JMIR Publications

Journal of Medical Internet Research

The leading peer-reviewed journal for digital medicine, and health & healthcare in the Internet age.

JMIR's Thomson Reuter Impact Factor of 5.175 for 2016

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  • 15 years of non-smoking vs. 15 years of smoking one pack a day (right). Source: The Authors; Copyright: Titus Josef Brinker; URL:; License: Creative Commons Attribution (CC-BY).

    A Dermatologist's Ammunition in the War Against Smoking: A Photoaging App


    This viewpoint reviews the perspectives for dermatology as a specialty to go beyond the substantial impact of smoking on skin disease and leverage the impact of skin changes on a person's self-concept and behavior in the design of effective interventions for smoking prevention and cessation.

  • MyPersonality Project website (montage). Source: myPersonality Project Website /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Computerized Adaptive Testing Provides Reliable and Efficient Depression Measurement Using the CES-D Scale


    Background: The Center for Epidemiologic Studies Depression Scale (CES-D) is a measure of depressive symptomatology which is widely used internationally. Though previous attempts were made to shorten the CES-D scale, few have attempted to develop a Computerized Adaptive Test (CAT) version for the CES-D. Objective: The aim of this study was to provide evidence on the efficiency and accuracy of the CES-D when administered using CAT using an American sample group. Methods: We obtained a sample of 2060 responses to the CESD-D from US participants using the myPersonality application. The average age of participants was 26 years (range 19-77). We randomly split the sample into two groups to evaluate and validate the psychometric models. We used evaluation group data (n=1018) to assess dimensionality with both confirmatory factor and Mokken analysis. We conducted further psychometric assessments using item response theory (IRT), including assessments of item and scale fit to Samejima’s graded response model (GRM), local dependency and differential item functioning. We subsequently conducted two CAT simulations to evaluate the CES-D CAT using the validation group (n=1042). Results: Initial CFA results indicated a poor fit to the model and Mokken analysis revealed 3 items which did not conform to the same dimension as the rest of the items. We removed the 3 items and fit the remaining 17 items to GRM. We found no evidence of differential item functioning (DIF) between age and gender groups. Estimates of the level of CES-D trait score provided by the simulated CAT algorithm and the original CES-D trait score derived from original scale were correlated highly. The second CAT simulation conducted using real participant data demonstrated higher precision at the higher levels of depression spectrum. Conclusions: Depression assessments using the CES-D CAT can be more accurate and efficient than those made using the fixed-length assessment.

  • Blood pressure monitor. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Personalized Hypertension Management Using Patient-Generated Health Data Integrated With Electronic Health Records (EMPOWER-H): Six-Month Pre-Post Study


    Background: EMPOWER-H (Engaging and Motivating Patients Online With Enhanced Resources-Hypertension) is a personalized-care model facilitating engagement in hypertension self-management utilizing an interactive Web-based disease management system integrated with the electronic health record. The model is designed to support timely patient-provider interaction by incorporating decision support technology to individualize care and provide personalized feedback for patients with chronic disease. Central to this process were patient-generated health data, including blood pressure (BP), weight, and lifestyle behaviors, which were uploaded using a smartphone. Objective: The aim of this study was to evaluate the program among patients within primary care already under management for hypertension and with uncontrolled BP. Methods: Using a 6-month pre-post design, outcome measures included office-measured and home-monitored BP, office-measured weight, intervention contacts, diet, physical activity, smoking, knowledge, and health-related quality of life. Results: At 6 months, 55.9% of participants (N=149) achieved office BP goals (<140/90 mm Hg; P<.001) and 86.0% achieved clinically meaningful reduction in office BP (reduction in systolic BP [SBP] ≥5 mm Hg or diastolic BP [DBP] ≥3 mm Hg). At baseline, 25.2% of participants met home BP goals (<135/85 mm Hg), and this percentage significantly increased to 71.4% (P<.001) at 6 months. EMPOWER-H also significantly reduced both office and home SBP and DBP, decreased office-measured weight and consumption of high-salt and high-fat foods (all P<.005), and increased intake of fruit and vegetables, minutes of aerobic exercise, and hypertension knowledge (all P<.05). Patients with higher home BP upload frequencies had significantly higher odds of achieving home BP goals. Patients receiving more total intervention, behavioral, pharmaceutical contacts had significantly lower odds of achieving home BP goals but higher improvements in office BP (all P<.05). Conclusions: EMPOWER-H significantly improved participants’ office-measured and home-monitored BP, weight, and lifestyle behaviors, suggesting that technologically enabled BP home-monitoring, with structured use of patient-generated health data and a personalized care-plan facilitating patient engagement, can support effective clinical management. The experience gained in this study provides support for the feasibility and value of using carefully managed patient-generated health data in the day-to-day clinical management of patients with chronic conditions. A large-scale, real-world study to evaluate sustained effectiveness, cost-effectiveness, and scalability is warranted.

