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Journal Description

The Journal of Medical Internet Research (JMIR), now in its 21st year, is the pioneer open access eHealth journal and is the flagship journal of JMIR Publications. It is the leading digital health journal globally in terms of quality/visibility (Impact Factor 2019: 5.03), ranking Q1 in the medical informatics category, and is also the largest journal in the field. The journal focuses on emerging technologies, medical devices, apps, engineering, telehealth and informatics applications for patient education, prevention, population health and clinical care. As a leading high-impact journal in its disciplines (health informatics and health services research), it is selective, but it is now complemented by almost 30 specialty JMIR sister journals, which have a broader scope, and which together receive over 6.000 submissions a year. Peer-review reports are portable across JMIR journals and papers can be transferred, so authors save time by not having to resubmit a paper to different journal but can simply transfer it between journals. 

As an open access journal, we are read by clinicians, allied health professionals, informal caregivers, and patients alike, and have (as with all JMIR journals) a focus on readable and applied science reporting the design and evaluation of health innovations and emerging technologies. We publish original research, viewpoints, and reviews (both literature reviews and medical device/technology/app reviews).

We are also a leader in participatory and open science approaches, and offer the option to publish new submissions immediately as preprints, which receive DOIs for immediate citation (eg, in grant proposals), and for open peer-review purposes. We also invite patients to participate (eg, as peer-reviewers) and have patient representatives on editorial boards.

Be a widely cited leader in the digitial health revolution and submit your paper today!


Recent Articles:

  • Source:; Copyright: Macau Photo Agency; URL:; License: Licensed by JMIR.

    Mental Health Burden in Different Professions During the Final Stage of the COVID-19 Lockdown in China: Cross-sectional Survey Study


    Background: COVID-19 resulted in considerable mental health burden in the Chinese general population and among health care workers at the beginning and peak of the pandemic. However, little is known about potentially vulnerable groups during the final stage of the lockdown. Objective: The aim of this survey study was to assess the mental health burden of different professions in China in order to find vulnerable groups, possible influencing factors, and successful ways of coping during the last 4 weeks of the lockdown in Hubei Province. Methods: A cross-sectional online survey asked participants about current residence, daily working hours, exposure to COVID-19 at work, and media preferences. We used a shortened version of the Depression, Anxiety and Stress Scale (DASS-21) to assess mental health. Further assessments included perceived stress (Simplified Chinese version of the 14-item Perceived Stress Scale), coping strategies for all participants, and specific stressors for health care workers. We followed the reporting guidelines of the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement for observational studies. Results: The sample (N=687) consisted of 158 doctors, 221 nurses, 24 other medical staff, 43 students, 60 teachers/government staff, 135 economy staff, 26 workers/farmers, and 20 professions designated under the “other” category. We found increased depression (n=123, 17.9%), anxiety (n=208, 30.3%), and stress (n=94, 13.7%) in our sample. Professions that were vulnerable to depression were other medical staff and students. Doctors, nurses, and students were vulnerable to anxiety; and other medical staff, students, and economy staff were vulnerable to stress. Coping strategies were reduced to three factors: active, mental, and emotional. Being female and emotional coping were independently associated with depression, anxiety, or stress. Applying active coping strategies showed lower odds for anxiety while mental coping strategies showed lower odds for depression, anxiety, and stress. Age, being inside a lockdown area, exposure to COVID-19 at work, and having a high workload (8-12 hours per day) were not associated with depression, anxiety, or stress. WeChat was the preferred way of staying informed across all groups. Conclusions: By the end of the lockdown, a considerable part of the Chinese population showed increased levels of depression and anxiety. Students and other medical staff were the most affected, while economy staff were highly stressed. Doctors and nurses need support regarding potential anxiety disorders. Future work should focus on longitudinal results of the pandemic and develop targeted preventive measures. Trial Registration:

  • Source: Jennifer Joe; Copyright: Jennifer Joe; URL:; License: Licensed by the authors.

    Development and External Validation of a Machine Learning Tool to Rule Out COVID-19 Among Adults in the Emergency Department Using Routine Blood Tests: A...


