Marise Jeannine Kasteleyn

BACKGROUND Hospital healthcare is facing major challenges, including ageing, multimorbidity, rising costs, and staff shortages. This puts the delivery of high-quality healthcare under pressure. Hybrid healthcare can help alleviate current pressure on healthcare systems. Once implemented, it is essential to monitor and evaluate hybrid care. Through concept-mapping, the HHQA-model was created which covers and connects all the important aspects high-quality hybrid care needs to address. Based on the items and clusters within the model, a corresponding questionnaire has been developed. To implement the questionnaire in practice, its content should be validated. OBJECTIVE This study aimed to iteratively refine the HHQA-questionnaire by evaluating and improving its content validity, focusing on comprehensibility, relevance, and comprehensiveness from the perspective of hospital employees and client representatives. METHODS This qualitative study was iterative in nature and was performed within Zuyderland Medical Center, located in Heerlen, the Netherlands. Four group-based think-aloud sessions were organized. During these sessions, participants verbally reflected while progressing through half of the questionnaire. This was audio recorded and transcribed verbatim. Transcripts were coded and analyzed using the Framework Method, with feedback from each session returned to the questionnaire’s developer to inform iterative refinement. RESULTS The four think-aloud sessions contained a total number of thirty-one participants. Comprehensibility was refined by improving clarity through better language use and terminology ensuring each item measures a single aspect, and clarifying scope and improving item applicability. Relevance was improved by enhancing wording and clarifying the target audience of items. Comprehensiveness was generally regarded as adequate, although it was only partially assessable. Some items required rewording to better align with the cluster. Alternatives were suggested for items that did not fit their cluster. Additionally, changes to cluster titles were suggested for some clusters as they were potentially unclear or misleading. The answer options were substantially revised to bring them more in line with the item they belong to and their audience. CONCLUSIONS Relevance and comprehensiveness were assessed as reasonably good and were further improved. Even after four iterations, the comprehensibility of the questionnaire can be improved further. This is evident for both items and answer options. The reliability of the HHQA-questionnaire should be tested before implementing and testing the questionnaire in another Dutch hospital, filtering could be used to facilitate easier answering, and patients should stay part of the audience of the HHQA-questionnaire.

Background: There is growing recognition of the role of health apps in addressing health care system challenges, yet app quality and evidence vary widely, and consumers have little decision support at the point of download. Objective: This study aimed to explore which sources of recommendations European residents use and trust when choosing health apps and whether residents support government review and rating of health apps. Methods: We conducted a cross-sectional online survey (December 7, 2022, to February 16, 2023) in 26 languages targeting residents of the European Economic Area, the United Kingdom, and Ukraine. The survey contained 11 questions covering demographics, types of apps used, sources of advice used and trusted, and views on government review and rating. We included only fully completed responses (N=1228). Descriptive statistics are presented as counts and percentages. For subgroup analyses, we dichotomized trust responses (“I trust” vs other responses) and tested associations with gender (Fisher exact test), age group, and education level (chi-square test); an adjusted significance threshold was applied ( P <.004) to account for multiple testing. We followed the CHERRIES (Checklist for Reporting Results of Internet E-Surveys) guidelines for reporting online surveys and STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) recommendations for observational studies. Results: A total of 1228 respondents from 33 countries completed the survey; 1110 (90.4%) reported using one or more health apps. COVID-19 apps (763/1228, 62.1%) and activity apps (737/1228, 60.0%) were the most frequently used, whereas disease management (86/1228, 7.0%), diagnostic (77/1228, 6.3%), and treatment apps (70/1228, 5.7%) were the least used. Sources used to choose apps included family and friends (434/1228, 35.3%), health professionals (412/1228, 33.6%), and government or health authorities (358/1228, 29.2%). The most trusted sources were health professionals (987/1228, 80.4%), pharmacists (750/1228, 61.1%), and government or health authorities (736/1228, 59.9%). No statistically significant differences in trust by gender were observed (all P >.0038). Some differences by age and education were observed for select sources (eg, government or health authorities: χ ² ₁ =8.546; P =.003; family and friends: χ ² =19.133; P <.001). Overall, 1060 (86.3%) of 1228 respondents supported government review and rating of health apps (either directly or by commissioning another organization). Conclusions: In this large multilingual European survey, most respondents reported experience with health apps and placed greatest trust in health professionals, pharmacists, and government or health authorities, yet professional recommendations were used less often than informal sources. There is clear public support for government-led review and rating schemes to guide consumer choice. Efforts to make trustworthy, easy-to-find information available at the point of download and to support health care professionals in recommending high-quality apps could help bridge the gap between trusted and used sources.

