Journal of Medical Internet Research

The leading peer-reviewed journal for health and healthcare in the Internet age.

JMIR's Thomson Reuter Impact Factor of 4.7 for 2013

The effectiveness of self-management smartphone and tablet apps in long term condition management.

Background: Long term conditions and their concomitant management place considerable pressure on patients, communities, and health care systems worldwide. International clinical guidelines on the majority of long term conditions recommend the inclusion of self-management programmes in routine management. Self-management programmes have been associated with improved health outcomes however, the successful and sustainable transfer of research programmes into clinical practice has been inconsistent. Recent developments in mobile technology, such as smartphone and tablet computer apps, could help in developing a platform for the delivery of self- management interventions that are adaptable, low-cost and easily accessible. Objective: We conducted a systematic review to assess the effectiveness of smartphone and tablet apps in self-management of key symptoms of long term conditions. Methods: We searched PubMed, Embase, EBSCO databases, the Cochrane library and Joanna Briggs library for randomised controlled trials that assessed the effectiveness of smartphone and tablet apps in self-management of diabetes mellitus, cardiovascular disease and chronic lung diseases from 2005-2015. Registers of current and ongoing trials were searched and the grey literature. The reference lists of all primary studies and review articles were checked for additional references. The last search was run in June 2015. Results: Six of the interventions demonstrated a statistically significant improvement in the primary measure of clinical outcome. Where the intervention comprised of an app only, three studies demonstrated a statistically significant improvement. Interventions to address diabetes mellitus (5/9) were the most common, followed by chronic lung disease (3/9) and cardiovascular disease (1/9). Three studies included multiple intervention groups using permutations of an intervention involving an app. The duration of the intervention ranged from a 6 week intervention to 1 year and final follow-up data ranged from 3 months to 1 year. Sample size ranged from 48 to 288 participants. Conclusions: The evidence indicates the potential of apps in improving symptom management through self-management interventions. The use of apps in mHealth has the potential to improve health outcomes among those living with chronic diseases through enhanced symptom control. Further innovation, optimisation, and rigorous research around the potential of apps in mHealth technology will move the field towards the reality of improved health care delivery and outcomes.

2015-07-01

Thomson Reuters, producer of the Journal Citation Reports and Web of Science and other database products, is creating a new edition of Web of Science; and we are proud to report that JMIR journals have been selected for the content expansion. 

The new Thomson Reuters Web of Science edition, which launches later in 2015, will include influential journals covering a variety of disciplines. "The journals selected have been identified as important to key opinion leaders, funders, and evaluators worldwide.", say a Thomson Reuters communication about the database. "We are proud that the Thomson Reuters team recognizes the influence of the JMIR journals", says Gunther Eysenbach, publisher at JMIR Publications.

The following journals are confirmed to be part of the initial release:

JMIR Publications is working on getting its newer journals such as JMIR Mental Health into the collection as well. JMIR Publications is now publishing over a dozen journals with topics covering innovation in health and technology.

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  • Pediatric basic life support training.

    Improving Pediatric Basic Life Support Performance Through Blended Learning With Web-Based Virtual Patients: Randomized Controlled Trial

    Abstract:

    Background: E-learning and blended learning approaches gain more and more popularity in emergency medicine curricula. So far, little data is available on the impact of such approaches on procedural learning and skill acquisition and their comparison with traditional approaches. Objective: This study investigated the impact of a blended learning approach, including Web-based virtual patients (VPs) and standard pediatric basic life support (PBLS) training, on procedural knowledge, objective performance, and self-assessment. Methods: A total of 57 medical students were randomly assigned to an intervention group (n=30) and a control group (n=27). Both groups received paper handouts in preparation of simulation-based PBLS training. The intervention group additionally completed two Web-based VPs with embedded video clips. Measurements were taken at randomization (t0), after the preparation period (t1), and after hands-on training (t2). Clinical decision-making skills and procedural knowledge were assessed at t0 and t1. PBLS performance was scored regarding adherence to the correct algorithm, conformance to temporal demands, and the quality of procedural steps at t1 and t2. Participants’ self-assessments were recorded in all three measurements. Results: Procedural knowledge of the intervention group was significantly superior to that of the control group at t1. At t2, the intervention group showed significantly better adherence to the algorithm and temporal demands, and better procedural quality of PBLS in objective measures than did the control group. These aspects differed between the groups even at t1 (after VPs, prior to practical training). Self-assessments differed significantly only at t1 in favor of the intervention group. Conclusions: Training with VPs combined with hands-on training improves PBLS performance as judged by objective measures.

  • Collage from https://www.youtube.com/watch?v=JPuQIt_w8l4 and title cover of the October 2013 issue of the Multiple Sclerosis Journal (which contained results from the CoSMo study, showing that prevalence of chronic cerebrospinal venous insufficiency (CCSVI) in multiple sclerosis (MS) did not differ from that in other neurological diseases or healthy controls). Collage (cc-by) Eysenbach, JMIR Publications.

