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Abstract

Background:

Electronic health can help improve perioperative outcomes and overcome organizational constraints related to human resources and health care-related costs. In this initial report, we assess patient compliance with a digital platform including pre- and rehabilitation programs, checklists, electronic patient-reported outcomes (ePROs), and remote monitoring after surgery.

Materials and Methods:

Twenty-four patients undergoing major uro-oncological surgery were prospectively included and followed from the surgical decision time point to the 3-month follow-up visit by Betty.care app. The primary end-point was patient compliance with the digital tool materials, grouped into four domains: safety, education, ePRO collection, and remote monitoring.

Results and Limitations:

The mean age was 62 years. The mean hospital stay was 1.8 days (50% of outpatient surgeries). Four complications occurred (16.7%), including one emergency readmission. The compliance of patients for fulfilling or reading all safety, education, and ePRO questionnaires was 79.2%, 76.5%, and 86.2%, respectively. The activation of real-time notifications as predefined by Betty.care detected half of the complications. All the generated alerts were related to a confirmed postoperative grade 2 or 3 complication. The mean duration of daily remote monitoring was 18.5 days after discharge. Satisfaction with their perioperative pathway was scored 8.4 out of 10 by patients.

Conclusions:

In conclusion, the implementation of a mobile app that provides a holistic approach to the perioperative period, integrating prehabilitation, rehabilitation, ePRO collection, checklists, and remote monitoring is feasible in clinical practice with good patient compliance. These preliminary findings suggest that the Betty.care digital platform could improve outcomes, facilitate recovery, and secure at-home discharge.

Introduction

Surgery is an important part of global health care, with more than 230 million surgeries performed worldwide yearly.¹ In France, 8.5 million surgeries are performed each year, including 6 million under general anesthesia. Despite continuous improvement in perioperative care, the rate of postoperative complications remains high. Although the risk of complications is poorly characterized in many parts of the world, several studies in industrialized countries have shown a perioperative rate of death from inpatient surgery of nearly 1% and a rate of major complications of up to 17%.^2,3 These rates are likely to be much higher, approximately 25%, when taking into account any grade complications. These surgical complications represent a considerable cause of death, disability, and health-related costs. However, data suggest that at least half of all surgical complications are avoidable.^4,5

A growing body of evidence shows that patient education before surgery and close postoperative monitoring could improve outcomes and reduce rates of adverse events.^6–9 The implementation of the World Health Organization’s safety checklist has demonstrated that better awareness of the risk of the planned surgery could lead to a significant reduction in complication and mortality rates.⁵

More generally, optimized perioperative pathways could improve outcomes after surgery by reducing hospital stay and costs and by decreasing perioperative complications.^6–9 Enhanced patient preparation and awareness of surgery help to minimize side effects, improve patients’ postoperative psychological and physiological status, and ease postoperative recovery.^10,11 Moreover, some evidence exists on the benefits of integrating physical exercise, optimizing nutrition, and preoperative patient counselling in improving postoperative outcomes.^12–14

However, the launch and maintenance of optimized perioperative pathways involving several caregivers can be challenging because of organizational and financial constraints and lack of health care resources. Over the past decade, eHealth has emerged as a promising tool to enhance adherence to educational programs and treatment outcomes. Moreover, eHealth can be used throughout the whole perioperative setting without the need for excessive human effort and financial support.¹⁵ Therefore, eHealth could facilitate the spread of optimized pathways and at-home recovery and could also reduce geographic inequalities in access to optimized care.¹⁶

In addition, the benefits of remote monitoring are currently well established, allowing early detection of complications and continuous monitoring of patients.¹⁷ A recent systematic review has highlighted the benefit of remote monitoring by reducing postdischarge readmission and emergency department visits.¹⁷ Remote monitoring enables more accurate records of patients’ daily status and, thus, could help health care delivery and emergency medical care when needed.¹⁸ Telemonitoring could also support the transition to an outpatient recovery pathway. Nevertheless, despite these early promising results, studies on the feasibility and safety of using remote monitoring for patients after surgery remain limited.

Other trials have suggested that remote patient-reported outcome (PRO) measure monitoring could lead to significant quality-of-life improvement in the postsurgery setting as well as better fatigue and depression scores.¹⁹ Given these considerations, we identified the only mobile app in French language that combined remote prehabilitation, rehabilitation, PRO measures, and telemonitoring in the postsurgery setting.

