Implementation and Evaluation of a Smartphone Application for the Perioperative Care of Neurosurgery Patients at an Academic Medical Center: Implications for Patient Satisfaction, Surgery Cancelations, and Readmissions

Implementation and Evaluation of a Smartphone Application for the Perioperative Care of... Abstract BACKGROUND Smartphone applications (apps) in the health care arena are being increasingly developed with the aim of benefiting both patients and their physicians. The delivery of adequate instructions both before and after a procedure or surgery is of paramount importance in ensuring the best possible outcome for patients. OBJECTIVE To demonstrate that app-based instructions with built-in reminders may improve patient understanding and compliance and contribute to reducing the number of surgery cancellations and postoperative complications and readmissions. METHODS We prospectively accrued 56 patients undergoing routine neurosurgery procedures who subsequently downloaded the app. The median age was 54 (range 27-79). Patients were followed for successful registration and use of the app, compliance with reading instructions before and after surgery, and sending pain scores and/or wound images. The number of surgeries cancelled, postoperative complications, 30-d readmissions, and phone calls for surgery-related questions were examined. RESULTS Fifty-four of the 56 patients successfully registered, downloaded, and used the app and read and complied with instructions both before and after surgery. There were no cancelled surgeries. There was 1 postoperative complication. There were no readmissions. Eight of the 54 patients (14.8%) called the office on a single occasion for a surgery related question. CONCLUSION We demonstrate the utility of a smartphone application in the perioperative neurosurgical care setting with regard to patient compliance and satisfaction as well as surgery cancellations and readmissions. Further study of a larger number of patients with a control group is warranted. Applications, Neurosurgery, Patient satisfaction, Perioperative care, Readmissions, Smartphone, Surgical cancellations ABBREVIATIONS ABBREVIATIONS Apps applications DVT deep venous thrombosis PE pulmonary embolism The effective delivery of instructions both before and after procedures is of paramount importance in ensuring the best possible outcome for patients. However, studies have shown that the majority of medical information provided by physicians in the clinic is forgotten.1-2 Preoperatively, failure to follow these instructions can lead to cancelled interventions, causing patient frustration and financial losses for physicians and hospitals.3 Postoperatively, it can increase the risk of complications and readmissions.4 Smartphone applications (apps) in the health care arena are being increasingly developed with the aim of benefiting both patients and their physicians. While digital health strategy will be transformative in the next decade, the health care sector has been slow to adopt fast-growing new technologies, including the use of smartphones and tablets, until recently. From 2009 to 2012, we witnessed an approximate 9-fold increase in the number of education-based surgical apps available for the Apple iPhone and Android.5 Interestingly, the majority lacked medical professional involvement.6 An app for the perioperative care of surgical patients could serve as a patient engagement tool, improve patient–physician communication, and provide a solution to the episodic and disconnected care of patients, as what happens between health care visits and after discharge is important and strongly predictive of outcomes. Furthermore, a perioperative care app would eliminate the need for printed instructions and inconsistencies in the delivery of instructions within academic hospitals or between different surgery locations, reduce call volume to a practice, and increase patient satisfaction.7 We conducted a prospective evaluation of a new smartphone app developed by a team of physicians and designed to provide tailored, surgeon-driven pre- and postoperative instructions. These instructions are categorized in a user-friendly manner to optimize understanding. The app also permitted patients to send pain scores and images of their wound at regular intervals while allowing physicians and their staff to send messages to their patients. We hypothesized that the app should improve compliance with instructions, prevent canceled surgeries, reduce complications and readmissions, and improve patient satisfaction. METHODS Faculty and staff of the Department of Neurosurgery at MedStar Georgetown University Hospital (AA, FAS, NN, JMV) registered and created secure online accounts at www.trackmyrecovery.com. They subsequently created specific pre- and postoperative instructions for individual surgeries based on standard templates of nursing, anesthesia, and surgery-specific instructions. Surgery-specific instructions were tailored according to physician preference and were associated with reminders in the form of push notifications that patients would receive both before and after surgery. All patients consented to have any part of their participation published, including any or all images. IRB approval was not required given the observational nature of the study. Patients with smartphones or tablets (Apple and Android) who knew how to download apps were selected. All other patients were excluded. Patient demographics and the surgeries performed were recorded. Once securely registered online by the practice, these patients received an email with instructions to download TrackMyRecovery® (Favorhealth, Inc., Sarasota, Florida) and activate instructions. The patients’ specific pre- and postoperative instructions were available electronically by logging into the app (Figures 1A-1E). Through the app, patients were prompted to perform specific tasks, such as reading these instructions. Confirmation of completed tasks was sent to the web portal as a newsfeed where physicians and staff had full access (Figure 2). Patients also received specific, timely, push notification (text message) reminders before and after their surgeries. Patients could send pain scores and wound images through the app securely to the web portal. Providers received automatic email notifications of these submissions and could send messages back to the patient's app to enhance communication. All patients were also given the standard surgical packet of documents containing instructions. FIGURE 1. View largeDownload slide TrackMyRecovery® app interface. A, home page; B, patient instructions; C, preoperative instructions; D, postoperative instructions; and E, report pain level. FIGURE 1. View largeDownload slide TrackMyRecovery® app interface. A, home page; B, patient instructions; C, preoperative instructions; D, postoperative instructions; and E, report pain level. FIGURE 2. View largeDownload slide TrackMyRecovery® patient newsfeed. FIGURE 2. View largeDownload slide TrackMyRecovery® patient newsfeed. All parties (physicians, residents, physician assistants, nurse practitioners, office assistants, and patients) accepted the terms of use. The web portal and app were developed using a standard, HIPAA-compliant privacy policy approved by Medstar Inc. The primary end points were (1) successful registration and use of the app; (2) compliance with reading instructions before and after surgery; and (3) sending pain scores and/or wound images. The secondary endpoints were (1) preoperative surgery cancellation within 48 h due to noncompliance with instructions (eg, failure to maintain NPO status, obtain specialty clearance, or discontinue blood thinners); (2) after-discharge, postoperative complication within 6 wk (eg, wound infection, deep venous thrombosis [DVT], pulmonary embolism [PE], pneumonia, urinary tract infection); (3) readmission within 30 d; and (4) number of perioperative phone calls to the practice for surgery-related questions. Once fully recovered, patients were sent an email requesting that they complete an online questionnaire (surveymonkey.com) regarding the use and benefits of the app in order to measure patient satisfaction. Patients were under no obligation to do so and could respond anonymously. STROBE Reporting Guidelines were implemented in preparing this manuscript. RESULTS Case Illustrations A 39-yr-old woman developed worsening neck pain with a cervical radiculopathy refractory to conservative measures. A standard anterior cervical discectomy and fusion was planned for advanced disc degeneration, stenosis, and loss of regional lordosis. She was registered on the web portal, downloaded the app, and activated her specific