Asthma Mobile Applications to Improve Self-Management

More than 17 million cases of adult asthma were reported in the United States in 2015, with an estimated 50% having poorly controlled asthma. Non-adherence to evidence-based guidelines for self-management is strongly correlated to poor control. Appropriate utilization of good self-management skills through an individualized asthma action plan (AAP) has been shown to improve patient outcomes, but mounting evidence indicates AAPs are underutilized. Adult patients can face many barriers to utilizing their AAP, such as unfamiliarity with how to use the plan and forgetting to take their medications. Patients may also be unaware of symptom trends and peak flow changes, which can lead to exacerbations. Patients can have difficulty recalling the frequency and duration of asthmatic exacerbations, night awakenings, and level of limited activity with exacerbations. Accurate recall of asthma exacerbations is vital, but can also be challenging for patients. Finding solutions to overcome the barriers of using the AAP is essential. Mobile applications, also referred to as apps (e.g., smartphone, web-based apps), are a relatively new technology that is showing potential to improve management of long-term illnesses. Asthma mobile apps are a potentially effective tool to facilitate use of an AAP for good self-management. However, there are multiple asthma mobile apps, and minimal research has been undertaken to narrow the selection to evidence-based content apps that are patient-preferred. Identifying patient-preferred, evidence-based content apps will help health care providers confidently recommend an appropriate app that patients are more likely to use for improved self-management. The purpose of this project was to identify apps with evidence-based content and evaluate the perceived benefits associated with using an asthma mobile app for self-management. The findings of this project will help health care providers confidently recommend patients an available app with the most benefits and appreciable ease of use, to facilitate use of their individualized AAPs. The project objectives included (a) identification of appropriate asthma mobile apps that have evidence-based content to facilitate use of the asthma action plan in patients >18 years; (b) education of patients with asthma regarding the potential benefits of using each selected asthma mobile app to facilitate self-management; (c) assessment and evaluation of patient-perceived benefits through a post-questionnaire to determine perceived app benefits and the app most preferred by patients; and (d) dissemination of the project results to the participating asthma clinic and a professional conference. AsthmaMD and Asthma Ally were the evidence-based mobile apps selected to present to patients. These two apps were found to have the most complete evidence-based content available to the public. Each app can assist a patient to keep accurate self-recorded history to document medication adherence, symptoms, and exacerbations. Several functions found to be patient preferred with statistical significance are available in the AsthmaMD app. These functions include various ways for patients to learn about their asthma, a medication reminder, and monitoring medication adherence. Patient preference to have access to an environmental conditions monitor was found with statistical significance in the Asthma Ally app. AsthmaMD was reported by 64% of patients as having the most helpful app functions. Ninety-one percent of the participants expressed interested in using an asthma app for self-management of their asthma

Running Head: ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT1 Asthma Mobile Applications to Improve Self-Management Lilia Buchmuller, DNP FNP Student University of Utah College of Nursing In partial fulfillment of the requirements for the Doctor of Nursing Practice ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 2 Executive Summary More than 17 million cases of adult asthma were reported in the United States in 2015, with an estimated 50% having poorly controlled asthma. Non-adherence to evidence-based guidelines for self-management is strongly correlated to poor control. Appropriate utilization of good self-management skills through an individualized asthma action plan (AAP) has been shown to improve patient outcomes, but mounting evidence indicates AAPs are underutilized. Adult patients can face many barriers to utilizing their AAP, such as unfamiliarity with how to use the plan and forgetting to take their medications. Patients may also be unaware of symptom trends and peak flow changes, which can lead to exacerbations. Patients can have difficulty recalling the frequency and duration of asthmatic exacerbations, night awakenings, and level of limited activity with exacerbations. Accurate recall of asthma exacerbations is vital, but can also be challenging for patients. Finding solutions to overcome the barriers of using the AAP is essential. Mobile applications, also referred to as apps (e.g., smartphone, web-based apps), are a relatively new technology that is showing potential to improve management of long-term illnesses. Asthma mobile apps are a potentially effective tool to facilitate use of an AAP for good self-management. However, there are multiple asthma mobile apps, and minimal research has been undertaken to narrow the selection to evidence-based content apps that are patientpreferred. Identifying patient-preferred, evidence-based content apps will help health care providers confidently recommend an appropriate app that patients are more likely to use for improved self-management. The purpose of this project was to identify apps with evidence-based content and evaluate the perceived benefits associated with using an asthma mobile app for self-management. The findings of this project will help health care providers confidently recommend patients an available app with the most benefits and appreciable ease of use, to facilitate use of their individualized AAPs. The project objectives included (a) identification of appropriate asthma mobile apps that have evidence-based content to facilitate use of the asthma action plan in patients >18 years; (b) education of patients with asthma regarding the potential benefits of using each selected asthma mobile app to facilitate self-management; (c) assessment and evaluation of patient-perceived benefits through a post-questionnaire to determine perceived app benefits and the app most preferred by patients; and (d) dissemination of the project results to the participating asthma clinic and a professional conference. AsthmaMD and Asthma Ally were the evidence-based mobile apps selected to present to patients. These two apps were found to have the most complete evidence-based content available to the public. Each app can assist a patient to keep accurate self-recorded history to document medication adherence, symptoms, and exacerbations. Several functions found to be patient preferred with statistical significance are available in the AsthmaMD app. These functions include various ways for patients to learn about their asthma, a medication reminder, and monitoring medication adherence. Patient preference to have access to an environmental conditions monitor was found with statistical significance in the Asthma Ally app. AsthmaMD was reported by 64% of patients as having the most helpful app functions. Ninety-one percent of the participants expressed interested in using an asthma app for self-management of their asthma. Project committee members: Jennifer Hamilton, APRN, DNP, CPNP (Project Chair). Julie Balk, DNP, APRN, FNP-BC, CNE (FNP Specialty Track Director). Pam Hardin, PhD, RN (Assistant Dean for MS and ENP Programs). ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 3 Table of Contents Acknowledgments………………………………………………………………… 5 Problem Statement………………………………………………………………... 6 Clinical Significance……………………………………………………………… 7 Objectives…………………………………………………………………………. 9 Literature Review…………………………………………………………………. 10 Theoretical Framework…………………………………………………………… 15 Implementation……………….…………………………………………………... 17 Evaluation………………………………………………………………………… 21 Results…………………………………………………………………………….. 23 Future Recommendations………………………………………………………… 25 DNP Essentials……………………………………………………………………. 25 Conclusions……………………………………………………………………….. 26 References………………………………………………………………………… 28 Appendices………………………………………………………………………... A. Defense PowerPoint Presentation ……………….……………………...... 33 B. Asthma Mobile Apps Selection Summary ……………………………….. 37 C. IRB Exemptions………….………………….……………………………. 39 D. Talking Points Handouts .......……….…………………………………… 43 E. Cover Letter…………………………………..….……………………….. 52 F. Patient Survey…………...………………………………………………... 54 G. Survey Results ……………………………………………………………. 60 H. Report to Clinic Stakeholders…………………………..…………............ 64 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 4 I. Professional Conference Application Submission………………………... 68 J. Defense Poster Presentation 71 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT Acknowledgements Rob, Nick, Amanda, Marie, Jessica, William, Amanda S., Dave, Chris, and Peter, thank you for all your love and support! 