Factors Associated with Veteran Self-Reported Use of Digital Health Devices.

BACKGROUND: Digital health devices (DHDs), technologies designed to gather, monitor, and sometimes share data about health-related behaviors or symptoms, can support the prevention or management of chronic conditions. DHDs range in complexity and utility, from tracking lifestyle behaviors (e.g., pedometer) to more sophisticated biometric data collection for disease self-management (e.g., glucometers). Despite these positive health benefits, supporting adoption and sustained use of DHDs remains a challenge. OBJECTIVE: This analysis examined the prevalence of, and factors associated with, DHD use within the Veterans Health Administration (VHA). DESIGN: National survey. PARTICIPANTS: Veterans who receive VHA care and are active secure messaging users. MAIN MEASURES: Demographics, access to technology, perceptions of using health technologies, and use of lifestyle monitoring and self-management DHDs. RESULTS: Among respondents, 87% were current or past users of at least one DHD, and 58% were provided a DHD by VHA. Respondents 65 + years were less likely to use a lifestyle monitoring device (AOR 0.57, 95% CI [0.39, 0.81], P = .002), but more likely to use a self-management device (AOR 1.69, 95% [1.10, 2.59], P = .016). Smartphone owners were more likely to use a lifestyle monitoring device (AOR 2.60, 95% CI [1.42, 4.75], P = .002) and a self-management device (AOR 1.83, 95% CI [1.04, 3.23], P = .037). CONCLUSIONS: The current analysis describes the types of DHDs that are being adopted by Veterans and factors associated with their adoption. Results suggest that various factors influence adoption, including age, access to technology, and health status, and that these relationships may differ based on the functionalities of the device. VHA provision of devices was frequent among device users. Providing Veterans with DHDs and the training needed to use them may be important factors in facilitating device adoption. Taken together, this knowledge can inform future implementation efforts, and next steps to support patient-team decision making about DHD use.

Improving Veteran Engagement with Virtual Care Technologies: a Veterans Health Administration State of the Art Conference Research Agenda.

Although the availability of virtual care technologies in the Veterans Health Administration (VHA) continues to expand, ensuring engagement with these technologies among Veterans remains a challenge. VHA Health Services Research & Development convened a Virtual Care State of The Art (SOTA) conference in May 2022 to create a research agenda for improving virtual care access, engagement, and outcomes. This article reports findings from the Virtual Care SOTA engagement workgroup, which comprised fourteen VHA subject matter experts representing VHA clinical care, research, administration, and operations. Workgroup members reviewed current evidence on factors and strategies that may affect Veteran engagement with virtual care technologies and generated key questions to address evidence gaps. The workgroup agreed that although extensive literature exists on factors that affect Veteran engagement, more work is needed to identify effective strategies to increase and sustain engagement. Workgroup members identified key priorities for research on Veteran engagement with virtual care technologies through a series of breakout discussion groups and ranking exercises. The top three priorities were to (1) understand the Veteran journey from active service to VHA enrollment and beyond, and when and how virtual care technologies can best be introduced along that journey to maximize engagement and promote seamless care; (2) utilize the meaningful relationships in a Veteran's life, including family, friends, peers, and other informal or formal caregivers, to support Veteran adoption and sustained use of virtual care technologies; and (3) test promising strategies in meaningful combinations to promote Veteran adoption and/or sustained use of virtual care technologies. Research in these priority areas has the potential to help VHA refine strategies to improve virtual care user engagement, and by extension, outcomes.

Value of Information Analysis of a Web-Based Self-Management Intervention for Chronic Obstructive Pulmonary Disease.

