Conceptualization and Assessment of Digital Health Technology Literacy

윤정희 성균관대학교 일반대학원 2020 국내박사

오늘날 디지털헬스의 등장은 건강 분야에도 영향을 미치고 있다. 또한 매체가 다양해지고 수많은 정보가 쏟아지는 가운데 건강정보를 이해하는 개인의 능력이 중요해지고 있다. 이러한 능력은‘헬스리터러시’또는 건강이해능력’이라고 불리며, 개인의 건강 관리와 건강의 질에 영향으로 그 중요성이 강조되고 있다. 더불어 최근 신종 코로나바이러스와 같은 비대면 사회로의 확산은 디지털 헬스를 필수적으로 만들면서 디지털헬스 기술 및 서비스를 다루는 개인의 능력도 중요해졌다. 이와 같은 의료환경의 변모는 특히 노인이나 기술적 취약 계층에서 중요해지며 디지털헬스 기술리터러시에 대한 관심이 높아졌다. 그러나 디지털 기술 차원의 리터러시는 그 개념이 모호하거나 이론적 배경이 부족한 편이다. 또한 이를 측정하기 위한 표준도구조차 전무한 실정으로 유사한 개념의 리터러시는 대부분 인터넷에 집중되어 광범위한 디지털 헬스 기술 및 서비스를 다루지 못한 한계가 있으며, 자가보고 설문 형태로 실제 수행 능력과 차이가 있어 개인의 능력을 평가하는데 한계가 있다. 따라서 본 연구는 체계적 문헌고찰 및 연구분석을 통해 선행된 디지털헬스 기술리터러시 (Digital Health Technology Literacy)의 개념을 살펴보고 구성요인을 파악하여 새롭게 문항을 개발하고자 했다. 또한 디지털헬스의 매핑 작업을 토대로 실제 디지털헬스 기술 및 서비스의 수행 능력을 반영할 수 있는 10가지의 척도를 개발하였다. 이는 2020년 1월부터 2월까지 일개 병원에서 만성질환자와 일반인 590명을 대상으로 조사되었고 내용적 타당도, 탐색적 요인분석, 수렴 타당도를 포함한 확인적 요인분석, 모델 적합도를 실시하였다. 문헌고찰 결과 디지털헬스 기술리터러시는 진화된 헬스리터러시 요인과 디지털 기기 및 서비스와 관련된 디지털의 기능적, 의사소통적, 비판적 리터러시, 그리고 디지털 기기 및 데이터를 포함한 디지털헬스 고유의 특징, 사회적 지지와 촉진 요인 등 총 5가지 도메인으로 구성하였다. 이를 기반해 세분화된 문헌고찰과 전문가 검토를 통해 20개의 범주 내 115개 문항을 개발하였고 최종적으로 디지털 기능적 그리고 비판적 리터러시의 2가지 영역으로 구성된 4개의 범주(34개 문항)를 추출하였다. 최종 개발된 문항은 ROC 분석을 통해 유효한 기준점 점수(Cut-off)를 확인하였다. 최종 버전의 도메인별 Cronbach’s α값은 1) 디지털 기능적 리터러시; 1차 범주 (0.939), 2 차 범주 (0.916), 3 차 범주 (0.911) 및 2) 디지털 비판적 리터러시 (0.873)로 신뢰 수준에서 내적 일관성을 보였다. 모델적합지수의 경우 χ2 (521) = 2983.252, P <0.000, SRMR = 0.065, RMSEA = 0.090, TLI = 0.807, CFI = 0.821로 도구의 타당성을 확인하였다. 34개의 문항의 기준 점수는 34점 만점으로 민감도 86.37 %, 특이도는 82.22 %에서 최적으로 만나는 22점이 기준점으로 확인되었다. 본 연구를 통해 개발된 측정도구는 디지털 기술을 이용한 개인건강기록 및 건강정보를 찾고, 평가 및 소통하며 건강 관련 의사결정을 개선하고 개인건강 행동을 적용하는 능력을 측정함으로써, 디지털헬스 환경에서 다양한 계층에 디지털 기술 및 서비스의 균등한 기회를 제공하기 위한 지표로 활용될 수 있음을 제안하고자 한다. 또한 지속적인 건강관리가 필요한 만성질환자를 포함한 성인의 디지털헬스 기술리터러시를 쉽고 간편하게 측정하여 그 수준에 맞는 디지털헬스 기반 교육과 중재 시 사정, 평가 도구로 의료진 및 연구자, 서비스 제공자에게 도움이 될 수 있는 가능성을 제시하였다. 더 나아가 향후 지역사회 건강증진을 위한 디지털헬스 보급에 디지털헬스 기술리터러시의 실태 및 개인과 집단의 역량 수준을 파악하기 위한 보다 객관적이고 체계적인 도구로 활용되기를 기대해본다. Background: Along with the digitalization of healthcare, the abilities and skills of an individual to understand online health information and to use health-related digital technology and services are becoming important. These abilities and skills are called eHealth literacy, which is an essential factor to affect people’s health and the quality of healthcare. However, as digital health has a broad spectrum of digital technology applications compared with eHealth, an assessment of diverging skills is essential with various ranges of skills. Purpose: The study examines the current status of digital health by reviewing the literature and conducting a survey, in addition to exploring a novel concept regarding a technology literacy related to digital health with performance-based competency in digital technology and services, and develops and validates a tool Digital Health Technology Literacy-Assessment Questionnaire (DHTL-AQ), developed through this concept. Method: The domains and items were generated from the literature review followed by item development and refinement process conducted with experts. The initial DHTL-AQ validation version consisted of 5 digital health-related domains (20 categories, 115 items) to assess health information seeking, digital health behaviors, and to explore associated factors related to technology literacy related to digital health. The tool tested 590 participants from a general population and patients with chronic disease in an outpatient clinic from January to February in 2020. To examine the concurrent validity of the DHTL-AQ with performed technology literacy, participants were tested 10 app task ability scale through a survey. Participants were assigned to three groups (high, moderated, and low) based on their mean score obtained on the performed task ability score level. The items were evaluated using exploratory factor analysis and convergent validity analysis, and confirmatory factor analysis to identify final factor structure and items. To measure different valid score profiles in population, further ROC analysis was conducted to calculate the cut-off scores of the DHTL-AQ. Results: The final DHTL-AQ had 34 items that were sorted into 2 domains and 4 categories: 1) digital functional literacy (3 categories, 29 items), 2) digital critical literacy (1 category, 5 items). The final version of each category’s Cronbach’s alpha was: 1) digital functional literacy—1st category (0.939), 2nd category (0.916), 3rd category (0.911); and 2) digital critical literacy (0.873). Fit indices of the final DHTL-AQ were as follows: χ2 (521) =2983.252, P<0.000, SRMR=0.065, RMSEA=0.090, TLI=0.807, CFI=0.821. The cut off value of the 4 categories was 22 out of 34, with a sensitivity of 86.37% and a specificity of 82.22%. Discussion: The Digital Health Technology Literacy-Assessment Questionnaire (DHTL-AQ) has good properties and will assist healthcare providers and researchers in assessing, evaluating and providing digital technology-based health interventions for chronic diseases.

