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Journal Description

The Journal of Medical Internet Research (JMIR), now in its 20th 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 2017: 4.671, ranked #1 out of 22 journals) and in terms of size (number of papers published). The journal focuses on emerging technologies, medical devices, apps, engineering, and informatics applications for patient education, prevention, population health and clinical care. As 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. 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 journals. 

As open access journal, we are read by clinicians, allied health professionals, informal caregivers, and patients alike, and have (as 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: pxhere; Copyright: pxhere; URL: https://pxhere.com/en/photo/764703; License: Public Domain (CC0).

    Digital Health Professions Education on Diabetes Management: Systematic Review by the Digital Health Education Collaboration

    Abstract:

    Background: There is a shortage of health care professionals competent in diabetes management worldwide. Digital education is increasingly used in educating health professionals on diabetes. Digital diabetes self-management education for patients has been shown to improve patients’ knowledge and outcomes. However, the effectiveness of digital education on diabetes management for health care professionals is still unknown. Objective: The objective of this study was to assess the effectiveness and economic impact of digital education in improving health care professionals’ knowledge, skills, attitudes, satisfaction, and competencies. We also assessed its impact on patient outcomes and health care professionals’ behavior. Methods: We included randomized controlled trials evaluating the impact of digitalized diabetes management education for health care professionals pre- and postregistration. Publications from 1990 to 2017 were searched in MEDLINE, EMBASE, Cochrane Library, PsycINFO, CINAHL, ERIC, and Web of Science. Screening, data extraction and risk of bias assessment were conducted independently by 2 authors. Results: A total of 12 studies met the inclusion criteria. Studies were heterogeneous in terms of digital education modality, comparators, outcome measures, and intervention duration. Most studies comparing digital or blended education to traditional education reported significantly higher knowledge and skills scores in the intervention group. There was little or no between-group difference in patient outcomes or economic impact. Most studies were judged at a high or unclear risk of bias. Conclusions: Digital education seems to be more effective than traditional education in improving diabetes management–related knowledge and skills. The paucity and low quality of the available evidence call for urgent and well-designed studies focusing on important outcomes such as health care professionals’ behavior, patient outcomes, and cost-effectiveness as well as its impact in diverse settings, including developing countries.

  • Source: Pixabay; Copyright: HansMartinPaul; URL: https://pixabay.com/en/non-smoking-stop-smoking-fag-2497308/; License: Public Domain (CC0).

    A Smoking Prevention Program Delivered by Medical Students to Secondary Schools in Brazil Called “Education Against Tobacco”: Randomized Controlled Trial

    Abstract:

    Background: Smoking is the largest preventable cause of mortality in Brazil. Education Against Tobacco (EAT) is a network of more than 3500 medical students and physicians across 14 countries who volunteer for school-based smoking prevention programs. EAT educates 50,000 adolescents per year in the classroom setting. A recent quasi-experimental study conducted in Germany showed that EAT had significant short-term smoking cessation effects among adolescents aged 11 to 15 years. Objective: The aim is to measure the long-term effectiveness of the most recent version of the EAT curriculum in Brazil. Methods: A randomized controlled trial was conducted among 2348 adolescents aged 12 to 21 years (grades 7-11) at public secondary schools in Brazil. The prospective experimental design included measurements at baseline and at 6 and 12 months postintervention. The study groups comprised randomized classes receiving the standardized EAT intervention (90 minutes of mentoring in a classroom setting) and control classes in the same schools (no intervention). Data were collected on smoking status, gender, social aspects, and predictors of smoking. The primary endpoint was the difference in the change in smoking prevalence between the intervention group and the control group at 12-month follow-up. Results: From baseline to 12 months, the smoking prevalence increased from 11.0% to 20.9% in the control group and from 14.1% to 15.6% in the intervention group. This difference was statistically significant (P<.01). The effects were smaller for females (control 12.4% to 18.8% vs intervention 13.1% to 14.6%) than for males (control 9.1% to 23.6% vs intervention 15.3% to 16.8%). Increased quitting rates and prevented onset were responsible for the intervention effects. The differences in change in smoking prevalence from baseline to 12 months between the intervention and control groups were increased in students with low school performance. Conclusions: To our knowledge, this is the first randomized trial on school-based tobacco prevention in Brazil that shows significant long-term favorable effects. The EAT program encourages quitting and prevents smoking onset, especially among males and students with low educational background. Trial Registration: ClinicalTrials.gov NCT02725021; https://clinicaltrials.gov/ct2/show/NCT02725021

  • Source: Pexels; Copyright: Soumil Kumar; URL: https://www.pexels.com/photo/photo-of-person-typing-on-computer-keyboard-735911/; License: Licensed by the authors.

