Using a mobile app for monitoring post-operative quality of recovery of patients at home: a feasibility study

Gains and limitations of a connected tracking solution in the perioperative follow-up of colorectal surgery patients

AIM

The means to target shorter hospital stay include information technology strategies to improve communication between caregivers and patients in order to limit potentially avoidable readmissions. The aim of the present study was to analyse the benefits and limitations of a smartphone-based connected tracking solution in the perioperative follow-up of colorectal surgery patients.

METHOD

This was a retrospective monocentric cohort study of consecutive patients after colorectal surgery between February and December 2018. The mobile health application included information delivery and daily structured questionnaires on a personalized patient electronic profile, before the hospital stay and for 7 days post-discharge. The medical team answered automatic alerts in real time.

RESULTS

A total of 93 eligible patients were approached and 36 had to be excluded (26 no smartphone, five no email, five not French speaking). Among the potential users, 50 (88%) engaged in an mHealth app and seven refused. Of these 50 patients, seven dropped out. Of the remaining 43 patients, the app detected 12 adverse events, and 10 (83%) were handled through the app. Healthcare providers responded to patient-generated alerts after a median time of 90 min (range 9-448 min). Patients' mean satisfaction level was 4 ± 0.97 out of 5.

CONCLUSION

In total, 88% of smartphone-equipped patients showed a willingness to engage in mHealth. Reasons for exclusion were the absence of connection tools and a language barrier. Patients who responded to the survey were satisfied with the solution and 83% of post-discharge adverse events were solved through the app, avoiding emergency consultations.

Usability of Mobile Health Apps for Postoperative Care: Systematic Review

BACKGROUND

Mobile health (mHealth) apps are increasingly used postoperatively to monitor, educate, and rehabilitate. The usability of mHealth apps is critical to their implementation.

OBJECTIVE

This systematic review evaluates the (1) methodology of usability analyses, (2) domains of usability being assessed, and (3) results of usability analyses.

METHODS

The A Measurement Tool to Assess Systematic Reviews checklist was consulted. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guideline was adhered to. Screening was undertaken by 2 independent reviewers. All included studies were assessed for risk of bias. Domains of usability were compared with the gold-standard mHealth App Usability Questionnaire (MAUQ).

RESULTS

A total of 33 of 720 identified studies were included for data extraction. Of the 5 included randomized controlled trials (RCTs), usability was never the primary end point. Methodology of usability analyses included interview (10/33), self-created questionnaire (18/33), and validated questionnaire (9/33). Of the 3 domains of usability proposed in the MAUQ, satisfaction was assessed in 28 of the 33 studies, system information arrangement was assessed in 11 of the 33 studies, and usefulness was assessed in 18 of the 33 studies. Usability of mHealth apps was above industry average, with median System Usability Scale scores ranging from 76 to 95 out of 100.

CONCLUSIONS

Current analyses of mHealth app usability are substandard. RCTs are rare, and validated questionnaires are infrequently consulted. Of the 3 domains of usability, only satisfaction is regularly assessed. There is significant bias throughout the literature, particularly with regards to conflicts of interest. Future studies should adhere to the MAUQ to assess usability and improve the utility of mHealth apps.

Feasibility of Perioperative eHealth Interventions for Older Surgical Patients: A Systematic Review

OBJECTIVES

EHealth interventions are increasingly being applied in perioperative care but have not been adequately studied for older surgical patients who could potentially benefit from them. Therefore, we evaluated the feasibility of perioperative eHealth interventions for this population.

DESIGN

A systematic review of prospective observational and interventional studies was conducted. Three electronic databases (PubMed, EMBASE, CINAHL) were searched between January 1999 and July 2019. Study quality was assessed by Methodological Index for Non-Randomized Studies (MINORS) with and without control group.

SETTING AND PARTICIPANTS

Studies of surgical patients with an average age ≥65 years undergoing any perioperative eHealth intervention with active patient participation (with the exception of telerehabilitation following orthopedic surgery) were included.

MEASURES

The main outcome measure was feasibility, defined as a patient's perceptions of usability, satisfaction, and/or acceptability of the intervention. Other outcomes included compliance and study completion rate.

RESULTS

Screening of 1569 titles and abstracts yielded 7 single-center prospective studies with 223 patients (range n = 9-69 per study, average age 66-74 years) undergoing oncological, cardiovascular, or orthopedic surgery. The median MINORS scores were 13.5 of 16 for 6 studies without control group, and 14 of 24 for 1 study with a control group. Telemonitoring interventions were rated as "easy to use" by 89% to 95% of participants in 3 studies. Patients in 3 studies were satisfied with the eHealth intervention and would recommend it to others. Acceptability (derived from consent rate) ranged from 71% to 89%, compliance from 53% to 86%, and completion of study follow-up from 54% to 95%.

CONCLUSIONS AND IMPLICATIONS

Results of 7 studies involving perioperative eHealth interventions suggest their feasibility and encourage further development of technologies for older surgical patients. Future feasibility studies require clear definitions of appropriate feasibility outcome measures and a comprehensive description of patient characteristics such as functional performance, level of education, and socioeconomic status.

Reducing ER Visits and Readmissions after Head and Neck Surgery Through a Phone-based Quality Improvement Program

Objective:

Evaluate the impact of a patient phone calls and virtual wound checks within 72 hours of discharge on reducing emergency room (ER) visits and readmissions.

Methods:

Single arm trial with comparison to historical control data of patients undergoing multi subsite head and neck cancer operations or laryngectomy between July 2017 and June 2018 at a tertiary academic medical center. Patients were contacted within 72 hours of hospital discharge. As a supplement to the call, patients were given the opportunity to video conference with and/or send pictures to the provider with additional questions via a designated wound care phone.

Results:

Ninety-one patients met inclusion criteria, of whom 83 (91.2%) were contacted. Six patients (7%) were readmitted, of whom three had not been able to be reached. The patients who had been unable to be contacted were readmitted for dysphagia (2), and a urinary tract infection (1). The contacted patients were advised to go the ER during the call for concerns for postoperative bleeding (2) and gastrointestinal bleeding (1). Twenty-five patients (30%) utilized the wound care phone. 18 patients (21.7%) reported that the phone call survey prevented them from going to the ER. When compared to the prior year, there was as statistically significant decrease in ER visits ( P < .05), and no change in readmissions.

Conclusions:

Implementation of a phone call in the early postoperative period has the potential to decrease unnecessary ER visits and enhance patient satisfaction. This may decrease strain on the health care system and improve patient care.

Level of Evidence:

4

Utilization of mobile application improves perioperative education and patient satisfaction in general surgery patients

INTRODUCTION

Clear and accurate communication is paramount in delivering high quality surgical care. Through the development of a mobile application, we provided patients with a source of education and instruction throughout the peri-operative period.

METHODS

Patients >18 years old with a smart-phone undergoing elective general surgery procedures were eligible. Patients received perioperative educational materials and text message reminders of time-sensitive events via the application. A System Usability Scale and survey was administered.

RESULTS

100 patients were enrolled; 51% completed the survey. The average SUS score was 86, correlating with >90th percentile usability. 86% of patients felt that the application improved their surgical experience, 96% said the application provided essential reminders, and 90% felt that application clarified information. 84% of patients did not identify any inconsistency between the application and surgeon.

CONCLUSION

Utilizing patient's smart phones to aid in perioperative education is feasible and improves patient satisfaction. This application has a high usability score, indicating ease of use.

Mutual-Aid Mobile App for Emergency Care: Feasibility Study

BACKGROUND

Improving the quality of patient care through the use of mobile devices is one of the hot topics in the health care field. In unwanted situations like an accident, ambulances and rescuers often require a certain amount of time to arrive at the scene. Providing immediate cardiopulmonary resuscitation (CPR) to patients might improve survival.

OBJECTIVE

The primary objective of this study was to evaluate the feasibility of an emergency and mutual-aid app model in Taiwan and to provide a reference for government policy.

METHODS

A structured questionnaire was developed as a research tool. All questionnaires were designed according to the technology acceptance model, and a Likert scale was used to measure the degree of agreement or disagreement. Moreover, in-depth interviews were conducted with six experts from medical, legal, and mobile app departments. Each expert was interviewed once to discuss feasible countermeasures and suggestions. Statistical Package for the Social Sciences (SPSS version 19; IBM Corp, Armonk, New York) was used to perform all statistical analyses, including descriptive statistics, independent sample t-tests, variance analysis, and Pearson correlation analysis.

