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A digital assistant for healthcare providers targeting 10 to 15-year-old patients with asthma and their family: results from a pilot study

Authors:

Abstract

Background: Asthma is one of the most common chronic conditions worldwide. Successful asthma management requires knowledge about the condition, treatment adherence, and behavioral skills. In addition, when treating children with asthma, a trustful and empathetic collaboration between healthcare providers, patients and their family is necessary for successful asthma management. However, resources of healthcare providers are limited to few face-to-face consultations, and personal support in the everyday life of chronic patients is not feasible. Digital assistants may overcome this challenge, because they are computer programs that imitate human interactions and can be designed to support healthcare providers in reaching out to patients in their everyday lives. Until now, however, it has not been clear whether digital assistants would be adopted by healthcare providers, patients or supportive family members and whether they could have a positive impact on the management of asthma in children. Objective: The goal of this project was to develop and test an empathetic digital assistant for healthcare providers that targets 10 to 15-year-olds with asthma and a supportive family member. Method: The digital assistant MAX was collaboratively designed by healthcare providers, young patients, a media didactician, a clinical psychologist and computer scientists. MAX communicated with all relevant stakeholders along a pre-defined intervention schedule, i.e., with healthcare providers via email, with patients via a mobile chat app and with a family member via SMS. The 14 lessons focused on asthma knowledge (e.g., what to do in case of an asthma attack), treatment adherence (i.e., discussion of medication plans), and behavioral skills (i.e., inhalation and breathing techniques). A family member was requested to actively participate in seven lessons. Healthcare providers were requested to assess patients’ inhalation technique based on video clips recorded by a family member. A pilot study was carried out to assess reach, impact, therapeutic alliance, technical feasibility and acceptability of MAX. Reach was measured by the proportion of patients approached and those who started to interact with MAX. Impact was assessed via a pre-post asthma knowledge test of a validated asthma quiz and by the number of inhalation mistakes made after healthcare providers gave their feedback. Therapeutic alliance between MAX and patients was assessed by the Session Alliance Inventory. Finally, technical feasibility and acceptance of MAX were evaluated by patients’ adherence, the number of technical shortcomings, and qualitative feedback gathered from healthcare providers, patients and family members. The study was approved by the first author’s institutional review board. Results: Overall, 99 children with asthma were screened by healthcare providers at 6 study sites (4 hospitals and 2 local Swiss Lung Association sites, a home care provider for integrated care in Switzerland) between January and April 2019. Overall, 49 (49.5% of those screened) young patients (33 male, 27 iOS and 22 Android users) with an average of 12 years (SD=1.54) fulfilled all inclusion criteria (i.e., asthma diagnosis, 10 to 15 years old, German-speaking, smartphone available, interested in investing ca. 4h of their time, supportive family member with smartphone access), and started to interact with MAX. Thirty-nine (79.6%) patients who completed Lesson 2 indicated that they had lived with asthma for 5.61 years (SD=4.17) and 13 (30%) reported that they were uncertain about how to manage their asthma. The average completion rate of the 49 participants regarding the 14 MAX lessons was 80.4%, and 37 (75.5%) patients completed all lessons in 3 weeks. A paired t-test with the baseline observation carried forward showed that asthma knowledge had increased significantly from the first lesson until the last lesson with a large effect (d=0.91). Out of 192 random lesson assessments, patients indicated 86 times (44.8%) that they learned a lot, 73 times (38.0%) that they learned some new aspects and 33 times (17.2%) that they already knew everything about asthma. The technical quality of all 42 inhalation video clips was good, and it took healthcare providers ca. 118s to assess each video clip. Patients received feedback on their inhalation technique within 1.9 days through a second chat channel of the MAX app dedicated to communication with their healthcare provider. On average, healthcare providers identified 1 inhalation mistake in each video clip, and 3 serious inhalation mistakes were identified and corrected in a second video clip. Out of 275 lessons, patients indicated 269 times (97.8%) that they were supported by family members in collaborative exercises. Only 74 (0.5%) of all chat interactions took place in the chat channel dedicated to healthcare provider communication whereas 15’087 (99.5%) interactions took place in the scalable chat channel with MAX. Therapeutic alliance was rated very high by the patients, who also enjoyed using the mobile app and stated they wanted to continue working with MAX. The young patients also found the MAX app easy to use and reported that it offered clear benefits. Overall, MAX was assessed very positively by all relevant stakeholders, and several suggestions for improvement and technical barriers, particularly related to the technical infrastructure in the participating hospitals, were provided (e.g., lack of easy WIFI access to patients or access to state-of-the-art browser technology for healthcare providers). Conclusion: Digital assistants for healthcare providers targeting 10 to 15-year-old patients with asthma and a family member have the potential to improve asthma knowledge, treatment adherence, and behavioral skills. The reach of such interventions is limited by the technical infrastructure of healthcare providers. Future work should assess the impact of digital assistants on asthma outcomes.
