A total of 8 patients engaged with text messaging, attended clinic, and completed clinical evaluation, radiological assessment, and PROM scores. The average age was 70 years (range 59-85 years). The results are shown in Figure 1. The patient who did not answer the second question stated that it would have been yes, but as she was attending clinic she preferred “to tell you in person.”

The typical values chosen by surgeons for the existing PROMs were an OKS of 24 or less (out of a total of 48) and an HHS of less than 70 (out of 100) as indicating a poor score needing surgical opinion [19]. Both of these values are subjective, decided by the surgeons’ experience. The table shows that 4 binary VSF results (positive or negative) matched the clinical evaluation and in 3 cases related to the existing PROM. In 1 case, a positive VSF result did not match (a patient planned for revision surgery); 3 of 4 mixed responses did not match clinical or radiographic findings but had concerning PROM scores.

The 5 patients who did not engage with messaging were questioned on their reasons for not responding, and the reasons are summarized in Figure 2. The 8 patients who engaged with the text messages were asked the questions as outlined in Textbox 1. The transcribed recordings were analyzed by OB.

A total of 5 confirmed that it was appropriate to receive such messages, and 2 volunteered that it was a good idea. A total of 5 expressed surprise that they had received text messages from the Health Board, and 3 patients thought it may have been a scam; patients highlighted how important it was for a message sender to identify themselves. One suggested that instead of an unknown phone number they would prefer the message to be assigned a contact name, such as “(name of) Hospital.” However, the clarity of the first message was praised for having identifiable names and knowledge of their surgeon and procedure.

A total of 2 patients praised the VSF for being simple, and 2 said they would be happy to answer more questions by text message. Although all liked the brevity of the VSF, 5 patients wanted to expand on their answers, and 2 patients did provide additional information they thought was useful.

A total of 6 patients said they would be happy to receive further text messages from CAVUHB. The same number would be happy to communicate with their surgeon by text message if they were unable to see them in person, and 2 patients volunteered they would be happy to communicate with other members of the team instead of their surgeon. While 2 patients expressed a preference for communicating in future on a land line, 1 patient thought that text messaging would be “a good way for the NHS to save money.”

A total of 2 patients said they would not be happy using email to communicate in the future, and 2 would be happy to “touch base” using text messages on an annual basis, especially when there were unexpected gaps between appointments.

Finally, 2 patients expressed dismay at the time spent attending or the distance travelled to an outpatient clinic when there were no problems.

Appreciating the limitations of this study is an important part of its message. This was pilot study with a small sample to meet the requirements of ethical approval under Continuing Service Improvement. The Health Board does not routinely follow arthroplasty patients up in outpatient clinic more than 1 year postoperatively; our population of patients was more than 2 years after arthroplasty. The Health Board agreement was for a small scale pilot study only as prior patient consent had not been obtained; the patients were not informed of this study from the start of their surgical experience, which may have affected their opinions and engagement. Encouragingly, of the patients who did not respond, none refused to participate. Reasons for not engaging related to wrong numbers and physical or personal reasons related to mobile use more generally.

The methodology was pragmatic, sampling within the confines of existing patient clinics. Further work requires patients to be identified, consented, and involved from the outset of the study. This project focused on the patient-doctor communication and primarily the patients’ views on text messaging. We have not considered other surgeons’ views apart from those of the authors (who by definition are biased favorably toward the project). Investigation into other orthopedic surgeons’ views, as well as those of administration staff who may be involved in the response and analysis of the text message communication, are required. Data security would need to be improved in the future (in line with Good Clinical Practice guidelines [20]). Texting patients sequentially from a smartphone is impractical for a large population as is transposing data from a survey tool to a spreadsheet. An ideal system would be a text messaging system allowing identification of patients, automatic sending and responding, and data capture with analysis and auditing. We suggest including applicable elements of the Checklist for Reporting Results of Internet E-Surveys, an existing matrix for designing Web-based surveys [21].

Our results show more than half of long-term arthroplasty patients have a mobile device and reported that they regularly used it. Of those, nearly two-thirds readily engaged with the text messaging intervention. In studies using Web-based surveys with orthopedic patients, less than half of patients (who had enrolled at the start of their patient experience) responded. In comparison, response rates in our study suggest text messaging may be a feasible option for long-term follow-up for at least a proportion of patients. This we believe could readily increase with better records of mobile numbers and increasingly prevalence in use of devices [22]. Texting is a limited format but short messages are attractive. There were conflicting opinions regarding communication via email and telephone. It is unlikely that there is a single method acceptable to all patients, and assumptions should not be made [13].

This was the first time the Oswestry VSF has been described in practice. The measure requires further validation as a clinical tool, which is beyond the scope of this paper. It was chosen specifically for its relevance, brevity, and ease of response. Patients made positive comments about its short length, although the results suggest it may be too brief for this group of patients. While some patients may be willing to complete an OKS by text message, the ideal orthopedic PROM for text message responses has yet to be devised. A text-based PROM should be designed to be useable by a patient who may have poor eyesight and arthritic fingers, who may take 25 minutes to read and respond to a single text message (as one patient described).

Of 4 positive VSF outcomes, 3 matched clinical and radiological findings. The one negative PROM matched clinical findings. PROMs delivered via mobile technology may play a useful role in filtering patients into groups: for example, satisfied patients who can be safely observed remotely, and unsatisfied patients who need clinical attention potentially more quickly than in existing outpatient formats. The problem, as seen from these small numbers, is that nearly half of the patients cannot be easily classified by the mobile PROMs. One author (JR) uses existing PROMs preoperatively and postoperatively to monitor trends in patient symptoms and satisfaction. The literature suggests that it is more useful to monitor the change in score than absolute values and that PROMs are more likely to identify satisfied patients [23]. Combining PROMs delivered by mobile technology with automated radiography reporting could allow trends to be monitored and changes correlated with radiographic findings. A combination of mobile messaging and radiographs has potential as a long-term, low-cost follow-up system for a large proportion of arthroplasty patients.

As a result of our pilot study, we suggest future research into mobile technology delivered PROMs should do the following:

This pilot study on the use of text messaging to deliver PROMs to patients is an important first step to conducting rigorous research into new ways of monitoring outcomes in the long-term arthroplasty follow-up. Mobile technology, which is readily embraced by the arthroplasty demographic of today and could be universally used by the patients of tomorrow, should be engaged with and used by orthopedic surgery in the NHS. We have shown that many patients are willing and able to engage with mobile technology–delivered PROMs. Patient opinions on text messaging as a form of communication with their surgeons are generally positive, and text messaging could form an acceptable part of patient follow-up. For future research, we emphasize the importance of the involvement and engagement of patients and hospitals in these systems from the start of the arthroplasty pathway.