RESULTS

We conducted this study between October 20, 2017, and November 10, 2017, at the Taipei Medical University Hospital. Questionnaires were distributed to medical personnel, visiting guests, family members, and volunteers. A total of 113 valid questionnaires were finally obtained after the exclusion of incomplete questionnaires. Cronbach α values for self-efficacy (perceived ease of use), use attitude (perceived usefulness), and use willingness and frequency were above .85, meeting the criterion of greater than .70. We observed that the reliability of each subquestion was acceptable and the values for use attitude (perceive usefulness) and use willingness and frequency were more than .90.

CONCLUSIONS

The findings suggest that perceived ease of use and perceived usefulness of the app model affect use willingness. However, perceived usefulness had an intermediary influence on use willingness. Experts in law, medical, and technology fields consider that an emergency and mutual-aid model can be implemented in Taiwan. Along with the development of an emergency and mutual-aid app model, we recommend an increase in the number of automated external defibrillators per region and promotion of correct knowledge about CPR in order to decrease morbidity and mortality.

Determining the unmet needs of patients with intracranial meningioma-a qualitative assessment

BACKGROUND

Meningiomas are the most common primary benign brain neoplasms, but despite their commonality, the supportive needs of this patient population have been overlooked. The aim of this study is to identify unmet needs of meningioma patients, caregivers, and health care providers.

METHODS

We adopted a patient-centered approach by using qualitative interviewing with patients diagnosed with a meningioma who have undergone treatment in the last 10 years since the date of their interview. Informal caregivers (family and/or friends) of the patient population and health care providers who are normally involved in the management and care of meningioma patients were also interviewed. Interview transcripts were subjected to thematic analysis.

RESULTS

Of the 50 participants interviewed, there were 30 patients, 12 caregivers, and 8 health care professionals. Thematic analysis revealed 4 overarching themes: (1) access to targeted postoperative care, (2) financial struggles for patients and their families, (3) lack of information specific to meningiomas and postsurgical management, and (4) lack of psychosocial support.

CONCLUSION

This study identified supportive needs specific to the meningioma patient population, which predominantly falls within the postoperative phase. The postoperative journey of this patient population could potentially extend to the rest of the patient's life, which necessitates resources and information directed to support postoperative recovery and management. The development of directly relevant supportive resources that support meningioma patients in their postoperative recovery is necessary to improve the health-related quality of life in this patient population.

Mobile technology: Usage and perspective of patients and caregivers presenting to a tertiary care emergency department

BACKGROUND

Developments in information technology (IT) have driven a push in healthcare innovation in the emergency department (ED). Many of these applications rely on mobile technology (MT) such as smartphones but not everyone is comfortable with MT usage. Our study aims to characterize the technology usage behavior of users in the ED so as to guide the implementation of IT interventions in the ED.

METHODS

A cross-sectional survey was conducted in the emergency department of a tertiary hospital. Patients and their caregivers aged 21 and above were recruited. The survey collected demographic information, technology usage patterns, and participant reported comfort level in the usage of MT. We performed descriptive statistics and multivariate logistic regression to identify factors differentially associated with comfort in usage of MT.

RESULTS

A total of 498 participants were recruited, and 299 (60%) were patients. English was the most commonly written and read language (66.9%) and 64.2% reported a comfort level of 3/5 or more in using MT. Factors that were associated with being comfortable in using MT include having a tertiary education, being able to read and write English, as well as being a frequent user of IT. Caregivers were more likely to display these characteristics.

CONCLUSION

A large proportion of ED patients are not comfortable in the usage of MT. Factors that predicted comfort level in the usage of MT were common amongst caregivers. Future interventions should take this into consideration in the design of MT interventions.

University of California Technology Wellness Index: A Physician-Centered Framework to Assess Technologies' Impact on Physician Well-Being

Technology is increasingly being incorporated into the everyday workflows of physicians. There are concerns that electronic medical records and other digital technologies will contribute to the growing epidemic of physician burnout. However, some technologies, such as telemedicine, have demonstrated positive effects on physician health by saving time, enhancing work-life balance, improving quality, and restoring more control and flexibility to their practices. Organizations often lack data to evaluate the impact of technologies on physician health. The University of California Technology Wellness Index is a framework that provides a fast, systematic, physician-centered method to assess the impact of technology on physician well-being.

Should Lack of Social Support Prevent Access to Organ Transplantation?

Transplantation programs commonly rely on clinicians' judgments about patients' social support (care from friends or family) when deciding whether to list them for organ transplantation. We examine whether using social support to make listing decisions for adults seeking transplantation is morally legitimate, drawing on recent data about the evidence-base, implementation, and potential impacts of the criterion on underserved and diverse populations. We demonstrate that the rationale for the social support criterion, based in the principle of utility, is undermined by its reliance on tenuous evidence. Moreover, social support requirements may reinforce transplant inequities, interfere in patients' personal relationships, and contribute to biased and inconsistent listing procedures. As such, accommodating the needs of patients with limited social support would better balance ethical commitments to equity, utility, and respect for persons in transplantation. We suggest steps for researchers, transplantation programs, and policymakers to improve fair use of social support in transplantation.

Implementation and Evaluation of a Smartphone Application for the Perioperative Care of Neurosurgery Patients at an Academic Medical Center: Implications for Patient Satisfaction, Surgery Cancelations, and Readmissions

BACKGROUND

Smartphone applications (apps) in the health care arena are being increasingly developed with the aim of benefiting both patients and their physicians. The delivery of adequate instructions both before and after a procedure or surgery is of paramount importance in ensuring the best possible outcome for patients.

OBJECTIVE

To demonstrate that app-based instructions with built-in reminders may improve patient understanding and compliance and contribute to reducing the number of surgery cancellations and postoperative complications and readmissions.

METHODS

We prospectively accrued 56 patients undergoing routine neurosurgery procedures who subsequently downloaded the app. The median age was 54 (range 27-79). Patients were followed for successful registration and use of the app, compliance with reading instructions before and after surgery, and sending pain scores and/or wound images. The number of surgeries cancelled, postoperative complications, 30-d readmissions, and phone calls for surgery-related questions were examined.

RESULTS

Fifty-four of the 56 patients successfully registered, downloaded, and used the app and read and complied with instructions both before and after surgery. There were no cancelled surgeries. There was 1 postoperative complication. There were no readmissions. Eight of the 54 patients (14.8%) called the office on a single occasion for a surgery related question.

CONCLUSION

We demonstrate the utility of a smartphone application in the perioperative neurosurgical care setting with regard to patient compliance and satisfaction as well as surgery cancellations and readmissions. Further study of a larger number of patients with a control group is warranted.

Perioperative monitoring of inguinal hernia patients with a smartphone application

INTRODUCTION

Patient Reported Outcomes have become standard in the evaluation of inguinal hernia repair. However, the chosen outcomes remain heterogeneous and the measurements time-consuming or inadequate. Perioperative measurement of pain and recovery could benefit from the contemporary possibilities that mobile health applications offer.

METHODS

An application for smartphones and tablets was developed using the twitch crowdsourcing concept, classical questionnaires, experiences from randomised clinical trials, and patients' input.

RESULTS

Dichotomous questions and numeric rating scales, both pre- and post-operative, were implemented in the freely available Q1.6 application. Content, timing and frequencies were adapted to the inguinal hernia patient's daily life and assumed recovery. Certain combinations of answers were set as alert notifications to detect adverse events. Data are displayed on a web-based dashboard enabling real-time monitoring. Legal aspects were examined and taken into account.

DISCUSSION

The Q1.6 inguinal hernia app is an innovative tool for perioperative monitoring of pain and recovery of inguinal hernia patients. Previous limitations of classical measurements such as a large heterogeneity, retrospective data recording and different forms of bias can be eliminated. The `big data´ generated in this manner might be used for large-scale research to improve inguinal hernia surgery. The Q1.6 platform is not only hernia specific; it is also an innovative tool to measure PROs in any other domain.

Mobile messaging and smartphone apps for patient communication and engagement in spine surgery

Mobile health (mHealth) applications are rapidly becoming increasingly available to patients. These interventions utilize simple mobile messaging (SMS) and software applications on mobile devices for a variety of purposes. In the surgical population mHealth applications have shown promise in increasing medication and protocol adherence, monitoring patients after surgery, and helping modify behaviors associated with poor surgical outcomes. There is a paucity of spine specific applications at this time. Further development and study of efficacy of spine specific mHealth applications is needed.

