메인 Dysphagia Feasibility of a Mobile Application to Enhance Swallowing Therapy for Patients Undergoing...
문제 보고This book has a different problem? Report it to us
"네" 선택하시는 조건: "네" 선택하시는 조건: "네" 선택하시는 조건: "네" 선택하시는 조건:
파일 열기 성공했습니다
파을 내용은 책 (또는 만화)입니다
책 내용이 적당합니다
파일의 제목, 작성자와 언어가 책 설명과 일치합니다. 다른 필드는 보조이므로 무시하셔도 좋습니다.
"아니요" 선택하시는 조건: "아니요" 선택하시는 조건: "아니요" 선택하시는 조건: "아니요" 선택하시는 조건:
- 잘못된 파일입니다
- 이 파일이 DRM으로 보호돼 있습니다
- 파일은 책이 아닙니다 (예: xls, html, xml)
- 파일은 기사입니다
- 파일은 책에 일부입니다
- 파일은 잡지입니다
- 파일은 시험지 또는 테스트입니다
- 파일은 스팸입니다
책의 내용이 적당하지 않으며 차단되어야 한다고 생각합니다
파일의 제목, 작성자와 언어가 책 설명과 일치하지 않습니다. 다른 필드는 무시하셔도 좋습니다.
Change your answer
Dysphagia DOI 10.1007/s00455-017-9850-y ORIGINAL ARTICLE Feasibility of a Mobile Application to Enhance Swallowing Therapy for Patients Undergoing Radiation-Based Treatment for Head and Neck Cancer Heather M. Starmer1,7 • Rina Abrams2 • Kimberly Webster2 • Jennifer Kizner3 Beth Beadle4 • F. Christopher Holsinger1 • Harry Quon5 • Jeremy Richmon6 • Received: 25 May 2017 / Accepted: 18 September 2017 Ó Springer Science+Business Media, LLC 2017 Abstract Dysphagia following treatment for head and neck cancer is one of the most significant morbidities impacting quality of life. Despite the value of prophylactic exercises to mitigate the impact of radiation on long-term swallowing function, adherence to treatment is limited. The purpose of this investigation was to explore the feasibility of a mobile health application to support patient adherence to swallowing therapy during radiation-based treatment. 36 patients undergoing radiation therapy were provided with the VibrentTM mobile application as an adjunct to standard swallowing therapy. The application included exercise videos, written instructions, reminders, exercise logging, and educational content. 80% of participants used the app during treatment and logged an average of 102 exercise sessions over the course of treatment. 25% of participants logged at least two exercise sessions per day over the 7-week treatment period, and 53% recorded at least one session per day. Exit interviews regarding the patient experience with the VibrentTM mobile application were largely positive, but also provided actionable strategies to improve future versions of the application. The VibrentTM mobile application appears to be a tool that can be feasibly integrated into existing patient care practices and may assist patients in adhering to treatment recommendations and facilitate communication between patients and providers between encounters. Keywords Mobile application Dysphagia Deglutition Deglutition disorders Swallowing Head and neck cancer Introduction Pre; sented at the American Speech Language Hearing Association Annual Convention, November 2016. & Heather M. Starmer Hstarmer@stanford.edu 1 Department of Otolaryngology – Head and Neck Surgery, Stanford University, Palo Alto, CA, USA 2 Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, USA 3 Stanford Healthcare, Palo Alto, CA, USA 4 Department of Radiation Oncology, Stanford University, Palo Alto, CA, USA 5 Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD, USA 6 Department of Otolaryngology – Head and Neck Surgery, Mass Eye and Ear Infirmary, Boston, MA, USA 7 Stanford Cancer Center, 900 Blake Wilbur Drive Suite 3073, Palo Alto, CA 94305, USA Head and neck cancer is the 6th most common type of cancer in the world and has recently seen a dramatic rise in the West secondary to the human papilloma virus (HPV) . Treatment may include surgery, radiation, chemotherapy, and/or immunotherapy, often delivered in various combinations. The majority of patients receive radiation therapy, which typically spans a 6- to 7-week period. Radiation-based therapy to the head and neck has been associated with the development of disuse atrophy, fibrosis, sensory deficits, and cranial nerve injuries, all of which can contribute to post-radiation dysphagia [2–4]. Dysphagia following treatment for head and neck cancer is one of the most significant morbidities impacting quality of life and may contribute to increased post-treatment mortality through complications including aspiration pneumonia, respiratory failure, and poor nutritional status [5, 6]. To combat the development of dysphagia-related 123 H. M. Starmer et al.: Mobile Application for Swallowing Therapy During Radiation complications, prophylactic swallowing therapy has been accepted as a mainstay