key: cord-0025267-8okndzra authors: Greenstein, Jay; Topp, Robert; Etnoyer-Slaski, Jena; Staelgraeve, Michael; McNulty, John title: Effect of a Mobile Health App on Adherence to Physical Health Treatment: Retrospective Analysis date: 2021-12-02 journal: JMIR Rehabil Assist Technol DOI: 10.2196/31213 sha: 1364a9405b65ed28186aaa1679ba80ad6483ec11 doc_id: 25267 cord_uid: 8okndzra BACKGROUND: Adherence to prescribed medical interventions can predict the efficacy of the treatment. In physical health clinics, not adhering to prescribed therapy can take the form of not attending a scheduled clinic visit (no-show appointment) or prematurely terminating treatment against the advice of the provider (self-discharge). A variety of interventions, including mobile phone apps, have been introduced for patients to increase their adherence to attending scheduled clinic visits. Limited research has examined the impact of a mobile phone app among patients attending chiropractic and rehabilitation clinic visits. OBJECTIVE: This study aims to compare adherence to prescribed physical health treatment among patients attending a chiropractic and rehabilitation clinic who did and did not choose to adopt a phone-based app to complement their treatment. METHODS: The medical records of new patients who presented for care during 2019 and 2020 at 5 community-based chiropractic and rehabilitation clinics were reviewed for the number of kept and no-show appointments and to determine whether the patient was provider-discharged or self-discharged. During this 24-month study, 36.28% (1497/4126) of patients seen in the targeted clinics had downloaded the Kanvas app on their mobile phone, whereas the remaining patients chose not to download the app (usual care group). The gamification component of the Kanvas app provided the patient with a point every time they attended their visits, which could be redeemed as an incentive. RESULTS: During both 2019 and 2020, the Kanvas app group was provider-discharged at a greater rate than the usual care group. The Kanvas app group kept a similar number of appointments compared with the usual care group in 2019 but kept significantly more appointments than the usual care group in 2020. During 2019, both groups exhibited a similar number of no-show appointments; however, in 2020, the Kanvas app group demonstrated more no-show appointments than the usual care group. When collapsed across years and self-discharged, the Kanvas app group had a greater number of kept appointments compared with the usual care group. When provider-discharged, both groups exhibited a similar number of kept appointments. The Kanvas app group and the usual care group were similar in the number of no-show appointments when provider-discharged, and when self-discharged, the Kanvas app group had more no-show appointments compared with the usual care group. CONCLUSIONS: Patients who did or did not have access to the Kanvas app and were provider-discharged exhibited a similar number of kept appointments and no-show appointments. When patients were self-discharged and received the Kanvas app, they exhibited 3.2 more kept appointments and 0.94 more no-show appointments than the self-discharged usual care group. In health care, adherence has been defined as "the extent to which a person's behavior corresponds with the recommendations from a healthcare provider" [1] and is the primary determinant of treatment success [1] . When the prescribed medical treatment involves physiotherapy to treat chronic musculoskeletal pain, adherence to the prescribed therapy has been reported to be critical for the successful resolution of the problem [2] . Low adherence to prescribed treatment has been identified as a challenge among many health care disciplines, including physiotherapy. Maintaining adherence to prescribed medical treatment is essential to facilitate maximum recovery following an injury and promote optimal health [3] . Sluijs et al [4] reported that between one-third and two-thirds of patients involved in treatment programs that included physiotherapy are not adherent with the prescribed treatment plan. A component of not adhering to prescribed medical treatment in primary care is not attending scheduled clinic appointments. When a patient prematurely terminates treatment against the advice of the provider, it is termed self-discharge as compared with the patient completing their prescribed treatment, which is termed provider-discharged. Not attending a single scheduled clinic appointment is termed a no-show appointment and is defined as an appointment in which the patient did not present for treatment or did not contact the clinic to cancel the appointment [5] . Both self-discharge and no-show appointments reduce revenue, result in suboptimal use of clinical and administrative staff, may lengthen wait times for patients, and negatively affect the continuity of care [6] . In primary care, the rate of no-show appointments ranges from 19% [7] to 42% [8] and is estimated to cost the US health care system US $150 billion per year [9] . Moore et al [10] reported that no-show appointments negatively affected 25% of scheduled time in a family medicine clinic and resulted in a loss of 14% of the anticipated daily revenue. Patients with frequent no-show appointments experienced worse health care outcomes [3] . In a nationwide survey of physical therapists, investigators reported that 10.4% of their patients' appointments were no-show appointments in private clinics, which was significantly lower than the percentage of patients who were no-show appointments in hospital campus clinics (14.53%) [11] . This low adherence to physiotherapy treatment has not changed over the past 27 years [11] . Other investigators have reported adherence rates with prescribed physiotherapy to be as low as 37.6% [12] . Thus, a primary explanation for the less-than-expected impact of physiotherapy in treating chronic musculoskeletal problems [13] may be a lack of adherence to the prescribed therapy by the patients and not the efficacy of the prescribed physiotherapy. A variety of procedures have been introduced in outpatient clinics in an attempt to reduce the problem of self-discharge and no-show appointments. Providers have introduced different methods to reduce no-show appointments, including reminder procedures or penalizing the patient financially for a no-show appointment. The efficacy of these methods has not been clearly determined. Satiani et al [14] reported that automated reminder systems did not significantly reduce the rate of no-show appointments. Other investigators found no effect [15] or only moderate effects [7] of automatic reminder systems to reduce no-show appointments. However, when appointment reminders were from actual clinic staff, the no-show rate was significantly reduced [16] . A continuous quality improvement study by Teo et al [17] indicated that reminders from an actual person resulted in lower no-show appointments (3%) when compared with message or voice mail reminders (24%). In a randomized controlled trial (RCT) where physical therapy patients received clinic appointment reminders sent to their cell phone, the no-show appointment rate was lower (11%) compared with patients who did not receive an appointment reminder (16%) [18] . A comprehensive review of the literature concluded that reminder interventions, including telephone, mail, SMS text messaging, and email reminders, all moderately reduced no-show outpatient clinic appointments [19] . This finding is consistent with a more recent meta-analysis of the literature that concluded that patients who received a text-based electronic notification of an upcoming health care appointment were 25% less likely to no-show for their appointment [20] . Penalizing or imposing a financial charge on patients for no-show appointments has been proposed as an effective approach to reducing this problem by economists [21] . However, a large empirical study did not demonstrate the efficacy of imposing a financial charge on no-show appointments to reduce future no-show appointments among outpatients [22] . Reminder procedures or penalizing the patient financially for no-show appointments have not consistently demonstrated reductions in no-show appointments. A number of recent studies have presented evidence that supports the feasibility, acceptability, and efficacy of digital health interventions in treating different chronic medical conditions. In addition to providing text-based messaging about upcoming health care appointments, mobile phone apps have been designed to promote patient engagement in their care, including improving self-care and adherence to prescribed health care therapies. In a review of 279 commercially available mobile phone apps to manage pain that included education, self-monitoring, social support, and goal setting, the authors concluded that the efficacy of most apps was not supported by empirical research [23] . A more recent review of 15 studies evaluating the effects of phone-based apps involving pain management concluded that these apps are workable, well-liked by patients and health care professionals, and can result in reductions in pain [24] . In a more recent study, Huber et al [25] reported that a multidisciplinary phone-based app to manage pain, Kaia, including prescribed exercises, education, relaxation exercises, and coaching, resulted in statistically and clinically significant reductions in pain. MacIsaac et al [26] examined an innovative, smartphone app-based resilience intervention-the JoyPop app-introduced among first-year undergraduate students. After using the app at least twice daily for 4 weeks, 156 participants reported improved emotional regulation and depression. This positive impact of the JoyPop app was directly related to the frequency of using the app. Irvine et al [27] studied a mobile web intervention called FitBack that was designed to encourage users to adopt cognitive and behavioral strategies based on social cognitive theory and the theory of planned behavior to support their self-efficacy to engage in prescribed pain management and prevention behaviors. The findings of this study demonstrated that the standalone mobile web intervention that tailored content to users' preferences and interests was an effective tool for self-management of lower back pain. The researchers concluded that there is considerable value in this type of intervention as a potentially cost-effective tool that can reach large numbers of patients to encourage adherence to prescribed medical treatment [27] . More recently, electronic medical record (EMR)-tethered patient portals have become available on phone-based apps. In a study of 957 patients who accessed an EMR-tethered portal, participants reported positive experiences and decreases in health system use and exhibited fewer no-show appointments [28] . The authors of a retrospective, observational study of 46,544 primary care patients reported that adoption, use, and benefits of using EMR-tethered portals available on a phone app were not clearly linked. However, these authors concluded that patients who used the messaging and laboratory functions of the app were less likely to exhibit no-show appointments compared with other user subgroups [29] . In addition to these individual trials, a number of review articles support the positive impact of technology-based health interventions. Ramsey et al [30] , after their review of 21 peer-reviewed journal articles, reported the efficacy and increasing access to digital technologies, including eHealth and mobile health (mHealth), may improve the mental and physical health of youth undergoing cancer treatment and survivors of childhood cancer. Following a systematic review, Badawy et al [31] concluded that mobile phone app interventions could improve medication adherence among adolescents with chronic health conditions, and the