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Background High-frequency patient-reported outcome (PRO) assessments are used to measure patients' symptoms after surgery for surgical research; however, the quality of those longitudinal PRO data has seldom been discussed. Objective The aim of this study was to determine data quality-influencing factors and to profile error trajectories of data longitudinally collected via paper-and-pencil (P&P) or web-based assessment (electronic PRO [ePRO]) after thoracic surgery. Methods We extracted longitudinal PRO data with 678 patients scheduled for lung surgery from an observational study (n=512) and a randomized clinical trial (n=166) on the evaluation of different perioperative care strategies. PROs were assessed by the MD Anderson Symptom Inventory Lung Cancer Module and single-item Quality of Life Scale before surgery and then daily after surgery until discharge or up to 14 days of hospitalization. Patient compliance and data error were identified and compared between P&P and ePRO. Generalized estimating equations model and 2-piecewise model were used to describe trajectories of error incidence over time and to identify the risk factors. Results Among 678 patients, 629 with at least 2 PRO assessments, 440 completed 3347 P&P assessments and 189 completed 1291 ePRO assessments. In total, 49.4% of patients had at least one error, including (1) missing items (64.69%, 1070/1654), (2) modifications without signatures (27.99%, 463/1654), (3) selection of multiple options (3.02%, 50/1654), (4) missing patient signatures (2.54%, 42/1654), (5) missing researcher signatures (1.45%, 24/1654), and (6) missing completion dates (0.30%, 5/1654). Patients who completed ePRO had fewer errors than those who completed P&P assessments (ePRO: 30.2% [57/189] vs. P&P: 57.7% [254/440]; P Conclusions It is possible to improve data quality of longitudinally collected PRO through ePRO, compared with P&P. However, ePRO-related sampling bias needs to be considered when designing clinical research using longitudinal PROs as major outcomes.

Background Maintaining a healthy lifestyle is important for wheelchair users’ well-being, as it can have a major impact on their daily functioning. Mobile health (mHealth) apps can support a healthy lifestyle; however, these apps are not necessarily suitable for wheelchair users with spinal cord injury or lower limb amputation. Therefore, a new mHealth app (WHEELS) was developed to promote a healthy lifestyle for this population. Objective The objectives of this study were to develop the WHEELS mHealth app, and explore its usability, feasibility, and effectiveness. Methods The WHEELS app was developed using the intervention mapping framework. Intervention goals were determined based on a needs assessment, after which behavior change strategies were selected to achieve these goals. These were applied in an app that was pretested on ease of use and satisfaction, followed by minor adjustments. Subsequently, a 12-week pre-post pilot study was performed to explore usability, feasibility, and effectiveness of the app. Participants received either a remote-guided or stand-alone intervention. Responses to semistructured interviews were analyzed using content analysis, and questionnaires (System Usability Score [SUS], and Usefulness, Satisfaction, and Ease) were administered to investigate usability and feasibility. Effectiveness was determined by measuring outcomes on physical activity, nutrition, sleep quality (Pittsburgh Sleep Quality Index), body composition, and other secondary outcomes pre and post intervention, and by calculating effect sizes (Hedges g). Results Sixteen behavior change strategies were built into an app to change the physical activity, dietary, sleep, and relaxation behaviors of wheelchair users. Of the 21 participants included in the pilot study, 14 participants completed the study. The interviews and questionnaires showed a varied user experience. Participants scored a mean of 58.6 (SD 25.2) on the SUS questionnaire, 5.4 (SD 3.1) on ease of use, 5.2 (SD 3.1) on satisfaction, and 5.9 (3.7) on ease of learning. Positive developments in body composition were found on waist circumference (P=.02, g=0.76), fat mass percentage (P=.004, g=0.97), and fat-free mass percentage (P=.004, g=0.97). Positive trends were found in body mass (P=.09, g=0.49), BMI (P=.07, g=0.53), daily grams of fat consumed (P=.07, g=0.56), and sleep quality score (P=.06, g=0.57). Conclusions The WHEELS mHealth app was successfully developed. The interview outcomes and usability scores are reasonable. Although there is room for improvement, the current app showed promising results and seems feasible to deploy on a larger scale.

Background HIV pre-exposure prophylaxis (PrEP) has considerable potential for reducing incidence among high-risk groups, such as gay, bisexual, and other men who have sex with men (GBM). However, PrEP’s effectiveness is closely linked with consistent use, and a variety of individual-level barriers, including alcohol use, could impede optimal uptake and use. Web-based interventions can encourage medication adherence, HIV prevention behaviors, and responsible drinking and may help support PrEP care, particularly in resource-limited settings. Objective We previously developed a web application called Game Plan that was designed to encourage heavy drinking GBM to use HIV prevention methods and reduce their alcohol use and was inspired by brief motivational interventions. This paper aims to describe the web-based content we designed for integration into Game Plan to help encourage PrEP uptake and consistent use among GBM. In this paper, we also aim to describe this content and its rationale. Methods Similar to the original site, these components were developed iteratively, guided by a thorough user-centered design process involving consultation with subject-matter experts, usability interviews and surveys, and user experience surveys. Results In addition to Game Plan’s pre-existing content, the additional PrEP components provide specific, personal, and digestible feedback to users about their level of risk for HIV without PrEP and illustrate how much consistent PrEP use could reduce it; personal feedback about their risk for common sexually transmitted infections to address low-risk perceptions; content challenging common beliefs and misconceptions about PrEP to reduce stigma; content confronting familiar PrEP and alcohol beliefs; and a change planning module that allows users to select specific goals for starting and strategies for consistent PrEP use. Users can opt into a weekly 2-way SMS text messaging program that provides similar feedback over a 12-week period after using Game Plan and follows up on the goals they set. Conclusions Research preliminarily testing the efficacy of these components in improving PrEP outcomes, including uptake, adherence, sexually transmitted infection rates, and alcohol use, is currently ongoing. If supported, these components could provide a scalable tool that can be used in resource-limited settings in which face-to-face intervention is difficult.

Background Diagnosing major depressive disorder (MDD) is challenging, with diagnostic manuals failing to capture the wide range of clinical symptoms that are endorsed by individuals with this condition. Objective This study aims to provide evidence for an extended definition of MDD symptomatology. Methods Symptom data were collected via a digital assessment developed for a delta study. Random forest classification with nested cross-validation was used to distinguish between individuals with MDD and those with subthreshold symptomatology of the disorder using disorder-specific symptoms and transdiagnostic symptoms. The diagnostic performance of the Patient Health Questionnaire–9 was also examined. Results A depression-specific model demonstrated good predictive performance when distinguishing between individuals with MDD (n=64) and those with subthreshold depression (n=140) (area under the receiver operating characteristic curve=0.89; sensitivity=82.4%; specificity=81.3%; accuracy=81.6%). The inclusion of transdiagnostic symptoms of psychopathology, including symptoms of depression, generalized anxiety disorder, insomnia, emotional instability, and panic disorder, significantly improved the model performance (area under the receiver operating characteristic curve=0.95; sensitivity=86.5%; specificity=90.8%; accuracy=89.5%). The Patient Health Questionnaire–9 was excellent at identifying MDD but overdiagnosed the condition (sensitivity=92.2%; specificity=54.3%; accuracy=66.2%). Conclusions Our findings are in line with the notion that current diagnostic practices may present an overly narrow conception of mental health. Furthermore, our study provides proof-of-concept support for the clinical utility of a digital assessment to inform clinical decision-making in the evaluation of MDD.

Background Within the context of the COVID-19 pandemic, this paper suggests a data science strategy for analyzing global research on coronaviruses. The application of reproducible research principles founded on text-as-data information, open science, the dissemination of scientific data, and easy access to scientific production may aid public health in the fight against the virus. Objective The primary goal of this paper was to use global research on coronaviruses to identify critical elements that can help inform public health policy decisions. We present a data science framework to assist policy makers in implementing cutting-edge data science techniques for the purpose of developing evidence-based public health policies. Methods We used the EpiBibR (epidemiology-based bibliography for R) package to gain access to coronavirus research documents worldwide (N=121,231) and their associated metadata. To analyze these data, we first employed a theoretical framework to group the findings into three categories: conceptual, intellectual, and social. Second, we mapped the results of our analysis in these three dimensions using machine learning techniques (ie, natural language processing) and social network analysis. Results Our findings, firstly, were methodological in nature. They demonstrated the potential for the proposed data science framework to be applied to public health policies. Additionally, our findings indicated that the United States and China were the primary contributors to global coronavirus research during the study period. They also demonstrated that India and Europe were significant contributors, albeit in a secondary position. University collaborations in this domain were strong between the United States, Canada, and the United Kingdom, confirming the country-level findings. Conclusions Our findings argue for a data-driven approach to public health policy, particularly when efficient and relevant research is required. Text mining techniques can assist policy makers in calculating evidence-based indices and informing their decision-making process regarding specific actions necessary for effective health responses.

Background Skin cancer is the most common cancer type affecting humans. Traditional skin cancer diagnosis methods are costly, require a professional physician, and take time. Hence, to aid in diagnosing skin cancer, artificial intelligence (AI) tools are being used, including shallow and deep machine learning–based methodologies that are trained to detect and classify skin cancer using computer algorithms and deep neural networks. Objective The aim of this study was to identify and group the different types of AI-based technologies used to detect and classify skin cancer. The study also examined the reliability of the selected papers by studying the correlation between the data set size and the number of diagnostic classes with the performance metrics used to evaluate the models. Methods We conducted a systematic search for papers using Institute of Electrical and Electronics Engineers (IEEE) Xplore, Association for Computing Machinery Digital Library (ACM DL), and Ovid MEDLINE databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. The studies included in this scoping review had to fulfill several selection criteria: being specifically about skin cancer, detecting or classifying skin cancer, and using AI technologies. Study selection and data extraction were independently conducted by two reviewers. Extracted data were narratively synthesized, where studies were grouped based on the diagnostic AI techniques and their evaluation metrics. Results We retrieved 906 papers from the 3 databases, of which 53 were eligible for this review. Shallow AI-based techniques were used in 14 studies, and deep AI-based techniques were used in 39 studies. The studies used up to 11 evaluation metrics to assess the proposed models, where 39 studies used accuracy as the primary evaluation metric. Overall, studies that used smaller data sets reported higher accuracy. Conclusions This paper examined multiple AI-based skin cancer detection models. However, a direct comparison between methods was hindered by the varied use of different evaluation metrics and image types. Performance scores were affected by factors such as data set size, number of diagnostic classes, and techniques. Hence, the reliability of shallow and deep models with higher accuracy scores was questionable since they were trained and tested on relatively small data sets of a few diagnostic classes.

