Enhance Patient Self-management Research Articles

A qualitative study of stakeholders' experiences with and acceptability of a technology-supported health coaching intervention (SHARE-S) delivered in coordination with cancer survivorship care.

Healthy cancer survivorship involves patients' active engagement with preventative health behaviors and follow-up care. While clinicians and patients have typically held dual responsibility for activating these behaviors, transitioning some clinician effort to technology and health coaches may enhance guideline implementation. This paper reports on the acceptability of the Shared Healthcare Actions & Reflections Electronic systems in survivorship (SHARE-S) program, an entirely virtual multicomponent intervention incorporating e-referrals, remotely-delivered health coaching, and automated text messages to enhance patient self-management and promote healthy survivorship. SHARE-S was evaluated in single group hybrid implementation-effectiveness pilot study. Patients were e-referred from the clinical team to health coaches for three health self-management coaching calls and received text messages to enhance coaching. Semi-structured qualitative interviews were conducted with 21 patient participants, 2 referring clinicians, and 2 health coaches to determine intervention acceptability (attitudes, appropriateness, suitability, convenience, and perceived effectiveness) and to identify important elements of the program and potential mechanisms of action to guide future implementation. SHARE-S was described as impactful and convenient. The nondirective, patient-centered health coaching and mindfulness exercises were deemed most acceptable; text messages were less acceptable. Stakeholders suggested increased flexibility in format, frequency, timing, and length of participation, and additional tailored educational materials. Patients reported tangible health behavior changes, improved mood, and increased accountability and self-efficacy. SHARE-S is overall an acceptable and potentially effective intervention that may enhance survivors' self-management and well-being. Alterations to tailored content, timing, and dose should be tested to determine impact on acceptability and outcomes.

Enhancing Care Partnerships Using a Rheumatology Dashboard: Bringing Together What Matters Most to Both Patients and Clinicians.

Dashboards can support person-centered care by helping people partner with their clinicians to coproduce care based on preferences, shared decision-making, and evidence-based treatments. We engaged caregivers of children with juvenile idiopathic arthritis (JIA), adults with rheumatoid arthritis (RA), and clinicians in a pilot study to assess their experiences and the utility and impact of an electronic previsit questionnaire and point-of-care dashboard to support coproduction of rheumatology care. We employed a mixed-methods design to assess users' perceptions of a customized electronic health record rheumatology module at four pediatric rheumatology practices and two adult rheumatology practices. We surveyed a convenience sample of caregivers of children with JIA (n=113), adults with RA (n=116), and clinicians (n=12). We conducted semistructured interviews with 13 caregivers and patients and six care teams. Experiences were evaluated using descriptive statistics and thematic analyses. Caregivers of children with JIA and adults with RA reported the dashboards were useful during discussions (88%) and helped them talk about what mattered most (82%), make health care decisions (83%), and create a treatment plan (77%). Clinicians provided similar feedback. Two-thirds (67%) of caregivers and adults and 55% of clinicians would recommend the dashboard to peers. System usability scores (77.1 ± 15.6) were above average. Dashboards helped users make sense of health information, communicate more effectively, and make decisions. Improvements to the dashboards and workflows could enhance patient self-management and clinician efficiency. Visual point-of-care dashboards can support caregivers, patients, and clinicians to coproduce rheumatology care. Findings demonstrate a need to spread and scale for broader benefit and impact.

The emerging role of digital health in the management of asthma.

The most common reasons seen for lack of asthma control include misconceptions about disease control, low controller treatment adherence, poor inhaler technique, and the resulting underuse of controllers and overuse of short-acting beta2 agonists (SABAs). Narrowing these care gaps may be achieved through well-designed patient education that considers the patient's motivation, beliefs, and capabilities regarding their asthma and its management and empowers the patient to become an active participant in treatment decisions. Digital health technologies (DHTs) and digital therapeutic (DT) devices provide new opportunities to monitor treatment behaviors, improve communication between healthcare providers and patients, and generate data that inform educational interactions. DHT and DT have been proven effective in enhancing patient self-management in other chronic conditions, particularly diabetes. Accelerated integration of DHT and DT into the management of asthma patients is facilitated by the use of digital inhalers that employ sensor technology ("smart" inhalers). These devices efficiently provide real-time feedback on controller adherence, SABA use, and inhaler technique that have the strong potential to optimize asthma control.