Background: Digitalization in geriatric rehabilitation presents unique challenges, making it essential to align eHealth solutions with patients’ digital skills. The Quickscan Digital Skills (QDS) is a tool designed to help health care professionals match eHealth interventions to individual skill levels. Objective: This study aimed to explore the applicability of QDS by comparing it to self-reported digital skills and to gain insight into the digital skills of patients in geriatric rehabilitation. Methods: In this multicenter cross-sectional study, participants from 13 geriatric rehabilitation centers in the Netherlands completed a survey, including demographic questions, QDS, and a numeric rating scale (NRS) for self-reported digital skills. Participants were categorized into 3 skill levels (beginner, intermediate, and experienced) based on the cutoff points in QDS scores. Cutoff points were predetermined, guided by the information provided on QDS. Descriptive statistics for median age and frequencies for skill levels were calculated. Comparative analysis using a Kruskal-Wallis test assessed differences between QDS and NRS within these groups, and Spearman rank-order correlation examined the relationship between the two measures. To gain more insight into the different skill levels between groups, data were visualized and associations among age, gender, and digital skill levels were examined using ordinal logistic regression analysis. Results: A total of 463 patients (median age 78, IQR 12 years; 282/463, 60.9% female) participated in this study. Based on QDS scores, 42.1% (195/463) were classified as beginners, 19.4% (90/463) as intermediates, and 38.4% (178/463) as experienced users. A moderate positive correlation was found between QDS and NRS scores. Digital skills generally declined with age: 69.8% (37/53) of participants younger than 65 years were experienced users compared to only 13.2% (5/38) of those older than 91 years. A logistic regression analysis showed that increasing age was significantly associated with lower digital skill levels (odds ratio 0.93, 95% CI 0.92-0.95; P<.001). The association between age and digital skills does not differ between males and females. Conclusions: This study suggests that QDS is a promising and practical screening tool for assessing digital skills in patients in geriatric rehabilitation. Self-reported digital skills with an NRS do not capture the differentiation in the assessed abilities by QDS. QDS could be a practical tool for identifying digital skill levels in patients in geriatric rehabilitation and can support more personalized eHealth implementation. Further research should explore the parametric properties of QDS and how the scores relate to actual eHealth use.

BACKGROUND Digitalization in geriatric rehabilitation presents unique challenges, making it essential to align eHealth solutions with patients’ digital skills. The Quickscan Digital Skills (QDS) is a tool designed to help health care professionals match eHealth interventions to individual skill levels. OBJECTIVE This study aimed to explore the applicability of QDS by comparing it to self-reported digital skills and to gain insight into the digital skills of patients in geriatric rehabilitation. METHODS In this multicenter cross-sectional study, participants from 13 geriatric rehabilitation centers in the Netherlands completed a survey, including demographic questions, QDS, and a numeric rating scale (NRS) for self-reported digital skills. Participants were categorized into 3 skill levels (beginner, intermediate, and experienced) based on the cutoff points in QDS scores. Cutoff points were predetermined, guided by the information provided on QDS. Descriptive statistics for median age and frequencies for skill levels were calculated. Comparative analysis using a Kruskal-Wallis test assessed differences between QDS and NRS within these groups, and Spearman rank-order correlation examined the relationship between the two measures. To gain more insight into the different skill levels between groups, data were visualized and associations among age, gender, and digital skill levels were examined using ordinal logistic regression analysis. RESULTS A total of 463 patients (median age 78, IQR 12 years; 282/463, 60.9% female) participated in this study. Based on QDS scores, 42.1% (195/463) were classified as beginners, 19.4% (90/463) as intermediates, and 38.4% (178/463) as experienced users. A moderate positive correlation was found between QDS and NRS scores. Digital skills generally declined with age: 69.8% (37/53) of participants younger than 65 years were experienced users compared to only 13.2% (5/38) of those older than 91 years. A logistic regression analysis showed that increasing age was significantly associated with lower digital skill levels (odds ratio 0.93, 95% CI 0.92-0.95; P<.001). The association between age and digital skills does not differ between males and females. CONCLUSIONS This study suggests that QDS is a promising and practical screening tool for assessing digital skills in patients in geriatric rehabilitation. Self-reported digital skills with an NRS do not capture the differentiation in the assessed abilities by QDS. QDS could be a practical tool for identifying digital skill levels in patients in geriatric rehabilitation and can support more personalized eHealth implementation. Further research should explore the parametric properties of QDS and how the scores relate to actual eHealth use.