instructions. Postoperatively, she became concerned about a wound infection and sent serial wound images from the app to the web portal (Figures 3A-3C). The wound images revealed a reaction to the benzoin placed on the skin prior to the application of steri-strips. Through the app, she was instructed to remove the steri-strips and send daily wound images. The cutaneous reaction resolved. The ability to send wound images and instructional messages avoided telephone calls to the office and an unnecessary office visit. FIGURE 3. View largeDownload slide Sequential photographs sent by the patient via the app because of concerns about a possible wound infection allowing for telemedicine and avoiding an emergency room visit. A, post-op day #2; B, post-op day #5; and C, post-op day #10. FIGURE 3. View largeDownload slide Sequential photographs sent by the patient via the app because of concerns about a possible wound infection allowing for telemedicine and avoiding an emergency room visit. A, post-op day #2; B, post-op day #5; and C, post-op day #10. A 55-yr-old man had worsening low back and left leg pain over several years. His imaging studies revealed an unstable isthmic L5-S1 spondylolisthesis with left foraminal stenosis. He underwent a left-sided minimally invasive posterior transforaminal lumbar interbody fusion with pedicle screw instrumentation and reduction at L5-S1. He was discharged on postoperative day 2 with complete relief of his left leg pain. While recovering at home, he began to develop new and worsening right-sided leg pain in a similar distribution and submitted daily pain scores (Figure 4). He was contemplating a visit to the ER because of the severity of his symptoms. Given the rise in pain levels submitted through the app, he was contacted by our staff. He was found to be without neurological deficit with a presumed contralateral L5 radiculopathy from the reduction of his spondylolisthesis. The patient was prescribed a Medrol dose pack and his symptoms resolved. In this clinical scenario, the ability to send pain scores alerted the staff to a developing postoperative problem that was mitigated with medication, thus avoiding a costly ER visit or readmission. FIGURE 4. View largeDownload slide Daily pain scores sent by the patient via the app documenting new and worsening postoperative pain. FIGURE 4. View largeDownload slide Daily pain scores sent by the patient via the app documenting new and worsening postoperative pain. Participants Fifty-six patients undergoing routine neurosurgery procedures were prospectively accrued. There were 23 men and 33 women with a median age of 54 (range 27-79). Fifty-five patients underwent spinal surgery and 1 underwent cranial surgery. Demographics are listed in Table 1. TABLE 1. Patient Demographics Average age ± SD  Patients (n = 56) 52 ± 14  Sex     Male  23   Female  33  Procedure     Lumbar discectomy/foraminotomy  24   Lumbar laminectomy  10   Posterior lumbar fusion  8   Lateral lumbar fusion  2   Anterior lumbar fusion  2   Anterior cervical fusion  9   Suboccipital craniectomy  1  Average age ± SD  Patients (n = 56) 52 ± 14  Sex     Male  23   Female  33  Procedure     Lumbar discectomy/foraminotomy  24   Lumbar laminectomy  10   Posterior lumbar fusion  8   Lateral lumbar fusion  2   Anterior lumbar fusion  2   Anterior cervical fusion  9   Suboccipital craniectomy  1  View Large Main Results Primary end points: 56 of 56 patients meeting inclusion criteria agreed to participate in the study, of whom, 54 patients successfully downloaded, registered, and used the TrackMyRecovery® app. All of these 54 patients read and complied with both pre- and postoperative instructions based on data sent from the app to the web portal and sent wound images and/or pain scores (Table 2). TABLE 2. Primary and Secondary Endpoints   Patients (n = 56)  Downloaded, registered, and used app  54  Complied with written instructions before and after surgery  54  Wound images and/or pain scores  54  Canceled surgeries  0  Complications  1  Readmissions  0  Perioperative phone calls     No calls  46   1 call  8  Completed questionnaire  28    Patients (n = 56)  Downloaded, registered, and used app  54  Complied with written instructions before and after surgery  54  Wound images and/or pain scores  54  Canceled surgeries  0  Complications  1  Readmissions  0  Perioperative phone calls     No calls  46   1 call  8  Completed questionnaire  28  View Large Secondary end points: There were no cancelled surgeries. After having undergone an anterior cervical fusion, 1 patient experienced a postoperative complication in the form of a mild superficial wound infection, which was treated with oral antibiotics and resolved completely. There were no readmissions. After downloading the app, 8 of 54 patients (14.8%) called the office on a single occasion with questions regarding perioperative care. Twenty-eight of 54 patients (51.9%) completed the online questionnaire regarding the benefits of use of the app (Table 2) and reported high satisfaction scores (Figures 5A-5F). FIGURE 5. View largeDownload slide Patient responses to online questionnaire regarding A, the usefulness of having in-app electronic instructions; B, the usefulness of the automatic notifications and reminders; C, whether the app made patients feel that they were being closely monitored; D, whether the app helped patients better prepare for and recover from surgery; E, the usefulness of having the ability to report pain scores; and F, the usefulness of having the ability to send wound images. FIGURE 5. View largeDownload slide Patient responses to online questionnaire regarding A, the usefulness of having in-app electronic instructions; B, the usefulness of the automatic notifications and reminders; C, whether the app made patients feel that they were being closely monitored; D, whether the app helped patients better prepare for and recover from surgery; E, the usefulness of having the ability to report pain scores; and F, the usefulness of having the ability to send wound images. DISCUSSION Patient Engagement and Satisfaction Patient engagement is an increasingly important component of strategies to reform health care. Measures to individualize patient care and strengthen the patient's role in the process have been shown to improve health outcomes.8 These include web-based patient education tools, innovative uses of technology, and strategies to deliver timely information.9 Furthermore, highly engaged patients consistently report more positive care experiences.8 Ensuring patient satisfaction is a top priority for physicians and hospital networks. Preoperative Considerations: Compliance and Surgery Cancellations Patient compliance with pre- and postoperative instructions is of paramount importance in ensuring the best possible outcomes. The great majority of physician practices deliver instructions to patients by providing a surgical packet with printed materials. Many packets are generic and overwhelming to patients, and this problem is compounded by increasing time constraints, which may limit the ability of providers to deliver thorough verbal instructions.3 Additionally, age and anxiety may impair patients’ understanding and retention, and patients reportedly retain only 40% to 80% of the medical information presented by providers.2 Furthermore, many patients are unable to adequately recall information with high fidelity even with adequate education.1 Lack of understanding and poor compliance with instructions before surgery can lead to last-minute surgery cancelations. Patients who fail to discontinue blood thinners as directed or obtain a cardiology evaluation are often rescheduled on the day of surgery. This represents a substantial loss of revenue for hospitals, ambulatory surgery centers, and physicians. Elective surgery cancelation rates range from 6% to 20%, with the most common cited reasons being patient noncompliance with instructions, a change in the medical condition or recent illness, and institutional or equipment issues.10-15 Investigators have considered other ways to reduce cancellations, with telephone prompts and mailed reminders being the most effective.16 Methods to improve patient understanding and compliance with instructions have included preoperative educational classes and instructional videos.17-18 However, patients who attended the educational classes did not demonstrate significantly higher levels of adherence compared to controls.17 Patients that viewed instructional videos did demonstrate higher levels of knowledge, but the role of this educational method has not been thoroughly evaluated.18 Despite these efforts, there remains significant room for improvement and the