Engage Patients | Higgs Boson Health

CareConvoy mobile platform helps patients stay engaged to promote optimal outcomes

Feasibility study of a novel digital health platform for patients undergoing transcatheter aortic valve replacement

Duke Department of Neurosurgery, Higgs Boson Health, Duke Division of Cardiovascular and Thoracic Surgery

Vishal Venkatraman, BS; Madison Ponder, BSPH; Ziad F. Gellad MD, MPH; Shivanand P. Lad MD, Ph.D; Edana Christy, NP; Ryan Plichta, MD; John Kevin Harrison, MD; George Chad Hughes, MD; Julie Doberne MD, Ph.D

Key Results

78%

Found CareConvoy Helpful Pre-Operatively

86%

Would Recommend CareConvoy to Others

Abstract

Introduction: Despite abundant evidence indicating that digital health solutions improve outcomes in chronic medical conditions, there are few validated solutions for acute surgical episodes. Transcatheter aortic valve replacement (TAVR) is a less invasive alternative to open surgery that is becoming more prevalent. We assessed the feasibility of CareConvoy, a smartphone application that combines patient education and outcomes tracking for patients undergoing TAVR procedures. Methods: CareConvoy was offered to patients receiving TAVR at an academic health center. Pre‐ and postoperatively, patients completed app‐based tasks and reported clinical results using validated NYHA and KCCQ‐12 surveys. Additionally, users reported levels of satisfaction with the digital platform.

Results: Sixty‐nine patients were invited to use CareConvoy, of which 43 (62%) downloaded and used the platform. The median age of patients was 77 years and 66.7% were male. The platform was accessed at an average of 2.6 times per user, with 79.1% of patients logging in one to three times. On average, 5.2 frequently asked questions were viewed. Of the 37 patients who completed the feedback survey (86%), 73.0% said it was helpful in preparation for surgery and 86.5% would recommend CareConvoy to others.

Discussion: It is possible to utilize a digital health platform to guide patients undergoing TAVR through their interventional journey. Additional research is warranted to assess whether digital patient navigation tools provide an added benefit over traditional perioperative care alone, in terms of long‐term patient engagement and outcomes.

KEYWORDS

digital health, heart surgery, mobile applications, TAVR, technology

Introduction

Aortic stenosis (AS) is a common condition associated with aging, affecting around 10% of adults over the age of 80. If left untreated, symptomatic AS has a mortality rate of 25% per year. It has been estimated that 290,000 elderly patients in the United States are candidates for transcatheter aortic valve replacement (TAVR). TAVR has become a well‐established, minimally invasive alternative to surgical aortic valve replacement (SAVR). Extensive research, including the landmark PARTNER trials, showed that TAVR outperformed conservative therapy and had equivalent outcomes to SAVR. Recent studies suggest that these beneficial effects can be sustained over time and may apply to younger patients with decreased perioperative mortality risk recovery and discharge.

Engagement and education of patients are critical components of modern healthcare delivery. Providers must be able to educate patients effectively about their future treatment. With the proliferation of smartphones in society, digital and mobile programs (“apps”) providing remote patient care and monitoring are growing. These are used to gather data, educate patients, and enhance communication between them and their clinicians. Mobile health apps have been found to benefit patients with chronic illnesses such as diabetes and cardiovascular disease by allowing for remote data collection, reducing patient visits and hospitalizations, and facilitating self‐care. Additionally, mobile applications can inform health care delivery by increasing the amount of data available for clinical decision making, reducing healthcare resource utilization, and even perhaps reducing stress on healthcare professionals through its use as a positive patient care tool.

Despite an abundance of evidence indicating that digital health solutions improve outcomes in chronic medical conditions, there are comparatively few vetted solutions for acute surgical events. Many mobile applications have been shown to be feasible for collecting patient‐reported outcomes following prostate surgery, hepatopancreaticobiliary surgery, lung surgery, and C‐sections. However, no peer‐reviewed research has established the feasibility of a comprehensive, longitudinal software platform for pre‐, peri‐, and post‐TAVR management. To address this gap, we examined CareConvoy (Higgs Boson, Inc.), a commercially available patient education, outcomes, and analytics‐based smartphone platform for structural heart procedures, and tested its feasibility in a pilot study of patients undergoing TAVR.

