Browsing by Author "Mirro, Michael J."

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    Achieving Guideline-Directed Heart Rate Control Early Posthospitalization
    (Elsevier, 2019) Jungbauer, Carsten; Maier, Lars S.; Emoto, Kikuo; Zirille, Francis M.; Mirro, Michael J.; Medicine, School of Medicine
    Guidelines for the treatment of heart failure (HF) recommend the titration of β blockers (BB) to a target dosage shown to be effective in clinical trials. The benefit of BBs is associated with heart rate (HR) control, with a target resting HR <70 bpm which in clinical trials have been associated with improved clinical outcomes. The primary purpose of this study was to gauge the ability to achieve guideline-directed medical therapy HR control in the early posthospitalization period for HF patients with the wearable cardioverter defibrillator (WCD), assessing whether the WCD could be used to evaluate HR both at rest and during activity to determine if targets were being met and to adequately direct clinical decision making. The WCD platform allows continuous recording of HR. To assess the guideline-directed therapy goals for reduction of resting HR, HR was evaluated both at rest (nighttime: midnight-7 a.m.; daytime: 7 a.m. midnight), and during activity of daily living. HR data during activity of daily living (ADL) and rest were collected from patients with HF that wore the WCD for ≥5 weeks (n = 1,353) between 2015 and 2017. First, 643,891 activity episodes from 1,353 patients were analyzed. Daytime and nighttime resting HRs significantly dropped from beginning to end of WCD use (day: 72.5 bpm vs 69.0 bpm, p <0.0001; night: 68.1 vs 64.3, p <0.0001). However, 43% of patients still had an average daytime resting HR ≥70 bpm during the last week of WCD use. When comparing a patient’s peak activity HR during the first week of WCD use to the last week, there was no difference (93.6 bpm vs 94.1 bpm, p = 0.23). During ADL, 31% of patients had a HR ≥100 bpm, 14% of patients had a HR ≥110 bpm, and 6% had a HR ≥120 bpm. In conclusion, months after hospital discharge, 43% of patients did not meet guideline-directed resting target HR control, indicating they may not have been effectively managed with BB. HR during ADL may have also been higher than preferred. Remote HR monitoring may help physicians to adequately titrate guideline-directed medical therapy, thus improving clinical outcomes in HF patients.
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    Erratum to: Providing Patients with Implantable Cardiac Device Data through a Personal Health Record: A Qualitative Study
    (Thieme Medical Publishers, 2017-10) Daley, Carly N.; Chen, Elizabeth M.; Roebuck, Amelia E.; Ghahari, Romisa Rohani; Sami, Areej F.; Skaggs, Cayla G.; Carpenter, Maria D.; Mirro, Michael J.; Toscos, Tammy R.; BioHealth Informatics, School of Informatics and Computing
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    Impact of electronic personal health record use on engagement and intermediate health outcomes among cardiac patients: a quasi-experimental study
    (Oxford University Press, 2016-01) Toscos, Tammy; Daley, Carly; Heral, Lisa; Doshi, Riddhi; Chen, Yu-Chieh; Eckert, George J.; Plant, Robert L.; Mirro, Michael J.; Biostatistics, School of Public Health
    Objectives: To determine the impact of tethered personal health record (PHR) use on patient engagement and intermediate health outcomes among patients with coronary artery disease (CAD). Methods: Adult CAD patients (N = 200) were enrolled in this prospective, quasi-experimental observational study. Each patient received a PHR account and training on its use. PHRs were populated with information from patient electronic medical records, hosted by a Health Information Exchange. Intermediate health outcomes including blood pressure, body mass index, and hemoglobin A1c (HbA1c) were evaluated through electronic medical record review or laboratory tests. Trends in patient activation measure® (PAM) were determined through three surveys conducted at baseline, 6 and 12 months. Frequency of PHR use data was collected and used to classify participants into groups for analysis: Low, Active, and Super users. Results: There was no statistically significant improvement in patient engagement as measured by PAM scores during the study period. HbA1c levels improved significantly in the Active and Super user groups at 6 months; however, no other health outcome measures improved significantly. Higher PAM scores were associated with lower body mass index and lower HbA1c, but there was no association between changes in PAM scores and changes in health outcomes. Use of the PHR health diary increased significantly following PHR education offered at the 6-month study visit and an elective group refresher course. Conclusions: The study findings show that PHR use had minimal impact on intermediate health outcomes and no significant impact on patient engagement among CAD patients.