Engaging Patients in Co-Design of Mobile Health Tools for Surgical Site Infection Surveillance: Implications for Research and Implementation

Background: As the use of patient-owned devices, including smartphones and tablets, to manage day-to-day activities grows, so does healthcare industry's interest to better leverage technology to engage patients. For surgical care, a unique opportunity exists to capture patient-generated health data (PGHD) including photographs. As part of a broader initiative to evaluate PGHD for surgical site infection (SSI) surveillance, we sought evidence regarding patient involvement and experience with PGHD for SSI monitoring and surveillance. Methods: Through a scoping review of the literature and semi-structured stakeholder interviews we gathered evidence on what is currently known about patient perspectives of and experiences with mobile health (mHealth) interventions for post-operative recovery. We presented findings to and discussed with the ASSIST PGHD Stakeholder Advisory Group (PSAG) to generate priorities for further examination. Results: Our scoping review yielded 34 studies that addressed post-discharge use of PGHD for monitoring and surveillance of SSI. Of these, 16 studies addressed at least one outcome regarding patient experience; the most commonly measured outcome was patient satisfaction. Only three studies reported on patient involvement in the development of PGHD tools and interventions. We conducted interviews (n = 24) representing a range of stakeholder perspectives. Interviewees stressed the importance of patient involvement in tool and program design, noting patient involvement ensures the "work" that patients do in their daily lives to manage their health and healthcare is recognized. Discussion of evidence with the ASSIST PSAG resulted in formal recommendations for direct involvement of patients and caregivers for future work. Conclusions: While mHealth initiatives to advance post-operative management offer the ability to improve patient engagement, work is needed to ensure the patient voice is reflected. Active engagement with patients and caregivers in the development of new technology, the design of new workflows, and the conduct of research and evaluation ensures that the patient experiences and values are incorporated.

Does "hospital loyalty" matter? Factors related to the intention of using a mobile app

PURPOSE

This study aimed to explore the association between hospital loyalty, perceived usefulness of a mobile app, perceived ease of use of that mobile app, and satisfaction with the app's use as well as predicting patients' intended use of the app.

PATIENTS AND METHODS

Purposive sampling was adopted in a cross-sectional survey. The participants were outpatients at the traditional Chinese medicine departments of three hospitals in northern Taiwan (n=125). The self-report questionnaire comprised information about sociodemographics and scales related to hospital loyalty, perceived usefulness of the mobile app, its perceived ease of use, satisfaction with its use, and its usage intention. The data were analyzed using structural equation modeling.

RESULTS

The four factors explained 70% variance in usage intention. The perceived usefulness of the mobile app directly and indirectly affects their usage intention, but its perceived ease of use had only indirect effects on the usage intention. Perceived usefulness and perceived ease of use influence the usage intention through satisfaction. The women's hospital loyalty does not directly affect the usage intention of the mobile app, but indirectly affects it through perceived usefulness and perceived ease of use of the mobile app.

CONCLUSION

Intended use of the app by women is mainly related to their experience of which is usefulness, ease of use and satisfaction of service are the most important factors contributing to continuous use. Hospital loyalty does not directly affect intention to use as expected. The influence of loyalty must be related to the patients' perception of the product, in terms of usefulness, ease to use, and satisfaction. The finding is helpful to understand patients' preference and support their behavioral adherence.

The influence of mobile health applications on patient - healthcare provider relationships: A systematic, narrative review

OBJECTIVE

To explore the influence of mobile health applications on various dimensions of patient and healthcare provider relationships.

METHODS

A systematic, narrative review of English literature reporting experiences and outcomes of using mobile health applications was performed, evaluating communication and relationships between patients and healthcare professionals. Findings were framed thematically within the four dimensions of relationship-centred care. The methodological quality of included articles was appraised.

RESULTS

Thirty-seven articles were included, all of them meeting tenets of relationship-centred care. After adopting mobile health applications patients perceived an overall positive impact on their relationship with healthcare providers, indicating they are ready to transition from traditional clinical ecounters to a different modality. Use of the applications supported patients in assuming active roles in the management of their health in collaboration with health professionals. Reluctance of providers to using mobile health needs to be acknowledged and addressed when encouraging wider use of applications in clinical practice.

CONCLUSION

The use of mobile health applications can influence communication and relationships between patients and providers positively, facilitating relationship-centered healthcare.

PRACTICE IMPLICATION

Implementation of mobile health can support patients' self-efficacy, improve access to healthcare services and improve relationships between patients and providers in ambulatory and hospital settings.

Factors influencing day surgery patients' quality of postoperative recovery and satisfaction with recovery: a narrative review

The aim of healthcare services is to provide a high quality of care. One way to ensure that this aim has been fulfilled is to assess patients' satisfaction with their care. Although satisfaction is a complex concept, it is an important outcome in perioperative care. The objective of this paper is to discuss and reflect on factors that can affect patients' quality of postoperative recovery and satisfaction with recovery after day surgery. Involving patients in shared decision-making (SDM) and providing sufficient preoperative and postoperative information can improve their satisfaction. It is important to assess whether patients experience poor recovery, which can be both distressing and dissatisfying. We suggest that patients' age, sex, mental health status, and health literacy (HL) skills should be assessed preoperatively, since these factors seem to have a negative impact on patients' postoperative recovery. Identifying factors that have a negative impact on patients' quality of postoperative recovery and satisfaction with recovery after day surgery will assist healthcare professionals in supporting vulnerable patients, such as those with limited HL and poor mental health. Treating patients with respect and dignity and providing SDM can increase their quality of postoperative recovery and satisfaction with recovery.

Adoption of Enhanced Recovery after Surgery Protocols in Breast Reconstruction in Alberta Is High before a Formal Program Implementation

Supplemental Digital Content is available in the text.

Background:

Enhanced recovery after surgery (ERAS) techniques have consistently demonstrated improved patient outcomes across multiple surgical specialties. We have lead international consensus guidelines on ERAS protocols for breast reconstruction and recently implemented these guidelines in Alberta. This study looks at adoption rates of ERAS pathways for breast reconstruction within Alberta, whereas also addressing barriers to ERAS implementation.

Methods:

A retrospective analysis of online operative reports in the Synoptec database consisting of patients undergoing alloplastic or autogenous breast reconstruction in Alberta was conducted. Primary outcomes of interest included whether ERAS protocols were utilized and what the reported barriers to ERAS utilization were.

Results:

Of the 372 patients undergoing breast reconstruction surgery, 215 (57%) patients were placed on an ERAS protocol. Autogenous reconstruction patients were more likely than alloplastic reconstruction patients to be placed on ERAS protocols (72% versus 53%, P = 0.002). A lack of resources was the most commonly cited reason for not adopting ERAS protocols for both autogenous and alloplastic reconstruction groups (53% and 53%). Surgeons in Southern Alberta were more likely than surgeons in Northern Alberta to utilize ERAS protocols for their alloplastic (73% versus 8%, P < 0.001) and autogenous (99% versus 4%, P < 0.001) reconstructions.

Conclusions:

Adoption of ERAS protocols in Alberta was strong (57% adherence) before a formal program implementation. We are encouraged that the recent official launch of ERAS protocols in breast reconstruction within the province will further enhance the uptake and care of this unique surgical population.

The Use of Data Collected From mHealth Apps to Inform Evidence-Based Quality Improvement: An Integrative Review

BACKGROUND

The global acceptance and use of technology in health care has resulted in an abundance of mobile health (mHealth) applications (apps) available for use in the delivery and improvement of care. With so many apps available to patients and clinicians, it is important to understand how data from apps are being used to inform quality improvement in practice.

AIM

The aim of this integrative review is to establish current knowledge of how mHealth apps are used to produce data to inform quality improvement in health care.

METHODS

Scopus, Web of Science, CINAHL, and Medline Plus Full Text databases were searched for peer-reviewed papers written in English. The inclusion criteria comprised of full-text, empirical research studies relating to mobile health application use (not development) in clinical care.

RESULTS

Nineteen studies met inclusion criteria. The functions of the apps outlined in the studies can be summarized into four different categories: communication, illness management, clinical management, and education/information. The types of data collected by the apps included numerical, textual, photographic, and graphical with several apps able to collect a variety of data types. Analysis of the studies showed that although data collection is rarely outlined as the explicit purpose of mHealth apps, data collected through such technology are and can be used to inform practice change both in real time and retrospectively.

LINKING EVIDENCE TO ACTION

This review highlights while this is an emerging area, data obtained from mHealth apps can and are being used to inform quality improvement in health care. Further research is required in this area to adequately understand how data from mHealth apps can be used to produce quality improvement, specifically in relation to nursing. This review also highlights a need for the development of apps that aim to capture data to inform quality improvement, particularly from the patient perspective.