    Scientific Versus Experiential Evidence: Discourse Analysis of the Chronic Cerebrospinal Venous Insufficiency Debate in a Multiple Sclerosis Forum

    Abstract:

    Background: The vascular hypothesis of multiple sclerosis (MS), called chronic cerebrospinal venous insufficiency (CCSVI), and its treatment (known as liberation therapy) was immediately rejected by experts but enthusiastically gripped by patients who shared their experiences with other patients worldwide by use of social media, such as patient online forums. Contradictions between scientific information and lay experiences may be a source of distress for MS patients, but we do not know how patients perceive and deal with these contradictions. Objective: We aimed to understand whether scientific and experiential knowledge were experienced as contradictory in MS patient online forums and, if so, how these contradictions were resolved and how patients tried to reconcile the CCSVI debate with their own illness history and experience. Methods: By using critical discourse analysis, we studied CCSVI-related posts in the patient online forum of the German MS Society in a chronological order from the first post mentioning CCSVI to the time point when saturation was reached. For that time period, a total of 117 CCSVI-related threads containing 1907 posts were identified. We analyzed the interaction and communication practices of and between individuals, looked for the relation between concrete subtopics to identify more abstract discourse strands, and tried to reveal discourse positions explaining how users took part in the CCSVI discussion. Results: There was an emotionally charged debate about CCSVI which could be generalized to 2 discourse strands: (1) the “downfall of the professional knowledge providers” and (2) the “rise of the nonprofessional treasure trove of experience.” The discourse strands indicated that the discussion moved away from the question whether scientific or experiential knowledge had more evidentiary value. Rather, the question whom to trust (ie, scientists, fellow sufferers, or no one at all) was of fundamental significance. Four discourse positions could be identified by arranging them into the dimensions “trust in evidence-based knowledge,” “trust in experience-based knowledge,” and “subjectivity” (ie, the emotional character of contributions manifested by the use of popular rhetoric that seemed to mask a deep personal involvement). Conclusions: By critical discourse analysis of the CCSVI discussion in a patient online forum, we reconstruct a lay discourse about the evidentiary value of knowledge. We detected evidence criteria in this lay discourse that are different from those in the expert discourse. But we should be cautious to interpret this dissociation as a sign of an intellectual incapability to understand scientific evidence or a naïve trust in experiential knowledge. Instead, it might be an indication of cognitive dissonance reduction to protect oneself against contradictory information.

  • public-domain-images-free-high-resolution-quality-photos-unsplash-0190_v222.

    “Nothing About Me Without Me”: An Interpretative Review of Patient Accessible Electronic Health Records

    Abstract:

    Background: Patient accessible electronic health records (PAEHRs) enable patients to access and manage personal clinical information that is made available to them by their health care providers (HCPs). It is thought that the shared management nature of medical record access improves patient outcomes and improves patient satisfaction. However, recent reviews have found that this is not the case. Furthermore, little research has focused on PAEHRs from the HCP viewpoint. HCPs include physicians, nurses, and service providers. Objective: We provide a systematic review of reviews of the impact of giving patients record access from both a patient and HCP point of view. The review covers a broad range of outcome measures, including patient safety, patient satisfaction, privacy and security, self-efficacy, and health outcome. Methods: A systematic search was conducted using Web of Science to identify review articles on the impact of PAEHRs. Our search was limited to English-language reviews published between January 2002 and November 2014. A total of 73 citations were retrieved from a series of Boolean search terms including “review*” with “patient access to records”. These reviews went through a novel scoring system analysis whereby we calculated how many positive outcomes were reported per every outcome measure investigated. This provided a way to quantify the impact of PAEHRs. Results: Ten reviews covering chronic patients (eg, diabetes and hypertension) and primary care patients, as well as HCPs were found but eight were included for the analysis of outcome measures. We found mixed outcomes across both patient and HCP groups, with approximately half of the reviews showing positive changes with record access. Patients believe that record access increases their perception of control; however, outcome measures thought to create psychological concerns (such as patient anxiety as a result of seeing their medical record) are still unanswered. Nurses are more likely than physicians to gain time efficiencies by using a PAEHR system with the main concern from physicians being the security of the PAEHRs. Conclusions: This review implements a novel scoring system, which shows there is a lack of rigorous empirical testing that separates the effect of record access from other existing disease management programs. Current research is too targeted within certain clinical groups’ needs, and although there are positive signs for the adoption of PAEHRs, there is currently insufficient evidence about the effect of PAEHRs on health outcomes for patients or HCPs.

  • Screenshot of AlcoholHelpCenter home page.

    Mapping Power Law Distributions in Digital Health Social Networks: Methods, Interpretations, and Practical Implications

    Abstract:

    Background: Social networks are common in digital health. A new stream of research is beginning to investigate the mechanisms of digital health social networks (DHSNs), how they are structured, how they function, and how their growth can be nurtured and managed. DHSNs increase in value when additional content is added, and the structure of networks may resemble the characteristics of power laws. Power laws are contrary to traditional Gaussian averages in that they demonstrate correlated phenomena. Objectives: The objective of this study is to investigate whether the distribution frequency in four DHSNs can be characterized as following a power law. A second objective is to describe the method used to determine the comparison. Methods: Data from four DHSNs—Alcohol Help Center (AHC), Depression Center (DC), Panic Center (PC), and Stop Smoking Center (SSC)—were compared to power law distributions. To assist future researchers and managers, the 5-step methodology used to analyze and compare datasets is described. Results: All four DHSNs were found to have right-skewed distributions, indicating the data were not normally distributed. When power trend lines were added to each frequency distribution, R2 values indicated that, to a very high degree, the variance in post frequencies can be explained by actor rank (AHC .962, DC .975, PC .969, SSC .95). Spearman correlations provided further indication of the strength and statistical significance of the relationship (AHC .987. DC .967, PC .983, SSC .993, P<.001). Conclusions: This is the first study to investigate power distributions across multiple DHSNs, each addressing a unique condition. Results indicate that despite vast differences in theme, content, and length of existence, DHSNs follow properties of power laws. The structure of DHSNs is important as it gives insight to researchers and managers into the nature and mechanisms of network functionality. The 5-step process undertaken to compare actor contribution patterns can be replicated in networks that are managed by other organizations, and we conjecture that patterns observed in this study could be found in other DHSNs. Future research should analyze network growth over time and examine the characteristics and survival rates of superusers.

