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JAMA Surgery | Original Investigation
Effect of Home Monitoring via Mobile App on the Number
of In-Person Visits Following Ambulatory Surgery
A Randomized Clinical Trial
Kathleen A. Armstrong, MD, MSc; Peter C. Coyte, PhD, MA; Mitchell Brown, MD, MEd;
Brett Beber, MD; John L. Semple, MD, MSc
Invited Commentary
IMPORTANCE In the age of information and patient-centered care, new methods of delivering
Supplemental content
postoperative care must be developed and evaluated.
OBJECTIVE To determine whether follow-up care delivered via a mobile app can be used to
avert in-person follow-up care visits compared with conventional, in-person follow-up care in
the first 30 days following ambulatory surgery.
DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial was conducted from
February 1 to August 31, 2015, among ambulatory patients undergoing breast reconstruction
at an academic ambulatory care hospital. Patients were randomly assigned to receive
follow-up care via a mobile app or at an in-person visit during the first 30 days after the
operation. Analysis was intention-to-treat.
MAIN OUTCOMES AND MEASURES The primary end point was the number of in-person
follow-up visits during the first 30 days after the operation. Secondary end points were the
number of telephone calls and emails to health care professionals, patient-reported
convenience and satisfaction scores, and rates of complications.
RESULTS Of the 65 women in the study (mean [SD] age, 47.7 [13.4] years), 32 (49%) were in
the mobile app group, and 33 (51%) were in the in-person follow-up care group. Those in the
mobile app group attended a mean of 0.66 in-person visits, vs 1.64 in-person visits in the
in-person follow-up care group, for a difference of 0.40 times fewer in-person visits (95% CI,
0.24-0.66; P < .001) and sent more emails to their health care professionals during the first
30 days after the operation (mean, 0.65 vs 0.15; incidence rate ratio, 4.13; 95% CI, 1.55-10.99;
P = .005) than did patients in the in-person follow-up care group. This statistically significant
difference was maintained at 3 months postoperatively. The mobile app group reported
higher convenience scores than the in-person follow-up care group (incidence rate ratio, 1.39;
95% CI, 1.09-1.77; P = .008). There was no difference between groups in the number of
telephone communications, satisfaction scores, or complication rates.
CONCLUSIONS AND RELEVANCE Patients undergoing ambulatory breast reconstruction can
use follow-up care via a mobile app to avert in-person follow-up visits during the first 30 days
after the operation. Mobile app follow-up care affects neither complication rates nor
patient-reported satisfaction scores, but it improves patient-reported convenience scores.
TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02318953
JAMA Surg. doi:10.1001/jamasurg.2017.0111
Published online March 22, 2017.
Author Affiliations: Division of
Plastic and Reconstructive Surgery,
Department of Surgery, University of
Toronto, Toronto, Ontario, Canada
(Armstrong, Brown, Beber, Semple);
Institute of Health Policy,
Management and Evaluation,
University of Toronto, Toronto,
Ontario, Canada (Coyte); Women’s
College Research Institute, Women’s
College Hospital, University of
Toronto, Toronto, Ontario, Canada
(Semple).
Corresponding Author: John L.
Semple, MD, MSc, Women’s College
Research Institute, Women’s College
Hospital, University of Toronto, 76
Grenville St, 10th Floor, Toronto, ON
M5S 1B2, Canada (john.semple
@wchospital.ca).