implementation of new strategies to address these problems. Postoperative Considerations: Compliance, Complications, and Readmissions Postoperatively, noncompliance with instructions can increase complications. Improper wound care can lead to infections, which represents one of the most common causes of readmissions.4 Failure to follow mobility restrictions can cause increased pain or implant failure, while immobility can lead to DVT, PE, or pneumonia. During the recovery process, patient understanding of instructions is further impaired by pain and analgesic use. All of these issues can contribute to postoperative readmissions, which carry a substantial financial burden estimated to be $12 to 17 billion a year for Medicare patients19-20 or $13 400 per spinal surgery.21 A number of studies have documented 30-d readmission rates following spinal and cranial surgery ranging from 2.6% to 21.3% and 14% to 24%, respectively.19-20,22 The leading causes were found to be wound complications, sepsis, pain management, and DVT/PE.19 Greater surgical complexity, longer surgery times, advanced age, and comorbidities were associated with higher readmissions.19-20 Smartphone Apps With over 40 000 mobile health apps and an estimated 65% of the United States population owning a smartphone, the potential for incorporation of smartphone apps into clinical and surgical practice is remarkable.5 We hypothesized that an app that provides clear, user-friendly, and organized pre- and postoperative instructions tailored by the surgeon could improve the delivery of perioperative care and ameliorate the aforementioned problems. Any chosen instruction can be associated with a push notification sent to the patient as a text message at a designated time before or after surgery. These powerful reminders should improve compliance with instructions and can be tailored to reach specific goals. Preoperatively, we focused reminders on the most important elements that could lead to surgery cancelations: preoperative clearance evaluation by specialists, laboratory work, medication management (discontinuing nonsteroidal anti-inflammatory drug or other blood thinners), preoperative illness, and day-of-surgery instructions. Postoperatively, we targeted factors after neurosurgery that could lead to readmissions by reinforcing viewable instructions with additional reminders. Wound care and infections were monitored with daily prompts to send wound images as needed. Postoperative pain management was monitored with daily prompts to send pain scores as needed. We added reminders on mobility and bowel regimen to prevent DVT, PE, or postoperative constipation. To improve understanding of the proposed surgical intervention, hyperlinks from the app to websites and approved videos were added when appropriate. Interpretation of Results The results of our initial analysis on the utility of the app are very promising. Physicians and staff were able to create and individualize instructions based on standard templates with autopopulated content in less than 5 min for a particular surgery. They were trained to register and monitor patients through pre- and postoperative phases, and the instructions could be changed at any time before or after surgery for each individual patient. The great majority of patients (96.4%) successfully downloaded, logged on, and activated instructions on the TrackMyRecovery® app. One patient, who failed to download the app, was registered by the staff incorrectly with an inaccurate date of birth. The other chose not to proceed after forgetting her password. All patients using the app were documented to have read both pre- and postoperative instructions according to in-app responses sent to the practice's online web portal. All patients sent wound images and/or pain scores when prompted or when concerned. There were no last-minute surgery cancelations in this cohort of 54 app users. Hospital-wide and departmental cancelation rates at our institution were not available during this period. There was 1 mild superficial wound infection, which was treated with oral antibiotics and resolved completely. There were no other postoperative complications. None of the 54 app users were readmitted after surgery. There were no ER visits. Only 14.8% of patients, on a single occasion each, called the office after downloading the app with surgery-related questions. While there are no published data on this topic to our knowledge, anecdotal evidence and personal communications with staff suggest that use of the app reduced office telephone traffic. Patient satisfaction surveys were completed by more than half of the patients studied. The great majority of patients responded very favorably with regard to the usefulness of electronic instructions, reminders, and the ability to send wound images and pain scores (Figures 5A-5F). Based on the analysis of this cohort, we posit that the use of an app for delivery of perioperative instructions with built-in reminders improved compliance while allowing providers to track the patient's journey before and after surgery. These findings are corroborated by Deng et al,3 who found that patients receiving text message reminders demonstrated increased compliance and had fewer procedures cancelled compared to controls who received only leaflet instructions. Furthermore, the ability to send wound images through the app could lead to an early diagnosis of wound infection or dehiscence, potentially preventing a lengthy readmission or additional surgery. Martinez-Ramos et al4 reported that patients’ concerns about the surgical site were adequately resolved by sending pictures to the staff, and that this reduced readmissions by 55.2%. This is supported by Semple and colleagues,23 who found that the use of an app and pictures sent by patients is effective for monitoring patient home recovery. In addition to decreasing readmission rates, use of an app to monitor postoperative recovery may enable clinicians to safely discharge patients earlier, thereby reducing patients’ length of stay. Given that decreasing length of stay and readmission rates improves patient satisfaction, and that our cohort reported high satisfaction scores, an app of this kind represents a useful tool for adjusting to the recent patient-centered reimbursement guidelines.24 Limitations The present study has several limitations. The patient cohort is small, and the noncomparative nature of the analysis limits our capacity to make far-reaching conclusions with respect to clinical efficacy and cost savings. A prospective controlled study is needed to further validate our findings. Furthermore, patients with smartphones or tablets who are proficient with apps are generally younger and therefore likely to be more compliant with instructions. The median age of our patient cohort was 54. As previously mentioned, complication and readmission rates increase with greater surgical complexity, longer surgery times, and advanced age. Less than half of the patients studied (n = 22) underwent instrumented spinal fusions or suboccipital craniectomy, while the majority underwent lumbar discectomy/foraminotomy or laminectomy surgeries. The potential for expanding the use of smartphone technology in the health care sector is untold. An app of this kind can be implemented across surgical disciplines with a focus on reducing specialty-specific readmissions with tailored built-in reminders and online educational tools. Standardized outcome measures and enhanced recovery pathways will be incorporated in electronic instructions for each patient before and after surgery for outcomes-based research. Other patient metrics can be tracked by specialty after surgery for practice analytics. App integration with wearable technologies such as Fitbit® and others will allow for monitoring activity during the recovery process, while sharing of patients’ personal health information will be facilitated by Apple's CareKit® framework. CONCLUSION The purpose of this study was to evaluate the ability of a smartphone app in the perioperative care setting to produce high levels of patient compliance and satisfaction and to reduce surgery cancellations, postoperative complications, and readmissions. The app was used effectively in a cohort of 54 patients undergoing routine neurosurgery procedures. It yielded 100% compliance with instructions and excellent patient satisfaction scores. Our study demonstrates the utility of a smartphone application whereby easily accessible instructions with built-in reminders may improve patient compliance and communication while reducing surgery cancellations, postoperative complications, and readmissions and improving patient satisfaction. A larger, controlled cohort study with long-term follow-up across various medical disciplines is necessary to corroborate these findings. Disclosures Jean-Marc Voyadzis is a cofounder of Favorhealth Inc, (Sarasota, Florida, United States) the company that developed the TrackMyRecovery® app and www.trackmyrecovery.com webportal. He is a shareholder. The other authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. REFERENCES 1. Hutson MM, Blaha JD. Patients' recall of preoperative instruction for informed consent for an operation. J Bone Joint Surg Am . 