Burden incurred by patients and their caregivers after outpatient surgery: a prospective observational study

Opportunities and Challenges for Augmented Reality in Family Caregiving: Qualitative Video Elicitation Study

BACKGROUND

Although family caregivers play a critical role in care delivery, research has shown that they face significant physical, emotional, and informational challenges. One promising avenue to address some of caregivers' unmet needs is via the design of digital technologies that support caregivers' complex portfolio of responsibilities. Augmented reality (AR) applications, specifically, offer new affordances to aid caregivers as they perform care tasks in the home.

OBJECTIVE

This study explored how AR might assist family caregivers with the delivery of home-based cancer care. The specific objectives were to shed light on challenges caregivers face where AR might help, investigate opportunities for AR to support caregivers, and understand the risks of AR exacerbating caregiver burdens.

METHODS

We conducted a qualitative video elicitation study with clinicians and caregivers. We created 3 video elicitations that offer ways in which AR might support caregivers as they perform often high-stakes, unfamiliar, and anxiety-inducing tasks in postsurgical cancer care: wound care, drain care, and rehabilitative exercise. The elicitations show functional AR applications built using Unity Technologies software and Microsoft Hololens2. Using elicitations enabled us to avoid rediscovering known usability issues with current AR technologies, allowing us to focus on high-level, substantive feedback on potential future roles for AR in caregiving. Moreover, it enabled nonintrusive exploration of the inherently sensitive in-home cancer care context.

RESULTS

We recruited 22 participants for our study: 15 clinicians (eg, oncologists and nurses) and 7 family caregivers. Our findings shed light on clinicians' and caregivers' perceptions of current information and communication challenges caregivers face as they perform important physical care tasks as part of cancer treatment plans. Most significant was the need to provide better and ongoing support for execution of caregiving tasks in situ, when and where the tasks need to be performed. Such support needs to be tailored to the specific needs of the patient, to the stress-impaired capacities of the caregiver, and to the time-constrained communication availability of clinicians. We uncover opportunities for AR technologies to potentially increase caregiver confidence and reduce anxiety by supporting the capture and review of images and videos and by improving communication with clinicians. However, our findings also suggest ways in which, if not deployed carefully, AR technologies might exacerbate caregivers' already significant burdens.

CONCLUSIONS

These findings can inform both the design of future AR devices, software, and applications and the design of caregiver support interventions based on already available technology and processes. Our study suggests that AR technologies and the affordances they provide (eg, tailored support, enhanced monitoring and task accuracy, and improved communications) should be considered as a part of an integrated care journey involving multiple stakeholders, changing information needs, and different communication channels that blend in-person and internet-based synchronous and asynchronous care, illness, and recovery.

Long-term economic outcomes of ureteral injury in the United States

OBJECTIVES

Ureteral injuries (UIs) during surgical procedures can have serious consequences for patients. Although UIs can result in substantial clinical burden, few studies report the impact of these injuries on payer reimbursement and patient cost-sharing. This retrospective study evaluated 30-day, 90-day, and 1-year healthcare resource utilization for patients with UIs and estimated patient and payer costs.

METHODS

Patients aged ≥ 12 years who underwent abdominopelvic surgery from January 2016 to December 2018 were identified in a United States claims database. Patients were followed for 1 year to estimate all-cause healthcare visits and costs for patients and payers. Surgeries resulting in UIs within 30 days from the surgery date were matched to surgeries without UIs to estimate UI-attributable visits and costs.

RESULTS

Five hundred and twenty-two patients with UIs were included. Almost a third (29.9%) of patients with UIs had outpatient surgery. Patients with UIs had slightly more healthcare visits and a 15.3% higher 30-day hospital readmission rate than patients without UIs. Patient costs due to UIs were not statistically significant, but annual payer costs attributable to UIs were $38,859 (95% CI = 28,142-49,576), largely driven by inpatient costs.

CONCLUSIONS

UIs add substantial cost for payers and result in more healthcare visits for patients. These findings highlight the importance of including inpatient and outpatient settings for UI prevention. Although UIs are rare, the associated patient and payer burdens are high; thus, protocols or techniques are needed to recognize and avert UIs as current guideline recommendations are lacking.

Shared Decision Making in the Geriatric Surgery Verification Program: Assessing Baseline Performance

CONTEXT

As part of the launch of the Geriatric Surgery Verification program in 2019, the American College of Surgeons issued care standards for older patients, including requirements for preoperative documentation of patients' goals. Hospital performance on these standards prior to the Geriatric Surgery Verification program is unknown.

