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APP REVIEWS

Rheumatoid Arthritis

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Dr. Vanessa Rambihar
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Rheumatoid arthritis — a chronic autoimmune disease affecting 1 in 100 Canadians [1] — is characterized by inflammation, joint pain, and stiffness, with fatigue and progressive destruction of symmetrical joints. The main goals of treatment are slowing of chronic damage to joints and reduction of symptoms to improve quality of life and functioning for patients [2]. These goals are best achieved with the constant adjustment and evaluation of disease-modifying drugs based on patient symptoms and response to treatment, with the guidance of a rheumatologist. Due to the variable and unpredictable course of symptoms, the use of a mobile health app to track symptoms over time can be one way to improve collaborative management of this chronic disease. Canadian consensus guidelines have recommended a shared-decision making approach between patients and physicians to direct treatment approaches [2], and the potential to use mobile apps to support this management has been suggested [5].

There are multiple types of apps available for RA management, including symptom tracking, educational, clinician-focused, and patient-focused apps. We limited our review to patient-facing tracking apps as they might enable patients to evaluate their symptoms over time with a view to sharing their symptom burden with clinicians in order to tailor their treatment and management plans.

We reviewed four such symptom tracking apps promoted for patient monitoring of symptoms of RA. Current guidelines recommend using validated measures of patient function, composite disease activity measures, a 28- or 44-joint count, lab values including ESR and CRP and visual analogue pain scales [4] [5], however Canadian consensus statements suggest that since multiple composite disease activity measures are available, the choice should be individual to the treating physician [2]. Based on our review and the evidence available, there is currently a lack of high-quality apps that use only validated or calculated composite measures to track patient symptoms. Currently available apps for patients are limited to simple symptom trackers, using some but not all of the validated measures and not calculating the composite disease activity scores [3]. However these apps can still be used by patients to more optimally share their disease burden with their family doctors or specialists in order to better explain the course of their symptoms and direct therapy adjustment.

Apps Reviewed

MyRA
4 stars4 stars4 stars4 stars4 stars
ArthritisID
3.5 stars3.5 stars3.5 stars3.5 stars3.5 stars
Track + React
3.5 stars3.5 stars3.5 stars3.5 stars3.5 stars

ArthritisID

3.5 stars3.5 stars3.5 stars3.5 stars3.5 stars

ArthritisID is a Canadian app built as a patient screening tool for all types of arthritis, including RA, with education around disease prognosis and treatment options. It was created by tThe Arthritis Research Centre of Canada and Arthritis Consumer Experts and provides evidence-based recommendations on disease management. There is a questionnaire with a 28-joint count, reminders for patients, and comprehensive education around diseases and medications. This is a basic and straightforward app, but with minimal interactivity for tracking and no update since 2014. Symptoms are tracked chronologically and the data collected is not analyzed or synthesized to help summarize symptom burdens to enhance sharing with clinicians. This app would be best used for patient self-education, rather than tracking and sharing symptoms with clinicians.

Detailed Review View All

Features

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This app was built to help individuals understand the type of arthritis they may have and learn about approaches to disease treatment and prevention. This app has an interactive initial questionnaire to determine symptoms and provide some feedback on general types of arthritis. There is a useful initial explanatory video by a rheumatologist, along with informational statistics scattered throughout the app. Didactic text is available to highlight various conditions, pharmacologic and non-pharmacologic treatment options, and red flags that are most suggestive of each condition. A summary shows a log of painful joints and questionnaire answers, which can be shared with a physician. There is a useful set of suggested questions that patients can use to speak with their physicians. There is no EMR integration or downloadable data, and thus summary screens must be shared directly with physicians in this format.

Effectiveness

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This app uses a 28-joint count which is part of the composite disease activity scores used by international RA guidelines. There are comprehensive descriptions of the various types of arthritis that individuals may experience, as well as a comprehensive review of treatment options that would be useful for patients’ basic understanding of their condition. A very brief overview of exercise-based therapy is given under the ‘self-care’ heading which may minimize the importance of this approach. The main use for this app is to help an individual who has not yet been diagnosed with any type of arthritis identify what might be causing painful joint symptoms.

Usability

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This app is easy to use, with clear video and audio descriptions to guide patients, but it is somewhat simplistic. Font size can be increased and various aspects of the joint symptom screen can be magnified for better ability to select swollen joints. Data entry is clear, but results are only viewable in the same format they were entered – that is, as static entries without an ability to easily analyze symptoms over time.

Privacy & Security

+-

The in-app terms of use statement is brief but clearly mentions that the tool can not be held responsible for adverse effects from using information from the app. There is no password to limit access to the app. The data can be stored under an anonymous or unidentifiable nickname as desired by the user.

