The Political Economy of Digital Health Equity: Structural Analysis.

Digital technologies have produced many innovations in care delivery and enabled continuity of care for many people when in-person care was impossible. However, a growing body of research suggests that digital health can also exacerbate health inequities for those excluded from its benefits for reasons of cost, digital literacy, and structural discrimination related to characteristics such as age, race, ethnicity, and socioeconomic status. In this paper, we draw on a political economy perspective to examine structural barriers to progress in advancing digital health equity at the policy level. Considering the incentive structures and investments of powerful actors in the field, we outline how characteristics of neoliberal capitalism in Western contexts produce and sustain digital health inequities by describing 6 structural challenges to the effort to promote health equity through digital health, as follows: (1) the revenue-first incentives of technology corporations, (2) the influence of venture capital, (3) inequitable access to the internet and digital devices, (4) underinvestment in digital health literacy, (5) uncertainty about future reimbursement of digital health, and (6) justified mistrust of digital health. Building on these important challenges, we propose future immediate and long-term directions for work to support meaningful change for digital health equity.

Antibiotic Prescribing by Digital Health Care Providers as Compared to Traditional Primary Health Care Providers: Cohort Study Using Register Data.

BACKGROUND:  "Direct-to-consumer (DTC) telemedicine" is increasing worldwide and changing the map of primary health care (PHC). Virtual care has increased in the last decade and with the ongoing COVID-19 pandemic, patients' use of online care has increased even further. In Sweden, online consultations are a part of government-supported health care today, and there are several digital care providers on the Swedish market, which makes it possible to get in touch with a doctor within a few minutes. The fast expansion of this market has raised questions about the quality of primary care provided only in an online setting without any physical appointments. Antibiotic prescribing is a common treatment in PHC. OBJECTIVE:  This study aimed to compare antibiotic prescribing between digital PHC providers (internet-PHC) and traditional physical PHC providers (physical-PHC) and to determine whether prescriptions for specific diagnoses differed between internet-PHC and physical-PHC appointments, adjusted for the effects of attained age at the time of appointment, gender, and time relative to the COVID-19 pandemic. METHODS:  Antibiotic prescribing data based on Anatomical Therapeutic Chemical (ATC) codes were obtained for Region Sörmland residents from January 2020 until March 2021 from the Regional Administrative Office. In total, 160,238 appointments for 68,332 Sörmland residents were included (124,398 physical-PHC and 35,840 internet-PHC appointments). Prescriptions issued by internet-PHC or physical-PHC physicians were considered. Information on the appointment date, staff category serving the patient, ICD-10 (International Statistical Classification of Diseases, Tenth Revision) diagnosis codes, ATC codes of prescribed medicines, and patient-attained age and gender were used. RESULTS:  A total of 160,238 health care appointments were registered, of which 18,433 led to an infection diagnosis. There were large differences in gender and attained age distributions among physical-PHC and internet-PHC appointments. Physical-PHC appointments peaked among patients aged 60-80 years while internet-PHC appointments peaked at 20-30 years of age for both genders. Antibiotics with the ATC codes J01A-J01X were prescribed in 9.3% (11,609/124,398) of physical-PHC appointments as compared with 6.1% (2201/35,840) of internet-PHC appointments. In addition, 61.3% (6412/10,454) of physical-PHC infection appointments resulted in antibiotic prescriptions, as compared with only 25.8% (2057/7979) of internet-PHC appointments. Analyses of the prescribed antibiotics showed that internet-PHC followed regional recommendations for all diagnoses. Physical-PHC also followed the recommendations but used a wider spectrum of antibiotics. The odds ratio of receiving an antibiotic prescription (after adjustments for attained age at the time of appointment, patient gender, and whether the prescription was issued before or during the COVID-19 pandemic) during an internet-PHC appointment was 0.23-0.39 as compared with a physical-PHC appointment. CONCLUSIONS:  Internet-PHC appointments resulted in a significantly lower number of antibiotics prescriptions than physical-PHC appointments, adjusted for the large differences in the characteristics of patients who consult internet-PHC and physical-PHC. Internet-PHC prescribers showed appropriate prescribing according to guidelines.

A prospective cohort study: The effects of preoperative E-health on the postoperative course of tonsillectomy patients.