    Background: Conventional diagnosis of COVID-19 with reverse transcription polymerase chain reaction (RT-PCR) testing (hereafter, PCR) is associated with prolonged time to diagnosis and significant costs to run the test. The SARS-CoV-2 virus might lead to characteristic patterns in the results of widely available, routine blood tests that could be identified with machine learning methodologies. Machine learning modalities integrating findings from these common laboratory test results might accelerate ruling out COVID-19 in emergency department patients. Objective: We sought to develop (ie, train and internally validate with cross-validation techniques) and externally validate a machine learning model to rule out COVID 19 using only routine blood tests among adults in emergency departments. Methods: Using clinical data from emergency departments (EDs) from 66 US hospitals before the pandemic (before the end of December 2019) or during the pandemic (March-July 2020), we included patients aged ≥20 years in the study time frame. We excluded those with missing laboratory results. Model training used 2183 PCR-confirmed cases from 43 hospitals during the pandemic; negative controls were 10,000 prepandemic patients from the same hospitals. External validation used 23 hospitals with 1020 PCR-confirmed cases and 171,734 prepandemic negative controls. The main outcome was COVID 19 status predicted using same-day routine laboratory results. Model performance was assessed with area under the receiver operating characteristic (AUROC) curve as well as sensitivity, specificity, and negative predictive value (NPV). Results: Of 192,779 patients included in the training, external validation, and sensitivity data sets (median age decile 50 [IQR 30-60] years, 40.5% male [78,249/192,779]), AUROC for training and external validation was 0.91 (95% CI 0.90-0.92). Using a risk score cutoff of 1.0 (out of 100) in the external validation data set, the model achieved sensitivity of 95.9% and specificity of 41.7%; with a cutoff of 2.0, sensitivity was 92.6% and specificity was 59.9%. At the cutoff of 2.0, the NPVs at a prevalence of 1%, 10%, and 20% were 99.9%, 98.6%, and 97%, respectively. Conclusions: A machine learning model developed with multicenter clinical data integrating commonly collected ED laboratory data demonstrated high rule-out accuracy for COVID-19 status, and might inform selective use of PCR-based testing.

  • CDC in Chinese Internet. Source: Image created by the Authors (Runxi Zeng); Copyright: The Authors (Runxi Zeng); URL:; License: Creative Commons Attribution (CC-BY).

    Social Media Use for Health Communication by the CDC in Mainland China: National Survey Study 2009-2020


    Background: In recent years, public health incidents that pose a serious threat to public life have occurred frequently in China. The use of social media by public health authorities has helped to reduce these threats by increasing effective risk communication between the government and the public. Objective: The aim of this study is to reveal how China’s Center for Disease Control and Prevention (CDC) uses social media to improve three aspects of health communication between the government and the public: adoption, operation, and interaction. Methods: To analyze the 134 CDC government Weibo accounts at the provincial- and prefecture-level administration regions in mainland China, we collected their account data and extracted 1215 Weibo tweets. We also supplemented the data to reveal the overall performance of the CDC’s government Weibo use during the COVID-19 crisis. Results: The registration rate of the CDC’s government Weibo accounts increased year by year, and the local authorities registered Weibo accounts before the central government authorities. In total, 29.8% (n=134) of the 450 CDC facilities have registered an account. Among the 134 CDC facilities that have registered Weibo accounts, the registration rate in the eastern region (n=68, 50.7%) was higher than those in the central region (n=30, 22.4%) and the western region (n=36, 26.9%). Nearly 90.0% of these Weibo accounts had official certification, but there were dropouts in the specific operating process. One-third of the accounts have not been updated for more than 1 year, and the number of Weibo followers was polarized, with a maximum and minimum difference of 1 million. The response rate to users’ comments was less than 1%. Emergency information, multimedia content, and original content were more helpful in promoting communication between the government and the public. Such interaction was partially improved during the COVID-19 pandemic. The CDC updated the daily epidemic situation and provided popular science information for epidemic prevention and control for the public in a timely manner. Conclusions: China’s CDC is using more social media to popularize daily health information and has taken the first step to improve communication between the government and the public. However, equal dialogue, two-way interactions, and effective communication with the public still need improvement.

  • Image (shot from above) of a person in front of a laptop, looking at Twitter. Source: Authors/Placeit; Copyright: Kimberly Acquaviva; URL:; License: Licensed by the authors.

    Documenting Social Media Engagement as Scholarship: A New Model for Assessing Academic Accomplishment for the Health Professions


    Background: The traditional model of promotion and tenure in the health professions relies heavily on formal scholarship through teaching, research, and service. Institutions consider how much weight to give activities in each of these areas and determine a threshold for advancement. With the emergence of social media, scholars can engage wider audiences in creative ways and have a broader impact. Conventional metrics like the h-index do not account for social media impact. Social media engagement is poorly represented in most curricula vitae (CV) and therefore is undervalued in promotion and tenure reviews. Objective: The objective was to develop crowdsourced guidelines for documenting social media scholarship. These guidelines aimed to provide a structure for documenting a scholar’s general impact on social media, as well as methods of documenting individual social media contributions exemplifying innovation, education, mentorship, advocacy, and dissemination. Methods: To create unifying guidelines, we created a crowdsourced process that capitalized on the strengths of social media and generated a case example of successful use of the medium for academic collaboration. The primary author created a draft of the guidelines and then sought input from users on Twitter via a publicly accessible Google Document. There was no limitation on who could provide input and the work was done in a democratic, collaborative fashion. Contributors edited the draft over a period of 1 week (September 12-18, 2020). The primary and secondary authors then revised the draft to make it more concise. The guidelines and manuscript were then distributed to the contributors for edits and adopted by the group. All contributors were given the opportunity to serve as coauthors on the publication and were told upfront that authorship would depend on whether they were able to document the ways in which they met the 4 International Committee of Medical Journal Editors authorship criteria. Results: We developed 2 sets of guidelines: Guidelines for Listing All Social Media Scholarship Under Public Scholarship (in Research/Scholarship Section of CV) and Guidelines for Listing Social Media Scholarship Under Research, Teaching, and Service Sections of CV. Institutions can choose which set fits their existing CV format. Conclusions: With more uniformity, scholars can better represent the full scope and impact of their work. These guidelines are not intended to dictate how individual institutions should weigh social media contributions within promotion and tenure cases. Instead, by providing an initial set of guidelines, we hope to provide scholars and their institutions with a common format and language to document social media scholarship.

