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The Impact of a Text Messaging Service (Tonsil-Text-To-Me) on Pediatric Perioperative Tonsillectomy Outcomes: Cohort Study With a Historical Control Group

The Impact of a Text Messaging Service (Tonsil-Text-To-Me) on Pediatric Perioperative... Background: Tonsillectomy is a common pediatric surgical procedure performed in North America. Caregivers experience complex challenges in preparing for their child’s surgery and coordinating care at home and, consequently, could benefit from access to educational resources. A previous feasibility study of Tonsil-Text-To-Me, an automated SMS text messaging service that sends 15 time-sensitive activity reminders, links to nutrition and hydration tips, pain management strategies, and guidance on monitoring for complications, showed promising results, with high levels of caregiver satisfaction and engagement. Objective: This study aimed to pilot-test Tonsil-Text-To-Me in a real-world context to determine whether and how it might improve perioperative experiences and outcomes for caregivers and patients. Methods: Caregivers of children aged 3 to 14 years undergoing tonsillectomy were included. Data from a historical control group and an intervention group with the same study parameters (eg, eligibility criteria and surgery team) were compared. Measures included the Parenting Self-Agency Measure, General Health Questionnaire-12, Parents’ Postoperative Pain Measure, Client Satisfaction Questionnaire-8, and engagement analytics, as well as analgesic consumption, pain, child activity level, and health service use. Data were collected on the day before surgery, 3 days after surgery, and 14 days after surgery. Participants in the intervention group received texts starting 2 weeks before surgery up to the eighth day after surgery. Descriptive and inferential statistics were used. Results: In total, 51 caregivers (n=32, 63% control; n=19, 37% intervention) who were predominately women (49/51, 96%), White (48/51, 94%), and employed (42/51, 82%) participated. Intervention group caregivers had a statistically significant positive difference in Parenting Self-Agency Measure scores (P=.001). The mean postoperative pain scores were higher for the control group (mean 10.0, SD 3.1) than for the intervention group (mean 8.5, SD 3.7), both of which were still above the 6/15 threshold for clinically significant pain; however, the difference was not statistically significant (t =1.446; P=.16). Other positive but nonsignificant trends for the intervention group compared with the control group were observed for the highest level of pain (t =0.882; P=.38), emergency department visits (χ =1.3; P=.52; Cramer V=0.19), and other measures. Engagement with 39 2 https://periop.jmir.org/2022/1/e39617 JMIR Perioper Med 2022 | vol. 5 | iss. 1 | e39617 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR PERIOPERATIVE MEDICINE Wozney et al resources linked in the texts was moderate, with all but 1 being clicked on for viewing at least once by 79% (15/19) of the participants. Participants rated the intervention as highly satisfactory across all 8 dimensions of the Client Satisfaction Questionnaire (mean 29.4, SD 3.2; out of a possible value of 32.0). Conclusions: This cohort study with a historical control group found that Tonsil-Text-To-Me had a positive impact on caregivers’ perioperative care experience. The small sample size and unclear impacts of COVID-19 on the study design should be considered when interpreting the results. Controlled trials with larger sample sizes for evaluating SMS text messaging interventions aimed to support caregivers of children undergoing tonsillectomy surgery are warranted. (JMIR Perioper Med 2022;5(1):e39617) doi: 10.2196/39617 KEYWORDS tonsillectomy; otorhinolaryngology; text messaging; caregivers; surgery; perioperative; patient discharge; aftercare; short messaging service; pain management; mobile phone SMS text messages are convenient, cost-effective, asynchronous Introduction (ie, can be read by participants at times they prefer), and do not require labor-intensive face-to-face contact. SMS text messaging Tonsillectomy is one of the most common pediatric surgical interventions have been shown to improve not only medical procedures performed in North America, comprising 16% of appointment adherence but also treatment compliance for a all ambulatory surgeries performed on the pediatric population range of clinical contexts [18,19]. Leveraging clinical [1]. As the surgery is frequently performed on an outpatient recommendations from our previous Delphi study [20] and basis, most of the perioperative care is undertaken by caregivers results of the early feasibility study [21], our team developed at home [2]. Caregivers can become confused, anxious, or an automated SMS text messaging service, Tonsil-Text-To-Me overwhelmed because of a lack of knowledge about how to (TTTM), to provide just-in-time support to caregivers across prepare for their child’s surgery; how to monitor for the perioperative pathway. The results of the feasibility and complications such as postoperative pain, nausea, or reduced usability study showed that caregivers viewed the TTTM system oral intake; and how to administer appropriate pain medication as an improvement over the standard model of information [3,4]. These uncertainties can contribute to the 33% of caregivers delivery with no safety or security concerns, and although the who make unscheduled health care visits to the clinic or SMS text messages were fully automated, participants saw them emergency department (ED) after surgery [5]. In a study as reinforcing a sense of support from their health care team. evaluating >36,000 tonsillectomies with or without adenoidectomies, 7% of patients revisited the hospital, and 1% The objectives of this study were to investigate whether TTTM of patients revisited a second time. Acute pain accounted for was effective at decreasing caregivers’ level of preoperative 18% of the first revisits and 11% of the second revisits, whereas anxiety and distress, reducing postsurgery health care use, fever and vomiting or dehydration were the primary diagnoses improving pain management, and having a positive impact on in 28% and 18% of the revisits, respectively [6]. A large child outcomes (eg, hydration, level of activity, and pain-related proportion of return visits to hospitals are treat-and-release visits behavior). We expected that caregivers receiving TTTM would that may have been avoided through more adequate symptom report high satisfaction levels consistent with the feasibility control at home [7]. study results. Efforts to support families through this perioperative period Methods typically include health care providers offering verbal instructions or sharing web-based and printed resources and Study Design pamphlets. Studies have shown that caregivers typically After receiving institutional review board approval, we correctly recall only parts of the information explained to them conducted a prospective quasi-experimental pilot study to at the clinic [8], and almost half of this information is compare data from a historical usual care group (control) with remembered incorrectly [9,10]. With >90% of adults in North a group receiving TTTM (intervention) in addition to usual care. America owning internet-enabled devices, it is common for Although not involving random allocation, the historical control caregivers to use the internet to learn about their child’s health group data offer a useful comparator for early pilot studies where issues or seek alternative treatment options [11,12]. However, researchers are interested in refining parameter estimates for the reliability, quality, and readability of the evidence found in larger controlled trials [21]. The original study plan aligned these web-based resources, particularly for tonsillectomy, may with criteria for when a historical control group would have be questionable or difficult to understand [13-15]. By following less risk to validity (eg, precisely defined standard treatment, outdated or inaccurate information, caregivers risk making same participant eligibility for both groups, same methods of decisions that can negatively affect recovery, such as evaluation, and performed in the same organization) [22,23]. underdosing their child’s postoperative analgesics [16]. As this was an exploratory study with limited funding, we set Improving timely access to quality perioperative education a sample size goal based on guidelines [24] for 30 participants might help to better prepare families and reduce these potential in each group. Data collection occurred at time point 1 (T1; the negative effects [17]. https://periop.jmir.org/2022/1/e39617 JMIR Perioper Med 2022 | vol. 5 | iss. 1 | e39617 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR PERIOPERATIVE MEDICINE Wozney et al day before the surgery), time point 2 (T2; 3 days after surgery), inclusion criteria for the control and intervention groups were and time point 3 (T3; 14 days after surgery). the same. Informed consent was obtained from all participants. Setting and Population Intervention The study took place at a pediatric otolaryngology clinic within The TTTM service sent 15 texts to caregivers over a 3-week a teaching hospital in Nova Scotia, Canada (IWK Health period, including 8 before surgery, 1 on the day of surgery, and Centre). More than 300 tonsillectomies were performed at this 6 during the week after surgery (Textbox 1). The automated clinic in 2017, the year preceding this study. Surgeries were service sent messages timed to the surgery date so that often scheduled 3 to 6 months after the consultation visit, time-sensitive information (eg, what to bring to the hospital on resulting in a large time gap in which usual care instruction the day of surgery) arrived at the right time (eg, the evening booklets could be misplaced or critical information forgotten. before surgery). The message content was based on Caregivers of children aged 3 to 14 years who received a evidence-based recommendations [15] and included reminders surgical referral at the IWK Health Centre for tonsillectomy on when to start or stop activities, tips on pain management, with or without adenoidectomy were approached. Caregivers and recommendations on when to follow up with a provider. aged ≥18 years, with a cell phone, and who were able to To support active engagement with the content of the brief understand the SMS text messages in English were eligible. We messages (122-135 characters), 8 texts also included a link to excluded families from the study if the child had complex an external resource (eg, web-based tour of the day surgery unit, medical needs beyond routine tonsillectomy surgical care; a map of directions to the hospital, and a list of soft food). Of the peritonsillar abscess or suspicion of malignancy; nonelective 15 messages, 10 (67%) were set to be delivered in the morning, indications; and complex chronic conditions, craniofacial and 5 (33%) were set to be delivered in the evening. abnormalities, diabetes, or a disorder in hemostasis. The Textbox 1. Tonsil Text-to-Me SMS