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Research Original Investigation
Monitoring via Mobile App and In-Person Visits After Ambulatory Surgery
I
n the age of patient-centric care, delivery models must
evolve to become more convenient for patients and costeffective to the health system, while also maintaining a high
degree of patient satisfaction and convenience. Many centers
are now substituting in-person follow-up care with care delivered via telephone or a mobile app.1-6 Studies show that these
remote modes of follow-up are safe and that patients are
as equally satisfied with them as they are with in-person follow-up care.1-6
Women’s College Hospital in Toronto, Ontario, Canada, offers specialized surgical procedures, including breast reconstruction typically following mastectomy for breast cancer. The
goal of surgery is to restore a breast mound and improve the
quality of life of cancer survivors.7-9 These procedures are performed on an ambulatory basis; all patients go home on the
day of or the day after surgery. Patients often travel significant distances to receive this care. Traveling for surgery is not
unique to patients who undergo breast reconstruction; surgical care programs have become regionalized to ensure higher
volumes in specific centers of excellence, which means that
more patients travel to receive that care.10,11
In general, the morbidity and mortality rates following
ambulatory surgery are very low.12 Complication rates in this
subset of patients undergoing breast reconstruction are approximately 5% to 7.5%,13,14 making most follow-up visits
perfunctory.
The QoC Health Inc mobile app allows patients to submit
photographs and answers to a validated quality of recovery
questionnaire and a pain visual analog scale using a mobile device for the first 30 days after the operation. Surgeons are able
to follow patient reports on a web portal. This technology has
been used for patients who have undergone ambulatory breast
reconstruction.15 Our study builds on preexisting data15,16 by
determining whether receiving follow-up via the mobile app
can avert the need for in-person follow-up care.
Methods
This pragmatic, single-center, open, controlled, 2-arm parallelgroup superiority randomized clinical trial was conducted from
February 1 to August 31, 2015, to compare follow-up care delivered via mobile app vs in person during the first 30 days following ambulatory breast reconstruction. Permutated-block
randomization was conducted by blocks of 4 to 6 using the program RALLOC in Stata statistical software (StataCorp).17 The
complete research protocol is available in the Supplement.18
This study complies with the standards outlined in the TriCouncil Policy Statement and was approved by the Women’s
College Hospital Research Ethics Board. During a 5-month period, eligible patients were consecutively approached by a senior author not directly involved in patient care (K.A.A.) during their preoperative visits, and written informed consent was
obtained.
All ambulatory patients undergoing elective breast reconstruction at Women’s College Hospital were included in this
study. Patients had to be able to use a mobile device and communicate in English. All patients were nonsmokers with a body
E2
Key Points
Question For patients undergoing ambulatory surgery, can
follow-up care via a mobile app avert in-person visits compared
with conventional, in-person follow-up care during the first 30
days after the operation?
Findings In this randomized clinical trial of 65 patients, those who
used the mobile app attended fewer in-person visits for follow-up
care during the first 30 days after the operation than patients in
the in-person follow-up care group. This difference was statistically
significant.
Meaning Follow-up care delivered via a mobile app can be used to
avert in-person visits following ambulatory surgery.
mass index of 30 or less (calculated as weight in kilograms divided by height in meters squared) because these are requirements for ambulatory breast reconstruction. Patients were excluded if they experienced chronic pain, were taking narcotic
(morphine-like) medication for pain on a regular basis, or had
an allergy to local anesthetics or morphine-like medications.
Pain ratings captured in the pain visual analog scale and quality of recovery 9-item questionnaire are important for judging the quality of postoperative recovery. Preexisting pain or
an inability to take narcotics would compromise the reliability of these measures.
Procedures were performed by 3 surgeons (M.B., B.B., and
J.L.S.), with more than 90% of cases being performed by 2 surgeons within this group of surgeons. Randomization was performed by an outside statistician and occurred in equal proportions (1:1) between those using the mobile app and those
receiving in-person follow-up care. After a patient agreed to
participate in the study, she was provided a sequentially numbered envelope containing her group assignment by the enrolling senior author. All patients received what is currently
the standard of care in this hospital. Patients in the conventional follow-up group had planned clinic follow-up at approximately 1 week and 4 weeks after the operation. This is the
follow-up schedule currently used by all surgeons.
The mobile app follow-up group had no planned inperson follow-up at 1 week and 4 weeks after the operation.
However, these visits were replaced with an examination of
the surgical site via photographs submitted through the mobile app, as well as monitoring of the results of the pain visual
analog scale, and quality of recovery 9-item questionnaire. Patient reporting began after discharge from the recovery room.