Smartphone Use and Interest in a Spine Surgery Recovery Mobile Application Among Patients in a US Academic Neurosurgery Practice

BACKGROUND

Mobile applications (apps) are serving an increasingly important role in healthcare for patients and providers alike. In addition to streamlining active communication of patient-reported outcomes regarding quality of life, pain, and opioid consumption, smartphones equipped with activity tracking afford the opportunity to passively and objectively measure mobility, a key metric of recovery in spine surgery. However, app development is a resource-intensive process.

OBJECTIVE

To survey adult neurosurgery patients regarding access to and interest in this platform.

METHODS

In June and July 2017, a paper-based anonymous survey was distributed to patients in the waiting room of the adult neurosurgery clinic of a large US academic medical center. Patients’ smartphone use and interest in using a mobile app following spine surgery were the primary and secondary outcomes, respectively.

RESULTS

Of 146 included responses, 102 patients (70%) regularly used a smartphone, and this number increased to 77% among patients with a history of spine surgery (n = 66, 45% of respondents). Seventy-one percent of patients with previous spine surgery expressed an interest in using a postoperative monitoring and communication app, compared to 81% of patients without prior spine operations (n = 80, 55%).

CONCLUSION

Among neurosurgery patients, there is a high level of access to and interest in smartphone apps to aid postoperative recovery. These results are useful for other neurosurgeons considering mobile app development for this purpose.

Benefits of Enhanced Recovery After Surgery for fusion in degenerative spine surgery: impact on outcome, length of stay, and patient satisfaction

OBJECTIVE

Enhanced Recovery After Surgery (ERAS) proposes a multimodal, evidence-based approach to perioperative care. Thanks to the improvement in care protocols and the fluidity of the patient pathway, the first goal of ERAS is the improvement of surgical outcomes and patient experience, with a final impact on a reduction in the hospital length of stay (LOS). The implementation of ERAS in spinal surgery is in the early stages. The authors report on their initial experience in applying an ERAS program to several degenerative spinal fusion procedures.

METHODS

The authors selected two 2-year periods: the first from before any implementation of ERAS principles (pre-ERAS years 2012–2013) and the second corresponding to a period when the paradigm was applied widely (post-ERAS years 2016–2017). Patient groups in these periods were retrospectively compared according to three degenerative conditions requiring fusion: anterior cervical discectomy and fusion (ACDF), anterior lumbar interbody fusion (ALIF), and posterior lumbar fusion. Data were collected on patient demographics, operative and perioperative data, LOSs, 90-day readmissions, and morbidity. ERAS-trained nurses were involved to support patients at each pre-, intra-, and postoperative step with the help of a mobile application (app). A satisfaction survey was included in the app.

RESULTS

The pre-ERAS group included 1563 patients (159 ALIF, 749 ACDF, and 655 posterior fusion), and the post-ERAS group included 1920 patients (202 ALIF, 612 ACDF, and 1106 posterior fusion). The mean LOS was significantly shorter in the post-ERAS group than in the pre-ERAS group for all three conditions. It was reduced from 6.06 ± 1.1 to 3.33 ± 0.8 days for the ALIF group (p < 0.001), from 3.08 ± 0.9 to 1.3 ± 0.7 days for the ACDF group (p < 0.001), and from 6.7 ± 4.8 to 4.8 ± 2.3 days for posterior fusion cases (p < 0.001). There was no significant difference in overall complications between the two periods for the ALIF (11.9% pre-ERAS vs 11.4% post-ERAS, p = 0.86) and ACDF (6.0% vs 8.2%, p = 0.12) cases, but they decreased significantly for lumbar fusions (14.8% vs 10.9%, p = 0.02). Regarding satisfaction with overall care among 808 available responses, 699 patients (86.5%) were satisfied or very satisfied, and regarding appreciation of the mobile e-health app in the perceived optimization of care management, 665 patients (82.3%) were satisfied or very satisfied.

CONCLUSIONS

The introduction of the ERAS approach at the authors’ institution for spinal fusion for three studied conditions resulted in a significant decrease in LOS without causing increased postoperative complications. Patient satisfaction with overall management, upstream organization of hospitalization, and the use of e-health was high. According to the study results, which are consistent with those in other studies, the whole concept of ERAS (primarily reducing complications and pain, and then reducing LOS) seems applicable to spinal surgery.

A Mobile Phone-Based Self-Monitoring Tool for Perioperative Gastric Cancer Patients With Incentive Spirometer: Randomized Controlled Trial

BACKGROUND

An incentive spirometer (IS) is a medical device used to help patients improve the functioning of their lungs. It is provided to patients who have had any surgery that might jeopardize respiratory function. An incentive spirometer plays a key role in the prevention of postoperative complications, and the appropriate use of an IS is especially well known for the prevention of respiratory complications. However, IS utilization depends on the patient's engagement, and information and communication technology (ICT) can help in this area.

OBJECTIVE

This study aimed to determine the effect of mobile ICT on the usage of an IS (Go-breath) app by postoperative patients after general anesthesia.

METHODS

For this study, we recruited patients from April to May 2018, who used the Go-breath app at a single tertiary hospital in South Korea. The patients were randomly classified into either a test or control group. The main function of the Go-breath app was to allow for self-reporting and frequency monitoring of IS use, deep breathing, and active coughing in real time. The Go-breath app was identical for both the test and control groups, except for the presence of the alarm function. The test group heard an alarm every 60 min from 9 am to 9 pm for 2 days. For the test group alone, a dashboard was established in the nurse's station through which a nurse could rapidly assess the performance of multiple patients. To evaluate the number of performances per group, we constructed an incentive spirometer index (ISI).

RESULTS

A total of 44 patients were recruited, and 42 of them completed the study protocol. ISI in the test group was 20.2 points higher than that in the control group (113.5 points in the test group and 93.2 points in the control group, P=.22). The system usability scale generally showed almost the same score in the 2 groups (79.3 points in the test group and 79.4 points in the control group, P=.94). We observed that the performance rates of IS count, active coughing, and deep breathing were also higher in the test group but with no statistically significant difference between the groups. For the usefulness "yes or no" question, over 90% (38/42) of patients answered "yes" and wanted more functional options and information.

CONCLUSIONS

The use of the Go-breath app resulted in considerable differences between the test group and control group but with no statistically significant differences.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03569332; https://clinicaltrials.gov/ct2/show/NCT03569332 (Archived by WebCite at http://www.webcitation.org/74ihKmQIX).

Change in Patient Comfort Using Mobile Phones Following the Use of an App to Monitor Tuberculosis Treatment Adherence: Longitudinal Study

Background

As mHealth apps proliferate, it is necessary for patients to feel capable and comfortable using devices that run them. However, limited research is available on changes in comfort level before and after the use of an mHealth app.

Objective

The objective of this study was to determine whether patients with tuberculosis who used an mHealth app called Video Directly Observed Therapy (VDOT) to monitor their antituberculosis treatment became more comfortable using mobile phones after the intervention and to identify factors associated with change in comfort.

Methods

We analyzed data from a longitudinal study assessing the feasibility and acceptability of the VDOT app among patients receiving antituberculosis treatment from public health departments in San Diego, San Francisco, and New York City. Comfort levels on six domains of mobile phone use (making phone calls, taking pictures, recording videos, text messaging, internet and email use on the phone) were measured on a 10-point scale (1=very uncomfortable; 10=very comfortable) at the start and end of treatment using VDOT via telephone interviews. The main outcomes were change in comfort level on each domain (recoded as binary measures) and an overall change score (sum of individual measures). Linear and logistic regression analyses were performed to assess whether sociodemographics, risk factors, and VDOT perceptions were associated with change of comfort measures.

Results

Among 120 participants with complete data, mean age was 39.8 years (SD 14.8, range 18-87 years), 46.7% (56/120) were female, and 76.7% (92/120) were foreign born. The combined comfort level at baseline was high overall (mean 48.8, SD 14.2, interquartile range 43.0-60.0) and the mean comfort score increased by 1.92 points at follow-up (P=.07). Statistically significant increases in comfort on individual domains included taking pictures (P=.02) and recording videos (P=.002). Females were more likely to have increased comfort in using the internet on the phone compared to males (odds ratio [OR] 3.03, 95% CI 1.08-8.52, P=.04). Participants who worked less hours per week were more likely to have increased comfort recording videos although this did not meet statistical significance (OR 1.03, 95% CI 1.00-1.05, P=.06).

