Impact of a Mobile App to Support Home Recovery of Patients Undergoing Bariatric Surgery

Improving sustainability and mitigating the environmental impact of anaesthesia and surgery along the perioperative journey: a narrative review

Climate change, environmental degradation, and biodiversity loss are adversely affecting human health and exacerbating existing inequities, intensifying pressures on already strained health systems. Paradoxically, healthcare is a high-polluting industry, responsible for 4.6% of global greenhouse gas emissions and a similar proportion of air pollutants. Perioperative services are among the most resource-intensive healthcare services and are responsible for some unique pollutants. Opportunities exist to mitigate pollution throughout the entire continuum of perioperative care, including those that occur upstream of the operating room in the process of patient selection and optimisation, delivery of anaesthesia and surgery, and the postoperative recovery period. Within a patient-centred, holistic approach, clinicians can advocate for healthy public policies that modify the determinants of surgical illness, can engage in shared decision-making to ensure appropriate clinical decisions, and can be stewards of healthcare resources. Innovation and collaboration are required to redesign clinical care pathways and processes, optimise logistical systems, and address facility emissions. The results will extend beyond the reduction of public health damages from healthcare pollution to the provision of higher value, higher quality, patient-centred care.

Feasibility of app-based home monitoring after abdominal surgery: A systematic review

BACKGROUND

Abdominal surgery presents great challenges postoperatively. Considering financial healthcare constraints, the use of mobile applications has received increased interest. This systematic review was conducted to assess and report the feasibility of app-based home monitoring after abdominal surgery.

METHODS

MEDLINE, EMBASE, and The Cochrane Library were searched on the October 17, 2023. This systematic review was conducted in accordance with the PRISMA guidelines.

RESULTS

Thirty-six articles were included, 17 of these originating from USA or Canada. The response rate varied between 11.9 ​% and 100 ​%. Bariatric, upper gastrointestinal, and colorectal surgery reported the highest response rates. All included studies had a degree of bias.

CONCLUSION

This study found varying response rates. The data indicated that the response rates were high within bariatric surgery, with additional factors potentially affecting this. The degree of bias was generally high, and the quality of the included studies limits the conclusions.

Study protocol for a non-inferiority, multicenter, randomized study to evaluate a smartphone app-based follow-up program after bariatric surgery (BELLA plus trial)

INTRODUCTION

Adherence to follow-up (FU) care after bariatric surgery is poor despite strong recommendations. In our pilot Bella trial, we demonstrated that a completely remote follow-up program via smartphone is feasible and safe for patients after bariatric surgery. Building on this, we aim to verify our results in a multicenter, randomized controlled setting.

METHODS

This trial plans to enroll 410 participants undergoing primary bariatric surgery in seven German bariatric centers. Participants are randomized into two groups: a control group receiving in-person FU according to the standard in the bariatric centers, and an interventional group monitored using a smartphone application (app). The app sends standardized questionnaires and reminders regarding regular vitamin intake and exercises. The built-in messaging function enables patients to communicate remotely with medical care professionals. After one year, all participants are evaluated at their primary bariatric centers. The primary outcome is weight loss 12 months after surgery. The secondary outcomes include obesity-related comorbidities, quality of life, serum values of vitamins and minerals, body impedance analysis, visits to the emergency department or readmission, patient compliance, and medical staff workload.

DISCUSSION

The current study is the first prospective, individually randomized-controlled, multicenter trial where a mobile application completely replaces traditional in-person visits for post-bariatric surgery follow-ups in bariatric centers.

