The impact of adherence to enhanced recovery pathway elements on outcomes following bowel surgery
Notice bibliographique
Résumé
Introduction: Enhanced recovery pathways (ERPs) are evidence-based, multimodal, standardized care plans that integrate multiple steps and interventions in the perioperative period aiming to improve patient recovery after surgery. International guidelines recommend the incorporation of a large number of interventions into ERPs. However, the impact of overall adherence to the pathway and the relative contribution of each intervention are unclear. The objective of the research contained within this thesis is two-fold: (1) to estimate the extent to which adherence to care process is associated with outcomes, and identify key ERP elements associated with successful recovery following bowel resection; (2) to assess the validity and usability of a novel mobile device app for patient education and self-reporting of adherence within an established ERP. Methods: A review of prospectively collected data entered in a registry specifically designed for ERPs was performed. Patients undergoing elective bowel resection between 2012 and 2014 at the Montreal General Hospital treated within an ERP comprising 23 care elements were included in the study. Primary outcome was successful recovery defined as: absence of complications, discharge by postoperative day 4 and no readmission. Secondary outcomes were: length of hospital stay (LOS), 30-day morbidity and severity (Comprehensive complication index, CCI, 0-100). Subsequently, we performed a prospective pilot study implementing a novel mobile device app specifically designed to provide patients with daily recovery milestones and to record adherence to different ERP processes and patient reported outcomes (PROs). Validity was measured by the agreement index (Cohen's kappa coefficient for categorical, and interclass correlation coefficient (ICC) for continuous variables) between patient reported data through the app and data recorded by a clinical auditor. Acceptability and usability of the app were measured by the System Usability Scale (SUS). Results: In our retrospective study, we analyzed data from 347 patients, with a median length of hospital stay of 4 days (IQR 3-7), and median adherence to 18 (IQR 16-20) elements. There was a positive association between adherence and successful recovery with no hospital readmission, length of stay, 30-day postoperative morbidity and the complication severity. Laparoscopy, early mobilization out of bed, and early termination of IV fluid infusion were significantly associated with improved outcomes. In our app validation study, we included 45 patients undergoing bowel surgery. Overall, patients completed 89% of the available perioperative questionnaires through the app. Substantial (kappa > 0.6) or almost-perfect agreement (kappa > 0.8) and strong correlation (ICC > 0.7) between data collected through the app and by the clinical auditor was found for 14 out of 15 ERP processes and 4 out of 6 PROs. Patient reported usability and satisfaction was high, and only few patients needed technical support to use the app. Forty (89%) patients found that the app was helpful to achieve their daily goals, and 34 (76%) thought it increased their motivation to recover after surgery. Conclusion: In an established ERP where overall adherence was high, we found that increased adherence to ERP interventions was associated with successful early recovery and a reduction in postoperative morbidity and complication severity. Given the significant impact of adherence to postoperative elements, we successfully piloted a novel mobile device app which proved to be a valid tool to record patient adherence and patient reported outcomes, and had high usability and patient satisfaction. Our findings suggest that future studies should investigate the use of mobile device apps as strategies to increase adherence to ERP interventions and improve outcomes.
Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.
Comment cette classification a été obtenuedéplier
Prédiction distillée sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Apprise à partir de 10 348 étiquettes directes de Codex et de 10 348 étiquettes directes de Gemma. Le mode candidate est l'union des têtes enseignantes seuillées; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont ni des étiquettes humaines ni des étiquettes directes de modèles de pointe.
Scores Codex et Gemma par catégorie
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,002 | 0,005 |
| Méta-épidémiologie (sens strict) | 0,001 | 0,000 |
| Méta-épidémiologie (sens large) | 0,001 | 0,001 |
| Bibliométrie | 0,000 | 0,001 |
| Études des sciences et des technologies | 0,001 | 0,000 |
| Communication savante | 0,000 | 0,001 |
| Science ouverte | 0,000 | 0,000 |
| Intégrité de la recherche | 0,000 | 0,001 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,000 | 0,001 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule tête enseignante, pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».