Cocreation to Facilitate Communication and Collaboration Between Multidisciplinary Stakeholders in eHealth Research and Development: Case Study of the CARRIER (Coronary Artery Disease: Risk Estimations and Interventions for Prevention and Early Detection) Consortium

BACKGROUND

Collaboration with diverse stakeholders in eHealth research is fundamental yet complex. Stakeholders from various disciplines do not "speak the same language" and have different levels of power and interest, resulting in contrasting objectives, priorities, and expectations. An approach to constructive communication and collaboration is necessary to overcome this complex dynamic. Cocreation, known in the field of eHealth most often to involve end users, may also be suitable for facilitating stakeholder engagement and alignment.

OBJECTIVE

This paper provides insights into the application of cocreation, specifically in the early phases of research that focus on involving and aligning relevant stakeholders from different academic and professional backgrounds.

METHODS

The case for this study was a group discussion with members of a multidisciplinary consortium that works on developing a personalized eHealth intervention for atherosclerotic cardiovascular disease. Using stakeholder mapping, health and medicine experts, big data scientists, software developers, and an innovation manager (N=8) were invited to participate. The discussion was based on a user scenario and structured according to the Six Thinking Hats of de Bono, representing 6 different types of thinking. The discussion was recorded, transcribed verbatim, and analyzed thematically with the use of ATLAS.ti software.

RESULTS

First, informative and intuitive thinking served the preparatory purpose of familiarization with the project details and other participants. Second, positive and critical thinking constituted the body of the discussion and resulted in an in-depth conversation. Third, creative and organizational thinking were action oriented and focused on solutions and planning to safeguard future progress. The participants repeatedly reflected on various intervention-related themes, ranging from intervention content to technical functionalities and from legal requirements to implementation in practice. Moreover, project-related matters were discussed, including stakeholder management and time and budget constraints.

CONCLUSIONS

This paper demonstrates how cocreation can be of value for multidisciplinary stakeholder engagement and alignment. Based on stakeholder mapping (with whom to discuss), a dream user scenario (what to discuss), and the Six Thinking Hats of de Bono (how to discuss), the participants shared information, discussed differences, searched for solutions, and moved toward a collective approach regarding intervention development. The lessons learned may further improve the understanding of how cocreation can contribute to multidisciplinary collaboration.

Reasons and predictors of non-participation in a personalized digital prehabilitation care trial for patients undergoing elective cardiothoracic surgery

OBJECTIVES

Prehabilitation through a digital platform could preoperatively improve the physical and mental fitness of patients undergoing cardiothoracic surgery, thereby improving treatment outcomes. This study aimed to describe the reasons and predictors of non-participation in a personalized digital prehabilitation care trial (Digital Cardiac Counseling randomized controlled trial) for patients undergoing elective cardiothoracic surgery.

METHODS

Adult patients scheduled for elective cardiothoracic surgery at the Maastricht University Medical Center+ were approached to participate in a digital prehabilitation care trial, in which patients were informed about their care pathway, monitored for symptom progression, and screened for preoperative modifiable risk factors. Baseline characteristics of all eligible patients and reasons of non-participation were registered prospectively. Predictors of non-participation were determined using logistic regression.

RESULTS

Between May 2020 and August 2022, 815 patients were eligible for participation; 421 (52%) did not participate in the personalized digital prehabilitation care trial. Reasons of non-participation were "lack of internet access or insufficient digital skills" (32%), "wishing no participation" (39%), and "other reasons" (30%; e.g., vision or hearing impairments, analphabetism, language barriers). Independent predictors of non-participation were age (OR 1.024 (1.003-1.046), P = 0.024), socioeconomic status (OR 0.267 (0.133-0.536), P < 0.001) current smoker (OR 1.823 (1.124-2.954), P = 0.015), and EuroSCORE II (OR 1.160 (1.042-1.292), P = 0.007).

