Four ways the AHA thinks mobile health research needs to improve

By Jonah Comstock
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MyHeart Counts, an app based on AHA guidelines. MyHeart Counts, an app based on AHA guidelines.

A new review published in Circulation, the journal of the American Heart Association, looked at mobile health interventions around cardiovascular health over the last 10 years and concluded that a number of improvements are needed to the general state of mobile health efficacy studies.

"Our literature searches uncovered a wide variety of products that have been developed," researchers wrote. "However, the reviews also identified the paucity of published empirical evaluation of their effectiveness. To date, many devices have no published evaluation, and those that have undergone evaluation are often limited to measuring customer satisfaction and user sustained engagement. Although such intermediate measures are important, they fall far short of actually determining whether the users of these products had clinically meaningful changes in biological parameters."

The authors, led by Lora Burke from the University of Pittsburgh, looked at 69 studies, mostly RCTs, that investigated the use of mobile technology to reduce cardiovascular disease risk factors. Ten studies targeted weight loss, 14 focused on increasing physical activity, 14 were concerned with smoking cessation, 15 addressed blood glucose management in people with diabetes, 13 focused on hypertension, and three pertained to lipid management.

Based on the limitations they discovered in these studies, writers identified four general areas where clinical researchers can improve. First, studies need to apply more rigorous analytic methods, the authors wrote. Second, they need to cover a more diverse group of participants, especially seeking ethnic and socioeconomic diversity. Third, studies need to last longer than six months to confirm that mobile health interventions have a long term effect, but -- finally -- academics also need to adopt faster research methods, so studies can be completed in time to still be relevant in the face of quickly evolving technology.

"In particular, the fields of obesity and physical activity interventions are littered with interventions that work over the short term but fail to support durable lifestyle change," researchers wrote. "Perhaps most challenging, studies to date have almost uniformly evaluated a single technology compared with standard care, and there have been almost no head-to-head studies comparing various technologies with each another."

Looking specifically at the weight loss studies, AHA found that successful mobile health interventions generally were comparable to successful online interventions. Successful technologies were "comprehensive, multicomponent interventions that are personally tailored, promote regular self-monitoring, and involve a qualified interventionist". However, in both the areas of activity increase and weight loss, researchers found that the apps and devices people use the most are not the ones being studied most.

"Although great strides have been made, we do not have an answer to the question that consumers are most likely to ask: Are commercial mobile weight loss apps efficacious?" they wrote. "We know little about the efficacy of the more than 1000 apps that purport to help consumers lose weight. Moreover, few, if any, research-tested apps have been widely disseminated or commercialized. Academic-industry partnerships are needed from the intervention development stage to formative evaluation to confirmatory research and then to dissemination and implementation."

In the area of smoking cessation, researchers found that most studies concerned text message interventions. The interventions were generally effective, but researchers caution that "not all text messaging programs are created equal" and more research should be done to establish best practices. In addition, researchers questioned why more work hadn't been done on smoking cessation apps.

"Smartphones provide a range of potential features and functions not available via text messaging modalities that have not been adequately leveraged to date for smoking cessation," they wrote. "For example, movement and location sensors in smartphones could be used to learn the contexts in which users smoke and deliver interventions preemptively before the urge to smoke occurs. Sensors connected to smartphones such as carbon monoxide monitors provide objective measures of smoking status."

Finally, the AHA researchers argue that everyone who supports mobile health should be working to improve the state of the evidence, not just mobile app developers who need the evidence to secure customers or reimbursement.

"The responsibility for generating evidence should not fall solely only on the product developers," the paper authors wrote. "The research and clinical communities also must help to generate these needed data. Our review of the evidence to date, even with its flaws and limitations, clearly demonstrates the great potential that mobile technologies can have to aid in lifestyle modification. Thus, clinicians should not conclude that mobile technologies are generally unproven and thus can be ignored. The current absence of evidence should not be used as evidence of an absence of effectiveness. Instead, we need to embrace the challenge of producing this needed evidence on how effective these new technologies are and how we can best adopt them in our practice to promote better patient health."

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