  • Source: Shutterstock; Copyright: And-One; URL:; License: Licensed by JMIR.

    Components and Outcomes of Internet-Based Interventions for Caregivers of Older Adults: Systematic Review


    Background: When trying to access interventions to improve their well-being and quality of life, family caregivers face many challenges. Internet-based interventions provide new and accessible opportunities to remotely support them and can contribute to reducing their burden. However, little is known about the link existing between the components, the use of behavior change techniques, and the outcomes of these Internet-based interventions. Objective: This study aimed to provide an update on the best available evidence about the efficacy of Internet-based interventions for caregivers of older adults. Specifically, the components and the use of behavior change techniques and how they impact on the efficacy of the intervention were sought. Methods: A systematic review searched primary source studies published between 2000 and 2015. Included studies were scored with a high level of evidence by independent raters using the GRADE criteria and reported caregiver-specific outcomes about interventions delivered through the Internet for caregivers of people aged 50 years and older. A narrative synthesis identified intervention components (eg, content, multimedia use, interactive online activities, and provision of support), behavior change techniques, and caregiver outcomes (eg, effects on stressors, mediators, and psychological health). The risk of bias within the included studies was assessed. Results: A total of 2338 articles were screened and 12 studies describing 10 Internet-based interventions were identified. Seven of these interventions led to statistically significant improvements in caregiver outcomes (eg, reducing depression or anxiety, n=4). These efficacious interventions used interactive components, such as online exercises and homework (n=4) or questionnaires on health status (n=2) and five of them incorporated remote human support, either by professionals or peers. The most frequently used behavior change techniques included in efficacious interventions were provision of social support (n=6) and combinations of instructions to guide behavior change and barrier identification (n=5). The design and aim of the included studies did not permit determining exactly which component and/or behavior change technique was more efficacious in producing positive outcomes in caregivers. The risk for selection bias was low for all the studies, and low to high for performance, detection, and attrition biases. Conclusions: In sum, Internet-based interventions that incorporate professional and social support, and provide instructions to change behavior and problem solve in an interactive manner appear to lead to positive outcomes in caregivers. Studies isolating the specific effect of components are needed to improve our understanding of the underlying mechanism of action.

  • PlayForward: Elm City Stories characters (montage). Source: play2PREVENT Lab /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Video Game Intervention for Sexual Risk Reduction in Minority Adolescents: Randomized Controlled Trial


    Background: Human immunodeficiency virus (HIV) disproportionately impacts minority youth. Interventions to decrease HIV sexual risk are needed. Objective: We hypothesized that an engaging theory-based digital health intervention in the form of an interactive video game would improve sexual health outcomes in adolescents. Methods: Participants aged 11 to 14 years from 12 community afterschool, school, and summer programs were randomized 1:1 to play up to 16 hours of an experimental video game or control video games over 6 weeks. Assessments were conducted at 6 weeks and at 3, 6, and 12 months. Primary outcome was delay of initiation of vaginal/anal intercourse. Secondary outcomes included sexual health attitudes, knowledge, and intentions. We examined outcomes by gender and age. Results: A total of 333 participants were randomized to play the intervention (n=166) or control games (n=167): 295 (88.6%) were racial/ethnic minorities, 177 (53.2%) were boys, and the mean age was 12.9 (1.1) years. At 12 months, for the 258 (84.6%) participants with available data, 94.6% (122/129) in the intervention group versus 95.4% (123/129) in the control group delayed initiation of intercourse (relative risk=0.99, 95% CI 0.94-1.05, P=.77). Over 12 months, the intervention group demonstrated improved sexual health attitudes overall compared to the control group (least squares means [LS means] difference 0.37, 95% CI 0.01-0.72, P=.04). This improvement was observed in boys (LS means difference 0.67, P=.008), but not girls (LS means difference 0.06, P=.81), and in younger (LS means difference 0.71, P=.005), but not older participants (LS means difference 0.03, P=.92). The intervention group also demonstrated increased sexual health knowledge overall (LS means difference 1.13, 95% CI 0.64-1.61, P<.001), in girls (LS means difference 1.16, P=.001), boys (LS means difference 1.10, P=.001), younger (LS means difference 1.18, P=.001), and older (LS means difference=1.08, P=.002) participants. There were no differences in intentions to delay the initiation of intercourse between the two groups (LS means difference 0.10, P=.56). Conclusions: An interactive video game intervention improves sexual health attitudes and knowledge in minority adolescents for at least 12 months. Trial Registration: NCT01666496; (Archived by WebCite at

  • Source:; Copyright: Photo-Mix; URL:; License: Public Domain (CC0).