of treatment [7–10]. Evidence has demonstrated that preventative exercise protocols and maintaining an oral diet during treatment are the most effective strategies for preventing long-term swallowing complications [11–13]. Although maintenance of oral diet and completion of exercises has the potential to minimize long-term dysphagia risk, adherence during complex treatment regimens is poor [14–16]. Recent research has cited issues such as poor comprehension of the rationale for the exercises and confusion about how to do the exercises as reasons for non-adherence . Adherence to treatment recommendations may have a significant impact on outcomes and as such, providers should consider strategies to facilitate adherence, particularly in populations where adherence has been demonstrated as sub-optimal. While many previous studies have documented challenges to adherence, few have specifically evaluated interventions aimed specifically at improving adherence. Service delivery models have been shown to have an impact on adherence with clinician directed and adjunctive telepractice showing improved adherence in the head and neck population [10, 17]. It must be considered, however, whether daily clinician-directed therapy is feasible in the current healthcare system. As such, exploration of strategies to maintain the benefit of clinician-directed therapies with reduced burden on the health care system is attractive. Given the difficulty patients experience adhering to treatment recommendations, we sought to determine if a customizable mobile-based application (VibrentTM) as an adjunct to routine clinic visits and instruction from speechlanguage pathologists (SLPs) is a feasible technique to enhance adherence. Prior studies have demonstrated that the feasibility and efficacy of telecommunication in improving patient care and mobile applications are rapidly being developed for many health and wellness purposes [18–20]. For example, medication adherence has been shown in multiple investigations to improve with use of mobile health applications [19, 21]. Further, mobile health applications have been associated with improved exercise adherence and functional outcomes in comparison with paper based, traditional care . Our goal in this investigation was to determine whether a mobile application would be used by a population of patients undergoing radiation-based head and neck cancer treatment as well as to determine aspects of the program that may require revision prior to a formal clinical trial. We hypothesized that the interactive VibrentTM mobile-based application could be effectively utilized by patients to extend the current standard of ‘‘in clinic’’ prophylactic and therapeutic swallowing therapy. 123 Methods Sequential patients scheduled for radiation therapy for head and neck cancers were invited to participate in this feasibility trial at two academic medical centers (Johns Hopkins Hospital and Stanford University Hospital). Institutional Review Board approval was granted at both institutions. Subjects were screened for eligibility during their initial pre-radiation SLP visit. Patients were excluded from participating if they did not speak English, did not own a smartphone or tablet, were not [ 18 years of age, or were unable to use the mobile application due to cell phone carrier data plan limitations. At the time of enrollment, each patient completed a brief survey regarding their comfort and familiarity with technology in general, with their personal cellphone, and with their tablet. Responses were ranked on a 5-point Likert scale where ‘‘1’’ represented ‘‘no comfort’’ and ‘‘5’’ represented ‘‘extreme comfort.’’ Enrolled patients were instructed to use the VibrentTM application in addition to current standard of care SLP exercises at each institution. SLP care consisted of pre-radiation evaluation, education, and administration of prophylactic swallowing exercises; follow up 3–4 weeks into radiation; follow up the final week of radiation; and post-radiation assessment * 2 months after the conclusion of radiation. The SLP or study coordinator consented each participant and assisted in downloading and setting up the app on the chosen mobile device(s). Use and features of the app were reviewed until the patient indicated comfort/competency. Training in use of the application was performed verbally by the treating clinician. If participants had difficulties