    Digital Trespass: Ethical and Terms-of-Use Violations by Researchers Accessing Data From an Online Patient Community

    Abstract:

    With the expansion and popularity of research on websites such as Facebook and Twitter, there has been increasing concern about investigator conduct and social media ethics. The availability of large data sets has attracted researchers who are not traditionally associated with health data and its associated ethical considerations, such as computer and data scientists. Reliance on oversight by ethics review boards is inadequate and, due to the public availability of social media data, there is often confusion between public and private spaces. In addition, social media participants and researchers may pay little attention to traditional terms of use. In this paper, we review four cases involving ethical and terms-of-use violations by researchers seeking to conduct social media studies in an online patient research network. These violations involved unauthorized scraping of social media data, entry of false information, misrepresentation of researcher identities of participants on forums, lack of ethical approval and informed consent, use of member quotations, and presentation of findings at conferences and in journals without verifying accurate potential biases and limitations of the data. The correction of these ethical lapses often involves much effort in detecting and responding to violators, addressing these lapses with members of an online community, and correcting inaccuracies in the literature (including retraction of publications and conference presentations). Despite these corrective actions, we do not regard these episodes solely as violations. Instead, they represent broader ethical issues that may arise from potential sources of confusion, misinformation, inadequacies in applying traditional informed consent procedures to social media research, and differences in ethics training and scientific methodology across research disciplines. Social media research stakeholders need to assure participants that their studies will not compromise anonymity or lead to harmful outcomes while preserving the societal value of their health-related studies. Based on our experience and published recommendations by social media researchers, we offer potential directions for future prevention-oriented measures that can be applied by data producers, computer/data scientists, institutional review boards, research ethics committees, and publishers.

  • Source: Stokpic; Copyright: Ed Gregory; URL: https://stokpic.com/project/casual-business-woman-typing-on-laptop-whilst-in-bed/; License: Public Domain (CC0).

    How Do Adolescents Use Electronic Diaries? A Mixed-Methods Study Among Adolescents With Depressive Symptoms

    Abstract:

    Background: Depression in adolescence is common. Less than half of the adolescents with depression receive mental health care; furthermore, treatment tends to be suspended, and its success rates are low. There is a need for these adolescents to have a safe place to share their thoughts. Studies have shown that writing may be a useful treatment method for people with mental health problems. Objective: This study aims to describe the use of an electronic diary (e-diary) among adolescents with depressive symptoms. Methods: This paper describes a substudy of a randomized controlled trial. We used a mixed-methods approach to understand the way in which e-diaries were used by participants in the intervention under the randomized controlled trial. Data were collected during 2008-2010 at 2 university hospitals in Finland. Study participants (N=89) were 15-17-year-old adolescents who had been referred to an adolescent outpatient psychiatric clinic due to depressive symptoms. Participants were instructed to use the e-diary at least once a week to describe their thoughts, feelings, and moods. The content of the e-diary data was analyzed using descriptive statistics and inductive content analysis. Results: Overall, 53% (47/89) of the adolescents used the e-diary. Most of them (39/47, 83%) logged into the program during the first week, and about one-third (19/47, 40%) logged into the e-diary weekly as suggested. The number of words used in the e-diary per each log ranged between 8 and 1442 words. The 3 topics most often written about in the e-diary were related to mental health problems (mental disorder), social interaction (relationship), and one’s own development (identity). Conclusions: An e-diary may be a usable tool to reflect experiences and thoughts, especially among adolescents who have signs of depression. The results of this study can be used to develop user-centered electronic health applications that allow users to express their own thoughts and experiences in ways other than systematic mood monitoring.

  • Source: iStock; Copyright: scyther5; URL: https://www.istockphoto.com/ca/photo/coding-code-program-compute-coder-develop-developer-development-gm655147056-119168287; License: Licensed by the authors.

    Tweet Classification Toward Twitter-Based Disease Surveillance: New Data, Methods, and Evaluations

    Abstract:

    Background: The amount of medical and clinical-related information on the Web is increasing. Among the different types of information available, social media–based data obtained directly from people are particularly valuable and are attracting significant attention. To encourage medical natural language processing (NLP) research exploiting social media data, the 13th NII Testbeds and Community for Information access Research (NTCIR-13) Medical natural language processing for Web document (MedWeb) provides pseudo-Twitter messages in a cross-language and multi-label corpus, covering 3 languages (Japanese, English, and Chinese) and annotated with 8 symptom labels (such as cold, fever, and flu). Then, participants classify each tweet into 1 of the 2 categories: those containing a patient’s symptom and those that do not. Objective: This study aimed to present the results of groups participating in a Japanese subtask, English subtask, and Chinese subtask along with discussions, to clarify the issues that need to be resolved in the field of medical NLP. Methods: In summary, 8 groups (19 systems) participated in the Japanese subtask, 4 groups (12 systems) participated in the English subtask, and 2 groups (6 systems) participated in the Chinese subtask. In total, 2 baseline systems were constructed for each subtask. The performance of the participant and baseline systems was assessed using the exact match accuracy, F-measure based on precision and recall, and Hamming loss. Results: The best system achieved exactly 0.880 match accuracy, 0.920 F-measure, and 0.019 Hamming loss. The averages of match accuracy, F-measure, and Hamming loss for the Japanese subtask were 0.720, 0.820, and 0.051; those for the English subtask were 0.770, 0.850, and 0.037; and those for the Chinese subtask were 0.810, 0.880, and 0.032, respectively. Conclusions: This paper presented and discussed the performance of systems participating in the NTCIR-13 MedWeb task. As the MedWeb task settings can be formalized as the factualization of text, the achievement of this task could be directly applied to practical clinical applications.

