Links: Abstract . Comments . Draft Report . Presentation
Park MJ, Kim HS, Kim KS. Cellular phone and Internet-based individual intervention on blood pressure and obesity in obese patients with hypertension. International journal of medical informatics. 2009 Oct;78(10):704-10.
Globally overweight and obesity, representing at least 300 million clinically obese persons, poses a major risk for chronic diseases, including type 2 diabetes, cardiovascular disease, hypertension and stroke
One of the authors of this paper, Hee-Sung Kim, has experience with previous research studies using ICT for chronic disease management dated back to 2003. No further work in this area is established for the other authors.
Objectives of Study
The aim of the study is to evaluate whether an intervention using short message service (SMS) by cellular phone and Internet would improve blood pressure (BP), weight control, and serum lipids of obese patients with hypertension during 8 weeks. The authors cite the rationale for this as “no study has been done to test the direct efficacy of the cellular phone or internet-based system” on improving of these measures for hypertension”. Logan etal, 2007 presented a paper on use of both inventions, which is referenced by authors making this not a novel research.
Firstly, the intervention is not clearly defined, “.. intervention group were requested to record their blood pressure and body weight in a weekly web based diary through the Internet or by cellular phones.” No justification is given for the choosing SMS or descriptive given of how the patient would input information, if any, from the cellular phone. No clear indication is stated as to how the input of information on BP, weight and drug information would allow the system to give advice about fast food intake and exercise duration. In addition, given that the data is self-reported, there is no indication of any objective way to confirm the data reported on which the decisions are made for the SMS alerts. In the research by Logan etal (2007), a Bluetooth-enabled home BP monitor is used for greater validity of information.
Secondly, omitted is the actual population size of the data collected from which the participants are drawn as well as how the sample is selected. Associated with this is the potential for selection bias, as it is unclear who selected the control group and what other factors may have been considered in addition to matching the age, sex, systolic BP, diastolic BP and body weight to the intervention group at the same department. Amongst other internal validities that are observed, this appears to pose the single most important threat, as it is possible to pull patient records with no change in the clinical outcome variables, unless this was a blinded process.
Thirdly, usage data of the intervention is omitted. Review done on related articles presenting studies with the use of ICT intervention such as by Patrick etal (2009), Raab etal (2009), Cocosila etal (2009), Morak etal (2008), Logan etal, (2007), and Kwon etal (2004), report results in addition to the clinical outcome. Data expected are those such as mean number of logon times per patient per day, alerts sent from both SMS and internet, entries for clinical measures such as blood pressure, weight, drug entries and most frequent comments over the period. In addition, how did the researchers analyze this data when not all patients had access to a computer of phone?
Fourthly, given that the study incorporates the behavioural pattern of patients, the theoretical approach used is not stated explicitly for self-efficacy
This study is contributing to the body of literature on behavioural change through online intervention, still a relatively new area of research and will prompt development of more in-depth research. However, the results must be taken with caution base on the fundamentally flawed methodological issues that is associated with the research.
Hee-Seung Kim has authored one publication
Another critical element missing from this and past reports of similar study by the authors is the lack of information regarding the patients’ perspective on the ease of use, acceptance and effectiveness of the interventions. It would be valuable to know the extent to which patients find the ICT interventions to be helpful in disease self-management, increased self-efficacy, and treatment adherence, as the technology becomes an integral part of people's everyday life. This information would also help to inform future research and long-term planning.
The authors conclude, “the intervention using SMS of cellular phone and Internet improved blood pressure, body weight, waist circumference, and HDL-C at 8 weeks in obese hypertensive patients.” However, given the number of concerns regarding the methodological issues, limited timeline of this intervention, and lack of generalization due to low sample size; these will greatly limit the level of confidence in all inferences that might be drawn from this study deeming the results not valid. Overall, the poor quality of reporting has detracted from the goal of the study.
Questions to the Authors
1. What is the usage data of the cellular phone and internet intervention such as daily frequency response rate per patient per measure, number of alerts sent, and number of entries for clinical measures over the 8 weeks period?
2. How was the data analyzed to determine alerts to be sent if not all patients had access to a computer of phone?
3. What is the actual population size of the data collected from which the participants are drawn?
4. Who did the selection of the control group and how exactly was this done? What were the variables used for matching? What is the potential for a selection bias?
5. What is the rationale for exclusion of patients that changed medication during the period of the interventions and how many persons were excluded due to this in the intervention and control group?
6. What specific differences are identified using the paired t-test with Bonferroni correction and why is ANOVA used rather than t-test when comparing the groups?
7. What exactly was the paired t-test with Bonferroni correction used for?
8. Are the findings presented in the results of statistical significance only or were these also verified for clinical significance?
9. What measurement is used to determine self-efficacy in the adherence to control of hypertension?
10. Why is the patient’s perspective not included on the usability and effectiveness of the intervention?
11. Do you think doing a qualitative study of patients' perspectives might have altered the results or help to inform future research and long-term planning.
Thank you to the Professor Eysenbach and fellow graduate students of the 2009 CATCH-IT Journal Club at the University of Toronto, for their helpful and insightful discussion and comments that contributed to this report.
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