Text messaging improves preoperative exercise in patients undergoing bariatric surgery

Two novel prehabilitation apps to help patients stop smoking and risky drinking prior to hip and knee arthroplasty

PURPOSE

Daily smoking or risky drinking increases the risk of complications after surgery by ~50%. Intensive prehabilitation aimed at complete cessation reduces the complication rate but is time-consuming. The purpose of this study was to carry out preoperative pilot tests (randomized design) of the feasibility (1A) and validation (1B) of two novel prehabilitation apps, habeat® (Ha-app) or rehaviour® (Re-app).

METHODS

Patients scheduled for hip or knee arthroplasty with daily smoking, risky drinking, or both were randomised to one of the two apps. In part 1A, eight patients and their staff measured feasibility on a visual analog scale (VAS) and were interviewed about what worked well and the challenges requiring improvement. In part 1B, seven patients and their staff tested the improved apps for up to two weeks before validating the understanding, usability, coverage, and empowerment on a VAS and being interviewed.

RESULTS

In 1A, all patients and staff returned scores of ≥5 for understanding the apps and mostly suggested technical improvements. In 1B, the scores varied widely for both apps, with no consensus achieved. Two of four patients (Ha-app) and one-third of the patients (Re-app) found the apps helpful for reducing smoking, but without successful quitting. The staff experienced low app competencies among patients and high time consumption. Specifically, patients most often needed help for the Ha-app, and the staff most often for Re-app; however, the staff reported the Re-app dashboard was more user-friendly. Support and follow-up from an addiction specialist staff member were suggested to complement the apps, thereby increasing the time consumption for staff.

CONCLUSIONS

This pilot study to test prototype apps generated helpful feedback for the app developers. Based on the patient and staff comments, multiple improvements in functionality seem required before scaling up the evaluation for effect on prehabilitation and postoperative complications.

A non-randomised feasibility study of a mHealth follow-up program in bariatric surgery

BACKGROUND

Behavioural support via mobile health (mHealth) is emerging. This study aimed to assess the feasibility, acceptability, cost, and potential effect on weight of a mHealth follow-up program in bariatric surgery.

METHODS

This was a non-randomised feasibility study describing intervention development and proof in the concept of a mHealth follow-up program in bariatric surgery. The study compares a prospective cohort with a historical control group and was conducted in a tertiary bariatric surgery service in Australia. The intervention group included individuals who had bariatric surgery (2019-2021) and owned a smart device, and the historical control group received usual postoperative care (2018). The intervention involved usual care plus codesigned biweekly text messages, monthly email newsletters, and online resources/videos over a 6-month period. The primary outcome measures included feasibility (via recruitment and retention rate), acceptability (via mixed methods), marginal costs, and weight 12 months postoperatively. Quantitative analysis was performed, including descriptive statistics and inferential and regression analysis. Multivariate linear regression and mixed-effects models were undertaken to test the potential intervention effect. Qualitative analysis was performed using inductive content analysis.

RESULTS

The study included 176 participants (n = 129 historical control, n = 47 intervention group; mean age 56 years). Of the 50 eligible patients, 48 consented to participate (96% recruitment rate). One participant opted out of the mHealth program entirely without disclosing their reason (98% retention rate). The survey response rate was low (n = 16/47, 34%). Participants agreed/strongly agreed that text messages supported new behaviours (n = 13/15, 87%); however, few agreed/strongly agreed that the messages motivated goal setting and self-monitoring (n = 8/15, 53%), dietary change (n = 6/15, 40%), or physical activity (n = 5/15, 33%). Interviews generated four main themes (n = 12): 'motivators and expectations', 'preferences and relevance', 'reinforced information", and 'wanting social support'. The intervention reinforced information, email newsletters were lengthy/challenging to read, and text messages were favoured, yet tailoring was recommended. The intervention cost AUD 11.04 per person. The mean 12-month weight was 86 ± 16 kg and 90 ± 16 kg (intervention and historical control) with no statistically significant difference. Intervention recipients enrolled at 3 months postoperatively demonstrated a statistically significant difference in 12-month weight (p = 0.014).

