Participatory Development of an Integrated, eHealth-Supported, Educational Care Pathway (Diabetes Box) for People With Type 2 Diabetes: Development and Usability Study.

BACKGROUND: Type 2 diabetes (T2D) tremendously affects patient health and health care globally. Changing lifestyle behaviors can help curb the burden of T2D. However, health behavior change is a complex interplay of medical, behavioral, and psychological factors. Personalized lifestyle advice and promotion of self-management can help patients change their health behavior and improve glucose regulation. Digital tools are effective in areas of self-management and have great potential to support patient self-management due to low costs, 24/7 availability, and the option of dynamic automated feedback. To develop successful eHealth solutions, it is important to include stakeholders throughout the development and use a structured approach to guide the development team in planning, coordinating, and executing the development process. OBJECTIVE: The aim of this study is to develop an integrated, eHealth-supported, educational care pathway for patients with T2D. METHODS: The educational care pathway was developed using the first 3 phases of the Center for eHealth and Wellbeing Research roadmap: the contextual inquiry, the value specification, and the design phase. Following this roadmap, we used a scoping review about diabetes self-management education and eHealth, past experiences of eHealth practices in our hospital, focus groups with health care professionals (HCPs), and a patient panel to develop a prototype of an educational care pathway. This care pathway is called the Diabetes Box (Leiden University Medical Center) and consists of personalized education, digital educational material, self-measurements of glucose, blood pressure, activity, and sleep, and a smartphone app to bring it all together. RESULTS: The scoping review highlights the importance of self-management education and the potential of telemonitoring and mobile apps for blood glucose regulation in patients with T2D. Focus groups with HCPs revealed the importance of including all relevant lifestyle factors, using a tailored approach, and using digital consultations. The contextual inquiry led to a set of values that stakeholders found important to include in the educational care pathway. All values were specified in biweekly meetings with key stakeholders, and a prototype was designed. This prototype was evaluated in a patient panel that revealed an overall positive impression of the care pathway but stressed that the number of apps should be restricted to one, that there should be no delay in glucose value visualization, and that insulin use should be incorporated into the app. Both patients and HCPs stressed the importance of direct automated feedback in the Diabetes Box. CONCLUSIONS: After developing the Diabetes Box prototype using the Center for eHealth and Wellbeing Research roadmap, all stakeholders believe that the concept of the Diabetes Box is useful and feasible and that direct automated feedback and education on stress and sleep are essential. A pilot study is planned to assess feasibility, acceptability, and usefulness in more detail.

Patient and Staff Experience of Remote Patient Monitoring-What to Measure and How: Systematic Review.

BACKGROUND: Patient and staff experience is a vital factor to consider in the evaluation of remote patient monitoring (RPM) interventions. However, no comprehensive overview of available RPM patient and staff experience-measuring methods and tools exists. OBJECTIVE: This review aimed at obtaining a comprehensive set of experience constructs and corresponding measuring instruments used in contemporary RPM research and at proposing an initial set of guidelines for improving methodological standardization in this domain. METHODS: Full-text papers reporting on instances of patient or staff experience measuring in RPM interventions, written in English, and published after January 1, 2011, were considered for eligibility. By "RPM interventions," we referred to interventions including sensor-based patient monitoring used for clinical decision-making; papers reporting on other kinds of interventions were therefore excluded. Papers describing primary care interventions, involving participants under 18 years of age, or focusing on attitudes or technologies rather than specific interventions were also excluded. We searched 2 electronic databases, Medline (PubMed) and EMBASE, on February 12, 2021.We explored and structured the obtained corpus of data through correspondence analysis, a multivariate statistical technique. RESULTS: In total, 158 papers were included, covering RPM interventions in a variety of domains. From these studies, we reported 546 experience-measuring instances in RPM, covering the use of 160 unique experience-measuring instruments to measure 120 unique experience constructs. We found that the research landscape has seen a sizeable growth in the past decade, that it is affected by a relative lack of focus on the experience of staff, and that the overall corpus of collected experience measures can be organized in 4 main categories (service system related, care related, usage and adherence related, and health outcome related). In the light of the collected findings, we provided a set of 6 actionable recommendations to RPM patient and staff experience evaluators, in terms of both what to measure and how to measure it. Overall, we suggested that RPM researchers and practitioners include experience measuring as part of integrated, interdisciplinary data strategies for continuous RPM evaluation. CONCLUSIONS: At present, there is a lack of consensus and standardization in the methods used to measure patient and staff experience in RPM, leading to a critical knowledge gap in our understanding of the impact of RPM interventions. This review offers targeted support for RPM experience evaluators by providing a structured, comprehensive overview of contemporary patient and staff experience measures and a set of practical guidelines for improving research quality and standardization in this domain.

