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In Sweden, day surgery is performed in almost 2 million patients per year. Patient satisfaction is closely related to potential adverse events during the recovery process. A way to empower patients and give them the opportunity to affect care delivery is to let them evaluate their recovery process. The most common evaluation method is a follow-up telephone call by a nurse one or two days after surgery. In recent years, mHealth apps have been used to evaluate the nurse-patient relationship for self-management in chronic diseases or to evaluate pain after surgery. To the best of our knowledge, no previous research has explored the recovery process after day surgery via mobile phone in a Swedish cohort.
The objective of the study is to describe the process of developing a mobile phone app using a Swedish Web-based Quality of Recovery (SwQoR) questionnaire to evaluate postoperative recovery after day surgery.
The development process included five steps: (1) setting up an interdisciplinary task force, (2) evaluating the potential needs of app users, (3) developing the Swedish Web version of a QoR questionnaire, (4) constructing a mobile phone app, and (5) evaluating the interface and design by staff working in a day-surgery department and patients undergoing day surgery. A task force including specialists in information and communication technology, eHealth, and nursing care worked closely together to develop a Web-based app. Modifications to the QoR questionnaire were inspired by instruments used in the field of recovery for both children and adults. The Web-based app, Recovery Assessment by Phone Points (RAPP) consists of two parts: (1) a mobile app installed on the patient’s private mobile phone, and (2) an administrator interface for the researchers.
The final version of the SwQoR questionnaire, which includes 31 items, was successfully installed in RAPP. The interface and the design were evaluated by asking for user opinions about the design and usefulness of the app with 10 day surgery patients. Some minor adjustments were made concerning text size and screen color.
Taking advantage of joint expertise, a useable Web-based app adaptable to different technical platforms was constructed. In addition, the SwQoR was successfully transferred into digital format for use on mobile phones.
In Sweden, almost 2 million day surgeries are performed in adults each year [
Studies show that patient satisfaction is directly related to their experience with adverse events related to anesthesia and surgery [
The development process included the following steps: (1) setting up an interdisciplinary team, (2) evaluating the potential needs of app users, (3) developing the Swedish Web version of a QoR questionnaire, (4) constructing a mobile app, and (5) evaluation of the interface and design of the app by staff working at a day-surgery department and patients undergoing day surgery.
Interdisciplinary research involves the translation of scientific knowledge between members of the research team [
Prior to the first meeting, all members in the group read the same articles describing mHealth [
Focus of the app from the perspectives of the health care organization and the patient.
Health care organization | Patient |
To get reports back from the patients | Provide personalized feedback to the health care about the recovery process |
To support the management of the individual patient in follow-up contacts by a health professional | A feeling of being cared for |
|
A sense of empowerment |
To reduce serious recovery problems associated with suffering and costs |
|
To learn more about postoperative reactions and recovery and to improve surgical and anesthetic procedures in the long-term |
|
Being easy to understand for nurses and medical doctors in the health care system | Being easy to understand for patients in the health care system |
Reduce unplanned or unnecessary health care contacts | Reduce unplanned or unnecessary health care contacts |
In order to determine the potential needs of users of the app, the researchers reviewed the literature and brainstormed during a workshop. The members shared their own personal experiences in postoperative recovery as both patients and researchers in the field of anesthesia and postoperative care. In order to make the app user friendly, the research team established that it would be important to use the patients’ own mobile phone [
Myles et al [
The revision and rationale for items in the SwQoR.
QoR-24 | Revision/rationale | SwQoR |
Able to breathe easy | - | Able to breathe easy |
Sleeping well | - | Sleeping well |
Being able to enjoy food | - | Being able to enjoy food |
Feeling rested | - | Feeling rested |
Having a general feeling of well-being | - | Having a general feeling of well-being |
Feeling in control | - | Feeling in control |
Pain in the surgical wound | - | Pain in the surgical wound |
Feeling relaxed | - | Feeling relaxed |
Speaking normally | - | Speaking normally |
Able to brush teeth | Merged into one item and linguistic revision | Able to look after personal hygiene |
Able to look after own appetence | ||
Able to write | Linguistic revision | Able to write as usual |
Able to return to work | Linguistic revision | Able to return to work or usual duties about the home |
Nausea | Merged into one item |
Nausea and vomiting |
Vomiting | ||
Feeling restless | - | Feeling restless |
Shivering or twitching | - | Shivering or twitching |
Feeling too cold | - | Feeling too cold |
Dizziness | - | Dizziness |
Nightmares | - | Nightmares |
Anxiety | - | Anxiety |
Depressed | - | Depressed |
Feeling lonely | - | Feeling lonely |
Difficulties getting to sleep | - | Difficulties getting to sleep |
|
[ |
Headache |
[ |
Muscle pain | |
|
[ |
Back pain |
|
[ |
Sore throat |
|
[ |
Difficulties concentrating |
|
[ |
Trouble urinating |
Difficulties defecating | [ |
Feeling constipated |
Diarrhea |
aFrom PRiC, personal communication with Ulrica Nilsson, 20150427
Our goals were that the app should be easy to use, be safe and secure, and allow aggregation of data to a study database. A wishing list of app functions, interface, and design were established and presented to the commissioned software company, which developed the Web-based app Recovery Assessed by Phone Points (RAPP) in close collaboration with the interdisciplinary team.