  • (cc) Couturier et al, CC-BY-SA-2.0, please cite as (http://www.jmir.org/article/viewFile/4379/1/61224).

    Comparing Patients’ Opinions on the Hospital Discharge Process Collected With a Self-Reported Questionnaire Completed Via the Internet or Through a...

    Abstract:

    Background: Hospital discharge, a critical stage in the hospital-to-home transition of patient care, is a complex process with potential dysfunctions having an impact on patients’ health on their return home. No study has yet reported the feasibility and usefulness of an information system that would directly collect and transmit, via the Internet, volunteer patients’ opinions on their satisfaction concerning the organization of hospital discharge. Objective: Our primary objective was to compare patients’ opinions on the discharge process collected with 2 different methods: self-questionnaire completed on a dedicated website versus a telephone interview. The secondary goal was to estimate patient satisfaction. Methods: We created a questionnaire to examine hospital discharge according to 3 dimensions: discharge logistics organization, preplanned posthospital continuity-of-care organization, and patients’ impressions at the time of discharge. A satisfaction score (between 0 and 1) for each of those dimensions and an associated total score were calculated. Taking advantage of the randomized SENTIPAT trial that questioned patients recruited at hospital discharge about the evolution of their health after returning home and randomly assigned them to complete a self-questionnaire directly online or during a telephone interview, we conducted an ancillary study comparing satisfaction with the organization of hospital discharge for these 2 patient groups. The questionnaire was proposed to 1141 patients included in the trial who were hospitalized for ≥2 days, among whom 867 eligible patients had access to the Internet at home and were randomized to the Internet or telephone group. Results: Of the 1141 patients included, 755 (66.17%) completed the questionnaire. The response rates for the Internet (39.1%, 168/430) and telephone groups (87.2%, 381/437) differed significantly (P<.001), but their total satisfaction scores did not (P=.08) nor did the satisfaction subscores (P=.58 for discharge logistics organization, P=.12 for preplanned posthospital continuity-of-care organization, and P=.35 for patients’ impressions at the time of discharge). The total satisfaction score (median 0.83, IQR 0.72-0.92) indicated the patients’ high satisfaction. Conclusions: The direct transmission of personal health data via the Internet requires patients’ active participation and those planning surveys in the domain explored in this study should anticipate a lower response rate than that issued from a similar survey conducted by telephone interviews. Nevertheless, collecting patients’ opinions on their hospital discharge via the Internet proved operational; study results indicate that conducting such surveys via the Internet yields similar estimates to those obtained via a telephone survey. The results support the establishment of a permanent dedicated website that could also be used to obtain users’ opinions on other aspects of their hospital stay and follow-up. Trial Registration: Clinicaltrials.gov NCT01769261; http://clinicaltrials.gov/ct2/show/NCT01769261 (Archived by WebCite at http://www.webcitation.org/6ZDF5bdQb).

  • Screenshot from https://mycw3.eclinicalweb.com/empi/jsp/100mp/login.jsp. Copyright ©2015 eClinicalWeb. Licensed under the fair use/fair dealings clause for educational/scientific use.

    Patient Portals and Patient Engagement: A State of the Science Review

    Abstract:

    Background: Patient portals (ie, electronic personal health records tethered to institutional electronic health records) are recognized as a promising mechanism to support greater patient engagement, yet questions remain about how health care leaders, policy makers, and designers can encourage adoption of patient portals and what factors might contribute to sustained utilization. Objective: The purposes of this state of the science review are to (1) present the definition, background, and how current literature addresses the encouragement and support of patient engagement through the patient portal, and (2) provide a summary of future directions for patient portal research and development to meaningfully impact patient engagement. Methods: We reviewed literature from 2006 through 2014 in PubMed, Ovid Medline, and PsycInfo using the search terms “patient portal” OR “personal health record” OR “electronic personal health record”. Final inclusion criterion dictated that studies report on the patient experience and/or ways that patients may be supported to make competent health care decisions and act on those decisions using patient portal functionality. Results: We found 120 studies that met the inclusion criteria. Based on the research questions, explicit and implicit aims of the studies, and related measures addressed, the studies were grouped into five major topics (patient adoption, provider endorsement, health literacy, usability, and utility). We discuss the findings and conclusions of studies that address the five topical areas. Conclusions: Current research has demonstrated that patients’ interest and ability to use patient portals is strongly influenced by personal factors such age, ethnicity, education level, health literacy, health status, and role as a caregiver. Health care delivery factors, mainly provider endorsement and patient portal usability also contribute to patient’s ability to engage through and with the patient portal. Future directions of research should focus on identifying specific populations and contextual considerations that would benefit most from a greater degree of patient engagement through a patient portal. Ultimately, adoption by patients and endorsement by providers will come when existing patient portal features align with patients’ and providers’ information needs and functionality.