Methods

CareConvoy

CareConvoy is a cloud‐based, HIPAA‐compliant application that serves as a virtual patient navigator for surgical procedures such as TAVR. The platform was designed for mobile operating systems including iOS (Apple, Inc.) and Android (Google, Inc.), as well as a Web Application to allow for the widest possible utilization. CareConvoy supports patients through all phases of the surgical journey: awareness, evaluation, presurgery, surgery, and follow‐up. Patients and their families can access multimedia educational resources to learn about their procedure, how to prepare for surgery, and what to expect during recovery. Patients can also self‐report outcomes through in‐app surveys, access frequently asked questions (FAQs) relevant to their procedure, and receive notifications and reminders from their medical providers. In addition, CareConvoy can send automatic reminders for appointment confirmation, completion of pre‐op screening, and completion of patient outcomes surveys.

The CareConvoy TAVR platform was designed by an interdisciplinary group of experts in cardiology, cardiac surgery, behavior change, psychometrics, and computer science. The content in the platform was developed to present information to patients at a 7th grade reading level. Literacy evaluation was performed by the Duke Patient Education Governance Council. The goal was to make the platform accessible and patient‐centered while improving communication and patient knowledge.

Patients undergoing TAVR and their designated caregivers were invited to download the application 2–4 weeks before their surgery. Patients received surveys selected by surgeons at Duke University Medical Center that were designed to record baseline and postoperative patient‐reported outcomes (PROs). Postoperative surveys were automatically available to patients after discharge, and reminders to complete these were provided via automated notifications. All survey items were closed questions with structured answers. Patients either responded to the surveys directly while accessing the application (self‐administered) or by having a clinical staff member administer the survey and add the information to the patient's record (via proxy). The KCCQ‐12 survey, a validated tool to quantify the impact of heart failure on quality of life, was administered through CareConvoy pre‐operatively and 1 month post- operatively. The KCCQ survey scores patients from 0 to 100, with lower scores indicating more severe impairments on quality of life. In addition, patients took the NYHA Functional Classification Questionnaire, which has been used to self‐ classify patients into Categories I–IV based on the severity of their heart failure).

Subjects and Setting

Institutional Review Board approval was obtained before beginning the study, and electronic consent was obtained in the application from all subjects at enrollment. Patients were invited to enroll if they were scheduled for a TAVR procedure between March 2019 and March 2020 at Duke University Medical Center. Additional inclusion criteria included English as the primary language, ability to obtain or access a smartphone or computer capable of running the CareConvoy app, and capacity to consent. Patients could also participate if they had a family member or friend access CareConvoy for them through the in‐app caregiver function. Patients were considered engaged with CareConvoy if they downloaded and logged into the platform at least once.

Data Collection & Analysis

Data were collected and stored securely via Amazon Web Services (Amazon Web Services, Inc.). Two members of the research team (MP and VV) independently reviewed the patient responses and associated electronic health record data. Descriptive statistics for the surveys were calculated using Google Sheets and SAS 9.4 (SAS Institute, Inc.). Continuous variables were reported as means, standard deviation, median, first quartile, third quartile, and minimum and maximum values. Categorical variables were reported as numbers and percentages.

PROs were requested before surgery and at 1 month post- operatively. Patient feedback on the application was collected 5 days postoperatively. Patients were reminded to complete the surveys and patient feedback via automated push notifications. Additionally, we measured the use of the application by assessing the number of account sign‐ins, task completion, addition of caregiver(s), and FAQs viewed (Table 1).

Table displaying data on patient characteristics for patients undergoing elective TAVR surgery who used CareConvoy

Results

Patient Characteristics and Application Use

A total of 69 patients from six cardiac surgeons and cardiologists participated in this feasibility study. The median age was 77 years old (range 57–91), 46 were male (66.7%) and 63 (91.3%) had Medicare insurance (Table 1).

Of the 69 patients invited, 43 (62.3%) patients and their caregivers downloaded and logged in to the platform at least once. A total of 28 of these patients (65.1%) logged in on an iOS device and 9 (20.9%) on an Android device. Sixteen patients (37.2%) added a total of 19 caregivers, of which 13 (68.4%) logged in (Table 2). Screenshots of the CareConvoy application interface are shown in Figure 1.

Users logged on to the application with their username and password an average of 2.6 times, with 34 (79.1%) users signing in one to three times. Because users could securely access content repeatedly without signing in to the application by signing in to their phone, we were not able to capture the total number of times the patients opened the application (Table 2).

The average number of questions viewed was 5.2. The top three most viewed FAQs were: (1) “What are the risks of TAVR?” (2) “Will I need someone to assist me after I return home?” and (3) “How long will I stay in the hospital?”

CareConvoy Feedback and PROs Survey Results

Of 43 patients who used CareConvoy, 37 (86.0%) patients completed the CareConvoy feedback survey. Twenty‐nine (78.4%) of these 37 patients found CareConvoy helpful pre‐operatively, 22 (59.5%) found CareConvoy helpful for recovery postoperatively and 32 (86.5%) said that they would recommend CareConvoy to a friend or family member (Table 3).

