In this study, we used the intervention mapping (IM) approach, a systematic and comprehensive methodology grounded in theory and developed in collaboration with key stakeholders (health care providers, patients, and informal caregivers) [13,14]. The 6 steps of the IM approach are (1) identification of the problem by performing a needs assessment, (2) identification of outcomes and change objectives, (3) selection of theory-based intervention methods and practical strategies, (4) development of an intervention, (5) generation of an adoption and implementation plan, and (6) generation of an evaluation plan. In this study, we completed the first 3 steps of the IM protocol.

The development of this remote intervention was performed on the existing platform of Cardiovitaal Cardiac Rehabilitation Amsterdam currently only used by patients who have started outpatient physical rehabilitation. This existing digital platform is used by patients to monitor physical (eg, blood pressure and steps per day) and psychological (symptoms of anxiety and depression) health. In addition, patients and health care providers use this platform to communicate using videocalling or the chat function. The design of the early coaching program was incorporated in the existing digital platform. At the beginning of this study, a multidisciplinary research group of health care providers comprised physical therapists (PK, ICDvD), physical therapist (Ilonka Pol), psychologist (VRJ), cardiologist (RAK), and registered nurse (Christine Dolman). All participants had expertise in the field of CR. The research group met on 3 occasions to discuss each step. The authors (PK and ICDvD) completed each step only after group consensus was reached. During each step the following tasks were completed.

For this study, patients were identified through an electronic patient file search of the Amsterdam University Medical Center and approached by telephone shortly after hospital discharge (2 to 4 days). We aimed to include a heterogenous sample to obtain a wide variety of viewpoints to increase the generalizability of our program.

We included patients with an acute coronary syndrome (ACS), coronary revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]), or referral to CR. Patients were excluded if they had cognitive problems (Mini-Mental State Exam <24) or were unable to speak Dutch. Recruitment of patients ended when no new information was discovered in the data analysis (data saturation).

The Medical Ethics Committee of the Amsterdam University Medical Center approved the study protocol (NL65218.018.18).

An exploratory literature review synthesizes the extant literature and usually identifies the gaps in knowledge that an empirical study addresses [16]. The objective of our exploratory literature review was to assess information and support needs after (acute) cardiac hospitalization. A comprehensive search was performed in PubMed to identify relevant studies concerning this topic. For this search, automatic term mapping was used to match the entered terms with Medical Subject Headings to enhance the search strategy. The following terms were used in the search builder: (coronary artery disease) OR (acute coronary syndrome) OR (percutaneous coronary intervention) OR (coronary artery bypass graft) AND (information needs OR support needs). The search strategy included terms occurring in the title and main text with no restrictions for date range but limited to the English language. During the screening process, articles were selected on title, abstract, and full text. The literature search was conducted by ICDvD and continuously discussed with PK and BV.

Semistructured interviews were conducted to assess patients’ information and support needs. An interview guide was developed by the research group, in several rounds, until consensus was reached about the final version (Multimedia Appendix 1). These 30-minute interviews took place at the Amsterdam University Medical Center or at the patient’s home. During the COVID-19 pandemic, interviews were continued by telephone. All patients gave informed consent for their personal data being used in this study. Interviews were performed by 2 physical therapists (PK and ICDvD), a physician assistant (Tarik Hoek Spaans), and 2 registered nurses (Bonita Meek and Miranda Balfoort).

All interviews were transcribed and were analyzed with qualitative data analysis software (MAXQDA 2018, VERBI GmbH). Three types of coding were used consecutively: open, axial, and selective. Initial codes were created by studying the segmented information. The codes were then abstracted into categories and subcategories. The underlying meanings of these categories were linked together to create overall themes. All data were independently coded for themes by 2 researchers (PK, ICDvD). A third researcher (BV) reviewed all codes and decided appropriate themes together with PK and ICDvD.

The initial exploratory literature search identified 4606 electronic database papers. After removal of duplicates and non-English articles, the remaining papers were screened by title and abstract. After the screening procedure (see Figure 1 for flowchart), 38 articles were studied to identify the information and support needs of cardiac patients (see Multimedia Appendix 2 for an extraction table of our literature search).

