Patient Adherence to a Mobile Phone–Based Heart Failure Telemonitoring Program: A Longitudinal Mixed-Methods Study

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Abstract

Background

Telemonitoring (TM) can improve heart failure (HF) outcomes by facilitating patient self-care and clinical decision support. However, these outcomes are only possible if patients consistently adhere to taking prescribed home readings.

Objective

The objectives of this study were to (1) quantify the degree to which patients adhered to taking prescribed home readings in the context of a mobile phone–based TM program and (2) explain longitudinal adherence rates based on the duration of program enrollment, patient characteristics, and patient perceptions of the TM program.

Methods

A mixed-methods explanatory sequential design was used to meet the 2 research objectives, and all explanatory methods were guided by the unified theory of acceptance and use of technology 2 (UTAUT2). Overall adherence rates were calculated as the proportion of days patients took weight, blood pressure, heart rate, and symptom readings over the total number of days they were enrolled in the program up to 1 year. Monthly adherence rates were also calculated as the proportion of days patients took the same 4 readings over each 30-day period following program enrollment. Next, simple and multivariate regressions were performed to determine the influence of time, age, sex, and disease severity on adherence rates. Additional explanatory methods included questionnaires at 6 and 12 months probing patients on the perceived benefits and ease of use of the TM program, an analysis of reasons for patients leaving the program, and semistructured interviews conducted with a purposeful sampling of patients (n=24) with a range of adherence rates and demographics.

Results

Overall average adherence was 73.6% (SD 25.0) with average adherence rates declining over time at a rate of 1.4% per month ( P<.001). The multivariate regressions found no significant effect of sex and disease severity on adherence rates. When grouping patients’ ages by decade, age was a significant predictor ( P=.04) whereby older patients had higher adherence rates over time. Adherence rates were further explained by patients’ perceptions with regard to the themes of (1) performance expectancy (improvements in HF management and peace of mind), (2) effort expectancy (ease of use and technical issues), (3) facilitating conditions (availability of technical support and automated adherence calls), (4) social influence (support from family, friends, and trusted clinicians), and (5) habit (degree to which taking readings became automatic).

Conclusions

The decline in adherence rates over time is consistent with findings from other studies. However, this study also found adherence to be the highest and most consistent over time in older age groups and progressively lower over time for younger age groups. These findings can inform the design and implementation of TM interventions that maximize patient adherence, which will enable a more accurate evaluation of impact and optimization of resources.

International Registered Report Identifier (IRRID)

RR2-10.2196/resprot.9911

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Most cited references 32

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Understanding factors affecting patient and public engagement and recruitment to digital health interventions: a systematic review of qualitative studies

Siobhan O’Connor, Peter Hanlon, Catherine A O'Donnell … (2016)

Background Numerous types of digital health interventions (DHIs) are available to patients and the public but many factors affect their ability to engage and enrol in them. This systematic review aims to identify and synthesise the qualitative literature on barriers and facilitators to engagement and recruitment to DHIs to inform future implementation efforts. Methods PubMed, MEDLINE, CINAHL, Embase, Scopus and the ACM Digital Library were searched for English language qualitative studies from 2000 – 2015 that discussed factors affecting engagement and enrolment in a range of DHIs (e.g. ‘telemedicine’, ‘mobile applications’, ‘personal health record’, ‘social networking’). Text mining and additional search strategies were used to identify 1,448 records. Two reviewers independently carried out paper screening, quality assessment, data extraction and analysis. Data was analysed using framework synthesis, informed by Normalization Process Theory, and Burden of Treatment Theory helped conceptualise the interpretation of results. Results Nineteen publications were included in the review. Four overarching themes that affect patient and public engagement and enrolment in DHIs emerged; 1) personal agency and motivation; 2) personal life and values; 3) the engagement and recruitment approach; and 4) the quality of the DHI. The review also summarises engagement and recruitment strategies used. A preliminary DIgital Health EnGagement MOdel (DIEGO) was developed to highlight the key processes involved. Existing knowledge gaps are identified and a number of recommendations made for future research. Study limitations include English language publications and exclusion of grey literature. Conclusion This review summarises and highlights the complexity of digital health engagement and recruitment processes and outlines issues that need to be addressed before patients and the public commit to digital health and it can be implemented effectively. More work is needed to create successful engagement strategies and better quality digital solutions that are personalised where possible and to gain clinical accreditation and endorsement when appropriate. More investment is also needed to improve computer literacy and ensure technologies are accessible and affordable for those who wish to sign up to them. Systematic review registration International Prospective Register of Systematic Reviews CRD42015029846 Electronic supplementary material The online version of this article (doi:10.1186/s12911-016-0359-3) contains supplementary material, which is available to authorized users.

