Impact of age, sex and surgery type on engagement with an online patient education and support platform developed for total hip and knee replacement patients.

BACKGROUND: Patients should be active participants in the management of their condition and provided with appropriate information throughout their care pathway. We piloted an online digital platform (ODP) to deliver patient education and support (PES) for patients undergoing total hip (THR) and knee replacements (TKR). The aim of this study is to analyse the demographics of patients using the ODP, determine how and when they accessed the ODP and how different sexes and age groups interacted with the ODP.
METHODS: Demographics and program library logs for patients registered to the ODP between 21st September 2017 and 28th May 2020 was obtained. Associations between age, sex, type of surgery and engagement were assessed using statistical comparisons.
RESULTS: 1195 patients were registered on the ODP of which 832 (69.6%) accessed their carepacs. Patients accessed the content within their carepacs a mean of 29.1 times, spending a mean total time of 83 minutes. There was greater engagement for patients with a THR carepac (75.5%) compared to TKR (63.8%) (p<0.001). There were no differences in the proportion of patients that accessed the ODP or the total time spent on the platform dependent upon age (p = 0.34). Females accessed the platform more than males (p = 0.03). The use of a computer to access the ODP increased as age increased, whereas the use of a phone was favoured by the younger age groups (p<0.001).
CONCLUSION: An ODP providing information to patients regarding their surgery is effective and demonstrates high levels of patient engagement. An online resource such as this does not discriminate against age or sex in terms of accessibility and can be useful for information provision.

Introduction

Patients listed for primary joint replacements should be provided with appropriate information that is tailored to their specific condition. This supports shared decision making and allows them to make informed choices about their care [1]. NICE guidelines recommend that information should be specific to the procedure that are being offered, should be delivered in a format that can be easily understood and should start at the first appointment and continue whenever it is needed throughout the care pathway [2,3]. This encourages patients to actively participate in their own care, and promotes self-management of their condition. This is something that healthcare workers should be striving to provide [2,3].

Health literacy, defined as the “capacity to obtain, interpret, and understand basic health information and services and the competence to use such information and services to enhance health” remains a significant issue [4,5]. Failure to understand their condition and the expected outcomes of treatment can increase the risk of patients developing complications and lead to poorer outcomes6. Providing individualised education materials, designed for their specific condition improves the patient’s health literacy and reduces anxiety surrounding their condition [6,7]. Information delivery direct to the patient also eliminates the need for patients to obtain information themselves and therefore reduces the risk of the patient relying on possible misinformation. In addition, patient education pre-operatively has been shown to reduce patient’s length of stay in hospital and reduce overall costs of care. It results in increased empowerment, improved adherence to the care plan, improved independence and overall satisfaction with the procedure and outcome [8].

A systematic review including 14 studies assessing internet-based patient education programs compared to the traditional forms of patient education, such as printed materials highlighted improved patient satisfaction and an increased patient knowledge when using the internet-based programs [9]. However, a limitation identified within these studies was the exclusion of patients who were deemed to be inexperienced with internet use. In routine practice, this could exclude a large proportion of older patients, particularly in the population receiving THR and TKR. The average age across the studies included within the systematic review was 56.3 years which is much younger than the average age of patient receiving a THR (69.4 years) [10] or TKR (70.1 years) in the UK [10]. Therefore, from this systematic review, it was not possible to conclude that an internet-based program would be appropriate and beneficial for all patients undergoing a joint replacement given that certain groups were excluded.

Since 2017, South Tees NHS Trust has used an online digital platform (ODP) to deliver and provide patient education and support (PES) to patients undergoing THR and TKR. A concern when introducing an ODP, was that it might discriminate against specific demographics of patients who may be less technologically literate. These concerns were identified by a small number of patients already using the ODP [11], that suggested older patients might have some apprehensions navigating an online platform in comparison to the comfort of printed materials. The following study therefore aimed to determine: 1) How engagement and time spent on the ODP varied depending on whether the patient was undergoing a THR or TKR; 2) How engagement and time spent on the platform varied depending on age and sex; 3) How the method and time of access on the platform varied depending on age and sex.

Materials and methods

Study population

This study was a retrospective cohort of a consecutive series of patients registered on to the ODP between 21st September 2017 and 28th May 2020 that received either a THR or TKR carepac. All patients registered on the ODP were included and there were no specific exclusions applied to the study population.