Conclusions

Findings suggest that, despite a high level of comfort using mobile phones at baseline, experience using the VDOT app was associated with increased comfort using mobile phone features. Additional research involving participants with lower baseline mobile phone experience is needed. An implication of these findings is that as patients begin to use mHealth apps for one health condition, they could acquire skills and confidence to more quickly adapt to using mHealth apps for other conditions.

Electronic Health Program to Empower Patients in Returning to Normal Activities After Colorectal Surgical Procedures: Mixed-Methods Process Evaluation Alongside a Randomized Controlled Trial

BACKGROUND

Long-term recovery takes longer than expected despite improved surgical techniques and Enhanced Recovery After Surgery programs. An electronic health (eHealth) care program ("ikherstel") was developed to partially substitute perioperative care for patients undergoing colorectal surgical procedures. Successfully tested eHealth programs are not always implemented in usual care, and it is, therefore, important to evaluate the process to optimize future implementation.

OBJECTIVE

The aim of this study was to evaluate whether the eHealth intervention was executed as planned.

METHODS

A mixed-methods process evaluation was carried out alongside a multicenter randomized controlled trial (RCT). This evaluation was performed using the Linnan and Steckler framework for the quantitative part of this study, measuring the components reach, dose delivered, dose received, fidelity, and participants' attitudes. Total implementation scores were calculated using the averaging approach, in which the sum of all data points is divided by the number of data points and the total adherence to the protocol is measured. For the qualitative part, the Unified Theory of Acceptance and Use of Technology framework was used. The quantitative data were based on participants' questionnaires, a logistic database, a weblog, and participants' medical files and were obtained by performing semistructured interviews with participants of the RCT.

RESULTS

A total of 151 participants of 340 eligible patients were included in the RCT, of which 73 participants were allocated to the intervention group. On the basis of the quantitative process data, total implementation scores for the website, mobile app, electronic consult, and activity tracker were 64%, 63%, 44%, and 67%, respectively. Participants in the qualitative part experienced the program as supportive and provided guidance on their recovery process after colorectal surgery. Most frequently mentioned barriers were the limited interaction with and feedback from health care professionals and the lack of tailoring of the convalescence plan in case of a different course of recovery.

CONCLUSIONS

The intervention needs more interaction with and feedback from health care professionals and needs more tailored guidance in case of different recovery or treatment courses. To ensure a successful implementation of the program in daily practice, some adjustments are required to optimize the program in a blended care form.

TRIAL REGISTRATION

Netherlands Trial Registry NTR5686; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC= 5686 (Archieved by WebCite at http://www.webcitation.org/75LrJaHrr).

Mobile educational follow-up application for patients with peripheral arterial disease

OBJECTIVE

to describe the development of a prototype mobile educational application for nursing follow-up aimed at patients diagnosed with peripheral arterial disease.

METHOD

a prototype-based technological production study. The construction followed the contextualized instructional design model using two steps: analysis and design and development.

RESULTS

the pedagogical content of the application was based on a survey of needs of patients with Peripheral Arterial Disease and treatments recommended in the literature. The prototype developed contained concepts, risk factors, signs and symptoms, treatment, importance of medications and their side effects, frequent doubts, necessary health care, and follow-up of patients by monitoring the evolution of the cicatricial process of lesions and possible complications, clarification of doubts and stimulus for continuation of treatment.

CONCLUSION

the use of health applications is a technological tool with the potential to improve the follow-up of patients regarding the progress of the disease and self-care, monitoring of risk factors, co-participation of the patient in the treatment, family participation, as well as planning of individualized care, and cost reduction for the health system.

Effect of a Mobile App on Preoperative Patient Preparation for Major Ambulatory Surgery: Protocol for a Randomized Controlled Trial

BACKGROUND

Inadequate preoperative patient preparation causes organizational, economic, and emotional problems to patients and professionals. In Spain, no current evidence is available on either the rate of compliance or the impact of good compliance with preoperative recommendations by patients in the ambulatory setting. However, it is known that around 25% of surgical cancellations in the major ambulatory surgery (MAS) are due to poor compliance with these recommendations and, therefore, avoidable. Introducing innovative tools based on mobile health (mHealth) apps may help patients meet the preoperative recommendations and, consequently, reduce the rate of cancellations in the ambulatory setting.

OBJECTIVE

The objective of this study was to evaluate the effectiveness of the Listeo+ mHealth app as a tool for improving compliance with preoperative recommendations in MAS versus standard of care (SOC).

METHODS

A multicenter, randomized, open-label clinical trial that compares SOC with the additional use of Listeo+, a specific mHealth app for MAS preoperative patient monitoring, is being conducted. The study will include patients aged ≥18 years with surgical indication for MAS who meet the necessary technological and connectivity requirements. Patients in the control group will receive written preoperative recommendations, while those in the intervention group will additionally use the Listeo+ mHealth app. There will be a competitive recruitment of 790 patients during 6 months in 4 hospitals in Andalusia (Spain) that belong to the National Health System. The primary efficacy outcome is the level of compliance with preoperative recommendations. Secondary outcomes include the rate of cancellations, associated resource consumption, and perceived usability and utility with Listeo+ by participants of the intervention group. Simple randomization 1:1 procedure will be used to allocate patients to each study group.

RESULTS

The technological development of Listeo+ and the integration and interoperability of information systems was completed in September 2017. Subsequently, simulation tests were performed with Listeo+, and a pilot study was initiated with real patients that concluded successfully in October 2017. Patient recruitment began in December 2017 in the 4 participating centers. After an intermediate analysis performed 10 months after the start of the recruitment phase, the data collection and cleaning phases are estimated to be completed in April 2019, and the analysis with the final results will be conducted in July 2019.

CONCLUSIONS

Progress in the integration and interoperability of information systems represents a major step forward in the field of mHealth. The app will allow health professionals to monitor in real-time patients' preparation and critical preoperative recommendations fulfillment. We expect a reduction in avoidable preoperative cancellations due to a lack of or a poor patient preparation. Self-assessed Web-based questionnaires and focus group will provide important information about the perceived usability and utility of Listeo+ app among patients and health care professionals.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/10938.

The Use of Smartphone Applications (Apps) for Enhancing Communication With Surgical Patients: A Systematic Review of the Literature

Background. The widespread use and development of smartphones and mHealth apps has the potential to overcome communication deficiencies in health care. Objective. To carry out a literature review of studies that evaluate patients’ experience on the use of perioperative mHealth apps. Methods. An up-to-date systematic review on studies assessing patients’ use of mHealth apps for communicating with the health care team in the perioperative period was performed following the PRISMA statement. Results. Ten studies (in 11 articles) were identified: 8 feasibility studies and 2 randomized controlled trials. Nine studies included apps used for postoperative monitoring while 1 study also provided preoperative guidance. Discussion. An analysis of barriers and motivations of patients and health care professionals to the use of perioperative mHealth apps was performed. Barriers included patients’ lack of confidence when using apps and potential lack of time from health care professionals to monitor information submitted by patients. Motivations included patients’ sense of being looked after and potential cost-effectiveness and increased efficiency of health care services. This analysis led to the concept of the “ideal app” that would need to be developed following adequate protocols and security standards. Features of the ideal app include preoperative advice on medications and investigations, information on surgery, and a remote follow-up tool to improve safety and to minimize unnecessary clinic appointments and associated costs. Conclusion. There is an overall positive impression of the use of perioperative mHealth apps. However, further studies are required to assess the impact that they have on patients’ care and healthcare professional services.

What Kind Of A Mobile Health App Do Patients Truly Want? A Pilot Study Among Ambulatory Surgery Patients

BACKGROUND

An increasing number of surgeries are performed as ambulatory surgeries, and mobile health applications (m-health apps) have therefore been designed to help provide patients with more convenient health-care services and improve the working efficiency of health-care professionals (HCPs). To find an effective approach to design such m-health apps, a study to evaluate ambulatory surgery patients' preferences is necessary.

METHODS

A structured questionnaire was distributed to 360 patients undergoing ambulatory surgery to understand their demographic characteristics, preferences regarding the features and functions of m-health apps and willingness to engage with m-health apps.

RESULTS

In total, 84.16% of ambulatory surgery patients stated that they would be willing to engage with an m-health app during the perioperative period. In addition, their top 10 necessary features and functions of m-health apps were related mainly to ambulatory surgery and communication with HCPs. Furthermore, younger age (χ ²=10.42, p<0.01), employment (χ ²=9.04, p<0.01), higher education (χ ²=13.67, p<0.01), longer daily use of phones (χ ²=11.84, p<0.01) and more frequent usage of m-health apps (χ ²=23.23, p<0.01) were associated with patients' willingness to engage with m-health apps, but only more frequent usage of m-health apps (OR=2.97, 95% CI=1.54-5.71, p<0.01) was found to be a predictor.

