15250-m-cuypers

200 Chapter 10 no information was available about patient characteristics from those patients who were possibly eligible but were not offered a DA. In particular in hospitals with low implementation rates, a selection bias could have occurred if only patients were included who favored DA use. Another limitation is that the implementation period was not exactly simultaneous for all three DAs. Implementation of DA1 started almost a year ahead of DA2 and DA3. Moreover, a previous version of DA1 was studied in an earlier trial, which could have helped achieving the higher overall implementation of DA1 26 . Furthermore, each participating hospital was linked to one of the three regions, and consequently implemented its respective DA. Possibly, some patients or care providers could have been more supportive of another DA and overall DA uptake would have been higher if all formats would be matched according to patient or care providers’ preferences. For example, one patient might benefit more from an elaborate DA, while for another patient optimal understanding and satisfaction is reached with a concise DA 34-37 . Finally, no information was available from patients who received, and possibly also used a DA but did not consent to participate in the survey study. Patient evaluations from the three DAs in the current study were all favorable towards implementation. To further understand the observed differences in implementation rates between hospitals, future steps towards sustained DA use should include further investigation into barriers at the level of care providers and organizational barriers. Conclusion Overall implementation rate of the DAs in clinical routine was 40%. A wide variation in uptake across hospitals was observed for each DA. Most patients were satisfied with the DA they received, and only few barriers of usage were perceived by patients. Offering an online-only DA led to less patient-reported facilitators compared to a paper-only or hybrid DA.