Usability and Preliminary Effectiveness of a Preoperative mHealth App for People Undergoing Major Surgery: Pilot Randomized Controlled Trial

Mindfulness-Based Interventions for Surgical Patients and Impact on Postoperative Outcomes, Patient Wellbeing, and Satisfaction

Several psychosocial factors can impact surgical outcomes and overall patient wellbeing following surgery. Although advances in surgical interventions and pain management protocols can reduce surgical trauma and enhance recovery from surgery, additional intervention is warranted to optimize surgical outcomes and patient quality of life (QoL) in the short- and long-term. Research on mindfulness techniques suggests that mindfulness-based interventions (MBI) effectively promote health behaviors, reduce pain, and improve psychological wellbeing and QoL. Thus, there has been an increase in research evaluating the use of MBIs to improve postoperative outcomes and wellbeing in surgical patients. The authors provide a brief overview of psychosocial outcomes of surgery and MBIs and review the literature on the impact of MBIs on postoperative outcomes. The extant literature indicates that MBIs are feasible and acceptable for use in surgical patient populations and provides preliminary evidence of the benefits of mindfulness across a range of surgical patient populations. However, more research is needed to assess the long-term efficacy of MBIs delivered online and in-person across the perioperative continuum.

Iterative Patient Testing of a Stimuli-Responsive Swallowing Activity Sensor to Promote Extended User Engagement During the First Year After Radiation: Multiphase Remote and In-Person Observational Cohort Study

BACKGROUND

Frequent sensor-assisted monitoring of changes in swallowing function may help improve detection of radiation-associated dysphagia before it becomes permanent. While our group has prototyped an epidermal strain/surface electromyography sensor that can detect minute changes in swallowing muscle movement, it is unknown whether patients with head and neck cancer would be willing to wear such a device at home after radiation for several months.

OBJECTIVE

We iteratively assessed patients' design preferences and perceived barriers to long-term use of the prototype sensor.

METHODS

In study 1 (questionnaire only), survivors of pharyngeal cancer who were 3-5 years post treatment and part of a larger prospective study were asked their design preferences for a hypothetical throat sensor and rated their willingness to use the sensor at home during the first year after radiation. In studies 2 and 3 (iterative user testing), patients with and survivors of head and neck cancer attending visits at MD Anderson's Head and Neck Cancer Center were recruited for two rounds of on-throat testing with prototype sensors while completing a series of swallowing tasks. Afterward, participants were asked about their willingness to use the sensor during the first year post radiation. In study 2, patients also rated the sensor's ease of use and comfort, whereas in study 3, preferences were elicited regarding haptic feedback.

RESULTS

The majority of respondents in study 1 (116/138, 84%) were willing to wear the sensor 9 months after radiation, and participant willingness rates were similar in studies 2 (10/14, 71.4%) and 3 (12/14, 85.7%). The most prevalent reasons for participants' unwillingness to wear the sensor were 9 months being excessive, unwanted increase in responsibility, and feeling self-conscious. Across all three studies, the sensor's ability to detect developing dysphagia increased willingness the most compared to its appearance and ability to increase adherence to preventive speech pathology exercises. Direct haptic signaling was also rated highly, especially to indicate correct sensor placement and swallowing exercise performance.

CONCLUSIONS

Patients and survivors were receptive to the idea of wearing a personalized risk sensor for an extended period during the first year after radiation, although this may have been limited to well-educated non-Hispanic participants. A significant minority of patients expressed concern with various aspects of the sensor's burden and its appearance.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03010150; https://clinicaltrials.gov/study/NCT03010150.

Digital health coaching to improve patient preparedness for elective lower limb arthroplasty: a quality improvement project

Major surgery carries high risks with comorbidities, frailty and health risk behaviours meaning patients are often unprepared for the physiological insult. Since 2018, the Prepwell programme at South Tees Hospitals NHS Foundation Trust has supported patients to improve their preoperative health and fitness. In April 2020, the face-to-face service was suspended due to the pandemic, leading to the team implementing a three-tiered remote digital support pathway, including digital health coaching via a mobile phone application.

