Positive effects of audit and feedback on antimicrobial use in hospitalized patients limited to audited patients.

Objective: Audit and feedback is an antimicrobial stewardship (AMS) strategy, with the potential to also optimize antimicrobial use in non-audited patients. This study aimed to determine whether audit and feedback reduce antimicrobial use in both audited and non-audited patients. Design: Before-after trial with a 1-year intervention period and 2.5-year historical cohort. Setting: 750-bed community hospital in the Netherlands. Patients: All patients admitted to the urology wards during the 3.5-year study period were observed. Patients were classified as using antimicrobials if any antimicrobial was used for therapeutic reasons. Patients using antimicrobials prophylactically were excluded from measurements. Intervention: The AMS team provided audit and feedback on antimicrobial use for patients using antimicrobials for 2 days. Retrospectively, antimicrobial use and length of stay (LOS) were compared with the historical cohort. Results: Audits modified antimicrobial treatment in 52.8% of the cases. De-escalating, stopping, and switching from intravenous to oral treatment accounted for 72% of these modifications. Compared to patients from the cohort, who also used antimicrobials for 2 days, antimicrobial use decreased from 14.21 DDD/patient (95% CI, 13.08-15.34) to 11.45 DDD/patient (95% CI, 8.26-14.64; P = .047) for audited patients. Furthermore, mean LOS decreased from 7.42 days (95% CI, 6.79-8.06) to 6.13 days (95% CI, 5.38-6.89; P = .031). However, looking at all patients admitted to the urology wards, the percentage of patients using antimicrobials and total antimicrobial use remained unchanged. Conclusions: Audit and feedback reduce antimicrobial use and LOS, but only for audited patients. Positive effects are not automatically transferred to patients for whom no audits have been performed.

The Stress of Measuring Plantar Tissue Stress in People with Diabetes-Related Foot Ulcers: Biomechanical and Feasibility Findings from Two Prospective Cohort Studies.

Reducing high mechanical stress is imperative to heal diabetes-related foot ulcers. We explored the association of cumulative plantar tissue stress (CPTS) and plantar foot ulcer healing, and the feasibility of measuring CPTS, in two prospective cohort studies (Australia (AU) and The Netherlands (NL)). Both studies used multiple sensors to measure factors to determine CPTS: plantar pressures, weight-bearing activities, and adherence to offloading treatments, with thermal stress response also measured to estimate shear stress in the AU-study. The primary outcome was ulcer healing at 12 weeks. Twenty-five participants were recruited: 13 in the AU-study and 12 in the NL-study. CPTS data were complete for five participants (38%) at baseline and one (8%) during follow-up in the AU-study, and one (8%) at baseline and zero (0%) during follow-up in the NL-study. Reasons for low completion at baseline were technical issues (AU-study: 31%, NL-study: 50%), non-adherent participants (15% and 8%) or combinations (15% and 33%); and at follow-up refusal of participants (62% and 25%). These underpowered findings showed that CPTS was non-significantly lower in people who healed compared with non-healed people (457 [117; 727], 679 [312; 1327] MPa·s/day). Current feasibility of CPTS seems low, given technical challenges and non-adherence, which may reflect the burden of treating diabetes-related foot ulcers.

eHealth implementation in Europe: a scoping review on legal, ethical, financial, and technological aspects.

Background: The evolution of eHealth development has shifted from standalone tools to comprehensive digital health environments, fostering data exchange among diverse stakeholders and systems. Nevertheless, existing research and implementation frameworks have primarily emphasized technological and organizational aspects of eHealth implementation, overlooking the intricate legal, ethical, and financial considerations. It is essential to discover what legal, ethical, financial, and technological challenges should be considered to ensure successful and sustainable implementation of eHealth. Objective: This review aims to provide insights into barriers and facilitators of legal, ethical, financial, and technological aspects for successful implementation of complex eHealth technologies, which impacts multiple levels and multiple stakeholders. Methods: A scoping review was conducted by querying PubMed, Scopus, Web of Science, and ACM Digital Library (2018-2023) for studies describing the implementation process of eHealth technologies that facilitate data exchange. Studies solely reporting clinical outcomes or conducted outside Europe were excluded. Two independent reviewers selected the studies. A conceptual framework was constructed through axial and inductive coding, extracting data from literature on legal, ethical, financial, and technological aspects of eHealth implementation. This framework guided systematic extraction and interpretation. Results: The search resulted in 7.308 studies that were screened for eligibility, of which 35 (0.48%) were included. Legal barriers revolve around data confidentiality and security, necessitating clear regulatory guidelines. Ethical barriers span consent, responsibility, liability, and validation complexities, necessitating robust frameworks. Financial barriers stem from inadequate funding, requiring (commercial) partnerships and business models. Technological issues include interoperability, integration, and malfunctioning, necessitating strategies for enhancing data reliability, improving accessibility, and aligning eHealth technology with existing systems for smoother integration. Conclusions: This research highlights the multifaceted nature of eHealth implementation, encompassing legal, ethical, financial, and technological considerations. Collaborative stakeholder engagement is paramount for effective decision-making and aligns with the transition from standalone eHealth tools to integrated digital health environments. Identifying suitable stakeholders and recognizing their stakes and values enriches implementation strategies with expertise and guidance across all aspects. Future research should explore the timing of these considerations and practical solutions for regulatory compliance, funding, navigation of responsibility and liability, and business models for reimbursement strategies.