Herein, we evaluated the patient’s compliance with the Betty.care app. The Betty.care digital tool allows the all-in-one implementation of an optimized pathway, gathering prehabilitation and rehabilitation protocols, patient education, checklists, PRO collection, and remote monitoring.

Materials and Methods

The BETTY-USE study is an observational prospective study, conducted according to Good Clinical Practice and the Declaration of Helsinki. The study was approved by the National Ethics Committee (Institutional Review Board: IRB00010835).

From September to November 2023, we prospectively assessed the patient’s compliance with the Betty.care app (version 1), which is a digital platform dedicated to all surgeries and includes a combined experience of pre- and rehabilitation programs, electronic patient-reported outcomes (ePROs), and remote monitoring after surgery (https://betty.care). The free app was downloaded by the patients. An ePRO is a patient’s systematic response to questionnaires about their health status, collected by electronic methods.

Twenty-four consecutive patient candidates for major cancer surgery (prostate, bladder, and kidney cancers) were enrolled at the preoperative visit by two surgeons. The inclusion criteria were major once-urological therapeutic surgeries with tumor removal with curative intent. Exclusion criteria were oncological diagnostic surgery and non-oncology cases, patients who did not agree to use a digital telemonitoring tool, and minors. The minimal follow-up for data analysis was 3 months after surgery. Specific ePROs were collected in a subgroup of patients (n = 18) undergoing radical prostatectomy. All patients were managed according to an institutionally approved enhanced recovery after surgery protocol, as part of the standard of care.

The patients were introduced to the platform by their surgeon, who also assigned the specific radical prostatectomy module, in addition to the common pathway, if appropriate. The patients were then fully autonomous for downloading the app (France Connect system) and in the use of the platform after an initial connection, followed by an information panel in the application on their first login. The patients were then free to answer the questionnaires, to read the educational materials as often as they wanted, and would otherwise receive reminders depending on the questionnaire with a link to the application. All patients were also free to reach out to the medical team at any time via phone or email. More generally, they were clearly instructed that the remote monitoring tool was not meant to replace more traditional care practices but only to supplement them.

The patient app included checklists before key moments (anesthesiologist visit, admission, discharge, postoperative visit), alerts for starting or stopping activities (medications, physical activity, compressive stockings, diet, work), and educational materials (podcasts, videos on physical activities, articles) for improving patient information and condition before and after surgery, including physiotherapy exercises. For example, advice on walking programs, aerobic training, home-based moderate-intensity exercise regimens, diet, oral nutrition, and cardiorespiratory fitness were provided through videos and podcasts with a scheduled timeline according to the surgery date. ePROs and experience measurements were prospectively collected to record patient satisfaction, experience, and specific outcomes, such as continence and sexual function, through validated questionnaires (French translation of Expanded Prostate Cancer Index Composite for Clinical Practice) in patients undergoing radical prostatectomy.²⁰ These ePROs were collected at baseline before surgery, 6 weeks after surgery before the postoperative visit, and then every 6 months for 2 years.

The patient app communicated with a surgeon app (“Betty Pro” app). Thereby, the surgeon could check at any time within his app the patient characteristics (medical history, identity, medications, allergies) and receive remote monitoring alerts in real time. Illustrations of both apps are shown in Figure 1.

FIG. 1.

Examples of visuals of the patient and surgeon apps.

The primary end-point was patient compliance with the digital tool. Compliance with the digital tool indicated whether the patients responded to their digital questionnaires and/or read the digital materials at the expected frequency.

All the functionalities provided by the digital tool were grouped into four domains for analysis: safety (demographics/medical history questionnaires, checklists before visits/hospitalization/discharge), education (articles, videos, podcasts for prehabilitation and rehabilitation purposes), ePRO collection, and remote monitoring.

The secondary end-point was to assess the patient’s satisfaction, the mean patient follow-up within the app, the ability of the remote monitoring tool to detect postoperative complications, length of stay, same-day discharge, and the complications or unscheduled hospitalizations. To evaluate satisfaction, at the end of the study, all patients had to complete a satisfaction score. A final open-ended question also allowed the patient to leave additional comments.

Perioperative complications were reported according to the Clavien–Dindo classification.²¹ SPSS 22.0 software (SPSS, Inc., Chicago, IL, USA) was used for analysis.