Intervention: Description of the Online Digital Platform (ODP) intervention

Our ODP was developed to with the aim of providing patients and their family members with information related to their planned elective hip or knee replacement procedure, in a digital multimedia format, commencing at the point of listing for surgery and continuing through out their care pathway. In many institutions this information is provided in a single pre-operative face to face ‘surgery school’ alongside a written booklet of information. However, the ‘surgery school’ is resource intensive and information transfer is limited by the time available for these sessions. Therefore, when redesigning our own patient education and support offering we opted to digitize all of our resources and provide them using an online digital platform.

The ODP uses the GoWellHealth platform and allows the clinical team to prescribe bundles of content (termed a carepac) over a given period of time. The format, structure, timing and duration of the carepac is determined by the clinical team based on the content uploaded within the ODP content ‘library’. A number of different carepacs can be created that are individualized to the procedure and patient group. These carepacs can then be delivered to the patient digitally to ensure information is provided across the entirety of the patient’s care pathway. Consent is taken to register patients on the platform at the point of listing for surgery. Once the patient is registered they can access their account from which they can interact with the prescribed daily content or view information in their library of content. The information provided includes educational materials about their condition and planned surgical procedure; what to expect before, during and after surgery; exercises to do before and after surgery to aid recovery; lifestyle advice, including information about weight management, diet and smoking cessation; and advice about maximizing function independence and quality of life before and after surgery. Interactive patient questionnaires including Patient Reported Outcome Measures, Health questionnaires, Occupational therapy questionnaires and follow questionnaire post-surgery are also provided.

The ODP content is created and updated regularly by the patient’s multidisciplinary care team (surgeon, nursing staff, Occupational therapists, Physiotherapists, anaesthetists). Access to the ODP is offered at the point of listing for surgery and continues until 12 months after surgery with content added to the individuals account depending where they are on the surgical pathway. The ODP supports a variety of media types including audio, video, e-mail, interactive forms and PDF documents. It can be accessed through any internet ready device including phone, tablet or computer and is supported by both Apple and Android devices.

The ODP was chosen as information can be provided to patients in a safe, understandable and time dependent manner that is driven by the clinical multidisciplinary teams. It also offers a secure and confidential communication module, allowing the patient to directly message their clinical team if they have any queries or concerns (including sending of any photos) which the team can respond through the platform. All patient interactions with the ODP are recorded within a digital program library log.

Outcomes measures

For each participant demographic (age and sex), operative (THR or TKR) and program library log data was extracted from the ODP. Engagement with the ODP was assessed using 4 metrics derived from the program library log: 1) the date and time the ODP was accessed to view content; 2) the total number of times the ODP was accessed by each individual; 3) the duration of each access period; 4) the device type that was used to access the content. When analysing the duration of each access per item of content, the time was capped at a maximum of 30 minutes. This was to correct for instances when the patient accessing the information may have left the content open inadvertently, leading to outlying results. Each piece of content was designed to be short and concise, therefore not expected to take the patient longer than 30 minutes per item of content.

Ethics

Verbal or written consent to register patients on the platform is taken when the patient is listed for surgery to satisfy local information governance policies and GDPR. Within this consent process patients also agree that data generated from the ODP can be used for the purpose of research and quality improvement. This project is registered as a service evaluation with the local Trust’s research and development department (REF 061219NC—Evaluation of the Go Well Health platform).

Statistical analysis

For the purpose of comparative analysis, the ages of the patients were categorised into 5 groups: ≤50, 51-60, 61-70, 71-80 and >80 years old.

Outcome data analysed dependent upon the distribution and type of the data. Graphical plots were used to assess time of access. Parametric data (continuous normally distributed) was analysed using a Student’s t-test mean or ANOVA and results are reported using mean and standard deviation (SD). Non-parametric data (continuous non-normally distributed) was analysed using Mann-Whitney U test or Kruskall-Wallis test and results are reported using median and interquartile range (IQR). Chi-squared or Fishers test were used for categorical data analysis.

A p value of <0.05 selected to indicate statistical significance. No formal samples size calculation was undertaken as all patients meeting the inclusion criteria over the study time frame were included. Analysis was conducted using SPSS version 26 (International Business Machines Corporation®).

Results

During the period of analysis, a total of 1195 patients were registered on to the ODP. The patients had an average age of 67.4 years (range 24 to 98 years), 558 (46.7%) were male and 637 (53.3%) were female. Overall, 971 (81.2%) of the 1195 patients that were registered activated their account with 832 (69.6%) of these patients subsequently accessing their account to view the content provided. Characteristics of the proportion of patients activating their account and subsequently accessing the content provided are reported in Table 1.

Table 1

Summary of number of patients registered, activated and accessed dependent on type of surgery, sex and age.