Enhancing Self-Management of Percutaneous Endoscopic Gastrostomy Tubes Through the Implementation of a Standardized Education and Assessment Pathway: A Quality Improvement Initiative.

Intraduodenal infusion of levodopa-carbidopa intestinal gel by percutaneous endoscopic gastrostomy tube with jejunal extension is a treatment option to reduce motor and nonmotor complications in patients with advanced Parkinson's disease when oral therapy no longer provides sufficient benefit. Medication management is of central focus; however, there was no standardized patient education on stoma-site care and tube maintenance, leading to the development of stoma-site complications. As a quality improvement (QI) initiative, a standardized education and assessment pathway was developed and implemented in an urban academic outpatient clinic to enhance patient self-management and reduce stoma-site complications. A retrospective chart review was conducted to establish baseline incidence of cutaneous stoma-site complications. QI interventions were implemented using a rapid-cycle improvement model. Routine stoma assessments by a nurse who specializes in wound, ostomy, and continence care were implemented at set points, and patient education on PEG tube care and maintenance was reinforced at each session. Results demonstrated a significant reduction in moderate-to-severe tube and stoma-site-related complication. Implementation of a similar standardized education and assessment pathway in patients with percutaneous endoscopic gastrostomy tubes may lead to a decrease in stoma-site-related complications and overall better patient self-management.

Peningkatan Self Management Melalui Program Telemonitoring Terhadap Kepatuhan Medikasi Pasien Congestive Heart Failure (CHF): A Literatur Review

Congestive Heart Failure (CHF) is a chronic complex syndrome characterized by the inability of the heart to support Congestive Heart failure is a clinical syndrome characterized by shortness of breath, swelling of the ankles, and fatigue. One of the actions taken for the treatment is to improve self-management and patient medication adherence through a telemonitoring program. The study review's purpose was to identify the effect of a telemonitoring program in improving the self-management of congestive heart failure patients on medication adherence. The literature review used some electronic databases including Pubmed, Google Scholar, and ScienceDirect, and obtained seven articles that meet the inclusion criteria. The results showed that the telemonitoring program was effective in increasing medication adherence, blood pressure control adherence, improving medication regimens, reducing treatment costs, and improving self-management of patients with congestive heart failure. The telemonitoring program becomes an appropriate solution to enhance patient self-management on medication adherence as prevention and management of this disease. Telemonitoring programs were also known to reduce readmission of congestive heart failure patients to hospitals or clinics, reduce treatment costs, increase adherence to treatment regimens, and patient self-care management.

Cultural and Digital Health Literacy Appropriateness of App- and Web-Based Systems Designed for Pregnant Women With Gestational Diabetes Mellitus: Scoping Review.

BackgroundThe prevalence of women diagnosed with gestational diabetes mellitus (GDM) is increasing dramatically. Mobile technologies to enhance patient self-management offer many advantages for women diagnosed with GDM. However, to our knowledge, although mobile health (mHealth) and telemedicine systems for GDM management exist, evidence on their cultural and digital health literacy appropriateness levels is limited.ObjectiveThis review aimed to search and assess the literature on mHealth and telemedicine systems designed for women diagnosed with GDM. Our assessment of these technologies focused on their cultural and digital health literacy appropriateness as well as the systems’ effectiveness in improving glycemic control and maternal and infant outcomes.MethodsWe conducted a scoping review using a framework adapted from Arksey and O’Malley. Four electronic databases were searched for relevant studies: PubMed, MEDLINE (EBSCO), Web of Science, and Scopus. The databases were searched between January 2010 and January 2022. The inclusion criteria were pregnant women diagnosed with GDM, use of telemedicine for monitoring and management, and vulnerable or disadvantaged patients. We used terms related to mobile apps and telemedicine: GDM, vulnerable populations, periphery, cultural appropriateness, and digital health literacy. Studies were screened and selected independently by 2 authors. We extracted the study data on a Microsoft Excel charting table and categorized them into final themes. The results were categorized according to the cultural and digital health literacy features presented.ResultsWe identified 17 studies that reported on 12 telemedicine and mHealth app interventions. We assessed the studies in three domains: cultural appropriateness, digital health literacy, and maternal and infant outcomes. In the literature, we found that existing digital technologies may improve glycemic control and diabetes self-management. However, there is a lack of assessment of cultural and digital health literacy appropriateness for pregnant women diagnosed with GDM. Considerations in app design regarding cultural appropriateness were found in only 12% (2/17) of the studies, and only 25% (3/12) of the interventions scored ≥3 out of 5 in our assessment of digital health literacy.ConclusionsmHealth and telemedicine can be an effective platform to improve the clinical management of women with GDM. Although studies published on the use of mHealth and telemedicine systems exist, there is a limited body of knowledge on the digital health literacy and cultural appropriateness of the systems designed for women diagnosed with GDM. In addition, as our study was restricted to the English language, relevant studies may have been excluded. Further research is needed to evaluate, design, and implement better tailored apps regarding cultural and digital literacy appropriateness for enhancing pregnant women’s self-management as well as the effectiveness of these apps in improving maternal and infant health outcomes.