PURPOSE: At our clinic, a significant portion of tonsillectomy (TE) preoperative assessments are conducted remotely. The aim of our study was to examine the variation in TE complications, contact rates, and reasons for patient contact between those evaluated preoperatively at the outpatient clinic (OPC), or remotely through virtual visits (VV), or via a digital care pathway (DCP). This investigation is critical for optimizing patient flow through the volume-intensive process of TE. METHODS: We conducted a prospective cohort study involving 422 patients who underwent TE at Helsinki University Hospital ENT clinic to investigate their 30-day postoperative course. We extracted information on postoperative contacts, complications, and demographic data. Postoperative contact rate was the primary outcome measure to evaluate whether telehealth patients suffered fewer postoperative issues. RESULTS: Patients from the OPC were least likely to seek medical assistance in the 30-day postoperative period. However, no significant difference was discovered compared to the remotely assessed DCP patients, and over entire TE episodes, the DCP patients had the fewest unplanned contacts compared to the VV and OPC cohorts. Furthermore, the care paths shared similar complication and contact method profiles with comparable post-tonsillectomy hemorrhage incidence. CONCLUSION: A preoperative DCP for TE appeared to carry similar postoperative contact and complication rates, as well as comparable contact method profiles compared to the OPC model. Given the high patient satisfaction and cost-consciousness associated with the DCP, our findings encourage a broader implementation of highly developed DCPs in preoperative assessment for TE.

[Design and evaluation options of multimedia applications to support the care of people with mild dementia]. / Gestaltungs- und Evaluationsmöglichkeiten von Multimediaanwendungen zur Unterstützung der Betreuung von Menschen mit leichter Demenz.

BACKGROUND: In order to cognitively and physically activate people with dementia (MMD) in institutional settings, there are numerous touch-based multimedia applications specifically designed for this target group that are actually being used in practice. In contrast, the use of similar applications in domestic settings has been relatively limited. AIM AND METHOD: This study is based on 11 expert interviews guided by questions and examines design options and requirements for application content as well as requirements for study designs to provide evidence of the effectiveness of touch-based multimedia applications for MMD and their caregiving relatives (PA). RESULTS: There is a high degree of consensus regarding the criteria for requirements for touch-based multimedia applications. Acceptance is highly dependent on user competence, usage practices, experiences and incentive structures; however, there are diverse opinions about their structural and content-related design. The quality of life is mentioned as an essential evaluation parameter for multimedia applications. DISCUSSION: The highly variable individual life circumstances of MMD and their PAs, along with limited access options and a lack of suitability of the multimedia applications, may be causal factors for their relatively limited use, especially in domestic settings. Daily performance capabilities and individual disease progression pose special requirements for the scientific evaluation and the demonstration of the effectiveness of touch-based multimedia applications.

[Digital care beds in long-term care-Support, relief for caregivers or just illusion? An ethnographic explorative study]. / Digitale Pflegebetten in der Langzeitpflege ­ Unterstützung, Entlastung für Pflegende oder nur Illusion? Eine ethnografisch-explorative Studie.

BACKGROUND: The digitalization of care items, in this case the care bed, is a logical consequence of the general shortage of personnel and resources in professional care and an increase in the number of very old people in need of long-term care. Sensors integrated into the nursing bed, interfaces for data transmission and connection to a monitoring system are generated for moments of support and relief for professional nurses and to increase the nursing outcome. Accompanying nursing research examines the implementation of 97 digital care beds in a long-term care facility for old people. METHOD: Mixed methods research approach over 24 months RESULTS: The lack or implementation of a consistent care process, unfavorable accompanying circumstances, interdependent contextual factors and an insufficient implementation management have a negative impact on the implementation and integration of the digital care beds into the care routines. CONCLUSION: For a successful implementation of digital assistance systems (dAS), they have to be considered in the care process besides a reliable technical connection. Furthermore, an implementation management as well as the review and adaptation of all relevant context factors are required.

Digital support for quality assurance in 24-hour caregiving at home: a randomized controlled trial investigating the effects on quality of life and professional skills of paid 24h-caregivers.

