Smartphone applications for remote patient monitoring reduces clinic utilization after full-endoscopic spine surgery

Abstract

Introduction

The rising number of outpatient spine surgeries creates challenges in postoperative management and care. Telemedicine offers a unique opportunity to reduce in-person clinic visits and improve resource allocation. We aimed to investigate the impact of a validated smartphone application on clinic utilization following full-endoscopic spine surgery (FESS).

Methods

We evaluated patients undergoing FESS from 2020 to 2022 and a pre-COVID control group (CG) from 2018 to 2019. Subsequently, we divided the patients into three groups: one using the application (intervention group, IG), and two CGs (2020–2022, CG and 2018–2019, historical control group (HG)). We analyzed the post-surgical hospitalization rate, all follow-ups, and virtually transmitted patient-reported outcomes.

Results

A total of 115 patients were included in the IG. The CG consisted of 137 and the HG of 202 patients (CG and HG in the following). Group homogeneity was satisfactory regarding patient age (p = 0.9), sex (p = 0.88), and body mass index (p = 0.99). IG patients were treated as outpatients significantly more often [14.78% vs. 29.2% vs. 37.62% (p < 0.001)]. Additionally, IG patients showed significantly higher follow-up compliance [74.78% vs. 40.14% vs. 37.13% (p < 0.001)] 3-month post-surgery and fewer in-patient follow-up visits [(0.5 ± 0.85 vs. 1.32 ± 0.8 vs. 1.33 ± 0.7 (p < 0.001)].

Conclusion

Our results underline the feasibility, efficacy, and safety of remote patient monitoring following FESS. Furthermore, they highlight the opportunity to implement a virtual wound checkup, and to substantially improve postoperative follow-up compliance via telemedicine.

Keywords

Telecare telemedicine spinal surgery smartphone application full-endoscopic spine-surgery remote patient monitoring‌

Introduction

The advent of telehealth marked a significant milestone in the constantly evolving medical field. Although the COVID-19 pandemic accelerated the shift towards remote healthcare visits and consultations, the potential advantages of telehealth had been under investigation well before this global crisis.¹ The continuous integration of telehealth into healthcare systems worldwide and the exploration of new areas of application underscore its utility.^2,3

Telehealth has demonstrated its ability to enhance patient safety and satisfaction while also eliminating the need for patients to travel to physicians’ offices, resulting in reduced direct costs and transportation time.⁴ Asynchronous telehealth enables individuals to provide essential health information at predetermined timepoints, allowing healthcare providers to make longitudinal observations of their progress. This approach has proven highly successful for several medical applications, including Parkinson's disease, diabetes, implantable cardioverter defibrillators, and physical therapy.^5–8 Furthermore, telehealth consultations play a vital role in making recent medical advances more accessible to rural areas by extending coverage of specialized care.⁹

In the surgical field, post-surgical in-person visits are still the norm, especially for wound checks to allow for early detection of wound healing issues or infections. However, modern high-resolution cameras, installed in virtually every smartphone, provide the surgeon with sufficient visualization of the wound's condition with successful trials in abdominal, cardiac, and vascular surgery.^10–13 Despite the recent publication of a consensus paper emphasizing the importance of telehealth in spine surgery and proposing potential implementation strategies, as well as a report showcasing the effectiveness of telemedicine in developing surgical plans, the adoption of telemedicine in spine surgery remains limited to video consultations.^14–16 However, global demographic changes and the concomitant rise in degenerative pathologies are expected to substantially increase the number of spine surgeries, challenging healthcare systems and necessitating a judicious use of finite hospital resources.¹⁷ The aim of this study was to assess the impact of postoperative remote patient monitoring (RPM) via a smartphone application (SPINEHealthie)^18,19 on clinic utilization patterns for patients undergoing full-endoscopic spine surgery (FESS). SPINEHealthie combines RPM via the assessment of patient-reported outcomes (PROMs), virtual follow-ups, and patient-provider communication through a chat function. Despite being an emerging field, FESS has been proven to be a safe and efficient surgical technique for spinal pathologies with substantially lower invasiveness and complications when compared to open spine surgery, facilitating safe outpatient monitoring.^20,21 Furthermore, FESS diminishes surgical site infections and is a safe surgical approach especially for elderly and obese patients.^22–25 Hence, FESS presents an ideal surgical modality for asynchronous virtual follow-up and continuous RPM.