Enhancing patient self-management after a first stroke: An application of the wearable devices and the health management platform

BackgroundPost-stroke disability restricts a patient's physical activity, affects the patient's quality of life, and leads to higher medical costs. Therefore, it is essential to promote patients' continuous exercise during this period of recovery. ObjectiveThis study aimed to verify the effectiveness of applying a health management platform combined with wearable devices to enhance stroke patients’ self-management of recovery and to allow comparisons with active care intervention management. MethodThis quasi-experimental study aimed at examining those participants who had sustained a stroke for the first time. A 90-day experiment was implemented with the intervention of monitoring and active care from the researchers who also interviewed the selected participants at the end of the study. A total of 26 participants were examined (14 in the experimental group and 12 in the control group). ResultThe participants in the experimental group made significant progress between the pre- and post-tests. Firstly, their six-minute walking distance improved by 89.5 m (p < 0.001). Secondly, their sit-to-stand transfers in 60 s improved 2.85 times (p = 0.017), and their Berg balance test improved by 6.36 points (p = 0.003). Finally, the Partners in Health scale (PIH) scores also improved. According to the data collected in the interviews, the researchers' intervention improved the patients’ self-management ability. ConclusionThe short-term physical performance in the experimental group after the intervention was better than that in the control group. In clinical practice, it is suggested that continuous interaction between medical staff and patients be sustained while applying wearable devices to promote the patient's self-management ability.

Development and real-life use assessment of a self-management smartphone application for patients with inflammatory arthritis. A user-centred step-by-step approach.

Mobile health applications (apps) are increasing in interest to enhance patient self-management. Few apps are actually used by patients and have been developed for patients with inflammatory arthritis (IA) treated with disease-modifying anti-rheumatic drugs which use entails risk of adverse effects such as infections. To develop Hiboot, a self-management mobile app for patients with IA, by using a user-centred step-by-step approach and assess its real-life use. The app development included first a qualitative study with semi-guided audiotaped interviews of 21 patients to identify the impact of IA on daily life and patient treatments practices and an online cross-sectional survey of 344 patients to assess their health apps use in general and potential user needs. A multidisciplinary team developed the first version of the app via five face-to-face meetings. After app launch, a second qualitative study of 21 patients and a users' test of 13 patients and 3 rheumatologists led to the app's current version. The number of app installations, current users and comments were collected from the Google Play store and the Apple store. The qualitative study revealed needs for counselling, patient-health professional partnership, and skills to cope with risk situations; 86.8% participants would be ready to use an app primarily on their rheumatologist's recommendation. Six functionalities were implemented: a safety checklist before treatment administration, aids in daily life situations based on the French academic recommendations, treatment reminders, global well-being self-assessment, periodic counselling messages, and a diary. The Hiboot app was installed 20,500 times from September 2017 to October 2020, with 4300 regular current users. Scores were 4.4/5 stars at Android and iOS stores. Hiboot is a free self-management app for patients with IA developed by a step-by-step process including patients and health professionals. Further evaluation of the Hiboot benefit is needed.

