The Atrial Fibrillation Health Literacy Information Technology System: Pilot Assessment

Jared W Magnani, Courtney L Schlusser, Everlyne Kimani, Bruce L Rollman, Michael K Paasche-Orlow, Timothy W Bickmore, Jared W Magnani, Courtney L Schlusser, Everlyne Kimani, Bruce L Rollman, Michael K Paasche-Orlow, Timothy W Bickmore

Abstract

Background: Atrial fibrillation (AF) is a highly prevalent heart rhythm condition that has significant associated morbidity and requires chronic treatment. Mobile health (mHealth) technologies have the potential to enhance multiple aspects of AF care, including education, monitoring of symptoms, and encouraging and tracking medication adherence. We have previously implemented and tested relational agents to improve outcomes in chronic disease and sought to develop a smartphone-based relational agent for improving patient-centered outcomes in AF.

Objective: The objective of this study was to pilot a smartphone-based relational agent as preparation for a randomized clinical trial, the Atrial Fibrillation Health Literacy Information Technology Trial (AF-LITT).

Methods: We developed the relational agent for use by a smartphone consistent with our prior approaches. We programmed the relational agent as a computer-animated agent to simulate a face-to-face conversation and to serve as a health counselor or coach specific to AF. Relational agent's dialogue content, informed by a review of literature, focused on patient-centered domains and qualitative interviews with patients with AF, encompassed AF education, common symptoms, adherence challenges, and patient activation. We established that the content was accessible to individuals with limited health or computer literacy. Relational agent content coordinated with use of the smartphone AliveCor Kardia heart rate and rhythm monitor. Participants (N=31) were recruited as a convenience cohort from ambulatory clinical sites and instructed to use the relational agent and Kardia for 30 days. We collected demographic, social, and clinical characteristics and conducted baseline and 30-day assessments of health-related quality of life (HRQoL) with the Atrial Fibrillation Effect on Quality of life (AFEQT) measure; self-reported medication adherence with the Morisky 8-item Medication Adherence Scale (MMAS-8); and patient activation with the Patient Activation Measure (PAM).

Results: Participants (mean age 68 [SD 11]; 39% [12/31] women) used the relational agent for an average 17.8 (SD 10.0) days. The mean number of independent log-ins was 19.6 (SD 10.7), with a median of 20 times over 30 days. The mean number of Kardia uses was 26.5 (SD 5.9), and participants using Kardia were in AF for 14.3 (SD 11.0) days. AFEQT scores improved significantly from 64.5 (SD 22.9) at baseline to 76.3 (SD 19.4) units at 30 days (P<.01). We observed marginal but statistically significant improvement in self-reported medication adherence (baseline: 7.3 [SD 0.9], 30 days: 7.7 [SD 0.5]; P=.01). Assessments of acceptability identified that most of the participants found the relational agent useful, informative, and trustworthy.

Conclusions: We piloted a 30-day smartphone-based intervention that combined a relational agent with dedicated content for AF alongside Kardia heart rate and rhythm monitoring. Pilot participants had favorable improvements in HRQoL and self-reported medication adherence, as well as positive responses to the intervention. These data will guide a larger, enhanced randomized trial implementing the smartphone relational agent and the Kardia monitor system.

Keywords: atrial fibrillation; health-related quality of life; mHealth; medication adherence.

Conflict of interest statement

Conflicts of Interest None declared.

Figures

Figure 1
Figure 1
Screenshots of the relational agent: (a) symptoms menu and (b) an emphatic gesture.