Methods

Patient selection and data collection

This study was an analysis of prospectively and retrospectively collected data of 454 patients >18 years that underwent FESS due to degenerative pathologies at a university clinic. Data was obtained via the electronic patient charts and the SPINEHealthie app database. FESS was defined as the utilization of a working channel endoscope that incorporates a light source, a camera, and an irrigation channel. Patients of the intervention group (IG) furthermore were required to have access to a mobile smartphone that supported the app (iOS or Android). Acute pathologies of the spine, e.g. traumatic injuries, were not considered for inclusion, nor were procedures utilizing microsurgical techniques without the use of endoscopic instruments.

Patients were subdivided into three groups: the IG included all patients who enrolled with the smartphone application (02/2021–12/2022); a control group (CG, 01/2020–12/2022); and an additional, historical control group (HG) to account for potential distortions due to the COVID-19 pandemic.

Demographic parameters included sex, age, body mass index (BMI), surgical details, as well as comorbidities. Additionally, we assessed inpatient treatment, in-person follow-ups, telemedicine visits, and a virtual surgical site examination. Telemedicine visits were not assessed for the 2018–2019 CG as telemedicine was not established during that period. To account for post-surgical complications, data including the utilization of the emergency department (ED), clinic readmission, and revision surgeries within the first 100 days after the surgery was acquired.

Data was obtained following the approval of the Institutional Review Board of the University of Washington, and collected pseudonymously according to national law, and in accordance with the 2013 Declaration of Helsinki.

Smartphone application and PROM collection

For this study, SPINEHealthie—an IRB approved smartphone application—was used as previously described.¹⁸ In brief, after informed consent and registration, it allows for asynchronous virtual patient-provider communication, and virtual follow-ups. The follow-ups include a survey to assess the patient's well-being and progress as well as a surgical site wound check-up through image transfer (Figure 1). It enables virtual patient monitoring via patient surveys that prospectively collect PROMs daily for the first 7 days post-surgery, as well as at 2 weeks, 3 months, and at chronic timepoints (Figure 2). PROMs include questionnaires assessing a visual analog score (VAS) of the respective anatomical region (i.e. neck/back and extremity pain), and the Oswestry Disability Index (ODI) for functional outcome.²⁶ The accuracy and effectiveness of the digitally collected PROMs when compared to the collection of traditional paper PROMs has been previously described.¹⁹ Patients of the SPINEHealthie group were asked to utilize the app for virtual follow-ups after 2 weeks and 3 months, analogous to the previously established clinic standard for in-person follow-ups. PROMs from the CGs were collected prospectively via traditional paper questionnaires during the postoperative in-person follow-ups. The reported PROMs refer to the postoperative development of symptoms (i.e. pain and function) and do not include patient experience or satisfaction measures. Every patient, irrespective of the assigned group, was given the opportunity to have in-patient or telemedicine visits.

Figure 1.

Questionnaire for the 2-week follow-up assessing the wound condition and inflammation-associated symptoms. Furthermore, the patients are asked to report on a potential return to work. The patients are asked to upload an image of their surgical wound via the application.

Figure 2.

(a) Patient interface from the application. The app utilizes a VAS that allows patients to rate the pain in their necks/backs and extremities pre-surgery and at various timepoints post-surgery. Analogously, they can report their ODI as a functional surrogate. The bar graphs are color coded with green representing no pain/disability, and red representing severe pain/disability. The bar graphs for this patient indicate pain relief just 1 day after surgery. Additionally, the interface gives information about the performed surgery and any reported events that occurred post-surgery (e.g. hospitalization). (b) Recovery timeline of the patients with their weekly stepping data and their daily stepping goal. (c) Example of an image transferred for a surgical wound check-up. The image depicts the surgical wound site at the lumbar spine 2-week post-surgery. In the evaluation, the patient did not report any wound-related issues. The image can be appreciated through the “image” icon (top right). VAS: visual analog score; ODI: Oswestry Disability Index.