IDF21-0101 Blood Glucose Control using a Mobile Health Application in Asia – A Retrospective Real-World Data Analysis

Background: Mobile health (mHealth) solutions have the potential to reduce the clinical and psychological burden of diabetes and enhance patient self-management. Previous real world data analyses showed significant improvement in blood glucose (BG) control with the use of a mHealth application for people with diabetes after 6 months. However, there is under-representation of Asian data while user behaviours and outcomes remain little known. Aim: We aimed to investigate the potential impact of mySugr Logbook app usage on parameters of BG control in Asia – Singapore, Philippines and Hong Kong. Method: We analysed changes in BG control [mean BG, tests in range (TeIR), estimated HbA1c (eHbA1c)] in a sample of highly engaged users, defined as ≥2 logs on at least 14 out of 30 days, over a 6-month period. We also analysed measures of glycaemic variability [high blood glucose index (HBGI) and Low blood glucose index (LBGI)]. Data from the first month (t0) of use was compared to month 6 (t1) using paired t-tests in individuals who logged continuously for 6 months. Subgroup analysis was performed on those with suboptimal glycaemic control (eHbA1c >7.0%). Results: A total of 1761 users satisfying criteria above have been using mySugr app over a 6-month period. Of this, 63.7% had Type 2 diabetes (T2D), 14.4% had Type 1 diabetes (T1D), 21.9% was others/unknown. Baseline eHBA1c and mean BG were 6.6% and 142.6 ± 36.4 mg/dl respectively. In 357 individuals who logged continuously, t0 eHbA1c 6.7±0.9% fell 0.2% (p<0.01) at t1. In those with eHbA1c>7% (n=107) at baseline, mean t0 eHbA1c 8.1 ± 1.4%, reduced by 0.5% (p<0.01) with TeIR improving by 10.9% (p<0.01) at t1. Likewise, HBGI decreased from 11 (high risk) to 9 (moderate risk) (p<0.01) whilst the LBGI did not significantly change and remained at low risk level (<2.5) (p=0.300). Discussion: This real-world data shows improvements in BG control in those with higher eHbA1c at baseline over a 6-month period in highly engaged users. A clinically relevant decrease in eHbA1c by 0.5% for those with baseline eHbA1c>7% at 6 months of mHealth application usage was shown to be statistically significant. Although mySugr app supports manual logging of BG data, it was previously observed that users who manually logged data had lower retention rates compared to those who used connected BG meters that enable automatic transfer of data. This preliminary work suggests a positive impact of connected BG meters and mobile health applications in supporting diabetes self-management.

The patient's perspective of diabetic foot ulceration: A phenomenological exploration of causes, detection and care seeking.

Diabetic foot ulceration can contribute to lowered life expectancy and quality of life for people with diabetes, and yet, scant attention has been given to improving preventive and educational measures. This article uses a phenomenological approach to explore individuals' lived experiences of diabetic foot ulcerations to explore factors that can be harnessed to achieve improved outcomes. This was a qualitative study using semi-structured interviews grounded in a phenomenological framework to explore how patients perceive and understand their foot problems. Study participants were recruited from February 2020 to February 2021 from a tertiary referral centre that treats foot problems in persons with diabetes. A total of 15 Hispanic, Native American and White patients participated in the study. We conducted in-depth semi-structured interviews which were audio recorded with the participant's consent. Interview data were transcribed and analysed with Dedoose data management software. Analysis revealed findings in two primary domains: (1) how patients perceive foot ulceration, with themes around limited understandings of foot ulceration, close sensory observation of foot problems and barriers to ulcer perception and (2) how patients experience the timing of foot ulceration, with themes on how time perceptions shifted as foot problems became more serious, which correlated closely to how patients responded to their foot problems. Despite the close sensory observation of their feet, people with diabetes face an array of barriers to recognizing and understanding the implications of diabetic foot ulceration, which can lead to delayed care seeking. Nurses can play a critical role in promoting patient education and improving patient self-management of foot ulcers. This phenomenological study offers important lessons to guide nurses and other providers in enhancing patient self-management of DFUs and improving care outcomes by expanding an understanding of DFU early warning signs, the imperative to seek medical care quickly, and addressing possible barriers.

A Mobile App to Support Self-management of Chronic Kidney Disease: Development Study.