1991; 73( 2): 160- 162. Google Scholar CrossRef Search ADS PubMed  2. Kessels RP. Patients' memory for medical information. J R Soc Med . 2003; 96( 5): 219- 222. Google Scholar PubMed  3. Deng X, Wang Y, Zhu T, Zhang W, Yin Y, Ye L. Short message service (SMS) can enhance compliance and reduce cancellations in a sedation gastrointestinal endoscopy center: a prospective randomized controlled trial. J Med Syst . 2015; 39( 1): 169. Google Scholar CrossRef Search ADS PubMed  4. Martínez-Ramos C, Cerdán MT, López RS. Mobile phone-based telemedicine system for the home follow-up of patients undergoing ambulatory surgery. Telemed J E Health . 2009; 15( 6): 531- 537. Google Scholar CrossRef Search ADS PubMed  5. Mobasheri MH, Johnston M, Syed UM, King D, Darzi A. The uses of smartphones and tablet devices in surgery: a systematic review of the literature. Surgery . 2015; 158( 5): 1352- 1371. Google Scholar CrossRef Search ADS PubMed  6. Kulendran M, Lim M, Laws G et al.   Surgical smartphone applications across different platforms: their evolution, uses, and users. Surg Innov . 2014; 21( 4): 427- 440. Google Scholar CrossRef Search ADS PubMed  7. Morsli H, Mathew D. CRT-708 Development and evaluation of a smartphone application for the perioperative care of patients undergoing routine cardiology procedures. JACC . 2015; 8( 2_S): S46- S46. 8. Hibbard JH, Greene J. What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health Aff (Millwood) . 2013; 32( 2): 207- 214. Google Scholar CrossRef Search ADS PubMed  9. Gruman J, Rovner MH, French ME et al.   From patient education to patient engagement: implications for the field of patient education. Patient Educ Couns . 2010; 78( 3): 350- 356. Google Scholar CrossRef Search ADS PubMed  10. Argo JL, Vick CC, Graham LA, Itani KM, Bishop MJ, Hawn MT. Elective surgical case cancellation in the Veterans Health Administration system: identifying areas for improvement. Am J Surg . 2009; 198( 5): 600- 606. Google Scholar CrossRef Search ADS PubMed  11. Dexter F, Marcon E, Epstein RH, Ledolter J. Validation of statistical methods to compare cancellation rates on the day of surgery. Anesth Analg . 2005; 101( 2): 465- 473; table of contents. Google Scholar CrossRef Search ADS PubMed  12. Xue W, Yan Z, Barnett R, Fleisher L, Liu R. Dynamics of elective case cancellation for inpatient and outpatient in an academic center. J Anesth Clin Res . 2013; 4( 5): 314- 323. Google Scholar PubMed  13. Sanjay P, Dodds A, Miller E, Arumugam P, Woodward A. Cancelled elective operations: an observational study from a district general hospital. J Health Organ Manag . 2007; 21( 1): 54- 58. Google Scholar CrossRef Search ADS PubMed  14. Kumar R, Gandhi R. Reasons for cancellation of operation on the day of intended surgery in a multidisciplinary 500 bedded hospital. J Anaesthesiol Clin Pharmacol . 2012; 28( 1): 66- 69. Google Scholar CrossRef Search ADS PubMed  15. Cihoda JH, Alves JR, Fernandes LA, de Souza Neto EP. The analysis for the causes of surgical cancellations in a Brazilian university hospital. Care Manag J . 2015; 16( 1): 41- 47. Google Scholar CrossRef Search ADS PubMed  16. Macharia WM, Leon G, Rowe BH, Stephenson BJ, Haynes RB. An overview of interventions to improve compliance with appointment keeping for medical services. JAMA . 1992; 267( 13): 1813- 1817. Google Scholar CrossRef Search ADS PubMed  17. Kim K, Chin G, Moore T, Schwarzkopf R. Does a preoperative educational class increase patient compliance. Geriatr Orthop Surg Rehabil . 2015; 6( 3): 153- 156. Google Scholar CrossRef Search ADS PubMed  18. Stern C, Lockwood C. Knowledge retention from preoperative patient information. Int J Evid Based Healthc . 2005; 3( 3): 45- 63. Google Scholar PubMed  19. Akins PT, Harris J, Alvarez JL et al.   Risk factors associated with 30-day readmissions after instrumented spine surgery in 14,939 patients. Spine (Phila Pa 1976) . 2015; 40( 13): 1022- 1032. Google Scholar CrossRef Search ADS PubMed  20. Bernatz JT, Anderson PA. Thirty-day readmission rates in spine surgery: systematic review and meta-analysis. Neurosurg Focus . 2015; 39( 4): E7, http://thejns.org/doi/abs/10.3171/2015.7.FOCUS1534. Google Scholar CrossRef Search ADS PubMed  21. Qasim M, Andrews RM. Post-surgical readmissions among patients living in the poorest communities, 2009: Statistical Brief #142. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs . Rockville, MD: Agency for Healthcare Research and Quality; 2012. 22. Moghavem N, Morrison D, Ratliff JK, Hernandez-Boussard T. Cranial neurosurgical 30-day readmissions by clinical indication. J Neurosurg . 2015; 123( 1): 189- 197. Google Scholar CrossRef Search ADS PubMed  23. Semple JL, Sharpe S, Murnaghan ML, Theodoropoulos J, Metcalfe KA. Using a mobile app for monitoring post-operative quality of recovery of patients at home: a feasibility study. JMIR Mhealth and Uhealth . 2015; 3( 1): e18, http://mhealth.jmir.org/article/citations/3929. Google Scholar CrossRef Search ADS PubMed  24. Tsai TC, Orav EJ, Jha AK. Patient satisfaction and quality of surgical care in US hospitals. Ann Surg . 2015; 261( 1): 2- 8. Google Scholar CrossRef Search ADS PubMed  Acknowledgments We wish to thank Analyn Coburn, Anna Armistead, and Samantha Simpson for their contributions to the data collection. COMMENT In a prospective observational study of 56 patients, the authors of this article evaluated the utility of a patient centered smartphone application. They concluded that there is a place for perioperative smartphone applications to help with increasing compliance, decreasing cancellations, and preventing readmissions. Without a larger group and a control group, it is difficult to say whether the 54 patients who interacted with the app would have had improved compliance, fewer office phone calls, no cancellations, and no readmissions even without the use of the application. It would have been interesting to see what the data would have yielded when observing a similar patient population at the same institution without having the patients use the application. As more medical applications develop, creators are quick to publish data solely based on innovation and novelty, however many of such articles fall short on presenting meaningful data for scholarly inquiry. Applications rooted to improving patient care are all but groundbreaking, however the merit in this article is earned through the triumph of increasing patient engagement and satisfaction. It is rather intuitive to hypothesize that complications and readmissions decrease by being able to prompt a patient with targeted perioperative information, but the notion of involving the patient more in his/her care is a success in this article that should be emphasized more. There has been literature supporting patient engagement initiatives and improved outcomes1 and this paper certainly follows the trend. Remote monitoring programs, increased education, and a shared decision-making approach all facilitate patient engagement methods. With the continued rise in optimizing healthcare value–improving outcomes while reducing costs2,3–introducing mobile applications is a useful technique to help reach this goal by creating more patient engagement and using hospital staff resources more efficiently. We would like to congratulate the authors for the app development and would be interested in its continued clinical application. The user interface seems easy to use and the user feedback seems promising. Sanjay Konakondla Danville, Pennsylvania Clemens M. Schirmer Wilkes Barre, Pennsylvania 1. Kimball AB, Corey KC, Kvedar JC. Engaging patients to decrease costs and improve outcomes. Med Econ. 2015;92(2):36-37. 2. Lee TH. Turning Doctors into Leaders. Harv Bus Rev. 2010;88(4):50-58. 3. Porter ME, Lee TH. The Strategy That Will Fix Health Care. Harv Bus Rev. 2013. Copyright © 2017 by the Congress of Neurological Surgeons http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Operative Neurosurgery Oxford University Press

Implementation and Evaluation of a Smartphone Application for the Perioperative Care of Neurosurgery Patients at an Academic Medical Center: Implications for Patient Satisfaction, Surgery Cancelations, and Readmissions