BACKGROUND: Regarding the care of older adults, 24-h home-care represents a cornerstone, with > 32,000 service users in Austria. Our research project 24hQuAALity aimed to develop and evaluate a distributed client-server software solution for the support and quality assurance of this home-care service. In this trial, we investigated the effects of this intervention on the quality of life and professional skills of paid 24h-caregivers in Austria. METHODS: The application used in our study comprises an e-learning platform, an integrated emergency management, networking opportunities, and an electronic care documentation system in the native language of the 24h-caregivers. The trial was conducted using a parallel three-arm study design to evaluate (i) a control group, which performed usual home care, (ii) a partial intervention group, which used the e-learning and networking platforms, and (iii) a full intervention group, which used the entire intervention (e-learning platform, networking platform, and digital care documentation). Primary self-reported outcomes were the standardized ASCOT for Carers score and a score based on responses to project-specific efficacy questions. RESULTS: Among the 110 24h-caregivers who were randomly classified into the three groups, ASCOT for Carers score data were available for 57 and 35 24h-caregivers at 5- and 9-month follow-up examinations, respectively. At 9 months, 24h-caregivers receiving any intervention rated the ASCOT for Carers score (not significantly) better than the controls (p = 0.05, ηp2 = 0.15), mainly in the domain "feeling encouraged and supported". At 9 months, 24h-caregivers receiving any intervention rated the project-specific Efficacy score significantly better than the controls (p = 0.02, ηp2 = 0.20), mainly due to better ratings in the subitems "satisfaction with current docu", "docu supports doing my job", " I'm well prepared for emergencies", "my professional skills are adequate for doing my job", and "communication with contacts". CONCLUSIONS: Providing e-learning and e-documentation devices to 24h-caregivers improved their care-related quality of life, mainly because they felt more encouraged and supported. Moreover, these interventions improved their self-perceived professional skills. As an extrapolation of findings, we found that these interventions could empower 24h-caregivers and improve the quality of home-care services provided by them. TRIAL REGISTRATION: Digital Support for Quality Assurance in 24-h Caregiving at Home was registered and posted on the ClinicalTrials.gov public website (ClinicalTrials.gov Identifier: NCT04581538).

Telemedicine in Swedish primary health care - a web-based survey exploring patient satisfaction.

BACKGROUND: Direct-to-consumer telemedicine (TM), with patients having access to a physician via video or text chat, has gradually been introduced into Swedish primary care during the last two decades. Earlier studies have concluded that patients were generally satisfied with TM and the satisfaction rate was consistently above 80% and comparable with in-person visits. Despite the number of studies looking at user experience, studies assessing what factors influence patient satisfaction are lacking. To further develop digital care, it is important to explore the patients' opinions of this relatively new phenomenon. The primary aim of this study was to explore patient opinions regarding satisfaction with TM-provided care, based on different age groups, sex, symptoms, and which type of health care professional they were assessed by. METHODS: The study was a quantitative web survey performed in 2020-2021 in which 688 patients using a TM provider in Southern Sweden responded. The results were analysed using Chi-2 test with the main outputs; satisfaction level and percentage that would use TM for similar symptoms in the future. RESULTS: The results from the survey population show that patients that were assessed by a doctor were more likely to intend to use TM in the future and were more satisfied with the visit than patients assessed by a nurse. Our results also show that patients older than 70 years of age were less likely to use TM again compared to the total population. CONCLUSION: This study shows that patient satisfaction with TM varied depending on the patient's age. The older patients were less satisfied than their younger equivalents. For patient satisfaction to be high, it was also crucial which health care provider the patient had been assessed by. The patients were more satisfied when assessed by a doctor than by a nurse. In addition, the study shows that patient satisfaction with TM was generally comparable to traditional care.

Effectiveness of digital care platform CMyLife for patients with chronic myeloid leukemia: results of a patient-preference trial.

BACKGROUND: Two most important factors determining treatment success in chronic myeloid leukemia (CML) are adequate medication compliance and molecular monitoring albeit still being suboptimal. The CMyLife platform is an eHealth innovation, co-created with and for CML patients, aiming to improve their care, leading to an increased quality of life and the opportunity of hospital-free care. OBJECTIVE: To explore the effectiveness of CMyLife in terms of information provision, patient empowerment, medication compliance, molecular monitoring, and quality of life. METHODS: Effectiveness of CMyLife was explored using a patient-preference trial. Upon completion of the baseline questionnaire, participants actively used (intervention group) or did not actively use (questionnaire group) the CMyLife platform for at least 6 months, after which they completed the post-intervention questionnaire. Scores between the intervention group and the questionnaire group were compared with regard to the within-subject change between baseline and post-measurement using Generalized Estimating Equation models. RESULTS: At baseline, 33 patients were enrolled in the questionnaire group and 75 in the intervention group. Online health information knowledge improved significantly when actively using CMyLife and patients felt more empowered. No significant improvements were found regarding medication compliance and molecular monitoring, which were already outstanding. Self-reported effectiveness showed that patients experienced that using CMyLife improved their medication compliance and helped them to oversee their molecular monitoring. Patients using CMyLife reported more symptoms but were better able to manage these. CONCLUSIONS: Since hospital-free care has shown to be feasible in time of the COVID-19 pandemic, eHealth-based innovations such as CMyLife could be a solution to maintain the quality of care and make current oncological health care services more sustainable. TRIAL REGISTRATION: ClinicalTrials.gov NCT04595955 , 22/10/2020.

