Patients' experiences and perspectives regarding the use of digital technology to support exercise-based cardiac rehabilitation: a qualitative interview study.

Introduction: Despite the well-known benefits of exercise-based cardiac rehabilitation for the secondary prevention of cardiovascular disease, participation in cardiac rehabilitation programmes and adherence to secondary prevention recommendations remain limited. Digital technologies have the potential to address low participation and adherence but attempts at implementing digital health interventions in real-life clinical practice frequently encounter various barriers. Studies about patients' experiences and perspectives regarding the use of digital technology can assist developers, researchers and clinicians in addressing or pre-empting patient-related barriers. This study was therefore conducted to investigate the experiences and perspectives of cardiac rehabilitation patients in Austria with regard to using digital technology for physical activity and exercise. Methods: Twenty-five current and former cardiac rehabilitation patients (18 men and 7 women, age range 39 to 83) with various cardiac conditions were recruited from a clinical site in Salzburg, Austria. Semi-structured qualitative interviews were audio-recorded and transcribed verbatim. The analysis followed a descriptive phenomenological approach, applying the framework analysis method. Results: The sample was diverse, including interviewees who readily used digital devices to support their physical activity, exercise and health monitoring, and interviewees who did not. Simplicity, convenience and accessibility were highlighted as important facilitators for the use of digital technology, while annoyance with digital devices, concerns about becoming dependent on them, or simply a preference to not use digital technology were commonly stated reasons for non-use. Interviewees' views on data protection, data sharing and artificial intelligence revealed wide variations in individuals' prior knowledge and experience about these topics, and a need for greater accessibility and transparency of data protection regulation and data sharing arrangements. Discussion: These findings support the importance that is attributed to user-centred design methodologies in the conceptualisation and design of digital health interventions, and the imperative to develop solutions that are simple, accessible and that can be personalised according to the preferences and capabilities of the individual patient. Regarding data protection, data sharing and artificial intelligence, the findings indicate opportunity for information and education, as well as the need to offer patients transparency and accountability in order to build trust in digital technology and digital health interventions.

Use and perceptions of digital technology for daily life, physical activity and health information among former cardiac rehabilitation patients in Austria: A cross-sectional survey.

Objective: Digital health technologies offer great potential to improve access and adherence to cardiovascular disease secondary prevention measures such as regular physical activity (PA). However, the use and perceptions of digital technology (DT) among cardiac rehabilitation (CR) patients are not well understood. The aim of this study was therefore to explore the use of DT in former CR patients' daily lives, for PA and for health information; and to gain insight into patient perceptions of DT for PA, including barriers, facilitators and requested features. Methods: A cross-sectional postal survey was conducted between May 2022 and January 2023. Five Austrian CR centres contacted 500 former patients who had completed a phase 2 CR programme from January 2019 onwards. One-hundred seventeen patients (mean [SD] age, 69 ± 10 years, 22% female) responded. Descriptive and thematic analyses were conducted for closed and open-ended questions, respectively. Results: Results indicated high DT usage for communication and informational aspects, and to a large extent also for PA and health information seeking. Main facilitators of DT use for PA were attributed to health and behavioural monitoring. Main barriers were lack of perceived need, lack of interest and poor usability. Most frequently requested features included pulse and blood pressure measurement, step count and compatibility to other devices. Conclusions: Patients generally used and perceived DT as beneficial in daily life and for secondary prevention purposes such as PA. The survey identified facilitators, barriers and feature requests, which may inform the design and implementation of digital health interventions for CR patients.

Translation to German and linguistic validation of the Rapid Assessment of Physical Activity (RAPA) questionnaire.