This chapter explores the integration of Digital Health into Primary Care and emphasises the need for strategic planning, readiness assessment, and overcoming barriers to adoption. It covers the key components for successful Digital Health integration, including policy support, infrastructure, financial resources, and the digital literacy of both providers and patients. The chapter highlights the importance of aligning Digital Health tools with existing workflows, ensuring compliance with regulations, and addressing technical challenges such as interoperability and infrastructure gaps. It also examines the role of education and training in preparing Primary Care providers, offering insights into curriculum development and continuous professional development programs to enhance Digital Health competencies. By addressing these factors, the chapter aims to provide a comprehensive framework for clinicians, administrators, and policymakers to navigate the digital transformation in Primary Care effectively.

Background: Chronic obstructive pulmonary disease (COPD) exacerbations cause physiological and psychological distress, affecting overall health and quality of life. Early diagnosis of exacerbations is crucial for preserving lung function, preventing hospitalizations, and reducing health care costs. While remote patient monitoring (RPM) offers the potential for early exacerbation detection, challenges remain in recognizing symptoms in a timely manner. A noninvasive breath analysis device is under development to monitor patients with COPD and detect exacerbations before symptoms arise by measuring breath biomarkers through volatile organic compounds. This study encompassed the initial cocreation phase to align the use of the breath analysis device and corresponding care process with current COPD exacerbation management and user needs. Objective: We aimed to explore perspectives on COPD care processes, exacerbation management, and RPM in the Netherlands through 3 objectives: (1) identify stakeholders in COPD exacerbation care, (2) understand existing COPD care, and (3) explore stakeholder experiences and expectations regarding RPM in COPD care. Methods: Following the Center for eHealth Research and Disease Management Roadmap, 4 research activities were conducted between March 2024 and September 2024 for the initial cocreation phase: (1) desk research, (2) interviews, (3) project group meeting, and 4) coanalysis focus group. Desk research involved reviewing literature and COPD (exacerbation) care guidelines. Semistructured interviews (N=34) were conducted with 18 patients, 14 health care professionals (HCPs), 1 caregiver, and 1 hospital policy adviser. Topics included COPD diagnosis, exacerbation management, stakeholder roles in COPD care, and RPM experiences or expectations. The project group meeting between interviews and the focus group verified interim findings and guided the focus group content. In total, 6 patients participated in a coanalysis focus group to review interview quotes on exacerbations and RPM. The framework method was used to analyze the interviews and the focus group through abductive coding. Results: Seven key stakeholders were identified in COPD care, patients, pulmonologists, general practitioners, nurse practitioners, nurse specialists, physiotherapists, and informal caregivers. We observed a lack of uniformity in COPD care, exacerbation management, and information provision across HCPs. Patients reported struggling to recognize exacerbations. Although patients with experience in RPM reported positive experiences, they questioned the added value in early detection of exacerbations. Those without RPM experience were receptive to its use for symptom tracking but were concerned about reduced in-person care and overreliance on data. HCPs reported seeing value in RPM for between-visit monitoring and efficiently allocating resources but stressed the need for clear guidelines and noted barriers, such as language proficiency and technology usability. Conclusions: This study highlights the opportunities to improve COPD care and optimize exacerbation management with RPM. Future research should refine RPM processes, balance objective data with patient-reported symptoms, enhance communication among HCPs and with patients, provide clear exacerbation management guidelines, and ensure inclusivity.

