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Table 2 Summary of studies reviewed

From: Effective behavioral intervention strategies using mobile health applications for chronic disease management: a systematic review

Year/Author/Country Purpose of Study Sample Types of Disease Types of Outcomes and Measurements Main Results
2009 Kearney et al. United Kingdom To evaluate the impact of a mobile phone-based remote monitoring, advanced symptom management system (ASyMS©) on the incidence, severity and distress of six chemotherapy-related symptoms in patients with lung, breast, or colorectal cancer. n = 112 (56 in each intervention or control group) patients from 7 clinical sites throughout the UK. Inclusion criteria: commencing a new course of chemotherapy treatment, receiving outpatient chemotherapy, age ≥ 18, written informed consent given, able to read and write English, and deemed by members of the clinical team as being physically and psychologically fit to participate in the study. Chemotherapy related toxicity in patients with lung, breast, or colorectal cancer • Severity and distress of the six symptoms including vomiting, nausea, diarrhea, hand-foot syndrome, sore mouth/throat, and fatigue.
• Incidence – (did symptom occur? Y/N), Severity and distress (scores 0–3) of the six individual symptoms.
• ASyMS has integrated the Common Toxicity Criteria Adverse Events (CTCAE) grading system and the Chemotherapy Symptom Assessment Scale.
• Paper version of the electronic symptom questionnaire was administrated at baseline, chemotherapy cycles 2, 3, 4, and 5 in both groups.
• Two of the six symptoms measured (fatigue and hand-foot syndrome) showed statistical significance between the control and intervention groups (respectively, p = 0.040, p = 0.031).
• Patients reported improved communication with health professionals, improvements in the management of their symptoms, and feeling reassured their symptoms were being monitored while at home when using ASyMS.
2013 Kristjánsdóttir et al. Norway To study the long term effects of a 4-week smartphone intervention with diaries and therapist feedback following an inpatient chronic pain rehabilitation program (11-month follow up of 2013 Kristjánsdóttir et al. study) n = 135 (intervention group: 69/control group: 66) Inclusion criteria: female, age ≥ 18, participating in the inpatient multidimensional rehabilitation programfor chronic pain, having chronic widespread pain > 6 months (with or without diagnosis of fibromyalgia), not participating in another research project at the rehab center, being able to use a smartphone, and not being diagnosed with a profound psychiatric disorder. Chronic widespread pain or Fibromyalgia • Catastrophizing [Pain catastrophizing scale (PCS)]
• Acceptance [Chronic pain acceptance questionnaire (CPAQ)]
• Emotional distress [modified General Health Questionnaire (GHQ)]
• Importance and success in living according to one’s own values in 6 domains (family, intimate relationships, friendship, work, health, and personal growth) [Chronic Pain Values Inventory (CPVI)]
• Pain, fatigue, sleep disturbance [Visual analog scales (VAS)]
• Impact of Fibromyalgia on functioning and symptom levels the past week [Fibromyalgia Impact Questionnaire (FIQ)]
• Functioning [Short-Form Health Survey (SF-8)]
• Use of noninteractive website [self-report at T3 (4 weeks after discharge)]
• Feasibility of the smartphone intervention (single question for post-intervention)
Short-term follow-up results:
• Intervention group reported less catastrophizing (p < 0.001).
• Results from the per-protocol analysis indicate intervention with diaries and written personalized feedback reduced catastrophizing and increased acceptance and effects persisted 5 months after the intervention.
• Increased improvement in values-based living in the intervention group
• Control group showed an increased level of fatigue and a tendency toward an increase in sleep disturbance at the 5-month follow-up.
Long-term 11-month follow-up results:
• The between-group differences on catastrophizing, acceptance, functioning, and symptom level were no longer evident (p > 0.10).
• More improvement in catastrophizing scores during the follow-up period (T2-T5) in the intervention group (p = 0.045)
• Positive effect on acceptance was found within the intervention group (p < 0.001).
• Small to large negative effects were found within the control group on functioning and symptom levels, emotional distress, and fatigue (p = 0.05).
• Reduction in disease impact (measured by FIQ) found for intervention group (p = 0.03).
• Long-term results are ambiguous.
2013 Garcia-Palacios et al. Spain To compare compliance with paper diary vs. smartphone diary, aggregated ecological momentary assessment (EMA) data vs. retrospective data, and assess acceptability of EMA procedures. n = 40 (intervention group:20/control group:20) Inclusion criteria: met criteria for FMS, defined by the American College of Rheumatology and were diagnosed by a rheumatologist. Fibromyalgia syndrome (FMS) • EMA pain and fatigue (0–10 Numerical Rating Scales)
• Mood (face-based pictorial 7-point scale)
• Weekly retrospective rating of pain and fatigue [Brief Pain Inventory (BPI) and Brief Fatigue Inventory (BFI)]
• Acceptability and preferences (self-report)
• Smartphone condition (smartphone diary) showed higher levels of compliance than paper condition (paper diary) (p < 0.01).