Background In China, the internet has become one of the most important ways to obtain information about breast cancer. However, quantitative evaluations of the quality of Chinese health websites and the breast cancer treatment information they publish are lacking. Objective This study aimed to evaluate the quality of Chinese breast cancer websites and the value, suitability, and accuracy of the breast cancer treatment information they publish. Methods Chinese breast cancer health websites were searched and manually screened according to their Alexa and Baidu search engine rankings. For each website included in the survey, which was conducted on April 8, 2019, the three most recently published papers on the website that met the inclusion criteria were included for evaluation. Three raters assessed all materials using the LIDA, DISCERN, and Suitability Assessment of Materials (SAM) tools and the Michigan Checklist. Data analysis was completed with the Statistical Package for Social Sciences (SPSS) version 20.0 and Microsoft Excel 2010. Results This survey included 20 Chinese breast cancer websites and 60 papers on breast cancer treatment. The LIDA tool was used to evaluate the quality of the 20 websites. The LIDA’s scores of the websites (mean=54.85, SD 3.498; total possible score=81) were low. In terms of the layout, color scheme, search facility, browsing facility, integration of nontextual media, submission of comments, declaration of objectives, content production method, and robust method, more than half of the websites scored 0 (never) or 1 (sometimes). For the online breast cancer treatment papers, the scores were generally low. Regarding suitability, 32 (53.33%) papers were evaluated as presenting unsuitable material. Regarding accuracy, the problems were that the papers were largely not original (44/60, 73%) and lacked references (46/60, 77%). Conclusions The quality of Chinese breast cancer websites is poor. The color schemes, text settings, user comment submission functions, and language designs should be improved. The quality of Chinese online breast cancer treatment information is poor; the information has little value to users, and pictorial information is scarcely used. The online breast cancer treatment information is accurate but lacks originality and references. Website developers, governments, and medical professionals should play a full role in the design of health websites, the regulation of online health information, and the use of online health information.

Background The last two decades have witnessed a burgeoning rise in the prevalence of diabetes globally. It has already reached epidemic proportions in Saudi Arabia, with reported high risk among women. As a result, diabetes monitoring and self-management programs are being highly prioritized for diabetes control and management. Objective To investigate measuring and sharing practices of the self-monitoring of blood glucose (SMBG) among patients with type 1 or 2 diabetes using insulin. Methods A cross-sectional study was conducted on a sample of 203 patients attending primary care clinics at a tertiary care center. The questionnaire assessed the measuring, recording, and sharing of SMBG practices of patients having diabetes with their physicians. The methods used for recording and sharing were categorized into paper-based and electronic-based. In addition, the determinants of the different methods used and frequency of sharing were analyzed. Results The overall monitoring prevalence was 95% (193/203), and 57% (117/203) of participants shared the SMBG results. Among the 193 individuals that performed self-monitoring, 138 (72%) performed daily monitoring, and 147 (76%) recorded their blood sugar levels. Almost 55% (81/147) used paper-based materials like notebooks and paper for recording, while the rest (66/147, 45%) used digital devices like laptops and smartphones. A shift towards the use of digital devices and smart applications was observed in patients below 50 years of age. The digitally recorded blood glucose measurements were being shared thrice more often than the recordings made on paper or in notebooks (OR [odds ratio] 2.8; P=.01). Patients >50 years of age (OR 2.3; P=.02), with lesser formal education, married (OR 4.2; P Conclusions Good monitoring and optimal sharing practices were found. Sharing using electronic devices can be emphasized. Diabetes self-management programs can incorporate the use of digital technology in training sessions. Digital literacy and its applications in health care may enhance SMBG practices resulting in better diabetes control.

Background Vietnam is one of the first low- to middle-income countries to develop and implement a national-scale electronic immunization registry. This system was finalized into the National Immunization Information System (NIIS) and scaled up to a national-level system in 2017. As a result, immunization coverage and the timeliness of vaccinations have drastically improved. The time spent on planning and reporting vaccinations has drastically reduced; as a result, vaccination planning and reporting has become more accurate and effective. However, to date, end users have been tasked with managing both the NIIS and paper-based systems in parallel until a formal assessment of the readiness to fully transition to the NIIS is conducted. Objective This study aims to evaluate the readiness to move to an entirely digital NIIS in 2 provinces of Vietnam—Ha Noi and Son La. Methods All health facilities were surveyed to assess their infrastructure, capacity, and need for human resources. NIIS end users were observed and interviewed to evaluate their NIIS knowledge and skill sets. Data from immunization cards and facility paper-based logbooks were compared with data from the NIIS, and vaccine stocks at selected facilities were tallied and compared with data from the NIIS. Results Of the 990 health facilities evaluated, most used the NIIS to enter and track immunizations (987/990, 99.7%) and vaccine stocks (889/990, 90.8%). Most had stable electricity (971/990, 98.1%), at least 1 computer (986/990, 99.6%), and ≥2 trained NIIS end users (825/990, 83.3%). End users reported that the NIIS supported them in managing and reporting immunization data and saving them time (725/767, 94.5%). Although many end users were able to perform basic skills, almost half struggled with performing more complex tasks. Immunization data were compiled from the NIIS and immunization cards (338/378, 89.4%) and paper-based logbooks (254/269, 94.4%). However, only 54.5% (206/378) of immunization IDs matched, 57% (13/23) of Bacillus Calmette-Guérin vaccination records were accurate, and 70% (21/30) of the facilities had consistent physical vaccine stock balances. The feedback received from NIIS end users suggests that more supportive supervision, frequent refresher training for strengthening their skill sets, and detailed standardized guides for improving data quality are needed. Conclusions The readiness to transition to a digital system is promising; however, additional resources are required to address the timeliness, completeness, and accuracy of the data.

Background Children with osteogenesis imperfecta (OI) experience a diversity of symptoms that expose them to difficult physical, mental, and social challenges. Sisom (DHealth) is an interactive assessment and communication tool designed to help children aged 6-12 years with chronic conditions express their symptoms. Recently, the co-design of the Sisom OI paper prototype was launched by seeking the perspectives of end users, including children with OI and their clinicians. Objective The aim of this study is to describe the experiences that children with OI were prompted to share with researchers during the co-design of the Sisom OI paper prototype. Methods A secondary analysis of qualitative data was conducted at a university-affiliated, pediatric, orthopedic hospital. The data sources consisted of interview transcripts, drawings, field notes, and observations derived from interviewing 12 children with OI who participated in the co-design of the Sisom OI paper prototype. The themes and subthemes identified from the data sources were generated using qualitative description. Results Three themes were identified. The first, Relating to Others, described the balance between feeling different versus feeling similar to other children. The subthemes were Common OI Experience, Feeling Different, and Feeling Just Like Others. The second, Relating to Their Condition, described children’s positive and negative interactions with their own condition and health care. The subthemes were Understanding Their Condition, Special Relationship with the Hospital, and Difficult Treatments and Procedures. The third, Reflecting on Capabilities, described children’s recognition of their strengths and limitations. The subthemes were Perceiving Limitations, Overcoming Isolation, and Celebrating Strengths. Conclusions This co-design process provided children with OI the space to not only contribute to the development of the end product but also eloquently describe their experiences. These findings, based on the descriptions given by the children themselves, offer us a unique understanding of what it means to grow up with OI.

Background Patient-clinician secure messaging is an important function in patient portals and enables patients and clinicians to communicate on a wide spectrum of issues in a timely manner. With its growing adoption and patient engagement, it is time to comprehensively study the secure messages and user behaviors in order to improve patient-centered care. Objective The aim of this paper was to analyze the secure messages sent by patients and clinicians in a large multispecialty health system at Mayo Clinic, Rochester. Methods We performed message-based, sender-based, and thread-based analyses of more than 5 million secure messages between 2010 and 2017. We summarized the message volumes, patient and clinician population sizes, message counts per patient or clinician, as well as the trends of message volumes and user counts over the years. In addition, we calculated the time distribution of clinician-sent messages to understand their workloads at different times of a day. We also analyzed the time delay in clinician responses to patient messages to assess their communication efficiency and the back-and-forth rounds to estimate the communication complexity. Results During 2010-2017, the patient portal at Mayo Clinic, Rochester experienced a significant growth in terms of the count of patient users and the total number of secure messages sent by patients and clinicians. Three clinician categories, namely “physician—primary care,” “registered nurse—specialty,” and “physician—specialty,” bore the majority of message volume increase. The patient portal also demonstrated growing trends in message counts per patient and clinician. The “nurse practitioner or physician assistant—primary care” and “physician—primary care” categories had the heaviest per-clinician workload each year. Most messages by the clinicians were sent from 7 AM to 5 PM during a day. Yet, between 5 PM and 7 PM, the physicians sent 7.0% (95,785/1,377,006) of their daily messages, and the nurse practitioner or physician assistant sent 5.4% (22,121/408,526) of their daily messages. The clinicians replied to 72.2% (1,272,069/1,761,739) patient messages within 1 day and 90.6% (1,595,702/1,761,739) within 3 days. In 95.1% (1,499,316/1,576,205) of the message threads, the patients communicated with their clinicians back and forth for no more than 4 rounds. Conclusions Our study found steady increases in patient adoption of the secure messaging system and the average workload per clinician over 8 years. However, most clinicians responded timely to meet the patients’ needs. Our study also revealed differential patient-clinician communication patterns across different practice roles and care settings. These findings suggest opportunities for care teams to optimize messaging tasks and to balance the workload for optimal efficiency.

Background While diabetic foot ulcers (DFU) are a common complication of diabetes, little is known about the content and readability of online patient education materials (PEM) for DFU. The recommended reading grade level for these materials is grades 6-8. Objective The aim of this paper was to evaluate the quality and readability of online PEM on DFU. Methods A Google search was performed using 4 different search terms related to DFU. Two readability formulas were used to assess the readability of the included PEM. These included the Flesch-Kincaid grade level and the Flesch-Reading ease score. The DISCERN tool was used to determine quality and reliability. Results A total of 41 online PEM were included. The average Flesch-Reading ease score for all PEM was 63.43 (SD 14.21), indicating a standard difficulty level of reading. The average reading grade level was 7.85 (SD 2.38), which is higher than the recommended reading level for PEM. The mean DISCERN score was 45.66 (SD 3.34), and 27% (11/41) of the articles had DISCERN scores of less than 39, corresponding to poor or very poor quality. Conclusions The majority of online PEM on DFU are written above the recommended reading levels and have significant deficiencies in quality and reliability. Clinicians and patients should be aware of the shortcomings of these resources and consider the impact they may have on patients’ self-management.

Background Mobile health (mHealth) is an emerging field of scientific interest worldwide. Potential benefits include increased patient engagement, improved clinical outcomes, and reduced health care costs. However, mHealth is often studied in projects or trials, and structural implantation in clinical practice is less common. Objective The purpose of this paper is to outline the design of the Box and its implementation and use in an outpatient clinic setting. The impact on logistical outcomes and patient and provider satisfaction is discussed. Methods In 2016, an mHealth care track including smartphone-compatible devices, named the Box, was implemented in the cardiology department of a tertiary medical center in the Netherlands. Patients with myocardial infarction, rhythm disorders, cardiac surgery, heart failure, and congenital heart disease received devices to measure daily weight, blood pressure, heart rate, temperature, and oxygen saturation. In addition, professional and patient user comments on the experience with the care track were obtained via structured interviews. Results From 2016 to April 2020, a total of 1140 patients were connected to the mHealth care track. On average, a Box cost €350 (US $375), not including extra staff costs. The median patient age was 60.8 (IQR 52.9-69.3) years, and 73.59% (839/1140) were male. A median of 260 (IQR 105-641) measurements was taken on a median of 189 (IQR 98-372) days. Patients praised the ease of use of the devices and felt more involved with their illness and care. Professionals reported more productive outpatient consultations as well as improved insight into health parameters such as blood pressure and weight. A feedback loop from the hospital to patient to focus on measurements was commented as an important improvement by both patients and professionals. Conclusions In this study, the design and implementation of an mHealth care track for outpatient follow-up of patients with various cardiovascular diseases is described. Data from these 4 years indicate that mHealth is feasible to incorporate in outpatient management and is generally well-accepted by patients and providers. Limitations include the need for manual measurement data checks and the risk of data overload. Moreover, the tertiary care setting in which the Box was introduced may limit the external validity of logistical and financial end points to other medical centers. More evidence is needed to show the effects of mHealth on clinical outcomes and on cost-effectiveness.

