Influence of urban land cover changes and climate change for the exposure of European cities to flooding during high-intensity precipitation

The extent and location of impervious surfaces within urban areas due to past and present city development strongly affects the amount and velocity of run-off during high-intensity rainfall and consequently influences the exposure of cities towards flooding. The frequency and intensity of extreme rainfall are expected to increase in many places due to climate change and thus further exacerbate the risk of pluvial flooding. This paper presents a combined hydrological-hydrodynamic modelling and remote sensing approach suitable for examining the susceptibility of European cities to pluvial flooding owing to recent changes in urban land cover, under present and future climatic conditions. Estimated changes in impervious urban surfaces based on Landsat satellite imagery covering the period 1984–2014 are combined with regionally downscaled estimates of current and expected future rainfall extremes to enable 2-D overland flow simulations and flood hazard assessments. The methodology is evaluated for the Danish city of Odense. Results suggest that the past 30 years of urban development alone has increased the city's exposure to pluvial flooding by 6% for 10-year rainfall up to 26% for 100-year rainfall. Corresponding estimates for RCP4.5 and RCP8.5 climate change scenarios (2071–2100) are in the order of 40 and 100%, indicating that land cover changes within cities can play a central role for the cities' exposure to flooding and conversely also for their adaptation to a changed climate

The development of complex digital health solutions: formative evaluation combining different methodologies

The development of digital health solutions for current health care settings requires an understanding of the complexities of the health care system, organizational setting, and stakeholder groups and of the underlying interplay between stakeholders and the technology. The digital health solution was founded on the basis of an information and communication technology platform and point-of-care devices enabling home-based monitoring of disease progression and treatment outcome for patients with rheumatoid arthritis (RA).The aim of this paper is to describe and discuss the applicability of an iterative evaluation process in guiding the development of a digital health solution as a technical and organizational entity in three different health care systems.The formative evaluation comprised the methodologies of contextual understanding, participatory design, and feasibility studies and included patients, healthcare professionals, and hardware and software developers. In total, the evaluation involved 45 patients and 25 health care professionals at 3 clinical sites in Europe.The formative evaluation served as ongoing and relevant input to the development process of the digital health solution. Through initial field studies key stakeholder groups were identified and knowledge obtained about the different health care systems, the professional competencies involved in routine RA treatment, the clinics' working procedures, and the use of communication technologies. A theory-based stakeholder evaluation achieved a multifaceted picture of the ideas and assumptions held by stakeholder groups at the three clinical sites, which also represented the diversity of three different language zones and cultures. Experiences and suggestions from the patients and health care professionals were sought through participatory design processes and real-life testing and actively used for adjusting the visual, conceptual, and practical design of the solution. The learnings captured through these activities aided in forming the solution and in developing a common understanding of the overall vision and aim of this solution. During this process, the 3 participating sites learned from each other's feed-back with the ensuing multicultural inspiration. Moreover, these efforts also enabled the consortium to identify a 'tipping point' during a pilot study, revealing serious challenges and a need for further development of the solution. We achieved valuable learning during the evaluation activities, and the remaining challenges have been clarified more extensively than a single-site development would have discovered. The further obstacles have been defined as has the need to resolve these before designing and conducting a real-life clinical test to assess the outcome from a digital health solution for RA treatment.A formative evaluation process with ongoing involvement of stakeholder groups from 3 different cultures and countries have helped to inform and influence the development of a novel digital health solution, and provided constructive input and feedback enabling the consortium to control the development process

The Parker Model: applying a qualitative 3-step approach to optimally utilize input from stakeholders when introducing new device technologies in the management of chronic rheumatic diseases

Background and Objective: Qualitative methods such as semi-structured interviews and focus-groups are used to evaluate the applicability and relevance of device technologies in clinical practice, but when used alone, often lack generalizability. This study aimed to assess the face validity and feasibility of using a composite, 3-step qualitative method (the Parker Model), to inform the development and implementation of ava®, an electromechanical device (e-Device) for subcutaneous self-administration of the biologic, certolizumab pegol (CZP), used to treat rheumatic diseases. Methods: The Parker Model combines concept mapping (CM), participatory design (PD), and stakeholder evaluation (SE). CM, a structured group process, was used to identify patients’ opinions and concerns regarding the e-Device. Patients used this information in iterative PD sessions to create personal e-Device prototypes in cooperation with a designer and a healthcare professional. SE was performed based on semi-structured group and individual interviews with patients and disease-management stakeholders. Results: The study recruited 14 patients, 2 doctors, 2 nurses, 1 medical secretary, and 4 other public servants. Three CM workshops revealed 4 key considerations: technical usability, physical design, concerns, enthusiasm. Four personalized prototypes were developed during PD sessions. SE confirmed that the identified considerations were pivotal for the implementation and adaptation of the e-Device. Conclusions: This study is the first to apply a composite, qualitative research model when introducing an e-Device for the treatment and management of rheumatic disease. Results show that input from patients and other stakeholders using the Parker Model can add value to the development and implementation of an e-Device.</p

Patients with rheumatoid arthritis acquire sustainable skills for home monitoring: a prospective dual-country cohort study (ELECTOR clinical trial I)

Objective: In an eHealth setting, to investigate intra- and interrater reliability and agreement of joint assessments and Disease Activity Score using C-reactive protein (DAS28-CRP) in patients with rheumatoid arthritis (RA) and test the effect of repeated joint assessment training. Methods: Patients with DAS28-CRP ≤ 5.1 were included in a prospective cohort study (clinicaltrials.gov: NCT02317939). Intrarater reliability and agreement of patient-performed joint counts were assessed through completion of 5 joint assessments over a 2-month period. All patients received training on joint assessment at baseline; only half of the patients received repeated training. A subset of patients was included in an appraisal of interrater reliability and agreement comparing joint assessments completed by patients, healthcare professionals (HCP), and ultrasonography. Cohen’s κ coefficients and intraclass correlation coefficients (ICC) were used for quantifying of reliability of joint assessments and DAS28-CRP. Agreement was assessed using Bland-Altman plots. Results: Intrarater reliability was excellent with ICC of 0.87 (95% CI 0.83–0.90) and minimal detectable change of 1.13. ICC for interrater reliability ranged between 0.69 and 0.90 (good to excellent). Patients tended to rate DAS28-CRP slightly higher than HCP. In patients receiving repeated training, a mean difference in DAS28-CRP of –0.08 was observed (limits of agreements of –1.06 and 0.90). After 2 months, reliability between patients and HCP was similar between groups receiving single or repeated training. Conclusion: Patient-performed assessments of joints and DAS28-CRP in an eHealth home-monitoring solution were reliable and comparable with HCP. Patients can acquire the necessary skills to conduct a correct joint assessment after initial and thorough training. [clinicaltrials.gov (NCT02317939)]</p