CONCLUSION

This study presents an initial evaluation of ambulatory surgery patients' preferences regarding m-health apps. Gaining these insights will be useful to help us design an evidence-based, highly functional m-health app that best meets the needs of patients undergoing ambulatory surgery.

Theoretical Advancements in mHealth: A Systematic Review of Mobile Apps

There are now few hundred thousand healthcare apps, yet there is a gap in our understanding of the theoretical mechanisms for which, and how, technological features translate into improved healthcare outcomes. In particular, the technological convergence, within mobile health (mHealth) apps, of the processes of mass and interpersonal communication, and human-computer interaction requires greater parsing in the literature. This paper analyzed 85 empirical studies on mHealth apps using the Input-Mechanism-Output model. We found in the literature that, firstly, there is a greater emphasis on technological inputs (87%) of accessibility, usability, usage, and data quality, than health outputs (52%) such as system process efficiencies and individual level behavioral or health outcomes. Secondly, there is little evidence of explanatory mechanisms (19%) of how the effects of mHealth apps are achieved. While we believe that successful apps would require research that incorporates technological inputs, theoretical mechanisms and health outputs, such studies are a rarity (n = 3). There is a minor increase in rigor with randomized control trials (n = 5), and a preponderance of discussion around social influence (n = 8) and gamification (n = 7), albeit in a scattered manner. We discuss the implications of the trend towards socialization and gamification findings in terms of future research, particularly in terms of study design guided by theoretical mechanisms.

Postoperative care via smartphone following carpal tunnel release

Introduction

This study explores a novel smartphone application for postoperative care following carpal tunnel release (CTR). We hypothesized that a software-based ‘virtual visit’ for CTR could be safe, effective and convenient for the patient.

Methods

Our group developed the software application utilized in this study. Interactive steps with video instructions enabled patients to complete dressing and suture removal, capture a wound photo, answer a question about median nerve symptoms and capture a video of finger range of motion. Adult patients undergoing endoscopic or open CTR were enrolled. Prior to their scheduled postoperative visit, patients received and completed the module using their smartphone. Agreement between findings of the virtual visit and the corresponding in-person clinical visit was assessed using kappa values.

Results

Twenty-two patients were contacted regarding study enrolment and 17 patients were enrolled (ages 23–63, mean 48.2, 6M, 11F). Of 16 patients who participated, all completed dressing removal. Ten of 16 patients removed their sutures successfully. Fourteen patients captured a clinically adequate wound photo and 15 patients answered a question about median nerve symptoms. Fourteen patients captured a range of motion video. Software assessments of surgical wounds, nerve symptoms and physical exams agreed strongly with clinical assessments.

Discussion

Most patients were able to respond to a question about their symptoms, provide clinical assessment of their wound via a photo and record a video of their range of motion. Suture removal was the most difficult task. More investigation is needed to determine which patients can reliably remove their sutures.

Postoperative Home Monitoring After Joint Replacement: Feasibility Study

BACKGROUND

We conducted a prospective observational study of patients undergoing elective primary hip or knee replacements to examine the feasibility of a postoperative home monitoring system as transitional care to support patients following their surgery in real time.

OBJECTIVE

The primary outcome was the mean percentage of successful wireless transmissions from home of blood pressure levels, heart rate, oxygen saturation levels, and pain scores until postoperative day 4 with a feasibility target of ≥90%.

METHODS

Patients with an expected length of stay ≤1 day, age 18-80 years, Revised Cardiac Risk Index ≤ class 2, and caretakers willing to assist at home were eligible. Patient satisfaction, as a secondary outcome, was also evaluated. Wireless monitoring equipment (remote patient monitoring, Telus Canada) was obtained and a multidisciplinary care team was formed.

RESULTS

We conducted the study after obtaining Research Ethics Board approval; 54 patients completed the study: 21 males, 33 females. In total, we evaluated 9 hips, 4 hip resurfacing, 26 total knees, and 15 hemi-knees. The mean transmission rate was 96.4% (SD 5.9%; 95% CI 94.8-98.0). The median response to "I would recommend the Remote Monitoring System program to future patients" was 4.5 (interquartile range 4-5), with 1 being "strongly disagree" and 5 "strongly agree." At 30 days postop, there was no mortality or readmission.

CONCLUSIONS

This is an evolving new paradigm for postoperative care and the first feasibility study on monitoring biometrics after primary hip or knee replacement. Postoperative home monitoring combines current technology with real-time support by a multidisciplinary transitional care team after discharge, facilitating postsurgical care with successful wireless transmission of vitals. The postoperative home monitoring implementation is, therefore, generalizable to other surgical discharges from hospitals.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02143232; https://clinicaltrials.gov/ct2/show/NCT02143232 (Archived by WebCite at http://www.webcitation.org/71ugAhhIk).

The Evolution of Surgical Enhanced Recovery Pathways: a Review

PURPOSE OF REVIEW

Enhanced recovery pathways are a well-defined perioperative health care program utilizing evidence-based interventions in a protocol-like manner designed to standardize techniques including drug selection and dosing to improve results and to reduce overall costs including facilitating earlier discharge from hospitals after surgery.

RECENT FINDINGS

A PubMed and World Wide Web search was performed with the following key words: enhanced recovery, surgical enhanced recovery, recovery pathways, and enhanced recovery pathways surgery. This introduction to enhanced recovery pathways reflects its 20-year history, worldwide appeal, and ever growing presence in our practices. Many clinical teams have not, as of yet, incorporated enhanced recovery pathway principles to their practices and therefore, continued evolution should include increasing outreach and formalized guidelines in the future.

Mobile Health Technology Is Here-But Are Hospice Informal Caregivers Receptive?

BACKGROUND:

Mobile health applications (mHealth apps) represent a rapidly emerging technology that is being used to improve health-care delivery. In home hospice, informal caregivers play an essential role in attending to the day-to-day needs of their terminally ill loved ones. Using mHealth apps by caregivers in this setting could potentially improve the support provided to both patients and caregivers at the end of life (EoL).

OBJECTIVES:

To explore informal caregivers' receptivity and concerns in using mHealth apps along with app features, caregivers perceived to be most useful in home hospice care.

DESIGN:

Eighty semistructured phone interviews were conducted with informal caregivers who received care from a nonprofit hospice organization. Study data were analyzed using content analysis, coding for themes of receptivity and interest.

RESULTS:

Sixty-two (78%) participants were receptive to using an mHealth app in home hospice care. Informal caregivers were interested in features that addressed: (1) communication to improve patient care (n = 44, 70%), (2) access to patient care information (n = 30, 48%), (3) education (n = 24, 39%), and (4) updates from health-care personnel and scheduling services (n = 10, 16%).

CONCLUSIONS:

A substantial majority of informal caregivers voiced receptivity to using mHealth apps and expressed interest in features that enhance communication and provide information to improve patient care. Although more research is needed to examine how to incorporate this technology into existing home hospice care, our study suggests that informal caregivers are likely to use this technology they feel will help enhance home-based EoL care delivery.

Holding It Together-Patients' Perspectives on Postoperative Recovery When Using an e-Assessed Follow-Up: Qualitative Study

Background

There is an emerging trend to perform surgeries as day surgery. After a day surgery, most of the recovery period takes place at home, and patients are responsible for their own recovery. It has been suggested that electronic health (eHealth) technologies can support patients in this process. A mobile app has recently been developed to assess and follow up on postoperative recovery after a day surgery.

Objective

The aim of this study was to explore experiences associated with postoperative recovery after a day surgery in patients using a mobile app to assess the quality of their recovery.

Methods

This is a qualitative interview study with an explorative and descriptive design. Participants were recruited from 4 different day surgery units in different parts of Sweden. The study included 18 participants aged >17 years who had undergone day surgery and used the Recovery Assessment by Phone Points, a mobile app for follow-up on postoperative recovery after day surgery. Participants were purposively selected to ensure maximum variation. Semistructured individual interviews were conducted. Data were analyzed using thematic analysis.

Results

A total of two themes and six subthemes emerged from the data: (1) the theme Give it all you’ve got with the subthemes Believing in own capacity, Being prepared, and Taking action, where participants described their possibilities of participating and themselves contributing to improving their postoperative recovery; and (2) the theme The importance of feeling safe and sound with the subthemes Feeling safe and reassured, Not being acknowledged, and Not being left alone, which describe the importance of support from health care professionals and next of kin.