    Cardiac Patients’ Experiences and Perceptions of Social Media: Mixed-Methods Study


    Background: Traditional in-person cardiac rehabilitation has substantial benefits for cardiac patients, which are offset by poor attendance. The rapid increase in social media use in older adults provides an opportunity to reach patients who are eligible for cardiac rehabilitation but unable to attend traditional face-to-face groups. However, there is a paucity of research on cardiac patients’ experiences and perspectives on using social media to support their health. Objective: The aim of this study was to describe cardiac rehabilitation patients’ experiences in using social media in general and their perspective on using social media, particularly Facebook, to support their cardiac health and secondary prevention efforts. Methods: A mixed-methods study was undertaken among cardiac rehabilitation patients in both urban and rural areas. First, this study included a survey (n=284) on social media use and capability. Second, six focus group interviews were conducted with current Facebook users (n=18) to elucidate Facebook experience and perspectives. Results: Social media use was low (28.0%, 79/282) but more common in participants who were under 70 years of age, employed, and had completed high school. Social media users accessed Web-based information on general health issues (65%, 51/79), medications (56%, 44/79), and heart health (43%, 34/79). Participants were motivated to invest time in using Facebook for “keeping in touch” with family and friends and to be informed by expert cardiac health professionals and fellow cardiac participants if given the opportunity. It appeared that participants who had a higher level of Facebook capability (understanding of features and the consequences of their use and efficiency in use) spent more time on Facebook and reported higher levels of “liking,” commenting, or sharing posts. Furthermore, higher Facebook capability appeared to increase a participants’ willingness to participate in a cardiac Facebook support group. More capable users were more receptive to the use of Facebook for cardiac rehabilitation and more likely to express interest in providing peer support. Recommended features for a cardiac rehabilitation Facebook group included a closed group, expert cardiac professional involvement, provision of cardiac health information, and ensuring trustworthiness of the group. Conclusions: Cardiac health professionals have an opportunity to capitalize on cardiac patients’ motivations and social media, mostly Facebook, as well as the capability for supporting cardiac rehabilitation and secondary prevention. Participants’ favored purposeful time spent on Facebook and their cardiac health provides such a purpose for a Facebook intervention. The study results will inform the development of a Facebook intervention for secondary prevention of cardiovascular disease.

  • Source: The Authors; Copyright:; URL:; License: Licensed by the authors.

    Blending Face-to-Face and Internet-Based Interventions for the Treatment of Mental Disorders in Adults: Systematic Review


    Background: Many studies have provided evidence for the effectiveness of Internet-based stand-alone interventions for mental disorders. A newer form of intervention combines the strengths of face-to-face (f2f) and Internet approaches (blended interventions). Objective: The aim of this review was to provide an overview of (1) the different formats of blended treatments for adults, (2) the stage of treatment in which these are applied, (3) their objective in combining face-to-face and Internet-based approaches, and (4) their effectiveness. Methods: Studies on blended concepts were identified through systematic searches in the MEDLINE, PsycINFO, Cochrane, and PubMed databases. Keywords included terms indicating face-to-face interventions (“inpatient,” “outpatient,” “face-to-face,” or “residential treatment”), which were combined with terms indicating Internet treatment (“internet,” “online,” or “web”) and terms indicating mental disorders (“mental health,” “depression,” “anxiety,” or “substance abuse”). We focused on three of the most common mental disorders (depression, anxiety, and substance abuse). Results: We identified 64 publications describing 44 studies, 27 of which were randomized controlled trials (RCTs). Results suggest that, compared with stand-alone face-to-face therapy, blended therapy may save clinician time, lead to lower dropout rates and greater abstinence rates of patients with substance abuse, or help maintain initially achieved changes within psychotherapy in the long-term effects of inpatient therapy. However, there is a lack of comparative outcome studies investigating the superiority of the outcomes of blended treatments in comparison with classic face-to-face or Internet-based treatments, as well as of studies identifying the optimal ratio of face-to-face and Internet sessions. Conclusions: Several studies have shown that, for common mental health disorders, blended interventions are feasible and can be more effective compared with no treatment controls. However, more RCTs on effectiveness and cost-effectiveness of blended treatments, especially compared with nonblended treatments are necessary.

  • PiiA application of the EORTC QLQ-C30 questionnaire for 4-point-scale questions in German (montage). Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Reliability of an e-PRO Tool of EORTC QLQ-C30 for Measurement of Health-Related Quality of Life in Patients With Breast Cancer: Prospective Randomized Trial