text messaging and data collection schedule. ENT: ear, nose, and throat. Before surgery 14 days before: Acknowledge sign-up, clinic contact number, and how to stop receiving texts 10 days before: Link to a coloring book story about day surgery for the child 7 days before: Information on stopping medication 6 days before: Link to the day surgery web-based tour video 4 days before: Link to the checklist for what to bring to the hospital 3 days before: Link to a list of soft food ideas 2 days before: Link to pain management tips, how to cancel surgery, and reminder that it is okay for the child to eat as usual that day 1 day before: Reminder on when to stop solid foods and link to parking instructions for hospital Time point 1 data collection (day before surgery) Day of surgery Link to checklist for what to bring to the hospital and tips on how to ask their child about their pain After surgery 1 day after: Link to tips on encouraging food and fluid intake and clinic contact number 2 days after: Information on physical symptoms typical of peak pain period and guidance on resumption of physical activity 3 days after: Information on typical peak pain, pain occurrences, and tips on pain management Time point 2 data collection (3 days after surgery) 5 days after: Information on when the child might return to school 7 days after: Information on resuming physical activities 8 days after: Provided information on the ENT Clinic helpline in case of continued pain and discomfort. Time point 3 data collection (14 days after surgery) use of technology, and preferences for using technology in Measures different health-related capacities. Demographics Several demographic measures were collected at baseline: age, gender, ethnicity, employment status, education level, current https://periop.jmir.org/2022/1/e39617 JMIR Perioper Med 2022 | vol. 5 | iss. 1 | e39617 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR PERIOPERATIVE MEDICINE Wozney et al satisfaction with health services. Responses are scored from 1 Caregiver Self-efficacy to 4, and thus, the possible total scores ranged from 8 to 32. Preoperative caregiver self-efficacy was measured at T1 using Higher scores indicate greater satisfaction. Engagement with 3 problem-solving items from the Parenting Self-Agency the TTTM messages was operationalized as the number of texts Measure (PSAM) [25] (ie, “I feel sure of myself as a parent,” received, number of clicks on embedded links, and number of “I can solve most problems between my child and me,” and caregivers who opted out of the service by texting “STOP” “when things are going badly between my child and me, I keep before all texts were received. Aggregate engagement analytics trying until things begin to change”). The PSAM is a self-report were compiled at T3 through the SMS text messaging platform. measure of general self-efficacy for parents of children aged 3 to 12 years. Respondents rated each of the 3 items using a Recruitment and Enrollment 5-point Likert scale ranging from 1=never to 5=always. A total The original study plan was to begin recruitment for the score between 3 and 15 was computed. intervention group immediately after data collection for the historical control group. However, institutional IT approval and Caregiver Distress the privacy process related to technical infrastructure caused Preoperative caregiver distress was measured at T1 using the significant delays, further compounded by the COVID-19 well-validated short form of the General Health pandemic’s impacts on clinical research [30]. Questionnaire-12 (GHQ-12) [26]. The GHQ-12 covers several domains associated with a person’s level of distress and is Control group cohort data was collected over a 10-month period worded in such a way as to comprise 6 positive and 6 negative starting in 2017. A 4-month period was used for active items. Response items are scored on a 4-point scale (ranging recruitment, there was a 3- to 4-month wait for surgery, and the from 0 to 3), and a global score between 0 and 36 is calculated, postsurgery follow-up period lasted for ≥2 weeks. Control group with higher scores indicating higher levels of distress. participants (ie, caregivers) were recruited through advertisements displayed at the clinic and through clinic nurses Child’s Pain who introduced the study to caregivers. In addition, caregivers At T2 and T3, caregivers were asked to report their child’s were able to self-enroll by visiting our web-based recruitment average level of pain in the past 24 hours and the highest level site and completing a 5-minute guided screening and web-based of pain in the past 24 hours on a scale of 0 (no pain) to 10 (worst consent process. Once enrollment was confirmed, the research pain). The well-established 15-item Parents’ Postoperative Pain coordinator generated a study ID in REDCap (Research Measure (PPPM) [27] was used to measure caregiver-reported Electronic Data Capture; Vanderbilt University) [31], and an pain-related behavior of their child at T2. A sum score was automated questionnaire schedule sent surveys to caregivers on computed by tallying the number of yes=1 and no=0 responses the day before the surgery (T1), during the peak pain period on for a total score of 15. As per guidelines, a score of 6/15 day 3 (T2), and 14 days after surgery (T3). REDCap also sent signified clinically significant pain [28]. 2 reminder emails for surveys that were not completed. Child’s Activity Intervention group data collection ran from May 2021 to December 2021. Recruitment flow was adjusted for the As a proxy measure of fluid intake, we asked caregivers at T2 intervention group to allow for flexibility in changing to report “yes” or “no” as to whether their child had urinated at COVID-19 pandemic precautions and hospital restrictions; for least twice in the previous 24-hour period. The child’s activity example, as in-clinic recruitment was not possible, level was measured at T2 and T3 by asking caregivers to report distance-delivered recruitment materials were developed. the level of physical activity on a 4-item scale (ie, bedridden, Potential participants were identified by screening the surgical sluggish but walking, easily tired but active, or normal) during wait-list for families whose surgery dates fell within the study the past 24 hours. timeline. A postcard with study details was mailed, and a Analgesic Therapy follow-up phone call was made. After informed consent was Caregivers reported the number of doses per type of analgesic confirmed, the research coordinator generated a study ID in (eg, acetaminophen, ibuprofen, and morphine) administered REDCap, and an automated questionnaire schedule sent surveys within the past 24-hour period at T2 and T3. to caregivers on the day before the surgery (T1), during the peak pain period on day 3 (T2), and 14 days after surgery (T3). A Health Care Use booking clerk entered the participant’s information into the At T3, caregivers were asked to report on the number of surgery booking interface, where they flagged the study postoperative ED visits; hospitalizations; family physician visits; participant to receive the texts. Using a secure file transfer calls to ear, nose, and throat (ENT) nurses or surgeons; acute protocol, we sent a daily report for those enrolled in the TTTM or unplanned clinic visits; calls to 811 (local nonurgent health intervention to the SMS text messaging service vendor care advice line); and the number of antibiotic courses prescribed SimplyCast. SimplyCast’s secure SMS text messaging service in relation to the tonsillectomy since surgery day. sent SMS text messages with periodic embedded links per the defined schedule to caregivers based on surgery data outlined Satisfaction and Intervention Engagement in the SMS text message schedule (see the Results section). Intervention group participants were asked to rate their satisfaction with the TTTM service at T3 using the Client Satisfaction Questionnaire [29], which is a unidimensional, 8-item measure used worldwide to assess client or patient https://periop.jmir.org/2022/1/e39617 JMIR Perioper Med 2022 | vol. 5 | iss. 1 | e39617 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR PERIOPERATIVE MEDICINE Wozney et al Statistical Analysis Ethics Approval We used SPSS software (IBM Corp) [32] and Jeffreys’s This study has been funded by an IWK Health Centre Amazing Statistics Program [33] for data analysis. Standard Translating Research Into Care grant and has been approved by descriptive statistics, including means, SDs, frequencies, and the IWK Health Centre Research Ethics Board (1021845). percentages, were used to summarize the continuous preoperative and postoperative measures as appropriate. Results Differences between the 2 groups were tested with Overview paired-sample t tests (2-tailed) or chi-square tests where appropriate. Where assumptions of normal distribution and An overview of recruitment and enrollment is presented in the equality of variance were violated, Mann-Whitney U tests were Figure 1 flow diagram. A total of 100 caregivers were used. Effect sizes were extracted (ie, Cohen d, Cramer V, odds approached during control group data collection and 61 during ratios [ORs], and rank-biserial correlation) where applicable. intervention group data collection. Approximately 82% (82/100) All statistical tests were performed using 2-tailed tests at the consented to participate in the historical control group, and 59% 0.05 level of significance. Analysts were not blinded to group (36/61) consented to participate in the intervention group. allocation. Approximately 28% (10/36) of intervention group participants withdrew before T1 data collection for reasons that included changed or canceled surgery dates and changes in legal guardianship status. Figure 1. Flowchart of study participants in the historical control and intervention groups. 