• Retrospective assessment produces overestimation of events (pain and fatigue, p < 0.01).
• Smartphone condition preferred and accepted over paper diary, even in participants with low familiarity with technology.
2014 Vuorinen et al. Finland To study whether multidisciplinary care with telemonitoring leads to decreased HF-related hospitalization n = 94 (intervention group: 47/control group: 47) Inclusion criteria: diagnosis of systolic heart failure, age 18–90 years, NYHA (New Work Heart Association) functional class ≥2, left ventricular ejection fraction ≤35%, need for a regular check-up visit, and time from the last visit of less than 6 months. Heart failure (HF) • Number of HF-related hospital days (data from hospital electronic health record system)
• Clinical effectiveness [death from any cause, heart transplant operation or listing for transplant operation, left ventricular ejection fraction (LVEF,%) measured by echocardiography, plasma concentration of N-terminal of the prohormone brain natriuretic peptide (NT-proBNP, ng/1), creatinine, sodium, and potassium]
• Self-care behavior (European Heart Failure Self-Care Behavior Scale)
• Use of health care resources (analyzed outpatient visits)
• No difference found in the number of HF-related hospital days (p = 0.351).
• Intervention group used more health care resources.
• No statistically significant differences in patients’ clinical health status or self-care behavior.
2015 Cingi et al. Turkey To investigate the impact of a mobile patient engagement application on health outcomes and quality of life n = 2282 interventions (physician on call patient engagement trial, POPET for patients with allergic rhinitis or asthma) POPET-AR (intervention group: 88/control group: 51) POPET-Asthma (intervention group: 60/control group:29) Allergic rhinitis (AR) and asthma patients • Health outcomes and quality of life [AR groups: Rhinitis Quality of Life Questionnaire (RQLQ), asthma groups: Asthma Control Test (ACT)] • POPET-AR group showed better clinical improvement than the control group in terms of overall RQLQ score as well in measures of general problems, activity, symptoms other than nose/eye, and emotion domains (p < 0.05).
• More patients in the POPET-Asthma group achieved a well-controlled asthma score compared to the control group (p < 0.05).
2015 Dicianno et al. United States To determine feasibility of the interactive mobile health and rehabilitation (iMHere) system and its effects on psychosocial and medical outcomes n = 23 (intervention group:13/control group:10) Inclusion criteria: age 18–40, primary diagnosis of myelomeningocele with hydrocephalus, ability to use smartphone, and living within 100 miles of testing site to allow for technical support. Spina bifida (SB) • Usage (the number of participant responses to reminders, use of secure messaging, or photo uploads)
• Physical independence (Craig Handicap Assessment and Reporting Technique Short Form, Physical independence domain)
• Self management skill (Adolescent Self-Management and Independence Scale II)
• Depressive symptoms (The Beck Depression Inventory-II)
• Perception of patient-centered care (Patient Assessment of Chronic Illness Care)
• Quality of Life (World Health Organization Quality of Life Brief Instrument)
• Number of UTIs (diagnosed UTIs)
• Number of wounds (unique skin breakdown episodes that were at least stage II)
• Number of emergency department (ED) visits (ED visits for any reason)
• Number of ED visits due to UTI or wound
• Number of planned and unplanned hospitalizations
• Number of hospitalizations due to UTI or wound
• Smartphone system was found to be feasible and associated with short-term self-reported improvements in self-management skills.
2015 Hägglund et al. Sweden To evaluate whether a home intervention system (HIS) using a tablet had an effect on self-care behavior. n = 82 (intervention group:42/control group:40) Inclusion criteria: hospitalized and diagnosed for HF with reduced ejection fraction (HFrEF) and/or preserved EF (HFpEF), treatment with diuretics, and referred straight to primary care. Heart failure (HF) • Disease-specific self-care (European Heart Failure Self-Care Behavior Scale)
• Health-related quality of life (HRQoL) (Kansas City Cardiomyopathy Questionnaire)
• Adherence (frequency of HIS use)
• Knowledge (Dutch Heart Failure Knowledge Scale)
• HF-related hospital days (patients’ case books)
• Intervention group showed improvement in self-care and HRQoL, reduction in HF-related hospital days.