METHODS

Patients scheduled for elective lower limb arthroplasty were offered 8 weeks of digital health coaching preoperatively. Following consent, participants were assigned a personal health coach to set individual behaviour change goals supported by online resources, alongside a digitally delivered exercise programme. Participants completed self-assessment questionnaires at Entry to, and Exit from, the programme, with outcome data collected 21 days postoperatively. The primary outcome was the change in Patient Activation Measure (PAM).

RESULTS

Fifty-seven of 189 patients (30.2%) consented to referral for digital health coaching. Forty participants completed the 8-week programme. Median PAM increased from 58.1 to 67.8 (p=0.002). Thirty-five per cent of participants were in a non-activated PAM level at Entry, reducing to 15% at Exit with no participants in PAM level 1 at completion. Seventy-one percent of non-activated participants improved their PAM by one level or more, compared with 45% for the whole cohort. Median LOS was 2 days, 1 day less than the Trust's arthroplasty patient population during the study period (unadjusted comparison).

CONCLUSIONS

Digital health coaching was successfully implemented for patients awaiting elective lower limb arthroplasty. We observed significant improvements in participants' PAM scores after the programme, with the largest increase in participants with lower activation scores at Entry. Further study is needed to confirm the effects of digital health coaching in this and other perioperative groups.

The use of digital technologies to support home-based prehabilitation prior to major surgery: A systematic review

BACKGROUND

Prehabilitation is a multidimensional and multidisciplinary approach, to prepare patients for surgery, with the aim of improving postoperative outcomes. Worldwide, healthcare systems are facing challenges with a gap between demand and supply of healthcare services. Telehealth is seen as a solution for delivering sustainable and efficient treatments. The effect of providing prehabilitation using telehealth solutions is unclear.

OBJECTIVE

This systematic review investigated the existing literature regarding the effects and feasibility of technologies for remotely supporting home-based prehabilitation compared to standard care on pre- and postoperative outcomes in adults undergoing elective major surgery.

METHODS

A literature search identified relevant studies published between 1 January 2012 and December 2022 in PubMed, PsychInfo, Cinahl and the Cochrane Library. We included RCTs, feasibility and pilot studies. The quality of studies was evaluated using Cochrane's Risk of bias assessment and by narratively rating the certainty of evidence.

RESULTS

Six randomized controlled trials and 20 pilot/feasibility studies were included. The number and content of the interventions varied, depending on context and resources. Multiple approaches in the use of digital healthcare solutions were applied and the results highlight the potential of providing health services remotely.

CONCLUSION

The use of technologies to support remote home-based prehabilitation in patients undergoing elective major surgery is feasible and has high acceptability, though telehealth is a broad term and wide-ranging strategies are used. Digital technologies for supporting home-based prehabilitation are likely to play an essential role in future health care as resources are scarce and innovative solutions are needed.

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.

Consumer Perspectives on the Adoption of a Prehabilitation Multimodal Online Program for Patients Undergoing Cancer Surgery

This study aimed to explore patients' perspectives on the adoption of a prehabilitation multimodal online program. Patients recovering from gastrointestinal cancer surgery at a tertiary hospital between October 2021 and November 2022 were invited to participate. An e-Health program including intensity exercises, nutrition and psychological counselling was used. Patients were instructed to navigate the e-Health program over 24 h using an iPad and then complete the study survey. Patients' characteristics, use of technology, views and minimal expected outcomes from a preoperative online program were collected. Of the 30 patients included, most were female, most reported confidence in the use of technology, most considered the online program safe and most agreed it would be beneficial for their health. "Poor preoperative health" and "lack of motivation and encouragement" were identified as the main barriers to the uptake of a preoperative online program, while program 'simplicity' and perceived 'benefits' were the main facilitators. Significant improvement in postoperative outcomes is perceived to influence patients' willingness to participate in a preoperative multimodal e-Health program. Gastrointestinal cancer patients perceived the adoption of a preoperative multimodal e-Health application as safe to be performed at home and of potential benefit to their health. A range of patient's characteristics, barriers and facilitators to the uptake of an online program were identified. These should be considered in future preoperative multimodal online programs to enhance patient experience, adherence and efficacy. The safety and efficacy of the online prehabilitation program will need to be determined in a larger randomized controlled trial.

