160 Chapter 7 one academic hospital, and results may vary in other settings. Additionally, factors such as overlapping local studies and healthcare providers' awareness might contribute to compliance variations between teaching and academic hospitals. Despite, the significant increase in compliance with active ERAS elements, the study did not demonstrated improvement in clinical outcomes. The study was not powered on clinical outcomes, in the context of clinical outcomes which had already seen significant enhancements since the introduction of the ERAS protocol. It is essential to consider potential impact in larger groups where improved adherence to active elements might translate into clinical benefits. Additionally, the quality of implementation of the ERAS protocol may have varied among healthcare providers or institutions, leading to inconsistent results across study sites. This highlights the need for standardized implementation and continuous monitoring to ensure protocol effectiveness. Furthermore, the ERAS App did not improve patient-reported outcomes (PROMs) or postoperative activity. It is possible that increased adherence to the ERAS protocol may not have a direct impact on PROMs such as quality of life or patient satisfaction. A potential social desirability bias in self-reported questionnaires could have influenced the observed outcomes.33 The ERAS App did not lead to an activity improvement when compared to the control group. Most patients exceeded their daily step goals, indicating that the goal-setting may have been too simplistic to motivative patients for increased physical activity. The ERAS APPtimize group's increased activity in the final days suggests that the follow-up period might have been too short to capture sustained improvements. Additionally, unusually high baseline activity levels (e.g., 23,000 steps per day), possibly due to preoperative motivation, have led to an unrepresentative baseline level. Several limitations to this study need to be addressed. Firstly, the exclusion of patients undergoing palliative surgery, surgery after neoadjuvant chemotherapy or radiotherapy, or multiple organ resections, may have resulted in a selection bias. These patients may benefit the most from the app, and their exclusion may underestimate the true impact of the app. Secondly, non-completing participants had significantly more complications (Table S4), which suggests that the ERAS App may not be optimal for patients with complications. This highlights the need for further research. Thirdly, not all participants had optimal postoperative activity goals, as the baseline measurement may have been too short or goals may not have been sufficiently challenging. Lastly, it is important to note that patients in the control group may have been more actively participating in the ERAS care pathway compared to their peers as. This may have resulted in a decreased compliance difference between the two study groups. Despite the demonstrated effect of the ERAS App, opportunities for further optimization were identified. Dynamic features catering to individual recovery progress and adapting to postoperative complications hold promise. However, it's important to exercise caution
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