BackgroundChronic kidney disease (CKD) is a common and costly condition that is usually accompanied by multiple comorbidities including type 2 diabetes, hypertension, and obesity. Proper management of CKD can delay or prevent kidney failure and help mitigate cardiovascular disease risk, which increases as kidney function declines. Smart device apps hold potential to enhance patient self-management of chronic conditions including CKD.ObjectiveThe objective of this study was to develop a mobile app to facilitate self-management of nondialysis-dependent CKD.MethodsOur stakeholder team included 4 patients with stage 3-4 nondialysis-dependent CKD; a kidney transplant recipient; a caretaker; CKD care providers (pharmacists, a nurse, primary care physicians, a nephrologist, and a cardiologist); 2 health services and CKD researchers; a researcher in biomedical informatics, nutrition, and obesity; a system developer; and 2 programmers. Focus groups and in-person interviews with the patients and providers were conducted using a focus group and interview guide based on existing literature on CKD self-management and the mobile app quality criteria from the Mobile App Rating Scale. Qualitative analytic methods including the constant comparative method were used to analyze the focus group and interview data.ResultsPatients and providers identified and discussed a list of requirements and preferences regarding the content, features, and technical aspects of the mobile app, which are unique for CKD self-management. Requirements and preferences centered along themes of communication between patients and caregivers, partnership in care, self-care activities, adherence to treatment regimens, and self-care self-efficacy. These identified themes informed the features and content of our mobile app. The mobile app user can enter health data including blood pressure, weight, and blood glucose levels. Symptoms and their severity can also be entered, and users are prompted to contact a physician as indicated by the symptom and its severity. Next, mobile app users can select biweekly goals from a set of predetermined goals with the option to enter customized goals. The user can also keep a list of medications and track medication use. Our app includes feedback mechanisms where in-range values for health data are depicted in green and out-of-range values are depicted in red. We ensured that data entered by patients could be downloaded into a user-friendly report, which could be emailed or uploaded to an electronic health record. The mobile app also includes a mechanism that allows either group or individualized video chat meetings with a provider to facilitate either group support, education, or even virtual clinic visits. The CKD app also includes educational material on CKD and its symptoms.ConclusionsPatients with CKD and CKD care providers believe that a mobile app can enhance CKD self-management by facilitating patient-provider communication and enabling self-care activities including treatment adherence.

Outcomes of Remote Patient Monitoring for Automated Peritoneal Dialysis: A Randomized Controlled Trial

Introduction: We hypothesize that remote patient monitoring (RPM) for automated peritoneal dialysis (APD) and feedback could enhance patient self-management and improve outcomes. The aim of this study was to evaluate the efficacy of RPM-APD compared to traditional APD (T-APD) without RPM. Methods: In this multicenter, randomized controlled trial, patients on APD were randomized to T-APD (n = 29) or RPM-APD (n = 28) at 12 weeks and followed until 25 weeks. Health-related quality of life (HRQOL), patient and medical staff satisfaction with RPM-APD, and dialysis-related outcomes were compared between the 2 groups. Results: We found no significant differences in HRQOL scores at the time of enrollment and randomization between RPM-APD and T-APD. At the end of the study, the RPM-APD group showed better HRQOL for the sleep domain (p = 0.049) than the T-APD group and the T-APD group showed better HRQOL for the sexual function domain (p = 0.030) than the RPM-APD group. However, we found no significant interactions between the time and groups in terms of HRQOL. Different HRQOL domains significantly improved over time in patients undergoing RPM-APD (effects of kidney disease, p = 0.025) and T-APD (burden of kidney disease, p = 0.029; physical component summary, p = 0.048). Though medical staff satisfaction with RPM-APD was neutral, most patients were quite satisfied with RPM-APD (median score 82; possible total score 105 on 21 5-item scales) and the rating scores were maintained during the study period. We found no significant differences in dialysis adherence, accuracy, adequacy, overhydration status, blood pressure, or the number of unplanned visits between the 2 groups. Discussion/Conclusion: Although HRQOL and dialysis-related outcomes were comparable between RPM-APD and T-APD, RPM-APD was positive in terms of patient satisfaction. Further long-term and large-scale studies will be required to determine the efficacy of RPM-APD. Trial Registration: CRIS identifier: KCT0003390, registered on December 14, 2018 – retrospectively registered, https://cris.nih.go.kr/cris/search/search_result_st01.jsp?seq=12348.