Objective: Technology-based programs can be cost-effective in the management of chronic obstructive pulmonary disease (COPD). However, cost-effectiveness estimates always contain some uncertainty, and decisions based upon them carry some risk. We conducted a value of information (VOI) analysis to estimate the value of additional research of a web-based self-management intervention for COPD to reduce the costs associated with uncertainty. Methods: We used a 10,000-iteration cost-effectiveness model from the health care payer perspective to calculate the expected value of perfect information (EVPI) at the patient- and population-level. An opportunity loss was incurred when the web-based intervention did not produce a greater net monetary benefit than usual care in an iteration. We calculated the probability of opportunity loss and magnitude of opportunity costs as a function of baseline health utility. We aggregated opportunity costs over the projected incident population of inpatient COPD patients over 10 years and estimated it as a function of the willingness-to-pay (WTP) threshold. Costs are in 2022 U.S. Dollars. Results: Opportunity losses were found in 22.7% of the iterations. The EVPIpatient was $78 per patient (95% confidence interval: $75-$82). The probability that the intervention was the optimal strategy varied across baseline health utilities. The EVPIpopulation was $506,666,882 over 10 years for a WTP of $50,000. Conclusions: Research estimated to cost up to $500 million would be warranted to reduce uncertainty. Future research could focus on identifying the impact of baseline health utilities to maximize the cost savings of the intervention. Other considerations for future research priorities include implementation efforts for technology-based interventions.

Engaging Operational Partners Is Critical for Successful Implementation of Research Products: a Coincidence Analysis of Access-Related Projects in the Veterans Affairs Healthcare System.

BACKGROUND/OBJECTIVE: The Veterans Health Administration (VHA) has prioritized timely access to care and has invested substantially in research aimed at optimizing veteran access. However, implementing research into practice remains challenging. Here, we assessed the implementation status of recent VHA access-related research projects and explored factors associated with successful implementation. DESIGN: We conducted a portfolio review of recent VHA-funded or supported projects (1/2015-7/2020) focused on healthcare access ("Access Portfolio"). We then identified projects with implementable research deliverables by excluding those that (1) were non-research/operational projects; (2) were only recently completed (i.e., completed on or after 1/1/2020, meaning that they were unlikely to have had time to be implemented); and (3) did not propose an implementable deliverable. An electronic survey assessed each project's implementation status and elicited barriers/facilitators to implementing deliverables. Results were analyzed using novel Coincidence Analysis (CNA) methods. PARTICIPANTS/KEY RESULTS: Among 286 Access Portfolio projects, 36 projects led by 32 investigators across 20 VHA facilities were included. Twenty-nine respondents completed the survey for 32 projects (response rate = 88.9%). Twenty-eight percent of projects reported fully implementing project deliverables, 34% reported partially implementing deliverables, and 37% reported not implementing any deliverables (i.e., resulting tool/intervention not implemented into practice). Of 14 possible barriers/facilitators assessed in the survey, two were identified through CNA as "difference-makers" to partial or full implementation of project deliverables: (1) engagement with national VHA operational leadership; (2) support and commitment from local site operational leadership. CONCLUSIONS: These findings empirically highlight the importance of operational leadership engagement for successful implementation of research deliverables. Efforts to strengthen communication and engagement between the research community and VHA local/national operational leaders should be expanded to ensure VHA's investment in research leads to meaningful improvements in veterans' care. The Veterans Health Administration (VHA) has prioritized timely access to care and has invested substantially in research aimed at optimizing veteran access. However, implementing research findings into clinical practice remains challenging, both within and outside VHA. Here, we assessed the implementation status of recent VHA access-related research projects and explored factors associated with successful implementation. Only two factors were identified as "difference-makers" to adoption of project findings into practice: (1) engagement with national VHA leadership or (2) support and commitment from local site leadership. These findings highlight the importance of leadership engagement for successful implementation of research findings. Efforts to strengthen communication and engagement between the research community and VHA local/national leaders should be expanded to ensure VHA's investment in research leads to meaningful improvements in veterans' care.

Depression Symptoms and Physical Activity in Veterans With COPD: Insights From a Web-Based, Pedometer-Mediated Physical Activity Intervention.