Recommendations for the Development of Psychological Smartphone Applications in the Context of Bariatric Surgery: Focus Groups with Professionals and Patients

To explore the experiences and preferences of patients and healthcare professionals regarding the development of an app to provide psychological intervention to improve emotion regulation in the context of bariatric surgery (BS). Sixteen people (6 patients who underwent BS and 10 professionals) participated in two separate focus group sessions. We performed a content analysis of transcribed focus group discussions to extract and organize categories, subcategories and areas. Both sets of stakeholders provided information about how to develop and implement an app. According to participants' comment, content should include information (i.e., nutrition, exercise) and emotional regulation skills. Patients and professionals mentioned that the app should include visual information, continuous emotional assessments and peer contact. It was also mentioned that the app should be used before and after BS and its contents should be developed by a multidisciplinary team (i.e., collaboration of endocrinologist, nutritionists and psychologists). Participants in both focus groups considered technology to be useful in the context of BS, especially as part of blended interventions (combining face-to-face and online sessions). Patients and professionals seem to be receptive towards the use of technology in a BS context. Specific recommendations are identified for designing and implementing app solutions for BS. More efforts should be made in the future to develop and implement evidence-based apps according to patients and professionals' needs.

The Utilisation of Digital Applications for Measuring Patient Outcomes Following Bariatric Surgery: a Systematic Review and Meta-analysis of Comparative Studies

In the context of escalating obesity rates, bariatric surgery holds a crucial role in managing severely obese patients. With a demonstrated effectiveness in weight loss and with the advent of ambulatory surgery, bariatric surgery allows for a streamlined care pathway, ideally suited for postoperative surveillance using digital health applications. The aim of this systematic review and meta-analysis is to evaluate the effect of eHealth-delivered health services or support for adults undergoing bariatric surgery. Five studies, encompassing 2210 patients, were analysed. The intervention group showed a 10% increase in total weight reduction and a 22% reduction in excess weight loss. ED visitation rates also trended towards reduction. Despite the absence of clear statistical superiority for DHA, the findings suggest potential benefits of DHA in postoperative monitoring.

Effectiveness of current perioperative telemonitoring on postoperative outcome in patients undergoing major abdominal surgery: A systematic review of controlled trials

BACKGROUND

Perioperative telemonitoring of patients undergoing major surgery might lead to improved postoperative outcomes. The aim of this systematic review is to evaluate the effectiveness of current perioperative telemonitoring interventions on postoperative clinical, patient-reported, and financial outcome measures in patients undergoing major surgery.

METHODS

For this systematic review, PubMed, CINAHL, and Embase databases were searched for eligible articles published between January 1, 2009 and March 15, 2021. Studies were eligible as they described: (P) patients aged 18 years or older who underwent major abdominal surgery, (I) perioperative telemonitoring as intervention, (C) a control group receiving usual care, (O) any type of postoperative clinical, patient-reported, or financial outcome measures, and (S) an interventional study design.

RESULTS

The search identified 2958 articles of which 10 were eligible for analysis, describing nine controlled trials of 2438 patients. Perioperative telemonitoring comprised wearable biosensors (n = 3), websites (n = 3), e-mail (n = 1), and mobile applications (n = 2). Outcome measures were clinical (n = 8), patient-reported (n = 5), and financial (n = 2). Results show significant improvement of recovery time, stoma self-efficacy and pain in the early postoperative phase in patients receiving telemonitoring. Other outcome measures were not significantly different between the groups.

CONCLUSION

Evidence for the effectiveness of perioperative telemonitoring in major surgery is scarce. There is a need for good quality studies with sufficient patients while ensuring that the quality and usability of the technology and the adoption in care processes are optimal.

Patient factors related to patient engagement technology (PET) usage in thoracic surgery

BACKGROUND

We evaluated using Patient Engagement Technology (PET) to capture Patient Reported Outcomes (PROs) in thoracic surgery patients. METHODSY: atients using a PET received surveys including the Patient-Reported Outcomes Measurement Information System Global-10 (PROMIS-10) and a health literacy (HL) screen. The relationship of patient-level factors with survey completion was assessed through univariate and logistic regression analyses.

RESULTS

703 patients enrolled in a PET. 52 ​% were female and 83 ​% were white with a median age of 63.72 ​% had adequate HL. 81 ​% completed the PROMIS-10 survey. Univariate analysis found lower rates of PROMIS-10 completion in male patients and those with inadequate HL. Logistic regression analysis showed adequate HL (OR 1.76) and white race (OR 1.72) were associated with PROMIS-10 survey completion, while male gender (OR 0.65) had the opposite effect.