with use of the app following this training session, the treating clinician would attempt to clarify for the patient. When this was not adequate, the participants were referred to the developers for additional assistance. Patients then had access to the app on their personal device for a 4-month period during and immediately following radiation. Screenshots of the application provided in Fig. 1. The VibrentTM mobile application was developed by Vibrent Health (Fairfax, VA) with swallowing features customized at the request of the SLP investigators of this study. Specific exercises included effortful swallow, Masako, Mendelsohn, effortful pitch glides, and jaw stretches. Patients were asked initially to perform 3 sets of 10 reps of each exercise twice daily. When patient logged pain levels reached a pre-defined threshold (e.g., 4 and 8), exercise dose was automatically adjusted to reduce patient burden. For example, if a patient logged a pain level of 4–7, they were asked to perform 2 sets of 10 reps. The application included reminders to complete exercises twice daily and a logging feature to capture completion of exercises. Additionally, instructional video workouts were H. M. Starmer et al.: Mobile Application for Swallowing Therapy During Radiation Fig. 1 In-app screen shots provided for swallowing and jaw range of motion exercises. Additional resources such as informational videos provided weekly to support patients at specific points of treatment, high-quality educational website links, and research literature were provided and used at the patients’ discretion. In addition to capturing completion of exercise data, the application had interactive queries if a patient did not complete their exercises to determine the reason for non-adherence. Participants were asked to log pain levels and weight on a daily basis. All data entered by participants was immediately available to the SLP provider through an online provider portal. Communication between patients and providers was possible through a messaging system. VibrentTM complies with the highest security standards established by Health Insurance Portability and Accountability Act (HIPPA) and the Department of Defense. All data exchanges between mobile applications or web browsers and the website are encrypted. Data stored in the mobile application as well as the website are secured and encrypted. Data are exchanged over the Internet securely using HTTPS/SSL. At the conclusion of the VibrentTM app trial, patients participated in semi-structured interviews with their primary SLP. Participants were asked to describe their experience with the app, their likes and dislikes, and how the app may have impacted their communication and care with the SLP. They were asked which aspects of the program were felt to be most beneficial and what were the barriers to use. Interviews were recorded, transcribed, and reviewed for common themes. Data regarding app usage were downloaded, collated into an Excel database, and analyzed using standard descriptive statistics. Results A total of 36 patients were enrolled in this feasibility study. Participants were largely male (78%), Caucasian (94%), married (75%), with at least a college degree (61%) (Table 1). The majority of patients had oropharyngeal primary tumors (83%) and most received chemoradiation as their primary treatment (75%). When asked to judge comfort levels with technology, smartphones, and tablets, average comfort with technology in general was 3.94 (SD 1.17), with smartphones was 4.03 (SD 1.27), and with tablets was 4.03 (SD 1.73). Overall, there were 7004 entries into the VibrentTM app including adherence data, weight, and surveys. There were 1888 swallowing exercise sessions logged yielding a mean exercise log of 52.4 sessions per participant (SD 53.74, range 0–243). Given the 3-month data collection window, participants had a maximum of 180 therapy logs expected. Thus, on average, there was a 29% adherence rate. 25% of participants logged at least two exercise sessions per day over the 7-week treatment period and 53% recorded at least one session per day. In investigating daily adherence with app logging of exercises over the 7-week treatment course, 47% logged less than one exercise session per day, 27% logged between 1 and 2 sessions daily, and 25% logged [ 2 sessions daily. One-fifth of participants had very poor adherence/logging (\ 10 