2015 Martin et al. United States To investigate whether a fully automated mHealth intervention with tracking and texting components increases physical activity. n = 48 [unblinded = 32 (smart texts = 16, no texts = 16), blinded = 16] Unblinded participants were randomized to smart texts or no texts in phase II (weeks 4–5). Inclusion criteria: ages 18–69, using a Fitbug compatible smartphone (iPhone≥4S, Galaxy≥S3). Cardiovascular disease (CVD) • Mean change in accelerometer-measured daily step count (measured by Fitbug Orb)
• Attainment of prescribed 10,000 steps/day goal (measured by Fitbug Orb)
• Changes in total daily activity and aerobic time (measured by Fitbug Orb)
• Intervention with texting component increased physical activity (p < 0.001).
2015 Piette et al. United States To compare the effects of systematic feedback to HF patients’ caregivers and HF patients receiving standard mHealth. n = 372 (intervention group:189/control group: 183) Inclusion criteria: HF diagnosis, ejection fraction < 40%, able to name eligible CarePartner (CP) that is a relative or friend living outside their home. Heart failure (HF) • HF-related quality of life (Minnesota Living with Heart Failure Questionnaire)
• Patient-CP communication (quantitative telephone surveys)
• Medication adherence and self-care (Revised Heart Failure Self-Care Behavior Scale)
• mHealth + CP (intervention) group showed improvement in medication adherence and caregiver communication.
• mHealth + CP may improve qualify of life in patients with greater depressive symptoms and also decrease patients’ risk of shortness of breath and sudden weight gains.
2016 Cubo et al. Spain To evaluate the cost-effectiveness of home-based motor monitoring (HBMM) with in-office visits versus in-office visits alone in patients with advanced Parkinson’s disease n = 40 (intervention group: 20/control group: 20) Inclusion criteria: non-demented outpatients from a tertiary regional movement disorders clinic, Mini-Mental Scale score > 24, and diagnosed with idiopathic, advanced PD. Parkinson’s disease (PD) • Motor (Unified Parkinson’s Disease Rating Scale and Hoehn and Yahr staging Scale) and non-motor (Non-Motor Symptoms Questionnaire Scale) symptom severities
• Cost-effectiveness (incremental cost-effectiveness ratio)
• Direct costs (standardized questionnaire)
• Quality of life (EuroQoL)
• Neuropsychiatric symptoms (Hospital Anxiety Depression Scale, Scale for Evaluation of Neuropsychiatric Disorders, Parkinson Psychiatric Rating Scale)
• Comorbidities (Cumulative Illness Rating scale-Geriatric)
• HBMM was found to be cost-effective in improvement of functional status, motor severity, and motor complications.
2016 DeVito Dabbs et al. United States To compare the efficacy of an mHealth intervention in promoting self-management behaviors and self-care agency, rehospitalization, and mortality at home during the first year after lung transplantation. n = 201 (intervention group: 99/control group: 102) Inclusion criteria: age > 18, received transplantation at the University of Pittsburgh Medical Center, and could read and speak English. Lung transplant recipients (LTRs) • Self-monitoring (percentage of days that LTRs performed self-monitoring)
• Adherence to regimen (Health Habits Survey)
• Critical health (percentage of critical indicators)
• Self-care agency (Perception of Self-Care Agency)
• Health outcomes (medical records)
• The intervention group performed self-monitoring (p < 0.001), adhered to medical regimen. (p = 0.046), and reported abnormal health indicators (p < 0.001) more frequently. Than the usual care group.
• Both groups did not differ in re-hospitalization (p = 0.51) or mortality (p = 0.25).
2016 Ginis et al. Israel and Belgium To determine the feasibility and effectiveness of the gait training CuPiD-system for people with Parkinson’s disease in the home environment. n = 40 (intervention group: 22/control group: 18) Inclusion criteria: ability to walk 0 min continuously, score of ≥24 on Montreal Cognitive Assessment, Hoehn and Yahr Stage II to III in ON-state, and on stable PD medication. Parkinson’s disease (PD) • Single and dual task gait (gait speed)
• Balance (mini-Balance Evaluation Systems Test, Four Square Step Test, Falls Efficacy Scale-International)
• Endurance and physical capacity (2 Minute Walk Test, Physical Activity Scale for the Elderly)
• Disease severity (Movement Disorders Unified Parkinson’s Disease Rating Scale – motor examination)
• Freezing of gait (New FOG Questionnaire, Ziegler protocol)
• Cognition (Color Trail Test A & B, sitting & walking verbal fluency) Quality of life (Short Form 36 Health Survey)
The CuPiD-system was feasible and effective, as the intervention group improved significantly more on balance and maintained quality of life compared to the control group.