References

    1. Writing Group Members. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, Das SR, de Ferranti S, Després J, Fullerton HJ, Howard VJ, Huffman MD, Isasi CR, Jiménez MC, Judd SE, Kissela BM, Lichtman JH, Lisabeth LD, Liu S, Mackey RH, Magid DJ, McGuire DK, Mohler 3rd ER, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Rosamond W, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Woo D, Yeh RW, Turner MB, American Heart Association Statistics Committee. Stroke Statistics Subcommittee Heart disease and stroke statistics-2016 update: a report from the American Heart Association. Circulation. 2016 Jan 26;133(4):e38–360. doi: 10.1161/CIR.0000000000000350.
    1. January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland Jr JC, Conti JB, Ellinor PT, Ezekowitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG, Tchou PJ, Tracy CM, Yancy CW, ACC/AHA Task Force Members 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014 Dec 02;130(23):e199–267. doi: 10.1161/CIR.0000000000000041.
    1. Magnani JW, Rienstra M, Lin H, Sinner MF, Lubitz SA, McManus DD, Dupuis J, Ellinor PT, Benjamin EJ. Atrial fibrillation: current knowledge and future directions in epidemiology and genomics. Circulation. 2011 Nov 01;124(18):1982–93. doi: 10.1161/CIRCULATIONAHA.111.039677.
    1. Suman-Horduna I, Roy D, Frasure-Smith N, Talajic M, Lespérance F, Blondeau L, Dorian P, Khairy P, AF-CHF Trial Investigators Quality of life and functional capacity in patients with atrial fibrillation and congestive heart failure. J Am Coll Cardiol. 2013 Jan 29;61(4):455–60. doi: 10.1016/j.jacc.2012.10.031.
    1. Groenveld HF, Crijns HJ, Van den Berg MP, Van Sonderen E, Alings AM, Tijssen JG, Hillege HL, Tuininga YS, Van Veldhuisen DJ, Ranchor AV, Van Gelder IC, RACE II Investigators The effect of rate control on quality of life in patients with permanent atrial fibrillation: data from the RACE II (Rate Control Efficacy in Permanent Atrial Fibrillation II) study. J Am Coll Cardiol. 2011 Oct 18;58(17):1795–803. doi: 10.1016/j.jacc.2011.06.055.
    1. Cherian TS, Shrader P, Fonarow GC, Allen LA, Piccini JP, Peterson ED, Thomas L, Kowey PR, Gersh BJ, Mahaffey KW. Effect of atrial fibrillation on mortality, stroke risk, and quality-of-life scores in patients with heart failure (from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation [ORBIT-AF]) Am J Cardiol. 2017 Jun 01;119(11):1763–1769. doi: 10.1016/j.amjcard.2017.02.050.
    1. Aronis KN, Edgar B, Lin W, Martins MA, Paasche-Orlow MK, Magnani JW. Health literacy and atrial fibrillation: relevance and future directions for patient-centred care. Eur Cardiol. 2017;12(1):52–7. doi: 10.15420/ecr.2017:2:2.
    1. McCorkle R, Ercolano E, Lazenby M, Schulman-Green D, Schilling LS, Lorig K, Wagner EH. Self-management: enabling and empowering patients living with cancer as a chronic illness. CA Cancer J Clin. 2011;61(1):50–62. doi: 10.3322/caac.20093. doi: 10.3322/caac.20093.
    1. Bickmore TW, Utami D, Matsuyama R, Paasche-Orlow MK. Improving access to online health information with conversational agents: a randomized controlled experiment. J Med Internet Res. 2016;18(1):e1. doi: 10.2196/jmir.5239.
    1. Wang C, Bickmore T, Bowen DJ, Norkunas T, Campion M, Cabral H, Winter M, Paasche-Orlow M. Acceptability and feasibility of a virtual counselor (VICKY) to collect family health histories. Genet Med. 2015 Oct;17(10):822–30. doi: 10.1038/gim.2014.198.