  • This is a royalty free image by imagerymajestic (http://www.freedigitalphotos.net/images/Computing_g368-Businessman_In_Tension_p89760.html).

    Association Between Acute Medical Exacerbations and Consuming or Producing Web-Based Health Information: Analysis From Pew Survey Data

    Abstract:

    Background: The Internet is an increasingly important resource for individuals who seek information from both health professionals and peers. While the demographic and health characteristics of persons who use health information technology has been well described, less is known about the relationship between these health characteristics and level of engagement with health information technology. Even less is known about whether persons who produce Web-based health information differ in health status from persons who consume such content. Objective: We explored the health characteristics of persons who engage with the Internet for the purposes of consuming or producing Web-based health information, and specifically, whether healthier versus sicker persons engage with health information technology in different ways. Methods: We analyzed data from the 2012 Pew Health survey, a landline and cell phone survey of 3104 adults in the United States. Using multiple logistic regression with sampling weights, we examined the association between sociodemographic and health characteristics and the consumption or production of Web-based health information. Sociodemographic variables included age, sex, race, and education. Health characteristics included self-reported health status, presence of chronic condition(s), and having an acute medical exacerbation. Acute medical exacerbations were defined as an emergency department visit, hospitalization, or other serious medical emergency in the last 12 months. Results: The majority of the sample reported good or excellent health (79.7%), although 50.3% reported having at least one chronic condition. About a fifth (20.2%) of the sample experienced an acute medical exacerbation in the past year. Education was the sociodemographic characteristic most strongly associated with consuming Web-based health information. The strongest health-related predictors of consuming Web-based health information were an acute medical exacerbation (OR 2.39, P<.001) and having a chronic condition (OR 1.54, P=.007). Having an acute medical exacerbation was the only predictor of producing Web-based health information (OR 1.97, P=.003). All participants, regardless of health status, were most interested in Web-based health information regarding diseases or medical problems. However, persons with acute medical exacerbations were more likely to seek Web-based health information regarding medical tests, procedures, and drugs compared to persons without acute medical exacerbations. Conclusions: Producers of Web-based health information differ from consumers of this information in important health characteristics that could skew the content of peer-generated Web-based health information and overrepresent the experiences of persons with acute medical exacerbations. Providers may have a role to play in directing patients towards high-quality, easy-to-understand online information, especially information regarding treatments and procedures.

  • © kebox_fotolia. Image purchased by authors.

    Gender Differences in Searching for Health Information on the Internet and the Virtual Patient-Physician Relationship in Germany: Exploratory Results on How...

    Abstract:

    Background: Many studies have shown that women use the Internet more often for health-related information searches than men, but we have limited knowledge about the underlying reasons. We also do not know whether and how women and men differ in their current use of the Internet for communicating with their general practitioner (GP) and in their future intention to do so (virtual patient-physician relationship). Objective: This study investigates (1) gender differences in health-related information search behavior by exploring underlying emotional, motivational, attitudinal as well as cognitive variables, situational involvement, and normative influences, and different personal involvement regarding health-related information searching and (2) gender differences in the virtual patient-physician relationship. Methods: Gender differences were analyzed based on an empirical online survey of 1006 randomly selected German patients. The sample was drawn from an e-panel maintained by GfK HealthCare. A total of 958 usable questionnaires were analyzed. Principal component analyses were carried out for some variables. Differences between men (517/958) and women (441/958) were analyzed using t tests and Kendall’s tau-b tests. The survey instrument was guided by several research questions and was based on existing literature. Results: Women were more engaged in using the Internet for health-related information searching. Gender differences were found for the frequency of usage of various Internet channels for health-related information searches. Women used the Internet for health-related information searches to a higher degree for social motives and enjoyment and they judged the usability of the Internet medium and of the information gained by health information searches higher than men did. Women had a more positive attitude toward Web 2.0 than men did, but perceived themselves as less digitally competent. Women had a higher health and nutrition awareness and a greater reluctance to make use of medical support, as well as a higher personal disposition of being well-informed as a patient. Men may be more open toward the virtual patient-physician relationship. Conclusions: Women have a stronger social motive for and experience greater enjoyment in health-related information searches, explained by social role interpretations, suggesting these needs should be met when offering health-related information on the Internet. This may be interesting for governmental bodies as well as for the insurance and the pharmaceutical industries. Furthermore, women may be more easily convinced by health awareness campaigns and are, therefore, the primary target group for them. Men are more open to engaging in a virtual relationship with the GP; therefore, they could be the primary target group for additional online services offered by GPs. There were several areas for GPs to reinforce the virtual patient-physician relationship: the fixing of personal appointments, referral to other doctors, writing prescriptions, and discussions of normal test results and doctor’s notes/certificates of health.

