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Use of a mobile health application by adult non-congenital cardiac surgery patients: A feasibility study [1]

['Sandra M. Ragheb', 'Max Rady College Of Medicine', 'University Of Manitoba', 'Winnipeg', 'Manitoba', 'Anna Chudyk', 'Department Of Family Medicine', 'Rady Faculty Of Health Sciences', 'St. Boniface Research Centre', 'Health Services']

Date: 2022-08 

Principle findings

This prospective cohort study is one of the first to evaluate the use of mHealth for peri-operative CS patient education. Previous research in this area focused primarily on postoperative patient care [16,21,22,27] with the employment of telemedicine [28], rather than providing comprehensive peri-operative patient education using an app-based platform. The majority of enrolled participants reported high satisfaction with the app and rated the app highly in terms of its usability. The mHealth app employed in this study utilized content developed by the CS team based on evidence-based ERPs that were customized to the local clinical setting. Additionally, the engagement of patients in the development of the app was particularly important, given that patients expressed their desire to be included in the app design and development processes [29] and the importance of patient engagement in research [23], including mHealth technology design [24]. Inviting caregivers to share app use with patients is helpful to assist inexperienced patients with app navigation if needed and improve their overall knowledge of the CS journey to better support the patient’s recovery [30].

The app used for this initiative achieved a task completion rate of 75%, with a 5% attrition rate due to technical difficulties. These are promising results given that adherence to mHealth app usage has been commonly cited as a major hindrance to the integration of such technologies in patient care [31]. Previous studies reported low adherence to app usage and high attrition rate mostly due to technological difficulties [32], and lack of interest in technology uptake [33]. In our study, there was a gradual decrease in app usage over time, with post-discharge tasks achieving the lowest completion rate. This pattern was similarly demonstrated in other studies [34–37]. This decline in app usage during the post-operative period could be attributed to the long duration between app teaching at the time of consent and surgery date, and the patients’ direct contact with the treating team in hospital at the time of surgery. Education reinforcement by the medical team at the time of discharge could be beneficial to increase usability of the app post-discharge. Despite a gradual decrease in our app usage through its content, the lowest completed task was accessed by 62% of participants. In fact, the completion rate presented in the study could be underestimated with our current methodology, given that participants had to click the “Complete Task” button at the bottom of each task for the task to be considered complete. This was the case for one of the participants who mentioned that they completed all tasks, but the app reported 20% completion rate. The high adherence rate in our study could be attributed to the simplicity of the app, a crucial feature for mHealth uptake [38,39]. This is supported by the majority of participants agreeing that the app was easy to use and their confidence in using it without assistance.

Several concerns have been raised regarding the use of mHealth in older adults. Specifically, the slow uptake of mHealth in older adults has been attributed to technical difficulties, low self-efficacy to operate devices, and poor perception of app usefulness [29] Despite having a similar percentage of participants between the two age groups (≥65 years and <65 years) disagreeing with the difficulty of app usage and the need for a technical person to help them navigate the app, as well as an overall higher task completion rate by older participants, more participants ≥65 years indicated their preference for written material over the app. This could speak to the unfamiliarity with app-based technologies in general in this age group rather than technical illiteracy hindering app use. As some participants recommended, a longer educational session to familiarize patients with the app could be helpful to increase older patients acceptability of mHealth for patient education [40] The design of the app could also be refined specifically for older patients through additional patient engagement activities carried out with older adult patients [24].

Certain survey questions did not receive favourable rating from participants. The low satisfaction in the domains of medication management, physical activity, and nutrition could be attributed to multiple factors. First, some participants expressed their limited physical abilities as a barrier to perform physical activity, which was inaccurately reflected on the app’s usefulness in the survey responses. Second, the app provided general information about commonly used medications and the physical activity and nutritional requirements, rather than a personalized plan for each patient. Personalization of app content has been shown to highly affect behavioural change in patients [25,29]. However, complex medical comorbidities in the CS patient population and the various peri-operative considerations that are unique to each patient preclude the customization of ERPs to each patient [41]. Additionally, the decrease in the number of patients that would like to use the app frequently in the post-surgery survey could be due to the reduced need to review educational material regarding the surgery as patient’s recovery progressed, rather than diminishing interest in app usage and usefulness after surgery.

The feasibility of the mHealth intervention in this study was not associated with an improvement in HRQoL, however this was not the primary goal of this initiative at this stage. The reduction in anxiety and improvement in mobility and mean EQ-Visual score is likely attributed to undergoing the surgery and improvement in health independent of app usage. Previous systematic reviews regarding mHealth interventions indicated an improvement in quality of life using telehealth interventions that facilitated patient-provider interaction and targeted symptom management specifically [33,42], whereas the mHealth app used in our study targets the domain of patient education and intends to replace paper-based patient education. Moreover, the small sample size in this study may have impacted the ability to detect subtle correlations between mHealth usage and quality of life improvement. Similarly, the hospital readmission rate found in this study is in line with previous studies conducted at St. Boniface Hospital [33,40,42,43]. The rate of hospitalization in Manitoba, however, is lower than other Canadian jurisdictions [44], which could have potentially affected the ability to detect an association between app usage and hospital readmission rates.

This study has several strengths. The intervention employed in this study offered various benefits to patients, as discussed previously. In addition, there has been increasing recognition of the importance of patient-reported outcomes (PROs) such as quality of life besides traditionally measured objective outcomes. Also, PROs provide a more accurate capture of patient experience as opposed to clinician-performed assessments [45]. A subgroup analysis was performed to evaluate the feasibility of mHealth by patient age, with all CS patients recruited in the study regardless of age. Adherence to app usage was measured through the app, providing an objective and accurate assessment, rather than relying on self-reported questionnaires [43].

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[1] Url: https://journals.plos.org/digitalhealth/article?id=10.1371/journal.pdig.0000055

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