    1. Sequeira SS, Eggermont LH, Silliman RA, Bickmore TW, Henault LE, Winter MR, Nelson K, Paasche-Orlow MK. Limited health literacy and decline in executive function in older adults. J Health Commun. 2013;18(Suppl 1):143–57. doi: 10.1080/10810730.2013.825673.
    1. Bickmore TW, Silliman RA, Nelson K, Cheng DM, Winter M, Henault L, Paasche-Orlow MK. A randomized controlled trial of an automated exercise coach for older adults. J Am Geriatr Soc. 2013 Oct;61(10):1676–83. doi: 10.1111/jgs.12449.
    1. Bickmore TW, Schulman D, Sidner C. Automated interventions for multiple health behaviors using conversational agents. Patient Educ Couns. 2013 Aug;92(2):142–8. doi: 10.1016/j.pec.2013.05.011.
    1. Ellis T, Latham NK, DeAngelis TR, Thomas CA, Saint-Hilaire M, Bickmore TW. Feasibility of a virtual exercise coach to promote walking in community-dwelling persons with Parkinson disease. Am J Phys Med Rehabil. 2013 Jun;92(6):472–81; quiz 482. doi: 10.1097/PHM.0b013e31828cd466.
    1. Bickmore TW, Silliman RA, Nelson K, Cheng DM, Winter M, Henault L, Paasche-Orlow MK. A randomized controlled trial of an automated exercise coach for older adults. J Am Geriatr Soc. 2013 Oct;61(10):1676–83. doi: 10.1111/jgs.12449.
    1. Puskar K, Schlenk EA, Callan J, Bickmore T, Sereika S. Relational agents as an adjunct in schizophrenia treatment. J Psychosoc Nurs Ment Health Serv. 2011 Aug;49(8):22–9. doi: 10.3928/02793695-20110705-01.
    1. Bickmore T, Silliman R, Nelson K, Cheng D, Winter M, Henault L, Paasche-Orlow M. A randomized controlled trial of an automated exercise coach for older adults. J Am Geriatr Soc. 2013 Oct;61(10):1676–83. doi: 10.1111/jgs.12449.
    1. Bickmore TW, Puskar K, Schlenk EA, Pfeifer LM, Sereika SM. Maintaining reality: relational agents for antipsychotic medication adherence. Interact Comput. 2010 Jul 01;22(4):276–88. doi: 10.1016/j.intcom.2010.02.001.
    1. Bickmore TW, Pfeifer LM, Paasche-Orlow MK. Using computer agents to explain medical documents to patients with low health literacy. Patient Educ Couns. 2009 Jun;75(3):315–20. doi: 10.1016/j.pec.2009.02.007.
    1. Halcox JP, Wareham K, Cardew A, Gilmore M, Barry JP, Phillips C, Gravenor MB. Assessment of remote heart rhythm sampling using the AliveCor heart monitor to screen for atrial fibrillation: the REHEARSE-AF study. Circulation. 2017 Nov 07;136(19):1784–1794. doi: 10.1161/CIRCULATIONAHA.117.030583.
    1. Steinhubl SR, Mehta RR, Ebner GS, Ballesteros MM, Waalen J, Steinberg G, Van Crocker Jr P, Felicione E, Carter CT, Edmonds S, Honcz JP, Miralles GD, Talantov D, Sarich TC, Topol EJ. Rationale and design of a home-based trial using wearable sensors to detect asymptomatic atrial fibrillation in a targeted population: the mHealth Screening To Prevent Strokes (mSToPS) trial. Am Heart J. 2016 May;175:77–85. doi: 10.1016/j.ahj.2016.02.011.
    1. Pantelopoulos A, Faranesh A, Milescu A, Hosking P, Venkatraman S, Heneghan C. iproc. 2017. [2017-11-27]. Screening of Atrial Fibrillation Using Wrist Photoplethysmography from a Fitbit Tracker