Human cues in eHealth to promote lifestyle change: An experimental field study to examine adherence to self-help interventions.

eHealth lifestyle interventions without human support (self-help interventions) are generally less effective, as they suffer from lower adherence levels. To solve this, we investigated whether (1) using a text-based conversational agent (TCA) and applying human cues contribute to a working alliance with the TCA, and whether (2) adding human cues and establishing a positive working alliance increase intervention adherence. Participants (N = 121) followed a TCA-supported app-based physical activity intervention. We manipulated two types of human cues: visual (ie, message appearance) and relational (ie, message content). We employed a 2 (visual cues: yes, no) x 2 (relational cues: yes, no) between-subjects design, resulting in four experimental groups: (1) visual and relational cues, (2) visual cues only, (3) relational cues only, or (4) no human cues. We measured the working alliance with the Working Alliance Inventory Short Revised form and intervention adherence as the number of days participants responded to the TCA's messages. Contrary to expectations, the working alliance was unaffected by using human cues. Working alliance was positively related to adherence (t(78) = 3.606, p = .001). Furthermore, groups who received visual cues showed lower adherence levels compared to those who received relational cues only or no cues (U = 1140.5, z = -3.520, p < .001). We replicated the finding that establishing a working alliance contributes to intervention adherence, independently of the use of human cues in a TCA. However, we were unable to show that adding human cues impacted the working alliance and increased adherence. The results indicate that adding visual cues to a TCA may even negatively affect adherence, possibly because it may create confusion concerning the true nature of the coach, which may prompt unrealistic expectations.

Use Intention and User Expectations of Human-Supported and Self-Help eHealth Interventions: Internet-Based Randomized Controlled Trial.

BACKGROUND: Self-help eHealth interventions provide automated support to change health behaviors without any further human assistance. The main advantage of self-help eHealth interventions is that they have the potential to lower the workload of health care professionals. However, one disadvantage is that they generally have a lower uptake. Possibly, the absence of a relationship with a health care professional (referred to as the working alliance) could lead to negative expectations that hinder the uptake of self-help interventions. The Unified Theory of Acceptance and Use of Technology (UTAUT) identifies which expectations predict use intention. As there has been no previous research exploring how expectations affect the adoption of both self-help and human-supported eHealth interventions, this study is the first to investigate the impact of expectations on the uptake of both kinds of eHealth interventions. OBJECTIVE: This study investigated the intention to use a self-help eHealth intervention compared to a human-supported eHealth intervention and the expectations that moderate this relationship. METHODS: A total of 146 participants were randomly assigned to 1 of 2 conditions (human-supported or self-help eHealth interventions). Participants evaluated screenshots of a human-supported or self-help app-based stress intervention. We measured intention to use the intervention-expected working alliance and the UTAUT constructs: performance expectancy, effort expectancy, and social influence. RESULTS: Use intention did not differ significantly between the 2 conditions (t142=-1.133; P=.26). Performance expectancy (F1,140=69.269; P<.001), effort expectancy (F1,140=3.961; P=.049), social influence (F1,140=90.025; P<.001), and expected working alliance (F1,140=26.435; P<.001) were positively related to use intention regardless of condition. The interaction analysis showed that performance expectancy (F1,140=4.363; P=.04) and effort expectancy (F1,140=4.102; P=.045) more strongly influenced use intention in the self-help condition compared to the human-supported condition. CONCLUSIONS: As we found no difference in use intention, our results suggest that we could expect an equal uptake of self-help eHealth interventions and human-supported ones. However, attention should be paid to people who have doubts about the intervention's helpfulness or ease of use. For those people, providing additional human support would be beneficial to ensure uptake. Screening user expectations could help health care professionals optimize self-help eHealth intervention uptake in practice. TRIAL REGISTRATION: OSF Registries osf.io/n47cz; https://osf.io/n47cz.

How to Use Costs in Value-Based Healthcare: Learning from Real-life Examples.