CONCLUSION

Although this study observed high rates of recruitment and retention, findings should be considered with caution as mHealth may have been embraced more by the intervention cohort as a result of the 2019 coronavirus pandemic. Of the various digital strategies developed and tested, the text message approach was the most acceptable; however, future intervention iterations could be strengthened through tailoring information when possible. The use of email newsletters and online resources/videos requires further testing of effectiveness to determine their value for continued use in bariatric surgery services.

Prehabilitation for general surgery: a systematic review of randomized controlled trials

BACKGROUND

Prehabilitation seeks to optimize patient health before surgery to improve outcomes. Randomized controlled trials (RCTs) have been conducted on prehabilitation, however an updated synthesis of this evidence is required across General Surgery to inform potential Supplementary discipline-level protocols. Accordingly, this systematic review of RCTs aimed to evaluate the use of prehabilitation interventions across the discipline of General Surgery.

METHODS

This study was registered with PROSPERO (CRD42023403289), and adhered to PRISMA 2020 and SWiM guidelines. PubMed/MEDLINE and Ovid Embase were searched to 4 March 2023 for RCTs evaluating prehabilitation interventions within the discipline of General Surgery. After data extraction, risk of bias was assessed using the Cochrane RoB 2 tool. Quantitative and qualitative data were synthesized and analysed. However, meta-analysis was precluded due to heterogeneity across included studies.

RESULTS

From 929 records, 36 RCTs of mostly low risk of bias were included. 17 (47.2%) were from Europe, and 14 (38.9%) North America. 30 (83.3%) investigated cancer populations. 31 (86.1%) investigated physical interventions, finding no significant difference in 16 (51.6%) and significant improvement in 14 (45.2%). Nine (25%) investigated psychological interventions: six (66.7%) found significant improvement, three (33.3%) found no significant difference. Five (13.9%) investigated nutritional interventions, finding no significant difference in three (60%), and significant improvement in two (40%).

CONCLUSIONS

Prehabilitation interventions showed mixed levels of effectiveness, and there is insufficient RCT evidence to suggest system-level delivery across General Surgery within standardized protocols. However, given potential benefits and non-inferiority to standard care, they should be considered on a case-by-case basis.

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.

Designing Digital Health Technology to Support Patients Before and After Bariatric Surgery: Qualitative Study Exploring Patient Desires, Suggestions, and Reflections to Support Lifestyle Behavior Change

Background

A patient’s capability, motivation, and opportunity to change their lifestyle are determinants of successful outcomes following bariatric surgery. Lifestyle changes before and after surgery, including improved dietary intake and physical activity levels, have been associated with greater postsurgical weight loss and improved long-term health. Integrating patient-centered digital technologies within the bariatric surgical pathway could form part of an innovative strategy to promote and sustain healthier behaviors, and provide holistic patient support, to improve surgical success. Previous research focused on implementing digital technologies and measuring effectiveness in surgical cohorts. However, there is limited work concerning the desires, suggestions, and reflections of patients undergoing bariatric surgery. This qualitative investigation explores patients’ perspectives on technology features that would support behavior changes during the pre- and postoperative periods, to potentially maintain long-term healthy lifestyles following surgery.

Objective

This study aims to understand how digital technologies can be used to support patient care during the perioperative journey to improve weight loss outcomes and surgical success, focusing on what patients want from digital technologies, how they want to use them, and when they would be of most benefit during their surgical journey.

Methods

Patients attending bariatric surgery clinics in one hospital in the North of England were invited to participate. Semistructured interviews were conducted with purposively sampled pre- and postoperative patients to discuss lifestyle changes and the use of digital technologies to complement their care. The interviews were audio recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes from the data. Ethical approval was obtained from the National Health Service Health Research Authority.

Results

A total of 20 patients were interviewed (preoperative phase: 40% (8/20); postoperative phase: 60% (12/20). A total of 4 overarching themes were developed and related to the optimization of technology functionality. These centered on providing tailored content and support; facilitating self-monitoring and goal setting; delivering information in an accessible, trusted, and usable manner; and meeting patient information-seeking and engagement needs during the surgical pathway. Functionalities that delivered personalized feedback and postoperative follow-up were considered beneficial. Individualized goal setting functionality could support a generation of digitally engaged patients with bariatric conditions as working toward achievable targets was deemed an effective strategy for motivating behavior change. The creation of digital package of care checklists between patients and clinicians was a novel finding from this study.