current literature indicates that these mobile phone app interventions are feasible and accepted by adolescents, and there is modest evidence to support the efficacy of these interventions. These findings are consistent with those of Oikonomidi et al [32] , who conducted a systematic review of mHealth behavior change interventions (SMS text messages and smartphone apps) in RCTs. After reviewing 231 RCTs, the authors concluded that mHealth behavior change interventions lack information that would be useful for providers, including the long-term impact of the interventions' health outcomes and information needed for replication of the RTC. Finally, Shah and Badawy [33] provided a systematic evaluation of the feasibility, accessibility, satisfaction, and health outcomes of telemedicine services among pediatric populations with different health conditions. After reviewing 11 articles in this area, the authors concluded that telemedicine services for the general public and pediatric care are comparable with or better than in-person services. Although promising, technology-based health interventions, including mobile phone apps designed to support adherence to prescribed medical treatment, have not been extensively studied on adherence to outpatient physical health treatment. This study aims to compare adherence to prescribed physical health treatment among patients attending a chiropractic and rehabilitation clinic who did and did not choose to adopt a phone-based app to complement their treatment. Hypothesis 1: Patients receiving physical health treatment who choose to receive the phone-based app compared with physical health patients who choose not to receive the phone app will exhibit greater rates of completing their prescribed therapy (fewer self-discharge and greater provider-discharge). Hypothesis 2: Patients receiving physical health treatment who choose to receive the phone-based app compared with physical health patients who choose not to receive the phone app will exhibit fewer no-show appointments and more kept appointments. Research question 1: Does self-selecting to receive the phone-based app or not and being self-discharged versus provider-discharged differentially affect no-show and kept appointments among patients prescribed physical health treatment? A retrospective analysis of all new outpatient medical records from a multisite physical health practice was performed between January 2019 and December 2020. Beginning in January 2019, all new patients admitted to this practice were offered the opportunity to download a phone-based app, the Kanvas app, during their initial visit to complement their treatment. New patients who downloaded and registered on the phone-based app self-selected into the Kanvas app group. New patients admitted to this physical health practice during this same time who did not download and register on the app self-selected into the usual care group. Each patient's medical record was accessed 4 months after their initial visit to determine whether they prematurely terminated treatment against the advice of the provider (self-discharged) or if they completed their prescribed treatment (provider-discharged). The number of no-show appointments and the number of kept appointments were also extracted from each patient's medical records. This resulted in a quasi-experimental, 2-group design in which the records of all patients initially presenting for treatment between January 2019 and December 2020 were reviewed and included in the analysis. The medical records of new patients who presented during the study period for care at 1 of 5 community-based physical health clinics in the Greater Washington DC area (n=4203) were initially screened as participants in this study. These clinics specialize in treating pain and increasing functional abilities. During the initial visit, all patients were informed that they could download a mobile app on their phone that they could use to complement the care they were receiving at the clinic. At this time, all patients were told about the components of the app and the reward structure as a result of using the app. Patients were also told that the use of the app was voluntary and would in no way affect their care or relationship with their provider or the clinical agency. Patients were excluded from the study if, following their initial visit, they were referred to another medical clinic for care, were employed by one of the targeted clinics, or died before completing therapy (77/4203, 1.83%). This record review study was approved by the Sport and Spine Rehab Clinical Research Foundation institutional review board number SSR.2021.1. During the initial visit at one of the targeted clinics, each patient completed an initial assessment with a practitioner (physical therapist or chiropractor) who prescribed a plan of care that included home exercises and a series of follow-up clinic visits. This plan of care and the number and frequency of follow-up clinic visits were individualized to the type and severity of the patient's condition. Patients were scheduled for their next follow-up visit during the initial visit and were informed that their account would be charged US $25 if they did not attend this scheduled visit or did not contact the clinic to cancel the appointment within 24 hours of the appointment (no-show appointment). The Kanvas app is a customized private practice app designed for patient engagement with their specific health care provider. The initial screen includes various tiles in which the patient can engage with the office. These tiles include contact us, about us, refer a friend, request an appointment, review us, and home exercise (Figures 1 and 2) . In addition, a built-in gamification system, the rewards tile (Figure 3) , was designed to reward the patient for attending their scheduled clinic appointments. This feature is Office of Inspector General compliant, offering an item as a reward valued at