2 2 ethnicity (χ =1.9; P=.39), employment status (χ =3.0; P=.28), 2 2 Demographics or number of children in the household (χ =1.0; P=.60). An overview of baseline demographics is presented in Table 1. All but 1 participant were women caregivers. Most were White, Preferences for using SMS text messages for different health employed with a university degree, and living in a household care service use contexts are reported in Table 2. Respondents with ≥2 children. There were no significant group differences in both groups reported high use of SMS text messaging in daily at baseline regarding the age of the caregiver (χ =3.3; P=.35), life, with 98% (50/51) reporting that they send SMS text 2 2 messages at least once a day. When asked to rank the top 3 gender (χ =3.5; P=.17), education level (χ =5.8; P=.12), 2 3 reasons for using their mobile phones, respondents in both control and intervention groups indicated that receiving and https://periop.jmir.org/2022/1/e39617 JMIR Perioper Med 2022 | vol. 5 | iss. 1 | e39617 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR PERIOPERATIVE MEDICINE Wozney et al sending SMS text messages was the number 1 reason (32/32, (49/51, 96%) and consult with health care professionals (36/51, 100%, and 19/19, 100%, respectively), followed by receiving 71%) were among the top ways that respondents wanted to use and making phone calls (22/32, 69%, and 17/19, 90%, their mobile phones. respectively). Being able to receive appointment reminders Table 1. Baseline demographic characteristics of caregivers (N=51). Characteristics Control group (n=32), n (%) Intervention group (n=19), n (%) Age (years) 18 to 25 0 (0) 1 (5) 26 to 35 11 (34) 9 (47) 36 to 45 20 (63) 9 (47) ≥46 1 (3) 0 (0) Gender Woman 32 (100) 17 (90) Man 0 (0) 1 (5) Other or prefer not to say 0 (0) 1 (5) Ethnicity White 31 (97) 17 (90) Middle Eastern 1 (3) 1 (5) African Canadian, African American, or Caribbean 0 (0) 1 (5) Highest educational level High school or less 3 (9) 4 (21) College diploma 10 (31) 2 (10) University degree 18 (56) 10 (53) Other 1 (3) 3 (16) Employment Unemployed 3 (9) 5 (26) Employed 28 (87) 14 (74) Prefer not to say 1 (3) 0 (0) Number of children in the household 1 7 (22) 5 (26) 2 18 (56) 8 (42) ≥3 7 (22) 6 (32) https://periop.jmir.org/2022/1/e39617 JMIR Perioper Med 2022 | vol. 5 | iss. 1 | e39617 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR PERIOPERATIVE MEDICINE Wozney et al Table 2. Baseline technology use and preferences of caregivers (N=51). Technology uses and preferences Control group (n=32), n (%) Intervention group (n=19), n (%) Number of texts sent per week At least once a day 32 (100) 18 (95) More than once a week but less than once a day 0 (0) 1 (5) Less than once per week 0 (0) 0 (0) Would you like to use your mobile phone for the following Receive appointment and vaccination reminders Yes 30 (94) 19 (100) No 2 (6) 0 (0) Consult with physicians and nurses Yes 23 (72) 13 (68) No 9 (28) 6 (32) Get help sticking with a medication regimen Yes 12 (37) 4 (21) No 20 (63) 15 (79) Receive test results Yes 23 (72) 13 (68) No 9 (28) 6 (32) Talk with a professional about health concerns Yes 16 (50) 9 (47) No 16 (50) 10 (53) Access emergency services Yes 20 (63) 7 (37) No 12 (37) 12 (63) –0.24). Overall, on the GHQ-12, both control (mean 2.53, SD Caregiver Self-efficacy and Distress 0.57) and intervention group (mean 2.42, SD 0.61) participants Out of a possible total score of 15, at T1, the mean scores on reported challenges in feeling “capable of making decisions” the 3 PSAM items were 12.5 (SD 1.1) for the control group and and in feeling that they were “playing a useful part in things” 13.7 (SD 1.1) for the intervention group. A Mann-Whitney U (Table 3). The effect size for mean differences on the GHQ-12 test indicated that the mean scores on parenting self-efficacy in this analysis was small (Cohen d=0.32, 95% CI –0.26 to were significantly higher for the intervention group, with a small 0.88), and the independent-sample t test indicated a effect size (U=136.50; P=.002; r =0.53, 95% CI –0.73 to rb nonsignificant difference (t =1.090; P=.28). https://periop.jmir.org/2022/1/e39617 JMIR Perioper Med 2022 | vol. 5 | iss. 1 | e39617 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR PERIOPERATIVE MEDICINE Wozney et al Table 3. Caregivers’ GHQ-12 scores at time point 1 (N=51). a a GHQ-12 items (have you done the following) Control group (n=32), mean (SD) Intervention group (n=19), mean (SD) Been able to concentrate on what you were doing 2.09 (0.86) 2.16 (0.83) Lost much sleep over worry 1.16 (1.02) 1.84 (0.96) Felt that you are playing a useful part in things 2.31 (0.69) 2.32 (0.67) Felt capable of making decisions about things 2.53 (0.57) 2.42 (0.61) Felt constantly under strain 1.37 (0.91) 1.32 (1.20) Felt you could not overcome your difficulties 0.72 (0.77) 1.05 (1.08) Been able to enjoy your normal day-to-day activities 2.16 (0.57) 2.16 (0.83) Been able to face your problems 2.25 (0.62) 1.06 (0.80) Been feeling unhappy or depressed 1.06 (0.80) 1.21 (1.08) Been losing confidence in yourself 0.72 (0.73) 0.84 (1.02) Been thinking of yourself as worthless 0.31 (0.54) 0.84 (1.02) Been feeling reasonably happy 2.09 (0.69) 1.74 (0.93) Overall score 18.78 (3.02) 20.37 (3.34) GHQ-12: General Health Questionnaire-12. 92%). In the intervention group, the most common behavior Child’s Pain change was wanting to be close to their caregiver more than At T2, on a scale of 0 (no pain) to 10 (worst pain), the control usual (14/17, 82%) and eating less (14/17, 82%; Table 4). The group reported a slightly lower average level of pain (mean least frequently reported pain-related change in behavior for 4.38, SD 1.76) than the intervention group (mean 4.65, SD the control group was acting more worried than usual (8/24, 2.26). The mean score for the highest level of pain at T2 was 33%), and for the intervention group, it was the child taking 7.37 (SD 1.88) for the control group and slightly lower at 6.70 medication when they normally refuse (3/17, 18%). The mean (SD 2.97) for the intervention group. Independent-sample t tests PPPM score was higher for the control group (mean 10.0, SD did not indicate a significant difference between the groups, 3.1) than for the intervention group (mean 8.5, SD 3.7), both and only small effects were observed on the average level of of which were still above the 6/15 threshold for clinically pain (t =–0.433; P=.67; Cohen d=0.14, 95% CI –0.76 to 0.49) significant pain. An independent-sample t test did not report a and the highest level of pain (t =0.882; P=.38; Cohen d=0.28, significant difference in PPPM scores (t =1.446; P=.16), 95% CI –0.34 to 0.90). although a small effect size was found (Cohen d=0.46, 95% CI –0.02 to 1.08). The most frequently reported pain-related change in behavior at T2 in the control group was eating less than usual (22/24, https://periop.jmir.org/2022/1/e39617 JMIR Perioper Med 2022 | vol. 5 | iss. 1 | e39617 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR PERIOPERATIVE MEDICINE Wozney et al Table 4. Frequency of caregivers’ endorsement of PPPM items at time point 2 (N=41). PPPM items (when your child was recovering from surgery, did she or he do the Control group (n=24), n (%) Intervention group (n=17), n (%) following?) Whine or complain more than usual 17 (71) 10 (59) Cry more easily than usual 15 (63) 9 (53) Play less than usual 21 (88) 12 (71) Not do the things she or he normally does 15 (63) 12 (71) Act more worried than usual 8 (33) 6 (35) Act more quiet than usual 17 (71) 11 (65) Have less energy than usual 18 (75) 11 (65) Refuse to eat 12 (50) 10 (59) Eat less than usual 22 (92) 14 (82) Hold the sore part of his or her body 13 (54) 7 (41) Try not to bump the sore part of his or her body 15 (63) 6 (35) Groan or moan more than usual 16 (67) 8 (47) Look more flushed than usual 16 (67) 11 (65) Want to be close to you more than usual 21 (88) 14 (82) Take medication when she or he normally refuses 14 (58) 3 (18) PPPM: Parents’ Postoperative Pain Measure. T3 (14 days after surgery), only one of the caregivers reported Analgesic Therapy offering analgesics within the previous 24-hour period. Analgesic therapy was consistent across the groups. At T2, Chi-square group difference tests on use or nonuse of medication caregivers in both the control and intervention groups reported did not indicate a significant association, although small effects administering on average 3.75 (SD 0.61) and 3.59 (SD 1.73) 2 were demonstrated at both T2 (χ =0.9; P=.32; OR 0.33, 95% doses of acetaminophen, respectively, and 3.46 (SD 1.06) and CI 0.01-8.79) and T3 (χ =0.8; P=.36; OR 0.39, 95% CI 3.59 (SD 1.73) doses of ibuprofen, respectively, within the 0.01-10.37). previous 24 hours (range 0-8; Table 5). Across both groups at a b Table 5. Average analgesic doses administered in the previous 24 hours (T2 and T3 ; N=76). Dosages Control group Intervention group T2 (3 days after surgery) Acetaminophen, mean (SD; range) 3.75 (0.61; 2-4) 3.59 (1.73; 0-8) Ibuprofen, mean (SD; range) 3.46 (1.06; 0-4) 3.59 (1.73; 0-8) Morphine, mean (SD; range) 1.12 (1.15; 0-4) 0.59 (1.06; 0-4) T3 (14 days after surgery) Acetaminophen, mean (SD; range) 0.05 (0.21; 0-1) 0 (0; 0) Ibuprofen, mean (SD; range) 0.05 (0.21; 0-1) 0 (0; 0) Morphine, mean (SD; range) 0 (0; 0) 0 (0; 0) T2: time point 2. T3: time point 3. Control group: n=24; intervention group: n=17. Control group: n=22; intervention group: n=13. the children were at their normal level of activity in the past 24 Child’s Activity hours compared with 24% (4/17) in the intervention group. A In terms of fluid intake, all caregivers reported that their children caregiver in each group reported that their child was bedridden. had urinated at least twice in the past 24 hours. In addition, at Most caregivers in the control group reported that their child T2, caregivers in the control group reported that 13% (3/24) of was “easily tired but active” (16/24, 67%), whereas caregivers https://periop.jmir.org/2022/1/e39617 JMIR Perioper Med 2022 | vol. 5 | iss. 1 | e39617 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR PERIOPERATIVE MEDICINE Wozney et al in the intervention group reported that their child was “sluggish for >24 hours (χ =0.6; P=.45; Cramer V=0.13), ED visits but walking” (6/17, 35%) or “easily tired but active” (6/17, (χ =1.3; P=.52; Cramer V=0.19), visits to outpatient walk-in 35%). By T3, most (21/23, 91% control group; 13/13, 100% clinics (χ =1.2; P=.27; Cramer V=0.18), calls to the ENT clinic intervention group) of the caregivers reported that their children 1 had returned to normal activity levels. We created a dichotomous (χ =2.1; P=.35; Cramer V=0.24), or calls to 811 or family variable of normal activity versus reduced activity (ie, easily physician (χ =1.85; P=.17; Cramer V=0.23). tired, sluggish, or bedridden). The chi-square group difference for normal activity and reduced activity showed no significant Satisfaction and Engagement differences at T2 (χ =0.8; P=.35; OR 2.15, 95% CI 0.41-11.20). The results of the Client Satisfaction Questionnaire-8 showed high levels of satisfaction with TTTM across all 8 dimensions Health Service Use (Table 6). The mean total satisfaction score, out of a possible Hospital admissions were reported by 13% (3/23) of the 32, was 29.4 (SD 3.6, range 24.0-32.0). respondents in the control group and 8% (1/13) of those in the All caregivers engaged with the full TTTM intervention, and intervention group, with visits to the ED reported by 17% (4/23) none texted “STOP” to cease the messages. Engagement with and 8% (1/13), respectively. The number of calls to the ENT the linked resources within the texts was moderate, with 90% clinic, family physicians, or 811 (local health information (9/10) of the embedded links within the texts being viewed at phoneline) was higher in the control group (8/23, 35%) than in least once by 79% (15/19) of the participants. All participants the intervention group (4/13, 31%). Antibiotic prescriptions (19/19, 100%) viewed the web-based tour video and both were reported by 9% (2/23) of the caregivers in the control checklists of what to bring to the hospital. Approximately 79% group and 15% (2/13) of the caregivers in the intervention group. (15/19) viewed the presurgery tips on nonpharmacological However, chi-square and Cramer V tests showed no significant postsurgery pain management; however, only 58% (11/19) differences and only small associations for hospital admissions 2 