Impacto asistencial de la incorporación del mhealth en la práctica clínica
- Autores: Mar Gomis Pastor
- Directores de la Tesis: María Antonia Mangues Bafalluy (dir. tes.)
- Lectura: En la Universitat Autònoma de Barcelona ( España ) en 2020
- Idioma: español
- Tribunal Calificador de la Tesis: Carlos Codina Jané (presid.), Jose María Guerra Ramos (secret.), Marcela Jirón (voc.)
- Programa de doctorado: Programa de Doctorado en Medicina por la Universidad Autónoma de Barcelona
- Materias:
- Enlaces
- Tesis en acceso abierto en: TESEO
- Resumen
Multimorbidity and therapeutic complexity are undermining health outcomes in chronic populations such as the outpatient heart transplant (HTx) recipients. Medication nonadherence may be a consequence of this complexity and is a direct cause of graft loss and death after HTx. Nevertheless, even these are recognized problems, little is known about how best to quantify this complexity or the strategies that could reduce its burden.
Based on this background, four sequential phases were implemented and abbreviated as The mHeart Study. This thesis is the result of the specific goals of these phases, presented as consecutive studies. All of them were conducted in the outpatient setting of the Heart Transplant Unit of a tertiary university hospital. The first phase aimed to quantitatively measure therapeutic complexity by using a validated quantitative index in chronic-stage HTx recipients. Therapeutic complexity observed was the highest compared with those previously published in chronic diseases and was mainly influenced by a higher count of drugs to treat comorbidities.
Based on the results obtained in the first study, strategies were urgently needed to reduce post-HTx complexity. Therefore, the second phase aimed to develop the mHeart software and to implement an eHealth behavioral-based intervention model to provide healthcare to complex populations in the outpatient setting. The study the model implemented, outlines the facilitators and barriers, and the willingness to use the model reported by potential users. The tool was seek to improve medication safety and efficacy, to enhance patient-providers interactions and to provide comprehensive clinical care. Clinical pharmacists’ skills on patient engagement, motivational interviewing and managerial experience were essential to lead the implementation. The patients confirmed that 98% of them were willing to use the mHeart system.
The third study came to validate the main clinical aim of the mHeart tool, which is to improve medication nonadherence in HTx recipients. With this aim in mind, the mHeart strategy designed consisted of an intensive follow-up program based on multilevel individually-tailored digital interventions aiming to change behavior by a pharmacist using the mHeart technology in an interdisciplinary environment. The mHeart electronic patient-reported outcome measures (ePROMs) met the existing quality standards, and the exploratory clinical intervention established showed a promising improvement of 30% in medication adherence rates. These results supported the mHeart mobile application widespread use in larger research and usual clinical practice.
Based on above-mentioned stages, this thesis work went further including a randomized clinical trial. An alarming 36% of the recipients were non-adherent to immunosuppressive treatment at baseline according to the SMAQ test, and 41% of patients were unaware of the consequences of forgetting to take their antirejection medicines. Therefore, the main objective of this long-term study was to improve recipients’ adherence to immunosuppressive medication, their experience of therapeutic regimens, and to optimize in-clinic healthcare delivery. The intervention consisted of a long-term mHeart strategy versus a traditional in-clinic follow-up by a multidisciplinary team. The mHeart strategy positively impacted on the health outcomes preestablished. At the end of the study, medication adherence rates were statistically significantly improved in the intervention group (85%) versus the control group (46%). Furthermore, the strategy had a positive impact on patients’ experience of therapeutic regimens and showed statistically significant reductions in the number of patients needing to travel to the clinic for follow-up appointments.
The implications of the thesis will be a promising starting point for an emerging way of providing further assistance to the most complex populations based on eHealth.