  • Source: Shutterstock; Copyright: asiandelight; URL:; License: Licensed by the authors.

    Use of Telehealth During the COVID-19 Pandemic: Scoping Review


    Background: With over 37.8 million cases and over 1 million deaths worldwide, the COVID-19 pandemic has created a societal and economic upheaval of unparalleled magnitude. A positive transformation has been brought about by innovative solutions in the health care sector that aim to mitigate the impact of COVID-19 on human health. For instance, the use of telehealth has been on the rise amidst this public health emergency. Objective: Given the unprecedented scale of the pandemic with no definitive endpoint, we aimed to scope the existing telehealth-related literature during a defined period of the ongoing pandemic (ie, January to June 2020). Methods: Our scoping review was guided by the Joanna Briggs Institute Reviewer Manual. We systematically searched PubMed and Embase databases with specific eligibility criteria. Data extracted from the shortlisted articles included first author and affiliation, journal title, publication type, terminologies used to describe telehealth and their accompanying definitions, health discipline or medical specialties and subspecialties wherein telehealth had been applied, the purpose of telehealth use, and the authors’ overall sentiment on telehealth use. We collated the available information and used descriptive statistics to analyze the synthesized data. Results: In all, 543 articles published across 331 different journals were included in this scoping review. The Journal of Medical Internet Research and its sister journals featured the highest number of articles (25/543, 4.6%). Nearly all (533/543, 98.2%) articles were in English. The majority of the articles were opinions, commentaries, and perspectives (333/543, 61.3%). Most authors of the articles reviewed were from high-income countries (470/543, 86.6%), especially from the United States of America (237/543, 43.6%). In all, 39 different definitions were used to describe terms equivalent to telehealth. A small percentage (42/543, 7.7%) of the articles focused on the provision of COVID-19–related care. Moreover, 49.7% (270/543) of the articles primarily focused on the provision of multiple components of clinical care, and 23% (125/543) of the articles focused on various specialties and subspecialties of internal medicine. For a vast majority (461/543, 84.9%) of the articles, the authors expressed a celebratory sentiment about the use of telehealth. Conclusions: This review identified considerable emerging literature on telehealth during the first six months of the COVID-19 pandemic, albeit mostly from high-income countries. There is compelling evidence to suggest that telehealth may have a significant effect on advancing health care in the future. However, the feasibility and application of telehealth in resource-limited settings and low- and middle-income countries must be established to avail its potential and transform health care for the world’s population. Given the rapidity with which telehealth is advancing, a global consensus on definitions, boundaries, protocols, monitoring, evaluation, and data privacy is urgently needed.

  • Source:; Copyright: Vlado/Placeit; URL:; License: Licensed by JMIR.

    Real-Time Communication: Creating a Path to COVID-19 Public Health Activism in Adolescents Using Social Media


    The COVID-19 pandemic and related public health efforts limiting in-person social interactions present unique challenges to adolescents. Social media, which is widely used by adolescents, presents an opportunity to counteract these challenges and promote adolescent health and public health activism. However, public health organizations and officials underuse social media to communicate with adolescents. Using well-established risk communication strategies and insights from adolescent development and human-computer interaction literature, we identify current efforts and gaps, and propose recommendations to advance the use of social media risk communication for adolescents during the COVID-19 pandemic and future disasters.

  • Source: Pexels; Copyright: Andrea Piacquadio; URL:; License: Licensed by JMIR.

    Perceived Impact of an Online Community Care Platform for Dutch Older Adults on Local Participation, Informal Caregiving, and Feelings of Connectedness:...


    Background: In a changing ageing society wherein older adults are increasingly expected to take care of themselves instead of relying on health care services, online community care platforms can help older adults to meet these expectations. A considerable number of these online community care platforms have been introduced in several European countries based on their potential. However, their actual impact is unclear. Objective: The aim of this study was to investigate the self-reported use, expectations, and perceived impact of a Dutch online community care platform called Grubbenvorst-Online among Dutch older adults. The following 2 questions were studied: (1) What is the self-reported use of Grubbenvorst-Online among older adults? (2) What are their expectations and perceived impact of Grubbenvorst-Online regarding local participation, their social network, mutual informal caregiving, and feelings of connectedness? Methods: An observational pretest-posttest study was conducted. Participants were recruited via a web-based message on the Grubbenvorst-Online platform and data were collected via postal questionnaires among older users at the start of the study and 4 months later. Data regarding the expectations and the perceived impact of Grubbenvorst-Online were compared and tested. Results: Forty-seven Grubbenvorst-Online users with an average age of 74 years participated in this study. They were healthy, predominantly “internet-skilled,” and they found the internet important for maintaining social contacts. In general, the use of the online community care platform decreased during the 4-month follow-up period. The perceived impact of Grubbenvorst-Online was significantly lower than that expected regarding information provision (P=.003), seeking help from fellow villagers (P<.001), giving help to fellow villagers (P<.001), and consulting care or welfare services (P<.001). Conclusions: The findings of this study indicate that online community care platforms perhaps do not provide enough “added value” in their current form. We suggest a new direction in which online community care platforms primarily support existing offline initiatives aimed at stimulating local participation, informal caregiving, and feelings of connectedness.