Results

Patient characteristics and postoperative outcomes

Twenty-four patient candidates for major uro-oncological surgery have been prospectively included (Table 1). Only one patient declined his participation. Mean age was 62 years (median 62; standard deviation [SD] 7.8; range 44–74). Mean body–mass index (BMI) was 26.5 kg/m² (median 26; SD 4.2; range 19.8–37.4). The mean American Society of Anesthesiologists (ASA) score was 2, including two ASA 3 patients. Mean hospital stay was 1.8 days (median 2; SD 1.4; range 1–8), including 50% of same-day discharge surgeries. Mean operative time and blood loss were 105 min (median: 103; SD 31.2; range 60–210) and 184 mL (median 100; SD 142; range 50–550). These values were collected through the patient and the surgeon apps and double-checked with the electronic medical record. Four complications occurred (16.7%) including three grade 2 (urinary tract infection: 7-day antibiotics regimen) and one grade 3 (acute urinary retention and bladder catheterization) complications. Only one emergency readmission was reported.

Table 1.

Baseline Characteristics of the Overall Cohort

Patient Characteristics	n = 24
Age (years)	62.0
Range	44–74
BMI (kg/m²)	26.5
BMI (kg/m²)	19.8–37.4
ASA score (%)
2	22 (91.7%)
3	2 (8.3%)
Surgery (%)
Radical prostatectomy	20 (83.3%)
Nephrectomy	1 (4.2%)
Radical cystectomy	1 (4.2%)
Hospital stay (days)	1.8
Range	1–8
Same-day discharge	12 (50%)
Operative time (min)	105
Range	60–210
Blood loss (mL)	184
Range	50–550
Complications (%) including	4 (16.7%)
Grade 2	3
Grade 3	1
Readmission (%)	1 (4.2%)

ASA, American Society of Anesthesiologists; BMI, body mass index.

Figure 2 illustrates the compliance with all safety, education, and ePRO domain materials available at the patient level.

FIG. 2.

Compliance to all safety, education, and ePRO domain materials available at the patient level. *: no ePRO collection for these 6 patients. ePRO, electronic patient-reported outcome.

Safety domain

All patients (100%) completed both demographics and medical history questionnaires (Table 2). At four time points (anesthesiologist visit, before admission, at discharge, postoperative surgical visit), patients were asked to fulfill a dedicated checklist, specific for each step during the perioperative course. These materials were completed by 79.2% of patients at all time points (n = 19). For the remaining five patients, only the initial checklist before the anesthesiologist’s visit was fulfilled.

Table 2.

Examples of Questionnaires and Checklists Are Included in the Patient App

Demographics

- Age

- Sex

- Size

- Weight

- Smoking habits

- Type of operation

Medical history

- Do you have currently medical problems ? (If yes, please list)

- Have you been treated for medical problems in the past ? (If yes, please list)

- Do you have any allergy ? (If yes, please list)

- Have you already undergone surgery ? (If yes, please list)

- Have you suffered from any issue related to a previous anesthesia ? (If yes, please list)

- Do you take medications on a regular basis? (If yes, please list)

Checklist and questionnaire before and during anesthesiologist visit

- Reminder to complete the medical history questionnaire (2 days before the visit)

- Reminder to bring (the day before the visit) :

○ Last biological analysis

○ Radiology reports

○ Physician’s reports

- Questions to ask (the day of the visit) :

○ Do I need to perform specific analyses before my surgery ? (If yes, which ones)

○ Do I need to stop medications before my surgery ? (If yes, how many days before ?)

○ Do I need to begin a new treatment before my surgery ? (If yes, how many days before ?)

○ Do I need to wear stockings ?

○ Do I need to follow any specific diet ? (If yes, how many days before ?)

Education

A total of eight educational materials were available in the app. Four additional materials were also implemented for patients undergoing radical prostatectomy (specific additional module). A total of 264 [8 × 6 patients undergoing kidney/bladder surgery + (8 + 4) × 18 patients undergoing radical prostatectomy] materials could be read by the 24 patients. The mean number of seen materials was 5 for the 6 patients undergoing kidney/bladder surgery (median 4.5; SD 2.7; range 2–8) and 10 for the 18 patients undergoing radical prostatectomy (median 12; SD 3.1; range 4–12).

ePROs

For radical prostatectomy, the specific module also included validated ePROs that could be completed before the surgery and during the postoperative follow-up at 6 weeks, and then every 6 months after the surgery, to record the recovery of urinary and erectile function. At the time of analysis, a total of 80 ePROs could be fulfilled by the patients. All patients were followed at least until the postoperative visit and therefore can complete the two preoperative and the two postoperative ePROs. Four patients were followed with enough time to complete the 6-month follow-up reports. Overall, the compliance rate for ePRO collection was 86.2% (69 questionnaires fulfilled). At each time point, the mean number of ePROs completed was 1.7 at baseline (median 2; SD 0.6; range 0–2), 1.3 at 6 weeks (median 2; SD 0.9; range 0–2), and 1.75 at 6 months after surgery (median 2; SD 0.5; range 1–2).