	Number of patients registered		Number of patients activating their ODP account		P value	Number of patients accessing their ODP account 1 or more times		P value
Total	1195		971 (81.1%)			832 (69.6%)
	THR	TKR	THR	TKR		THR	TKR
Total	585	610	486 (83.1%)	485 (79.5%)	p = 0.03	443 (75.7%)	389 (63.8%)	p<0.001
Sex
Male	263	295	215 (81.7%)	235 (79.6%)	p = 0.59	195 (74.1%)	191 (64.7%)	p = 0.04
Female	322	315	271 (84.1%)	250 (79.4%)	p = 0.12	248 (77.0%)	198 (62.9%)	p<0.001
Age group
≤50	66	46	53 (80.3%)	34 (76.1%)	p = 0.49	48 (72.7%)	27 (58.7%)	p = 0.15
51–60	88	82	68 (77.3%)	68 (82.9%)	p = 0.44	60 (68.2%)	53 (64.6%)	p = 0.63
61–70	194	214	171 (88.1%)	173 (80.8%)	p = 0.06	158 (81.4%)	147 (68.7%)	p = 0.004
71–80	178	211	149 (83.7%)	165 (78.2%)	p = 0.04	136 (76.4%)	126 (59.7%)	p<0.001
>80	59	57	101 (87.0%)	45 (78.9%)	p = 0.19	41 (35.3%)	36 (63.2%)	p<0.001

Across the study period the ODP was accessed a total of 24,222 times by 832 patients with a median of 15 (IQR 5 to 56) accesses per patient and a median of 38 minutes (IQR 17-104) spent on the platform per patient (Table 2). The distribution of the data was non-normal due to it being skewed by a proportion of patients that engaged heavily with the ODP, spending considerable time accessing multiple pieces of content. The time spent on the platform per access was also skewed with a median time per access of 3.0 minutes (IQR 2.0 to 4.5) and model access time of 1-2 minutes (Table 2 and Fig 1).

Table 2

Summary of number of accesses, time spent on the platform and time per access dependent upon type of surgery, sex and age.

Category	Number of times accessed	Total time spent on platform(mins)	Time per access(mins)
Total n = 832	Mean 29.1 (SD 39.3)Median 15 (IQR 5–56)	Mean 83 (SD 104)Median 38 (IQR 17–104)	Mean 3.9 (SD 3.7)Median 3.0 (IQR 2.0–4.5)
Hip n = 443	Median 18 (IQR 7–44)	Median 59 (IQR 21–124)	Median 3.0 (IQR 2.0–4.4)
Knee n = 389	Median 12 (IQR 3–31)	Median 38 (IQR 12–91)	Median 3.1 (IQR 1.0–4.7)
Male n = 386	Median 13 (IQR 4–33)	Median 42 (IQR 16–101)	Median 3.1 (IQR 1.9–4.7)
Female n = 446	Median 17 (IQR 5–38)	Median 54 (IQR 18–118)	Median 3.0 (IQR 2.0–4.2)
≤50 n = 75	Median 19 (IQR 5–48)	Median 41 (IQR 17–105)	Median 2.2 (IQR 1.3–3.3)
51–60 n = 113	Median 18 (IQR 4–37)	Median 55 (IQR 16–107)	Median 2.8 (IQR 2.0–4.1)
61–70 n = 305	Median 16 (IQR 5–39)	Median 44 (IQR 16–117)	Median 3.0 (IQR 2.0–4.2)
71–80 n = 262	Median 12 (IQR 4–32)	Median 52 (IQR 18–115)	Median 3.4 (IQR 2.2–5.1)
>80 n = 77	Median 13 (IQR 5–26)	Median 50 (IQR 14–80)	Median 3.3 (IQR 2.1–5.0)

Fig 1

Access times for each interaction with the ODP.

Impact of hip and knee replacement upon engagement and time spent on the ODP

Of the 1195 patients, 585 patients were registered for a THR carepac and 610 were registered for a TKR carepac (Table 1). Significantly more patients undergoing THR activated their ODP account when compared to patients undergoing a TKR (83.1% versus 79.5%, p = 0.03). The activation rate was not influenced by sex, however there was a relationship with age with higher rates of activation in patients aged 61-70 years (p = 0.06) and 71-80 years (p = 0.04) in the THR group being observed (Table 1). Similarly more THR patients accessed the program to view at least 1 piece of content compared to TKR patients (75.5% versus 63.8%, p<0.001) (Table 1). This relationship was observed for both male (p = 0.04) and female patients (p<0.001) and was again driven by higher rates in patients aged 61-70 years (p = 0.004) and 71-80 years (p<0.001) in the THR group (Table 1).