Reliability

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The app is self-described as the “most comprehensive free arthritis app” for consumers. The app was initially created in 2011 and hasn’t been updated since August 2014. The app vendor is ACE Planning and Consulting and was developed by two large arthritis research and advocacy organizations — The Arthritis Research Centre of Canada and Arthritis Consumer Experts — as part of a national awareness program for arthritis. The former is connected to three universities in Canada as well as the Arthritis Society and arthritis treatment centres. The information on medications and review of a step-wise treatment plan for RA in particular is consistent with the Canadian Rheumatology Association principles. However, the app does not specifically prompt that a patient’s time course or symptom load should trigger a patient to seek in-person medical attention. The app did not crash during use.

Accessibility

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The app is free and available in French and English. It is available for iOS only. The app uses clear and plain language in a way that is appropriate for the target age group. The ability to zoom into areas that require touch selection and text magnification text are particularly helpful for the intended patient population. The videos do not have closed captions.

Track + React

3.5 stars3.5 stars3.5 stars3.5 stars3.5 stars

Track + React is an app built by the Arthritis Foundation to support self-management of arthritis and to improve communication of patient-reported health and well-being to physicians. There is a comprehensive questionnaire with a well-designed interactive interface, which tracks symptoms related to nutrition, physical activity, psychological and social factors, sleep, and medication adherence and side effects. This app does not specifically include a joint count, or other validated measures for symptom tracking other than patient functional status. This app allows patients to graph each of these areas of function over time in order to share with physicians, with useful in-app education for patients based on American guidelines for activity and diet. This app is best used to track symptoms of overall health, well-being and symptom load, but does not provide the most useful information to be shared with rheumatologists for disease management and medication review.

Detailed Review View All

Features

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Track + React was created to support self-management of arthritis and improve communication with physicians with the stated goal of improving patient well-being and health. It is a combination tracking and educational app which reviews nutrition, physical activity, psychological and social factors, sleep quality, and medication adherence and side effects. The graphing function demonstrates the disease’s impact when reviewing with physicians. There are excellent educational links to review nutrition and fitness suggestions based on American guidelines [6] [7]. Feedback to physicians is shared by printing the data from the online version of the app which is automatically synced with the app using the same log-in and password used on registration.

Effectiveness

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The app only collects basic data specifically relevant to RA but provides excellent comprehensive data tracking on the categories of nutrition, fitness, sleep, medication, and overall status each day. There isn’t a clear joint count and no review of relevant RA lab work, though it does include a pain visual analogue scale which is one feature representative of composite disease activity. This app does provide clear recommendations for fitness and diet based on American guidelines [6] [7] and provides an opportunity for patients to define goals and receive rewards for tracking their behaviours, but it is less useful as an RA-specific platform.

Usability

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This app uses sophisticated technology to provide a clean, user friendly interface. There are links to describe and expand on information and terms that might be new to users, and the app contains educational pieces throughout. The app allows the user to create notes and show results over seven days, seven weeks or seven months. While overall visually appealing and clear, the app did also utilize text in small fonts with sliders that might be difficult to use.

Privacy & Security

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The privacy policy is available on the registration page immediately on entering the app. There is a statement explaining that data is encrypted in the Arthritis Foundation’s secure database. General usage data is not individually identifiable. Of note, personal information is required to sign up for the app though personal health information is not shared except in accordance with HIPAA. Certain tools are only accessible by providing personal information, though there is a privacy preference form which may be modified to limit sharing as desired.

Reliability

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This app was created by the Arthritis Foundation which supports education, research, and advocacy surrounding arthritis. The app grants access after a registration process that provides a login email address and password. Technical support and feedback can be provided via a link to email. The app did not crash during use.

Accessibility

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This app was initially created in 2012 and most recently updated in 2018. It is available for iOS in English. Text cannot be made bigger or smaller and interactive sliders used for symptom grading may be difficult for those with symptomatic joints.

MyRA

4 stars4 stars4 stars4 stars4 stars

MyRA is a sophisticated app designed to track patient symptoms and function over time. It creates visually appealing summary reports of symptom progression to share with clinicians. This app is easy to use and has a modern interface with flexible options for patient input (text, audio, visual), which makes it enjoyable to use. This app takes into account multiple variables of disease activity including a 44-joint count, lab values, and rating scales that include medication efficacy, fatigue, and functional status. A useful function in the app is the ability to create a summary pdf, including graphs of disease activity based on symptoms elicited over time, in a clear and concise format that can be easily shared with clinicians or saved by the patient. The limitation with this app is that there is less in-app education around RA and medications. This app would best meet needs as a symptom-tracking app that produces data to be shared with physicians to track symptom progress.

