Evaluation of a digital patient education programme in patients with coronary artery disease, a survey-based study

Evaluation of a digital patient education programme in patients with coronary artery disease, a survey-based study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of a digital patient education programme in patients with coronary artery disease, a survey-based study Anna Sandberg, Annica Ravn-Fischer, Annika Johnsson, Maria Lachonius, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4235951/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Sep, 2024 Read the published version in BMC Health Services Research → Version 1 posted 4 You are reading this latest preprint version Abstract Introduction Patient education programmes focusing on risk factor modification and lifestyle changes are well established as part of cardiac rehabilitation in patients with coronary artery disease (CAD). As participation rates are low, digital patient education programmes (DPE) are interesting alternatives to increase access. Understanding patients’ perceptions of DPE are important in terms of successful implementation in clinical practice but are not well known. Therefore, the aim of this study was to assess patients’ perceptions of using a DPE in terms of end-user acceptance and usability, perceived significance for lifestyle changes and secondary preventive goal fulfilment in patients with CAD. Methods This was a cross-sectional survey-based study. The survey was distributed to all 1625 patients with acute coronary syndrome or chronic CAD with revascularisation, who were registered users of the DPE between 2020–2022. The survey contained 64 questions about e.g., acceptance and usability, perceived significance for making lifestyle changes and secondary preventive goal fulfilment. Patients who had never logged in to the DPE received questions about their reasons for not logging in. Results A total of 366 patients (mean age: 69.1 ± 11.3 years, 20% female) completed the survey and among those 207 patients (57%) had used the DPE. Patients reported that the DPE was simple to use (80%) and improved access to healthcare (67–75%). A total of 69% of the patients were generally satisfied with the DPE, > 60% reported that the DPE increased their knowledge about secondary preventive treatment goals and approximately 60% reported having a healthy lifestyle today. On the other hand, 35% of the patients would have preferred a hospital-based education programme. Among the 159 patients (43%) who had never used the DPE, the most reported reason was a perceived need for more information about how to use the DPE (52%). Conclusions This study shows an overall high level of patient acceptance and usability of the DPE, which supports its continued development and long-term role in cardiac rehabilitation in patients with CAD. Future studies should assess associations between participation in the DPE and clinical outcomes, such as secondary preventive goal fulfilment and hospitalisation. Cardiovascular disease digital technologies distance education eHealth health care surveys health education secondary prevention telemedicine usability testing Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Introduction As early mortality for patients with acute coronary artery disease (CAD) has declined in recent years, there is a large need for effective secondary prevention strategies to further improve long-term prognosis ( 1 , 2 ). Secondary prevention provided through comprehensive cardiac rehabilitation (CR) programmes is essential to reduce the risk of mortality, recurrent cardiovascular events, and to improve health-related quality of life ( 3 , 4 ). As CR has also been found to be cost-effective ( 5 ), participation has received the highest class of recommendation and level of evidence in European guidelines and should be offered to all patients with a diagnosis of CAD ( 6 ). Multidisciplinary CR is a complex intervention that should include individual patient assessment, management and control of cardiovascular risk factors, physical activity counselling, exercise training prescription, dietary advice, psychosocial management, vocational support, and lifestyle behaviour change including patient adherence and self-management ( 7 ). Patient education programmes, as part of CR, can be defined as a planned, and patient-centered intervention that focuses on treatment, risk factor modification, and lifestyle change ( 8 ). A central part of such programmes is to promote self-care behaviour and to encourage patients to take an active part in managing their disease, aiming to improve health outcomes ( 9 ). Education programmes for patients with CAD have been shown to improve disease-related knowledge, self-reported health behaviours, and psychological outcomes ( 8 , 10 , 11 ), but with no clear effects on hospitalisations and mortality ( 10 ). Despite the beneficial effects of centre-based CR programmes, participation rates are low ( 2 , 12 ). Well-known barriers for CR-participation include e.g. a long distance to the hospital, transportation difficulties ( 13 ) and most recently the Covid-19 pandemic likely caused most centre-based CR programmes to temporarily close down. These challenges have increased the need to develop more accessible modes of CR delivery, such as digital health interventions ( 14 ). Some studies have indicated that for the secondary prevention of CAD, digital patient education programmes (DPE) may have positive effects on psychosocial outcomes, modifiable risk factors and to increase patient knowledge and satisfaction ( 15 , 16 ). There is, however, a large heterogeneity across modes of delivery and various outcomes and additionally the patients’ perceptions of DPE are not well-known ( 15 , 17 , 18 ). To understand patient acceptance and usability of digital health systems is crucial for a successful implementation into clinical practice ( 17 , 18 ). Therefore, the aim of this study was to assess the perceptions of DPE as part of CR, in terms of end-user acceptance and usability, perceived significance for lifestyle changes and secondary preventive goal fulfilment in patients with CAD. Materials and methods Design This is a cross-sectional survey-based study. The digital patient education programme The DPE was developed in 1177, the Swedish national platform for developing digital support and treatment programmes, as an alternative or adjunct to the usual care centre-based education programme. The developers consisted of participants from the CR team with multi-professional competence as well as patients and their relatives. The design of the DPE was performed in an iterative process. The DPE covers similar core content as the centre-based education programme, targeting the secondary prevention of CAD, including information about the disease and treatment, risk factors, medications, emotional responses, lifestyle recommendations such as physical activity and exercise, healthy food choices, tobacco and alcohol use. The DPE also includes education modules about the follow-up visits to the out-patient CR centre and information from the Heart- and Lung Association. Overall, the DPE consists of 13 modules including written information, short video clips and illustrations. There are also interactive functions with opportunities for patients and healthcare professionals to send messages and for patients to fill in a questionnaire (Alcohol Use Disorders Identification Test, AUDIT), the results of which are shared digitally with the healthcare professionals. Patients need to have access to the internet, basic computer skills and they are required to have a digital identification to log on to the 1177 platform. The information in the DPE is only available in Swedish. Patients had access to the DPE for 1 year. Participants and data collection procedure As part of usual care, patients with a diagnosis of CAD, including acute coronary syndromes or chronic CAD with percutaneous coronary intervention or after coronary artery bypass grafting are offered participation in an education programme as a standard component of CR, usually initiated before discharge from hospital. Participation in the DPE was followed-up during regular visits to the outpatient CR-centre after a few weeks. The DPE was launched in April 2020 and, during the Covid-19 pandemic when the centre-based education programme was put on hold, the DPE was the only available education programme alternative. All eligible patients with CAD who were registered users in the DPE between April 2020 and June 2022 at the Sahlgrenska University Hospital were contacted by mail with an invitation to participate in the study. Patients who wanted to participate in the study could answer the survey in two ways: 1) By answering the paper survey and return it together with the written consent form in a pre-paid envelope to the researchers, or 2) By answering the survey digitally and in those cases, patients gave digital informed consent. Non-responders did not receive any reminder. The study was approved by the Swedish Ethical Review Board (registration number 2022-01783-01). Survey design and content The survey was designed by a research team consisting of physiotherapists, nurses, and cardiologists, all with extensive clinical experience in CR, and one representative with expertise in developing support and treatment programmes at the 1177 platform. The aim of the survey was to assess patients' perceptions among both patients who had experience with using the DPE, and those who received access to the DPE but never logged in. Therefore, the first question asked whether the patient had logged in to the DPE (yes/no). Patients who had never logged in, received one follow-up question with predetermined reasons for not logging in and the possibility to add further reasons in free text. Patients who had logged in to the DPE received 64 questions in total about if they had completed the different DPE modules, if they found the modules interesting and the perceived significance for making lifestyle changes and secondary preventive goal fulfilment after completing the DPE. The last question provided an opportunity for patients to share additional experiences or opinions about the DPE in free text. The survey included questions concerning patients’ acceptance of using the DPE (3 questions). Those questions were designed based on clinical experience and evaluated whether patients would have preferred the traditional centre-based programme over the DPE. The survey's questions concerning usability was inspired by the Telehealth Usability Questionnaire (TUQ) that evaluates the usability of telehealth services and implementation ( 19 ). Attributes of usability include six different factors and the factor description similar to Parmanto et al. was used, to ensure internal and external validity of our instrument ( 19 ): 1. Usefulness (4 questions) refers to the patients’ perception of how the DPE functions to provide patient education similar to the traditional centre-based programme. 2. Ease of use and learnability (2 questions) deals with if the DPE was simple to use and if it was easy to learn how to use. 3. Interface quality (3 questions) handles with how pleasant the DPE was to use for the patient. 4. Interaction quality (3 questions) measures the patient’s interaction with the clinician and these questions were modified to suit the DPE (i.e. written information and videos). 5. Reliability (1 question) refers to if the DPE is as reliable as an in-person visit. 