The CoroPrevention-SDM Approach: A Technology-supported Shared

Decision Making Approach for a Comprehensive Secondary Prevention

Program for Cardiac Patients

Cindel Bonneux

, Deeman Yousif Mahmood

, Martijn Scherrenberg

, Maarten Falter

Gustavo Rovelo Ruiz

, Hanne Kindermans

, Dominique Hansen

, Reijo Laaksonen

, Paul Dendale

and Karin Coninx

Faculty of Sciences, HCI and eHealth, UHasselt, Diepenbeek, Belgium

Faculty of Medicine and Life Sciences, UHasselt, Diepenbeek, Belgium

Faculty of Sciences, EDM, UHasselt, Diepenbeek, Belgium

Faculty of Medicine and Life Sciences, Healthcare and Ethics, UHasselt, Diepenbeek, Belgium

Faculty of Rehabilitation Sciences, REVAL/BIOMED, UHasselt, Diepenbeek, Belgium

Finnish Cardiovascular Research Center Tampere, University of Tampere, Tampere, Finland

cindel.bonneux, deeman.mahmood, martijn.scherrenberg, maarten.falter, gustavo.roveloruiz, hanne.kindermans,

Keywords:

Shared Decision Making, Holistic Approach, Secondary Prevention, Cardiovascular Diseases, Behaviour

Change, eHealth.

Abstract:

After a cardiac event, secondary prevention is recommended to foster recovery and reduce the risk of recurrent

events. European guidelines and EAPC position statements on prevention of cardiovascular diseases recom-

mend a holistic approach that actively engages patients by using shared decision making (SDM). It has been

demonstrated that telerehabilitation can be a feasible and effective add-on or alternative compared to conven-

tional in-hospital secondary prevention. However, till date, there is no eHealth solution that offers a holistic

approach for secondary prevention that includes SDM. In this paper, we present the CoroPrevention-SDM

approach, a technology-supported shared decision making approach for a comprehensive secondary preven-

tion program for cardiac patients. The CoroPrevention Tool Suite consists of three applications that support

patients and caregivers in following this approach: 1) a caregiver dashboard that includes decision support sys-

tems and supports SDM, 2) a patient mobile application that supports patients in making behaviour changes

in their daily life, and 3) an extended ePRO application that collects patient reported outcomes and patient

preferences. In a formative usability study, we assessed patients’ and caregivers’ opinion about our approach.

The study indicated that both are willing to use our proposed approach to collaboratively set behavioural goals

during SDM encounters.

1 INTRODUCTION

Cardiovascular diseases are world’s leading cause

of death, accounting for an estimated 17.9 million

deaths globally in 2019 (World Health Organization,

2021). After a cardiac incident, patients typically en-

rol in cardiac rehabilitation as a secondary prevention

to foster recovery and reduce their risk of recurrent

events (Ambrosetti et al., 2021). In this paper, we fo-

cus on two interrelated needs for a guideline-based

secondary prevention program, namely its holistic

perspective and integration of shared decision mak-

ing. Furthermore, we elaborate on our technology-

supported shared decision making approach in the

CoroPrevention project, a large-scale H2020 funded

project on secondary prevention for high-risk pa-

tients. In this section, we consider the state of the art

for the two identiﬁed needs and raise ideas to move

beyond the currently implemented clinical practices.

1.1 The Need for a Holistic Approach

1.1.1 State of the Art

European guidelines and EAPC position statements

(Ambrosetti et al., 2021; Visseren et al., 2021) rec-

Bonneux, C., Mahmood, D., Scherrenberg, M., Falter, M., Rovelo Ruiz, G., Kindermans, H., Hansen, D., Laaksonen, R., Dendale, P. and Coninx, K.

The CoroPrevention-SDM Approach: A Technology-supported Shared Decision Making Approach for a Comprehensive Secondary Prevention Program for Cardiac Patients.

DOI: 10.5220/0011042300003188

In Proceedings of the 8th International Conference on Information and Communication Technologies for Ageing Well and e-Health (ICT4AWE 2022), pages 59-69

ISBN: 978-989-758-566-1; ISSN: 2184-4984

ommend that a comprehensive, secondary prevention

program includes the following key components: pa-

rameter monitoring, education, medication, physical

activity, nutrition, smoking cessation, and stress man-

agement. For each of these key components, eHealth

solutions have been developed and are even com-

mercially available. Numerous apps are available in

smartphone’s app stores that enable users to set med-

ication reminders, measure their health parameters,

track their physical activity, record their nutrition in-

take, perform stress relief exercises, or offer smok-

ing cessation support. However, the main disadvan-

tages of these applications are twofold: 1) most of

these applications are not tailored to the risk proﬁle

of a cardiac patient, and 2) to follow a comprehen-

sive, secondary prevention program, the patient has to

use several different applications. Using multiple ap-

plications can result in a higher cognitive burden and

interference of (or even conﬂicting) advice offered by

different applications.