Remote monitoring

The activation of real-time notifications as predefined by Betty.care detected two out of four complications, including that leading to readmission. All the generated alerts were related to a confirmed postoperative grade 2 or 3 complication. Patients without remote monitoring alerts had a lower complication rate (9.1%) and the absence of high-grade (>2) complication or readmission.

Patients reported a mean pain level of 2 out of 10 (median 2; SD 1; range 1–4) during 3 days on average after discharge, and took painkillers for a mean of 6 days (median 2; SD 3; range 1–8), including 3 days with the full dose of the drug. The mean duration of daily remote monitoring was 18.5 days after discharge (median 18; SD 13.3; range 1–45).

Patient satisfaction

At the time of the postoperative visit, patients were asked to score their satisfaction regarding their global perioperative pathway. On a scale from 0 to 10, the mean score was 8.4.

Predictive factors analysis

We compared the patient compliance according to all patient characteristics. No predictive factor has been detected, except age. Patients with a compliance rate <75% (mean: 50% compliance) were significantly older (64 vs. 61 years, p < 0.05) than those using the app with >75% compliance (mean: 93% compliance).

Discussion

In this study, we demonstrated that the patient compliance to an optimized perioperative pathway, through a mobile app, was satisfactory for all domains provided by the digital tool.

Indeed, the overall compliance ranged from 76% to 100% according to the type of digital tool functions. The patient’s adherence to daily recording was also important, as the mean duration of temperature and pain level recording was 18.5 postdischarge days. Interestingly, this adherence was satisfactory in a population of relatively old patients with a mean age of 62 years. This was in line with contemporary statistics, suggesting that over 90% and 87% of patients use mobile phones and the internet.²² Previous studies in cancer patients have also found that the elderly population (>70 years old) could exhibit good adherence to digital tools.²³ Our findings confirmed that the penetration of connected objects in daily life facilitates the wide adoption of telemedicine and ePRO collection. In the present study, we chose to evaluate the patient’s compliance with Betty.care according to the different domains provided by the app. Indeed, Betty.care is, to our knowledge, the first digital tool aiming to integrate various materials and functionalities, including prehabilitation and rehabilitation protocols, demographics and medical history questionnaires, checklists, ePRO collection, and remote monitoring, providing a holistic approach to surgery. All of these materials were grouped into four domains: safety, education, PRO, and remote monitoring. Overall, compliance was >75% in all these domains, reaching 100% for the initial safety questionnaires. Interestingly, we did not observe a significant drop in patient compliance over time, but follow-up was limited to a 3-month postoperative time. In a recent study, patients have reported that the collection of PROs by a smartphone app was easier or equivalent to the traditional approach, reinforcing the interest of remote monitoring for increasing the patient adherence to PRO collection.²⁴

Our findings also suggested that the mobile app was able to reproduce the benefits observed in our previous on-site experience in terms of length of stay, complications, readmission, and short-term functional recovery.^11,25,26 Several factors may concur with our findings. Interventions dedicated to improving patient information may help anticipate potential issues associated with oncologic surgery or surgery in general. The preoperative period is crucial as patients may be more receptive to modifying their physiological and psychological perceptions and capitalize on advice and physical condition improvements before surgery.

Our experience taught us that the maintenance of prehabilitation on-site programs and their diffusion to all patients could be challenging, mainly due to the motivation of care teams, the absence of financial and incentive support for such programs, and the lack of human resources across different health care systems.²⁶ Such pitfalls could be overcome by digital tools. As an example, a recent study has proven that a perioperative combined eHealth care program delivering personalized care by use of goal attainment scaling reduced the time required to return to normal activities after major abdominal surgeries.¹⁵ Other mobile apps also showed potential in terms of compliance and changing risk behavior before a major surgery. Nevertheless, the proven benefits in terms of functional recovery remain unclear.^27,28 eHealth offers the advantage of being accessible to almost every patient in the whole perioperative setting.¹⁶

For this study, we did not activate real-time notifications during the telemonitoring period in the outpatient recovery pathway. However, the study found a correlation between the remote monitoring alerts and the occurrence of complications/readmission. Hypothetically, incorporating real-time alarms with the predefined Betty.care alerts into daily practice would have detected all high-grade complications and 50% of any grade complications. Moreover, these notifications would not have negatively impacted workload as all alerts were related to a confirmed postoperative complication in our study. Future reports will evaluate the performance of the notification protocol on complication detection. Our preliminary findings suggested that the remote monitoring by Betty.care provides early detection of complications, and the ability to better monitor complications in real time could, in fine, improve the patient’s quality of care.

