Internet and Smartphones Help Capture Patient-Reported Outcomes

Author: Bob Kronemyer

Anesthesiology News

For internet users and smartphone owners, electronic capture of perioperative patient-reported outcomes (PROs) is a viable concept.

That is the verdict of two feasibility studies from the 2019 annual meeting of the American Society for Enhanced Recovery (posters 31 and 32).

Historically, systematic capture of the recovery process has been limited to a clinic or hospital setting, said presenting author Jamie Romeiser, MPH, a PhD student in the population health and clinical outcomes research program at Stony Brook University Medical Center, in New York. “Also, post-discharge follow-up has been impractical due to resource burdens. But the substantial increase in both internet use and smartphone ownership over the past five years affords a practical opportunity to capture post-discharge PROs.

“Nearly three-quarters of patients responded with an email and text combined approach, which is extremely high compared to usual hospital surveys,” said Romeiser.

Romeiser said one of the major goals of enhanced recovery after surgery (ERAS) pathways is to decrease the amount of time patients spend in the hospital. As a result, patients are spending more of their recovery at home.

“Within our quality assurance (QA) programs, we were interested in implementing a web-based system that can track a part of this recovery process by collecting PRO surveys over time,” Romeiser said. “We were particularly interested in which method of sending these surveys might reach the largest population over a specified time period.”

Through an institutionally approved global ERAS QA program, the investigators examined both the feasibility of collecting PRO data using multiple web-based mechanisms and the distribution of the nine-item Quality of Recovery questionnaire over the perioperative time period in ERAS patients.

A total of 478 patients managed with ERAS pathways chose to participate during their preoperative surgery appointment, at which time these patients provided their mobile phone number and email address, and noted whether they owned a smartphone.

HIPAA-compliant, web-based survey links were rolled out via email only (wave 1), text only (wave 2), and a combination of email and text (wave 3) at three different time intervals: four days before surgery, seven days after surgery and 30 days after surgery.

The complementary approach of both email and text was the most successful method for obtaining responses at all time points compared with text or email alone. Preoperatively, 74% of patients responded to the survey via receiving a combination of email and text versus 66% who received a text message only and 42% who received an email message only.

Similarly, for seven days post-op, the response rates were 65% versus 49% versus 42%, respectively; and for 30 days post-op, 64% versus 47% versus 43%.

“We were surprised that response rates were as high as they were,” Romeiser said. “Even at 30 days after surgery, response rates still were above 60% for the combination method of email and text. Response rates over time also did not decline nearly as much when using the email and text approach as compared to the text-alone method.

“Our results show that it is feasible to collect patient-reported outcomes in that critical recovery time period after discharge from the hospital,” Romeiser said.

Convenience for Busy New Mothers

In a related study, PROs for new mothers were collected after hospital discharge. According to Romeiser, evaluation of a mother’s recovery often does not occur until an obstetric visit six weeks after delivery.

“Therefore, within our quality assurance programs, we were interested in implementing a web-based system that can track a part of the early recovery process that sometimes gets neglected,” she said.

“By collecting PROs over the first 30 days after delivery, we can begin to understand the recovery process during this time period from the patient’s perspective.”

A total of 718 parturients joined the program, for whom survey rates varied significantly between the methods of contact at the two time points. The strategy of both email and text was the most successful method for obtaining responses at both times. At seven days post-delivery, 66% of participants responded via email and text, compared with 47% by text alone and 39% by email alone. At 30 days, the participants’ response rates were 48% for the combination approach, 32% for text only and 36% for email only.

“We understand that new moms are incredibly busy and literally have their hands full,” Romeiser said. “So we were surprised that response rates were as high as they were when using the complementary email and text methods. Interestingly, response rates decreased more for this group compared to the single methods alone, but still remained higher overall.”

Web-Based Feedback Is Another Idea

“The next frontier in the ERAS arena may be optimizing the patient experience immediately following discharge,” said Elisha Dickstein, MD, an assistant professor of anesthesiology and perioperative and pain medicine at the Mount Sinai Hospital, in New York City.

Dr. Dickstein said he was not surprised to learn that the combination of email and text messaging achieved superior results than either modality individually. “I was, however, somewhat surprised to see the impressive percentages of responders,” he said.

The study is a promising starting point to encourage patients to self-report outcomes using web-based methods, according to Dr. Dickstein. “But for any institutional effort to be successful, I believe there needs to be uniform acknowledgment, across several services, that these efforts to enhance the patient experience are beneficial and appreciated,” he said. “An increased surgical presence in this effort would likely yield even more fruitful results.”

Dr. Dickstein also believes that the response rate would improve, and better clinical care could be achieved, if more complex artificial intelligence–guided messaging “could provide the patient with real-time responses to their concerns or guarantee a live response from a clinician.”

Yaakov Beilin, MD, the director of obstetric anesthesia at Icahn School of Medicine at Mount Sinai, in New York City, also was not surprised by the results. “Web-based methods are an easy way to communicate,” he said. “Thus, if patients can provide us feedback via some sort of a web-based application, I think that would be very useful to the clinician.”

To increase compliance with patient feedback, “the more methods available the better, because not everyone uses the same electronic platforms,” Dr. Beilin said.

Dr. Beilin noted that the study assumes patients are comfortable using email and text messaging and will want to respond, “which may not be the case. The study also makes the assumption that everyone has access to the internet and smartphones.”

Despite those caveats, web-based methods for assessing patients “may be the future for finding out how satisfied our patients are with their care,” Dr. Beilin said.