BACKGROUND: Healthcare organizations measure costs for business operations but do not routinely incorporate costs in decision-making on the value of care. AIM: Provide guidance on how to use costs in value-based healthcare (VBHC) delivery at different levels of the healthcare system. SETTING AND PARTICIPANTS: Integrated practice units (IPUs) for diabetes mellitus (DM) and for acute myocardial infarction (AMI) at the Leiden University Medical Center and a collaboration of seven breast cancer IPUs of the Santeon group, all in the Netherlands. PROGRAM DESCRIPTION AND EVALUATION: VBHC aims to optimize care delivery to the patient by understanding how costs relate to outcomes. At the level of shared decision-making between patient and clinician, yearly check-up consultations for DM type I were analyzed for patient-relevant costs. In benchmarking among providers, quantities of cost drivers for breast cancer care were assessed in scorecards. In continuous learning, cost-effectiveness analysis was compared with radar chart analysis to assess the value of telemonitoring in outpatient follow-up. DISCUSSION: Costs vary among providers in healthcare, but also between provider and patient. The joint analysis of outcomes and costs using appropriate methods helps identify and optimize the aspects of care that drive desired outcomes and value.

Mobile health for cardiovascular risk management after cardiac surgery: results of a sub-analysis of The Box 2.0 study.

Aims: Lowering low-density lipoprotein (LDL-C) and blood pressure (BP) levels to guideline recommended values reduces the risk of major adverse cardiac events in patients who underwent coronary artery bypass grafting (CABG). To improve cardiovascular risk management, this study evaluated the effects of mobile health (mHealth) on BP and cholesterol levels in patients after standalone CABG. Methods and results: This study is a post hoc analysis of an observational cohort study among 228 adult patients who underwent standalone CABG surgery at a tertiary care hospital in The Netherlands. A total of 117 patients received standard care, and 111 patients underwent an mHealth intervention. This consisted of frequent BP and weight monitoring with regimen adjustment in case of high BP. Primary outcome was difference in systolic BP and LDL-C between baseline and value after three months of follow-up. Mean age in the intervention group was 62.7 years, 98 (88.3%) patients were male. A total of 26 449 mHealth measurements were recorded. At three months, systolic BP decreased by 7.0 mmHg [standard deviation (SD): 15.1] in the intervention group vs. -0.3 mmHg (SD: 17.6; P < 0.00001) in controls; body weight decreased by 1.76 kg (SD: 3.23) in the intervention group vs. -0.31 kg (SD: 2.55; P = 0.002) in controls. Serum LDL-C was significantly lower in the intervention group vs. controls (median: 1.8 vs. 2.0 mmol/L; P = 0.0002). Conclusion: This study showed an association between home monitoring after CABG and a reduction in systolic BP, body weight, and serum LDL-C. The causality of the association between the observed weight loss and decreased LDL-C in intervention group patients remains to be investigated.

Effectiveness of Human-Supported and Self-Help eHealth Lifestyle Interventions for Patients With Cardiometabolic Risk Factors: A Meta-Analysis.

OBJECTIVE: eHealth is a useful tool to deliver lifestyle interventions for patients with cardiometabolic diseases. However, there are inconsistent findings about whether these eHealth interventions should be supported by a human professional, or whether self-help interventions are equally effective. METHODS: Databases were searched between January 1995 and October 2021 for randomized controlled trials on cardiometabolic diseases (cardiovascular disease, chronic kidney disease, type 1 and 2 diabetes mellitus) and eHealth lifestyle interventions. A multilevel meta-analysis was used to pool clinical and behavioral health outcomes. Moderator analyses assessed the effect of intervention type (self-help versus human-supported), dose of human support (minor versus major part of intervention), and delivery mode of human support (remote versus blended). One hundred seven articles fulfilled eligibility criteria and 102 unique ( N = 20,781) studies were included. RESULTS: The analysis showed a positive effect of eHealth lifestyle interventions on clinical and behavioral health outcomes ( p < .001). However, these effects were not moderated by intervention type ( p = .169), dose ( p = .698), or delivery mode of human support ( p = .557). CONCLUSIONS: This shows that self-help eHealth interventions are equally effective as human-supported ones in improving health outcomes among patients with cardiometabolic disease. Future studies could investigate whether higher-quality eHealth interventions compensate for a lack of human support.Meta-analysis registration: PROSPERO CRD42021269263 .

An omission in guidelines. Cardiovascular disease prevention should also focus on dietary policies for healthcare facilities.

Suboptimal diet is a major modifiable risk factor in cardiovascular disease. Governments, individuals, educational institutes, healthcare facilities and the industry all share the responsibility to improve dietary habits. Healthcare facilities in particular present a unique opportunity to convey the importance of healthy nutrition to patients, visitors and staff. Guidelines on cardiovascular disease do include policy suggestions for population-based approaches to diet in a broad list of settings. Regrettably, healthcare facilities are not explicitly included in this list. The authors propose to explicitly include healthcare facilities as a setting for policy suggestions in the current and future ESC Guidelines for cardiovascular disease prevention in clinical practice.

