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Patient outcomes are improved and the burden to the health care system is reduced when individuals are active self-managers of their own health. There is a need for technology that facilitates self-management of rheumatoid arthritis (RA) and can reduce the number of patient visits, promptly identify treatment needs, and reduce the costs associated with poor RA management. A mobile app named LiveWith Arthritis (eTreatMD, Vancouver, BC) has been developed that allows patients with RA to use their mobile device to regularly collect self-management data and to take objective measurements of the impact of RA on their finger joints using optical imaging technology.
The objectives of this pilot study were to (1) gather preliminary data as to whether a mobile app with hand optical imaging capabilities improves self-management behaviors (self-efficacy in managing symptoms and patient activation), (2) determine if app use shows promise in improving health outcomes (Pain, Health Assessment Questionnaire-II [HAQ-II]), and (3) determine barriers to using the mobile app in adults with RA.
This pilot study used a mixed-methods design. The quantitative portion was a traditional 2-group experimental design, and the qualitative portion was a follow-up telephone interview for intervention participants who did not complete the study. Measures of self-management included the Patient-Reported Outcomes Measurement Information System (PROMIS) self-efficacy in managing symptoms (P-SEMS) and Patient Activation Measure (PAM). Health outcomes included pain by Visual Analog Scale and disability by HAQ-II.
The final sample consisted of 21 intervention participants and 15 controls. There was a statistically significant improvement in P-SEMS and promising trends for improvement in PAM, HAQ-II, and pain scores for participants who used the app. Of the intervention participants who did not complete the study, 12 completed the qualitative interview on barriers to use. Qualitative content analysis revealed 3 themes for barriers to using the app, including (1) frustration with technology, (2) RA made the app difficult to use, and (3) satisfaction with current self-management system.
The LiveWith Arthritis app shows promise for improving self-management behaviors and health outcomes in adults with RA. Future study with a larger sample size is required to confirm findings. Initial app experience is important for adoption and continual use of the app. Individuals with significant disability to the hand would benefit from voice-activated app features. Participants who already have a system of managing their RA may not feel compelled to switch methods, even when a novel optical imaging feature is available.
Rheumatoid arthritis (RA) is a chronic and debilitating systemic inflammatory disease that destroys joints throughout the body. Although RA can manifest in a variety of joints, most patients experience RA symptoms in their hands and wrists [
Although the hand is the primary area for painful and disabling symptoms, it is also an area that can be monitored to predict disease flares and monitor disease progression. While clinicians can use radiographic imaging to monitor RA progression, measurement is infrequent due to the cost of implementation, the availability of radiologists for interpretation, and radiation exposure risks. The use of noninvasive optical imaging methods to analyze interphalangeal joint disease is an emerging technology used mostly in clinical settings [
In addition to monitoring, self-management of the day-to-day symptoms of RA is critical to reducing disease progression. The Institute of Medicine states that self-management is 1 of the 20 most urgent areas of need to improve health care quality in the United States [
The objectives of this pilot study were to (1) gather preliminary data as to whether a mobile app with hand optical imaging capabilities improves self-management behaviors (self-efficacy in managing symptoms and patient activation), (2) determine if app use shows promise in improving health outcomes (Pain, Health Assessment Questionnaire-II [HAQ-II]), and (3) determine barriers to use of the mobile app in adults with RA.
The LiveWith Arthritis app is a mobile app that allows a patient to monitor the progression of RA inflammation and deformity in their hands using optical imaging from a mobile device camera. The app also supports self-management behaviors with features to monitor and manage the variables associated with RA such as pain levels, treatments, and other lifestyle and environmental data (eg, diet, activity, and weather; see
The LiveWith system architecture (see
App self-management features.
App system architecture.
Hand analysis takes place after the patient takes a digital image of their hand with a standard sheet of white paper (letter size) in the background (see
Web portal.
Hand optical imaging using letter size paper for calibration.
Imaging hand calibration requirements include (1) all 4 corners of the paper are in the photo, (2) the hand is within the paper's edges, (3) fingers are spread, and (4) the background behind the paper is darker and free of clutter.
Output report including analyzed hand image, changes since last image, recommendations, and measurements of anatomical features of hand.