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Oxford University Press
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Copyright © 2017 by the Congress of Neurological Surgeons
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2332-4252
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10.1093/ons/opx112
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Abstract

Abstract BACKGROUND Smartphone applications (apps) in the health care arena are being increasingly developed with the aim of benefiting both patients and their physicians. The delivery of adequate instructions both before and after a procedure or surgery is of paramount importance in ensuring the best possible outcome for patients. OBJECTIVE To demonstrate that app-based instructions with built-in reminders may improve patient understanding and compliance and contribute to reducing the number of surgery cancellations and postoperative complications and readmissions. METHODS We prospectively accrued 56 patients undergoing routine neurosurgery procedures who subsequently downloaded the app. The median age was 54 (range 27-79). Patients were followed for successful registration and use of the app, compliance with reading instructions before and after surgery, and sending pain scores and/or wound images. The number of surgeries cancelled, postoperative complications, 30-d readmissions, and phone calls for surgery-related questions were examined. RESULTS Fifty-four of the 56 patients successfully registered, downloaded, and used the app and read and complied with instructions both before and after surgery. There were no cancelled surgeries. There was 1 postoperative complication. There were no readmissions. Eight of the 54 patients (14.8%) called the office on a single occasion for a surgery related question. CONCLUSION We demonstrate the utility of a smartphone application in the perioperative neurosurgical care setting with regard to patient compliance and satisfaction as well as surgery cancellations and readmissions. Further study of a larger number of patients with a control group is warranted. Applications, Neurosurgery, Patient satisfaction, Perioperative care, Readmissions, Smartphone, Surgical cancellations ABBREVIATIONS ABBREVIATIONS Apps applications DVT deep venous thrombosis PE pulmonary embolism The effective delivery of instructions both before and after procedures is of paramount importance in ensuring the best possible outcome for patients. However, studies have shown that the majority of medical information provided by physicians in the clinic is forgotten.1-2 Preoperatively, failure to follow these instructions can lead to cancelled interventions, causing patient frustration and financial losses for physicians and hospitals.3 Postoperatively, it can increase the risk of complications and readmissions.4 Smartphone applications (apps) in the health care arena are being increasingly developed with the aim of benefiting both patients and their physicians. While digital health strategy will be transformative in the next decade, the health care sector has been slow to adopt fast-growing new technologies, including the use of smartphones and tablets, until recently. From 2009 to 2012, we witnessed an approximate 9-fold increase in the number of education-based surgical apps available for the Apple iPhone and Android.5 Interestingly, the majority lacked medical professional involvement.6 An app for the perioperative care of surgical patients could serve as a patient engagement tool, improve patient–physician communication, and provide a solution to the episodic and disconnected care of patients, as what happens between health care visits and after discharge is important and strongly predictive of outcomes. Furthermore, a perioperative care app would eliminate the need for printed instructions and inconsistencies in the delivery of instructions within academic hospitals or between different surgery locations, reduce call volume to a practice, and increase patient satisfaction.7 We conducted a prospective evaluation of a new smartphone app developed by a team of physicians and designed to provide tailored, surgeon-driven pre- and postoperative instructions. These instructions are categorized in a user-friendly manner to optimize understanding. The app also permitted patients to send pain scores and images of their wound at regular intervals while allowing physicians and their staff to send messages to their patients. We hypothesized that the app should improve compliance with instructions, prevent canceled surgeries, reduce complications and readmissions, and improve patient satisfaction. METHODS Faculty and staff of the Department of Neurosurgery at MedStar Georgetown University Hospital (AA, FAS, NN, JMV) registered and created secure online accounts at www.trackmyrecovery.com. They subsequently created specific pre- and postoperative instructions for individual surgeries based on standard templates of nursing, anesthesia, and surgery-specific instructions. Surgery-specific instructions were tailored according to physician preference and were associated with reminders in the form of push notifications that patients would receive both before and after surgery. All patients consented to have any part of their participation published, including any or all images. IRB approval was not required given the observational nature of the study. Patients with smartphones or tablets (Apple and Android) who knew how to download apps were selected. All other patients were excluded. Patient demographics and the surgeries performed were recorded. Once securely registered online by the practice, these patients received an email with instructions to download TrackMyRecovery® (Favorhealth, Inc., Sarasota, Florida) and activate instructions. The patients’ specific pre- and postoperative instructions were available electronically by logging into the app (Figures 1A-1E). Through the app, patients were prompted to perform specific tasks, such as reading these instructions. Confirmation of completed tasks was sent to the web portal as a newsfeed where physicians and staff had full access (Figure 2). Patients also received specific, timely, push notification (text message) reminders before and after their surgeries. Patients could send pain scores and wound images through the app securely to the web portal. Providers received automatic email notifications of these submissions and could send messages back to the patient's app to enhance communication. All patients were also given the standard surgical packet of documents containing instructions. FIGURE 1. View largeDownload slide TrackMyRecovery® app interface. A, home page; B, patient instructions; C, preoperative instructions; D, postoperative instructions; and E, report pain level. FIGURE 1. View largeDownload slide TrackMyRecovery® app interface. A, home page; B, patient instructions; C, preoperative instructions; D, postoperative instructions; and E, report pain level. FIGURE 2. View largeDownload slide TrackMyRecovery® patient newsfeed. FIGURE 2. View largeDownload slide TrackMyRecovery® patient newsfeed. All parties (physicians, residents, physician assistants, nurse practitioners, office assistants, and patients) accepted the terms of use. The web portal and app were developed using a standard, HIPAA-compliant privacy policy approved by Medstar Inc. The primary end points were (1) successful registration and use of the app; (2) compliance with reading instructions before and after surgery; and (3) sending pain scores and/or wound images. The secondary endpoints were (1) preoperative surgery cancellation within 48 h due to noncompliance with instructions (eg, failure to maintain NPO status, obtain specialty clearance, or discontinue blood thinners); (2) after-discharge, postoperative complication within 6 wk (eg, wound infection, deep venous thrombosis [DVT], pulmonary embolism [PE], pneumonia, urinary tract infection); (3) readmission within 30 d; and (4) number of perioperative phone calls to the practice for surgery-related questions. Once fully recovered, patients were sent an email requesting that they complete an online questionnaire (surveymonkey.com) regarding the use and benefits of the app in order to measure patient satisfaction. Patients were under no obligation to do so and could respond anonymously. STROBE Reporting Guidelines were implemented in preparing this manuscript. RESULTS Case Illustrations A 39-yr-old woman developed worsening neck pain with a cervical radiculopathy refractory to conservative measures. A standard anterior cervical discectomy and fusion was planned for advanced disc degeneration, stenosis, and loss