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The application of mobile health (mHealth) platforms to monitor recovery in the postdischarge period has increased in recent years. Despite widespread enthusiasm for mHealth, few studies have evaluated the usability and user experience of mHealth in patients with surgical drainage.
Our objectives were to (1) develop an image-based smartphone app, SurgCare, for postdrainage monitoring and (2) determine the feasibility and clinical value of the use of SurgCare by patients with drainage.
We enrolled 80 patients with biliary or peritoneal drainage in this study. A total of 50 patients were assigned to the SurgCare group, who recorded drainage monitoring data with the smartphone app; and 30 patients who manually recorded the data were assigned to the conventional group. The patients continued to record data until drain removal. The primary aim was to validate feasibility for the user, which was defined as the proportion of patients using each element of the system. Moreover, the secondary aim was to evaluate the association of compliance with SurgCare and the occurrence of unexpected events.
The average submission duration was 14.98 days, and the overall daily submission rate was 84.2%. The average system usability scale was 83.7 (SD 3.5). This system met the definition of “definitely feasible” in 34 patients, “possibly feasible” in 10 patients, and “not feasible” in 3 patients. We found that the occurrence rates of complications in the SurgCare group and the conventional group were 6% and 26%, respectively, with statistically significant differences
Patients can learn to use a smartphone app for postdischarge drainage monitoring with high levels of user satisfaction. We also identified a high degree of compliance with app-based drainage-recording design features, which is an aspect of mHealth that can improve surgical care.
Surgical drainage is a therapeutic procedure with multiple purposes, including relieving symptoms, bypassing occlusions, and monitoring postoperative conditions [
In the last decade, apps for mobile devices have radically changed modern lifestyles. Additionally, the healthcare sector has been enriched by numerous apps [
We developed an internet-based remote app to monitor drainage and conducted a study to investigate the adequacy of the remote app with regard to helping patients and caregivers properly manage drains at home. This study focused on the feasibility and clinical value of the remote app for patients with percutaneous or surgical drainage.
Patients who were eligible to participate in this study were adult inpatients (aged ≥20 years) in the acute care surgery department of a medical center. We enrolled patients who were undergoing percutaneous or surgical drainage of the biliary tract or peritoneal cavity at our department from May 2019 to October 2019. All patients who fulfilled the inclusion criteria were approached to participate in this study. Notably, patients were excluded if they had neurologic or cognitive disorders prohibiting their usage of the app or ability to give informed consent. To calculate the sample size, we used the following parameters: α=.05, a power of 80%, an enrollment ratio of 1.6, and a complication decreasing rate of 18%. We recruited 50 patients to participate in the app group and 30 patients to participate in the conventional group.
The institutional review board of Chang Gung Memorial Hospital approved this study protocol (201900495B0). A research assistant helped the enrolled patients and caregivers install the app on their smartphones and instructed them how to use the app before the operation. Before patients were enrolled in this study, the research assistant evaluated their familiarity with wearable devices and smartphones. If the patients were not confident about using these devices, we provided further instructions to their caregivers.
SurgCare (
The app transmits digital images of the surgical wound and drainage to the medical staff as shown in
SurgCare was developed by surgical professionals and software programmers to fulfill the needs of patients caring for drains at home and was only used by patients who were followed in our institute.
Furthermore, the research assistant monitored the synchronizing of the data on weekdays and called the patients if their information was missing. If there was a change in fluid color, persistent changes in vital signs or abnormal drainage, this information was provided by smart devices to the medical doctors who then arranged further management. Patients continued to transmit data until their drains were removed. The research assistant did not have contact with the conventional group when patients were at home. Another medical staff member who did not participate in designing this system independently reviewed and analyzed the data.
Screenshots of the SurgCare app showing the records of date, drain method, drainage amount, color, and image of drained material and wound status.
Image of drainage-inserted wound and drainage content. A: wound with percutaneous gallbladder drainage; B: wound with percutaneous biliary drainage; C: yellowish bile drainage; D: mucus-like white bile drainage.
System architecture of the mobile device for recording postdrainage care.