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Factors Determining the Success and Failure of eHealth Interventions: Systematic Review of the Literature

Conceição Granja, Wouter Janssen, Monika Alise Johansen (2018)

Background eHealth has an enormous potential to improve healthcare cost, effectiveness, and quality of care. However, there seems to be a gap between the foreseen benefits of research and clinical reality. Objective Our objective was to systematically review the factors influencing the outcome of eHealth interventions in terms of success and failure. Methods We searched the PubMed database for original peer-reviewed studies on implemented eHealth tools that reported on the factors for the success or failure, or both, of the intervention. We conducted the systematic review by following the patient, intervention, comparison, and outcome framework, with 2 of the authors independently reviewing the abstract and full text of the articles. We collected data using standardized forms that reflected the categorization model used in the qualitative analysis of the outcomes reported in the included articles. Results Among the 903 identified articles, a total of 221 studies complied with the inclusion criteria. The studies were heterogeneous by country, type of eHealth intervention, method of implementation, and reporting perspectives. The article frequency analysis did not show a significant discrepancy between the number of reports on failure (392/844, 46.5%) and on success (452/844, 53.6%). The qualitative analysis identified 27 categories that represented the factors for success or failure of eHealth interventions. A quantitative analysis of the results revealed the category quality of healthcare (n=55) as the most mentioned as contributing to the success of eHealth interventions, and the category costs (n=42) as the most mentioned as contributing to failure. For the category with the highest unique article frequency, workflow (n=51), we conducted a full-text review. The analysis of the 23 articles that met the inclusion criteria identified 6 barriers related to workflow: workload (n=12), role definition (n=7), undermining of face-to-face communication (n=6), workflow disruption (n=6), alignment with clinical processes (n=2), and staff turnover (n=1). Conclusions The reviewed literature suggested that, to increase the likelihood of success of eHealth interventions, future research must ensure a positive impact in the quality of care, with particular attention given to improved diagnosis, clinical management, and patient-centered care. There is a critical need to perform in-depth studies of the workflow(s) that the intervention will support and to perceive the clinical processes involved.

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Effectiveness of Remote Patient Monitoring After Discharge of Hospitalized Patients With Heart Failure: The Better Effectiveness After Transition -- Heart Failure (BEAT-HF) Randomized Clinical Trial.

Michael Ong, Patrick S Romano, Sarah Edgington … (2016)

It remains unclear whether telemonitoring approaches provide benefits for patients with heart failure (HF) after hospitalization.

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Author and article information

Contributors

Patrick Ware:

Institute of Health Policy, Management and EvaluationDalla Lana School of Public HealthToronto155 College StreetToronto, ON, M5T 3M6Canada1 647 227 6015patrick.ware@mail.utoronto.ca

ORCID: http://orcid.org/0000-0002-5325-9871

Journal

Journal ID (nlm-ta): JMIR Mhealth Uhealth

Journal ID (iso-abbrev): JMIR Mhealth Uhealth

Journal ID (publisher-id): JMU

Title: JMIR mHealth and uHealth

Publisher: JMIR Publications (Toronto, Canada )

ISSN (Electronic): 2291-5222

Publication date Collection: February 2019

Publication date (Electronic): 26 February 2019

Volume: 7

Issue: 2

Electronic Location Identifier: e13259

Affiliations

[1 ] Institute of Health Policy, Management and Evaluation Dalla Lana School of Public Health Toronto Toronto, ON Canada

[2 ] Centre for Global eHealth Innovation Techna Institute University Health Network Toronto, ON Canada

[3 ] Ted Rogers Centre for Heart Research University Health Network Toronto, ON Canada

[4 ] Department of Medicine University of Toronto Toronto, ON Canada

[5 ] Peter Munk Cardiac Centre University Health Network Toronto, ON Canada

[6 ] Institute of Biomaterials and Biomedical Engineering University of Toronto Toronto, ON Canada

[7 ] Canadian Centre for Health Economics Toronto, ON Canada

Author notes

Corresponding Author: Patrick Ware patrick.ware@ 123456mail.utoronto.ca

Author information

Patrick Ware http://orcid.org/0000-0002-5325-9871

Mala Dorai http://orcid.org/0000-0002-1155-2383

Heather J Ross http://orcid.org/0000-0003-4384-3027

Joseph A Cafazzo http://orcid.org/0000-0002-3114-4440

Audrey Laporte http://orcid.org/0000-0002-5667-9206

Chris Boodoo http://orcid.org/0000-0002-5733-7697

Emily Seto http://orcid.org/0000-0002-8723-5915

Article

Publisher ID: v7i2e13259

DOI: 10.2196/13259

PMC ID: 6412156

PubMed ID: 30806625

SO-VID: a057f200-81d6-438c-8f01-ca02a73bd3f6

Copyright © ©Patrick Ware, Mala Dorai, Heather J Ross, Joseph A Cafazzo, Audrey Laporte, Chris Boodoo, Emily Seto. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 26.02.2019.

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR mhealth and uhealth, is properly cited. The complete bibliographic information, a link to the original publication on http://mhealth.jmir.org/.as well as this copyright and license information must be included.

History

Date received : 29 December 2018

Date revision requested : 24 January 2019

Date revision received : 25 January 2019

Date accepted : 11 February 2019

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