Introduction: Self-management for patients with chronic obstructive pulmonary disease (COPD) is essential in preventing relapse and rehospitalization. This study aimed to adapt a self-management-supporting digital monitoring system that was designed for COPD patients at home, to older patients with COPD and their healthcare professionals during inpatient geriatric rehabilitation. It evaluated feasibility, usability, and adherence based on qualitative and quantitative data collected across three iterations. Methods: This participatory mixed-methods study, conducted between October 2022 and June 2023, included interviews with patients and focus groups with healthcare professionals on the usability and feasibility of the system. Qualitative data were coded and analyzed using the framework method. Quantitative data from the monitoring system were descriptively analyzed. Results: Five healthcare professionals and 10 patients participated. Adjustments to the system and its use were made between iterations. Most patients used the system frequently. Insight into energy balance and health status was described as valuable features in a digital monitoring system. Other important aspects were easy initiation and use of the system and integration into the treatment program. Discussion: While the digital monitoring system and its use underwent various adaptations, further changes such as integration into the treatment program are needed for the system to be usable and feasible during geriatric rehabilitation. To transfer an eHealth intervention for home use to use during inpatient rehabilitation, substantial adaptations and time are required. Impact: This study highlights the importance of tailored digital health systems, offering guidance on implementing eHealth solutions in complex settings such as geriatric COPD rehabilitation.

BACKGROUND Chronic obstructive pulmonary disease (COPD) exacerbations cause physiological and psychological distress, affecting overall health and quality of life. Early diagnosis of exacerbations is crucial for preserving lung function, preventing hospitalizations, and reducing health care costs. While remote patient monitoring (RPM) offers the potential for early exacerbation detection, challenges remain in recognizing symptoms in a timely manner. A noninvasive breath analysis device is under development to monitor patients with COPD and detect exacerbations before symptoms arise by measuring breath biomarkers through volatile organic compounds. This study encompassed the initial cocreation phase to align the use of the breath analysis device and corresponding care process with current COPD exacerbation management and user needs. OBJECTIVE We aimed to explore perspectives on COPD care processes, exacerbation management, and RPM in the Netherlands through 3 objectives: (1) identify stakeholders in COPD exacerbation care, (2) understand existing COPD care, and (3) explore stakeholder experiences and expectations regarding RPM in COPD care. METHODS Following the Center for eHealth Research and Disease Management Roadmap, 4 research activities were conducted between March 2024 and September 2024 for the initial cocreation phase: (1) desk research, (2) interviews, (3) project group meeting, and 4) coanalysis focus group. Desk research involved reviewing literature and COPD (exacerbation) care guidelines. Semistructured interviews (N=34) were conducted with 18 patients, 14 health care professionals (HCPs), 1 caregiver, and 1 hospital policy adviser. Topics included COPD diagnosis, exacerbation management, stakeholder roles in COPD care, and RPM experiences or expectations. The project group meeting between interviews and the focus group verified interim findings and guided the focus group content. In total, 6 patients participated in a coanalysis focus group to review interview quotes on exacerbations and RPM. The framework method was used to analyze the interviews and the focus group through abductive coding. RESULTS Seven key stakeholders were identified in COPD care, patients, pulmonologists, general practitioners, nurse practitioners, nurse specialists, physiotherapists, and informal caregivers. We observed a lack of uniformity in COPD care, exacerbation management, and information provision across HCPs. Patients reported struggling to recognize exacerbations. Although patients with experience in RPM reported positive experiences, they questioned the added value in early detection of exacerbations. Those without RPM experience were receptive to its use for symptom tracking but were concerned about reduced in-person care and overreliance on data. HCPs reported seeing value in RPM for between-visit monitoring and efficiently allocating resources but stressed the need for clear guidelines and noted barriers, such as language proficiency and technology usability. CONCLUSIONS This study highlights the opportunities to improve COPD care and optimize exacerbation management with RPM. Future research should refine RPM processes, balance objective data with patient-reported symptoms, enhance communication among HCPs and with patients, provide clear exacerbation management guidelines, and ensure inclusivity.