Designing a Mobile e-Coaching App for Immigrant Informal Caregivers: Qualitative Study Using the Persuasive System Design Model.

BACKGROUND: Informal caregivers are vital in caring for their family and friends at home who may have illnesses or disabilities. In particular, the demands for caregiving can be even more challenging for those with limited resources, support systems, and language barriers, such as immigrant informal caregivers. They face complex challenges in providing care for their relatives. These challenges can be related to sociocultural diversity, language barriers, and health care system navigation. Acknowledging the global context of the increasing number of immigrants is essential in designing inclusive mobile health apps. OBJECTIVE: This study aims to investigate the needs of immigrant informal caregivers in Sweden and discuss the application of the Persuasive System Design Model (PSDM) to develop an e-coaching prototype. By addressing the unique challenges faced by immigrant informal caregivers, this study will contribute to the development of more effective and inclusive mobile health apps. METHODS: The participants were considered immigrants and included in the study if they and their parents were born outside of Sweden. Through various channels, such as the National Association of Relatives, rehabilitation departments at municipalities, and immigrant groups, we recruited 13 immigrant informal caregivers. These immigrant informal caregivers were primarily women aged 18 to 40 years. Most participants belonged to the Middle Eastern region whereas some were from North Africa. However, all of them spoke Arabic. We used semistructured interviews to gather data from the participants in Arabic, which were translated into English. Data were analyzed using thematic analysis and discussed in relation to the extended PSDM. The needs of the caregivers were compared with the description of persuasive design principles, and a design principle was chosen based on the match. The PSDM was extended if the need description did not match any principles. Several brainstorming and prototyping sessions were conducted to design the mobile e-coaching app. RESULTS: Immigrant informal caregivers have various needs in their caregiving role. They reported a need for training on the illness and future caregiving needs, assistance with understanding the Swedish language and culture, and help with accessing internet-based information and services. They also required recognition and appreciation for their efforts, additional informal support, and easy access to health care services, which can be important for their mental health. The PSDM was adapted to the informal caregiving context by adding "facilitating conditions" and "verbal encouragement" as additional persuasive design principles. This study also presents the subsequent mobile e-coaching app for immigrant informal caregivers in Sweden. CONCLUSIONS: This study revealed important immigrant informal caregivers' needs based on which design suggestions for a mobile e-coaching app were presented. We also proposed an adapted PSDM, for the informal caregiving context. The adapted PSDM can be further used to design digital interventions for caregiving.

Preferences for coaching strategies in a personalized virtual coach for emotional eaters: an explorative study.

Objectives: Emotional eating is recognized as a potential contributor to weight gain. Emotional eaters often hide their problems because of feelings of shame about their behavior, making it challenging to provide them with the necessary support. The introduction of a virtual coach might offer a potential solution in assisting them. To find out whether emotional eaters are receptive to online personalized coaching, we presented emotional eaters with two essential proto-typical problem situations for emotional eaters: "experiencing cravings" and "after giving in to cravings," and asked them whether they preferred one of the three coaching strategies presented: Validating, Focus-on-Change and Dialectical. Methods: An experimental vignette study (2 × 3 design) was carried out. The vignettes featured two distinct personas, each representing one of the two common problem scenarios experienced by emotional eaters, along with three distinct coaching strategies for each scenario. To identify potential predictors for recognition of problem situations, questionnaires on emotional eating (DEBQ), personality traits (Big-5), well-being (PANAS), and BMI were administrated. Results: A total of 62% of the respondents identified themselves with "after giving in to cravings" and 47% with "experiencing cravings." BMI, emotional eating and emotional stability appeared to be predictors in recognizing both the problem situations. In "experiencing cravings," the participating women preferred Dialectical and the Validation coaching strategies. In the "after giving in to cravings" condition, they revealed a preference for the Dialectical and the Focus-on-Change coaching strategies. Conclusion: Using vignettes allowed a less threatening way of bringing up sensitive topics for emotional eaters. The personas representing the problem situations were reasonably well recognized. To further enhance this recognition, it is important for the design and content of the personas to be even more closely related to the typical problem scenarios of emotional eaters, rather than focusing on physical characteristics or social backgrounds. This way, users may be less distracted by these factors. With the knowledge gained about the predictors that may influence recognition of the problem situations, design for coaching can be more customized. The participants represented individuals with high emotional eating levels, enhancing external validity.

Understanding acceptance of contactless monitoring technology in home-based dementia care: a cross-sectional survey study among informal caregivers.