  • NOMAD questionnaire on-screen and CFA on paper. Source: Image created by the Authors; Copyright: The Authors; URL: http://www.jmir.org/2019/2/e12376/; License: Public Domain (CC0).

    Toward an Objective Assessment of Implementation Processes for Innovations in Health Care: Psychometric Evaluation of the Normalization Measure Development...

    Abstract:

    Background: Successfully implementing eMental health (eMH) interventions in routine mental health care constitutes a major challenge. Reliable instruments to assess implementation progress are essential. The Normalization MeAsure Development (NoMAD) study developed a brief self-report questionnaire that could be helpful in measuring implementation progress. Based on the Normalization Process Theory, this instrument focuses on 4 generative mechanisms involved in implementation processes: coherence, cognitive participation, collective action, and reflexive monitoring. Objective: The aim of this study was to translate the NoMAD questionnaire to Dutch and to confirm the factor structure in Dutch mental health care settings. Methods: Dutch mental health care professionals involved in eMH implementation were invited to complete the translated NoMAD questionnaire. Confirmatory factor analysis (CFA) was conducted to verify interpretability of scale scores for 3 models: (1) the theoretical 4-factor structure, (2) a unidimensional model, and (3) a hierarchical model. Potential improvements were explored, and correlated scale scores with 3 control questions were used to assess convergent validity. Results: A total of 262 professionals from mental health care settings in the Netherlands completed the questionnaire (female: 81.7%; mean age: 45 [SD=11]). The internal consistency of the 20-item questionnaire was acceptable (.62≤alpha≤.85). The theorized 4-factor model fitted the data slightly better in the CFA than the hierarchical model (Comparative Fit Index=0.90, Tucker Lewis Index=0.88, Root Mean Square Error of Approximation=0.10, Standardized Root Mean Square Residual=0.12, χ22=22.5, P≤.05). However, the difference is small and possibly not outweighing the practical relevance of a total score and subscale scores combined in one hierarchical model. One item was identified as weak (λCA.2=0.10). A moderate-to-strong convergent validity with 3 control questions was found for the Collective Participation scale (.47≤r≤.54, P≤.05). Conclusions: NoMAD’s theoretical factor structure was confirmed in Dutch mental health settings to acceptable standards but with room for improvement. The hierarchical model might prove useful in increasing the practical utility of the NoMAD questionnaire by combining a total score with information on the 4 generative mechanisms. Future research should assess the predictive value and responsiveness over time and elucidate the conceptual interpretability of NoMAD in eMH implementation practices.

  • Source: Freepik; Copyright: freepic.diller; URL: https://www.freepik.com/free-photo/young-business-man-blows-his-nose-while-working-his-laptop-workplace_2455302.htm; License: Licensed by JMIR.

    Causal Relationships Among Pollen Counts, Tweet Numbers, and Patient Numbers for Seasonal Allergic Rhinitis Surveillance: Retrospective Analysis

    Abstract:

    Background: Health-related social media data are increasingly used in disease-surveillance studies, which have demonstrated moderately high correlations between the number of social media posts and the number of patients. However, there is a need to understand the causal relationship between the behavior of social media users and the actual number of patients in order to increase the credibility of disease surveillance based on social media data. Objective: This study aimed to clarify the causal relationships among pollen count, the posting behavior of social media users, and the number of patients with seasonal allergic rhinitis in the real world. Methods: This analysis was conducted using datasets of pollen counts, tweet numbers, and numbers of patients with seasonal allergic rhinitis from Kanagawa Prefecture, Japan. We examined daily pollen counts for Japanese cedar (the major cause of seasonal allergic rhinitis in Japan) and hinoki cypress (which commonly complicates seasonal allergic rhinitis) from February 1 to May 31, 2017. The daily numbers of tweets that included the keyword “kafunshō” (or seasonal allergic rhinitis) were calculated between January 1 and May 31, 2017. Daily numbers of patients with seasonal allergic rhinitis from January 1 to May 31, 2017, were obtained from three healthcare institutes that participated in the study. The Granger causality test was used to examine the causal relationships among pollen count, tweet numbers, and the number of patients with seasonal allergic rhinitis from February to May 2017. To determine if time-variant factors affect these causal relationships, we analyzed the main seasonal allergic rhinitis phase (February to April) when Japanese cedar trees actively produce and release pollen. Results: Increases in pollen count were found to increase the number of tweets during the overall study period (P=.04), but not the main seasonal allergic rhinitis phase (P=.05). In contrast, increases in pollen count were found to increase patient numbers in both the study period (P=.04) and the main seasonal allergic rhinitis phase (P=.01). Increases in the number of tweets increased the patient numbers during the main seasonal allergic rhinitis phase (P=.02), but not the overall study period (P=.89). Patient numbers did not affect the number of tweets in both the overall study period (P=.24) and the main seasonal allergic rhinitis phase (P=.47). Conclusions: Understanding the causal relationships among pollen counts, tweet numbers, and numbers of patients with seasonal allergic rhinitis is an important step to increasing the credibility of surveillance systems that use social media data. Further in-depth studies are needed to identify the determinants of social media posts described in this exploratory analysis.