In scientiﬁc literature, numerous studies were

published that evaluated eHealth interventions for

secondary prevention of cardiovascular diseases (Jin

et al., 2019; Brørs et al., 2019). A review performed

by Brørs et al. (Brørs et al., 2019) concluded that the

majority of studies included two or three secondary

prevention components, of which education was em-

ployed in 21 out of the 24 included studies. To the

best of our knowledge, there is no eHealth solution

that fully supports a comprehensive, secondary pre-

vention program, including all key components as de-

ﬁned by Ambrosetti et al. (Ambrosetti et al., 2021)

and that was subject to extensive evaluation on medi-

cal effectiveness and user experience.

1.1.2 Looking Beyond the State of the Art

When working on risk factor reduction to prevent re-

current cardiovascular events, the main parameters to

control are blood pressure, weight, cholesterol, and

glucose levels. For each of these parameters, a tar-

get value can be deﬁned (in line with the European

guidelines and EAPC position statements (Ambrosetti

et al., 2021; Visseren et al., 2021)) and an outcome

goal can be set (i.e. respectively lowering blood pres-

sure, healthy weight, lowering cholesterol, and dia-

betes management). To improve a parameter value

and achieve the associated outcome goal, different

strategies can be followed. For example, a healthy

weight can be achieved by increasing physical ac-

tivity, eating healthier, or a combination of both. It

is important that patients understand how they can

work on an outcome goal. Setting the goal of los-

ing weight until your body mass index (BMI) is below

25 is too abstract for a patient. In the context of be-

haviour change, people need to set actionable goals

that are directly linked to behaviours over which they

have direct control (Medynskiy et al., 2011). There-

fore, we suggest that in a rehabilitation program the

outcome goals for secondary prevention should be

linked to behavioural goals. The following ﬁve be-

havioural goals should be considered when aiming at

a healthy lifestyle to prevent recurrent cardiac events:

medication adherence, start moving, healthy nutri-

tion, smoke-free living, and stress relief. For each

of these behavioural goals, speciﬁc, short-term goals

should be set (Medynskiy et al., 2011). After deﬁn-

ing the behavioural goals for the upcoming period, it

is equally important that follow-up is done and that

feedback is provided on the progress towards the be-

havioural goals (Scobbie et al., 2011). Therefore, it

is essential that patients can monitor their parame-

ters and caregivers can remotely follow up on these

reported values.

1.2 The Need for Shared Decision

Making

1.2.1 State of the Art

From a clinical point of view, patients should reduce

their cardiovascular disease (CVD) risk as soon as

possible, as much as possible. This would require

optimizing all outcome goals at the same time, and

thus working on multiple behavioural goals simulta-

neously. After a cardiac incident, some patients want

to drastically change their life and are eager to work

on multiple or even all behavioural goals at the same

time. However, this is not advised, since some be-

haviour changes oppose each other (e.g. smoking ces-

sation and losing weight) which results in disillusion-

ment for the patient. Furthermore, working on mul-

tiple behaviour changes simultaneously is not feasi-

ble for everyone. For those patients for whom a dras-

tic approach is not feasible, a more gradual approach

in which they target one behaviour change at a time

works better. In such cases, it has to be decided which

behavioural goal is targeted ﬁrst. There is evidence

that some factors (which can be linked to behaviour

changes) have a bigger effect on CVD risk than oth-

ers (SCORE2 working group and ESC Cardiovascular

risk collaboration, 2021; SCORE2-OP working group

and ESC Cardiovascular risk collaboration, 2021).

However, if the patient is not willing or able to work

on the behaviour change, it will be almost impossi-

ble to achieve the desired effects. Moreover, there are

patients for whom it will be difﬁcult or even impos-

sible to tackle a certain risk factor. E.g., for a person

with severe rheumatism, it will be very challenging to

ICT4AWE 2022 - 8th International Conference on Information and Communication Technologies for Ageing Well and e-Health

achieve the exercise targets and it is better to focus on

reducing the other CVD risk factors.