    Background: Breast cancer represents the most common malignant disease in women worldwide. As currently systematic palliative treatment only has a limited effect on survival rates, the concept of health-related quality of life (HRQoL) is gaining more and more importance in the therapy setting of metastatic breast cancer. One of the major patient-reported outcomes (PROs) for measuring HRQoL in patients with breast cancer is provided by the European Organization for Research and Treatment of Cancer (EORTC). Currently, paper-based surveys still predominate, as only a few reliable and validated electronic-based questionnaires are available. Facing the possibilities associated with evolving digitalization in medicine, validation of electronic versions of well-established PRO is essential in order to contribute to comprehensive and holistic oncological care and to ensure high quality in cancer research. Objective: The aim of this study was to analyze the reliability of a tablet-based measuring application for EORTC QLQ-C30 in German language in patients with adjuvant and (curative) metastatic breast cancer. Methods: Paper- and tablet-based questionnaires were completed by a total of 106 female patients with adjuvant and metastatic breast cancer recruited as part of the e-PROCOM study. All patients were required to complete the electronic- (e-PRO) and paper-based versions of the HRQoL EORTC QLQ-C30 questionnaire. A frequency analysis was performed to determine descriptive sociodemographic characteristics. Both dimensions of reliability (parallel forms reliability [Wilcoxon test] and test of internal consistency [Spearman rho and agreement rates for single items, Pearson correlation and Kendall tau for each scale]) were analyzed. Results: High correlations were shown for both dimensions of reliability (parallel forms reliability and internal consistency) in the patient’s response behavior between paper- and electronic-based questionnaires. Regarding the test of parallel forms reliability, no significant differences were found in 27 of 30 single items and in 14 of 15 scales, whereas a statistically significant correlation in the test of consistency was found in all 30 single items and all 15 scales. Conclusions: The evaluated e-PRO version of the EORTC QLQ-C30 is reliable for patients with both adjuvant and metastatic breast cancer, showing a high correlation in almost all questions (and in many scales). Thus, we conclude that the validated paper-based PRO assessment and the e-PRO tool are equally valid. However, the reliability should also be analyzed in other prospective trials to ensure that usability is reliable in all patient groups. Trial Registration: NCT03132506; (Archived by WebCite at

  • Source: Pixabay; Copyright: Free-Photos; URL:; License: Public Domain (CC0).

    User Acceptance of Computerized Cognitive Behavioral Therapy for Depression: Systematic Review


    Background: Computerized cognitive behavioral therapy (cCBT) has been proven to be effective in depression care. Moreover, cCBT packages are becoming increasingly popular. A central aspect concerning the take-up and success of any treatment is its user acceptance. Objective: The aim of this study was to update and expand on earlier work on user acceptance of cCBT for depression. Methods: This paper systematically reviewed quantitative and qualitative studies regarding the user acceptance of cCBT for depression. The initial search was conducted in January 2016 and involved the following databases: Web of Science, PubMed, the Cochrane Library, and PsycINFO. Studies were retained if they described the explicit examination of the user acceptance, experiences, or satisfaction related to a cCBT intervention, if they reported depression as a primary outcome, and if they were published in German or English from July 2007 onward. Results: A total of 1736 studies were identified, of which 29 studies were eligible for review. User acceptance was operationalized and analyzed very heterogeneously. Eight studies reported a very high level of acceptance, 17 indicated a high level of acceptance, and one study showed a moderate level of acceptance. Two qualitative studies considered the positive and negative aspects concerning the user acceptance of cCBT. However, a substantial proportion of reviewed studies revealed several methodical shortcomings. Conclusions: In general, people experience cCBT for depression as predominantly positive, which supports the potential role of these innovative treatments. However, methodological challenges do exist in terms of defining user acceptance, clear operationalization of concepts, and measurement.

  • Source: Pixabay; Copyright: StartupStockPhotos; URL:; License: Public Domain (CC0).

    Putting the Focus Back on the Patient: How Privacy Concerns Affect Personal Health Information Sharing Intentions


    Background: Health care providers are driven by greater participation and systemic cost savings irrespective of benefits to individual patients derived from sharing Personal Health Information (PHI). Protecting PHI is a critical issue in the sharing of health care information systems; yet, there is very little literature examining the topic of sharing PHI electronically. A good overview of the regulatory, privacy, and societal barriers to sharing PHI can be found in the 2009 Health Information Technology for Economic and Clinical Health Act. Objective: This study investigated the factors that influence individuals’ intentions to share their PHI electronically with health care providers, creating an understanding of how we can represent a patient’s interests more accurately in sharing settings, instead of treating patients like predetermined subjects. Unlike privacy concern and trust, patient activation is a stable trait that is not subject to change in the short term and, thus, is a useful factor in predicting sharing behavior. We apply the extended privacy model in the health information sharing context and adapt this model to include patient activation and issue involvement to predict individuals’ intentions. Methods: This was a survey-based study with 1600+ participants using the Health Information National Trends Survey (HINTS) data to validate a model through various statistical techniques. The research method included an assessment of both the measurement and structural models with post hoc analysis. Results: We find that privacy concern has the most influence on individuals’ intentions to share. Patient activation, issue involvement, and patient-physician relationship are significant predictors of sharing intention. We contribute to theory by introducing patient activation and issue involvement as proxies for personal interest factors in the health care context. Conclusions: Overall, this study found that although patients are open to sharing their PHI, they still have concerns over the privacy of their PHI during the sharing process. It is paramount to address this factor to increase information flow and identify how patients can assure that their privacy is protected. The outcome of this study is a set of recommendations for motivating the sharing of PHI. The goal of this research is to increase the health profile of the patients by integrating the testing and diagnoses of various doctors across health care providers and, thus, bring patients closer to the physicians.