6. Satisfaction and future use (4 questions) are related to overall patient satisfaction with the DPE and how willing the patient would be to use the DPE in the future. Prior to distribution, content validity of the survey was tested by asking five experienced healthcare professionals to provide feedback and to address whether the questions measure what they intend to. They also provided feedback on whether the survey seemed to have all the questions needed for the purpose of the study. Based on their comments some of the questions were slightly modified. Face validity was tested by interviewing five patients with CAD on how they perceived the questions in the survey. No modifications needed to be made. Data analysis Demographic characteristics and survey results were presented descriptively. Continuous variables were presented with the mean and standard deviation and categorical variables were presented using frequencies and percentages. The survey mainly consisted of grading scales and in some cases, the patients were able to write a free text answer when the given answers were not applicable or to provide additional information. For the five-level grading scale questions, the patients were asked to agree or disagree on a scale from “completely disagree” to “completely agree”. For this study, answering “Completely agree” and “Strongly agree” were combined to form the category “Agree” while answering, “Completely disagree” and “Slightly disagree” were combined to form the category “Disagree”. This entails a survey result presentation with responses of agree, partially agree, disagree and not relevant. Data were analysed using SPSS version 28.0 (IBM Corp, Armonk, NY). Results The survey was distributed to 1625 patients and was completed by 366 patients (23%) of which 74 (20%) were women. The average age of the patients was 69.1 ± 11.3 years. Of the 366 responses, 207 patients (57%) responded that they had used the DPE, and 159 patients (43%) responded that they had never used the DPE. Non-users of the digital patient education programme The average age among the 159 non-users was 71.4 ± 10.6 years of which 29 patients (18%) were women. The most common reasons for not using the DPE were a perceived need of more information about how to use the DPE, n = 60 (52%), digital education was not found appealing, n = 49 (39%) and the need for more information about the purpose of the DPE, n = 44 (39%). On the other hand, 14 patients (13%) stated that not having a unique digital identification was a major reason for not using the DPE. The detailed survey result of reasons for not using the DPE are presented in Fig. 1 . Figure 2 presents additional reasons (n = 56), given in free text by the non-users. The most common reasons, given in free text, for not using the DPE were that the patients did not know about the DPE, n = 14 (25%) and that the patients forgot to participate in the DPE, n = 8 (16%). Users of the digital patient education programme The average age of the 207 patients who used the DPE was 67.3 ± 11.6 years and 46 patients (22%) were women. Perceived acceptance and usability Patient’s acceptance The survey results showed that 70 patients (35%) would have preferred to take part in a DPE at the hospital, 51 patients (26%) would have preferred the DPE as a group session and 70 patients (35%) would have preferred to participate in a DPE in real time with the possibility to ask questions to the healthcare providers (Table 1 ). Usefulness Patients stated that the DPE improved their access to healthcare services due to being able to use the DPE whenever it suited them, n = 150 (75%) and due to being able to use the DPE on several occasions, n = 132 (67%). In addition, 102 patients (52%) found that the DPE saved time by not having to travel to the hospital and 134 patients (69%) found that the DPE provided their healthcare needs (Table 1 ). Ease of use and learnability In total, 159 patients (80%) found the DPE simple to use and 161 patients (81%) found the DPE easy to learn to use (Table 1 ). Interface Quality As shown in Table 1 , most patients, n = 173 (90%) agreed that the DPE was simple and easy to understand, 100 patients (51%) liked using the DPE, and 127 patients (64%) found that the DPE did everything they would want it to do. Interaction Quality For 137 patients (70%) the written information was a good support, and 131 patients (66%) perceived the short video clips to be a good support, and 149 patients (76%) found the scope of the DPE satisfying (Table 1 ). Reliability Eighty-six patients (43%) believed that the DPE was equivalent to an in-person patient education programme (Table 1 ). Satisfaction and future use The majority of patients, n = 140 (70%) would use the DPE again, 127 patients (64%) accepted the DPE as a way of receiving healthcare services and 137 patients (69%) were generally satisfied with the DPE (Table 1 ). Table 1 Patient’s acceptance and usability factors of the digital patient education Survey questions Agree Partially agree Disagree Not relevant Patient’s acceptance of using the DPE, n (%) I would have preferred to take part in a DPE at the hospital 70 (35) 29 ( 15 ) 92 (46) 7 ( 4 ) I would have preferred the DPE as a group session 51 ( 26 ) 41 ( 21 ) 99 (50) 7 ( 4 ) I would have preferred to participate in a DPE in real time with the possibility to ask questions to the healthcare providers 70 (35) 50 ( 25 ) 71 (36) 7 ( 4 ) Usefulness, n (%) The DPE improved my access to healthcare services because I could take part when it suited me 150 (75) 23 ( 12 ) 17 ( 9 ) 10 ( 5 ) The DPE improved my access to healthcare services because I could take part on several occasions 132 (67) 36 ( 18 ) 19 ( 10 ) 11 ( 6 ) The DPE saved me time traveling to a hospital 102 (52) 40 ( 20 ) 35 ( 18 ) 20 ( 10 ) The DPE provided my healthcare needs 134 (69) 33 ( 17 ) 22 ( 11 ) 6 ( 3 ) Ease of use and learnability, n (%) It was simple to use the DPE 159 (80) 26 ( 13 ) 9 ( 5 ) 4 ( 2 ) It was easy to learn to use the DPE 161 (81) 27 ( 14 ) 8 ( 4 ) 4 ( 2 ) Interface Quality, n (%) I liked using the DPE 100 (51) 53 ( 27 ) 32 ( 16 ) 13 ( 7 ) The DPE did everything I would want it to be able to do 127 (64) 43 ( 22 ) 19 ( 10 ) 9 ( 5 ) The DPE was simple and easy to understand 173 (90) 8 ( 4 ) 6 ( 3 ) 6 ( 3 ) Interaction Quality, n (%) The written information was a good support 137 (70) 42 ( 22 ) 10 ( 5 ) 6 ( 3 ) The short video clips were a good support 131 (66) 29 ( 15 ) 20 ( 10 ) 17 ( 9 ) The scope of the DPE was satisfying 149 (76) 25 ( 13 ) 15 ( 8 ) 6 ( 3 ) Reliability, n (%) I think the DPE is the same as an in-person patient education 86 (43) 59 ( 30 ) 47 ( 24 ) 8 ( 4 ) Satisfaction and future use, n (%) I would use the DPE services again 140 (70) 27 ( 14 ) 24 ( 12 ) 9 ( 5 ) The DPE was an acceptable way to receive healthcare services 127 (64) 50 ( 25 ) 17 ( 9 ) 5 ( 3 ) In general, I am satisfied with the DPE 137 (69) 39 ( 19 ) 18 ( 9 ) 6 ( 3 ) Variables are presented as number (%). DPE, Digital patient education. Digital patient education modules of coronary artery disease, pharmacological treatment, exercise based cardiac rehabilitation, and risk factors The survey results showed that > 80% of the patients completed the DPE modules about CAD, pharmacological treatment, exercise-based cardiac rehabilitation and risk factors (Fig. 3 ) and 81–90% of the patients found these modules interesting (details not shown). Digital patient education modules about healthy lifestyle recommendations As seen in Fig. 4 , 166 patients (84%) completed the DPE module about healthy diet/nutrition and 171 patients (88%) completed the module about physical activity. A total of 82% of the patients found the module healthy diet/nutrition interesting and 87% found the physical activity module interesting (details not shown). The corresponding result for completing the modules about alcohol and tobacco use were 143 patients (74%) and 155 patients (59%), respectively (Fig. 4 ). Additionally, 65% of the patients found the alcohol use module interesting and 58% of the patients found the tobacco use module interesting (details not shown). Digital patient education modules of emotional reactions, follow-up visit at the cardiac rehabilitation outpatient clinic and the Heart- and Lung Association There were 142 patients (76%) who completed the module of emotional reactions and 70% of the patients found the module interesting. A total of 127 patients (66%) completed the module follow-up visit at the cardiac rehabilitation outpatient clinic and 81% of the patients agreed that this module was interesting. For the module Heart- and Lung Association, 101 patients (54%) completed the module and 43% of the patients found it interesting (details not shown). Knowledge of secondary prevention and healthy lifestyle As seen in Fig. 5 , > 60% of the patients agreed that the DPE increased their knowledge about treatment goals for blood pressure, hyperlipidaemia, pharmacological treatment, and exercise based cardiac rehabilitation. Regarding healthy lifestyle recommendations, 131 patients (78%) found that the DPE increased their knowledge about daily physical activity and, 109 patients (67%) agreed that the DPE increased their knowledge about recommended healthy food choices. Corresponding results for increased knowledge about alcohol use was 88 patients (62%) and 64 patients (57%) for tobacco use. However, 34 patients (30%) responded that information about tobacco and smoking cessation was irrelevant (Fig. 6 ). Motivation of making healthy lifestyle changes and having a healthy lifestyle today The survey results show that approximately 55% of the patients agreed that the DPE motivated them to make healthy lifestyle changes in terms of daily physical activity and participation in exercise based cardiac rehabilitation (Fig. 7 ). The corresponding results of healthy dietary habits was 95 patients (47%) and for alcohol use, 70 patients (35%). Regarding tobacco use, 50 patients (26%) found the DPE motivating to change behaviour, but 114 patients (59%) found the item of tobacco use irrelevant (Fig. 7 ). Figure 8 shows that about 60% of the patients agreed to have a healthy lifestyle today regarding exercise, n = 123 (61%), daily physical activity, n = 146 (72%), dietary habits, n = 126 (62%) and alcohol habits, n = 120 (59%). The corresponding result for tobacco use was 88 patients (44%), but 102 patients (51%) found tobacco use irrelevant (Fig. 8 ). Additional experiences and opinions about digital patient education In total, 90 patients (44%) gave 130 comments altogether in free text with additional experiences and opinions about the DPE. The comments were sorted into seven categories of responses. Most comments, n = 33 (25%) concerned ideas or reflections for improvement of the DPE. All categories with examples of comments are presented in Table 2 . Table 2 Free text comments of additional experiences and opinions about the digital patient education, presented by category. Category Number of comments (%) Examples of comments Ideas or reflections for improvement of the DPE 33 ( 25 ) Patients suggested that the DPE should not have time limited period of use and to add a reminder function. Patients suggested to combine the DPE with in-person education. Positive feedback for the DPE 26 ( 20 ) Patients found the DPE to be good and well developed. Patients found it positive not to have scheduled visits with a clinic. Comments related to disease knowledge and treatment options 23 ( 18 ) A few patients found the knowledge in the DPE superficial, some patients would like wider or deeper knowledge. Criticism of the DPE 19 ( 15 ) Some patients experienced that the DPE assumed that one had poor lifestyle habits and that the DPE did not inform about what to do if you already have a healthy lifestyle. Comments about the timing of the survey 12 ( 9 ) Patients thought that the DPE evaluation survey was sent a long time after they had participated in the DPE, and some found it difficult to remember details. Not used the DPE 11 ( 8 ) Patients commented that they had not used the DPE. Digital related comments 6 ( 5 ) Some patients had difficulty with the digital technology or did not appreciate having to read digitally. Comments are presented by numbers and (%). DPE, digital patient education. Discussion This survey-based study provides increased knowledge of patients’ perceptions of a DPE as part of CR, in terms of user acceptance and usability, perceived significance on healthy lifestyle changes and secondary preventive goal fulfilment in patients after having suffered an acute CAD. Digital health systems are progressing rapidly across all fields of medicine, including cardiology ( 17 ). In our study, the DPE was delivered on a web-based platform and included written