The benefit of remote monitoring has been demonstrated at both clinical and medico-economic levels. In cancer care, a randomized trial including 609 cancer patients receiving oral therapy has compared the use of a mobile telemedicine application, combined with follow-up by nurses, with standard care. The findings showed a significant decrease in unscheduled hospitalizations and treatment-related grade ≥3 toxicities, as well as a better patient experience.²⁹

Other studies have assessed the added value of digital health around surgery with conflicting results.^30–33 Although the usefulness of remote monitoring has been highlighted, the benefits in terms of complications reduction and improved outcomes remain unclear. One explanation is probably that such digital tools did not integrate a completely optimized pathway with patient education, rehabilitation, and rehabilitation materials as Betty.care does. Thus, to date, the added value of continuous remote monitoring of morbidity and mortality after surgery has not been established yet. Large datasets and future studies are needed to elaborate on this aspect.

In addition, we observed a low rate of unscheduled readmission even after major cancer surgeries and a high rate of same-day discharge for this major oncological surgery (50%). The use of digital platforms has a clear impact on a wider adherence to outpatient surgery and to a fast-track procedure, allowing faster discharge, which may result in cost reductions at the hospital and health care levels.^34–36

Recently, Nijland et al. were the first to conduct a prospective study combining same-day discharge with remote monitoring. A success rate of 88 percent was achieved, which was higher than in our cohort. The authors noted that specific preparation in the preoperative pathway was a positive factor contributing to this success.³⁷ Our experience was also in line with these considerations and highlighted the importance of a combination of prehabilitation, enhanced recovery after surgery, rehabilitation protocols, as well as a fully organized at-home discharge.

This study was conducted on a relatively small and selected population of patients undergoing major uro-oncological surgeries. The compliance to Betty.care and its benefits could be lower in a population of patient candidates for less-impact surgery. The app also offers noncontinuous remote measurements operated by the patients themselves, which could increase the risk of missing data, and therefore, limit trend analysis. This study was also conducted in urology, and confirmation of the findings in other specialty surgeries is needed. To date, ePROs were only developed in this pilot study for the postradical prostatectomy setting, given our local patient flow and the will to test it within future clinical trials. However, further studies will also focus on the development of ePROs for other surgical conditions. Despite the limitations of the BETTY-USE study, the results suggest that a digital platform gathering several domains of an optimized perioperative pathway (checklists, education materials for prehabilitation and rehabilitation, remote monitoring, ePRO) get good patient acceptance and could be a valuable tool for reducing postoperative complications, easing recovery, and securing at-home discharge.

Conclusions

In conclusion, the implementation of a mobile app that provides a holistic approach to the perioperative period, integrating prehabilitation, rehabilitation, PRO collection, checklists, and remote monitoring is feasible in clinical practice with good patient compliance. These preliminary findings suggest that the Betty.care digital platform could improve outcomes, facilitate recovery, and secure at-home discharge.

Footnotes

Authors’ Contributions

Conceptualization: D.D.A. and G.P. Data curation: D.D.A., B.B., R.A.-Z., and R.-G.R. Formal analysis: D.D.A. and G.P. Supervision: C.A., J.-B.B., and G.P. Writing: D.D.A. and G.P. Writing—reviewing and editing: B.B., R.-A.Z., R.-G.R., N.K.N., C.A., and J.-B.B.

Informed Consent

All patients gave their written consent.

Author Disclosure Statement

J.-B.B. and G.P. have ownership in AIMED2 company.

Funding Information

No funding was received for this article.

Abbreviations Used

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Patient Compliance to a Perioperative Digital Platform for Pre- and Rehabilitation Programs,Outcomes Reporting,and Remote Monitoring After Surgery: A Pilot Study

Abstract

Background:

Materials and Methods:

Results and Limitations:

Conclusions:

Introduction

Materials and Methods

Results

Patient characteristics and postoperative outcomes

Safety domain

Education

ePROs

Remote monitoring

Patient satisfaction

Predictive factors analysis

Discussion

Conclusions

Footnotes

Authors’ Contributions

Informed Consent

Author Disclosure Statement

Funding Information

Abbreviations Used

References