Using Smart Displays to Implement an Evidence-Based eHealth System for Older Adults with Multiple Chronic Conditions

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PROJECT SUMMARY / ABSTRACT In addition to their debilitating impact on health and well-being, multiple chronic conditions (MCCs) account for 90% of Medicare spending. Among beneficiaries, 65% have 3 or more conditions such as diabetes and hypertension, and 23% have 5 or more. MCCs are often addressed in primary care, where time pressures prevent focusing on self-management—although such skills are crucial for living successfully with MCCs. Our long-term goal is to improve health and self-management for these patients, while reducing healthcare costs. An AHRQ-funded P50 supported our development of Elder Tree (ET). That eHealth system was shown in a randomized trial to improve quality of life and health factors among older adults with MCCs who were high users of primary care. ET provides tools, motivation, and support to help patients manage their health. Despite positive results, many did not use ET extensively, a very common problem with health apps. Our central question is whether adapting and delivering ET with voice-controlled technology can increase ET use, thereby improving quality of life and health outcomes even more than ET on a laptop. Smart speakers, used by talking and listening rather than typing and reading, offer the tantalizing but unproven promise of being easy to use, which may in part explain why the technology is being adopted faster than the internet or TV. Smart displays raise expectations even higher by adding a visual element that enables the system to "show" as well as "tell." We propose an R61/R33 project including a randomized clinical trial involving 282 (after attrition) patients age 65+ with 5 or more chronic conditions, 3 of which must be hypertension, hyperlipidemia, obesity, diabetes, or pre-diabetes. In the proposed 12-month trial plus 6-month follow-up, patients will be randomly assigned to receive ET via a laptop (ET-Text) or a smart display (ET-Voice). The project has the following specific aims: Aim 1: During the R61 phase, continue and complete development of the platform and operational procedures for delivering ET to the smart display group. Aim 2: During the R33 phase, conduct a balanced randomized clinical trial to test these hypotheses: Primary outcome: ET-Voice (vs. ET-Text) patients will have better functional health (a measure including physical function, pain, fatigue, sleep disturbance, anxiety, and depression) over time. Secondary outcomes: ET-Voice (vs. ET-Text) patients will have better outcomes for loneliness, number of symptoms, and healthcare use over time. In addition, amount of ET use, ease of use, and usefulness will be higher for the ET-Voice (vs. ET-Text) group. Mediators: Effects of study arm on outcomes will be mediated by ET use at 6 months and by Self-Determination Theory constructs of competence, social relatedness, and intrinsic motivation. Moderators: ET-Voice (vs. ET-Text) will show greater improvements in the primary outcome for: those age 65-74 vs. 75+ years old, women vs. men, those with 8+ vs. 5-7 chronic conditions, and those with more physical barriers to technology use (e.g. tremors). We will explore whether these moderation effects are also observed for the secondary outcomes.