Abstract published by the Center for Digital Health Interventions, ETH Zurich & University of St.Gallen, October 5, 2019.
Full manuscript in preparation
A digital assistant for healthcare providers targeting 10 to 15-year-old
patients with asthma and their family: results from a pilot study
T. Kowatsch1, S. Harperink1, U. Dittler2, G. Xiao3, C. Stanger4, H. Oswald5 & A. Moeller6
1Center for Digital Health Interventions, ETH Zurich & University of St.Gallen, Zurich & St.Gallen,
Switzerland; 2Hochschule Furtwangen University, Furtwangen, Germany; 3Johns Hopkins School of Medicine,
Baltimore, USA; 4Center for Technology and Behavioral Health, Geisel School of Medicine, Dartmouth College,
USA; 5Cantonal Hospital Winterthur, Winterthur, Switzerland; 6University Children’s Hospital Zurich,
Switzerland
Background: Asthma is one of the most common chronic conditions worldwide. Successful asthma
management requires knowledge about the condition, treatment adherence, and behavioral skills. In
addition, when treating children with asthma, a trustful and empathetic collaboration between
healthcare providers, patients and their family is necessary for successful asthma management.
However, resources of healthcare providers are limited to few face-to-face consultations, and personal
support in the everyday life of chronic patients is not feasible. Digital assistants may overcome this
challenge, because they are computer programs that imitate human interactions and can be designed to
support healthcare providers in reaching out to patients in their everyday lives. Until now, however, it
has not been clear whether digital assistants would be adopted by healthcare providers, patients or
supportive family members and whether they could have a positive impact on the management of
asthma in children.
Objective: The goal of this project was to develop and test an empathetic digital assistant for
healthcare providers that targets 10 to 15-year-olds with asthma and a supportive family member.
Method: The digital assistant MAX was collaboratively designed by healthcare providers, young
patients, a media didactician, a clinical psychologist and computer scientists. MAX communicated
with all relevant stakeholders along a pre-defined intervention schedule, i.e., with healthcare providers
via email, with patients via a mobile chat app and with a family member via SMS. The 14 lessons
focused on asthma knowledge (e.g., what to do in case of an asthma attack), treatment adherence (i.e.,
discussion of medication plans), and behavioral skills (i.e., inhalation and breathing techniques). A
family member was requested to actively participate in seven lessons. Healthcare providers were
requested to assess patients’ inhalation technique based on video clips recorded by a family member.
A pilot study was carried out to assess reach, impact, therapeutic alliance, technical feasibility
and acceptability of MAX. Reach was measured by the proportion of patients approached and those
who started to interact with MAX. Impact was assessed via a pre-post asthma knowledge test of a
validated asthma quiz and by the number of inhalation mistakes made after healthcare providers gave
their feedback. Therapeutic alliance between MAX and patients was assessed by the Session Alliance
Inventory. Finally, technical feasibility and acceptance of MAX were evaluated by patients’
adherence, the number of technical shortcomings, and qualitative feedback gathered from healthcare
providers, patients and family members. The study was approved by the first author’s institutional
review board.
Results: Overall, 99 children with asthma were screened by healthcare providers at 6 study sites (4
hospitals and 2 local Swiss Lung Association sites, a home care provider for integrated care in
Switzerland) between January and April 2019. Overall, 49 (49.5% of those screened) young patients
(33 male, 27 iOS and 22 Android users) with an average of 12 years (SD=1.54) fulfilled all inclusion
criteria (i.e., asthma diagnosis, 10 to 15 years old, German-speaking, smartphone available, interested
in investing ca. 4h of their time, supportive family member with smartphone access), and started to
interact with MAX. Thirty-nine (79.6%) patients who completed Lesson 2 indicated that they had
lived with asthma for 5.61 years (SD=4.17) and 13 (30%) reported that they were uncertain about how
to manage their asthma. The average completion rate of the 49 participants regarding the 14 MAX
lessons was 80.4%, and 37 (75.5%) patients completed all lessons in 3 weeks. A paired t-test with the
baseline observation carried forward showed that asthma knowledge had increased significantly from
the first lesson until the last lesson with a large effect (d=0.91). Out of 192 random lesson
assessments, patients indicated 86 times (44.8%) that they learned a lot, 73 times (38.0%) that they
learned some new aspects and 33 times (17.2%) that they already knew everything about asthma. The
technical quality of all 42 inhalation video clips was good, and it took healthcare providers ca. 118s to
assess each video clip. Patients received feedback on their inhalation technique within 1.9 days
through a second chat channel of the MAX app dedicated to communication with their healthcare
provider. On average, healthcare providers identified 1 inhalation mistake in each video clip, and 3
serious inhalation mistakes were identified and corrected in a second video clip. Out of 275 lessons,
patients indicated 269 times (97.8%) that they were supported by family members in collaborative
exercises. Only 74 (0.5%) of all chat interactions took place in the chat channel dedicated to healthcare
provider communication whereas 15087 (99.5%) interactions took place in the scalable chat channel
with MAX. Therapeutic alliance was rated very high by the patients, who also enjoyed using the
mobile app and stated they wanted to continue working with MAX. The young patients also found the
MAX app easy to use and reported that it offered clear benefits. Overall, MAX was assessed very
positively by all relevant stakeholders, and several suggestions for improvement and technical
barriers, particularly related to the technical infrastructure in the participating hospitals, were provided
(e.g., lack of easy WIFI access to patients or access to state-of-the-art browser technology for
healthcare providers).