There was a difference in the number of times patients accessed the platform with patients with a THR carepac accessing the system a higher median number of times compared to TKR (18 versus 12, p<0.001) (Table 2). The median total time spent on the program was also higher for THR patients at 59 minutes (IQR 21 to 124) compared to 38 minutes (IQR 12 to 91) for TKR patients (p<0.001). The median time per access was similar for the THR and TKR groups (3.0 and 3.1 minutes respectively) (Table 2).

Engagement and time spent on the platform depending on age and sex

There was no significant difference in the proportion of patients accessing the ODP dependent upon their age group (p = 0.10) or sex (p = 0.75). There were no observed differences in the number of times patients accessed the ODP (p = 0.19) or the total time spent on the platform dependent upon their age group (p = 0.34) (Table 2). However, the two oldest age groups (71-80 years p<0.001; >80 years p = 0.008) spent significantly longer on the program per access when compared with patients aged ≤50 years (Table 2). Patients aged ≤50 years spent a median time of 2.2 minutes on the program per access whereas patients 71-80 years and >80 years spent a median of 3.4 and 3.3 minutes on the program per access respectively.

When analysing the impact of sex we found that females accessed the program significantly more than males (p = 0.03). Female patients accessed a median of 17 times (IQR 5 to 38) whereas males accessed a median of 13 times (IQR 4 to 33) (Table 2). However, there was no difference in the median total time spent on the program between males and females (p = 0.08).

Method and time of access on the platform depending on age and sex

All three devices that could be used to access the carepacs (computer, tablet, phone) were used by individuals in each of the age groups to varying degrees. The use of a computer increased in prevalence as age increased (36.8% in ≤50 years compared to 63.7% in >80 years) (Fig 2). In contrast the use of a phone to access the program was favoured by the younger age groups (39.8% in ≤50 years compared to 19.9% in >80 years). This observed difference in device use was statistically significant (p<0.001). The use of a tablet remained consistent throughout age groups ≤50 years to 71-80 with a decrease of use within the >80 age group.

Fig 2

Type of device used to access the ODP dependent upon age group.

The times of day that both programs were used were similar in distribution. There was variation in use across the 24-hour period (Fig 3) with a peak usage between 10 am—11 am. The was little activity between 1 am—6 am. All age groups accessed the program more frequently during the day typically from mid-morning until early evening although each individual age group had patients which accessed it outside of these peak times (Fig 4).

Fig 3

Number of accesses to the ODP across the day.

Fig 4

Number of accesses to the ODP across the day dependent upon age group.

Discussion

This study demonstrates that an ODP for the delivery of PES can achieve high levels of patient engagement and activity. Furthermore, this method of information delivery does not seem to discriminate against patients based on their age and sex as we observed excellent engagement and interaction irrespective of these factors.

This study included the entire patient population who had accessed the ODP and, as demonstrated within our results, captured a wide age range and sex distribution that is representative of the wider population of patients undergoing these procedures [12]. We found that the different age groups engaged with the program to a similar extent and for similar total lengths of time. The finding that there was no significant difference in rate of engagement for the older population compared to the younger groups is a new and reassuring finding as it addresses previous patient concerns for the older generation and such technological advancements [11].

Health literacy has a big impact on a patient’s understanding and management of their condition and is said to be a predictor of a patients reported state of health [13]. Written information on health conditions and procedures needs to be tailored to the patient’s reading level and there has been criticism that the format and content of previous patient facing information is too complex and above their level of health literacy [5]. A patient’s understanding can be influenced by their literacy levels, understanding of medical terminology and understanding of the healthcare system. The ODP we have developed has helped us to address this possible disadvantage by providing information in a variety of formats (written, video, audio, interactive forms). It is reassuring that levels of activation (>80%) and interaction (70%) are high, coupled with a high median number of accesses which when combined suggest that patients are finding content on the ODP that they can engage with and that keeps them coming back.

A study published in 2017 [14] looked into the different modes of education delivery that patients preferred and it found that patients liked a variety of different formats including both written information and videos such as is being delivered via our ODP. An area of concern highlighted in this study was patient education regarding pain management and dealing with this after discharge from hospital. Our internet-based program allows patients to access the necessary information easily from home and provides support, especially during the immediate period after discharge from hospital when pain is a reported issue. This also fits with the Department of Health long term aims to deliver more care at home via digital solutions [15].