The effect of preoperative behaviour change interventions on pre- and post-surgery health behaviours, health outcomes, and health inequalities in adults: A systematic review and meta-analyses

BACKGROUND

Prehabilitation interventions are being delivered across surgical specialities to improve health risk behaviours leading to better surgical outcomes and potentially reduce length of hospital stay. Most previous research has focused on specific surgery specialities and has not considered the impact of interventions on health inequalities, nor whether prehabilitation improves health behaviour risk profiles beyond surgery. The aim of this review was to examine behavioural Prehabilitation interventions across surgeries to inform policy makers and commissioners of the best available evidence.

METHODS AND FINDINGS

A systematic review and meta-analysis of randomised controlled trials (RCTs) was conducted to determine the effect of behavioural prehabilitation interventions targeting at least one of: smoking behaviour, alcohol use, physical activity, dietary intake (including weight loss interventions) on pre- and post-surgery health behaviours, health outcomes, and health inequalities. The comparator was usual care or no treatment. MEDLINE, PubMed, PsychINFO, CINAHL, Web of Science, Google Scholar, Clinical trials and Embase databases were searched from inception to May 2021, and the MEDLINE search was updated twice, most recently in March 2023. Two reviewers independently identified eligible studies, extracted data, and assessed risk of bias using the Cochrane risk of bias tool. Outcomes were length of stay, six-minute walk test, behaviours (smoking, diet, physical activity, weight change, and alcohol), and quality of life. Sixty-seven trials were included; 49 interventions targeted a single behaviour and 18 targeted multiple behaviours. No trials examined effects by equality measures. Length of stay in the intervention group was 1.5 days shorter than the comparator (n = 9 trials, 95% CI -2.6 to -0.4, p = 0.01, I2 83%), although in sensitivity analysis prehabilitation had the most impact in lung cancer patients (-3.5 days). Pre-surgery, there was a mean difference of 31.8 m in the six-minute walk test favouring the prehabilitation group (n = 19 trials, 95% CI 21.2 to 42.4m, I2 55%, P <0.001) and this was sustained to 4-weeks post-surgery (n = 9 trials, mean difference = 34.4m (95%CI 12.8 to 56.0, I2 72%, P = 0.002)). Smoking cessation was greater in the prehabilitation group before surgery (RR 2.9, 95% CI 1.7 to 4.8, I2 84%), and this was sustained at 12 months post-surgery (RR 1.74 (95% CI 1.20 to 2.55, I2 43%, Tau2 0.09, p = 0.004)There was no difference in pre-surgery quality of life (n = 12 trials) or BMI (n = 4 trials).

CONCLUSIONS

Behavioural prehabilitation interventions reduced length of stay by 1.5 days, although in sensitivity analysis the difference was only found for Prehabilitation interventions for lung cancer. Prehabilitation can improve functional capacity and smoking outcomes just before surgery. That improvements in smoking outcomes were sustained at 12-months post-surgery suggests that the surgical encounter holds promise as a teachable moment for longer-term behavioural change. Given the paucity of data on the effects on other behavioural risk factors, more research grounded in behavioural science and with longer-term follow-up is needed to further investigate this potential.

Usability evaluation and Compatibility test of digital self-management support system for children with cancer and their caregivers: using cloud automation testing platform (Preprint)

BACKGROUND

Despite the increasing development of different smartphone apps in the health care domain, most of these apps lack proper evaluation. In fact, with the rapid development of smartphones and wireless communication infrastructure, many health care systems around the world are using these apps to provide health services for people without sufficient scientific efforts to design, develop, and evaluate them.

OBJECTIVE

The objective of this study was to evaluate the usability of CanSelfMan, a self-management app that provides access to reliable information to improve communication between health care providers and children with cancer and their parents/caregivers, facilitating remote monitoring and promoting medication adherence.