Conclusions

Perceptions of patients undergoing bariatric surgery validated the integration of digital technologies within the surgical pathway, offering enhanced connectedness and support. Recommendations are made relating to the design, content, and functionality of digital interventions to best address the needs of this cohort. These findings have the potential to influence the co-design and integration of person-centered, perioperative technologies.

Are eHealth interventions for adults who are scheduled for or have undergone bariatric surgery as effective as usual care? A systematic review

This systematic review aimed to evaluate the effect of eHealth-delivered interventions for adults who undergo bariatric surgery on postoperative weight loss, weight loss maintenance, eating psychopathology, quality of life, depression screening, and self-efficacy. Six electronic databases were searched, with 14 studies (across 17 reports) included, involving 1633 participants. With substantial heterogeneity, qualitative descriptions have been provided. Interventions were delivered via an online program or internet modules (n = 2), telephone (n = 2), text messages (n = 2), videoconferencing (n = 3), mobile application (n = 1), and audiovisual media (n = 1). Three studies included a combination, including internet modules and telephone (n = 1), wireless fidelity scales, emails, and telephone (n = 1), and a combination of online treatment, weekly emails, and access to a private Facebook group (n = 1). All the eHealth interventions, except for one, implemented behavior change techniques, including self-monitoring, problem solving, social support, goal setting, and shaping knowledge. Both eHealth intervention and control groups lost weight across the included studies, and eHealth was found to be as effective as or more effective than the control for weight loss. Two studies measured weight loss maintenance; both eHealth and control groups regained weight in the longer term. The interventions showed significant improvement on assessment measures for eating psychopathology. In conclusion, when bariatric surgery patients have limited or no access to healthcare teams or require additional support, eHealth may be a suitable option. Future studies implementing eHealth interventions would benefit from reporting intervention components as per the behavior change techniques taxonomy and further consideration of delivering eHealth in a stepped care approach would be beneficial.

Perioperative digital behaviour change interventions for reducing alcohol consumption, improving dietary intake, increasing physical activity and smoking cessation: a scoping review

BACKGROUND

Evidence suggests that unhealthy lifestyle behaviours are modifiable risk factors for postoperative complications. Digital behaviour change interventions (DBCIs), for instance text messaging programs and smartphone apps, have shown promise in achieving lifestyle behaviour change in a wide range of clinical populations, and it may therefore be possible to reduce postoperative complications by supporting behaviour change perioperatively using digital interventions. This scoping review was conducted in order to identify existing research done in the area of perioperative DBCIs for reducing alcohol consumption, improving dietary intake, increasing physical activity and smoking cessation.

MAIN TEXT

This scoping review included eleven studies covering a range of surgeries: bariatric, orthopaedic, cancer, transplantation and elective surgery. The studies were both randomised controlled trials and feasibility studies and investigated a diverse set of interventions: one game, three smartphone apps, one web-based program and five text message interventions. Feasibility studies reported user acceptability and satisfaction with the behaviour change support. Engagement data showed participation rates ranged from 40 to 90%, with more participants being actively engaged early in the intervention period. In conclusion, the only full-scale randomised controlled trial (RCT), text messaging ahead of bariatric surgery did not reveal any benefits with respect to adherence to preoperative exercise advice when compared to a control group. Two of the pilot studies, one text message intervention, one game, indicated change in a positive direction with respect to alcohol and tobacco outcomes, but between group comparisons were not done due to small sample sizes. The third pilot-study, a smartphone app, found between group changes for physical activity and alcohol, but not with respect to smoking cessation outcomes.

CONCLUSION

This review found high participant satisfaction, but shows recruitment and timing-delivery issues, as well as low retention to interventions post-surgery. Small sample sizes and the use of a variety of feasibility outcome measures prevent the synthesis of results and makes generalisation difficult. Future research should focus on defining standardised outcome measures, enhancing patient engagement and improving adherence to behaviour change prior to scheduled surgery.