For this type of situations, where there is no clear

best choice and the decision has to be made by bal-

ancing the pros and cons of different options (i.e. the

behaviour changes), it is recommended to use shared

decision making (Wennberg et al., 2003). More-

over, shared decision making is at the core of patient-

centered care and the European Society of Cardiology

also acknowledges that patient engagement (in clini-

cal decision making) is needed to improve cardiovas-

cular care (Graham et al., 2017; Institute of Medicine,

2001). Shared decision making (SDM) combines

the patient’s preferences, values, goals, and context

with the clinical evidence and caregivers’ expertise

to make an informed decision (Kon, 2010; Stiggel-

bout et al., 2012), i.e. in this case which behavioural

goal(s) the patient will work on ﬁrst. When making

this decision, the risk reduction of the different be-

haviour changes should be balanced with the patient’s

motivation to work on these behaviour changes. We

propose to use a digital decision aid or SDM tool in

a shared decision making encounter with the patient,

to support a dialogue about the balancing exercise be-

tween the patient’s motivation for behaviour change

and necessary health risk reduction. Decision aids

are tools that support patients and caregivers in SDM

by making the decision explicit, offering information

about the available options (and their advantages and

disadvantages), and assisting in clarifying congruence

between personal preferences/values and the decision

at hand (Stacey et al., 2017).

To actively participate in shared decision making

and become the manager of their own disease, pa-

tients need to understand their condition and their own

preferences (Joseph-Williams et al., 2014). There-

fore, education is an essential component when con-

sidering shared decision making in the context of sec-

ondary prevention. This education can be delivered

by caregivers during the encounters using a SDM tool,

but also patients can learn on their own using digital

resources such as articles, videos, and infographics

(Sankaran et al., 2018).

1.2.2 Looking Beyond the State of the Art

Recently, Bonneux et al. (Bonneux et al., 2019) pro-

posed three levels of decision-making in cardiac reha-

bilitation (CR):

Level 1 The CR program: the key components to in-

clude and when they get the patient’s focus

Level 2 The key components of the CR program: the

details of the included components

Level 3 The actions for the key components: the de-

tails of what the patient can do to implement

the lifestyle changes in daily life

Cardiac rehabilitation can be considered as a tool

for secondary prevention of cardiovascular disease

(Mampuya, 2012). Therefore, we believe that these

three decision-making levels can be utilized in the

context of secondary prevention of CVD as well. Fur-

thermore, Bonneux et al. (Bonneux et al., 2019) made

a categorization of different tools that can support

patients and caregivers at different points in time in

following a SDM approach for these three levels of

decision-making.

Inspired by patients’ and caregivers’ need for

a holistic approach and shared decision making in

the context of secondary prevention of cardiovas-

cular diseases, we developed the CoroPrevention-

SDM approach. In Section 2, we describe patients’

and caregivers’ requirements for tools supporting

SDM for a comprehensive secondary prevention pro-

gram. In Section 3 and Section 4, we present our

CoroPrevention-SDM approach and highlight how

the digital support that was realised in CoroPreven-

tion fulﬁlls patients’ and caregivers’ needs.

2 PATIENTS’ AND CAREGIVERS’

REQUIREMENTS FOR

SHARED DECISION MAKING

TOOLS

To support patients and caregivers in shared deci-

sion making for the behavioural goals of a secondary

prevention program, the approach of Bonneux et al.

(Bonneux et al., 2019) can be adapted. Whereas guid-

ance of the patient is necessary throughout the sec-

ondary prevention program, shared decision making

is often facilitated in a discrete way, in a number of

(physical) shared decision making encounters. When

looking at a single SDM encounter, we can deﬁne

three points in time where digital tools can support

caregivers and patients in shared decision making:

1. Preceding to the SDM encounter

2. During the SDM encounter

3. After the SDM encounter

For these three moments in time, we describe in the

next sections the goals and needs for both patients and

caregivers regarding support for shared decision mak-

ing.

The CoroPrevention-SDM Approach: A Technology-supported Shared Decision Making Approach for a Comprehensive Secondary

Prevention Program for Cardiac Patients

Figure 1: The patient’s goals and needs preceding to, during, and after the SDM encounter.

2.1 The Patient’s Perspective

From the patient’s perspective, the aim is to increase

self-management of the disease and therefore become

an active participant in the SDM process. This leads

to a process that balances patient and caregiver de-

cisions regarding the rehabilitation approach. The pa-

tient’s goals and needs that can be supported by digital

tools are depicted in Figure 1. Preceding to a SDM

encounter, digital tools can support patients in be-

coming informed about what will happen during the

encounter. In this regard, patients should think about

their preference to be involved in the decision-making

process e.g. do they want to take the decision, make a

shared decision, or leave the decision to the caregiver.

