A Mobile Phone App Improves Patient-Physician Communication and Reduces Emergency Department Visits After Colorectal Surgery

Non-emergency department (ED) interventions to reduce ED utilization: a scoping review

BACKGROUND

Emergency department (ED) crowding is a global burden. Interventions to reduce ED utilization have been widely discussed in the literature, but previous reviews have mainly focused on specific interventions or patient groups within the EDs. The purpose of this scoping review was to identify, summarize, and categorize the various types of non-ED-based interventions designed to reduce unnecessary visits to EDs.

METHODS

This scoping review followed the JBI Manual for Evidence Synthesis and the PRISMA-SCR checklist. A comprehensive structured literature search was performed in the databases MEDLINE and Embase from 2008 to March 2024. The inclusion criteria covered studies reporting on interventions outside the ED that aimed to reduce ED visits. Two reviewers independently screened the records and categorized the included articles by intervention type, location, and population.

RESULTS

Among the 15,324 screened records, we included 210 studies, comprising 183 intervention studies and 27 systematic reviews. In the primary studies, care coordination/case management or other care programs were the most commonly examined out of 15 different intervention categories. The majority of interventions took place in clinics or medical centers, in patients' homes, followed by hospitals and primary care settings - and targeted patients with specific medical conditions.

CONCLUSION

A large number of studies have been published investigating interventions to mitigate the influx of patients to EDs. Many of these targeted patients with specific medical conditions, frequent users and high-risk patients. Further research is needed to address other high prevalent groups in the ED - including older adults and mental health patients (who are ill but may not need the ED). There is also room for further research on new interventions to reduce ED utilization in low-acuity patients and in the general patient population.

Remote Symptom Monitoring with Clinical Alerts Following Mastectomy: Do Early Symptoms Predict 30-Day Surgical Complications

BACKGROUND

Electronic patient-reported outcome measures (ePROMs) for real-time remote symptom monitoring facilitate early recognition of postoperative complications. We sought to determine whether remote, electronic, patient-reported symptom-monitoring with Recovery Tracker predicts 30-day readmission or reoperation in outpatient mastectomy patients.

METHODS

We conducted a retrospective review of breast cancer patients who underwent outpatient (< 24-h stay) mastectomy with or without reconstruction from April 2017 to January 2022 and who received the Recovery Tracker on Days 1-10 postoperatively. Of 5,130 patients, 3,888 met the inclusion criteria (2,880 mastectomy with immediate reconstruction and 1,008 mastectomy only). We focused on symptoms concerning for surgical complications and assessed if symptoms reaching prespecified alert levels-prompting a nursing call-predicted risk of 30-day readmission or reoperation.

RESULTS

Daily Recovery Tracker response rates ranged from 45% to 70%. Overall, 1,461 of 3,888 patients (38%) triggered at least one alert. Most red (urgent) alerts were triggered by pain and fever; most yellow (less urgent) alerts were triggered by wound redness and pain severity. The 30-day readmission and reoperation rates were low at 3.8% and 2.4%, respectively. There was no statistically significant association between symptom alerts and 30-day reoperation or readmission, and a clinically relevant increase in risk can be excluded (odds ratio 1.08; 95% confidence interval 0.8-1.46; p = 0.6).

CONCLUSIONS

Breast cancer patients undergoing mastectomy with or without reconstruction in the ambulatory setting have a low burden of concerning symptoms, even in the first few days after surgery. Patients can be reassured that symptoms that do present resolve quickly thereafter.

Digital Health Interventions and Patient Safety in Abdominal Surgery: A Systematic Review and Meta-Analysis

Importance

Over the past 2 decades, several digital technology applications have been used to improve clinical outcomes after abdominal surgery. The extent to which these telemedicine interventions are associated with improved patient safety outcomes has not been assessed in systematic and meta-analytic reviews.

Objective

To estimate the implications of telemedicine interventions for complication and readmission rates in a population of patients with abdominal surgery.

Data Sources

PubMed, Cochrane Library, and Web of Science databases were queried to identify relevant randomized clinical trials (RCTs) and nonrandomized studies published from inception through February 2023 that compared perioperative telemedicine interventions with conventional care and reported at least 1 patient safety outcome.

Study Selection

Two reviewers independently screened the titles and abstracts to exclude irrelevant studies as well as assessed the full-text articles for eligibility. After exclusions, 11 RCTs and 8 cohort studies were included in the systematic review and meta-analysis and 7 were included in the narrative review.

Data Extraction and Synthesis

Data were extracted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline and assessed for risk of bias by 2 reviewers. Meta-analytic estimates were obtained in random-effects models.

Main Outcomes and Measures

Number of complications, emergency department (ED) visits, and readmissions.

Results

A total of 19 studies (11 RCTs and 8 cohort studies) with 10 536 patients were included. The pooled risk ratio (RR) estimates associated with ED visits (RR, 0.78; 95% CI, 0.65-0.94) and readmissions (RR, 0.67; 95% CI, 0.58-0.78) favored the telemedicine group. There was no significant difference in the risk of complications between patients in the telemedicine and conventional care groups (RR, 1.05; 95% CI, 0.77-1.43).