Since 75% of complications occur within the first 2 weeks of
discharge,12 we used daily monitoring for 2 weeks and then
weekly monitoring for the remaining 2 weeks (totaling 30 days
of monitoring). Patients were reminded by email to complete
regular reporting if a submission was not received. The data
entered through the mobile app reached a double-encrypted
server. The surgeon used a wireless interface to access those
data and monitor the patient’s condition (not in real time).
High pain scores were flagged in the database for quick viewing. Any red flags (abnormally high pain scores or abnormally
low quality of recovery 9-item questionnaire scores) prompted
in-person follow-up. Physicians summarized the clinical
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Monitoring via Mobile App and In-Person Visits After Ambulatory Surgery
findings recorded by the mobile app using the prototypical subjective, objective, assessment, and plan note19 at 1 or more time
points during the 30-day monitoring period.
Outcome Measures
The main outcome was the total number of follow-up visits (including specialists, family physician, and emergency department) associated with the surgery. These data were captured
at 30 days after the surgery by patient survey and reconfirmed via review of the medical record.
The secondary outcomes included the total number of telephone calls and emails to the health care team associated with
the surgery, satisfaction and convenience scores, and postoperative complications. All secondary outcome data were captured by telephone survey 30 days after the surgery. Patientreported satisfaction and convenience scores were recorded
using a 5-point Likert scale. Complications were defined as adverse events that were attributed to the surgery and required
a medical or surgical intervention.
Original Investigation Research
person follow-up care. A covariate adjustment was performed if any of the relevant variables remained unbalanced
after randomization.
The average patient who underwent breast reconstruction attends 2 in-person follow-up visits within the first month
after surgery. We assumed that we could avert at least 1 inperson visit in the group using the mobile app and that we
would have an equal number of participants in both groups.
Therefore, the E test between 2 Poisson mean values for count
data was used to generate a sample size of 64 (32 patients per
group) at a power of 95% (α = .05).20 Assuming a 10% dropout rate, we increased the sample size target to 36 patients per
group.
The study was also powered to detect a 5–percentagepoint difference in the complication rates between groups using
the Fisher exact test comparing 2 independent proportions
(α = .05). This magnitude of increase was thought to be a clinically relevant difference given the known variability in the rates
of complication reported in the literature.21
Statistical Analysis
Descriptive statistics (frequencies and mean [SD] values) were
calculated for all clinical and outcome variables. All data obtained in this study were entered into Excel and analyzed using
Stata version 13 (StataCorp LP).
We used person-level Poisson regression to determine if
there was a statistically significant difference between patients using the mobile app and those receiving in-person follow-up care in count data including the number of in-person
follow-up visits attended, the number of telephone calls and
emails to health care professionals, and the 5-point patientreported satisfaction and convenience scores. The goodness
of fit of all Poisson regression models was confirmed with the
χ2 test. Complications were recorded as a binary variable. A
2-sample test of proportions was used to determine if there was
a statistically significant difference in complication rates between patients using the mobile app and those receiving in-
Figure 1. Flow Diagram of Study Recruitment
7 Declined
70 Randomized
3 Excluded
2 Operations
cancelled
1 Declineda
33 Completed in-person
follow-up
a
Demographic and Surgical Data
A total of 77 eligible patients were approached consecutively
during the 5-month study period. Figure 1 demonstrates the
flow scheme of all study patients. A total of 65 patients were
enrolled in the study: 33 completed in-person follow-up care
and 32 completed mobile app follow-up care. No patients were
lost to follow-up. There were no missing data. The trial was
completed 30 days after the final patient had surgery. See the
Table for patient demographics. Major surgery was defined as
a bilateral mastectomy and immediate reconstruction or a delayed pedicled autologous breast reconstruction based largely
on the length and complexity of the procedures. Using a lenient P value of .10, we found that prior radiotherapy (8 [24%]
vs 15 [47%]) and mean distance from the hospital to the patient’s home (120 vs 53 km) were unbalanced between the inperson and mobile app groups. All other variables were well
balanced (Table).