  • Online recruitment document.

    eHealth, Participatory Medicine, and Ethical Care: A Focus Group Study of Patients’ and Health Care Providers’ Use of Health-Related Internet Information

    Abstract:

    Background: The rapid explosion in online digital health resources is seen as transformational, accelerating the shift from traditionally passive patients to patients as partners and altering the patient–health care professional (HCP) relationship. Patients with chronic conditions are increasingly engaged, enabled, and empowered to be partners in their care and encouraged to take responsibility for managing their conditions with HCP support. Objective: In this paper, we focus on patients’ and HCPs’ use of health-related Internet information and how it influences the patient-HCP relationship. In particular, we examine the challenges emerging in medical encounters as roles and relationships shift and apply a conceptual framework of relational ethics to examine explicit and nuanced ethical dimensions emerging in patient-HCP interactions as both parties make increased use of health-related Internet information. Methods: We purposively sampled patients and HCPs in British Columbia, Canada, to participate in focus groups. To be eligible, patients self-reported a diagnosis of arthritis and at least one other chronic health condition; HCPs reported a caseload with >25% of patients with arthritis and multimorbidity. We used a semistructured, but flexible, discussion guide. All discussions were audiotaped and transcribed verbatim. Elements of grounded theory guided our constant comparison thematic analytic approach. Analysis was iterative. A relational ethics conceptual lens was applied to the data. Results: We recruited 32 participants (18 patients, 14 HCPs). They attended seven focus groups: four with patients and three with rehabilitation professionals and physicians. Predominant themes to emerge were how use of health-related Internet information fostered (1) changing roles, (2) patient-HCP partnerships, and (3) tensions and burdens for patients and HCPs. Conclusions: Relational aspects such as mutual trust, uncertainty, and vulnerability are illuminated in patient-HCP interactions around health-related Internet information and the negotiated space of clinical encounters. New roles and associated responsibilities have key ethical dimensions that make clear the changes are fundamental and important to understand in ethical care. When faced with tensions and burdens around incorporating health-related Internet information as a resource in clinical encounters, participants described a particular ambivalence illustrating the fundamental changes being negotiated by both patients and HCPs.

  • CC by Pöllö [http://commons.wikimedia.org/wiki/File:Tablets_pills_medicine_medical_waste.jpg].

    Characterizing the Discussion of Antibiotics in the Twittersphere: What is the Bigger Picture?

    Abstract:

    Background: User content posted through Twitter has been used for biosurveillance, to characterize public perception of health-related topics, and as a means of distributing information to the general public. Most of the existing work surrounding Twitter and health care has shown Twitter to be an effective medium for these problems but more could be done to provide finer and more efficient access to all pertinent data. Given the diversity of user-generated content, small samples or summary presentations of the data arguably omit a large part of the virtual discussion taking place in the Twittersphere. Still, managing, processing, and querying large amounts of Twitter data is not a trivial task. This work describes tools and techniques capable of handling larger sets of Twitter data and demonstrates their use with the issue of antibiotics. Objective: This work has two principle objectives: (1) to provide an open-source means to efficiently explore all collected tweets and query health-related topics on Twitter, specifically, questions such as what users are saying and how messages are spread, and (2) to characterize the larger discourse taking place on Twitter with respect to antibiotics. Methods: Open-source software suites Hadoop, Flume, and Hive were used to collect and query a large number of Twitter posts. To classify tweets by topic, a deep network classifier was trained using a limited number of manually classified tweets. The particular machine learning approach used also allowed the use of a large number of unclassified tweets to increase performance. Results: Query-based analysis of the collected tweets revealed that a large number of users contributed to the online discussion and that a frequent topic mentioned was resistance. A number of prominent events related to antibiotics led to a number of spikes in activity but these were short in duration. The category-based classifier developed was able to correctly classify 70% of manually labeled tweets (using a 10-fold cross validation procedure and 9 classes). The classifier also performed well when evaluated on a per category basis. Conclusions: Using existing tools such as Hive, Flume, Hadoop, and machine learning techniques, it is possible to construct tools and workflows to collect and query large amounts of Twitter data to characterize the larger discussion taking place on Twitter with respect to a particular health-related topic. Furthermore, using newer machine learning techniques and a limited number of manually labeled tweets, an entire body of collected tweets can be classified to indicate what topics are driving the virtual, online discussion. The resulting classifier can also be used to efficiently explore collected tweets by category and search for messages of interest or exemplary content.

  • Website homepage.

    Web-Based Cognitive Behavioral Therapy for Female Patients With Eating Disorders: Randomized Controlled Trial

    Abstract:

    Background: Many patients with eating disorders do not receive help for their symptoms, even though these disorders have severe morbidity. The Internet may offer alternative low-threshold treatment interventions. Objective: This study evaluated the effects of a Web-based cognitive behavioral therapy (CBT) intervention using intensive asynchronous therapeutic support to improve eating disorder psychopathology, and to reduce body dissatisfaction and related health problems among patients with eating disorders. Methods: A two-arm open randomized controlled trial comparing a Web-based CBT intervention to a waiting list control condition (WL) was carried out among female patients with bulimia nervosa (BN), binge eating disorder (BED), and eating disorders not otherwise specified (EDNOS). The eating disorder diagnosis was in accordance with the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, and was established based on participants’ self-report. Participants were recruited from an open-access website, and the intervention consisted of a structured two-part program within a secure Web-based application. The aim of the first part was to analyze participant’s eating attitudes and behaviors, while the second part focused on behavioral change. Participants had asynchronous contact with a personal therapist twice a week, solely via the Internet. Self-report measures of eating disorder psychopathology (primary outcome), body dissatisfaction, physical health, mental health, self-esteem, quality of life, and social functioning were completed at baseline and posttest. Results: A total of 214 participants were randomized to either the Web-based CBT group (n=108) or to the WL group (n=106) stratified by type of eating disorder (BN: n=44; BED: n=85; EDNOS: n=85). Study attrition was low with 94% of the participants completing the posttest assignment. Overall, Web-based CBT showed a significant improvement over time for eating disorder psychopathology (F97=63.07, P<.001, d=.82) and all secondary outcome measures (effect sizes between d=.34 to d=.49), except for Body Mass Index. WL participants also improved on most outcomes; however, effects were smaller in this group with significant between-group effects for eating disorder psychopathology (F201=9.42, P=.002, d=.44), body dissatisfaction (F201=13.16, P<.001, d=.42), physical health (F200=12.55, P<.001, d=.28), mental health (F203=4.88, P=.028, d=.24), self-esteem (F202=5.06, P=.026, d=.20), and social functioning (F205=7.93, P=.005, d=.29). Analyses for the individual subgroups BN, BED, and EDNOS showed that eating disorder psychopathology improved significantly over time among Web-based CBT participants in all three subgroups; however, the between-group effect was significant only for participants with BED (F78=4.25, P=.043, d=.61). Conclusions: Web-based CBT proved to be effective in improving eating disorder psychopathology and related health among female patients with eating disorders. Trial Registration: Nederlands Trial Register (NTR): NTR2415; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2415 (Archived by WebCite at http://www.webcitation.org/6T2io3DnJ).

  • Screenshot showing a video clip embedded in the online virtual patient activity used in this study.

    Medical Student and Tutor Perceptions of Video Versus Text in an Interactive Online Virtual Patient for Problem-Based Learning: A Pilot Study

    Abstract:

    Background: The impact of the use of video resources in primarily paper-based problem-based learning (PBL) settings has been widely explored. Although it can provide many benefits, the use of video can also hamper the critical thinking of learners in contexts where learners are developing clinical reasoning. However, the use of video has not been explored in the context of interactive virtual patients for PBL. Objective: A pilot study was conducted to explore how undergraduate medical students interpreted and evaluated information from video- and text-based materials presented in the context of a branched interactive online virtual patient designed for PBL. The goal was to inform the development and use of virtual patients for PBL and to inform future research in this area. Methods: An existing virtual patient for PBL was adapted for use in video and provided as an intervention to students in the transition year of the undergraduate medicine course at St George’s, University of London. Survey instruments were used to capture student and PBL tutor experiences and perceptions of the intervention, and a formative review meeting was run with PBL tutors. Descriptive statistics were generated for the structured responses and a thematic analysis was used to identify emergent themes in the unstructured responses. Results: Analysis of student responses (n=119) and tutor comments (n=18) yielded 8 distinct themes relating to the perceived educational efficacy of information presented in video and text formats in a PBL context. Although some students found some characteristics of the videos beneficial, when asked to express a preference for video or text the majority of those that responded to the question (65%, 65/100) expressed a preference for text. Student responses indicated that the use of video slowed the pace of PBL and impeded students’ ability to review and critically appraise the presented information. Conclusions: Our findings suggest that text was perceived to be a better source of information than video in virtual patients for PBL. More specifically, the use of video was perceived as beneficial for providing details, visual information, and context where text was unable to do so. However, learner acceptance of text was higher in the context of PBL, particularly when targeting clinical reasoning skills. This pilot study has provided the foundation for further research into the effectiveness of different virtual patient designs for PBL.

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  • The effectiveness of self-management smartphone and tablet apps in long term condition management.

    Date Submitted: Jul 1, 2015

    Open Peer Review Period: Jul 2, 2015 - Aug 27, 2015

    Background: Long term conditions and their concomitant management place considerable pressure on patients, communities, and health care systems worldwide. International clinical guidelines on the majo...

    Background: Long term conditions and their concomitant management place considerable pressure on patients, communities, and health care systems worldwide. International clinical guidelines on the majority of long term conditions recommend the inclusion of self-management programmes in routine management. Self-management programmes have been associated with improved health outcomes however, the successful and sustainable transfer of research programmes into clinical practice has been inconsistent. Recent developments in mobile technology, such as smartphone and tablet computer apps, could help in developing a platform for the delivery of self- management interventions that are adaptable, low-cost and easily accessible. Objective: We conducted a systematic review to assess the effectiveness of smartphone and tablet apps in self-management of key symptoms of long term conditions. Methods: We searched PubMed, Embase, EBSCO databases, the Cochrane library and Joanna Briggs library for randomised controlled trials that assessed the effectiveness of smartphone and tablet apps in self-management of diabetes mellitus, cardiovascular disease and chronic lung diseases from 2005-2015. Registers of current and ongoing trials were searched and the grey literature. The reference lists of all primary studies and review articles were checked for additional references. The last search was run in June 2015. Results: Six of the interventions demonstrated a statistically significant improvement in the primary measure of clinical outcome. Where the intervention comprised of an app only, three studies demonstrated a statistically significant improvement. Interventions to address diabetes mellitus (5/9) were the most common, followed by chronic lung disease (3/9) and cardiovascular disease (1/9). Three studies included multiple intervention groups using permutations of an intervention involving an app. The duration of the intervention ranged from a 6 week intervention to 1 year and final follow-up data ranged from 3 months to 1 year. Sample size ranged from 48 to 288 participants. Conclusions: The evidence indicates the potential of apps in improving symptom management through self-management interventions. The use of apps in mHealth has the potential to improve health outcomes among those living with chronic diseases through enhanced symptom control. Further innovation, optimisation, and rigorous research around the potential of apps in mHealth technology will move the field towards the reality of improved health care delivery and outcomes.