information, short video clips and illustrations. Of the patients using the DPE, most (69%) were generally satisfied with the DPE, and the majority considered the DPE to be simple to use and easy to learn to use and 70% of the patients would consider using it again. These results support the long-term role and continued development of the DPE. By assessing and evaluating the usability of digital health systems, the effectiveness of both the technology and service/s offered can be improved ( 19 ) and usability evaluation is also important for a successful implementation of those systems ( 20 ). However, digital health systems may not suit all patients. Our results indicated that some patients preferred the DPE while some patients would rather have participated in the centre-based patient education programme, where you can also interact with health care professionals and other persons with CAD. A previous systematic review showed that secondary preventive e-Health programmes were mainly offered to patients with CAD who could either not attend centre-based CR or as an adjunct, rather than completely replacing centre-based patient education ( 15 ). From a person-centred perspective, it could be beneficial for accessibility to patient education in the future to offer patients both a centre-based and a digital patient education programme, or a hybrid of both, so that patients have the ability to choose the setting themselves. More research is needed to develop and evaluate the effectiveness of these different setting options. One aspect that may affect a patient’s ability to initiate or maintain positive health behaviours is health literacy. According to WHO, health literacy refers to the personal characteristics and social resources needed for individuals and communities to access, understand, appraise and use information and services to make decisions about health ( 21 ). Low health literacy levels have shown to be particularly common in individuals with cardiovascular diseases ( 22 ) and a study that evaluated CR programs and health literacy levels showed that more than 60% of patients with CAD had low levels of health literacy ( 23 ). Moreover, low health literacy is associated with poorer general health status and an increased probability of rehospitalisation and mortality ( 14 ). Health literacy may influence many aspects of our study. Our survey results of accessing and using the DPE, showed that the majority (57%) of the patients had used the DPE, although a significant percentage (43%) of the patients had not used the DPE. This result can be compared with a nationwide registry study showing that only 37% of the patients with first-time myocardial infarction attend patient education as a part of centre-based CR ( 24 ). Reasons for not using the DPE are multifaceted and need to be discussed in the light of further development and implementation of the DPE. Firstly, our results indicated that the non-users of the DPE were on average four years older than the patients using the DPE. A previous systematic review demonstrated that higher age was a predictive factor of non-participation in cardiac telerehabilitation programmes ( 25 ). This systematic review also included additional predictive factors for non-participation, such as lower education level and current smoking, which was not part of the data collection in our study ( 25 ). Secondly, our study showed that patients would have needed more information about how to use and the purpose of using the DPE. It may be hypothesised that this finding is related to the short hospital stay after an acute coronary event and that the patient receives a lot of information during this hospital admission. In the future, to increase the numbers of DPE users, adjustments to factors such as age should be explored, and healthcare professionals need to improve their delivery strategies for patient information about the DPE during admission to hospital. Moreover, previous research has shown the potential importance of email reminders and patient education about how to use a web-based intervention of lifestyle changes in patients with coronary heart disease or chronic back pain ( 26 ). These suggestions may also be a way forward to increase the number of patients using the DPE in the future. Furthermore, health literacy includes understanding and using health information ( 21 ). In our study, > 60% of the patients found that the DPE increased their knowledge about treatment goals for blood pressure, hyperlipidaemia, pharmacological treatment, and exercise based cardiac rehabilitation. These findings are in line with the results from an observational study by Williamsson et al. ( 27 ). Their study objective was to evaluate 12 weeks of center-based CR including structured patient education in patients with CAD by assessing patients CAD-related knowledge at three times; before and after 12 weeks and at 3 months follow-up. CAD knowledge was measured using the Coronary Artery Disease Education Questionnaire-2nd Version (CADE-Q-II). The authors concluded that patients with CAD who received patient education within CR showed improvements in disease-related knowledge that persisted at 3-month follow-up ( 27 ). However, our study results of increased knowledge about the treatment goals of secondary disease prevention are based on the patients' perceptions of increased knowledge and not an assessment of their actual knowledge. Integrating some kind of quiz or questionnaire in the DPE for patients to evaluate their own knowledge and for healthcare professionals to be able to assess patient knowledge may be a part of future DPE development. The promotion of adherence to pharmacologic therapies and lifestyle recommendations is an important part of cardiac rehabilitation programmes ( 7 ). However, making and maintaining lifestyle changes can be challenging. About 60% of the patients in our study reported having a healthy lifestyle today regarding exercise, daily physical activity, dietary habits, and alcohol use and, the majority of the patients were motivated by the DPE to make healthy lifestyle changes with regards to physical activity and exercise-based cardiac rehabilitation. These findings are in line with a systematic review by Ghisi et al. ( 28 ), showing that educational interventions (individual or group-based) as part of CR was associated with increased levels of physical activity, healthier dietary habits, and smoking cessation. However, any related improvement in response to cardiac symptoms, medication compliance or psychosocial well-being were more uncertain ( 28 ). In addition, a systematic review by Shi et al. ( 29 ) demonstrated that patient education about secondary prevention more than doubled the probability of adherence to physical activity guidelines at < 6 months and 6–12 months follow up in patients with coronary heart disease. The patients were three times more likely to adhere to healthy dietary advice at < 6 months and more likely to sustain this healthy behaviour at 6–12 months follow up when participated in educational interventions for secondary prevention ( 29 ). Furthermore, a Swedish nationwide registry study from 2019 demonstrated that participating in a centre-based patient education programme, as part of CR, was associated with 50% reduction of all-cause and CV mortality in patients with first-time myocardial infarction ( 24 ). Associations between participation in a DPE and similar clinical outcomes should be assessed in future studies. Strengths and limitations One strength in this study was that patients could choose to answer the survey on paper or digitally. Web-based surveys are shown to have a significantly lower response rate than paper-based surveys but on the other hand, web-based data collection has a considerable cost advantage compared with paper-based data collection ( 30 ). The survey response rate in our study was 23%, which can be compared with a cross-sectional study from Switzerland that evaluated patient hospital satisfaction with a response rate ranging from 16.1 to 80.0% ( 31 ). In addition, a survey-based study exploring patients’ opinions regarding satisfaction with telemedicine-provided care had a response rate of 5.8% ( 32 ). Suggested strategies as the use of e-mail pre-notification, email invitation and two reminders are examples of methods for increasing the response rates in web-based surveys ( 33 ). Another strength was the inclusion of open-ended questions, which provided additional information on patients’ experience of the DPE. To avoid sampling bias, all patients with CAD who were registered users of the DPE were given the opportunity to participate in the study. The current study is not without limitations. As all surveys were sent at the same time point, the time between participating and evaluating the DPE differs among the patients. A longer time interval between participation and filling out the survey may have affected patients' perceptions of the DPE. No demographic patient information was collected in this study. Data such as level of education, occupational status, or travel distance to the hospital, could have enable deeper result analysis. Conclusions This study adds new knowledge about a digital patient education programme (DPE), as part of CR, in patients with acute CAD. The survey results demonstrate overall high levels of patient acceptance and usability of the DPE, and this supports its long-term role and continued development. The majority of respondents reported that the DPE increased their knowledge about secondary preventive treatment goals and most of the patients reported having a healthy lifestyle today, which is important to reduce the risk of recurrent coronary events. Associations between participation in the DPE and clinical outcomes must however be further evaluated in future studies. Abbreviations Alcohol Use Disorders Identification Test; AUDIT, Cardiac rehabilitation; CR Coronary artery disease; CAD, Digital patient education programme; DPE, Telehealth usability questionnaire; TUQ Declarations Acknowledgements We would like to thank all the participants for their time to participate in the study. We would also like to thank Dr Kate Bramley-Moore for proofreading assistance. Authors’ contributions MB, AR-F, AJ were responsible for the conception and design of the study. MB and AJ performed the data collection. MB, AS, AR-F, AJ, ML were involved in the analysis and interpretation of data. AS and MB were responsible for the first drafts of this paper, which was revised critically by AR-F, AJ and ML. All authors read and approved the final manuscript. Funding The study was financed through funding from the Innovation Platform in Region Västra Götaland (VGRINN-957811). The funding body had no role in study design, data collection, analysis and interpretation of results, or in writing the manuscript. Open access funding was provided by the University of Gothenburg. Availability of data and materials Informed consent was not obtained for publication of patient data. Upon reasonable request, deidentified data may be available from the corresponding author. Ethical approval and consent to participate The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Swedish Ethical Review Board in Stockholm (registration number 2022-01783-01). All methods were carried out in accordance with relevant guidelines and regulations. Informed written consent was obtained from the participants before entering the study. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. References Jernberg T, Johanson P, Held C, Svennblad B, Lindback J, Wallentin L, et al. Association between adoption of evidence-based treatment and survival for patients with ST-elevation myocardial infarction. JAMA. 2011;305:1677–84. Kotseva K, De Backer G, De Bacquer D, Ryden L, Hoes A, Grobbee D, et al. 