Statistical analysis

Statistical calculations and data analysis were carried out using GraphPad Prism (Version 9.5.0; GraphPad Software, Boston, MA). Continuous variables are depicted as means ± standard deviation or as the number of cases with percentages for categorical variables. Continuous variables were analyzed by using Student's t test or Mann–Whitney U test for nonnormally distributed variables. Group comparisons were performed using ANOVA or Kruskal–Wallis test for non-parametric data. Chi-square or Fisher's exact test was used for categorical parameters when appropriate. A p-value < 0.05 was determined as statistically significant.

Results

A total of 454 patients were included in the current study. The IG included 115 patients registered with the SPINEHealthie app. The control cohorts consisted of 137 patients enrolled between 2020 and 2022 (CG), and 202 patients enrolled between 2018 and 2019 (HG). Table 1 shows a comparison of patient demographics, surgical details, and postoperative clinic utilization characteristics. Comparison of the IG with the CG and HG yielded satisfying homogeneity for patients’ demographics. Interestingly, patients of the IG had a higher number of comorbidities and a higher number of operated segments (Table 1). Furthermore, patients of the IG were less frequently treated as inpatients with a significantly lower number of postoperative nights spent in the hospital. Meanwhile, patients using the smartphone application exhibited a significantly lower utilization of in-patient follow-ups, and telemedicine appointments while showing significantly higher postoperative follow-up compliance. No significant differences in safety measures (i.e. ED utilization, clinic readmission, and revision surgery) were reported between groups.

Table 1.

Patient demographics, surgical information, and postoperative clinic utilization comparing the intervention (IG) and control groups (CG, HG). Values are shown as mean (SD) or as total numbers (%). p-values show a comparison of the cohorts.

Parameter	SPINE Healthie 2021-2022	2020–2022	2018–2019	p-value
Parameter	(n = 115)	(n = 137)	(n = 202)	p-value
Age	58.4 (15.58)	58.67 (16.35)	58.08 (15.47)	0.9
Sex				0.88
Female	39 (33.91%)	48 (35.04%)	74 (36.63%)
Male	76 (66.09%)	89 (64.96%)	128 (63.37%)
BMI	30.03 (6.4)	29.87 (5.86)	29.93 (6.06)	0.99
Comorbidities	5.5 (5.28)	3.71 (3.31)	3.72 (3.25)	0.013
Anatomical location				0.86
Cervical	19 (16.52%)	17 (12.41%)	33 (16.34%)
Thoracic	4 (3.48%)	5 (3.65%)	6 (2.97%)
Lumbar	92 (80%)	115 (83.94%)	163 (80.69%)
Previous spine surgery	40 (34.78%)	43 (31.39%)	69 (34.16%)	0.82
Operated levels	1.435 (0.65)	1.197 (0.46)	1.337 (0.53)	0.002
1	74 (64.35%)	114 (83.21%)	139 (68.81%)
2	33 (28.7%)	19 (13.87%)	59 (29.21%)
3	7 (6.09%)	4 (2.92%)	3 (1.49%)
4	1 (0.87%)	0 (0%)	1 (0.5%)
Surgery time per level (min)	117.1 (71.79)	123.1 (59.43)	110.7 (35.91)	0.56
Blood loss per level (ml)	9.31 (11.15)	7.44 (5.71)	5.77 (5.88)	<0.001
Revision surgery	0 (0%)	2 (1.47%)	3 (1.49%)	0.42
Inpatient	17 (14.78%)	40 (29.2%)	76 (37.62%)	<0.001
Hospital nights	0.365 (1.4)	0.61 (2.34)	0.56 (1.09)	0.001
In-person follow-up	0.5 (0.85)	1.32 (0.8)	1.33 (0.7)	<0.001
1 visit	27 (23.48%)	58 (42.34%)	95 (47.26%)
2 visits	6 (5.22%)	52 (37.96%)	79 (39.3%)
3 visits	5 (4.35%)	5 (3.65%)	5 (2.49%)
4 visits	1 (0.87%)	1 (0.73%)	0 (0%)
Virtual follow-up
14d	96 (83.45%)
90d	86 (74.78%)
Any follow-up
14d	100 (86.96%)	104 (75.91%)	165 (81.68%)	0.08
90d	88 (76.52%)	55 (40.14%)	75 (37.13%)	<0.001
Telemedicine	8 (7.0%)	24 (17.52%)		0.022
ED utilization 100d	18 (15.38%)	17 (12.41%)	32 (15.84%)	0.86
Surgery-related	12 (66.7%)	11 (64.71%)	17 (53.13%)
Others	6 (33.3%)	6 (35.29%)	15 (46.88%)
Readmission 100d	1 (0.88%)	3 (2.19%)	6 (2.97%)	0.47
Surgery-related	0	3	2
Others	1	0	4