Furthermore, digital tools can support patients in re-

ﬂecting on their current status, gaining insight into

their progress over the last months and into the next

possible steps. Referring back to the above mentioned

two aims for the patient, information and reﬂection,

we activate and empower the patient to become ac-

tive participants in the SDM consultation. During the

SDM encounter, digital tools can support patients in

improving their understanding, reﬂecting on past be-

haviour, stating their preferences, and understanding

what actions should be taken. The desired result is

that the patient can make an informed decision to-

gether with the caregiver during the SDM consulta-

tion and is motivated to work on the agreed behaviour

changes. After the SDM encounter, mobile eHealth

applications can support patients in making the agreed

behaviour changes at home. These applications can

provide patients guidance in how to achieve the be-

havioural goals and how to bring the decisions that

were made during the encounter into practice in their

daily life. There will be moments when the patient

has a setback. At those moments, the tools can sup-

port the patient to feel comfortable while getting back

on track. However, it is important to note that the

tools cannot replace the support of the caregiver but

are rather facilitating the caregiver in this role. In the

next section, we discuss how tools can support care-

givers in achieving their goals.

2.2 The Caregiver’s Perspective

From the caregiver’s perspective, the aim is to make

guideline-based recommendations for the patient’s

treatment, to support the patient in making behaviour

changes, and to follow up on the patient’s progress for

a healthy lifestyle. Similarly as patients, caregivers

have different goals and needs that can be supported

by digital tools at different points in time (Figure 2).

Preceding to the SDM encounter, caregivers can use

digital tools to prepare themselves for the upcoming

appointment, so they can make (together with the pa-

tient) well-informed decisions during the encounter.

Digital tools can support caregivers in reviewing the

patient’s evolution since last consultation and pending

goals. In addition, decision support systems can sup-

port caregivers in preparing for prescribing guideline-

based care to their patients. During the SDM en-

counter, a digital tool can support the caregiver in

discussing the outcome goals that are needed from

a clinical point of view (i.e. transferring knowledge

to the patient) and collaboratively setting behavioural

goals that are in line with the clinical evidence and

the patient’s preferences (i.e. facilitating collaborative

discussion and motivating the patient). The desired

result is that the patient can make an informed deci-

sion together with the caregiver during the SDM con-

sultation and that the patient is motivated to make the

agreed behaviour changes. Between SDM encoun-

ters, caregivers want to follow up on their patients’

progress. However, there is only limited time avail-

able for this follow-up. Therefore, digital tools, such

as dashboard visualizations and alerts, can support

caregivers in following up on the patient’s progress.

Digital tools can alert the caregiver when the patient

deviates from the agreed goals and action plans, so the

caregiver can contact the patient or take this into ac-

count during the next SDM encounter. At those mo-

ICT4AWE 2022 - 8th International Conference on Information and Communication Technologies for Ageing Well and e-Health

Figure 2: The caregiver’s goals and needs preceding to, during, and after the SDM encounter.

ments in time, the support of the caregiver can help

the patient getting back on track in case of difﬁcul-

ties.

As can be seen in Figure 1 and Figure 2, the goals

and needs of the different stakeholders in the SDM

process are not complementary, but in essence are the

same goals from different (patient and caregiver) per-

spectives. When looking at the goals and needs of

both stakeholders, we can conclude that these can be

satisﬁed by a selection of the tools proposed in the

categorization of Bonneux et al. (Bonneux et al.,

2019). In the next section, we introduce a possible

timeline for a single SDM encounter and present ac-

companying tools to satisfy the needs of the different

stakeholders (patients and caregivers) in the context

of secondary prevention of cardiovascular diseases.

3 TIMELINE FOR A SHARED

DECISION MAKING

ENCOUNTER

In this paper, we present the CoroPrevention-SDM

approach, a technology-supported shared decision

making approach for a comprehensive secondary pre-

vention program for cardiac patients. As recom-

mended by guidelines and EAPC position statements

(Ambrosetti et al., 2021; Graham et al., 2017; Vis-

seren et al., 2021), the CoroPrevention secondary pre-

vention program implements a holistic approach that

targets the risk factors for cardiovascular diseases and

incorporates shared decision making. To satisfy all

requirements that were stated above (i.e. offering a

holistic approach for secondary prevention, support-

ing shared decision making, and satisfying all patient

and caregiver needs identiﬁed in Section 2), we de-

signed and developed the CoroPrevention Tool Suite.