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Cochrane Database Syst Rev. 2007:CD005108. Anderson L, Brown JP, Clark AM, Dalal H, Rossau HK, Bridges C, et al. Patient education in the management of coronary heart disease. Cochrane Database Syst Rev. 2017;6:CD008895. Shi W, Ghisi GLM, Zhang L, Hyun K, Pakosh M, Gallagher R. Systematic review, meta-analysis and meta-regression to determine the effects of patient education on health behaviour change in adults diagnosed with coronary heart disease. J Clin Nurs. 2023;32:5300–27. Jernberg T, Boberg B, Bäck M. SWEDEHEART annual report 2019. Matador Kommunikation AB: 2020. Resurreccion DM, Moreno-Peral P, Gomez-Herranz M, Rubio-Valera M, Pastor L, Caldas de Almeida JM, et al. Factors associated with non-participation in and dropout from cardiac rehabilitation programmes: a systematic review of prospective cohort studies. Eur J Cardiovasc Nurs. 2019;18:38–47. Scherrenberg M, Wilhelm M, Hansen D, Voller H, Cornelissen V, Frederix I, et al. The future is now: a call for action for cardiac telerehabilitation in the COVID-19 pandemic from the secondary prevention and rehabilitation section of the European Association of Preventive Cardiology. Eur J Prev Cardiol. 2021;28:524–40. Brors G, Pettersen TR, Hansen TB, Fridlund B, Holvold LB, Lund H, et al. Modes of e-Health delivery in secondary prevention programmes for patients with coronary artery disease: a systematic review. BMC Health Serv Res. 2019;19:364. Oudkerk Pool MD, Hooglugt JQ, Schijven MP, Mulder BJM, Bouma BJ, de Winter RJ et al. Review of Digitalized Patient Education in Cardiology: A Future Ahead? Cardiology. 2021;146:263 – 71. Frederix I, Caiani EG, Dendale P, Anker S, Bax J, Böhm A, et al. ESC e-Cardiology Working Group Position Paper: Overcoming challenges in digital health implementation in cardiovascular medicine. Eur J Prev Cardiol. 2019;26:1166–77. Ramachandran HJ, Jiang Y, Teo JYC, Yeo TJ, Wang W. Technology Acceptance of Home-Based Cardiac Telerehabilitation Programs in Patients With Coronary Heart Disease: Systematic Scoping Review. J Med Internet Res. 2022;24:e34657. Parmanto B, Lewis AN Jr., Graham KM, Bertolet MH. Development of the Telehealth Usability Questionnaire (TUQ). Int J Telerehabil. 2016;8:3–10. Khajouei R, Farahani F. A combination of two methods for evaluating the usability of a hospital information system. BMC Med Inf Decis Mak. 2020;20:84. Dodson SBA, Batterham RW, Osborne RH. November. Information Sheet 1 in The Health Literacy Toolkit for Low- and Middle-Income Countries. Information sheet 1: What is health literacy? In Ophelia Toolkit: A step-by-step guide for identifying and responding to health literacy needs within local communities. Part A: Introduction to health literacy: WHO; 2014. https://iris.who.int/bitstream/handle/10665/205244/B5148.pdf?sequence=1 . Accessed 16 2023. Diederichs C, Jordan S, Domanska O, Neuhauser H. Health literacy in men and women with cardiovascular diseases and its association with the use of health care services - Results from the population-based GEDA2014/2015-EHIS survey in Germany. PLoS ONE. 2018;13:e0208303. Machado B, Fernandes A, Cruzeiro S, Jesus R, Araújo N, Araújo I. Cardiac rehabilitation program and health literacy levels: A cross-sectional, descriptive study. Nurs Health Sci. 2019;21:406–12. Wallert J, Olsson EM, Pingel R, Norlund F, Leosdottir M, Burell G, et al. Attending Heart School and long-term outcome after myocardial infarction: A decennial SWEDEHEART registry study. Eur J Prev Cardiol. 2020;27:145–54. Brouwers RWM, Brini A, Kuijpers R, Kraal JJ, Kemps HMC. Predictors of non-participation in a cardiac telerehabilitation programme: a prospective analysis. Eur Heart J Digit Health. 2022;3:81–9. Schweier R, Romppel M, Richter C, Grande G. Dissemination strategies and adherence predictors for web-based interventions-how efficient are patient education sessions and email reminders? Health Educ Res. 2016;31:384–94. Williamson TM, Rouleau CR, Aggarwal SG, Arena R, Hauer T, Campbell TS. The impact of patient education on knowledge, attitudes, and cardiac rehabilitation attendance among patients with coronary artery disease. Patient Educ Couns. 2021;104:2969–78. Ghisi GL, Abdallah F, Grace SL, Thomas S, Oh P. A systematic review of patient education in cardiac patients: do they increase knowledge and promote health behavior change? Patient Educ Couns. 2014;95:160–74. Shi W, Ghisi GLM, Zhang L, Hyun K, Pakosh M, Gallagher R. Systematic review, meta-analysis and meta-regression to determine the effects of patient education on health behaviour change in adults diagnosed with coronary heart disease. J Clin Nurs. 2022. Braekman E, Demarest S, Charafeddine R, Drieskens S, Berete F, Gisle L, et al. Unit Response and Costs in Web Versus Face-To-Face Data Collection: Comparison of Two Cross-sectional Health Surveys. J Med Internet Res. 2022;24:e26299. Perneger TV, Peytremann-Bridevaux I, Combescure C. Patient satisfaction and survey response in 717 hospital surveys in Switzerland: a cross-sectional study. BMC Health Serv Res. 2020;20:158. Rockler Meurling C, Adell E, Wolff M, Calling S, Milos Nymberg V. Borgström Bolmsjö B. Telemedicine in Swedish primary health care - a web-based survey exploring patient satisfaction. BMC Health Serv Res. 2023;23:129. Sammut R, Griscti O, Norman IJ. Strategies to improve response rates to web surveys: A literature review. Int J Stud Nurs. 2021;123:104058. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 02 Sep, 2024 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 11 Apr, 2024 Submission checks completed at journal 08 Apr, 2024 Editor assigned by journal 08 Apr, 2024 First submitted to journal 08 Apr, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4235951","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":289065481,"identity":"15d84459-09bd-4a96-a81e-aad610376e48","order_by":0,"name":"Anna Sandberg","email":"","orcid":"","institution":"Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg","correspondingAuthor":false,"prefix":"","firstName":"Anna","middleName":"","lastName":"Sandberg","suffix":""},{"id":289065482,"identity":"1f8a2052-bc50-4cc2-a9a0-212c0541d105","order_by":1,"name":"Annica Ravn-Fischer","email":"","orcid":"","institution":"Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg","correspondingAuthor":false,"prefix":"","firstName":"Annica","middleName":"","lastName":"Ravn-Fischer","suffix":""},{"id":289065483,"identity":"473e4aa4-79ee-478a-8394-1ccb89f4454a","order_by":2,"name":"Annika Johnsson","email":"","orcid":"","institution":"Center for Digital Health, Sahlgrenska University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Annika","middleName":"","lastName":"Johnsson","suffix":""},{"id":289065484,"identity":"188a0876-ff12-4507-bb32-11e8faf8bc07","order_by":3,"name":"Maria Lachonius","email":"","orcid":"","institution":"Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"","lastName":"Lachonius","suffix":""},{"id":289065485,"identity":"8103f4e1-22bb-4dcf-b775-009217fbc072","order_by":4,"name":"Maria Bäck","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxklEQVRIiWNgGAWjYJCCA2DEw3yAZC1sCaRaxMNjQJxa3fazDw/8YLgjz99z5vNrHoY6OYJazM6kGxzsYXhmOONs7zZrHobDxoS1HEhjOABUybiBn3ebMQ/DgcQGglrOP2M4+IfhsP0Gfp5nQC119YS13EhjOAy0JXEDbw/zYx4G5gTCDrvxjOGwjMGz5BlnjpkxzjE4bEiEw9KYP76puGPb35P8+MObijp5grZAACRG2CQYiIwaOGD+QKKGUTAKRsEoGCEAAKUaPySr5JSTAAAAAElFTkSuQmCC","orcid":"","institution":"Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg","correspondingAuthor":true,"prefix":"","firstName":"Maria","middleName":"","lastName":"Bäck","suffix":""}],"badges":[],"createdAt":"2024-04-08 11:14:37","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4235951/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4235951/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-024-11374-5","type":"published","date":"2024-09-02T15:57:40+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":54864819,"identity":"245fce65-1e26-49f1-a816-88bb925a3b2a","added_by":"auto","created_at":"2024-04-17 20:40:32","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":224756,"visible":true,"origin":"","legend":"\u003cp\u003ePresentation of the predetermined reasons for not using the digital patient education\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4235951/v1/f7f5406640fb821bdc6b8680.jpg"},{"id":54865821,"identity":"14477e8a-8268-47e9-9791-f305278ef974","added_by":"auto","created_at":"2024-04-17 20:48:31","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":153903,"visible":true,"origin":"","legend":"\u003cp\u003ePresentation of categorised reasons given in free text for not using the digital patient education. The category “other reasons” include, i.e. visual impairment, moving to another city or not feeling well among others.\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4235951/v1/2d191371699d1887fe1534c9.jpg"},{"id":54864818,"identity":"7d321221-1a66-4c8b-a928-d58d451719ec","added_by":"auto","created_at":"2024-04-17 20:40:32","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":156000,"visible":true,"origin":"","legend":"\u003cp\u003ePresentation of patients completing the digital patient educational modules about coronary artery disease, pharmacological treatment, exercise-based cardiac rehabilitation, and risk factors\u003c/p\u003e","description":"","filename":"Picture3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4235951/v1/072a89f9fb415ccca54f5b71.jpg"},{"id":54864821,"identity":"1bf96456-3ba8-4d5b-953a-f22c5f5e0611","added_by":"auto","created_at":"2024-04-17 20:40:32","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":151241,"visible":true,"origin":"","legend":"\u003cp\u003ePresentation of patients completing the digital patient educational modules about healthy lifestyle recommendations\u003c/p\u003e","description":"","filename":"Picture4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4235951/v1/a825433005528f36081ee908.jpg"},{"id":54864822,"identity":"833b5564-4a54-4ebb-9d7d-6a9217b34d15","added_by":"auto","created_at":"2024-04-17 20:40:32","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":140738,"visible":true,"origin":"","legend":"\u003cp\u003eProportion of patients who found that the digital patient education had increased their knowledge about treatment goal regarding blood pressure, hyperlipidaemia, pharmacological treatment and exercise-based cardiac rehabilitation\u003c/p\u003e","description":"","filename":"Picture5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4235951/v1/f151f70600ae5a9f8b5120c5.jpg"},{"id":54864825,"identity":"e7f8ccc3-4dc7-464f-90e5-1e0235d8a62d","added_by":"auto","created_at":"2024-04-17 20:40:32","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":136906,"visible":true,"origin":"","legend":"\u003cp\u003eProportions of patients who found that the digital patient education had increased their knowledge about factors of a healthy lifestyle including daily physical activity, dietary habits, use of tobacco and alcohol\u003c/p\u003e","description":"","filename":"Picture6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4235951/v1/8a12450e0591cbe4d85bc8c4.jpg"},{"id":54864823,"identity":"67649c5c-0d70-45bb-b7fa-85fbd7f55a7d","added_by":"auto","created_at":"2024-04-17 20:40:32","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":153187,"visible":true,"origin":"","legend":"\u003cp\u003eProportion of patients who agreed that the digital patient education had motivated them to make significant healthy lifestyle changes regarding exercise-based cardiac rehabilitation, daily physical activity, dietary habits, alcohol habits and tobacco use\u003c/p\u003e","description":"","filename":"Picture7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4235951/v1/56dcaff5c4e5e8ed54259e8b.jpg"},{"id":54864824,"identity":"cb53ab9c-ecb2-4d9d-b871-9b32e37984ae","added_by":"auto","created_at":"2024-04-17 20:40:32","extension":"jpg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":157373,"visible":true,"origin":"","legend":"\u003cp\u003eProportion of patients who have a healthy lifestyle regarding physical exercise, daily physical activity, dietary habits, alcohol habits and tobacco use\u003c/p\u003e","description":"","filename":"Picture8.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4235951/v1/be5cbaa8979fbb895cfac911.jpg"},{"id":64185940,"identity":"28f1f566-ac19-4163-999b-6c3131634d3c","added_by":"auto","created_at":"2024-09-09 16:23:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2146145,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4235951/v1/8c9c3358-d807-4ed7-9315-144af346c515.