A total of 33 of 43 patients (36.7%) completed baseline KCCQ‐ 12 surveys and 33 of 43 patients (36.7%) completed the baseline NYHA survey. At the one month Postoperatively, 20 patients (46.5%) completed the KCCQ‐12 survey. Twelve patients (27.9%) completed the 1‐month postoperative NYHA survey. The average KCCQ‐12 score at baseline was 44.9 and increased to an average of 56.4 postoperatively (Figure 1). Preoperatively, seven patients were NYHA Class I, 18 Class II, 5 Class III, and 3 Class IV, Class IV representing the most severe (Figure 2). One month postoperatively, there were nine Class I patients and three Class II patients (Figure 2).

Figure showing results of the KCCQ-12 survey collected via CareConvoy

Table displaying CareConvoy patient feedback survey results

Discussion

We demonstrated the feasibility of using a mobile health application (CareConvoy) to engage patients during their TAVR perioperative care in this feasibility study. The vast majority of patients checked in at least once, viewed FAQs before the surgery, and completed patient‐ reported outcome surveys. The majority of users who responded to the CareConvoy feedback survey found the application beneficial for both pre‐ and postsurgical preparation and recovery. Overall, 86.5% of these patients found CareConvoy to be helpful and would recommend it to a friend or family member.

The majority of patients completed the KCCQ‐12 and NYHA surveys via the application at baseline and postoperatively. Our results suggest that it is possible to collect and analyze outcomes data remotely for TAVR, using a mobile software platform. Given the stress placed on healthcare staff when administering surveys to patients manually, allowing patients to self‐report helps alleviate this burden and allows providers to focus on other value‐added tasks.

It has been shown that offering comprehensive information and communication to patients before treatment helps them feel secure and empowered to take control of their recovery.16 Other authors have demonstrated that mobile apps can help increase patient‐ provider relationships and clinical data collection and as they become increasingly integrated into healthcare systems, they may play a critical role in improving patient outcomes. Mobile software platforms help bridge the communication gap between in‐person patient visits, by providing patients with on‐demand information regarding their procedures and immediate access to their healthcare team, hence enhancing patients' trust and ease during the surgical process. The frequently asked questions data, for example, can help clinicians find what information their patients most want to understand about their surgeries. The results from our study suggest that patients are worried about risks of TAVR and how the recovery period will be, which could guide future consultations with patients and future educational modules on CareConvoy.

An area of future improvement that both this feasibility study and other mobile health apps demonstrate the need for is in long‐ term patient engagement. Over 95% of patients in our study completed preoperative surveys via the software platform, and the majority utilized preoperative educational features such as FAQs. By contrast, slightly more than 20% completed long‐term postoperative feedback surveys and KCCQ‐12 and NYHA PROs. Other authors have remarked that as mobile health apps grow more prevalent, many suffer from attrition, reducing the relevance of data collection for the study. Potential hurdles to long‐term involvement include the patients' functional condition and the workload associated with performing in‐app tasks.18 This is especially true for procedures such as TAVR, where the target population is older and potentially more functionally constrained than younger patient populations. To address the issue of long‐term engagement, potential solutions include developing even more simplified versions of the platform that are easier to use for those unfamiliar with smartphone technology, utilizing SMS/text messaging‐only modes of communication, and utilizing shorter surveys that take less time to complete. Additionally, it may empower patients further if they are shown the outcomes of their data and are able to visualize, and quantify in real‐time, how their condition has improved. Previous studies have noted that patients provided positive feedback when presented with their study results and often noted reluctance to participate because they had not received personalized feedback from their care teams in previous app‐based studies.

Future studies will seek to quantify the impact of the TAVR mobile health application on patient quality metrics, including 30‐ and 90‐day readmission rates, postoperative complication rates, impact on clinical outcomes such as KCCQ‐12 and NYHA and clinical staff burden. When integrating new technology into any healthcare setting, provider input may significantly streamline the integration of applications into already complex clinical workflows. Continually enhancing the experience and usability, from both the patient and provider perspectives, will allow the realization of the full potential of mobile health applications for patients undergoing acute interven- tional procedures.

Figure displauing results of the NHYA survey collected via CareConvoy

Limitations

We demonstrated the feasibility of using a mobile health application (CareConvoy) to engage patients during their TAVR perioperative care in this feasibility study. The vast majority of patients checked in at least once, viewed FAQs before the surgery, and completed patient‐ reported outcome surveys. The majority of users who responded to the MMS feedback survey found the application beneficial for both pre‐ and postsurgical preparation and recovery. Overall, 86.5% of these patients found MMS to be helpful and would recommend it to a friend or family member.