This was a mixed-methods design. The quantitative portion was a traditional 2-group experimental design, and the qualitative portion was a follow-up telephone interview for intervention participants who did not complete the study. Participants were adults (aged over 18 years) with RA enrolled in a longitudinal cohort called the Rheumatology and Arthritis Investigational Network Database (RAIN-DB) [
We enrolled 34 participants in the intervention group and 29 subjects in the control group. Data were collected at 2 visits, baseline and follow-up, which were 6 months apart. The baseline visit for intervention participants included meeting with a research assistant to download the app on the participant’s smartphone and to take an image of the hand to teach the patient how to use this feature of the app. Intervention participants were instructed to use the imaging technology at least once per month and the app for self-management regularly. Intervention participants were compensated US $50 for their time spent using the app. Control participants received usual care.
To evaluate whether the mobile app technology could improve self-management and self-efficacy, we used 2 questionnaires, the Patient-Reported Outcomes Measurement Information System (PROMIS) Self-Efficacy Managing Symptoms (P-SEMS) and the Patient Activation Measure (PAM).
The P-SEMS tool measures an individual’s perceived self-efficacy in managing the symptoms of their disease. Regarding health, self-efficacy is the foundation for an individual’s decision to act and implement healthy behaviors to manage their illness or symptoms and take control of their health through implementation of specific health behaviors to achieve improved outcomes [
The PAM is a 13-item self-report instrument designed to assess an individual’s level of patient activation. It measures the patient’s self-reported knowledge, skills, and confidence in self-management of their chronic condition [
Pain was measured using the Visual Analog Scale (VAS). The VAS measures pain from 0 to 10, with 0 meaning no pain and 10 being
Intervention participants who did not complete the study were invited to participate in a qualitative telephone interview about the barriers to using the mobile app. Participants were asked, “tell me more about your experience using the app” with follow-up probes about their likes and dislikes of the app features, overall experience, and barriers to using the app. The qualitative interviews were transcribed verbatim.
Statistical analyses were conducted using Stata Statistical Software 15 (StataCorp, College Station, TX) [
Our final sample consisted of 21 intervention participants (62% original sample, 21/34) and 15 control participants (52% of original sample, 15/29). Intervention participants who withdrew from the study tended to have a slightly higher HAQ-II (0.63 vs 0.54) and pain score (3.2 vs 2.5) and lower PAM (67.4 vs 71.9) and P-SEMS (45.4 vs 47.3) at baseline compared with intervention participants who completed the study. These demographic changes were similar to the control group, with dropouts more likely to have a lower PAM (64.4 vs 68.8) and P-SEMS (46.4 vs 47.1) than controls who completed the study. Control participants who dropped out were more likely to have lower pain (2.6 vs 3.17) and lower HAQ-II (0.54 vs 0.63). None of these differences were statistically significant.
Our qualitative sample consisted of subjects who dropped out of the intervention group. We were able to reach and invite all 13 intervention participants who dropped out of the study. However, 1 intervention participant dropped out due to a diagnosis of lymphoma and ongoing health concerns, preventing her participation. The remaining 12 intervention participants who did not complete the study participated in the qualitative component of our study.
The outcome variables are presented in
Quantitative outcome variables.
Variable | Intervention | Control | |
P-SEMSa | 2.80 | −1.66 | .04 |
PAMb | 6.37 | 2.30 | .46 |
HAQ-IIc | 0.02 | 0.05 | .83 |
Pain | −0.61 | 0.18 | .38 |
aP-SEMS: Patient-Reported Outcomes Measurement Information System Self-Efficacy Managing Symptoms.
bPAM: Patient Activation Measure.
cHAQ-II: Health Assessment Questionnaire-II.
A 2-sample
Participants with higher PAM and P-SEMS scores had lower HAQ-II scores and lower pain scores at both baseline and follow-up. Changes in PAM and P-SEMS scores were negatively correlated with changes in HAQ-II (Pearson correlations: −0.33,
There were 3 themes that arose from the qualitative interviews about the barriers to using the app for intervention participants who dropped out of the study. These themes were (1) frustration with technology, (2) RA made the app difficult to use, and (3) satisfaction with current self-management system. These themes and representative quotes are displayed in
Participants described frustration with technology especially with initial use of the app. Participants who did not have a good initial experience did not feel confident to return to the app or use it as directed on their own.