Digital Support to Multimodal Community-Based Prehabilitation: Looking for Optimization of Health Value Generation

Prehabilitation has shown its potential for most intra-cavity surgery patients on enhancing preoperative functional capacity and postoperative outcomes. However, its large-scale implementation is limited by several constrictions, such as: i) unsolved practicalities of the service workflow, ii) challenges associated to change management in collaborative care; iii) insufficient access to prehabilitation; iv) relevant percentage of program drop-outs; v) need for program personalization; and, vi) economical sustainability. Transferability of prehabilitation programs from the hospital setting to the community would potentially provide a new scenario with greater accessibility, as well as offer an opportunity to effectively address the aforementioned issues and, thus, optimize healthcare value generation. A core aspect to take into account for an optimal management of prehabilitation programs is to use proper technological tools enabling: i) customizable and interoperable integrated care pathways facilitating personalization of the service and effective engagement among stakeholders; ii) remote monitoring (i.e. physical activity, physiological signs and patient-reported outcomes and experience measures) to support patient adherence to the program and empowerment for self-management; and, iii) use of health risk assessment supporting decision making for personalized service selection. The current manuscript details a proposal to bring digital innovation to community-based prehabilitation programs. Moreover, this approach has the potential to be adopted by programs supporting long-term management of cancer patients, chronic patients and prevention of multimorbidity in subjects at risk.

Behavioral weight management interventions in metabolic and bariatric surgery: A systematic review and meta-analysis investigating optimal delivery timing

Metabolic and bariatric surgery (MBS) yields unprecedented clinical outcomes, though variability is high in weight change and health benefits. Behavioral weight management (BWM) interventions may optimize MBS outcomes. However, there is a lack of an evidence base to inform their use in practice, particularly regarding optimal delivery timing. This paper evaluated the efficacy of BWM conducted pre- versus post- versus pre- and post-MBS. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and included pre- and/or post-operative BWM interventions in adults reporting anthropometric and/or body composition data. Thirty-six studies (2,919 participants) were included. Post-operative BWM yielded greater decreases in weight (standardized mean difference [SMD] = -0.41; 95% confidence interval [CI]: -0.766 to -0.049, p < 0.05; I² = 93.5%) and body mass index (SMD = -0.60; 95% CI: -0.913 to -0.289, p < 0.001; I² = 87.8%) relative to comparators. There was no effect of BWM delivered pre- or joint pre- and post-operatively. The risk of selection and performance bias was generally high. Delivering BWM after MBS appears to confer the most benefits on weight, though there was high variability in study characteristics and risk of bias across trials. This provides insight into the type of support that should be considered post-operatively.

Digital technology to support lifestyle and health behaviour changes in surgical patients: systematic review

BACKGROUND

Digital technologies (such as smartphone applications, activity trackers, and e-learning platforms) have supported patients with long-term conditions to change their lifestyle health behaviours. The aim of this study was to examine the effectiveness of digital technologies in supporting patients undergoing elective surgery to change their health behaviours.

METHODS

A systematic review was conducted of articles reporting a digital intervention supporting behaviour change in adult patients who underwent elective bariatric, oncological or orthopaedic surgery. MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Scopus were searched from inception to March 2019 for quantitative intervention studies with a specific focus on physical activity, dietary intake, and weight loss in patients before and after surgery (PROSPERO: CRD42019127972). The Joanna Briggs Institute critical appraisal checklist was used to assess study quality.

RESULTS

Of 3021 citations screened, 17 studies were included comprising 4923 surgical patients; these included experimental (pre-post design, feasibility studies, and RCTs) and observational studies. Three factors were identified as effective for supporting health behaviour change in elective surgical populations: digital technology delivery, implementation, and theoretical underpinning. Six of eight studies that referred to behaviour change theories observed significant improvements in health behaviour relating to reduced weight regain, and improved lifestyle choices for physical activity and diet. Meta-analysis was not possible because of heterogeneous outcome measures.

CONCLUSION

Digital technologies may effectively support behavioural change in patients undergoing elective surgery.

The value of teachable moments in surgical patient care and the supportive role of digital technologies

Evidence strongly supports improved outcomes following surgery when patients are more physically active, have better dietary intake, or are generally fitter prior to surgery. Having an operation is a major life event for patients, and many are not educated around what they can do as individuals to aid a speedier and more successful recovery following their operation. What if there was a time point before surgery where clinicians could inspire patients to adjust their lifestyles for the better, in order to see fewer complications after surgery? This is where the concept of teachable moments comes into play.

This commentary explores the concept of teachable moments and their value in surgical patient care and discusses the potentially under-utilized opportunities on hand to the surgical multidisciplinary team to remotely support patients using digital health technologies.