BACKGROUND: Depression is known to limit physical activity (PA) among individuals with chronic obstructive pulmonary disease (COPD). However, whether and how depression influences the effectiveness of PA interventions is unknown. PURPOSE: The study examined the association between baseline depression symptoms and change in daily step count and whether group assignment to a web-based, pedometer-mediated PA intervention moderated the association between baseline depression symptoms and change in daily step count. METHODS: Secondary analysis included two cohorts of U.S. Veterans with COPD (n = 212; 97% male; mean age 69 ± 8 years) assessed at baseline and 3 months. Cohorts 1 and 2 were randomly assigned to the same PA intervention (n = 111) or a control group (n = 101). Multivariate regressions tested the main effects of baseline depression symptoms (BDI-II total and cognitive-affective and somatic subscales) on change in daily steps, as well as the interaction between baseline BDI-II and subscales and group assignment on change in daily steps. RESULTS: Greater BDI-II total score (B = -31.8, SE = 14.48, p = .030) and somatic subscale scores (B = -99.82, SE = 35.76, p = .006) were associated with less improvement in daily step count. There was a significant interaction between baseline cognitive-affective subscale and the intervention predicting change in daily step count (B = -88.56, SE = 42.31, p = .038). When cognitive-affective subscale scores were ≥1 SD above the mean, the intervention was no longer associated with an increase in daily step count (p = .585). CONCLUSIONS: Depression should be routinely assessed and targeted as part of PA promotion efforts.

United States (U.S.) Veterans have high rates of chronic obstructive pulmonary disease (COPD), a progressive lung disease that causes shortness of breath. Promoting physical activity (PA) is an important component to the management of COPD resulting in improved outcomes. Technology-based interventions (i.e., pedometers, websites) are effective at increasing PA in persons with COPD. However, depression symptoms, such as low mood and motivation, may influence their effectiveness. This secondary data analysis examined whether depression symptoms were related to improvement in daily step count. Two cohorts of U.S. Veterans were randomized to either a web-based, pedometer-mediated PA intervention (i.e., pedometer, goal setting and feedback, education and online community) or a control group (i.e., pedometer only or usual care). Daily step count was assessed at baseline and at 3 months. Across both groups, greater overall depression symptoms and greater bodily symptoms of depression (i.e., fatigue) were associated with less improvement in daily step count. Veterans with greater cognitive-affective symptoms of depression (i.e., low mood, loss of interest, or pleasure) who were assigned to the intervention group showed no improvement in daily step count compared with controls. Results highlight the importance of detecting and treating depression as part of PA interventions.

Pain in Veterans with COPD: relationship with physical activity and exercise capacity.

BACKGROUND: Pain is a common but underappreciated symptom experienced by people with Chronic Obstructive Pulmonary Disease (COPD). The relationships between pain and physical activity (PA) and exercise capacity are poorly understood. METHODS: This retrospective secondary analysis includes three cohorts of Veterans with COPD who participated in longitudinal studies evaluating PA and exercise capacity with objective measures of daily step counts and 6-min walk test (6MWT) distance, respectively. Pain was assessed using the bodily pain domain of the Veterans RAND-36. In two cohorts, participants were randomly assigned to a web-based, pedometer-mediated PA intervention which has previously been demonstrated to improve PA. RESULTS: Three-hundred and seventy-three (373) unique study participants were included in this analysis. Eighty-three percent (n = 311) of the population reported at least mild pain and/or at least a little bit of interference due to pain at baseline. Cross-sectionally, greater bodily pain was associated with lower 6MWT distance (ß = 0.51; 95% CI 0.20, 0.82; p = 0.0013). Longitudinally, worsening bodily pain was associated with a decline in 6MWT distance (ß = 0.30; 95% CI 0.03, 0.58; p = 0.0312). There was no association between baseline bodily pain and baseline daily step counts, baseline bodily pain and change in PA, or change in bodily pain and change in PA. Compared to usual care, our PA intervention improved bodily pain scores (ß = 6.17; 95% CI 1.84, 10.45; p = 0.0054). Bodily pain scores did not affect the impact of the intervention on daily step counts. CONCLUSION: Pain is highly prevalent and significantly associated with lower exercise capacity among Veterans with COPD. Worsening pain co-occurred with decline in exercise capacity but not PA. Our intervention reduced pain, although pain did not affect the impact of the intervention on PA.

