An app for patient education and self-audit within an enhanced recovery program for colorectal surgery: A pilot study on validity and usability.

Nicolo Pecorelli, MD1, Julio F Fiore Jr., MSc, PhD1, Pepa Kaneva, MSc1, Abarna Somasundram, BSc1, Patrick Charlebois, MD2, A S Liberman, MD2, Barry L Stein, MD2, Franco Carli, MD, MPhil2, Liane S Feldman, MD2. 1Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, 2McGill University Health Centre

Introduction: While patient engagement and clinical audit are key components of successful enhanced recovery programs (ERPs), they require substantial resource allocation. The objective of this study was to assess the validity and usability of a novel mobile device application for education and self-reporting of adherence for patients undergoing colorectal surgery within an established ERP.

Methods and procedures: Prospectively recruited patients undergoing colorectal surgery within an ERP received a tablet (iPad, Apple®) at their bedside during their hospital stay. Patients were instructed on how to use a novel app specifically designed to provide daily recovery milestones and record adherence to 15 different ERP processes and 6 patient reported outcomes (PROs) using a daily questionnaire for each day in hospital. Primary outcome was validity as measured by the agreement index (Cohen’s kappa coefficient for categorical, and interclass correlation coefficient (ICC) for continuous variables) between patient reported data through the app and those recorded by a clinical auditor. Secondary outcomes included acceptability and usability of the app as measured by the System Usability Scale (SUS).

Results: Thirty-four patients participated in the study (mean age 61 years, 62% female, 62% laparoscopic surgery, 9% rectal surgery, 56% malignancy). Overall, patients completed 122 of 136 (90%) of the available questionnaires through the app. Median time to complete a questionnaire was 195 seconds (IQR 147–269). Substantial (kappa > 0.6) or almost-perfect agreement (kappa > 0.8) and strong correlation (ICC > 0.7) was found for 14 ERP processes and 5 PROs. Use of preoperative carbohydrate drink (kappa = 0.530) and ability to use the bathroom independently (kappa = 0.576) were the only elements with moderate agreement. Patient reported usability was high; median SUS score was 93 (IQR 83-99), with 79% of patients reporting an overall SUS score higher than 80 of 100. Scores were particularly high for the SUS learnability domain (median 100, IQR 81-100). Only 5 (15%) patients needed technical support to use the app. Twenty-nine (85%) patients found the app was helpful to achieve their daily goals, and 25 (73%) patients thought it increased their motivation to recover after surgery.

Conclusions: This novel application provides a mechanism to record patient adherence to care processes and patient reported outcomes, with high agreement with traditional clinical audit, high usability and patient satisfaction. Future studies should investigate the use of mobile device apps as strategies to increase adherence to perioperative interventions.

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