Bold indicates statistical significance with a p-value <0.05.

BMI: body mass index; CG: control group; HG: historical control group; ED: emergency department; SD: standard deviation.

Remote wound check at 2-week post-surgery

Table 2 summarizes the outcomes of postoperative 2-week wound check-up. Only minor wound-related issues were reported. A representative image of a postoperative wound is depicted in Figure 1.

Table 2.

Results from the patients’ remote surgical wound check 2-week post-surgery.

Parameter	SPINEhealthie 2021–2022
Parameter	(n = 82)
Remote wound check	82 (71.3%)
Fever	0 (0%)
Sweat	5 (6.1%)
Chills	3 (3.66%)
Drainage	1 (1.22%)
Redness	4 (4.9%)
Tenderness	5 (6.1%)

Bold indicates statistical significance with a p-value <0.05.

Reported functional outcomes and postoperative pain development

Table 3 entails the postoperative recovery. At baseline, patients of the CGs reported significantly more pain and a worse ODI. Patients of all groups reported significant benefits after the surgery with significantly larger reduction of the ODI in both CGs when compared to the IG at first follow-up. At the last follow-up, no significant differences were observable between the groups.

Table 3.

Reported PROMs.

Parameter	SPINEhealthie 2021-2022	2020–2022	2018–2019	p-value
Pre-surgery	(n = 102)	(n = 89)	(n = 162)
VAS neck/back	4.88 (2.74)	5.88 (2.91)	6.06 (2.73)	0.012
VAS extremity	4.78 (3.1)	6.34 (2.68)	6.06 (3.19)	0.001
ODI	18.08 (8.98)	23.01 (9.3)	22.56 (8.05)	<0.001
2 week	(n = 96)	(n = 46)	(n = 93)
VAS neck/back	−2.03 (2.79)	−1.29 (3.67)	−1.93 (2.88)	0.428
VAS extremity	−2.43 (3.6)	−2.02 (3.96)	−2.34 (3.99)	0.83
ODI	−0.97 (8.47)	−7.41 (11.83)	−4.32 (8.76)	0.004
3 month	(n = 88)	(n = 30)	(n = 57)
VAS neck/back	−2.79 (3.06)	−2.64 (2.6)	−2.34 (3.07)	0.67
VAS extremity	−2.91 (3.47)	−2.92 (3.01)	−3.35 (2.76)	0.652
ODI	−7.83 (9.86)	−9.59 (10.2)	−10.38 (9.85)	0.288

Note: Values shown at the 2-week and 3-month timepoint represent the absolute change when compared to pre-surgery.

Bold indicates statistical significance with a p-value <0.05.

PROM: patient-reported outcomes; VAS: visual analog score; ODI: Oswestry Disability Index.

Discussion

Our presented results highlight the capability of RPM to optimize postoperative follow-up compliance in the surgical field. Furthermore, they add another tool to directly monitor and study the post-surgical recovery after FESS while generating invaluable data for patient safety, satisfaction, and clinical research.

