Reliever-Triggered Inhaled Glucocorticoid in Black and Latinx Adults with Asthma.

BACKGROUND: Black and Latinx patients bear a disproportionate burden of asthma. Efforts to reduce the disproportionate morbidity have been mostly unsuccessful, and guideline recommendations have not been based on studies in these populations. METHODS: In this pragmatic, open-label trial, we randomly assigned Black and Latinx adults with moderate-to-severe asthma to use a patient-activated, reliever-triggered inhaled glucocorticoid strategy (beclomethasone dipropionate, 80 µg) plus usual care (intervention) or to continue usual care. Participants had one instructional visit followed by 15 monthly questionnaires. The primary end point was the annualized rate of severe asthma exacerbations. Secondary end points included monthly asthma control as measured with the Asthma Control Test (ACT; range, 5 [poor] to 25 [complete control]), quality of life as measured with the Asthma Symptom Utility Index (ASUI; range, 0 to 1, with lower scores indicating greater impairment), and participant-reported missed days of work, school, or usual activities. Safety was also assessed. RESULTS: Of 1201 adults (603 Black and 598 Latinx), 600 were assigned to the intervention group and 601 to the usual-care group. The annualized rate of severe asthma exacerbations was 0.69 (95% confidence interval [CI], 0.61 to 0.78) in the intervention group and 0.82 (95% CI, 0.73 to 0.92) in the usual-care group (hazard ratio, 0.85; 95% CI, 0.72 to 0.999; P = 0.048). ACT scores increased by 3.4 points (95% CI, 3.1 to 3.6) in the intervention group and by 2.5 points (95% CI, 2.3 to 2.8) in the usual-care group (difference, 0.9; 95% CI, 0.5 to 1.2); ASUI scores increased by 0.12 points (95% CI, 0.11 to 0.13) and 0.08 points (95% CI, 0.07 to 0.09), respectively (difference, 0.04; 95% CI, 0.02 to 0.05). The annualized rate of missed days was 13.4 in the intervention group and 16.8 in the usual-care group (rate ratio, 0.80; 95% CI, 0.67 to 0.95). Serious adverse events occurred in 12.2% of the participants, with an even distribution between the groups. CONCLUSIONS: Among Black and Latinx adults with moderate-to-severe asthma, provision of an inhaled glucocorticoid and one-time instruction on its use, added to usual care, led to a lower rate of severe asthma exacerbations. (Funded by the Patient-Centered Outcomes Research Institute and others; PREPARE ClinicalTrials.gov number, NCT02995733.).

Enhancing asthma research and improving health equity through decentralized clinical trials (DCTs) and mHealth technology.

The COVID-19 pandemic led to widespread disruption and termination of clinical research and a prompt adoption of mobile health (mHealth) technologies in the healthcare space. As the United States' healthcare system has rapidly become reliant on remotely conducted activities, the implementation of decentralized methods using mHealth technology in research investigation has become a necessary alternative to traditional in-person cohort studies. The aim of this article is to: report successful and unsuccessful examples of remote asthma clinical studies, explore the benefits and potential drawbacks of virtual clinical investigation, discuss the potential impact on equity and representation in asthma research, and provide suggestions through which investigators can implement decentralized clinical trials. Enhanced study accessibility, participant diversity, safety measures, and research efficacy are some of the benefits identified with a focused discussion on the impact on equity that decentralized clinical trials renders. Furthermore, potential concerns regarding regulatory compliance, data privacy, and effective mHealth design and solutions are discussed. Despite the setbacks and interruptions faced by the study participants and investigators due to the pandemic, the transition to decentralized clinical studies using mHealth technology is a positive, feasible step toward innovation and equity in the allergy and immunology field.

ASTHMAXcel PRO patient satisfaction and usability field testing.