  • A young woman shows off her flu shot after receiving vaccine at a local drug store. Source: Wikimedia Commons; Copyright: Whoisjohngalt; URL:; License: Creative Commons Attribution + ShareAlike (CC-BY-SA).

    Enhancing Seasonal Influenza Surveillance: Topic Analysis of Widely Used Medicinal Drugs Using Twitter Data


    Background: Uptake of medicinal drugs (preventive or treatment) is among the approaches used to control disease outbreaks, and therefore, it is of vital importance to be aware of the counts or frequencies of most commonly used drugs and trending topics about these drugs from consumers for successful implementation of control measures. Traditional survey methods would have accomplished this study, but they are too costly in terms of resources needed, and they are subject to social desirability bias for topics discovery. Hence, there is a need to use alternative efficient means such as Twitter data and machine learning (ML) techniques. Objective: Using Twitter data, the aim of the study was to (1) provide a methodological extension for efficiently extracting widely consumed drugs during seasonal influenza and (2) extract topics from the tweets of these drugs and to infer how the insights provided by these topics can enhance seasonal influenza surveillance. Methods: From tweets collected during the 2012-13 flu season, we first identified tweets with mentions of drugs and then constructed an ML classifier using dependency words as features. The classifier was used to extract tweets that evidenced consumption of drugs, out of which we identified the mostly consumed drugs. Finally, we extracted trending topics from each of these widely used drugs’ tweets using latent Dirichlet allocation (LDA). Results: Our proposed classifier obtained an F1 score of 0.82, which significantly outperformed the two benchmark classifiers (ie, P<.001 with the lexicon-based and P=.048 with the 1-gram term frequency [TF]). The classifier extracted 40,428 tweets that evidenced consumption of drugs out of 50,828 tweets with mentions of drugs. The most widely consumed drugs were influenza virus vaccines that had around 76.95% (31,111/40,428) share of the total; other notable drugs were Theraflu, DayQuil, NyQuil, vitamins, acetaminophen, and oseltamivir. The topics of each of these drugs exhibited common themes or experiences from people who have consumed these drugs. Among these were the enabling and deterrent factors to influenza drugs uptake, which are keys to mitigating the severity of seasonal influenza outbreaks. Conclusions: The study results showed the feasibility of using tweets of widely consumed drugs to enhance seasonal influenza surveillance in lieu of the traditional or conventional surveillance approaches. Public health officials and other stakeholders can benefit from the findings of this study, especially in enhancing strategies for mitigating the severity of seasonal influenza outbreaks. The proposed methods can be extended to the outbreaks of other diseases.

  • Chinese older adults using mobile phones. Source: Image created by the author; Copyright: The Authors; License: Creative Commons Attribution (CC-BY).

    The Digital Divide and Health Disparities in China: Evidence From a National Survey and Policy Implications


    Background: The digital divide persists despite broad accessibility of mobile tools. The relationship between the digital divide and health disparities reflects social status in terms of access to resources and health outcomes; however, data on this relationship are limited from developing countries such as China. Objective: The aim of this study was to examine the current rates of access to mobile tools (Internet use and mobile phone ownership) among older Chinese individuals (aged ≥45 years), the predictors of access at individual and community levels, and the relationship between access to mobile tools and health outcomes. Methods: We drew cross-sectional data from a national representative survey, the China Health and Retirement Longitudinal Study (CHARLS), which focused on the older population (aged ≥45 years). We used two-level mixed logistic regression models, controlling for unobserved heterogeneity at the community and individual levels for data analysis. In addition to individual-level socioeconomic status (SES), we included community-level resources such as neighborhood amenities, health care facilities, and community organizations. Health outcomes were measured by self-reported health and absence of disability based on validated scales. Results: Among the 18,215 participants, 6.51% had used the Internet in the past month, and 83% owned a mobile phone. In the multivariate models, Internet use was strongly associated with SES, rural or urban residence, neighborhood amenities, community resources, and geographic region. Mobile phone ownership was strongly associated with SES and rural/urban residence but not so much with neighborhood amenities and community resources. Internet use was a significant predictor of self-reported health status, and mobile phone ownership was significantly associated with having disability even after controlling for potential confounders at the individual and community levels. Conclusions: This study is one of the first to examine digital divide and its relationship with health disparities in China. The data showed a significant digital divide in China, especially in the older population. Internet access is still limited to people with higher SES; however, the mobile phone has been adopted by the general population. The digital divide is associated with not only individual SES but also community resources. Future electronic health (eHealth) programs need to consider the accessibility of mobile tools and develop culturally appropriate programs for various social groups.