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of a digital patient education programme in patients with coronary artery disease, a survey-based study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAs early mortality for patients with acute coronary artery disease (CAD) has declined in recent years, there is a large need for effective secondary prevention strategies to further improve long-term prognosis (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Secondary prevention provided through comprehensive cardiac rehabilitation (CR) programmes is essential to reduce the risk of mortality, recurrent cardiovascular events, and to improve health-related quality of life (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). As CR has also been found to be cost-effective (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), participation has received the highest class of recommendation and level of evidence in European guidelines and should be offered to all patients with a diagnosis of CAD (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Multidisciplinary CR is a complex intervention that should include individual patient assessment, management and control of cardiovascular risk factors, physical activity counselling, exercise training prescription, dietary advice, psychosocial management, vocational support, and lifestyle behaviour change including patient adherence and self-management (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePatient education programmes, as part of CR, can be defined as a planned, and patient-centered intervention that focuses on treatment, risk factor modification, and lifestyle change (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). A central part of such programmes is to promote self-care behaviour and to encourage patients to take an active part in managing their disease, aiming to improve health outcomes (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Education programmes for patients with CAD have been shown to improve disease-related knowledge, self-reported health behaviours, and psychological outcomes (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), but with no clear effects on hospitalisations and mortality (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite the beneficial effects of centre-based CR programmes, participation rates are low (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Well-known barriers for CR-participation include e.g. a long distance to the hospital, transportation difficulties (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) and most recently the Covid-19 pandemic likely caused most centre-based CR programmes to temporarily close down. These challenges have increased the need to develop more accessible modes of CR delivery, such as digital health interventions (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Some studies have indicated that for the secondary prevention of CAD, digital patient education programmes (DPE) may have positive effects on psychosocial outcomes, modifiable risk factors and to increase patient knowledge and satisfaction (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). There is, however, a large heterogeneity across modes of delivery and various outcomes and additionally the patients\u0026rsquo; perceptions of DPE are not well-known (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). To understand patient acceptance and usability of digital health systems is crucial for a successful implementation into clinical practice (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Therefore, the aim of this study was to assess the perceptions of DPE as part of CR, in terms of end-user acceptance and usability, perceived significance for lifestyle changes and secondary preventive goal fulfilment in patients with CAD.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eDesign\u003c/h2\u003e\n \u003cp\u003eThis is a cross-sectional survey-based study.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003eThe digital patient education programme\u003c/h2\u003e\n \u003cp\u003eThe DPE was developed in 1177, the Swedish national platform for developing digital support and treatment programmes, as an alternative or adjunct to the usual care centre-based education programme. The developers consisted of participants from the CR team with multi-professional competence as well as patients and their relatives. The design of the DPE was performed in an iterative process. The DPE covers similar core content as the centre-based education programme, targeting the secondary prevention of CAD, including information about the disease and treatment, risk factors, medications, emotional responses, lifestyle recommendations such as physical activity and exercise, healthy food choices, tobacco and alcohol use. The DPE also includes education modules about the follow-up visits to the out-patient CR centre and information from the Heart- and Lung Association. Overall, the DPE consists of 13 modules including written information, short video clips and illustrations. There are also interactive functions with opportunities for patients and healthcare professionals to send messages and for patients to fill in a questionnaire (Alcohol Use Disorders Identification Test, AUDIT), the results of which are shared digitally with the healthcare professionals. Patients need to have access to the internet, basic computer skills and they are required to have a digital identification to log on to the 1177 platform. The information in the DPE is only available in Swedish. Patients had access to the DPE for 1 year.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eParticipants and data collection procedure\u003c/h2\u003e\n \u003cp\u003eAs part of usual care, patients with a diagnosis of CAD, including acute coronary syndromes or chronic CAD with percutaneous coronary intervention or after coronary artery bypass grafting are offered participation in an education programme as a standard component of CR, usually initiated before discharge from hospital. Participation in the DPE was followed-up during regular visits to the outpatient CR-centre after a few weeks. The DPE was launched in April 2020 and, during the Covid-19 pandemic when the centre-based education programme was put on hold, the DPE was the only available education programme alternative. All eligible patients with CAD who were registered users in the DPE between April 2020 and June 2022 at the Sahlgrenska University Hospital were contacted by mail with an invitation to participate in the study. Patients who wanted to participate in the study could answer the survey in two ways: 1) By answering the paper survey and return it together with the written consent form in a pre-paid envelope to the researchers, or 2) By answering the survey digitally and in those cases, patients gave digital informed consent. Non-responders did not receive any reminder. The study was approved by the Swedish Ethical Review Board (registration number 2022-01783-01).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003eSurvey design and content\u003c/h2\u003e\n \u003cp\u003eThe survey was designed by a research team consisting of physiotherapists, nurses, and cardiologists, all with extensive clinical experience in CR, and one representative with expertise in developing support and treatment programmes at the 1177 platform.\u003c/p\u003e\n \u003cp\u003eThe aim of the survey was to assess patients\u0026apos; perceptions among both patients who had experience with using the DPE, and those who received access to the DPE but never logged in. Therefore, the first question asked whether the patient had logged in to the DPE (yes/no). Patients who had never logged in, received one follow-up question with predetermined reasons for not logging in and the possibility to add further reasons in free text. Patients who had logged in to the DPE received 64 questions in total about if they had completed the different DPE modules, if they found the modules interesting and the perceived significance for making lifestyle changes and secondary preventive goal fulfilment after completing the DPE. The last question provided an opportunity for patients to share additional experiences or opinions about the DPE in free text.\u003c/p\u003e\n \u003cp\u003eThe survey included questions concerning \u003cem\u003epatients\u0026rsquo; acceptance of using the DPE\u003c/em\u003e (3 questions). Those questions were designed based on clinical experience and evaluated whether patients would have preferred the traditional centre-based programme over the DPE. The survey\u0026apos;s questions concerning \u003cem\u003eusability\u003c/em\u003e was inspired by the Telehealth Usability Questionnaire (TUQ) that evaluates the usability of telehealth services and implementation (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e). Attributes of usability include six different factors and the factor description similar to Parmanto et al. was used, to ensure internal and external validity of our instrument (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e):\u003c/p\u003e\u003cspan\u003e\n \u003cp\u003e\u003cem\u003e1. Usefulness\u003c/em\u003e (4 questions) refers to the patients\u0026rsquo; perception of how the DPE functions to provide patient education similar to the traditional centre-based programme.\u003c/p\u003e\n \u003c/span\u003e \u003cspan\u003e\n \u003cp\u003e\u003cem\u003e2. Ease of use and learnability\u003c/em\u003e (2 questions) deals with if the DPE was simple to use and if it was easy to learn how to use.\u003c/p\u003e\n \u003c/span\u003e \u003cspan\u003e\n \u003cp\u003e\u003cem\u003e3. Interface quality\u003c/em\u003e (3 questions) handles with how pleasant the DPE was to use for the patient.\u003c/p\u003e\n \u003c/span\u003e \u003cspan\u003e\n \u003cp\u003e\u003cem\u003e4. Interaction quality\u003c/em\u003e (3 questions) measures the patient\u0026rsquo;s interaction with the clinician and these questions were modified to suit the DPE (i.e. written information and videos).\u003c/p\u003e\n \u003c/span\u003e \u003cspan\u003e\n \u003cp\u003e\u003cem\u003e5. Reliability\u003c/em\u003e (1 question) refers to if the DPE is as reliable as an in-person visit.\u003c/p\u003e\n \u003c/span\u003e \u003cspan\u003e\n \u003cp\u003e\u003cem\u003e6. Satisfaction and future use\u003c/em\u003e (4 questions) are related to overall patient satisfaction with the DPE and how willing the patient would be to use the DPE in the future.\u003c/p\u003e\n \u003c/span\u003e\n \u003cp\u003ePrior to distribution, content validity of the survey was tested by asking five experienced healthcare professionals to provide feedback and to address whether the questions measure what they intend to. They also provided feedback on whether the survey seemed to have all the questions needed for the purpose of the study. Based on their comments some of the questions were slightly modified. Face validity was tested by interviewing five patients with CAD on how they perceived the questions in the survey. No modifications needed to be made.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003eData analysis\u003c/h2\u003e\n \u003cp\u003eDemographic characteristics and survey results were presented descriptively. Continuous variables were presented with the mean and standard deviation and categorical variables were presented using frequencies and percentages. The survey mainly consisted of grading scales and in some cases, the patients were able to write a free text answer when the given answers were not applicable or to provide additional information. For the five-level grading scale questions, the patients were asked to agree or disagree on a scale from \u0026ldquo;completely disagree\u0026rdquo; to \u0026ldquo;completely agree\u0026rdquo;. For this study, answering \u0026ldquo;Completely agree\u0026rdquo; and \u0026ldquo;Strongly agree\u0026rdquo; were combined to form the category \u0026ldquo;Agree\u0026rdquo; while answering, \u0026ldquo;Completely disagree\u0026rdquo; and \u0026ldquo;Slightly disagree\u0026rdquo; were combined to form the category \u0026ldquo;Disagree\u0026rdquo;. This entails a survey result presentation with responses of agree, partially agree, disagree and not relevant. Data were analysed using SPSS version 28.0 (IBM Corp, Armonk, NY).