Background: There is a growing interest to support home-based dementia care via contactless monitoring (CM) technologies which do not require any body contact, and allow informal caregivers to remotely monitor the health and safety of people with dementia (PwD). However, sustainable implementation of CM technologies requires a better understanding of informal caregivers' acceptance. This study aimed to examine the (1) general acceptance of CM technology for home-based dementia care, (2) acceptance of different sensor types and use scenarios, and (3) differences between accepters and refusers of CM technology. Method: A cross-sectional online survey was conducted among n = 304 informal caregivers of community-dwelling PwD [Mean(SD) age = 58.5 (10.7)] in the Netherlands and Germany. The survey contained a textual and graphical introduction to CM technologies, as well as questions targeting (1) general acceptance of CM technology, (2) acceptance of seven different contactless sensor types, (3) acceptance of five different use scenarios, and (4) caregivers' own and their care recipients' personal characteristics. Data were examined using descriptive and bivariate analyses. Results: Participants' general acceptance of CM technology was slightly positive. We found significant differences in acceptability between contactless sensor types (p < .001). RF-based sensors (e.g., radar) and light sensors were considered most acceptable, whereas camera-based sensors and audio sensors (e.g., microphones, smart speakers) were seen as least acceptable for home-based dementia care. Furthermore, participants' acceptance of different use scenarios for CM technology varied significantly (p < .001). The intention to use CM technology was highest for detecting emergencies (e.g., falls, wandering), and lowest for predicting acute situations (e.g., fall prediction). Lastly, accepters and refusers of CM technology significantly differed regarding gender (p = .010), their relation with the PwD (p = .003), eHealth literacy (p = .025), personal innovativeness (p < .001), usage of safety technology (p = .002), and the PwD's type of cognitive impairment (p = .035) and housing situation (p = .023). Conclusion: Our findings can inform the development and implementation of acceptable CM technology to support home-based dementia care. Specifically, we show which sensor types and use scenarios should be prioritized from the informal caregiver's view. Additionally, our study highlights several personal characteristics associated with informal caregivers' acceptance of CM technology that should be taken into account during implementation.

Exploring tailored virtual emotion regulation approaches for individuals with emotional eating.

BACKGROUND: Emotional eating is a complex problem fostering obesity and resulting from maladaptive emotion regulation. Traditional behavioural weight loss interventions have shown insignificant effect. They can be improved by targeting the specific needs of individuals with emotional eating. OBJECTIVE: The current study explored a tailored online approach with the aim to positively influence affect (positive and negative) and emotion regulation by applying one of three exercises: body scan, opposite action, and positive reappraisal. DESIGN: An embedded mixed-method design (questionnaire data (t0, t1, t2) and perceived usefulness of exercises in t2) was used to evaluate the effects of a two-week online quasi-experimental pilot study. SUBJECTS/SETTING: In total, 80 participants with self-reported emotional eating difficulties (DEBQ-E; Memo = 3.48, SD = .64, range 1.62-4.92) finished baseline measurements; 15 completed the intervention. The study sample was predominantly female (95%), from 18 till 66 (Mage = 38,0 ± SD = 14.25). RESULTS: Participants reported that the exercises helped them to pay attention to their physical sensations, and to see positive aspects in negative matters. The exercises were considered difficult by the participants, with too little explanation, and dull, due to minor variation. The observed changes revealed small, and moreover, not significant improvements of the three exercises on positive and negative affect and overall emotion dysregulation. Although the quantitative results did not reach significance, the qualitative data highlighted which aspects of the tailored exercises may have contributed to mood and emotion regulation outcomes. A notable observation in the present study is the substantial dropout rate, with the number of participants decreasing from 80 at baseline (T0) to 15 at the post-intervention stage (T2). CONCLUSIONS: Future studies should identify tailored online exercises in emotion regulation skills in more detail and explore the contexts in which they are most effective in a personalized virtual coach virtual coach to be developed for individuals with emotional eating. Given the high dropout rate, more emphasis should be given to a proper presentation of the exercises, as well as more explanation of their usefulness and how to perform them.

Emotional eating is eating in response to negative emotions, and is problematic because it may lead to overweight, depression, and low self-image. People with emotional eating behaviour have difficulty regulating emotions and need mental healthcare but may feel too ashamed to seek help. Moreover, healthcare is not always available at the time of need. Our goal in this research project is to develop a virtual coach application that is available 24/7. This study examined what users of such an application would think of a series of online exercises that can help you recognize and take control of your own negative emotions. We wanted participants to tell us what they thought of the exercises. We also measured whether performing the exercises had an effect on how a person felt (well-being) and whether their skills in handling their own emotions improved.The outcome was that participants found the exercises insightful, but that completion was dull. It also revealed that the measured effects were small.

Designing and Evaluating IT Applications for Informal Caregivers: Protocol for a Scoping Review.

