Evaluation of Postoperative Recovery in Day Surgery Patients Using a Mobile Phone Application: a Multicentre Randomised Trial

Jaensson M, Dahlberg K, Eriksson M et al.

British Journal of Anaesthesia 2017; 119 (5): 1030–1038



  • Patient satisfaction is affected by adverse events after Anaesthesia1 during postoperative recovery
  • Complications may not occur until after discharge.
  • Lack of information/feedback regarding what to expect (the ‘normal’) can affect patient satisfaction

Aim of Study

  • To investigate whether a systematic follow-up e-assessment using Recovery Assessment by Phone Points (RAPP), compared with standard care, had a positive effect on day surgery patients’ postoperative recovery
  • To investigate whether there were differences in women and men’s recovery scores

Design and Outcome

  • Multicentre, two group, parallel, single-blinded randomised controlled trial conducted from October 2015 to July 2016 at four Day Surgery Units in Sweden.

Primary outcome

  • Cost-effectiveness when using the RAPP

Secondary outcomes

  • To explore whether a systematic e-assessment follow-up after day surgery has a positive effect on postoperative recovery
  • To determine whether differences in postoperative recovery have an association with patient characteristics.


  • Patient inclusion criteria: undergoing day surgery, >17yrs of age, access to a smartphone, ability to understand spoken and written Swedish
  • Randomisation – computerised random number list generator – sealed envelopes.  Random assignment 1:1 ratio.
  • Single blinded – investigators performing the statistical analysis were blinded to group allocation.
  • Control group provided with standard information regarding recovery and who to call if any concerns or questions.
  • RAPP application – utilises SwQoR (Swedish web version of quality of recovery) – questionnaire with 24 negatively worded items scored on an 11 point numerical visual analogue scale (0 – none of the time, 10 – all of the time)
  • RAPP – Day 1 until day 14 completed with daily reminders sent to phone
  • Standard care group filled a paper-based questionnaire in a prepaid envelope on day 7 and day 14



  • To compare differences between intervention and control group; absolute number, percentage, mean and standard deviation were used.
  • Unit non-response – if reported on day 6 or 13 – used last value carried forward (LVCF)
  • Sample was analysed using χ2 test, Mann-Whitney U-test or independent Student’s t-test
  • The significant symptoms were analysed using Cohens effect size (ES) 0.2 – 0.5 = small effect, 0.5-0.8 = moderate effect and >0.8 = large effect between RAPP and control group



  • 1797 patients assessed for eligibility
  • 770 patients were excluded – 1027 randomised to RAPP or control group.  30 patients excluded (cancelled surgery, technical issues, declined participation or other).
  • 997 patients included – 494 to RAPP group and 503 to control group.
  • Day 7 785 patients answered, Day 14 733 patients answeredThe RAPP group scored less discomfort from postoperative symptoms compared with the control group in 8 of the 24 SwQoR items on day 7.


  • On day 7 – 69% of RAPP group reported good postoperative recovery (SwQoR score <31) versus 57% in the control group (p = 0.001).
  • On day 14 – 70% versus 64% (p=0.06)
  • Women scored less discomfort in 7 of 24 SwQoR items on day 7 compared to the control group.
  • Global SwQoR(Swedish web version of quality of recovery) was significantly lower in the RAPP group compared to the control group for women at day 7 (mean 29.45 vs 37.84, p = 0.003) and men (mean 26.54 vs 31.35, p=0.008).
  • 67% women in the RAPP group had a good postoperative recovery versus 54% in the control group on day 7 (p=0.008) .
  • There were no significant differences at any time for men between a good and a poor postoperative recovery.

Limitations of the Study

Arbitrary ‘good postoperative recovery’ – defined as above average and improving with time.

  • Recruitment to study:
    • 18.6% (336 of 1797) declined to participate – does the reason pertain to the app.
    • Exclusion criteria – people potentially more likely to require support/help.
    • Non-responders – due to APP or other complications never addressed.
  • Application:
    • Assumes a level of capability/comfort with technology/APPs; may alter responses
    • Unable to correct errors once submitted
    • ‘Do you want to be contacted by a nurse’ – offer of direct access to services may influence perception of care/recovery
  • Questionnaire design:
    • Validity and reliability in Swedish cohort only and no meta-analysis of phone based assessment
    • Did the paper based patients actually report on day 7 and day 14?
    • Not all potential complications covered
  • Design:
    • Differences between day units; 1 unit – follow-up call provided, likely to impact on satisfaction.
    • Informed on day of surgery – affect mind set of patient.
    • Single-blinded – patients may be more negative given not using RAPP ‘ascertainment bias’
  • Analysis:
    • LVCF – assumed no change over the course of one day – can only be done for RAPP group
    • Not merged groups of symptoms as previously done – allows for the perception of greater sttistically significant results and could impact reliability and validity


Conclusion/Journal Club Discussion

The degree to which healthcare experience meets patient expectations is an important indicator of satisfaction

RAPP group reported significantly less pain, swelling, dizziness, headache, sore mouth, sleeping, wellbeing and relaxation compared to the control group.

Systematic e-assessment can improve recovery and increase patient satisfaction.  It can also identify key areas of improvement.

Future progress in assessing patient satisfaction will inevitably need to evolve with the digital era.

There is scope to easily gather information and give patients more control of their care.

The implications for data protection and ensuring privacy if using digital assessment.

Patient age and IT education could impact on access to care/follow-up.

Discussion regarding our own provision of day surgery follow-up and instigated a potential audit of this area.



1. Myles P S, Williams D L, Hendrata M, Anderson H, Weeks A M.  Patient satisfaction after anaesthesia and surgery: results of a prospective survey of 10,811 patients.  Br J Anaesth 2000; 84: 6-10

2. Berg K, Arestedt K, Kjellgren K.  Postoperative recovery from the perspective of day surgery patients: a phenomenographic study.  Int J Nurs Stud 2013; 50: 1630-8.

3. Nilsson U, Jaensson M, Dahlberg K et al.  RAPP, a systematic e-assessment of postoperative recovery in patients undergoing day surgery: study protocol for a mixed-methods study design including a multicentre, two-group, parallel, single-blind randomised controlled trial and qualitative interview studies.

Summary by Dr C Donovan-Hawthorn. Journal Club 09 November 2017.

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