viewed the postsurgery link regarding how to ask their child lasting for <24 hours (χ =0.01; P=.92; Cramer V=0.02), lasting about their level of pain (Table 7). Table 6. Results of the CSQ-8 (N=13). CSQ-8 dimensions Values, mean (SD) Quality of service 3.62 (0.51) Kind of service you wanted 3.69 (0.48) The extent to which the program met your needs 3.69 (0.48) Recommend the program to a friend 3.69 (0.48) Satisfaction with the amount of help received 3.77 (0.44) Services helped you to deal with problems 3.54 (0.52) Overall satisfaction with the service 3.69 (0.48) Return to the program for help 3.69 (0.48) CSQ-8: Client Satisfaction Questionnaire-8. Highest possible score=4. Table 7. Participants’ engagement with the linked resources within the SMS text messages. Embedded links topic Intervention group (n=19), n (%) Coloring book 11 (58) Web-based tour 19 (100) Checklist 19 (100) Soft food list 15 (79) Postsurgery pain 15 (79) Parking 13 (69) Eating and drinking 9 (48) Asking about pain 11 (58) https://periop.jmir.org/2022/1/e39617 JMIR Perioper Med 2022 | vol. 5 | iss. 1 | e39617 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR PERIOPERATIVE MEDICINE Wozney et al with health service–related SMS text messages, an even less Discussion intensive and complex technology than mobile apps. Caregivers actively engaged in learning about the skills and strategies Principal Findings offered through the texts. Given the large and potentially In this study, a brief 15-message TTTM intervention that was permanent migration to web-based supports and services during delivered adjunct to usual care during the COVID-19 pandemic the COVID-19 pandemic, the need to support caregivers in revealed high uptake and engagement. A positive, significant using relevant technologies that can tailor what information difference in preoperative caregiver self-efficacy was found, they receive, when, and in what way may be even more pressing. suggesting that SMS text messages may have helped caregivers The early stage of research in this field presents numerous lines to develop positive expectations regarding their ability to handle of future inquiry. Both groups in our study reported clinically postoperative activities with their child. Furthermore, caregivers significant levels of pain 3 days after surgery, and the embedded receiving the texts reported improvements over usual care links to pain management strategies were engaged with the least. related to the highest level of child’s pain intensity, child’s A better understanding of how SMS text messaging pain-related behavior, health care use, and child’s return to interventions might be optimized to improve adherence to best normal activity levels, although statistical significance was not practice pain management strategies and promote the use of noted. These results are not unlike other SMS text messaging nonpharmacological pain management strategies could help to intervention studies that target the perioperative experiences of ensure that the most minimally invasive technology is used to adults [34,35] and suggest that pediatric perioperative pathways produce optimal outcomes. Drawing from persuasive system are a rich area for further research. In the following sections, design frameworks [44] and behavior change theories [45], there we detail the strengths and limitations of this study, as well as may be both content and functionality improvements that can future lines of inquiry. be made to the intervention that might support improved pain The study has several strengths. First, research on the use of management in particular. Second, monitoring and reporting technology to support perioperative education for pediatric on participant recruitment, satisfaction, feasibility, and outcome tonsillectomy is nascent, despite being one of the most efficacy in demographically diverse populations will help to frequently performed pediatric surgeries. A systematic review determine the utility and cultural relevance of these [36] of phone- and internet-based pain and recovery support interventions. Our study, based in an east coast Canadian programs for pediatric tonsillectomy found only 4 relevant organization context, adds to the knowledge base but used a randomized controlled trials. Only 1 clinical trial of an SMS demographically homogenous sample. As concepts of pain, text messaging intervention for perioperative pediatric pain management [46], and caregiving [47] are deeply tonsillectomy has been published; it was conducted outside of influenced by culture and ethnicity, it is critical, especially North America [19] and had a high risk of bias [36]. during this period of early evidence building, to expand our Contributing our preliminary cohort study findings to this understanding of whether and how interventions such as TTTM emerging academic literature can inform future trial designs for should be tailored to be more culturally affirming [48]. research teams facing similar pragmatic limitations and help to Limitations refine outcomes of interest to maximize translational research potential [37]. Second, TTTM is designed to support caregivers Several study limitations should be noted. Our ability to conduct across the full perioperative period (ie, before, day of, and for more robust analyses was limited because of sampling. 2 weeks after their child’s surgery) and was assessed using Unforeseen delays occurred because of IT infrastructure multiple measures (eg, analgesic use, caregiver self-efficacy, approvals, and the COVID-19 pandemic limited the time frame child pain levels, and health service use). Among for completing research activities. The use of historical control technology-based pediatric-related intervention studies, most group data is prone to type I errors [21]; however, baseline have measured only child and system outcomes [38] or measured demographic equivalence, no significant changes to the surgery them at only 1 postoperative time point [39,40]. Our itself, and the postoperative recommendations for parents comprehensive findings suggest that patient-level (eg, child between group conditions likely limited potential impacts. Given pain) and system-level (eg, hospital visits) outcomes should be differences observed in recruitment and follow-up rates, some complemented with an assessment of the quality-of-care consideration of the external validity of the research is measures that help us to understand caregiver experiences (eg, warranted; for example, changes to clinic and research staff caregiver distress) and behaviors across the perioperative period. may have introduced selection bias, and different recruitment Given the volume of tonsillectomy surgeries performed each and consent pathways (ie, the historical control group had a year in North America [1], even modest individual-level web-based consent option, whereas, for the intervention group, improvements in pain management or improved perceptions of it was phone based) may confound the findings in ways we did self-efficacy for managing care at home derived from brief SMS not measure. It would be important for future research to be text messages could have significant real-world benefits. Finally, powered sufficiently to detect group differences and trial TTTM as caregivers’ role in pediatric perioperative care is vital [41], as a stand-alone intervention, not just as an adjunct to usual and they increasingly expect and prefer to receive information care. Data derived from this pilot study can be used to calculate about surgical procedures through their smartphones [42], our the sample size for a future randomized controlled trial. The study offers some of the earliest findings into how SMS text extent to which pandemic-related environmental factors for messaging as a modality might meet that need. Participants in families (eg, caregivers spending more time at home with their our study, as well as other studies [43], report high satisfaction children and children’s normal activities affected by public https://periop.jmir.org/2022/1/e39617 JMIR Perioper Med 2022 | vol. 5 | iss. 1 | e39617 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR PERIOPERATIVE MEDICINE Wozney et al health restrictions) and health care organizations (eg, hospital The results should be viewed with caution, given the unclear visit requirements and physical distancing guidelines) affected impacts of the COVID-19 pandemic on preoperative levels of the study results is unclear. caregiver distress, health service use, and typical caregiver-child interactions. Continued research into SMS text messaging Conclusions interventions targeting pediatric perioperative experience is Preliminary results from this prospective cohort intervention warranted, especially given caregivers’ high satisfaction with study with a historical control group revealed that TTTM had TTTM and high rates of texting in their everyday lives. a positive impact on caregivers’ perioperative care experience. Acknowledgments The study was supported by an IWK Health Foundation, Translating Research Into Care grant. The authors would like to thank the IWK information management-IT team, the Dalhousie Research in Medicine trainees, the Centre for Research in Family Health team, Evan Maynard from SimplyCast, Benjamin Rose-Davis, Barbara Marshall, and Nicole Hartling. Conflicts of Interest None declared. References 1. Boss EF, Marsteller JA, Simon AE. Outpatient tonsillectomy in children: demographic and geographic variation in the United States, 2006. 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JMIR Mhealth Uhealth 2016 Jan 22;4(1):e10 [FREE Full text] [doi: 10.2196/mhealth.4994] [Medline: 26800712] Abbreviations ED: emergency department ENT: ear, nose, and throat GHQ-12: General Health Questionnaire-12 OR: odds ratio PPPM: Parents’ Postoperative Pain Measure PSAM: Parenting Self-Agency Measure REDCap: Research Electronic Data Capture T1: time point 1 T2: time point 2 T3: time point 3 TTTM: Tonsil-Text-To-Me Edited by R Lee; submitted 16.05.22; peer-reviewed by S Azadnajafabad, S Badawy, B Nievas Soriano, M Abbasi-Kangevari; comments to author 28.06.22; revised version received 03.08.22; accepted 04.08.22; published 20.09.22 Please cite as: Wozney L, Vakili N, Chorney J, Clark A, Hong P The Impact of a Text Messaging Service (Tonsil-Text-To-Me) on Pediatric Perioperative Tonsillectomy Outcomes: Cohort Study With a Historical Control Group JMIR Perioper Med 2022;5(1):e39617 URL: https://periop.jmir.org/2022/1/e39617 doi: 10.2196/39617 PMID: ©Lori Wozney, Negar Vakili, Jill Chorney, Alexander Clark, Paul Hong. 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The Impact of a Text Messaging Service (Tonsil-Text-To-Me) on Pediatric Perioperative Tonsillectomy Outcomes: Cohort Study With a Historical Control Group

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JMIR Publications
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2561-9128
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10.2196/39617
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Abstract