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  • What do Persons with Multiple Sclerosis need from an mHealth app for Physical Activity? A qualitative exploratory study.

    Date Submitted: Sep 19, 2017

    Open Peer Review Period: Sep 20, 2017 - Nov 15, 2017

    Background: Multiple sclerosis (MS) is one of the world’s most common neurologic disorders. The most common symptoms are overwhelming fatigue, visual disturbances, altered sensation, cognitive probl...

    Background: Multiple sclerosis (MS) is one of the world’s most common neurologic disorders. The most common symptoms are overwhelming fatigue, visual disturbances, altered sensation, cognitive problems and difficulties with mobility. Evidence suggests that physical activity (PA) helps people with MS stay active and reduces fatigue as well as improving quality of life. The use of mobile apps for health and wellbeing promotion has grown exponentially in recent years. There is currently a gap on mHealth applications for MS and to our knowledge no study has explored persons with MS perspectives to mHealth solutions for PA. Objective: The aim of this study was to: 1) generate insight as to persons with MS specific needs and characteristics for MS mHealth applications for Physical Activity; 2) detect perceived obstacles and facilitators for such mHealth solutions from persons with MS and healthcare professionals; and 3) provide validated MS personas to help further development of mHealth solutions for MS. Methods: A qualitative study was conducted in Kliniken Valens, Switzerland; a clinic specialized in neurological, musculoskeletal, and geriatric rehabilitation. Two series of focus groups, interviews and structured questionnaires took place. One with persons with MS and the other with healthcare professionals who work with MS. Demographic characteristics, satisfaction with life (SWLS), eHealth literacy (eHEALS), and technology use were assessed as well as user needs, barriers, facilitators and desired features for mHealth MS apps. Themes were identified during analysis such as: MS related barriers and facilitators; mHealth Design Considerations and General Motivational Aspects. Information and insights were used to create MS personas for design purposes. Results: A total of 12 persons with MS and 12 healthcare professionals participated in the study, median ages of 43.5 years and 40 respectively. Participants were well educated with an even distribution between genders. Desired features for mHealth applications for persons with MS were: a) activity tracking, b) incentives for completing tasks and objectives, c) customizable goal setting, d) optional sociability and e) game-like attitude among others. Potential barriers to mHealth apps adoption like a) rough on-boarding experiences, b) lack of clear use benefits and c) disruption of the healthcare provider-patient relationship. Potential facilitators were identified such as a) endorsements from experts, b) playfulness and c) tailored to specific persons with MS needs. Four MS personas were developed to provide designers and computer scientists means to help in the creation of future mHealth solutions for MS. Conclusions: The potential of mHealth apps for increasing physical activity in persons with MS holds promise. Allowing for realistic goal setting and positive feedback, while minimizing usability burdens seems to be critical for the adoption of such apps. Fatigue management is especially important in this population so more attention should be focused in that area.

  • Implications of patient portal transparency in oncology: Experiences of patients, oncologists and medical informaticists

    Date Submitted: Sep 18, 2017

    Open Peer Review Period: Sep 20, 2017 - Nov 15, 2017

    Background: Providing patients with unrestricted access to their electronic medical records through patient portals has impacted patient-provider communication and patients’ personal health knowledg...

    Background: Providing patients with unrestricted access to their electronic medical records through patient portals has impacted patient-provider communication and patients’ personal health knowledge. However, little is known about how patient portals are used in oncology. Objective: We aimed to understand attitudes of the portal’s adoption for oncology and to identify the advantages and disadvantages of using the portal to communicate and view medical information. Methods: In depth semi-structured interviews were conducted with 60 participants: 35 patients, 13 oncologists and 12 medical informaticists. Interviews were recorded, transcribed and thematically analyzed to identify critical incidents and general attitudes encountered by participants. Results: Two primary themes were discovered: 1) implementation practices influence attitudes, in which the decision-making and execution process of introducing portals throughout the hospital did not include the input of oncologists. Lack of oncologists’ involvement led to a lack of knowledge about portal functionality, such as not knowing the time period when test results would be disclosed to patients; 2) perceptions of portals as communication tools varies by user type, meaning that each participant group (patients, oncologists, and medical informaticists) had varied opinions about how the portal should be used to transmit and receive information. Oncologists and medical informaticists had difficulty understanding one another’s culture and communication processes in their fields, while patients had preferences for how they would like to receive communication, but it largely depended upon the type of test being disclosed. Conclusions: The majority of patients (54%) who participated in this study viewed lab results or scan reports via the portal before being contacted by a clinician. Most were relatively comfortable with this manner of disclosure, but still preferred face-to-face or telephone communication. Findings from this study indicate that portal education is needed for both patients and oncologists, especially when portals are implemented across entire health systems since highly specialized areas of medicine may have unique needs and uses. Patient portals in oncology can potentially alter the way diagnoses are delivered and how patients and oncologists communicate. Therefore, communication about the portal should be established during initial consultations so patients can decide whether they want to be informed in such a manner.