of regional lordosis. She was registered on the web portal, downloaded the app, and activated her specific instructions. Postoperatively, she became concerned about a wound infection and sent serial wound images from the app to the web portal (Figures 3A-3C). The wound images revealed a reaction to the benzoin placed on the skin prior to the application of steri-strips. Through the app, she was instructed to remove the steri-strips and send daily wound images. The cutaneous reaction resolved. The ability to send wound images and instructional messages avoided telephone calls to the office and an unnecessary office visit. FIGURE 3. View largeDownload slide Sequential photographs sent by the patient via the app because of concerns about a possible wound infection allowing for telemedicine and avoiding an emergency room visit. A, post-op day #2; B, post-op day #5; and C, post-op day #10. FIGURE 3. View largeDownload slide Sequential photographs sent by the patient via the app because of concerns about a possible wound infection allowing for telemedicine and avoiding an emergency room visit. A, post-op day #2; B, post-op day #5; and C, post-op day #10. A 55-yr-old man had worsening low back and left leg pain over several years. His imaging studies revealed an unstable isthmic L5-S1 spondylolisthesis with left foraminal stenosis. He underwent a left-sided minimally invasive posterior transforaminal lumbar interbody fusion with pedicle screw instrumentation and reduction at L5-S1. He was discharged on postoperative day 2 with complete relief of his left leg pain. While recovering at home, he began to develop new and worsening right-sided leg pain in a similar distribution and submitted daily pain scores (Figure 4). He was contemplating a visit to the ER because of the severity of his symptoms. Given the rise in pain levels submitted through the app, he was contacted by our staff. He was found to be without neurological deficit with a presumed contralateral L5 radiculopathy from the reduction of his spondylolisthesis. The patient was prescribed a Medrol dose pack and his symptoms resolved. In this clinical scenario, the ability to send pain scores alerted the staff to a developing postoperative problem that was mitigated with medication, thus avoiding a costly ER visit or readmission. FIGURE 4. View largeDownload slide Daily pain scores sent by the patient via the app documenting new and worsening postoperative pain. FIGURE 4. View largeDownload slide Daily pain scores sent by the patient via the app documenting new and worsening postoperative pain. Participants Fifty-six patients undergoing routine neurosurgery procedures were prospectively accrued. There were 23 men and 33 women with a median age of 54 (range 27-79). Fifty-five patients underwent spinal surgery and 1 underwent cranial surgery. Demographics are listed in Table 1. TABLE 1. Patient Demographics Average age ± SD  Patients (n = 56) 52 ± 14  Sex     Male  23   Female  33  Procedure     Lumbar discectomy/foraminotomy  24   Lumbar laminectomy  10   Posterior lumbar fusion  8   Lateral lumbar fusion  2   Anterior lumbar fusion  2   Anterior cervical fusion  9   Suboccipital craniectomy  1  Average age ± SD  Patients (n = 56) 52 ± 14  Sex     Male  23   Female  33  Procedure     Lumbar discectomy/foraminotomy  24   Lumbar laminectomy  10   Posterior lumbar fusion  8   Lateral lumbar fusion  2   Anterior lumbar fusion  2   Anterior cervical fusion  9   Suboccipital craniectomy  1  View Large Main Results Primary end points: 56 of 56 patients meeting inclusion criteria agreed to participate in the study, of whom, 54 patients successfully downloaded, registered, and used the TrackMyRecovery® app. All of these 54 patients read and complied with both pre- and postoperative instructions based on data sent from the app to the web portal and sent wound images and/or pain scores (Table 2). TABLE 2. Primary and Secondary Endpoints   Patients (n = 56)  Downloaded, registered, and used app  54  Complied with written instructions before and after surgery  54  Wound images and/or pain scores  54  Canceled surgeries  0  Complications  1  Readmissions  0  Perioperative phone calls     No calls  46   1 call  8  Completed questionnaire  28    Patients (n = 56)  Downloaded, registered, and used app  54  Complied with written instructions before and after surgery  54  Wound images and/or pain scores  54  Canceled surgeries  0  Complications  1  Readmissions  0  Perioperative phone calls     No calls  46   1 call  8  Completed questionnaire  28  View Large Secondary end points: There were no cancelled surgeries. After having undergone an anterior cervical fusion, 1 patient experienced a postoperative complication in the form of a mild superficial wound infection, which was treated with oral antibiotics and resolved completely. There were no readmissions. After downloading the app, 8 of 54 patients (14.8%) called the office on a single occasion with questions regarding perioperative care. Twenty-eight of 54 patients (51.9%) completed the online questionnaire regarding the benefits of use of the app (Table 2) and reported high satisfaction scores (Figures 5A-5F). FIGURE 5. View largeDownload slide Patient responses to online questionnaire regarding A, the usefulness of having in-app electronic instructions; B, the usefulness of the automatic notifications and reminders; C, whether the app made patients feel that they were being closely monitored; D, whether the app helped patients better prepare for and recover from surgery; E, the usefulness of having the ability to report pain scores; and F, the usefulness of having the ability to send wound images. FIGURE 5. View largeDownload slide Patient responses to online questionnaire regarding A, the usefulness of having in-app electronic instructions; B, the usefulness of the automatic notifications and reminders; C, whether the app made patients feel that they were being closely monitored; D, whether the app helped patients better prepare for and recover from surgery; E, the usefulness of having the ability to report pain scores; and F, the usefulness of having the ability to send wound images. DISCUSSION Patient Engagement and Satisfaction Patient engagement is an increasingly important component of strategies to reform health care. Measures to individualize patient care and strengthen the patient's role in the process have been shown to improve health outcomes.8 These include web-based patient education tools, innovative uses of technology, and strategies to deliver timely information.9 Furthermore, highly engaged patients consistently report more positive care experiences.8 Ensuring patient satisfaction is a top priority for physicians and hospital networks. Preoperative Considerations: Compliance and Surgery Cancellations Patient compliance with pre- and postoperative instructions is of paramount importance in ensuring the best possible outcomes. The great majority of physician practices deliver instructions to patients by providing a surgical packet with printed materials. Many packets are generic and overwhelming to patients, and this problem is compounded by increasing time constraints, which may limit the ability of providers to deliver thorough verbal instructions.3 Additionally, age and anxiety may impair patients’ understanding and retention, and patients reportedly retain only 40% to 80% of the medical information presented by providers.2 Furthermore, many patients are unable to adequately recall information with high fidelity even with adequate education.1 Lack of understanding and poor compliance with instructions before surgery can lead to last-minute surgery cancelations. Patients who fail to discontinue blood thinners as directed or obtain a cardiology evaluation are often rescheduled on the day of surgery. This represents a substantial loss of revenue for hospitals, ambulatory surgery centers, and physicians. Elective surgery cancelation rates range from 6% to 20%, with the most common cited reasons being patient noncompliance with instructions, a change in the medical condition or recent illness, and institutional or equipment issues.10-15 Investigators have considered other ways to reduce cancellations, with telephone prompts and mailed reminders being the most effective.16 Methods to improve patient understanding and compliance with instructions have included preoperative educational classes and instructional videos.17-18 However, patients who attended the educational classes did not demonstrate significantly higher levels of adherence compared to controls.17 Patients that viewed instructional videos did demonstrate higher levels of knowledge, but the role of this educational method has not