Background: Tonsillectomy is a common pediatric surgical procedure performed in North America. Caregivers experience complex challenges in preparing for their child’s surgery and coordinating care at home and, consequently, could benefit from access to educational resources. A previous feasibility study of Tonsil-Text-To-Me, an automated SMS text messaging service that sends 15 time-sensitive activity reminders, links to nutrition and hydration tips, pain management strategies, and guidance on monitoring for complications, showed promising results, with high levels of caregiver satisfaction and engagement. Objective: This study aimed to pilot-test Tonsil-Text-To-Me in a real-world context to determine whether and how it might improve perioperative experiences and outcomes for caregivers and patients. Methods: Caregivers of children aged 3 to 14 years undergoing tonsillectomy were included. Data from a historical control group and an intervention group with the same study parameters (eg, eligibility criteria and surgery team) were compared. Measures included the Parenting Self-Agency Measure, General Health Questionnaire-12, Parents’ Postoperative Pain Measure, Client Satisfaction Questionnaire-8, and engagement analytics, as well as analgesic consumption, pain, child activity level, and health service use. Data were collected on the day before surgery, 3 days after surgery, and 14 days after surgery. Participants in the intervention group received texts starting 2 weeks before surgery up to the eighth day after surgery. Descriptive and inferential statistics were used. Results: In total, 51 caregivers (n=32, 63% control; n=19, 37% intervention) who were predominately women (49/51, 96%), White (48/51, 94%), and employed (42/51, 82%) participated. Intervention group caregivers had a statistically significant positive difference in Parenting Self-Agency Measure scores (P=.001). The mean postoperative pain scores were higher for the control group (mean 10.0, SD 3.1) than for the intervention group (mean 8.5, SD 3.7), both of which were still above the 6/15 threshold for clinically significant pain; however, the difference was not statistically significant (t =1.446; P=.16). Other positive but nonsignificant trends for the intervention group compared with the control group were observed for the highest level of pain (t =0.882; P=.38), emergency department visits (χ =1.3; P=.52; Cramer V=0.19), and other measures. Engagement with 39 2 https://periop.jmir.org/2022/1/e39617 JMIR Perioper Med 2022 | vol. 5 | iss. 1 | e39617 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR PERIOPERATIVE MEDICINE Wozney et al resources linked in the texts was moderate, with all but 1 being clicked on for viewing at least once by 79% (15/19) of the participants. Participants rated the intervention as highly satisfactory across all 8 dimensions of the Client Satisfaction Questionnaire (mean 29.4, SD 3.2; out of a possible value of 32.0). Conclusions: This cohort study with a historical control group found that Tonsil-Text-To-Me had a positive impact on caregivers’ perioperative care experience. The small sample size and unclear impacts of COVID-19 on the study design should be considered when interpreting the results. Controlled trials with larger sample sizes for evaluating SMS text messaging interventions aimed to support caregivers of children undergoing tonsillectomy surgery are warranted. (JMIR Perioper Med 2022;5(1):e39617) doi: 10.2196/39617 KEYWORDS tonsillectomy; otorhinolaryngology; text messaging; caregivers; surgery; perioperative; patient discharge; aftercare; short messaging service; pain management; mobile phone SMS text messages are convenient, cost-effective, asynchronous Introduction (ie, can be read by participants at times they prefer), and do not require labor-intensive face-to-face contact. SMS text messaging Tonsillectomy is one of the most common pediatric surgical interventions have been shown to improve not only medical procedures performed in North America, comprising 16% of appointment adherence but also treatment compliance for a all ambulatory surgeries performed on the pediatric population range of clinical contexts [18,19]. Leveraging clinical [1]. As the surgery is frequently performed on an outpatient recommendations from our previous Delphi study [20] and basis, most of the perioperative care is undertaken by caregivers results of the early feasibility study [21], our team developed at home [2]. Caregivers can become confused, anxious, or an automated SMS text messaging service, Tonsil-Text-To-Me overwhelmed because of a lack of knowledge about how to (TTTM), to provide just-in-time support to caregivers across prepare for their child’s surgery; how to monitor for the perioperative pathway. The results of the feasibility and complications such as postoperative pain, nausea, or reduced usability study showed that caregivers viewed the TTTM system oral intake; and how to administer appropriate pain medication as an improvement over the standard model of information [3,4]. These uncertainties can contribute to the 33% of caregivers delivery with no safety or security concerns, and although the who make unscheduled health care visits to the clinic or SMS text messages were fully automated, participants saw them emergency department (ED) after surgery [5]. In a study as reinforcing a sense of support from their health care team. evaluating >36,000 tonsillectomies with or without adenoidectomies, 7% of patients revisited the hospital, and 1% The objectives of this study were to investigate whether TTTM of patients revisited a second time. Acute pain accounted for was effective at decreasing caregivers’ level of preoperative 18% of the first revisits and 11% of the second revisits, whereas anxiety and distress, reducing postsurgery health care use, fever and vomiting or dehydration were the primary diagnoses improving pain management, and having a positive impact on in 28% and 18% of the revisits, respectively [6]. A large child outcomes (eg, hydration, level of activity, and pain-related proportion of return visits to hospitals are treat-and-release visits behavior). We expected that caregivers receiving TTTM would that may have been avoided through more adequate symptom report high satisfaction levels consistent with the feasibility control at home [7]. study results. Efforts to support families through this perioperative period Methods typically include health care providers offering verbal instructions or sharing web-based and printed resources and Study Design pamphlets. Studies have shown that caregivers typically After receiving institutional review board approval, we correctly recall only parts of the information explained to them conducted a prospective quasi-experimental pilot study to at the clinic [8], and almost half of this information is compare data from a historical usual care group (control) with remembered incorrectly [9,10]. With >90% of adults in North a group receiving TTTM (intervention) in addition to usual care. America owning internet-enabled devices, it is common for Although not involving random allocation, the historical control caregivers to use the internet to learn about their child’s health group data offer a useful comparator for early pilot studies where issues or seek alternative treatment options [11,12]. However, researchers are interested in refining parameter estimates for the reliability, quality, and readability of the evidence found in larger controlled trials [21]. The original study plan aligned these web-based resources, particularly for tonsillectomy, may with criteria for when a historical control group would have be questionable or difficult to understand [13-15]. By following less risk to validity (eg, precisely defined standard treatment, outdated or inaccurate information, caregivers risk making same participant eligibility for both groups, same methods of decisions that can negatively affect recovery, such as evaluation, and performed in the same organization) [22,23]. underdosing their child’s postoperative analgesics [16]. As this was an exploratory study with limited funding, we set Improving timely access to quality perioperative education a sample size goal based on guidelines [24] for 30 participants might help to better prepare families and reduce these potential in each group. Data collection occurred at time point 1 (T1; the negative effects [17]. https://periop.jmir.org/2022/1/e39617 JMIR Perioper Med 2022 | vol. 5 | iss. 1 | e39617 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR PERIOPERATIVE MEDICINE Wozney et al day before the surgery), time point 2 (T2; 3 days after surgery), inclusion criteria for the control and intervention groups were and time point 3 (T3; 14 days after surgery). the same. Informed consent was obtained from all participants. Setting and Population Intervention The study took place at a pediatric otolaryngology clinic within The TTTM service sent 15 texts to caregivers over a 3-week a teaching hospital in Nova Scotia, Canada (IWK Health period, including 8 before surgery, 1 on the day of surgery, and Centre). More than 300 tonsillectomies were performed at this 6 during the week after surgery (Textbox 1). The automated clinic in 2017, the year preceding this study. Surgeries were service sent messages timed to the surgery date so that often scheduled 3 to 6 months after the consultation visit, time-sensitive information (eg, what to bring to the hospital on resulting in a large time gap in which usual care instruction the day of surgery) arrived at the right time (eg, the evening booklets could be misplaced or critical information forgotten. before surgery). The message content was based on Caregivers of children aged 3 to 14 years who received a evidence-based recommendations [15] and included reminders surgical referral at the IWK Health Centre for tonsillectomy on when to start or stop activities, tips on pain management, with or without adenoidectomy were approached. Caregivers and recommendations on when to follow up with a provider. aged ≥18 years, with a cell phone, and who were able to To support active engagement with the content of the brief understand the SMS text messages in English were eligible. We messages (122-135 characters), 8 texts also included a link to excluded families from the study if the child had complex an external resource (eg, web-based tour of the day surgery unit, medical needs beyond routine tonsillectomy surgical care; a map of directions to the hospital, and a list of soft food). Of the peritonsillar abscess or suspicion of malignancy; nonelective 15 messages, 10 (67%) were set to be delivered in the morning, indications; and complex chronic conditions, craniofacial and 5 (33%) were set to be delivered in the evening. abnormalities, diabetes, or a disorder in hemostasis. The Textbox 1. Tonsil Text-to-Me SMS text messaging and data collection schedule. ENT: ear, nose, and throat. Before surgery 14 days before: Acknowledge sign-up, clinic contact number, and how to stop receiving texts 10 days before: Link to a coloring book story about day surgery for the child 7 days before: Information on stopping medication 6 days before: Link to the day surgery web-based tour video 4 days before: Link to the checklist for what to