Detailed Review View All

Features

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MyRA was created for patients with RA to track symptoms and functionality and see visual summary reports of these symptoms over time. This app offers multiple levels of tracking with various scales to characterize symptoms, including aspects of the disease beyond joint pain. The user can document medications, add notes on their efficacy, and document overall symptoms like morning stiffness, fatigue, and functional status. It is a highly interactive app with the ability to personalize symptom reports almost like a journal. There are links to websites for information on RA, however there is no easy-access in-app education on RA, disease progression, symptom management, or treatment explanations. The app allows patients to create a very clear and visually appealing summary PDF with graphs showing progression of symptoms that can be easily emailed to themselves or their healthcare provider. This app could be integrated well into a physician visit.

Effectiveness

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This app allows comprehensive tracking of symptoms using the reliable 44-joint count and lab data which are both components of composite scores for disease activity calculations. It tracks medication utility and responses which can be used as feedback for physicians and reinforces the need for constant evaluation and dynamic feedback in the treatment of RA. This app was created by a company called Crescendo Bioscience, which has also created a blood test that claims to measure patients at higher risk for RA-related joint damage based on biomarkers – though this has not been validated or studied for diagnosing RA or determining therapy. This blood test is referenced in the app however, based on our review, it is not currently used in any international guidelines as an evidence-based classification for risk.

Usability

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This app has a tutorial section on the website that introduces patients to the app and includes an overview video with patient endorsements. It is easy to learn and logical though it may require some basic understanding of device functions and symbols, including the microphone to record notes and the camera to take pictures of medications. The joint pain scale has three grades for severity and zooms in to focus on smaller joints. This uses appropriately sized buttons for users who may have symptomatic joints. There is good flexibility in the ability to submit entries from previous dates. Reminders can be set to notify users to input symptom data. The summary pdf gives a very clear picture of the patient’s symptoms in graphical format over any time period selected that would be useful to share with family physicians and specialists to determine the efficacy of medications.

Privacy & Security

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Voluntary collection of person information includes email address, postal code and email preferences but these elements are not retained, other than for limited purposes as described in the user agreement. Details of in-app use might be stored and transmitted to inform the company to direct upgrades, without being tied to personal information. Information entered into the software is stored on the mobile product. Personal health information is only transmitted with consent and is de-identified if used in other ways. This app is not password protected.

Reliability

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The app is frequently updated, most recently in March 2018. This app did not crash during use.

Accessibility

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This free app is available for iOS, and available in the U.S. on Android phones with some noted limitations. This app is only available in English. Larger text size is not available for those with visual impairments, however intuitive button sizes and locations make for otherwise easy use.

References

  1. Canadian Agency for Drugs and Technology in Health. “Clinical and economic overview: Biological response modifier agents for adults with rheumatoid arthritis”; 2010. Accessed March 2018. [Online]: Available: https://www.cadth.ca/media/pdf/TR_RA_Clinical_and_Economic_Overview_e.pdf
  2. Bykerk, V., Akhavan, P., Hazlewood, G., et al. “Canadian Rheumatology Association Recommendations for Pharmacological Management of Rheumatoid Arthritis with Traditional and Biologic Disease-modifying Antirheumatic Drugs.” The Journal of Rheumatology, August 2012. [Online]. Available: http://www.jrheum.org/content/39/8/1559#ref-1
  3. Grainger, R., Townsley, H., White, B., et al. “Apps for People With Rheumatoid Arthritis to Monitor Their Disease Activity: A Review of Apps for Best Practice and Quality”. JMIR MHealth and UHealth 2017: 5 (2): 1-13.
  4. Smolen J, Breedveld F, Burmester G, et al. “Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force.” Ann Rheum Dis 2016 Jan;75(1):3-15.
  5. Anderson J, Caplan L, Yazdany J, et al. “Rheumatoid arthritis disease activity measures: American College of Rheumatology recommendations for use in clinical practice.” Arthritis Care Res 2012 May;64 (5):640-647
  6. US Departments of Agriculture and Health and Human Services. 2010 Dietary Guidelines for Americans. Accessed March 2018. [Online]. Available: https://health.gov/dietaryguidelines/dga2010/dietaryguidelines2010.pdf
  7. US Department of Health and Human Services. Accessed March 2018. [Online]. 2008 Physical Activity Guidelines for Americans. Available: https://health.gov/paguidelines/guidelines/
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