Total Number of In-Person Follow-up Visits
During the First 30 Days
77 Patients eligible
36 Randomized to
in-person follow-up
Results
34 Randomized to mobile
app follow-up
2 Declineda
32 Completed mobile
app follow-up
When questioned, the patients’ reasons for declining participation after
randomization were unclear.
The in-person group attended a mean 1.64 in-person visits during the first 30 days after surgery (median, 2 visits; range, 0-4
visits). This mean includes 3 patients who visited the emergency department. The mobile app group attended a mean 0.66
in-person visits during the first 30 days after surgery (median, 1 visit; range, 0-3 visits). No patients in the mobile app
group visited the emergency department. The mobile app
group was 0.40 times less likely to attend in-person follow-up care during the first 30 days after surgery compared
with the in-person group (95% CI, 0.24-0.66; P < .001). This
difference was maintained at 3 months postoperatively (incidence rate ratio [IRR], 0.66; 95% CI, 0.46-0.95; P = .03).
The number of patients who underwent prior radiotherapy
and the distance from the patient’s home to the hospital remained
unbalanced between the 2 groups after randomization. It is rea-
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Research Original Investigation
Monitoring via Mobile App and In-Person Visits After Ambulatory Surgery
Table. Patient Demographics
Follow-up Care
In Person
(n = 33)
Characteristic
Age, mean (SD), y
45.1 (14.1)
Prior radiotherapy, No. (%)
Body mass index, mean
8 (24)
c
24.1
Major surgery, No. (%)d
Mobile App
(n = 32)
P Value
50.3 (12.3)
.14a
15 (47)
.06b
a
Wilcoxon rank-sum test.
a
.41
b
Pearson χ2 test.
.42b
c
Calculated as weight in kilograms
divided by height in meters
squared.
d
Major surgery included bilateral
mastectomy and immediate
reconstruction or a delayed
pedicled autologous breast
reconstruction.
24.3
3 (9)
5 (16)
I
22 (67)
19 (59)
II
11 (33)
12 (38)
American Society of Anesthesiologists class, No. (%)
0
Total Number of Emails and Telephone Calls
During the First 30 Days
The group receiving in-person follow-up care made a mean
0.30 telephone calls to their health care professionals during
the first 30 days after surgery (median, 0 telephone calls; range,
0-2 telephone calls). The group using the mobile app made a
mean of 0.31 telephone calls during the first 30 days after surgery (median, 0 telephone calls; range, 0-2 telephone calls).
There was no statistically significant difference between groups
(IRR, 1.03; 95% CI, 0.43-2.48; P = .95). However, the group
using the mobile app did send more emails than did the inperson group during the first 30 days after surgery (IRR, 4.13;
95% CI, 1.55-10.99; P = .005). The group using the mobile app
sent a mean of 0.65 emails (median, 0.5 emails; range, 0-3
emails) and the in-person group sent a mean of 0.15 emails (median, 0 emails; range, 0-1 emails). These findings were robust
after adjustment for the unbalanced covariates of prior radiotherapy and distance from the patient’s home to the hospital
(IRR, 4.38; 95% CI, 1.62-11.84; P = .004 and IRR, 4.84; 95% CI,
1.69-13.84; P = .003, respectively).
Patient-Reported Satisfaction and Convenience Scores
Satisfaction and convenience scores were garnered using a
5-point Likert scale (Figure 2 and Figure 3). There was no
statistically significant difference in satisfaction scores
between groups (IRR, 0.95; 95% CI, 0.76-1.20; P = .70).
However, the group using the mobile app reported higher
convenience scores than did the group receiving in-person
follow-up care (IRR, 1.39; 95% CI, 1.09-1.77; P = .008).