  • Homepage of RAW Mindfulness Program. Source: Sadhbh Joyce / Placeit; Copyright: JMIR Publications; URL: http://www.jmir.org/2019/2/e12894/; License: Creative Commons Attribution (CC-BY).

    Resilience@Work Mindfulness Program: Results From a Cluster Randomized Controlled Trial With First Responders

    Abstract:

    Background: A growing body of research suggests that resilience training can play a pivotal role in creating mentally healthy workplaces, particularly with regard to protecting the long-term well-being of workers. Emerging research describes positive outcomes from various types of resilience training programs (RTPs) among different occupational groups. One specific group of workers that may benefit from this form of proactive resilience training is first responders. Given the nature of their work, first responders are frequently exposed to stressful circumstances and potentially traumatic events, which may impact their overall resilience and well-being over time. Objective: This study aimed to examine whether a mindfulness-based RTP (the Resilience@Work [RAW] Mindfulness Program) delivered via the internet can effectively enhance resilience among a group of high-risk workers. Methods: We conducted a cluster randomized controlled trial (RCT) comprising 24 Primary Fire and Rescue and Hazmat stations within New South Wales. Overall, 12 stations were assigned to the 6-session RAW Mindfulness Program and 12 stations were assigned to the control condition. A total of 143 active full-time firefighters enrolled in the study. Questionnaires were administered at baseline, immediately post training, and at 6-month follow-up. Measurements examined change in both adaptive and bounce-back resilience as well as several secondary outcomes examining resilience resources and acceptance and mindfulness skills. Results: Mixed-model repeated measures analysis found that the overall test of group-by-time interaction was significant (P=.008), with the intervention group increasing in adaptive resilience over time. However, no significant differences were found between the intervention group and the control group in terms of change in bounce-back resilience (P=.09). At 6-month follow-up, the group receiving the RAW intervention had an average increase in their resilience score of 1.3, equating to a moderate-to-large effect size compared with the control group of 0.73 (95% CI 0.38-1.06). Per-protocol analysis found that compared with the control group, the greatest improvements in adaptive resilience were observed among those who completed most of the RAW program, that is, 5 to 6 sessions (P=.002). Conclusions: The results of this RCT suggest that mindfulness-based resilience training delivered in an internet format can create improvements in adaptive resilience and related resources among high-risk workers, such as first responders. Despite a number of limitations, the results of this study suggest that the RAW Mindfulness Program is an effective, scalable, and practical means of delivering online resilience training in high-risk workplace settings. To the best of our knowledge, this is the first time a mindfulness-based RTP delivered entirely via the internet has been tested in the workplace. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12615000574549; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368296 (Archived by WebCite at http://www.webcitation.org/75w4xtrpw).

  • Patient falling. Source: iStock; Copyright: Toa55; URL: https://www.istockphoto.com/kr/%EC%82%AC%EC%A7%84/%EC%97%AC%EC%9E%90%EC%97%90%EC%97%90%EC%84%9C-%EB%B9%A0%EC%A7%80%EB%8A%94-%EC%9A%95%EC%8B%A4-%EB%95%8C%EB%AC%B8%EC%97%90-%EB%AF%B8-%EB%81%84-%EB%9F%AC%EC%9A%B4-%ED%91%9C%EB%A9%B4-gm854848716-140565309; License: Licensed by the authors.