CONCLUSIONS

Half of the eligible patients did not participate in a personalized digital prehabilitation care trial. Non-participants were vulnerable patients, with a more unfavorable risk profile and more modifiable risk factors, who could potentially benefit the most from prehabilitation.

A big data-driven eHealth approach to prevent, detect, and reduce atherosclerotic cardiovascular disease burden

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Netherlands Organisation for Scientific Research (NWO)

eHealth is a promising tool to support citizens and patients to reduce their risk of future atherosclerotic vascular disease (ASCVD). Currently, many eHealth initiatives are developed, however their use is limited. To improve the adoption of eHealth initiatives, personalization is needed according to preferences and understanding of the individual. Together with stakeholders, we used the design thinking method to create a dream user-scenario for an eHealth solution to improve cardiovascular outcomes. This point-of-view shows the essential concepts of such an eHealth initiative and focuses on scientific solutions and the most important challenges faced during its development.

In the user-scenario a federated data infrastructure collects distributed medical and non-medical data from different organizations, while ensuring maximal privacy. This data, that is currently not available, is used in a screening model to identify citizens with an increased risk for ASCVD. Citizens at risk are offered the use of an eCoach, which is connected to a counterfactual prediction model to calculate a residual risk for hypothetical interventions. This risk is visualized in a personalized way to support the shared decision making process of personalized lifestyle and healthcare goals. eHealth modules, integrated in the eCoach, encourages the patient in achieving these goals. Relevant outcomes are monitored and are used to adjust the intensity of the modules and follow-up accordingly. To realize this federated data infrastructure, an ethical and legal framework should be developed to ensue responsible data handling.

Digital health to reduce the burden of atherosclerotic cardiovascular disease. Solutions proposed by the CARRIER consortium (Preprint)

Digital health is a promising tool to support people with an elevated risk for atherosclerotic cardiovascular disease (ASCVD) and patients with an established disease to improve cardiovascular outcomes. Many digital health initiatives have been developed and employed. However, barriers to their large-scale implementation have remained. This paper focuses on these barriers and presents solutions as proposed by the Dutch CARRIER (ie, Coronary ARtery disease: Risk estimations and Interventions for prevention and EaRly detection) consortium. We will focus in 4 sections on the following: (1) the development process of an eHealth solution that will include design thinking and cocreation with relevant stakeholders; (2) the modeling approach for two clinical prediction models (CPMs) to identify people at risk of developing ASCVD and to guide interventions; (3) description of a federated data infrastructure to train the CPMs and to provide the eHealth solution with relevant data; and (4) discussion of an ethical and legal framework for responsible data handling in health care. The Dutch CARRIER consortium consists of a collaboration between experts in the fields of eHealth development, ASCVD, public health, big data, as well as ethics and law. The consortium focuses on reducing the burden of ASCVD. We believe the future of health care is data driven and supported by digital health. Therefore, we hope that our research will not only facilitate CARRIER consortium but may also facilitate other future health care initiatives.

Last-minute cancellation of adult patients scheduled for cardiothoracic surgery in a large Dutch tertiary care centre

OBJECTIVES

Unanticipated cancellation of a surgical procedure is a common problem, causing distress to the patient and increases in healthcare costs. However, limited evidence exists on the effects of last-minute cancellations of cardiothoracic surgical procedures in particular. The goal of this study was to gain insight into the prevalence of and the reasons for last-minute cancellations and to examine whether cancellation is associated with adverse medical outcomes.

METHODS

Patients who were scheduled for elective cardiothoracic surgical procedures between January 2017 and June 2019 were evaluated. The reasons for the cancellations were assigned to the categories medically related or process related. We examined the differences in patient characteristics between those designated as no cancellation, medically related cancellations and process-related cancellations. Lastly, we examined the outcomes of patients who experienced a last-minute cancellation of a scheduled operation.