  • An Electronic Wellness Program to Improve Diet and Exercise in College Students

    Date Submitted: Jun 26, 2015

    Open Peer Review Period: Jun 26, 2015 - Aug 21, 2015

    Background: In transitioning from adolescence to adulthood, college students are faced with significant challenges to their health habits. Independence, stress, and perceived lack of time by college...

    Background: In transitioning from adolescence to adulthood, college students are faced with significant challenges to their health habits. Independence, stress, and perceived lack of time by college students have been known to result in poor eating and exercise habits, which can lead to increased disease risk. Objective: To assess the feasibility and efficacy of an electronic wellness program in improving diet and physical activity in college students. Methods: A 24-week diet and physical activity program was delivered via e-mail to 148 college students. The intervention involved weekly tailored, interactive diet and physical activity goals. The control group received non-diet-non-exercise-related health fact sheets. Anthropometric and blood pressure measurements, food frequency and physical activity surveys were conducted at baseline, week 12, and week 24. Students’ choice of fruit as a snack was also monitored at study visits. Results: Students were 18-20 years old, 69% female from a diverse college campus (46% Caucasian, 23% Asian, 20% African American, 11% other). At week 24, 84% of students reported reading at least half of all emails. Mean change (± standard error) from baseline of saturated fat intake was significant between the treatment groups at week 24, 0.7±0.42% kcal for Control and -0.3±0.30% kcal for Intervention (P = 0.048). A significant difference in percent of snacks chosen that were fruit (χ2 (1, N=221) = 11.7, P < 0.001) was detected between the Intervention and the Control group at week 24. No significant changes in anthropometric measures or physical activity were detected. Conclusions: Use of an electronic wellness program is feasible in college students and resulted in a decrease in saturated fat intake and an increase in observed fruit intake compared to Control.

  • User Preferences of an Alcohol Self-management application: An initial evaluation

    Date Submitted: Jun 26, 2015

    Open Peer Review Period: Jun 26, 2015 - Aug 21, 2015

    Background: The prevalence of at-risk drinking and alcohol use disorders are increasing. There have been advances in technology and this has resulted in numerous smartphone applications for this disor...

    Background: The prevalence of at-risk drinking and alcohol use disorders are increasing. There have been advances in technology and this has resulted in numerous smartphone applications for this disorder. However, there remain to be concerns about the evidence based of previous developed application. Objective: The following study aims to illustrate how the authors have made use of innovative methodologies to overcome the issues relating to the accuracy of tracking the amount of alcohol one has consumed; and the following study also aims to determine user perceptions about the innovative tracker and various other features of an alcohol self-management applications amongst a group of individuals from the general population of a developed country (Canada). Methods: A native alcohol self-management application was developed. n order to determine user perspectives towards this new innovative application, the authors took advantage and made use of crowdsourcing to acquire user perspectives. Results: Our results showed that smartphone ownership is highest amongst the age group of 35 to 44 years old (91%) and lowest for those aged between 55 and 64 (58%). Our analysis also showed that 25-34 and 35-44 year olds drink more frequently than the other groups. Results suggest that notification and information were the two most useful functions, with psychotherapy expected to be the least useful. Females indicated that notification service was the most useful function, while males preferred the information component. Conclusions: This study has demonstrated how the authors have made use of innovative technologies to overcome the existing concern pertaining to the utilization of the BAC levels as a tracker. In addition, the authors have managed to highlight user preferences with regards to an alcohol application.

  • Does Academic Blogging Enhance Promotion and Tenure? A Survey of US and Canadian Medicine and Pediatric Department Chairs

    Date Submitted: Jun 25, 2015

    Open Peer Review Period: Jun 26, 2015 - Aug 21, 2015

    Background: The use of electronic educational (e-learning) technology continues to grow. Many medical journals operate companion blogs (an application of e-learning technology) that enable rapid disse...

    Background: The use of electronic educational (e-learning) technology continues to grow. Many medical journals operate companion blogs (an application of e-learning technology) that enable rapid dissemination of scientific knowledge and discourse. Participating faculty members in promotion and tenure academic tracks spend valuable time and effort contributing, editing and directing these medical journal blogs. Objective: We sought to understand (a) whether faculty blog authorship is acknowledged by medicine and pediatrics chairs as academic achievement and (b) whether blog authorship helps faculty achieve promotion and tenure. Methods: The author’s surveyed 277 chairs of both US and Canadian medicine and pediatric departments regarding their attitudes toward the role of faculty participation in e-learning (in general) and blogging (in particular) in the promotion and tenure process. The survey was completed by 23% (61/267) of surveyed chairs. Results: A majority of respondents (87%) viewed educational scholarship as either important or very important for promotion. Only 21% perceived value to faculty effort in producing content for a journal-based blog. If faculty were to participate in blog authorship, eighty percent of surveyed chairs favored involvement in a journal-based as compared with society-based or personal blogs. We identified a "favorable group" of chairs (n=19, 31%) who rated leadership roles in e-learning tools as important or very important and an "unfavorable group" of chairs (n=42, 69%) who rated leadership roles in e-learning tools as somewhat important, not important, or no response. The "favorable group" were more likely to be aware of faculty bloggers within their departments (58% vs. 24%), viewed serving on editorial boards of e-learning tools more favorably (79% vs. 29%), and were more likely to value effort spent contributing to journal-based blogs (53% vs. 10%). Conclusions: This survey demonstrates that department chairs prefer participation in journal-based blogs. A minority perceive value to faculty blogging effort. The authors identified a dichotomous valuation of participation in e-learning for promotion and tenure.