The material included within the ODP is created by the medical team and can be updated quickly and efficiently as required. It allows the language used to be tailored to an understandable level or altered if feedback suggests otherwise. Patients also have the option of video and audio if preferred over the written media. The high uptake of usage of the program and the consistent usage across all groups of patients has demonstrated that the information is accessible and useful. There is an abundance of information regarding THR and TKR available on the internet but by providing a specific platform containing this information, we can reduce the risk of patients accessing information which is inaccurate or misleading. The volume of information provided on the platform is vast and too much to be feasibly covered during a clinic appointment. An advantage of the ODP is that it allows the patient to browse the information at their own pace and re-visit any topics they wish, patients have reported that this reinforced the information that was discussed at clinic appointments [11].

During the coronavirus pandemic many face to face clinic appointments were cancelled emphasising that our reliance on clinic appointments to give information is not always feasible. Patients who had their appointments cancelled included those who were immediately post-surgery but the ODP provided them with information on exercises and what to expect post-operatively and also provided a way to contact their team with any issues or concerns. These remotely accessed information sources are becoming more relevant due to the difficulty maintaining face to face appointments as well as ever-increasing time constraints in clinic. Providing a resource such as this means that potentially vulnerable people can browse the information in their own time from the safety of their home.

The patients who used the platform used it on their phones, tablets and computers. The older age category of patients preferred to use a computer to access the platform. If a program was designed that relied on smartphone-based applications, rather than a server that can be accessed across any device, this could potentially impact on certain patients’ engagement and usage of the program, especially more elderly patients. This is supported by a study carried out in Australia which looked at cardiac education provided via mobile technology and found that the youngest age group (<56 years) was 4 times more likely to engage with mobile based technology and 5 times more likely to engage with information via a mobile application when compared with the oldest age group (69 years) [16]. Information such as this supports that a smartphone only platform would not be beneficial across all patient groups.

Limitations

A number of patients who were registered to the ODP did not activate their accounts and, of those who did activate their accounts, a proportion did not access the content provided. The present study did not aim to understand why these patients did not activate their accounts or access the content as this could be due to a number of reasons (e.g. incorrect email provided). Patients are offered and provided with access to the ODP, it is then their responsibility to engage with the content provided and actively participate in their own care. Future studies could aim to evaluate these passive participants in order to fully understand the value of implementing an ODP to deliver PES for patients undergoing THR and TKR.

Conclusion

A web-based ODP to deliver patient education and support demonstrates high levels of patient engagement irrespective of the patient’s age and sex. This method of information delivery is adaptable to individual patient requirements and can be helpful for the remote management of potentially vulnerable patient groups. A web-based ODP may be preferable over an app-based PES given the reliance on a computer to access the program in the older patient groups.

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Reviewer #1: Intervention: This is a study investigating the use of an Internet-based patient education and support program for patients having hip and knee joint replacement. The patient education and support program is briefly described in the introduction and in the methodology section, but no details are given to what specific educational information is given to patients. This information should be provided using something such as the TIDIER Framework, description of evidence informing the educational materials, and readability level. This is particularly important given the readers do not have access to the program. OR is it publicly available? Having more details on the program is important for readers to appraise the study results.

Background: The introduction does not provide the background and current state of the literature on patient education and support program. As well, it does not highlight the importance of conducting this study. The introduction is focused on the authors’ specific situation and does not acknowledge previous research done. The introduction should be revised to focus on previous research in this area to highlight knowledge gap. This would provide the justification needed to understand the importance of conducting this study.

Methods: The authors should revise the objectives to make them clearer and more specific (e.g., to specify population of interest). There are minimal methods included – what is the study design and research methods used? It appears to be more of a quality improvement type initiative rather than a study. Results in the abstract related to age appears to be contradictory in the 2 sentences. In the conclusion, the intervention is described as being effective. How as effectiveness measured? From my understanding of the results, it was only access that was measured.

Results: The result section is difficult to understand and follow. The authors should revised to make it clearer. Furthermore, authors should provide a table of the statistical test conducted with the results (e.g., T-Tests and results). For example, both mean and median is presented with a p value but it is unclear what statistical analysis was done to achieve the p value.

For access to the education program, results indicate that patients accessed it 29.1 times. Are you able to also add the time periods for when it was accessed? Was it over 1 month or over 6 months?

Of concern is that a significant number of patients never accessed the program. Was anything done to understand why or to help them gain the knowledge elsewhere?