The CoroPrevention Tool Suite takes a holistic ap-

proach for secondary prevention by offering the fol-

lowing 7 modules, when it reaches the full target im-

plementation: parameter monitoring, education, med-

ication, physical activity, healthy nutrition, smoking

cessation, and stress management (Figure 3). The

modules in the Tool Suite are gradually elaborated

further during the project. Most of these modules

can directly be linked to the behavioural goals, i.e.

medication adherence, start moving, healthy nutri-

tion, smoke-free living, and stress relief. The two re-

maining modules, education and parameter monitor-

ing, are essential to support the shared decision mak-

ing process and remote follow-up by the caregiver.

Figure 3: The seven modules of the CoroPrevention Tool

Suite to implement a comprehensive secondary prevention

program for cardiac patients.

The CoroPrevention Tool Suite is composed of

three digital tools that support patients and caregivers

in shared decision making for the secondary preven-

tion program (Figure 4). The ﬁrst tool is an extended

ePRO application. In the context of the CoroPre-

vention Tool Suite, Electronic Patient-reported Out-

comes (ePRO) are questionnaires for patients to indi-

cate how they are feeling and what they prefer. Pa-

tients use the extended ePRO application on a tablet

in the waiting room (prior to the SDM encounter) to

inform themselves about the SDM process, report on

their current status, and state their preferences. A

The CoroPrevention-SDM Approach: A Technology-supported Shared Decision Making Approach for a Comprehensive Secondary

Prevention Program for Cardiac Patients

Figure 4: The timeline and accompanying tools to be used during a single encounter to support shared decision making for a

comprehensive secondary prevention program.

caregiver dashboard with integrated clinical decision

support systems and shared decision making support

is the second tool of the CoroPrevention Tool Suite.

This dashboard is used by caregivers to prepare for

the encounter and to follow up on their patients be-

tween encounters. Furthermore, the caregiver dash-

board can be used during a consultation on a shared

display to encourage collaboration and spark discus-

sion with the patient. The third tool is a smartphone

application that patients use at home to follow up

on their behaviour change process and receive sup-

port for decision-making in daily life. Figure 4 pro-

vides an overview of the usage of the different tools of

the CoroPrevention Tool Suite for a single SDM en-

counter. The tools are categorized according to the

three moments in time that were identiﬁed before:

preceding to the SDM encounter, during the SDM en-

counter, and after the SDM encounter.

4 SHARED DECISION MAKING

IN THE COROPREVENTION

TOOL SUITE

In this section, we describe the CoroPrevention Tool

Suite according to the timeline for a single encounter,

i.e. preceding to the SDM encounter, during the SDM

encounter, and after the SDM encounter.

4.1 Preparation of the SDM Encounter

Given the short time available for live encounters

(with an average of just about 10 minutes per pa-

tient (Elmore et al., 2016)), it is important that both

patients and caregivers are well prepared for the en-

counter. To preserve more time during the encounter

for shared decision making, patients can already pro-

vide a status update about their risk factors and related

behavioural goals in the extended ePRO application

preceding to the encounter. In shared decision mak-

ing, it is crucial that the patient’s preferences are taken

into account. These preferences can range from very

high-level e.g. which goals would the patient like to

work on, to very speciﬁc e.g. which sports activities

does the patient like to perform. Patients might be

unsure to state their preferences in front of their care-

givers, because they are overwhelmed and did not ex-

pect that their caregivers would ask them about their

preferences. Therefore, the patient’s preferences are

collected before the SDM encounter in the extended

ePRO application. These preferences are depicted on

the shared display during the SDM encounter, which

can encourage patients to talk about their preferences.

For patients that might then still be reluctant to talk

about them, the caregiver can take into account the

ICT4AWE 2022 - 8th International Conference on Information and Communication Technologies for Ageing Well and e-Health

Figure 5: Goal setting of behavioural goals in the caregiver dashboard. The patient and caregiver discuss the patient’s status

and motivation for the behavioural goals and decide upon the patient’s behavioural goals for the upcoming period.

preferences that were collected by the system. Col-

lecting this information before the SDM encounter

does not only lead to more time for decision-making

during the encounter, but also provides patients a clear

moment to reﬂect on their status, behaviour, and pref-

erences. Furthermore, a video offered in the extended

ePRO application before the ﬁrst SDM encounter al-

ready provides the patient some information about

shared decision making in general and familiarizes

him/her with the process that will follow.