  • Source: Pexels; Copyright: Photo by Andrew Wilus from Pexels; URL:; License: Licensed by JMIR.

    A Mobile- and Web-Based Health Intervention Program for Diabetes and Prediabetes Self-Management (BetaMe/Melon): Process Evaluation Following a Randomized...


    Background: Technology-assisted self-management programs are increasingly recommended to patients with long-term conditions such as diabetes. However, there are a number of personal and external factors that affect patients’ abilities to engage with and effectively utilize such programs. A randomized controlled trial of a multi-modal online program for diabetes self-management (BetaMe/Melon) was conducted in a primary care setting, and a process evaluation was completed at the end of the study period. Objective: This process evaluation aimed to examine the utilization patterns of BetaMe/Melon, identify which components participants found most (and least) useful, and identify areas of future improvement. Methods: Process evaluation data were collected for intervention arm participants from 3 sources: (1) the mobile/web platform (to identify key usage patterns over the 16-week core program), (2) an online questionnaire completed during the final study assessment, and (3) interviews conducted with a subset of participants following the study period. Participants were classified as “actively engaged” if any usage data was recorded for the participant (in any week), and patterns were reported by age, gender, ethnicity, and diabetes/prediabetes status. The online questionnaire asked participants about the usefulness of the program and whether they would recommend BetaMe/Melon to others according to a 5-point Likert Scale. Of 23 invited participants, 18 participated in a digitally recorded, semistructured telephone interview. Interview data were thematically analyzed. Results: Out of the 215 participants, 198 (92%) received an initial health coaching session, and 160 (74%) were actively engaged with the program at some point during the 16-week core program. Engagement varied by demographic, with women, younger participants, and ethnic majority populations having higher rates of engagement. Usage steadily declined from 50% at Week 0 to 23% at Week 15. Participants ranked component usefulness as education resources (63.7%), health coaches (59.2%), goal tracking (48.8%), and online peer support (42.1%). Although 53% agreed that the program was easy to use, 64% would recommend the program to others. Interview participants found BetaMe/Melon useful overall, with most identifying beneficial outcomes such as increased knowledge, behavioral changes, and weight loss. Barriers to engagement were program functionality, internet connectivity, incomplete delivery of all program components, and participant motivation. Participants suggested a range of improvements to the BetaMe/Melon program. Conclusions: The program was generally well received by participants; active engagement was initially high, although it declined steadily. Maintaining participant engagement over time, individualizing programs, and addressing technical barriers are important to maximize potential health benefits from online diabetes self-management programs. Clinical Trial: Australian New Zealand Clinical Trial Registry ACTRN12617000549325;

  • An older adult managing medications. Source: Shutterstock. Image created by Pixel-shot; Copyright: Jessica Ivo; URL:; License: Licensed by the authors.

    Stakeholder Feedback of Electronic Medication Adherence Products: Qualitative Analysis


    Background: Medication management among older adults continues to be a challenge, and innovative electronic medication adherence products have been developed to address this need. Objective: The aim of this study is to examine user experience with electronic medication adherence products, with particular emphasis on features, usefulness, and preferences. Methods: Older adults, caregivers, and health care providers tested the usability of 22 electronic medication adherence products. After testing 5 products, participants were invited to participate in a one-on-one interview to investigate their perceptions and experiences with the features, usefulness, and preference for electronic medication adherence products tested. The interviews were audio recorded, transcribed, and analyzed using exploratory inductive coding to generate themes. The first 13 interviews were independently coded by 2 researchers. The percentage agreement and Cohen kappa after analyzing those interviews were 79% and 0.79, respectively. A single researcher analyzed the remaining interviews. Results: Of the 37 participants, 21 (57%) were older adults, 5 (14%) were caregivers, and 11 (30%) were health care providers. The themes and subthemes generated from the qualitative analysis included product factors (subthemes: simplicity and product features, including availability and usability of alarms, portability, restricted access to medications, and storage capacity) and user factors (subthemes: sentiment, affordability, physical and cognitive capability, and technology literacy and learnability). Conclusions: Electronic medication adherence products have the potential to enable independent medication management in older adults. The choice of a particular product should be made after considering individual preferences for product features, affordability, and the sentiment of the users. Older adults, caregivers, and health care providers prefer electronic medication adherence products that are simple to set up and use, are portable, have easy-to-access medication compartments, are secure, and have adequate storage capacity.

  • Source: freepik; Copyright: diana.grytsku; URL:; License: Licensed by JMIR.