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe survey was distributed to 1625 patients and was completed by 366 patients (23%) of which 74 (20%) were women. The average age of the patients was 69.1\u0026thinsp;\u0026plusmn;\u0026thinsp;11.3 years. Of the 366 responses, 207 patients (57%) responded that they had used the DPE, and 159 patients (43%) responded that they had never used the DPE.\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003eNon-users of the digital patient education programme\u003c/b\u003e\u003c/h2\u003e \u003cp\u003eThe average age among the 159 non-users was 71.4\u0026thinsp;\u0026plusmn;\u0026thinsp;10.6 years of which 29 patients (18%) were women. The most common reasons for not using the DPE were a perceived need of more information about how to use the DPE, n\u0026thinsp;=\u0026thinsp;60 (52%), digital education was not found appealing, n\u0026thinsp;=\u0026thinsp;49 (39%) and the need for more information about the purpose of the DPE, n\u0026thinsp;=\u0026thinsp;44 (39%). On the other hand, 14 patients (13%) stated that not having a unique digital identification was a major reason for not using the DPE. The detailed survey result of reasons for not using the DPE are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents additional reasons (n\u0026thinsp;=\u0026thinsp;56), given in free text by the non-users. The most common reasons, given in free text, for not using the DPE were that the patients did not know about the DPE, n\u0026thinsp;=\u0026thinsp;14 (25%) and that the patients forgot to participate in the DPE, n\u0026thinsp;=\u0026thinsp;8 (16%).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eUsers of the digital patient education programme\u003c/h2\u003e \u003cp\u003eThe average age of the 207 patients who used the DPE was 67.3\u0026thinsp;\u0026plusmn;\u0026thinsp;11.6 years and 46 patients (22%) were women.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePerceived acceptance and usability\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003ePatient\u0026rsquo;s acceptance\u003c/h2\u003e \u003cp\u003eThe survey results showed that 70 patients (35%) would have preferred to take part in a DPE at the hospital, 51 patients (26%) would have preferred the DPE as a group session and 70 patients (35%) would have preferred to participate in a DPE in real time with the possibility to ask questions to the healthcare providers (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eUsefulness\u003c/h2\u003e \u003cp\u003ePatients stated that the DPE improved their access to healthcare services due to being able to use the DPE whenever it suited them, n\u0026thinsp;=\u0026thinsp;150 (75%) and due to being able to use the DPE on several occasions, n\u0026thinsp;=\u0026thinsp;132 (67%). In addition, 102 patients (52%) found that the DPE saved time by not having to travel to the hospital and 134 patients (69%) found that the DPE provided their healthcare needs (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eEase of use and learnability\u003c/h2\u003e \u003cp\u003eIn total, 159 patients (80%) found the DPE simple to use and 161 patients (81%) found the DPE easy to learn to use (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eInterface Quality\u003c/h2\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, most patients, n\u0026thinsp;=\u0026thinsp;173 (90%) agreed that the DPE was simple and easy to understand, 100 patients (51%) liked using the DPE, and 127 patients (64%) found that the DPE did everything they would want it to do.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eInteraction Quality\u003c/h2\u003e \u003cp\u003eFor 137 patients (70%) the written information was a good support, and 131 patients (66%) perceived the short video clips to be a good support, and 149 patients (76%) found the scope of the DPE satisfying (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eReliability\u003c/h2\u003e \u003cp\u003eEighty-six patients (43%) believed that the DPE was equivalent to an in-person patient education programme (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eSatisfaction and future use\u003c/h2\u003e \u003cp\u003eThe majority of patients, n\u0026thinsp;=\u0026thinsp;140 (70%) would use the DPE again, 127 patients (64%) accepted the DPE as a way of receiving healthcare services and 137 patients (69%) were generally satisfied with the DPE (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient\u0026rsquo;s acceptance and usability factors of the digital patient education\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurvey questions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePartially agree\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDisagree\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot relevant\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient\u0026rsquo;s acceptance of using the DPE, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI would have preferred to take part in a DPE at the hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70 (35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e92 (46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI would have preferred the DPE as a group session\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51 (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e99 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI would have preferred to participate in a DPE in real time with the possibility to ask questions to the healthcare providers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70 (35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e71 (36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUsefulness, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe DPE improved my access to healthcare services because I could take part when it \u003cem\u003esuited me\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e150 (75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe DPE improved my access to healthcare services because I could take part on \u003cem\u003eseveral occasions\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e132 (67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe DPE saved me time traveling to a hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e102 (52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe DPE provided my healthcare needs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e134 (69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEase of use and learnability, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIt was simple to use the DPE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e159 (80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIt was easy to learn to use the DPE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e161 (81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInterface Quality, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI liked using the DPE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100 (51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe DPE did everything I would want it to be able to do\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e127 (64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe DPE was simple and easy to understand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e173 (90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInteraction Quality, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe written information was a good support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e137 (70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe short video clips were a good support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e131 (66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe scope of the DPE was satisfying\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e149 (76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReliability, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI think the DPE is the same as an in-person patient education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86 (43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47 (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSatisfaction and future use, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI would use the DPE services again\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e140 (70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe DPE was an acceptable way to receive healthcare services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e127 (64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn general, I am satisfied with the DPE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e137 (69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eVariables are presented as number (%). DPE, Digital patient education.\u003c/p\u003e \u003cp\u003e \u003cb\u003eDigital patient education modules of coronary artery disease, pharmacological treatment, exercise based cardiac rehabilitation, and risk factors\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe survey results showed that \u0026gt;\u0026thinsp;80% of the patients completed the DPE modules about CAD, pharmacological treatment, exercise-based cardiac rehabilitation and risk factors (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) and 81\u0026ndash;90% of the patients found these modules interesting (details not shown).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eDigital patient education modules about healthy lifestyle recommendations\u003c/h2\u003e \u003cp\u003eAs seen in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, 166 patients (84%) completed the DPE module about healthy diet/nutrition and 171 patients (88%) completed the module about physical activity. A total of 82% of the patients found the module healthy diet/nutrition interesting and 87% found the physical activity module interesting (details not shown). The corresponding result for completing the modules about alcohol and tobacco use were 143 patients (74%) and 155 patients (59%), respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Additionally, 65% of the patients found the alcohol use module interesting and 58% of the patients found the tobacco use module interesting (details not shown).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eDigital patient education modules of emotional reactions, follow-up visit at the cardiac rehabilitation outpatient clinic and the Heart- and Lung Association\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThere were 142 patients (76%) who completed the module of emotional reactions and 70% of the patients found the module interesting. A total of 127 patients (66%) completed the module follow-up visit at the cardiac rehabilitation outpatient clinic and 81% of the patients agreed that this module was interesting. For the module Heart- and Lung Association, 101 patients (54%) completed the module and 43% of the patients found it interesting (details not shown).