Telehealth is a rapidly evolving field, accelerated by the COVID-19 pandemic that exposed a substantial lack of alternatives to traditional in-person consultations. Despite COVID-19-associated restrictions being suspended globally, novel applications for telehealth are surging with stunning results regarding efficiency and patient satisfaction. The wide spectrum of diverse utilizations includes virtual follow-ups, RPM of chronic diseases, and supervision of mental health.^27–29 Our application presents yet another promising implementation of telehealth in the surgical field.

The statistical comparison showed satisfying results for homogeneity regarding age, sex, and BMI between the patient cohorts. In opposition to the belief that young patients have a higher affinity for telehealth, our analysis revealed no significant age-differences between app- and non-app-users. Interestingly, patients of the IG had a significantly higher number of comorbidities, contradicting the idea of a bias towards a younger, healthier population for telemedicine usage. Via RPM, a statistically significant reduction of clinic visits was reported. This is supported by data from a previous study, indicating that our patients appreciated the application's opportunity to directly contact their surgeon using the chat function.¹⁸ Through the implementation of our application, significantly more patients had a same-day discharge, most importantly while maintaining the highest levels of patient care and safety. This is corroborated by equal numbers for ED utilization, and hospital readmissions when compared to the control cohorts. With some COVID-19 restrictions still being implemented in 2021, patients were provided an alternative to an in-patient follow-up with attendance rates comparable to pre-pandemic levels for the first postoperative visit. Furthermore, the implementation of SPINEHealthie substantially increased the rate of 3-month follow-ups, even when compared to pre-pandemic timepoints, giving surgeons better feedback regarding their patients’ recovery. Through the data generated by the application, we were able to demonstrate benefits following FESS including significant pain alleviation as early as 2 weeks after the surgery, and significant functional improvements after 3 months. The provided wound check after 2 weeks revealed only very few, mild wound-related issues with no necessity for a surgical intervention, emphasizing the safety and efficacy of FESS. Most importantly, patients across all groups reported postoperative benefits without statistically different outcomes after 3 months.

The presented study adds to the considerable literature of mobile health (mHealth) applications as novel and versatile tools for postoperative care. Several reports indicate feasibility and demand for mHealth solutions as auxiliary tools for postoperative care.^30,31 Especially remote wound checks, a feature that is included in the toolkit of our presented application, have shown success as clinical guidance for the early identification of wound-related issues.^32–34 Furthermore, mHealth allows for an implementation of procedure-specific education alongside tracking and supporting the patient's recovery after elective orthopedic surgery as invaluable features.^35–37

The SPINEHealthie app encourages surgeons to follow their patients’ progress daily, allowing for proactive communication. This may aid in the detection and treatment of post-surgical complications, e.g. a relapse of pain, before exacerbation necessitates higher levels of care. We encourage providers to follow their patients’ recovery daily in the first postoperative week, to actively reach out to them in case of a delayed recovery, and schedule timely in-person visits whenever necessary. As of today, six national centers actively enroll patients in the application with monthly cross-institutional meetings in which optimizations of the enrollment processes and content of the application are discussed. This allows for dynamic changes of the application to optimize the workflow and to implement new questionnaires for research questions, as well as patient satisfaction assessments. Thus, the continuous, prospective acquisition of PROMs has the capacity to improve future research by defining benchmark outcomes through large sets of independent and unbiased data. Simultaneously, we strive to keep the application user-friendly through a simple, and intuitive interface. Furthermore, we aim to widen the focus of the application through the implementation of procedure-specific education. As the number of patients is continuously growing, it is the authors’ aim to assess and evaluate the patients’ feedback in order to maintain the high standard of care and the exceptional response rates.

The authors acknowledge that there are limitations to this study. The main limitation is the inevitable loss to follow-up, and the short follow-up period of 100 days. While a return rate of more than 85% for any follow-up through the application was satisfactory, some data got lost. Additionally, the COVID-19 pandemic may have distorted the results.

The presented study introduces a novel, safe approach for RPM following FESS, combining asynchronous virtual surgical wound follow-up with possible continuous patient monitoring through the collection of the patients’ stepping data, and direct patient-provider communication. High response rates indicate its capacity to be utilized by both young and elderly patients. Furthermore, continuous monitoring serves as immediate feedback for the provider, enabling a timely intervention in case of symptom persistence or aggravation for an improvement in short- and long-term outcomes.