Background: ASTHMAXcel PRO, an enhanced version of the ASTHMAXcel mobile application, has been developed to deliver comprehensive, guideline-based asthma education while also facilitating the collection of patient-reported outcomes (PROs) and enhancing user experience.Objective: To perform field testing and conduct formative and summative evaluation of the ASTHMAXcel PRO application to assess its impact on patient satisfaction, usability, and usage.Methods: Twenty-eight adult patients completed a baseline visit during which ASTHMAXcel PRO was introduced, health literacy was assessed, and demographic data were collected. They were instructed to use the app for 4 weeks. The Questionnaire for User Interface Satisfaction (QUIS) and the Unified Theory of Acceptance and Use of Technology (UTAUT) questionnaire were administered at baseline and 4 weeks to assess user satisfaction and technology acceptance, respectively. Semi-structured interviews were conducted to gather feedback regarding the application from patients.Results: The baseline total scores were high for both UTAUT and QUIS (mean (SD): 64.2 (10.1), 6.8 (2.2) respectively) indicating that user satisfaction and acceptance began at high levels. UTAUT total score, as well as all domain scores, improved significantly from baseline to 4 weeks (p < 0.02). QUIS total score along with several domain scores (screen, system capabilities, usability) also increased from baseline to 4-weeks (p = 0.03, 0.01, 0.03, 0.01, respectively). These improvements remained significant when adjusting for age, gender, education, and health literacy. Patients reported that the application was helpful, informative, and easy to understand and use.Conclusion: The significant increases in satisfaction and technology adoption observed among ASTHMAXcel PRO users demonstrate that the application is viable and has the potential to improve upon usability challenges faced by existing mobile health applications.

Developing and Evaluating the DiabetesXcel Mobile Application for Adult Patients With Type 2 Diabetes.

The authors trialed a mobile application, DiabetesXcel, which included type 2 diabetes-focused educational videos and modules, in 50 adults of Bronx, NY, a region with a high prevalence of diabetes and diabetes complications. From baseline to 4 months and from baseline to 6 months, there was significantly improved quality of life, self-management, knowledge, self-efficacy, depression, A1C, and LDL cholesterol among those who used DiabetesXcel. There was also a significant decrease in diabetes-related emergency department visits and hospital admissions from baseline to 6 months. This study demonstrates that DiabetesXcel could be beneficial for type 2 diabetes management.

Using K-Means Clustering to Identify Physician Clusters by Electronic Health Record Burden and Efficiency.

Objectives: Electronic health records (EHRs) have transformed the way modern medicine is practiced, but they remain a major source of documentation burden among physicians. This study aims to use data from Signal, a tool provided by the Epic EHR, to analyze physician metadata in the Montefiore Health System via cluster analysis to assess EHR burden and efficiency. Methods: Data were obtained for a one-month period (July 2020) representing a return to normal operation post-telemedicine implementation. Six metrics from Signal were used to phenotype physicians: time on unscheduled days, pajama time, time outside of 7 AM to 7 PM, turnaround time, proficiency score, and visits closed the same day. k-Means clustering was employed to group physicians, and the clusters were assessed overall and by sex and specialty. Results: Our results demonstrate the partitioning of physicians into a higher-efficiency, lower-time outside of scheduled hours (TOSH) cluster and a lower-efficiency, higher-TOSH cluster even when stratified by sex and specialty. Intra-cluster comparisons showed general homogeneity of physician metrics with the exception of the higher-efficiency, lower-TOSH cluster when stratified by sex. Conclusions: Taken together, the clusters uniquely reflect the EHR efficiency-burden of the Montefiore Health System. Applying k-means clustering to readily available EHR data allows for a scalable, efficient, and adaptable approach of assessing physician EHR burden and efficiency, allowing health systems to examine documentation trends and target wellness interventions.

The Relationship Between Depressive Symptoms, eHealth Literacy, and Asthma Outcomes in the Context of a Mobile Health Intervention.

