Physical Activity Intervention for Urban Black Women With Asthma: Protocol for a Randomized Controlled Efficacy Study.

BACKGROUND: Black women experience a higher prevalence of poor asthma outcomes and physical inactivity than their White counterparts. Black women comprise a particularly vulnerable group of patients with asthma, with some of the highest rates of asthma in adults, high health care use (emergency department visits and hospitalizations), and the highest crude asthma mortality rate of all race or ethnicity groups. Despite recommendations to engage in regular physical activity, fewer than 15% of Black women meet the 2008 National Physical Activity Guidelines, the lowest of all racial subgroups of adults. Given the connection between physical inactivity and poor asthma outcomes, addressing physical activity among Black women with asthma is imperative. OBJECTIVE: This 2-arm randomized controlled trial aims to (1) determine the efficacy of a lifestyle walking intervention on asthma control compared to an education (control) group over 24 weeks, (2) examine the maintenance effects of the lifestyle walking intervention on asthma control at 48 weeks, (3) explore the behavioral mediators (eg, self-efficacy, social support, self-regulation, and daily physical activity levels) and contextual moderators (eg, baseline asthma severity, neighborhood environment, comorbid conditions, and social determinants of health) that contribute to treatment responsiveness, and (4) assess the reach and implementation potential of the intervention. METHODS: The proposed study (ACTION [A Lifestyle Physical Activity Intervention for Minority Women with Asthma]) delivers a 24-week lifestyle walking intervention designed for and by urban Black women with asthma. Participants (n=224) will be recruited through 2 urban health care systems that care for a diverse Black population. Patients will be randomized to one of two groups: (1) ACTION intervention (group sessions, physical activity self-monitoring-Fitbit, and text-based support for step goal setting) or (2) education control (an individual asthma education session and SMS text messages related to asthma education). Outcome assessments will take place at baseline, 12, 24, and 48 weeks. The primary outcome is a change in asthma control from baseline to week 24 as assessed by the asthma control questionnaire-6 (ACQ-6). Secondary outcomes include asthma-related quality of life, health care use, and asthma exacerbations and behavioral outcomes such as self-efficacy, self-regulation, social support, and physical activity. RESULTS: This study was funded by the National Institute of Minority Health Disparities in August 2022. We pilot-tested our recruitment and intervention procedures and began recruitment in April 2023, with the enrollment of our first participant in May 2023. The anticipated completion of the study is April 2027. CONCLUSIONS: This study will deliver a new approach to physical activity interventions in Black women with asthma and help to provide guidance for addressing physical activity within this subgroup. This study will also provide a potential framework for future studies in minoritized populations with other disease conditions associated with low levels of physical activity. TRIAL REGISTRATION: ClinicalTrials.gov NCT05726487; https://clinicaltrials.gov/study/NCT05726487. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/55700.

Telehealth and Health Equity in Older Adults With Heart Failure: A Scientific Statement From the American Heart Association.

Enhancing access to care using telehealth is a priority for improving outcomes among older adults with heart failure, increasing quality of care, and decreasing costs. Telehealth has the potential to increase access to care for patients who live in underresourced geographic regions, have physical disabilities or poor access to transportation, and may not otherwise have access to cardiologists with expertise in heart failure. During the COVID-19 pandemic, access to telehealth expanded, and yet barriers to access, including broadband inequality, low digital literacy, and structural barriers, prevented many of the disadvantaged patients from getting equitable access. Using a health equity lens, this scientific statement reviews the literature on telehealth for older adults with heart failure; provides an overview of structural, organizational, and personal barriers to telehealth; and presents novel interventions that pair telemedicine with in-person services to mitigate existing barriers and structural inequities.

Effects of the COVID-19 pandemic on recruitment for the working women walking program.

