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Mobile devices such as smartphones and tablets have surged in popularity in recent years, generating numerous possibilities for their use in health care as mobile health (mHealth) tools. One advantage of mHealth is that it can be provided asynchronously, signifying that health care providers and patients are not communicating in real time. The integration of asynchronous mHealth into daily clinical practice might therefore help to make health care more efficient for patients with rheumatoid arthritis (RA). The benefits have been reviewed in various medical conditions, such as diabetes and asthma, with promising results. However, to date, it is unclear what evidence exists for the use of asynchronous mHealth in the field of RA.
The objective of this study was to map the different asynchronous mHealth interventions tested in clinical trials in patients with RA and to summarize the effects of the interventions.
A systematic search of Pubmed, Scopus, Cochrane, and PsycINFO was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Studies were initially screened and later assessed by two independent researchers. Disagreements on inclusion or exclusion of studies were resolved by discussion.
The literature search yielded 1752 abstracts. After deduplication and screening, 10 controlled intervention studies were included. All studies were assessed to be at risk for bias in at least one domain of the Cochrane risk-of-bias tool. In the 10 selected studies, 4 different types of mHealth interventions were used: SMS reminders (to increase medication adherence or physical activity; n=3), web apps (for disease monitoring and/or to provide medical information; n=5), smartphone apps (for disease monitoring; n=1), and pedometers (to increase and track steps; n=1). Measured outcomes varied widely between studies; improvements were seen in terms of medication compliance (SMS reminders), reaching rapid remission (web app), various domains of physical activity (pedometer, SMS reminders, and web apps), patient-physician interaction (web apps), and self-efficacy (smartphone app).
SMS reminders, web apps, smartphone apps, and pedometers have been evaluated in intervention studies in patients with RA. These interventions have been used to monitor patients or to support them in their health behavior. The use of asynchronous mHealth led to desirable outcomes in nearly all studies. However, since all studies were at risk of bias and methods used were very heterogeneous, high-quality research is warranted to corroborate these promising results.
An increase in the prevalence of rheumatoid arthritis (RA), as well as a general shortage of rheumatologists to treat patients with RA, has been described [
The World Health Organization defines mHealth as “medical and public health practice supported by mobile devices such as mobile phones, tablets (…)” [
The objective of this scoping review was to map the different asynchronous mHealth interventions tested in clinical trials in patients with RA and to summarize the effects of the interventions. Ultimately, this should help to identify promising implementations and future research opportunities.
We conducted a scoping review of the literature. This type of review is suitable to map the available evidence in new and developing fields. The value of scoping reviews to evidence-based health care and practice lies in the examination of a broader area to identify gaps in the research knowledge base, clarify key concepts, and report on the types of evidence that address and inform practice in the field [
A review protocol was developed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement [
The search was performed without date, language, or publication status restrictions.
Duplicate studies were excluded. The full search strategies for all databases can be found in
The following inclusion criteria were used: (1) the study population comprised only patients with RA, or the majority of the study population consisted of patients with RA, for whom the data were reported separately, (2) the study evaluated an asynchronous mHealth intervention (ie, the health care provider and patient were not in direct synchronous contact), (3) the study type was randomized controlled trial (RCT), randomized controlled crossover trial, or quasi-experimental clinical trial, (4) the study reported outcomes in relation to the mHealth intervention, and (5) the study was published in English as a full-length paper and an original report.
Studies that reported only qualitative outcomes (eg, from focus groups, semistructured interviews, etc) were excluded from the review. References of retrieved studies were screened for additional relevant studies. Interventions that used a web app were taken into account, as these are easily accessible through mobile devices (smartphone and/or tablet) and therefore regarded as mHealth in this review.
Initially, the title and abstract were screened independently for eligibility criteria and blinded to each other with the online tool Rayyan [
Data were extracted by one reviewer using a standardized template and verified by a second reviewer. The following data were extracted from each included study: the year of the study, the number of participants, patient characteristics, type of study, type of intervention, duration of study and follow-up, outcome measures, univariate outcomes, and statistical significance. Disagreements or discrepancies in data extraction were resolved by discussion.
