A Digital Communication Intervention to Support Older Adults and Their Care Partners Transitioning Home After Major Surgery: Protocol for a Qualitative Research Study

Background Older adults (aged ≥65 years) account for approximately 30% of inpatient procedures in the United States. After major surgery, they are at high risk of a slow return to their previous functional status, loss of independence, and complications like delirium. With the development and refinement of Enhanced Recovery After Surgery protocols, older patients often return home much earlier than historically anticipated. This put a larger burden on care partners, close family or friends who partner with the patient and guide them through recovery. Without adequate preparation, both patients and their care partners may experience poor long-term outcomes. Objective This study aimed to improve and streamline recovery for patients aged ≥65 years by exploring the communication needs of patients and their care partners. Information from this study will be used to inform an intervention developed to address these needs and define processes for its implementation across surgical clinics. Methods This qualitative research protocol has two aims. First, we will define patient and care partner needs and perspectives related to digital health innovation. To achieve this aim, we will recruit dyads of patients (aged ≥65 years) who underwent elective major surgery 30-90 days prior and their respective care partners (aged ≥18 years). Participants will complete individual interviews and surveys to obtain demographic data, characterize their perceptions of the surgical experience, identify intervention targets, and assess for the type of intervention modality that would be most useful. Next, we will explore clinician perspectives, tools, and strategies to develop a blueprint for a digital intervention. To achieve this aim, clinicians (eg, geriatricians, surgeons, and nurses) will be recruited for focus groups to identify current obstacles affecting surgical outcomes for older patients, and we will review current assessments and tools used in their clinical practice. A hybrid deductive-inductive approach will be undertaken to identify relevant themes. Insights from both clinicians and patient-care partners will guide the development of a digital intervention strategy to support older patients and their care partners after surgery. Results This study has been approved by the Massachusetts General Hospital and Harvard Institutional Review Boards. Recruitment began in December 2023 for the patient and care partner interviews. As of August 2024, over half of the interviews have been performed, deidentified, and transcribed. Clinician recruitment is ongoing, with no focus groups conducted yet. The study is expected to be completed by fall 2024. Conclusions This study will help create a scalable digital health option for older patients undergoing major surgery and their care partners. We aim to enhance our understanding of patient recovery needs; improve communication with surgical teams; and ultimately, reduce the overall burden on patients, their care partners, and health care providers through real-time assessment. International Registered Report Identifier (IRRID) DERR1-10.2196/59067

gained through this proposal are foundational to future research to improve caregiver preparedness and reduce patient anxiety in the perioperative setting.
PUBLIC HEALTH RELEVANCE: Smartphone-based education and remote self-monitoring are scalable solutions that can address unmet information needs and address poor care coordination, anxiety, and caregiver burden among older adults transitioning home after major surgery.This proposal outlines the development and refinement of the myPOSH intervention, a digital health solution to support the needs of older adults undergoing major surgery and their care-partners.The findings from this work can be scaled and spread to increase the value of care provided for a variety of health conditions and will drive future efforts to improve transitions home after major surgery.

CRITIQUE 1
Significance: 2 Investigator(s): 2 Innovation: 5 Approach: 3 Environment: 1 Overall Impact: The goal of this study is to improve care outcomes of older adults and their carepartners (family/loved one who partners in care) transitioning home after major surgery by addressing unmet communication needs.Per the application, people over the age of 65 account for over 40% of inpatient operations performed in the United States.These patients increasingly transition home from hospital earlier in their recovery and can experience negative outcomes such as delirium, functional decline, and loss of independence.When combined with sleep disturbance and medical burdens, these issues cause anxiety --compounding the strain on family and care-partners.These compounded effects impact transitions home and contribute to adverse outcomes including poor long-term survival.
The application seeks to develop a tool to act as a virtual coach to prepare and support older patients and care-partners transitioning home after major surgery.The investigator team and study environment are strong.The application presents a study aimed at addressing a significant issue, however the innovation of the project is not particularly high.There are some minor issues in the approach section.

Significance: Strengths
• Older adults account for over 40 percent of inpatient operations and over one third of outpatient procedures performed annually across the United States.This number is expected to rise as the population age.Recovering from major surgery can be stressful for older adults and their carepartners due to negative outcomes that they may experience including delirium, functional decline and loss of independence.• Being informed prior to transitioning home is an important process that can improve patient and care-partner's confidence during their hospital stay and as they transition home.• From the application, communication during surgical discharge is often inadequate.Up to 80% of patients do not recall information provided, 71% of nurses say they do not have enough time to meet patient engagement and education needs, and 50% of patients recall information that is incorrect.Weaknesses • None noted.

Investigator(s): Strengths
• The PI, collaborators, and other researchers well suited to the project.
• The investigators have complementary and integrated expertise, including experience relevant to implementation in clinical settings.• are their leadership approach, governance and organizational structure appropriate for the project?
• The investigators have demonstrated ongoing records of accomplishments that have advanced their field(s).Weaknesses • PI listed at only 10% effort.Subaward PI listed with an average of just above 10% per year, but in year 1 only listed at 0.89% which falls below a combined 20% for both PIs in year 1.

Innovation: Strengths
• The application seeks to address a gap in communication during care transitions for older adults, easing care-person burden and improving patient outcomes post-surgery.Weaknesses • The application does not show high innovation in clinical practice or approaches to care.The innovation might be considered in the patient population being served by the myPOSH tool.

Approach: Strengths
• The overall strategy, methodology, and analyses are well-reasoned and appropriate to accomplish the specific aims of the project.• The application includes a strong preliminary studies section demonstrating the case for the use of digital tools to improve care for older adults during transitions from surgery to home in for patients undergoing major surgeries for multiple conditions.• Relevant use of theory to frame the development and assessment of MyPOSH.The assessment domains are informed by the Geriatric 5 Ms: Mind, Mobility, Medications, What Matters Most, and Multicomplexity.• Strong qualitative methods section in Aim 1, including the use of theory in data collection and analysis and a description of a hybrid deductive -inductive approach to analysis.• Aims 2 and 3 are well described.
• The project includes a detailed project timeline.
• The application includes a strong dissemination plan.
• Inclusion/exclusion criteria are justified in the research plan.
• Overall, the investigators present strategies to ensure a robust and unbiased approach.

Weaknesses
• Occasionally interviews are used interchangeably with focus groups in the methods section and other places of the application; however, this is only a minor weakness.• More detail is needed on how the study will assess for differences in usual care (UC), and how those differences will be treated during analysis.• For aim 3, it is not clear in the application who will provide the training to surgeons and clinical staff.HITR BRINDLE, M • No plans to make sure surgeons and clinical staff who participate in Aim 2 acceptability study are not also used in Aim 3 for the feasibility study.

Environment: Strengths
• The scientific environment in which the work will be done is strong and will contribute to the probability of success • Letters of support are provided and show institutional support for the project.

Additional Review Criteria:
How well does the proposed research plan align with AHRQ's mission and research priorities?Acceptable Does the approach focus on rigorously testing promising interoperable interventions that improve care transitions?Acceptable/Yes Is the usability of the intervention evaluated?Acceptable/Yes Does the approach measure interoperability, relevant patient outcomes and reductions in adverse events?Acceptable Is the intervention designed with sustainability and scalability in mind?Acceptable/Yes