BACKGROUND: A growing number of informal caregivers in many countries are important for effective functioning of health care in our society. Hence, they must receive the required support and services to continue providing care. IT applications can be used to support informal caregivers in their caregiving activities. However, evidence-informed guidelines for developing such IT applications and their evaluation are scarce. Hence, this scoping review can aid researchers and designers by providing design recommendations for IT apps for caregivers and potentially improve the design of IT applications for caregivers to meet their needs better. OBJECTIVE: This study aims to describe the proposal for a scoping review of current practices and recommendations in designing and evaluating IT applications for informal caregivers. The scoping review will also discuss the opportunities and challenges in designing these IT applications. METHODS: We will use a 5-step scoping review methodology to map relevant literature published as follows: (1) identify the research question, (2) identify relevant studies, (3) select relevant studies for review, (4) chart the data from selected literature, and (5) summarize and report results. A structured search will be conducted in PubMed, Scopus, IEEE digital library, Web of Science, and ACM Digital Library databases. In addition, hand searches of reference lists and keyword searches in Google Scholar will also be conducted. Inclusion criteria will be researched (journal and conference) articles focused on IT applications designed for use by informal caregivers and study type to be qualitative studies. Two reviewers will independently identify articles for review and extract data. Conflicts will be discussed, and a third reviewer will be consulted if a consensus cannot be reached. These data will be analyzed using thematic analysis. RESULTS: The results from this scoping review will be presented in a narrative form, and additional data on study characteristics will be presented in diagrams or tabular format. Uppsala University first initiated this scoping review protocol in December 2021 as part of the European Union-funded project ENTWINE. This work was also supported by the Swedish Research Council and the Swedish Cancer Society. The results will be presented in August 2023 and will be disseminated through a report to the European Union and a peer-reviewed journal publication. In addition, the team plans to share its findings on various public platforms, including social media, blog posts, and relevant conferences and workshops. CONCLUSIONS: This is, to our knowledge, the first study to map the literature on the design and evaluation of IT applications for informal caregivers. The scoping review's results will detail the requirements, design suggestions, and user preferences, as well as the usability criteria and features of IT applications for informal caregivers. A mapping of studies could inform the design and implementation of future IT applications for informal caregivers. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/47650.

Design suggestions for a persuasive e-coaching application: A study on informal caregivers' needs.

Objective: Informal caregivers such as relatives or close friends of patients are essential for caregiving at home. However, caregiving is a complex experience that may affect the caregivers' well-being. Therefore, there is a need to provide support for caregivers, which we address in this article by proposing design suggestions for an e-coaching application. This study identifies the unmet needs of caregivers in Sweden and provides design suggestions for an e-coaching application using the persuasive system design (PSD) model. The PSD model offers a systematic approach to designing IT interventions. Methods: A qualitative research design was used, and semi-structured interviews were conducted with 13 informal caregivers from different municipalities in Sweden. A thematic analysis was performed to analyze the data. The PSD model was used to map the needs emerging from this analysis to propose design suggestions for an e-coaching application for caregivers. Results: Six needs were identified, and based on them, we proposed design suggestions for an e-coaching application using the PSD model. These unmet needs are monitoring and guidance, assistance to avail formal care services, access to practical information without being overwhelmed, feeling of community, access to informal support, and grief acceptance. The last two needs could not be mapped using the existing PSD model, resulting in an extended PSD model. Conclusion: This study revealed the important needs of informal caregivers based on which design suggestions for an e-coaching application were presented. We also proposed an adapted PSD model. This adapted PSD model can be further used for designing digital interventions in caregiving.

Implementation of eMental health technologies for informal caregivers: A multiple case study.

Introduction: Informal caregivers offer continuous unpaid support to loved ones who are unable to live independently. Providing care can be a very burdensome commitment, that heavily impacts informal caregivers' mental health. eMental health is a possible, yet challenging, solution to improve caregivers' mental health and their overall experience of caregiving. In fact, eMental health technologies often face challenges of implementation. The present work gathers knowledge on how to best deal with these challenges by collecting testimonies of implementation experts of eight eMental health technologies for informal caregivers with the aim of comparing them and extracting lessons learned. Methods: For this multiple case study, technologies were selected (through informal suggestions and independent search) according to the following inclusion criteria: they were intended for informal caregivers as main user group, were aimed at improving informal caregivers' mental wellbeing and caregiving experience and were available and running in real life settings in Europe. Ten interviews were conducted (two pilots and eight included cases). The interviewees were asked to provide a description of the technology and its aims and their implementation approach, method and frameworks used. Finally, determinants of implementation, the influence of the Covid-19 pandemic on implementation processes and lessons learned were investigated. Results: The results highlight key differences between technologies developed within academia and the industry regarding efficacy testing and use and use and choice of frameworks. Also, similarities in terms of recognized barriers such as financing are illustrated. Discussion: Possible ways to overcome main barriers and examples of best practices, such as structuring a business model and discussing tool maintenance and long-term hosting in advance, are discussed.