Association Between the Use of a Digital Health Platform During Pregnancy and Helping Users Avoid Emergency and In-Person Care: Retrospective Observational Study.

BACKGROUND: Almost one-third of pregnant people visit the emergency room during pregnancy. Although some emergency care is necessary, gaps in patient education and inaccessibility of preventive services have been identified as key reasons for high-cost, low-value care in pregnancy. Digital platforms present a promising solution for providing resources to supplement routine prenatal care, thereby reducing the use of low-value in-person services. OBJECTIVE: This study aimed to describe the relationship between the use of Maven and in-person care avoidance (emergency room or office visits) during pregnancy. Maven is a digital prenatal health platform that supplements routine prenatal care. Maven offers educational content (articles, videos, and classes), care coordination (through a care advocate), and provider services (web-based appointments and communication with providers) designed to complement prenatal care. Specifically, the aims of this study were to examine whether the use of Maven is associated with in-person care avoidance overall and whether improvements in pregnancy-related knowledge facilitate in-person care avoidance. To assess aim 2, we tested if the use of Maven is associated with improvements in self-reported understanding of warning signs and medically accurate information and if self-reported understanding of medically accurate information and warning signs is associated with in-person care avoidance in a population of Maven users. METHODS: In this retrospective study, we used adjusted logistic regression to examine the relationship between digital platform use, avoidance of in-person care, and the platform's influence on pregnancy-related knowledge (learning medically accurate information and recognizing warning signs). Demographics, medical history, and in-person care avoidance were self-reported. RESULTS: Of the 5263 users, 280 (5.32%) reported that Maven helped them avoid in-person care during pregnancy. More users who reported avoiding in-person care also reported that the digital platform helped them understand warning signs (231/280, 82.5%) and learned medically accurate information (185/280, 66.1%). In the adjusted models, all modes of digital service use (assessed as quartiles) were associated with avoiding in-person care in a dose-response manner (eg, web-based provider appointments: Q2 adjusted odds ratio [aOR] 1.57, 95% CI 1.00-2.41; Q3 aOR 2.53, 95% CI 1.72-3.72; Q4 aOR 5.26, 95% CI 3.76-7.42). Users were more likely to avoid in-person care if they reported that Maven helped them recognize warning signs (aOR 3.55, 95% CI 2.60-4.94) or learn medically accurate information (aOR 2.05, 95% CI 1.59-2.67). CONCLUSIONS: These results suggest that digital platforms can be effective in helping patients to avoid in-person care. The educational pathway suggests that digital platforms can be particularly effective in helping patients recognize warning signs and learn medically accurate information, which may help them avoid in-person care by recognizing when in-person care is medically appropriate. Future work is needed to assess other pathways through which digital resources can support pregnant people and improve perinatal care use.

Improvement, Implementation, and Evaluation of the CMyLife Digital Care Platform: Participatory Action Research Approach.

BACKGROUND: The evaluation of a continuously evolving eHealth tool in terms of improvement and implementation in daily practice is unclear. The CMyLife digital care platform provides patient-centered care by empowering patients with chronic myeloid leukemia, with a focus on making medication compliance insightful, discussable, and optimal, and achieving optimal control of the biomarker BCR-ABL1. OBJECTIVE: The aim of this study was to investigate to what extent the participatory action research approach is suitable for the improvement and scientific evaluation of eHealth innovations in daily clinical practice (measured by user experiences) combined with the promotion of patient empowerment. METHODS: The study used iterative cycles of planning, action, and reflection, whereby participants' experiences (patients, health care providers, the CMyLife team, and app suppliers) with the platform determined next actions. Co-design workshops were the foundation of this cyclic process. Moreover, patients filled in 2 sets of questionnaires for assessing experiences with CMyLife, the actual use of the platform, and the influence of the platform after 3 and at least 6 months. Data collected during the workshops were analyzed using content analysis, which is often used for making a practical guide to action. Descriptive statistics were used to characterize the study population in terms of information related to chronic myeloid leukemia and sociodemographics, and to describe experiences with the CMyLife digital care platform and the actual use of this platform. RESULTS: The co-design workshops provided insights that contributed to the improvement, implementation, and evaluation of CMyLife and empowered patients with chronic myeloid leukemia (for example, simplification of language, and improvement of the user friendliness of functionalities). The results of the questionnaires indicated that (1) the platform improved information provision on chronic myeloid leukemia in 67% (33/49) of patients, (2) the use of the medication app improved medication compliance in 42% (16/38) of patients, (3) the use of the guideline app improved guideline adherence in 44% (11/25) of patients, and (4) the use of the platform caused patients to feel more empowered. CONCLUSIONS: A participatory action research approach is suited to scientifically evaluate digital care platforms in daily clinical practice in terms of improvement, implementation, and patient empowerment. Systematic iterative evaluation of users' needs and wishes is needed to keep care centered on patients and keep the innovation up-to-date and valuable for users.

