A mobile device application (app) to improve adherence to an enhanced recovery program for colorectal surgery: a randomized controlled trial
Increased adherence with enhanced recovery pathways (ERP) is associated with improved outcomes. However, adherence to postoperative elements that rely on patient participation remains suboptimal. Mobile device apps may improve delivery of health education material and have the potential to foster behavior change and improve patient compliance. The objective of this study was to estimate the extent to which a novel mobile device app affects adherence to an ERP for colorectal surgery in comparison to standard written education.
This was a superiority, parallel-group, assessor-blind, sham-controlled randomized trial involving 97 patients undergoing colorectal resection. Participants were randomly assigned with a 1:1 ratio into one of two groups: (1) iPad including a novel mobile device app for postoperative education and self-assessment of recovery, or (2) iPad without the app. The primary outcome measure was mean adherence (%) to a bundle of five postoperative ERP elements requiring patient participation: mobilization, gastrointestinal motility stimulation, breathing exercises, and consumption of oral liquids and nutritional drinks.
In the intervention group, app usage was high (94% completed surveys on POD0, 82% on POD1, 72% on POD2). Mean overall adherence to the bundle on the two first postoperative days was similar between groups: 59% (95% CI 52–66%) in the intervention group and 62% (95% CI 56–68%) in the control group [Adjusted mean difference 2.4% (95% CI − 5 to 10%) p = 0.53].
In this randomized trial, access to a mobile health application did not improve adherence to a well-established enhanced recovery pathway in colorectal surgery patients, when compared to standard written patient education. Future research should evaluate the impact of applications integrating novel behavioral change techniques, particularly in contexts where adherence is low.
KeywordsRecovery pathways Technology Mobile application Colorectal
SAGES SMART™ Enhanced Recovery Grant. Seamless MD provided the mobile app without charge.
Compliance with ethical standards
Lawrence Lee received an investigator-initiated research grant from Johnson & Johnson for an unrelated project. Liane S. Feldman received investigator initiated research grant from Merck (unrelated project) and educational grant from Medtronic (unrelated project). Juan Mata, Nicolò Pecorelli, Pepa Kaneva, Dan Moldoveanu, Alexandre Gosselin-Tardiff, Mohsen Alhashemi, Stephan Robitaille, Saba Balvardi, Barry L. Stein, Sender Liberman, Patrick Charlebois, and Julio F. Fiore Jr., have no conflicts of interest or financial ties to disclose.
- 3.Lassen K, Soop M, Nygren J, Cox PB, Hendry PO, Spies C, Von Meyendflet MF, Fearon KC, Revhaug A, Norderval S, Lunjgqvist O, Lobo DN, Dejong CH (2009) Consensus review of optimal perioperative care in colorectal surgery: enhanced recovery after surgery (ERAS) group recommendations. Arch Surg 144(10):961–969CrossRefGoogle Scholar
- 5.Lee L, Mata J, Ghitulescu GA, Boutros M, Stein B, Charlebois P, Liberman AS, Fried G, Morin N, Carli F, Latimer E, Feldman LS (2015) Cost-effectiveness of enhanced recovery versus conventional perioperative management for colorectal surgery. Ann Surg 262(6):1026–1033. https://doi.org/10.1097/sla.0000000000001019 CrossRefPubMedGoogle Scholar
- 6.Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught C, Macfie J, Liberman AS, Soop M, Hill A, Kennedy RH, Lobo DN, Fearon K, Ljungqvist O (2013) Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations. World J Surg 37(2):259–284CrossRefGoogle Scholar
- 7.Carmichael JC, Keller DS, Baldini G, Bordeianou L, Weiss E, Lee L, Boutros M, McClane J, Feldman LS, Steele SR (2017) Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 60(8):761–784. https://doi.org/10.1097/dcr.0000000000000883 CrossRefPubMedGoogle Scholar
- 8.Pecorelli N, Hershorn O, Baldini G, Fiore JF Jr, Stein BL, Liberman AS, Charlebois P, Carli F, Feldman LS (2017) Impact of adherence to care pathway interventions or recovery following bowel resection within an established enhanced recovery program. Surg Endosc 31(4):1760–1771. https://doi.org/10.1007/s00464-016-5169-2 CrossRefPubMedGoogle Scholar
- 9.Berian JR, Rosenthal RA, Baker TL, Coleman J, Finlayson E, Katlic MR, Lagoo-Deenadayalan SA, Tang VL, Robinson TN, Ko CY, Russell MM (2018) Hospital standards to promote optimal surgical care of the older adult: a report from the coalition for quality in geriatric surgery. Ann Surg 267(2):280–290. https://doi.org/10.1097/sla.0000000000002185 CrossRefPubMedGoogle Scholar
- 16.Pecorelli N, Fiore JF Jr, Kaneva P, Abarna S, Charlebois P, Liberman AS, Stein BL, Carli F, Feldman LS (2018) An app for patient education and self-audit within an enhanced recovery program for colorectal surgery: a pilot study on validity and usability. Surg Endosc 32(5):2263–2273. https://doi.org/10.1007/s00464-017-5920-3 CrossRefPubMedGoogle Scholar
- 20.Slankamenac K, Nederlof N, Pessaux P, DeJonge J, Winhjoven B, Breitenstein S, Oberkoffler C, Graf R, Puhan M, Clavien P (2014) The comprehensive complication index: a novel and more sensitive endpoint for assessing outcome and reducing sample size in randomized controlled trials. Ann Surg 260(5):757–762CrossRefGoogle Scholar
- 24.Feroci F, Lenzi E, Baraghini M, Garzi A, Vannucchi A, Cantafio S, Scatizzi M (2013) Fast-track surgery in real life: how patient factors influence outcomes and compliance with an enhanced recovery clinical pathway after colorectal surgery. Surg Laparosc Endosc Percutaneous Tech 23(3):259–265CrossRefGoogle Scholar
- 26.Han A, Cho M, Cho S, Lee C, Choi C, Kim S, Hong H (2016) Use of mobile internet application to improve adherence to immunosuppressive medication adherence in kidney transplant recipients : preliminary results of the PRIMA (ImPRoving Adherence to Immunosuppressive Therapy by Mobile Internet Application) study. In 26th international congress of the transplantation society. Seoul 2016Google Scholar
- 30.Webb TL, Joseph J, Yardley L, Michie S (2010) Using the internet to promote health behavior change: a systematic review and meta-analysis of the impact of theoretical basis, use of behavior change techniques, and mode of delivery on efficacy. J Med Internet Res. 12(1):e4. https://doi.org/10.2196/jmir.1376 CrossRefPubMedPubMedCentralGoogle Scholar
- 31.Glanz K, Bishop DB (2010) The role of behavioral science theory in development and implementation of public health interventions. Annu Rev Public Health 31:399–418. https://doi.org/10.1146/annurev.publhealth.012809.103604 CrossRefPubMedGoogle Scholar