METHODS

We performed debugging and compatibility tests in a simulated environment to identify possible errors. Then, at the end of the 3-week period of using the app, children with cancer and their parents/caregivers filled out the User Experience Questionnaire (UEQ) to evaluate the usability of the CanSelfMan app and their level of user satisfaction.

RESULTS

During the 3 weeks of CanSelfMan use, 270 cases of symptom evaluation and 194 questions were recorded in the system by children and their parents/caregivers and answered by oncologists. After the end of the 3 weeks, 44 users completed the standard UEQ user experience questionnaire. According to the children's evaluations, attractiveness (mean 1.956, SD 0.547) and efficiency (mean 1.934, SD 0.499) achieved the best mean results compared with novelty (mean 1.711, SD 0.481). Parents/caregivers rated efficiency at a mean of 1.880 (SD 0.316) and attractiveness at a mean of 1.853 (SD 0.331). The lowest mean score was reported for novelty (mean 1.670, SD 0.225).

CONCLUSIONS

In this study, we describe the evaluation process of a self-management system to support children with cancer and their families. Based on the feedback and scores obtained from the usability evaluation, it seems that the children and their parents find CanSelfMan to be an interesting and practical idea to provide reliable and updated information on cancer and help them manage the complications of this disease.

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.

Präoperative Physiotherapie vor viszeralen abdominalen Operationen digital umsetzen? – Eine qualitative Machbarkeitsstudie

Hintergrund Große Operationen am Bauchraum stellen die größte Gruppe der Operationen in Deutschland dar. Besonders Patient*innen mit Komorbiditäten zeigen ein hohes Risiko für die Entwicklung postoperativer respiratorischer Komplikationen und damit einhergehend postoperativer Einbußen der körperlichen Funktionsfähigkeit. Obwohl präoperative Physiotherapie positiven Einfluss auf die Komplikationsrate nehmen kann, wird sie in Deutschland nicht regelhaft umgesetzt.

Ziel Untersuchung der Machbarkeit einer digitalen Umsetzung präoperativer Physiotherapie aus der Perspektive von Ärzt*innen, Physiotherapierenden und Patient*innen. Dazu werden Bedarfe an eine digitale Intervention sowie inhaltliche und technische Anforderungen erfragt.

Methode In einer qualitativen Studie wurden 2 Ärzt*innen, 5 Physiotherapierende und 2 Patienten interviewt. Die Daten wurden transkribiert und mittels qualitativer Inhaltsanalyse nach Schreier 35 ausgewertet.

Ergebnisse Die Ergebnisse bestätigten die hohe Relevanz der präoperativen Versorgung. Digitale Interventionen können die in diesem Zusammenhang existierende Versorgungslücke schließen. Die formulierten Anforderungen an eine Individualisierung und einen motivierenden Charakter können insbesondere durch Apps realisiert werden.

Diskussion Die zu entwickelnde App soll darauf abzielen 1.) eine Verhaltensänderung anzubahnen, 2.) Wissen zu vermitteln und 3.) Übungen anzuleiten. Vor dem Hintergrund der Zielsetzungen und dem Kontext, in dem die App Anwendung finden soll, ist von einer hohen Komplexität bei der Entwicklung und besonders der Implementierung auszugehen. Gleichzeitig ermöglicht die vorgelegte Analyse eine direkte Bearbeitung der identifizierten Herausforderungen.

Schlussfolgerung Die Entwicklung einer App als Teil der präoperativen Vorbereitung hat das Potenzial, eine aktuelle Versorgungslücke zu schließen und die möglichen negativen Folgen einer Operation zu adressieren. Die vorgelegte Studie gibt Hinweise für die nächsten Entwicklungsschritte.

Clinical feasibility of the Q1.6 Inguinal Hernia application: a prospective cohort study

PURPOSE

Patient-reported outcomes (PROs) are essential to evaluate inguinal hernia surgery. There is a need for digital and disease-specific PRO measurement. Current measuring instruments (PROMs) have several disadvantages, for example, fixed measuring moments with a chance of recall bias. The Q1.6 Inguinal Hernia application has been developed to overcome these challenges. This pilot study reports the first clinical feasibility results.