The technical solution consisted of two parts, a mobile app for patients and a Web-based administrator interface for the researchers. A patient interacts with the mobile app to report his or her postoperative recovery. In the development and testing phases, the app was designed in HTML5 (the most recent version of the markup language used for structuring and presenting content for the World Wide Web) and JavaScript to largely mimic a native mobile app. The Web-based technical solution was a mobile app platform that made it easier to implement the solution regardless of the end user’s technical equipment. Thus, it is possible to use RAPP regardless of the type of mobile phone being used.
In the development phase, none of the data imputed by patients were collected. Study-specific log-in codes were set up and used in connection with the installation of RAPP on the participants’ mobile phone.
A difference between answering a questionnaire on the small screen on a mobile phone and answering on a paper is that one item at a time is shown on the screen versus multiple items on a paper page [
A member of the research team wrote down all responses as field notes. Staff working at one of the day-surgery departments also had the opportunity to provide feedback on the device’s interface. The included staff members were nurses (n=10), surgeons (n=5), and anesthesiologists (n=2), all with experience from working in a day-care setting. This testing was carried out in connection with a lecture about postoperative recovery, in which also the app (RAPP) was demonstrated. The staff was invited to give their opinion about the layout of the interface. There was one researcher that took field notes.
As the study did not collect or handle any sensitive personal data, ethical approval was not required according to the Swedish Act concerning the Ethical Review of Research Involving Humans (SFS 2003: 460) [
There were four patients that reported that the background color was an issue and three patients had comments about the text size. Regarding obstacles to use, five patients thought the scale to be confusing. There were two that found it impractical that they could not move back and forth between questions. When discussing the overall opinion of the app, three patients suggested that it would be easier if the dot on the visual analog scale (
The staff working in the day-care settings gave similar feedback. They commented about the text size, the background color, and several of the staff found the scale confusing. Overall, all staff were positive to RAPP. They found the questions in the SwQoR relevant, and they also confirmed the need for systematic follow-up in the recovery process.
Patient and staff feedback led to several changes in the app. The text background was changed to a darker color (
During the testing, it became clear that not all of the text was visible on the screen of some older mobile phone models with small screens. Thus, the app was reprogrammed so that it would also fit smaller screens. Overall, the app was considered easy to use, to understand, and to navigate by both patients and personnel.
An example of the Recovery Assessed by Phone Points (RAPP) after the patients’ feedback, the background has a darker background and the text has been increased. (During the last 24 hours I have: Slept well, None of the time-All the time).
The patient can move the dot simply by touching the line. (During the last 24 hours Have you had any of the following: pain, None of the time-All the time) © Ulla-Carin Ekblom.
This project is unique in its intention to develop a mobile phone app that will be used with the patients´ own mobile phones in the peri-operative context. To our knowledge, there are no published papers with focus on the development process of an app for evaluating postoperative recovery. However, in others areas, there are some newly published articles [
A new patient safety law (The Swedish Code of Statutes, SFS 2014:821) was implemented in January 2015. This law gives patients even more power to affect their care. Notably, patient participation is a core element in patient-centered care [
The provision of health care can be evaluated using different methods, each with advantages and disadvantages. A paper questionnaire is easy to use, has low implementation cost, and needs little support to the patients, but disadvantages include costly delivery of the questionnaire and potential negative attitude of respondents toward answering a lot of questions [
A number of studies have compared electronic evaluation of patient-reported outcomes (ePRO) and paper and pencil administration and shown an advantage for ePRO [
According to literature, mobile features used in other studies are, for example, text messages, pedometers for physical activity, or video, voice, or multimedia messages [
Our projects overall aims are to integrate society’s need for quality auditing and assurance in health care with the patients´ need for safe and reliable information and communication regarding their postoperative recovery. We believe that the project will increase patients’ self-care. Using systematic follow-up remote symptom monitoring during postoperative recovery enables evaluations and comparisons of the usefulness and cost-effectiveness of different technical approaches to care, drug treatment, care activities, and competence development. It is also hoped that the use of systematic follow-up will help guide improvements in areas of anesthesia and postoperative care among patients who currently have low-quality postoperative recovery.
Having members from different disciplines work together is a way of avoiding fragmented research [
The respondents are also asked to give responses about their recovery after anesthesia and surgery. The patients may be affected by the residuals of anesthesia and miss responding within a specific time frame [
Another factor that could affect the use of health care information technology is staff attitudes toward technology and perhaps the fear of dehumanizing care [
With joint expertise, a useable Web-based app, RAPP, adaptable to different technical platforms was developed and tested for understandability and user-friendliness. The SwQoR has also successfully been transferred into digital format for use on mobile phones.
evaluation of patient-reported outcomes
postoperative nausea and vomiting
Postoperative Recovery in Children
Recovery Assessed by Phone Points
This research was funded by FORTE (2014-4765). Örebro University has been helpful in supporting the cooperation between members and institutions on this team. We would like to thank Johan Andersson, Johan Pettersson, Marc Biskop, and Christian Danielsson, students in system architecture at Örebro University, for their demonstration showing that it is possible to construct a Web-based app to measure postoperative recovery and cognition.
KD, ME, and UN made substantial contributions to the conception and design. Acquisition of data, or analysis, and interpretation of data were made by KD and MJ. KD, ME, MJ, UN, and ÅG drafted the article or revised it critically for important intellectual content. Final approval of the version to be published was made by KD, ME, MJ, UN, and ÅG.
Author UN and Örebro University Enterprise AB hold shares in RAPP-AB.