The authors aim to 1) analyze demographic characteristics of patients using the PES, 2) determine how and when patients access the PES, and 3) investigate if there are differences in 1 and 2 based on age and gender. The discussion and conclusion states that the PES support high level of patient engagement and activity independent of age and gender. However, the reader does not see how the data collected is related to patient engagement and activity as the relationship is not clear. Patient engagement and activity were not specifically measured by the study. The abstract conclusion states it was effective but how was effectiveness measured?

The background indicates that patients should be actively involved in decisions about their care – how was this measured? Also it describes patients inclusion in decision making is important but this intervention was only provided after they were placed on the list for surgery. How did the intervention support decision making?

The narrative uses gender but the results only report on sex (male, female) – how was gender measured? If it was based on male/female, then please change to sex.

The discussion is hard to follow as it includes a broad discussion of different topics related to PES that do not all appear to be of importance for this study. The authors should revised to make clear discussion points related to their specific findings. For example, start with a statement that links findings from this study with the broader literature discussed. Currently it discusses broader literature and the final sentence makes a link. I suggest the broader literature should be moved to the background and focus the discussion on discussing the results of this study as it relates to the literature. The last paragraph discusses the data but does not link to broader literature – what do people like to use from the broader literature – phones, tablets, or computers.

Conclusions – please remove ‘effectively engages’ or add evidence in the results that indicates how they were engaged and how effectiveness was measured.

No study limitations are provided – this is important to add.

Specific comments:

Line 9: Gender should not be written with an “s”.

Line 13. The authors should spell out the dates.

Line 23. Please give the number found instead of writing “p=NS”.

Lines 42-43. The authors should review the sentence as it is difficult to understand.

Line 52. Please specify overall satisfaction. Satisfaction with what?

Line 78. Patients are made aware of the program by which individual and how?

Line 102. The authors should spell out the dates.

Line 108. Why did a 30-minute cap was used? How long is interacting with the PES supposed to be? The readers need more information on that decision.

Line 114-119. This section is unclear making it difficult to clearly understand how the data will be statistically analyzed. The authors should revise the section.

Line 121. Informed consent should be discussed at the beginning of the methodology section.

Lines 133-135. Were patients characteristics similar between hip and knee replacement sample?

Line 135. Please modify “Range” to “range”.

Line 136. The total time access should be discussed with the average of time the program was access (lines 140-145).

Line 140. The authors should not describe patients are “hip patients” or “knee patients”. The authors should refer to the participants as “patient who underwent hip replacement” or something similar to this.

Line 142. Please be consistent across the manuscript when referring to PES (is “platform” referring to PES?).

Line 144. What is the difference between number of time access and interaction with the PES?

Lines 142-145. The reader does not understand why access to the program is described with mean (SD) and also with median (IQR).

Lines 138-149. This section is confusing for the reader making it difficult to follow. The authors should revised to make it clearer.

Line 159. “…the program per access when compared with patients aged <50 years. Patients aged ≤50 years…” Please be consistent with aged. Is it <50 years or ≤50 years?

Line 173. Please insert “statistically” before “significant”.

Lines 174-175. The authors should review the sentence as it is difficult to understand.

Lines 190-203. This should be in the introduction.

Lines 210-212. “The finding that there was no difference in the rate of engagement for the older population compared to the younger groups is a new and reassuring finding, particularly given the growth in these types of information platforms within orthopaedics.” Can the authors provide more information of why it is a “reassuring finding”.

Lines 225-231. This study did not measure health literacy of participants. As a result, “Having an online PES has helped us to combat this possible disadvantage.” should be revised as this is a strong conclusion not supported by study aims and results.

Figure 4 – YAY is in the title and it should be BY. Also the headings do not line up correctly in the PDF.

**********

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Reviewer #1: No

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20 Feb 2022

Marie-Pascale Pomey

Academic Editor

PLOS ONE

Date: 31st January 2022

Dear Academic Editor,

Manuscript number: PONE-D-21-03212

Manuscript Title: Impact of age, gender and surgery type on engagement with an online patient education and support program developed for hip and knee replacement patients

Thank you for your time in reviewing our manuscript and providing us the opportunity to revise our work for reconsideration for your journal. The authors have considered each of the reviewers comments, please see the below responses in italics to each of the comments.

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Authors response: Manuscript formatted as per PLOS one guidelines

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Authors response: Tables have been included following the paragraph they are mentioned in.

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Authors response: Statistical reporting updated as per the guidelines.

4. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

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We will update your Data Availability statement to reflect the information you provide in your cover letter.

Authors response: Paul -Where can the minimal data set underlying the results be found?