CONCLUSIONS

PETs are an effective means of collecting PROs, but use is affected by gender, race, and health literacy.

Bariatric Patient Engagement in a Pre-surgery Virtual Patient Navigation Platform (VPNP)

BACKGROUND

This study analyzed patient engagement with a virtual patient navigation platform (VPNP) designed to help guide bariatric surgery candidates through the complex pre-operative workup for surgery.

METHODS

Data on baseline sociodemographic and medical history was collected on patients enrolled in the bariatric program at a single academic institution between March and May 2021. The System Usability Scale (SUS) survey was administered to assess VPNP usability. Two groups emerged: "engaged" (ENG; n = 30) who activated their accounts and completed the SUS, and "not-engaged" (NEG; n = 35) who did not activate their accounts (n = 13) or did not use the app (n = 22) and were therefore ineligible for the SUS survey.

RESULTS

Analyses demonstrated that only insurance status differed between groups (private insurance: 60% versus 34.3% for ENG versus NEG, respectively; p = 0.038). SUS survey analysis demonstrated high perceived usability (median score = 86.3), corresponding to the 97th percentile of usability. The top three reasons for disengagement included being too busy (22.9%), not being interested (20%), and being unsure about the purpose of the app (20%).

CONCLUSIONS

The VPNP scored in the 97th percentile of usability. However, given a majority of patients did not engage with the app, and engagement was associated with completing pre-surgery requirements faster (unpublished), future work will focus on mitigating identified reasons for patients not engaging.

Mobile applications in gastrointestinal surgery: a systematic review

BACKGROUND

Mobile applications can facilitate or improve gastrointestinal surgical care by benefiting patients, healthcare providers, or both. The extent to which applications are currently in use in gastrointestinal surgical care is largely unknown, as reported in literature. This systematic review was conducted to provide an overview of the available gastrointestinal surgical applications and evaluate their prospects for surgical care provision.

METHODS

The PubMed, EMBASE and Cochrane databases were searched for articles up to October 6th 2022. Articles were considered eligible if they assessed or described mobile applications used in a gastrointestinal surgery setting for healthcare purposes. Two authors independently evaluated selected studies and extracted data for analysis. Descriptive data analysis was conducted. The revised Cochrane risk of bias (RoB-2) tool and ROBINS-I assessment tool were used to determine the methodological quality of studies.

RESULTS

Thirty-eight articles describing twenty-nine applications were included. The applications were classified into seven categories: monitoring, weight loss, postoperative recovery, education, communication, prognosis, and clinical decision-making. Most applications were reported for colorectal surgery, half of which focused on monitoring. Overall, a low-quality evidence was found. Most applications have only been evaluated on their usability or feasibility but not on the proposed clinical benefits. Studies with high quality evidence were identified in the areas of colorectal (2), hepatopancreatobiliary (1) and bariatric surgery (1), reporting significantly positive outcomes in terms of postoperative recovery, complications and weight loss.

CONCLUSIONS

The interest for applications and their use in gastrointestinal surgery is increasing. From our study, it appears that most studies using applications fail to report adequate clinical evaluation, and do not provide evidence on the effectiveness or safety of applications. Clinical evaluation of objective outcomes is much needed to evaluate the efficacy, quality and safety of applications being used as a medical device across user groups and settings.

Readiness for implementation of novel digital health interventions for postoperative monitoring: a systematic review and clinical innovation network analysis

An increasing number of digital health interventions (DHIs) for remote postoperative monitoring have been developed and evaluated. This systematic review identifies DHIs for postoperative monitoring and evaluates their readiness for implementation into routine health care. Studies were defined according to idea, development, exploration, assessment, and long-term follow-up (IDEAL) stages of innovation. A novel clinical innovation network analysis used coauthorship and citations to examine collaboration and progression within the field. 126 DHIs were identified, with 101 (80%) being early stage innovations (IDEAL stage 1 and 2a). None of the DHIs identified had large-scale routine implementation. There is little evidence of collaboration, and there are clear omissions in the evaluation of feasibility, accessibility, and the health-care impact. Use of DHIs for postoperative monitoring remains at an early stage of innovation, with promising but generally low-quality supporting evidence. Comprehensive evaluation within high-quality, large-scale trials and real-world data are required to definitively establish readiness for routine implementation.

