (ICTs) in clinical settings. Systematic searches of relevant bibliographic databases identified studies about interventions promoting ICT adoption by healthcare professionals. Content analysis was performed by two reviewers using a specific grid. One hundred and one (101) studies were included in the review. Perception of the benefits of the innovation (system usefulness) was the most common facilitating factor, followed by ease of use. Issues regarding design, technical concerns, familiarity with ICT, and time were the most frequent limiting factors identified. Our results suggest strategies that could effectively promote the successful adoption of ICT in healthcare professional practices.

Effectiveness of telemonitoring integrated into existing clinical services on hospital admission for exacerbation of chronic obstructive pulmonary disease: researcher blind, multicentre, randomised controlled trial

Objective To test the effectiveness of telemonitoring integrated into existing clinical services such that intervention and control groups have access to the same clinical care. Design Researcher blind, multicentre, randomised controlled trial. Setting UK primary care (Lothian, Scotland). Participants Adults with at least one admission for chronic obstructive pulmonary disease (COPD) in the year before randomisation. We excluded people who had other significant lung disease, who were unable to provide informed consent or complete the study, or who had other significant social or clinical problems. Interventions Participants were recruited between 21 May 2009 and 28 March 2011, and centrally randomised to receive telemonitoring or conventional self monitoring. Using a touch screen, telemonitoring participants recorded a daily questionnaire about symptoms and treatment use, and monitored oxygen saturation using linked instruments. Algorithms, based on the symptom score, generated alerts if readings were omitted or breached thresholds. Both groups received similar care from existing clinical services. Main outcome measures The primary outcome was time to hospital admission due to COPD exacerbation up to one year after randomisation. Other outcomes included number and duration of admissions, and validated questionnaire assessments of health related quality of life (using St George’s respiratory questionnaire (SGRQ)), anxiety or depression (or both), self efficacy, knowledge, and adherence to treatment. Analysis was intention to treat. Results Of 256 patients completing the study, 128 patients were randomised to telemonitoring and 128 to usual care; baseline characteristics of each group were similar. The number of days to admission did not differ significantly between groups (adjusted hazard ratio 0.98, 95% confidence interval 0.66 to 1.44). Over one year, the mean number of COPD admissions was similar in both groups (telemonitoring 1.2 admissions per person (standard deviation 1.9) v control 1.1 (1.6); P=0.59). Mean duration of COPD admissions over one year was also similar between groups (9.5 days per person (standard deviation 19.1) v 8.8 days (15.9); P=0.88). The intervention had no significant effect on SGRQ scores between groups (68.2 (standard deviation 16.3) v 67.3 (17.3); adjusted mean difference 1.39 (95% confidence interval −1.57 to 4.35)), or on other questionnaire outcomes. Conclusions In participants with a history of admission for exacerbations of COPD, telemonitoring was not effective in postponing admissions and did not improve quality of life. The positive effect of telemonitoring seen in previous trials could be due to enhancement of the underpinning clinical service rather than the telemonitoring communication. Trial registration ISRCTN96634935. Funding: The trial was funded by an NHS applied research programme grant from the Chief Scientist Office of the Scottish government (ARPG/07/03). The funder had no role in study design and the collection, analysis, and interpretation of data and the writing of the article and the decision to submit it for publication. NHS Lothian supported the telemonitoring service and the clinical services.

Patients’ Engagement With “Sweet Talk” – A Text Messaging Support System for Young People With Diabetes

Background Guidelines for optimizing type 1 diabetes in young people advocate intensive insulin therapy coupled with personal support from the health care team. “Sweet Talk” is a novel intervention designed to support patients between clinic visits using text messages sent to a mobile phone. Scheduled messages are tailored to patient profiles and diabetes self-management goals, and generic messages include topical “newsletters” and anonymized tips from other participants. The system also allows patients to submit data and questions to the diabetes care team. Objectives The aim was to explore how patients with type 1 diabetes interact with the Sweet Talk system in order to understand its utility to this user group. Methods Subjects were 64 young people with diabetes who were participating in the intervention arms of a randomized controlled trial. All text messages submitted to Sweet Talk during a 12-month period were recorded. Messaging patterns and content were analyzed using mixed quantitative and qualitative methods. Results Patients submitted 1180 messages during the observation period (mean 18.4, median 6). Messaging frequency ranged widely between participants (0-240) with a subset of 5 high users contributing 52% of the total. Patients’ clinical and sociodemographic characteristics were not associated with total messaging frequency, although girls sent significantly more messages unrelated to diabetes than did boys (P = .002). The content of patients’ messages fell into 8 main categories: blood glucose readings, diabetes questions, diabetes information, personal health administration, social messages, technical messages, message errors, and message responses. Unprompted submission of blood glucose values was the most frequent incoming message type (35% of total). Responses to requests for personal experiences and tips generated 40% of all the incoming messages, while topical news items also generated good responses. Patients also used the service to ask questions, submit information about their self-management, and order supplies. No patients nominated supporters to receive text messages about their self-management goals. Another option that was not used was the birthday reminder service. Conclusions Automated, scheduled text messaging successfully engaged young people with diabetes. While the system was primarily designed to provide “push” support to patients, submission of clinical data and queries illustrates that it was seen as a trusted medium for communicating with care providers. Responses to the newsletters and submission of personal experiences and tips for circulation to other participants also illustrate the potential value of such interventions for establishing a sense of community. Although participants submitted relatively few messages, positive responses to the system suggest that most derived passive support from reading the messages. The Sweet Talk system could be readily adapted to suit other chronic disease models and age groups, and the results of this study may help to inform the design of future text message support interventions.