Can Technology-Based Physical Activity Programs for Chronic Obstructive Pulmonary Disease Be Cost-Effective?

Objective: To evaluate the cost-effectiveness of a technology-based physical activity (PA) intervention for chronic obstructive pulmonary disease (COPD). Design: A secondary data analysis was performed from a randomized controlled trial in COPD of an activity monitor alone or an activity monitor plus a web-based PA intervention. Models estimated cost per quality-adjusted life year (QALY) and incremental cost-effectiveness ratios (ICERs) compared with usual care. Results: The estimated ICER for both groups was below the willingness-to-pay threshold of $50,000/QALY (activity monitor alone = $10,437/QALY; website plus activity monitor intervention = $13,065/QALY). A probabilistic simulation estimated 76% of the activity monitor-alone group and 78% of the intervention group simulations to be cost-effective. Conclusion(s): Both the activity monitor-alone group and the activity monitor plus website group were cost-effective at the base case by using conventional willingness-to-pay thresholds. Further research would benefit from a more direct estimate of health utilities and downstream health care costs. Clinical Trials.gov NCT01102777.

Secure Messaging, Diabetes Self-management, and the Importance of Patient Autonomy: a Mixed Methods Study.

BACKGROUND: Diabetes is a complex, chronic disease that requires patients' effective self-management between clinical visits; this in turn relies on patient self-efficacy. The support of patient autonomy from healthcare providers is associated with better self-management and greater diabetes self-efficacy. Effective provider-patient secure messaging (SM) through patient portals may improve disease self-management and self-efficacy. SM that supports patients' sense of autonomy may mediate this effect by providing patients ready access to their health information and better communication with their clinical teams. OBJECTIVE: We examined the association between healthcare team-initiated SM and diabetes self-management and self-efficacy, and whether this association was mediated by patients' perceptions of autonomy support from their healthcare teams. DESIGN: We surveyed and analyzed content of messages sent to a sample of patients living with diabetes who use the SM feature on the VA's My HealtheVet patient portal. PARTICIPANTS: Four hundred forty-six veterans with type 2 diabetes who were sustained users of SM. MAIN MEASURES: Proactive (healthcare team-initiated) SM (0 or ≥ 1 messages); perceived autonomy support; diabetes self-management; diabetes self-efficacy. KEY RESULTS: Patients who received at least one proactive SM from their clinical team were significantly more likely to engage in better diabetes self-management and report a higher sense of diabetes self-efficacy. This relationship was mediated by the patient's perception of autonomy support. The majority of proactive SM discussed scheduling, referrals, or other administrative content. Patients' responses to team-initiated communication promoted patient engagement in diabetes self-management behaviors. CONCLUSIONS: Perceived autonomy support is important for diabetes self-management and self-efficacy. Proactive communication from clinical teams to patients can help to foster a patient's sense of autonomy and encourage better diabetes self-management and self-efficacy.

Engineering a Virus-like Particle to Display Peptide Insertions Using an Apparent Fitness Landscape.

Peptide insertions in the primary sequence of proteins expand functionality by introducing new binding sequences, chemical handles, or membrane disrupting motifs. With these properties, proteins can be engineered as scaffolds for vaccines or targeted drug delivery vehicles. Virus-like particles (VLPs) are promising platforms for these applications since they are genetically simple, mimic viral structure for cell uptake, and can deliver multiple copies of a therapeutic agent to a given cell. Peptide insertions in the coat protein of VLPs can increase VLP uptake in cells by increasing cell binding, but it is difficult to predict how an insertion affects monomer folding and higher order assembly. To this end, we have engineered the MS2 VLP using a high-throughput technique, called Systematic Mutagenesis and Assembled Particle Selection (SyMAPS). In this work, we applied SyMAPS to investigate a highly mutable loop in the MS2 coat protein to display 9,261 non-native tripeptide insertions. This library generates a discrete map of three amino acid insertions permitted at this location, validates the FG loop as a valuable position for peptide insertion, and illuminates how properties such as charge, flexibility, and hydrogen bonding can interact to preserve or disrupt capsid assembly. Taken together, the results highlight the potential to engineer VLPs in a systematic manner, paving the way to exploring the applications of peptide insertions in biomedically relevant settings.