Comparing Digital to Conventional Physical Therapy for Chronic Shoulder Pain: Randomized Controlled Trial.

BACKGROUND: Chronic shoulder pain (CSP) is a common condition with various etiologies, including rotator cuff disorders, adhesive capsulitis, shoulder instability, and shoulder arthritis. It is associated with substantial disability and psychological distress, resulting in poor productivity and quality of life. Physical therapy constitutes the mainstay treatment for CSP, but several barriers exist in accessing care. In recent years, telerehabilitation has gained momentum as a potential solution to overcome such barriers. It has shown numerous benefits, including improving access and convenience, promoting patient adherence, and reducing costs. However, to date, no previous randomized controlled trial has compared fully remote digital physical therapy to in-person rehabilitation for nonoperative CSP. OBJECTIVE: The aim of this study is to compare clinical outcomes between digital physical therapy and conventional in-person physical therapy in patients with CSP. METHODS: We conducted a single-center, parallel-group, randomized controlled trial involving 82 patients with CSP referred for outpatient physical therapy. Participants were randomized into digital or conventional physical therapy (8-week interventions). The digital intervention consisted of home exercise, education, and cognitive behavioral therapy (CBT), using a device with movement digitalization for biofeedback and asynchronous physical therapist monitoring through a cloud-based portal. The conventional group received in-person physical therapy, including exercises, manual therapy, education, and CBT. The primary outcome was the change (baseline to 8 weeks) in function and symptoms using the short-form of Disabilities of the Arm, Shoulder, and Hand questionnaire. Secondary outcome measures included self-reported pain, surgery intent, analgesic intake, mental health, engagement, and satisfaction. All questionnaires were delivered electronically. RESULTS: A total of 90 participants were randomized into digital or conventional physical therapy, with 82 receiving the allocated intervention. Both groups experienced significant improvements in function measured by the short-form of the Disabilities of the Arm, Shoulder, and Hand questionnaire, with no differences between groups (-1.8, 95% CI -13.5 to 9.8; P=.75). For secondary outcomes, no differences were observed in surgery intent, analgesic intake, and mental health or worst pain. Higher reductions were observed in average and least pain in the conventional group, which, given the small effect sizes (least pain 0.15 and average pain 0.16), are unlikely to be clinically meaningful. High adherence and satisfaction were observed in both groups, with no adverse events. CONCLUSIONS: This study shows that fully remote digital programs can be viable care delivery models for CSP given their scalability and effectiveness, assessed through comparison with high-dosage in-person rehabilitation. TRIAL REGISTRATION: ClinicalTrials.gov (NCT04636528); https://clinicaltrials.gov/study/NCT04636528.

Low Adoption of Video Consultations in Post-COVID-19 General Practice in Northern Europe: Barriers to Use and Potential Action Points.

In the wake of the COVID-19 pandemic, video consultation was introduced in general practice in many countries around the world as a solution to provide remote health care to patients. It was assumed that video consultation would find widespread adoption in post-COVID-19 general practice. However, adoption rates remain low across countries in Northern Europe, suggesting that barriers to its use exist among general practitioners and other practice staff. In this viewpoint, we take a comparative approach, reflecting on similarities and differences in implementation conditions of video consultations in 5 Northern European countries' general practice settings that might have created barriers to its use within general practice. We convened at a cross-disciplinary seminar in May 2022 with researchers and clinicians from 5 Northern European countries with expertise in digital care in general practice, and this viewpoint emerged out of dialogues from that seminar. We have reflected on barriers across general practice settings in our countries, such as lacking technological and financial support for general practitioners, that we feel are critical for adoption of video consultation in the coming years. Furthermore, there is a need to further investigate the contribution of cultural elements, such as professional norms and values, to adoption. This viewpoint may inform policy work to ensure that a sustainable level of video consultation use can be reached in the future, one that reflects the reality of general practice settings rather than policy optimism.

Effectiveness and Medicoeconomic Evaluation of Home Monitoring of Patients With Mild COVID-19: Covidom Cohort Study.