Review comments to the Author

Intervention: This is a study investigating the use of an Internet-based patient education and support program for patients having hip and knee joint replacement. The patient education and support program is briefly described in the introduction and in the methodology section, but no details are given to what specific educational information is given to patients. This information should be provided using something such as the TIDIER Framework, description of evidence informing the educational materials, and readability level. This is particularly important given the readers do not have access to the program. OR is it publicly available? Having more details on the program is important for readers to appraise the study results.

Authors response:

We have revised the “Materials and Methods” section to include more detail. Please see “Intervention: Description of the Online Digital Platform (ODP) Intervention”.

Background: The introduction does not provide the background and current state of the literature on patient education and support program. As well, it does not highlight the importance of conducting this study. The introduction is focused on the authors’ specific situation and does not acknowledge previous research done. The introduction should be revised to focus on previous research in this area to highlight knowledge gap. This would provide the justification needed to understand the importance of conducting this study.

Authors response: We have revised the first paragraph and added an additional reference relating to the NICE clinical guidelines. We have adjusted the introductory paragraph regarding health literacy which highlights why patient education and support was provided and why it is useful. The systematic review in the discussion has been moved to the introduction section to provide more literature.

Methods: The authors should revise the objectives to make them clearer and more specific (e.g., to specify population of interest). There are minimal methods included – what is the study design and research methods used? It appears to be more of a quality improvement type initiative rather than a study. Results in the abstract related to age appears to be contradictory in the 2 sentences. In the conclusion, the intervention is described as being effective. How as effectiveness measured? From my understanding of the results, it was only access that was measured.

Authors response: We have revised the three objectives at the end of the introduction section so they are more clear and specific and are in line with what have analysed in the results section. We have revised the conclusion and removed reference to “effectiveness”.

Results: The result section is difficult to understand and follow. The authors should revised to make it clearer. Furthermore, authors should provide a table of the statistical test conducted with the results (e.g., T-Tests and results). For example, both mean and median is presented with a p value but it is unclear what statistical analysis was done to achieve the p value.

Authors response: Table 1 has been amended to include the p values. The Results section has also been revised and should be clearer to follow. Mean value has been removed and has instead been discussed in terms of median and IQR as the data is skewed.

For access to the education program, results indicate that patients accessed it 29.1 times. Are you able to also add the time periods for when it was accessed? Was it over 1 month or over 6 months?

Authors response: The time period that was analysed is as discussed in the methods section (21st September 2017 to 28th May 2020). We have reiterated this.

Of concern is that a significant number of patients never accessed the program. Was anything done to understand why or to help them gain the knowledge elsewhere?

Authors response: This has been added in as a limitation within the discussion section.

The authors aim to 1) analyze demographic characteristics of patients using the PES, 2) determine how and when patients access the PES, and 3) investigate if there are differences in 1 and 2 based on age and gender. The discussion and conclusion states that the PES support high level of patient engagement and activity independent of age and gender. However, the reader does not see how the data collected is related to patient engagement and activity as the relationship is not clear. Patient engagement and activity were not specifically measured by the study. The abstract conclusion states it was effective but how was effectiveness measured?

Authors response: Revised the aims/objectives of the manuscript.

The background indicates that patients should be actively involved in decisions about their care – how was this measured? Also it describes patients inclusion in decision making is important but this intervention was only provided after they were placed on the list for surgery. How did the intervention support decision making?

Authors response: The background has been reworded to describe how patients should be actively involved in their care, this includes decision-making, active participation and self-management. Within this manuscript, we look at patient engagement (number of times accessed, how long they spent on the platform) with the platform which is how we have measured how actively involved patients have been with their own care.

Please see “Intervention: Description of the Online Digital Platform (ODP) Intervention” within the Materials and Methods section for a more in depth description of the intervention and how this supports decision making and when they are provided the content.

The narrative uses gender but the results only report on sex (male, female) – how was gender measured? If it was based on male/female, then please change to sex.

Authors response: All references to “gender” have been changed to “sex”.

The discussion is hard to follow as it includes a broad discussion of different topics related to PES that do not all appear to be of importance for this study. The authors should revised to make clear discussion points related to their specific findings. For example, start with a statement that links findings from this study with the broader literature discussed. Currently it discusses broader literature and the final sentence makes a link. I suggest the broader literature should be moved to the background and focus the discussion on discussing the results of this study as it relates to the literature. The last paragraph discusses the data but does not link to broader literature – what do people like to use from the broader literature – phones, tablets, or computers.

Authors response: We have reworked the discussion and have also added in some additional references (e.g. supportive literature for the use of phones, tablets and computers).

