App-Assisted Follow-up Improves Postoperative Recovery Score

Using an app to monitor postsurgical recovery led to improved quality of recovery scores, according to a recent study published in JAMA Surgery.

In the randomized clinical trial of women undergoing breast reconstruction or gynecologic surgical resection, researchers compared quality of recovery and patient satisfaction between conventional in-person postsurgical follow up and home-based follow up care using a smartphone application.

In addition to these primary outcomes, they assessed number of contacts with the medical system, postoperative complications, costs of follow up care, the surgeons’ contact with patients, and surgeons’ perceptions of app-assisted care.

The study investigators said that while there has been an increase in health care-focused mobile applications—ranging from platforms encouraging healthy behaviors to managing chronic conditions—app-assisted postsurgical management has not been fully explored.

“Is it acceptable to patient and physicians,” they wondered. “Can complications be identified earlier”?

In recent years, postsurgical care has been “revolutionized” by Enhanced Recovery After Surgery Society (ERAS): evidenced-based best practices associated with better patient outcomes, increased postoperative satisfaction, and decreased health care costs.

With the improved recovery associated with ERAS protocols, patients are ready for discharge earlier. When discharged early, however, patients recuperating at home have less opportunity to ask questions or address concerns compared to those with longer hospital stays.

Previous studies have shown reduced postoperative anxiety and high patient satisfaction with the use of postoperative mobile apps. 

In the current study, researchers recruited 36 women who had breast reconstruction (mean [SD] age, 45.30 [9.13] years and 36 who underwent gynecologic oncology surgery (mean [SD age, 54.90 [11.18] years). Study participants were randomly assigned to the home monitoring/app-assisted group or the control group, who received usual in-person follow-up.

The postoperative period was defined as 6 weeks.

On postoperative day 1, app users began inputting findings (data) on their condition daily and continued reporting daily for 2 weeks. Afterwards, they reported weekly.

Data included Quality of Recovery (QoR15) scale scores, a postoperative assessment of 15 dimensions of health on elements such as patient support, comfort, emotions, physical independence and pain, and the Patient Satisfaction Questionnaire III (PSQIII), addressing satisfaction with overall care, communication with their surgeon, access to care, and convenience.

App users were also queried about adverse events, such as diarrhea, vaginal bleeding, urinary frequency and urgency, and wound complications.

Digital technology enabled app users to submit surgical site photos and drain volumes. 

Additionally, the research coordinator monitored the portal daily for pre-set “red flags.” Any red flags were brought to the surgeon’s attention and prompted action, either via a telephone call or an in-person visit.

Results showed that the app group had significantly higher mean (SD) QoR15 scores than the control group (2 weeks: 127.58 [22.03] vs 117.68 [17.52], P = .02; 6 weeks: 136.64 [17.53] vs 129.76 [16.42], P= .03). This represents a clinically relevant difference of 10 points at 2 weeks and 7 points at six weeks.

Measured by the PSQIII, patients in both groups were equally satisfied with follow-up care.

Direct costs were not significantly lower in either group. Indirect costs were lower in the app group at 2 weeks postoperatively, which likely reflected their slightly lower number of unplanned office visits.

One concern with early discharge is the potential for complications that could have been identified in the hospital. The current study found the mean (SD) number of postoperative complications similar in both groups, as were the number of phone calls and emails to the surgeons’ offices and visits to emergency departments. 

Surgeons in this study said the app allowed them to maintain closer contact with patients. In 2 cases, surgical site photographs flagged by the research coordinator prompted early office follow-up and management of wound issues, avoiding ER visits.

Still, study investigators acknowledged study limitations. Technical challenges required extensive troubleshooting by the research coordinator. And in-person postoperative visits were unavoidable if hands-on tasks, such as removing sutures, were required.

Of course, digital literacy depends on numerous factors and may not be for everyone. During the recruiting phase of the study, many patients declined to participate, the study investigators reported. 

On the other hand, in-person care may be best, “this canalso be a burden for patients who have to travel long distances to the clinic, take time off of work, and arrange for child care,” the authors noted.

Reference

Temple-Oberle C, Yakaback S, Webb C, Elmi Assadzadeh G, Nelson G. Effect of smartphone app postoperative home monitoring after oncologic surgery on quality of recovery. JAMA Surg. Published online April 12, 2023. doi:10.1001/jamasurg.2023.0616