Implementation and User Evaluation of an eHealth Technology Platform Supporting Patients With Cardiovascular Disease in Managing Their Health After a Cardiac Event: Mixed Methods Study.

BACKGROUND: eHealth technology can help patients with cardiovascular disease adopt and maintain a healthy lifestyle by supporting self-management and offering guidance, coaching, and tailored information. However, to support patients over time, eHealth needs to blend in with their needs, treatment, and daily lives. Just as needs can differ between patients, needs can change within patients over time. To better adapt technology features to patients' needs, it is necessary to account for these changes in needs and contexts of use. OBJECTIVE: This study aimed to identify and monitor patients' needs for support from a web-based health management platform and how these needs change over time. It aimed to answer the following research questions: "How do novice and more advanced users experience an online health management platform?" "What user expectations support or hinder the adoption of an online health management platform, from a user perspective?" and "How does actual usage relate to user experiences and adoption?" METHODS: A mixed methods design was adopted. The first method involved 2 rounds of usability testing, followed by interviews, with 10 patients at 0 months (round 1) and 12 patients at 6 months (round 2). In the second method, log data were collected to describe the actual platform use. RESULTS: After starting cardiac rehabilitation, the platform was used frequently. The patients mentioned that they need to have an incentive, set goals, self-monitor their health data, and feel empowered by the platform. However, soon after the rehabilitation program stopped, use of the platform declined or patients even quit because of the lack of continued tailored or personalized advice. The reward system motivated them to log data, but most participants indicated that being healthy should be the main focus, not receiving gifts. A web-based platform is flexible, accessible, and does not have any obligations; however, it should be implemented as an addition to regular care. CONCLUSIONS: Although use of the platform declined in the longer term, patients quitting the technology did not directly indicate that the technology was not functioning well or that patients no longer focused on achieving their values. The key to success should not be user adherence to a platform but adherence to healthy lifestyle habits. Therefore, the implementation of eHealth should include the transition to a stage where patients might no longer need support from a technology platform to be independently and sustainably adherent to their healthy lifestyle habits. This emphasizes the importance of conducting multi-iterative evaluations to continuously monitor whether and how patients' needs and contexts of use change over time. Future research should focus on how this transition can be identified and monitored and how these insights can inform the design and implementation of the technology.

How Reflective Automated e-Coaching Can Help Employees Improve Their Capacity for Resilience: Mixed Methods Study.

BACKGROUND: An eHealth tool that coaches employees through the process of reflection has the potential to support employees with moderate levels of stress to increase their capacity for resilience. Most eHealth tools that include self-tracking summarize the collected data for the users. However, users need to gain a deeper understanding of the data and decide upon the next step to take through self-reflection. OBJECTIVE: In this study, we aimed to examine the perceived effectiveness of the guidance offered by an automated e-Coach during employees' self-reflection process in gaining insights into their situation and on their perceived stress and resilience capacities and the usefulness of the design elements of the e-Coach during this process. METHODS: Of the 28 participants, 14 (50%) completed the 6-week BringBalance program that allowed participants to perform reflection via four phases: identification, strategy generation, experimentation, and evaluation. Data collection consisted of log data, ecological momentary assessment (EMA) questionnaires for reflection provided by the e-Coach, in-depth interviews, and a pre- and posttest survey (including the Brief Resilience Scale and the Perceived Stress Scale). The posttest survey also asked about the utility of the elements of the e-Coach for reflection. A mixed methods approach was followed. RESULTS: Pre- and posttest scores on perceived stress and resilience were not much different among completers (no statistical test performed). The automated e-Coach did enable users to gain an understanding of factors that influenced their stress levels and capacity for resilience (identification phase) and to learn the principles of useful strategies to improve their capacity for resilience (strategy generation phase). Design elements of the e-Coach reduced the reflection process into smaller steps to re-evaluate situations and helped them to observe a trend (identification phase). However, users experienced difficulties integrating the chosen strategies into their daily life (experimentation phase). Moreover, the identified events related to stress and resilience were too specific through the guidance offered by the e-Coach (identification phase), and the events did not recur, which consequently left users unable to sufficiently practice (strategy generation phase), experiment (experimentation phase), and evaluate (evaluation phase) the techniques during meaningful events. CONCLUSIONS: Participants were able to perform self-reflection under the guidance of the automated e-Coach, which often led toward gaining new insights. To improve the reflection process, more guidance should be offered by the e-Coach that would aid employees to identify events that recur in daily life. Future research could study the effects of the suggested improvements on the quality of reflection via an automated e-Coach.

Patterns in the Use of Heart Failure Telemonitoring: Post Hoc Analysis of the e-Vita Heart Failure Trial.