Setting your clock: associations between timing of objective physical activity and cardiovascular disease risk in the general population.

AIMS: Little is known about the impact of daily physical activity timing (here referred to as 'chronoactivity') on cardiovascular disease (CVD) risk. We aimed to examined the associations between chronoactivity and multiple CVD outcomes in the UK Biobank. METHODS AND RESULTS: physical activity data were collected in the UK-Biobank through triaxial accelerometer over a 7-day measurement period. We used K-means clustering to create clusters of participants with similar chronoactivity irrespective of the mean daily intensity of the physical activity. Multivariable-adjusted Cox-proportional hazard models were used to estimate hazard ratios (HRs) comparing the different clusters adjusted for age and sex (model 1), and baseline cardiovascular risk factors (model 2). Additional stratified analyses were done by sex, mean activity level, and self-reported sleep chronotype. We included 86 657 individuals (58% female, mean age: 61.6 [SD: 7.8] years, mean BMI: 26.6 [4.5] kg/m2). Over a follow-up period of 6 years, 3707 incident CVD events were reported. Overall, participants with a tendency of late morning physical activity had a lower risk of incident coronary artery disease (HR: 0.84, 95%CI: 0.77, 0.92) and stroke (HR: 0.83, 95%CI: 0.70, 0.98) compared to participants with a midday pattern of physical activity. These effects were more pronounced in women (P-value for interaction = 0.001). We did not find evidence favouring effect modification by total activity level and sleep chronotype. CONCLUSION: Irrespective of total physical activity, morning physical activity was associated with lower risks of incident cardiovascular diseases, highlighting the potential importance of chronoactivity in CVD prevention.

Identifying barriers and facilitators to adopting healthier dietary choices in clinical care: a cross-sectional observational study.

Background and aims: Adopting healthier diets can drastically improve societal health. Our environment plays a crucial role in daily dietary choices and hospitals in particular can stimulate patients to adopt healthier eating habits. Unfortunately, no robust clinically applicable cuing tools exist to help guide in-hospital dietary interventions. The purpose of this study was to identify patient-related barriers and facilitators to adopting healthier dietary choices. Methods and results: This cross-sectional observational study was conducted on the cardiology ward of a university medical center between June 2020 and January 2021. Of the 594 patients asked and the 312 completed surveys on healthy eating intentions, 285 responses were considered for analysis. Notably, the majority of respondents were male (68.8%), with an average hospital stay of 3.3 days. The results indicate that cardiac patients attribute significantly greater influence on their dietary behavior to doctors compared to other caregivers, including dieticians (X2 = 37.09, df = 9, p < 0.001). Also, younger patients (below 70 years of age) were more inclined to plan changing dietary behavior than older patients. Most mentioned facilitators for adopting a healthier diet were more information/counseling, help in preparing food, support from family and friends, and more emphasis from a doctor. Conclusion: The study highlights the importance of involving doctors in formulating dietary policies and patient-directed interventions within hospital settings. It also sheds light on the barriers and facilitators for promoting healthier dietary behaviors among patients during their hospitalization.

COVID-box Experiences of Patients and Health Care Professionals (COVID-box Project): Single-Center, Retrospective, Observational Study.