We formally tested the usability and feasibility of the app with postdischarge drainage patients at a major academic medical center. The app was loaded onto an iOS or Android smartphone or tablet. We assessed patients’ baseline familiarity with smartphones prior to testing. User tasks included waking up the device, launching the app, inputting information (including drainage amount, color, and the presence of discomfort), capturing an image, reviewing and retaking or accepting captured images, responding to questions, and submitting the data.
Following usability testing of the app, participants were asked to rate their performance and to provide feedback on the app. Participants also used a system usability scale to evaluate their satisfaction with the app [
We evaluated the compliance of the patients with the use of SurgCare. If patients submitted data on more than 80% of days on which they had a drain, they were classified in the good compliance group. If the number of days on which data were submitted was less than 80% of the total number of days for which they had the drains, we classified them in the poor compliance group.
In this study, the feasibility was assessed as in past studies [
The clinical outcome of interest was validation that the use of the app leads to fewer complications and a lower incidence of unexpected hospital return. We compared the high compliance group with the poor compliance group and conventional group with regard to the total compliance rate, incidence of drain dysfunction, incidence of drain dislodgement, and rate of infection. We also analyzed the rates of unexpected hospital return and readmission in these groups.
Pearson’s chi-square test and Fisher exact test were used to compare categorical variables. Quantitative variables were compared with Student’s
In total, 105 patients underwent 108 procedures during the study period. Out of these 105 patients, 3 patients with repeated procedures were excluded. After being approached, 8 patients refused to participate in this project, and another 14 patients had cognitive problems and were excluded from this study. Of the 80 patients who were approached, were eligible, and agreed to participate, 6 patients were lost to follow-up. A total of 47 participants completed the usability testing, 26 of whom had caregiver assistance or proxy participation. Another 27 patients were included in the conventional group; these patients used the traditional hand recording method to track the drainage amount and color. The study flow diagram is shown in
Demographics and basic clinical information of SurgCare group are presented in
Flow diagram of the study design.
Demographic characteristics of SurgCare participants with surgical and percutaneous drainage (N=47).
Characteristics | Value | |
Age, mean (SD) | 61.4 (15.9) | |
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Male | 29 (62) |
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Female | 18 (38) |
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Hypertension | 21 (45) |
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Diabetes mellitus | 16 (34) |
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Renal insufficiency | 7 (15) |
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Chronic obstructive pulmonary disease | 3 (6) |
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Malignancy | 3 (6) |
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Biliary drainage | 25 (53) |
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Peritoneal drainage | 22 (47) |
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Independent | 21 (45) |
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Caregivers | 26 (55) |
System usability scale, mean (SD) | 83.7 (3.5) | |
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Definite feasible | 34 (72) |
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Possibly feasible | 10 (21) |
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Not feasible | 3 (6) |
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Total drainage days, N | 836 |
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Day submitted, n (%) | 704 (84) |
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Day missed, n (%) | 132 (16) |
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Dysfunction | 1 (2) |
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Dislodge | 0 (0) |
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Infection | 2 (4) |
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Unexpected return | 3 (6) |
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Unexpected readmission | 2 (4) |
To compare SurgCare group with the conventional group, we identified gender, age, underlying chronic disorders, drainage site, and method of participation for both the groups. Total occurrence of complication was lower in SurgCare group (6%) than in the conventional group (26%) with statistical significance of
Comparison of the characteristics and prognosis of patients within the SurgCare and conventional groups.
Characteristics | SurgCare | Conventional | ||
Patients, n | 47 | 27 | —a | |
Age, mean (SD) | 60.2 (17.1) | 63.6 (13.4) | .36 | |
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.60 | |||
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Male | 29 (62) | 15 (56) |
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Female | 16 (38) | 12 (44) |
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Hypertension | 21 (45) | 8 (30) | .23 |
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Diabetes mellitus | 16 (34) | 6 (22) | .43 |
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Renal insufficiency | 7 (15) | 5 (19) | .75 |
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Chronic obstructive pulmonary disease | 3 (6) | 2 (7) | >.99 |
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Malignancy | 3 (6) | 3 (11) | .66 |
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.08 | |||
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Biliary drainage | 25 (53) | 20 (74) |
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Peritoneal drainage | 22 (47) | 7 (26) |
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.37 | |||
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Independent | 21 (45) | 15 (56) |
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Caregivers | 26 (55) | 12 (44) |
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3 (6) | 7 (26) | .03b | |
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Dysfunction | 1 (2) | 3 (11) | .14 |
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Dislodge | 0 (0) | 3 (11) | .045b |
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Infection | 2 (4) | 1 (4) | >.99 |
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Unexpected hospital return | 3 (6) | 7 (26) | .03b |
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Unexpected readmission | 2 (4) | 4 (15) | .11 |
aNot applicable.
bFisher Exact test.