Conclusions – please remove ‘effectively engages’ or add evidence in the results that indicates how they were engaged and how effectiveness was measured.

Authors response: Have removed “effectively engages” and reworded this to “demonstrates high levels of patient engagement”. Engagement was measured via how patients used the platform (e.g. time spent, number of times accessed) all of which have been analysed and reported within the manuscript.

No study limitations are provided – this is important to add.

Authors response: We have added a section for limitations and discussed those that did not activate their accounts or access the content.

Specific comments:

Line 9: Gender should not be written with an “s”.

Have changed all references to ‘gender’ to ‘sex’, the ‘s’ has automatically been removed as result.

Line 13. The authors should spell out the dates.

Have spelled out the dates.

Line 23. Please give the number found instead of writing “p=NS”.

Number found has been given.

Lines 42-43. The authors should review the sentence as it is difficult to understand.

Sentence has been reviewed.

Line 52. Please specify overall satisfaction. Satisfaction with what?

Sentence has been reviewed.

Line 78. Patients are made aware of the program by which individual and how?

Clarified this is done at the patient’s initial consultation and by their treating surgeon.

Line 102. The authors should spell out the dates.

Have spelled out the dates.

Line 108. Why did a 30-minute cap was used? How long is interacting with the PES supposed to be? The readers need more information on that decision.

This sentence has been elaborated.

Line 114-119. This section is unclear making it difficult to clearly understand how the data will be statistically analyzed. The authors should revise the section.

Revised, this should read clearer now.

Line 121. Informed consent should be discussed at the beginning of the methodology section.

Updated within the study methods section.

Lines 133-135. Were patients characteristics similar between hip and knee replacement sample?

Table one has been updated and now has total, THR and TKR each categorised into sex and age categories and also includes registered, activated and accessed.

Line 135. Please modify “Range” to “range”.

Corrected.

Line 136. The total time access should be discussed with the average of time the program was access (lines 140-145).

Moved this sentence.

Line 140. The authors should not describe patients are “hip patients” or “knee patients”. The authors should refer to the participants as “patient who underwent hip replacement” or something similar to this.

Have re-referred to these patients consistently as assigned to “total hip replacement (THR) carepacs” or “total knee replacement (TKR) carepacs”. It is not possible to say underwent THR/TKR as some of these patients would not have had their operation yet and are viewing pre-operative information.

Line 142. Please be consistent across the manuscript when referring to PES (is “platform” referring to PES?).

Have referred to the platform as ‘online digital platform (ODP)’.

Line 144. What is the difference between number of time access and interaction with the PES?

The wording has been changed as we note access and interaction has been used interchangeably to mean the same thing. Interaction has been changed to accessed.

Lines 142-145. The reader does not understand why access to the program is described with mean (SD) and also with median (IQR).

Revised – discussed using median and IQR, removed mean.

Lines 138-149. This section is confusing for the reader making it difficult to follow. The authors should revised to make it clearer.

Revised this section.

Line 159. “…the program per access when compared with patients aged <50 years. Patients aged ≤50 years…” Please be consistent with aged. Is it <50 years or ≤50 years?

Corrected.

Line 173. Please insert “statistically” before “significant”.

Inserted.

Lines 174-175. The authors should review the sentence as it is difficult to understand.

Reworded.

Lines 190-203. This should be in the introduction.

Moved to the second paragraph in the introduction.

Lines 210-212. “The finding that there was no difference in the rate of engagement for the older population compared to the younger groups is a new and reassuring finding, particularly given the growth in these types of information platforms within orthopaedics.” Can the authors provide more information of why it is a “reassuring finding”.

Reinforced with previous qualitative research on our online digital platform.

Lines 225-231. This study did not measure health literacy of participants. As a result, “Having an online PES has helped us to combat this possible disadvantage.” should be revised as this is a strong conclusion not supported by study aims and results.

Health literacy paragraph revised.

Figure 4 – YAY is in the title and it should be BY. Also the headings do not line up correctly in the PDF.

Corrected.

All of the above amendments have been reflected in the manuscript. We welcome additional comments if any.

Thank you for your time in reconsidering our manuscript and we look forward to your response.

Sincerely,

Rebecca Martin, Natalie Clark and Paul Baker

Secretary to Prof Baker Department of Trauma and Orthopaedics,

James Cook University Hospital,

Marton Road,

Middlesbrough,

TS4 3BW

Email: rmartin37@qub.ac.uk

Telephone: 07889005185

Submitted filename: Cover Letter in Response to Reviewers Comments NC RM 2.docx

Click here for additional data file.

1 May 2022