    1. Hickey KT, Hauser NR, Valente LE, Riga TC, Frulla AP, Masterson CR, Whang W, Garan H, Jia H, Sciacca RR, Wang DY. A single-center randomized, controlled trial investigating the efficacy of a mHealth ECG technology intervention to improve the detection of atrial fibrillation: the iHEART study protocol. BMC Cardiovasc Disord. 2016 Jul 16;16:152. doi: 10.1186/s12872-016-0327-y.
    1. Desteghe L, Raymaekers Z, Lutin M, Vijgen J, Dilling-Boer D, Koopman P, Schurmans J, Vanduynhoven P, Dendale P, Heidbuchel H. Performance of handheld electrocardiogram devices to detect atrial fibrillation in a cardiology and geriatric ward setting. Europace. 2017 Jan;19(1):29–39. doi: 10.1093/europace/euw025.
    1. Tarakji KG, Wazni OM, Callahan T, Kanj M, Hakim AH, Wolski K, Wilkoff BL, Saliba W, Lindsay BD. Using a novel wireless system for monitoring patients after the atrial fibrillation ablation procedure: the iTransmit study. Heart Rhythm. 2015 Mar;12(3):554–9. doi: 10.1016/j.hrthm.2014.11.015.
    1. Bickmore TW, Pfeifer LM, Byron D, Forsythe S, Henault LE, Jack BW, Silliman R, Paasche-Orlow MK. Usability of conversational agents by patients with inadequate health literacy: evidence from two clinical trials. J Health Commun. 2010;15(Suppl 2):197–210. doi: 10.1080/10810730.2010.499991.
    1. Bickmore TW, Paasche-Orlow MK. The role of information technology in health literacy research. J Health Commun. 2012;17(Suppl 3):23–9. doi: 10.1080/10810730.2012.712626.
    1. Bickmore T, Gruber A, Picard R. Establishing the computer-patient working alliance in automated health behavior change interventions. Patient Educ Couns. 2005 Oct;59(1):21–30. doi: 10.1016/j.pec.2004.09.008.
    1. Bickmore T, Vardoulakis L, Schulman D. Tinker: a relational agent museum guide. Auton Agent Multi-Agent Syst. 2013 Jan 4;27(2):254–276. doi: 10.1007/s10458-012-9216-7.
    1. Bickmore T, Schulman D, Yin L. Maintaining engagement in long-term interventions with relational agents. Appl Artif Intell. 2010 Jul 01;24(6):648–666. doi: 10.1080/08839514.2010.492259.
    1. Clarkesmith DE, Lip GY, Lane DA. Patients' experiences of atrial fibrillation and non-vitamin K antagonist oral anticoagulants (NOACs), and their educational needs: a qualitative study. Thromb Res. 2017 May;153:19–27. doi: 10.1016/j.thromres.2017.03.002.
    1. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010 Feb;137(2):263–72. doi: 10.1378/chest.09-1584.
    1. Baker DW, Williams MV, Parker RM, Gazmararian JA, Nurss J. Development of a brief test to measure functional health literacy. Patient Educ Couns. 1999 Sep;38(1):33–42.
    1. Spertus J, Dorian P, Bubien R, Lewis S, Godejohn D, Reynolds MR, Lakkireddy DR, Wimmer AP, Bhandari A, Burk C. Development and validation of the Atrial Fibrillation Effect on QualiTy-of-Life (AFEQT) Questionnaire in patients with atrial fibrillation. Circ Arrhythm Electrophysiol. 2011 Feb;4(1):15–25. doi: 10.1161/CIRCEP.110.958033.
    1. Morisky DE, Ang A, Krousel-Wood M, Ward HJ. Predictive validity of a medication adherence measure in an outpatient setting. J Clin Hypertens (Greenwich) 2008 May;10(5):348–54.
    1. Hibbard JH, Stockard J, Mahoney ER, Tusler M. Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Serv Res. 2004 Aug;39(4 Pt 1):1005–26. doi: 10.1111/j.1475-6773.2004.00269.x.
    1. Bailey GR, Barner JC, Weems JK, Leckbee G, Solis R, Montemayor D, Pope ND. Assessing barriers to medication adherence in underserved patients with diabetes in Texas. Diabetes Educ. 2012;38(2):271–9. doi: 10.1177/0145721711436134.