Patients report a lack of (consistent) information after hospital discharge and that information needs were not always correctly perceived by health care providers [17-19]. The highest priority of information needs comprised information about medication and side effects, wound care, postoperative pain, physical activity, and dealing with emotions [20-28].

The greatest needs of information were found in young and middle-aged patients with a higher education [20,21]. No differences in type of information needs were found between men and women; however, women preferred to receive information before revascularization while men preferred it afterward [29,30]. Patients who were hospitalized after an acute coronary event were in greater need of information and emotional support than those treated electively [31].

High levels of anxiety were reported in the weeks after hospital discharge, especially in female patients and those with a lower education [32,33]. Patients reported distressing body signals, difficulties with sleeping, and insecurity about engaging in physical activity and returning to work [20,32,34-36]. Spouses reported high levels of psychological distress linked to anxiety, financial worry, and loneliness [37-39], highlighting a need to include spouses and informal caregivers in decision making and support programs [40-42].

In general, patient knowledge about risk factors and management of heart disease was limited, and patients often attributed the cause of their disease to nonmodifiable risk factors (ie, age, heredity) instead of lifestyle factors such as smoking, lack of physical activity, and unhealthy food choices [43-46]. However, reduction of mortality risk was rated as most important by patients with ACS [47].

In addition to having difficulties with understanding medical information, patients experienced problems with the referral process from hospital discharge to CR, which in turn led to a discontinuity in the health care process [48]. Those with a lower socioeconomic status felt especially excluded from CR while also having high information needs [49]. Moreover, these patients tended to have health beliefs that were not based on medical evidence, a predictor of nonadherence to CR [50,51]. Patients described advanced communication skills and pedagogical competences as important skills for health care providers [52]. Furthermore, the ability to build trust and tailor information to the individual were described by patients as important skills for health care providers [53,54].

Data saturation was achieved after 17 eligible patients were included. Ten patients participated in an interview at the hospital or at home, and 7 patients took part in telephone interviews. Our total study population comprised 17 patients (9 females) with a median age of 64 years. Ten patients were diagnosed with ACS and 7 patients with angina pectoris. An overview of baseline characteristics is presented in Table 1.

Our data revealed 6 main themes: psychological distress, distressing body signals, lack of information at hospital discharge, passive coping style, disrupted health care process after hospital discharge, and social support. Qualitative findings with reference to individual patients can be found in Table 1.

The logic model of change was developed based on the findings in step 1. First, behavioral and environmental outcomes were defined. Second, the influence of these outcomes on the health problem and quality of life was described. Third, performance objectives were formulated for the behavioral and environmental outcomes. Fourth, a theoretical framework and determinants to influence were selected. Last, a determinant matrix was developed that describes how each determinant is related to the performance objectives.

The results from step 2 were used to design the program. In this step, the research group matched the 6 determinants and performance objectives with theory-based and practical strategies, in line with the IM taxonomy [57]. The selection of theory-based strategies was based on the theoretical framework of Kok et al [57]; please see this paper for a detailed explanation of the theory-based strategies.

The results of this study suggest that patients’ needs after hospital discharge comprise information and support about the following topics: CAD, medication and side effects, daily physical activities, psychological distress, and body signals. In addition, we present a systematic approach to develop an early remote coaching program using the IM protocol.

The overall objective of this remote coaching program is to bridge the gap from hospital discharge to the start of center-based CR by stimulating self-management behavior and influencing the following determinants: knowledge, skills, social support, attitudes, and self-efficacy. We selected theory-based techniques that match these determinants, as research indicates the value of theory-based interventions [57,58]. Moreover, patients were actively involved in the development of this coaching program. To assure adoption of the intervention, patients have been asked to participate in the future refinement of the final intervention in step 4 of the IM approach.

A recent systematic review reports that core components of CR, such as nutrition counseling and psychological and weight management are addressed in one-third of digital CR programs; less than one-third of these programs address management of lipids, diabetes, smoking cessation, and blood pressure [59]. Since our CR program aims to bridge the gap between hospital discharge and the start of CR, we chose to assess the needs of patients in the early phase after hospital discharge. Our study shows that in this phase patients value social support, disease specific information, and information about physical activities and psychological distress. Research shows that health care needs change over time. Nevertheless, knowledge about pathology and how to manage psychological distress remain important even after a 2-year follow-up period [60].