    Novel Approach to Inpatient Fall Risk Prediction and Its Cross-Site Validation Using Time-Variant Data

    Abstract:

    Background: Electronic medical records (EMRs) contain a considerable amount of information about patients. The rapid adoption of EMRs and the integration of nursing data into clinical repositories have made large quantities of clinical data available for both clinical practice and research. Objective: In this study, we aimed to investigate whether readily available longitudinal EMR data including nursing records could be utilized to compute the risk of inpatient falls and to assess their accuracy compared with existing fall risk assessment tools. Methods: We used 2 study cohorts from 2 tertiary hospitals, located near Seoul, South Korea, with different EMR systems. The modeling cohort included 14,307 admissions (122,179 hospital days), and the validation cohort comprised 21,172 admissions (175,592 hospital days) from each of 6 nursing units. A probabilistic Bayesian network model was used, and patient data were divided into windows with a length of 24 hours. In addition, data on existing fall risk assessment tools, nursing processes, Korean Patient Classification System groups, and medications and administration data were used as model parameters. Model evaluation metrics were averaged using 10-fold cross-validation. Results: The initial model showed an error rate of 11.7% and a spherical payoff of 0.91 with a c-statistic of 0.96, which represent far superior performance compared with that for the existing fall risk assessment tool (c-statistic=0.69). The cross-site validation revealed an error rate of 4.87% and a spherical payoff of 0.96 with a c-statistic of 0.99 compared with a c-statistic of 0.65 for the existing fall risk assessment tool. The calibration curves for the model displayed more reliable results than those for the fall risk assessment tools alone. In addition, nursing intervention data showed potential contributions to reducing the variance in the fall rate as did the risk factors of individual patients. Conclusions: A risk prediction model that considers longitudinal EMR data including nursing interventions can improve the ability to identify individual patients likely to fall.

  • Source: Freepik; Copyright: sirinarth; URL: https://www.freepik.com/free-photo/man-s-hands-typing-on-laptop-keyboard_1236179.htm#term=consult%20computer&page=5&position=3; License: Licensed by JMIR.

    Cost-Effectiveness of Telemedicine in Remote Orthopedic Consultations: Randomized Controlled Trial

    Abstract:

    Background: Telemedicine consultations using real-time videoconferencing has the potential to improve access and quality of care, avoid patient travels, and reduce health care costs. Objective: The aim of this study was to examine the cost-effectiveness of an orthopedic videoconferencing service between the University Hospital of North Norway and a regional medical center in a remote community located 148 km away. Methods: An economic evaluation based on a randomized controlled trial of 389 patients (559 consultations) referred to the hospital for an orthopedic outpatient consultation was conducted. The intervention group (199 patients) was randomized to receive video-assisted remote orthopedic consultations (302 consultations), while the control group (190 patients) received standard care in outpatient consultation at the hospital (257 consultations). A societal perspective was adopted for calculating costs. Health outcomes were measured as quality-adjusted life years (QALYs) gained. Resource use and health outcomes were collected alongside the trial at baseline and at 12 months follow-up using questionnaires, patient charts, and consultation records. These were valued using externally collected data on unit costs and QALY weights. An extended sensitivity analysis was conducted to address the robustness of the results. Results: This study showed that using videoconferencing for orthopedic consultations in the remote clinic costs less than standard outpatient consultations at the specialist hospital, as long as the total number of patient consultations exceeds 151 per year. For a total workload of 300 consultations per year, the annual cost savings amounted to €18,616. If costs were calculated from a health sector perspective, rather than a societal perspective, the number of consultations needed to break even was 183. Conclusions: This study showed that providing video-assisted orthopedic consultations to a remote clinic in Northern Norway, rather than having patients travel to the specialist hospital for consultations, is cost-effective from both a societal and health sector perspective. This conclusion holds as long as the activity exceeds 151 and 183 patient consultations per year, respectively. Trial Registration: ClinicalTrials.gov NCT00616837; https://clinicaltrials.gov/ct2/show/NCT00616837 (Archived by WebCite at http://www.webcitation.org/762dZPoKX)

  • Health Care and Cybersecurity: Bibliometric Analysis of the Literature

    Abstract:

    Background: Over the past decade, clinical care has become globally dependent on information technology. The cybersecurity of health care information systems is now an essential component of safe, reliable, and effective health care delivery. Objective: The objective of this study was to provide an overview of the literature at the intersection of cybersecurity and health care delivery. Methods: A comprehensive search was conducted using PubMed and Web of Science for English-language peer-reviewed articles. We carried out chronological analysis, domain clustering analysis, and text analysis of the included articles to generate a high-level concept map composed of specific words and the connections between them. Results: Our final sample included 472 English-language journal articles. Our review results revealed that majority of the articles were focused on technology: Technology–focused articles made up more than half of all the clusters, whereas managerial articles accounted for only 32% of all clusters. This finding suggests that nontechnological variables (human–based and organizational aspects, strategy, and management) may be understudied. In addition, Software Development Security, Business Continuity, and Disaster Recovery Planning each accounted for 3% of the studied articles. Our results also showed that publications on Physical Security account for only 1% of the literature, and research in this area is lacking. Cyber vulnerabilities are not all digital; many physical threats contribute to breaches and potentially affect the physical safety of patients. Conclusions: Our results revealed an overall increase in research on cybersecurity and identified major gaps and opportunities for future work.

  • Source: Kadena Air Base (Tara A Williamson); Copyright: US Air Force; URL: https://www.kadena.af.mil/News/Article-Display/Article/417911/heart-health-makes-happy-humans/; License: Public Domain (CC0).