The global pandemic of coronavirus disease 2019 (COVID-19) affected many aspects of randomized controlled trials, including recruiting and screening participants. The purpose of this paper is to (a) describe adjustments to recruitment and screening due to COVID-19, (b) compare the proportional recruitment outcomes (not completed, ineligible, and eligible) at three screening stages (telephone, health assessment, and physical activity assessment) pre- and post-COVID-19 onset, and (c) compare baseline demographic characteristics pre- and post-COVID-19 onset in the Working Women Walking program. The design is a cross-sectional descriptive analysis of recruitment and screening data from a 52-week sequential multiple assignment randomized trial (SMART). Participants were women 18-70 years employed at a large urban medical center. Recruitment strategies shifted from in-person and electronic to electronic only post-COVID-19 onset. In-person eligibility screening for health and physical activity assessments continued post-COVID-19 onset with Centers for Disease Control and Prevention precautions. Of those who expressed interest in the study pre- and post-COVID-19 onset (n = 485 & n = 269 respectively), 40% (n = 194) met all eligibility criteria pre-COVID-19 onset, and 45.7% (n = 123) post-COVID-19 onset. Although there were differences in the proportions of participants who completed or were eligible for some of the screening stages, the final eligibility rates did not differ significantly pre-COVID-19 versus post-COVID-19 onset. Examination of differences in participant demographics between pre- and post-COVID-19 onset revealed a significant decrease in the percentage of Black women recruited into the study from pre- to post-COVID-19 onset. Studies recruiting participants into physical activity studies should explore the impact of historical factors on recruitment.

Effect of health information technology (HIT)-based discharge transition interventions on patient readmissions and emergency room visits: a systematic review.

OBJECTIVE: To systematically synthesize and appraise the evidence on the effectiveness of health information technology (HIT)-based discharge care transition interventions (CTIs) on readmissions and emergency room visits. MATERIALS AND METHODS: We conducted a systematic search on multiple databases (MEDLINE, CINAHL, EMBASE, and CENTRAL) on June 29, 2020, targeting readmissions and emergency room visits. Prospective studies evaluating HIT-based CTIs published as original research articles in English language peer-reviewed journals were eligible for inclusion. Outcomes were pooled for narrative analysis. RESULTS: Eleven studies were included for review. Most studies (n = 6) were non-RCTs. Several studies (n = 9) assessed bridging interventions comprised of at least 1 pre- and 1 post-discharge component. The narrative analysis found improvements in patient experience and perceptions of discharge care. DISCUSSION: Given the statistical and clinical heterogeneity among studies, we could not ascertain the cumulative effect of CTIs on clinical outcomes. Nevertheless, we found gaps in current research and its implications for future work, including the need for a HIT-based care transition model for guiding theory-driven design and evaluation of HIT-based discharge CTIs. CONCLUSIONS: We appraised and aggregated empirical evidence on the cumulative effectiveness of HIT-based interventions to support discharge transitions from hospital to home, and we highlighted the implications for evidence-based practice and informatics research.

Smartphone Ownership and Interest in Mobile Health Technologies for Self-care Among Patients With Chronic Heart Failure: Cross-sectional Survey Study.

BACKGROUND: Heart failure (HF) is a highly prevalent chronic condition that places a substantial burden on patients, families, and health care systems worldwide. Recent advances in mobile health (mHealth) technologies offer great opportunities for supporting many aspects of HF self-care. There is a need to better understand patients' adoption of and interest in using mHealth for self-monitoring and management of HF symptoms. OBJECTIVE: The purpose of this study is to assess smartphone ownership and patient attitudes toward using mHealth technologies for HF self-care in a predominantly minority population in an urban clinical setting. METHODS: We conducted a cross-sectional survey of adult outpatients (aged ≥18 years) at an academic outpatient HF clinic in the Midwest. The survey comprised 34 questions assessing patient demographics, ownership of smartphones and other mHealth devices, frequently used smartphone features, use of mHealth apps, and interest in using mHealth technologies for vital sign and HF symptom self-monitoring and management. RESULTS: A total of 144 patients were approached, of which 100 (69.4%) participated in the study (63/100, 63% women). The participants had a mean age of 61.3 (SD 12.25) years and were predominantly Black or African American (61/100, 61%) and Hispanic or Latino (18/100, 18%). Almost all participants (93/100, 93%) owned a cell phone. The share of patients who owned a smartphone was 68% (68/100). Racial and ethnic minorities that identified as Black or African American or Hispanic or Latino reported higher smartphone ownership rates compared with White patients with HF (45/61, 74% Black or African American and 11/18, 61% Hispanic or Latino vs 9/17, 53% White). There was a moderate and statistically significant association between smartphone ownership and age (Cramér V [ΦC]=0.35; P<.001), education (ΦC=0.29; P=.001), and employment status (ΦC=0.3; P=.01). The most common smartphone features used by the participants were SMS text messaging (51/68, 75%), internet browsing (43/68, 63%), and mobile apps (41/68, 60%). The use of mHealth apps and wearable activity trackers (eg, Fitbits) for self-monitoring of HF-related parameters was low (15/68, 22% and 15/100, 15%, respectively). The most popular HF-related self-care measures participants would like to monitor using mHealth technologies were physical activity (46/68, 68%), blood pressure (44/68, 65%), and medication use (40/68, 59%). CONCLUSIONS: Most patients with HF have smartphones and are interested in using commercial mHealth apps and connected health devices to self-monitor their condition. Thus, there is a great opportunity to capitalize on the high smartphone ownership among racial and ethnic minority patients to increase reach and enhance HF self-management through mHealth interventions.