    1. Thurston MM, Bourg CA, Phillips BB, Huston SA. Impact of health literacy level on aspects of medication nonadherence reported by underserved patients with type 2 diabetes. Diabetes Technol Ther. 2015 Mar;17(3):187–93. doi: 10.1089/dia.2014.0220.
    1. Hibbard JH, Mahoney ER, Stockard J, Tusler M. Development and testing of a short form of the patient activation measure. Health Serv Res. 2005 Dec;40(6 Pt 1):1918–30. doi: 10.1111/j.1475-6773.2005.00438.x.
    1. Clarkesmith DE, Pattison HM, Khaing PH, Lane DA. Educational and behavioural interventions for anticoagulant therapy in patients with atrial fibrillation. Cochrane Database Syst Rev. 2017 Dec 05;4:CD008600. doi: 10.1002/14651858.CD008600.pub3.
    1. King AC, Bickmore TW, Campero MI, Pruitt LA, Yin JL. Employing virtual advisors in preventive care for underserved communities: results from the COMPASS study. J Health Commun. 2013;18(12):1449–64. doi: 10.1080/10810730.2013.798374.
    1. Watson A, Bickmore T, Cange A, Kulshreshtha A, Kvedar J. An internet-based virtual coach to promote physical activity adherence in overweight adults: randomized controlled trial. J Med Internet Res. 2012;14(1):e1. doi: 10.2196/jmir.1629.
    1. Baker DW, Wolf MS, Feinglass J, Thompson JA, Gazmararian JA, Huang J. Health literacy and mortality among elderly persons. Arch Intern Med. 2007 Jul 23;167(14):1503–9. doi: 10.1001/archinte.167.14.1503.
    1. Paasche-Orlow MK, Wolf MS. The causal pathways linking health literacy to health outcomes. Am J Health Behav. 2007;31(Suppl 1):S19–26. doi: 10.5555/ajhb.2007.31.supp.S19.
    1. Levinthal BR, Morrow DG, Tu W, Wu J, Murray MD. Cognition and health literacy in patients with hypertension. J Gen Intern Med. 2008 Aug;23(8):1172–6. doi: 10.1007/s11606-008-0612-2.
    1. Holman H, Lorig K. Patient self-management: a key to effectiveness and efficiency in care of chronic disease. Public Health Rep. 2004;119(3):239–43. doi: 10.1016/j.phr.2004.04.002.
    1. Holman HR, Lorig KR. Patient education: essential to good health care for patients with chronic arthritis. Arthritis Rheum. 1997 Aug;40(8):1371–3. doi: 10.1002/1529-0131(199708)40:8&lt;1371::AID-ART2&gt;;2-J.
    1. Mar CM, Vivancos J, Reig G, González A, Cardona P, Ramírez-Moreno JM, Martí J, Fernández CS, ALADIN Study Investigators Satisfaction, quality of life and perception of patients regarding burdens and benefits of vitamin K antagonists compared with direct oral anticoagulants in patients with nonvalvular atrial fibrillation. J Comp Eff Res. 2017 Mar 29;6(4):303–12. doi: 10.2217/cer-2016-0078.
    1. Akintade BF, Chapa D, Friedmann E, Thomas SA. The influence of depression and anxiety symptoms on health-related quality of life in patients with atrial fibrillation and atrial flutter. J Cardiovasc Nurs. 2015;30(1):66–73. doi: 10.1097/JCN.0000000000000107.
    1. Zhang L, Gallagher R, Neubeck L. Health-related quality of life in atrial fibrillation patients over 65 years: a review. Eur J Prev Cardiol. 2015 Aug;22(8):987–1002. doi: 10.1177/2047487314538855.
    1. Dorian P, Burk C, Mullin CM, Bubien R, Godejohn D, Reynolds MR, Lakkireddy DR, Wimmer AP, Bhandari A, Spertus J. Interpreting changes in quality of life in atrial fibrillation: how much change is meaningful? Am Heart J. 2013 Aug;166(2):381–387.e8. doi: 10.1016/j.ahj.2013.04.015.