METHODS

All surgically treated inguinal hernia patients were eligible for inclusion. The application uses "twitch crowdsourcing"; after unlocking a smartphone or tablet, a single short question is asked. This can easily be repeated multiple times a day/week/month. Questions from validated questionnaires were implemented. The adaptive question engine generates an individualised set of questions. Alerts are generated when a complication is suspected.

RESULTS

A total of 229 patients were given over 50.000 questions of which 92% were answered. Pre- and postoperative patient characteristics and their reported clinical outcomes confirmed a standard inguinal hernia population. Compliance with the application was 91.7% after 14 days, 69.0% after 3 months and 28.8% after one year. After months 3, 6 and 11, respectively, 3.0%, 4.4% and 4.5% of patients reported inguinal pain or discomfort (NRS ≥ 4). Patients were highly satisfied (92.8% preferred the app over standard care).

CONCLUSIONS

This smartphone application shows promising results for clinical practice. It might allow for continuous digital patient-reported outcome measurement using non-intrusive, concise questions. Remote monitoring may become standard postoperative care after (inguinal hernia) surgery. The current application will be further improved and evaluated for cost-effectiveness, safety and validity.

Sociodemographic Characteristics Associated with an eHealth System Designed to Reduce Depressive Symptoms among Patients with Breast or Prostate Cancer: Prospective Study (Preprint)

Background

eHealth interventions have become a topic of interest in the field of mental health owing to their increased coordination and integration of different elements of care, in treating and preventing mental ill health in patients with somatic illnesses. However, poor usability, learnability, and user engagement might affect the effectiveness of an eHealth intervention. Identifying different sociodemographic characteristics that might be associated with higher perceived usability can help improve the usability of eHealth interventions.

Objective

This study aimed to identify the sociodemographic characteristics that might be associated with the perceived usability of the NEVERMIND (Neurobehavioural Predictive and Personalised Modelling of Depressive Symptoms During Primary Somatic Diseases) eHealth system, comprising a mobile app and a sensorized shirt, in reducing comorbid depressive symptoms in patients with breast or prostate cancer.

Methods

The study included a total of 129 patients diagnosed with breast (n=80, 62%) or prostate (n=49, 38%) cancer, who received a fully automated mobile app and sensorized shirt (NEVERMIND system). Sociodemographic data on age, sex, marital status, education level, and employment status were collected at baseline. Usability outcomes included the System Usability Scale (SUS), a subjective measure that covers different aspects of system usability; the user version of the Mobile App Rating Scale (uMARS), a user experience questionnaire; and a usage index, an indicator calculated from the number of days patients used the NEVERMIND system during the study period.

Results

The analysis was based on 108 patients (n=68, 63%, patients with breast cancer and n=40, 37%, patients with prostate cancer) who used the NEVERMIND system for an average of 12 weeks and completed the study. The overall mean SUS score at 12 weeks was 73.4 (SD 12.5), which indicates that the NEVERMIND system has good usability, with no statistical differences among different sociodemographic characteristics. The global uMARS score was 3.8 (SD 0.3), and women rated the app higher than men (β=.16; P=.03, 95% CI 0.02-0.3), after adjusting for other covariates. No other sociodemographic characteristics were associated with higher uMARS scores. There was a statistical difference in the use of the NEVERMIND system between women and men. Women had significantly lower use (β=–0.13; P=.04, 95% CI −0.25 to −0.01), after adjusting for other covariates.

Conclusions

The findings suggest that the NEVERMIND system has good usability according to the SUS and uMARS scores. There was a higher favorability of mobile apps among women than among men. However, men had significantly higher use of the NEVERMIND system. Despite the small sample size and low variability, there is an indication that the NEVERMIND system does not suffer from the digital divide, where certain sociodemographic characteristics are more associated with higher usability.

Trial Registration

German Clinical Trials Register RKS00013391; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013391

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.