Strengths and limitations
RECRUITMENT
It was a strength that the estimated number of patients was included in part (IA), but the low number of participants biased the validation part (IB), and only smokers participated. The preliminary results of IB are probably not representative of the apps. Furthermore, the recruitment was strongly impacted by the COVID-19 pandemic, and participants were not included consecutively, which could lead to a selection bias.Self-reported alcohol intake may be underestimated, leading to false negative responses. In contrast, it is not over-estimated. For smoking, the under-estimation is lesser, and also, here, over-estimation is rather seldom. Overall, this means that if the patient report to be a smoker or drinking risky, as in this project, the risk of a false positive seems neglectable.The preliminary prototypes evaluated in IA were improved during the test period, and therefore, the final versions tested in IB differed from those in IA; thus, the results and comments cannot be compared across IA and IB. For security and safety reasons, the apps and the dashboards in this study were not connected to the department’s patient recording system. This may have increased the already high need for staff resources and competencies to introduce the apps to the patients, use the dashboard, and follow up, all of which may be a limitation. In general, pharmacotherapy is recommended to increase the successful quit rate in the perioperative period [The length of education and level of health literacy of the patients may impact the compliance with programs aiming at lifestyle intervention. However, in previous face-to-face studies, the intensive programs for lifestyle intervention used in this project have an overall major effect on smoking and drinking across the patient groups [This study should be generalized only with caution beyond Europe. Even across Europe, the cultural differences include differences in IT literacy and language. Thus, phrases may be stigmatizing by some persons and not by others; this could even be the case within the same country or municipality. Language may be considered more stigmatizing in an app without staff to adapt a dialog to the patients’ different vulnerabilities and situations. This could limit outreach via apps and other IT solutions to surgical patients needing perioperative risk reduction.