A Patient-Centered Mobile Health System That Supports Asthma Self-Management (breathe): Design, Development, and Utilization

Abstract

Background: Uncontrolled asthma poses substantial negative personal and health system impacts. Web-based technologies, including smartphones, are novel means to enable evidence-based care and improve patient outcomes.

Objective: The aim of this study was to design, develop, and assess the utilization of an asthma collaborative self-management (CSM) platform (breathe) using content based on international evidence-based clinical guidelines.

Methods: We designed and developed breathe as a Web-based mobile health (mHealth) platform accessible on smartphones, tablets, or desktop with user-centered design methods and International Organization for Standardization-certified quality development processes. Moreover, breathe was envisioned as a multifunctional, CSM mHealth platform, with content based on international clinical practice guidelines and compliant with national privacy and security specifications. The system enabled CSM (patient, provider, and breathe) and self-monitoring of asthma patients through (1) assessment of asthma control, (2) real-time access to a dynamic asthma action plan, (3) access to real-time environmental conditions, and (4) risk-reduction messaging. The data collection protocol collected user data for 12 months, with clinic visits at baseline and 6 and 12 months. Utilization outcomes included user interactions with the platform, user impressions, self-reported medication use, asthma symptom profile, reported peak flow measurement, and the delivery and impact of email reminders.

Results: We enrolled 138 patients with a mean age of 45.3 years to receive the breathe intervention. Majority were female (100/138, 72.5%), had a smartphone (92/138, 66.7%), and had a mean Asthma Control Test score of 18.3 (SD 4.9). A majority reported that breathe helped in the management of their asthma. Moreover, breathe scored 71.1 (SD 18.9) on the System Usability Scale. Overall, 123 patients had complete usage analytics datasets. The platform sent 7.96 reminder emails per patient per week (pppw), patients accessed breathe 3.08 times, journaled symptoms 2.56 times, reported medication usage 0.30 times, and reported peak flow measurements 0.92 times pppw. Furthermore, breathe calculated patients' action plan zone of control 2.72 times pppw, with patients being in the green (well-controlled) zone in 47.71% (8300/17,396) of the total calculations. Usage analysis showed that 67.5% (83/123) of the participants used the app at week 4 and only 57.7% (71/123) by week 45. Physician visits, email reminders, and aged 50 years and above were associated with higher utilization.

Conclusions: Individuals with asthma reported good usability and high satisfaction levels, reacted to breathe notifications, and had confidence in the platform's assessment of asthma control. Strong utilization was seen at the intervention's initiation, followed by a rapid reduction in use. Patient reminders, physician visits, and being aged 50 years and above were associated with higher utilization.

Trial registration: ClinicalTrials.gov NCT01964469; https://ichgcp.net/clinical-trials-registry/NCT01964469.

Keywords: asthma; internet; mobile applications; monitoring, physiologic; patient compliance; risk reduction behavior; self report; self-management; smartphone; telemedicine.

Conflict of interest statement

Conflicts of Interest: PPM reports grants from the Natural Sciences and Engineering Research Council of Canada (NSERC), Canadian Institute for Health Research (CIHR), MITACS, and Ontario Centres of Excellence (OCE) during the conduct of this study. PPM is a member of advisory boards at Roche Canada. The work developed in this paper was not funded by any of these companies. MSY reports grants from Canada Health Infoway during the conduct of the study. MF, AKT, and CM have nothing to disclose. ASL reports grants from Canada Health Infoway, from Ontario Ministry of Health and Long-Term Care, during the conduct of the study. TT reports grants from Ontario Ministry of Health and Long-Term Care, grants from Ontario Ministry of the Environment and Climate Change, grants from CIHR, grants from Health Canada, grants from Canadian Respiratory Research Network, outside the submitted work. MDL received honoraria from the Astra Zeneca Severe Asthma PRECISION Program, and funds were paid directly to Queen's University for participation in multicenter clinical trials from Astra Zeneca, GlaxoSmithKline, Hoffman LaRoche Ltd, Janssen, and Novartis; grants were paid directly to Queen's University from the OLA, the Government of Ontario's Innovation Fund, Allergen NCE, Canadian Institutes of Health Research; and personal fees were paid by the Public Service Occupational Health Program Regions and Programs Bureau Health Canada or Government of Canada for preparation of a report on pollution exposure at post and the role of surveillance spirometry, outside the submitted work. SG has nothing to disclose. AGD reports that his employer was paid from grants from Canada Health Infoway and The Lung Association to cost recover his time spent on this project. JAC reports grants from Canada Health Infoway during the conduct of the study. CL declares that he is a member of advisory boards or equivalent in commercial organizations as AstraZeneca, Novartis, Boehringer Ingelheim, and GlaxoSmithKline as well as receiving funding from commercial organizations as AstraZeneca, Novartis, Boehringer Ingelheim, Pfizer, and Bayer. The work developed in this project was not funded by any of these companies.

©Plinio Pelegrini Morita, Melanie S Yeung, Madonna Ferrone, Ann K Taite, Carole Madeley, Andrea Stevens Lavigne, Teresa To, M Diane Lougheed, Samir Gupta, Andrew G Day, Joseph A Cafazzo, Christopher Licskai. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 28.01.2019.

Figures

Figure 1

Examples of the various features designed for breathe. The first row provides examples of the main home screen, the current zone of control that the patient is in, and environment information. The second row provides examples of the journaling feature where users can report symptoms, medication intake, and review entries. The last row has examples of the desktop version of breathe, where the zone of control review and action plans are displayed. These are not actual plans, medications, or patient data but instead, prototypes of the breathe interface.

Figure 2

Architecture of the breathe platform (Ontario Lung Association [OLA], Air Quality Health Index [AQHI], Clinical Data Repository [CDR]). In cases where peak flow was part of the action plan, peak flow ranges were entered by the provider. Patients were responsible for entering peak flow measurements.

Figure 3

Panel A: Total calculations of zone of control calculations per month of the intervention calculated from enrollment Panel B: Percentage of zone of control calculations per month of the intervention.

Figure 4

Attrition in breathe use throughout the 12-months of the study, with Eysenbach attrition curve plotted as a reference.

Figure 5

App use tracked by number of logins by time of day exploring the effectiveness of reminders. Note that automatic app reminders are default to send around 7:00 pm.

Figure 6

Sustained effect of email reminders on app use over the 12 months of intervention.

Figure 7

Panel A: Number of reported “good days” (no symptoms) and symptom episodes since enrollment. Panel B: Percentage of reported “good days” (no symptoms) and symptom episodes since enrollment.

Figure 8

Self-reported controller medication use showing the effect of clinic visits (surveillance effect) on self-reporting behavior (clinic visits were scheduled at 6 and 12 months from the beginning of the intervention).