OBJECTIVES

To assess baseline performance of the Geriatric Surgery Verification (GSV) standard for documentation of preoperative goals for older patients, and to determine factors associated with standard adherence.

METHODS

Using natural language processing, this study examines the electronic health records of patients aged 65 years or older who underwent coronary artery bypass grafts (CABG) or colectomies in 2017 or 2018 at three hospitals. The primary outcome was adherence to at least one of the three components of GSV Standard 5.1, which requires preoperative documentation of overall health goals, treatment goals, and patient-centered outcomes.

RESULTS

A total of 2630 operations and 2563 patients were included. At least one component of the standard was met in 307 (11.7%) operations and all three components were met in 5 (0.2%). Higher likelihood of meeting the standard was demonstrated for patients who were female (odds ratio [OR] 1.30; 95% CI 1.00-1.68), undergoing colectomy (OR 2.82; 95% CI 2.15-3.72), or with more comorbidities (Charlson scores >3 [OR 1.55; 95% CI 1.14-2.09]).

CONCLUSION

Before GSV program implementation, clinicians for two major operations almost never met the GSV standard for preoperative discussion of patient goals. Interdisciplinary teams will need to adjust clinical practice to meet best-practice communication standards for older patients.

Preoperative Education for Less Outpatient Pain after Surgery (PELOPS trial) in orthopedic patients-study protocol for a randomized controlled trial

Background

Successful pain management after outpatient surgery requires proper education leading to correct decisions on the analgesics use at home. Despite different strategies adopted, up to ½ of patients receive little or no information about the treatment of postoperative pain, 1/3 of them are not able to follow postoperative analgesia instructions. This leads to higher rates of unmet needs in pain treatment, post-discharge emergency calls, and readmissions. Structured educational interventions using psychological empowering techniques may improve postoperative pain management. We hypothesize that preoperative education on use of an improved pain scale to make correct pain management decisions will improve the quality of post-operative pain management at home and reduce analgesics-related side effects.

Methods

A total of 414 patients scheduled for an outpatient orthopedic surgery (knee/shoulder arthroscopic interventions) are included in this randomized (1:1) controlled trial. Patients in the control arm receive standard information on post-discharge pain management. Patients in the experimental arm receive structured educational intervention based on the rational perception of postoperative pain and discomfort (anchoring and improved pain scale), and the proper use of analgesics. There is no difference in post-discharge analgesics regimen in both arms. Patients are followed for 30 days post-discharge, with the primary outcome expressed as total pain relief score at 5 days. Secondary outcomes include the incidence of severe pain during 30 days, changes in sleep quality (Pittsburg Sleep Quality Assessment), and patients’ perception of postoperative pain management assessed with the International Pain Outcomes questionnaire at day 30 post-discharge.

Discussion

The developed intervention, based on an improved pain scale, offers the advantages of being non-surgery-specific, is easily administered in a short amount of time, and can be delivered individually or in-group, by physicians or nurses.

Trial registration

ClinicalTrials.govNCT03754699. Registered on November 27, 2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06387-6.

Recent Increases in Outpatient Total Hip Arthroplasty Have Not Increased Early Complications

BACKGROUND

Outpatient total hip arthroplasty (THA) has increased in recent years. Recent regulatory changes may allow and incentivize outpatient THA in more patients; however, there are concerns regarding safety. The purpose of this study is to assess early complications in outpatient THA compared to longer hospitalization.

METHODS

We identified patients undergoing primary THA in the National Surgical Quality Improvement Program database between 2015 and 2018. Patients were stratified by length of stay (LOS): 0 days (LOS 0), 1-2 days, and ≥3 days. Thirty-day rates of any complication, wound complications, readmissions, and reoperation were assessed. Multivariate analysis was performed.

RESULTS

In total, 4813 (4%) patients underwent outpatient THA, 84,627 (64%) had LOS of 1-2 days, and 42,293 (32%) had LOS ≥3 days. LOS 0 patients were younger, had lower body mass index, and less medical comorbidities compared to those with postsurgical hospitalization. Any complication was experienced in 3.2% of the LOS 0 group, 5.3% of the LOS 1-2 group, and 15.6% for the LOS ≥3 group (P < .0001). Readmission rates were 1.6%, 2.6%, and 4.7% for the 3 groups, respectively (P < .0001). After controlling for confounding variables, patients with LOS 1-2 days had higher odds for any complication (odds ratio 1.56 [1.32-1.83) and readmission (odds ratio 1.41 [1.12-1.78]) compared to LOS 0 days. Patients with LOS ≥3 days had higher odds for complications compared to LOS 0 or 1-2 days.