Clinical and cost effectiveness of mobile phone supported self monitoring of asthma: multicentre randomised controlled trial

Objective To determine whether mobile phone based monitoring improves asthma control compared with standard paper based monitoring strategies. Design Multicentre randomised controlled trial with cost effectiveness analysis. Setting UK primary care. Participants 288 adolescents and adults with poorly controlled asthma (asthma control questionnaire (ACQ) score ≥1.5) from 32 practices. Intervention Participants were centrally randomised to twice daily recording and mobile phone based transmission of symptoms, drug use, and peak flow with immediate feedback prompting action according to an agreed plan or paper based monitoring. Main outcome measures Changes in scores on asthma control questionnaire and self efficacy (knowledge, attitude, and self efficacy asthma questionnaire (KASE-AQ)) at six months after randomisation. Assessment of outcomes was blinded. Analysis was on an intention to treat basis. Results There was no significant difference in the change in asthma control or self efficacy between the two groups (ACQ: mean change 0.75 in mobile group v 0.73 in paper group, mean difference in change −0.02 (95% confidence interval −0.23 to 0.19); KASE-AQ score: mean change −4.4 v −2.4, mean difference 2.0 (−0.3 to 4.2)). The numbers of patients who had acute exacerbations, steroid courses, and unscheduled consultations were similar in both groups, with similar healthcare costs. Overall, the mobile phone service was more expensive because of the expenses of telemonitoring. Conclusions Mobile technology does not improve asthma control or increase self efficacy compared with paper based monitoring when both groups received clinical care to guidelines standards. The mobile technology was not cost effective. Trial registration Clinical Trials NCT00512837.

Understanding the potential role of mobile phone-based monitoring on asthma self-management: qualitative study.

Background National and international healthcare policy increasingly seeks technological solutions to the challenge of providing care for people with long‐term conditions. Novel technologies, however, have the potential to change the dynamics of disease monitoring and self‐management. We aimed to explore the opinions and concerns of people with asthma and primary care clinicians on the potential role of mobile phone monitoring technology (transmitting symptoms and peak flows, with immediate feedback of control and reminder of appropriate actions) in supporting asthma self‐management.

Telemonitoring based service redesign for the management of uncontrolled hypertension: multicentre randomised controlled trial.

Objective To determine if an intervention consisting of telemonitoring and supervision by usual primary care clinicians of home self measured blood pressure and optional patient decision support leads to clinically important reductions in daytime systolic and diastolic ambulatory blood pressure in patients with uncontrolled blood pressure. Design Multicentre randomised controlled trial. Setting 20 primary care practices in south east Scotland. Participants 401 people aged 29-95 years with uncontrolled blood pressure (mean daytime ambulatory measurement ≥135/85 mm Hg but ≤210/135 mm Hg). Intervention Self measurement and transmission of blood pressure readings to a secure website for review by the attending nurse or doctor and participant, with optional automated patient decision support by text or email for six months. Main outcome measures Blinded assessment of mean daytime systolic ambulatory blood pressure six months after randomisation. Results 200 participants were randomised to the intervention and 201 to usual care; primary outcome data were available for 90% of participants (182 and 177, respectively). The mean difference in daytime systolic ambulatory blood pressure adjusted for baseline and minimisation factors between intervention and usual care was 4.3 mm Hg (95% confidence interval 2.0 to 6.5; P=0.0002) and for daytime diastolic ambulatory blood pressure was 2.3 mm Hg (0.9 to 3.6; P=0.001), with higher values in the usual care group. The intervention was associated with a mean increase of one general practitioner (95% confidence interval 0.5 to 1.6; P=0.0002) and 0.6 (0.1 to 1.0; P=0.01) practice nurse consultations during the course of the study. Conclusions Supported self monitoring by telemonitoring is an effective method for achieving clinically important reductions in blood pressure in patients with uncontrolled hypertension in primary care settings. However, it was associated with increase in use of National Health Service resources. Further research is required to determine if the reduction in blood pressure is maintained in the longer term and if the intervention is cost effective. Trial registration Current Controlled Trials ISRCTN72614272.

Activity monitoring in patients with depression: A systematic review

BACKGROUND Altered physical activity is an important feature of depression. It is manifested in psychomotor retardation, agitation and withdrawal from engagement in normal activities. Modern devices for activity monitoring (actigraphs) make it possible to monitor physical activity unobtrusively but the validity of actigraphy as an indicator of mood state is uncertain. We carried out a systematic review of digital actigraphy in patients with depression to investigate the associations between measured physical activity and depression. METHODS Systematic review and meta-analysis. Studies were identified from Medline, EMBASE and Psycinfo databases and included if they were either case control or longitudinal studies of actigraphy in adults aged between 18 and 65 diagnosed with a depressive disorder. Outcomes were daytime and night-time activity and actigraphic measures of sleep. RESULTS We identified 19 eligible papers from 16 studies (412 patients). Case control studies showed less daytime activity in patients with depression (standardised mean difference -0.76, 95% confidence intervals -1.05 to -0.47). Longitudinal studies showed moderate increase in daytime activity (0.53, 0.20 to 0.87) and a reduction in night-time activity (-0.36, -0.65 to -0.06) over the course of treatment. LIMITATIONS All study participants were unblinded. Only seven papers included patients treated in the community. CONCLUSIONS Actigraphy is a potentially valuable source of additional information about patients with depression. However, there are no clear guidelines for use of actigraphy in studies of patients with depression. Further studies should investigate patients treated in the community. Additional work to develop algorithms for differentiating behaviour patterns is also needed.