OBJECTIVE: The ASTHMAXcel PRO mobile app provides asthma education and collects asthma outcome data. The objective of this study was to evaluate the associations between health/electronic health literacy (eHealth literacy) and depressive symptoms with app usage and clinical outcomes. METHODS: Adults with persistent asthma were recruited to use the app. Participants completed the Patient Health Questionnaire-9 to assess for depressive symptoms, Asthma Control Test, Mini Asthma Quality of Life (QOL) Questionnaire, and the Newest Vital Sign tool to measure health literacy. Data on a subset of participants were available on eHealth literacy ( n = 24) and average number of app logins across 2 months ( n = 40). RESULTS: The total study sample included 96 participants (46% non-Hispanic Black, 44.4% Hispanic). The average participant age was 44.0 (standard deviation = 14.9) years, with 74% identifying as female. Increased depressive symptoms were associated with worse asthma control ( ß = -0.46, p < .001) and asthma QOL ( ß = -0.38, p < .001), but not eHealth literacy. Higher eHealth literacy was associated with worse asthma QOL ( ß = -0.48, p = .02) and more app logins ( ß = 0.59, p = .04). Newest Vital Sign scores were not associated with any of the other measures. CONCLUSIONS: Depressive symptoms were associated with worse asthma outcomes. eHealth literacy was associated with increased patient engagement with the app and worse asthma QOL, which may reflect patients with worse QOL seeking out health information on the Internet (although directionality could not be assessed). Digital health literacy may be key to increasing patient engagement with mobile health interventions.Trial Registration: National Clinical Trial No. 03847142, https://clinicaltrials.gov/ct2/show/NCT03847142 .

Evaluating the effect and user satisfaction of an adapted and translated mobile health application ASTHMAXcel© among adults with asthma in Pune, India.

OBJECTIVE: ASTHMAXcel© is a mobile application previously shown to improve asthma knowledge, control, and quality of life. In this study, we translated the application to Marathi for pilot testing in Pune, India in order to evaluate its impact on user satisfaction and asthma knowledge among adult asthma patients. METHODS: ASTHMAXcel© was adapted to Marathi with the help of asthma patients and clinicians from Bharati Hospital. 57 different asthma patients were then recruited and received the Asthma Knowledge Questionnaire (AKQ), Asthma Control Questionnaire (ACQ), and Mini Asthma Quality of Life Questionnaire (Mini-AQLQ) to complete at baseline. Study participants then completed the adapted ASTHMAXcel© application. Post-intervention, participants filled out a post-AKQ and Questionnaire for User Interface Satisfaction (QUIS). A subset of participants was also interviewed for qualitative feedback. Paired t-tests and Pearson's correlation were used for statistical analysis. RESULTS: Mean AKQ improved from 5.0+/-2.4 to 12.4+/-1.6 (p = 0.0001). QUIS results revealed that participants were highly satisfied with the application, scoring an average of 50 out of 54 maximum points. Better baseline asthma control was correlated with greater overall experience with the application (-0.110, p = 0.0417). Finally, the qualitative feedback revealed four themes for future refinement. CONCLUSION: The adapted version of ASTHMAXcel© was linked to significant improvement in patient asthma knowledge and a high level of user satisfaction. These results support the potential utility of mHealth applications in promoting guideline-based asthma care in India. However, further studies are needed to establish a causal relationship between ASTHMAXcel© and improved clinical outcomes.

Asthma history influences gait performance and associated prefrontal cortex activation patterns in older adults.

Walking and cognition are interrelated due to dependence on shared brain regions that include the prefrontal cortex (PFC). Limited literature indicates that asthma is associated with poor mobility in older adults but the mechanisms underlying this relationship are unknown. Therefore, we tested the hypothesis that asthma history was associated with poor gait performance due to limited attention resources and neural inefficiency. Participants, older adults age ≥ 65 years reporting positive (n = 36) and negative (n = 36) history of asthma, walked under single and dual-task conditions with a functional near-infrared-spectroscopy (fNIRS) sensor placed on their forehead to assess task-related changes in PFC oxygenated hemoglobin (HbO2). Results showed that positive asthma history was associated with slower gait and higher fNIRS-derived HbO2 under dual-task walking. These findings suggest that limited attention resources and neural inefficiency underlie the association between asthma and poor walking performance in older adults.