Thirty-one patients in the mobile app group (97%) agreed or
strongly agreed that the type of follow-up care they received
.07a
53
Figure 2. Satisfaction Scores Between Groups
70
Patients, %
sonable to anticipate that patients who underwent prior radiotherapy may require more follow-up because of a higher potential of delayed wound healing and other complications. It
is also reasonable to anticipate that patients who live further
from the hospital may attend fewer in-person follow-up visits. After adjustment for these covariates, the significant difference in the number of in-person follow-ups during the first
30 days after surgery was robust between the in-person group
and the mobile app group (prior radiotherapy: IRR, 0.42; 95%
CI, 0.25-0.70; P = .001; and distance from home to the hospital: IRR, 0.38; 95% CI, 0.23-0.64; P < .001).
E4
1 (3)
120
60
In-person
50
Mobile app
40
30
20
10
0
Strongly
Disagree
Disagree
Neutral
Agree
Strongly
Agree
Patients’ responses to the question, “Were you satisfied with the type of
follow-up care (mobile app or in-person) you received?
Figure 3. Convenience Scores Between Groups
Patients, %
III
Distance from the hospital to patient home, mean (SD), km
.54b
90
80
70
60
50
40
30
20
10
0
In-person
Mobile app
Strongly
Disagree
Disagree
Neutral
Agree
Strongly
Agree
Patients’ responses to the question, “Would you describe the type of follow-up
care (mobile app or in-person) you received as convenient?”
was convenient. Only 16 patients in the in-person group
(48%) agreed or strongly agreed that the type of follow-up
care they received was convenient.
Again, because the covariates of prior radiotherapy and the
distance from the patient’s home to the hospital remained unbalanced between groups after randomization, we adjusted for
these covariates and found that the significant difference in
the convenience scores between the mobile app group and the
in-person group was robust (IRR, 1.39; 95% CI, 1.08-1.79; P = .01
and IRR, 1.35; 95% CI, 1.05-1.73; P = .02, respectively).
Complications
Four patients in the in-person group developed a postoperative complication. Two patients developed superficial infec-
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Monitoring via Mobile App and In-Person Visits After Ambulatory Surgery
tions at the incisional surgical site22 requiring oral antibiotics,
1 patient developed a seroma23 requiring drainage with a percutaneous needle, and 1 patient developed a deep incisional
infection at the surgical site22 requiring removal of the implant
and administration of intravenous antibiotics for 10 days. Two
patients in the mobile app group developed a postoperative complication. One patient developed a superficial infection at the
incisional surgical site22 requiring oral antibiotics, and 1 patient developed a deep incisional infection at the surgical site22
requiring removal of the implant and oral antibiotics. There was
no statistically significant difference detected in the rates of complications (P = .42). The overall rate of reoperation was 3% (2
of 65 patients). There were no complications among the 8 patients who underwent a major surgery.
Discussion
Follow-up via a mobile app can be used to eliminate inperson follow-up visits during the first 30 days following ambulatory breast reconstruction surgery. Patients using the
mobile app attended 0.40 times fewer in-person visits for follow-up care and sent more emails to their health care professionals during the first 30 days after surgery than did patients
in the in-person follow-up group. This finding is important because a common criticism of telemedicine or virtual communication between patients and health care professionals is
whether it truly replaces in-person care.24 There was no statistically significant difference between groups in satisfaction scores; however, patients using the mobile app were more
likely to agree or strongly agree that the type of follow-up care
they received was convenient. Improving patient convenience without compromising satisfaction is another critical
finding as we look for ways to build a patient-centric health
care system that supports quicker recovery and resumption
of normal daily living. There was no statistically significant
difference between groups in the rate of postoperative
complications.