  • Personal Healthcare Management: Assessing the Relationship With Chronic Disease Prevalence

    Date Submitted: Sep 19, 2017

    Open Peer Review Period: Sep 20, 2017 - Nov 15, 2017

    Background: The use of personal healthcare management (PHM) is increasing rapidly within the U.S. due to implementation of health technology across the healthcare continuum and increased regulatory re...

    Background: The use of personal healthcare management (PHM) is increasing rapidly within the U.S. due to implementation of health technology across the healthcare continuum and increased regulatory requirements for healthcare professionals and organizations promoting the use of PHM, particularly the use of messaging, online scheduling, and online requests for prescription renewals. Limited research has been conducted comparing PHM use across groups based upon chronic condition. Objective: The purpose of this research is to describe the overall utilization of PHM and compare individual characteristics associated with PHM in groups with no reported chronic conditions, with one chronic condition and with two or more such conditions. Methods: Datasets drawn from the National Health Interview Series were analyzed using multiple logistic regression to determine the level of PHM use in relation to demographic, socioeconomic, or health-related factors. Data from 47,814 individuals were analyzed using logistic regression. Results: Approximately 12 percent of respondents reported using PHM, but higher rates of use were reported by individuals with higher levels of education and income. The overall rate of PHM remained stable between 2009 and 2014, despite increased focus on the promotion of patient engagement initiatives. Demographic factors predictive of PHM use were younger, non-Hispanic, and people who lived in the western region of the United States were the most likely to use PHM. There were also differences in PHM use based upon socioeconomic factors. Respondents with college level education were over 2.5 times more likely to use PHM than respondents without college level education. Health related factors were also predictive of PHM use. Individuals with health insurance and a usual place for healthcare were more likely to use PHM than individuals with no health insurance and no usual place for healthcare. Individuals reporting a single chronic condition or multiple chronic conditions reported slightly higher levels of PHM use than individuals reporting no chronic condition. Individuals with no chronic conditions who did not experience barriers to accessing healthcare were more likely to use PHM than individuals with one or more chronic conditions. Conclusions: The findings of this study illustrated the disparities in PHM use based upon a number of chronic conditions, and that multiple factors influence the use of PHM, including economics and education. These findings provide evidence of the challenge associated with engaging patients through the use of electronic health information as the healthcare industry continues to evolve.

  • Burnout and workplace needs of physician mothers: A cross-sectional online survey of 5,782 physician mothers

    Date Submitted: Sep 19, 2017

    Open Peer Review Period: Sep 19, 2017 - Sep 28, 2017

    Background: Burnout among physicians has reached an all-time high, with serious consequences for patient care, physician safety, and the healthcare system. Objective: Our goal was to examine burnout a...

    Background: Burnout among physicians has reached an all-time high, with serious consequences for patient care, physician safety, and the healthcare system. Objective: Our goal was to examine burnout and career satisfaction in physician mothers. We were particularly interested in how burnout was associated with understudied factors relevant to mothers, including fertility, pregnancy, caregiving duties, and gender-based discrimination. Methods: This was a cross-sectional online survey of the members of the Physician Mothers Group (PMG) which is an online private Facebook group of over 60,000 female physicians who are mothers. This survey was distributed in June and July 2016. Measurements included self-reported burnout, career satisfaction, history of discrimination, reproductive and physical health, caregiver status, desired workplace changes. Results: Of the estimated 16,059 PMG members who viewed the survey post, 5,782 completed the survey (estimated participation rate 36%, or 16% of active members). Overall, 40%(N=2208) of respondents reported burnout, with 38.2% being mothers. Burnout was related to higher work hours, discrimination, history of depression or anxiety, medical mistakes, and being a caregiver for a severely ill friend or family member. Burnout was more common in those who work in emergency medicine or family medicine, or practice in military and public hospitals, with 45.2%, 46.9%, 52.4%, and 46.2% of physicians reporting burnout, respectively. The most highly valued workplace changes reported by physician mothers included flexibility in working schedules, option to not work on weekends or overnight, and higher pay. In addition, administrative support including scribes and protected time for charting were common workplace change suggestions. Conclusions: Burnout is common, especially among certain subgroups of physician mothers. Approaches to reducing burnout among physician mothers may include supporting more flexible workplace structures, addressing gender discrimination, and providing additional support for those with caregiver responsibilities. Clinical Trial: N/A

  • Integrative analysis of the canonical TGFβ-Smad signaling pathway in breast cancer

    Date Submitted: Sep 15, 2017

    Open Peer Review Period: Sep 17, 2017 - Nov 12, 2017

    Background: Breast cancer deaths are mainly attributed to metastasis, while epithelial to mesenchymal transition (EMT) plays a pivotal role in promoting cancer cell metastasis. EMT is activated by var...