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    Naturalistic Decision Making in Everyday Self-care Among Older Adults With Heart Failure
    (Wolters Kluwer, 2020-12-23) Daley, Carly N.; Cornet, Victor P.; Toscos, Tammy R.; Bolchini, Davide P.; Mirro, Michael J.; Holden, Richard J.; Regenstrief Institute, School of Medicine
    BACKGROUND: Every day, older adults living with heart failure make decisions regarding their health that may ultimately affect their disease trajectory. Experts describe these decisions as instances of naturalistic decision making influenced by the surrounding social and physical environment and involving shifting goals, high stakes, and the involvement of others. OBJECTIVE: This study applied a naturalistic decision-making approach to better understand everyday decision making by older adults with heart failure. METHODS: We present a cross-sectional qualitative field research study using a naturalistic decision-making conceptual model and critical incident technique to study health-related decision making. The study recruited 24 older adults with heart failure and 14 of their accompanying support persons from an ambulatory cardiology center. Critical incident interviews were performed and qualitatively analyzed to understand in depth how individuals made everyday health-related decisions. RESULTS: White, male (66.7%), older adults' decision making accorded with a preliminary conceptual model of naturalistic decision making occurring in phases of monitoring, interpreting, and acting, both independently and in sequence, for various decisions. Analyses also uncovered that there are barriers and strategies affecting the performance of these phases, other actors can play important roles, and health decisions are made in the context of personal priorities, values, and emotions. CONCLUSIONS: Study findings lead to an expanded conceptual model of naturalistic decision making by older adults with heart failure. In turn, the model bears implications for future research and the design of interventions grounded in the realities of everyday decision making.
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    Patient-centered Design Grounded in User and Clinical Realities: Towards Valid Digital Health
    (Sage, 2019-09) Cornet, Victor P.; Daley, Carly; Bolchini, Davide; Toscos, Tammy; Mirro, Michael J.; Holden, Richard J.; Medicine, School of Medicine
    Valid design of patient-centered digital health or health information technology (IT) systems is based on a thorough and accurate understanding of both “user reality” and “clinical reality.” Type 1 Design Error (User-Reality Error) occurs when designers do not accommodate user characteristics, tasks, context of use, needs, or preferences. Type 2 Design Error (Clinical-Reality Error) occurs when designers do not accommodate the clinical reality, including biomedical knowledge, clinical workflows, and organizational requirements. Both types of errors can invalidate the design, leading to products being rejected by patient end-users or their healthcare delivery systems, product non-use or inappropriate use, and risk of harm. This paper describes our attempts to achieve valid health IT design and avoid the two design errors. We performed iterative, patient-centered design to prototype a mobile application, Power to the Patient (P2P), supporting heart failure self-care management. Our multidisciplinary team of human factors, cardiology, and design experts developed and iteratively refined requirements based on data collection, review, and testing with patient research participants, a patient advisory board, a clinical advisory board, and experts on the team. We describe our process and reflect on working with multiple stakeholders toward the goal of valid health IT design.
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    Providing Patients with Implantable Cardiac Device Data through a Personal Health Record: A Qualitative Study
    (Thieme, 2017-10) Daley, Carly N.; Chen, Elizabeth M.; Roebuck, Amelia E.; Ghahari, Romisa Rohani; Sami, Areej F.; Skaggs, Cayla G.; Carpenter, Maria D.; Mirro, Michael J.; Toscos, Tammy R.; BioHealth Informatics, School of Informatics and Computing
    Erratum to: Providing Patients with Implantable Cardiac Device Data through a Personal Health Record: A Qualitative Study. [Appl Clin Inform. 2017]
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    Untold Stories in User-Centered Design of Mobile Health: Practical Challenges and Strategies Learned From the Design and Evaluation of an App for Older Adults With Heart Failure
    (JMIR Publications, 2020-07-21) Cornet, Victor Philip; Toscos, Tammy; Bolchini, Davide; Ghahari, Romisa Rohani; Ahmed, Ryan; Daley, Carly; Mirro, Michael J.; Holden, Richard J.; Medicine, School of Medicine
    Background User-centered design (UCD) is a powerful framework for creating useful, easy-to-use, and satisfying mobile health (mHealth) apps. However, the literature seldom reports the practical challenges of implementing UCD, particularly in the field of mHealth. Objective This study aims to characterize the practical challenges encountered and propose strategies when implementing UCD for mHealth. Methods Our multidisciplinary team implemented a UCD process to design and evaluate a mobile app for older adults with heart failure. During and after this process, we documented the challenges the team encountered and the strategies they used or considered using to address those challenges. Results We identified 12 challenges, 3 about UCD as a whole and 9 across the UCD stages of formative research, design, and evaluation. Challenges included the timing of stakeholder involvement, overcoming designers’ assumptions, adapting methods to end users, and managing heterogeneity among stakeholders. To address these challenges, practical recommendations are provided to UCD researchers and practitioners. Conclusions UCD is a gold standard approach that is increasingly adopted for mHealth projects. Although UCD methods are well-described and easily accessible, practical challenges and strategies for implementing them are underreported. To improve the implementation of UCD for mHealth, we must tell and learn from these traditionally untold stories.