bring to the hospital 3 days before: Link to a list of soft food ideas 2 days before: Link to pain management tips, how to cancel surgery, and reminder that it is okay for the child to eat as usual that day 1 day before: Reminder on when to stop solid foods and link to parking instructions for hospital Time point 1 data collection (day before surgery) Day of surgery Link to checklist for what to bring to the hospital and tips on how to ask their child about their pain After surgery 1 day after: Link to tips on encouraging food and fluid intake and clinic contact number 2 days after: Information on physical symptoms typical of peak pain period and guidance on resumption of physical activity 3 days after: Information on typical peak pain, pain occurrences, and tips on pain management Time point 2 data collection (3 days after surgery) 5 days after: Information on when the child might return to school 7 days after: Information on resuming physical activities 8 days after: Provided information on the ENT Clinic helpline in case of continued pain and discomfort. Time point 3 data collection (14 days after surgery) use of technology, and preferences for using technology in Measures different health-related capacities. Demographics Several demographic measures were collected at baseline: age, gender, ethnicity, employment status, education level, current https://periop.jmir.org/2022/1/e39617 JMIR Perioper Med 2022 | vol. 5 | iss. 1 | e39617 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR PERIOPERATIVE MEDICINE Wozney et al satisfaction with health services. Responses are scored from 1 Caregiver Self-efficacy to 4, and thus, the possible total scores ranged from 8 to 32. Preoperative caregiver self-efficacy was measured at T1 using Higher scores indicate greater satisfaction. Engagement with 3 problem-solving items from the Parenting Self-Agency the TTTM messages was operationalized as the number of texts Measure (PSAM) [25] (ie, “I feel sure of myself as a parent,” received, number of clicks on embedded links, and number of “I can solve most problems between my child and me,” and caregivers who opted out of the service by texting “STOP” “when things are going badly between my child and me, I keep before all texts were received. Aggregate engagement analytics trying until things begin to change”). The PSAM is a self-report were compiled at T3 through the SMS text messaging platform. measure of general self-efficacy for parents of children aged 3 to 12 years. Respondents rated each of the 3 items using a Recruitment and Enrollment 5-point Likert scale ranging from 1=never to 5=always. A total The original study plan was to begin recruitment for the score between 3 and 15 was computed. intervention group immediately after data collection for the historical control group. However, institutional IT approval and Caregiver Distress the privacy process related to technical infrastructure caused Preoperative caregiver distress was measured at T1 using the significant delays, further compounded by the COVID-19 well-validated short form of the General Health pandemic’s impacts on clinical research [30]. Questionnaire-12 (GHQ-12) [26]. The GHQ-12 covers several domains associated with a person’s level of distress and is Control group cohort data was collected over a 10-month period worded in such a way as to comprise 6 positive and 6 negative starting in 2017. A 4-month period was used for active items. Response items are scored on a 4-point scale (ranging recruitment, there was a 3- to 4-month wait for surgery, and the from 0 to 3), and a global score between 0 and 36 is calculated, postsurgery follow-up period lasted for ≥2 weeks. Control group with higher scores indicating higher levels of distress. participants (ie, caregivers) were recruited through advertisements displayed at the clinic and through clinic nurses Child’s Pain who introduced the study to caregivers. In addition, caregivers At T2 and T3, caregivers were asked to report their child’s were able to self-enroll by visiting our web-based recruitment average level of pain in the past 24 hours and the highest level site and completing a 5-minute guided screening and web-based of pain in the past 24 hours on a scale of 0 (no pain) to 10 (worst consent process. Once enrollment was confirmed, the research pain). The well-established 15-item Parents’ Postoperative Pain coordinator generated a study ID in REDCap (Research Measure (PPPM) [27] was used to measure caregiver-reported Electronic Data Capture; Vanderbilt University) [31], and an pain-related behavior of their child at T2. A sum score was automated questionnaire schedule sent surveys to caregivers on computed by tallying the number of yes=1 and no=0 responses the day before the surgery (T1), during the peak pain period on for a total score of 15. As per guidelines, a score of 6/15 day 3 (T2), and 14 days after surgery (T3). REDCap also sent signified clinically significant pain [28]. 2 reminder emails for surveys that were not completed. Child’s Activity Intervention group data collection ran from May 2021 to December 2021. Recruitment flow was adjusted for the As a proxy measure of fluid intake, we asked caregivers at T2 intervention group to allow for flexibility in changing to report “yes” or “no” as to whether their child had urinated at COVID-19 pandemic precautions and hospital restrictions; for least twice in the previous 24-hour period. The child’s activity example, as in-clinic recruitment was not possible, level was measured at T2 and T3 by asking caregivers to report distance-delivered recruitment materials were developed. the level of physical activity on a 4-item scale (ie, bedridden, Potential participants were identified by screening the surgical sluggish but walking, easily tired but active, or normal) during wait-list for families whose surgery dates fell within the study the past 24 hours. timeline. A postcard with study details was mailed, and a Analgesic Therapy follow-up phone call was made. After informed consent was Caregivers reported the number of doses per type of analgesic confirmed, the research coordinator generated a study ID in (eg, acetaminophen, ibuprofen, and morphine) administered REDCap, and an automated questionnaire schedule sent surveys within the past 24-hour period at T2 and T3. to caregivers on the day before the surgery (T1), during the peak pain period on day 3 (T2), and 14 days after surgery (T3). A Health Care Use booking clerk entered the participant’s information into the At T3, caregivers were asked to report on the number of surgery booking interface, where they flagged the study postoperative ED visits; hospitalizations; family physician visits; participant to receive the texts. Using a secure file transfer calls to ear, nose, and throat (ENT) nurses or surgeons; acute protocol, we sent a daily report for those enrolled in the TTTM or unplanned clinic visits; calls to 811 (local nonurgent health intervention to the SMS text messaging service vendor care advice line); and the number of antibiotic courses prescribed SimplyCast. SimplyCast’s secure SMS text messaging service in relation to the tonsillectomy since surgery day. sent SMS text messages with periodic embedded links per the defined schedule to caregivers based on surgery data outlined Satisfaction and Intervention Engagement in the SMS text message schedule (see the Results section). Intervention group participants were asked to rate their satisfaction with the TTTM service at T3 using the Client Satisfaction Questionnaire [29], which is a unidimensional, 8-item measure used worldwide to assess client or patient https://periop.jmir.org/2022/1/e39617 JMIR Perioper Med 2022 | vol. 5 | iss. 1 | e39617 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR PERIOPERATIVE MEDICINE Wozney et al Statistical Analysis Ethics Approval We used SPSS software (IBM Corp) [32] and Jeffreys’s This study has been funded by an IWK Health Centre Amazing Statistics Program [33] for data analysis. Standard Translating Research Into Care grant and has been approved by descriptive statistics, including means, SDs, frequencies, and the IWK Health Centre Research Ethics Board (1021845). percentages, were used to summarize the continuous preoperative and postoperative measures as appropriate. Results Differences between the 2 groups were tested with Overview paired-sample t tests (2-tailed) or chi-square tests where appropriate. Where assumptions of normal distribution and An overview of recruitment and enrollment is presented in the equality of variance were violated, Mann-Whitney U tests were Figure 1 flow diagram. A total of 100 caregivers were used. Effect sizes were extracted (ie, Cohen d, Cramer V, odds approached during control group data collection and 61 during ratios [ORs], and rank-biserial correlation) where applicable. intervention group data collection. Approximately 82% (82/100) All statistical tests were performed using 2-tailed tests at the consented to participate in the historical control group, and 59% 0.05 level of significance. Analysts were not blinded to group (36/61) consented to participate in the intervention group. allocation. Approximately 28% (10/36) of intervention group participants withdrew before T1 data collection for reasons that included changed or canceled surgery dates and changes in legal guardianship status. Figure 1. Flowchart of study participants in the historical control and intervention groups. 2 2 ethnicity (χ =1.9; P=.39), employment status (χ =3.0; P=.28), 2 2 Demographics or number of children in the household (χ =1.0; P=.60). An overview of baseline demographics is presented in Table 1. All but 1 participant were women caregivers. Most were White, Preferences for using SMS text messages for different health employed with a university degree, and living in a household care service use contexts are reported in Table 2. Respondents with ≥2 children. There were no significant group differences in both groups reported high use of SMS text messaging in daily at baseline regarding the age of the caregiver (χ =3.3; P=.35), life, with 98% (50/51) reporting that they send SMS text 2 2 messages at least once a day. When asked to rank the top 3 gender (χ =3.5; P=.17), education level (χ =5.8; P=.12), 2 3 reasons for using their mobile phones, respondents in both control and intervention groups indicated that receiving and https://periop.jmir.org/2022/1/e39617 JMIR Perioper Med 2022 | vol. 5 | iss. 1 | e39617 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR PERIOPERATIVE MEDICINE Wozney et al sending SMS text messages was the number 1 reason (32/32, (49/51, 96%) and consult with health care professionals (36/51, 100%, and 19/19, 100%, respectively), followed by receiving 71%) were among the top ways that respondents wanted to use and making phone calls (22/32, 69%, and 17/19, 90%, their mobile phones. respectively). Being able to receive appointment reminders Table 1. Baseline demographic characteristics of caregivers (N=51). Characteristics Control group (n=32), n (%) Intervention group (n=19), n (%) Age (years) 18 to 25 0 (0) 1 (5) 26 to 35 11 (34) 9 (47) 36 to 45 20 (63) 9 (47) ≥46 1 (3) 0 (0) Gender