Feasibility and Acceptability of Mobile Phone Self-monitoring and Automated Feedback to Enhance Telephone Coaching for People With Risky Substance Use: The QUIT-Mobile Pilot Study.

This study evaluates the feasibility, acceptability, and perceived benefits of mobile-phone delivered self-monitoring queries and feedback integrated into the evidence-based Quit Using Drugs Intervention Trial (QUIT) screening and brief telephone health coaching intervention to prevent progression from risky drug use to addiction as the QUIT-Mobile intervention. Participants (n = 20) were primarily Black/African American and Latino men in Los Angeles with risky substance use. Self-monitoring surveys were sent by text-message twice-weekly for 6 weeks and once-weekly from 6 to 12-weeks. Surveys consisted of 10 questions regarding drug and alcohol use (ie, # days of use) and cravings, quality of life, and medication adherence. Feedback messages praised or encouraged drug use reductions. Coaches monitored patient responses and discussed them in QUIT's telephone coaching sessions. Participants' experiences were assessed qualitatively at 3-month follow-up. Nineteen out of 20 participants that completed the qualitative evaluation from the 12-week follow-up reported: (1) self-monitoring surveys helped them adhere to drug use reduction goals and reflect on associations between self-monitoring domains; (2) preference for higher frequency (twice-weekly) self-monitoring during the 6-week coaching period, and then weekly surveys thereafter but not monthly; and (3) self-monitoring and coaching were mutually reinforcing for their drug use reduction goals. Results are consistent with prior similar research suggesting that mobile phone self-monitoring of drug use and related factors is feasible and acceptable among diverse adults with risky drug use. Findings also suggest the potential benefits of integrating electronic self-monitoring and feedback into substance use reduction interventions such as QUIT to enhance patient self-management and coaching or counseling intervention components.

1223-P: Diabetes in Pregnancy in the Caribbean: A Systems Enablement Approach to Universal Access, Screening, and Treatment

In Trinidad and Tobago there is a high background prevalence of diabetes in women of reproductive age and wide variability of screening practices for diabetes in pregnancy (DiP). A systems enablement approach was implemented to achieve national consensus on clinical guidelines and facilitate universal screening. A secure ICT solution (app) for real-time communication of blood glucose results was designed and piloted to standardize reporting systems and integrate services for pregnancy care. National consensus was achieved through consultations with healthcare professionals and followed up with training on the standardized guidelines for DIP and continuous medical education for over 300 in the field to improve adoption. The app facilitated a system of data capture, storage and retrieval among antenatal caregivers, patients and health administrators. The app is scalable and can integrate with other standards-based ICT health systems. The app was pilot tested and 658 pregnant women, 7 lab technologists and 24 doctors were trained registered users. All pregnant women registered on the app were screened using a standard 75g 2-hour OGTT after an overnight fast. Gestational diabetes prevalence was 14.1%. The high GDM prevalence justifies a need for systems change and universal screening for diabetes in pregnancy in Trinidad and Tobago. The app facilitates timely delivery of results to patient and healthcare provider. Training healthcare teams in diagnosis and management of diabetes in pregnancy using ICT simultaneously provides the platform to enhance patient self-management. Disclosure S. Teelucksingh: None. H. Chow: None. F.K. Lutchmansingh: None. S. Ramsewak: None.

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.

BackgroundPast 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.ObjectiveThe 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.MethodsA 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.ResultsThe 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).ConclusionsOur 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 RegistrationClinicalTrials.gov NCT02949037; https://clinicaltrials.gov/ct2/show/NCT02949037International Registered Report Identifier (IRRID)RR2-10.2196/resprot.6993

Understanding Adults With Chronic Kidney Disease and Their Caregivers' Self-Management Experiences: A Qualitative Study Using the Theoretical Domains Framework.