The Promise of Patient Portals for Individuals Living With Chronic Illness: Qualitative Study Identifying Pathways of Patient Engagement.

BACKGROUND: Patients play a critical role in managing their health, especially in the context of chronic conditions like diabetes. Electronic patient portals have been identified as a potential means to improve patient engagement; that is, patients' involvement in their care. However, little is known about the pathways through which portals may help patients engage in their care. OBJECTIVE: Our objective is to understand how an electronic patient portal facilitates patient engagement among individuals with diabetes. METHODS: This qualitative study employed semistructured telephone interviews of 40 patients living with diabetes since at least 2011, who had experienced uncontrolled diabetes, and had used secure messaging through a portal at least 4 times over 18 months. The interviews were recorded, transcribed, coded, and analyzed using primarily an inductive approach to identify how patients living with diabetes use an online health portal to support diabetes self-management. RESULTS: Overall, patients who used the portal reported feeling engaged in their health care. We identified four pathways by which the portal facilitates patient engagement and some challenges. The portal provides a platform that patients use to (1) better understand their health by asking questions about new symptoms, notes, or labs, (2) prepare for medical appointments by reviewing labs and notes, (3) coordinate care between VA (Veterans Affairs) and non-VA health care teams, and (4) reach out to providers to request help between visits. Several patients reported that the portal helped improve the patient-provider relationship; however, aspects of the portal design may hinder engagement for others. Patients reported challenges with both secure messaging and access to medical records that had negative impacts on their engagement. Benefits for patient engagement were described by many types of portal users with varying degrees of diabetes control. CONCLUSIONS: Patient portals support engagement by facilitating patient access to their health information and by facilitating patient-provider communication. Portals can help a wide range of users engage with their care.

The Relationship of Personality and Behavior Change in a Physical Activity Intervention: The Role of Conscientiousness and Healthy Neuroticism.

This study examined the role of personality traits in a 5-week physical activity intervention study for working adults. We tested whether personality traits predicted individual differences in change in daily steps over time. Fifty-two participants ages 35 to 69 (M age = 49.71, SD = 8.64) wore a Fitbit Zip step counter for 35 days and completed a personality questionnaire. Participants were randomly assigned to either an implementation intention group or a control group. Both groups wore a Fitbit and had the goal to increase their daily steps. For the present study, the sample was collapsed across groups. Higher conscientiousness was associated with greater increases in daily steps. Also, individuals with healthy neuroticism, the combination of higher neuroticism and higher conscientiousness, showed greater increases in daily steps. The findings highlight that the efficacy of physical activity interventions may depend on personality traits. Intervention outcomes may be improved if personality is taken into account when designing the programs.

Experimental Evaluation of Coevolution in a Self-Assembling Particle.

Protein evolution occurs via restricted evolutionary paths that are influenced by both previous and subsequent mutations. This effect, termed epistasis, is critical in population genetics, drug resistance, and immune escape; however, the effect of epistasis on the level of protein fitness is less well characterized. We generated and characterized a 6615-member library of all two-amino acid combinations in a highly mutable loop of a virus-like particle. This particle is a model of protein self-assembly and a promising vehicle for drug delivery and imaging. In addition to characterizing the effect of all double mutants on assembly, thermostability, and acid stability, we observed many instances of epistasis, in which combinations of mutations are either more deleterious or more beneficial than expected. These results were used to generate rules governing the effects of multiple mutations on the self-assembly of the virus-like particle.