BACKGROUND: During the COVID-19 pandemic, several home monitoring programs have described the success of reducing hospital admissions, but only a few studies have investigated the experiences of patients and health care professionals. OBJECTIVE: The objective of our study was to determine patients' and health care professionals' experiences and satisfaction with employing the COVID-box. METHODS: In this single-center, retrospective, observational study, patients and health care professionals were asked to anonymously fill out multiple-choice questionnaires with questions on a 5-point or 10-point Likert scale. The themes addressed by patients were the sense of reassurance and safety, experiences with teleconsultations, their appreciation for staying at home, and the instructions for using the COVID-box. The themes addressed by health care professionals who treated patients with the COVID-box were the characteristics of the COVID-box, the technical support service and general satisfaction, and their expectations and support for this telemonitoring concept. Scores were interpreted as insufficient (≤2 or ≤5, respectively), sufficient (3 or 6-7, respectively), or good (≥4 or ≥8, respectively) on a 5-point or 10-point Likert scale. RESULTS: A total of 117 patients and 25 health care professionals filled out the questionnaires. The median score was 4 (IQR 4-5) for the sense of safety, the appreciation for staying at home, and experiences with teleconsultations, with good scores from 76.5% (88/115), 86% (56/65), and 83.6% (92/110) of the patients, respectively. Further, 74.4% (87/117) of the patients scored the home monitoring program with a score of ≥8. Health care professionals scored the COVID-box with a minimum median score of 7 (IQR 7-10) on a 10-point scale for all domains (ie, the characteristics of the COVID-box and the technical support service and general satisfaction). For the sense of safety, user-friendliness, and additional value of the COVID-box, the median scores were 8 (IQR 8-10), 8 (IQR 7-9), and 10 (IQR 8-10), respectively, with good scores from 86% (19/22), 75% (15/20), and 96% (24/25) of the health care professionals, respectively. All health care professionals (25/25, 100%) gave a score of ≥8 for supporting this home monitoring concept, with a median score of 10 (IQR 10-10). CONCLUSIONS: The positive experiences and satisfaction of involved users are key factors for the successful implementation of a novel eHealth solution. In our study, patients, as well as health care professionals, were highly satisfied with the use of the home monitoring program-the COVID-box project. Remote home monitoring may be an effective approach in cases of increased demand for hospital care and high pressure on health care systems.

Sbk2, a Newly Discovered Atrium-Enriched Regulator of Sarcomere Integrity.

BACKGROUND: Heart development relies on tight spatiotemporal control of cardiac gene expression. Genes involved in this intricate process have been identified using animals and pluripotent stem cell-based models of cardio(myo)genesis. Recently, the repertoire of cardiomyocyte differentiation models has been expanded with iAM-1, a monoclonal line of conditionally immortalized neonatal rat atrial myocytes (NRAMs), which allows toggling between proliferative and differentiated (ie, excitable and contractile) phenotypes in a synchronized and homogenous manner. METHODS: In this study, the unique properties of conditionally immortalized NRAMs (iAMs) were exploited to identify and characterize (lowly expressed) genes with an as-of-yet uncharacterized role in cardiomyocyte differentiation. RESULTS: Transcriptome analysis of iAM-1 cells at different stages during one cycle of differentiation and subsequent dedifferentiation identified ≈13 000 transcripts, of which the dynamic changes in expression upon cardiomyogenic differentiation mostly opposed those during dedifferentiation. Among the genes whose expression increased during differentiation and decreased during dedifferentiation were many with known (lineage-specific) functions in cardiac muscle formation. Filtering for cardiac-enriched low-abundance transcripts, identified multiple genes with an uncharacterized role during cardio(myo)genesis including Sbk2 (SH3 domain binding kinase family member 2). Sbk2 encodes an evolutionarily conserved putative serine/threonine protein kinase, whose expression is strongly up- and downregulated during iAM-1 cell differentiation and dedifferentiation, respectively. In neonatal and adult rats, the protein is muscle-specific, highly atrium-enriched, and localized around the A-band of cardiac sarcomeres. Knockdown of Sbk2 expression caused loss of sarcomeric organization in NRAMs, iAMs and their human counterparts, consistent with a decrease in sarcomeric gene expression as evinced by transcriptome and proteome analyses. Interestingly, co-immunoprecipitation using Sbk2 as bait identified possible interaction partners with diverse cellular functions (translation, intracellular trafficking, cytoskeletal organization, chromatin modification, sarcomere formation). CONCLUSIONS: iAM-1 cells are a relevant and suitable model to identify (lowly expressed) genes with a hitherto unidentified role in cardiomyocyte differentiation as exemplified by Sbk2: a regulator of atrial sarcomerogenesis.

The Box-eHealth in the Outpatient Clinic Follow-up of Patients With Acute Myocardial Infarction: Cost-Utility Analysis.