BACKGROUND: Covidom was a telemonitoring solution for home monitoring of patients with mild to moderate COVID-19, deployed in March 2020 in the Greater Paris area in France to alleviate the burden on the health care system. The Covidom solution included a free mobile application with daily monitoring questionnaires and a regional control center to quickly handle patient alerts, including dispatching emergency medical services when necessary. OBJECTIVE: This study aimed to provide an overall evaluation of the Covidom solution 18 months after its inception in terms of effectiveness, safety, and cost. METHODS: Our primary outcome was to measure effectiveness using the number of handled alerts, response escalation, and patient-reported medical contacts outside of Covidom. Then, we analyzed the safety of Covidom by assessing its ability to detect clinical worsening, defined as hospitalization or death, and the number of patients with clinical worsening without any preceding alert. We evaluated the cost of Covidom and compared the cost of hospitalization for Covidom and non-Covidom patients with mild COVID-19 cases seen in the emergency departments of the largest network of hospitals in the Greater Paris area (Assistance Publique-Hôpitaux de Paris). Finally, we reported on user satisfaction. RESULTS: Of the 60,073 patients monitored by Covidom, the regional control center handled 285,496 alerts and dispatched emergency medical services 518 times. Of the 13,204 respondents who responded to either of the follow-up questionnaires, 65.8% (n=8690) reported having sought medical care outside the Covidom solution during their monitoring period. Of the 947 patients who experienced clinical worsening while adhering to daily monitoring, only 35 (3.7%) did not previously trigger alerts (35 were hospitalized, including 1 who died). The average cost of Covidom was €54 (US $1=€0.8614) per patient, and the cost of hospitalization for COVID-19 worsening was significantly lower in Covidom than in non-Covidom patients with mild COVID-19 cases seen in the emergency departments of Assistance Publique-Hôpitaux de Paris. The patients who responded to the satisfaction questionnaire had a median rating of 9 (out of 10) for the likelihood of recommending Covidom. CONCLUSIONS: Covidom may have contributed to alleviating the pressure on the health care system in the initial months of the pandemic, although its impact was lower than anticipated, with a substantial number of patients having consulted outside of Covidom. Covidom seems to be safe for home monitoring of patients with mild to moderate COVID-19.

The Effectiveness of Digital Apps Providing Personalized Exercise Videos: Systematic Review With Meta-Analysis.

BACKGROUND: Among available digital apps, those providing personalized video exercises may be helpful for individuals undergoing functional rehabilitation. OBJECTIVE: We aimed to assess the effectiveness of apps providing personalized video exercises to support rehabilitation for people with short- and long-term disabling conditions, on functional capacity, confidence in exercise performance, health care consumption, health-related quality of life, adherence, and adverse events. METHODS: In this systematic review, we searched MEDLINE, CENTRAL, and Embase databases up to March 2022. All randomized controlled trials evaluating the effect of apps providing personalized video exercises to support rehabilitation for any condition requiring physical rehabilitation were included. Selection, extraction, and risk of bias assessment were performed by 2 independent reviewers. The primary outcome was functional capacity at the end of the intervention. The secondary outcomes included confidence in exercise performance, care consumption, health-related quality of life, adherence, and adverse events. A meta-analysis was performed where possible; the magnitude of the effect was assessed with the standardized mean difference (SMD). RESULTS: From 1641 identified references, 10 papers (n=1050 participants, 93% adults) were included: 7 papers (n=906 participants) concerned musculoskeletal disorders and 3 (n=144 participants) concerned neurological disorders. Two (n=332 participants) were employee based. The apps were mostly commercial (7/10); the videos were mostly elaborated on by a physiotherapist (8/10). The duration of app use was 3-48 weeks. All included studies had a high overall risk of bias. Low-quality evidence suggested that the use of apps providing personalized video exercises led to a significant small to moderate improvement in physical function (SMD 0.35, 95% CI 0.19-0.51; Phet=.86; I2=0%) and confidence in exercise performance (SMD 0.67; 95% CI 0.37-0.96; Phet=.22; I2=33%). Because of the very low quality of the evidence, the effects on quality of life and exercise adherence were uncertain. Apps did not influence the rate of adverse events. CONCLUSIONS: Apps providing personalized video exercises to support exercise performance significantly improved physical function and confidence in exercise performance. However, the level of evidence was low; more robust studies are needed to confirm these results. TRIAL REGISTRATION: PROSPERO CRD42022323670; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=323670.

Cost analysis of face-to-face visits, virtual visits, and a digital care pathway in the treatment of tonsillitis patients.

