Wired ran an issue about biggest tech trends for 2017. One of the articles, of course, revolved around smartphones / apps / wearables / sensors. Something about our ability to make healthcare more “quantified.” A fancy way of saying we’ll have increased ability to track various health metrics, and that’ll lead to better health.
The author cited one group who found using Apple Watches, amongst other things, helped their patients maintain healthy blood pressure. Then the author cited another study showing a reduction in hospital readmissions when using an app.
There is an issue with cherry picking here as other mobile health studies find zero benefit, if not detrimental effects. Even other studies which used an app to help with heart failure / hospital readmission find no benefit,
However, the below study did find a 40% reduction in hospital readmission when using an app after suffering a heart attack. That’s worth looking at.
Let’s look at the group who partook in the app process. They input their height, weight, blood pressure, physical activity per day, and diet. They also followed educational materials. The non app group did none of this. They came back a few months after being assessed. That was it.
The non app group was not randomized this way. They chose to not participate. It doesn’t take much thinking to find an obvious potential difference between the group who signs up for this and the group who doesn’t. Bolding mine,
“One of the main limitations of the study is the lack of randomization between the groups. As this was a pilot study, we made a choice to not match the groups for age or gender […] Thus, individuals who agreed to participate in the study may represent a group of motivated patients who tend to adhere more vehemently to risk factor modifications.”
Does anybody think the author of the Wired article, a doctor…a Stanford / Harvard / Singularity one (seriously), should be using this two year old study, with only 42 subjects, as evidence of a huge healthcare trend to look forward to in 2017?? Why wouldn’t the trend have happened two years ago?!?
This isn’t a criticism of the research. The authors are very clear this is a pilot study. This is a criticism of journalism and hype men.
What else was different between the groups? For the app group-
“Should the patients have questions regarding the program or the content they could submit feedback using the designated tab, and answers were returned within 24 hours.”
“Patients who entered values for metrics such as blood pressure, lipids, glucose, or weight which were two standard deviations over than their prior entries or the normal limits for lab values were asked to verify the intended entry. If patients confirmed these values, messages to consult their physician appeared, as these changes in weight, blood pressure, or lab values could represent a potential danger to their health.”
“While no hard CVD endpoints such as repeat events or death have been reported,”
It’s important to differentiate here between readmissions and re-events. While the app group did not go back to the hospital as much, we have no data for whether they e.g. had the same amount of repeat heart attacks.
And why might the app group not have gone back to the hospital as much? They clearly could have been healthier due to their almost guaranteed higher interest in taking care of themselves, but what about the fact they could ask questions and get responses within 24 hours? What about the fact if they entered a certain high reading they were told to contact their physician?
How many times do people go back to the ER when they don’t need to? When they can’t get their doctor on the phone? When they’re being extra cautious? When they don’t know they could’ve called their doctor instead?
Rather than contact a doctor the non-app group may very well have instead gone to the ER.
One reason we don’t have hard cardiovascular data for this study is because it only had a three month follow up. Here’s what one of the other app studies linked earlier found,
“Among the patients that used the HF app, 90% found it useful on day 3, 88.9% on day 14 and 66.7% on day 31 after discharge.”
We have an obvious trend where who knows if the app group would even keep using it past three months due to lack of usefulness? How long was it until your friend threw their FitBit in a drawer? 3-6 months?
As a reminder, the one app tracked,
“height, weight, blood pressure, laboratory values, minutes of physical activity per day, and current dietary habits. Patients were asked via daily tasks and reminders to update these indices.
and helped complete educational tasks.
If anything, the app was not the reason these people did better. The tracking / dedication / education / interest / INCREASED ability to contact a human was. If somebody is ready to do this, if somebody is signing up for this:
“Specifically for this population, patients were taken through the intake process by a study coordinator, and asked to input their own CVD risk factor indices including height, weight, blood pressure, laboratory values, minutes of physical activity per day, and current dietary habits.
Patients were asked via daily tasks and reminders to update these indices. Patients only received automated reminders to complete educational or recall tasks once logged into the system, with occasional reminder emails sent if the patient had not logged in recently.
No text messages or phone communication was used.
Should the patients have questions regarding the program or the content they could submit feedback using the designated tab, and answers were returned within 24 hours.
In addition to tasks requesting the patient enter their indices of CVD risk such as weight, blood pressure, diet, and physical activity, patients were also asked to complete educational tasks on a regular basis. Education modules consisted of plans to enhance their physical activity and dietary measures produced by Mayo Clinic investigators. These were also available under a “library” tab within the program that the patients could access at any time.”
The app is not what “turned the switch.” One article’s title about this study was “Yes, There’s An App To Reduce Heart Failure Readmissions.”
App = application. In the context of what this app provided, there’s been an app to reduce hospital readmissions for hundreds of years. Pen and paper. (And a phone.) We’re talking an innovation in how we write something down. Not why we write it down. Spotify changes how we listen to music. Not why we do. If you want to turn music on, you’re going to do it with or without Spotify. Changing behavior is the app to reduce readmission rates. Not a new download. (At least in this scenario.)
Could an app be preferable for some? Sure. And that’s great we have it available. But let’s not pretend we have some big innovation going on here. I’m just old enough to remember having clients write food diaries on paper rather than in their phone. While a study would be nice, I’ve seen zero difference in before / after smartphones. Say it takes a bit longer to write things down on pen and paper than with an app. People watch television for FIVE HOURS a day. Whether it takes them seven minutes to write down their food diary or four is irrelevant.
-> Not sure this is feasible either. Making people write with pen / paper when they have access to a smartphone seems like a good way to hurt compliance. Due to the ubiquity of smartphones and the unlikelihood people have pen and paper on them, not sure it’d be a fair comparison at this point.
—> Though I recently had a baby and during our discharge it was hammered home the importance of monitoring defecation. After a couple days, Mom and I realized a peel and stick dry erase board would be easier than the apps we were trying-
Say it aloud and it sounds silly. “I would have never lost weight if not for downloading my X calorie counting app.” Said anybody ever? If a person was ready to make the change, then whether they needed to look at a food label or look up an item in MyFitnessPal doesn’t matter.
The best part of all this is we haven’t even discussed what the app was for…tracking calories…monitoring physical activity…education on these topics…somehow the Singularity of healthcare still revolves around eating less and moving more.