been thoroughly evaluated.18 Despite these efforts, there remains significant room for improvement and the implementation of new strategies to address these problems. Postoperative Considerations: Compliance, Complications, and Readmissions Postoperatively, noncompliance with instructions can increase complications. Improper wound care can lead to infections, which represents one of the most common causes of readmissions.4 Failure to follow mobility restrictions can cause increased pain or implant failure, while immobility can lead to DVT, PE, or pneumonia. During the recovery process, patient understanding of instructions is further impaired by pain and analgesic use. All of these issues can contribute to postoperative readmissions, which carry a substantial financial burden estimated to be $12 to 17 billion a year for Medicare patients19-20 or $13 400 per spinal surgery.21 A number of studies have documented 30-d readmission rates following spinal and cranial surgery ranging from 2.6% to 21.3% and 14% to 24%, respectively.19-20,22 The leading causes were found to be wound complications, sepsis, pain management, and DVT/PE.19 Greater surgical complexity, longer surgery times, advanced age, and comorbidities were associated with higher readmissions.19-20 Smartphone Apps With over 40 000 mobile health apps and an estimated 65% of the United States population owning a smartphone, the potential for incorporation of smartphone apps into clinical and surgical practice is remarkable.5 We hypothesized that an app that provides clear, user-friendly, and organized pre- and postoperative instructions tailored by the surgeon could improve the delivery of perioperative care and ameliorate the aforementioned problems. Any chosen instruction can be associated with a push notification sent to the patient as a text message at a designated time before or after surgery. These powerful reminders should improve compliance with instructions and can be tailored to reach specific goals. Preoperatively, we focused reminders on the most important elements that could lead to surgery cancelations: preoperative clearance evaluation by specialists, laboratory work, medication management (discontinuing nonsteroidal anti-inflammatory drug or other blood thinners), preoperative illness, and day-of-surgery instructions. Postoperatively, we targeted factors after neurosurgery that could lead to readmissions by reinforcing viewable instructions with additional reminders. Wound care and infections were monitored with daily prompts to send wound images as needed. Postoperative pain management was monitored with daily prompts to send pain scores as needed. We added reminders on mobility and bowel regimen to prevent DVT, PE, or postoperative constipation. To improve understanding of the proposed surgical intervention, hyperlinks from the app to websites and approved videos were added when appropriate. Interpretation of Results The results of our initial analysis on the utility of the app are very promising. Physicians and staff were able to create and individualize instructions based on standard templates with autopopulated content in less than 5 min for a particular surgery. They were trained to register and monitor patients through pre- and postoperative phases, and the instructions could be changed at any time before or after surgery for each individual patient. The great majority of patients (96.4%) successfully downloaded, logged on, and activated instructions on the TrackMyRecovery® app. One patient, who failed to download the app, was registered by the staff incorrectly with an inaccurate date of birth. The other chose not to proceed after forgetting her password. All patients using the app were documented to have read both pre- and postoperative instructions according to in-app responses sent to the practice's online web portal. All patients sent wound images and/or pain scores when prompted or when concerned. There were no last-minute surgery cancelations in this cohort of 54 app users. Hospital-wide and departmental cancelation rates at our institution were not available during this period. There was 1 mild superficial wound infection, which was treated with oral antibiotics and resolved completely. There were no other postoperative complications. None of the 54 app users were readmitted after surgery. There were no ER visits. Only 14.8% of patients, on a single occasion each, called the office after downloading the app with surgery-related questions. While there are no published data on this topic to our knowledge, anecdotal evidence and personal communications with staff suggest that use of the app reduced office telephone traffic. Patient satisfaction surveys were completed by more than half of the patients studied. The great majority of patients responded very favorably with regard to the usefulness of electronic instructions, reminders, and the ability to send wound images and pain scores (Figures 5A-5F). Based on the analysis of this cohort, we posit that the use of an app for delivery of perioperative instructions with built-in reminders improved compliance while allowing providers to track the patient's journey before and after surgery. These findings are corroborated by Deng et al,3 who found that patients receiving text message reminders demonstrated increased compliance and had fewer procedures cancelled compared to controls who received only leaflet instructions. Furthermore, the ability to send wound images through the app could lead to an early diagnosis of wound infection or dehiscence, potentially preventing a lengthy readmission or additional surgery. Martinez-Ramos et al4 reported that patients’ concerns about the surgical site were adequately resolved by sending pictures to the staff, and that this reduced readmissions by 55.2%. This is supported by Semple and colleagues,23 who found that the use of an app and pictures sent by patients is effective for monitoring patient home recovery. In addition to decreasing readmission rates, use of an app to monitor postoperative recovery may enable clinicians to safely discharge patients earlier, thereby reducing patients’ length of stay. Given that decreasing length of stay and readmission rates improves patient satisfaction, and that our cohort reported high satisfaction scores, an app of this kind represents a useful tool for adjusting to the recent patient-centered reimbursement guidelines.24 Limitations The present study has several limitations. The patient cohort is small, and the noncomparative nature of the analysis limits our capacity to make far-reaching conclusions with respect to clinical efficacy and cost savings. A prospective controlled study is needed to further validate our findings. Furthermore, patients with smartphones or tablets who are proficient with apps are generally younger and therefore likely to be more compliant with instructions. The median age of our patient cohort was 54. As previously mentioned, complication and readmission rates increase with greater surgical complexity, longer surgery times, and advanced age. Less than half of the patients studied (n = 22) underwent instrumented spinal fusions or suboccipital craniectomy, while the majority underwent lumbar discectomy/foraminotomy or laminectomy surgeries. The potential for expanding the use of smartphone technology in the health care sector is untold. An app of this kind can be implemented across surgical disciplines with a focus on reducing specialty-specific readmissions with tailored built-in reminders and online educational tools. Standardized outcome measures and enhanced recovery pathways will be incorporated in electronic instructions for each patient before and after surgery for outcomes-based research. Other patient metrics can be tracked by specialty after surgery for practice analytics. App integration with wearable technologies such as Fitbit® and others will allow for monitoring activity during the recovery process, while sharing of patients’ personal health information will be facilitated by Apple's CareKit® framework. CONCLUSION The purpose of this study was to evaluate the ability of a smartphone app in the perioperative care setting to produce high levels of patient compliance and satisfaction and to reduce surgery cancellations, postoperative complications, and readmissions. The app was used effectively in a cohort of 54 patients undergoing routine neurosurgery procedures. It yielded 100% compliance with instructions and excellent patient satisfaction scores. Our study demonstrates the utility of a smartphone application whereby easily accessible instructions with built-in reminders may improve patient compliance and communication while reducing surgery cancellations, postoperative complications, and readmissions and improving patient satisfaction. A larger, controlled cohort study with long-term follow-up across various medical disciplines is necessary to corroborate these findings. Disclosures Jean-Marc Voyadzis is a cofounder of Favorhealth Inc, (Sarasota, Florida, United States) the company that developed the TrackMyRecovery® app and www.trackmyrecovery.com webportal. He is a shareholder. The other authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. REFERENCES 1. Hutson MM, Blaha JD. Patients' recall of preoperative instruction for informed consent for an operation. J Bone Joint Surg Am . 