PURPOSE: The aim of this study was to compare the costs of two different telemedicine-assisted tonsillitis care pathways with traditional face-to-face visits at the Department of Otorhinolaryngology - Head and Neck Surgery (ORL-HNS) at Helsinki University Hospital. METHODS: We characterized and analyzed the patient flows and their individual episodes of all tonsillitis patients at the Department of ORL-HNS between September 2020 and August 2022. Records were collected by doctors at the clinic. We investigated costs and allocated resources in four categories: invoice from the Department of ORL-HNS to the public payer, expenses to the Department, patient fees, and doctor's resource. RESULTS: At least a third of the tonsillitis patients were eligible for telemedicine. The digital care pathway was 12.6 % less expensive for the public payer compared to the previous virtual visit model. For the Department, the expense of the digital care pathway was 58.8 % less per patient than the virtual visit model. Patient fees decreased 79.5 %. The digital care pathway reduced the doctor's resource from 30.28 min to 19.78 min, which accounts for a 34.7 % reduction. Patients finished the digital care pathway in a median of 62 min (SD = 60) compared to the 2-4 h which they would spend on an outpatient clinic visit. CONCLUSION: Our study demonstrates that tonsillitis patients are eligible for preoperative telemedicine. With at least a third of the tonsillitis patients being eligible for telemedicine, major cost savings can be achieved with efficient e-health-assisted solutions.

Co-Designing Digital Technologies for Improving Clinical Care in People with Parkinson's Disease: What Did We Learn?

The healthcare model is shifting towards integrated care approaches. This new model requires patients to be more closely involved. The iCARE-PD project aims to address this need by developing a technology-enabled, home-based, and community-centered integrated care paradigm. A central part of this project is the codesign process of the model of care, exemplified by the active participation of patients in the design and iterative evaluation of three sensor-based technological solutions. We proposed a codesign methodology used for testing the usability and acceptability of these digital technologies and present initial results for one of them, MooVeo. Our results show the usefulness of this approach in testing the usability and acceptability as well as the opportunity to incorporate patients' feedback into the development. This initiative will hopefully help other groups incorporate a similar codesign approach and develop tools that are well adapted to patients' and care teams' needs.

A comprehensive eHealth implementation guide constructed on a qualitative case study on barriers and facilitators of the digital care platform CMyLife.

BACKGROUND: Substantial proliferation of eHealth has enabled a move in patient-centred cancer care from the traditional in-person care model to real-time, dynamic, and technology supported on-demand care. However, in general, the uptake of these innovations is low. Studies show that eHealth is helpful in providing patient empowerment through e.g. providing high quality and timely information, enabling self-monitoring and shared decision making, but dropout rates are high and guidance for optimal implementation is lacking. AIM: To explore barriers to and facilitators for nationwide implementation and consolidation of CMyLife, a multi-component, patient-centred, digital care platform, and to construct a comprehensive implementation guide for launching digital care platforms in daily clinical practice. METHODS: The first qualitative case study of a digital care platform like CMyLife was performed including five focus group- and eighteen in-depth interviews with stakeholders. Data were collected using a semi-structured interview guide, based on the frameworks of Grol and Flottorp. Transcripts of the interviews were analysed and barriers and facilitators were identified and categorized according to the frameworks. An iterative process including participation of main stakeholders and using the CFIR-ERIC framework led to creating a comprehensive implementation guide for digital care platforms. RESULTS: In total, 45 barriers and 41 facilitators were identified. Main barriers were lack of connectivity between information technology systems, changing role for both health care providers and patients, insufficient time and resources, doubts about privacy and security of data, and insufficient digital skills of users. Main facilitators mentioned were motivating patients and health care providers by clarifying the added value of use of a digital care platform, clear business case with vision, demonstrating (cost) effectiveness, using an implementation guide, and educating patients and health care providers about how to use CMyLife. Based on these barriers and facilitators a clear and comprehensive implementation guide was developed for digital care platforms. CONCLUSION: Several barriers to and facilitators for implementation were identified, a clear overview was presented, and a unique comprehensive implementation guide was developed for launching future digital care platforms in daily clinical practice. The next step is to validate the implementation guide in other (oncological) diseases.

Impacts of Digital Care Programs for Musculoskeletal Conditions on Depression and Work Productivity: Longitudinal Cohort Study.