Based on our results, we developed a comprehensive coaching program using remote counseling as the main strategy and considered its positive impact on psychosocial health, physical health, and clinical status [9-11]. In this study, we chose to complement behavioral counseling sessions with educational video clips. The use of video modeling has potential benefits such as facilitation of knowledge acquisition, improving self-care behaviors, and reducing psychological distress [61]. Moreover, video modeling is effective in patients with low health literacy and removes inconsistencies between health care providers [62,63].

Informal caregivers were invited to actively participate in this intervention since research shows that many informal caregivers suffer from psychological distress after their partner’s hospitalization [37-42]. In addition, informal caregivers play an important role in the recovery of the patient; however, hypervigilance in informal caregivers can undermine patients’ health and recovery [64]. It is therefore important to inform and support informal caregivers in their new role. A recent study shows that patients and informal caregivers prefer the same content and delivery formats for digital interventions (eg, health video clips, contact with health care provider) [65]. It is thus expected that informal caregivers can benefit from this remote coaching program.

For this coaching program to be successful, health care providers need to encourage patients to reflect on the obtained knowledge and skills and offer strategies to adopt behavior changes in daily life. Therefore, health care providers should be well trained in applying behavior change techniques and have the ability to build trust in patients.

First, we consider the use of the IM protocol a strength since digital health behavior interventions often lack theoretical grounding, as expertise from different scientific areas is often lacking in the design phase [66]. In line with the IM protocol, the development of this intervention was supported by researchers with expertise in various fields (cardiology, physical therapy, psychology, and nursing science), ensuring a firm theoretical approach.

Second, patients’ needs and expectations were taken into account in the early phase of the design process, which contributed to the usability and utility of this intervention [67]. Results from our literature study and interviews indicated that the interval between hospital discharge and CR was too long and that patients wanted to be in contact with a health care provider to receive support and information. It remains unclear, however, if this remote coaching program is applicable for older adult cardiac patients with comorbidities, as they are often reluctant to use eHealth apps [68]. Nevertheless, a recent systematic review shows that older adults (aged 65 years and older) exhibited greater engagement with digital health interventions than younger adults (aged younger than 65 years). Despite the technological barriers, older adults might view digital coaching as social interaction, which is often desired by older adults. In addition, older adults might have more time to engage in digital technologies [69]. In this study, 17 patients with various ages, cardiac diagnoses, and comorbidities were included, and the results of the interviews supported the findings from the literature. It is therefore expected that this intervention is suitable for a wide variety of patients referred for CR. To assure adoption of this intervention by older adults, a thorough evaluation of the feasibility of this intervention should be conducted in step 4 of the IM approach.

Third, the use of a remote intervention is considered a strength since it can resolve several barriers at the patient level (distance to center, transportation) and health care system level (referral problems, limited facilities) [70]. In addition, this study shows that patients are in need of information and support directly after hospital discharge, despite current guidelines, which recommend initiation of CR within 4 to 6 weeks after hospital discharge [4,5]. Delayed participation in CR negatively impacts physical and psychological outcomes, while early initiation of CR positively impacts health outcomes [71-73]. An early remote coaching program starting directly after hospital discharge might help to overcome logistical issues and delays in CR initiation and is therefore well suited for the period between hospital discharge and the start of CR.

Finally, patients in this study were involved in the first steps of the intervention development. Due to the nature of this study, we used a small sample size to explore patients’ needs. However, information obtained from the interviews was supplemented with data from our scoping literature study. We therefore expect that our results are generalizable to the greater cardiac population. Future studies should focus on program refinement (IM step 4) of this remote coaching program and assess its feasibility and effectiveness in studies with larger sample sizes. It would be interesting to assess the effectiveness of this early remote coaching program on symptoms of psychological distress and participation in outpatient CR.

This study shows that patients with CAD are in need of tailored information and support after hospital discharge. The main areas of information and support are CAD, medication and side effects, physical activity, psychological distress, and body signals. In addition, this study presents the development of a remote intervention, using the IM protocol, to bridge the gap from hospital discharge to the start of CR.