Severe asthma in adult, inner-city predominantly African-American and latinx population: demographic, clinical and phenotypic characteristics.

INTRODUCTION: The burden of asthma morbidity with co-existing atopy among the racial/ethnic minorities in the socio-economically disadvantaged NYC borough of the Bronx is unusually high. The multidisciplinary Montefiore Asthma Center (MAC) provides guideline-based treatment to this high-risk population through the joint efforts of Allergists/Immunologists, Pulmonologists, and on-site health educators. METHODS: The objective of this prospective, observational study was to define the demographic and clinical characteristics of severe asthma, evaluate improvement in asthma severity and lung function through the course of treatment at the MAC, and describe the asthma phenotypes of the patients managed at the MAC. Adults with severe asthma receiving treatment at the MAC were followed from their first to their last visit at the MAC. Patient demographics, along with asthma severity and co-existing allergies, were assessed. Possible phenotypes were defined (based on presence or absence of atopy, age at asthma onset, and blood eosinophil counts). RESULTS: 227 patients were included in the final analysis, of which 55.5% were Hispanic and 33.9% identified as non-Hispanic Black. Ninety-one percent (91%) of our cohort was found to be atopic and allergic rhinoconjunctivitis (ARC) was the most commonly identified co-existing allergic condition (86.3%). Mean Asthma Control Test (ACT) scores improved from 11.1 (± 4.9) at the initial visit to 14.8 (± 6.1) at the last visit. The spirometric values did not improve despite treatment at MAC. CONCLUSION: A multidisciplinary severe asthma center is an ideal setting to phenotype patients and offer personalized guideline-based management and education to adults with severe asthma.

Online Registry of COVID-19-Associated Mucormycosis Cases, India, 2021.

We established an online registry of coronavirus disease-associated mucormycosis cases in India. We analyzed data from 65 cases diagnosed during April-June 2021, when the Delta variant predominated, and found that patients frequently received antibacterial drugs and zinc supplementation. Online registries rapidly provide relevant data for emerging infections.

Developing and pilot testing ASTHMAXcel, a mobile app for adults with asthma.

Objective: We sought to compare the impact of ASTHMAXcel, a novel, guideline-based, patient-facing mobile app to human-delivered asthma education.Methods: We conducted a focus group with asthma patients in the Bronx to identify desired mobile app features. ASTHMAXcel was designed based on patient feedback and consistent with NAEPP, BTS/SIGN, and GINA guidelines. The app was reviewed by internists, allergist/immunologists, and pulmonologists specializing in asthma treatment, asthma educators, and a behavioral scientist, and iteratively refined. The refined version of ASTHMAXcel was administered once via tablet at our outpatient Montefiore Asthma Center (MAC). Asthma knowledge was measured through the Asthma Knowledge Questionnaire (AKQ) pre and post-intervention. We also recorded process outcomes including completion time and patient satisfaction. In parallel, human-delivered education was delivered once at MAC. These outcomes were similarly collected.Results: 60 patients were enrolled with 30 in the ASTHMAXcel and 30 in the human-educator group. Mean AKQ in the ASTHMAXcel group vs human-educator group pre-intervention was 9.9 vs 10.5, p = 0.27. Mean AKQ post-intervention in the ASTHMAXcel group vs human-educator group was 12.3 vs 14.4, p = 0.0002. The mean AKQ improvement for both groups were 2.4 vs 3.9, p = 0.007. Patients were highly satisfied in the ASTHMAXcel group scoring on average 27.9 out of 30 maximum points on the satisfaction survey. There was no difference in satisfaction scores or completion times (minutes) of either intervention.Conclusion: ASTHMAXcel was associated with an increase in AKQ, but the human-educator group experienced a greater improvement. ASTHMAXcel demonstrated no differences in process outcomes vs human-delivered education.