Universal eye health and its relation to digital health : a systematic analysis

Mikhail, Maria Ezzat Azer Graduate School of Public Health, Yonsei Universit 2021 국내석사

배경: 안구 건강에 대한 다양한 글로벌 공중 보건 부문의 적극적인 노력에도 불구하고. 현재 사용할 수 있지만 아직 모든 사람이 사용할 수있는 것은 아닙니다. 여기에서 안구 건강 서비스 제공의 사회적 불평등을 줄이고 안과 진료 서비스 범위를 개선하기 위해 보편적 안구 건강 개발에 대한 요구가 나타났습니다. 모바일 건강은 오늘날 건강 관리 전달의 중요한 영역이되었습니다. 이 연구는 보편적 인 안구 건강의 가용성과 접근성과이를 개선하는 추가 요소로서 디지털 건강의 역할을 연구하는 것을 목표로합니다. 방법: 이것은 관찰 후 연구입니다. 저소득 국가의 디지털 안구 건강 현황에 대한 심층 연구에 사용 된 2 가지 방법 다른 세계 보건기구 지역에서 연구 된 국가의 국가 프로필 및 체계적인 분석. 문헌은 세 개의 검색 엔진에서 검색되었습니다. 리뷰 기사의 개요는 환자, 개입, 비교 및 결과 프레임 워크를 사용하여 수행되었습니다. 검색 키워드는 "모바일 건강", "스마트 건강", "눈 건강", "백내장"등입니다. 당사의 37 개 간행물은 세 가지 예상 결과 범주와 관련하여 적합한 것으로 확인되었습니다. 결과: 디지털 건강은 연구 대상 국가에서 보편적 인 안구 건강을 달성하는 데 중요한 요소로 밝혀졌습니다. 디지털 건강의 효과를 나타내는 결과의 세 가지 범주는 안구 질환 환자의 삶의 질, 안구 건강 서비스의 질 및 안구 건강 서비스에 대한 접근이라는 안구 건강 시스템 개선에 도움이되는 체계적인 분석에서 발견되었습니다. 이러한 결과가 이집트의 디지털 안구 건강에 미치는 영향도 확인되었습니다. 결론: 디지털 건강은 많은 연구 국가에서 보편적 인 안구 건강의 달성과 확장에 중요한 추가 요소로 부상했습니다. 휴대용 스크리닝 장치, 안저 영상 및 망막 진단 AI 혁신과 모바일 안과는 오늘날 눈 분야에서 흑마가되었지만 이러한 기술이 필요한 많은 국가에서 여전히 사용이 제한적입니다. 백내장 수술 지표에 대한 연구 및 데이터 수집을위한 전자 건강 기록의 사용은 확장이 필요한 매우 좁은 범위에서도 여전히 사용되고 있으며, 국가에 대한 실제 평가를 할 수 있도록 UEH 지표를 모니터링하는 것이 매우 필요하기 때문입니다. '국가 안구 계획의 진전과 특히 저소득 국가에서 안과 서비스 및 환자 생활의접근성과 질을 개선합니다 Abstract Background Despite the vigorous efforts of different Global public health sectors regarding eye health. It became now available, but not yet to everyone. From here appeared the urge of the development of Universal Eye Health (UEH) to ensure reducing social inequality in eye health services delivery and improving eye services’ coverage. Digital Health has also become an important frontier in health care services delivery nowadays. This research aims to study the availability and accessibility of UEH and the role of Digital Health as an additive factor in improving it. Methods This is an observational retrospective study. 2 methods where used for in-depth study of current situation of digital eye health in LMICs; Country profiles of the studied countries from different WHO regions and systematic analysis. Literatures have been searched at three search engines: PubMed, Google Scholar, and Cochrane Library. An overview of review articles was conducted using patient, intervention, comparison, and outcome (PICO) framework. Search keywords were; “Digital health”, “Smart health”, “eye health”, “Cataract”, and etc. Our 37 publications were identified as suitable regarding the three expected categories of outcomes. Results Digital health was found to be an important factor in the attainment of UEH in the studied countries. Three categories of outcomes representing the effect of digital health were found in the systematic analysis which helped in improving the eye health system: quality of life of patients with ocular diseases, quality of eye health services and access to the eye health services. Implication of these results on digital eye health in Egypt was identified as well. Conclusion Digital health was found to be an important additive factor in the attainment and expansion of UEH in many of the studied countries. Portable screening devices, Fundus photography, and retinal diagnostics AI innovations and Teleophthalmology have become the black horse of the eye field nowadays but still used in a limited range in many countries in need of such technologies. Using EHRs in research and gathering data for cataract surgical indicators still also used in a very narrow scope which needed to broaden. As it is strongly needed to monitor UEH indicators to be able to have a real assessment of the countries’ progress in their national eye plans and improve access and quality of eye services and of patient life, especially in LMICs. Keywords: Universal Eye Health, Cataract, Diabetic Retinopathy, Retinal Diagnostics, and Digital health.