Background:Self-management support interventions are widely accepted in chronic kidney disease (CKD) care; however, interventions rarely consider individual behaviors by incorporating a behavioral theoretical framework. The Theoretical Domains Framework (TDF) can be used to facilitate an understanding of patients and their caregivers’ behaviors to successfully self-manage CKD.Objectives:(1) To understand behaviors of patients with CKD and their caregivers and identify potential intervention approaches to support CKD self-management and (2) to explore relationships between the 14 TDF domains and CKD self-management.Design:Qualitative descriptive study using both content and thematic analysisSetting:Purposive criterion was used to recruit participants from across Canada.Patients:Canadian patients with CKD and their caregivers.Measurements:Focus groups and telephone interviews using a semistructured interview guide.Methods:We conducted a secondary analysis of qualitative data collected from focus groups and telephone interviews from July 2017 to January 2018. Two research team members coded the transcribed data to the 14 TDF domains using a modified approach of the Framework Method. We linked the common TDF domains to relevant intervention functions from the Behaviour Change Wheel (BCW) to identify potential intervention approaches. We also identified and mapped relationships between the relevant TDF domains to report emerging themes.Results:Six focus groups (37 participants) and 11 telephone interview transcripts were analyzed. Five TDF domains that influenced CKD self-management behavior were identified: environmental context and resources, knowledge, beliefs about capabilities, beliefs about consequences, and social influences. Four BCW intervention functions were identified: education, modeling, persuasion, and environmental restructuring. Four emergent themes, shaped by the populated 14 TDF domains, were identified: What does this mean for me? Help me help myself, How does this make me feel? and Who am I?Limitations:The TDF was not used to design the interview guide; therefore, there may be underrepresentation of some TDF domains relevant for self-management.Conclusion:Our findings highlight 5 TDF domains that can influence CKD self-management behavior and 4 possible intervention approaches to influence behavior change in patients with CKD and their caregivers. Emergent themes highlight participants’ interpretation of being diagnosed with CKD, their motivations, feelings, values, and altered identity. This work will inform the codesign of a behavior change intervention to enhance patient self-management of CKD.

Wearable Devices Can Improve Quality of Life in Chronic Heart Failure

Introduction: Chronic heart failure (HF) requires ongoing management of diet and medications in order to avoid HF exacerbation that may cause troublesome symptoms and require acute intervention or hospitalization. In many cases, implanted device data (i.e. from cardiac resynchronization therapy (CRT) device or pulmonary artery pressure monitor show physiological changes in resting heart rate (HR) and intrathoracic fluid prior to clinical symptoms (i.e. weight gain, dyspnea, edema). However, implanted device data are not generally available to patients to enable anticipatory therapeutic changes. Hypothesis: Consumer wearable devices may offer an opportunity to enhance patient self-management, avoid HF exacerbation, and improve quality of life (QoL). Methods: In a 4-month pilot observational study, subjects with HF and an implanted CRT device wore a Jawbone Up3 device continuously. After 1 month, Jawbone resting HR data were compared to CRT device data to determine Jawbone HR signals that correlate to increased intrathoracic fluid measurements. Subjects were instructed to contact their HF care team in the event of individualized elevated resting HR signals. Subjects assessed QoL using valid and reliable psychometric instruments (Minnesota Living with Heart Failure [MLHF], SF-36) at the beginning and end of the study. Results: Eight of 11 subjects completed the 4-month study. Two subjects had poor correlation of HR data between Jawbone and CRT device without actionable signals to indicate impending HF worsening. No adverse events were reported. 6 of 8 subjects had improvement in MLHF score, with 5 subjects reaching clinical significance (>5 point change). There was statistically significant improvement in physical subscore (P = .03), non-significant improvement in total score (P = .07), and nonsignificant change in emotional subscore. SF-36 demonstrated significant improvement in emotional wellbeing (P = .03) with nonsignificant changes in other scales. Conclusions: In this pilot study, patients experienced no adverse outcomes and some evidence of clinically relevant improvement in quality of life after wearing a consumer-grade health monitor to track resting heart rate. Limitations included small sample size, as well as imprecision of the wearable monitor for resting HR data. In addition, permanent pacing limited the utility of resting HR data for several subjects. These pilot findings suggest that self-monitoring with a wearable device may improve quality of life for patients with HF, including perceived physical function and emotional wellbeing. Further study is needed to better characterize the utility of wearable devices to enable self-monitoring and improved HF outcomes.