BACKGROUND: Smartphone compatible wearables have been released on the consumers market, enabling remote monitoring. Remote monitoring is often named as a tool to reduce the cost of care. OBJECTIVE: The primary purpose of this paper is to describe a cost-utility analysis of an eHealth intervention compared to regular follow-up in patients with acute myocardial infarction (AMI). METHODS: In this trial, of which clinical results have been published previously, patients with an AMI were randomized in a 1:1 fashion between an eHealth intervention and regular follow-up. The remote monitoring intervention consisted of a blood pressure monitor, weight scale, electrocardiogram device, and step counter. Furthermore, two in-office outpatient clinic visits were replaced by e-visits. The control group received regular care. The differences in mean costs and quality of life per patient between both groups during one-year follow-up were calculated. RESULTS: Mean costs per patient were €2417±2043 (US $2657±2246) for the intervention and €2888±2961 (US $3175±3255) for the control group. This yielded a cost reduction of €471 (US $518) per patient. This difference was not statistically significant (95% CI -€275 to €1217; P=.22, US $-302 to $1338). The average quality-adjusted life years in the first year of follow-up was 0.74 for the intervention group and 0.69 for the control (difference -0.05, 95% CI -0.09 to -0.01; P=.01). CONCLUSIONS: eHealth in the outpatient clinic setting for patients who suffered from AMI is likely to be cost-effective compared to regular follow-up. Further research should be done to corroborate these findings in other patient populations and different care settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT02976376; https://clinicaltrials.gov/ct2/show/NCT02976376. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/resprot.8038.

A Preoperative Virtual Reality App for Patients Scheduled for Cardiac Catheterization: Pre-Post Questionnaire Study Examining Feasibility, Usability, and Acceptability.

BACKGROUND: Pre- and postoperative anxiety is a common phenomenon associated with negative postoperative outcomes. Symptoms of posttraumatic stress disorder, such as fear, nightmares, and sleep deprivation, are prevalent in approximately 30% to 50% of patients following discharge from intensive care units after cardiac surgery. Preliminary evidence suggests a promising role of virtual reality (VR) in preventing stress-related reactions using stress inoculation training. Such training enables cognitive preparation of individuals for stressful situations, thereby becoming more tolerant and resistant to stress, subsequently reducing the risk of potential negative psychological consequences. This study investigated a preoperative VR app-Pre-View-aimed at better informing and preparing patients for cardiac catheterization. OBJECTIVE: This study aims to assess the feasibility, usability, and acceptability of Pre-View in patients undergoing cardiac catheterization. METHODS: Eligible participants were adults scheduled for elective cardiac catheterization. Pre-View comprised an interactive virtual representation of the whole care process related to cardiac catheterization, from entering the hospital for admission to postprocedural stay and discharge. These processes were represented through 360° videos and interactive photos. Self-report questionnaires were completed at baseline (ie, before catheterization and after undergoing the VR experience) and after cardiac catheterization. Outcome measures included user experience and satisfaction, VR presence and immersive tendencies, and user friendliness. The perceived effectiveness was assessed exploratively. RESULTS: A total of 8 individuals, with a mean age of 67 (SD 7.5) years, participated in this study. Half of them underwent the VR experience at the hospital and the other half at home. Participants reported high levels of presence in the virtual environment (Presence Questionnaire score: mean 129.1, SD 13.4). The usability of Pre-View was well evaluated (System Usability Scale score: mean 89.1, SD 12.0), and patient satisfaction was high (Client Satisfaction Questionnaire score: mean 27.1, SD 3.2). Usability and satisfaction scores were higher for participants who underwent Pre-View at home versus those who underwent Pre-View at the hospital, although the latter group was significantly older; 72.8 versus 61.3, respectively. All participants reported Pre-View to be effective in terms of feeling better informed about the care process of cardiac catheterization. Most participants (7/8, 88%) reported Pre-View to be effective in terms of feeling better prepared for cardiac catheterization, acknowledging the potential of Pre-View in reducing negative psychological consequences after catheterization. CONCLUSIONS: The results provide initial support for the feasibility and acceptability of a preoperative VR app, creating a virtual environment that supports patient education and preparation for upcoming cardiac catheterization. More studies are needed to further investigate the effects of VR as a tool to better prepare patients for medical procedures, its effectiveness in reducing negative patient outcomes (eg, anxiety, stress, and postoperative recovery outcomes), and the generalizability of effects across different settings and patient populations.

Clarifying responsibility: professional digital health in the doctor-patient relationship, recommendations for physicians based on a multi-stakeholder dialogue in the Netherlands.