Next to patients, caregivers also need to be well-

prepared for a SDM encounter. If desired, caregivers

can prepare themselves for the encounter by checking

the patient’s performance in the last months and pend-

ing goals in the caregiver dashboard. Furthermore,

clinical decision support systems (CDSS) can support

caregivers in prescribing guideline-based care to their

patients. In the CoroPrevention caregiver dashboard,

we incorporated the EXPERT tool (Hansen et al.,

2017a; Hansen et al., 2017b) for guideline-based ex-

ercise prescription and a decision support system for

medication prescription. A detailed description of

these systems is beyond the scope of this SDM arti-

cle. Using DSS systems during encounters with pa-

tients can be cumbersome and might affect the pa-

tient’s perception of the caregiver’s credibility and au-

thority. Also, using a clinical decision support system

before the SDM encounter leaves more time during

the SDM encounter to discuss the decisions that were

made with input of the CDSS, set goals, and decide

upon the actions that the patient should take to achieve

these goals.

4.2 Shared Decision Making

Consultation

During the SDM encounter, the dashboard acts as a

SDM tool that supports the shared decision making

conversation between the caregiver and the patient.

They start by discussing the patient’s evolution in

the past period and his/her current status for the be-

havioural goals and related outcome goals. For the

outcome goals (e.g. lowering blood pressure, lower-

ing cholesterol, and healthy weight), shared decision

making is not possible in our approach, as these goals

are determined based on clinical guidelines and the

caregiver’s expertise. Moreover, cholesterol and hy-

pertension are more inﬂuenced by medication than

by lifestyle changes. Therefore, the caregiver will

strongly emphasize the importance of medication ad-

herence to reduce the patient’s CVD risk. Neverthe-

less, behaviour changes such as reducing salt intake,

exercising more, and eating healthier can be other

ways to work on these outcome goals. Therefore,

it is still important to discuss the patient’s outcome

goals during the encounters. Based on the patient’s

outcome goals and status, the behavioural goals (e.g.

increasing physical activity, eating healthier, and quit-

The CoroPrevention-SDM Approach: A Technology-supported Shared Decision Making Approach for a Comprehensive Secondary

Prevention Program for Cardiac Patients

ting smoking) that the patient should work on from

a clinical point of view can be determined and dis-

cussed (Figure 5). The patient’s motivation (that was

collected in the extended ePRO application) to work

on these behavioural goals is depicted to spark discus-

sion and encourage the patient to state his/her prefer-

ences. During the discussion, the patient and care-

giver agree upon a feasible behavioural goal for the

patient (i.e. decision-making level 1). After deciding

upon the behavioural goal, they discuss and record the

plans to achieve this goal (i.e. decision-making level

2 and possibly even decision-making level 3). If the

patient and caregiver agree to set multiple behavioural

goals, the process restarts to set the next behavioural

goal. During this process, the caregiver’s role is not

only to support the patient in decision-making, but

also to motivate the patient to work on the agreed be-

havioural goals. At the end of the SDM encounter,

a feasible set of behavioural goals has been agreed

upon and action plans have been recorded to support

the patient in achieving these goals. This informa-

tion is used to conﬁgure the mobile application that

belongs to the CoroPrevention Tool Suite on the pa-

tient’s smartphone, that will guide the patient until the

next SDM encounter.

4.3 Remote Follow-up

Between SDM encounters, at home, the mobile ap-

plication supports the patient in working on the be-

havioural goals and making smaller decisions in daily

life (i.e. decision-making level 3). In the mobile ap-

plication, patients receive support to make decisions

on a daily basis (e.g. which sports activities will I

perform today) and can follow up on their medication

intake. Furthermore, they can record their progress

(e.g. tracking sports activities) and follow up on their

journey towards a healthy lifestyle. Based on the pa-

tient’s progress, the mobile application makes recom-

mendations to increase/decrease the support for the

behavioural goals. However, patients can also decide

themselves to start or stop working on a behavioural

goal (patient autonomy) and as such, become the

manager of their own disease. When the patient ac-

tivates a new behavioural goal, the mobile application

supports the patient in setting feasible goals and con-

structing action plans. However, there will also be

moments when the patient has difﬁculties. At those

moments, the mobile application (and caregivers) will

be there to help the patient getting back on track. The

data that is collected in the patient mobile application

is used as input in the next SDM discussion.