Electronic Health Record Usage Patterns: Assessing Telemedicine's Impact on the Provider Experience During the COVID-19 Pandemic.

Telemedicine has been widely implemented during the coronavirus disease 2019 (COVID-19) pandemic; however, its impact on those providing care remains largely understudied. Provider documentation data collected by the electronic health record (EHR) represents an underutilized tool for assessing the provider experience. Through Epic Signal, we collected data regarding the actions logged in the EHR by health care providers of the Montefiore Health System (Bronx, NY) before and after the implementation of telemedicine during the pandemic. Focusing on five metrics (appointments per day, visits closed same day, time spent outside 7 AM-7 PM, time spent on unscheduled days, and pajama time), we performed a preliminary analysis of providers across the institution, by specialty, and according to demographic characteristics such as gender and years since graduation. We observed that after telemedicine implementation, a greater proportion of providers had fewer appointments per day, closed more notes same day, and spent less time in the EHR outside of normal working hours for each of the time-related metrics. We additionally found that providers who graduated longer ago as well as female providers spent more time documenting in the EHR after hours. This brief analysis highlights the potential of using EHR data to inform decisions based on provider well-being, specifically in the setting of telemedicine implementation.

Developing and evaluating ASTHMAXcel adventures: A novel gamified mobile application for pediatric patients with asthma.

BACKGROUND: The ASTHMAXcel mobile application has been linked to favorable outcomes among adult patients with asthma. OBJECTIVE: To assess the impact of ASTHMAXcel Adventures, a gamified, guideline-based, pediatric version on asthma control, knowledge, health care utilization, and patient satisfaction. METHODS: Pediatric patients with asthma received the ASTHMAXcel Adventures mobile intervention on-site only at baseline (visit 1), 4 months (visit 2), and 6 months (visit 3). The asthma control test, asthma illness representation scale-self-administered, pediatric asthma impact survey, and Client Satisfaction Questionnaire-8 were used to assess asthma control, knowledge, and patient satisfaction. Patients reported the number of asthma-related emergency department (ED) visits, hospitalizations, and oral prednisone use. RESULTS: A total of 39 patients completed the study. The proportion of controlled asthma increased from visit 1 to visits 2 and 3 (30.8% vs 53.9%, P = .04; 30.8% vs 59.0%, P = .02), and largely seen in boys. The mean asthma illness representation scale-self-administered scores increased from baseline pre- to postintervention, with sustained improvements at visits 2 and 3 (3.55 vs 3.76, P < .001; 3.55 vs 3.80, P = .001; 3.55 vs 3.99, P < .001). The pediatric asthma impact survey scores improved from baseline to visits 2 and 3 (43.33 vs 34.08, P < .001; 43.33 vs 31.74, P < .001). ED visits and prednisone use significantly decreased from baseline to visits 2 and 3 (ED: 0.46 vs 0.13, P = .03; 0.46 vs 0.02, P = .02; prednisone use, 0.49 vs 0.13, P = .02; 0.49 vs 0.03, P = .003. Satisfaction was high with mean client satisfaction questionnaire score of approximately 30 (out of 32) at all visits. CONCLUSION: ASTHMAXcel Adventures improved asthma control, knowledge, and quality of life, and reduced ED visits and prednisone use with high satisfaction scores.

Longitudinal trends in asthma emergency department visits, pollutant and pollen levels, and weather variables in the Bronx from 2001-2008.