Previous prospective and retrospective cohort studies have
been performed in a variety of ambulatory patient populations and have shown similar results.3,6,25,26 Hwa and Wren3
found that surveys conducted by physician assistants could
be safely used as a substitute for in-person follow-up among
patients who underwent open herniorrhaphy and laparoscopic cholecystectomy, with a high degree of patient satisfaction. Jones et al26 found that telephone interviews and standardized postoperative questionnaires pose no additional risk
to pediatric patients undergoing tonsillectomy and/or adenoidectomy compared with their previous experience with sched-
ARTICLE INFORMATION
Accepted for Publication: January 8, 2017.
Published Online: March 22, 2017.
doi:10.1001/jamasurg.2017.0111
Author Contributions: Dr Armstrong had full
access to all the data in the study and takes
responsibility for the integrity of the data and the
accuracy of the data analysis.
Original Investigation Research
uled postsurgical clinic follow-ups. Our study is unique in that
it is the first randomized clinical trial, to our knowledge, to
examine the effect of replacing in-person follow-up care with
follow-up care delivered via a mobile app. It is also the first
time, to our knowledge, that a mobile app has been used as
the platform for collecting patient-reported outcomes or survey data. All previous studies have relied on telephone
interviews.3,6,25,26
A growing number of procedures, including complex operations such as autologous breast reconstruction, are offered in an ambulatory setting. Patients using the mobile app
require approximately 2 minutes to input the quality of recovery, pain visual analog scale, and photographs of the surgical
site. This ease of use allows patients to submit data frequently (ie, daily or weekly), providing a continuous, richer inflow of information than could ever be achieved by telephone or in-person follow-up care. As we look for ways to
improve clinical care, the granular data collected via the mobile app could be used to augment the National Surgical Quality Improvement Programs occurring across the country.27,28
Limitations
The limitations of this trial include the single ambulatory patient population. These findings are likely generalizable to other
ambulatory patient populations, given the similar findings already discussed, but are not generalizable to individuals receiving inpatient breast reconstruction. In addition, we were
unable to conduct the study in a blinded fashion owing to the
nature of the intervention. We did not power our study to detect a significant difference in the number of emergency department visits between groups. This is an unexpected and
important finding that should be investigated in the future.
Conclusions
Mobile app follow-up care is suitably targeted to low-risk postoperative ambulatory patients. Patients using the mobile app
attended 0.40 times fewer in-person visits for follow-up care
and sent more emails to their health care professionals during the first 30 days after surgery than did patients in the inperson follow-up group. The mobile app group was more likely
than the in-person group to agree or strongly agree that their
type of follow-up care was convenient. Complication rates and
patient satisfaction scores were comparable between the
groups. These are important findings given the current demands on the health care system and the push toward patientcentric care. In the future, we will report on the cost-effective
nature of this solution.
Study concept and design: Armstrong, Coyte,
Semple.
Acquisition, analysis, or interpretation of data: All
authors.
Drafting of the manuscript: Armstrong, Coyte.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Armstrong, Coyte.
Obtained funding: Armstrong, Coyte, Semple.
jamasurgery.com
Administrative, technical, or material support:
Brown, Beber, Semple.
Study supervision: Coyte, Semple.
Conflict of Interest Disclosures: Dr Semple
reported holding shares in QoC Health Inc. No other
disclosures were reported.
Funding/Support: Drs Semple, Coyte, and
Armstrong have received funding from the
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Research Original Investigation
Monitoring via Mobile App and In-Person Visits After Ambulatory Surgery
Canadian Institutes of Health Research e-Health
Catalyst Grants and Strategy for Patient-Oriented
Research Networks. Dr Semple holds a Research
Chair with the Canadian Breast Cancer Foundation.
Role of the Funder/Sponsor: The funding sources
had a role in the design and conduct of the study;
and collection, management, analysis, and
interpretation of the data. They had no role in the
preparation, review, or approval of the manuscript;
and decision to submit the manuscript for
publication.
Additional Contributions: Alex Kiss, PhD, Institute
of Health Policy, Management, and Evaluation,
University of Toronto, provided statistical
assistance. He was not compensated for his
contribution.
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CA. The essential SOAP note in an EHR age. Nurse
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