PURPOSE: To produce a culturally adapted translation of the Rapid Assessment of Physical Activity (RAPA) questionnaire for German speaking Austrians and to conduct a linguistic validation of the new language version. METHODS: The original English RAPA questionnaire was translated into German for Austria and underwent an independent forward and back translation, followed by cognitive debriefing interviews with older adults aged 55 to 78 years with and without health conditions (n = 13), for linguistic validation. RESULTS: Several distinct choices were made in the translation of the RAPA questionnaire to German, including the use of colloquial terms for 'physical activity' and 'intensity'; and the decision to keep to the original examples and images of different physical activities for illustrating the intensity levels (light, moderate, vigorous) of physical activity. In cognitive debriefing, interviewees commented that some example activities for the respective intensity levels could - depending on the individual - also represent a higher or lower intensity level; and that the wording of RAPA items 4 and 5, which describe the category 'under-active regular' aerobic activity, was difficult to understand. Both issues were addressed and resolved through minor iterative modifications made during the cognitive debriefing process. CONCLUSIONS: A new version of the RAPA questionnaire in German for Austria has been produced by forward and back translation and linguistic validation. The questionnaire may now undergo psychometric evaluation.

Determinants of Physical Activity in the Cardiac Population: Protocol for a Systematic Review.

BACKGROUND: Lack of physical activity is a critical contributing risk factor to cardiovascular disease. Hence, regular physical activity is a mainstay in the primary and secondary prevention of cardiovascular disease. Despite the extensive promotion of physical activity in both primary and secondary prevention programs, including cardiac rehabilitation, physical activity levels in the cardiac population remain low. Therefore, it is crucial to understand critical determinants that influence physical activity behavior. OBJECTIVE: This study aims to deliver a systematic review of studies with collated observational data exploring the association between determinants and physical activity behavior in the target population. These new insights inform the design of future interventions targeted at lasting heart-healthy physical activity behavior in the cardiac population. METHODS: Primary studies with observational quantitative data on determinants and their association with physical activity behavior in the cardiac population will be included. Information on relevant primary studies will be retrieved from various databases, including Embase, CINAHL, MEDLINE, PsycInfo, and Web of Science Core Collection. Six reviewers will independently double-screen articles. Studies will be selected according to the prespecified inclusion and exclusion criteria. Data will be extracted and entered into suitable worksheets. The US-based National Heart, Lung, and Blood Institute's Study Quality Assessment Tool for Observational Studies will be used to assess the quality of all eligible primary studies. The results will be presented in a descriptive and narrative synthesis. If the type and quality of data are suitable, meta-analyses will be conducted. Study reporting will follow the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. RESULTS: Data collection started in September 2020, and the literature search was updated in July 2021. Data synthesis is ongoing, and the literature search will be updated in October 2022. CONCLUSIONS: This review will be valuable to relevant stakeholders, including clinicians and health care professionals, intervention developers, and decision makers in health care. It lays a comprehensive foundation for understanding the determinants of physical activity to inform the design of secondary prevention interventions relevant to the cardiac population. TRIAL REGISTRATION: PROSPERO CRD42020206637; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=206637. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/39188.

Research on Digital Technology Use in Cardiology: Bibliometric Analysis.

BACKGROUND: Digital technology uses in cardiology have become a popular research focus in recent years. However, there has been no published bibliometric report that analyzed the corresponding academic literature in order to derive key publishing trends and characteristics of this scientific area. OBJECTIVE: We used a bibliometric approach to identify and analyze the academic literature on digital technology uses in cardiology, and to unveil popular research topics, key authors, institutions, countries, and journals. We further captured the cardiovascular conditions and diagnostic tools most commonly investigated within this field. METHODS: The Web of Science electronic database was queried to identify relevant papers on digital technology uses in cardiology. Publication and citation data were acquired directly from the database. Complete bibliographic data were exported to VOSviewer, a dedicated bibliometric software package, and related to the semantic content of titles, abstracts, and keywords. A term map was constructed for findings visualization. RESULTS: The analysis was based on data from 12,529 papers. Of the top 5 most productive institutions, 4 were based in the United States. The United States was the most productive country (4224/12,529, 33.7%), followed by United Kingdom (1136/12,529, 9.1%), Germany (1067/12,529, 8.5%), China (682/12,529, 5.4%), and Italy (622/12,529, 5.0%). Cardiovascular diseases that had been frequently investigated included hypertension (152/12,529, 1.2%), atrial fibrillation (122/12,529, 1.0%), atherosclerosis (116/12,529, 0.9%), heart failure (106/12,529, 0.8%), and arterial stiffness (80/12,529, 0.6%). Recurring modalities were electrocardiography (170/12,529, 1.4%), angiography (127/12,529, 1.0%), echocardiography (127/12,529, 1.0%), digital subtraction angiography (111/12,529, 0.9%), and photoplethysmography (80/12,529, 0.6%). For a literature subset on smartphone apps and wearable devices, the Journal of Medical Internet Research (20/632, 3.2%) and other JMIR portfolio journals (51/632, 8.0%) were the major publishing venues. CONCLUSIONS: Digital technology uses in cardiology target physicians, patients, and the general public. Their functions range from assisting diagnosis, recording cardiovascular parameters, and patient education, to teaching laypersons about cardiopulmonary resuscitation. This field already has had a great impact in health care, and we anticipate continued growth.

