55 2 Mobile applications in gastrointestinal surgery: a systematic review DISCUSSION Healthcare apps may offer great possibilities to support or improve gastrointestinal surgical care, provided that the development and validation process are properly conducted and the app itself complies with professional standards and medical device regulations [8,9]. This systematic review showed that most the gastrointestinal apps, which have been described in literature, at best had low-quality evidence and were limited in their evaluation methodology. Small sample sizes, lack of comparison with a control group and subjective outcomes defined were common limitations. Most of the identified apps were only assessed on their usage, usability, satisfaction and feasibility, which was rarely measured with a valid and reusable questionnaire. Studies of higher-level evidence in the area of colorectal.38,42 Hepatopancreatobiliary53 and bariatric surgery33 reported mostly positive outcomes on postoperative recovery, complications and weight loss. In total, the review retrieved 29 apps developed for use by patients, surgeons, or both. In the selected studies, there was a predominant focus on monitoring the patient’s postoperative condition and symptoms in the area of colorectal surgery. Apps that fall within the same category share many similar functionalities, with minimum variance in functionality. It is fair to state that apps that fall into different categories are not mutually exclusive in their functionalities regarding their category inclusion. Across all app categories, studies have indicated a potential benefit of apps, except for the categories of communication and prognosis. Users of apps generally seemed to be satisfied with the apps, while reported patient engagement was highly variable across the categories and domains. Patient engagement with the app is, of course, a driver of the potential clinical effect of apps aimed at patient care. Patient engagement not only depends on the specific features that the app offers but also relates to the context and phase of care the patient is receiving, the patients’ digital literacy, and the apps’ overall usability and stability. Most studies did not report participants’ digital literacy, although it can be assumed that participants had sufficient proficiency, as patients with insufficient proficiency probably did not participate. It is important to acknowledge digital literacy and to compensate for digital literacy as well as possible, as the effectiveness of apps may be substantially less. Although over 150 gastrointestinal surgical apps for use on a smartphone or tablet are available in the app stores, only a limited amount (29) is reflected in studies as could be retrieved from scientific literature by this systematic review. 54-56 Non-validated or poorly validated apps are potentially harmful, especially if they may have a direct effect on clinical outcomes such as diagnosis or decision support tools. This underlines the need for high quality clinical research to safeguard the effectiveness and safety of apps, and to provide HCP's a better understanding of the potential impact of an app on surgical care. It is important to realize that apps can be published in the app stores claiming to be effective or reliable without presenting a snippet of evidence to support clinical safety
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