CONCLUSION

Outpatient THA had lower odds for readmission or complications compared to LOS 1-2 days. Despite increased outpatient surgery, many patients had postsurgical hospitalization and, due to patient factors, this remains an integral patient of post-THA care.

Longer Length of Stay Is Associated With More Early Complications After Total Knee Arthroplasty

Background

Length of stay (LOS) following total knee arthroplasty (TKA) has decreased over recently years. In 2018, the Centers for Medicare and Medicaid Services removed TKA from Inpatient-Only List (IPO), incentivizing further expansion of outpatient TKA. However, many patients may still require postsurgical hospitalization. The purpose of this study was to assess early outcomes for TKA based on length of stay (LOS).

Methods

We identified patients undergoing elective, primary TKA in the National Surgical Quality Improvement Program database using CPT code 27447 between 2015 and 2018. Patients were stratified by length of stay (LOS) 0 days, 1-2 days, and ≥3 days. Thirty-day rates of any complication, wound complications, readmission, and reoperation were assessed. Multivariate analysis was performed to adjust for confounding variables.

Results

5,655 (3%) patients underwent outpatient TKA, 130,543 (59%) had LOS 1-2 days, and 84,986 (38%) had LOS ≥3 days. Any complication was experienced in 4.1% of those with LOS 0 days, 4.3% for those with LOS of 1-2 days, and 10.5% for patients with LOS ≥3 days (p<0.0001). Readmission occurred in 2.2%, 2.6%, and 4.0% for the 3 groups, respectively (p<0.0001). After multivariate analysis, there was no significant difference in any outcome measure between patients with LOS 0 and 1-2 days, however those with LOS ≥3 days had higher odds of complications, reoperation, and readmission.

Conclusion

A significant number of patients had LOS ≥3 days following TKA and had more comorbidities and complications. Outpatient TKA was not associated with increased early complication compared to those with LOS of 1-2 days. Despite expansion of outpatient surgery, postsurgical hospitalization remains an integral part of care following TKA. Level of Evidence: III.

Has Removal From the Inpatient-Only List Increased Complications After Outpatient Total Knee Arthroplasty?

BACKGROUND

On 1/1/2018, the Centers for Medicare and Medicaid Services removed total knee arthroplasty (TKA) from the Inpatient-Only (IPO) list. This change allowed expansion of outpatient TKA, potentially to include older, more frail patients at greater risk for perioperative complications. The purpose of this study was to evaluate the impact of removing TKA from the IPO list on early complications.

METHODS

Patients undergoing TKA in the National Surgical Quality Improvement Program database were identified using CPT code 27447. Only cases with length of stay of zero days were included. Rates of 30-day complications, readmissions, and reoperation were compared before and after TKA was removed from the IPO list (2015-2017 vs 2018). The analysis was performed both with and without propensity score matching.

RESULTS

212,313 patients underwent TKA during the study period. 2466 (1.5%) were outpatient TKA in 2015-2017 and 3189 (5.6%) in 2018. After propensity matching, there were 2458 patients in each cohort. Rates of total 30-day complications were significantly lower in 2018 (3.7%) than the years TKA remained on the IPO (4.5%, P = .04). Similarly, rates of any reoperation decreased from 1.2% during 2015-2017 to 0.6% in 2018 (P = .03). There were no significant changes in rates of readmission (2.5% vs 2.2%, P = .5) or wound complications (0.8% vs 0.8%, P = 1.0).

CONCLUSION

Removal of TKA from the IPO list did not result in an increase in complications or readmissions. These data suggest, despite the regulatory change, surgeons have continued to exercise sound judgment as to what patients can safely undergo outpatient TKA.

Outpatients' perception of their preoperative information regarding their health literacy skills and their preoperative anxiety level: Protocol for a prospective multicenter cross-sectional study