"Don't Watch This Video!" Online Privacy, Porn, Sutura, and Health Among Senegal's Digital Dissidents

Friend, Juliana G ProQuest Dissertations & Theses University of Cali 2022 해외박사(DDOD)

소속기관이 구독 중이 아닌 경우 오후 4시부터 익일 오전 9시까지 원문보기가 가능합니다.

This dissertation explores how sutura – the Senegalese ethic of discretion – has transformed within shifting landscapes of digital media use. In historically contingent ways, sutura has predicated one’s moral legitimacy, legible gender identity, and national belonging on one’s ability to shield aspects of life considered “intimate” from public view. Those who disrupt gender expectations may be construed as lacking sutura. This can undermine their claims to moral belonging. What happens when social media allows users to share intimate life with wide audiences in real time? What does digital media use entail for sutura, and for the configurations of gender and moral belonging invoked in its name? I show that fears of non-consensual digital exposure and image-based sexual abuse have grown in tandem with the importance of digitally mediated intimacy as a site for defining oneself as an ethical Senegalese subject. This affects sexually stigmatized Senegalese acutely and paradoxically. For example, sex workers face high risks of non-consensual exposure online. Yet others may accuse them of transgressing sutura through purported “digital dissidence,” indiscreet or excessively embodied online behavior.Rather than provoking straightforward censorship, perceived digital transgressions of sutura produce unlikely collaborations between “digital dissidents” and institutions that seek to align everyday practices with national ideals of ethical intimacy. Drawing on over 18 months of ethnography and participatory action research, I trace these unlikely interactions across multiple sites: from digital sexual health programs, to Muslim youth groups, to pornography production.In this dissertation, sutura is more than an object of research. I argue that sutura challenges the intransigent analytical distinction between “communication” and “health.” Moreover, it illustrates the gendered operation of health/communicative inequities. Magnified by anxieties about social media’s capacity to multiply affective or erotic attachments, sutura may be invoked to conflate communicative excess with bodily excess, and associate both with gendered illegibility. However, digital dissidents reject the devaluing of their communicative practice. For them, sutura is not a boundary dividing the “intimate” from the “public,” but rather, a practice of collective protection. They reframe digital privacy as mutual aid. I argue that digital dissidents’ reimagining of sutura disrupts dominant paradigms in digital privacy policy that emphasize individual awareness and responsibility. If we heed the expertise of those most vulnerable to digital harms, we can better leverage digital health strategies to promote health equity. By reclaiming sutura, digital dissidents gesture to an alternative digital future, one marked by the equal distribution of digital privacy, health, and protection.

Effectiveness of digital health-supported lifestyle modification on patients with non-alcoholic fatty liver disease: A systematic review and meta-analysis