Conclusions and Relevance

Findings of this systematic review and meta-analysis suggest that perioperative telehealth interventions are associated with reduced risk of readmissions and ED visits after abdominal surgery. However, the mechanisms of action for specific types of abdominal surgery are still largely unknown and warrant further research.

Physical Therapist and Patient Perspectives on Mobile Technology to Support Home Exercise Prescription for People With Arthritis: A Qualitative Study

Introduction Mobile applications (apps) for exercise prescription may enhance communication between healthcare providers and patients while addressing common barriers to exercise among people with osteoarthritis. However, little is known about preferences and barriers to the use of mobile apps by physical therapists or people aging with osteoarthritis. Therefore, we aimed to examine physical therapist and patient perspectives on mobile apps to support physical therapist-prescribed home exercise for people with osteoarthritis. Methods Eighteen physical therapists and 17 individuals with a history of physical therapy for osteoarthritis participated in the study. Focus groups (n = 6, three each with physical therapists and patients) were conducted to gather perspectives on three commercially available mobile apps designed for physical therapy exercise prescription. Semi-structured questions assessed feature preferences, ease of use, exercise completion support, clinical feasibility, and potential barriers and facilitators to using the apps. Recordings of the focus groups were transcribed verbatim. The study team iteratively coded transcripts using thematic analysis. Results Perspectives of patients and physical therapists intersected but differed on the mobile apps. All patients preferred video exercise prescription over traditional methods and both patients and therapists predicted challenges and opportunities with mobile communication. Four themes emerged: accountability, data-driven, communication boost, and duality of technology. Facilitators of home exercise through mobile apps included exercise tracking, feedback loop, personalization, and the potential for reduced in-person visits. Barriers included technological challenges, complex interface design, lack of universal applicability, and security concerns. Conclusion Mobile app technology has the potential to support exercise adherence for people with osteoarthritis. However, patients' and therapists' perspectives differ and highlight numerous challenges that limit the universal clinical adoption of this technology. While physical therapists acknowledged the potential to improve the rehabilitation experience with mobile apps, there was concern about reimbursement and time constraints in the current fee-for-service environment.

iColon, a patient-focused mobile application for perioperative care in colorectal surgery: Results from 444 patients

AIM

The aim of this study is to assess if a patient-focused mobile application can increase compliance with active Enhanced Recovery After Surgery (ERAS) items and thereby improve surgery-related outcomes and patient satisfaction.

METHOD

This is a prospective observational study of patients admitted for elective colorectal surgery, under the ERAS protocol, and having access to the mobile application iColon during all perioperative phases.

RESULTS

The 444 participants were included in the study. The overall adherence to the use of iColon was 62.4%. The overall adherence to active ERAS items was 74.1%. Adherence to the use of iColon significantly impacted adherence to active ERAS items. The use of the application was negatively related with factors such as age, type of disease, and postoperative complications. In the postdischarge phase, low adherence to active ERAS items typically indicates an increased likelihood of readmission; however, the use of iColon correlated significantly with a reduction in the 30-day readmission rate. A survey regarding patient satisfaction and confidence in using iColon resulted in positive feedback in more than 94% of cases, while 92.7% reported better quality of care.

CONCLUSION

Our findings suggest that digital health tools are beneficial and effective in the follow up of patients after early discharge. Our mobile application, iColon, represents user-friendly technology that is well-accepted. It has real-world implications in increasing adherence to active ERAS items, which results in an improvement in perceived quality of care by its users.

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.

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.

Remote Monitoring of Colorectal Cancer Survivors Using a Smartphone App and Internet of Things-Based Device: Development and Usability Study

BACKGROUND

Patients with colorectal cancer who undergo surgery face many postoperative problems. These problems include the risk of relapse, side effects, and long-term complications.

OBJECTIVE

This study sought to design and develop a remote monitoring system as a technological solution for the postdischarge care of these patients.

METHODS

This research was conducted in 3 main steps: system feature extraction, system design, and evaluation. After feature extraction from a systematic review, the necessary features were defined by 18 clinical experts in Iran. In the next step, the architecture of the system was designed based on the requirements; the software and hardware parts of the system were embedded in the architecture, then the software system components were drawn using the unified modeling language diagrams, and the details of software system implementation were identified. Regarding the hardware design, different accessible hardware modules were evaluated, and suitable ones were selected. Finally, the usability of the system was evaluated by demonstrating it over a Skype virtual meeting session and using Nilsen's usability principles.

RESULTS

A total of 21 mandatory features in 5 main categories, including patient information registration, periodic monitoring of health parameters, education, reminders, and assessments, were defined and validated for the system. The software was developed using an ASP.Net core backend, a Microsoft SQL Server database, and an Ionic frontend alongside the Angular framework, to build an Android app. The user roles of the system included 3 roles: physicians, patients, and the system administrator. The hardware was designed to contain an Esp8266 as the Internet of Things module, an MLX90614 infrared temperature sensor, and the Maxim Integrated MAX30101 sensor for sensing the heartbeat. The hardware was designed in the shape of a wristband device using SolidWorks 2020 and printed using a 3D printer. The firmware of the hardware was developed in Arduino with the capability of firmware over the air. In evaluating the software system from the perspective of usability, the system received an average score of 3.8 out of 5 from 4 evaluators.