    Patient-Level Prediction of Cardio-Cerebrovascular Events in Hypertension Using Nationwide Claims Data

    Abstract:

    Background: Prevention and management of chronic diseases are the main goals of national health maintenance programs. Previously widely used screening tools, such as Health Risk Appraisal, are restricted in their achievement this goal due to their limitations, such as static characteristics, accessibility, and generalizability. Hypertension is one of the most important chronic diseases requiring management via the nationwide health maintenance program, and health care providers should inform patients about their risks of a complication caused by hypertension. Objective: Our goal was to develop and compare machine learning models predicting high-risk vascular diseases for hypertensive patients so that they can manage their blood pressure based on their risk level. Methods: We used a 12-year longitudinal dataset of the nationwide sample cohort, which contains the data of 514,866 patients and allows tracking of patients’ medical history across all health care providers in Korea (N=51,920). To ensure the generalizability of our models, we conducted an external validation using another national sample cohort dataset, comprising one million different patients, published by the National Health Insurance Service. From each dataset, we obtained the data of 74,535 and 59,738 patients with essential hypertension and developed machine learning models for predicting cardiovascular and cerebrovascular events. Six machine learning models were developed and compared for evaluating performances based on validation metrics. Results: Machine learning algorithms enabled us to detect high-risk patients based on their medical history. The long short-term memory-based algorithm outperformed in the within test (F1-score=.772, external test F1-score=.613), and the random forest-based algorithm of risk prediction showed better performance over other machine learning algorithms concerning generalization (within test F1-score=.757, external test F1-score=.705). Concerning the number of features, in the within test, the long short-term memory-based algorithms outperformed regardless of the number of features. However, in the external test, the random forest-based algorithm was the best, irrespective of the number of features it encountered. Conclusions: We developed and compared machine learning models predicting high-risk vascular diseases in hypertensive patients so that they may manage their blood pressure based on their risk level. By relying on the prediction model, a government can predict high-risk patients at the nationwide level and establish health care policies in advance.

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  • Languages, Length of Residence, and Diagnosis as Promising Predictors of Diverse eHealth Activities Among Immigrants: Case of First-Generation Immigrants from Pakistan in the Oslo Area, Norway

    Date Submitted: Aug 21, 2018

    Open Peer Review Period: Feb 21, 2019 - Apr 18, 2019

    Background: Immigrant populations are often disproportionally affected by chronic diseases, such as Type-2 diabetes [T2D]. Use of information and communication technology is one promising approach to...

    Background: Immigrant populations are often disproportionally affected by chronic diseases, such as Type-2 diabetes [T2D]. Use of information and communication technology is one promising approach to provide health-related information, knowledge, and support in managing the chronic condition to a wider population. However, knowledge is scarce regarding eHealth activities for self-care among immigrants, especially in European countries. Objective: By setting the first-generation immigrants from Pakistan in the Oslo area, Norway, as a target group, we aimed to understand their diverse eHealth activities for T2D self-care in relation to target-group specific user factors such as proficiency in relevant languages (Urdu, Norwegian, English), length of residence in Norway, and diagnosis of T2D, compared to general factors like age, gender, education, digital skills, and self-rated health status. Methods: We used data from a survey among the target population (N=176) conducted in 2015-2016. Dichotomous data about whether or not an informant had experienced each type of eHealth activity for T2D self-care in the last 12 months were used as dependent variables for logistic regression analysis [LRA], and the total number of positive answers (variety) was used in Poisson regression analysis. Independent variables consisted of data regarding user factors named above. Best-fit method based on Akaike information criterion was employed as the selection criterion between models. Results: LRA yielded 7 models regarding the followings: (A) information seeking by (a) search engines (b) web portals or email subscriptions; (B) communication and consultation (d) by closed conversation with a few acquaintances using ICT (e) on social network services (f) on peer-portals; (C) active decision making by using applications for (h) tracking health information and (i) self-assessment of health status. Variables positively associated (p<.05) with eHealth experience were Urdu literacy (for (a), (b), (e) and variety), length of residence in Norway (for (d), (e), and variety), Norwegian language proficiency (for (f) and (i)), and diagnosis of T2D (for (a)), while having English proficiency was negatively associated with using social network services. Among general user factors, younger age (for (h), (i) and variety), a composite variable of education and digital skills (for (h) and (i)) and being female (for (d)) showed a positive association with each experience of eHealth. Self-assessment of health status did not remain in any model. Conclusions: In our sample, target-group specific user factors were dominant factors characterizing diverse eHealth activities compared to general user factors. The yielded knowledge will serve as a basis of further research on designing, developing, and disseminating eHealth services, and for studies exploring the influence of relevant user factors for eHealth activities in other user groups and contexts.