    Capitated Telehealth Coaching Hospital Readmission Service in Australia: Pragmatic Controlled Evaluation


    Background: MonashWatch is a telehealth public hospital outreach pilot service as a component of the Government of Victoria’s statewide redesign initiative called HealthLinks: Chronic Care. Rather than only paying for hospitalizations, projected funding is released earlier to hospitals to allow them to reduce hospitalization costs. MonashWatch introduced a web-based app, Patient Journey Record System, to assess the risk of the journeys of a cohort of patients identified as frequent admitters. Telecare guides call patients using the Patient Journey Record System to flag potential deterioration. Health coaches (nursing and allied health staff) triage risk and adapt care for individuals. Objective: The aim was a pragmatic controlled evaluation of the impact of MonashWatch on the primary outcome of bed days for acute nonsurgical admissions in the intention-to-treat group versus the usual care group. The secondary outcome was hospital admission rates. The net promoter score was used to gauge satisfaction. Methods: Patients were recruited into an intention-to-treat group, which included active telehealth and declined/lost/died groups, versus a systematically sampled (4:1) usual care group. A rolling sample of 250-300 active telehealth patients was maintained from December 23, 2016 to June 23, 2019. The outcome—mean bed days in intervention versus control—was adjusted using analysis of covariance for age, gender, admission type, and effective days active in MonashWatch. Time-series analysis tested for trends in change patterns. Results: MonashWatch recruited 1373 suitable patients who were allocated into the groups: usual care (n=293) and intention-to-treat (n=1080; active telehealth: 471/1080, 43.6%; declined: 485, 44.9%; lost to follow-up: 178 /1080, 10.7%; died: 8/1080, 0.7%). Admission frequency of intention-to-treat compared to that of the usual care group did not significantly improve (P=.05), with a small number of very frequent admitters in the intention-to-treat group. Age, MonashWatch effective days active, and treatment group independently predicted bed days. The analysis of covariance demonstrated a reduction in bed days of 1.14 (P<.001) in the intention-to-treat group compared with that in the usual care group, with 1236 bed days estimated savings. Both groups demonstrated regression-to-the-mean. The downward trend in improved bed days was significantly greater (P<.001) in the intention-to-treat group (Sen slope –406) than in the usual care group (Sen slope –104). The net promoter score was 95% in the active telehealth group compared with typical hospital scores of 77%. Conclusions: Clinically and statistically meaningful reductions in acute hospital bed days in the intention-to-treat group when compared to that of the usual care group were demonstrated (P<.001), although admission frequency was unchanged with more short stay admissions in the intention-to-treat group. Nonrandomized control selection was a limitation. Nonetheless, MonashWatch was successful in the context of the HealthLinks: Chronic Care capitation initiative and is expanding.

  • Source: Adobe Stock; Copyright: Photo by Sebra from Adobe Stock; URL:; License: Licensed by JMIR.

    Association Rule Mining and Prognostic Stratification of 2-Year Longevity in Octogenarians Undergoing Endovascular Therapy for Lower Extremity Arterial...


    Background: Two-year longevity is a crucial consideration in revascularization strategies for patients with symptomatic lower extremity arterial disease (LEAD). However, factors associated with 2-year longevity and risk stratification in octogenarians or nonagenarians have been underreported. Objective: This paper aims to investigate the associated variables and stratify the 2-year prognosis in older patients with LEAD. Methods: We performed logistic regression and association rule mining based on the Apriori algorithm to discover independent variables and validate their associations with 2-year longevity. Malnutrition, inflammation, and stroke factors were identified. C statistics and Kaplan-Meier analysis were used to assess the impact of different numbers of malnutrition, inflammation, and stroke factors on 2-year longevity. Results: We recruited a total of 232 octogenarians or nonagenarians (mean age 85 years, SD 4.2 years) treated with endovascular therapy. During the study period, 81 patients died, and 27 of those (33%) died from a cardiac origin within 2 years. Association rules analysis showed the interrelationships between 2-year longevity and the neutrophil-lymphocyte ratio (NLR) and nutritional status as determined by the Controlling Nutritional Status (CONUT) score or Geriatric Nutritional Risk Index (GNRI). The cut-off values of NLR, GNRI, and CONUT were ≥3.89, ≤90.3, and >3, respectively. The C statistics for the predictive power for 2-year longevity were similar between the CONUT score and the GNRI-based models (0.773 vs 0.760; P=.57). The Kaplan-Meier analysis showed that 2-year longevity was worse as the number of malnutrition, inflammation, and stroke factors increased from 0 to 3 in both the GNRI-based model (92% vs 68% vs 46% vs 12%, respectively; P<.001) and the CONUT score model (87% vs 75% vs 49% vs 10%, respectively; P<.001). The hazard ratio between those with 3 factors and those without was 18.2 (95% CI 7.0-47.2; P<.001) in the GNRI and 13.6 (95% CI 5.9-31.5; P<.001) in the CONUT score model. Conclusions: This study demonstrated the association and crucial role of malnutrition, inflammation, and stroke factors in assessing 2-year longevity in older patients with LEAD. Using this simple risk score might assist clinicians in selecting the appropriate treatment.