Objective: To evaluate how asthma-related emergency department visits (AREDV), air pollutant levels, pollen counts, and weather variables changed from 2001 to 2008 in the Bronx, NY. Methods: 42,065 daily AREDV values (1 January 2001 to 31 December 2008) were collected using our institution's Clinical Looking Glass software. Daily values of sulfur dioxide (SO2), carbon monoxide (CO), ozone (O3), nitrogen dioxide (NO2), temperature, and humidity were obtained from the National Climatic Data Center's Bronx station. Daily tree pollen counts were obtained from the Armonk counting station near the Bronx. Median values for each variable were analyzed using the Mann-Whitney test to compare 2001-2004 and 2005-2008 values. Simple linear regression examined associations between AREDV and individual pollutants. Due to seasonal variations of the variables, each season was considered separately. Results: There were significant decreases for AREDV, SO2, CO, and humidity for all seasons, and for NO2 in the spring and winter. Significant increases occurred for O3 in the spring, fall, and winter; for temperature in the summer and winter; and for tree pollen in the spring. Significant positive associations were found between AREDV and SO2, CO, NO2, and humidity, respectively, while significant negative associations were found between AREDV and O3 and temperature, respectively. Conclusions: From 2001 to 2008, significant: a) decreases in AREDV, SO2, CO, and humidity for all seasons, and decreases in NO2 for the spring and winter; and b) increases in O3, temperature, and spring tree pollen were observed. By tracking and anticipating environmental and pollutant changes, efforts can be made to minimize AREDV.

The association of environmental, meteorological, and pollen count variables with asthma-related emergency department visits and hospitalizations in the Bronx.

Objective: To better understand how meteorological variables, air quality variables, and pollen counts collectively contribute to asthma-related emergency department visits (AREDV) and asthma-related hospitalizations (ARH) among pediatric and adult patients in the New York City borough of the Bronx. Methods: The numbers of daily adult and pediatric AREDV and ARH from 2001 to 2008 were obtained from three Bronx hospitals. After removing outliers, interpolating missing data, and standardizing variable values by scaling the data using z-scores, data were analyzed using Spearman rank tests and linear regression models for the full year and each season. Results: There were a total of 42,065 AREDV and 1,664 ARH at both Bronx hospitals. With the exception of a spring peak in AREDVs, AREDVs and ARHs follow a cyclical pattern, climbing in the fall, plateauing in the winter, dropping in the spring, and reaching a low in the summer. Among the 11 air quality, meteorological, and pollen count variables, temperature and tree pollen made the greatest contribution to AREDV with scaled coefficients of -0.337 and 0.311 respectively; equating to an additional AREDV for every 5.0-unit decrease in temperature and an additional AREDV for every 186.0-unit increase in tree pollen. These two variables were confirmed to have independent associations with AREDV prior to the data interpolation. Grass pollen was also found to have a relatively large contribution to AREDV during the summer with a scaled coefficient of 0.314, equating to an additional AREDV for every 2.3-unit increase in grass pollen. Conclusion: There are distinct peaks of increased AREDVs that are closely associated with increased tree pollen counts in the spring and decreasing temperatures in the fall. Early anticipation of these air quality, meteorological, and pollen factor changes based on ongoing surveillance could potentially guide clinical practice and minimize AREDVs in the Bronx.

Effect of ivermectin on allergy-type manifestations in occult strongyloidiasis.

BACKGROUND: The immunomodulatory effects of helminths have been well described. However, there is a relative lack of literature regarding the link between parasites and allergic diseases. A number of patients with allergic symptoms have positive serologic test results for Strongyloides stercoralis. OBJECTIVE: To identify patients with allergy-type symptoms and coexisting Strongyloides infection and to analyze the effect of Strongyloides eradication therapy with ivermectin on these symptoms. METHODS: The medical records of our allergy clinic sites were reviewed for Strongyloides test results between January 2011 and October 2014. Each allergy-type symptom was assessed separately with regard to improvement after ivermectin therapy. RESULTS: Among the 1,446 patients who had Strongyloides serologic tests ordered, 127 (8.8%) had positive test results. Eighty-four patients had follow-up data regarding allergy-type symptoms after ivermectin treatment. Among these, 52 patients (61.9%) reported skin-related problems (pruritus, urticaria, angioedema, and/or rash). Forty-nine patients (58.3%) had asthma, and 73.8% had allergic rhinoconjunctivitis. Although respiratory symptoms typically did not respond to ivermectin treatment, 24 of 48 patients (50%) with skin symptoms reported a significant subjective improvement of symptoms after ivermectin treatment. Peripheral eosinophil counts significantly decreased after ivermectin treatment from 450 to 200/µL (P < .001). CONCLUSION: Serologic testing for strongyloides may be indicated for patients with allergy-type symptoms and a suggestive exposure history. Patients with strongyloidiasis and primarily cutaneous symptoms experienced significant symptomatic improvement after ivermectin therapy.

