SMS-based collection of PROMs on hand surgery global outreach trips: a pilot feasibility study

Abstract

Purpose :

As the burden of surgical care and associated outreach trips to low- and middle-income (LMIC) countries increases, it is important to collect post-operative data to assess and improve the quality, safety, and efficacy of the care provided. In this pilot study, we aimed to evaluate the feasibility of SMS-based mobile phone follow-up to obtain patient-reported outcome measures (PROMs) after hand surgery on a surgical outreach trip to Vietnam.

Methods :

Patients undergoing surgery on a week-long outreach trip to Hospital 175 in Ho Chi Minh City, Vietnam who owned a mobile phone were included in this study. All eight eligible patients elected to participate and were sent an SMS-based, HIPAA-compliant text message with a link to a contextualized QuickDASH on the following post-operative time points: one day, one week, two weeks, four weeks, and twelve weeks. Patient characteristics and instrument completion rates were reported.

Results :

The eight patients had a mean age of 45.4 years and lived a mean distance of 72.7 km from the hospital. Seven (87.5%), seven (87.5%) , eight (100%), six (75%), and eight (100%) patients completed follow up questionnaires at one day, one week, two weeks, four weeks, and twelve weeks post-operatively, respectively.

Conclusion :

This pilot study demonstrates that collection of PROMs after hand surgery outreach trips to LMIC via SMS-based messaging is feasible up to twelve weeks post-operatively.

Clinical Relevance :

SMS-based messaging can be used to obtain post-operative outcome measures up to twelve weeks after surgical outreach trips to LMIC. This technology can be scaled and contextualized based on location to ensure patient care on outreach trips is safe and effective.

Introduction:

The global burden of basic surgical care is substantial and growing. Injuries (falls, traffic accidents, etc.) account for approximately 5.7 millions deaths annually and an estimated 15% of the world’s disability is a result of surgically treatable conditions (1). An additional 143 million surgical procedures are needed in low- and middle-income countries (LMIC) annually to prevent disability and save lives (1). Historically, surgical intervention has been a low global health priority, however recently, there has been an acknowledgement that surgery is a key component of healthcare and an interest in strengthening local surgical capacity (2). Despite the increase in resources invested (3,4) and number of global surgical outreach trips conducted (5,6), post-operative patient follow up is limited. This paucity of post-operative data collection is not only a barrier to assessing and improving the quality, safety, and efficacy of care delivered, but also to evaluating the impact of surgical outreach trips.

Surgeons and healthcare systems with plentiful resources and established patient registries describe difficulty collecting outcome data (7–9). This challenge persists in LMIC (4,10,11). For example, in a feasibility study of a randomized controlled trial for open tibial fractures in Uganda, Kisitu et al. noted follow-up rates of 67% at four weeks, 53% at eight weeks, and 53% at three months (12). In a study evaluating surgical care received in Madagascar, White et al. reported a 44% three month follow-up rate when attempting to call patients (13). In reviewing the Surgical Implant Generation Network (SIGN) Online Surgical Database of over 36,000 intramedullary nails used for long bone fractures in LMICs, authors report an overall follow up rate of 18.1% (14). A 2019 systematic review and meta-analysis of clinical outcomes and complications of SIGN nail use demonstrated a 23% follow up rate (ranging from 6 weeks to 2 years). (15) These studies identified several barriers to follow-up which include: travel distances, limited communication about treatment, and lack of physical addresses (12,13,16).

One potential approach to overcome these barriers could be the use of mobile phones and short message service (SMS), the text messaging service component available on mobile phones. Mobile phone use for collection of patient reported outcomes has been validated in the United States in multiple orthopaedic specialties (17–19). While the use of SMS has been studied in several medical fields in LMIC to improve medication adherence, clinic follow-up reminders, promoting secondary prevention (20,21), we are unaware of any studies evaluating the use of SMS to capture outcomes post-operatively. As international mobile phone ownership is high (five billion people have mobile phone subscriptions) and mobile-cellular networks are expansive (95% of people live in coverage areas) (22,23), it may be possible to leverage this technology to remotely obtain post-operative outcome data in LMICs. In this pilot study, we aimed to evaluate the feasibility of SMS-based mobile phone follow-up to obtain patient-reported outcome measures (PROMs) after hand surgery on an outreach trip to Vietnam.

Methods:

Patient enrollment and procedures:

Because this investigation was focused on ensuring safety and quality of care of patients, it was deemed a quality improvement study and formal consent was not required. Patients who were offered surgical intervention on a week-long surgical outreach trip to Hospital 175 in Ho Chi Minh City, Vietnam in February 2020 were invited to participate. Inclusion criteria included the ownership of a mobile phone. Patients were made aware that their participation was to track their health and function over time post-operatively. Participating patients completed a demographic form and listed their mobile phone number. Patients were sent an SMS-based text message with a link to a patient reported outcome measure instrument. SMS reminders were sent after enrollment, serving as a learning session. Patients subsequently received an SMS based reminder with a link to the outcome collection instrument at one day, one week, two weeks, four weeks, and twelve weeks post-operatively.

SMS-based text messaging reminders:

SMS-based text messaging reminders were sent via the case-management platform developed by Memora Health (Boston, MA). This web-based Health Insurance Portability and Accountability Act (HIPAA)-compliant platform sends a text message reminder to each patient with a link to the patient reported outcome measure instrument (Figure 1).

Figure 1:

A) Illustration (translated to English) of the SMS-based text message reminders that link to B) the patient reported outcome instruments.

