Prediction of time to return to work after gynaecological surgery: a prospective cohort study in the Netherlands

Variables impacting prolonged post-anesthesia care unit length of stay in gynecologic cancer patients in the era of same day minimally invasive hysterectomy

OBJECTIVES

Minimally invasive surgery for treatment of gynecologic malignancies is associated with decreased pain, fewer complications, earlier return to activity, lower cost, and shorter hospital stays. Patients are often discharged the day of surgery, but occasionally stay overnight due to prolonged post-anesthesia care unit (PACU) stays. The objective of this study was to identify risk factors for prolonged PACU length of stay (LOS).

METHODS

This is a single institution retrospective review of patients who underwent minimally invasive hysterectomy for gynecologic cancer from 2019 to 2022 and had a hospital stay <24-h. The primary outcome was PACU LOS. Demographics, pre-operative diagnoses, and surgical characteristics were recorded. After Box-Cox transformation, linear regression was used to determine significant predictors of PACU LOS.

RESULTS

For the 661 patients identified, median PACU LOS was 5.04 h (range 2.16-23.76 h). On univariate analysis, longer PACU LOS was associated with increased age (ρ = 0.106, p = 0.006), non-partnered status [mean difference (MD) = 0.019, p = 0.099], increased alcohol use (MD = 0.018, p = 0.102), increased Charlson Comorbidity Index (CCI) score (ρ = 0.065, p = 0.097), and ASA class ≥3 (MD = 0.033, p = 0.002). Using multivariate linear regression, increased age (R2 = 0.0011, p = 0.043), non-partnered status (R2 = 0.0389, p < 0.001), and ASA class ≥3 (R2 = 0.0250, p = 0.023) were associated with increased PACU LOS.

CONCLUSIONS

Identifying patients at risk for prolonged PACU LOS, including patients who are older, non-partnered, and have an ASA class ≥3, may allow for interventions to improve patient experience, better utilize hospital resources, decrease PACU overcrowding, and limit postoperative admissions and complications. The relationship between non-partnered status and PACU LOS is the most novel relationship identified in this study.

Early return to work: Single-port vs. multiport laparoscopic surgery for benign ovarian tumor

Objective

To compare the return to work (RTW) time between single-port laparoscopic surgery (SPLS) and multiport laparoscopic surgery (MPLS) for benign ovarian tumors.

Methods

A cross-sectional cohort study was conducted, which consisted of 335 women of reproductive age with benign ovarian tumors and who were keen on returning to work as early as possible. Surgical outcomes, postoperative pain score, postoperative satisfaction with the cosmesis score (CS), and the RTW time of the SPLS group were compared with those of the MPLS group. Besides, the RTW time and CS were calculated from the questionnaire survey by a single specialized gynecologist.

Results

Women who met the inclusion criteria were included in the SPLS (n = 106) and MPLS groups (n = 229). The RTW time in the SPLS group (22.13 ± 27. 06 days) was significantly shorter than that in the MPLS group (46.08 ± 57.86 days) (P &lt; 0.001). The multivariate Cox analysis results showed that age (HR = 0.984, 95% CI, 0.971−0.997, P = 0.020), SPLS (HR = 3.491, 95% CI, 2.422−5. 032, P &lt; 0.001), and return to normal activity time (HR = 0.980, 95% CI, 0.961−0.998, P = 0.029) were independent factors of the RTW time.

Conclusions

SPLS may be advantageous in terms of shortening the RTW time for women with benign ovarian tumors.

Effects of Video-Based Patient Education and Consultation on Unplanned Health Care Utilization and Early Recovery After Coronary Artery Bypass Surgery (IMPROV-ED): Randomized Controlled Trial

BACKGROUND

Health care utilization after coronary artery bypass graft (CABG) surgery is high and is partly of an unplanned nature. eHealth applications have been proposed to reduce care consumption, which involve and assist patients in their recovery. In this way, health care expenses could be reduced and quality of care could be improved.

OBJECTIVE

The aim of this study was to evaluate if an eHealth program can reduce unplanned health care utilization and improve mental and physical health in the first 6 weeks after CABG surgery.

METHODS

A single-blind randomized controlled trial was performed, in which patients scheduled for nonacute CABG surgery were included from a single center in the Netherlands between February 2020 and October 2021. Participants in the intervention group had, alongside standard care, access to an eHealth program consisting of online education videos and video consultations developed in conjunction with the Dutch Heart Foundation. The control group received standard care. The primary outcome was the volume and costs of a composite of unplanned health care utilization, including emergency department visits, outpatient clinic visits, rehospitalization, patient-initiated telephone consultations, and visits to a general practitioner, measured using the Medical Technology Assessment Medical Consumption Questionnaire. Patient-reported anxiety and recovery were also assessed. Intention-to-treat and "users-only" analyses were used.

