The impact of adherence to enhanced recovery pathway elements on outcomes following bowel surgery
Bibliographic record
Abstract
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.
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.002 | 0.005 |
| Meta-epidemiology (narrow) | 0.001 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.000 | 0.001 |
| Science and technology studies | 0.001 | 0.000 |
| Scholarly communication | 0.000 | 0.001 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.001 |
| Insufficient payload (model declined to judge) | 0.000 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".