Woman 32 (100) 17 (90) Man 0 (0) 1 (5) Other or prefer not to say 0 (0) 1 (5) Ethnicity White 31 (97) 17 (90) Middle Eastern 1 (3) 1 (5) African Canadian, African American, or Caribbean 0 (0) 1 (5) Highest educational level High school or less 3 (9) 4 (21) College diploma 10 (31) 2 (10) University degree 18 (56) 10 (53) Other 1 (3) 3 (16) Employment Unemployed 3 (9) 5 (26) Employed 28 (87) 14 (74) Prefer not to say 1 (3) 0 (0) Number of children in the household 1 7 (22) 5 (26) 2 18 (56) 8 (42) ≥3 7 (22) 6 (32) https://periop.jmir.org/2022/1/e39617 JMIR Perioper Med 2022 | vol. 5 | iss. 1 | e39617 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR PERIOPERATIVE MEDICINE Wozney et al Table 2. Baseline technology use and preferences of caregivers (N=51). Technology uses and preferences Control group (n=32), n (%) Intervention group (n=19), n (%) Number of texts sent per week At least once a day 32 (100) 18 (95) More than once a week but less than once a day 0 (0) 1 (5) Less than once per week 0 (0) 0 (0) Would you like to use your mobile phone for the following Receive appointment and vaccination reminders Yes 30 (94) 19 (100) No 2 (6) 0 (0) Consult with physicians and nurses Yes 23 (72) 13 (68) No 9 (28) 6 (32) Get help sticking with a medication regimen Yes 12 (37) 4 (21) No 20 (63) 15 (79) Receive test results Yes 23 (72) 13 (68) No 9 (28) 6 (32) Talk with a professional about health concerns Yes 16 (50) 9 (47) No 16 (50) 10 (53) Access emergency services Yes 20 (63) 7 (37) No 12 (37) 12 (63) –0.24). Overall, on the GHQ-12, both control (mean 2.53, SD Caregiver Self-efficacy and Distress 0.57) and intervention group (mean 2.42, SD 0.61) participants Out of a possible total score of 15, at T1, the mean scores on reported challenges in feeling “capable of making decisions” the 3 PSAM items were 12.5 (SD 1.1) for the control group and and in feeling that they were “playing a useful part in things” 13.7 (SD 1.1) for the intervention group. A Mann-Whitney U (Table 3). The effect size for mean differences on the GHQ-12 test indicated that the mean scores on parenting self-efficacy in this analysis was small (Cohen d=0.32, 95% CI –0.26 to were significantly higher for the intervention group, with a small 0.88), and the independent-sample t test indicated a effect size (U=136.50; P=.002; r =0.53, 95% CI –0.73 to rb nonsignificant difference (t =1.090; P=.28). https://periop.jmir.org/2022/1/e39617 JMIR Perioper Med 2022 | vol. 5 | iss. 1 | e39617 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR PERIOPERATIVE MEDICINE Wozney et al Table 3. Caregivers’ GHQ-12 scores at time point 1 (N=51). a a GHQ-12 items (have you done the following) Control group (n=32), mean (SD) Intervention group (n=19), mean (SD) Been able to concentrate on what you were doing 2.09 (0.86) 2.16 (0.83) Lost much sleep over worry 1.16 (1.02) 1.84 (0.96) Felt that you are playing a useful part in things 2.31 (0.69) 2.32 (0.67) Felt capable of making decisions about things 2.53 (0.57) 2.42 (0.61) Felt constantly under strain 1.37 (0.91) 1.32 (1.20) Felt you could not overcome your difficulties 0.72 (0.77) 1.05 (1.08) Been able to enjoy your normal day-to-day activities 2.16 (0.57) 2.16 (0.83) Been able to face your problems 2.25 (0.62) 1.06 (0.80) Been feeling unhappy or depressed 1.06 (0.80) 1.21 (1.08) Been losing confidence in yourself 0.72 (0.73) 0.84 (1.02) Been thinking of yourself as worthless 0.31 (0.54) 0.84 (1.02) Been feeling reasonably happy 2.09 (0.69) 1.74 (0.93) Overall score 18.78 (3.02) 20.37 (3.34) GHQ-12: General Health Questionnaire-12. 92%). In the intervention group, the most common behavior Child’s Pain change was wanting to be close to their caregiver more than At T2, on a scale of 0 (no pain) to 10 (worst pain), the control usual (14/17, 82%) and eating less (14/17, 82%; Table 4). The group reported a slightly lower average level of pain (mean least frequently reported pain-related change in behavior for 4.38, SD 1.76) than the intervention group (mean 4.65, SD the control group was acting more worried than usual (8/24, 2.26). The mean score for the highest level of pain at T2 was 33%), and for the intervention group, it was the child taking 7.37 (SD 1.88) for the control group and slightly lower at 6.70 medication when they normally refuse (3/17, 18%). The mean (SD 2.97) for the intervention group. Independent-sample t tests PPPM score was higher for the control group (mean 10.0, SD did not indicate a significant difference between the groups, 3.1) than for the intervention group (mean 8.5, SD 3.7), both and only small effects were observed on the average level of of which were still above the 6/15 threshold for clinically pain (t =–0.433; P=.67; Cohen d=0.14, 95% CI –0.76 to 0.49) significant pain. An independent-sample t test did not report a and the highest level of pain (t =0.882; P=.38; Cohen d=0.28, significant difference in PPPM scores (t =1.446; P=.16), 95% CI –0.34 to 0.90). although a small effect size was found (Cohen d=0.46, 95% CI –0.02 to 1.08). The most frequently reported pain-related change in behavior at T2 in the control group was eating less than usual (22/24, https://periop.jmir.org/2022/1/e39617 JMIR Perioper Med 2022 | vol. 5 | iss. 1 | e39617 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR PERIOPERATIVE MEDICINE Wozney et al Table 4. Frequency of caregivers’ endorsement of PPPM items at time point 2 (N=41). PPPM items (when your child was recovering from surgery, did she or he do the Control group (n=24), n (%) Intervention group (n=17), n (%) following?) Whine or complain more than usual 17 (71) 10 (59) Cry more easily than usual 15 (63) 9 (53) Play less than usual 21 (88) 12 (71) Not do the things she or he normally does 15 (63) 12 (71) Act more worried than usual 8 (33) 6 (35) Act more quiet than usual 17 (71) 11 (65) Have less energy than usual 18 (75) 11 (65) Refuse to eat 12 (50) 10 (59) Eat less than usual 22 (92) 14 (82) Hold the sore part of his or her body 13 (54) 7 (41) Try not to bump the sore part of his or her body 15 (63) 6 (35) Groan or moan more than usual 16 (67) 8 (47) Look more flushed than usual 16 (67) 11 (65) Want to be close to you more than usual 21 (88) 14 (82) Take medication when she or he normally refuses 14 (58) 3 (18) PPPM: Parents’ Postoperative Pain Measure. T3 (14 days after surgery), only one of the caregivers reported Analgesic Therapy offering analgesics within the previous 24-hour period. Analgesic therapy was consistent across the groups. At T2, Chi-square group difference tests on use or nonuse of medication caregivers in both the control and intervention groups reported did not indicate a significant association, although small effects administering on average 3.75 (SD 0.61) and 3.59 (SD 1.73) 2 were demonstrated at both T2 (χ =0.9; P=.32; OR 0.33, 95% doses of acetaminophen, respectively, and 3.46 (SD 1.06) and CI 0.01-8.79) and T3 (χ =0.8; P=.36; OR 0.39, 95% CI 3.59 (SD 1.73) doses of ibuprofen, respectively, within the 0.01-10.37). previous 24 hours (range 0-8; Table 5). Across both groups at a b Table 5. Average analgesic doses administered in the previous 24 hours (T2 and T3 ; N=76). Dosages Control group Intervention group T2 (3 days after surgery) Acetaminophen, mean (SD; range) 3.75 (0.61; 2-4) 3.59 (1.73; 0-8) Ibuprofen, mean (SD; range) 3.46 (1.06; 0-4) 3.59 (1.73; 0-8) Morphine, mean (SD; range) 1.12 (1.15; 0-4) 0.59 (1.06; 0-4) T3 (14 days after surgery) Acetaminophen, mean (SD; range) 0.05 (0.21; 0-1) 0 (0; 0) Ibuprofen, mean (SD; range) 0.05 (0.21; 0-1) 0 (0; 0) Morphine, mean (SD; range) 0 (0; 0) 0 (0; 0) T2: time point 2. T3: time point 3. Control group: n=24; intervention group: n=17. Control group: n=22; intervention group: n=13. the children were at their normal level of activity in the past 24 Child’s Activity hours compared with 24% (4/17) in the intervention group. A In terms of fluid intake, all caregivers reported that their children caregiver in each group reported that their child was bedridden. had urinated at least twice in the past 24 hours. In addition, at Most caregivers in the control group reported that their child T2, caregivers in the control group reported that 13% (3/24) of was “easily tired but active” (16/24, 67%), whereas caregivers https://periop.jmir.org/2022/1/e39617 JMIR Perioper Med 2022 | vol. 5 | iss. 1 | e39617 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR PERIOPERATIVE MEDICINE Wozney et al in the intervention group reported that their child was “sluggish for >24 hours (χ =0.6; P=.45; Cramer V=0.13), ED visits but walking” (6/17, 35%) or “easily tired but active” (6/17, (χ =1.3; P=.52; Cramer V=0.19), visits to outpatient walk-in 35%). By T3, most (21/23, 91% control group; 13/13, 100% clinics (χ =1.2; P=.27; Cramer V=0.18), calls to the ENT clinic intervention group) of the caregivers reported that their children 1 had returned to normal activity levels. We created a dichotomous (χ =2.1; P=.35; Cramer V=0.24), or calls to 811 or family variable of normal activity versus reduced activity (ie, easily physician (χ =1.85; P=.17; Cramer V=0.23). tired, sluggish, or bedridden). The chi-square group difference for normal activity and reduced activity showed no significant Satisfaction and Engagement differences at T2 (χ =0.8; P=.35; OR 2.15, 95% CI 0.41-11.20). The results of the Client Satisfaction Questionnaire-8 showed high levels of satisfaction with TTTM across all 8 dimensions Health Service Use (Table 6). The mean total satisfaction score, out of a possible Hospital admissions were reported by 13% (3/23) of the 32, was 29.4 (SD 3.6, range 24.0-32.0). respondents in the control group and 8% (1/13) of those in the All caregivers engaged with the full TTTM intervention, and intervention group, with visits to the ED reported by 17% (4/23) none texted “STOP” to cease the messages. Engagement with and 8% (1/13), respectively. The number of calls to the ENT the linked resources within the texts was moderate, with 90% clinic, family physicians, or 811 (local health information (9/10) of the embedded links within the texts being viewed at phoneline) was higher in the control group (8/23, 35%) than in least once by 79% (15/19) of the participants. All participants the intervention group (4/13, 31%). Antibiotic prescriptions (19/19, 100%) viewed the web-based tour video and both were reported by 9% (2/23) of the caregivers in the control checklists of what to bring to the hospital. Approximately 79% group and 15% (2/13) of the caregivers in the intervention group. (15/19) viewed the presurgery tips on nonpharmacological However, chi-square and Cramer V tests showed no significant postsurgery pain management; however, only 58% (11/19) differences and only small associations for hospital admissions 2 viewed the postsurgery link regarding how to ask their child lasting for <24 hours (χ =0.01; P=.92; Cramer V=0.02), lasting about their level of pain (Table 7). Table 6. Results of the CSQ-8 (N=13). CSQ-8 dimensions Values, mean (SD) Quality of service 3.62 (0.51) Kind of service you wanted 3.69 (0.48) The extent to which the program met your needs 3.69 (0.48) Recommend the program to a friend 3.69 (0.48) Satisfaction