오주현 성균관대학교 일반대학원 2023 국내박사

Background/Aims: Lifestyle modification is a key intervention in patients with non-alcoholic fatty liver disease (NAFLD). Digital health technologies have emerged as potential tools to support lifestyle modification, but current evidence regarding this topic is limited. This systematic review and meta-analysis aimed to investigate the effectiveness of digital health-supported lifestyle changes in patients with NAFLD. Methods: Relevant studies were selected from MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials until April 5th, 2023, using the search terms NAFLD and digital health. The primary outcome was change in body weight, with secondary outcomes including change in alanine aminotransferase (ALT), aspartate aminotransferase (AST), and attrition rate, the proportion of participants who dropped out of the study before completion. Subgroup analyses of digital health modalities were performed, and the data were pooled using the random effect method. Results: Nine studies (967 patients with NAFLD) were analyzed, including eight randomized controlled trials and one prospective study. Digital health-supported lifestyle modification resulted in a greater mean reduction in body weight (weighted mean difference (WMD) -3.54 kg). Patients receiving digital health support also had greater reductions in ALT and AST compared to conventional treatment (WMD of ALT: -11.92 U/L and WMD of AST: -6.33 U/L). The attrition rate was not significantly different between the two groups. Telephone and mobile phone-based interventions were effective in reducing body weight, with mobile phone-based interventions showing greater reductions in AST levels. Conclusions: Digital health-supported lifestyle modification is effective in lowering body weight and improving laboratory findings in patients with NAFLD. The acceptable attrition rate suggests that NAFLD patients may benefit from digital health technology. 비알코올성 지방간질환(NAFLD) 환자에서 생활습관 개선은 중요한 치료 중 하나이다. 디지털 헬스케어 기술은 생활습관 개선을 지원하는 잠재적인 도구로 등장하였으나, 이에 대한 현재의 증거는 한정적이다. 본 체계적 문헌고찰과 메타분석에서는 NAFLD 환자에서 디지털 헬스케어를 통한 생활습관 변화의 효과를 조사하였다. NAFLD, 디지털 헬스케어, 원격진료를 검색어로 MEDLINE, Embase, Cochrane Central Register of Controlled Trials에서 2023년 4월 5일까지 연구를 검색하였다. 일차평가변수는 체중 감소이며, 이외에도 alanine aminotransferase (ALT), aspartate aminotransferase (AST), 탈락 비율(완료 전 연구 참가자의 비율) 등이 보조적결과변수로 사용되었다. 디지털 헬스케어 모드에 대한 부분집단 분석을 수행하였으며, 랜덤 효과 모형을 이용하여 데이터를 통합하였다. 8개의 무작위 대조군 연구와 1개의 전향적 연구를 포함한 967명의 NAFLD 환자에서 메타분석이 수행되었다. 디지털 헬스케어를 통한 생활습관 중재는 유의한 체중 감량을 보였으며, 가중 평균 차이(WMD)는 -3.54 kg였다. 디지털 헬스케어를 받은 환자들은 기존 치료군에 비해 ALT와 AST의 감소가 더욱 크게 나타났다(ALT의 WMD: -11.92 U/L, AST의 WMD: -6.33 U/L). 탈락 비율은 두 그룹 간에 유의미한 차이는 없었다. 전화와 모바일 기반의 개입은 모두 체중 감량을 유도하는 데 효과적이었으나 모바일 기반 개입이 ALT와 AST 감소에 더욱 높은 효과를 보였다. 본 연구 결과 디지털 헬스를 통한 생활 습관 변경은 NAFLD 환자에서 체중 감량과 간효소수치 개선에 효과적인 것으로 나타났다. 허용 가능한 수준의 포기율은 NAFLD 환자가 디지털 헬스 기술의 혜택을 받을 수 있음을 시사한다.

(A) prediction model for prevention and management of metabolic syndrome based on machine learning

이정훈 Graduate School, Yonsei University 2023 국내박사

Digital health-based lifestyle interventions (e.g., mobile applications, short message services, wearable devices, social media, and interactive websites) are widely used to manage metabolic syndrome (MetS). This study aimed to confirm the usefulness of digital health-based lifestyle interventions using healthcare devices and propose a novel prediction model of prevention and management for MetS. Participants with one or more MetS risk factors were recruited from December 2019 to September 2020, and finally, 106 participants were analyzed. Participants were provided with five healthcare devices and applications. Characteristics were compared at baseline and follow-up, and lifelog data that were collected during the clinical trial were analyzed. With these results, the frequency of use of healthcare devices for continuous self-care was quantified, and a novel prediction model for the prevention and management of MetS was developed. The model predicts persistence in continuous engagement as well as abbreviated risk factors for self-care effects. Representative machine-learning classifiers were used and compared. In both models, the random forest classifier showed the best performance, and feature selection was optimized through random forest-recursive feature elimination. As a result, the prediction model for persistence showed recall of 83.0%, precision of 92.4%, an F1-score of 0.874, a Matthews correlation coefficient (MCC) of 0.844, and accuracy of 94.9%. The prediction model for abbreviated risk factors showed a recall of 79.8%, a precision of 87.2%, an F1-score of 0.834, and an MCC of 0.797 for increased abbreviated risk factors, and a recall of 75.1%, a precision of 85.5%, an F1-score of 0.800, and an MCC of 0.747 for decreased abbreviated risk factors. The prediction model proposed showed high performance. Based on self-care with digital health-based lifestyle interventions, prediction models could be helpful for the prevention and management of MetS.

Cost-utility analysis of a home care program for peritoneal dialysis patients in a tertiary care hospital