Background The successful management of heart failure (HF) involves guideline-based medical therapy as well as self-management behavior. As a result, the management of HF is moving toward a proactive real-time technological model of assisting patients with monitoring and self-management. Objective The aim of this paper was to evaluate the efficacy of enhanced self-management via a mobile app intervention on health-related quality of life, self-management, and HF readmissions. Methods A single-center randomized controlled trial was performed. Participants older than 45 years and admitted for acute decompensated HF or recently discharged in the past 4 weeks were included. The intervention group (“app group”) used a mobile app, and the intervention prompted daily self-monitoring and promoted self-management. The control group (“no-app group”) received usual care. The primary outcome was the change in Minnesota Living with Heart Failure Questionnaire (MLHFQ) score from baseline to 6 and 12 weeks. Secondary outcomes were the Self-Care Heart Failure Index (SCHFI) questionnaire score and recurrent HF admissions. Results A total of 83 participants were enrolled and completed all baseline assessments. Baseline characteristics were similar between the groups except for the prevalence of ischemic HF. The app group had a reduced MLHFQ at 6 weeks (mean 37.5, SD 3.5 vs mean 48.2, SD 3.7; P=.04) but not at 12 weeks (mean 44.2, SD 4 vs mean 45.9, SD 4; P=.78), compared to the no-app group. There was no effect of the app on the SCHFI at 6 or 12 weeks. The time to first HF readmission was not statistically different between the app group and the no-app group (app group 11/42, 26% vs no-app group 12/41, 29%; hazard ratio 0.89, 95% CI 0.39-2.02; P=.78) over 12 weeks. Conclusions The adaptive mobile app intervention, which focused on promoting self-monitoring and self-management, improved the MLHFQ at 6 weeks but did not sustain its effects at 12 weeks. No effect was seen on HF self-management measured by self-report. Further research is needed to enhance engagement in the app for a longer period and to determine if the app can reduce HF readmissions in a larger study. Trial Registration ClinicalTrials.gov NCT03149510; https://clinicaltrials.gov/ct2/show/NCT03149510

Background Telehealth has provided many researchers, especially those conducting psychosocial research, with the tools necessary to transition from in-person to remote clinical trials during the COVID-19 pandemic. A growing body of research supports the effectiveness of telemental health for a variety of psychiatric conditions, but few studies have examined telemental health for individuals with comorbid medical diagnoses. Furthermore, little is known about the remote implementation of clinical trials examining telemental health interventions. Objective This paper outlines the procedural modifications used to facilitate conversion of an in-person randomized controlled trial of cognitive behavioral therapy (CBT) for depression in individuals with traumatic brain injury (TBI; CBT-TBI) to a telemental health study administered remotely. Methods Given the nature of remote implementation and specific challenges experienced by individuals with TBI, considerations related to treatment delivery, remote consent, data management, neuropsychological assessment, safety monitoring, and delivery of supportive material have been discussed. Feasibility, acceptability, and safety were evaluated by examining attendance and participant responses on self-report measures of treatment satisfaction and suicidal behavior. Results High rates of treatment attendance, assessment completion, study retention, and satisfaction with the intervention and modality were reported by participants who completed at least one telemental health CBT-TBI session. Conclusions Study modifications are necessary when conducting a study remotely, and special attention should be paid to comorbidities and population-specific challenges (eg, cognitive impairment). Preliminary data support the feasibility, acceptability, and safety of remotely conducting a randomized controlled trial of CBT-TBI. Trial Registration ClinicalTrials.gov NCT03307070; https://clinicaltrials.gov/ct2/show/NCT03307070

[EN] Background: Video is used daily for various purposes, such as leisure, culture, and even learning. Currently, video is a tool that is available to a large part of the population and is simple to use. This audio-visual format has many advantages such as its low cost, speed of dissemination, and possible interaction between users. For these reasons, it is a tool with high dissemination and educational potential, which could be used in the field of health for learning about and management of chronic diseases by adult patients. Objective: The following review determines whether the use of health educational videos by adult patients with chronic diseases is effective for their self-management according to the literature. Methods: An electronic literature search of the PubMed, CINAHL, and MEDLINE (via the EBSCOhost platform) databases up to April 2020 was conducted. The systematic scoping review followed the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) methodology. Results: After reviewing 1427 articles, 12 were selected as the most consistent with the proposed inclusion criteria. After their review, it was found that the studies showed that video is effective as a tool for improving care related to chronic diseases. Conclusions: Video is effective in improving the care and quality of life for patients with chronic diseases, whether the initiative for using video came from their health care professionals or themselves., This study was supported in part by Universidad Catolica San Vicente Martir.

Background The rapid diffusion of the internet has decreased consumer reliance on health care providers for health information and facilitated the patients’ ability to be an agent in control of their own health. However, empirical evidence is limited regarding the effects of health-related internet use among older adults, which is complicated by the proliferation of online health and medical sources of questionable scientific accuracy. Objective We explore the effects of health-related internet use, education, and eHealth literacy on medical encounters and patient-reported outcomes. Patient-reported outcomes are categorized into two dimensions: (1) self-reported health problem and (2) affective distress (feeling worried and anxious) due to information obtained. We were particularly interested in whether education and eHealth literacy moderate the association between perceived strain in medical encounters and patient-reported outcomes. Methods Our study sample consisted of online panel members who have used the internet as a resource for health information, randomly drawn from one of the largest probability-based online research panels. This paper specifically reports results obtained from older panel members (age≥60 years: n=194). First, we examined descriptive statistics and bivariate associations (Pearson correlations and independent samples t tests). We used hierarchical ordinary least squares regression analyses by running separate regressions for each patient-reported outcome. In model 1, we entered the main effects. In model 2, technology and medical encounter variables were included. Model 3 added the statistical interaction terms. Results Age (β=–.17; P=.02), gender (β=–.22; P=.01), and medical satisfaction (β=–.28; P=.01) were significant predictors of self-reported health problems. Affective distress was positively predicted by gender (β=.13; P=.05) and satisfaction with medical encounters (β=.34; P Conclusions This study provides evidence for the effect of health-related internet use on patient-reported outcomes with implications for medical encounters. The results could be used to guide educational and eHealth literacy interventions for older individuals.

Background Vaccination against COVID-19 is an important public health strategy to address the ongoing pandemic. Examination of online search behavior related to COVID-19 vaccines can provide insights into the public's awareness, concerns, and interest regarding COVID-19 vaccination. Objective The aim of this study is to describe online search behavior related to COVID-19 vaccines during the start of public vaccination efforts in the United States. Methods We examined Google Trends data from January 1, 2021, through March 16, 2021, to determine the relative search volume for vaccine-related searches on the internet. We also examined search query log data for COVID-19 vaccine-related searches and identified 5 categories of searches: (1) general or other information, (2) vaccine availability, (3) vaccine manufacturer, (4) vaccine side-effects and safety, and (5) vaccine myths and conspiracy beliefs. In this paper, we report on the proportion and trends for these different categories of vaccine-related searches. Results In the first quarter of 2021, the proportion of all web-based search queries related to COVID-19 vaccines increased from approximately 10% to nearly 50% of all COVID-19–related queries (P Conclusions This study demonstrates an increase in online search behavior related to COVID-19 vaccination in early 2021 along with an increase in the proportion of searches related to vaccine availability at pharmacies. These findings are consistent with an increase in public interest and intention to get vaccinated during the initial phase of public COVID-19 vaccination efforts.

Background A surveillance system is the foundation for disease prevention and control. Malaria surveillance is crucial for tracking regional and temporal patterns in disease incidence, assisting in recorded details, timely reporting, and frequency of analysis. Objective In this study, we aim to develop an integrated surveillance graphical app called FeverTracker, which has been designed to assist the community and health care workers in digital surveillance and thereby contribute toward malaria control and elimination. Methods FeverTracker uses a geographic information system and is linked to a web app with automated data digitization, SMS text messaging, and advisory instructions, thereby allowing immediate notification of individual cases to district and state health authorities in real time. Results The use of FeverTracker for malaria surveillance is evident, given the archaic paper-based surveillance tools used currently. The use of the app in 19 tribal villages of the Dhalai district in Tripura, India, assisted in the surveillance of 1880 suspected malaria patients and confirmed malaria infection in 93.4% (114/122; Plasmodium falciparum), 4.9% (6/122; P vivax), and 1.6% (2/122; P falciparum/P vivax mixed infection) of cases. Digital tools such as FeverTracker will be critical in integrating disease surveillance, and they offer instant data digitization for downstream processing. Conclusions The use of this technology in health care and research will strengthen the ongoing efforts to eliminate malaria. Moreover, FeverTracker provides a modifiable template for deployment in other disease systems.

Background Social distancing and stay-at-home orders are critical interventions to slow down person-to-person transmission of COVID-19. While these societal changes help contain the pandemic, they also have unintended negative consequences, including anxiety and depression. We developed StayWell, a daily skills-based SMS text messaging program, to mitigate COVID-19–related depression and anxiety symptoms among people who speak English and Spanish in the United States. Objective This paper describes the changes in StayWell participants’ anxiety and depression levels after 60 days of exposure to skills-based SMS text messages. Methods We used self-administered, empirically supported web-based questionnaires to assess the demographic and clinical characteristics of StayWell participants. Anxiety and depression were measured using the 2-item Generalized Anxiety Disorder (GAD-2) scale and the 8-item Patient Health Questionnaire-8 (PHQ-8) scale at baseline and 60-day timepoints. We used 2-tailed paired t tests to detect changes in PHQ-8 and GAD-2 scores from baseline to follow-up measured 60 days later. Results The analytic sample includes 193 participants who completed both the baseline and 60-day exit questionnaires. At the 60-day time point, there were significant reductions in both PHQ-8 and GAD-2 scores from baseline. We found an average reduction of –1.72 (95% CI –2.35 to –1.09) in PHQ-8 scores and –0.48 (95% CI –0.71 to –0.25) in GAD-2 scores. These improvements translated to an 18.5% and 17.2% reduction in mean PHQ-8 and GAD-2 scores, respectively. Conclusions StayWell is an accessible, low-intensity population-level mental health intervention. Participation in StayWell focused on COVID-19 mental health coping skills and was related to improved depression and anxiety symptoms. In addition to improvements in outcomes, we found high levels of engagement during the 60-day intervention period. Text messaging interventions could serve as an important public health tool for disseminating strategies to manage mental health. Trial Registration ClinicalTrials.gov NCT04473599; https://clinicaltrials.gov/ct2/show/NCT04473599 International Registered Report Identifier (IRRID) RR2-10.2196/23592