RESULTS

During the study period, 280 patients were enrolled and randomly allocated at a 1:1 ratio to the intervention or control group. The intention-to-treat analysis consisted of 136 and 135 patients in the intervention and control group, respectively. At 6 weeks, the primary endpoint had occurred in 43 of 136 (31.6%) patients in the intervention group and in 61 of 135 (45.2%) patients in the control group (hazard ratio 0.56, 95% CI 0.34-0.92). Recovery was faster in the intervention group, whereas anxiety was similar between study groups. "Users-only" analysis yielded similar results.

CONCLUSIONS

An eHealth strategy comprising educational videos and video consultations can reduce unplanned health care utilization and can aid in faster patient-reported recovery in patients following CABG surgery.

TRIAL REGISTRATION

Netherlands Trial Registry NL8510; https://trialsearch.who.int/Trial2.aspx?TrialID=NL8510.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1007/s12471-020-01508-9.

Efficacy of a new day surgery management mode based on WeChat: a study protocol for randomised controlled trials

INTRODUCTION

There is an enormous imbalance between the rapid development of day surgery and the current conventional medical services. Hence, an effective day surgery management mode should be developed that can be used to constantly follow up on patients both preoperatively and postoperatively. In this study, WeChat was chosen as the platform. This study aimed to investigate the feasibility and effectiveness of a new day surgery management mode.

METHODS AND ANALYSIS

This randomised controlled study investigated the efficacy of a new day surgery management mode based on WeChat. The target number of participants was 1000 per group. The application (app) will send personalised information based on the medical history of the patient and the type of surgery at different time points preoperatively and postoperatively. The healthcare worker can follow up the patient and acquire clinical data by simply signing into the app. The patient and the healthcare worker can also engage in video or voice chats using the app when necessary. Multiple departments, including anaesthesiology, internal medicine, surgery, nursing and psychology, will participate in this new mode.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the West China Hospital of Sichuan University Biomedical Research Ethics Committee. Results of this study will be published in peer-reviewed journals and presented at international conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2100050793.

Endometrial ablation plus levonorgestrel releasing intrauterine system versus endometrial ablation alone in women with heavy menstrual bleeding: study protocol of a multicentre randomised controlled trial; MIRA2 trial

Background

It is estimated that between 12 to 25% of women who undergo an endometrial ablation for heavy menstrual bleeding (HMB) are dissatisfied after two years because of recurrent menstrual bleeding and/or cyclical pelvic pain, with around 15% of these women ultimately having a hysterectomy. The insertion of a levonorgestrel-releasing intrauterine system (LNG-IUS) immediately after endometrial ablation may inactivate residual untreated endometrium and/or inhibit the regeneration of endometrial tissue. Furthermore, the LNG-IUS may prevent agglutination of the uterine walls preventing intrauterine adhesion formation associated with endometrial ablation. In these ways, insertion of an LNG-IUS immediately after endometrial ablation might prevent subsequent hysterectomies because of persisting uterine bleeding and cyclical pelvic pain or pain that arises de novo. Hence, we evaluate if the combination of endometrial ablation and an LNG-IUS is superior to endometrial ablation alone in terms of reducing subsequent rates of hysterectomy at two years following the initial ablative procedure.

Methods/design

We perform a multicentre randomised controlled trial in 35 hospitals in the Netherlands. Women with heavy menstrual bleeding, who opt for treatment with endometrial ablation and without contraindication for an LNG-IUS are eligible. After informed consent, participants are randomly allocated to either endometrial ablation plus LNG-IUS or endometrial ablation alone. The primary outcome is the hysterectomy rate at 24 months following endometrial ablation. Secondary outcomes include women’s satisfaction, reinterventions, complications, side effects, menstrual bleeding patterns, quality of life, societal costs.

Discussion

The results of this study will help clinicians inform women with HMB who opt for treatment with endometrial ablation about whether concomitant use of the LNG-IUS is beneficial for reducing the need for hysterectomy due to ongoing bleeding and/or pain symptoms.

Trial registration Dutch Trial registration: NL7817. Registered 20 June 2019, https://www.trialregister.nl/trial/7817.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01843-6.

Return to work following pelvic reconstructive surgery: secondary analysis of Operations and Pelvic Muscle Training in the Management of Apical Support Loss trial

BACKGROUND

Patients' return to work is an important part of surgical counseling and quality of life.

OBJECTIVE

This study aimed to evaluate the pattern of patients' return to work and loss of productivity after pelvic reconstructive surgery.

STUDY DESIGN

This was a secondary analysis of the randomized controlled trial Operations and Pelvic Muscle Training in the Management of Apical Support Loss. The primary outcome was return to work defined by the answer to "How many calendar weeks or workdays did you not go to work after the original prolapse surgery?" Furthermore, loss of productivity included hours and days per week worked and discontinuation of paid work because of urogynecologic conditions. Moreover, predictors affecting the timing of return to work and loss of productivity were assessed.