김경이 Graduate School, Yonsei University 2023 국내박사

서론: 코로나바이러스 감염증(COVID-19) 대유행 이후 다양한 디지털 헬스 기술이 빠르게 도입되었다. 여러 종류의 솔루션 중 한국의 보건복지부는 환자들의 의료접근성을 높여 궁극적으로는 삶의 질을 향상시키기 위하여 재택의료 사업을 시작했다. 이 사업은 대면 교육상담과 전화 또는 양방향 메신저를 활용한 비대면 환자 모니터링을 포함하고 있다. 본 연구에서는 복막투석을 시행하고 있는 말기신부전 환자를 대상으로 재택의료 사업을 평가한다. 복막투석 환자는 국내 말기신부전 환자의 3.9%에 불과하지만, 재택에서 투석을 하는 것에 대한 임상적 이점을 다룬 연구가 많다. 또한 의료비 부담이 증가함에 따라 복막투석은 다른 신대체요법에 비해 비용-효과적인 대안으로 간주된다. 복막투석에 대한 관심이 높아지면서, 새롭게 시작한 재택의료 사업의 장기적인 임상적, 경제적 효과를 검증하기 위한 연구가 필요하다. 연구방법: (임상효과분석) 복막투석 재택의료 사업의 사전-사후 임상적 효과를 평가하기 위하여 단일 상급종합병원에서 후향적 코호트 연구를 설계하였다. 2017년 6월부터 2022년 5월까지 총 186명의 복막투석 환자가 연구대상으로 선정되었다. 5년 간의 데이터는 재택의료 사업 시행 후 복막염 발생과 임상검사결과 (Hb, Ca x P, K, iPTH) 변화와 같은 임상적 변화 분석에 사용되었다. 분석방법으로는 카이제곱검정, 독립표본 t-검정, 시계열분석(ITS)을 사용하였다. (비용-효용분석) 재택의료 사업의 평생(lifetime) 비용-효과성을 평가하기 위해 마콥모형을 설계하고, 재택관리군과 기존 였다. 50세 복막투석 환자 1,000명을 포함한 가상의 코호트를 구축하고 모두 복막투석 단계에서 시작하여 매 1년 주기마다 상태(state) 전이를 확인하였다. 효과 변수는 질보정수명(QALY)으로 설정하고 제한적 사회적 관점으로 비용-효용분석을 수행했다. 1 QALY 당 지불의사(WTP) 임계치로는 1 GDP에 해당하는 40,043,036원으로 설정하였고, 비용과 효과(QALY) 데이터에 모두 4.5%의 할인율을 반영하였다. 반주기보정 후 주요 결과인 ICER와 INMB를 산출하였다. 불확실성이 큰 경제성평가의 제한점을 보완하기 위해 시나리오분석, 민감도분석 및 완벽한 정보의 기대값(EVPI)을 활용하여 결과의 변화를 확인하였다. 결과: (임상효과분석) 재택의료 사업 이후 복막염 발생이 감소했다. 1,000명의 환자-월 당 8.345건 발생(SE = 3.181, P = 0.012)하던 기준값은 매월 0.480건씩 증가하던 추세였다 (P = 0.018). 재택의료 사업 도입 후 복막염 발생 추이는 매월 0.886건 감소하는 추세로 변하였다 (P = 0.015). 1년 간 누적 발생으로 산출하면, 이는 27.31%의 발생이 20.93%로 감소한 것과 같다. 임상검사결과 분석 역시 개선되었다. 목표 수치에 도달한 비율이 Hb은 5.2%p 증가 (P = 0.002), Ca x P (1.1%p, P = 0.428) 및 K (-1.6%p, P = 0.200)는 유지된 반면, iPTH는 감소하였다 (-11.0%p, P = 0.000). (비용-효용분석) 기본분석에서 ICER는 1 QALY 당 4,571,500원으로 본 연구에서 설정한 WTP 임계치 이내에 속했으며, 시나리오에 관계없이 모든 기본분석 결과는 WTP 임계치를 벗어나지 않았다. 일원민감도분석을 시행하였고, 모든 시나리오에서 가장 민감한 변수는 복막투석비용 (재택사업)과 복막투석비용 (기존)으로 확인하였다. 10,000회의 몬테카를로 시뮬레이션 분석 결과, 재택의료 사업이 최적의 대안일 확률은 시나리오 1에서 62.05%, 시나리오 2에서 59.95%, 시나리오 3에서 61.70%, 시나리오 4에서 89.41%인 것으로 나타났고, 재택의료 사업이 최적의 대안일 확률이 50%를 넘는 WTP 임계치는 7,380,000원이었다. 마지막으로 EVPI를 측정하였고, 불확실성 없이 모든 변수에 대한 완벽한 정보를 가지고 있는 상황이라면 환자당 14,818,960원을 추가로 얻을 수 있다. 결론: 본 연구는 국내 최초로 복막투석 환자를 위한 재택의료 사업의 임상적 효과와 비용-효과를 평가하였다. 연구에서 복막염 발생 감소와 임상검사결과 개선의 임상적 효과성을 확인하였고, ICER가 WTP 임계치 미만이라는 점에서 비용-효과성을 확인하였다. 따라서 연구진은 복막투석 재택의료 사업이 임상적으로 효과적이며, 비용-효과적일 가능성이 높음을 시사하는 바이다. Background: A wide array of digital health technologies was rapidly adopted during the coronavirus disease (COVID-19) pandemic. The Ministry of Health and Welfare of Korea has initiated a home care program to increase access to care to improve quality of life. The program includes a face-to-face educational consultation and remote patient monitoring using telephone calls or bidirectional messenger services. In this study, we focused on patients with end-stage renal disease (ESRD) on peritoneal dialysis (PD). Although PD consists of the lowest proportion (3.9%) of the ESRD population in Korea, many studies address the clinical benefits of home-based dialysis, and it is widely considered a cost-effective alternative. This new home care program should be evaluated to verify its long-term clinical and economic effectiveness. Methods: Clinical effectiveness analyses A retrospective cohort study was designed as a pre-post study and conducted to analyze the clinical impact of a home care program for patients undergoing PD in a single tertiary care hospital. A total of 186 subjects on PD from June 2017 to May 2022 were the study subjects. Five-year data was used to identify the clinical changes after program implementation by analyzing the changes in peritonitis incidence and laboratory test results (hemoglobin, Hb; calcium-phosphorus product, Ca x P; potassium, K; and intact parathyroid hormone, iPTH). A chi-square (χ2) tests, unpaired Student’s t-test, and the interrupted time series (ITS) analyses with ordinary least square (OLS) linear regression were used in the analyses. Cost-utility analysis A Markov model was constructed to evaluate the lifetime cost-effectiveness of the PD home care program. Cohorts of 1,000 patients aged 50 years started from the PD health state and were simulated to make a state transition at each cycle (one-year in length). With the effectiveness variable as quality-adjusted life years (QALY), a cost-utility analysis was conducted with a limited societal perspective. A willingness to pay (WTP) threshold was set to KRW 40,043,036 (1 GDP) per increasing 1 QALY and the discount rate of 4.5% was applied for both QALYs and costs. A half-cycle correction was reflected, and the main outcomes were the incremental cost-effectiveness ratio (ICER) and incremental net monetary benefit (INMB). Scenario analyses, sensitivity analysis, and expected value of perfect information (EVPI) were performed to reflect the uncertainty. Results: Clinical effectiveness analyses The incidence of peritonitis was reduced in the most parsimonious model. The baseline value was 8.345 cases per 1,000 patient months (SE = 3.181, P = 0.012), and it continuously increased by 0.480 cases per 1,000 patient months (P-value for baseline trend = 0.018). After program initiation, the incidence trend significantly decreased by 0.886 cases per 1,000 patient months (P-value for trend change = 0.015). With the one-year cumulative value, it has decreased to 20.93% from 27.31% (counterfactual). The clinical laboratory test results also showed improvement. The proportion of individuals reaching the target range has increased in Hb (5.2%p, P = 0.002), maintained in Ca x P (1.1%p, P = 0.428) and K (-1.6%p, P = 0.200), while it decreased in iPTH (-11.0%p, P = 0.000). Cost-utility analysis In the base-case analysis, the ICER was calculated as KRW 4,571,500 per QALY, which is in the range of the WTP threshold. Regardless of the scenarios, the results of the base case analyses were in the range of the WTP threshold. A one-way sensitivity analysis was performed, and the most sensitive parameters were the costs of PD (home care) and PD (usual care) in every scenario. For the outcome of the Monte Carlo simulation (10,000 iterations), the home care group was an optimal overall strategy, with probabilities of 62.05% in Scenario 1, 59.95% in Scenario 2, 61.70% in Scenario 3, and 89.41% in Scenario 4. The WTP threshold where the probabilities of the home care group were optimal at above 50% was KRW 7,380,000. Finally, EVPI was measured, showing an additional KRW 14,818,960 per patient gained when all parameter information was obtained without uncertainty. Conclusion: This study evaluated the clinical effectiveness and cost-effectiveness of a novel home care program for PD patients in Korea. We found that this program reduced the incidence of peritonitis, improved laboratory test results, and demonstrated cost-effectiveness, as the ICER was under the WTP threshold. Therefore, our study suggests that conducting a home care program for PD patients is clinically effective and may be cost-effective.