BACKGROUND: Research on the use of home telemonitoring data and adherence to it can provide new insights into telemonitoring for the daily management of patients with heart failure (HF). OBJECTIVE: We described the use of a telemonitoring platform-including remote patient monitoring of blood pressure, pulse, and weight-and the use of the electronic personal health record. Patient characteristics were assessed in both adherent and nonadherent patients to weight transmissions. METHODS: We used the data of the e-Vita HF study, a 3-arm parallel randomized trial performed in stable patients with HF managed in outpatient clinics in the Netherlands. In this study, data were analyzed from the participants in the intervention arm (ie, e-Vita HF platform). Adherence to weight transmissions was defined as transmitting weight ≥3 times per week for at least 42 weeks during a year. RESULTS: Data from 150 patients (mean age 67, SD 11 years; n=37, 25% female; n=123, 82% self-assessed New York Heart Association class I-II) were analyzed. One-year adherence to weight transmissions was 74% (n=111). Patients adherent to weight transmissions were less often hospitalized for HF in the 6 months before enrollment in the study compared to those who were nonadherent (n=9, 8% vs n=9, 23%; P=.02). The percentage of patients visiting the personal health record dropped steadily over time (n=140, 93% vs n=59, 39% at one year). With univariable analyses, there was no significant correlation between patient characteristics and adherence to weight transmissions. CONCLUSIONS: Adherence to remote patient monitoring was high among stable patients with HF and best for weighing; however, adherence decreased over time. Clinical and demographic variables seem not related to adherence to transmitting weight. TRIAL REGISTRATION: ClinicalTrials.gov NCT01755988; https://clinicaltrials.gov/ct2/show/NCT01755988.

How to create value with unobtrusive monitoring technology in home-based dementia care: a multimethod study among key stakeholders.

BACKGROUND: There is a growing interest to support extended independent living of people with dementia (PwD) via unobtrusive monitoring (UM) technologies which allow caregivers to remotely monitor lifestyle, health, and safety of PwD. However, these solutions will only be viable if developers obtain a clear picture of how to create value for all relevant stakeholders involved and achieve successful implementation. The aim of this study was therefore to explore the value proposition of UM technology in home-based dementia care and preconditions for successful implementation from a multi-stakeholder perspective. METHODS: We conducted an expert-informed survey among potential stakeholders (n = 25) to identify key stakeholders for UM technology in home-based dementia care. Subsequently, focus groups and semi-structured interviews were conducted among 5 key stakeholder groups (n = 24) including informal caregivers (n = 5), home care professionals (n = 5), PwD (n = 4), directors and managers within home care (n = 4), and policy advisors within the aged care and health insurance sector (n = 6). The sessions addressed the value proposition- and business model canvas and were analyzed using thematic analysis. RESULTS: Stakeholders agreed that UM technology should provide gains such as objective surveillance, timely interventions, and prevention of unnecessary control visits, whereas pains mainly included information overload, unplannable care due to real-time monitoring, and less human interaction. The overall design-oriented need referred to clear situation classifications including urgent care (fall- and wandering detection), non-urgent care (deviations in eating, drinking, sleeping), and future care (risk predictions). Most important preconditions for successful implementation of UM technology included inter-organizational collaboration, a shared vision on re-shaping existing care processes, integrated care ICT infrastructures, clear eligibility criteria for end-users, and flexible care reimbursement systems. CONCLUSIONS: Our findings can guide the value-driven development and implementation of UM technology for home-based dementia care. Stakeholder values were mostly aligned, although stakeholders all had their own perspective on what UM technology should accomplish. Besides, our study highlights the complexity of implementing novel UM technology in home-based dementia care. To achieve successful implementation, organizational and financial preconditions, as well as digital data exchange between home care organizations, will be important.

Improving the Development and Implementation of Audit and Feedback Systems to Support Health Care Workers in Limiting Antimicrobial Resistance in the Hospital: Scoping Review.

BACKGROUND: For eHealth technologies in general and audit and feedback (AF) systems specifically, integrating interdisciplinary theoretical underpinnings is essential, as it increases the likelihood of achieving desired outcomes by ensuring a fit among eHealth technology, stakeholders, and their context. In addition, reporting on the development and implementation process of AF systems, including substantiations of choices, enables the identification of best practices and accumulation of knowledge across studies but is often not elaborated on in publications. OBJECTIVE: This scoping review aims to provide insights into the development and implementation strategies for AF systems for a real-world problem that threatens modern health care-antimicrobial resistance-and provide an interdisciplinary conceptual framework that can serve as a checklist and guidance for making informed choices in the development and implementation of future AF systems. METHODS: A scoping review was conducted by querying PubMed, Scopus, Web of Science, IEEE Xplore Digital Library, and Embase (≥2010) for studies describing either the development or implementation process, or both, of an AF system for antimicrobial resistance or infections in hospitals. Studies reporting only on effectiveness or impact were excluded. A total of 3 independent reviewers performed the study selection, and 2 reviewers constructed the conceptual framework through the axial and selective coding of often-used theories, models, and frameworks (TMFs) from the literature on AF and eHealth development and implementation. Subsequently, the conceptual framework was used for the systematic extraction and interpretation of the studies' descriptions of AF systems and their development and implementation. RESULTS: The search resulted in 2125 studies that were screened for eligibility, of which 12 (0.56%); 2012-2020) were included. These studies described the development and implementation processes heterogeneously in terms of study aims, study targets, target groups, methods, and theoretical underpinnings. Few studies have explicitly explained how choices for the development and implementation of AF systems were substantiated by the TMFs. The conceptual framework provided insights into what is reported on the development and implementation process and revealed underreported AF system constructs (eg, AF system design; engagement with the AF system; and comparison, goal setting, and action planning) and development and implementation (eg, champions) constructs. CONCLUSIONS: This scoping review showed the current heterogeneous reporting of AF systems and their development and implementation processes and exemplified how interdisciplinary TMFs can (and should) be balanced in a conceptual framework to capture relevant AF systems and development and implementation constructs. Thereby, it provides a concrete checklist and overall guidance that supports the professionalization and harmonization of AF system development and implementation. For the development and implementation of future AF systems and other eHealth technologies, researchers and health care workers should be supported in selecting and integrating TMFs into their development and implementation process and encouraged to explicitly report on theoretical underpinnings and the substantiation of choices.