Despite the benefits related to ambulatory surgery such as cost reduction due to lack of accommodation and patient satisfaction due to early home return, it may not lead to these expected benefits. Indeed, this kind of practice can increase responsibility for the person being treated and his or her relatives. It is therefore essential to inform them as well as possible to obtain their adherence to the proposed care protocol. Nevertheless, patients' failures to comply with preoperative instructions or the non-attendance of the patient may result in late cancellation of the scheduled surgery. In order to reduce this kind of dysfunction, the Assistance Publique-Hôpitaux de Paris (APHP) uses a reminder system by Short Message Service (SMS).This study is a descriptive cross-sectional multicenter study that focuses on outpatients' lived experiences of their preoperative preparation and information. It aims to collect patients' perceptions of their ability to follow preoperative instructions received by SMS the day before an operation performed for ambulatory surgery, according to their level of health literacy (HL) and preoperative anxiety. Indeed, poor communication between patients and doctors can contribute to preoperative anxiety, while low health literacy (LHL) can lead to poor understanding of preoperative preparation instructions. Therefore, it seems important to take these 2 criteria into account in this study. This research is designed to interview outpatients undergoing ambulatory surgery in the establishments of APHP. A self-questionnaire will be used for this purpose. The choice of this institution is justified by its decision to use in all care units the reminder of preoperative instructions by SMS.The main outcome is the perception of outpatients with LHL skills regarding preoperative information provided by doctors.French ethics review committee (Comité d'Ethique de la Recherche) of the University of Paris has approved the study protocol (IRB 00012020-14). Results from this study will be disseminated through oral communications and a scientific article in an international peer-reviewed journal.This protocol is registered on researchregistry.com (researchregistry5834). This version number is 1.1 Protocol dated July 22, 2020.

Assessment of caregiver burden in patients undergoing in- and out-patient neurosurgery

The objective of this study is to describe the caregiver burden, as well as the financial burden among caregivers after inpatient and outpatient neurosurgical patients. In this single center, observational study, adult patients undergoing elective inpatient or outpatient neurosurgery (supratentorial tumor resection or lumbar microdiscectomy) and his/her caregiver were recruited for the study. Bakas Caregiving Outcome Scale (BCOS) was used to assess caregiver burden and data was collected from preoperative period until post-operative day (POD) 30. Cost burden was assessed by a cost diary from day of surgery till POD 7. Forty-eight patient-caregiver pairs (21 inpatient craniotomies, 7 outpatient craniotomies, and 20 outpatient microdiscectomies) completed the study. BCOS values were in the negative impact range (<60) on POD1 in craniotomy group and improved to positive impact range (>60) after POD3. Median BCOS score remained at 60 in outpatient microdiscectomy. 56% of caregiver had at least 1 day of loss of income and 20% lost income throughout first 8 days. Median Cost (in Canadian dollars) associated with caregiving ranged from C$57 to C$250 amongst different groups. We concluded that caring for patients after craniotomy is psychologically demanding which leads to an increase in caregiver burden. In addition, there is a cost burden for the care givers in the form of missed workdays and additional direct expenses. Further studies are needed to recognize this problem and address the burden among the caregivers in the neurosurgical population.

Perioperative satisfaction and health economic questionnaires in patients undergoing an elective hip and knee arthroplasty: A prospective observational cohort study

Background:

Early hospital discharge shifts the recovery burden toward the patient and can leave patients and their caregivers anxious about the recovery process. Postoperative home care must be broadened to include appropriate and adequate support to address recovery at home. In this prospective study, patient and caregiver perspectives on the level of preparation/satisfaction and cost associated with management of recovery in the postoperative period were evaluated.

Methods:

We designed this prospective study to measure patient-reported outcomes and to inform the design of a postoperative home monitoring system. Patients undergoing inpatient total hip or knee replacements were recruited from a preadmission clinic at a university hospital. Patients and caregivers completed preoperative, postoperative, and health economic questionnaires. Bivariate analyses were conducted to understand factors associated with satisfaction with care.

Results:

Of 239 patients and caregivers recruited, preoperative questionnaire was completed by 98.8% of patients, the postoperative follow-up questionnaire was completed by 94.2% of patients, 75% of informal caregivers completed the postoperative follow-up questionnaires, and 93.7% completed the health economic questionnaire. The postoperative satisfaction scores were higher than the preoperative needs/expectation scores for both the overall and individual subscales. Patients undergoing hip arthroplasty reported higher satisfaction scores for postoperative pain management than patients undergoing knee arthroplasty (hip arthroplasty vs. knee arthroplasty: 4.07 ± 1.11 vs. 3.37 ± 1.51; P < 0.001). Patients who underwent knee arthroplasty reported better satisfaction scores with regard to having enough information on how to manage leg stiffness at home compared to patients undergoing hip arthroplasty (knee arthroplasty vs. hip arthroplasty: 3.13 ± 1.35 vs. 2.78 ± 1.30; P = 0.04).

Conclusion:

Overall, patients are generally satisfied with perioperative care, but they have distinct needs and expectations regarding perioperative medication and postoperative pain management. Virtual postoperative monitoring may be a useful tool during postoperative care to address many of patients’ concerns.

Does the Impact of Joint Arthroplasty Extend Beyond the Patient? The Effect of Total Joint Arthroplasty on Patient's Significant Others

BACKGROUND

This prospective cohort study evaluates the impact of total hip arthroplasty and total knee arthroplasty on patient's spouses/significant others (SSOs).