Conclusion: Digital assistants for healthcare providers targeting 10 to 15-year-old patients with
asthma and a family member have the potential to improve asthma knowledge, treatment adherence,
and behavioral skills. The reach of such interventions is limited by the technical infrastructure of
healthcare providers. Future work should assess the impact of digital assistants on asthma outcomes.
Project website (in English): https://www.c4dhi.org/projects/health-literacy-children-asthma/
Study website (in German): https://www.max-asthmacoach.ch
Acknowledgements: The intervention MAX Your Asthma Coach was evaluated in a feasibility study by student research assistant Samira
Harperink and Dr. Tobias Kowatsch, Scientific Director of the the Center for Digital Health Interventions (CDHI) at ETH Zurich and the
University of St.Gallen (www.c4dhi.org) and Assistant Professor for Digital Health at the University of St.Gallen. The story book of the
intervention was developed by media didacticist Prof. Dr. Ullrich Dittler from Hochschule Furtwangen University based on the educational
asthma comic “Spurensuche im Ferienlager” developed by Dr. med. Marie-Angela Schnyder and Raphael Santochi. The digital coaching
concept of the intervention was developed by Tobias Kowatsch with support by Prof. Catherine Stanger from Dartmouth College and Grace
Xiao from Johns Hopkins School of Medicine. Professor Dr. med. Alexander Möller of the University Children's Hospital Zurich, Dr. med.
Helmut Oswald of the Cantonal Hospital Winterthur, Franca Mayer and Maja Schaub of the Swiss Lung League were supported by Filipe
Barata, Samira Harperink, Jan-Niklas Kramer, Marcia Nißen, Peter Tinschert, Grace Xiao and Tobias Kowatsch from CDHI, Ullrich Dittler,
Nathalie Gasser, Valérie Rohrer, Dominique Mordelet, Judith Ruoss, Hugo Bossi and Corinne Kappeler, to quality control the learning
content. The concept of the video assessment of the inhalation technique was developed by Corinne Kappeler and Katrin Lerch from the
Lung League Thurgau and Bern, Alexander Möller, Helmut Oswald and Tobias Kowatsch. The video clips and graphics were designed and
produced by the team of Lutz Augspurger and Birgit Hepting from flipping ROCKS, Furtwangen, Germany. Dr. Dirk Volland, Michelle
Heppler, Andreas Filler and Christoph Göttert from Pathmate Technologies (Zurich & Mannheim) were responsible for the technical
development and operation of the intervention. The story book, the digital coaching concept and the inhalation assessment was implemented
by Samira Harperink and Tobias Kowatsch. The development of the intervention and the feasibility study were co-funded by CSS insurance
under the supervision of Gabriella Chiesa and Matthias Heuberger, the Swiss Lung League under the supervision of Philippe Giroud, Jean-
Marie Egger and Nathalie Gasser, ETH Zurich and the University of St.Gallen under the supervision of Prof. Dr. Elgar Fleisch. Prof. Dr.
med. Alexander Möller, Dr. med. Helmut Oswald, Dr. med. Linn Krüger (Inselspital Bern), Dr. med. Peter Salfeld (Kantonsspital
Münsterlingen), Corinne Kappeler, Bea Zwiker, Monika Ottiger (Lungenliga Thurgau), Dr. med. Reto Villiger (Spitalzentrum Biel),
Dominique Mordelet, Nicole Sterchi and Katrin Küng (Lungenliga Bern) introduced MAX as their digital assistant to the young patients and
conducted the video assessments.
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