Personas for Better Targeted eHealth Technologies: User-Centered Design Approach.

BACKGROUND: The full potential of eHealth technologies to support self-management and disease management for patients with chronic diseases is not being reached. A possible explanation for these lacking results is that during the development process, insufficient attention is paid to the needs, wishes, and context of the prospective end users. To overcome such issues, the user-centered design practice of creating personas is widely accepted to ensure the fit between a technology and the target group or end users throughout all phases of development. OBJECTIVE: In this study, we integrate several approaches to persona development into the Persona Approach Twente to attain a more holistic and structured approach that aligns with the iterative process of eHealth development. METHODS: In 3 steps, a secondary analysis was carried out on different parts of the data set using the Partitioning Around Medoids clustering method. First, we used health-related electronic patient record data only. Second, we added person-related data that were gathered through interviews and questionnaires. Third, we added log data. RESULTS: In the first step, 2 clusters were found, with average silhouette widths of 0.12 and 0.27. In the second step, again 2 clusters were found, with average silhouette widths of 0.08 and 0.12. In the third step, 3 clusters were identified, with average silhouette widths of 0.09, 0.12, and 0.04. CONCLUSIONS: The Persona Approach Twente is applicable for mixed types of data and allows alignment of this user-centered design method to the iterative approach of eHealth development. A variety of characteristics can be used that stretches beyond (standardized) medical and demographic measurements. Challenges lie in data quality and fitness for (quantitative) clustering.

The Visual Dictionary of Antimicrobial Stewardship, Infection Control, and Institutional Surveillance Data.

Objectives: Data and data visualization are integral parts of (clinical) decision-making in general and stewardship (antimicrobial stewardship, infection control, and institutional surveillance) in particular. However, systematic research on the use of data visualization in stewardship is lacking. This study aimed at filling this gap by creating a visual dictionary of stewardship through an assessment of data visualization (i.e., graphical representation of quantitative information) in stewardship research. Methods: A random sample of 150 data visualizations from published research articles on stewardship were assessed (excluding geographical maps and flowcharts). The visualization vocabulary (content) and design space (design elements) were combined to create a visual dictionary. Additionally, visualization errors, chart junk, and quality were assessed to identify problems in current visualizations and to provide improvement recommendations. Results: Despite a heterogeneous use of data visualization, distinct combinations of graphical elements to reflect stewardship data were identified. In general, bar (n = 54; 36.0%) and line charts (n = 42; 28.1%) were preferred visualization types. Visualization problems comprised color scheme mismatches, double y-axis, hidden data points through overlaps, and chart junk. Recommendations were derived that can help to clarify visual communication, improve color use for grouping/stratifying, improve the display of magnitude, and match visualizations to scientific standards. Conclusion: Results of this study can be used to guide data visualization creators in designing visualizations that fit the data and visual habits of the stewardship target audience. Additionally, the results can provide the basis to further expand the visual dictionary of stewardship toward more effective visualizations that improve data insights, knowledge, and clinical decision-making.

Improved outcomes in patients with diabetic foot ulcers despite of differences in baseline characteristics.