CONCLUSIONS

Sensor-based telemonitoring systems for patients with colorectal cancer after surgery are possible solutions that can make the process automatic for patients and caregivers. The apps for remote colorectal patient monitoring could be designed to be useful; however, more research regarding the developed system's implementation in clinic settings and hospitals is required to understand the probable barriers and limitations.

North American multicentre evaluation of a same-day discharge protocol for minimally invasive colorectal surgery using mHealth or telephone remote post-discharge monitoring

BACKGROUND

Same-day discharge (SDD) after colectomy is feasible but requires effective post-discharge remote follow-up. Previous studies have used in-person home visits or a mobile health (mHealth) phone app, but the use of simple telephone calls for remote follow-up has not yet been studied. Therefore, the objective of this study was to compare outcomes after SDD for minimally invasive colectomy using mHealth or telephone remote post-discharge follow-up.

METHODS

A prospective cohort study was undertaken at two university-affiliated colorectal referral institutions from 02/2020 to 05/2021. Adult patients without significant comorbidities undergoing elective minimally invasive colectomy. Patients were discharged on the day of surgery based on set criteria. Post-discharge remote follow-up was performed using a mHealth app at site 1 and scheduled telephone calls at site 2 up to postoperative day (POD) 7. The main outcome for this study was the success rate of SDD, defined as discharge on POD0 without emergency department (ED) visit or readmission within the first 3 days.

RESULTS

A total of 105 patients were recruited (site 1, n = 70; site 2, n = 35). Overall, 75% of patients were discharged on POD0 (site 1 81% vs. site 2 63%, p = 0.038), of which only two patients required an ED visit within the first 3 days, leading to an overall success rate of 73% (site 1 80% vs. site 2 60%, p = 0.029). The incidence of 30-day complications (16% vs. 20%, p = 0.583), ED visits (11% vs. 11%, p = 1.00), and readmissions (9% vs. 14%, p = 0.367) were similar between the two sites. There was only one patient at each study site that went to the ED without instructions through remote follow-up.

CONCLUSIONS

A high proportion of patients planned for SDD were discharged on POD0 with few patients requiring an early unplanned ED visit. These results were similar with an mHealth app or telephone calls for post-discharge remote follow-ups, suggesting that SDD is feasible regardless of the method of post-discharge remote follow-up.

Same-Day Discharge After Minimally Invasive Colectomy

This article describes elements of a same-day discharge program for minimally invasive colectomy as an evolution of enhanced recovery pathways for colorectal surgery.

Same day discharge following elective, minimally invasive, colorectal surgery : A review of enhanced recovery protocols and early outcomes by the SAGES Colorectal Surgical Committee with recommendations regarding patient selection, remote monitoring, and successful implementation

BACKGROUND

As enhanced recovery programs (ERPs) have continued to evolve, the length of hospitalization (LOS) following elective minimally invasive colorectal surgery has continued to decline. Further refinements in multimodal perioperative pain management strategies have resulted in reduced opioid consumption. The interest in ambulatory colectomy has dramatically accelerated during the COVID-19 pandemic. Severe restrictions in hospital capacity and fear of COVID transmission forced surgical teams to rethink strategies to further reduce length of inpatient stay.

METHODS

Members of the SAGES Colorectal Surgery Committee began reviewing the emergence of SDD protocols and early publications for SDD in 2019. The authors met at regular intervals during 2020-2022 period reviewing SDD protocols, safe patient selection criteria, surrogates for postoperative monitoring, and early outcomes.

RESULTS

Early experience with SDD protocols for elective, minimally invasive colorectal surgery suggests that SDD is feasible and safe in well-selected patients and procedures. SDD protocols are associated with reduced opioid use and prescribing. Patient perception and experience with SDD is favourable. For early adopters, SDD has been the natural evolution of well-developed ERPs. Like all ERPs, SDD begins in the office setting, identifying the correct patient and procedure, aligning goals and objectives, and the perioperative education of the patient and their supporting significant others. A thorough discussion with the patient regarding expected activity levels, oral intake, and pain control post operatively lays the foundation for a successful application of SDD programs. These observations may not apply to all patient populations, institutions, practice types, or within the scope of an existing ERP. However, if the underlying principles of SDD can be incorporated into an existing institutional ERP, it may further reduce the incidence of post operative ileus, prolonged LOS, and improve the effectiveness of oral analgesia for postoperative pain management and reduced opioid use and prescribing.

CONCLUSIONS

The SAGES Colorectal Surgery Committee has performed a comprehensive review of the early experience with SDD. This manuscript summarizes SDD early results and considerations for safe and stepwise implementation of SDD with a specific focus on ERP evolution, patient selection, remote monitoring, and other relevant considerations based on hospital settings and surgical practices.