Outpatient Cardiac Rehabilitation Closure and Home-Based Exercise Training During the First COVID-19 Lockdown in Austria: A Mixed-Methods Study.

OBJECTIVE: To assess the impact of the closure of group-based cardiac rehabilitation (CR) training during the first COVID-19 lockdown in spring 2020 on patients' physical activity, cardiorespiratory fitness, and cardiovascular risk, and to describe the patient experience of lockdown and home-based exercise training during lockdown. DESIGN: Mixed methods study. Prospectively collected post-lockdown measurements were compared to pre-lockdown medical record data. Quantitative measurements were supplemented with qualitative interviews about the patient experience during lockdown. SETTING: Outpatient CR centre in Salzburg, Austria. PARTICIPANTS: Twenty-seven patients [six female, mean (SD) age 69 (7.4) years] who attended weekly CR training sessions until the first COVID-19 lockdown in March 2020. OUTCOME MEASURES: Quantitative: exercise capacity (maximal ergometer test, submaximal ergometer training), cardiovascular risk (Framingham risk score, blood pressure, body mass index, lipids). Qualitative: individual semi-structured interviews. RESULTS: Exercise capacity had significantly reduced from pre- to post-lockdown: mean (SD) power (W) in maximal ergometry 165 (70) vs. 151 (70), p < 0.001; submaximal ergometer training 99 (40) vs. 97 (40), p = 0.038. There was no significant difference in Framingham risk score and other cardiovascular risk factors. Qualitative data showed that almost all patients had kept physically active during lockdown, but 17 (63%) said they had been unable to maintain their exercise levels, and 15 (56%) felt their cardiorespiratory fitness had deteriorated. Many patients missed the weekly CR training and the motivation and sense of community from training together with others. Several patients stated that without professional supervision they had felt less confident to carry out home-based exercise training at high intensity. CONCLUSION: This study highlights the importance of group-based supervised exercise training for patients who engage well in such a setting, and the detrimental impact of disruption to this type of CR service on physical activity levels and exercise capacity. Additionally, learning from the COVID-19 pandemic may inform the development and implementation of remote CR modalities going forward.

Health literacy interventions for secondary prevention of coronary artery disease: a scoping review.

Deficits in health literacy are common in patients with coronary artery disease (CAD), and this is associated with increased morbidity and mortality. In this scoping review, we sought to identify health literacy interventions that aimed to improve outcomes in patients with CAD, using a contemporary conceptual model that captures multiple aspects of health literacy. We searched electronic databases for studies published since 2010. Eligible were studies of interventions supporting patients with CAD to find, understand and use health information via one of the following: building social support for health; empowering people with lower health literacy; improving interaction between patients and the health system; improving health literacy capacities of clinicians or facilitating access to health services. Studies were assessed for methodological quality, and findings were analysed through qualitative synthesis. In total, 21 studies were included. Of these, 10 studies aimed to build social support for health; 6 of these were effective, including those involving partners or peers. Five studies targeted interaction between patients and the health system; four of these reported improved outcomes, including through use of teach-back. One study addressed health literacy capacities of clinicians through communication training, and two facilitated access to health services via structured follow-up-all reporting positive outcomes. Health literacy is a prerequisite for CAD patients to self-manage their health. Through use of a conceptual framework to describe health literacy interventions, we identified mechanisms by which patients can be supported to improve health outcomes. Our findings warrant integration of these interventions into routine clinical practice.