BACKGROUND: Implementation of digital health (eHealth) generally involves adapting pre-established and carefully considered processes or routines, and still raises multiple ethical and legal dilemmas. This study aimed to identify challenges regarding responsibility and liability when prescribing digital health in clinical practice. This was part of an overarching project aiming to explore the most pressing ethical and legal obstacles regarding the implementation and adoption of digital health in the Netherlands, and to propose actionable solutions. METHODS: A series of multidisciplinary focus groups with stakeholders who have relevant digital health expertise were analysed through thematic analysis. RESULTS: The emerging general theme was 'uncertainty regarding responsibilities' when adopting digital health. Key dilemmas take place in clinical settings and within the doctor-patient relationship ('professional digital health'). This context is particularly challenging because different stakeholders interact. In the absence of appropriate legal frameworks and codes of conduct tailored to digital health, physicians' responsibility is to be found in their general duty of care. In other words: to do what is best for patients (not causing harm and doing good). Professional organisations could take a leading role to provide more clarity with respect to physicians' responsibility, by developing guidance describing physicians' duty of care in the context of digital health, and to address the resulting responsibilities. CONCLUSIONS: Although legal frameworks governing medical practice describe core ethical principles, rights and obligations of physicians, they do not suffice to clarify their responsibilities in the setting of professional digital health. Here we present a series of recommendations to provide more clarity in this respect, offering the opportunity to improve quality of care and patients' health. The recommendations can be used as a starting point to develop professional guidance and have the potential to be adapted to other healthcare professionals and systems.

Lifestyle support preferences of patients with cardiovascular diseases: What lifestyle support might work best for whom?

Background: Lifestyle support is essential in preventing and treating cardiovascular diseases (CVD), and eHealth may be an easy and affordable solution to provide this support. However, CVD patients vary in their ability and interest to use eHealth. This study investigates demographic characteristics determining CVD patients' online and offline lifestyle support preferences. Methods: We used a cross-sectional study design. 659 CVD patients (Harteraad panel) completed our questionnaire. We assessed demographic characteristics and preferred lifestyle support type (coach, eHealth, family/friends, self-supportive). Results: Respondents mostly preferred being self-supportive (n = 179, 27.2%), and a coach in a group or individually (n = 145, 22.0%; n = 139, 21.1%). An app/internet to work independently (n = 89, 13.5%) or being in touch with other CVD patients (n = 44, 6.7%) was least preferred. Men were more likely to prefer being supported by family/friends (p = .016) or self-supportive (p < .001), while women preferred a coach individually or via an app/internet (p < .001). Older patients mostly preferred self-support (p = .001). Patients with low social support were more likely to prefer being coached individually (p < .001), but not support from family/friends (p = .002). Conclusion: Men and older patients are more interested in being self-supportive, and patients with lower levels of social support could need extra support outside their social network. eHealth could provide a solution, but attention should be paid to spike interest for digital interventions among certain groups.

Optimizing Smoking Cessation Counseling in a University Hospital: Results and Pitfalls.

Background: Healthcare professionals (HPs) can play a substantial role in smoking cessation counseling (SCC) but in practice often skip this task due to time constraints. This study evaluates the implementation of the rapid Ask-Advise-Connect (AAC) method in a University hospital setting. Methods: This mixed methods pre-post interventional study was performed at the Cardiology department of a University hospital and consisted of (1) a quantitative assessment of patient smoking registration and HP connection rates to external SCC from the Electronic Medical Record, (2) semi-structured interviews with 10 HPs to assess their attitudes toward AAC, and (3) a blended intervention aimed to implement AAC. The blended intervention consisted of face-to-face and online AAC psychoeducation for HPs followed-up with motivational messages on their smart pagers over a period of 6 weeks. Results: In total, 48,321 patient registrations and 67 HPs were included. Before AAC implementation, HPs assessed smoking status in 74.0% of patients and connected 9.3% of identified smokers with SCC. Post intervention, these percentages did not increase (73.2%, p = 0.20; and 10.9%, p = 0.18, respectively). Nonetheless, the vast majority (90%) of HPs feel it is important to discuss patient smoking, and view it as their duty to do so. Main barriers to AAC reported by HPs were forgetfulness and time pressure. Conclusion: This study shows that this AAC intervention does not increase Asking after smoking status or Connection of patients to SCC in a University Hospital. However, HPs hold positive attitudes toward AAC. A better understanding of the mechanisms required for optimizing HPs practice behavior is needed.

Value of Global Longitudinal Strain for Identification and Monitoring of Left Ventricular Dysfunction in Becker Muscular Dystrophy.