logged exercise sessions). Adherence to exercises declined over the course of radiation (Fig. 2). Participants logged a total of 2813 pain scores with an average of 78.14 pain levels logged per participant (SD 21.92, range 1–231). Participants logged a total of 1296 weights with an average of 36 weight logs per participant (SD 38.61, range 0–200) reflecting 40% adherence to daily weight logging. Intra-app surveys regarding failure to log exercises were completed 71 times by 23 unique patients (64% of total 123 H. M. Starmer et al.: Mobile Application for Swallowing Therapy During Radiation Table 1 Participant demographics (n = 36) Age Mean = 61.89 years SD = 8.49 Range = 44–83 Sex M = 28 F=8 Ethnicity Caucasian = 34 Asian = 1 African American = 1 Primary site Oropharynx = 30 patient feedback are shown in Table 2. Feedback was provided to improve on the app for future use. One common concern was regarding the way notifications were used in the app. They were reportedly too frequent and patients did not like that they could not delete them once viewed. Many participants indicated an interest in being able to customize their workout to a greater degree over time. Some technical issues with specific mobile devices were identified and appeared to be specific to more antiquated operating systems (Fig. 3). Sinonasal = 2 Thyroid = 2 Larynx = 1 Oral cavity = 1 Treatment Chemoradiation = 27 Surgery ? radiation = 6 Radiation = 3 Marital status Married = 27 Single = 5 Divorced = 2 Widowed = 2 Highest level of education High school = 8 Some college = 3 Bachelors degree = 12 [ Bachelors degree = 10 Fig. 2 Percentage of patient logging 70% of target by week sample). Entries revealed that the majority of patients had done the exercises but forgot to log them (70%) (Fig. 1). Other reasons for failing to log included the following: time (13%), fatigue (6%), pain (6%), app/internet issues (4%), and lack of understanding of the exercises (1%). Exit interviews revealed overall satisfaction with participant experience with the app. Features cited as beneficial by most patients included using the videos to reinforce proper performance of the exercises, reminders to keep on track with the exercises, and the feeling of increased accountability to providers. Specific quotes regarding 123 Discussion Mobile health applications are emerging as potential tools to enhance traditional healthcare. In 2015, smartphone ownership in the US was estimated to be 68% , demonstrating the potential scalability of health-related mobile services. Preliminary evidence in a number of patient populations (e.g., weight loss, asthma, and diabetes) suggests that mobile applications may enhance adherence to treatment recommendations and therefore improve health outcomes [19–22, 24, 25]. Multiple programmatic characteristics have previously been associated with more effective mobile health applications. Kuijpers et al.  suggested that there are seven critical elements of patient empowerment applications including education, self-monitoring, feedback, tailored information, self-management training, personal exercise program, and communication with providers or other survivors. During development of the VibrentTM mobile application, such characteristics were considered. Educational content is woven into the application in the form of links to high-quality information, inclusion of research supporting the importance of swallowing exercises during radiation, and strategies to manage treatment toxicities. The logging system within the app allowed patients to look at exercise adherence, pain, and weight over time. We provided automated feedback regarding adherence and performance. Weekly educational videos provided tailored information regarding treatment expectations over the course of radiation. Video workouts and written exercise instructions were provided and expectations were adjusted based on patient reported pain. Finally, the app provided a portal for direct communication with the provider. Govender et al.  performed a systematic review of the literature regarding adherence in swallowing therapy protocols during radiation. The intention was to identify behavioral change techniques that may facilitate improved outcomes in this population. While they acknowledge limited reporting of such measures in the majority of studies, some behavioral strategies that were noted more frequently in those with