METHODS

Patients and SSOs were provided similar outcome metrics (Global Health Patient-Reported Outcomes Measurement Information System, Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement) at preoperative and postoperative visits. Pearson correlation was used to evaluate scores.

RESULTS

Our sample included 99 patients (58 total hip arthroplasties and 41 total knee arthroplasties). We found strong correlation between patient and SSO mental status scores. We found moderate correlation for some physical function domains.

CONCLUSION

SSOs closely share total joint arthroplasty patient's mental and even some of the physical burden of disease and recovery.

Family Caregiver Strain and Challenges When Caring for Orthopedic Patients: A Systematic Review

Background: Caregivers represent the core of patients’ care in hospital structures, in the process of care and self-care after discharge. We aim to identify the factors that affect the strain of caring for orthopedic patients and how these factors are related to the quality of life of caregivers. We also want to evaluate the role of caregivers in orthopedic disease, focusing attention on the patient–caregiver dyad. Methods: A comprehensive search on PubMed, Cochrane, CINAHL and Embase databases was conducted. This review was reported following PRISMA statement guidance. Studies were selected, according to inclusion and exclusion criteria, about patient–caregiver dyads. For quality assessment, we used the MINORS and the Cochrane Risk of BIAS assessment tool. Results: 28 studies were included in the systematic review; in these studies, 3034 dyads were analyzed. Caregivers were not always able to bear the difficulties of care. An improvement in strain was observed after behavioral interventions from health-care team members; Conclusions: The role of the caregiver can lead to a deterioration of physical, cognitive and mental conditions. The use of behavioral interventions increased quality of life, reducing the strain in caregivers of orthopedic patients. For this reason, it is important to consider the impact that orthopedic disease has on the strain of the caregiver and to address this topic.

Rapid Discharge and Outpatient Total Joint Arthroplasty Introduce a Burden of Care to the Surgeon

BACKGROUND

Rapid-pathway outpatient (OTJA) and one-night inpatient (ITJA) arthroplasty require close follow-up by the surgeon. We quantify and characterize the total perioperative touches required in the first 7 days, and compare OTJA and ITJA patients.

METHODS

We reviewed 103 consecutive primary total joint arthroplasty (TJA) patients from April 2014 without exclusion; all patients were discharged either within 5 hours or the morning after surgery. All telephone and office visits during the first 7 days following surgery were studied. Specialized outpatient TJA education was included. We measured the frequency, duration, and subject matter of phone calls. Simple Poisson regression analysis and t-tests were used to determine significance.

RESULTS

None of the 103 rapid pathway patients were lost to follow-up. Average age was 61.2 years (range 26.9-83.0), with 49 females (47.6%), 78 total knee arthroplasties, average Charlson Comorbidity Index score of 2.1, and average body mass index of 29.5 kg/m². There were 253 touches required, averaging 2.5/patient. One hundred sixty were outgoing phone calls by the surgical team and 93 were incoming calls from patients. The average duration of each call was 4.74 minutes (SD 3.7). The entire group required 19 hours and 35 minutes of telephone contact. After including specialized education time, this cohort required 83.1 hours of clinical time, or 48.4 minutes per patient.

CONCLUSION

Postoperative care after rapid pathway TJA requires a significant burden of resources, shifted from the hospital to the surgeon. We found that both rapid pathway groups require similar work by the surgeon's team. This additional work should be considered by policymakers.

Postoperative Symptom Distress of Laparoscopic Cholecystectomy Ambulatory Surgery Patients

PURPOSE

The purposes of this study were to (1) identify symptoms that cause postoperative distress in ambulatory surgery patients; (2) identify symptom management techniques that effectively reduce distress of laparoscopic cholecystectomy (LC) postoperative symptoms at home after ambulatory surgery; and (3) identify facilitators and barriers to self-management of postoperative symptoms.

DESIGN

A qualitative descriptive study.

METHODS

Two focus groups of ambulatory surgery patients who had experienced a laparoscopic cholecystectomy procedure and their caregivers were queried to elicit understanding of postoperative symptoms and symptom management techniques.

FINDINGS

Themes identified included distressing symptoms and consequences of surgery, symptom management, and self-management facilitators and barriers. Pain was a major symptom after surgery and impacted mobility and sleep. Participants in our study wanted realistic information about symptoms and more specific information on symptom management. Caregivers were important to the success of symptom management but experienced their own stress.

CONCLUSIONS

Perianesthesia nurses should focus not only on the immediate recovery, but also prepare patients and their caregivers for the more prolonged issues of recovery at home.