Cardiac involvement is the main cause of death in Becker muscular dystrophy (BMD). Identification of left ventricular (LV) function is crucial, but standard echocardiographic measurements such as LV ejection fraction (LVEF) might not be sensitive enough to detect early myocardial dysfunction. We explored the value of LV global longitudinal strain (GLS) as a more accurate echocardiographic parameter to detect and monitor LV dysfunction in BMD. Furthermore, we studied possible factors associated with LV dysfunction and progression. A total of 40 patients with BMD (age 39.0 ± 13.2 years) and 21 matched controls were included. Clinical variables, pulmonary tests, serum biomarkers, and echocardiograms were collected at baseline and after 2 years. LV systolic function was assessed by LVEF and LV GLS; a significant progression in LV dysfunction was defined as an absolute LV GLS deterioration ≥15%. Responsiveness to cardiac disease progression was determined using standardized response means. Patients showed impaired LVEF and LV GLS compared with controls (p <0.001). Of interest, 31 patients (77.5%) showed impaired LV GLS (defined as greater than -18%), whereas only 24 patients (60%) had reduced LVEF. LV GLS and LVEF correlated with troponin I (ρ = 0.553 and -0.523) and N-terminal pro-b-type natriuretic peptide (ρ = 0.506 and -0.585), but not with skeletal muscle or pulmonary function. At follow-up (2.0 ± 0.5 years, n = 29), LV GLS worsened significantly (-1.3 ± 0.8%, p = 0.002, standardized response mean = 0.70, annually = 0.60%), whereas LVEF remained stable. No risk factors for LV dysfunction progression were identified. In BMD, LV GLS is frequently impaired and shows deterioration over time compared with LVEF. LV GLS could be used as a more sensitive parameter to identify and monitor LV dysfunction.

Facilitators of and Barriers to Lifestyle Support and eHealth Solutions: Interview Study Among Health Care Professionals Working in Cardiac Care.

BACKGROUND: Cardiovascular diseases (CVDs) pose a significant health threat and reduce both people's life expectancy and quality of life. Healthy living is a key component in the effective prevention and treatment of CVD. However, health care professionals (HCPs) experience difficulties in supporting lifestyle changes among their patients. eHealth can provide a solution to these barriers. OBJECTIVE: This study aims to provide insights into the factors HCPs find important in the support of patients with CVD in the uptake of and adherence to a healthy lifestyle and the perceived facilitators of and barriers to using eHealth to provide lifestyle support to patients with CVD. METHODS: In-depth interviews were conducted with 16 Dutch HCPs specializing in lifestyle support in cardiac care. RESULTS: We identified 13 themes, of which the first 12 concerned lifestyle support in general and were related to intervention, patient, or health care. Throughout these themes, the use of eHealth reoccurred as a potential facilitator of or solution to barriers to lifestyle support. Our final theme specifically concerned barriers to the adoption and usability of eHealth. CONCLUSIONS: HCPs do recognize the potential advantages of eHealth while experiencing barriers to using digital tools. Incorporating their needs and values in the development of lifestyle support programs, especially eHealth, could increase their use and lead to a more widespread adoption of eHealth into health care.

Experimental validation of absolute SPECT/CT quantification for response monitoring in patients with coronary artery disease.

BACKGROUND: Quantitative SPECT enables absolute quantification of uptake in perfusion defects. The aim of this experimental study is to assess quantitative accuracy and precision of a novel iterative reconstruction technique (Evolution; GE Healthcare) for the potential application of response monitoring using 99mTc-tetrofosmin SPECT/CT in patients with coronary artery disease (CAD). METHODS: Acquisitions of an anthropomorphic torso phantom with cardiac insert containing defects (with varying sizes), filled with 99mTc-pertechnetate, were performed on a SPECT/CT (Discovery 670 Pro, GE Healthcare). Subsequently, volumes of interest of the defects were manually drawn on CT to assess the recovery coefficient (RC). Bull's eye plots were composed to evaluate the uptake per segment. Finally, 99mTc-tetrofosmin SPECT/CT scans of 10 CAD patients were used to illustrate clinical application. RESULTS: The phantom study indicated that Evolution showed convergence after 7 iterations and 10 subsets. The average repeatability deviation of all configurations was 2.91% and 3.15% (%SD mean) for filtered (Butterworth) and unfiltered data, respectively. The accuracy after post-filtering was lower compared to the unfiltered data with a mean (SD) RC of 0.63 (0.05) and 0.70 (0.07), respectively (p < 0.05). More artificial defects were found on Bull's eye plots created with the unfiltered data compared to filtered data. Eight out of ten patients showed significant changes in uptake before and after treatment (p < 0.05). CONCLUSION: Quantification of 99mTc-tetrofosmin SPECT/CT seems feasible for CAD patients when 7 iterations (10 subsets), Butterworth post-filtering (cut off frequency 0.52 in cycles/cm, order of 5) and manual CT-delineation are applied. However, future prospective patient studies are required for clinical application.