BAILAMOS With mHealth Technology! Improving Physical Activity and Well-Being in Middle-Aged and Older Latinxs: A Pre-Post Feasibility Study.

Older Latinxs engage in lower levels of leisure-time physical activity (PA) compared with non-Latinx Whites. Latin dance is a culturally relevant type of leisure-time PA that may engage older Latinx populations, particularly when coupled with mobile health technologies (mHealth). This single group pre-post feasibility study described the PA and health outcomes of middle-aged and older Latinxs participating in BAILA TECH-an intervention that combines the BAILAMOS Latin dance program with mHealth (Fitbit Charge 2, Fitbit app, and motivational text messages). Participants (n = 20, Mage = 67 ± 7.1, female n = 15, 75%) were enrolled in the 16-week BAILA TECH intervention held twice a week. Participants received a Fitbit Charge 2 to assess PA at baseline, during the intervention, and postintervention. An mHealth platform (iCardia) collected Fitbit data and staff delivered weekly motivational and informational text messages. Participants completed questionnaires about PA, sedentary behavior, cardiorespiratory fitness, social support, quality of life, and cognitive function at baseline and postintervention. Paired t tests evaluated change in pre-post measures. There was a significant increase in device-assessed moderate-to-vigorous PA (d = 0.69), self-reported light-leisure (d = 1.91) and moderate-to-vigorous PA (d = 1.05), moderate-to-vigorous leisure PA (d = 1.55), predicted cardiorespiratory fitness (d = 1.10), and PA social support (d = 0.81 [family]; d = 0.95 [friends]) from baseline to postintervention. Although nonsignificant, there was a small effect on physical health-related quality of life (d = 0.32) and executive function (d = 0.29). These data describe an increase in PA levels and health-related outcomes of middle-aged and older Latinxs from participation in an mHealth-infused Latin dance intervention. An adequately powered trial is necessary to establish efficacy.

A Systematic Review of the Effect of Physical Activity on Asthma Outcomes.

BACKGROUND: Asthma is a chronic respiratory disease that affects millions worldwide. Medication management is the current mainstay of treatment; however, there is evidence to suggest additional benefit with lifestyle changes, particularly with increased physical activity. OBJECTIVE: To discover and evaluate the effects of physical activity on asthma outcomes. METHODS: Systematic search of PubMed, Excerpta Medica database, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Rehabilitation and Sports Medicine Source, Scopus, and Web of Science identified 11,155 results. Thirty-five articles met our inclusion criteria spanning 20 studies. Data extraction was conducted by 6 independent reviewers, and final results were evaluated by a seventh reviewer and the senior author. RESULTS: Wide variation among selected studies, including the heterogeneity of interventions and outcome variables, did not support a meta-analysis. Mixed results of the effects of physical activity on asthma outcomes were found. Most studies suggest that physical activity improves asthma control, quality of life, lung function parameters, and inflammatory serologies, whereas 3 found no improvements in any of these outcomes. No studies reported worsening asthma outcomes. CONCLUSIONS: This review highlights the emerging and promising role of physical activity as a nonpharmacologic treatment for asthma. Additional high-quality randomized controlled trials are needed to overcome the problems of measurement heterogeneity and the dilution of outcome effect size measurement related to physical activity interventions for asthma.