Background: The occurrence of exacerbations has major effects on the health of people with chronic obstructive pulmonary disease (COPD). Monitoring devices that measure (vital) parameters hold promise for timely identification and treatment of exacerbations. Stakeholders’ perspectives on the use of monitoring devices are of importance for the successful development and implementation of a device. Objective: This study aimed to explore the potential use and value of a wearable monitoring bracelet (MB) for patients with COPD at high risk for exacerbation. The perspectives of health care professionals as well as patients were examined, both immediately after hospitalization and over a longer period. Furthermore, potential facilitators and barriers to the use and implementation of an MB were explored. Methods: Data for this qualitative study were collected from January to April 2023. A total of 11 participants (eg, n=6 health care professionals [HCPs], 2 patients, and 3 additional patients) participated. In total, 2 semistructured focus groups were conducted via video calls; 1 with HCPs of various professional backgrounds and 1 with patients. In addition, 3 semistructured individual interviews were held with patients. The interviews and focus groups addressed attitudes, wishes, needs, as well as factors that could either support or impede the potential MB use. Data from interviews and focus groups were coded and analyzed according to the principles of the framework method. Results: HCPs and patients both predominantly emphasized the importance of an MB in terms of promptly identifying exacerbations by detecting deviations from normal (vital) parameters, and subsequently alerting users. According to HCPs, this is how an MB should support the self-management of patients. Most participants did not anticipate major differences in value and use of an MB between the short-term and the long-term periods after hospitalization. Facilitators of the potential use and implementation of an MB that participants highlighted were ease of use and some form of support for patients in using an MB and interpreting the data. HCPs as well as patients expressed concerns about potential costs as a barrier to use and implementation. Another barrier that HCPs mentioned, was the prerequisite of digital literacy for patients to be able to interpret and react to the data from an MB. Conclusions: HCPs and patients both recognize that an MB could be beneficial and valuable to patients with COPD at high risk for exacerbation, in the short as well as the long term. In particular, they perceived value in supporting self-management of patients with COPD. Stakeholders would be able to use the obtained insights in support of the effective implementation of MBs in COPD patient care, which can potentially improve health care and the overall well-being of patients with COPD.

Background: Profound scientific evaluation of novel digital health technologies (DHTs) is key to enhance successful development and implementation. As such, we previously developed the eHealth evaluation cycle. The eHealth evaluation cycle contains 5 consecutive study phases: conceptual, development, feasibility, effectiveness, and implementation. Objective: The aim of this study is to develop a better understanding of the daily practice of the eHealth evaluation cycle. Therefore, the objectives are to conduct a structured analysis of literature data to analyze the practice of the evaluation study phases and to determine which evaluation approaches are used in which study phase of the eHealth evaluation cycle. Methods: We conducted a systematic literature search in PubMed including the MeSH term “telemedicine” in combination with a wide variety of evaluation approaches. Original peer-reviewed studies published in the year 2019 (pre-COVID-19 cohort) were included. Nonpatient-focused studies were excluded. Data on the following variables were extracted and systematically analyzed: journal, country, publication date, medical specialty, primary user, functionality, evaluation study phases, and evaluation approach. RStudio software was used to summarize the descriptive data and to perform statistical analyses. Results: We included 824 studies after 1583 titles and abstracts were screened. The majority of the evaluation studies focused on the effectiveness (impact; 304/824, 36.9%) study phase, whereas uptake (implementation; 70/824, 8.5%) received the least focus. Randomized controlled trials (RCTs; 170/899, 18.9%) were the most commonly used DHT evaluation method. Within the effectiveness (impact) study phase, RCTs were used in one-half of the studies. In the conceptual and planning phases, survey research (27/78, 35%) and interview studies (27/78, 35%) were most frequently used. The United States published the largest amount of DHT evaluation studies (304/824, 36.9%). Psychiatry and mental health (89/840, 10.6%) and cardiology (75/840, 8.9%) had the majority of studies published within the field. Conclusions: We composed the first comprehensive overview of the actual practice of implementing consecutive DHT evaluation study phases. We found that the study phases of the eHealth evaluation cycle are unequally studied and most attention is paid to the effectiveness study phase. In addition, the majority of the studies used an RCT design. However, in order to successfully develop and implement novel DHTs, stimulating equal evaluation of the sequential study phases of DHTs and selecting the right evaluation approach that fits the iterative nature of technology might be of the utmost importance.