with the amount of help received 3.77 (0.44) Services helped you to deal with problems 3.54 (0.52) Overall satisfaction with the service 3.69 (0.48) Return to the program for help 3.69 (0.48) CSQ-8: Client Satisfaction Questionnaire-8. Highest possible score=4. Table 7. Participants’ engagement with the linked resources within the SMS text messages. Embedded links topic Intervention group (n=19), n (%) Coloring book 11 (58) Web-based tour 19 (100) Checklist 19 (100) Soft food list 15 (79) Postsurgery pain 15 (79) Parking 13 (69) Eating and drinking 9 (48) Asking about pain 11 (58) https://periop.jmir.org/2022/1/e39617 JMIR Perioper Med 2022 | vol. 5 | iss. 1 | e39617 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR PERIOPERATIVE MEDICINE Wozney et al with health service–related SMS text messages, an even less Discussion intensive and complex technology than mobile apps. Caregivers actively engaged in learning about the skills and strategies Principal Findings offered through the texts. Given the large and potentially In this study, a brief 15-message TTTM intervention that was permanent migration to web-based supports and services during delivered adjunct to usual care during the COVID-19 pandemic the COVID-19 pandemic, the need to support caregivers in revealed high uptake and engagement. A positive, significant using relevant technologies that can tailor what information difference in preoperative caregiver self-efficacy was found, they receive, when, and in what way may be even more pressing. suggesting that SMS text messages may have helped caregivers The early stage of research in this field presents numerous lines to develop positive expectations regarding their ability to handle of future inquiry. Both groups in our study reported clinically postoperative activities with their child. Furthermore, caregivers significant levels of pain 3 days after surgery, and the embedded receiving the texts reported improvements over usual care links to pain management strategies were engaged with the least. related to the highest level of child’s pain intensity, child’s A better understanding of how SMS text messaging pain-related behavior, health care use, and child’s return to interventions might be optimized to improve adherence to best normal activity levels, although statistical significance was not practice pain management strategies and promote the use of noted. These results are not unlike other SMS text messaging nonpharmacological pain management strategies could help to intervention studies that target the perioperative experiences of ensure that the most minimally invasive technology is used to adults [34,35] and suggest that pediatric perioperative pathways produce optimal outcomes. Drawing from persuasive system are a rich area for further research. In the following sections, design frameworks [44] and behavior change theories [45], there we detail the strengths and limitations of this study, as well as may be both content and functionality improvements that can future lines of inquiry. be made to the intervention that might support improved pain The study has several strengths. First, research on the use of management in particular. Second, monitoring and reporting technology to support perioperative education for pediatric on participant recruitment, satisfaction, feasibility, and outcome tonsillectomy is nascent, despite being one of the most efficacy in demographically diverse populations will help to frequently performed pediatric surgeries. A systematic review determine the utility and cultural relevance of these [36] of phone- and internet-based pain and recovery support interventions. Our study, based in an east coast Canadian programs for pediatric tonsillectomy found only 4 relevant organization context, adds to the knowledge base but used a randomized controlled trials. Only 1 clinical trial of an SMS demographically homogenous sample. As concepts of pain, text messaging intervention for perioperative pediatric pain management [46], and caregiving [47] are deeply tonsillectomy has been published; it was conducted outside of influenced by culture and ethnicity, it is critical, especially North America [19] and had a high risk of bias [36]. during this period of early evidence building, to expand our Contributing our preliminary cohort study findings to this understanding of whether and how interventions such as TTTM emerging academic literature can inform future trial designs for should be tailored to be more culturally affirming [48]. research teams facing similar pragmatic limitations and help to Limitations refine outcomes of interest to maximize translational research potential [37]. Second, TTTM is designed to support caregivers Several study limitations should be noted. Our ability to conduct across the full perioperative period (ie, before, day of, and for more robust analyses was limited because of sampling. 2 weeks after their child’s surgery) and was assessed using Unforeseen delays occurred because of IT infrastructure multiple measures (eg, analgesic use, caregiver self-efficacy, approvals, and the COVID-19 pandemic limited the time frame child pain levels, and health service use). Among for completing research activities. The use of historical control technology-based pediatric-related intervention studies, most group data is prone to type I errors [21]; however, baseline have measured only child and system outcomes [38] or measured demographic equivalence, no significant changes to the surgery them at only 1 postoperative time point [39,40]. Our itself, and the postoperative recommendations for parents comprehensive findings suggest that patient-level (eg, child between group conditions likely limited potential impacts. Given pain) and system-level (eg, hospital visits) outcomes should be differences observed in recruitment and follow-up rates, some complemented with an assessment of the quality-of-care consideration of the external validity of the research is measures that help us to understand caregiver experiences (eg, warranted; for example, changes to clinic and research staff caregiver distress) and behaviors across the perioperative period. may have introduced selection bias, and different recruitment Given the volume of tonsillectomy surgeries performed each and consent pathways (ie, the historical control group had a year in North America [1], even modest individual-level web-based consent option, whereas, for the intervention group, improvements in pain management or improved perceptions of it was phone based) may confound the findings in ways we did self-efficacy for managing care at home derived from brief SMS not measure. It would be important for future research to be text messages could have significant real-world benefits. Finally, powered sufficiently to detect group differences and trial TTTM as caregivers’ role in pediatric perioperative care is vital [41], as a stand-alone intervention, not just as an adjunct to usual and they increasingly expect and prefer to receive information care. Data derived from this pilot study can be used to calculate about surgical procedures through their smartphones [42], our the sample size for a future randomized controlled trial. The study offers some of the earliest findings into how SMS text extent to which pandemic-related environmental factors for messaging as a modality might meet that need. Participants in families (eg, caregivers spending more time at home with their our study, as well as other studies [43], report high satisfaction children and children’s normal activities affected by public https://periop.jmir.org/2022/1/e39617 JMIR Perioper Med 2022 | vol. 5 | iss. 1 | e39617 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR PERIOPERATIVE MEDICINE Wozney et al health restrictions) and health care organizations (eg, hospital The results should be viewed with caution, given the unclear visit requirements and physical distancing guidelines) affected impacts of the COVID-19 pandemic on preoperative levels of the study results is unclear. caregiver distress, health service use, and typical caregiver-child interactions. Continued research into SMS text messaging Conclusions interventions targeting pediatric perioperative experience is Preliminary results from this prospective cohort intervention warranted, especially given caregivers’ high satisfaction with study with a historical control group revealed that TTTM had TTTM and high rates of texting in their everyday lives. a positive impact on caregivers’ perioperative care experience. Acknowledgments The study was supported by an IWK Health Foundation, Translating Research Into Care grant. The authors would like to thank the IWK information management-IT team, the Dalhousie Research in Medicine trainees, the Centre for Research in Family Health team, Evan Maynard from SimplyCast, Benjamin Rose-Davis, Barbara Marshall, and Nicole Hartling. Conflicts of Interest None declared. References 1. Boss EF, Marsteller JA, Simon AE. Outpatient tonsillectomy in children: demographic and geographic variation in the United States, 2006. 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JMIR Mhealth Uhealth 2016 Jan 22;4(1):e10 [FREE Full text] [doi: 10.2196/mhealth.4994] [Medline: 26800712] Abbreviations ED: emergency department ENT: ear, nose, and throat GHQ-12: General Health Questionnaire-12 OR: odds ratio PPPM: Parents’ Postoperative Pain Measure PSAM: Parenting Self-Agency Measure REDCap: Research Electronic Data Capture T1: time point 1 T2: time point 2 T3: time point 3 TTTM: Tonsil-Text-To-Me Edited by R Lee; submitted 16.05.22; peer-reviewed by S Azadnajafabad, S Badawy, B Nievas Soriano, M Abbasi-Kangevari; comments to author 28.06.22; revised version received 03.08.22; accepted 04.08.22; published 20.09.22 Please cite as: Wozney L, Vakili N, Chorney J, Clark A, Hong P The Impact of a Text Messaging Service (Tonsil-Text-To-Me) on Pediatric Perioperative Tonsillectomy Outcomes: Cohort Study With a Historical Control Group JMIR Perioper Med 2022;5(1):e39617 URL: https://periop.jmir.org/2022/1/e39617 doi: 10.2196/39617 PMID: ©Lori Wozney, Negar Vakili, Jill Chorney, Alexander Clark, Paul Hong. Originally published in JMIR Perioperative Medicine (http://periop.jmir.org), 20.09.2022. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Perioperative Medicine, is properly cited. The complete bibliographic https://periop.jmir.org/2022/1/e39617 JMIR Perioper Med 2022 | vol. 5 | iss. 1 | e39617 | p. 14 (page number not for citation purposes) XSL FO RenderX JMIR PERIOPERATIVE MEDICINE Wozney et al information, a link to the original publication on http://periop.jmir.org, as well as this copyright and license information must be included. https://periop.jmir.org/2022/1/e39617 JMIR Perioper Med 2022 | vol. 5 | iss. 1 | e39617 | p. 15 (page number not for citation purposes) XSL FO RenderX

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Published: Sep 20, 2022

Keywords: tonsillectomy; otorhinolaryngology; text messaging; caregivers; surgery; perioperative; patient discharge; aftercare; short messaging service; pain management; mobile phone

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