Caregivers can follow up on their patients between

visits by receiving alerts about their patients’ progress

and behaviour, which can be consulted in the care-

giver dashboard. Given the busy schedules of care-

givers and the large number of patients that they have

to supervise, it should be avoided that caregivers re-

ceive too many alerts. Therefore, some alerts are han-

dled automatically by the CoroPrevention Tool Suite,

without requiring input of the caregiver (e.g. send-

ing tailored educational material to the patient to en-

courage the patient to take action). However, in some

cases (e.g. when the patient’s medication adherence is

very low), caregivers may want to intervene (e.g. call

the patient to assess barriers). The CoroPrevention

caregiver dashboard facilitates this decision to care-

givers by offering all information and triggering alerts

with regard to the status of a patient.

5 FORMATIVE EVALUATION OF

THE COROPREVENTION-SDM

APPROACH

To the best of our knowledge, the concept of set-

ting behavioural goals collaboratively during SDM

encounters has not yet been investigated in the past in

the context of secondary prevention of cardiovascular

diseases. We assessed patients’ and caregivers’ opin-

ion on our proposed shared decision making approach

for secondary prevention as part of a formative us-

ability study of the different applications of the Coro-

Prevention Tool Suite. The formative usability study

was approved by the Medical Ethical Committees of

Hasselt University and Jessa Hospital Hasselt. 10 car-

diac patients and 7 caregivers were asked about their

willingness to use the tools of our proposed SDM ap-

proach to set behavioural goals. After participants

were acquainted with the caregiver dashboard and/or

mobile application by performing an individual task-

based formative usability test regarding some of the

modules of the CoroPrevention Tool Suite, they ﬁlled

in a custom-made questionnaire consisting of sev-

eral Likert-scale questions. Caregivers were asked if

they were willing to use a caregiver dashboard during

their consultations with patients to discuss patients’

progress and set goals for a healthy lifestyle. Simi-

larly, patients were asked if they would be willing to

use a caregiver dashboard during a consultation with

a caregiver to discuss their progress and set goals for

a healthy lifestyle. Furthermore, patients were asked

if they would be willing to use a mobile application to

follow up at home on their journey towards a healthy

lifestyle.

The results of our survey are depicted in Figure 6.

All participants (both patients and caregivers) unani-

ICT4AWE 2022 - 8th International Conference on Information and Communication Technologies for Ageing Well and e-Health

Figure 6: Patients’ and caregivers’ willingness to use the digital tools of the CoroPrevention Tool Suite.

mously agreed that they would be willing to use the

proposed tools supporting the CoroPrevention-SDM

approach. There were a few neutral responses. For

the patients that participated in the study, these neu-

tral responses might be due to the fact that the car-

diac patients that participated in the usability study

already completed cardiac rehabilitation quite a long

time ago. Therefore, using these tools might be less

relevant for them at this moment. As a minor limita-

tion, we should note that there is a possibility for bias

in favour of more motivated patients, due to the way

in which we recruited our participants, i.e. people that

already participated in cardiac rehabilitation and were

willing to participate in a formative usability test.

6 CONTRIBUTIONS AND

FUTURE DIRECTIONS

European guidelines and EAPC position statements

(Ambrosetti et al., 2021; Graham et al., 2017; Vis-

seren et al., 2021) recommend that secondary preven-

tion programs offer a holistic approach and incorpo-

rate shared decision making as a means to engage pa-

tients. We are not aware of any existing system that

offers this support at the time of writing this paper.

Current systems include only some of the key compo-

nents of secondary prevention and/or do not support

shared decision making. This prompted us to design

and develop a technology-supported shared decision

making approach for a comprehensive secondary pre-

vention program for cardiac patients.

6.1 Summary of Contributions

The contributions of this paper are the following:

• Bringing together patients’ and caregivers’ needs

with the European guidelines and EAPC position

statements for secondary prevention in a holistic,

shared decision making approach for secondary

prevention of cardiovascular diseases;

• Incorporating the resulting needs in a Tool Suite

that supports patients and caregivers in following

a SDM approach for a comprehensive secondary

prevention program;

• Deriving initial insights on collaborative goal-

setting for behavioural goals based on a formative

usability study of our proposed approach and ac-

companying tools with patients and caregivers.

In Figure 1 and Figure 2, we provided an overview of

cardiac patients’ and their caregivers’ goals and asso-

ciated needs for tools supporting SDM for a compre-

hensive secondary prevention program. During the

design phase, this overview supported us in selecting

features that support the target users and ensuring that

the designed applications ﬁt with end users’ needs.