5 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 6 Asthma Mobile Applications Improving Asthma Self-Management Problem Statement Asthma in the United States currently presents with unusually high prevalence, with more than 17 million adult cases reported in 2017, with an estimated 50% of these cases poorly controlled, costing the nation billions each year (Center for Disease Control (CDC), 2013, 2017). Evidence suggests that, overall, asthma is poorly self-managed (Pinnock et al., 2015). Selfmanagement and the treatment of asthma are tied to the level of intermittent or persistent exacerbations of the disease (Global Initiative for Asthma, 2015; National Heart Lung Blood Institute (NHLBI), 2014). The national asthma guidelines recommend health care practitioners provide an asthma action plan (AAP) to the patient with asthma for improved self-management (NHLBI, 2014). However, the CDC (2013) reports these guidelines are underutilized. Adult patients may face many barriers to the utilization of their AAP, such as unfamiliarity with how to use their plan and forgetting to take their medications (Panzera et al., 2013). Improper administration of medications via an inhaler may become a barrier to effective medication treatment (Panzera et al., 2013). Patients may also be unaware of symptom trends and peak flow changes, which can exacerbate the condition (Panzera et al., 2013). Patients may also have difficulty recalling the frequency and duration of asthmatic exacerbations, night awakenings, and level of limited activity with exacerbations (Eakin & Rand, 2012). Accurate recall of asthma exacerbations is vital, but can also be challenging for patients (Eakin & Rand, 2012). Evidence suggests effective use of an individualized asthma action plan (AAP) leads to good asthma control (Eakin & Rand, 2012; GINA, 2016; NHLBI, 2014). Finding solutions to overcome the barriers to patients using their AAP for self-management is essential to increase effective use of this valuable tool. ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 7 Clinical Significance and Policy Implications The prevalence of asthma in the United States is at a record high (CDC, 2015). Between 2001-2009, asthma diagnoses increased by 4.3 million cases (CDC, 2013). According to the CDC (2013), asthma-related emergency department visits, hospitalizations, clinic visits, and associated deaths result in an annual cost of $56 billion dollars in the United States. Research indicates many individuals with asthma do not receive care and management for asthma based on the National Asthma Education Prevention Program (NAEPP) most current Expert Panel Review (EPR-3) nationally recognized guidelines (CDC, 2013). Many changes have been made in the NAEPP guidelines to improve patient outcomes; however, health care costs associated with asthma continue to rise. In order to reduce these health care costs as well as morbidity and mortality, the national guidelines recommend the following: patients be accurately assessed and asthma severity monitored; environmental triggers be modified; appropriate medications be provided along with demonstration of use; and patients and their care-takers be appropriately educated regarding asthma (CDC, 2013). At each clinic visit, the patients' asthma action plan is to be appropriately revised after assessment of asthma control has been taken into consideration (NHLBI, 2012). Providers develop appropriate asthma management for their patients by obtaining a thorough patient history of exacerbations, triggers, medication adherence, and response to medications (GINA, 2016; National Heart Lung and Blood Advisory Council (NHLBAC), 2015). In order for providers to develop an appropriate AAP, an accurate patient history is essential (GINA, 2016; NHLBAC, 2015). A well-kept record that documents triggers, such as air pollutants (e.g., pollens, particulates, tobacco smoke, etc.) is also essential to develop a plan for effective environmental modifications (GINA, 2016; NHLBAC, 2015). Providing patients the ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 8 ability to quickly and accurately document their asthma condition, lung function, and medication adherence empowers them to deliver valuable information to their practitioner (Wilson et al., 2010; Zolnierek & DiMatteo, 2009), which will lead to a more appropriate individualized AAP (Eakin & Rand, 2012). Cost-effective asthma management and environmental modification may decrease the public health care costs associated with asthma through cost-effective asthma management and environmental modification (CDC, 2013). Improved asthma management and decreased exacerbations will result in fewer hospitalizations, emergency department visits, and deaths (CDC, 2013). Health care costs for patients and their providers (private and public) will also be reduced, as asthma control is increased (CDC, 2013; GINA, 2016; NHLBI, 2012). Improving management of asthma in the adult population via the use of mobile applications and providing practitioners with accurate and timely patient information haves the potential to improve asthma self-management and reduce exacerbations in asthma patients (Archambault, 2011; Baysari & Westbrook, 2015; Eakin & Rand, 2012). Improving asthma control has clinical significance because of improved patient outcomes and individualized care (CDC, 2013; GINA, 2016; NHLBAC, 2015). Uncontrolled asthma increases morbidity and mortality, as well as costs to families, communities, and the health care system (CDC, 2013). It is critical that patients and caregivers are aware of the importance of having good self-management skills to obtain good asthma control. Evidence-based research has established that consistent AAP use by patients leads to better asthma control (GINA, 2016; NHLBAC, 2015). It is vital that patients understand that practitioners rely on an accurate and timely patient history (e.g., number of exacerbations, adherence to asthma medications, etc.), to appropriately develop an individualized AAP (GINA, ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 9 2016; NHLBAC, 2015). A good record via an asthma mobile app will provide practitioners with access to their patients' histories, facilitating timely revision of the AAP as necessary (Wiecha et al., 2015). Having an asthma mobile app with evidence-based content and that is personalized and easy to understand and use may encourage patient adherence to an AAP and thus improve self-management. However, further research is necessary to gain a better understanding of the perceived benefits encountered by patients using an asthma mobile app. Objectives The purpose of this project is to identify and evaluate perceived benefits associated with using an asthma mobile app with evidence-based content for the self-management of asthma. The results of this project help health care providers determine which app is preferred by patients and provides the most appreciable ease of use. The app with the most benefits and highest rated ease of use can then be confidently recommended by providers as a tool to provide solutions to overcome self-management barriers and facilitate use of individualized AAPs. • Objective 1: Identify appropriate asthma mobile apps with evidence-based content to facilitate use of the asthma action plan in patients >18 years. • Objective 2: Educate patients regarding the potential benefits of using each selected asthma mobile app with evidence-based content to facilitate the use of their asthma action plan for self-management. • Objective 3: Identify patient-perceived benefits of each selected asthma mobile app to facilitate self-management. • Objective 4: Disseminate project results to clinic stakeholders and present at a professional conference. ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 10 Literature Review As of 2015, more than 17 million adults and 6 million children in the United States were diagnosed as having asthma (CDC, 2017). Evidence suggests that overall asthma is poorly selfmanaged (Pinnock et al., 2015). Emergency room visits related to asthma cost the nation an average of $3,300 per person annually (Barnett & Nurmagambetov, 2011). Asthma is a chronic bronchial inflammatory disease affecting the lungs, with bronchial hyper-responsiveness and intermittent airflow obstruction (Brashers, 2010). Hyper-responsiveness to "triggers" (e.g., allergens, air pollutants, or exercise) initiates an inflammatory response, which often results in obstructed airways, causing shortness of breath, wheezing, coughing, and chest tightness (Brashers, 2010). There is no cure for asthma (NHLBAC, 2015). However, evidence-based research has shown that obtaining an accurate diagnosis, providing appropriate treatment/medications, assessing ongoing monitoring of the patient's asthma control, and developing a partnership between the provider and patient reduces exacerbations and leads to better asthma control (GINA, 2016; NHLBAC, 2015). Obtaining good asthma control will result in reduced asthma-related morbidity and mortality, as well as the exorbitant costs associated with poorly controlled asthma. In order to disseminate evidence-based practices for the treatment and management of asthma, guidelines were developed in 1991 by the NAEPP in cooperation with the National Heart, Lung, and Blood Institute (NHLBI), through an expert panel report (NHLBAC, 2015). There have been two subsequent revisions of this report, the most current revision in 2007 (EPR3) (NHLBAC, 2015). The EPR-3 nationally recognized asthma guidelines, as well as the internationally recognized Global Initiative for Asthma (GINA) guidelines, recommend patients with asthma be taught how to self-manage their asthma, and be provided an asthma action plan ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 11 by their provider (GINA, 2016; NHLBI, 2012). The asthma action plan includes goals set with the patient and describes what the patient is to do in order to control the condition. With an asthma action plan, patients are able to determine what medications to take, and how often, what to do with increased symptoms, and when to seek medical or emergent