  • Source: Unsplash; Copyright: Lucian Novosel; URL:; License: Licensed by JMIR.

    A Web-Based Mental Health Intervention to Improve Social and Occupational Functioning in Adults With Type 2 Diabetes (The Springboard Trial): 12-Month...


    Background: People with type 2 diabetes mellitus (T2DM) often experience mental health symptoms that exacerbate illness and increase mortality risk. Access to psychological support is low in people with T2DM. Detection of depression is variable in primary care and can be further hampered by mental health stigma. Electronic mental health (eMH) programs may provide an accessible, private, nonstigmatizing mental health solution for this group. Objective: This study aims to evaluate the efficacy over 12 months of follow-up of an eMH program (myCompass) for improving social and occupational functioning in a community sample of people with T2DM and self-reported mild-to-moderate depressive symptoms. myCompass is a fully automated and self-guided web-based public health program for people with depression or anxiety. The effects of myCompass on depressive symptoms, diabetes-related distress, anxiety symptoms, and self-care behavior were also examined. Methods: Adults with T2DM and mild-to-moderate depressive symptoms (N=780) were recruited via online advertisements, community organizations, and general practices. Screening, consent, and self-report questionnaires were administered online. Eligible participants were randomized to receive either myCompass (n=391) or an attention control generic health literacy program (Healthy Lifestyles; n=379) for 8 weeks. At baseline and at 3, 6, and 12 months postintervention, participants completed the Work and Social Adjustment Scale, the Patient Health Questionnaire-9 item, the Diabetes Distress Scale, the Generalized Anxiety Disorder Questionnaire-7 item, and items from the Self-Management Profile for Type 2 Diabetes. Glycosylated hemoglobin measurements were obtained at baseline and 6 and 12 months postintervention. Results: A total of 38.9% (304/780) of the trial participants completed all postintervention assessments. myCompass users logged in on an average of 6 times and completed an average of 0.29 modules. Healthy Lifestyles users logged in on an average of 4 times and completed an average of 1.37 modules. At baseline, the mean scores on several outcome measures, including the primary outcome of work and social functioning, were close to the normal range, despite a varied and extensive recruitment process. Intention-to-treat analyses revealed slightly greater improvement at 12 months in work and social functioning for the Healthy Lifestyles group relative to the myCompass group. All participants reported equivalent improvements in depression anxiety, diabetes distress, diabetes self-management, and glycemic control across the trial. Conclusions: The Healthy Lifestyles group reported higher ratings of social and occupational functioning than the myCompass group, but no differences were observed for any secondary outcome. Although these findings should be interpreted in light of the near-floor symptom scores at baseline, the trial yields important insights into how people with T2DM might be engaged in eMH programs and the challenges of focusing specifically on mental health. Several avenues emerge for continued investigation into how best to deal with the growing mental health burden in adults with T2DM. Trial Registration: Australian New Zealand Clinical Trials Registry Number (ACTRN) 12615000931572;

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  • Expanding telemonitoring in a virtual world: A case study of the expansion of a heart failure telemonitoring program during the COVID-19 pandemic

    Date Submitted: Nov 30, 2020

    Open Peer Review Period: Nov 30, 2020 - Jan 25, 2021

    Background: To minimize the spread and risk of a COVID-19 outbreak, societal norms have been challenged with respect to how essential services are delivered. With pressures to reduce the number of in-...

    Background: To minimize the spread and risk of a COVID-19 outbreak, societal norms have been challenged with respect to how essential services are delivered. With pressures to reduce the number of in-person ambulatory visits, innovative models of telemonitoring have been used during the pandemic as a necessary alternative to support access to care for patients with chronic conditions. The pandemic has led to healthcare organizations considering the adoption of telemonitoring interventions for the first time, while others have seen existing programs rapidly expand. Objective: At the Toronto General Hospital in Ontario, Canada, the rapid expansion of a telemonitoring program began on March 9, 2020, in response to COVID-19. The objective of this study was to understand experiences related to the expanded role of a telemonitoring program under the changing conditions of the pandemic. Methods: A single-case qualitative study was conducted with three embedded units of analysis. Semi-structured interviews probed the experiences of patients, clinicians, and program staff from the Medly telemonitoring program, at a Heart Function clinic in Toronto, Canada. Data was analyzed using inductive thematic analysis as well as Eakin and Gladstone’s value-adding approach to enhance the analytic interpretation of the study findings. Results: A total of 29 participants were interviewed, including patients (n=16), clinicians (n=9), and operational staff (n=4). Four themes were identified: (1) providing care continuity through telemonitoring; (2) adapting telemonitoring operations for a virtual healthcare system; (3) confronting virtual workflow challenges; and (4) fostering a meaningful patient-provider relationship. Beyond supporting virtual visits, the program’s ability to provide a more comprehensive picture of the patient’s health was valued. However, issues relating to the lack of system integration and alert-driven interactions jeopardized the perceived sustainability of the program. Conclusions: With the reduction of in-person visits during the pandemic, virtual services like telemonitoring have demonstrated significant value. Based on our study findings, we offer recommendations to proactively adapt and scale telemonitoring programs under the changing conditions of an increasingly virtual healthcare system. These include revisiting the scope and expectations for TM interventions, streamlining virtual patient onboarding processes, and personalizing the collection of patient information to build a stronger virtual relationship and a more holistic assessment of patient well-being.  