Patient-centered mobile health technology intervention to improve self-care in patients with chronic heart failure: Protocol for a feasibility randomized controlled trial.

This randomized controlled trial aims to determine the feasibility and preliminary efficacy of a patient-centered, mobile health technology intervention (iCardia4HF) in patients with chronic Heart Failure (HF). Participants (n = 92) are recruited and randomized 1:1 to the intervention or control group. The intervention group receives a commercial HF self-care app (Heart Failure Storylines), three connected health devices that interface with the app (Withings weight scale and blood pressure monitor, and Fitbit activity tracker), and a program of individually tailored text-messages targeting health beliefs, self-care self-efficacy, HF-knowledge, and physical activity. The control group receives the same connected health devices, but without the HF self-care app and text messages. Follow-up assessments occur at 30 days and 12 weeks. The main outcome of interest is adherence to HF self-care assessed objectively through time-stamped data from the electronic devices and also via patient self-reports. Primary measures of HF self-care include medication adherence and adherence to daily weight monitoring. Secondary measures of HF self-care include adherence to daily self-monitoring of HF symptoms and blood pressure, adherence to low-sodium diet, and engagement in physical activity. Self-reported HF self-care and health-related quality of life are assessed with the Self-care Heart Failure Index and the Kansas City Cardiomyopathy Questionnaire, respectively. Hospitalizations and emergency room visits are tracked in both groups over 12 weeks as part of our safety protocol. This study represents an important step in testing a scalable mHealth solution that has the potential to bring about a new paradigm in self-management of HF.

Using Fitbit as an mHealth Intervention Tool to Promote Physical Activity: Potential Challenges and Solutions.

Consumer-based physical activity (PA) trackers, also known as wearables, are increasingly being used in research studies as intervention or measurement tools. One of the most popular and widely used brands of PA trackers is Fitbit. Since the release of the first Fitbit in 2009, hundreds of experimental studies have used Fitbit devices to facilitate PA self-monitoring and behavior change via goal setting and feedback tools. Fitbit's ability to capture large volumes of PA and physiological data in real time creates enormous opportunities for researchers. At the same time, however, it introduces a number of challenges (eg, technological, operational, logistical), most of which are not sufficiently described in study publications. Currently, there are no technical reports, guidelines, nor other types of publications discussing some of these challenges and offering guidance to researchers on how to best incorporate Fitbit devices in their study design and intervention to achieve their research goals. As a result, researchers are often left alone to discover and address some of these issues during the study through "trial and error." This paper aims to address this gap. Drawing on our cumulative experience of conducting multiple studies with various Fitbit PA trackers over the years, we present and discuss various key challenges associated with the use of Fitbit PA trackers in research studies. Difficulties with the use of Fitbit PA trackers are encountered throughout the entire research process. Challenges and solutions are categorized in 4 main categories: study preparation, intervention delivery, data collection and analysis, and study closeout. Subsequently, we describe a number of empirically tested strategies used in 4 of our interventional studies involving participants from a broad range of demographic characteristics, racial/ethnic backgrounds, and literacy levels. Researchers should be prepared to address challenges and issues in a timely fashion to ensure that the Fitbit effectively assists participants and researchers in achieving research and outcome goals.

Effectiveness of Mobile Health Technology Interventions for Patients With Heart Failure: Systematic Review and Meta-analysis.

