Published in: Lancet Digital Health
Health-care providers, the gate keepers of health-care delivery, are important but understudied stakeholders in integrating digital health technologies (DHTs) into routine clinical practice. A doctor’s recommendation goes a long way in encouraging patients to use DHTs, and research increasingly suggests that a desire for DHTs exists among health-care providers.
Despite recent policy recommendations advocating the use of health apps in routine clinical practice, and publication of the National Institute for Health and Care Excellence (NICE) evidence framework for DHTs, such technologies are rarely recommended by health-care providers in practice.
We interviewed groups of digital health experts, practice nurses, allied health professionals, secondary care doctors, and general practitioners to determine the factors important to health-care providers for considering the recommendation of DHTs to patients. Combined with a pragmatic literature review, we identified nine factors which might affect digital decision making among healthcare providers.
Our results suggested that healthcare providers were most concerned about DHTs having a stamp of approval, whether from the National Health Service (NHS), Medicines and Healthcare products Regulatory Agency (MHRA), or otherwise, which received a statistically significantly higher ranking for all attributes except the presence of published studies of safety or clinical effectiveness. The presence of published studies was also valued significantly greater than all other attributes, except for a stamp of approval.
Having personally used a DHT previously and receiving recommendations from other health-care providers were also of some importance to health-care providers, both of which were statistically significantly more important than making DHTs easier to prescribe to patients, such as including them within EMIS Web or SystmOne. The cost of the DHT, whether it was created by health-care providers, the level of unmet need in the condition under consideration, having access to appropriate technology to demonstrate DHTs to patients, and ensuring apps are easy to prescribe did not result in a difference in preferences among health-care providers.
Trusted advocates of digital health such as ORCHA, NHS X, and NICE have a substantial role to play in this process of digital adoption, specifically in ensuring that: health-care providers are well informed of the benefits that digital health can deliver; know how and where to access DHTs that have been proven to be effective; are aware of what level of evidence is appropriate for each kind of DHT available; and that health-care systems understand the current barriers and facilitators to the implementation of digital health among this crucial but understudied stakeholder group.
Read the full research piece here: https://www.thelancet.com/journals/landig/article/PIIS2589-7500(19)30025-1/fulltext
Published in: BMJ Evidence-based mental health
Mobile health offers many opportunities; however, the ‘side-effects’ of health apps are often unclear. With no guarantee health apps first do no harm, their role as a viable, safe and effective therapeutic option is limited.
In this study we assessed the quality of apps for chronic insomnia disorder, available on the Android Google Play Store, and determine whether a novel approach to app assessment could identify high-quality and low-risk health apps in the absence of indicators such as National Health Service (NHS) approval.
In order to do this we used a subset of 24 questions from the Organisation for the Review of Care and Health Applications OBR, concerning data privacy, clinical efficacy and user experience, answered on a ‘yes’ or ‘no’ and evidence-driven basis, and applied this to 18 insomnia apps identified via the Android Google Play Store, in addition to the NHS-approved iOS app Sleepio.
We found that 63.2% of apps (12/19) provided a privacy policy, with seven (36.8%) stating no user data would be shared without explicit consent. 10.5% (2/19) stated they had been shown to be of benefit to those with insomnia, with cognitive behavioural therapy apps outperforming hypnosis and meditation apps (p=0.046). Both the number of app downloads (p=0.29) and user-review scores (p=0.23) were unrelated to ORCHA-24 scores. The NHS-approved app Sleepio, consistently outperformed non-accredited apps across all domains of the ORCHA-24.
Apps for chronic insomnia disorder exhibit substantial variation in adherence to published data privacy, user experience and clinical efficacy standards, which are not clearly correlated with app downloads or user-review scores. In the absence of formal app accreditation, the ORCHA-24 could feasibly be used to highlight the risk–benefit profiles of health apps prior to downloading.
Read the full research piece here: https://ebmh.bmj.com/content/20/4/e20
Published in: BMJ Evidence-based mental health
Poor-quality pharmaceuticals and medical devices rarely make it to market; however, the same cannot be said for app-based interventions. With a high availability but low evidence base for mHealth, apps are an increasingly uncertain prospect to users and healthcare professionals alike.
Although in a first-best situation, the burden of proof concerning app safety, clinical and cost-effectiveness ‘should’ ultimately lie with app developers; a number of barriers to evidence generation, including the fact that ‘acceptable evidence’ itself is largely open to interpretation, mean that it may be folly to expect this paucity of real-world effectiveness research to improve.
While the health technology assessment of established therapeutic modalities including pharmaceuticals and talking therapies benefits from the existence of approved evaluative guidelines, unfortunately the same cannot be said for app-based interventions, specifically with regard to outcomes measurement.
As such, it would seem that in order to prevent the comparative assessment of apps simply becoming an exercise comparing apples and oranges, there is a clear need for consensus and guidance for app developers, as to which patient-reported outcome measures, among the hundreds available, are of clinical use to those making decisions, and should therefore be used when developing app-based interventions.
By negating the fear that any evidence collected may be of poor quality, we can reincentivise developers to engage in evidence generation, and in doing so, maximise the likelihood of evidence-based decision-making taking a firm hold. However, only by dispelling the ambiguity around what acceptable evidence can and should look like, can we begin to do so.
Published in: BMJ Evidence-based mental health
With a consistent decline in mental health professionals, and ever increasing demand on NHS services, waiting lists for psychological services have been increasing for some time. In fact, in some CCGs, waiting times as long as 140 days (from seeing a GP to a first appointment with a psychologist) have been reported.
While waiting lists continue to grow, unmet needs grow in parallel with conditions often worsening. The charity MIND determined that one in 6 of those on waiting lists for mental health services are expected to attempt suicide, 4 in 10 are expected to self-harm and two-thirds are likely to see their condition deteriorate before having the opportunity to see a mental health professional.
Health-apps are one solution the NHS has recommended to fill the gap between patient need and he capacity of incumbent NHS psychological services. While some apps may be brilliant, not all apps are equal, and some can even be dangerous.
In 2015 the NHS recommended 14 health-apps within the NHS apps library for the treatment of depression or anxiety, only 4 of which provided any evidence of effectiveness, furthermore, only 2/14 used validated outcome measures.
As such, over 85% of health-apps recommended by the NHS for the treatment of depression or anxiety had no solid evidence to back up their effectiveness.
During a time of unprecedented NHS efficiency savings, the opportunity afforded by health-apps should be welcomed by NHS commissioners looking to extend the provision of high quality mental health services within existing budgets. However, this should not be done so without first guaranteeing the quality of these technologies, as this may result in a worsening of symptoms.