Effect of Telemedicine and the COVID-19 Pandemic on Medical Trainees' Usage of the Electronic Health Record in the Outpatient Setting.

OBJECTIVES: This study aimed to (1) determine the impact of COVID-19 (coronavirus disease 2019) and the corresponding increase in use of telemedicine on volume, efficiency, and burden of electronic health record (EHR) usage by residents and fellows; and (2) to compare these metrics with those of attending physicians. METHODS: We analyzed 11 metrics from Epic's Signal database of outpatient physician user logs for active residents/fellows at our institution across three 1-month time periods: August 2019 (prepandemic/pre-telehealth), May 2020 (mid-pandemic/post-telehealth implementation), and July 2020 (follow-up period) and compared these metrics between trainees and attending physicians. We also assessed how the metrics varied for medical trainees in primary care as compared with subspecialties. RESULTS: Analysis of 141 residents/fellows and 495 attendings showed that after telehealth implementation, overall patient volume, Time in In Basket per day, Time outside of 7 a.m. to 7 p.m., and Time in notes decreased significantly compared with the pre-telehealth period. Female residents, fellows, and attendings had a lower same day note closure rate before and during the post-telehealth implementation period and spent greater time working outside of 7 a.m. to 7 p.m. compared with male residents, fellows, and attendings (p < 0.01) compared with the pre-telehealth period. Attending physicians had a greater patient volume, spent more time, and were more efficient in the EHR compared with trainees (p < 0.01) in both the post-telehealth and follow-up periods as compared with the pre-telehealth period. CONCLUSION: The dramatic change in clinical operations during the pandemic serves as an inflection point to study changes in physician practice patterns in the EHR. We observed that (1) female physicians closed fewer notes the same day and spent more time in the EHR outside of normal working hours compared with male physicians, and (2) attending physicians had higher patient volumes and also higher efficiency in the EHR compared with resident physicians.

The impact of smartphone applications on bowel preparation, compliance with appointments, cost-effectiveness, and patients' quality of life for the colonoscopy process: A scoping review.

The aim of this scoping review is to evaluate the impact of smartphone application (SPA) technology in patients undergoing elective colonoscopy to measure compliance with appointments, cost-effectiveness, bowel preparation, and quality of life. The scoping review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. Ovid Medline, Web of Science, Science Direct, Scopus, Cochrane Library, and PubMed were screened up to Oct 14, 2020, and bibliographies of the retrieved articles were included. Based on pre-specified inclusion and exclusion criteria, 8 primary studies were included in the final analysis from a total of 3,979 non-duplicate articles. Seven out of eight studies measured the bowel preparation quality. In six of these studies, patients in the smartphone group had a successful bowel preparation when compared with the control arm; on the other hand, one study did not find any differences between groups. Adherence to colonoscopy screening was assessed by one study. Patients in the digital intervention arm were significantly more likely to complete a screening test. Patient satisfaction during the periprocedural period of colonoscopy was assessed by five studies which reported significantly higher patient satisfaction in the intervention arm compared to the control arm. None of the studies measured cost-effectiveness. We came to the conclusion that a well-designed, user-friendly SPA can help and guide patients undergoing colonoscopy through the process of following up on their appointments, adhering to bowel preparation, and better understanding their disease condition. Future trials investigating SPAs should include cost-effectiveness and adherence to appointments as an endpoint.