Footnotes

Declaration of conflicting interests

Dr. Hofstetter is a consultant for Joimax, Globus Medical, Innovasis, and Johnson & Johnson. The application is owned by the University of Washington and is used as a research and quality improvement tool without any commercial use. The other authors declare no conflicts of interest.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Jannik Leyendecker

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

References

Boodley

. Primary care telehealth practice. J Am Acad Nurse Pract 2006; 18: 343–345.

Garfan

Alamoodi

Zaidan

, et al. Telehealth utilization during the Covid-19 pandemic: a systematic review. Comput Biol Med 2021; 138: 104878.

Haque

. Telehealth beyond COVID-19. Psychiatr Serv 2021; 72: 100–103.

Oates

Lim

GHC

Nevins

, et al. Are surgical patients satisfied with remote consultations? A comparison of remote versus conventional outpatient clinic follow-up for surgical patients: a systematic review and meta-analysis of randomized controlled trials. J Patient Exp 2021; 8: 23743735211035916.

Lambert

Harvey

Avdalis

, et al. An app with remote support achieves better adherence to home exercise programs than paper handouts in people with musculoskeletal conditions: a randomised trial. J Physiother 2017; 63: 161–167.

Gong

Baptista

Russell

, et al. My diabetes coach, a mobile app-based interactive conversational agent to support type 2 diabetes self-management: randomized effectiveness-implementation trial. J Med Internet Res 2020; 22: e20322.

Motolese

Magliozzi

Puttini

, et al. Parkinson's disease remote patient monitoring during the COVID-19 lockdown. Front Neurol 2020; 11: 567413.

Guedon-Moreau

Lacroix

Sadoul

, et al. A randomized study of remote follow-up of implantable cardioverter defibrillators: safety and efficacy report of the ECOST trial. Eur Heart J 2013; 34: 605–614.

Palozzi

Schettini

Chirico

. Enhancing the sustainable goal of access to healthcare: findings from a literature review on telemedicine employment in rural areas. Sustainability-Basel 2020; 12: 3318.

10.

Segura-Sampedro

Rivero-Belenchon

Pino-Diaz

, et al. Feasibility and safety of surgical wound remote follow-up by smart phone in appendectomy: a pilot study. Ann Med Surg (Lond) 2017; 21: 58–62.

11.

Keegan

Bose

McDermott

, et al. Implementation of a patient-centered remote wound monitoring system for management of diabetic foot ulcers. Front Endocrinol (Lausanne) 2023; 14: 1157518.

12.

Yang

Kessler

Taebi

, et al. Remote follow-up with a mobile application is equal to traditional outpatient follow-up after bariatric surgery: the BELLA pilot trial. Obes Surg 2023; 33: 1702–1709.

13.

Zhang

Huang

, et al. Application of remote follow-up via the WeChat platform for patients who underwent congenital cardiac surgery during the COVID-19 epidemic. Braz J Cardiovasc Surg 2021; 36: 530–534.

14.

Iyer

Bovonratwet

Samartzis

, et al. Appropriate telemedicine utilization in spine surgery: results from a Delphi study. Spine (Phila Pa 1976) 2022; 47: 583–590.

15.

Lightsey

HMT

Crawford

Xiong

, et al. Surgical plans generated from telemedicine visits are rarely changed after in-person evaluation in spine patients. Spine J 2021; 21: 359–365.

16.

Franco

Montenegro

Gonzalez

, et al. Telemedicine for the spine surgeon in the age of COVID-19: multicenter experiences of feasibility and implementation strategies. Global Spine J 2021; 11: 608–613.

17.

Heck

Klug

Prasse

, et al. Projections from surgical use models in Germany suggest a rising number of spinal fusions in patients 75 years and older will challenge healthcare systems worldwide. Clin Orthop Relat Res 2023; 481: 1610–1619.

18.