The quality of each study was independently evaluated using the Cochrane Collaboration’s tool—a 7-domain tool for assessing risk of bias in which study characteristics are classified as having high, low, or unclear risk of bias [
The search yielded 1752 abstracts (Pubmed: n=286; Embase: n=1088; PsycInfo: n=9; Cochrane library: n=81; and Scopus: n=288). One additional abstract was added after cross-referencing. After deduplication, 1261 abstracts remained, of which 1245 did not meet the inclusion criteria. The main reasons to exclude abstracts were that they were not mHealth studies, the population was not patients with RA, they were conference abstracts, or they were the wrong study type (ie, review or not an intervention study). A total of 17 full-text studies were reviewed and ultimately 10 studies were included (
Study selection. mHealth: mobile health.
A description of the quantitative evidence for the mHealth interventions reported in the included studies is presented in
Evidence for effectiveness of mobile health trials in patients with RA.
Refa | Ptsb with RAc, n | Study duration (+ follow-up) | Intervention | Outcome measure | Resultsd | ||
|
|
|
|
|
Intervention, mean (SD) | Control, mean (SD) | |
[ |
63 | 6 mthse | LiveWith Arthritis smartphone app with optical imaging | Self-efficacy: P-SEMSf; PAMg | P-SEMS: 2.80h; PAM: 6.37h | P-SEMS: 1.66h; PAM: 2.30h | P-SEMS: .04; PAM: .46 |
[ |
160 | 12 mths | Physical activity intervention (web app) | Participants that meet Dutch public health physical activity recommendation (%) | 6 mthsi: 38; 12 mthsi: 26 | 6 mthsi: 22; 12 mthsi: 15 | .04; .12 |
[ |
96 | 6 mths | SMS reminders | CQR-9j | 3.32 (5.66) | –0.14 (7.56) | .02 |
[ |
20 | 16 wksk | Motivational counselling and SMS reminders | Daily sitting time (hours/day) | –0.30 (1.90) | 0.15 (1.43) | —l |
[ |
150 | 16 wks | Motivational counselling and SMS reminders | Daily sitting time (hours/day) | –1.61 (CI –1.97 to –1.25) | 0.59 (CI 0.24 to 0.95) | <.001 |
[ |
157 | 2 mths + 2 mths | Access to different sections of a web app: (1) social support, (2) gaming, (3) information, (4) 1 and 2, and (5) control group | Physical activity (β)m, (minutes); health care use (β), (number of visits); medication overuse (β), (POMI)n,o | Physical activity, group 4: β=3.39p; health care use, group 2: β=–0.41, group 4p: β=–0.33 | N/Aq | Physical activity, group 4: .02; health care use, group 2: .01, group 4: .02 |
[ |
320 | 12 mths | Sanoïa (web app) | Patient-physician interaction (PEPPI-5)r | 0.6 (5.52) | –0.91 (6.08) | .01 |
[ |
44 | 12 mths | Telemonitoring with RETE-MARCHE (web app) | Patients with CDAIs remission and comprehensive disease control after 1 year (%) | 38.1 | 25 | <.01 |
[ |
108 | 10 wks + 9 mths | Educational modules for improving self-efficacy in self-management of RA (web app)t | Self-efficacy (ASES)u |
PIv: 83.9 (19.0); 9 mths PI: 84.1 (16.3) | PI: 68.5 (23.8); 9 mths PI: 68.6 (23.3) | PI: <.001; 9 mths PI: <.001 |
[ |
96 | 21 wks | Activity tracking with pedometer ww or wox step targets | Physical activity (steps/day); Fatigue (PROMISy-fatigue) | Steps/day w: 1656 (2161), wo: 1441 (2829); Fatigue w: –4.8 (7.7), wo: –3.2 (7.2) | Steps/day: –747 (3064); Fatigue: –1.6 (8.1) | Steps/day: .003; Fatigue: .21 |
aRef: reference.
bPts: patients.
cRA: rheumatoid arthritis.
dIn the results column, between-group differences are presented.
emths: months.
fP-SEMS: Patient-Reported Outcomes Measurement Information System Self-Efficacy Managing Symptoms.