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge of secondary prevention and healthy lifestyle\u003c/h2\u003e \u003cp\u003eAs seen in Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, \u0026gt; 60% of the patients agreed that the DPE increased their knowledge about treatment goals for blood pressure, hyperlipidaemia, pharmacological treatment, and exercise based cardiac rehabilitation. Regarding healthy lifestyle recommendations, 131 patients (78%) found that the DPE increased their knowledge about daily physical activity and, 109 patients (67%) agreed that the DPE increased their knowledge about recommended healthy food choices. Corresponding results for increased knowledge about alcohol use was 88 patients (62%) and 64 patients (57%) for tobacco use. However, 34 patients (30%) responded that information about tobacco and smoking cessation was irrelevant (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eMotivation of making healthy lifestyle changes and having a healthy lifestyle today\u003c/h2\u003e \u003cp\u003eThe survey results show that approximately 55% of the patients agreed that the DPE motivated them to make healthy lifestyle changes in terms of daily physical activity and participation in exercise based cardiac rehabilitation (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). The corresponding results of healthy dietary habits was 95 patients (47%) and for alcohol use, 70 patients (35%). Regarding tobacco use, 50 patients (26%) found the DPE motivating to change behaviour, but 114 patients (59%) found the item of tobacco use irrelevant (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). Figure\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003e shows that about 60% of the patients agreed to have a healthy lifestyle today regarding exercise, n\u0026thinsp;=\u0026thinsp;123 (61%), daily physical activity, n\u0026thinsp;=\u0026thinsp;146 (72%), dietary habits, n\u0026thinsp;=\u0026thinsp;126 (62%) and alcohol habits, n\u0026thinsp;=\u0026thinsp;120 (59%). The corresponding result for tobacco use was 88 patients (44%), but 102 patients (51%) found tobacco use irrelevant (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eAdditional experiences and opinions about digital patient education\u003c/h2\u003e \u003cp\u003eIn total, 90 patients (44%) gave 130 comments altogether in free text with additional experiences and opinions about the DPE. The comments were sorted into seven categories of responses. Most comments, n\u0026thinsp;=\u0026thinsp;33 (25%) concerned ideas or reflections for improvement of the DPE. All categories with examples of comments are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFree text comments of additional experiences and opinions about the digital patient education, presented by category.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of comments (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExamples of comments\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIdeas or reflections for improvement of the DPE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients suggested that the DPE should not have time limited period of use and to add a reminder function.\u003c/p\u003e \u003cp\u003ePatients suggested to combine the DPE with in-person education.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive feedback for the DPE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients found the DPE to be good and well developed. \u003c/p\u003e \u003cp\u003ePatients found it positive not to have scheduled visits with a clinic.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComments related to disease knowledge and treatment options\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eA few patients found the knowledge in the DPE superficial, some patients would like wider or deeper knowledge.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriticism of the DPE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSome patients experienced that the DPE assumed that one had poor lifestyle habits and that the DPE did not inform about what to do if you already have a healthy lifestyle.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComments about the timing of the survey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients thought that the DPE evaluation survey was sent a long time after they had participated in the DPE, and some found it difficult to remember details.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot used the DPE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients commented that they had not used the DPE.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDigital related comments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSome patients had difficulty with the digital technology or did not appreciate having to read digitally.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eComments are presented by numbers and (%). DPE, digital patient education.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis survey-based study provides increased knowledge of patients\u0026rsquo; perceptions of a DPE as part of CR, in terms of user acceptance and usability, perceived significance on healthy lifestyle changes and secondary preventive goal fulfilment in patients after having suffered an acute CAD. Digital health systems are progressing rapidly across all fields of medicine, including cardiology (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In our study, the DPE was delivered on a web-based platform and included written information, short video clips and illustrations. Of the patients using the DPE, most (69%) were generally satisfied with the DPE, and the majority considered the DPE to be simple to use and easy to learn to use and 70% of the patients would consider using it again. These results support the long-term role and continued development of the DPE. By assessing and evaluating the usability of digital health systems, the effectiveness of both the technology and service/s offered can be improved (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) and usability evaluation is also important for a successful implementation of those systems (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). However, digital health systems may not suit all patients. Our results indicated that some patients preferred the DPE while some patients would rather have participated in the centre-based patient education programme, where you can also interact with health care professionals and other persons with CAD. A previous systematic review showed that secondary preventive e-Health programmes were mainly offered to patients with CAD who could either not attend centre-based CR or as an adjunct, rather than completely replacing centre-based patient education (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). From a person-centred perspective, it could be beneficial for accessibility to patient education in the future to offer patients both a centre-based and a digital patient education programme, or a hybrid of both, so that patients have the ability to choose the setting themselves. More research is needed to develop and evaluate the effectiveness of these different setting options.\u003c/p\u003e \u003cp\u003eOne aspect that may affect a patient\u0026rsquo;s ability to initiate or maintain positive health behaviours is health literacy. According to WHO, health literacy refers to the personal characteristics and social resources needed for individuals and communities to access, understand, appraise and use information and services to make decisions about health (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Low health literacy levels have shown to be particularly common in individuals with cardiovascular diseases (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) and a study that evaluated CR programs and health literacy levels showed that more than 60% of patients with CAD had low levels of health literacy (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Moreover, low health literacy is associated with poorer general health status and an increased probability of rehospitalisation and mortality (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Health literacy may influence many aspects of our study. Our survey results of accessing and using the DPE, showed that the majority (57%) of the patients had used the DPE, although a significant percentage (43%) of the patients had not used the DPE. This result can be compared with a nationwide registry study showing that only 37% of the patients with first-time myocardial infarction attend patient education as a part of centre-based CR (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eReasons for not using the DPE are multifaceted and need to be discussed in the light of further development and implementation of the DPE. Firstly, our results indicated that the non-users of the DPE were on average four years older than the patients using the DPE. A previous systematic review demonstrated that higher age was a predictive factor of non-participation in cardiac telerehabilitation programmes (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). This systematic review also included additional predictive factors for non-participation, such as lower education level and current smoking, which was not part of the data collection in our study (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Secondly, our study showed that patients would have needed more information about how to use and the purpose of using the DPE. It may be hypothesised that this finding is related to the short hospital stay after an acute coronary event and that the patient receives a lot of information during this hospital admission. In the future, to increase the numbers of DPE users, adjustments to factors such as age should be explored, and healthcare professionals need to improve their delivery strategies for patient information about the DPE during admission to hospital. Moreover, previous research has shown the potential importance of email reminders and patient education about how to use a web-based intervention of lifestyle changes in patients with coronary heart disease or chronic back pain (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). These suggestions may also be a way forward to increase the number of patients using the DPE in the future.\u003c/p\u003e \u003cp\u003eFurthermore, health literacy includes understanding and using health information (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). In our study, \u0026gt; 60% of the patients found that the DPE increased their knowledge about treatment goals for blood pressure, hyperlipidaemia, pharmacological treatment, and exercise based cardiac rehabilitation. These findings are in line with the results from an observational study by Williamsson et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Their study objective was to evaluate 12 weeks of center-based CR including structured patient education in patients with CAD by assessing patients CAD-related knowledge at three times; before and after 12 weeks and at 3 months follow-up. CAD knowledge was measured using the Coronary Artery Disease Education Questionnaire-2nd Version (CADE-Q-II). The authors concluded that patients with CAD who received patient education within CR showed improvements in disease-related knowledge that persisted at 3-month follow-up (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). However, our study results of increased knowledge about the treatment goals of secondary disease prevention are based on the patients' perceptions of increased knowledge and not an assessment of their actual knowledge. Integrating some kind of quiz or questionnaire in the DPE for patients to evaluate their own knowledge and for healthcare professionals to be able to assess patient knowledge may be a part of future DPE development.\u003c/p\u003e \u003cp\u003eThe promotion of adherence to pharmacologic therapies and lifestyle recommendations is an important part of cardiac rehabilitation programmes (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). However, making and maintaining lifestyle changes can be challenging. About 60% of the patients in our study reported having a healthy lifestyle today regarding exercise, daily physical activity, dietary habits, and alcohol use and, the majority of the patients were motivated by the DPE to make healthy lifestyle changes with regards to physical activity and exercise-based cardiac rehabilitation. These findings are in line with a systematic review by Ghisi et al. (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), showing that educational interventions (individual or group-based) as part of CR was associated with increased levels of physical activity, healthier dietary habits, and smoking cessation. However, any related improvement in response to cardiac symptoms, medication compliance or psychosocial well-being were more uncertain (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). In addition, a systematic review by Shi et al. (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) demonstrated that patient education about secondary prevention more than doubled the probability of adherence to physical activity guidelines at \u0026lt;\u0026thinsp;6 months and 6\u0026ndash;12 months follow up in patients with coronary heart disease. The patients were three times more likely to adhere to healthy dietary advice at \u0026lt;\u0026thinsp;6 months and more likely to sustain this healthy behaviour at 6\u0026ndash;12 months follow up when participated in educational interventions for secondary prevention (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Furthermore, a Swedish nationwide registry study from 2019 demonstrated that participating in a centre-based patient education programme, as part of CR, was associated with 50% reduction of all-cause and CV mortality in patients with first-time myocardial infarction (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Associations between participation in a DPE and similar clinical outcomes should be assessed in future studies.