Background People with intellectual and developmental disabilities are at increased health-related risk due to the COVID-19 pandemic. Virtual training programs that support providers in caring for the physical and mental health needs of this population, as well provide psychological support to the providers themselves, are needed during the pandemic. Objective This paper describes the design, delivery, and evaluation of a virtual educational COVID-19–focused Extension for Community Healthcare Outcomes program to support providers during the COVID-19 pandemic in caring for the mental health of people with intellectual and developmental disabilities. Methods A rapid design thinking approach was used to develop a 6-session program that incorporates mindfulness practice, a wellness check, COVID-19–related research and policy updates, a didactic presentation on a combination mental health and COVID-19 related topic, and a case-based discussion to encourage practical learning. We used the first 5 outcome levels of Moore’s evaluation framework—focusing on participation, satisfaction, learning, self-efficacy, and change in practice—which were rated (out of 5) by care providers from health and disability service sectors, as well as additional reflection measures about innovations to the program. Qualitative feedback from open-text responses from participants were analyzed using modified manifest content analysis. Results A total of 104 care providers from health and disability service sectors participated in the program. High levels of engagement (81 participants per session on average) and satisfaction (overall satisfaction score: mean 4.31, SD 0.17) were observed. Self-efficacy (score improvement: 19.8%), support, and coping improved. Participants also rated the newly developed COVID-19 program and its innovative components highly. Open text feedback showed participants felt that the Extension for Community Healthcare Outcomes program expanded their knowledge and competency and created a sense of being part of a community of practice; provided value for the COVID-19 innovations; supported resource-sharing within and beyond program participants; and facilitated changes to participants’ approaches to client care in practice and increased participants’ confidence in supporting clients and families. Conclusions The Extension for Community Healthcare Outcomes program is an effective model for capacity-building programs with a shared-learning approach. Future iterations should include targeted evaluation of long-term outcomes such as staff burnout.

Background An Ostomy Self-management Telehealth (OSMT) intervention by nurse educators and peer ostomates can equip new ostomates with critical knowledge regarding ostomy care. A telehealth technology assessment aim was to measure telehealth engineer support requirements for telehealth technology–related (TTR) incidents encountered during OSMT intervention sessions held via a secure cloud-based videoconferencing service, Zoom for Healthcare. Objective This paper examines technology-related challenges, issues, and opportunities encountered in the use of telehealth in a randomized controlled trial intervention for cancer survivors living with a permanent ostomy. Methods The Arizona Telemedicine Program provided telehealth engineering support for 105 OSMT sessions, scheduled for 90 to 120 minutes each, over a 2-year period. The OSMT groups included up to 15 participants, comprising 4-6 ostomates, 4-6 peer ostomates, 2 nurse educators, and 1 telehealth engineer. OSMT-session TTR incidents were recorded contemporaneously in detailed notes by the research staff. TTR incidents were categorized and tallied. Results A total of 97.1% (102/105) OSMT sessions were completed as scheduled. In total, 3 OSMT sessions were not held owing to non–technology-related reasons. Of the 93 ostomates who participated in OSMT sessions, 80 (86%) completed their OSMT curriculum. TTR incidents occurred in 36.3% (37/102) of the completed sessions with varying disruptive impacts. No sessions were canceled or rescheduled because of TTR incidents. Disruptions from TTR incidents were minimized by following the TTR incident prevention and incident response plans. Conclusions Telehealth videoconferencing technology can enable ostomates to participate in ostomy self-management education by incorporating dedicated telehealth engineering support. Potentially, OSMT greatly expands the availability of ostomy self-management education for new ostomates. Trial Registration ClinicalTrials.gov NCT02974634; https://clinicaltrials.gov/ct2/show/NCT02974634

Background Increasingly popular in the health care domain, electronic personal health records (PHRs) have the potential to foster engagement toward improving health outcomes, achieving efficiencies in care, and reducing costs. Despite the touted benefits of PHRs, their uptake is lackluster, with low adoption rates. Objective This paper reports findings from an empirical investigation of the sociotechnical factors affecting the adoption of PHRs. Methods A research model comprising personal and technological determinants of PHR adoption was developed and validated in this study. Demographic, technographic, and psychographic data pertaining to the use of PHRs were collected through a web-based questionnaire for past, current, and potential users. Partial least squares-based structural equation modeling was used to estimate a structural model of cognitive and affective factors impacting intentions to use PHRs. Results The analysis revealed that in addition to the expected positive impact of a PHR system’s usefulness and usability, system integration also positively affects consumers’ intention to adopt. The results also suggest that higher levels of perceived usability and integration do not translate into higher levels of perceived usefulness. The study also highlights the importance of subjective norms, technology awareness, and technology anxiety as direct antecedents of the intention to adopt PHRs. The differential effects of the adoption factors are also discussed. Conclusions We hope that our study will contribute to the understanding of consumer adoption of PHRs and help improve the design and delivery of consumer-centric health care technologies. After discussing the implications for research, we provide suggestions and guidelines for PHR technology developers and constituents in the health care delivery chain.

Background Smartphones have become an integral part of our lives with unprecedented popularity and a diverse selection of apps. The continuous upgrading of information technology has also enabled smartphones to display great potential in the field of health care. Objective We aimed to determine the future research direction of mobile health (mHealth) by analyzing its research trends and latest research hotspots. Methods This study collected mHealth-related literature published between 2000 and 2020 from the Web of Science database. Descriptive statistics of publication trends of mHealth research were determined by analyzing the annual number of publications in the literature and annual number of publications by country. We constructed visualization network maps of country (or regional) collaborations and author-provided keyword co-occurrences, as well as overlay visualization maps of the average publication year of author-provided keywords to analyze the hotspots and research trends in mHealth research. Results In total, 12,593 mHealth-related research papers published between 2000 and 2020 were found. The results showed an exponential growth trend in the number of annual publications in mHealth literature. JMIR mHealth and uHealth, the Journal of Medical Internet Research, and JMIR Research Protocols were the 3 top journals with respect to number of publications. The United States remained the leading contributor to the literature in this area (5294/12,593, 42.0%), well ahead of other countries and regions. Other countries and regions also showed a clear trend of annual increases in the number of mHealth publications. The 4 countries with the largest number of publications—the United States, the United Kingdom, Canada, and Australia—were found to cooperate more closely. The rest of the countries and regions showed a clear geographic pattern of cooperation. The keyword co-occurrence analysis of the top 100 authors demonstrated 5 clusters, namely, development of mHealth medical technology and its application to various diseases, use of mHealth technology to improve basic public health and health policy, mHealth self-health testing and management in daily life, adolescent use of mHealth, and mHealth in mental health. The research trends revealed a gradual shift in mHealth research from health policy and improving public health care to the development and social application of mHealth technologies. Conclusions To the best of our knowledge, the most current bibliometric analysis dates back to 2016. However, the number of mHealth research published between 2017 and 2020 exceeds the previous total. The results of this study shed light on the latest hotspots and trends in mHealth research. These findings provide a useful overview of the development of the field; they may also serve as a valuable reference and provide guidance for researchers in the digital health field.

Background Approximately 80% of pancreatic ductal adenocarcinoma (PDAC) patients suffer from anorexia, weight loss, and asthenia. Most PDAC patients receive chemotherapy, which often worsens their nutritional status owing to the adverse effects of chemotherapy. Malnutrition of PDAC patients is known to be associated with poor prognosis; therefore, nutritional management during chemotherapy is a key factor influencing the outcome of the treatment. Mobile apps have the potential to provide readily accessible nutritional support for patients with PDAC. Objective We aimed to evaluate the efficacy of a mobile app–based program, Noom, in patients receiving chemotherapy for PDAC. Methods We prospectively enrolled 40 patients who were newly diagnosed with unresectable PDAC from a single university-affiliated hospital in South Korea, and randomly assigned them into a Noom user group (n=20) and a non-Noom user group (n=20). The 12-week in-app interventions included meal and physical activity logging as well as nutritional education feedback from dietitians. The non-Noom user group did not receive any nutrition intervention. The primary outcomes were the changes in the nutritional status and quality of life (QoL) from the baseline to 12 weeks. The secondary outcomes included the changes in the skeletal muscle index (SMI) from the baseline to 12 weeks. The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Core Questionnaire (QLQ-C30) and the Patient-Generated Subjective Global Assessment (PG-SGA) were used as paper questionnaires to assess the QoL and nutritional status of the patients. Intention-to-treat and per-protocol analyses were conducted. Regarding the study data collection time points, we assessed the nutritional status and QoL at the baseline (T0), and at 4 (T1), 8 (T2), and 12 (T3) weeks. Abdominal computed tomography (CT) imaging was conducted at the baseline and after 8 weeks for tumor response and SMI evaluation. The skeletal muscle area (cm2) was calculated using routine CT images. The cross-sectional areas (cm2) of the L3 skeletal muscles were analyzed. Results Between February 2017 and January 2018, 48 patients were assessed for eligibility. Totally 40 patients with pancreatic cancer were included by random allocation. Only 17 participants in the Noom user group and 16 in the non-Noom user group completed all follow-ups. All the study participants showed a significant improvement in the nutritional status according to the PG-SGA score regardless of Noom app usage. Noom users showed statistically significant improvements on the global health status (GHS) and QoL scales compared to non-Noom users, based on the EORTC QLQ (P=.004). The SMI decreased in both groups during chemotherapy (Noom users, 49.08±12.27 cm2/m2 to 46.08±10.55 cm2/m2; non-Noom users, 50.60±9.05 cm2/m2 to 42.97±8.12 cm2/m2). The decrement was higher in the non-Noom user group than in the Noom user group, but it was not statistically significant (-13.96% vs. -3.27%; P=.11). Conclusions This pilot study demonstrates that a mobile app–based approach is beneficial for nutritional and psychological support for PDAC patients receiving chemotherapy. Trial Registration ClinicalTrials.gov NCT04109495; https://clinicaltrials.gov/ct2/show/NCT04109495.

Background Given the sudden shift to telemedicine during the early COVID-19 pandemic, we conducted a survey of practicing physicians’ experience with telehealth during the prepandemic and early pandemic periods. Our survey estimates that most patient visits in the United States during the early COVID-19 pandemic period were conducted via telehealth. Given this magnitude and the potential benefits and challenges of telehealth for the US health care system, in this paper, we obtain, summarize, and analyze telehealth views and experiences of US-based practicing-physicians. Objective The aim of this study was to examine the extent of shift toward telehealth training and care provision during the early pandemic from the US-based practicing physicians’ perspective. We also sought to determine the short- and long-term implications of this shift on the quality, access, and mode of US health care delivery. Methods We conducted a purposive, snowball-sampled survey of US practicing-physicians. A total of 148 physician completed the survey. Data were collected from July 17, 2020, through September 4, 2020. Results Sample training intensity scaled 21-fold during the early pandemic period, and patient-care visits conducted via telehealth increased, on average, from 13.1% directly before the pandemic to 59.7% during the early pandemic period. Surveyed physician respondents reported that telehealth patient visits and face-to-face patient visits are comparable in quality. The difference was not statistically significant based on a nonparametric sign test (P=.11). Moreover, physicians feel that telehealth care should continue to play a larger role (44.9% of total visits) in postpandemic health care in the United States. Our survey findings suggest a high market concentration in telehealth software, which is a market structural characteristic that may have implications on the cost and access of telehealth. The results varied markedly by physician employer type. Conclusions During the shift toward telehealth, there has been a considerable discovery among physicians regarding US telehealth physicians. Physicians are now better prepared to undertake telehealth care from a training perspective. They are favorable toward a permanently expanded telehealth role, with potential for enhanced health care access, and the realization of enhanced access may depend on market structural characteristics of telehealth software platforms.