gPAM: Patient Activation Measure.
hSD unknown.
iIntention-to-treat analysis.
jCQR-9: 9-item Compliance Questionnaire-Rheumatology.
kwks: weeks.
l—: not available.
mUnstandardized beta-coefficient (β) of multilevel linear model, including time exposed to intervention; no univariate results presented.
nPOMI: Prescription Opioid Misuse Index.
oNo significant differences were found in medication overuse.
pNo significant differences in the other groups.
qN/A: not applicable.
rPEPPI-5: 5-item Perceived Efficacy in Patient-Physician Interactions.
sCDAI: Clinical Disease Activity Index.
tNo primary outcome was defined.
uASES: Arthritis Self-Efficacy Scale.
vPI: postintervention.
ww: with.
xwo: without.
yPROMIS: Patient-Reported Outcomes Measurement Information System.
Three RCTs investigated the use of SMS reminders. Mary et al [
Two other RCTs [
Five RCTs investigated the use of an online platform [
Allam et al [
Shigaki et al [
A smartphone app was used in one study [
A pedometer was used in one study [
At least one domain of the risk-of-bias tool was scored as “at risk for bias in all studies.” Blinding participants was not performed in 9 out of 10 studies. No studies were classified as at high risk for selective reporting. The majority of studies (6/10, 60%) were at risk for bias on multiple domains, and in 70% (7/10) of studies, there was an unclear risk for bias on at least one domain. Results are presented in
Assessment of risk of bias with the Cochrane Collaboration’s tool. Green=low risk of bias, red=high risk of bias, and orange=unclear risk of bias.
With this review, we provide an overview of the effects of mHealth interventions tested in clinical trials in patients with RA. We identified 10 studies that examined 4 different types of mHealth tools [
The results of the studies in this review show that it is possible with mHealth interventions to effectively monitor patients to achieve remission sooner [
Based on the limited evidence available from mHealth intervention studies, we will cautiously discuss some potentially promising implementations and expectations. We distinguished two main implementations of asynchronous mHealth: (1) monitoring of patients, which can be subdivided into active and passive monitoring, and (2) supporting patients in their health behavior (
Identification of asynchronous mobile health (mHealth) uses in rheumatoid arthritis. PROs: patient-reported outcomes.
This review was broad in scope and did not focus on one type of mHealth intervention, allowing it to provide a clear overview of the current position of all mHealth tools tested in clinical trials in patients with RA. To maintain a broad scope, the study regarded web apps as mHealth tools because web apps are easily accessible through mobile phones. However, it is possible, that the adoption of, or adherence to, web apps is different on computers and mobile phones. This might lead to other outcomes of the interventions, which should be further examined in future research. Lastly, it is possible that due to biased preference, only studies with positive results are published, which could have led to an overrepresentation of positive effects in this review. However, there is little evidence that this occurred, as we examined trial registries (clinicaltrials.gov and isrctn.com) and encountered only one trial that was completed more than 2 years ago, which had not published its results.
There is a limited number of studies assessing the effect of asynchronous mHealth interventions in patients with RA. The available studies show that asynchronous mHealth interventions have been used to monitor patients or to support them in their health behavior. The reviewed studies reported significant beneficial results of SMS reminders, web apps, and smartphone apps on several outcomes. However, study methods varied widely, all studies were at risk of bias, and follow-up length was often short. Therefore, the results of the review indicate that all reviewed types of mHealth interventions show some promise, but also that these results need to be corroborated in future studies.
Search strategy.
Clinical Disease Activity Index
9-item Compliance Questionnaire-Rheumatology
mobile health
Preferred Reporting Items for Systematic Reviews and Meta-Analysis
patient-reported outcomes
Patient-Reported Outcomes Measurement Information System
Patient-Reported Outcomes Measurement Information System Self-Efficacy Managing Symptoms
rheumatoid arthritis
randomized controlled trial
telemonitoring intensive strategy
BS and WB wrote and edited the manuscript, BS and WB screened the abstracts, and BS and PdB assessed the quality of the studies. All other authors provided feedback and edited the manuscript.
None declared.