  • Voice-based Conversational Agents for the Prevention and Management of Chronic and Mental Conditions: A Systematic Literature Review

    Date Submitted: Nov 30, 2020

    Open Peer Review Period: Nov 30, 2020 - Dec 7, 2020

    Background: Chronic and mental conditions are increasingly prevalent worldwide. As devices in our everyday lives offer more and more voice-based self-service, voice-based conversational agents (VCAs)...

    Background: Chronic and mental conditions are increasingly prevalent worldwide. As devices in our everyday lives offer more and more voice-based self-service, voice-based conversational agents (VCAs) have the potential to support the prevention and management of these conditions in a scalable way. VCAs allow for a more natural interaction compared to text-based conversational agents, facilitate input for users who cannot type, allow for routine monitoring and support when in-person healthcare is not possible, and open the doors to voice and speech analysis. The state of the art of VCAs for chronic and mental conditions is, however, unclear. Objective: This systematic literature review aims to provide a better understanding of state-of-the-art research on VCAs delivering interventions for the prevention and management of chronic and mental conditions. Methods: We conducted a systematic literature review using PubMed Medline, EMBASE, PsycINFO, Scopus, and Web of Science databases. We included primary research that involved the prevention or management of chronic or mental conditions, where the voice was the primary interaction modality of the conversational agent, and where an empirical evaluation of the system in terms of system accuracy and/or in terms of technology acceptance was included. Two independent reviewers conducted screening and data extraction and measured their agreement with Cohen’s kappa. A narrative approach was applied to synthesize the selected records. Results: Twelve out of 7’170 articles met the inclusion criteria. The majority of the studies (N=10) were non-experimental, while the remainder (N=2) were quasi-experimental. The VCAs provided behavioral support (N=5), a health monitoring service (N=3), or both (N=4). The VCA services were delivered via smartphone (N=5), tablet (N=2), or smart speakers (N=3). In two cases, no device was specified. Three VCAs targeted cancer, while two VCAs each targeted diabetes and heart failure. The other VCAs targeted hearing-impairment, asthma, Parkinson's disease, dementia and autism, “intellectual disability”, and depression. The majority of the studies (N=7) assessed technology acceptance but only a minority (N=3) used validated instruments. Half of the studies (N=6) reported either performance measures on speech recognition or on the ability of VCA’s to respond to health-related queries. Only a minority of the studies (N=2) reported behavioral measure or a measure of attitudes towards intervention-related health behavior. Moreover, only a minority of studies (N=4) reported controlling for participant’s previous experience with technology. Conclusions: Considering the heterogeneity of the methods and the limited number of studies identified, it seems that research on VCAs for chronic and mental conditions is still in its infancy. Although results in system accuracy and technology acceptance are encouraging, there still is a need to establish evidence on the efficacy of VCAs for the prevention and management of chronic and mental conditions, both in absolute terms and in comparison to standard healthcare.

  • Prospective Pilot Study of Telehealth as Domiciliary Follow-up after Hematopoietic Cell Transplantation during the COVID-19 Pandemic

    Date Submitted: Nov 28, 2020

    Open Peer Review Period: Nov 28, 2020 - Jan 23, 2021

    Patients receiving hematopoietic cell transplantation are at increased risk of infectious complications. A higher mortality was shown for these patients affected by COVID19. In this prospective study...

    Patients receiving hematopoietic cell transplantation are at increased risk of infectious complications. A higher mortality was shown for these patients affected by COVID19. In this prospective study, we developed and tested a telemedicine platform to improve the domiciliary follow-up of patients who had received a transplant. Daily monitoring of vital signs, symptoms and psychological status was performed through a mobile phone application and clinically validated medical devices. Sixteen patients were enrolled for this proof-of-concept study. Thirty-eight percent of transplants were autologous and sixty-two percent were allogeneic. Four patients were not able to use the app due to their inability in using smartphone applications. Patients’ adherence in reporting study data was acceptable. The subjective perception of the study was considered positive from the majority of patients. We showed how to implement a specific telemedicine platform in the setting of transplanted patients with promising results.

  • Telemedicine intervention efficiency on mobility recovery after bariatric surgery: the MyGoodTrip randomized controlled trial

    Date Submitted: Nov 27, 2020

    Open Peer Review Period: Nov 27, 2020 - Jan 22, 2021

    Our aim was to evaluate a telemedicine intervention program dedicated to the promotion of physical activity including teleconsultation and telemonitoring following bariatric surgery. This study was an...