Conclusions

It is important that patients feel safe, reassured, and acknowledged during their postoperative recovery. They can achieve this themselves with sufficient support and information from the health care organization and their next of kin. Using a mobile app, both for assessment and to enable contact with the day surgery unit during the postoperative recovery period, can improve care and create a feeling of not being alone after surgery. We propose that postoperative recovery starts in the prerecovery phase when patients prepare for their recovery to get the best possible outcome from their surgery.

Sex Similarities in Postoperative Recovery and Health Care Contacts Within 14 Days With mHealth Follow-Up: Secondary Analysis of a Randomized Controlled Trial

Background

Previous studies have shown that women tend to have a poorer postanesthesia recovery than men. Our research group has developed a mobile phone app called Recovery Assessment by Phone Points (RAPP) that includes the Swedish Web version of the Quality of Recovery (SwQoR) questionnaire to monitor and assess postoperative recovery.

Objective

The aim of this study was to investigate sex differences in postoperative recovery and the number of health care contacts within 14 postoperative days in a cohort of day-surgery patients using RAPP.

Methods

This study was a secondary analysis from a single-blind randomized controlled trial. Therefore, we did not calculate an a priori sample size regarding sex differences. We conducted the study at 4 day-surgery settings in Sweden from October 2015 to July 2016. Included were 494 patients (220 male and 274 female participants) undergoing day surgery. The patients self-assessed their postoperative recovery for 14 postoperative days using the RAPP.

Results

There were no significant sex differences in postoperative recovery or the number of health care contacts. Subgroup analysis showed that women younger than 45 years reported significantly higher global scores in the SwQoR questionnaire (hence a poorer recovery) on postoperative days 1 to 10 than did women who were 45 years of age or older (P=.001 to P=.008). Men younger than 45 years reported significantly higher global scores on postoperative days 2 to 6 than did men 45 years of age or older (P=.001 to P=.006). Sex differences in postoperative recovery were not significant between the age groups.

Conclusions

This study found sex similarities in postoperative recovery and the number of health care contacts. However, subgroup analysis showed that age might be an independent factor for poorer recovery in both women and men. This knowledge can be used when informing patients what to expect after discharge.

Trial Registration

ClinicalTrials.gov NCT02492191; https://clinicaltrials.gov/ct2/show/NCT02492191 (Archived by WebCite at http://www.webcitation.org/6y2UtMbvz)

Accessible Communication Tools for Surgical Site Infection Monitoring and Prevention in Joint Reconstruction: Feasibility Study

Background

The National Surgical Quality Improvement Program logs surgical site infections (SSIs) as the most common cause of unplanned postoperative readmission for a variety of surgical interventions. Hospitals are making significant efforts preoperatively and postoperatively to reduce SSIs and improve care. Telemedicine, defined as using remote technology to implement health care, has the potential to improve outcomes across a wide range of parameters, including reducing SSIs.

Objective

The purpose of this study was to assess the feasibility and user satisfaction of two automated messaging systems, EpxDecolonization and EpxWound, to improve perioperative care in a quality improvement project for patients undergoing total joint replacement.

Methods

We designed two automated text messaging and calling systems named EpxDecolonization, which reminded patients of their preoperative decolonization protocol, and EpxWound, which monitored pain, wound, and fever status postoperatively. Daily patient responses were recorded and a post-usage survey was sent out to participants to assess satisfaction with the systems.

Results

Over the 40-week study period, 638 and 642 patients were enrolled in EpxDecolonization (a preoperative decolonization reminder) and EpxWound (a postoperative surgical site infection telemonitoring system), respectively. Patients could be enrolled in either or both EpxDecolonization and EpxWound, with the default option being dual enrollment. The proportion of sessions responded to was 85.2% for EpxDecolonization and 78.4% for EpxWound. Of the 1280 patients prescribed EpxWound and EpxDecolonization, 821 (64.14%) fully completed the postoperative system satisfaction survey. The median survey score (scale 1-9) was 9 for patient-rated overall care and 8 for whether the telemonitoring systems improved patient communication with providers. The majority of patients (69.0%, 566/821) indicated that the systems sent out an ideal number of messages (not too many, not too few).

Conclusions

EpxDecolonization and EpxWound demonstrated high response rates and improved patient-rated communication with providers. These preliminary data suggest that these systems are well tolerated and potentially beneficial to both patients and providers. The systems have the potential to improve both patient satisfaction scores and compliance with preoperative protocols and postoperative wound monitoring. Future efforts will focus on testing the sensitivity and specificity of alerts generated by each system and on demonstrating the ability of these systems to improve clinical quality metrics with more authoritative data.

The role of telemedicine in postoperative care

Telemedicine has become one of the most rapidly-expanding components of the health care system. Its adoption has afforded improved access to care, greater resource efficiency, and decreased costs associated with traditional office visits and has been well established in a wide array of fields. Telemedicine has been adopted in several domains of surgical care. In recent years, the role of telemedicine in postoperative care has caught attention as it has demonstrated excellent clinical outcomes, enhanced patient satisfaction, increased accessibility along with reduced wait times, and cost savings for patients and health care systems. In this narrative review, we describe the history of telemedicine, its adoption in the field of surgery and its various modalities, its use in the postoperative setting, and the potential benefits to both patients and healthcare systems. As telemedicine continues to emerge as a powerful tool for health care delivery, we also discuss several barriers to its widespread adoption as well as the future utility of telemedicine in postoperative care.

Mobile Web-Based Follow-up for Postoperative ACL Reconstruction: A Single-Center Experience

Background

The initial 6 weeks after surgery has been identified as an area for improvement in patient care. During this period, the persistence of symptoms that go unchecked can lead to unscheduled emergency room and clinic visits, calls to surgeons' offices, and readmissions.

Purpose

To analyze postoperative data from a previous study examining postoperative outcomes in 2 patient populations following breast reconstruction and anterior cruciate ligament (ACL) reconstruction with use of a patient-centered mobile application. Here, the authors establish whether this method of follow-up can provide useful insight specific to the orthopaedic patient population, and they determine whether the mobile platform has the potential to modify their postoperative treatment. In addition, the authors examine its utility for orthopaedic physicians and patients.

Study Design

Case series; Level of evidence, 4.

Methods

Eligible patients undergoing ACL reconstruction from 2 surgeons were consecutively recruited to use a mobile smartphone application that allowed physicians to monitor their recovery at home. Data from 32 patients were collected via the application and analyzed to evaluate recovery trends during the first 6 postoperative weeks. Following completion of the study, patients and physicians were interviewed on their experience.

Results

Data collected from each question in the mobile application provided insightful trends on daily real-time indicators of postoperative recovery. The application identified 1 patient who required in-person reassessment to rule out a possible infection, following surgeon review of an uploaded image. It was estimated that the majority of patients could have avoided follow-up at 2 and 6 weeks, owing to the application's efficacy. Participants described their satisfaction with the device as excellent (43%), good (40%), fair (10%), and poor (7%), and 94% (n = 30) of patients reported that they would respond to questions using a similar application in the future. Both physicians rated their experience as positive and identified useful traits in the web portal.

Conclusion

This system can accurately assess patient recovery; it has the potential to change how postoperative orthopaedic patients are followed, and it is well received by patients and physicians. Recognition of the study's limitations and employment of user feedback to improve the current application are essential before a formal randomized controlled trial is conducted.

Two-Way Social Media Messaging in Postoperative Cataract Surgical Patients: Prospective Interventional Study

Background

Social media offers a new way to provide education, reminders, and support for patients with a variety of health conditions. Most of these interventions use one-way, provider-patient communication. Incorporating social media tools to improve postoperative (postop) education and follow-up care has only been used in limited situations.

Objective

The aim of this study was to determine the feasibility and efficacy of two-way social media messaging to deliver reminders and educational information about postop care to cataract patients.

Methods

A total of 98 patients undergoing their first eye cataract surgery were divided into two groups: a no message group receiving usual pre- and postop care and a message group receiving usual care plus messages in a mobile social media format with standardized content and timing. Each patient in the message group received nine messages about hand and face hygiene, medication and postop visit adherence, and links to patient education videos about postop care. Patients could respond to messages as desired. Main outcome measures included medication adherence, postop visit adherence, clinical outcomes, and patients’ subjective assessments of two-way messaging. The number, types, content, and timing of responses by patients to messages were recorded.