BACKGROUND: Heart failure (HF) is a complex and serious condition associated with substantial morbidity, mortality, and health care costs. We conducted a systematic review and meta-analysis to evaluate the effects of mobile health (mHealth) interventions compared with usual care in patients with HF. METHODS: We searched MEDLINE, CENTRAL, CINAHL, and EMBASE databases to identify eligible randomized controlled trials (RCTs) of mHealth interventions. Primary outcomes included: all-cause mortality, cardiovascular mortality, HF-related hospitalizations, and all-cause hospitalizations. Meta-analyses using a random effects model were performed for all outcomes. Risk of bias and quality of evidence were evaluated using the Cochrane Tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. RESULTS: Sixteen RCTs involving 4389 patients were included. Compared with usual care, mHealth interventions reduced the risk of all-cause mortality (risk ratio [RR], 0.80; 95% confidence interval [CI], 0.65-0.97; absolute risk reduction [ARR], 2.1%; high-quality evidence), cardiovascular mortality (RR, 0.70; 95% CI, 0.53-0.91; ARR, 2.9%; high-quality evidence), and HF hospitalizations (RR, 0.77; 95% CI, 0.67-0.88; ARR, 5%; high-quality evidence), but had no effect on all-cause hospitalizations. Results were driven by mHealth interventions with remote monitoring and clinical feedback, which were associated with larger reductions than stand-alone mHealth interventions. However, subgroup differences were not statistically significant. CONCLUSIONS: mHealth interventions with remote monitoring and clinical feedback reduce mortality and HF-related hospitalizations, but might not reduce all-cause hospitalizations in patients with HF. Additional studies are needed to determine the efficacy of stand-alone mHealth interventions as well as active features of mHealth that contribute to efficacy.

Targeting of uncontrolled hypertension in the emergency department (TOUCHED): Design of a randomized controlled trial.

BACKGROUND: Uncontrolled or undiagnosed hypertension (HTN) is estimated to be as high as 46% in emergency departments (EDs). Uncontrolled HTN contributes significantly to cardiovascular morbidity and disproportionately affects communities of color. EDs serve high risk populations with uncontrolled conditions that are often missed by other clinical settings and effective interventions for uncontrolled HTN in the ED are critically needed. The ED is well situated to decrease the disparities in HTN control by providing a streamlined intervention to high risk populations that may use the ED as their primary care. METHODS: Targeting of UnControlled Hypertension in the Emergency Department (TOUCHED), is a two-arm single site randomized controlled trial of 770 adults aged 18-75 presenting to the ED with uncontrolled HTN comparing (1) usual care, versus (2) an Educational and Empowerment (E2) intervention that integrates a Post-Acute Care Hypertension Consultation (PACHT-c) with a mobile health BP self-monitoring kit. The primary outcome is differences in mean systolic blood pressure (SBP) at 6-months post enrollment. Secondary outcomes include differences in mean SBP and mean diastolic BP (DBP) at 3-months and mean DBP at 6-months. Additionally, improvement in cardiovascular risk score, medication adherence, primary care engagement, and HTN knowledge will also be assessed as part of this study. CONCLUSIONS: The TOUCHED trial will be instrumental in determining the effectiveness of a brief ED-based intervention that is portable to other urban EDs with high-risk populations. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT03749499.

Gerotechnology for Older Adults With Cardiovascular Diseases: JACC State-of-the-Art Review.

The growing population of older adults (age ≥65 years) is expected to lead to higher rates of cardiovascular disease. The expansion of digital health (encompassing telehealth, telemedicine, mobile health, and remote patient monitoring), Internet access, and cellular technologies provides an opportunity to enhance patient care and improve health outcomes-opportunities that are particularly relevant during the current coronavirus disease-2019 pandemic. Insufficient dexterity, visual impairment, and cognitive dysfunction, found commonly in older adults should be taken into consideration in the development and utilization of existing technologies. If not implemented strategically and appropriately, these can lead to inequities propagating digital divides among older adults, across disease severities and socioeconomic distributions. A systematic approach, therefore, is needed to study and implement digital health strategies in older adults. This review will focus on current knowledge of the benefits, barriers, and use of digital health in older adults for cardiovascular disease management.

Fitbit-Based Interventions for Healthy Lifestyle Outcomes: Systematic Review and Meta-Analysis.

