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BackgroundChronic disease represents a large and growing burden to the health care system worldwide. One method of managing this burden is the use of app-based interventions; however attrition, defined as lack of patient use of the intervention, is an issue for these interventions. While many apps have been developed, there is some evidence that they have significant issues with sustained use, with up to 98% of people only using the app for a short time before dropping out and/or dropping use down to the point where the app is no longer effective at helping to manage disease. ObjectiveOur objectives are to systematically appraise and perform a meta-analysis on dropout rates in apps for chronic disease and to qualitatively synthesize possible reasons for these dropout rates that could be addressed in future interventions. MethodsMEDLINE (Medical Literature Analysis and Retrieval System Online), PubMed, Cochrane CENTRAL (Central Register of Controlled Trials), and Embase were searched from 2003 to the present to look at mobile health (mHealth) and attrition or dropout. Studies, either randomized controlled trials (RCTs) or observational trials, looking at chronic disease with measures of dropout were included. Meta-analysis of attrition rates was conducted in Stata, version 15.1 (StataCorp LLC). Included studies were also qualitatively synthesized to examine reasons for dropout and avenues for future research. ResultsOf 833 studies identified in the literature search, 17 were included in the review and meta-analysis. Out of 17 studies, 9 (53%) were RCTs and 8 (47%) were observational trials, with both types covering a range of chronic diseases. The pooled dropout rate was 43% (95% CI 29-57), with observational studies having a higher dropout rate (49%, 95% CI 27-70) than RCTs in more controlled scenarios, which only had a 40% dropout rate (95% CI 16-63). The studies were extremely varied, which is represented statistically in the high degree of heterogeneity (I2>99%). Qualitative synthesis revealed a range of reasons relating to attrition from app-based interventions, including social, demographic, and behavioral factors that could be addressed. ConclusionsDropout rates in mHealth interventions are high, but possible areas to minimize attrition exist. Reducing dropout rates will make these apps more effective for disease management in the long term. Trial RegistrationInternational Prospective Register of Systematic Reviews (PROSPERO) CRD42019128737; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019128737

BackgroundThe health burden of type 2 diabetes can be mitigated by engaging patients in two key aspects of diabetes care: self-management and regular contact with health professionals. There is a clear benefit to integrating these aspects of care into a single clinical tool, and as mobile phone ownership increases, apps become a more feasible platform. However, the effectiveness of online health interventions is contingent on uptake by health care providers, which is typically low. There has been little research that focuses specifically on barriers and facilitators to health care provider uptake for interventions that link self-management apps to the user’s primary care physician (PCP). ObjectiveThis study aimed to explore PCP perspectives on proposed features for a self-management app for patients with diabetes that would link to primary care services. MethodsResearchers conducted 25 semistructured interviews. The interviewer discussed potential features that would link in with the patient’s primary care services. Interviews were audio-recorded, transcribed, and coded. Framework analysis and the Consolidated Criteria for Reporting Qualitative Research checklist were employed to ensure rigor. ResultsOur analysis indicated that PCP attitudes toward proposed features for an app were underpinned by perceived roles of (1) diabetes self-management, (2) face-to-face care, and (3) the anticipated burden of new technologies on their practice. Theme 1 explored PCP perceptions about how an app could foster patient independence for self-management behaviors but could also increase responsibility and liability for the PCP. Theme 2 identified beliefs underpinning a commonly expressed preference for face-to-face care. PCPs perceived information was more motivating, better understood, and presented with greater empathy when delivered face to face rather than online. Theme 3 described how most PCPs anticipated an initial increase in workload while they learned to use a new clinical tool. Some PCPs accepted this burden on the basis that the change was inevitable as health care became more integrated. Others reported potential benefits were outweighed by effort to implement an app. This study also identified how app features can be positively framed, highlighting potential benefits for PCPs to maximize PCP engagement, buy-in, and uptake. For example, PCPs were more positive when they perceived that an app could facilitate communication and motivation between consultations, focus on building capacity for patient independence, and reinforce rather than replace in-person care. They were also more positive about app features that were automated, integrated with existing software, flexible for different patients, and included secondary benefits such as improved documentation. ConclusionsThis study provided insight into PCP perspectives on a diabetes app integrated with primary care services. This was observed as more than a technological change; PCPs were concerned about changes in workload, their role in self-management, and the nature of consultations. Our research highlighted potential facilitators and barriers to engaging PCPs in the implementation process.

