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A pilot study of a mobile phone application to improve lifestyle and adherence of patients with kidney disease

A pilot study of a mobile phone application to improve lifestyle and adherence of patients with kidney disease
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  TAILPIECE/Correspondence A pilot study of a mobile phone applicationto improve lifestyle and adherence of patients with kidney disease End-stage renal disease (ESRD) is a major public healthproblem worldwide. 1 Mobile health (m-health) has poten-tial in the prevention and control of non-communicablediseases, 2 but there is little experience of m-health inpatients with kidney disease. We have conducted a pilotstudy of mobile phone text messages designed to improvelifestyle, adherence and clinical outcomes in patients withkidney disease. Methods An educative tool based on text messages and reminderswas developed in collaboration with the Carlos SlimInstitute for Health (ICSS). A multidisciplinary group of experts in nephrology, internal medicine, family medicine,general medicine and nutrition, generated short messagesabout kidney disease risk factors and medical alert infor-mation, healthy diet and lifestyle, as well as recommenda-tions to improve adherence to treatment and encouragethe attendance at follow-up appointments. Messages wereapproved when there was agreement between at least 80%of the experts.The messages were then adapted to the format of theshort message service (SMS) by ICSS informatics andmobile telephony experts. Messages were sent by a com-mercial service (Telcel). The programme had no cost forpatients, who were free to withdraw at any time fromthe study.The pilot study was approved by the appropriate ethicscommittee, and was tested for 4 months starting in June2012. Patients older than 14 years with a first kidney trans-plant performed at our hospital were invited to partici-pate, and they were included in the study at the time of discharge. Patients received daily SMS messages andreminders of follow-up appointments and daily medica-tion at an agreed frequency. In addition, a satisfactionquestionnaire was sent to all participants at the end of the study. They were asked to grade the usefulness of the messages on a scale from 0 (not useful at all) to 10(extremely useful).Patients were treated by their nephrologists accordingto usual clinical practice standards. Results Fifty short text messages about kidney disease risk factors,40 about healthy lifestyle and 35 recommendations toimprove adherence to treatment, attendance at follow-upappointments and medical alert information were sent to23 patients receiving a first kidney transplant (96% from aliving donor). The mean age of the patients was 33 years(SD 13) years and 43% of them were women. Details of the mobile phone programme are shown in Table 1.At the end of the study, patients rated the usefulness of the text messages (on a 0-10 scale) as 9.6 (SD 0.7). Theyrated the medication reminders as 9.8 (SD 0.5) and theappointment reminders as 9.8 (SD 0.6). They perceivedthe tool as helpful and considered that it could be imple-mented widely. Discussion Self-care programmes are an important form of preven-tion in those at high risk and they can improve outcomesin people with non-communicable diseases. Patient educa-tion for self-care can provide benefits in terms of know-ledge, self-efficacy and health status. 3,4 Techniques used inself-care programmes include the use of mobile phones,computer networks, web-based tools and telemedicine,amongst others. 4 These may be useful throughout theworld, particularly in low- and middle-income countries.Mobile telephony has a high penetration, even in ruraland isolated areas; in Mexico, for example, there weremore than 100 million mobile phone users at the endof 2012. 5 Table 1.  Mobile phone messaging.Median (IQR)Duration of the study (days) 58 (41–76)Text messages (/day) 0.8 (0.3–0.9)Medication reminders (/day) 3.0 (2–3)Follow-up appointment reminders (/month) 1.1 (0.3–1.8) IQR, interquartile range.  Journal of Telemedicine and Telecare 0(0) 1–2 ! The Author(s) 2015Reprints and 10.1177/1357633X14566591   J Telemed Telecare OnlineFirst, published on January 13, 2015 as doi:10.1177/1357633X14566591  Nonetheless, there is scarce information about the useof new information technologies in kidney disease. 