Behavioral and Educational Interventions to Improve Asthma Outcomes in Children : A Systematic Review

Background:Asthma, being a chronic inflammatory disease requires not only medical treatment but also complimentary healthcare, self-management strategies and interventions for the appropriate management and possible prevention of attack as well as reduction of school absences and days of restricted activity and decrease emergency room utilization. Methods:Randomized clinical trial (RCT) data reviewed for outcomes and processes associated with asthma educational and behavioral interventions provided by different types of health professionals. Thestudy group has synthesized studies that identified barriers and interventions to improve asthma symptoms and management in children through searching in MEDLINE,Cochrane EMBASE, TOXLine and CINAHL considering papers starting from 1999. Results:Physician-led interventions were most successful for outcomes related to the use of health care. Multidisciplinary teams were best in achieving symptom reduction and quality of life. Lay persons were best in achieving self-management/self-efficacy outcomes. Components most frequently employed in successful programs are skills to improve patient–clinician communication and education to enhance patient self-management. Fifty percent of interventions achieved reduction in the use of health care and one-third in symptom control. A combination approach including self-management and patient–clinician communication involving multidisciplinary team members may have the greatest effect on most outcomes. Conclusion: strong evidences suggest that the development of self-management and clinician–patient communication skills are essentially required and considered as critical factors for Asthma patients particularly children symptoms alleviation and outcomes improvement in the long term. This can be achieved by appropriate self-care, awareness programs through effectiveeducational and behavioral intervention which are crucial components associated with success across outcomes and providers.

Medical students as diabetes educators

Introduction: As in all chronic diseases, an important component of care in diabetes is patient education (diabetes self-management education). Many diabetic care programs have shown that using specially trained diabetes educators – nurses, allied health-care professionals – improves outcomes. In India too, the National Defense Education Program has trained graduates to be diabetes educators. We wanted to use the strength of our institute – an intelligent and motivated student body to function as a diabetes educator. We developed a module to train medical students to be effective diabetes educators. The objective of this was twofold: First, to enhance patient self-management of diabetes; second, studies have shown that even among doctors, lack of knowledge about practical diabetes management was common. We believed that in view of the impending diabetes epidemic in India, it is important that every newly graduating MBBS doctor has sufficient knowledge about diabetes to counsel and manage patients at the primary care level. Materials and Methods: A physician and an endocrinologist developed patient and student training modules. Modules were administered to students by the authors and to patients by the trained students. Improvement in knowledge and attitudes was assessed by improvement in posttest scores and by qualitative analysis of the patient and student feedback. Results: We found that patient knowledge about diabetes and its management improved after contact with the diabetes educator as assessed by a marked increase in posttest scores. Students found that training patients in diabetes care improved the depth and range of their knowledge about diabetes and its management. This method of using students as diabetes educators facilitates both patient and trainer learning. Students who worked with patients using this module noted patient questions and suggested additional points of interest be covered in the module based on patient questions. We are currently incorporating these points into the module. We believe that this module on practical management of diabetes can be included in the curriculum for MBBS students in our university. Conclusion: Using medical students as diabetes educators improves student knowledge and patient self management of diabetes

Fibromyalgia Syndrome: Current Considerations in Symptom Management.

Fibromyalgia syndrome (FMS), one of the most common rheumatic disorders, is estimated to affect up to 15 million people in the United States, 80% to 90% of whom are women. The syndrome is characterized by the presence of chronic widespread pain and various concurrent symptoms, which may include fatigue, cognitive disturbances (memory problems, difficulty concentrating, confusion), distressed mood (anxiety, depression), nonrestorative sleep, and muscular stiffness. Symptom management appears to be best addressed using a multimodal approach, with treatment strategies tailored to the individual. While medication may provide adequate symptom relief for some patients, experts generally recommend integrating both pharmacologic and nonpharmacologic approaches. Some patients may benefit from the adjunctive use of complementary and alternative medicine (CAM) modalities. Because symptom remission is rare and medication adverse effects can complicate symptom management, well-informed nursing care practices and patient education are essential. This article describes the existing treatment guidelines, discusses pharmacologic and nonpharmacologic approaches (including CAM-based modalities), and outlines nursing approaches aimed at enhancing patient self-management.