    1. Kotecha D, Ahmed A, Calvert M, Lencioni M, Terwee CB, Lane DA. Patient-reported outcomes for quality of life assessment in atrial fibrillation: a systematic review of measurement properties. PLoS One. 2016;11(11):e0165790. doi: 10.1371/journal.pone.0165790.
    1. Mark DB. Assessing quality-of-life outcomes in cardiovascular clinical research. Nat Rev Cardiol. 2016 May;13(5):286–308. doi: 10.1038/nrcardio.2016.10.
    1. Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, Pogue J, Reilly PA, Themeles E, Varrone J, Wang S, Alings M, Xavier D, Zhu J, Diaz R, Lewis BS, Darius H, Diener H, Joyner CD, Wallentin L, RE- LC. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009 Sep 17;361(12):1139–51. doi: 10.1056/NEJMoa0905561.
    1. Granger CB, Alexander JH, McMurray JJV, Lopes RD, Hylek EM, Hanna M, Al-Khalidi HR, Ansell J, Atar D, Avezum A, Bahit MC, Diaz R, Easton JD, Ezekowitz JA, Flaker G, Garcia D, Geraldes M, Gersh BJ, Golitsyn S, Goto S, Hermosillo AG, Hohnloser SH, Horowitz J, Mohan P, Jansky P, Lewis BS, Lopez-Sendon JL, Pais P, Parkhomenko A, Verheugt FW, Zhu J, Wallentin L. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011 Sep 15;365(11):981–92. doi: 10.1056/NEJMoa1107039.
    1. Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W, Breithardt G, Halperin JL, Hankey GJ, Piccini JP, Becker RC, Nessel CC, Paolini JF, Berkowitz SD, Fox KA, Califf RM. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011 Sep 08;365(10):883–91. doi: 10.1056/NEJMoa1009638.
    1. Brown JD, Shewale AR, Talbert JC. Adherence to Rivaroxaban, Dabigatran, and Apixaban for stroke prevention in incident, treatment-naïve nonvalvular atrial fibrillation. J Manag Care Spec Pharm. 2016 Nov;22(11):1319–1329. doi: 10.18553/jmcp.2016.22.11.1319. doi: 10.18553/jmcp.2016.22.11.1319.
    1. Beyer-Westendorf J, Ehlken B, Evers T. Real-world persistence and adherence to oral anticoagulation for stroke risk reduction in patients with atrial fibrillation. Europace. 2016 Aug;18(8):1150–7. doi: 10.1093/europace/euv421.
    1. Fang MC, Go AS, Chang Y, Borowsky LH, Pomernacki NK, Udaltsova N, Singer DE. Warfarin discontinuation after starting warfarin for atrial fibrillation. Circ Cardiovasc Qual Outcomes. 2010 Nov;3(6):624–31. doi: 10.1161/CIRCOUTCOMES.110.937680.
    1. Simons LA, Ortiz M, Freedman SB, Waterhouse BJ, Colquhoun D, Thomas G. Improved persistence with non-vitamin-K oral anticoagulants compared with warfarin in patients with atrial fibrillation: recent Australian experience. Curr Med Res Opin. 2016 Nov;32(11):1857–1861. doi: 10.1080/03007995.2016.1218325.
    1. Stirratt MJ, Dunbar-Jacob J, Crane HM, Simoni JM, Czajkowski S, Hilliard ME, Aikens JE, Hunter CM, Velligan DI, Huntley K, Ogedegbe G, Rand CS, Schron E, Nilsen WJ. Self-report measures of medication adherence behavior: recommendations on optimal use. Transl Behav Med. 2015 Dec;5(4):470–82. doi: 10.1007/s13142-015-0315-2.
    1. Magnani JW, Norby FL, Agarwal SK, Soliman EZ, Chen LY, Loehr LR, Alonso A. Racial differences in atrial fibrillation-related cardiovascular disease and mortality: The Atherosclerosis Risk in Communities (ARIC) study. JAMA Cardiol. 2016 Jul 01;1(4):433–41. doi: 10.1001/jamacardio.2016.1025.

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