  • Influence of climate on geographic pruritus internet searches: A retrospective analysis of Google searches in 16 German cities

    Date Submitted: Feb 18, 2019

    Open Peer Review Period: Feb 21, 2019 - Apr 18, 2019

    Background: The burden of pruritus is high, especially among patients with dermatologic diseases. Estimating the prevalence rates of pruritus and the people’s medical needs is challeng-ing since not...

    Background: The burden of pruritus is high, especially among patients with dermatologic diseases. Estimating the prevalence rates of pruritus and the people’s medical needs is challeng-ing since not all affected people consult a physician. Objective: To investigate pruritus search behavior trends in Germany and identify associations with external factors. Methods: Google AdWords Keyword Planner was used to quantify pruritus-related search que-ries in 16 German cities from August 2014 to July 2018. All identified keywords were qualitatively categorized and pruritus-related terms were descriptively analyzed. The number of search queries per 100,000 inhabitants of each city was compared to envi-ronmental factors such as temperature, humidity, particulate matter (PM10), and sun-shine duration to investigate potential correlations. Results: We included 1,150 pruritus-related keywords, which resulted in 2,851,290 queries. “Pruritus” (n=115,680) and “anal pruritus” (n=102,390) were the most searched for keywords. The most populated cities had the lowest number of queries/100,000 inhab-itants (Berlin, n=13,641; Hamburg, n=18,303; and Munich, n=21,363), while smaller cities (Kiel, n=35,027; and Freiburg, n=39,501) had the highest. Temperature had a greater effect on search query number (β coefficient: -7.94, 95% confidence interval [CI] [-10.74; -5.15]) than PM10 (-5.13, [-7.04, -3.22]), humidity (4.73, [2.70, 6.75]), or sunshine duration (0.66, [0.36, 0.97]). The highest relative number of search queries occurred during the winter (December to February). Conclusions: Google data analysis provided good insight into general search behaviors. Examining different cities across Germany and comparing search volumes with weather data were valuable for identifying trends and respective inhabitants’ needs.

  • Patient and health care provider experiences with a recently introduced patient portal in an academic hospital in the Netherlands, a mixed-methods study

    Date Submitted: Feb 18, 2019

    Open Peer Review Period: Feb 21, 2019 - Apr 18, 2019

    Background: In the Netherlands, the health care system and related information technology landscape are fragmented. Recently, hospitals have started to launch patient portals. It is not clear how thes...

    Background: In the Netherlands, the health care system and related information technology landscape are fragmented. Recently, hospitals have started to launch patient portals. It is not clear how these portals are used by patients and their health care providers. Objective: To explore use, usability and usefulness of a recently introduced patient portal in an academic hospital in order to learn lessons for the implementation of patient portals in a fragmented health care system. Methods: A mixed-methods study design was used. In the quantitative study arm characteristics of patients who used the portal were analysed in addition to their utilisation of the portal. In the qualitative study arms, think aloud observations were done among patients who logged in for the first time. Focus group discussions were conducted with patients and health care providers who were familiar with the portal. Thematic content analysis of qualitative data was carried out and overarching themes were identified using a framework analysis. Results: One year after the introduction of the portal, 13.5% of all patients who visited the hospital had logged in to the portal. Utilisation of the portal was associated with age, socioeconomic status and number of diagnoses. The portal was mostly used to check lab results and letters that were sent to the general practitioner and less frequently to send a message to their health care provider. Overarching themes that emerged from the qualitative analyses were: (1) usability and user friendliness of the portal, (2) HCP-patient communication through the portal (3) usefulness of the information that can be accessed through the portal, (4) integration of the portal in care and work processes, and (5) HCP and patient roles and relations. Conclusions: One year after implementation of the portal, adoption by patients and the perceived usability is promising. Patients and health care providers agree that the portal has the potential to increase patient engagement in their care processes. However, use of the portal is not yet firmly integrated in care practices or in the workflow of HCPs. Both HCPs and patients have uncertainties about how to use the new communication opportunities the portal provides. Clinical Trial: Ethical approval was requested and granted by the Research Ethics Committee of the Radboud University Nijmegen Medical Centre under number 2016-3091.

  • HIV digital vaccine strategy: An application of blockchain technology in preventing the spread of HIV

    Date Submitted: Feb 18, 2019

    Open Peer Review Period: Feb 21, 2019 - Apr 18, 2019

    The HIV epidemic imposes a heavy burden on societal development. Presently, the protection of susceptible populations is the most feasible method for eliminating the spread of HIV. Governments and oth...