Background Surveys play a vital role in cancer research. During the COVID-19 pandemic, the use of electronic surveys is crucial to improve understanding of the patient experience. However, response rates to electronic surveys are often lower compared with those of paper surveys. Objective The aim of this study was to determine the best approach to improve response rates for an electronic survey administered to patients at a cancer center during the COVID-19 pandemic. Methods We contacted 2750 patients seen at Moffitt Cancer Center in the prior 5 years via email to complete a survey regarding their experience during the COVID-19 pandemic, with patients randomly assigned to a series of variations of prenotifications (ie, postcard, letter) or incentives (ie, small gift, modest gift card). In total, eight combinations were evaluated. Qualitative interviews were conducted to understand the level of patient understanding and burden with the survey, and quantitative analysis was used to evaluate the response rates between conditions. Results A total of 262 (9.5%) patients completed the survey and 9 participated in a qualitative interview. Interviews revealed minimal barriers in understanding or burden, which resulted in minor survey design changes. Compared to sending an email only, sending a postcard or letter prior to the email improved response rates from 3.7% to 9.8%. Similarly, inclusion of an incentive significantly increased the response rate from 5.4% to 16.7%, especially among racial (3.0% to 12.2%) and ethnic (6.4% to 21.0%) minorities, as well as among patients with low socioeconomic status (3.1% to 14.9%). Conclusions Strategies to promote effective response rates include prenotification postcards or letters as well as monetary incentives. This work can inform future survey development to increase response rates for electronic surveys, particularly among hard-to-reach populations.

Background Telemedicine that combines information technology and health care augments the operational model of traditional medical services and brings new opportunities to the medical field. China promotes telemedicine with great efforts, and its practices in the deployment of telemedicine platforms and delivery of services have become important references for the research and development in this field. Objective Our work described in this paper focuses on a regional telemedicine platform that was built in 2014. We analyzed the system design scheme and remote consultations that were conducted via the system to understand the deployment and service delivery processes of a representative telemedicine platform in China. Methods We collected information on remote consultations conducted from 2015 to 2020 via the regional telemedicine platform that employs a centralized architectural system model. We used graphs and statistical methods to describe the changing trends of service volume of remote consultation, geographical and demographic distribution of patients, and waiting time and duration of consultations. The factors that affect consultation duration and patient referral were analyzed by multivariable linear regression models and binary logistic regression models, respectively. The attitudes toward telemedicine of 225 medical practitioners and 225 patients were collected using the snowball sampling method. Results The regional telemedicine platform covers all levels of medical institutions and hospitals in all 18 cities of Henan Province as well as some interprovince hospitals. From 2015 to 2020, 103,957 remote medical consultations were conducted via the platform with an annual increasing rate of 0.64%. A total of 86.64% (90,069/103,957) of medical institutions (as clients) that applied for remote consultations were tier 1 or 2 and from less-developed regions; 65.65% (68,243/103,945) of patients who applied for remote consultations were aged over 50 years. The numbers of consultations were high for departments focusing in the treatment of chronic diseases such as neurology, respiratory medicine, and oncology. The invited experts were mainly experienced doctors with senior professional titles. Year of consultation, tier of hospital, consultation department, and necessity of patient referral were the main factors affecting the duration of consultations. In surveys, we found that 60.4% (136/225) of medical practitioners and 53.8% (121/225) of patients had high satisfaction and believed that telemedicine is of vital importance for the treatment of illness. Conclusions The development of telemedicine in China shows a growing trend and provides great benefits especially to medical institutions located in less developed regions and senior citizens who have less mobility. Cases of remote consultations are mainly for chronic diseases. At present, the importance and necessity of telemedicine are well recognized by both patients and medical practitioners. However, the waiting time needs to be further reduced to improve the efficiency of remote medical services.

Background Patients on hemodialysis receive dialysis thrice weekly for about 4 hours per session. Intradialytic hypotension (IDH)—low blood pressure during hemodialysis—is a serious but common complication of hemodialysis. Although patients on dialysis already participate in their care, activating patients toward IDH prevention may reduce their risk of IDH. Interactive, technology-based interventions hold promise as a platform for patient activation. However, little is known about the usability challenges that patients undergoing hemodialysis may face when using tablet-based informatics interventions, especially while dialyzing. Objective This study aims to test the usability of a patient-facing, tablet-based intervention that includes theory-informed educational modules and motivational interviewing–based mentoring from patient peers via videoconferencing. Methods We conducted a cross-sectional, mixed methods usability evaluation of the tablet-based intervention by using think-aloud methods, field notes, and structured observations. These qualitative data were evaluated by trained researchers using a structured data collection instrument to capture objective observational data. We calculated descriptive statistics for the quantitative data and conducted inductive content analysis using the qualitative data. Results Findings from 14 patients cluster around general constraints such as the use of one arm, dexterity issues, impaired vision, and lack of experience with touch screen devices. Our task-by-task usability results showed that specific sections with the greatest difficulty for users were logging into the intervention (difficulty score: 2.08), interacting with the quizzes (difficulty score: 1.92), goal setting (difficulty score: 2.28), and entering and exiting videoconference rooms (difficulty score: 2.07) that are used to engage with peers during motivational interviewing sessions. Conclusions In this paper, we present implications for designing informatics interventions for patients on dialysis and detail resulting changes to be implemented in the next version of this intervention. We frame these implications first through the context of the role the patients’ physical body plays when interacting with the intervention and then through the digital considerations for software and interface interaction.

Background The COVID-19 pandemic and countries’ response measures have had a globally significant mental health impact. This mental health burden has also been fueled by an infodemic: an information overload that includes misinformation and disinformation. Suicide, the worst mental health outcome, is a serious public health problem that can be prevented with timely, evidence-based, and often low-cost interventions. Suicide ideation, one important risk factor for suicide, is thus important to measure and monitor, as are the factors that may impact on it. Objective This investigation had 2 primary aims: (1) to estimate and compare country-specific prevalence of suicide ideation at 2 different time points, overall and by gender and age groups, and (2) to investigate the influence of sociodemographic and infodemic variables on suicide ideation. Methods A repeated, online, 8-country (Canada, the United States, England, Switzerland, Belgium, Hong Kong, Philippines, and New Zealand), cross-sectional study was undertaken with adults aged ≥18 years, with measurement wave 1 conducted from May 29, 2020 to June 12, 2020 and measurement wave 2 conducted November 6-18, 2021. Self-reported suicide ideation was derived from item 9 of the Patient Health Questionnaire-9 (PHQ-9). Age-standardized suicide ideation rates were reported, a binomial regression model was used to estimate suicide ideation indication rates for each country and measurement wave, and logistic regression models were then employed to relate sociodemographic, pandemic, and infodemic variables to suicide ideation. Results The final sample totaled 17,833 adults: 8806 (49.4%) from measurement wave 1 and 9027 (50.6%) from wave 2. Overall, 24.2% (2131/8806) and 27.5% (2486/9027) of participants reported suicide ideation at measurement waves 1 and 2, respectively, a difference that was significant (P Conclusions Suicide ideation is prevalent and significantly increasing over time in this COVID-19 pandemic era, with considerable variability between countries. Younger adults and those residing in Hong Kong carried disproportionately higher rates. Social media appears to have an increasingly detrimental association with suicide ideation, although having a stronger SOC had a larger protective effect. Policies and promotion of SOC, together with disseminating health information that explicitly tackles the infodemic’s misinformation and disinformation, may importantly reduce the rising mental health morbidity and mortality triggered by this pandemic.

Background The prevalence of diabetes is increasing rapidly. Previous research has demonstrated the efficacy of a diabetes prevention program (DPP) in lifestyle modifications that can prevent or delay the onset of type 2 diabetes among individuals at risk. Digital DPPs have the potential to use technology, in conjunction with behavior change science, to prevent prediabetes on a national and global scale. Objective The aim of this study is to investigate the effects of a digital DPP (Virgin Pulse [VP] Transform for Prediabetes) on weight and physical activity among participants who had completed 12 months of the program. Methods This study was a secondary analysis of retrospective data of adults with prediabetes who were enrolled in VP Transform for Prediabetes for 12 months of the program. The program incorporates interactive mobile computing, remote monitoring, an evidence-based curriculum, behavior tracking tools, health coaching, and online peer support to prevent or delay the onset of type 2 diabetes. Results The sample (N=1095) was comprised of people with prediabetes who completed at least 9 months of the VP Transform for Prediabetes program. Participants were 67.7% (n=741) female, with a mean age of 53.6 (SD 9.75) years. After 12 months, participants decreased their weight by an average of 10.9 lbs (5.5%; P Conclusions These results suggest that VP Transform for Prediabetes is effective at preventing type 2 diabetes through a significant reduction in body weight and increase of physical activity. Furthermore, these results suggest that the DPP remains effective 12 months after beginning the program. A prospective randomized controlled clinical study is warranted to validate these findings.

Background Human papillomavirus (HPV) testing detects sexually transmitted infections with oncogenic types of HPV. For many HPV-positive women, this result has negative connotations. It produces anxiety, fear of cancer or death, and disease denial. Face-to-face counseling could present many difficulties in its implementation, but a counseling mobile app could be practical and may help HPV-positive women reduce the psychosocial impact of the result, improve their knowledge of HPV and cervical cancer, and increase adherence to follow-up. Objective This study aims to understand HPV-tested women’s perceptions about an app as a tool to receive information and support to reduce the emotional impact of HPV-positive results. We investigated their preferences regarding app design, content, and framing. Methods We conducted formative research based on a user-centered design approach. We carried out 29 individual online interviews with HPV-positive women aged 30 years and over and 4 focus groups (FGs) with women through a virtual platform (n=19). We shared a draft of the app's potential screens with a provisional label of the possible content, options menus, draft illustrations, and wording. This allowed us to give women understandable triggers to debate the concepts involved on each screen. The draft content and labels were developed drawing from the health belief model (HBM) and integrative behavioral model (IBM) variables and findings of mobile health literature. We used an FG guide to generate data for the information architecture (ie, how to organize contents into features). We carried out thematic analysis using constructs from the HBM and IBM to identify content preferences and turn them into app features. We used the RQDA package of R software for data processing. Results We found that participants required more information regarding the procedures they had received, what HPV-positive means, what the causes of HPV are, and its consequences on their sexuality. The women mentioned fear of the disease and stated they had concerns and misconceptions, such as believing that an HPV-positive result is a synonym for cancer. They accepted the app as a tool to obtain information and to reduce fears related to HPV-positive results. They would use a mobile app under doctor or health authority recommendation. The women did not agree with the draft organization of screens and contents. They believed the app should first offer information about HPV and then provide customized content according to the users’ needs. The app should provide information via videos with experts and testimonies of other HPV-positive women, and they suggested a medical appointment reminder feature. The app should also offer information through illustrations, or infographics, but not pictures or solely text. Conclusions Providing information that meets women’s needs and counseling could be a method to reduce fears. A mobile app seems to be an acceptable and suitable tool to help HPV-positive women.

