Why is it important to measure exposure to digital health interventions and how to tackle the challenge

Why Is It Important To Measure Exposure To Digital Health Interventions And How To Tackle The Challenge

Alexander: [00:00:00] Welcome to another episode of The Effective Statistician. Today I’m super excited to talk with, Jack about digital health innovations or interventions. Both start with I and, but both of these are also innovations which are a really interesting field to work on. Jack, before we dive into the questions itself, maybe you can talk a little bit. Towards yourself and how you got into working on a PhD in this area.

Jack: Yeah, of course. So hi, I’m Jack Elks. I’m currently doing a PhD looking at digital health interventions and how we engage with them and looking at trying to define engagement groups within a clinical trial setting. Going back a few years, I started in clinical trials in 2017 starting just after a Masters in Medical Statistics.

Really enjoyed clinical trials as an area. I [00:01:00] think it’s a really fascinating problem for statisticians to try and work out how we best design these trials and utilize patients in the best way to, to get answers. But having worked for, so I worked for a contract research organization called IQVIA.

So I’ve got a really good experience there of different types of trials that were available, different therapeutic areas, different types of interventions. And through that discovered my interest for digital health interventions and was attracted to the technology side of things and how they worked.

I wanted to delve deeper into this. I moved in 2019 to a job at Imperial Clinical Trials Unit, which is Where I am now to work with a company called Mayim Health to look at designing some of their trials for new interventions that they had, so apps for asthma, for COPD, for heart disease and diabetes as well.

And throughout those two years, discovered the challenge that we had about how we define engagement [00:02:00] groups for our analysis and trials, and that’s what led me to pick up this question as a PhD. And yeah, start it off. So that’s my journey.

Alexander: Yeah. And what’s that actually means engagement here?

We will dive a little bit deeper into it, into a moment. But let’s start with first some kind of questions to, to set the scenes. What are actually digital health interventions?

Jack: Digital health really is quite a broad term when we think about interventions. It’s quite encompassing. It can mean really the technology that a patient can engage with. That could be a health service that they’re accessing. It could be that the digital health intervention is delivering treatment.

And it can take the form of many different things that we’ll be familiar with. A website. It could be a mobile app that you download to your phone and you use these days as well. We’ve got AI to think about. So it could be something AI based that’s being used to either help a clinician monitor the health of that patient or the patient themselves to track and [00:03:00] monitor their own their own health.

But really it’s it’s something which can be described as a, an intervention that is accessed away from a hospital, away from a site and something where the patient. Typically is in control and able to decide when they’re accessing that intervention for how long as well and how often.

Alexander: And I think it can be both diagnostic and therapeutic. I think this is also a very interesting part. I think many of us first think when we think about these kind of things. Yeah, it’s imaging or monitoring or these kind of things. But that’s also opportunities, especially in the.

Intervention area. You’ve done especially also lots of research in the mental health space. Can you talk a little bit about the opportunities for interventions there?

Jack: Yeah, definitely. Digital health has been seen as a real potential solution to mental health sort of solving or helping mental [00:04:00] health treatment.

So the challenge at the moment with mental health is that they, the service available to patients is currently outpaced by the demand. It’s one in four women and perhaps the same again for men suffer with mental health conditions in their lifetime. And this number is growing. So the number of people who need treatment is increasing.

So that’s a big challenge. And at the moment, there’s not enough psychologists or clinical experts who are able to treat these patients. So digital health is something which can be seen as a solution to this, being able to provide. Support supplied there. Sorry, let me start that again. That was a waffle.

Go back. Okay, so I’m going to start that one again.

So in the area of mental health digital interventions can be, are seen as a potential solution here because at the moment the demand for these services is being outpaced by the supply or availability of these services. So [00:05:00] that’s not just in the number of clinical expert experts there are, but also in the number of people who have mental health conditions, it’s going up as well.

Digital health interventions have are seen as potential solutions because they can overcome traditional barriers. So that might include being able to physically access the treatment. So that might be not just the access to clinical experts, but also it could be the location of these as well.

So if you’re in a city, perhaps that’s a lot easier. But if you’re somewhere more urban, then there’s obviously the considerations around the travel, which. Wouldn’t be the case for digital interventions also in some cultures as well. There’s a stigma about getting access to treatments and digital health interventions are seen as a solution there because they can Someone more discreetly and get access to treatment as well

Alexander: Yeah, and I think they can very often go hand in hand with other interventions.

Yeah if you have worked a little bit in [00:06:00] that space, then you will often see that as these so called multimodal interventions so you have biological interventions like pharmaceutical treatments. You have also interventions that are more on the yeah, basically through discussions and interviewing techniques interventions but also other interventions like sports and, Other kind of, more, more structural things.

And in that kind of overall spectrum, there’s a lot of opportunity for this. By the way, there’s one interesting thing is that there’s also an emergent. Number of societies, like the Digital Medicine Society, other associations that are starting in that field, and also a number of new companies that evolve in that field, that are starting in that field.

Create [00:07:00] these applications, you can find probably lots of them in the app store or on Google play. And in Germany, there’s one specific thing that is quite interesting. In Germany, you can even get these. Apps on prescription and so basically paid through the national health insurance system.

Now that is only possible if these apps get through an approval system and that usually includes a clinical trial. So it’s a similar assessment. As if it would be a pharmacological intervention so that is a super interesting area as well. I’ve recorded a podcast about this with Stefan Walser quite some time ago.

And if you search for DIGA, which stands for digital health intervention in Germany, Then he will find that podcast episode quite easily. So [00:08:00] that’s a little bit just about background. So have you looked a little bit into how frequent these kind of applications are, how many of them are there?

Jack: Yeah, definitely. So this was a big motivating factor when starting my PhD. So if we take apps alone, for example, for mental health apps just on the Apple app store there’s over 10, 000 available. And that was a stat from a few years ago. So I’m sure this number is even more now.