    The HIV epidemic imposes a heavy burden on societal development. Presently, the protection of susceptible populations is the most feasible method for eliminating the spread of HIV. Governments and other relevant industries are actively attempting to solve the problem. In view of the unavailability of biological vaccines, the best measures that can currently be applied are identification of HIV-infected persons and provision of treatment and behavioral intervention. This paper proposes a HIV digital vaccine strategy based on blockchain technology. In the proposed strategy, a decentralized surveillance network is jointly constructed using HIV high-risk individuals as application nodes and accredited testing agencies as authentication nodes. Following testing at the authentication nodes, the results are uploaded to the blockchain, which results in HIV high-risk individuals being able to determine the HIV infection status of each other in a convenient, anonymous, and credible manner. This reduces the occurrence of high-risk sexual behavior and effectively protects susceptible populations. The proposed strategy is a promising solution to prevent the spread of HIV. The performance of the decentralized surveillance network may lead to the restructuring of current government-funded infectious disease prevention and control modes that are centered on centers for disease control and prevention and hospitals to introduce revolutionary changes in public health systems globally.

  • Predictors of patients’ intention to interact with doctors on online health platforms

    Date Submitted: Feb 18, 2019

    Open Peer Review Period: Feb 21, 2019 - Apr 18, 2019

    Background: Online health platforms provide opportunities for doctors and patients interact with each other and change the traditional communication mode between doctors and patients. However, little...

    Background: Online health platforms provide opportunities for doctors and patients interact with each other and change the traditional communication mode between doctors and patients. However, little is known about the predictors of patients’ intention to interact with doctors on online health platforms. Objective: The purpose of this study is to investigate what are the predictors of patients’ intention to interact with doctors on online health platforms. Methods: Based on two-factor theory and service convenience theory, we propose that the attributes of online health platforms including ease of use and perceived synchronicity influence patients’ intention to interact through convenience of online health platforms, while the attributes of physical health facilities like inaccessibility and discontinuity affect patients’ intention to interact through inconvenience of offline health facilities. We employed the survey method to validate our hypothesized relationships. Through developing the measurement instruments, we collected 334 valid answers from online health platforms users and utilized partial least square to analyze the data. Results: Ease of use (t=2.924, P <0.01) and perceived synchronicity (t=2.353, P <0.05) were found to influence convenience of online health platforms significantly, while inaccessibility (t=3.189, P <0.01) and discontinuity (t=3.149, P <0.01) were found to impact inconvenience of physical health facilities significantly. Meanwhile, both convenience of online health platforms (t=2.353, P <0.05) and inconvenience of physical health facilities (t=2.787, P <0.01) were found to affect patients’ intention to interact with doctors on online health platforms significantly. Therefore, all the proposed hypotheses were supported. Conclusions: Through including factors from both online health platforms and physical health facilities, we can understand patients’ intention to interact comprehensively. This study, not only contribute to literature of doctor-patient interaction and online health platforms, but also provide implications to promote doctor-patients interaction online and offline.

  • Trial Design, Feasibility, and Acceptability of an Intervention to Reduce Hypoglycemia Fear in Parents of Young Kids with Video-Based Telemedicine (REDCHIP)

    Date Submitted: Feb 15, 2019

    Open Peer Review Period: Feb 19, 2019 - Apr 16, 2019

    Background: Fear of hypoglycemia is common in parents of young children with type 1 diabetes (T1D) and problematically linked to maladaptive behaviors to avoid low blood glucose, parenting stress, and...

    Background: Fear of hypoglycemia is common in parents of young children with type 1 diabetes (T1D) and problematically linked to maladaptive behaviors to avoid low blood glucose, parenting stress, and burn-out. There are currently no interventions focused on reducing hypoglycemia fear in this population. Objective: To examine the feasibility and acceptability of a group-based telemedicine intervention to reduce fear of hypoglycemia in parents of young children with T1D. Methods: Forty-three families of a young child with T1D (1-6 years old; diagnosed with T1D for at least 6 months) enrolled in the study and 36 completed the Reducing Emotional Distress for Childhood Hypoglycemia in Parents (REDCHiP) intervention. We delivered a 10-session manualized cognitive behavioral intervention to reduce hypoglycemia fear using telemedicine (i.e., secure real-time videoconferencing). We assessed intervention feasibility with rates of attrition, intervention attendance, and fidelity to the treatment manual. Intervention completers answered a treatment satisfaction survey and a subset of completers (N=10) participated in qualitative interviews about intervention acceptability, facilitators, and challenges. Results: Total study attrition was 21%, including the long-term follow-up period (16% before or during the treatment phase of the study). On average, parents attended 94% of intervention sessions and average fidelity to the treatment manual was 89%. Intervention completers reported high satisfaction with the treatment groups (85% average satisfaction rating). Parents reported positive influencers of the REDCHiP intervention during qualitative interviews (i.e., knowledge, fear awareness, coping strategies, confidence, behavioral parenting strategies, and support). Parents did report some intervention challenges, including feeling fearful or overwhelmed, family stress, lack of trust, and difficulty connecting with other group members. Conclusions: The REDCHiP intervention demonstrated initial feasibility and acceptability. Next steps include determining the intervention’s impact on objective parent and child outcomes (e.g., glycemic control, parental fear of hypoglycemia, parental stress/distress). Clinical Trial: NICHD R21 HD081502

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