A web-based physical activity intervention benefits persons with low self-efficacy in COPD: results from a randomized controlled trial.

Promoting physical activity (PA) is of top priority in chronic obstructive pulmonary disease (COPD). This study examines the influence of an internet-delivered intervention on the relationship between exercise self-efficacy and changes in PA, physical health, and exercise capacity in COPD. 112 U.S. Veterans with COPD were randomized to either a comparison (pedometer alone) or an intervention group (pedometer plus access to an internet-mediated PA intervention). There was a significant interaction between baseline exercise self-efficacy and randomization group on change in PA. In the comparison group, there was a significant relationship between higher baseline exercise self-efficacy and greater change in PA, whereas in the intervention group, improvements in PA were independent of level of baseline self-efficacy. Similar patterns were found with physical health and exercise capacity as outcomes. The use of an internet-mediated intervention significantly benefited persons with COPD who had low baseline self-efficacy to increase PA and physical health.Clinical trial registration The randomized clinical trial was registered on ClinicalTrials.gov (NCT01772082).

Perceived Control and Aging: A Mini-Review and Directions for Future Research.

This brief review on perceived control and aging is organized according to 3 perspectives of research involving description, explanation, and modification. An extensive body of literature has utilized cross-sectional and correlational methods to describe the sociodemographic variations and outcomes associated with perceived control. This work has focused on differences in perceived control as a function of age, sex, education, socioeconomic status, and culture and has identified positive associations with many aging-related outcomes involving health and well-being. With growing evidence regarding the health benefits of perceived control in the context of a declining sense of control with aging, there has been an increased effort to uncover the mechanisms involved, with the hopes of developing methods to maintain and/or promote adaptive control beliefs throughout adulthood. Through longitudinal and experimental work, researchers are beginning to clarify the directionality and elucidate the mechanisms to explain the associations. Recent evidence from longitudinal studies shows that control beliefs have an impact on subsequent changes in health. Yet, the findings suggest that it is not a unidirectional relationship. A conceptual model suggesting an ongoing reciprocal relationship between perceived control and health and well-being is discussed. Research examining the mechanisms that link perceived control to aging-related outcomes can help to inform and to develop effective interventions that are tailored to the individual's specific barriers and goals. We consider new directions for research, including more attention to intraindividual variability and reactivity to daily challenges, such as stress, with the goal of advancing our understanding of how perceived control contributes to aging-related outcomes. More work is needed to develop strategies to enhance control beliefs in later life. Although it will not always be possible to modify control beliefs, researchers can take these beliefs into account when developing interventions. A personalized approach is recommended as a way to tailor interventions that are compatible with individuals' beliefs about control to facilitate adaptive behavior change. Conclusions focus on selected issues and considerations for future research.

Remote cognitive assessments for patients with multiple sclerosis: a feasibility study.

BACKGROUND: measuring cognitive function in patients with multiple sclerosis (MS) can be challenging given the obstacles faced when traveling to testing centers. OBJECTIVE: the purpose of this study was to evaluate the feasibility of remote cognitive assessment in patients with MS using the automated neuropsychological assessment metrics (ANAM-MS) and the symbol digit modalities test (SDMT). METHODS: patients meeting the McDonald criteria for MS (n = 24) were randomized to complete the live-in-office condition or a remote-in-office condition first, with all patients completing both sessions. Patients (n = 20) then completed a final remote-in-home testing session. Both remote sessions were proctored by a psychologist using a secure telehealth connection. RESULTS: scores on the live SDMT differed from scores in the two remote settings F(2, 38) = 4.46, p = 0.018. However, summary scores on the ANAM-MS were similar across the three settings, F(2, 36) = 2.21, p = 0.124. Satisfaction with telehealth testing was high on the part of the examiner and patients. Each telehealth testing session saved more than $144.00 in travel costs and lost wages. CONCLUSION: this study demonstrated that valid results can be obtained when evaluating patients remotely using ANAM-MS. Some differences were noted for the SDMT that suggest that either specific norms or a different implementation approach may be needed for telehealth.