A Contemporary Review of Smart Phone Applications in Bariatric and Metabolic Surgery: an Underdeveloped Support Service

This study aims to be a contemporary review of mHealth apps in bariatric and metabolic surgery (BMS) to assess their quality using the Silberg scale as well as features, themes, usability, and medical/allied health professional involvement (MAPI). Apps were identified using search terms in the Android and Apple app stores. 52 apps were included. 42 (80.7%) apps main target users were patients. More than half, 27 (52%), targeted US based users. 29 (56%) had payment-restricted content. 42 (81%) had MAPI and the mean Silberg score was 5.2. Compared to previous studies the quality of BMS apps is improving with more MAPI and useful functionality. Wider use of mHealth apps for patient centred follow-up, management and care are yet to be widely implemented and explored.

A smartphone application to improve adherence to vitamin and mineral supplementation after bariatric surgery

OBJECTIVE

This trial evaluated a smartphone application's effectiveness in improving adherence to vitamin and mineral supplementation postoperatively.

METHODS

This study was a randomized controlled trial comprising 140 patients undergoing bariatric surgery (gastric bypass or sleeve gastrectomy). Participants were randomized 1:1 to the 12-week intervention, using the smartphone application PromMera, or to standard care. The primary end point was adherence to vitamin and mineral supplementation.

RESULTS

Initiation rate and overall adherence to supplementation were high in both groups. Change in objectively measured adherence rate from before the intervention to 1 year post surgery, measured with pharmacy refill data, did not differ between groups for vitamin B₁₂ (-9.6% [SD = 27%] vs. -9.3% [SD = 30%]; p = 0.48) or calcium/vitamin D (-12.3% [SD = 29%] vs. -11.5% [SD = 32%]; p = 0.44). A modest effect on the secondary end point (subjectively measured adherence, using the Medication Adherence Report Scale-5) was seen immediately after the intervention (intervention group 0.00 [SD = 1.3] vs. control group -1.2 [SD = 3.5]; p = 0.021), but this effect did not persist 1 year post surgery. No differences were detected in the prevalence of biochemical deficiencies.

CONCLUSIONS

The use of the smartphone application PromMera did not obtain a lasting improvement in adherence to vitamin and mineral supplementation 1 year post bariatric surgery.

Feasibility and patient's experiences of perioperative telemonitoring in major abdominal surgery: an observational pilot study

BACKGROUND

Telemonitoring during the perioperative trajectory may improve patient outcomes and self-management. The aim of this study is to assess the feasibility of and patient's experiences with telemonitoring before and after major abdominal surgery to inform future study design.

METHODS

Patients planned for elective major abdominal surgery wore a sensor and answered well-being questions on a tablet daily for at least 2 weeks preoperatively up to 30-days postoperatively. Feasibility was assessed by participation and completion rate, compliance per day, weekly satisfaction scores, and reasons for nonscheduled contact.

RESULTS

Twenty-three patients were included (participation rate of 54.5%) with a completion rate of 69.6%. Median compliance with the wearable sensor and well-being questions was respectively: 94.7% and 83.3% preoperatively at home; 100% and 66.7% postoperatively in-hospital; and 95.4% and 85.8% postoperatively at home. Median weekly satisfaction scores for both wearing the sensor and well-being questions were 5 (IQR, 4-5). Contact moments were related to absence of sensor data and technological issues (76.0%) or patient discomfort and insecurity (24.0%).

CONCLUSIONS

In this study, telemonitoring showed high satisfaction and compliance during the perioperative trajectory. Future trial design regarding the effectiveness of telemonitoring requires embedding in clinical practice and support for patients, relatives, and healthcare personnel.