more favorable outcomes included H. M. Starmer et al.: Mobile Application for Swallowing Therapy During Radiation Table 2 Patient feedback during semi-structured interviews Positive feedback Constructive criticism ‘‘I felt like my therapist was with me every day doing my exercises. All ‘‘Reminders and logging could be more accepting of individual of my family and friends felt like they knew her’’ schedules’’ ‘‘The app was good because it made me feel like if I didn’t do the exercises, the teacher would yell at me’’ ‘‘The notifications are a problem because you can’t delete them. I have 430 notifications active that I cannot delete’’ ‘‘I knew when to do my exercises. Keeping everything in one place was ‘‘I should be able to customize when I want to do my exercises for very helpful’’ each day of the week’’ ‘‘It is easy, you don’t have to be computer literate to use it’’ Forgot to log (n=50, 70%) No time to do them (n=9, 13%) Fatigue (n=4, 6%) Pain/sores in mouth (n=4, 6%) App/internet issues (n=3, 4%) Didn't have exercises (n=1, 1%) Fig. 3 Patient reported reasons why exercises were not logged access to practical social support, behavioral practice/rehearsal, self-monitoring, and information from a credible source. Similar to the aforementioned Kuijpers study , our application was designed to utilize such techniques to impact patient adherence. Our primary outcome of interest in this investigation was whether the VibrentTM mobile application would be used by patients undergoing radiation therapy. Overall logging data were encouraging; however, significant variability was observed with patient engagement with the application. While some participants appeared to be ‘‘super-users’’ logging [ 100 exercise sessions over the course of their treatment, others had minimal interaction with the application. It was noted that those participants who did not log also did not use other features of the application, suggesting a lack of engagement not specific to the exercises. Future investigations will benefit from analysis of factors which may impact app use. Prophylactic swallowing exercises are an important aspect of dysphagia prevention in patients receiving radiation therapy for head and neck cancers [8, 10, 12]. Despite the value of these exercises, adherence to treatment recommendations has been limited in prior investigations [14, 15]. Reasons cited for non-adherence include the belief that exercises were not important, difficulty performing exercises, forgetting to do the exercises, pain, ‘‘Notification that I did not log my exercises going off at 10 pm was not appreciated as I got fatigued during treatment’’ fatigue, and time constraints [14, 16]. In an attempt to optimize potential adherence to exercises, we developed a custom mobile application to address some of the adherence issues cited by patients. The application was designed to overcome current limitations of SLP interventions restricted to only the clinic. Mortenson et al.  reported that of patients given exercises and instructed to complete them three times daily, 53% logged at least one exercise session per day the 5th week of treatment. Similarly, in our series, 53% of participants logged at least one exercise session per day for the entire 7-week treatment period. When divided into low (\ 1 session per day), moderate (1–2 sessions per day), and high adherence ([ 2 sessions per day), again outcomes are relatively similar between Mortenson’s findings and our own. Specifically, low adherence was reported in 40% versus 47%, 34% versus 27%, and 26% versus 25%, respectively. An important distinction between the treatments provided in our two studies is in regard to frequency of visits with the swallowing therapist over the course of treatment. Participants in the Mortenson study met with the swallowing therapist 9 times over the course of treatment compared to 3 times in our series. This suggests that use of the VibrentTM mobile application may allow for similar adherence with less direct contact with the clinician. Feasibility data and patient interviews suggest that a number of improvements to the application may increase its value for patients. Changes in the way patients can schedule their exercise sessions and log completed sessions will be of great value. Additionally, simplification of the notification system will reduce reported frustration with the app. Finally, we will work with