After evaluation, there were 34 patients for whom it was definitely feasible to use this app. For 10 patients, use of the app might be feasible, although they needed more support from the research assistant to help them operate the system. Another 3 patients were in the infeasible group because they completed less than 30% of the elements. The overall system usability score for the app was 83.3, which is considered good in usability testing.
In the good compliance group, we found that the rate of complications related to drainage was 3%, which was much lower than that in the poor compliance group (11%). With regard to unexpected hospital return (3% vs 11%) and readmission (3% vs 11%), the good compliance group had better results than the poor compliance group and the conventional group as shown in
Comparison of the prognosis of patients with SurgCare with good and poor compliance.
Characteristics | Good compliance | Poor compliance | |||
Patients, n | 38 | 9 | —a | ||
Age, mean (SD) | 60.3 (18.1) | 60.0 (13.1) | .96 | ||
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.27 | ||||
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Male | 22 (58) | 7 (78) |
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Female | 16 (42) | 2 (22) |
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Hypertension | 16 (42) | 5 (56) | .47 | |
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Diabetes mellitus | 15 (40) | 1 (11) | .11 | |
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Renal insufficiency | 7 (18) | 0 (0) | .32 | |
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Chronic obstructive pulmonary disease | 1 (3) | 2 (22) | .09 | |
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Malignancy | 2 (5) | 1 (11) | .48 | |
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.87 | ||||
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Biliary drainage | 20 (53) | 5 (56) |
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Peritoneal drainage | 18 (47) | 4 (44) |
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.14 | ||||
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Independent | 15 (40) | 6 (67) |
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Caregivers | 23 (61) | 3 (33) |
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Dysfunction | 1 (3) | 0 (0) | >.99 | |
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Dislodge | 0 (0) | 0 (0) | >.99 | |
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Infection | 1 (3) | 1 (11) | .32 | |
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Unexpected hospital return | 2 (5) | 1 (11) | .52 | |
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Unexpected readmission | 1 (3) | 1 (11) | .26 |
aNot applicable.
This study demonstrated the feasibility of using a mobile app to monitor the recovery status of patients with drains and to assist patients and caregivers in detecting abnormalities in a timely manner. Remote apps could support self-care and allow close follow-up [
The compliance with using apps is generally high. Apps for surgical patients must be developed carefully, keeping in mind that the users are very vulnerable [
Furthermore, 4 key categories of age-related barriers are associated with the use of mHealth by older adults, namely, barriers related to cognition, motivation, physical ability, and perception [
In contrast to the generally rapid growth of mHealth in medical fields, research on surgical topics has been limited. Among studies focusing on the application of mHealth to surgical issues, several have investigated wound care and pain scaling to validate the clinical usefulness of mHealth [
This study had several limitations that should be considered when interpreting the results. First, all assessments were conducted online, and inclusion relied exclusively on self-reported data. Therefore, the internal validity and generalizability to a larger clinical population might have been compromised. Second, there was a rather low postassessment response rate. The lack of data from approximately one-fifth of the sample limits the validity of our findings since it remains unclear how satisfied the nonresponders were and how they differed in terms of symptomatology. Third, the sample size was limited, and the sample did not represent all surgical patients. Subsequent research should, therefore, investigate the efficacy and cost-effectiveness of SurgCare in a fully powered randomized control trial. The study provided valuable information about the feasibility and adequacy of an internet-based intervention for the management of drains, which can be used to guide subsequent research.
In this study, we present a remote app that can improve patient compliance with postdischarge drainage care and monitoring and reduce the rate of major complications. The patients were enthusiastic about partnering with their health providers in novel ways to optimize their healthcare. Although mHealth will certainly not replace physician contact, it will serve as a digital assistant for diagnostic, therapeutic, and follow-up purposes, supporting patient recovery.
electronic health
mobile health
World Health Organization
None declared.