Outcome Measures:

A modified version of the shortened Disability of the Arm, Shoulder, and Hand questionnaire (QuickDASH) was administered in this investigation. The QuickDASH is an 11-item instrument that measures the magnitude of disability and symptoms specific to the upper extremity and has patients rate each item on a 5-point scale from “no difficulty/none” to “unable/extreme”. We updated and translated the QuickDASH with a sample of Vietnamese patients with hand and upper extremity conditions and bilingual advisors who work in the healthcare field, to incorporate relevant activities to increase the cultural competency of the instrument that reflect our patient population.

Descriptive Analysis:

Patient characteristics (date of birth, sex, distance from hospital, procedure performed) were reported. Instrument completion rates were reported as a measure of feasibility.

Results:

Eight patients met the inclusion criteria and all agreed to participate (our team operated on ten patients during this trip, however only eight were approached for inclusion based upon the timing of the system roll-out). All patients approached were included and all owned a mobile phone. All patients were male, with a mean age of 45.4 years. The mean distance patients lived from the hospital was 72.7km. The procedures performed were: distal radius fracture open reduction and internal fixation (ORIF), both bone forearm fracture ORIF, coronoid malunion ORIF and elbow ligament reconstruction, distal humerus malunion ORIF, humeral shaft malunion ORIF, ray resection and tissue rearrangement, tendon transfers for radial nerve palsy, and biopsy of a wrist mass. Seven (87.5%), seven (87.5%), eight (100%), six (75%), and eight (100%) patients completed follow up questionnaires at one day, one week, two weeks, four weeks, and twelve weeks post-operatively, respectively (Figure 2).

Figure 2:

Instrument completion rate (follow-up rate) by follow-up interval.

Discussion:

This pilot study demonstrates that collection of PROMs after hand surgery outreach trips to LMIC via SMS-based messaging is feasible up to twelve weeks post-operatively. In countries with robust resources, outcome measurement is a routine and important aspect of care. However, given that data collection is difficult in countries with robust resources, it is not surprising that the added barriers present in LMIC further limit outcome collection. As demonstrated in this pilot study, SMS-based messaging may help circumvent some of these barriers (e.g., patient distance from hospital) and enable outcome collection post-operatively.

In addition to understanding how patients improve post-operatively, this technology has the ability to identify patients with complications that may not be otherwise identified. Although text messaging is not equivalent to in-person follow-up, it may serve as an effective, remote method to ensure safety and quality care in low-resources settings. For example, if a patient’s pain score is increasing, the team can reach out to this patient to identify the cause (e.g. surgical site infection) and intervene if necessary. This may be particularly beneficial for a patient that lives hundreds of kilometers away and would not have otherwise pursued followed-up.

Future work may include the use of multimedia messaging services (MMS) which would allow transmission of photos, allowing for wound evaluation or radiograph review remotely. Additionally, future work should include cost-effectiveness evaluations of SMS-based follow-up, from multiple stakeholder perspectives. It is possible some patients were charged for data usage as part of this study. The cost saved by patients not having to travel hundreds of kilometers is difficult to measure, yet important. From a hospital and/or organization perspective, the travel costs saved by not flying surgeons or staff back to a country or having staff members travel to individual patients to obtain follow-up may be substantial. For example, Torchia et al. in detailing their post-operative follow-up program after treating orthopaedic patients in Peru, note a $20,041 direct mean annual cost. (25) Although their follow-up was thorough, this expense may limit generalizability and scalability. Lastly, the potential ability to capture complications via SMS earlier could lead to treatment modalities that are cheaper and also lead to improved patient outcomes.

While orthopaedic surgeons in LMICs are more likely to measure HRQoL compared to other specialists, this typically consists of a measurement of pain with evaluations of functional status being infrequently measured. (10) PROM collection may not only allow for evaluation of the quality, safety, and efficacy of care delivered from the patient’s perspective, but can be used to measure the benefits of the trip itself, to more sustainably measure the impact of the care provided and inform the planning of future outreach trips.

The above results should be viewed within their limitations. As a pilot investigation, a statistical analysis was not conducted. Feasibility was evaluated relative to that of similar studies (e.g. those studies reporting outcome collection after outreach trips report collection rates of 18-53%) (12–15). As a quality improvement initiative with the goal of evaluating feasibility of outcome collection after one outreach trip, the external validity is limited. As a pilot study, our sample does not permit analyses of the PROM scores, subgroups, or factors associated with decreased follow-up rates. Interestingly, all of the patients on whom we operated and approached for inclusion in this study were male. Prior studies in the United States note sex (female) as a predictor of higher response rates and longer follow-up times and longer questionnaires to be associated with worse response rates. (9) Importantly, this was our second trip to Hospital 175 and we have a strong relationship with their hand surgery team. Our success is underscored by the shared commitment to quality and safety with the host team and community. The importance of a supportive organizational culture, local champions, and receptive team members has been echoed in implementation literature and require further exploration (26,27). Other limitations to SMS-based messaging that may preclude successful collection include: patients changing phone numbers, patient distrust or hesitancy with the system, and patient privacy issues. These may be mitigated with a strong shared culture of quality of care, which can be used to engage patients.

As the number of outreach trips to LMICs and the resources invested in such trips increase, it is important to ensure the care provided is safe and improves the health of patients. We demonstrate SMS-based text messaging to be a feasible, HIPAA-compliant method to collect patient reported outcomes post-operatively on surgical outreach trips to LMICs. This technology can be scaled and contextualized based on location to ensure patient care on outreach trips is safe and effective.