Background Despite the importance of diagnosis and treatment, obstructive sleep apnea (OSA) remains a vastly underdiagnosed condition; this is partially due to current OSA identification methods and a complex and fragmented diagnostic pathway. Objective This prospective, single-arm, multistate feasibility pilot study aimed to understand the journey in a nonreferred sample of participants through the fully remote OSA screening and diagnostic and treatment pathway, using the Primasun Sleep Apnea Program (formally, Verily Sleep Apnea Program). Methods Participants were recruited online from North Carolina and Texas to participate in the study entirely virtually. Eligible participants were invited to schedule a video telemedicine appointment with a board-certified sleep physician who could order a home sleep apnea test (HSAT) to be delivered to the participant's home. The results were interpreted by the sleep physician and communicated to the participant during a second video telemedicine appointment. The participants who were diagnosed with OSA during the study and prescribed a positive airway pressure (PAP) device were instructed to download an app that provides educational and support-related content and access to personalized coaching support during the study’s 90-day PAP usage period. Surveys were deployed throughout the study to assess baseline characteristics, prior knowledge of sleep apnea, and satisfaction with the program. Results For the 157 individuals who were ordered an HSAT, it took a mean of 7.4 (SD 2.6) days and median 7.1 days (IQR 2.0) to receive their HSAT after they completed their first televisit appointment. For the 114 individuals who were diagnosed with OSA, it took a mean of 13.9 (SD 9.6) days and median 11.7 days (IQR 10.1) from receiving their HSAT to being diagnosed with OSA during their follow-up televisit appointment. Overall, the mean and median time from the first televisit appointment to receiving an OSA diagnosis was 21.4 (SD 9.6) days and 18.9 days (IQR 9.2), respectively. For those who were prescribed PAP therapy, it took a mean of 8.1 (SD 9.3) days and median 6.0 days (IQR 4.0) from OSA diagnosis to PAP therapy initiation. Conclusions These results demonstrate the possibility of a highly efficient, patient-centered pathway for OSA workup and treatment. Such findings support pathways that could increase access to care, reduce loss to follow-up, and reduce health burden and overall cost. The program’s ability to efficiently diagnose patients who otherwise may have not been diagnosed with OSA is important, especially during a pandemic, as the United States shifted to remote care models and may sustain this direction. The potential economic and clinical impact of the program’s short and efficient journey time and low attrition rate should be further examined in future analyses. Future research also should examine how a fast and positive diagnosis experience impacts success rates for PAP therapy initiation and adherence. Trial Registration ClinicalTrials.gov NCT04599803; https://clinicaltrials.gov/ct2/show/NCT04599803

Background Obesity, hypertension, and type 2 diabetes mellitus (T2DM) are worldwide epidemics that inflict burdens on both public health and health care costs. Self-management plays an important role in the proper management of these 3 chronic diseases, and in this context, mobile health (mHealth) can be a cost-effective self-management tool. Objective The aim of this pilot study is to evaluate the effects of an integrative mHealth approach for obesity, hypertension, and T2DM on body fat, blood pressure, and blood glucose levels and demonstrate the clinical outcomes. The participants were patients aged 40 to 70 years who were treated for T2DM (hemoglobin A1c [HbA1c] above 6.0%) without insulin or hypertension and obesity, controlled with pharmacotherapy. Methods This pilot study was performed using a controlled, randomized, 3-month, 2-period crossover design. A total of 37 participants were recruited from 2 university hospitals in South Korea. Integrative mHealth comprised 4 parts: self-measuring home devices for monitoring blood glucose and blood pressure; 2 smartphone apps, where one gathered lifestyle data, giving them feedback with health information, and the other provided drug information and reminders of the medication schedule; unmanned kiosks for official measurement of blood pressure and body composition; and web-based access to participants’ health information. Results Data from the 32 participants were analyzed. Their mean HbA1c level was 7.5% (SD 0.8, ranging from 6.1% to 9.4%). Approximately 38% (12/32) of the participants had hypertension. BMIs of all participants except 1 were >23 kg/m2. The input rates of food intake and exercise to the smartphone app were very low (24.9% and 5.3%, respectively). On the contrary, the input rate of medicine intake was high (84.0%). Moreover, there was no significant difference in the input rate of taking medicine irrespective of whether the mHealth period was before or after the conventional treatment period (80.3% and 87.3%, respectively; P=.06). Among the 3 input functions of food intake, exercise, and medicine intake in smartphone apps, the input of medicine intake was a more helpful, easier to use, and better-designed function than the others. There were no significant differences in changes in body weight (−0.519 kg vs 0 kg), BMI (−0.133 kg/m2 vs −0.167 kg/m2), body composition (body fat −0.255% vs 0.172%), blood pressure (systolic −0.226 mm Hg vs −2.839 mm Hg), and HbA1c (−0.269% vs –0.009%) between the integrative mHealth and conventional treatment groups. However, in proportion to the elevation in the input rate of taking medicine, body fat mass (P=.04) and HbA1c (P=.03) were lower in the integrative mHealth group. Conclusions Although smartphone apps can influence body fat and blood glucose levels, they have failed to show clinical improvement. A higher input rate of taking medicine was related to significantly lower body fat mass and HbA1c levels.

Background Personalized prevention tools such as mobile apps designed to reduce alcohol consumption are widespread in mobile app stores accessible in Russia. However, the quality and content of these mobile apps have not been systematically evaluated. Objective This study aimed to identify Russian-language mobile apps for reducing alcohol use and to evaluate their quality and potential to change alcohol-related health behavior. It further aimed to identify apps that could facilitate screening and brief interventions in primary health care in Russia. Methods A systematic search for mobile apps available in Russia was carried out between April 1 and 15, 2020, December 1 and 15, 2020, and in March 2021 in the iPhone App Store, Google Play Store, and the 4PDA forum. App quality was assessed using the Mobile App Rating Scale (MARS), and structured searches in electronic libraries and bibliographic databases were used to evaluate the apps’ evidence base. The number of features facilitating changes in lifestyle behavior was assessed using the App Behavior Change Scale (ABACUS). Results We identified 63 mobile apps for reducing alcohol use. The mean MARS quality ratings were high for the subscales of functionality (3.92 out of 5, SD 0.58) and aesthetics (2.96, SD 0.76) and low for engagement (2.42, SD 0.76) and information (1.65, SD 0.60). Additional searches in electronic libraries and bibliographic databases (eLibrary, CyberLeninka, Google Scholar) yielded no studies involving the identified apps. ABACUS scores ranged from 1 to 15 out of 25, with a mean of 5 (SD 3.24). Two of the identified apps might be useful for screening and brief interventions in Russian primary health care after improvements in content and scientific testing. Conclusions Russian-language mobile apps for reducing alcohol use are accessible in the app stores. Many of them are aesthetically pleasing, functional, and easy to use. However, information about their scientific trialing or testing is lacking. Most apps contain a low number of features that facilitate changes in lifestyle behavior. Further research should examine the context of Russian-language mobile apps for reducing alcohol use. Our findings underline the need to develop evidence-based apps to mitigate alcohol consumption in Russia and elsewhere. Trial Registration PROSPERO International Prospective Register of Systematic Reviews CRD42020167458; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=167458

Background Obesity is significantly associated with renal cell carcinoma. Surgery is the preferred treatment for demarcated lesions of renal cell carcinoma; however, obesity increases the complexity of surgical outcomes. Minimally invasive surgical techniques are preferred over open partial nephrectomy (OPN), but controversy remains regarding the most efficacious technique in patients with obesity. Objective This study aims to determine whether minimally invasive partial nephrectomy (MIPN) or OPN better preserves renal function and investigate short- and long-term renal outcomes in patients with obesity undergoing a partial nephrectomy. Methods We conducted a retrospective chart review of 242 adult patients aged ≥18 years who underwent MIPN or OPN between January 1, 2005, and December 31, 2016, at the University of Arkansas for Medical Sciences. Using creatinine as a measure of kidney function, patients’ preoperative levels were compared with their postoperative levels in 2-time frames: short (3-6 months postsurgery) or long (>6 months). The primary outcome was the change in creatinine values from preoperative to >6 months postoperatively in patients with obesity. Secondary outcomes included the change in creatinine values from preoperative to 3 to 6 months postoperatively in patients with obesity who underwent MIPN versus OPN. We also analyzed the creatinine values of nonobese patients (BMI Results A total of 140 patients were included in the study, of whom 75 were obese and 65 were nonobese. At >6 months after MIPN (n=20), the odds of patients with obesity having a decrease or no change in creatinine values was 1.24 times higher than those who had OPN (n=13; OR 1.24, 95% CI 0.299-6.729; P=.80). At 3 to 6 months after MIPN (n=27), the odds were 0.62 times lower than those after OPN (n=17; OR 0.62, 95% CI 0.140-2.753; P=.56). In the nonobese group, at 3 to 6 months after undergoing minimally invasive surgery (n=18), the odds of having a decrease or no change in creatinine values was 4.86 times higher than those who had open surgery (n=21; OR 4.86, 95% CI 1.085-21.809; P=.04). At more than 6 months after MIPN (n=14), the odds were 4.13 times higher than those after OPN (n=11; OR 4.13, 95% CI 0.579-29.485; P=.16). Conclusions We observed a nonstatistically significant preservation of renal function in patients with obesity who underwent OPN at 3 to 6 months postoperatively. Conversely, after 6 months, the same was true for MIPN, indicating the long-term benefit of MIPN. In the nonobese group, MIPN was favored over OPN.

Background Although the digitization of personal health information (PHI) has been shown to improve patient engagement in the primary care setting, patient perspectives on its impact in the emergency department (ED) are unknown. Objective The primary objective was to characterize the views of ED users in British Columbia, Canada, on the impacts of PHI digitization on ED care. Methods This was a mixed methods study consisting of an online survey followed by key informant interviews with a subset of survey respondents. ED users in British Columbia were asked about their ED experiences and attitudes toward PHI digitization in the ED. Results A total of 108 participants submitted survey responses between January and April 2020. Most survey respondents were interested in the use of electronic health records (79/105, 75%) and patient portals (91/107, 85%) in the ED and were amenable to sharing their ED PHI with ED staff (up to 90% in emergencies), family physicians (up to 91%), and family caregivers (up to 75%). In addition, 16 survey respondents provided key informant interviews in August 2020. Interviewees expected PHI digitization in the ED to enhance PHI access by health providers, patient-provider relationships, patient self-advocacy, and postdischarge care management, although some voiced concerns about patient privacy risk and limited access to digital technologies (eg, smart devices, internet connection). Many participants thought the COVID-19 pandemic could provide momentum for the digitization of health care. Conclusions Patients overwhelmingly support PHI digitization in the form of electronic health records and patient portals in the ED. The COVID-19 pandemic may represent a critical moment for the development and implementation of these tools.