Rural disparities impact response to a web-based physical activity self-management intervention in COPD: A secondary analysis.

PURPOSE: This secondary exploratory analysis examined rural-urban differences in response to a web-based physical activity self-management intervention for chronic obstructive pulmonary disease (COPD). METHODS: Participants with COPD (N = 239 US Veterans) were randomized to either a multicomponent web-based intervention (goal setting, iterative feedback of daily step counts, motivational and educational information, and an online community forum) or waitlist-control for 4 months with a 12-month follow-up. General linear modeling estimated the impact of rural/urban status (using Rural-Urban Commuting Area [RUCA] codes) on (1) 4- and 12-month daily step-count change compared to waitlist-control, and (2) intervention engagement (weekly logons and participant feedback). FINDINGS: Rural (n = 108) and urban (n = 131) participants' mean age was 66.7±8.8 years. Rural/urban status significantly moderated 4-month change in daily step counts between randomization groups (p = 0.041). Specifically, among urban participants, intervention participants improved by 1500 daily steps more than waitlist-control participants (p = 0.001). There was no difference among rural participants. In the intervention group, rural participants engaged less with the step-count graphs on the website than urban participants at 4 months (p = 0.019); this difference dissipated at 12 months. More frequent logons were associated with greater change in daily step counts (p = 0.004); this association was not moderated by rural/urban status. CONCLUSIONS: The web-based intervention was effective for urban, but not rural, participants at 4 months. Rural participants were also less engaged at 4 months, which may explain differences in effectiveness. Technology-based interventions can help address urban-rural disparities in patients with COPD, but may also contribute to them unless resources are available to support engagement with the technology.

Physical Activity and Systemic Biomarkers in Persons With COPD: Insights from a Web-Based Pedometer-Mediated Intervention.

Background: The relationships between physical activity (PA) and exercise performance and systemic biomarkers in persons with COPD have not been well characterized. The impact of PA promotion on biomarkers reflecting myocardial stress, systemic inflammation, and muscle injury is unclear. Methods: This secondary analysis used three previously published studies in persons with COPD, two examined a PA intervention that promoted community-based walking for 3 months, to explore these relationships. PA (daily step counts) and exercise performance (6-minute walk test; 6MWT) were assessed. Serum N-terminal pro-ß-type natriuretic peptide (NT-proBNP), the soluble receptor for advanced glycation end products (sRAGE), and muscle-type creatine kinase (CKMM) were assayed at baseline and three months. General linear models examined associations between PA/exercise performance and systemic biomarkers at baseline and the effect of the PA intervention on change in biomarkers. Results: Participants included 366 US Veterans - 98% male, mean age 70±8 years, and FEV1 % predicted 59±21%. Lower baseline NT-proBNP, but not sRAGE or CKMM, was associated with higher daily step count (-0.95 pg/ml per 1,000 steps/day, p=.060) and higher 6MWT distance (-0.80 pg/ml per 100 meters, p=.001). Change in daily step count, but not 6MWT, was significantly greater in the intervention (789±1,864) compared to the control group (-174±1,448; p=.002). The PA intervention had no significant impact on change in the systemic biomarkers. Interpretation: Exercise performance is associated with NT-proBNP in persons with COPD. A 3-month community-based walking intervention is not associated with myocardial stress or muscle injury as assessed by NT-proBNP and CKMM, respectively.

Stakeholder Perceptions of a Web-Based Physical Activity Intervention for COPD: A Mixed-Methods Study.

