Effectiveness of an internet-based perioperative care programme to enhance postoperative recovery in gynaecological patients: cluster controlled trial with randomised stepped-wedge implementation

BMJ Open 2018;8:e017781. doi:10.1136/ bmjopen-2017-017781

Presented by: Dr G Roberts


Perioperative care is often a fragmented process between disciplines, patients, clinicians and hospitals.  A proof of concept trial had previously demonstrated in gynaecological care that an internet-based peri-operative care platform could potentially empower patients during this period; the aim to enhance post-operative recovery through appropriate self-management strategies, reduce inappropriate recovery behaviour and ultimately enable a quicker return to work.

Design & Setting

  • Three year (2011 to 2014) study sequentially across nine hospitals using a stepped-wedge cluster randomised trial (https://www.bmj.com/content/350/bmj.h391)
  • Eligible hospitals had to perform at least 100 hysterectomies or laparoscopic adnexal surgery. Hospitals served as the control group until the care programme was sequentially implemented.
  • Study design did not allow for blinding, but group allocation was concealed from patient until consent obtained. Data analysts blinded.


Over 400 employed women aged between 18 – 65 scheduled for surgery of benign gynaecological disease.


  • Scheduled for hysterectomy (vaginal, laparoscopic or abdominal) and/or laparoscopic adnexal surgery.
  • Aged between 18 – 65.
  • Employed for at least eight hours a week.


  • Severe benign comorbidity or malignancy.
  • Pregnancy
  • Computer or internet illiterate.
  • Insufficient command of Dutch language.


Internet-based care programme sequentially rolled out using a multifaceted implementation strategy. Patients were allocated to either the care programme (intervention) or usual care (control).  The care programme included an e-health intervention equipping patients with tailored personalised convalescence advice that had been designed by patients, gynaecologists, GPs and occupational physicians. Post-operatively, the web portal contained an interactive self-assessment tool to monitor recovery.



  • Sick leave duration until full sustainable return to work (defined as the resumption of own work or other work with equal earnings, for at least four weeks without recurrence of sick leave).


  • Functional health status
  • Recovery
  • Self-efficacy
  • Coping
  • Pain


  • 433 participants recruited from potentially 1591.
  • Data for primary outcome obtained from 401 participants while data for secondary outcomes obtained from 334 participants.
  • 8% of participants in intervention group used the website programme as intended.
  • Median duration until full sustainable return to work was 49 days in intervention group and 62 days in control group.
  • No demonstrable difference in functional health status, self-efficacy and coping.


The use of internet-based information technology to facilitate a gynaecology patient’s perioperative journey may result in a reduction in post-operative sick days.  It would be worth other surgical specialties adopting and evaluating this method, while identifying those patients who might benefit most from this approach.


  • Assessment of both patient and organisation.
  • Intention-to-treat.
  • Sub-group analysis.


  • Cluster design may have led to recruitment bias.
  • The online platform had a proof of concept but not necessarily validated.
  • Just under a third of eligible patients were recruited, the majority of whom either declined to participate or were not eligible.
  • Due to the eligibility criteria requiring employed women who were computer literate, a high proportion of participants were deemed highly educated – How can conclusions apply across the general population?
  • There was significantly more loss-to-follow up in the intervention group.


  • There is a potentially large positive bio-psycho-social impact if these results are proved to be reproducible.
  • Reduction in sick days would have a positive socio-economic effect.

 Potential for impact

With more focus and energy being applied to the process of perioperative care by many stakeholders and the increasing use of information technology, this approach may prove to empower patients during their perioperative journey and lead to better recovery profiles.  Care is needed however to ensure that there is more to recovery than simply ‘return to work’.