6–8 In asmall study evaluating the usability of a prototype medi-cation enquiry system, which offered patients informationabout the safety of drugs in chronic kidney disease, a widerange in proficiency was observed in the use of the website, personal digital assistant and SMS platforms. 6 In across-sectional survey of racial differences related to own-ership and use of information technology in kidney trans-plant patients, the use of mobile phone text messaging wasfound to be ubiquitous, and similar between AfricanAmerican and white patients, although computer andInternet access was not. 7 The present pilot study represents the first step of aprogramme based on mobile telephony to improve out-comes in kidney disease patients. In contrast to previousreports, we developed a series of text messages and testeda delivery protocol that could be useful in preventing orimproving outcomes of chronic kidney disease. However,the effect of this kind of intervention on survival and func-tion of native or transplanted kidneys requires evaluationin further studies. This intervention could add benefits tomultiple intervention models that have been recentlyreported in the primary healthcare setting. 9 A holisticapproach to e-health development that is evidence-basedand people-centred, and that takes into account howpeople live within their own environments, may help tocounteract the growth of end-stage kidney disease.In conclusion, more than 100 messages to improve life-style, adherence and clinical outcome, as well as a deliveryprotocol by mobile phone SMS, were successfully devel-oped and tested in patients with kidney disease. This kindof intervention has the potential to facilitate changes inknowledge, attitudes, behaviours and clinical outcomes inpatients with kidney disease. Acknowledgements We thank the following for assistance with the creation of theSMS content: Guillermo Garcı ´a-Garcı ´a (Nephrology), Erika FGo ´mez-Garcı ´a (Renal Dietitian), Fabiola Martı ´n-del-Campo(Renal Dietitian). We are grateful to the company Telcel whoprovided the mobile telephony service. References 1. USRDS. United States Renal Data System 2013. See  (last checked 22October 2014).2. WHO. Resolution WHA58.28. Health action in relation tocrises and disasters, with particular emphasis on the earth-quakes and tsunamis of 26 December 2004. See  (last checked 22 October 2014).3. Cueto-Manzano AM, Martı ´nez-Ramı ´rez HR, Corte ´s-Sanabria L.Management of chronic kidney disease: primary health-caresetting, self-care and multidisciplinary approach.  ClinNephrol   2010; 74 (Suppl 1): 99–104.4. WHO. Global status report on noncommunicable diseases2010. See full_en.pdf  (last checked 22 October 2010).5. Instituto Federal de Telecomunicaciones. Manual para larecopilacio´n de datos administrativos de las telecomunica-ciones y de las TIC de la UIT. See (last checked 22 October 2014) [Spanish]6. Diamantidis CJ, Zuckerman M, Fink W, Aggarwal S,Prakash D, Fink JC. Usability testing and acceptance of anelectronic medication inquiry system for CKD patients.  Am J Kidney Dis  2013; 61 :644–645.7. Lockwood MB, Saunders MR, Lee CS, Becker YT,Josephson MA, Chon WJ. Kidney transplant and the digitaldivide: is information and communication technology a bar-rier or a bridge to transplant for African Americans?  ProgTransplant  2013; 23 :302–309.8. Chen SH, Tsai YF, Sun CY, Wu IW, Lee CC, Wu MS. Theimpact of self-management support on the progression of chronic kidney disease – a prospective randomized controlledtrial.  Nephrol Dial Transplant  2011; 26 :3560–3566.9. Cueto-Manzano AM, Martı´nez-Ramı´rez HR, Corte´s-Sanabria L.Comparison of primary health-care models in the manage-ment of chronic kidney disease.  Kidney Int Suppl  2013; 3 :210–214. Alfonso M Cueto-Manzano 1 , He´ctor Gallardo-Rinco´n 2 ,He ´ctor R Martı ´nez-Ramı ´rez 1 , Laura Corte ´s-Sanabria 1 ,Enrique Rojas-Campos 1 , Roberto Tapia-Conyer 2 ,Petra Martı ´nez 3 , Ignacio Cerrillos 3 , Jorge Andrade 3 andMiguel Medina 3 1 Unidad de Investigacio´ n Me´ dica en Enfermedades Renales,CMNO, IMSS, Guadalajara, Me´ xico 2 Direccio´ n de Soluciones Operativas, Instituto Carlos Slimde la Salud AC, Me´ xico DF, Me´ xico 3 Depto de Nefrologı´ a, Hospital de Especialidades, CMNO,IMSS, Guadalajara, Me´ xicoCorresponding author:Dr Alfonso M Cueto-Manzano, Unidad de Investigacio´ nMe´ dica en Enfermedades Renales, Hospital deEspecialidades, CMNO, IMSS, Belisario Domı´ nguez 1000,Col. Independencia, CP 44320, Guadalajara, Jalisco,MexicoEmail: 2  Journal of Telemedicine and Telecare 0(0)
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