This number is huge and it’s growing rapidly. And that’s just for apps. There are many different types of digital mental health interventions that we can talk about. So there’s virtual reality, if you like, for things like exposure therapy. So guiding a patient through perhaps a fear or a stressful situation that perhaps they’ve avoided and guiding them in a more controlled environment that allows them to to, Feel more comfortable and more able to handle that situation.

There’s apps which I’ve mentioned obviously, [00:09:00] so that’s things like Apps to help with mindfulness apps to help with depression apps to help with perhaps more formal treatment like cognitive behavioral therapy or attention bias modification and Could also talk about chatbots as well. So this could be a more automated service, which people can talk to, to be steered in the right direction of where they can get access to treatment and also more, perhaps more passive as well.

There’s digital technologies, which could be used as well to monitor patients more passively. So that could be thinking about the social activity of a person. So I’ve heard of it. Of trials which passively monitor patients via their phones to see how how are they communicating. So that could be, do they text their family members often?

Do they make calls? Are they leaving the house? And all of that is to help to understand when people perhaps get depressed and they withdraw [00:10:00] from society, then it helps put up some early warning signs to help people. either experts to reach out to that person and offer help or If it’s an app to remind that person that help is available to them as well So yes, there’s a lot of different areas where men digital health interventions are being applied in This area I think the for all of these the intention themselves, although it might be seen as just an app or just a website.

Actually, these are quite complex interventions and they often have a lot of different components to them. So we’ve talked briefly. About, is it monitoring does the app monitor or does it help that per person manage? But within that there will be different aspects as well that are available to that person.

So it could be perhaps to monitor a certain biomarker or to report a questionnaire they can fill in to report as well. So yeah, so there’s lots of different aspects as well that need to be considered.

Alexander: [00:11:00] I think these apps can interact with the users through email, through service, through homepage, through watching videos, lots of different ways how you can interact with these and Yeah,

Jack: and just to add to that, I think that’s a really good point that when we talk about digital interventions, the difference here compared to more traditional treatments is that idea about these are quite dynamic in the sense that they are, first of all, they’re always updated.

So there’s this sort of software update that happens perhaps yearly or weekly. More often, but also the actual intervention itself. If you take an app, for example, that can be quite dynamic. So a patient will start reporting how they feel and based on how they’re reporting to the app might actually change the information that’s being provided to that patient.

So over time it’s dynamic, it’s changing and often a different service, depending on how that patient is responding to the app.

Alexander: Yeah. And I think that is a super interesting area. If you [00:12:00] come from a typical pharmaceutical treatment area. Yes, there’s actually not so many things you can do.

Yeah, maybe you can. have different routes of application, or you can dose up or down, or you can maybe add a co medication. Let’s see, the number of ways you can actually change the treatment is quite limited. As compared to this digital space now that brings also quite a challenge and you talked about engagement earlier on.

So what does that mean? Engagement for digital health applications.

Jack: Yeah, so engagement as a concept, I think can be related quite similarly to perhaps it’s the dose or the prescription that someone is getting for a drug treatment, perhaps more the dose actually. So it’s how much of that are you actually taking the same for a complex intervention.

So [00:13:00] working in my area, if I think of an in person equivalent, so let’s take cognitive behavioral therapy, then engagement or Yeah, engagement to that would be how many of those sessions have you attended? So if there’s six available, it’s how many of those are you turning up to receive the therapy being offered?

Whereas for digital health interventions in the area of mental health, engagement is described as how are you interacting with that? digital treatment. So a simple way to look at this could be with, if I go back to the app idea again, so cognitive behavioral therapy, as I mentioned, can be an app. So if we think of engagement to cognitive behavioral therapy, that would be how are you interacting with that therapy via the app?

Are you logging in and looking at each module of treatment in one go? Are you accessing that? Perhaps in a different way where you’re doing smaller stints where you’re trying to review the content that’s being given to you through Half an [00:14:00] hour 15 minutes each day where you’re looking at this and do you come back to that and how often so yeah engagement’s more about I think very similar to the idea of it’s how that patient is accessing that treatment

Alexander: So it’s in a way related to exposure, but also adherence or compliance is also another kind of aspect in it.

Yeah. In the pharmaceutical world, we usually say if you don’t take the pill, it can’t work. Yeah. And here, of course, it’s a little bit the same. Yeah. And of course that has. Is, pill count or looking at number of injections or things like that. That’s pretty, pretty easy.

So to say, yeah. Although that is some people will argue that even that is not easy. Which I would probably agree with, however, see the number of different ways you can interact with an app, yeah, or with all the different features we talked about is.

Jack: [00:15:00] Absolutely. And I think this is the big difference.

So yes, I agree with you that it’s not so straightforward, but if we do take a drug treatment and we look at this idea of dose, then it’s very straightforward. The point is, Patient comes in, they take the treatment and then you know how much they’ve given because you knew the dose that was in that pill or that liquid that you gave them.

With an app, it’s, yes, we can measure it. So it can be something we can assess, but it’s not a single measure. So that’s the difference here. So with an app or with a website. These kind of interventions there’s a lot more measures available. So it’s not as straightforward as just looking at how many times that person has interacted.

But as you say, it’s looking at what are the features that they’re looking at? What are they doing in the app? How long are they spending there? Also, are they repeating content? So that’s perhaps another difference is with a drug treatment or anything like that. It’s quite straightforward. You take that treatment and they’ve taken [00:16:00] it.

There’s That’s it. Whereas with a app, for example, that patient may have read the material for a given feature or part of the therapy, but we don’t know whether or not that person actually has processed and taken on those suggested changes that’s been given to them. And they may come back and revisit that information again and again.