\u003c/p\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eOne strength in this study was that patients could choose to answer the survey on paper or digitally. Web-based surveys are shown to have a significantly lower response rate than paper-based surveys but on the other hand, web-based data collection has a considerable cost advantage compared with paper-based data collection (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). The survey response rate in our study was 23%, which can be compared with a cross-sectional study from Switzerland that evaluated patient hospital satisfaction with a response rate ranging from 16.1 to 80.0% (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). In addition, a survey-based study exploring patients\u0026rsquo; opinions regarding satisfaction with telemedicine-provided care had a response rate of 5.8% (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Suggested strategies as the use of e-mail pre-notification, email invitation and two reminders are examples of methods for increasing the response rates in web-based surveys (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Another strength was the inclusion of open-ended questions, which provided additional information on patients\u0026rsquo; experience of the DPE. To avoid sampling bias, all patients with CAD who were registered users of the DPE were given the opportunity to participate in the study. The current study is not without limitations. As all surveys were sent at the same time point, the time between participating and evaluating the DPE differs among the patients. A longer time interval between participation and filling out the survey may have affected patients' perceptions of the DPE. No demographic patient information was collected in this study. Data such as level of education, occupational status, or travel distance to the hospital, could have enable deeper result analysis.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study adds new knowledge about a digital patient education programme (DPE), as part of CR, in patients with acute CAD. The survey results demonstrate overall high levels of patient acceptance and usability of the DPE, and this supports its long-term role and continued development. The majority of respondents reported that the DPE increased their knowledge about secondary preventive treatment goals and most of the patients reported having a healthy lifestyle today, which is important to reduce the risk of recurrent coronary events. Associations between participation in the DPE and clinical outcomes must however be further evaluated in future studies.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAlcohol Use Disorders Identification Test; AUDIT, Cardiac rehabilitation; CR\u0026nbsp;Coronary artery disease; CAD,\u0026nbsp;Digital patient education programme; DPE, Telehealth usability questionnaire; TUQ\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all the participants for their time to participate in the study.\u0026nbsp;We would also like to thank Dr Kate Bramley-Moore for proofreading assistance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMB, AR-F, AJ were responsible for the conception and design of the study. MB and AJ performed the data collection. MB, AS, AR-F, AJ, ML were involved in the analysis and interpretation of data. AS and MB were responsible for the first drafts of this paper, which was revised critically by AR-F, AJ and ML. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was financed through funding from the Innovation Platform in Region V\u0026auml;stra G\u0026ouml;taland (VGRINN-957811). The funding body had no role in study design, data collection, analysis and interpretation of results, or in writing the manuscript. Open access funding was provided by the University of Gothenburg.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was not obtained for publication of patient data. Upon reasonable request, deidentified data may be available from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eThe study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Swedish Ethical Review Board in Stockholm (registration number 2022-01783-01). All methods were carried out in accordance with relevant guidelines and regulations.\u0026nbsp;Informed written consent was obtained from the participants before entering the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJernberg T, Johanson P, Held C, Svennblad B, Lindback J, Wallentin L, et al. Association between adoption of evidence-based treatment and survival for patients with ST-elevation myocardial infarction. JAMA. 2011;305:1677\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKotseva K, De Backer G, De Bacquer D, Ryden L, Hoes A, Grobbee D, et al. 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ESC e-Cardiology Working Group Position Paper: Overcoming challenges in digital health implementation in cardiovascular medicine. Eur J Prev Cardiol. 2019;26:1166\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRamachandran HJ, Jiang Y, Teo JYC, Yeo TJ, Wang W. Technology Acceptance of Home-Based Cardiac Telerehabilitation Programs in Patients With Coronary Heart Disease: Systematic Scoping Review. J Med Internet Res. 2022;24:e34657.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParmanto B, Lewis AN Jr., Graham KM, Bertolet MH. Development of the Telehealth Usability Questionnaire (TUQ). Int J Telerehabil. 2016;8:3\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhajouei R, Farahani F. A combination of two methods for evaluating the usability of a hospital information system. BMC Med Inf Decis Mak. 2020;20:84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDodson SBA, Batterham RW, Osborne RH. November. Information Sheet 1 in The Health Literacy Toolkit for Low- and Middle-Income Countries. Information sheet 1: What is health literacy? In Ophelia Toolkit: A step-by-step guide for identifying and responding to health literacy needs within local communities. Part A: Introduction to health literacy: WHO; 2014. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://iris.who.int/bitstream/handle/10665/205244/B5148.pdf?sequence=1\u003c/span\u003e\u003cspan address=\"https://iris.who.int/bitstream/handle/10665/205244/B5148.pdf?sequence=1\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 16 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDiederichs C, Jordan S, Domanska O, Neuhauser H. Health literacy in men and women with cardiovascular diseases and its association with the use of health care services - Results from the population-based GEDA2014/2015-EHIS survey in Germany. 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Telemedicine in Swedish primary health care - a web-based survey exploring patient satisfaction. BMC Health Serv Res. 2023;23:129.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSammut R, Griscti O, Norman IJ. Strategies to improve response rates to web surveys: A literature review. Int J Stud Nurs. 2021;123:104058.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cardiovascular disease, digital technologies, distance education, eHealth, health care surveys, health education, secondary prevention, telemedicine, usability testing","lastPublishedDoi":"10.21203/rs.3.rs-4235951/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4235951/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e \u003cp\u003ePatient education programmes focusing on risk factor modification and lifestyle changes are well established as part of cardiac rehabilitation in patients with coronary artery disease (CAD). As participation rates are low, digital patient education programmes (DPE) are interesting alternatives to increase access. Understanding patients\u0026rsquo; perceptions of DPE are important in terms of successful implementation in clinical practice but are not well known. Therefore, the aim of this study was to assess patients\u0026rsquo; perceptions of using a DPE in terms of end-user acceptance and usability, perceived significance for lifestyle changes and secondary preventive goal fulfilment in patients with CAD.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis was a cross-sectional survey-based study. The survey was distributed to all 1625 patients with acute coronary syndrome or chronic CAD with revascularisation, who were registered users of the DPE between 2020\u0026ndash;2022. The survey contained 64 questions about e.g., acceptance and usability, perceived significance for making lifestyle changes and secondary preventive goal fulfilment. Patients who had never logged in to the DPE received questions about their reasons for not logging in.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 366 patients (mean age: 69.1\u0026thinsp;\u0026plusmn;\u0026thinsp;11.3 years, 20% female) completed the survey and among those 207 patients (57%) had used the DPE. Patients reported that the DPE was simple to use (80%) and improved access to healthcare (67\u0026ndash;75%). A total of 69% of the patients were generally satisfied with the DPE, \u0026gt;\u0026thinsp;60% reported that the DPE increased their knowledge about secondary preventive treatment goals and approximately 60% reported having a healthy lifestyle today. On the other hand, 35% of the patients would have preferred a hospital-based education programme. Among the 159 patients (43%) who had never used the DPE, the most reported reason was a perceived need for more information about how to use the DPE (52%).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis study shows an overall high level of patient acceptance and usability of the DPE, which supports its continued development and long-term role in cardiac rehabilitation in patients with CAD. Future studies should assess associations between participation in the DPE and clinical outcomes, such as secondary preventive goal fulfilment and hospitalisation.\u003c/p\u003e","manuscriptTitle":"Evaluation of a digital patient education programme in patients with coronary artery disease, a survey-based study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-17 20:40:27","doi":"10.21203/rs.3.rs-4235951/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-04-12T03:47:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-09T02:42:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-09T02:42:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2024-04-08T11:13:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a3889fcd-ce2a-4670-bf9c-30fe897eb47b","owner":[],"postedDate":"April 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-09T16:14:23+00:00","versionOfRecord":{"articleIdentity":"rs-4235951","link":"https://doi.org/10.1186/s12913-024-11374-5","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2024-09-02 15:57:40","publishedOnDateReadable":"September 2nd, 2024"},"versionCreatedAt":"2024-04-17 20:40:27","video":"","vorDoi":"10.1186/s12913-024-11374-5","vorDoiUrl":"https://doi.org/10.1186/s12913-024-11374-5","workflowStages":[]},"version":"v1","identity":"rs-4235951","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4235951","identity":"rs-4235951","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}