Prasse

Yap

Sivakanthan

, et al. Remote patient monitoring following full endoscopic spine surgery: feasibility and patient satisfaction. J Neurosurg Spine 2023; 39: 1–10.

19.

Pan

Yap

Prasse

, et al. Validation of smartphone app-based digital patient reported outcomes in full-endoscopic spine surgery. Eur Spine J 2023; 32: 2903–2909.

20.

Hasan

Hartl

Hofstetter

. The benefit zone of full-endoscopic spine surgery. J Spine Surg 2019; 5: S41–S56.

21.

Kamson

Trescot

Sampson

, et al. Full-endoscopic assisted lumbar decompressive surgery performed in an outpatient, ambulatory facility: report of 5 years of complications and risk factors. Pain Physician 2017; 20: E221–E231.

22.

Bergquist

Greil

Khalsa

SSS

, et al. Full-endoscopic technique mitigates obesity-related perioperative morbidity of minimally invasive lumbar decompression. Eur Spine J 2023; 32: 2748–2754.

23.

Mahan

Prasse

Kim

, et al. Full-endoscopic spine surgery diminishes surgical site infections - a propensity score-matched analysis. Spine J 2023; 23: 695–702.

24.

Bae

Lee

. Transforaminal full-endoscopic lumbar discectomy in obese patients. Int J Spine Surg 2016; 10: 18.

25.

Kim

Kapoor

, et al. Feasibility of full endoscopic spine surgery in patients over the age of 70 years with degenerative lumbar spine disease. Neurospine 2018; 15: 131–137.

26.

Fairbank

Pynsent

. The Oswestry disability index. Spine (Phila Pa 1976) 2000; 25: 2940–2953; discussion 2952.

27.

White

Kauffman

Acierno

. Factors contributing to veterans’ satisfaction with PTSD treatment delivered in person compared to telehealth. J Telemed Telecare 2023; 29: 426–434.

28.

Sabbagh

Shah

Jenkins

, et al. The COVID-19 pandemic and follow-up for shoulder surgery: the impact of a shift toward telemedicine on validated patient-reported outcomes. J Telemed Telecare 2023; 29: 484–491.

29.

Phillips

Lord

Davis

, et al. Comparing telehealth to traditional office visits for patient management in the COVID-19 pandemic: a cross-sectional study in a respiratory assessment clinic. J Telemed Telecare 2023; 29: 374–381.

30.

Sreedharan

Nemeth

Hirsch

, et al. Patient and provider preferences for monitoring surgical wounds using an mHealth app: a formative qualitative analysis. Surg Infect (Larchmt) 2022; 23: 168–173.

31.

Bai

Mobbs

Walsh

, et al. mHealth apps for enhanced management of spinal surgery patients: a review. Front Surg 2020; 7: 573398.

32.

Kateera

Riviello

Goodman

, et al. The effect and feasibility of mHealth-supported surgical site infection diagnosis by community health workers after cesarean section in rural Rwanda: randomized controlled trial. JMIR mHealth uHealth 2022; 10: e35155.

33.

Henarejos

O'Connor

Barrasa

, et al. Implementing a mHealth-based patient and nurse educational program to reduce wound infection in rural Philippines. Ann Glob Health 2022; 88: 76.

34.

Nkurunziza

Williams

Kateera

, et al. mHealth-community health worker telemedicine intervention for surgical site infection diagnosis: a prospective study among women delivering via caesarean section in rural Rwanda. BMJ Glob Health 2022; 7: e009365.

35.

Semple

Sharpe

Murnaghan

, et al. Using a mobile app for monitoring post-operative quality of recovery of patients at home: a feasibility study. JMIR mHealth uHealth 2015; 3: e18.

36.

Symer

Abelson

Milsom

, et al. A mobile health application to track patients after gastrointestinal surgery: results from a pilot study. J Gastrointest Surg 2017; 21: 1500–1505.

37.

van Dijk-Huisman

Weemaes

ATR

Boymans

, et al. Smartphone app with an accelerometer enhances patients’ physical activity following elective orthopedic surgery: a pilot study. Sensors (Basel) 2020; 20: 4317.