Participants who had more severe hand RA and who were disabled by their disease had difficulty using both the optical imaging and other features of the app. Some participants recruited someone to assist them with photographing their hand, but this also made it difficult for the participants to use the app on a regular basis.
Some participants explained that the mobile app could not be integrated easily into their lifestyle as they had already had a system to manage their RA. These participants felt that the use of the mobile app would not add to their self-management needs and that their system was working for them.
Qualitative themes and representative quotes.
Theme | Representative quote |
Frustration with technology | |
Rheumatoid arthritis made the app difficult to use | |
Satisfaction with current self-management system |
Our study showed a statistically significant improvement in P-SEMS and showed promising trends for improvement in PAM, HAQ-II, and Pain scores for participants who used the LiveWith app. These results demonstrated the potential of the LiveWith app for improving self-management and increasing confidence in these behaviors. Future studies with a larger sample size are necessary to confirm these findings.
Pilot studies are generally underpowered to assess evidence of benefit at the 95% CI; therefore, we find it especially promising that those participants who completed the intervention had statistically significant improvement in their self-efficacy scores [
Our attrition rate was higher than the acceptable level of 20%, with a large percentage of both intervention and control group participants dropping out [
Although the purpose of our study was to learn more about self-managing behaviors, some participants believed collecting optical imaging hand data was the purpose of the study. Therefore, when there was difficulty using the optical imaging technology, the participants did not use the other self-managing aspects of the app. To our knowledge, there were no technology issues with the nonoptical imaging aspects of the app software, even as we went through various updates to the iOS and Android operating systems. Although the optical imaging is novel from a research and clinical perspective, it is unclear if this feature is essential to improve self-management behaviors. We believed that having the participants take an objective measurement of their hand would increase engagement and confidence in self-management. It is possible that requiring a hand image only once a month was too long of a time frame and reduced participant engagement with the app. We chose this length of time to watch for discernable changes in the hand and reduce overall burden to the patient. However, more frequent hand measuring may have reminded the participant about the day-to-day management of their disease and to use the other features of the app more regularly.
Participants who already had significant disability to the hand had difficulty operating the app. Some participants recruited others to aid them in using the app but found this to be additional work for them. It is assumed that traditional methods of self-management such as a pen-and-paper system may also have been difficult for this population. Future mobile app interventions should optimize voice technology and passive measurements to improve accessibility for patients with more progressive RA disability.
Some participants had pre-established routines of self-managing their disease through methods such as pen-and-paper journaling and felt it was sufficient. It is unclear whether a mobile app adds anything for a patient who already has a working system and is successfully managing their disease. Future studies should compare the use of a mobile app with pen-and-paper methods to see if simply using any self-management intervention shows improvement or if the mobile app shows superior improvement.
Our study had a small sample size and a large dropout rate. We experienced technology problems that caused delays and reduced the confidence of many of our participants. Our participants were a part of a larger longitudinal study and currently seeing a rheumatologist with regularity; therefore, they might have been more compliant than the general population. We did not include participants who completed the study in our qualitative interview process, which may have impacted our findings. Participants were required to own a smartphone to be included in the study; therefore, they might have had a more advanced knowledge of technology than the general population.
The use of a mobile app with optical imaging capabilities appears to improve self-efficacy in managing symptoms of RA and may improve other outcomes such as patient activation, pain, and disability. Future research should include a larger sample size and comparisons with other self-management interventions, such as traditional pen and paper, to help determine if the use of this app mediates the improvement to health outcomes.
Health Assessment Questionnaire-II
Patient Activation Measure
Patient-Reported Outcomes Measurement Information System
PROMIS Self-Efficacy in Managing Symptoms
rheumatoid arthritis
Rheumatology and Arthritis Investigational Network Database
Visual Analog Scale
This study was funded by the University of Nebraska Medical Center for Patient, Family, and Community Engagement in Chronic Care Management (CENTRIC). Debra Bergman served as study coordinator. Bartlett C Hamilton III assisted with the study. James O’Dell was the primary clinical partner. Harlan Sayles completed statistical analysis. Myra Schmaderer and Bunny Pozehl contributed to study design.
KM receives grant funding from Rheumatology Research Foundation.