중추신경계 탈수초 질환 환자에서태블릿 기반 인지기능 평가도구 개발

서다영 울산대학교 대학원 2023 국내석사

Background: Cognitive impairment (CI) is prevalent in patients with CNS demyelinating diseases such as multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD), and its monitoring is essential. The Symbol Digit Modalities Test (SDMT), which examines patients’ processing speed for 90 seconds, is the most widely used clinical assessment tool. However, this paper-and-pencil method is inconvenient and inflexible to conduct a precision evaluation. Objective: Recently, we developed a novel tablet-based modified digital SDMT (MD-SDMT), of which symbol-digit combination changes with every trial, and devised two protocols with different test times (MD-SDMT_1-min and MD-SDMT_2-min). We hypothesized that modifying the SDMT protocol is feasible and reliably evaluates CI with a shorter test time and improves patient preference. Methods: We prospectively enrolled patients with MS or NMOSD who visited the department of Neurology at Asan Medical Center between July 2021 and January 2022. Participants were assessed with the MD-SDMT_1-min and MD-SDMT_2-min protocols, along with the paper-based SDMT. Pearson correlations (r) between the MD-SDMT and the paper-based SDMT scores were evaluated. Participants also responded to a questionnaire about their experience with the assessment tools. Results: A total of 144 patients (99 with MS, 45 with NMOSD) were assessed during the study period. Both MD-SDMT scores correlated well with the paper-based SDMT scores (2-min, r = 0.88; 1-min, r = 0.85, all p <0.0001) in all participants. A total of 120 participants additionally responded to questionnaires. Patients preferred MD-SDMT protocols to the traditional paper-based SDMT with the order of the MD-SDMT_2-min (55.8%), the MD-SDMT_1-min (38.4%), and the paper-based SDMT (5.8%). Conclusion: Regardless of test time, MD-SDMT protocols reliably evaluated cognitive function with better patient preference than the paper-based protocol in patients with MS or NMOSD.