Background Individuals with comorbid conditions have been disproportionately affected by COVID-19. Since regulatory trials of COVID-19 vaccines excluded those with immunocompromising conditions, few patients with cancer and autoimmune diseases were enrolled. With limited vaccine safety data available, vulnerable populations may have conflicted vaccine attitudes. Objective We assessed the prevalence and independent predictors of COVID-19 vaccine hesitancy and acceptance among individuals with serious comorbidities and assessed self-reported side effects among those who had been vaccinated. Methods We conducted a cross-sectional, 55-item, online survey, fielded January 15, 2021 through February 22, 2021, among a random sample of members of Inspire, an online health community of over 2.2 million individuals with comorbid conditions. Multivariable regression analysis was utilized to determine factors independently associated with vaccine hesitancy and acceptance. Results Of the 996,500 members of the Inspire health community invited to participate, responses were received from 21,943 individuals (2.2%). Respondents resided in 123 countries (United States: 16,277/21,943, 74.2%), had a median age range of 56-65 years, were highly educated (college or postgraduate degree: 10,198/17,298, 58.9%), and had diverse political leanings. All respondents self-reported at least one comorbidity: cancer, 27.3% (5459/19,980); autoimmune diseases, 23.2% (4946/21,294); chronic lung diseases: 35.4% (7544/21,294). COVID-19 vaccine hesitancy was identified in 18.6% (3960/21,294), with 10.3% (2190/21,294) declaring that they would not, 3.5% (742/21,294) stating that they probably would not, and 4.8% (1028/21,294) not sure whether they would agree to be vaccinated. Hesitancy was expressed by the following patients: cancer, 13.4% (731/5459); autoimmune diseases, 19.4% (962/4947); chronic lung diseases: 17.8% (1344/7544). Positive predictors of vaccine acceptance included routine influenza vaccination (odds ratio [OR] 1.53), trust in responsible vaccine development (OR 14.04), residing in the United States (OR 1.31), and never smoked (OR 1.06). Hesitancy increased with a history of prior COVID-19 (OR 0.86), conservative political leaning (OR 0.93), younger age (OR 0.83), and lower education level (OR 0.90). One-quarter (5501/21,294, 25.8%) had received at least one COVID-19 vaccine injection, and 6.5% (1390/21,294) completed a 2-dose series. Following the first injection, 69.0% (3796/5501) self-reported local reactions, and 40.0% (2200/5501) self-reported systemic reactions, which increased following the second injection to 77.0% (1070/1390) and 67.0% (931/1390), respectively. Conclusions In this survey of individuals with serious comorbid conditions, significant vaccine hesitancy remained. Assumptions that the most vulnerable would automatically accept COVID-19 vaccination are erroneous and thus call for health care team members to initiate discussions focusing on the impact of the vaccine on an individual’s underlying condition. Early self-reported side effect experiences among those who had already been vaccinated, as expressed by our population, should be reassuring and might be utilized to alleviate vaccine fears. Health care–related social media forums that rapidly disseminate accurate information about the COVID-19 vaccine may play an important role.

Background Colorectal cancer survivors face multiple challenges after discharge. eHealth may potentially support them by providing tools such as smartphone apps. They have lots of capabilities to exchange information and could be used for remote monitoring of these patients. Objective In this study, we addressed the required features for apps designed to follow up colorectal cancer patients based on survivors’ and clinical experts’ views. Methods A mixed methods study was conducted. Features of related apps were extracted through the literature; the features were categorized, and then, they were modified. A questionnaire was designed containing the features listed and prioritized based on the MoSCoW (Must have, Should have, Could have, Won’t have) technique and an open question for each category. The link to the questionnaire was shared among clinical experts in Iran. The answers were analyzed using the content validity ratio (CVR), and based on the value of this measure, the minimum feature set of a monitoring app to follow up patients with colorectal cancer was addressed. In addition, a telephone interview with colorectal cancer survivors was conducted to collect their viewpoints regarding a remote monitoring system for colorectal cancer cases. Results The questionnaire contained 10 sections evaluating 9 categories of features. The questionnaire was completed by 18 experts. The minimum set of features in the app was identified as patient information registration, sign and symptom monitoring, education, reminders, and patient evaluation (0.42 < CVR < 0.85). Features including physical activity, personalized advice, and social network did not achieve the minimum score (–0.11 < CVR < 0.39). We interviewed 9 colorectal cancer survivors. Information registration, sign and symptom monitoring, education, and personalized advice were the features with high priority from the survivors’ perspectives. Scheduling, shopping, and financial support features were emphasized by survivors in the interview. Conclusions The requirement set could be used to design an app for the targeted population or patients affected by other cancers. As the views from both survivors and clinical experts were considered in this study, the remote system may more adequately fulfill the need for follow-up of survivors. This eases the patients’ and health care providers’ communication and interaction.

Background Tramadol is known to cause fewer adverse events (AEs) than other opioids. However, recent research has raised concerns about various safety issues. Objective We aimed to explore these new AEs related to tramadol using social media and conventional pharmacovigilance data. Methods This study used 2 data sets, 1 from patients’ drug reviews on WebMD (January 2007 to January 2021) and 1 from the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS; January 2016 to December 2020). We analyzed 2062 and 29,350 patient reports from WebMD and FAERS, respectively. Patient posts on WebMD were manually assigned the preferred terms of the Medical Dictionary for Regulatory Activities. To analyze AEs from FAERS, a disproportionality analysis was performed with 3 measures: proportional reporting ratio, reporting odds ratio, and information component. Results From the 869 AEs reported, we identified 125 new signals related to tramadol use not listed on the drug label that satisfied all 3 signal detection criteria. In addition, 20 serious AEs were selected from new signals. Among new serious AEs, vascular disorders had the largest signal detection criteria value. Based on the disproportionality analysis and patients’ symptom descriptions, tramadol-induced pain might also be an unexpected AE. Conclusions This study detected several novel signals related to tramadol use, suggesting newly identified possible AEs. Additionally, this study indicates that unexpected AEs can be detected using social media analysis alongside traditional pharmacovigilance data.

Background The Wellness Environment app study is a longitudinal study focused on promoting health in college students. Objective The two aims of this study were (1) to assess physical activity (PA) variation across the days of the week and throughout the academic year and (2) to explore the correlates that were associated with PA, concurrently and longitudinally. Methods The participants were asked to report their wellness and risk behaviors on a 14-item daily survey through a smartphone app. Each student was provided an Apple Watch to track their real time PA. Data were collected from 805 college students from Sept 2017 to early May 2018. PA patterns across the days of the week and throughout the academic year were summarized. Concurrent associations of daily steps with wellness or risk behavior were tested in the general linear mixed-effects model. The longitudinal, reciprocal association between daily steps and health or risk behaviors were tested with cross-lagged analysis. Results Female college students were significantly more active than male ones. The students were significantly more active during the weekday than weekend. Temporal patterns also revealed that the students were less active during Thanksgiving, winter, and spring breaks. Strong concurrent positive correlations were found between higher PA and self-reported happy mood, 8+ hours of sleep, ≥1 fruit and vegetable consumption, ≥4 bottles of water intake, and ≤2 hours of screen time (P Conclusions This study provides a comprehensive surveillance of longitudinal PA patterns and their independent association with a variety of wellness and risk behaviors in college students.

Background Delayed start-of-care nursing visits in home health care (HHC) can result in negative outcomes, such as hospitalization. No previous studies have investigated why start-of-care HHC nursing visits are delayed, in part because most reasons for delayed visits are documented in free-text HHC nursing notes. Objective The aims of this study were to (1) develop and test a natural language processing (NLP) algorithm that automatically identifies reasons for delayed visits in HHC free-text clinical notes and (2) describe reasons for delayed visits in a large patient sample. Methods This study was conducted at the Visiting Nurse Service of New York (VNSNY). We examined data available at the VNSNY on all new episodes of care started in 2019 (N=48,497). An NLP algorithm was developed and tested to automatically identify and classify reasons for delayed visits. Results The performance of the NLP algorithm was 0.8, 0.75, and 0.77 for precision, recall, and F-score, respectively. A total of one-third of HHC episodes (n=16,244) had delayed start-of-care HHC nursing visits. The most prevalent identified category of reasons for delayed start-of-care nursing visits was no answer at the door or phone (3728/8051, 46.3%), followed by patient/family request to postpone or refuse some HHC services (n=2858, 35.5%), and administrative or scheduling issues (n=1465, 18.2%). In 40% (n=16,244) of HHC episodes, 2 or more reasons were documented. Conclusions To avoid critical delays in start-of-care nursing visits, HHC organizations might examine and improve ways to effectively address the reasons for delayed visits, using effective interventions, such as educating patients or caregivers on the importance of a timely nursing visit and improving patients’ intake procedures.

Background Previous studies have shown inconsistencies in the accuracy of self-reported work hours. However, accurate documentation of work hours is fundamental for the formation of labor policies. Strict work-hour policies decrease medical errors, improve patient safety, and promote physicians’ well-being. Objective The aim of this study was to estimate physicians’ recall bias of work hours with a mobile app, and to examine the association between the recall bias and physicians’ work hours. Methods We quantified recall bias by calculating the differences between the app-recorded and self-reported work hours of the previous week and the penultimate week. We recruited 18 physicians to install the “Staff Hours” app, which automatically recorded GPS-defined work hours for 2 months, contributing 1068 person-days. We examined the association between work hours and two recall bias indicators: (1) the difference between self-reported and app-recorded work hours and (2) the percentage of days for which work hours were not precisely recalled during interviews. Results App-recorded work hours highly correlated with self-reported counterparts (r=0.86-0.88, P Conclusions Our study identified the existence of recall bias of work hours, the extent to which the recall was biased, and the influence of work hours on recall bias.

Background There are concerns that vaccine hesitancy may impede COVID-19 vaccine rollout and prevent the achievement of herd immunity. Vaccine hesitancy is a delay in acceptance or refusal of vaccines despite their availability. Objective We aimed to identify which people are more and less likely to take a COVID-19 vaccine and factors associated with vaccine hesitancy to inform public health messaging. Methods A Canadian cross-sectional survey was conducted in Canada in October and November 2020, prior to the regulatory approval of the COVID-19 vaccines. Vaccine hesitancy was measured by respondents answering the question “what would you do if a COVID-19 vaccine were available to you?” Negative binomial regression was used to identify the factors associated with vaccine hesitancy. Cluster analysis was performed to identify distinct clusters based on intention to take a COVID-19 vaccine, beliefs about COVID-19 and COVID-19 vaccines, and adherence to nonpharmaceutical interventions. Results Of 4498 participants, 2876 (63.9%) reported COVID-19 vaccine hesitancy. Vaccine hesitancy was significantly associated with (1) younger age (18-39 years), (2) lower education, and (3) non-Liberal political leaning. Participants that reported vaccine hesitancy were less likely to believe that a COVID-19 vaccine would end the pandemic or that the benefits of a COVID-19 vaccine outweighed the risks. Individuals with vaccine hesitancy had higher prevalence of being concerned about vaccine side effects, lower prevalence of being influenced by peers or health care professionals, and lower prevalence of trust in government institutions. Conclusions These findings can be used to inform targeted public health messaging to combat vaccine hesitancy as COVID-19 vaccine administration continues. Messaging related to preventing COVID among friends and family, highlighting the benefits, emphasizing safety and efficacy of COVID-19 vaccination, and ensuring that health care workers are knowledgeable and supported in their vaccination counselling may be effective for vaccine-hesitant populations.