The incidence of diabetes is increasing worldwide with concomitant raising number of patients with diabetic foot disease. Diabetic foot disease treatment has received more attention in the past decades, culminating in the creation of multidisciplinary outpatient clinics, but at the same time, complexity of patients seems to have increased. The aim of this article is to study differences in patient characteristics and outcomes (ulcer healing and ulcer-free survival days) in patients with a diabetic foot ulcer in two prospective cohorts with 15 years in between. Prospective cohort study of all patients in one diabetic foot centre of expertise in 2003-2004 and 2014-2018. Clinical outcomes were determined after a follow-up period of 12 months. Outcomes were differences in baseline characteristics and comorbidities, and differences in ulcer-related outcomes between both cohorts. We included all consecutive diabetic foot ulcer patients from our centre for the period 2003-2004 (n = 79) and 2014-2018 (n = 271). Age (67.0 ± 14.3 vs. 71.6 ± 11.5, p = 0.003) and prevalence of end-stage renal disease (1.3% vs. 7.7%, p = 0.036) were significantly higher in the more recent population. The more recent population had higher healing rate (53.2% vs. 76.4%, p < 0.001), higher median ulcer-free survival days once an ulcer had healed [173 days (IQR 85.3-295.5) vs. 257.0 (IQR 157.0-318.0), p = 0.026], and fewer minor amputations (20.3% vs. 8.1%, p = 0.002). People with diabetic foot ulcers treated in 2014-2018 were older and more frequently diagnosed with ESRD, compared to this population in 2003-2004, while other characteristics were similar; ulcer-related outcomes were better.

Factors Influencing Implementation of eHealth Technologies to Support Informal Dementia Care: Umbrella Review.

BACKGROUND: The worldwide increase in community-dwelling people with dementia underscores the need for innovative eHealth technologies that aim to provide support to both patients and their informal caregivers in the home setting. However, sustainable implementation of eHealth technologies within this target group can be difficult. OBJECTIVE: The goal of this study was to gain a thorough understanding of why it is often difficult to implement eHealth technologies in practice, even though numerous technologies are designed to support people with dementia and their informal caregivers at home. In particular, our study aimed to (1) provide an overview of technologies that have been used and studied in the context of informal dementia care and (2) explore factors influencing the implementation of these technologies. METHODS: Following an umbrella review design, five different databases were searched (PubMed, PsycINFO, Medline, Scopus, and Cochrane) for (systematic) reviews. Among 2205 reviews retrieved, 21 were included in our analysis based on our screening and selection procedure. A combination of deductive and inductive thematic analyses was performed, using the Nonadoption, Abandonment, Scale-Up, Spread, and Sustainability (NASSS) framework for organizing the findings. RESULTS: We identified technologies designed to be used "by informal caregivers," "by people with dementia," and "with people with dementia." Within those groups, most of the represented technologies included, respectively: (i) devices for in-home monitoring of lifestyle, health, and safety; (ii) technologies for supporting memory, orientation, and day structure; and (iii) technologies to facilitate communication between the informal caregiver and person with dementia. Most of the identified factors influencing implementation related to the condition of dementia, characteristics of the technology, expected/perceived value of users, and characteristics of the informal caregiver. Considerably less information has been reported on factors related to the implementing organization and technology supplier, wider institutional and sociocultural context of policy and regulations, and continued adaptation of technology over time. CONCLUSIONS: Our study offers a comprehensive overview of eHealth technologies in the context of informal dementia care and contributes to gaining a better understanding of a broad range of factors influencing their implementation. Our results uncovered a knowledge gap regarding success factors for implementation related to the organizational and broader context and continuous adaptation over the long term. Although future research is needed, the current findings can help researchers and stakeholders in improving the development and implementation of eHealth technologies to support informal dementia care.

Information needs of patients with chronic diseases and their relatives for web-based advance care planning: a qualitative interview study.

BACKGROUND: Advance care planning (ACP) enables persons to identify preferences for future treatment and care, and to discuss, record and review these preferences. However, the uptake of ACP among patients with chronic diseases is relatively low. Web-based ACP programs can support patients and their relatives in ACP. However, information needs of patients and their relatives for ACP are unknown. The aim of this study is to explore information needs of patients with chronic disease and their relatives for web-based ACP. METHODS: We conducted semi-structured interviews with patients with chronic diseases and relatives at their home or at the study center. In three cases, the patient and relative were paired since they preferred to be interviewed together. We asked about information they would search for when to start with ACP, where they would search for information, what search terms they would use on the Internet, and what content and information they would consider important on an ACP website. The interviewer asked participants to clarify their responses during the interview. We used thematic analysis to analyze the interviewees' responses. RESULTS: We interviewed nine patients with different chronic diseases including amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD) and kidney diseases, and seven relatives, namely partners or (adult) children. The interviewees were aged 24 to 80 years, nine were female and seven were male. Both patients with a chronic disease and relatives mentioned comparable information needs. Many interviewees indicated they would use the Internet to search for information about ACP. Mentioned search terms were "advance care planning", "treatment plan", "disease trajectory" and names of patient associations. Information needs concerned their disease trajectory and quality of life, medical treatment decisions, practical support in arranging care, the concept of ACP and guidance in ACP, communication of treatment and care preferences, peer support of others with chronic diseases, and information for relatives. Many appreciated encouragement of their healthcare providers to take a pro-active role in ACP. CONCLUSIONS: We conclude that information needs for ACP included guidance in ACP, support in making decisions about medical treatment, and practical support in arranging care. We recommend adapting web-based ACP information to the information needs of patients and their relatives to increase its findability, uptake and usefulness.