BACKGROUND: Unhealthy behaviors, such as physical inactivity, sedentary lifestyle, and unhealthful eating, remain highly prevalent, posing formidable challenges in efforts to improve cardiovascular health. While traditional interventions to promote healthy lifestyles are both costly and effective, wearable trackers, especially Fitbit devices, can provide a low-cost alternative that may effectively help large numbers of individuals become more physically fit and thereby maintain a good health status. OBJECTIVE: The objectives of this meta-analysis are (1) to assess the effectiveness of interventions that incorporate a Fitbit device for healthy lifestyle outcomes (eg, steps, moderate-to-vigorous physical activity, and weight) and (2) to identify which additional intervention components or study characteristics are the most effective at improving healthy lifestyle outcomes. METHODS: A systematic review was conducted, searching the following databases from 2007 to 2019: MEDLINE, EMBASE, CINAHL, and CENTRAL (Cochrane). Studies were included if (1) they were randomized controlled trials, (2) the intervention involved the use of a Fitbit device, and (3) the reported outcomes were related to healthy lifestyles. The main outcome measures were related to physical activity, sedentary behavior, and weight. All the studies were assessed for risk of bias using Cochrane criteria. A random-effects meta-analysis was conducted to estimate the treatment effect of interventions that included a Fitbit device compared with a control group. We also conducted subgroup analysis and fuzzy-set qualitative comparative analysis (fsQCA) to further disentangle the effects of intervention components. RESULTS: Our final sample comprised 41 articles reporting the results of 37 studies. For Fitbit-based interventions, we found a statistically significant increase in daily step count (mean difference [MD] 950.54, 95% CI 475.89-1425.18; P<.001) and moderate-to-vigorous physical activity (MD 6.16, 95% CI 2.80-9.51; P<.001), a significant decrease in weight (MD -1.48, 95% CI -2.81 to -0.14; P=.03), and a nonsignificant decrease in objectively assessed and self-reported sedentary behavior (MD -10.62, 95% CI -35.50 to 14.27; P=.40 and standardized MD -0.11, 95% CI -0.48 to 0.26; P=.56, respectively). In general, the included studies were at low risk for bias, except for performance bias. Subgroup analysis and fsQCA demonstrated that, in addition to the effects of the Fitbit devices, setting activity goals was the most important intervention component. CONCLUSIONS: The use of Fitbit devices in interventions has the potential to promote healthy lifestyles in terms of physical activity and weight. Fitbit devices may be useful to health professionals for patient monitoring and support. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42019145450; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019145450.

Effects of CPOE-based medication ordering on outcomes: an overview of systematic reviews.

BACKGROUND: Computerised provider order entry (CPOE) systems are widely used in clinical settings for the electronic ordering of medications, laboratory tests and radiological therapies. However, evidence regarding effects of CPOE-based medication ordering on clinical and safety outcomes is mixed. We conducted an overview of systematic reviews (SRs) to characterise the cumulative effects of CPOE use for medication ordering in clinical settings. METHODS: MEDLINE, EMBASE, CINAHL and the Cochrane Library were searched to identify published SRs from inception to 12 February 2018. SRs investigating the effects of the use of CPOE for medication ordering were included. Two reviewers independently extracted data and assessed the methodological quality of included SRs. RESULTS: Seven SRs covering 118 primary studies were included for review. Pooled studies from the SRs in inpatient settings showed that CPOE use resulted in statistically significant decreases in medication errors and adverse drug events (ADEs); however, there was considerable variation in the magnitude of their relative risk reduction (54%-92% for errors, 35%-53% for ADEs). There was no significant relative risk reduction on hospital mortality or length of stay. Bibliographic analysis showed limited overlap (24%) among studies included across all SRs. CONCLUSION: SRs on CPOEs included predominantly non-randomised controlled trials and observational studies with varying foci. SRs predominantly focused on inpatient settings and often lacked comparison groups; SRs used inconsistent definitions of outcomes, lacked descriptions regarding the effects on patient harm and did not differentiate among the levels of available decision support. With five of the seven SRs having low to moderate quality, findings from the SRs must be interpreted with caution. We discuss potential directions for future primary studies and SRs of CPOE.

A Walking Intervention Supplemented With Mobile Health Technology in Low-Active Urban African American Women With Asthma: Proof-of-Concept Study.