care (NHLBI, 2012). According to Eakin and Rand (2015), patients with asthma need to be actively involved in self-management of the condition through the use of the AAP provided to them by their provider to obtain good asthma control. Patient self-management behaviors include adherence to medications, using correct medication device techniques, avoiding environmental triggers, and tracking exacerbations (Eakin & Rand, 2015). Solid evidence-based research supports asthma being effectively controlled when asthma patients are able to adhere to self-management of the above behaviors (Eakin & Rand, 2015). Research indicates that adherence to medications is lacking in patients with asthma, and that controller medication therapy adherence ranges between 30-70% (Eakin & Rand, 2015). Many providers do not assess medication adherence on a routine basis in the clinic (Eakin & Rand, 2015). Verbal assessment may be inconsistent or incomplete, and patients may tend to exaggerate their medication adherence, which leads to recall and response bias (Eakin & Rand, 2015). Several studies suggest that having a non-judgmental and trusting relationship between patient and provider improves the accuracy of the communication about adherence to medication. By receiving more accurate information from a patient, the provider is better able to rely on the patient's records regarding adherence. A knowledge tool to support collaborative selfmanagement between the patient and practitioner is the asthma action plan (Licskai, Sands, & Ferrone, 2013). Asthma mobile applications provide a dynamic translation tool that has the potential to enhance collaborative self-management and accurate use (Licskai et al., 2013). ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 12 It is vital that patients remember to take their medications correctly or as directed in their asthma action plan, and have an impartial reminder for medications, such as with an alert system in a mobile app (Licskai et al., 2013). Good asthma control is more likely to be achieved through adherence to medication therapy as well as trigger avoidance. Less than 50% of patients use complete recommended environmental control methods to remove triggers, such as removing allergens from the home; for example smoking cessation or removing a pet if the patient is allergic (Eakin & Rand, 2015). Such control is essential to reducing morbidity and mortality in asthma patients (Eakin & Rand, 2015). It is also beneficial to be aware when triggers can be avoided, have a readily available method of documenting exacerbations, and have accessible treatment advice (e.g., asthma mobile application), which facilitates the translation of AAP "knowledge into action" (Licskai et al., 2013, p. 301). In a Licskai et al. (2013) pilot study for the development and testing of mobile solutions for asthma self-management, of 29 participants, investigators noted that "86% followed selfmanagement advice and 50% acted to reduce exposure risks" with their smart-phone application (p. 301). After using an asthma mobile app, 95% of participants desired to use a smart-phone application, and the large majority affirmed the smart-phone application improved clarity, timeliness, and ease of use (Licskai et al., 2013). Many mobile applications are inexpensive or free, provide convenience, and may have motivational power for improving asthma selfmanagement (Elias et al., 2013). This literature review did not find research determining which demographic groups of the asthma population are more likely to use an asthma mobile app. Corroborating findings from the Martinez-Perez, de la Torrez Diez, and Lopez-Coronado (2013) review and analysis found asthma to be one of the "most prevalent conditions" to "have fewer apps and research" (para. 4). ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 13 Martinez-Perez et al. (2013) did find apps that are more frequently used, including those that monitor or assist with a condition. Involving patients in determining the usefulness of health care developments is essential to meet their values and needs (Archambault, 2011) and obtain their engagement in self-management. In a national survey of mobile phone owners in the US, Krebs and Duncan (2015), found almost 50% of mobile phone owners downloaded an app that was health related. Some of the more common reasons found for not downloading an app included lack of interest, privacy concerns, and cost (Krebs & Duncan, 2015). Individuals who were more likely to use a healthrelated app included those who were obese, younger, Latino/Hispanic, more educated, and with higher incomes (Krebs & Duncan, 2015). Krebs and Duncan (2015) found that many were not willing to pay for an app. Those who used a health app felt the app helped improve their health, and most believed the app was safe and accurate (Krebs & Duncan, 2015). Almost half of those surveyed stopped using the app because of unknown costs or loss of interest, or because they found it burdensome to enter data (Krebs & Duncan, 2015). Aaron Smith (2015), author for Pew Internet Research, reports 64% of adults in America own some kind of smart phone. Sixty-four percent of smartphone users report having looked up health information for conditions (Smith, 2015). Eighty-five percent of smartphone users are young adults, and the prevalence of mobile phone and app use is estimated to increase (Smith, 2015). A feasibility study by Mulvaney et al. (2013) explored ecological momentary assessment using mobile phones to identify the characteristics of decision-making and adherence. In addition to assessing adherence to asthma medications, Mulvaney et al. found that mobile phone ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 14 apps may help assess adherence to asthma medications and symptoms. The Nhavoto and Gronlund (2014) literature review of 271 studies found that geographical information systems and mobile technologies provide benefits for patients, and improve retention rates and economic gains for providers. According to Nhavoto and Gronlund (2014), "the vast majority of papers report positive results" (para. 5). Information technology advancements now permit low-cost applications that may be supportive in monitoring the patient's condition, providing medication reminders, improving patient/provider communications, and providing warnings of triggers (Eakin & Rand, 2015). However, asthma-specific, evidenced-based mobile applications are somewhat limited (Huckvale, Morrison, Ouyang, Ghaghda, & Car, 2015). An asthma mobile app, such as the Asthma Health (iPhone) by the Icahn School of Medicine at Mount Sinai with Apple Research Kit or AsthmaMD (Androids), provides interactive decision aids for translating knowledge into action with traffic light type patterns to adhere to an AAP (Icahn, 2015; AsthmaMD, 2014; Asthma Ally, 2013; Nieder, 2012). These apps also have reminders, a symptom tracker, flow charts, and the ability to share information with a provider (Apple, 2015; AsthmaMD, 2014; Asthma Ally, 2014; Nieder, 2012). The previously mentioned apps have evidence-based content to facilitate self-management and are free of charge (Icahn, 2015; AsthmaMD, 2014; Nieder, 2012). The Asthma Health app allows patients to be involved in an asthma mobile health study if they choose (Icahn, 2015). The AsthmaMD app has a unique function that can chart peak flow values in addition to tracking symptoms to facilitate self-management (Nieder, 2012; AsthmaMD, 2014). Of the numerous mobile applications available to self-manage asthma, evidence suggests that many apps do not adhere to evidence-based guidelines, do not have tools that are acceptable ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 15 in medical practice, are not easily accessible, or are cost prohibitive (Huckvale, Morrison, Ouyang, Ghaghda & Car, 2015). For this reason, it is imperative providers recommend apps with evidence-based content that are reputable, accessible, and cost effective, in order to effectively improve self-management (Huckvale et al., 2015). Clinic settings are an ideal place to introduce this potentially valuable tool to patients, and determine what patients perceive as benefits and barriers with the use of an asthma mobile app to facilitate the use of their AAP (Baysari & Westbrook, 2015) An effective AAP empowers the patient to take action with pre-arranged, regularly revised guidance (Ring et al., 2012). Having a dynamic tool that has the potential to enhance accurate use of the AAP shows promise (Archambault, 2011; Wiecha et al., 2015). Research of asthma mobile app use for self-management needs to be conducted to determine whether prompting IT tools will increase adherence in this population and if mobile applications are effective for improving self-management decision-making. The majority of the research literature currently available indicates asthma mobile apps show potential to increase asthma control. Many research questions, such as privacy issues, and others not asked herein, need to be thoroughly researched in order to determine how mobile application may impact the selfmanagement of asthma. Theoretical Framework Bandura's theory of self-efficacy (1977) provides a sound theoretical framework for improving the self-management of asthma through mobile applications. Patients who report having higher self-efficacy are found to be more likely to be successful at self-management and have greater asthma control rates (Rastogi & Kipperman, 2013). Self-efficacy is individuals' belief in their ability to have an effect on their environment in order to be effective at a behavior ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 16 and/or reach a goal (Bandura, 1977). According to the theory of self-efficacy, the higher an individual's self-efficacy, the more likely he or she is to obtain the desired behavior or task (Bandura, 1977). Experiences can either increase or decrease one's sense of self-efficacy when undertaking a particular behavior or task (Bandura, 1977). Individuals are more likely to engage in tasks or behaviors when they have a positive experience with the four sources of self-efficacy: observing and learning experiences vicariously, being socially persuaded with positive feedback, having prior experiences of personal success with the task or behavior, and having had positive emotional and physiological experiences that influence a sense of self-efficacy (Bandura, 1977). The self-efficacy theory can be applied to the use of an asthma mobile app to facilitate the AAP. A history of mastering a task has a strong positive effect on self-efficacy. An individual's ability to obtain optimal control of his or her asthma can be enhanced with the mobile app through educational experiences, immediate positive feedback, reminders, alerts, a review of control with flow chart trends, and a method for increased medication adherence. A well-designed asthma mobile app with evidence-based content that is easy to understand and use will provide a good self-management tool that encourages self-efficacy and supports effective emotional and physiologic experiences. ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 17 Implementation Implementation of this DNP project followed presentation of the project to the DNP faculty, with their subsequent approval. See Appendix A. OBJECTIVE #1 Identify appropriate asthma mobile apps with evidence-based content to facilitate use of the asthma action plan in patients >18 years. 1. Asthma mobile apps with evidence-based content, released or updated between 2015-2016, were selected from the most widely used platforms (iOS and Android) for mobile applications. See Appendix B. Eligible apps included for evaluation are appropriate for adults, and are available as mobile applications for smart phones or tablets (Android or iOS platform). They are either free or a minimal cost, contain tools and content with one or more features of asthma diagnosis, and offer IT support. Mobile application criteria for exclusion included not being available for approved devices (e.g., smartphone, tablet), not iOS or Android platform-based, had declarations of not for health-related use, had technical ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 18 problems that persist with at least two attempts, were not available in English, or had inappropriate or missing evidence-based content approved by EPR-3 guidelines. Selection was made from the highest rated coverage of the eight domains used in the Huckvale et al. (2015) study: content consistent with approved EPR-3 evidence-based guidelines for self-management, facts about asthma, basics of treatment, how to avoid triggers, how to use interventions, skills for self-management, exacerbation management, action plan roles, and individualized care. Applications were assessed and rated as complete (satisfied criteria), partially complete (some criteria met), or lacking (few or no criteria met). An assessment rating of the apps was given for accuracy and appropriate advice with regard to consistency or inconsistency of essential evidence (e.g., only relevant for severe asthma). Function and ease of use (e.g., software issues) were also assessed using a Likert scale of 1-5, with 5 being easiest to use and 1 being very difficult to use. The two highest rated apps selected were Asthma MD and Asthma Ally. 2. The University of Utah IRB granted approval to conduct this research project. Intermountain Health Care's (IHC) IRB also gave approval to conduct this research project at an IHC facility. See Appendix C. OBJECTIVE #2 Educate patients regarding the potential benefits of using each selected asthma mobile app with evidence-based content to facilitate the use of their asthma action plan for selfmanagement. ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 19 1. Talking-point handouts of the two-selected asthma mobile apps for the most common platforms (Android and iOS) were developed to present hands-on learning to participants See Appendix D. Content expert and clinic stakeholders approved the handouts. 2. A request to conduct the projects research at the Allergy and Asthma Clinic in Salt Lake City, Utah was made to the clinic director. 3. Patients 18 years and up were recruited using convenience sampling at the Asthma and Allergy Clinic during their clinic appointment. All participants received an introductory study cover letter along with the app handouts. See Appendix E. 4. The educational component of the project proceeded as follows: (a) provision of an informative and constructive discussion and adequate information about the study, as well as replies to participant questions to ensure understanding; (b) sharing of the asthma mobile apps (AsthmaMD and Asthma Ally) via hands-on learning with each participant; and (c) demonstration of the benefits of using an asthma mobile app for self-management to facilitate participants' use of their asthma action plan (AAP). The participants' informed rights and privacy protection of the project proceeded as follows: (a) right to withdraw from the study at any time; (b) voluntary participation in a written survey served as implied consent for participation; (c) no information that might identify participants obtained; (d) surveys stored on a secured computer file password protected; (e) survey file contents destroyed at the end of data collection. ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 20 OBJECTIVIE #3 Identify patient-perceived benefits of each selected asthma mobile app to facilitate selfmanagement. 1. Participant surveys consisted of questions rated on Likert and binary scales and included open-ended questions. See Appendix F. Questions were designed to determine patients' perceived benefits and barriers to using an asthma mobile app. Questions included: Do you use a smartphone app to help manage your asthma, yes/no; If so, how do you benefit from the use of this app; If not, would you consider using an app, yes/no; If not, list reason(s) for not using an app; Are there features in these apps you would use, such as tracking medication use or reminder; If so, what other features, and which app has these features. 2. Surveys administered to participants after a hands-on learning demonstration of the selected asthma mobile apps in clinic to identify patient perceived benefits to using an asthma mobile app for self-management. OBJECTIVE #4 Disseminate this project's results to the clinic stakeholders and at a professional conference. 1. This doctoral project was further disseminated by providing clinic stakeholders with the project results by email. 2. Application was made to a professional conference to present the project findings for additional dissemination. ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 21 Evaluation OBJECTIVE #1 Identify appropriate asthma mobile apps with evidence-based content to facilitate use of the asthma action plan in patients >18 years. 1. The content expert and clinic stakeholders approved the selected appropriate asthma mobile apps evaluation and/or ratings. 2. The University of Utah and Intermountain Health Care IRB boards provided approval exemption. OBJECTIVE #2 Educate patients regarding the potential benefits of using each selected asthma mobile app with evidence-based content to facilitate the use of their asthma action plan for selfmanagement. 1. The content expert and stakeholders approved the designed talking-point handouts before distribution of the handouts to the participants. 2. The Salt Lake City Allergy and Asthma Clinic gave verbal approval to conduct this project at the Clinic. 3. This project was conducted at the approved asthma clinic, and hands-on learning of two selected asthma apps was provided to a convenience sample of 11 patients in the clinic regarding the potential benefits associated with using an asthma app for self-management. OBJECTIVE #3 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 22 Identify patient-perceived benefits of each selected asthma mobile app to facilitate selfmanagement. 1. The project chair and content expert reviewed and approved the survey, including the Likert and binary scales. and open-ended questions, was provided to the project chair and content expert for their review and approval was obtained. 2. Completed surveys were analyzed with descriptive statistics, T-tests, and common themes were identified from the open-ended questions, to evaluate the results of the patient-preferred apps and the perceived benefits to using an asthma mobile app. See Appendix G. OBJECTIVE #4 Disseminate this project's results to the clinic stakeholders and at a professional conference. 1. The survey results were provided to the content expert, clinic stakeholders, and project chair by email. See Appendix H. 2. A copy of an application to a professional conference was provided to the project chair for confirmation of intent to further disseminate this project. See Appendix I. Objectives Identified appropriate asthma mobile apps with evidencebased content to facilitate use of the asthma action plan in patients >18 years. Implementation 1. Conducted evaluation of asthma mobile apps with 8 domain criteria used by Huckvale et al. (2015) to find most appropriate evidencebased content asthma mobile app to demonstrate to patients. 2. Application made to the U of U and IHC IRB. Evaluation 1. Content expert and clinic stakeholders granted approval after review of evidence of appropriate asthma mobile app. 2. Approval received from U of U and IHC IRB. ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT Educated patients regarding the potential benefits of using each selected asthma mobile app with evidence-based content to facilitate self-management. Identified patient-perceived benefits of each selected asthma mobile app to facilitate self-management. Disseminated project results to clinic stakeholders and professional conference. 23 1. Developed talking-point handouts to educate patients regarding mobile apps and self-management. 2. Obtained clinic director's permission to conduct research. 3. Used hands-on learning and educated convenience sample of 11 patients in clinic about potential benefits associated with using asthma app for selfmanagement. 1. Developed a survey with Likert scale, binary scale, and open-ended questions to identify perceived benefits to using an asthma mobile app. 2. Surveyed participants regarding perceptions of asthma apps for selfmanagement. 1. Content expert and stakeholders approved talking-point handouts. 2. Received verbal approval from clinic director. 3. Provided hands-on learning to 11 participants. 1. Further dissemination of project accomplished by providing clinic stakeholders with project results. 2. Application made to present at professional conference for further dissemination of results. 1. Copy of project results shared with clinic stakeholders and application to professional conference provided to project chair for confirmation of intent to further disseminate project. 1. Received survey approval from content expert and project chair. 2. Descriptive statistics, T tests, and common themes used for analysis of survey results. Results A keyword (e.g., asthma, asthma management) search was conducted with both Google search and iOS App store to determine what asthma mobile apps are available with Android and iOS platforms. The keyword searches resulted in 207 apps. An analysis of the search results was conducted as described above for this study. ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 24 Of the 207 apps found with keyword word searches, only 16 apps specifically targeted the improvement of asthma and contained EPR-3 evidence. Searches in Google resulted in 16 apps not related to health, 55 not in English, and >100 health apps that were not asthma related; however, iOS App store searches usually contained apps related to asthma or asthma management. Of the 16 apps in which various levels of EPR-3 evidence-base content were found, only 5 apps contained content consistent with the 8 domain criteria used by Huckvale et al. (2015) throughout the app. Of these 5 asthma apps, 3 were not available to the public, leaving AsthmaMD and Asthma Ally as the best available asthma mobile apps for this study. The availability of new asthma management apps continues to expand each year. The asthma mobile apps that have managed to stay available and receive high user ratings have improved over time with multiple revisions, updates, and continued research. It is imperative that technical support is maintained, software updates continue, and patient feedback is incorporated in subsequent updates to improve software (e.g., reduce glitches) and potentially add helpful content and function. Eleven patients with asthma between the ages of 18-54 received a hands-on demonstration and survey. Of the 11 surveyed, 3 were male and 8 females. All 11 participants reported owning a cell phone of various types. Three participants reported having never downloaded a health-related app before. Fifty-five percent of participants reported using their health-related app regularly. One participant reported having downloaded an asthma app after the hands-on demonstration. Ten participants expressed interest in downloading an asthma mobile app to assist in self-management of their asthma. The patient survey questions analyzed with T-tests identified four areas with statistical significance. See Appendix D. Three of these areas were in favor of the AsthmaMD app and 1 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 25 was in favor of the Asthma Ally app. AsthmaMD was considered most helpful to learn about asthma (T = -3.1305, p-value = 0.005332), for reminding patients to take their medication(s) (T = -3.1717, p-value = 0.005519), and for tracking medication adherence (T = -2.5767, p-value = 0.02138). Asthma Ally's feature for notifying of environmental warnings was found to be most helpful (T = 3.0143, p-value = 0.01004) among those surveyed. The asthma app overall preferred by participants was the AsthmaMD app; however, AsthmaMD does not have an environmental conditions function. A common theme found with open ended questions included an expressed desire to have one asthma mobile app that included all four of the areas that were found to be statistically significant. Future Recommendations The study of asthma mobile apps is still in its infancy and will likely continue to evolve. This is a small study of 11 participants. Conducting this study on a larger scale would likely provide additional evidence on patient perceptions of asthma mobile apps for self-management of asthma control. Future studies of the use of asthma mobile apps for self-management should be conducted to assess patient outcomes. DNP Essentials Essential III: Clinical Scholarship and Analytical Methods for Evidence-Based Practice was used as a method to critically evaluate available literature, to determine the best evidence is being employed to decrease poor asthma control rates (AACN, 2006). A thorough literature review determined the best evidence-based guidelines to obtain optimal asthma control and the content criteria for evaluation of available asthma mobile apps. Evidence-based guidelines by EPR-3, based on the findings of the literature review and focused on improving practice and increasing patient self-efficacy, provided the foundation for asthma mobile app content criteria. ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 26 The analysis of health-based mobile applications for a specific patient population (AACN, 2006) addressed Essential V: Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Health. An assessment of available mobile applications design, evidence-base content, functionality, cost-effectiveness, and patient perception of supportive patient care technology/information systems helped determine the benefits of the mobile apps for patients (AACN, 2006). An interactive self-management information system/technology tool provided the opportunity for patients to improve their selfmanagement and for providers to engage in collaborative care (AACN, 2006). Essential VII: Clinical Prevention and Population Health for Improving the Nation's Health was included through analysis of biostatistical, environmental, epidemiological, and other scientific data to aid in the development of this study assessment of population health and clinical prevention (AACN, 2006). Conclusions Patients who are interested in having convenient technology to assist in managing their asthma face a plethora of available mobile applications. Sifting through what appears to be an endless sea of mobile applications increases the risk of choosing an inappropriate app that may be harmful instead of helpful. In a world where technology is used in almost every facet of life, it is reasonable for health care providers to be prepared to recommend an asthma mobile app that has evidence-based content, is user friendly, has good technical support, and is best suited to improve asthma self-management. Beyond this project's first stage of identifying apps that contain evidence-based content, those who use asthma mobile apps and those who do not, and the perceived benefits and barriers of use, a second stage should include assessing patient ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT outcomes among those who do use asthma mobile apps to determine if mobile applications are an effective method to encourage patient use of their asthma action plan. 27 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 28 References American Association of Colleges of Nursing(AACN). (2006). The essentials of doctoral education for advanced practice nursing. Retrieved from http://www.aacn.nche.edu/dnp/Essentials.pdf. Archambault, P. M. (2011). WikiBuild: A new application to support patient and healthcare professional involvement in the development of patient support tools. Journal of Medical Internet Research, 13(4), e114. doi: 10.2196/jmir.1961 Asthma Ally. (2013). 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Asthma self-management education and environmental management: Approaches to enhance reimbursement. Retrieved from http://www.cdc.gov/asthma/pdfs/Asthma_Reimbursement_Report.pdf ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 29 Center for Disease Control. (2017). Most recent asthma data. Retrieved from http://www.cdc.gov/asthma/most_recent_data.htm Eakin, M. N., & Rand, C. S. (2012). Improving patient adherence with asthma self-management practices: What works?. Annals of Allergy, Asthma & Immunology, 109((2), 90-92. doi: 10.1016/j.anai.2012.06.009 Elias, P., Rajan, N. O., McArthur, K., & Dacso, C. C. (2013). InSpire to promote lung assessment in youth: Evolving the self-management paradigms of young people with asthma. Medicine 2.0, 2(1), e1. doi: 10.2196/med20.2014 Global Initiative for Asthma. (2016). Global strategy for asthma management and prevention (2016 update). Retrieved from http://www.ucalgary.ca/icancontrolasthma/files/icancontrolasthma/wms-gina-2016-mainreport-final.pdf Huckvale, K., Morrison, C., Ouyang, J., Ghaghda, A., & Car, J. (2015). The evolution of mobile apps for asthma: An updated systematic assessment of content and tools. BMCMedicine, 13, 58. doi: 10.1186/s12916=015-0303-x Icahn School of Medicine. (2015). Asthma mobile health study. Retrieved from http://apps.icahn.mssm.edu/asthma/ Krebs, P., & Duncan, D. T. (2015). Health app use among US mobile phone owners: A national survey. Journal of Medical Internet Research, 3(4), e101. doi: 10.2196/mhealth.4924 Licskai, C. J., Sands, T. W., & Ferrone, M. (2013). Development and pilot testing of a mobile health solution for asthma self-management: Asthma action plan smartphone application pilot study. Canadian Respiratory Journal, 20(4), 301-306. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3956342/ ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 30 Martinez-Perez, B., de la Torre-Diez, I., & Lopez-Coronado, M. (2013). Mobile health applications for the most prevalent conditions by the World Health Organization: Review and analysis. Journal of Medical Internet Research, 15(6), e120. doi: 10.2196/jmir.2600 Mulvaney, S. A., Ho, Y. X., Cala, C. M., Chen, Q., Nian, H., Patterson, B. L., & Johnson, K. B. (2013). Assessing adolescent asthma symptoms and adherence using mobile phones. Journal of Medical Internet Research, 15(7), e141. doi: 10.2196/jmir.2413 Nieder, K. (2012). AsthmaMD is a well-designed free patient app for use in monitoring asthma. Retrieved from http://www.asthmamd.org/ Nhavoto, J. A., & Gronlund, A. (2014). Mobile technologies and geographic information systems to improve health care systems: A literature review. Journal of Medical Internet Research, 2(2), e21. doi: 10.2196/mhealth.3216 National Heart Lung Blood Advisory Council (NHLBAC). (2015). Needs assessment report for potential update of the expert panel report-3 (2007): Guidelines for the diagnosis and management of asthma January 2015. Retrieved from http://www.nhlbi.nih.gov/sites/www.nhlbi.nih.gov/files/Asthma-Needs-AssessmentReport.pdf National Heart Lung Blood Institute (NHLBI). (2012). Asthma care quick reference: Diagnosing and managing asthma (NIH Publication No. 12-5075). Retrieved from https://www.nhlbi.nih.gov/files/docs/guidelines/asthma_qrg.pdf Panzera, A. D., Schneider, T. K., Martinasek, M. P., Lindengerger, J. H., Couluris, M., Bryant, C. A., & McDermott R. J. (2013). Adolescent asthma self-management: Patient and parent-caregiver perspectives on using social media to improve care. Journal of School Health, 83(12), 921-930. doi: 10.1111/josh.12111 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 31 Pinnock, H., Epiphaniou, E., Pearce, G., Parke, H., Greenhalgh, T., Sheikh, A., Griffiths, C. J., & Taylor, S. J. (2015). Implementing supported self-management for asthma: A systematic review and suggested hierarchy of evidence of implementation studies. BMC Medicine, 13(127), doi: 10.1186/s12916-015-0361-0 Rastogi, D., Madhok, N., & Kipperman, S. (2013). Caregiver asthma knowledge, aptitude, and practice in high healthcare utilizing children: Effect of an educational intervention. Pediatric Allergy, Immunology, and Pulmonology, 26(3), 128-139. doi:10.1089/ped.2013.0226 Ring, N., Jepson, R., Pinnock, H., Wilson, C., Hoskins, G., Wyke, S., & Sheikh, A. (2012). Developing novel evidence-based interventions to promote asthma action plan use: A cross-study synthesis of evidence from randomized controlled trials and qualitative studies. BMC Medicine, 13: 216. doi: 10.1186/1745-6215-13-216 Smith, A. (2015). U.S. smartphone use in 2015. Retrieved from http://www.pewinternet.org/2015/04/01/us-smartphone-use-in-2015/ Wiecha, J. M., Adams, W. G., Rybin, D., Rizzodepaoli, M., Keller, J., & Clay, J. M. (2015). Evaluation of a web-based asthma self-management system: A randomized controlled pilot trial. BioMed Central Pulmonary Medicine, 15, 17. doi: 10.1186/s12890-015-00071 Wilson, S. R., Strub, P., Buist A. S., Knowles, S. B., Lavori, P. W., Lapidus, J., & Vollmer, W. M. (2010). Shared treatment decision making improves adherence and outcomes in poorly controlled asthma. American Journal of Respiratory Critical Care Medicine, 181(6), 566-577. doi: 10.1164/rccm.200906-0907OC ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 32 Zolnierek, K. B. H., & DiMatteo, M. R. (2009). Physician communication and patient adherence to treatment: A meta-analysis. Medical Care, 47(8), 826-834. doi: 10.1097/MLR.0b013e31819a5acc ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT Appendix A Defense PowerPoint Presentation 33 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 34 Running Head: ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 35 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 36 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT Appendix B Asthma Mobile Apps Selection Summary 37 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 38 Asthma Mobile Apps Selection Summary ASTHMA APPS COMPARED FOR 8 DOMAINS OF EVIDENCE-BASED CONTENT 8 My Breathefree (Cipla Digital) 1 My Asthma Score (Azzam Enajjar) 1 My Asthma Manager (@Point of Care) 1 1 3 Lung Manager (AstraZeneca) 6 Connolly Asthma App (URXmobile System) 1 Breathcount/Asthma (Segofoltas) 4 1 Asthma Tracker (Kantonsspital Baselland) 2 Asthma Track (dangerDown LLC) 2 1 Asthma Storyline (Self Care Catalysis) 2 Asthma Plus (Qurasoft GmbH) 2 1 8 Asthma MD (Asthma MD) 8 Asthma Health App (Icahn School of Medicine Mount Sinai) 1 Asthma Guide (Nicholas Gab) 2 7 Asthma Ally (OSIA Media) 6 Allergy Partners APpal (URXmobile Systems) 1 Advocate Asthma Coach (URXmobile Systems) 6 1 0 1 2 3 4 5 6 7 Most Complete More Complete Neutral Somewhat Complete Least Complete Not Available to U.S. General Public 8 9 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT Appendix C IRB Exemptions 39 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 40 IRB:IRB_00089039 PI:Lilia Buchmuller Title:Asthma Mobile Applications to Improve Self-Management Date:1/5/2017 This Amendment Application (Cover Letter change to contact IHC IRB regarding rights) qualifies for an expedited review by a designated University of Utah IRB member according to University IRB policy. The designated IRB member has reviewed and approved your amendment request for this study on 1/5/2017. The approval of the amendment is effective as of 1/5/2017. The approval of this amendment request does NOT change the exemption status of this study under Exemption Category 2. Note the following delineation of categories: • • Categories 1-6: Federal Exemption Categories defined in 45 CFR 46.101(b) Categories 7-11: Non-Federal Exemption Categories defined in University of Utah IRB policy at http://irb.utah.edu/_pdf/IGS-ExemptResearch.pdf You must adhere to all requirements for exemption described in University of Utah IRB policy (http://irb.utah.edu/_pdf/IGS-ExemptResearch.pdf ). This includes: • • • All research involving human subjects must be approved or determined exempt by the IRB before the research is conducted. All research activities must be conducted in accordance with the Belmont Report and must adhere to principles of sound research design and ethics. Orderly accounting and monitoring of research activities must occur. Ongoing Submissions for Exempt Projects • • Continuing Review: Since an exemption determination is not an approval, the study does not expire or need continuing review. This determination of exemption from continuing IRB review only applies to the research study as submitted to the IRB. You must follow the protocol as proposed in the application. Amendment Applications: Substantive changes to this project require an amendment application to the IRB to secure either approval or a determination of exemption. Investigators should contact the IRB Office if there are questions about whether an amendment consists of substantive changes. Substantive changes include, but are not limited to: o Changes to study personnel (to secure Conflict of Interest review for all personnel on the study) o Changes that increase the risk to participants or change the risk:benefit ratio of the study o Changes that affect a participant's willingness to participate in the study ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT Changes to study procedures or study components that are not covered by the Exemption Category determined for this study (listed above) o Changes to the study sponsor o Changes to the targeted participant population o Changes to the stamped consent document(s) Report Forms: Exempt studies must adhere to the University of Utah IRB reporting requirements for unanticipated problems and deviations: http://irb.utah.edu/submitapplication/forms/index.php Final Project Reports for Study Closure: Exempt studies must be closed with the IRB once the research activities are complete: http://irb.utah.edu/submit-application/finalproject-reports.php If you have questions about this, please contact our office at 581-3655 and we will be happy to assist you. Thank you again for submitting your proposal. o • • 41 Click IRB_00089039 to view the application and access the approved documents. Please take a moment to complete our customer service survey . We appreciate your opinions and feedback. ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 42 December 05, 2016 IRB # 1050352 Study Alias: Asthma apps and self-management PI: Lilia Buchmuller Title: Asthma Mobile Applications to Improve Self-Management Initial Application Exempt Determination IHC IRB (Corporate) Acknowledged: 12/01/2016 Submission Reference #: 009215 The above-mentioned project has been reviewed by a member of the Intermountain Healthcare Institutional Review Board and it has been determined the project is exempt from 45 CFR 46 per category 45 CFR 46.101(b)(2). If the scope of your project changes, please contact the Office of Research immediately to ensure you do not need IRB approval or a Waiver of Authorization from the Privacy Board to continue with this project. If you have any questions regarding this decision please contact the IRB analyst assigned to your study, Christopher Sisneros or call the IRB Office at [phone] opt. 1. ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT Appendix D Talking Point Handouts 43 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT Asthma Ally Mobile App Download app to electronic device [Android or Apple (iOS)] Create account with e-mail address and password Create Profile PROFILE: MANAGE PROFILE: 44 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT HOME: How do you feel today? Evaluation? Exposures? How well is your asthma controlled? 45 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT Asthma Control Test HEALTH CARE PROVIDERS: Add your Doctor 46 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT ANALYSIS OF TRENDS: Graphs and charts of Your Asthma History and Triggers 47 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT AsthmaMD Mobile App Download app to electronic device [Android or Apple (iOS)] Create account with e-mail address and password Create Profile Provide profile information to personalize the app and choose a password. Remember the password. You cannot obtain access the encrypted diary without it. You can also choose to enter your highest FEV1 value, and highest peak flow value. Manage medications details and reminders (form (pills/inhaler), frequency, dosage, administration). If you have been issued an asthma action plan by your provider Enter your action plan details into AsthmaMD action plan. 48 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT The Asthma Action Plan mode in Asthma MD has a dual mode screen. Tap on action plan at the bottom of the screen to enter the action plan. In the Action Plan you are in a dual screen mode (vertical and horizontal). In a vertical position you will have access to the interactive action plan. 49 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 50 In the horizontal mode you can view your full action plan and obtain information in each zone by scrolling up and down. To obtain more information in each zone tap in the color on the left. To collapse the color tap in the white area of the screen. Return to the vertical position to navigate out of the action plan ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 51 Keep track of peak flow, symptoms, triggers, and medications. Tracking your peak flow readings can create a graph. The data entered can be shared with your provider through an encrypted portal. You can choose what information is shared. ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT Appendix E Cover Letter 52 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 53 Consent Cover Letter Asthma Mobile Applications to Improve Self-Management The purpose of the project is to identify a few asthma mobile applications (apps) that have information based on medical evidence, are easy to use, and designed to assist patients in obtaining good asthma control. The identified evidence-based apps will be shared with participants to educate them of the potential benefits associated with app use to daily track symptoms, medication administration, identifying triggers, obtain alerts of environmental risk factors, sharing relevant information to coordinate with participant's provider to reduce asthma exacerbations, and overall improve self-management of asthma. After participants receive highlights of each asthma app, participants will be asked to fill out a short survey to determine what they like and didn't like about the apps. The app with the least barriers and highest rated ease of use can then be confidently recommended by providers as a tool to provide solutions to overcome self-management barriers, and facilitate use of individualized AAP's. A short survey will be provided after receiving education regarding 2 asthma mobile applications (apps). We would like to ask that you consent to completing the survey to help find which features you think will be most helpful for reaching optimal asthma control. The survey contains 10 questions and should not take more than 10 minutes to complete. You will not be ask to include any unique identifying information. No anticipated risks are associated with completing the survey. The survey will only be available to the principle investigator, project chair, and content experts. If you should have any questions or concerns related to the survey, or if you feel you have been harmed by this research please contact Jennifer Hamilton, DNP, PNP at the University of Utah 801-232-1665 or by email at [e-mail] If you have questions regarding your rights as a research subject or if problems arise which you do not feel you can discuss with the Investigator, please contact Intermountain's Office of Research at 1-800-321-2107. If you have any complaints, concerns, or questions, which you feel the investigator did not discuss, please contact the IRB. The University of Utah's IRB can be reached at [phone] or by email at [e-mail] The survey should only take 10 minutes to complete. Your participation in this project is voluntary. You do not have to participate. You can stop taking the survey at any time, and may skip or omit any part of the survey you choose without any penalty or loss of benefits... You are giving your consent by completing the survey. Thank you for your time and for completing the survey. ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT Appendix F Patient Survey 54 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 55 Asthma Mobile Applications Survey Age Range (Please Circle) 18-29 30-44 45-54 55-64 65-75 76 or older Sex (Please Circle) Male Female 1. Do you own a cell phone, tablet/iPad, or PDA? Yes No If no, skip to question 4 If yes, circle type of platform: Android iPhone Other: ________________________________________________________________________ 2. Have you ever down loaded a health care related mobile application (app), such as for weight management, diabetes management, education about medical conditions, etc.? Yes No If yes, what app? _______________________________________________________________ If yes, do you use the app regularly? No Yes If yes, how often? (daily, weekly, monthly, other): ____________________________________ 3. Have you ever down loaded an asthma management app? Yes No If yes, what app? _______________________________________________________________ If yes, do you use the app regularly? No Yes If yes, how often? (daily, weekly, monthly, other): ____________________________________ Please rate the following asthma app features for App A and App B on a scale of 1-5 with 1 being very helpful, 5 being not helpful at all: Example to rate 2 different exercise apps: Do you think an exercise app would help motivate you to exercise? (Circle appropriate rating for each app) ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT App A 1 (very helpful) 2 (Somewhat helpful) 3 (Neutral) 4 (Not very helpful) 5 (Not helpful at all) App B 1 (very helpful) 2 (Somewhat helpful) 3 (Neutral) 4 (Not very helpful) 5 (Not helpful at all) 4. Do you feel this app would help you learn about asthma? (Circle appropriate rating for each app) App A 1 (very helpful) 2 (Somewhat helpful) 3 (Neutral) 4 (Not very helpful) 5 (Not helpful at all) App B 1 (very helpful) 2 (Somewhat helpful) 3 (Neutral) 4 (Not very helpful) 5 (Not helpful at all) 5. Do you feel this app would assist you in managing your asthma? App A 1 (very helpful) 2 (Somewhat helpful) 3 (Neutral) 4 (Not very helpful) 5 (Not helpful at all) App B 1 (very helpful) 2 (Somewhat helpful) 3 (Neutral) 4 (Not very helpful) 5 (Not helpful at all) 6. Do you feel this app would assist in tracking triggers to your asthma? App A 1 (very helpful) 2 (Somewhat helpful) 3 (Neutral) 4 (Not very helpful) 5 (Not helpful at all) App B 1 (very helpful) 2 (Somewhat helpful) 3 (Neutral) 4 (Not very helpful) 5 (Not helpful at all) 7. Do you feel this app would be helpful with reminding you to take asthma medication? App A 1 (very helpful) 2 (Somewhat helpful) 3 (Neutral) 4 (Not very helpful) 5 (Not helpful at all) 56 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT App B 1 (very helpful) 2 (Somewhat helpful) 3 (Neutral) 4 (Not very helpful) 5 (Not helpful at all) 8. Do you feel this app would be helpful in tracking your medication? App A 1 (very helpful) 2 (Somewhat helpful) 3 (Neutral) 4 (Not very helpful) 5 (Not helpful at all) App B 1 (very helpful) 2 (Somewhat helpful) 3 (Neutral) 4 (Not very helpful) 5 (Not helpful at all) 9. Do you feel this app would be helpful with notifying you of environmental warnings? App A 1 (very helpful) 2 (Somewhat helpful) 3 (Neutral) 4 (Not very helpful) 5 (Not helpful at all) App B 1 (very helpful) 2 (Somewhat helpful) 3 (Neutral) 4 (Not very helpful) 5 (Not helpful at all) 10. Do you feel this app would be helpful with tracking exacerbation trend reports? App A 1 (very helpful) 2 (Somewhat helpful) 3 (Neutral) 4 (Not very helpful) 5 (Not helpful at all) App B 1 (very helpful) 2 (Somewhat helpful) 3 (Neutral) 4 (Not very helpful) 5 (Not helpful at all) 11. Do you feel this app would be beneficial in evaluating your asthma control? App A 1 (very helpful) 2 (Somewhat helpful) 3 (Neutral) 4 (Not very helpful) 5 (Not helpful at all) App B 1 (very helpful) 2 (Somewhat helpful) 3 (Neutral) 4 (Not very helpful) 5 (Not helpful at all) 12. Do you feel this app would give you better access to your treatment plan? App A 57 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 58 1 (very helpful) 2 (Somewhat helpful) 3 (Neutral) 4 (Not very helpful) 5 (Not helpful at all) App B 1 (very helpful) 2 (Somewhat helpful) 3 (Neutral) 4 (Not very helpful) 5 (Not helpful at all) 13. Do you feel this app would be helpful in coordinating your care with your provider? App A 1 (very helpful) 2 (Somewhat helpful) 3 (Neutral) 4 (Not very helpful) 5 (Not helpful at all) App B 1 (very helpful) 2 (Somewhat helpful) 3 (Neutral) 4 (Not very helpful) 5 (Not helpful at all) 14. Which feature do you believe would be most helpful in managing your asthma? App A: ________________________________________________________________________ Why? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ App B: ________________________________________________________________________ Why? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 15. Are you interested in downloading one of the asthma apps you learned about today to assist in managing your asthma? Yes No If yes, which app would you download? ______________________________________________________________________________ Why? ______________________________________________________________________________ ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 59 ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 16. If you could make changes to Asthma App A what would it be? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 17. If you could make changes to Asthma App B what would it be? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT Appendix G Survey Results 60 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 61 11 STUDY PARTICIPANTS: DISCRIPTIVE STATISTICS Ages 18-29 18% Ages 30-44 45% Ages 45-54 36% Male 27% Female 73% Own a cell phone 100% Downloaded health app 73% Report using app regularly 55% Daily use 45% Weekly use 9% Monthly 9% Other 36% Downloaded Asthma App Before 0% Survey Results with statistical Significance PARTICIPANTS T-TEST SURVEY RESULTS T Test Patient Perceptions Help learn about their asthma P-value T = -3.1305 p-value = 0.005332 T = -3.1717 Medication Reminder p-value = 0.005519 T = -2.5767 Track Med. Adherence Statistical Significance p-value = 0.02138 Statistically Significant in favor of AsthmaMD Statistically Significance in favor of AsthmaMD Statistically significant in favor of AsthmaMD ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT Environmental Triggers Awareness T = 3.0143 p-value = 0.01004 62 Statistically Significant in favor of Asthma Ally OPEN ENDED QUESTION COMMON THEMES Most helpful App Feature Asthma Ally: AsthmaMD: Environmental Trigger Tracking Asthma Action Plan Guide & Asthma Education 45% 64% Interested in downloading asthma management app 91% Interested in using an Asthma App for selfmanagement Likert Scale Analysis with T-Tests T Test/DF/P-value Patient Perceptions Between Selected Apps 95% Confidence Interval T = -3.1305 Help learn about their asthma p-value = 0.005332 T = -0.95831 Help manage asthma p-value = 0.3494 T = 0.48795 Track Triggers p-value = 0.631 T = -3.1717 Medication Reminder p-value = 0.005519 T = -2.5767 Track Med. Adherence p-value = 0.02138 Environmental Triggers Awareness Statistical Significance T = 3.0143 Statistically Significant in favor of AsthmaMD No Statistical Significance No Statistical Significance Statistically Significance in favor of AsthmaMD Statistically significant in favor of AsthmaMD Statistically Significant in favor of Asthma Ally ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT p-value = 0.01004 T=0 Exacerbation Trends Asthma Control Evaluation p-value = 1 T = -0.83045 p-value = 0.4161 T = -0.62622 Access to Treatment Plan p-value = 0.583 T=0 Coordinate Care with Provider p-value = 1 Absolutely no statistical Significance No Statistical Significance No statistical significance Absolutely no statistical Significance Open Ended Question Common Themes Asthma Ally: AsthmaMD: Most helpful App Feature Environmental Trigger Tracking Asthma Action Guide & Education Interested in downloading asthma management app 45% 64% Interested in using an Asthma App 91% 63 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT Appendix H Report to Clinic Stakeholders 64 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 65 Dear Dr. Hendershot and Clinic Stakeholders, I wish to express my gratitude for allowing me to conduct my DNP project study at your clinic. Your assistance was greatly appreciated. Your staff was very helpful and valuable. I could not have completed this study without your generous cooperation. I have included the study findings from the 11 participants surveyed in chart form below. Please feel free to contact me with any questions you may have. Best Regards, Lilia Buchmuller, RN, BSN ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 11 STUDY PARTICIPANTS: DISCRIPTIVE STATISTICS Ages 18-29 18% Ages 30-44 45% Ages 45-54 36% Male 27% Female 73% Own a cell phone 100% Downloaded health app 73% Report using app regularly 55% Daily use 45% Weekly use 9% Monthly 9% Other 36% Downloaded Asthma App Before 0% Likert Scale T-Test Analysis T Test/DF/P-value Patient Perceptions Between Selected Apps 95% Confidence Interval T = -3.1305 Help learn about their asthma p-value = 0.005332 T = -0.95831 Help manage asthma p-value = 0.3494 T = 0.48795 Track Triggers Statistical Significance p-value = 0.631 Statistically Significant in favor of AsthmaMD No Statistical Significance No Statistical Significance 66 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT T = -3.1717 Medication Reminder p-value = 0.005519 T = -2.5767 Track Med. Adherence p-value = 0.02138 Environmental Triggers Awareness T = 3.0143 p-value = 0.01004 T=0 Exacerbation Trends Asthma Control Evaluation p-value = 1 T = -0.83045 p-value = 0.4161 T = -0.62622 Access to Treatment Plan p-value = 0.583 T=0 Coordinate Care with Provider p-value = 1 Statistically Significance in favor of AsthmaMD Statistically significant in favor of AsthmaMD Statistically Significant in favor of Asthma Ally Absolutely no statistical Significance No Statistical Significance No statistical significance Absolutely no statistical Significance Open Ended Question Common Themes Asthma Ally: AsthmaMD: Most helpful App Feature Environmental Trigger Tracking Asthma Action Guide & Education Interested in downloading asthma management app 45% 64% Interested in using an Asthma App 91% 67 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT Appendix I Professional Conference Application Submission 68 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 69 (Abstract) ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT Lilia Buchmuller, RN, BSN, DNP-FNP Student University of Utah College of Nursing 10 S 2000E, Salt Lake City, Utah, 84112, USA 801-628-3876 | [e-mail] Purpose: The purpose of this project was to identify asthma mobile applications (apps) with evidence-based content and evaluate the perceived benefits associated with using an asthma mobile app for self-management. The findings of this project will help health care providers confidently recommend patients an available app with the most benefits and appreciable ease of use, to facilitate use of their individualized asthma action plans (AAP). Background: Over 17 million adults are reported by the Center for Disease Control in 2015. Adult patients with asthma can face many barriers to utilizing their AAP, such as unfamiliarity with how to use the plan and forgetting to take their medications. Patients may also be unaware of symptom trends and peak flow changes, which can lead to exacerbations. Patients can have difficulty recalling the frequency and duration of asthmatic exacerbations, night awakenings, and level of limited activity with exacerbations. Accurate recall of asthma exacerbations is vital, but can also be challenging for patients. Multiple asthma mobile apps are available with minimal research undertaken to narrow the selection to evidence-based content apps that are patientpreferred. Method: The project objectives included (a) identification of appropriate asthma mobile apps that have evidence-based content to facilitate use of the asthma action plan in patients >18 years; (b) education of patients with asthma regarding the potential benefits of using each selected asthma mobile app to facilitate self-management; (c) assessment and evaluation of patientperceived benefits through a post-questionnaire with descriptive statistics and T-Tests to determine perceived app benefits and the app most preferred by patients; and (d) dissemination of the project results to the participating asthma clinic and a professional conference. Results: Two evidence-based mobile apps were selected to present to patients. These two apps were found to have the most complete evidence-based content available to the public. Each app can assist a patient to keep accurate self-recorded history to document medication adherence, symptoms, and exacerbations. Several functions found to be patient preferred with statistical significance are available in AsthmaMD. These functions include various ways for patients to learn about their asthma, a medication reminder, and monitoring medication adherence. Patient preference to have access to an environmental conditions monitor was found with statistical significance in the Asthma Ally. AsthmaMD was reported by 64% of patients as having the most helpful app functions. Ninety-one percent of the participants expressed interested in using an asthma app for self-management of their asthma. ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 70 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT Appendix J Project Defense Poster 71 ASTHMA MOBILE APPLICATIONS TO IMPROVE SELF-MANAGEMENT 72