Mixed-Methods Analysis of Factors Impacting Use of a Postoperative mHealth App.
BACKGROUND
Limited communication and care coordination following discharge from hospitals may contribute to surgical complications. Smartphone apps offer a novel mechanism for communication and care coordination. However, factors which may affect patient app use in a postoperative, at-home setting are poorly understood.


OBJECTIVE
The objectives of this study were to (1) gauge interest in smartphone app use among patients after colorectal surgery and (2) better understand factors affecting patient app use in a postoperative, at-home setting.


METHODS
A prospective feasibility study was performed at a hospital that principally serves low socioeconomic status patients. After colorectal surgery, patients were enrolled and given a smartphone app, which uses previously validated content to provide symptom-based recommendations. Patients were instructed to use the app daily for 14 days after discharge. Demographics and usability data were collected at enrollment. Usability was measured with the System Usability Scale (SUS). At follow-up, the SUS was repeated and patients underwent a structured interview covering ease of use, willingness to use, and utility of use. Two members of the research team independently reviewed the field notes from follow-up interviews and extracted the most consistent themes. Chart and app log reviews identified clinical endpoints.


RESULTS
We screened 115 patients, enrolled 20 patients (17.4%), and completed follow-up interviews with 17 patients (85%). Reasons for nonenrollment included: failure to meet inclusion criteria (47/115, 40.9%), declined to participate (26/115, 22.6%), and other reasons (22/115, 19.1%). There was no difference in patient ratings between usability at first-use and after extended use, with SUS scores greater than the 95th percentile at both time points. Despite high usability ratings, 6/20 (30%) of patients never used the app at home after hospital discharge and 2/20 (10%) only used the app once. Interviews revealed three themes related to app use: (1) patient-related barriers could prevent use even though the app had high usability scores; (2) patients viewed the app as a second opinion, rather than a primary source of information; and (3) many patients viewed the app as an external burden.


CONCLUSIONS
Use patterns in this study, and response rates after prompts to contact the operative team, suggest that apps need to be highly engaging to be adopted by patients. The growing penetration of smartphones and the proliferation of app-based interventions are unlikely to improve care coordination and communication, unless apps address the barriers and patient perceptions identified in this study. This study shows that high usability alone is not sufficient to motivate patients to use smartphone apps in the postoperative period.
Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.
Aaron R
http://orcid.org/0000-0002-1210-3731
AR
Scott
Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.
Elizabeth A
http://orcid.org/0000-0002-6045-7147
EA
Alore
Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Health Services Research and Development Center of Innovation, Houston, TX, United States.|Alkek Department of Medicine, Baylor College of Medicine, Houston, TX, United States.
Aanand D
http://orcid.org/0000-0001-6936-7984
AD
Naik
Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.|Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Health Services Research and Development Center of Innovation, Houston, TX, United States.
David H
http://orcid.org/0000-0002-9529-7091
DH
Berger
Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.|Department of Surgery, Ben Taub General Hospital, Houston, TX, United States.
James W
http://orcid.org/0000-0002-6421-269X
JW
Suliburk
colorectal surgery; mHealth; smartphone apps