    Our aim was to evaluate a telemedicine intervention program dedicated to the promotion of physical activity including teleconsultation and telemonitoring following bariatric surgery. This study was an open label randomized controlled trial. Patients were included during the first week after bariatric surgery then randomized in two groups of telemedicine intervention: (i) physical coaching focusing on mobility (=TelePhys group) or (ii) dietary coaching (=TeleDiet group). The primary outcome was the difference in the delta number of steps measured during a period of 14 days at the first and sixth postoperative months between the two groups. Data were collected using the connected wireless watch pedometer. Body weight evolution and health-related quality of life were also evaluated. Ninety patients with mean age (SD) 40.6 years (+/-10.3) were included. Seventy-three patients were females (81%) and 62 had gastric bypass (69%). An increase of the mean number of steps between the first and the sixth month was found in both groups but this delta was significant only in the TeleDiet group (p=0.010). No difference was found when comparing the delta between the two intervention groups. A significant increase in quality of life was observed in both groups without any significant differences between the two interventions. Our study was not able to show a significant superiority of a telemedicine intervention dedicated to physical activity in mobility recovery after bariatric surgery. The early postoperative time frame for our intervention may explain our findings. Further research will need to focus on long-term interventions.

  • Remote evaluation of upper extremity motor function following stroke: The Arm Capacity and Movement Test (ArmCAM)

    Date Submitted: Nov 26, 2020

    Open Peer Review Period: Nov 26, 2020 - Jan 21, 2021

    Background: Developing a simple measure that can be administered remotely via videoconferencing is needed for telerehabilitation for rural and remote population, or during the COVID-19 pandemic. Objec...

    Background: Developing a simple measure that can be administered remotely via videoconferencing is needed for telerehabilitation for rural and remote population, or during the COVID-19 pandemic. Objective: To develop a valid and reliable measure [the Arm Capacity and Movement Test (ArmCAM)] administered remotely via videoconferencing to evaluate upper extremity motor function after stroke. Methods: A sample of individuals with stroke (N=31) was used to assess the reliability and validity of the ArmCAM (range: 0-30). Test-retest and inter-rater reliability were assessed through the intraclass correlation coefficients (ICC), standard error of measurement (SEM) and minimal detectable change (MDC). Validity was examined by the Pearson and Spearman rank correlation coefficients. Results: The ArmCAM consists of 10 items and takes 15 minutes to administer without any special equipment except for a computer and internet access. The ICC for test-retest reliability and inter-rater reliability were 0.997 and 0.993, respectively. The SEM and MDC95 were 0.74 and 2.05 points, respectively. With respect to validity, correlations between the ArmCAM and the Rating of Everyday Arm-use in the Community and Home Scale, Stroke Impact Scale-Hand, Fugl-Meyer Assessment for upper extremity, and Action Research Arm Test were good to excellent (correlation coefficients: 0.811-0.944). Conclusions: he ArmCAM has good reliability and validity. It is an easy-to-use assessment that is designed to be administered remotely via video conferencing. Clinical Trial: NA (This is not a clinical trial)

  • Digging for the truth: the case for active annotation in evaluating the credibility of online medical information

    Date Submitted: Nov 26, 2020

    Open Peer Review Period: Nov 26, 2020 - Jan 21, 2021

    Background: With the rapidly accelerating spread of dissemination of false medical information on the Web, the task of establishing the credibility of online sources of medical information becomes a p...

    Background: With the rapidly accelerating spread of dissemination of false medical information on the Web, the task of establishing the credibility of online sources of medical information becomes a pressing necessity. The sheer number of websites offering questionable medical information presented as reliable and actionable suggestions with possibly harmful effects poses an additional requirement for potential solutions, as they have to scale to the size of the problem. Machine learning is one such solution which, when properly deployed, can be an effective tool in fighting medical disinformation on the Web. Objective: We present a comprehensive framework for designing and curating of machine learning training datasets for online medical information credibility assessment. We show how the annotation process should be constructed and what pitfalls should be avoided. Our main objective is to provide researchers from medical and computer science communities with guidelines on how to construct datasets for machine learning models for various areas of medical information wars. Methods: The key component of our approach is the active annotation process. We begin by outlining the annotation protocol for the curation of high-quality training dataset, which then can be augmented and rapidly extended by employing the human-in-the-loop paradigm to machine learning training. To circumvent the cold start problem of insufficient gold standard annotations, we propose a pre-processing pipeline consisting of representation learning, clustering, and re-ranking of sentences for the acceleration of the training process and the optimization of human resources involved in the annotation. Results: We collect over 10 000 annotations of sentences related to selected subjects (psychiatry, cholesterol, autism, antibiotics, vaccines, steroids, birth methods, food allergy testing) for less than $7 000 employing 9 highly qualified annotators (certified medical professionals) and we release this dataset to the general public. We develop an active annotation framework for more efficient annotation of non-credible medical statements. The results of the qualitative analysis support our claims of the efficacy of the presented method. Conclusions: A set of very diverse incentives is driving the widespread dissemination of medical disinformation on the Web. An effective strategy of countering this spread is to use machine learning for automatically establishing the credibility of online medical information. This, however, requires a thoughtful design of the training pipeline. In this paper we present a comprehensive framework of active annotation. In addition, we publish a large curated dataset of medical statements labelled as credible, non-credible, or neutral.