자기주도적 건강관리 지원을 위한 정보 설계 연구

곽민정 국민대학교 테크노디자인전문대학원 2022 국내석사

건강검진은 질병 위험요인의 예방과 조기 진단, 치료가 목적이며, 이를 활용한 자기주도적 건강 관리의 지원에 적합한 정보 설계가 필요하다. 본 연구는 수검자에게 정보 전달이 필요한 시점을 확인하고, 건강 행동을 유도를 위한 정보 설계를 제안하는 것이 목적이다. 첫째, 안내 부족으로 자기주도적 건강관리의 어려움이 있는 검진 전 안내 단계의 연구 내용은 다음과 같다. 검진 안내 문제점 확인을 위해 현황 및 관련 연구 분석과 AIDA 모델로 안내 요소를 정의하였다. 서비스 디자인 방법론으로 안내 문제점 파악 후 아이데이션 워크샵과 서비스 블루프린트로 해결 방향과 아이디어를 도출하고 서비스 콘셉트를 제안하였다. 마지막으로 심층 인터뷰로 콘셉트를 검증하였다. 결과로 초기 수검자 특성을 고려한 검진 정보와 예약 접근성이 향상된 안내를 제안하였다. 20-30대에게는 정보 접근성이 향상된 안내, 40대에게는 질환 심각도 파악과 일정 예약의 편의성이 향상된 안내, 66세 이상에게는 오프라인과 커뮤니티 기반의 안내 서비스를 제시하였다. 둘째, 건강 관리 유도가 부족한 검진 후 건강 관리의 연구 내용은 다음과 같다. 관리 유도의 문제점 확인을 위해 현황 및 관련 연구 분석을 진행하고, 건강증진모형으로 행동인식평가요소를 정의하였다. 행동을 유도할 수 있는 정보를 설계하고, 관찰 실험 후 설문과 심층 인터뷰로 행동유도 방안을 검증하였다. 본 연구는 통합적 관점에서 건강 관리 경험을 고려한 전략적 메시지 전달로 자발적인 건강 관리를 위한 검진 안내 서비스를 제안하는 데 의의가 있다. 행동 유도로 검진 문제 해결에 효과적인 전달 방안을 제안하는 연구를 진행하였으나 향후 수검자와 이해관계자의 심층적인 고려가 필요하며, 라포와 습관 형성으로 유의한 결과가 나올수 있어 장기간의 후속 연구가 필요하다는 한계점이 있다. 본 연구에서 제안한 건강검진 정보 설계가 수검자 경험향상에 도움이 되기를 기대한다. The purpose of health checkup is prevention, early diagnosis, and treatment of disease risk factors, and it is necessary to design appropriate information to support self-directed health management using it. The purpose of this study is to identify when information delivery is necessary to examinees and to propose an information design to induce health behavior. First, the contents of the study in the guidance stage before examination, where self-directed health management is difficult due to lack of guidance, are as follows. In order to identify problems in the checkup guidance, the current status and related research analysis and guidance elements were defined with the AIDA model. After figuring out the guidance problems with the service design methodology, solution directions and ideas were derived through ideation workshops and service blueprints, and service concepts were proposed. Finally, the concept was verified through in-depth interviews. As a result, examination information considering the characteristics of the initial examinee and guidance with improved reservation accessibility were proposed. For those in their 20s and 30s, information with improved access to information, for those in their 40s, information with improved disease severity and convenience for schedule reservations, and offline and community-based information services for those aged 66 and older. Second, the research contents of health management after screening lacking health management guidance are as follows. In order to identify problems in management induction, analysis of the current status and related research was conducted, and behavioral recognition evaluation elements were defined as a health behavior model. Information that can induce behavior was designed, and after observation experiments, the method of inducing behavior was verified through questionnaires and in-depth interviews. This study is meaningful in proposing a checkup guide service for voluntary health management through strategic message delivery considering health care experience from an integrated point of view. Although a study was conducted to suggest an effective delivery method to solve the screening problem by inducing behavior, in-depth consideration of future examinees and stakeholders is required, and significant results can be obtained through rapport and habit formation, so a long-term follow-up study is required. there is. It is hoped that the health examination information design proposed in this study will help improve the examinee's experience.

Variable-Dose Support in an Online Mental Health Intervention: A Randomized, Controlled Exploratory Study

Brooks, Jack ProQuest Dissertations & Theses Duke University 2022 해외박사(DDOD)

소속기관이 구독 중이 아닌 경우 오후 4시부터 익일 오전 9시까지 원문보기가 가능합니다.

Digital health interventions are widely considered a highly promising solution to issues with access to evidence-based care. However, digital health interventions are limited by lower rates of engagement than are typically seen in traditional, face-to-face interventions. Despite the importance of engagement for intervention efficacy, engagement is rarely a primary outcome in intervention studies, and few studies have empirically tested intervention changes to improve engagement.Hazel was a two-arm, randomized controlled exploratory study designed to investigate the impact of intervention design on engagement as a primary outcome. We conducted a trial of a mental health intervention, based on the Unified Protocol, delivered entirely online. Participants were randomized to complete the 12-week intervention self-guided (the unsupported arm) or with 4 weeks of therapist support (the supported arm). We sought to measure engagement as comprehensively as possible and therefore collected numerous self-report, behavioral, and objective measures of multiple facets of engagement, including how participants felt about the intervention, how they used the intervention technology, and how their behavior changed over the course of the intervention. We collected engagement outcomes at baseline, weekly during the intervention, and immediately following completion of the intervention. We hypothesized that a low dose of therapist support would improve engagement and subsequent mental health outcomes while being more scalable and feasible to implement than offering therapist support during all intervention weeks. The aims of this small, exploratory study were to learn more about patterns of engagement with the intervention and identify issues with the current intervention and trial design. We used descriptive statistics and visualizations to understand and describe trends in the data rather than p-value significance testing, in line with best practices for pilot studies.We recruited 23 North Carolina-based adults with clinically elevated depression and/or anxiety symptoms. Overall, the intervention and trial design appeared acceptable to participants. Participants in both arms had relatively positive attitudes toward the intervention at all time points, and there was no evidence that the response burden of our outcome measures was too high. However, several of our measures showed little variation between participants or over time. Our findings provides guidance for future studies to select alternative measures and/or to administer some engagement measures less frequently. This represents a meaningful step forward for the field of engagement research, as prior to this study, there was almost no empirical guidance on how to select measures of engagement or how frequently to administer them.We observed a substantial drop in engagement for participants in the supported arm when video sessions began, contrary to our expectations that video sessions would improve engagement. Notably, video sessions began partway through the intervention and participants were blinded to condition until the onset of these sessions; changes to blinding and/or timing of video sessions might improve engagement. At the same time, those participants in the supported arm who did engage in video sessions (n=4) completed more of each weekly lesson than participants in the unsupported arm, indicating that there is evidence that therapist support can increase engagement.Secondary outcomes were sample diversity and depression and anxiety symptom change. Our sample was comparably diverse to other digital health studies in terms of race and socioeconomic status, and we overrecruited LGBTQ+-identified participants. Despite finding little evidence of changes in behavior or the theoretical mechanisms underlying the intervention, the majority of participants showed improvement in their symptoms.