RESULTS

A total of 2111 patients were included; of these, 301 (14.3%) had last-minute cancellations. In 78 (26%) cases, the cancellations were attributable to medical reasons (e.g. infection, comorbidities); 215 (71%) of the cancellations were process related (e.g. another patient in more urgent need of surgery, lack of staff). Almost 99% of the operations with a process-related cancellation were rescheduled compared to only 71.8% of the medically related cancelled operations (P < 0.001). Patients with a medically related cancellation had significantly higher 1-year mortality than patients who had no cancellation (unadjusted hazard ratio 2.50; 95% confidence interval, 1.30-4.78; P = 0.006); after adjustment for the EuroSCORE II, this effect remained significant.

CONCLUSIONS

Last-minute cancellations were commonly seen in our cohort, and the reasons for cancellation were significantly related to adverse medical outcomes.

Corrigendum to: Personalized teleprehabilitation in elective cardiac surgery: a study protocol of the Digital Cardiac Counselling randomized controlled trial

[This corrects the article DOI: 10.1093/ehjdh/ztab041.].

Personalized teleprehabilitation in elective cardiac surgery: a study protocol of the Digital Cardiac Counselling randomized controlled trial

Aims

Previous research has shown the possibility to use the pre-operative period to improve a patient's tolerance for surgery. However, there is limited experience with prehabilitation in cardiac surgery. The aim of this study is to evaluate the effect of a comprehensive personalized teleprehabilitation programme on major adverse cardiac events (MACE) in patients scheduled for elective cardiac surgery. Secondary outcomes are post-operative complications, cardiovascular risk factors, quality of life, and cost-effectiveness.

Methods and results

In this single-centre randomized controlled trial, patients are eligible for inclusion when they are ≥18 years of age and cardiac surgery is scheduled at least 8 weeks from informed consent. Participants will be randomized to the teleprehabilitation group or the control group. After a digital baseline screening for perioperative risk factors, patients in the intervention arm can pre-operatively be referred to one or more of the prehabilitation modules (functional exercise training, inspiratory muscle training, psychological support, nutritional support, and/or smoking cessation). The programme is targeted at a duration of at least 6 weeks. It is executed by a multidisciplinary team using (video)calls and supported by a custom-made digital platform. During the pre-operative period, the platform is also used to inform patients about their upcoming surgery and for telemonitoring.

Conclusion

Reducing perioperative risk factors might result in a reduction of MACE, post-operative complications, length of stay, and cardiovascular risk factors, as well as improved quality of life. Cost-effectiveness will be evaluated.

Microcirculatory perfusion derangements during continuous hemofiltration with fixed dose of ultrafiltration in stabilized intensive care unit patients

INTRODUCTION

Acute kidney injury (AKI) is a well-known complication in critically ill patients. Little is known about the timing and the ultrafiltration dose after initial resuscitation. In vivo microscopy of the microcirculation has been suggested as alternative for the assessment of volume status. Previous studies contribute to the understanding that intravascular hypovolemia is reflected by microcirculatory blood flow changes not detected by conventional methods. The aim of our study was to assess microcirculatory blood flow changes during negative fluid balance ultrafiltration in patients with oliguric AKI.

MATERIALS AND METHODS

Patients with oliguric AKI on renal replacement therapy were included after hemodynamic stabilization. Target was a predefined negative fluid balance; subsequently, a stepwise decrease in amount of substitution fluid was achieved. The data were recorded at baseline and after each change.

RESULTS

Fifteen patients were included in the study. Microcirculatory blood flow index did not change significantly between baseline and endpoint (2.90 [2.87-3.00] vs 2.90 [2.75-3.00], P=.57). During treatment, heart rate decreased from 96 (80-111) to 94 (79-110) beats per minute (P=.01), without a significant change in mean arterial blood pressure (80 [68-95 mm Hg] vs 79 [65-91 mm Hg], P=.5).

CONCLUSION

Microcirculatory blood flow is not altered by reduced substitution during renal replacement therapy.