Patient-Generated Health Data (PGHD) Interoperability: An Integrative Perspective.

With advances in Digital Health (DH) tools, it has become much easier to collect, use, and share patient-generated health data (PGHD). This wealth of data could be efficiently used in monitoring and controlling chronic illnesses as well as predicting health outcome. Although integrating PGHD into clinical practice is currently in a promising stage, there are several technical challenges and usage barriers that hinder the full utilization of the PGHD potential in clinical care and research. This paper aims to address PGHD opportunities and challenges while developing the DH-Convener project to integrate PGHD into the Electronic Health Record in Austria (ELGA). Accordingly, it provides an integrative technical-clinical-user approach for developing a fully functional health ecosystem for exchanging integrated data among patients, healthcare providers, and researchers.

Physical Activity in Cardiac Rehabilitation: Towards Citizen-Centered Digital Evidence-Based Interventions.

Physical activity is a vital part of cardiac rehabilitation (CR). However, heart-healthy physical activity levels in people with cardiovascular disease drop significantly after CR. This exploratory study employs qualitative and survey methods within a co-creation approach. The aim is to understand the mechanisms of healthy behavior and habit formation in order to create a novel evidence-based (post-)rehabilitation approach that employs digital means to sustain long-term physical activity levels in people with cardiovascular disease.

Application of Big Data to Support Evidence-Based Public Health Policy Decision-Making for Hearing.

Ideally, public health policies are formulated from scientific data; however, policy-specific data are often unavailable. Big data can generate ecologically-valid, high-quality scientific evidence, and therefore has the potential to change how public health policies are formulated. Here, we discuss the use of big data for developing evidence-based hearing health policies, using data collected and analyzed with a research prototype of a data repository known as EVOTION (EVidence-based management of hearing impairments: public health pOlicy-making based on fusing big data analytics and simulaTION), to illustrate our points. Data in the repository consist of audiometric clinical data, prospective real-world data collected from hearing aids and an app, and responses to questionnaires collected for research purposes. To date, we have used the platform and a synthetic dataset to model the estimated risk of noise-induced hearing loss and have shown novel evidence of ways in which external factors influence hearing aid usage patterns. We contend that this research prototype data repository illustrates the value of using big data for policy-making by providing high-quality evidence that could be used to formulate and evaluate the impact of hearing health care policies.

Big Data for Sound Policies: Toward Evidence-Informed Hearing Health Policies.

PURPOSE: The scarcity of health care resources calls for their rational allocation, including within hearing health care. Policies define the course of action to reach specific goals such as optimal hearing health. The process of policy making can be divided into 4 steps: (a) problem identification and issue recognition, (b) policy formulation, (c) policy implementation, and (d) policy evaluation. Data and evidence, especially Big Data, can inform each of the steps of this process. Big Data can inform the macrolevel (policies that determine the general goals and actions), mesolevel (specific services and guidelines in organizations), and microlevel (clinical care) of hearing health care services. The research project EVOTION applies Big Data collection and analysis to form an evidence base for future hearing health care policies. METHOD: The EVOTION research project collects heterogeneous data both from retrospective and prospective cohorts (clinical validation) of people with hearing impairment. Retrospective data from clinical repositories in the United Kingdom and Denmark will be combined. As part of a clinical validation, over 1,000 people with hearing impairment will receive smart EVOTION hearing aids and a mobile phone application from clinics located in the United Kingdom and Greece. These clients will also complete a battery of assessments, and a subsample will also receive a smartwatch including biosensors. Big Data analytics will identify associations between client characteristics, context, and hearing aid outcomes. RESULTS: The evidence EVOTION will generate is relevant especially for the first 2 steps of the policy-making process, namely, problem identification and issue recognition, as well as policy formulation. EVOTION will inform microlevel, mesolevel, and macrolevel of hearing health care services through evidence-informed policies, clinical guidelines, and clinical care. CONCLUSION: In the future, Big Data can inform all steps of the hearing health policy-making process and all levels of hearing health care services.