our developers to address some of the technical issues that interfered with seamless patient access. There are certainly limitations to this study that must be acknowledged. As our study was designed as a feasibility study, we did not measure the impact of use of the app on functional outcomes. Certainly determining whether use of the app is of value in improving functional outcomes will be a critical addition to future work. It must be 123 H. M. Starmer et al.: Mobile Application for Swallowing Therapy During Radiation acknowledged that this sample may not be reflective of head and neck cancer patients more broadly. The majority of participants had oropharyngeal cancer, likely reflecting the HPV-associated head and neck cancer epidemic seen in our clinics. Due to significant demographic differences between patients with HPV-positive and HPV-negative disease, the level of app utilization in this series may or may not be similar to what we would see with a broader group of head and neck patients. Specifically, patients with HPV-associated head and neck cancer are typically younger with higher levels of education than patients with HPV-negative disease and thus may have more experience with mobile technology [28, 29]. Efforts to engage a broader demographic in future studies are warranted. The VibrentTM mobile application has potential to improve adherence to swallowing exercise protocols during radiation for head and neck cancer with less need for inperson clinician encounters. While this technology does not appear to resonate with all patients, a subset of patients appears very motivated by the features integrated in this application. Future directions will include revision of the application based on patient and clinician feedback, investigation of differences in adherence between patients using the app and those using standard treatment options, and the impact of app use on functional swallowing outcomes. Conclusions The VibrentTM mobile application appears to be a tool that can be feasibly integrated into existing patient care practices. It may assist patients in adhering to treatment recommendations and facilitate communication between patients and providers between encounters. It was, however, noted that not all patients utilized the app as frequently as intended. Future efforts should include strategies to increase ease of use and functionality. Compliance with Ethical Standards Conflicts of interest The authors have no conflicts of interest to disclose. References 1. Chaturvedi AK, Engels EA, Anderson WF, et al. Incidence trends for human papilloma virus-related and -unrelated oral squamous cell carcinomas in the United States. J Clin Oncol. 2008;26:612–9. 2. King SN, Dunlap NE, Tennant PA, Pitts T. Pathophysiology of radiation-induced dysphagia in head and neck cancer. Dysphagia. 2016;31(3):339–51. 3. Starmer HM, Tippett D, Webster K, et al. Swallowing outcomes in patients with oropharyngeal cancer undergoing organ-preservation treatment. Head Neck. 2014;36(10):1392–7. 123 4. Lazarus C, Logeman J, Pauloski B, et al. Swallowing disorders in head and neck cancer patients treated with radiotherapy and adjuvant chemotherapy. Laryngoscope. 1996;106(9Pt1):1157–66. 5. Newman LA, Vieira F, Schwierzer V, et al. Eating and weight changes following chemoradiation therapy for advanced head and neck cancer. Arch Otolaryngol Head Neck Surg. 1998;124(5):589–92. 6. Hunter KU, Lee OE, Lyden TH, et al. Aspiration pneumonia after chemo-intensity-modulated radiation therapy of oropharyngeal carcinoma and its clinical and dysphagia-related predictors. Head Neck. 2014;36:120–5. 7. Carroll WR, Locher JL, Canon CL, et al. Pretreatment swallowing exercises improve swallow function after chemoradiation. Laryngoscope. 2008;118:39–43. 8. Kotz T, Federman AD, Kao J, et al. Prophylactic swallowing exercises in patients with head and neck cancer undergoing chemoradiation: a randomized trial. Arch Otolaryngol Head Neck Surg. 2012;138:376–82. 9. van der Molen L, van Rossum MA, Burkhead LM, et al. A randomized preventative rehabilitation trial in advanced head and neck cancer patients treated with chemoradiotherapy: feasibility, compliance, and short-term effects. Dysphagia. 2011;26:115–70. 10. Carnaby-Mann G, Crary MA, Schmalfus I, Amdur R. ‘‘Pharyngocise’’: randomized control trial of preventative exercises to maintain muscle structure and swallowing function during head and neck chemoradiotherapy. Int J Radiat Oncol Biol Phys. 2012;83:210–9. 