BACKGROUND: Physical inactivity is associated with worse asthma outcomes. African American women experience disparities in both physical inactivity and asthma relative to their white counterparts. We conducted a modified evidence-based walking intervention supplemented with mobile health (mHealth) technologies to increase physical activity (PA). OBJECTIVE: This study aimed to assess the preliminary feasibility of a 7-week walking intervention modified for African American women with asthma. METHODS: African American women with suboptimally controlled asthma were identified from a health system serving low-income minorities. At a baseline data collection visit, participants performed spirometry and incremental shuttle walk test, completed questionnaires, and were given an accelerometer to wear for 1 week. The intervention comprised an informational study manual and 3 in-person group sessions over 7 weeks, led by a nurse interventionist, in a community setting. The supplemental mHealth tools included a wearable activity tracker device (Fitbit Charge HR) and one-way text messages related to PA and asthma 3 times per week. A secure Web-based research platform, iCardia, was used to obtain Fitbit data in real time (wear time, moderate-to-vigorous physical activity [MVPA] and sedentary time) and send text messages. The feasibility of the intervention was assessed in the domains of recruitment capability, acceptability (adherence, retention, engagement, text messaging, acceptability, complaints, and concerns), and preliminary outcome effects on PA behavior (change in steps, duration, and intensity). RESULTS: We approached 22 women, of whom 10 were eligible; 7 consented, enrolled and completed the study. Group session attendance was 71% (5/7), 86% (6/7), and 86% (6/7), respectively, across the 3 sessions. All participants completed evaluations at each group session. The women reported being satisfied or very satisfied with the program (eg, location, time, and materials). None of them had concerns about using, charging, or syncing the Fitbit device and app. Participants wore their Fitbit device for at least 10 hours per day in 44 out of the 49 intervention days. There was an increase in Fitbit-measured MVPA from week 1 (19 min/week, SD 14 min/week) to the last week of intervention (22 min/week, SD 12 min/week; Cohen d=0.24, 95% CI 0.1 to 6.4). A slight decrease in step count was observed from week 1 (8926 steps/day, SD 2156 steps/day) to the last week of intervention (8517 steps/day, SD 1612 steps/day; Cohen d=-0.21, 95% CI -876.9 to 58.9). CONCLUSIONS: The initial feasibility results of a 7-week community-based walking intervention tailored for African American women with asthma and supplemented with mHealth tools are promising. Modifications to recruitment, retention, and the intervention itself are needed. These findings support the need to conduct a further modified pilot trial to collect additional data on feasibility and estimate the efficacy of the intervention on asthma and PA outcomes.

Study protocol for a sequential multiple assignment randomized trial (SMART) to improve physical activity in employed women.

INTRODUCTION: Physical activity monitors, motivational text messages, personal calls, and group meetings, have proven to be efficacious physical activity interventions. However, individual participant response to these interventions varies drastically. A SMART design (sequential multiple assignment randomized trial) provides an effective way to test interventions that start with an initial treatment and then transition to an augmented treatment for non-responders. We describe a SMART to determine the most effective adaptive intervention to increase physical activity (steps, moderate-to-vigorous physical activity) and improve cardiovascular health among employed women who are not regularly physically active. The SMART uses combinations of four treatments: 1) enhanced physical activity monitor (Fitbit wearable activity monitor and mobile app with goal setting and physical activity prescription), 2) text messages, 3) personal calls, and 4) group meetings. METHODS: Participants (N = 312) include women ages 18-70 employed at a large academic medical center. Women will be randomized to an initial intervention, either an enhanced physical activity monitor or enhanced physical activity monitor + text messaging. Non-responders to the initial intervention at 2 months will be randomized to either personal calls or groups meetings for the next 6 months. At 8 months, all participants will return to only an enhanced physical activity monitor until their final 12-month assessment. DISCUSSION: Results of this study will add to the literature on improving physical activity in employed women. This study will identify effective interventions for women who respond to less intensive treatments, while maximizing benefits for those who need a more intensive approach.

Daily Physical Activity in Patients With COPD After Hospital Discharge in a Minority Population.