Point-of-care (POC) Microfluidic Devices Analyzing Urine and Blood for Digital Health

우딘 광운대학교 대학원 2019 국내박사

With the emerging demand of patient-centered health care for resourceconstrained and even for resource-full communities, special attention is being paid to develop handheld, portable, and automatized point-of-care (POC) diagnostics devices going beyond to the laboratory settings. A major challenge of POC testing devices is the automatization of diagnostic procedures integrating the necessary functional units along with high analytical precision. Therefore, extensive research to address the issues by employing cutting edge technologies to ensure patient and end-user satisfaction are of great interest for POC testing efficiency. In this work, a couple of lab-on-a-chip (LOC) devices were designed, developed and characterized for analyzing urine and blood samples addressing the major obstacles of their respective conventional approaches for POC applications. Initially, a disposable hybrid microfluidic LOC device was developed and applied for rapid analysis of various indexes of urine for clinical examinations to address the time dependent and visual colorimetric errors in conventional urine analysis method. The developed device was implemented as a stand-alone hybrid LOC device by embedding the conventional paper-based urine test strip inside a plastic-made LOC and using an optical platform along with a “UrineAnalysis” Android app. The integration of strip sensor into the LOC device sucessfully addressed the time dependent inconstancy of the conventional dipstick urine analysis and the smartphone app used for analysis enhanced the visual interpretation of test strip in LOC device. The integration of the finger-actuating micro pump with the LOC device enabled quantitative investigation of even very small amount (40 μL) of urine sample including glucose, protein, pH and red blood cell (RBC). As a result, the user-friendly LOC device with smartphone-based optical platform, may be applicable as a diagnostic tool for rapid and quantitative POC urine analysis. Secondly, a microfluidic adapter translating a conventional 96-well cartridge into an unconventional 96-well LOC device for enzyme-linked immunosorbent assay (ELISA) was developed and successfully applied for blood analysis. The adapter was implemented by integrating a single array of conventional 96-well cartridge with an inexpensively made array of PDMS pillars which was fixed onto a plastic chip. Since the PDMS pillars possess hexagonal structured tinier wells on their top, the fixation of a 96-well array with an array of PDMS pillars enables a reaction space at the top of each pillar that is in cotact with the 96-well plate. Since the device provided multiple (eight) reaction chambers associating a 96-well array with eight PDMS pillars, a program controlled PDMS made actuator including micro-valves was designed and integrated with the LOC device to sequentially activate the multiple immuno-sensing zones for multiple ELISAs under similar environment. The developed adapter successfully demonstrated ELISA with an optimal sample and reagent volume of 10 μL with an assay time of 10 to 15 min for different assay steps, which was much lower than the conventional ELISA using 96-well micro plates. The device achieved a low detection limit (LOD) of 9.75 pg/mL to successfully detect the cardiac troponin I (cTnI) in blood sample without requiring manual pipetting. Therefore, the developed 96-well LOC adapter based hybrid microfluidic adapter is widely applicable for high throughput multiple ELISA for POC clinical applications. Thirdly, another facile method to unconventionally process sandwich ELISA was proposed to shorten the consumption of sample, reagents and incubation time of conventional 96-well microplate, and to enable the control over sample flow rate and reaction time to address the unspecific molecular binding observed in microfluidic paper-based analytical devices (μPADs) based ELISA. To execute the method, an active PDMS pump and valve controlled LOC device adapting a single 96-well microplate onto a single PDMS micropillar fixed with a plastic chip was designed and developed. The integration of active pump and valve with the chip enabled controlled flow rate of sample through the microchannel of the chip to control the reaction time and the fixation of a conventional 96-well plate onto a PDMS pillar accommodates a tinier reaction zone to facilitate ELISA with reduced consumption of expensive sample and reagents shortening the assay time, which are crucial for ELISA. The developed device was favorably applied for the detection of cTnI baiomarker with a low LOD of 4.88 pg/mL, using optimal assay solutions (30-60 μL) and shorter assay times (10-15 min) than those of conventional ELISA protocols using 96-well microplates. Also, the device shows reduced interefernce in the detection of analyte than that of μPAD with greater feasibilities for POC applications. Finally, since the demand of POC as an alternative to the clinical diagnostic is emerging rapidly; to make it more and more feasible for patient-centered as well as for resource-limited settings, an optic controlled LOC device was designed and developed to automatize the ELISA procedure in terms of sample and reagents loading into the reaction zone and to analyze the post-assayed colorimetric ELISA signal. For the automation, an optic platform including a smartphone app along with an imaging box and mechanical frame was developed and applied for ELISA to successfully detecet NTproBNP human cardiac biomarker with a low detection limit of 7.81 pg/mL. The platform showed it effectiveness to appropriately recognize the empty and filled states of the reation zone thereby to control the mechanical frame to actuate solutions into the reaction space in controlled manner for ELISA. Moreover, the repeatability of ELISA signal for optic controlled LOC device was found more enhanced than that of ELISA conducted using the manually operated LOC device. ……………………………… Key words: Point-of-care (POC), Lab-on-a-chip (LOC), Microfluidic paper-based analytical devices (μPADs), Microchannel, Enzyme-linked immunosorbent assay (ELISA), Digital health, Urine analysis, Blood analysis, PDMS pump, PDMS valve, PDMS pillar, 96-well, Cardiac troponin I (cTnI), Human NT-proBNP, Hue value, Relative GSV, Smartphone, Immuno-Sensing, Reaction zone.