11. Langmore S, Krisciunas GP, Miloro KV, et al. Does PEG cause dysphagia in head and neck cancer patients? Dysphagia. 2012;27(2):251–9. 12. Hutcheson KA, Bhayani MK, Beadle BM, et al. Eat and exercise during radiotherapy or chemoradiotherapy for pharyngeal cancers. Use it or lose it. JAMA. Otolaryngol Head Neck Surg. 2013;139(11):1127–34. 13. Ward MC, Bjateja P, Nwizu T, et al. Impact of feeding tube choice on severe late dysphagia after definitive chemoradiotherapy for human papilloma virus-negative head and neck cancer. Head Neck. 2016;38(Suppl 1):E1054–60. 14. Shinn EH, Basen-Engquist K, Baum G, et al. Adherence to preventative exercises and self-reported swallowing outcomes in post-radiation head and neck cancer patients. Head Neck. 2013;35(12):1707–12. 15. Mortensen HR, Jensen K, Aksglaede K, et al. Prophylactic swallowing exercises in head and neck cancer radiotherapy. Dysphagia. 2015;30(3):304–14. 16. Cnossen IC, van Uden-Kraan CF, Witte BL, et al. Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program. Eur Arch Otorhinolaryngol. 2017;274:1129–38. 17. Wall LR, Ward EC, Cartmill B, Hill AJ, Porceddu SV. Adherence to a prophylactic swallowing therapy program during (chemo) radiotherapy: impact of service delivery model and patient factors. Dysphagia. 2017;32(2):279–92. 18. Guarino H, Acosta M, Marsch LA, Xie H, Aponte-Melendez Y. A mixed-methods evaluation of the feasibility, acceptability, and preliminary efficacy of a mobile intervention for methadone maintenance clients. Psychol Addict Behav. 2016;30(1):1–11. 19. Hui CY, Walton R, McKinstry B, et al. The use of mobile applications to support self-management for people with asthma: a systematic review of controlled studies to identify features associated with clinical effectiveness and adherence. J Am Med Inform Assoc. 2016;24:619–32. 20. Litman L, Rosen Z, Spierer D, et al. Mobile exercise apps and increased leisure time exercise activity: a moderated mediation H. M. Starmer et al.: Mobile Application for Swallowing Therapy During Radiation 21. 22. 23. 24. 25. 26. analysis of the role of self-efficacy and barriers. J Med Internet Res. 2015;17(8):e195. Badaway SM, Barrera L, Sinno MG, Kaviany S, O’Dwyer LC, Kuhns LM. Text messaging and mobile phone apps as interventions to improve adherence in adolescents with chronic health conditions: a systematic review. JMIR mHealth uHealth. 2017;5(5):e66. Lambert TE, Harvey LA, Avdalis C, Chen LW, Jeyalingam S, et al. An app with remote support achieves better adherence to home exercise programs than paper handouts in people with musculoskeletal conditions: a randomized trial. J Physiother. 2017;63:161–7. Anderson M. Technology device ownership. Pew research center. Washington, DC. 2015. http://www.pewinternet.org/2015/10/29/ technology-device-ownership-2015/. Accessed 8 oct 2017. DiFillippo KN, Huang WH, Andrade JE, Chapman-Novakofski KM. The use of mobile apps to improve nutrition outcomes: a systematic literature review. J Telemed Telecare. 2015;21(5): 243–53. Rossi MCE, Nicolucci A, Pellegrini F, et al. Interactive diary for diabetes: a useful and easy-to-use new telemedicine system to support the decision making process in type 1 diabetes. Diabetes Tech Ther. 2009;11:19–24. Kuijpers W, Groen WG, Aaronson NK, van Harten WH. A systematic review of web-based interventions for patient empowerment and physical activity in chronic diseases: relevance for cancer survivors. J Med Internet Res. 2015;15(2):e37. 27. Govender R, Smith CH, Taylor SA, Barratt H, Gardner B. Swallowing interventions for the treatment of dysphagia after head and neck cancer: a systematic review of behavioural strategies used to promote patient adherence to swallowing exercises. BMC Cancer. 2017;17:43–58. 28. Dahlstrom KR, Bell D, Hanby D, et al. Socioeconomic characteristics of patients with oropharyngeal carcinoma according to tumor HPV status, patient smoking history, and sexual behavior. Oral Oncol. 2015;51(9):832–8. 29. Young D, Xiao CC, Murphy B, Moore M, Fakhry C, Day TA. Increase in head and neck cancer in younger patients due to human papillomavirus (HPV). Oral Oncol. 2015;51(8):727–30. Heather M. Starmer Rina Abrams MS, CCC-SLP Kimberly Webster Jennifer Kizner Beth Beadle MA, CCC-SLP, BCS-S MS, CCC-SLP MEd, CCC-SLP, BCS-S MD F. Christopher Holsinger Harry Quon MD MD Jeremy Richmon MD 123