BACKGROUND: Low physical activity in patients with chronic obstructive pulmonary disease (COPD) is associated with increased morbidity and mortality. To inform the design of a home-based physical activity promotion program for patients with COPD recently discharged from a minority-serving hospital, we conducted a cohort study to evaluate objectively measured daily physical activity and patient-reported outcomes. METHODS: This was a 12-week prospective cohort study of patients with a physician diagnosis of COPD recently hospitalized (≤ 12 weeks) for respiratory symptoms. Daily physical activity was recorded using wrist-based and "clip-on" pedometers, and analyzed as mean daily step counts averaged over 7 days. RESULTS: Twenty-two patients were enrolled a median (interquartile range, [IQR]) of 14 (7 to 29) days after hospital discharge. The median daily step count (IQR) in the first week after enrollment (week 1) was 3710 (1565 to 5129) steps. The median within-person change in daily step count (IQR) from week 1 to week 12 was 314 (-30 to 858) steps (p=0.28). Within-person correlation of week-to-week daily step counts was high (r ≥ 0.75). Time from hospital discharge to enrollment was not correlated with mean daily step counts on week 1 (r= -0.13) and only weakly correlated with change in mean daily step counts from week 1 to week 12 (r=0.37). CONCLUSIONS: Daily physical activity was variable in this cohort of recently hospitalized patients with COPD, but with little within-person change over a 12-week period. These observations highlight the need for flexible physical activity promotion programs addressing the needs of a heterogeneous patient population.

Use of a Wearable Technology and Motivational Interviews to Improve Sleep in Older Adults With Osteoarthritis and Sleep Disturbance: A Pilot Study.

The feasibility and preliminary efficacy of a mobile health self-management intervention aimed at improving sleep among older adults with osteoarthritis and disturbed sleep were evaluated. This was a one-group pre-/posttest pilot study. Feasibility was measured by the number of participants eligible, enrolled, and retained. Primary efficacy outcomes were Insomnia Severity Index (ISI) score and two sleep actigraphy variables: total sleep time (TST) and sleep efficiency (SE). Overall step count, self-efficacy (SEff), and acceptance of sleep difficulties (ASD) were mechanisms of action variables. Assessments were at baseline, Week 14 (postintervention), and Week 19 (follow up). Mixed effect models were used to measure change over time. Twenty-four participants (mean age = 71 years) were enrolled and 22 completed the study. Improvements of 1.2 (95% confidence interval [CI] [-2.43, -0.05]; p = 0.04) and 2.5 (95% CI [0.9, 4.9]; p = 0.02) points in the ISI and ASD scores, respectively, were found over the 19-week period. These findings add to a growing literature that suggests older adults might reap benefits from mobile health interventions. TARGETS: Older adults with osteoarthritis and insomnia symptoms. INTERVENTION DESCRIPTION: Activity trackers synced to a dashboard that triggered personalized weekly step goals and motivational messages augmented by telephone motivational interviews. MECHANISM OF ACTION: Physical activity, SEff, and ASD. OUTCOMES: Sleep measures. [Res Gerontol Nurs. 2019; 12(4):167-173.].

Telehealth for patients with chronic obstructive pulmonary disease (COPD): a systematic review and meta-analysis protocol.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a highly prevalent chronic disease characterised by persistent respiratory symptoms. A focus of COPD interventional studies is directed towards prevention of exacerbations leading to hospital readmissions. Telehealth as a method of remote patient monitoring and care delivery may be implemented to reduce hospital readmissions and improve self-management of disease. Prior reviews have not systematically assessed the efficacies of various telehealth functionalities in patients with COPD at different stages of disease severity. We aim to evaluate which COPD telehealth interventions, classified by their functionalities, are most effective in improving patient with COPD management measured by both clinical and resource utilisation outcomes. METHODS AND ANALYSIS: We will conduct a systematic review which will include randomised controlled trials comparing the efficacy of telehealth interventions versus standard care in patients with COPD with confirmed disease severity based on forced expiratory volume(%) levels. An electronic search strategy will be used to identify trials published since 2000 in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, CINHAL. Telehealth is described as remote monitoring and delivery of care where patient data/clinical information is routinely or continuously collected and/or processed, presented to the patient and transferred to a clinical care institution for feedback, triage and intervention by a clinical specialist. Two authors will independently screen articles for inclusion, assess risk of bias and extract data. We will merge studies into a meta-analysis if the interventions, technologies, participants and underlying clinical questions are homogeneous enough. We will use a random-effects model, as we expect some heterogeneity between interventions. In cases where a meta-analysis is not possible, we will synthesise findings narratively. We will assess the quality of the evidence for the main outcomes using GRADE. ETHICS AND DISSEMINATION: Research ethics approval is not required. The findings will be disseminated through publication in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42018083671.