We believe that the overview of goals and needs can

be generalized to any eHealth intervention supporting

shared decision making for a healthy lifestyle. There-

fore, we hope that our overview can be useful for

other researchers working in this ﬁeld.

In this paper, we presented the CoroPrevention-

SDM approach and accompanying Tool Suite consist-

ing of three applications supporting a shared decision

making approach for a comprehensive cardiac sec-

ondary prevention program. We illustrated how these

tools align with the categorization of tools to support

shared decision making of Bonneux et al. (Bonneux

et al., 2019) and with our conceptual ﬁgures (Figure

1 and Figure 2). Furthermore, we gave a high-level

overview of the core features of the different tools of

the CoroPrevention Tool Suite. However, a detailed

overview of the features and design of the different

applications is out of scope for this paper.

Lastly, we evaluated our proposed

CoroPrevention-SDM approach in a question-

naire that was part of a formative usability study. Our

survey showed that both patients and caregivers are

interested in using our proposed CoroPrevention Tool

Suite to set behavioural goals during shared decision

The CoroPrevention-SDM Approach: A Technology-supported Shared Decision Making Approach for a Comprehensive Secondary

Prevention Program for Cardiac Patients

making encounters. This gives a ﬁrst indication of

patients’ and caregivers’ willingness to use digital

tools for SDM, but a more thorough investigation

is needed to evaluate the impact of these tools on

patient outcomes, such as health parameters, but also

motivation and engagement in the decision-making

process.

6.2 Future Directions

In our formative usability tests using wireframes,

we collected preliminary insights on patients’ and

caregivers’ willingness to follow our proposed

CoroPrevention-SDM approach and evaluated the us-

ability of the different applications of the Coro-

Prevention Tool Suite. Currently, our proposed

CoroPrevention-SDM approach and supporting Tool

Suite are in development, and gradually extended

with additional modules. As a next step, we plan

to investigate if the tools of the CoroPrevention Tool

Suite support shared decision making. In a summa-

tive test with the application modules that will used in

the RCT, we will let patients and caregivers collabora-

tively set personalized goals during a SDM encounter.

Next, in the second half of 2022, a large-scale

randomized controlled trial (RCT) will start to eval-

uate our proposed technology-supported shared de-

cision making approach for a comprehensive sec-

ondary prevention program for cardiac patients (ref-

erence to https://clinicaltrials.gov/ anonymized for re-

view). In the RCT, 12000 coronary heart disease pa-

tients will be recruited across 6 European countries, of

which 2000 high-risk patients will be enrolled in the

nested RCT that evaluates the CoroPrevention-SDM

approach and accompanying Tool Suite. Over a pe-

riod of three years, patients and their supporting care-

givers will use the CoroPrevention Tool Suite to set

personalized goals for the patients and follow up on

their progress. Human-Computer Interaction related

outcomes will include the usability and user experi-

ence of the different tools, patients’ motivation for be-

haviour change, and the inﬂuence of the Tool Suite on

shared decision making.

7 CONCLUSIONS

In this paper, we identiﬁed varying needs and

requirements for a holistic approach for a sec-

ondary prevention program for cardiovascular dis-

eases. Based on these needs, we designed the

CoroPrevention-SDM approach and accompanying

Tool Suite. The CoroPrevention-SDM approach is

a technology-supported shared decision making ap-

proach for a comprehensive secondary prevention

program for cardiac patients. The CoroPrevention

Tool Suite consists of three applications supporting

our proposed approach: 1) an extended ePRO ap-

plication to collect patient’s status and preferences,

2) a caregiver dashboard with integrated clinical de-

cision support systems and shared decision making

support, and 3) a patient mobile application support-

ing behaviour change. A formative usability study of

the applications indicated that both patients and care-

givers are willing to use the designed applications and

follow the CoroPrevention-SDM approach. A more

thorough evaluation of our proposed approach and

supporting applications is planned for early 2022.

ACKNOWLEDGEMENTS

The research presented in this paper was supported

by grants from the Special Research Fund (BOF)

of Hasselt University (BOF18DOC26), and from

FWO (Fellowship 1SE1222N, and the FWO-ICA

project EXPERT network G0F4220N). The CoroPre-

vention project has received funding from the Euro-

pean Union’s Horizon 2020 research and innovation

programme under grant agreement No 848056.

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Prevention Program for Cardiac Patients