Objective: Clinician's experiences of providing care are identified as a key outcome associated with value-based healthcare (VBHC). In contrast to patient-reported experience measures, measurement tools to capture clinician's experiences in relation to VBHC initiatives have received limited attention to date. Progressing from an initial 18-item clinician experience measure (CEM), we sought to develop and evaluate the reliability of a set of 10 core clinician experience measure items in the CEM-10. Methods: A multi-method project was conducted using a consensus workshop with clinicians from a range of NSW Health local health districts to reduce the 18-item CEM to a short form 10-item core clinician experience measure (CEM-10). The CEM-10 was deployed with clinicians providing diabetes care, care for older adults and virtual care across all districts and care settings of New South Wales, Australia. Psychometric analysis was used to determine the internal consistency of the tool and its suitability for diverse clinical contexts. Results: Consensus building sessions led to a rationalised 10-item tool, retaining the four domains of psychological safety (two items), quality of care (three items), clinician engagement (three items) and interprofessional collaboration (two items). Data from four clinician cohorts (n = 1029) demonstrated that the CEM-10 four-factor model produced a good fit to the data and high levels of reliability, with factor loadings ranging from 0.77 to 0.92, with Cronbach's alpha (range: 0.79–0.90) and composite reliability (range: 0.80–0.92). Conclusions: The CEM-10 provides a core set of common clinician experience measurement items that can be used to compare clinician's experiences of providing care between and within cohorts. The CEM-10 may be supported by additional items relevant to particular initiatives when evaluating VBHC outcomes. What is known about the topic? Clinician experience of providing care is an outcome of interest for health systems and services internationally who are implementing value-based care initiatives. Review evidence indicates that measurement of clinician's experience of providing care should address experiences of being able to deliver quality care, collaborate with colleagues, experience psychological safety and engagement in decision-making in the workplace. What does this paper add? The paper reports the development of the short form clinician experience measure (CEM-10) and its initial validation in four value-based healthcare initiatives of NSW Health. What are the practical implications for practitioners? The CEM-10 can be used as a core set of items embedded within evaluations of value-based care initiatives to benchmark and examine experiences across clinician cohorts. This article belongs to the Special Issue: Value-based Healthcare. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to explore how people with diabetes and diverse health literacy levels conceptualise their experience and efforts to engage in self-management behaviours (their self-management 'schemas'). Design: A qualitative design was applied. Methods: Twenty-six people in Sydney, Australia, took part in semi-structured interviews, which were audio-recorded and coded using Framework analysis. Results: Half the participants (54%) had limited health literacy, whereas 38% adequate health literacy (using Newest Vital Sign). Regardless of health literacy, people described how monitoring increased self-management awareness and signalled periods of low self-management ('lulls'). Accounts of monitoring to sustain motivation were more apparent for participants with adequate health literacy. Most participants described simple and flexible rules (e.g. use artificial sweeteners; eat in moderation). Two schemas related to 'lulls': a 'problem-solving orientation' depicted lulls as inevitable and was associated with varied coping strategies; a 'willpower orientation' attributed lulls to lack of 'willpower,' and described willpower as a main coping strategy. Conclusion: There is considerable variation in how people think about their diabetes self-management and the strategies they use. Health literacy may contribute to some of this variation. Self-management interventions could benefit from depicting motivation as fluctuating and challenging ideas about willpower and self-blame. [ABSTRACT FROM AUTHOR]

A correction is presented to the article "Measuring clinician experience in value-based health care initiatives: a 10-item core clinician experience measure" which appeared in the last issue of the periodical.

Iodine deficiency has traditionally been associated with goiter and cretinism. More recently, iodine deficiency has been recognized as the leading worldwide cause of preventable intellectual impairment. Intellectual and neurologic deficits occur because of a lack of thyroid hormone during critical phases of brain development. More sensitive biologic tests may be useful in determining the true extent of iodine deficiency in populations. Thyroid stimulating hormone (TSH) levels among urban newborns from countries with known iodine deficiency problems were determined using a sensitive whole-blood spot assay. Results found prevalences of high TSH (>5 mu/L whole blood units using a sensitive monoclonal assay) ranging from 32-80% compared with a prevalence of 3% usually found in iodine-replete areas. These findings suggest that developing brains of newborns are at risk from the detrimental effects of iodine deficiency in these urban areas. The results presented suggest the need for effective intervention programs in urban areas as well. KEY WORDS: iodine deficiency * thyroid stimulating hormone * humans * newborns

Iodine deficiency is the leading cause of preventable intellectual impairment and is associated with a spectrum of neurologic and developmental pathology. More than one billion people are at risk. The developing fetus, newborn, and young child are the most susceptible to the effects of an iodine-deficient diet. If intervention is not initiated in a timely fashion, the pathophysiologic abnormalities become resistant to treatment and permanent intellectual, neurologic, and somatic deficits result. The technology of iodine deficiency intervention is well established. Lodized salt, the preferred method, is easy to produce, administer in physiologic doses, and is cost effective. The distribution of iodized salt and social marketing are key to a successful iodine deficiency elimination program. In remote regions, iodized oil is a useful interim intervention. However, it is clear that technology is not enough. Any national effort to eliminate iodine deficiency must extend far beyond the Ministry of Health. The program will quire the full participation of a range of national government ministries and agencies and the full support and participation of local or regional governments. J. Nutr. 124: 1473S--1478S, 1994.

Background: Stabilising blood glucose levels (BGL) after starting or changing insulin and related therapies can be challenging for diabetes services and the patient with type 2 diabetes. Traditionally, a credentialled diabetes educator (CDE) would talk with the patient over the phone to obtain a history of their BGLs over the previous week and provide advice on the insulin dose adjustments as required. This study trialled a smartphone application for sharing BGLs, with the ability to digitally transmit advice back to patients compared with their usual care. Aims: The aim of this study was to compare desirability, efficiency and ease of use. Methods: Participants were enrolled in either the traditional (n =50) or Health2Sync (H2S) (n =42) treatment group by patient preference. All insulin stabilisations were conducted by the CDE. Descriptive statistics were used for analysis. Results: The average total time taken to titrate patients was similar in both groups (p >0.05), however there were fewer failure of contacts reported with H2S (p <0.01) and time per interaction was also lower (p <0.01). Sensitivity analysis revealed that, excluding the influence of no contacts, H2S patients had a lower average time for titration (p <0.01). There was no difference in clinical outcomes as measured by HbA1c between the two groups (p =0.75). Conclusion: We demonstrated a high acceptance and clinical utility of the H2S application. Clinicians were happy to use H2S and found it easy and convenient for most patients. Importantly, this reduced frequency of contacts with patients, time per interaction and average time for titration (p <0.01). Patient selection for this communication intervention is important. [ABSTRACT FROM AUTHOR]

1. Brief description of the condition/disease Iodine deficiency disorders (IDD) result from insufficient iodine in the environment and inadequate intake of iodine from food. Because development of the central nervous [...]

To the Editor.-- Brent and Oakley (1) argue that 2000 additional healthy infants in the United States, or 200 000 more healthy infants in the world, could be born each […]