  • Needs for the ICT-based personalized health management program and the association among information provision, HRQOL, Decisional Conflict in Cancer Patients

    Date Submitted: Jun 24, 2015

    Open Peer Review Period: Jun 24, 2015 - Aug 19, 2015

    Background: Information communication technology (ICT), such as web- or smartphone-based tailored health management programs, can have a significant health impact on cancer patients. Objective: To det...

    Background: Information communication technology (ICT), such as web- or smartphone-based tailored health management programs, can have a significant health impact on cancer patients. Objective: To determine the relationship of three factors, health information provision, health-related quality of life (HRQOL), and decision conflicts, with the need for an ICT-based personalized health management program in a sample of Korean cancer survivors Methods: The health program needs of 625 cancer survivors from two hospitals in Korea were analyzed in this cross-sectional study. A multivariate logistic regression model was used to identify factors related to the need for an ICT-based tailored health management system. The association of the highest needs for an ICT-based tailored health management program with medical information experience, HRQOL, and decision conflicts was determined. In addition to level of need, patient intention and expectation for a web- or smartphone-based tailored health management program were also investigated. Results: Cancer survivors responded with a high prevalence of personalized health management program needs. Patients who reported the highest necessity of such a program included those with a higher income (adjusted odds ratio [aOR], 1.70, 95% CI, 1.10-2.63), those who had already received enough information about things patients can do to help themselves (aOR, 1.71, 95% CI, 1.09 to 2.66), and those who wished to receive more information (aOR, 1.59, 95% CI, 0.97 to 2.61). Moreover, participants who had cognitive functioning problems (aOR, 2.87, 95%CI, 1.34 to 6.17) and had appetite loss (aOR, 1.77, 95% CI, 1.07 to 2.93) replied that they needed a tailored healthcare program. Patients who perceived much more support from the decision-making process also showed the highest need for an ICT-based program (aOR, 0.49, 95% CI, 0.30 to 0.82). Conclusions: Taken together, our findings demonstrated that higher income, information provision experience, problematic HRQOL, and decisional conflicts had significant associations with the need for an ICT-based tailored self-management program.

  • The Effectiveness of Blended Learning in the Health Professions: A Meta-analysis

    Date Submitted: Jun 24, 2015

    Open Peer Review Period: Jun 24, 2015 - Aug 19, 2015

    Background: Blended learning has grown rapidly and is likely to emerge as the new normal model in education. Concerns about the effectiveness of blended learning have led to an increasing number of st...

    Background: Blended learning has grown rapidly and is likely to emerge as the new normal model in education. Concerns about the effectiveness of blended learning have led to an increasing number of studies on this topic. However, as of yet there has been no quantitative synthesis to evaluate the effectiveness of blended learning in health professions. Objective: We sought to assess the effectiveness of blended learning for health professional learners compared with no intervention and with non-blended learning. We also sought to explore factors that could explain differences in learning effects across study designs, participants, country socioeconomic status, durations, randomization, and quality scores for each of these questions. Methods: We conducted a search of citations in Medline, CINAHL, Science direct, Ovid Embase, Web of Science, and ERIC from 1991 through September 2014. Studies in any language that compared blended learning with no intervention or non-blended learning among health professional learners and assessed knowledge were included. Two reviewers independently evaluated study quality and abstracted information including characteristics of learners and intervention (study design, practice exercise, interactivity, peer discussion, and outcome assessment). Results: Fifty-six eligible articles were identified. Heterogeneity across studies was large (I2 ≥88.4) in all analyses. For studies comparing knowledge gained from blended learning versus no intervention, the pooled effect size was 1.55 (95% CI: 1.16–1.94; P<.001; n=18 interventions) with no significant publication bias, and exclusion of any single study did not change the overall results. For studies comparing non-blended learning (including pure e-learning and face-to-face learning), the pooled effect size was 0.94 (95% CI: 0.66–1.22; P<.001; n=46 interventions), and exclusion of any single study did not change the overall results. Although significant publication bias was found, the trim and fill method showed that the effect size changed to 0.22 (95% CI: 0.17-0.28) after adjustment. In the subgroup analyses, pre-posttest study design, high socioeconomic status of country, presence of practice exercise, and objective outcome assessment yielded larger effect sizes. Compared with both e-learning and face-to-face learning, blended learning was more effective. Conclusions: Blended learning appears to have a consistent positive effect for knowledge in comparison both with no intervention and with non-blended instruction in health professions.