Background About 1 in 3 adults aged 65 and older falls annually. Exercise interventions are effective in reducing the fall risk and fall rate among older adults. In 2020, startup company Age Bold Inc. disseminated the Bold Fall Prevention Program, aiming to reduce falls among older adults through a remotely delivered, digital exercise program. Objective We conducted a feasibility study to assess the delivery of the Bold Fall Prevention Program remotely and evaluate the program's impact on 2 primary outcomes—annualized fall rate and weekly minutes of physical activity (PA)—over 6 months of follow-up. Methods Older adults at high risk of falling were screened and recruited for the feasibility study via nationwide digital advertising strategies. Self-reported outcomes were collected via surveys administered at the time of enrollment and after 3 and 6 months. Responses were used to calculate changes in the annualized fall rate and minutes of PA per week. Results The remote delivery of a progressive digital fall prevention program and associated research study, including remote recruitment, enrollment, and data collection, was deemed feasible. Participants successfully engaged at home with on-demand video exercise classes, self-assessments, and online surveys. We enrolled 65 participants, of whom 48 (74%) were women, and the average participant age was 72.6 years. Of the 65 participants, 54 (83%) took at least 1 exercise class, 40 (62%) responded to at least 1 follow-up survey at either 3 or 6 months, 20 (31%) responded to both follow-up surveys, and 25 (39%) were lost to follow-up. Among all participants who completed at least 1 follow-up survey, weekly minutes of PA increased by 182% (ratio change=2.82, 95% CI 1.26-6.37, n=35) from baseline and annualized falls per year decreased by 46% (incidence rate ratio [IRR]=0.54, 95% CI 0.32-0.90, n=40). Among only 6-month survey responders (n=31, 48%), weekly minutes of PA increased by 206% (ratio change=3.06, 95% CI 1.43-6.55) from baseline to 6 months (n=30, 46%) and the annualized fall rate decreased by 28% (IRR=0.72, 95% CI 0.42-1.23) from baseline to 6 months. Conclusions The Bold Fall Prevention Program provides a feasible strategy to increase PA and reduce the burden of falls among older adults.

Background Access to exercise for cancer survivors is poor despite global recognition of its benefits. Telerehabilitation may overcome barriers to exercise for cancer survivors but is not routinely offered. Objective Following the rapid implementation of an exercise-based telerehabilitation program in response to COVID-19, a process evaluation was conducted to understand the impact on patients, staff, and the health service with the aim of informing future program development. Methods A mixed methods evaluation was completed for a telerehabilitation program for cancer survivors admitted between March and December 2020. Interviews were conducted with patients and staff involved in implementation. Routinely collected hospital data (adverse events, referrals, admissions, wait time, attendance, physical activity, and quality of life) were also assessed. Patients received an 8-week telerehabilitation intervention including one-on-one health coaching via telehealth, online group exercise and education, information portal, and home exercise prescription. Quantitative data were reported descriptively, and qualitative interview data were coded and mapped to the Proctor model for implementation research. Results The telerehabilitation program received 175 new referrals over 8 months. Of those eligible, 123 of 150 (82%) commenced the study. There were no major adverse events. Adherence to health coaching was high (674/843, 80% of scheduled sessions), but participation in online group exercise classes was low (n=36, 29%). Patients improved their self-reported physical activity levels by a median of 110 minutes per week (IQR 90-401) by program completion. Patients were satisfied with telerehabilitation, but clinicians reported a mixed experience of pride in rapid care delivery contrasting with loss of personal connections. The average health service cost per patient was Aus $1104 (US $790). Conclusions Telerehabilitation is safe, feasible, and improved outcomes for cancer survivors. Learnings from this study may inform the ongoing implementation of cancer telerehabilitation.

Background Hospitals have been identified as very high-risk places for COVID-19 transmission between health care workers and patients who do not have COVID-19. Health care workers are the most at-risk population to contract and transmit the infection, especially to already vulnerable patients who do not have COVID-19. In low-income countries, routine testing is not feasible due to the high cost of testing; therefore, presenting the risk of uncontrolled transmission within non–COVID-19 treatment wards. This challenge necessitated the development of an affordable intermediary screening tool that would enable early identification of potentially infected health care workers and for early real time DNA–polymerase chain reaction testing prioritization. This would limit the contact time of potentially infected health care workers with the patients but also enable efficient use of the limited testing kits. Objective The aims of this study are to describe an early warning in-hospital mobile risk analysis app for screening COVID-19 and to determine the feasibility and user-friendliness of the app among health care workers. Methods The primary result of this research project was the development of a mobile-based daily early warning system for in-hospital transmission of COVID-19. Overall, the Early Warning System for In-Hospital Transmission of COVID-19 (EWAS) mobile app was found to be feasible, with over 69% of the health care workers having logged more than 67% of the required times. Over 93% of the participants reported that the tool was easy to use. Results The primary result of this research project was the development of a mobile-based daily early warning system for in-hospital transmission of COVID-19. Overall, the Early Warning System for In-Hospital Transmission of COVID-19 (EWAS) mobile app was found to be feasible, with 69% of the health care workers (69/100) having logged more than 67% of the required times. Of the 100 participants, 93 reported that the tool was easy to use. Conclusions The EWAS mobile app is a feasible and user-friendly daily risk scoring tool for preventing in-hospital transmission of COVID-19. Although it was not designed to be a diagnostic tool but rather a screening tool, there is a need to evaluate its sensitivity in predicting persons likely to have contracted COVID-19.

Background Attempts to use virtual reality (VR) as a treatment for various psychiatric disorders have been made recently, and many researchers have identified the effects of VR in psychiatric disorders. Studies have reported that VR therapy is effective in social anxiety disorder (SAD). However, there is no prior study on the neural correlates of VR therapy in patients with SAD. Objective The aim of this study is to find the neural correlates of VR therapy by evaluating the treatment effectiveness of VR in patients with SAD using portable functional near-infrared spectroscopy (fNIRS). Methods Patients with SAD (n=28) were provided with 6 sessions of VR treatment that was developed for exposure to social situations with a recording system of each participant’s self-introduction in VR. After each VR treatment session, the first-person view (video 1) and third-person view (video 2) clips of the participant’s self-introduction were automatically generated. The functional activities of prefrontal regions were measured by fNIRS while watching videos 1 and 2 with a cognitive task, before and after whole VR treatment sessions, and after the first session of VR treatment. We compared the data of fNIRS between patients with SAD and healthy controls (HCs; n=27). Results We found that reduction in activities of the right frontopolar prefrontal cortex (FPPFC) in HCs was greater than in the SAD group at baseline (t=–2.01, P=.049). Comparing the frontal cortex activation before and after VR treatment sessions in the SAD group showed significant differences in activities of the FPPFC (right: t=–2.93, P Conclusions Activities of the FPPFC and OFC were associated with symptom reduction after VR treatment for SAD. Our study findings might provide a clue to understanding the mechanisms underlying VR treatment for SAD. Trial Registration Clinical Research Information Service (CRIS) KCT0003854; https://tinyurl.com/559jp2kp

Background Uptake of the COVID-19 vaccine among US young adults, particularly those that belong to racial and ethnic minorities, remains low compared to their older peers. Understanding vaccine perceptions and their influence on vaccination uptake among this population remains crucial to achieving population herd immunity. Objective We sought to study perceptions of COVID-19 vaccines as well as intended and actual vaccine uptake among one population of college students, faculty, and staff. Methods As part of a larger study aimed at investigating the dynamics of COVID-19 transmission, serology, and perception on a college campus, participants were asked about their views on the COVID-19 vaccine in February 2021. Vaccination status was assessed by self-report in April 2021. Logistic regression was used to calculate prevalence ratios with marginal standardization. Results We found that non-White participants were 25% less likely to report COVID-19 vaccination compared to White participants. Among those who were unvaccinated, Black and other non-White participants were significantly more likely to indicate they were unwilling to receive a COVID-19 vaccine compared to White participants. The most common reason for unwillingness to receive the vaccine was belief that the vaccine approval process was rushed. Conclusions There are racial differences in perceptions of the COVID-19 vaccine among young adults, and these differences might differentially impact vaccine uptake among young racial and ethnic minorities. Efforts to increase vaccine uptake among college populations might require campaigns specifically tailored to these minority groups.

Background COVID-19 became a pandemic rapidly after its emergence in December 2019. It belongs to the coronavirus family of viruses, which have struck a few times before in history. Data based on previous research regarding etiology and epidemiology of other viruses from this family helped played a vital role in formulating prevention and precaution strategies during the initial stages of this pandemic. Data related to COVID-19 in Pakistan were not initially documented on a large scale. In addition, due to a weak health care system and low economic conditions, Pakistan’s population, in general, already suffers from many comorbidities, which can severely affect the outcome of patients infected with COVID-19. Objective COVID-19 infections are coupled with a manifestation of various notable outcomes that can be documented and characterized clinically. The aim of this study was to examine these clinical manifestations, which can serve as indicators for early detection as well as severity prognosis for COVID-19 infections, especially in high-risk groups. Methods A retrospective observational study involving abstraction of demographic features, presenting symptoms, and adverse clinical outcomes for 1812 patients with COVID-19 was conducted. Patients were admitted to the four major hospitals in the Rawalpindi-Islamabad region of Pakistan, and the study was conducted from February to August 2020. Multivariate regression analysis was carried out to identify significant indicators of COVID-19 severity, intensive care unit (ICU) admission, ventilator aid, and mortality. The study not only relates COVID-19 infection with comorbidities, but also examines other related factors, such as age and gender. Results This study identified fever (1592/1812, 87.9%), cough (1433/1812, 79.1%), and shortness of breath (998/1812, 55.1%) at the time of hospital admission as the most prevalent symptoms for patients with COVID-19. These symptoms were common but not conclusive of the outcome of infection. Out of 1812 patients, 24.4% (n=443) required ICU admission and 21.5% (n=390) required ventilator aid at some point of disease progression during their stay at the hospital; 25.9% (n=469) of the patients died. Further analysis revealed the relationship of the presented symptoms and comorbidities with the progression of disease severity in these patients. Older adult patients with comorbidities, such as hypertension, diabetes, chronic kidney disease, and asthma, were significantly affected in higher proportions, resulting in requirement of ICU admission and ventilator aid in some cases and, in many cases, even mortality. Conclusions Older adult patients with comorbidities, such as hypertension, diabetes, asthma, chronic obstructive pulmonary disorder, and chronic kidney disease, are at increased risk of developing severe COVID-19 infections, with an increased likelihood of adverse clinical outcomes.