Results

Medication adherence was better in the message group at postop day 7, with high adherence in 47 patients (96%, 47/49) versus 36 patients (73%, 36/49) in the no message group (P=.004), but no statistically significant differences in medication adherence between the groups were noted at preop and postop day 30. Visit adherence was higher at postop day 30 in the message group (100%, 49/49) versus the no message group (88%, 43/49; P=.03) but was 100% (49/49) in both groups at postop day 1 and 7. Final visual outcomes were similar between groups. A total of 441 standardized messages were sent to the message group. Out of 270 responses generated, 188 (70%) were simple acknowledgments or “thank you,” and 82 (30%) responses were questions that were divided into three general categories: administrative, postop care, and clinical issues. Out of the 82 question responses, 31 (11%) were about administrative issues, 28 (10%) about postop care, and 23 (9%) about clinical symptoms. All the messages about symptoms were triaged by nurses or ophthalmologists and only required reassurance or information. Patients expressed satisfaction with messaging.

Conclusions

Two-way social media messaging to deliver postop information to cataract patients is feasible and improves early medication compliance. Further design improvements can streamline work flow to optimize efficiency and patient satisfaction.

Patient Satisfaction With an Early Smartphone-Based Cosmetic Surgery Postoperative Follow-Up

BACKGROUND

While prevalent in everyday life, smartphones are also finding increasing use as a medical care adjunct. The use of smartphone technology as a postoperative cosmetic surgery adjunct for care has received little attention in the literature.

OBJECTIVES

The purpose of this effort was to assess the potential efficacy of a smartphone-based cosmetic surgery early postoperative follow-up program. Specifically, could smartphone photography provided by the patient to the plastic surgeon in the first few days after surgery allay patient's concerns, improve the postoperative experience and, possibly, detect early complications?

METHODS

From August 2015 to March 2016 a smartphone-based postoperative protocol was established for patients undergoing cosmetic procedures. At the time of discharge, the plastic surgeon sent a text to the patient with instructions for the patient to forward a postoperative photograph of the operated area within 48 to 72 hours. The plastic surgeon then made a return call/text that same day to review the patient's progress. A postoperative questionnaire evaluated the patients' postoperative experience and satisfaction with the program.

RESULTS

A total of 57 patients were included in the study. Fifty-two patients responded to the survey. A total of 50 (96.2%) patients reported that the process improved the quality of their postoperative experience. The protocol allowed to detect early complications in 3 cases. The physician was able to address and treat the complications the following day prior to the scheduled clinic follow up.

CONCLUSIONS

The smartphone can be effectively utilized by the surgeon to both enhance the patient's postoperative experience and alert the surgeon to early postoperative problems.

LEVEL OF EVIDENCE

4.

Challenges During Implementation of a Patient-Facing Mobile App for Surgical Rehabilitation: Feasibility Study

Background

Translating research into practice, especially the implementation of digital health technologies in routine care, is increasingly important. Yet, there are few studies examining the challenges of implementing patient-facing digital technologies in health care settings.

Objective

The aim of this study was to report challenges experienced when implementing mobile apps for patients to support their postsurgical rehabilitation in an orthopedic setting.

Methods

A mobile app was tailored to the needs of patients undergoing rotator cuff repair. A 30-min usability session and a 12-week feasibility study were conducted with patients to evaluate the app in routine care. Implementation records (observation reports, issues log, and email correspondence) explored factors that hindered or facilitated patient acceptance. Interviews with clinicians explored factors that influenced app integration in routine care.

Results

Participant completion was low (47%, 9/19). Factors that affected patient acceptance included digital literacy, health status, information technology (IT) infrastructure at home, privacy concerns, time limitations, the role of a caregiver, inconsistencies in instruction received from clinicians and the app, and app advice not reflective of patient progress over time. Factors that negatively influenced app integration in routine care included competing demands among clinicians, IT infrastructure in health care settings, identifying the right time to introduce the app to patients, user interface complexity for older patients, lack of coordination among multidisciplinary clinicians, and technical issues with app installation.

Conclusions

Three insights were identified for mobile app implementation in routine care: (1) apps for patients need to reflect their journey over time and in particular, postoperative apps ought to be introduced as part of preoperative care with opportunities for patients to learn and adopt the app during their postoperative journey; (2) strategies to address digital literacy issues among patients and clinicians are essential; and (3) impact of the app on patient outcomes and clinician workflow needs to be communicated, monitored, and reviewed. Lastly, digital health interventions should supplement but not replace patient interaction with clinicians.

Acceptability of a digital health intervention alongside physiotherapy to support patients following anterior cruciate ligament reconstruction

Background

Physiotherapy rehabilitation following surgical reconstruction to the Anterior Cruciate Ligament (ACL) can take up to 12 months to complete. Given the lengthy rehabilitation process, a blended intervention can be used to compliment face-to-face physiotherapy with a digital exercise intervention. In this study, we used TRAK, a web–based tool that has been developed to support knee rehabilitation, which provides individually tailored exercise programs with videos, instructions and progress logs for each exercise, relevant health information and a contact option that allows a patient to email a physiotherapist for additional support. The aim of this study was to evaluate the acceptability of TRAK–based blended intervention in post ACL reconstruction rehabilitation.

Methods

A qualitative research design using semi-structured interviews was used on a convenience sample of participants following an ACL reconstruction, and their treating physiotherapists, in a London NHS hospital. Participants were asked to use TRAK alongside face-to-face physiotherapy for 16 weeks. Interviews were carried out, audio recorded, transcribed verbatim and coded by two researchers independently. Data were analyzed using thematic analysis.

Results

Of the 25 individuals that were approached to be part of the study, 24 consented, comprising 8 females and 16 males, mean age 30 years. 17 individuals used TRAK for 16 weeks and were available for interview. Four physiotherapists were also interviewed. The six main themes identified from patients were: the experience of TRAK rehabilitation, personal characteristics for engagement, strengths and weaknesses of the intervention, TRAK in the future and attitudes to digital healthcare. The main themes from the physiotherapist interviews were: potential benefits, availability of resources and service organization to support use of TRAK.

Conclusions

TRAK was found to be an acceptable method of delivering ACL rehabilitation alongside face-to-face physiotherapy. Patients reported that TRAK, specifically the videos, increased their confidence and motivation with their rehabilitation. They identified ways in which TRAK could be developed in the future to meet technological expectations and further support rehabilitation. For Physiotherapists time and availability of computers affected acceptability. Organization of care to support integration of digital exercise interventions such as TRAK into a blended approach to rehabilitation is required.

Enhanced Recovery After Surgery (ERAS) Protocol Enables Safe Same-Day Discharge After Alloplastic Breast Reconstruction

BACKGROUND

To compare enhanced recovery after surgery (ERAS) with traditional recovery after surgery (TRAS) for patients undergoing alloplastic breast reconstruction.

METHODS

A retrospective chart review of 2 patient groups (ERAS and TRAS) undergoing alloplastic breast reconstruction was performed. Data were collected from 2012 to 2013 (TRAS) and from 2013 to 2016 (ERAS). The ERAS protocol included day surgery, multimodal analgesia, and preoperative anti-emetic. The TRAS pathway involved overnight admission, narcotic-based analgesia, and no preoperative anti-emetic. Demographics, operative variables, and complications were compared between groups.

RESULTS

Seventy-eight ERAS patients and 78 TRAS patients were included. Length of stay was shorter for ERAS patients (0.38 nights ERAS and 1.45 nights TRAS; P < .001). The ERAS patients underwent significantly more bilateral surgery (80.8% ERAS and 55.1% TRAS; P < .001), immediate reconstruction (98.6% ERAS and 89.3% TRAS; P = .004), and had more implants versus expanders placed (66% [93/141] ERAS and 24.8% TRAS; P < .001). There were no differences in the number of post-operative emergency department visits (8% ERAS and 14% TRAS; P = .2) and readmissions (8% ERAS and 3.8% TRAS; P = .3) between the groups. There was no difference in the rate of hematoma (0.7% ERAS and 0% TRAS; P = .35), infection requiring explantation (1.4% ERAS and 0.8% TRAS; P = .65), infection requiring outpatient IV antibiotics (1.4% ERAS and 2.5% TRAS; P = .53), and infection requiring IV antibiotics and readmission (2.1% ERAS and 1.7% TRAS; P = .78) between the groups. There were no differences in the number of minor complications (22% ERAS and 23% TRAS; P = .82).

CONCLUSION

The ERAS protocol for alloplastic breast reconstruction is safe, without increased readmission or complication rates compared to TRAS, and significantly decreased length of stay.