In the United States (US), 48 million surgeries are performed annually, and despite
medical and surgical advancements, postoperative complications are the third leading
cause of death. Perioperative risk varies between patients based on their health and
surgical procedure. Patients with intermediate or high perioperative risk experience
extended hospital stays, higher readmission rates, and frequent adverse events, including
death. The national burden for such cases costs $31.35 billion annually. As a result, the
healthcare industry is prioritizing the advancement of perioperative care to reduce
postoperative complications and improve patient outcomes. While clinical care teams
provide clinical pathways for patients, patients find the perioperative journey complex
and impersonal. Patients often don't have access to a tailored preparation plan and
personal guidance, emotional support, and motivation despite the high level of
perioperative care detail and the vulnerable status of patients. Therefore, there is an
unmet need to provide patients with comprehensive perioperative care guidance and support
with the enhanced human touch to reduce postoperative complications. Integrating clinical
pathways prepared by interdisciplinary care teams and digital health platform offers
opportunities to improve patient outcomes through improved prehabilitation and
postoperative engagement.
PRELIMINARY DATA:
The first version of Pip included three pathways (nutrition, fitness, and smoking
cessation). In a pilot study with the Center for Perioperative Center (CPC) at the
University of Pittsburgh Medical Center (UPMC), implementation of Pip resulted in the
reduction of the median length of stay (LOS) by one day. The same-day surgery
cancellations were avoided 99.5 % of the time. Pip also received an aggregate patient
satisfaction score of 4.8 out of 5 (vs. industry benchmarks of 3.8-4.3).
Pip Care partnered with the UPMC CPC to digitize and implement clinical pathways, created
by perioperative experts at UPMC, into modular digital care contents. Pip Care, CPC, and
surgical offices developed a workflow that was both operationally and clinically
seamless. The Pip DHP was designed to replace the time-consuming clinic follow-ups and
care coordination through the different phases of the perioperative process. In addition
to Health Coach follow-up, patients were invited to not only receive notifications and
report outcomes, but to explore a library of educational multimedia resources on disease
processes and why optimization of said diseases is important prior to surgery. Pip also
identified patients who were not engaging with the clinical team and offered further
remediation to help prevent poor outcomes.
Pip Digital Platform Development. The Pip technology platform is powered by two connected
components: (1) Back-end platform utilized by health coaches and (2) Front-end native
digital mobile application utilized by patients. The front-end digital mobile application
contains four key features, which are represented by separate pages within the digital
application: (1) Pip My Plan, which displays when patients are assigned personalized care
plans and tasks by their Health Coach, (2) Pip Appointments, which patients schedule and
join weekly video or voice calls with the Health Coach, (3) Pip Messages patients have
access to unlimited engagement with their Health Coach, and (4) a library of health
system-approved education content, including articles and videos, to assist with their
surgery preparation and recovery. Figure 4 summarizes the initial Pip care plans: 8 total
care plans including 3 clinical pathways (smoking cessation, weight management, and
nutrition). To make the application patient-centered and accessible to all with mobile
technology while improving communication, language for the application (e.g., questions,
answers, instructions), and other content within the application are presented at a
maximum reading level of the eighth grade. Pip is designed to function on both iOS (Apple
Inc, Cupertino, CA) and Android (Google Inc, Mountain View, CA) operating systems.
Case Matched Pilot Clinical Study. A pilot clinical study at UPMC recently demonstrated
feasibility and improved outcomes in case matched patients. The investigators have
developed and validated the feasibility of the Pip Care digital platform with Health
Coach and digital protocols. This was a Quality Improvement approved descriptive,
prospective feasibility study of patients scheduled for elective surgery, invited to
enroll in Pip from 2.5-4 weeks preoperatively through 4 weeks postoperatively at UPMC
between 11/2/2022 - 3/27/2023. Descriptive primary endpoints included patient
satisfaction, patient engagement, Pip Health Coach evaluations, and other PROs. Secondary
endpoints included length of stay (LOS), readmission rates, and emergency department
utilization rates within 30 days. Mean age was 64 years.
High Engagement and Satisfaction Scores. Our primary outcomes focused on feasibility of
deployment of the combined platform and the patient assessment of the experience. Out of
283 patients invited to Pip, 172 patients (61%) were enrolled compared to industry
benchmarks between (5% and 30%). Of those enrolled, 143 (83%) had one or more Health
Coach sessions. During the study, of the patients who had one or more Health Coach
sessions, 138 (97%) proceeded to surgery, a 4-8% improvement compared to industry
benchmarks (90-93%). After surgery, 97 (70%) patients engaged with Pip postoperatively, a
35-126% improvement compared to industry benchmarks (31-52%). Pip received a total of 95
patient satisfaction survey submissions. Patients reported an overall high satisfaction
based on the satisfaction survey (average score 4.8 out of 5, n=95). Patients strongly
agree that Health Coach helped them throughout the perioperative process based on Pip
Health Coach evaluation (average score 4.97 out of 5, n=33). The average Net Promotor
Score, a customer experience metric, was 9.7 out of 10.
LOS and Readmission. Stabilized inverse probability of treatment weighting (SIPTW) was
created to reduce selection bias and balance the patient characteristics (i.e., age,
procedures, and perioperative risk score) in Pip and non-Pip cohorts. A total of 128
patients in the Pip cohort were compared to 268 patients in the non-Pip cohort. Pip was
significantly associated with a 24% reduction in postoperative LOS (mean 2.4 vs. 3.1
days; median 1.9 vs. 3.0 days; mean ratio: 0.76; 95%CI: 0.62-0.93). Pip was associated
with a 49% lower risk in 7-day readmission (relative risk: 0.51; 95%CI: 0.11-2.31) and
17% lower risk in 30-day readmission (relative risk: 0.83; 95%CI: 0.30-2.31), though not
statistically significant. Pip and non-Pip groups had similar risk in 30-day ED returns
(relative risk: 1.06; 95%CI: 0.56-2.01).
Patient Feedback to the Health Coach. An overwhelmingly positive aspect was the patient
feedback and response to the Health Coach. The following comments support current
evidence that high level engagement is very important to patients and their outcomes
"This has been a medical experience I will not forget. [The Health Coach] was patient and
kind and encouraging. His support was vital to my experience." - Patient
"Talking to [the Health Coach] has helped me to feel a bit better and know that I am
doing all that is in control to get ready for surgery." - Patient