Technology-based physical activity interventions have been shown to be efficacious in chronic obstructive pulmonary disease (COPD), though their potential impact has not been fully realized due to ineffective implementation. We used a convergent, parallel mixed-methods design to identify patient- and provider-facing barriers and facilitators to implementing a rigorously studied web-based physical activity intervention for COPD. Quantitative surveys (based on the unified theory of acceptance and use of technology; range 1 (poor usability)-5 (high usability)) and semi-structured interviews (guided by the practical robust implementation and sustainability model) assessed the perspectives of 15 patients and 15 health care providers. The patients and providers rated the usability of the intervention as high (median = 5.0, IQR = 1.0). For both patients and providers, the main facilitators included: the potential high impact of the intervention on patient health, the usefulness of the intervention for unmet clinical needs, and the perceived ease of use of the intervention. The main barriers identified were digital literacy and its fit with current clinical workflows. Implementation efforts may benefit from supporting patients' use of the website and developing strategies to integrate referrals to the intervention and the monitoring of patients into current clinical infrastructures.

Veteran Acceptance of Sleep Health Information Technology: a Mixed-Method Study.

Sleep disturbances, including chronic insomnia and sleep apnea, are major concerns for US veterans, with rising rates and detrimental effects on physical, mental, and social well-being. Sleep disturbances in veterans are also underdiagnosed and undertreated for reasons that include limited sleep clinician availability, long wait times, and the time commitment for treatment. Greater use of sleep health information technologies could improve access to assessment and treatment of sleep disturbances. However, the assessment of acceptance of these technologies among veterans is still ongoing. This mixed-method study combines data from two separate but similar randomized controlled trials to assess acceptance of sleep health information technologies for veterans with chronic insomnia. Sleep health information technologies included in these trials were the following: (1) a WatchPAT sleep monitor for home-based sleep assessment, including detection of sleep apnea, and (2) the VA mobile app Cognitive Behavioral Therapy for Insomnia (CBT-i Coach), which supports self-management of insomnia. The combined sample of 37 veterans receiving care within one New England VA medical center completed a six-week trial using both health information technology tools. Participants completed a survey and interview at the end of the 6 weeks. Overall, participants found the tools acceptable, easy to use, and useful and reported they would use them in the future. Thus, these sleep health information technologies appear to provide an acceptable remote option for assessing and managing sleep issues for veterans. ClinicalTrials.gov NCT02392000; http://clinicaltrials.gov/ct2/show/NCT02392000 and ClinicalTrials.gov NCT03305354; https://clinicaltrials.gov/ct2/show/NCT03305354.

Chronic Obstructive Pulmonary Disease Access and Adherence to Pulmonary Rehabilitation Intervention (CAPRI): Protocol for a randomized controlled trial and adaptations during the COVID-19 pandemic.

BACKGROUND: Pulmonary rehabilitation (PR) is the standard of care for chronic obstructive pulmonary disease (COPD) management. However, significant barriers limit access and adherence to PR and alternatives are needed. The purpose of this randomized controlled trial is to test the efficacy of a web-based, pedometer-mediated intervention to increase physical activity (PA) for persons with COPD who decline PR or meet U.S. guidelines for referral to PR but have not participated (CAPRI-1). In addition, we will test whether the intervention maintains PA following PR in an exploratory aim (CAPRI-2). METHODS: Participants with COPD (N = 120) will be recruited and randomized 1:1 to a 12-week web-based, pedometer-mediated intervention or usual care (UC) (CAPRI-1). The intervention provides: 1) objective monitoring of walking and iterative feedback, 2) individualized step-count goals, 3) motivational messages and educational content, and 4) an online community. The primary outcome is change in daily step count from baseline to 12 weeks. Secondary outcomes include: (a) exercise capacity; (b) self-reported PA; (c) PA intensity; (d) exercise self-regulatory efficacy, (e) health-related quality of life, (f) dyspnea, (g) depression symptoms, and (h) healthcare utilization. CAPRI-2 will test whether participants (N = 96) assigned to the intervention following PR completion show greater maintenance of daily step count compared to UC at 3, 6, 9, and 12 months. DISCUSSION: If the intervention is efficacious, it may be an alternative for those who cannot attend PR or a maintenance program following completion of conventional PR. We also present adaptations made to the protocol in response to the COVID-19 pandemic.