    Background: Breast cancer deaths are mainly attributed to metastasis, while epithelial to mesenchymal transition (EMT) plays a pivotal role in promoting cancer cell metastasis. EMT is activated by various stimuli, resulting in different therapeutic responses. The TGFβ signaling pathway is a canonical driver of EMT, and many molecular drugs are developed to target this pathway. However, the alternations of this pathway in BC remain elusive. Objective: The aim of this study was to investigate the relationship between the canonical TGFβ-Smad signaling pathway and breast cancer pathogenesis. Methods: Herein, we investigated the mutational, transcriptional, epigenetic and post-transcriptional alternations of 14 core members in this pathway through bioinformatics approach by analyses of 56,496 BC patients from various public databases, including COSMIC, Oncomine, DiseaseMeth and Starbase. A protein-protein interaction network was derived from Cytoscape software. Associations of these selected members with relapse free survival (RFS), overall survival (OS), distant metastases free survival (DMFS) and post progression survival (PPS) were performed using the Kaplan-Meier plotter online tool. Results: Our integrated analyses revealed that Smad4 was the most frequently mutated member of the TGFβ-Smad pathway in BC with a mutation frequency of 0.85% (30/3537). The expression levels of TGFβ1, TGFβ3, Smad1, Smad2 and Smad7 were significantly higher, whereas TGFβ2, ALK1, ALK2, ALK5, TGFβR2, Smad3, Smad4, Smad5 and Smad6 were downregulated in BC compared with normal subjects (P<0.001). Evaluation of epigenetic alteration identified that the promoters of ALK1 (P=0.000e+00), ALK2 (P=2.22e-16) and ALK5 (P=1.625e-12) were hypermethylated in 1,274 BC samples. In contrast, Smad2 (P=6.56e-04) was significantly hypomethylated in BC. Although all 14 members had potential diagnostic significances with different prediction power (AUC ranging from 0.788 to 1.00) in various subtypes of BC, only TGFβ3 could predict RFS (HR=0.69, 95% CI [0.62-0.77]), OS (HR=0.69, 95% CI [0.56-0.86]), DMFS (HR=0.8, 95% CI [0.66-0.97]) and PPS (HR=0.76, 95% CI [0.6-0.97]) for patients with BC in an independent manner. Additionally, 11 out of 14 members were associated with RFS in luminal A BC. Conclusions: Our results indicated that TGFβ-Smad pathway core members could serve as novel diagnostic and prognostic biomarkers in BC.

  • How Online Quality Ratings Influence Patients’ Choice of Medical Providers: A Controlled Experimental Survey Study

    Date Submitted: Sep 16, 2017

    Open Peer Review Period: Sep 17, 2017 - Nov 12, 2017

    Background: In recent years, the information environment for patients to learn about physician quality is being rapidly changed by online ratings from both commercial and government efforts. However,...

    Background: In recent years, the information environment for patients to learn about physician quality is being rapidly changed by online ratings from both commercial and government efforts. However, little is known about how various types of online ratings affect individuals’ choice of physicians. Objective: The objective of this research is to measure the relative importance of online quality ratings from governmental and commercial agencies on individuals’ choice of primary care physicians. Methods: In a choice-based conjoint experiment conducted on a sample of 1000 Amazon Mechanical Turk users in October 2016, individuals were asked to choose their preferred primary care physician from pairs of physicians with different ratings in clinical and non-clinical aspects of care provided by governmental and commercial agencies. Results: The relative log odds of choosing a physician increases by 1.3147 (95% CI: 1.2620-1.3682; p<0.0001) and 1.3247 (95% CI: 1.2717-1.3784; p<0.0001) units when the government clinical ratings and commercial non-clinical ratings move from two to four stars, respectively. The relative log odds of choosing a physician increases by 1.1253 (95% CI: 1.0742-1.1770; p<0.0001) units when the commercial clinical ratings move from two to four stars. The relative log odds of selecting a physician with four stars in non-clinical ratings provided by the government is 1.0350 (95% CI: 0.9847-1.0860; p<0.0001) units higher than a physician with two stars in this rating. The log odds of selecting a physician with four stars in non-clinical government ratings relative to a physician with two stars, is 0.2340 (95% CI: 0.1322-0.3357; p<0.0001) units higher for females compared to males. Similar star increase in non-clinical commercial ratings increases the relative odd logs of selecting the physician by female respondents by 0.1504 (95% CI: 0.0435-0.2571; p=0.0058) units. Conclusions: Individuals perceive non-clinical ratings provided by commercial websites as important as clinical ratings provided by government websites when choosing a primary care physician. There are significant gender differences in how the ratings are used. More research is needed on whether patients are making the best use of different types of ratings, as well as the optimal allocation of resources in improving physician ratings from the government’s perspective.