BACKGROUND: Comorbidity between musculoskeletal (MSK) pain and depression is highly common, and is associated with a greater symptom burden and greater loss of work productivity than either condition alone. Multimodal care programs tackling both physical and mental health components may maximize productivity recovery and return to work. Digital delivery of such programs can facilitate access, ensure continuity of care, and enhance patient engagement. OBJECTIVE: The aim of this study was to assess the impact of a completely remote multimodal digital care program (DCP) for MSK pain on mental health and work-related outcomes stratified by baseline depression levels. METHODS: Ad hoc analysis of an interventional, single-arm, cohort study of individuals with MSK pain undergoing a DCP was performed. Three subgroups with different baseline depression severity levels were established based on responses to the Patient Health Questionnaire (PHQ-9): cluster 1 (score<5: minimal depression), cluster 2 (scores 5-10: mild depression), and cluster 3 (score≥10: moderate depression). The mean changes in depression, anxiety, fear-avoidance beliefs, work productivity, and activity impairment and adherence between baseline and end of program (8-12 weeks) were assessed across subgroups by latent growth curve analysis. RESULTS: From a total of 7785 eligible participants, 6137 (78.83%) were included in cluster 1, 1158 (14.87%) in cluster 2, and 490 (6.29%) in cluster 3. Significant improvements in depression and anxiety scores were observed in clusters 2 and 3 but not in cluster 1, with average end-of-the program scores in clusters 2 and 3 below the initially defined cluster thresholds (score of 5 and 10, respectively). All clusters reported significant improvements in productivity impairment scores (mean changes from -16.82, 95% CI -20.32 to -13.42 in cluster 1 to -20.10, 95% CI -32.64 to -7.57 in cluster 3). Higher adherence was associated with higher improvements in depression in clusters 2 and 3, and with greater recovery in activities of daily living in cluster 3. Overall patient satisfaction was 8.59/10.0 (SD 1.74). CONCLUSIONS: A multimodal DCP was able to promote improvements in productivity impairment scores comparable to those previously reported in the literature, even in participants with comorbid depression and anxiety. These results reinforce the need to follow a biopsychosocial framework to optimize outcomes in patients with MSK pain. TRIAL REGISTRATION: ClinicalTrials.gov NCT04092946; https://clinicaltrials.gov/ct2/show/NCT04092946.

An evaluation of registered nurses' experiences of person-centered care and competence after participating in a course in digital competence in care.

BACKGROUND: Health care's rapid transition from in-person visits to more digital care meetings has challenged nurses to find new, sustainable ways of using digital technology. METHODS: The aim was to describe registered nurses'(RN) experiences with person-centred care (PCC) and competence after participating in a course in Digital Competence in Care (DCC). In this study, a qualitative descriptive design was used, and 16 individual interviews were carried out with RNs. Data were analysed using qualitative content analysis. The COREQ checklist was used in this study. RESULTS: The results were presented in four categories: being open to change and new ways of working with patients; struggling to handle requirements; developing new ways of working and focusing on patients despite the distance. CONCLUSIONS: The DCC course helped develop RNs' skills and practice of PCC in digital care meetings. Training in digital care theory increased RNs' competence and facilitated the creation of new knowledge. The RNs' professional role was strengthened by participating in the changing of work routines. Digital care meetings were shown to be distance bridging and complementary to physical care meetings contributing to PCC. The increased availability of health care via digital means has affected the consumption of care and tailored education needs for RNs must be met by nursing education programs. Digital care is accessible, efficient and enables care regardless of geographical conditions, its innovative development needs to be based on science and experience and RNs are key personnel in this process. TRIAL REGISTRATION: Not applicable.

[Remote work and the use of online communication in nursing homes during COVID-19-measures]. / Werken op afstand en gebruik van onlinecommunicatie in verpleeghuizen tijdens COVID-19-maatregelen.

The measures taken in Dutch nursing homes during the first wave of the COVID-19 pandemic resulted in both an increase and a decrease of challenging behavior in nursing home residents. Staff undertook various initiatives to reduce the negative effects. For example, video calling between residents and their relatives was facilitated. In addition, initiatives in digital care (telehealth) were deployed. The aim of this study was to explore nursing home practitioners' experiences with online communication between residents and relatives, working remotely in general and the remote treatment of challenging behavior in particular. One hundred and seventy-five nursing home professionals (psychologists, elderly care specialists, nursing specialists, daytime activities coordinators) completed an online questionnaire at the end of 2020/start of 2021. Open and closed questions showed that face-to-face contacts are preferred over online communication. Online communication was mainly seen as a (meaningful) addition. Although professionals wanted to continue some of their work remotely, and found this efficient and workload-reducing, they felt that this could impair their job satisfaction and the quality of care. For remote work and remote treatment, each task needs to be evaluated on whether it can be performed properly and whether that results in good care. More research into online communication, remote working and digital care in nursing homes is needed.