1991; 73( 2): 160- 162. Google Scholar CrossRef Search ADS PubMed  2. Kessels RP. Patients' memory for medical information. J R Soc Med . 2003; 96( 5): 219- 222. Google Scholar PubMed  3. Deng X, Wang Y, Zhu T, Zhang W, Yin Y, Ye L. Short message service (SMS) can enhance compliance and reduce cancellations in a sedation gastrointestinal endoscopy center: a prospective randomized controlled trial. J Med Syst . 2015; 39( 1): 169. Google Scholar CrossRef Search ADS PubMed  4. Martínez-Ramos C, Cerdán MT, López RS. Mobile phone-based telemedicine system for the home follow-up of patients undergoing ambulatory surgery. Telemed J E Health . 2009; 15( 6): 531- 537. Google Scholar CrossRef Search ADS PubMed  5. Mobasheri MH, Johnston M, Syed UM, King D, Darzi A. The uses of smartphones and tablet devices in surgery: a systematic review of the literature. Surgery . 2015; 158( 5): 1352- 1371. Google Scholar CrossRef Search ADS PubMed  6. Kulendran M, Lim M, Laws G et al.   Surgical smartphone applications across different platforms: their evolution, uses, and users. Surg Innov . 2014; 21( 4): 427- 440. Google Scholar CrossRef Search ADS PubMed  7. Morsli H, Mathew D. CRT-708 Development and evaluation of a smartphone application for the perioperative care of patients undergoing routine cardiology procedures. JACC . 2015; 8( 2_S): S46- S46. 8. Hibbard JH, Greene J. What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health Aff (Millwood) . 2013; 32( 2): 207- 214. Google Scholar CrossRef Search ADS PubMed  9. Gruman J, Rovner MH, French ME et al.   From patient education to patient engagement: implications for the field of patient education. Patient Educ Couns . 2010; 78( 3): 350- 356. Google Scholar CrossRef Search ADS PubMed  10. Argo JL, Vick CC, Graham LA, Itani KM, Bishop MJ, Hawn MT. Elective surgical case cancellation in the Veterans Health Administration system: identifying areas for improvement. Am J Surg . 2009; 198( 5): 600- 606. Google Scholar CrossRef Search ADS PubMed  11. Dexter F, Marcon E, Epstein RH, Ledolter J. Validation of statistical methods to compare cancellation rates on the day of surgery. Anesth Analg . 2005; 101( 2): 465- 473; table of contents. Google Scholar CrossRef Search ADS PubMed  12. Xue W, Yan Z, Barnett R, Fleisher L, Liu R. Dynamics of elective case cancellation for inpatient and outpatient in an academic center. J Anesth Clin Res . 2013; 4( 5): 314- 323. Google Scholar PubMed  13. Sanjay P, Dodds A, Miller E, Arumugam P, Woodward A. Cancelled elective operations: an observational study from a district general hospital. J Health Organ Manag . 2007; 21( 1): 54- 58. Google Scholar CrossRef Search ADS PubMed  14. Kumar R, Gandhi R. Reasons for cancellation of operation on the day of intended surgery in a multidisciplinary 500 bedded hospital. J Anaesthesiol Clin Pharmacol . 2012; 28( 1): 66- 69. Google Scholar CrossRef Search ADS PubMed  15. Cihoda JH, Alves JR, Fernandes LA, de Souza Neto EP. The analysis for the causes of surgical cancellations in a Brazilian university hospital. Care Manag J . 2015; 16( 1): 41- 47. Google Scholar CrossRef Search ADS PubMed  16. Macharia WM, Leon G, Rowe BH, Stephenson BJ, Haynes RB. An overview of interventions to improve compliance with appointment keeping for medical services. JAMA . 1992; 267( 13): 1813- 1817. Google Scholar CrossRef Search ADS PubMed  17. Kim K, Chin G, Moore T, Schwarzkopf R. Does a preoperative educational class increase patient compliance. Geriatr Orthop Surg Rehabil . 2015; 6( 3): 153- 156. Google Scholar CrossRef Search ADS PubMed  18. Stern C, Lockwood C. Knowledge retention from preoperative patient information. Int J Evid Based Healthc . 2005; 3( 3): 45- 63. Google Scholar PubMed  19. Akins PT, Harris J, Alvarez JL et al.   Risk factors associated with 30-day readmissions after instrumented spine surgery in 14,939 patients. Spine (Phila Pa 1976) . 2015; 40( 13): 1022- 1032. Google Scholar CrossRef Search ADS PubMed  20. Bernatz JT, Anderson PA. Thirty-day readmission rates in spine surgery: systematic review and meta-analysis. Neurosurg Focus . 2015; 39( 4): E7, http://thejns.org/doi/abs/10.3171/2015.7.FOCUS1534. Google Scholar CrossRef Search ADS PubMed  21. Qasim M, Andrews RM. Post-surgical readmissions among patients living in the poorest communities, 2009: Statistical Brief #142. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs . Rockville, MD: Agency for Healthcare Research and Quality; 2012. 22. Moghavem N, Morrison D, Ratliff JK, Hernandez-Boussard T. Cranial neurosurgical 30-day readmissions by clinical indication. J Neurosurg . 2015; 123( 1): 189- 197. Google Scholar CrossRef Search ADS PubMed  23. Semple JL, Sharpe S, Murnaghan ML, Theodoropoulos J, Metcalfe KA. Using a mobile app for monitoring post-operative quality of recovery of patients at home: a feasibility study. JMIR Mhealth and Uhealth . 2015; 3( 1): e18, http://mhealth.jmir.org/article/citations/3929. Google Scholar CrossRef Search ADS PubMed  24. Tsai TC, Orav EJ, Jha AK. Patient satisfaction and quality of surgical care in US hospitals. Ann Surg . 2015; 261( 1): 2- 8. Google Scholar CrossRef Search ADS PubMed  Acknowledgments We wish to thank Analyn Coburn, Anna Armistead, and Samantha Simpson for their contributions to the data collection. COMMENT In a prospective observational study of 56 patients, the authors of this article evaluated the utility of a patient centered smartphone application. They concluded that there is a place for perioperative smartphone applications to help with increasing compliance, decreasing cancellations, and preventing readmissions. Without a larger group and a control group, it is difficult to say whether the 54 patients who interacted with the app would have had improved compliance, fewer office phone calls, no cancellations, and no readmissions even without the use of the application. It would have been interesting to see what the data would have yielded when observing a similar patient population at the same institution without having the patients use the application. As more medical applications develop, creators are quick to publish data solely based on innovation and novelty, however many of such articles fall short on presenting meaningful data for scholarly inquiry. Applications rooted to improving patient care are all but groundbreaking, however the merit in this article is earned through the triumph of increasing patient engagement and satisfaction. It is rather intuitive to hypothesize that complications and readmissions decrease by being able to prompt a patient with targeted perioperative information, but the notion of involving the patient more in his/her care is a success in this article that should be emphasized more. There has been literature supporting patient engagement initiatives and improved outcomes1 and this paper certainly follows the trend. Remote monitoring programs, increased education, and a shared decision-making approach all facilitate patient engagement methods. With the continued rise in optimizing healthcare value–improving outcomes while reducing costs2,3–introducing mobile applications is a useful technique to help reach this goal by creating more patient engagement and using hospital staff resources more efficiently. We would like to congratulate the authors for the app development and would be interested in its continued clinical application. The user interface seems easy to use and the user feedback seems promising. Sanjay Konakondla Danville, Pennsylvania Clemens M. Schirmer Wilkes Barre, Pennsylvania 1. Kimball AB, Corey KC, Kvedar JC. Engaging patients to decrease costs and improve outcomes. Med Econ. 2015;92(2):36-37. 2. Lee TH. Turning Doctors into Leaders. Harv Bus Rev. 2010;88(4):50-58. 3. Porter ME, Lee TH. The Strategy That Will Fix Health Care. Harv Bus Rev. 2013. Copyright © 2017 by the Congress of Neurological Surgeons

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Operative NeurosurgeryOxford University Press

Published: Mar 1, 2018

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