Coronary artery bypass graft grafting (CABG) is the most prevalent cardiac surgery performed in the Netherlands, with roughly 7000 procedures annually [1
]. The care chain of CABG is costly, and several quality improvement initiatives have been successfully implemented that sought to contain costs and to improve patient outcomes [2
]. Despite the positive effects of these initiatives on costs, mortality, postoperative morbidity and process measures such as in-hospital length of stay, healthcare utilisation in the first 30 days after CABG remains an issue, placing a significant burden on the healthcare system. Readmissions after CABG are commonly reported and the readmission rate can be as high as 34% in the first 30 days [4
Insight into unplanned healthcare utilisation during this period is scarce (apart from readmissions), but it is reasonable to expect a short hospital stay after CABG is counterbalanced by the use of other healthcare services, especially because planned care is not initiated until 6 weeks after discharge. In this period, patients commonly experience psychological symptoms (e.g. anxiety, depression), have to deal with uncertainty and worry about what to expect (e.g. what level of postoperative pain is normal, is physical exercise allowed?) [6
]. Recall of information provided perioperatively is often incomplete and patients do not always know who to contact in case of complaints. They will then search for (sometimes unreliable) information on surgery or recovery and reach out to different healthcare providers, who have a varying degree of expertise in CABG care. Conflicting advice on recovery can further increase fear and insecurity, which will eventually hamper the recovery process and contribute to unplanned healthcare utilisation [7
We hypothesise that restructuring the postoperative period with an eHealth strategy will reduce unplanned healthcare utilisation through improved mental and physical health and faster recovery. In the IMPROV-ED trial, we aim to evaluate whether the use of an eHealth programme that consists of educational videos developed by the Dutch Heart Foundation (Hartstichting) and video consultations, is more effective than standard care in the reduction of unplanned healthcare utilisation and the improvement of patient outcomes in the first 6 weeks after CABG. In addition, a process and patient satisfaction evaluation of the newly developed eHealth strategy will be conducted.
The IMPROV-ED trial will be carried out to evaluate whether an eHealth initiative consisting of online education and video consultation can reduce healthcare utilisation by improving quality of life, decreasing anxiety and accelerating recovery within the first 6 weeks after discharge for CABG.
The IMPROV-ED trial is of clinical significance for several reasons. First, we will evaluate the influence of an eHealth strategy on healthcare utilisation, anxiety, quality of life and recovery. Positive results will yield a new postoperative protocol that will lead to better patient outcomes and reduced costs [25
]. In addition, the process and patient satisfaction evaluation will show the readiness of CABG patients for structured eHealth initiatives and will evaluate the currently used content and mode of administration, given the broad applicability of eHealth in general and the multitude of devices available [26
]. Second, the control arm of the trial will provide the first detailed insight into unplanned, transmural healthcare utilisation in the early postoperative period after CABG and will thereby show how to further improve post-CABG protocols, aside from eHealth, through multidisciplinary regional collaboration.
eHealth strategies in CABG patients have been successfully applied to guide secondary prevention [29
], to improve recovery [30
], and to assess physical functioning and quality of life [32
]. Although evidence on the effect of eHealth on healthcare utilisation in CABG patients is minimal, it is reasonable to expect a positive effect based on reduction of healthcare utilisation by eHealth strategies in other populations [8
]. According to post-CABG protocols, patients are expected to adopt new behaviours (e.g. relieve stress on the sternum, gradually increase in physical exercise, follow healthy diet) and to deal with the emotions and worries that go with cardiac surgery through self-management, and, thus, to take responsibility for their own recovery [6
]. eHealth has shown to be a useful method for patients to enhance their self-management through better understanding of their disease, increased independence and improved acceptance to adhere to lifestyle advice [37
]. The educational videos in our eHealth strategy facilitate self-management. By means of video consultation, the physician can guide and supervise the patient’s progress and maintain a good patient-physician relationship, which has been shown to enhance the patient’s self-management skills [37
The message and content of the educational videos were designed in such a way that they provide health information for patients with low/inadequate health literacy (approximately 36.4% of the general population in the Netherlands [38
]), without compromising health communication to patients with adequate health literacy. Meppelink et al. have assessed the features of health information (written vs spoken text vs animations vs illustrations) and concluded that spoken text combined with animation is the most effective way to communicate health information and that it suits both patients with low health literacy and those with adequate health literacy [39
]. In addition, to prevent cognitive overload, it is advised to only offer information when it is applicable to the patient’s situation instead of presenting all the information at once, especially to not overburden low health literate patients [40
]. We therefore decided to divide the information into the three main phases of CABG recovery (Fig. 2
The addition of our eHealth strategy to the postoperative protocol might yield additional costs in comparison to standard care. We believe that these additional costs will be balanced by reduced healthcare utilisation and will therefore result in less total costs and better patient outcomes. Another potential limitation is that we will only include patients that have sufficient computer and digital literacy skills and have access to a computer or tablet, which might diminish generalisability of our study protocol. Moreover, as in most eHealth research, our trial is not fully blinded, which could lead to bias when patients report healthcare utilisation.
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