RESULTS

Here, 180 patients (49%) were working before surgery. Of these patients, half returned to work 35 days after surgery, with 21 (13%) returning to work immediately after surgery and 43 (27%) returning to work within ≤2 weeks. The number of days missed did not differ between patients who underwent sacrospinous ligament fixation and those who underwent uterosacral ligament suspension (P=.23). At 3 months, 15 patients (9%) who were working before surgery had stopped working, but those who continued to work had similar hours per week as before surgery (36±12 vs 35±13; P=.48). Of note, 17 patients (11%) reported being less productive, on average working at 60% effectiveness. Most patients (96%) reported not missing any hours of household chores by 3 months after surgery. Patients who returned to work within 6 weeks had a higher rate of retreatment with either pessary or surgery within 2 years (5 of 85 [6.8%] vs 0 of 76 [0%]; P=.03). Those who returned to work within 2 weeks worked fewer hours before surgery (30±15 vs 36±12; P=.013), were less likely to have private insurance (77% vs 91%; P=.03), and had a higher rate of retreatment (3 of 30 [13%] vs 2 of 131 [1.7%]; P=.007). There was no difference in bulge symptoms and anatomic failure based on return to work.

CONCLUSION

Most patients returned to work within 35 days after surgery. Working less than full time and not having private insurance were predictors of earlier return to work.

Predictive factors of return to work after hysterectomy: a retrospective study

Purpose

Although hysterectomy is one of the most frequently performed gynaecological surgeries, there is a dearth of evidence on perioperative care. The aim of the current study was to identify sociodemographic, surgical-related and work-related predictors of recovery following different approaches of hysterectomy.

Methods

Eligible patients for this retrospective cohort study were women who underwent vaginal, abdominal or laparoscopic hysterectomy for both benign and malignant gynaecological disease in 2014 in Máxima Medical Centre in the Netherlands. The main outcome measure was full return to work (RTW). Data were collected using a patient survey. Potential prognostic factors for time to RTW were examined in univariate Cox regression analyses. The strongest prognostic factors were combined in a multivariable model.

Results

In total 83 women were included. Median time to full return to work was 8 weeks (interquartile range [IQR] 6–12). The multivariable analysis showed that higher age (hazard ratio [HR] 1.053, 95% confidence interval [CI] 1.012–1.095) and same day removal of indwelling catheter (HR 0.122, 95% CI 0.028–0.539) were predictors of shorter duration until full RTW after hysterectomy.

Conclusions

This study provided insight in the predictors of recovery after hysterectomy. By identifying patient specific factors, pre-operative counselling can be individualized, changes can be made in perioperative care and effective interventions can be designed to target those factors.

A WeChat-Based Mobile Platform for Perioperative Health Education for Gastrointestinal Surgery

Appropriately instructing and guiding patients before and after surgery is essential for their successful recovery. In recent years, however, the development of the enhanced recovery after surgery (ERAS) protocol has restricted the opportunity for healthcare professionals to spend time with their patients before and after surgery because of efficiency-driven, shortened hospital stay. Here, we embedded health education information of the perioperative period for gastrointestinal surgery on a WeChat-based mobile platform and evaluated the platform through medical staff evaluation, patient volunteer evaluation, and quantitative grading rubric. Clinicians and nurses believed that the mobile platform was attractively designed and easy to navigate, valuable, and adequate for patient health education. The content of health education was embedded into the WeChat-based mobile platform, thereby allowing patients and caregivers to access information at their own pace and enable repeat reading.

Postoperative Work and Activity Restrictions After Abdominal Surgery: A Systematic Review

OBJECTIVE

This systematic review aims to assess what is known about convalescence following abdominal surgery. Through a review of the basic science and clinical literature, we explored the effect of physical activity on the healing fascia and the optimal timing for postoperative activity.

BACKGROUND

Abdominal surgery confers a 30% risk of incisional hernia development. To mitigate this, surgeons often impose postoperative activity restrictions. However, it is unclear whether this is effective or potentially harmful in preventing hernias.

METHODS

We conducted 2 separate systematic reviews using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The first assessed available basic science literature on fascial healing. The second assessed available clinical literature on activity after abdominal surgery.

RESULTS

Seven articles met inclusion criteria for the basic science review and 22 for the clinical studies review. The basic science data demonstrated variability in maximal tensile strength and time for fascial healing, in part due to differences in layer of abdominal wall measured. Some animal studies indicated a positive effect of physical activity on the healing wound. Most clinical studies were qualitative, with only 3 randomized controlled trials on this topic. Variability was reported on clinician recommendations, time to return to activity, and factors that influence return to activity. Interventions designed to shorten convalescence demonstrated improvements only in patient-reported symptoms. None reported an association between activity and complications, such as incisional hernia.

CONCLUSIONS

This systematic review identified gaps in our understanding of what is best for patients recovering from abdominal surgery. Randomized controlled trials are crucial in safely optimizing the recovery period.

Prediction models in gynaecology: Transparent reporting needed for clinical application

The clinical application of prediction models is increasing within the field of gynaecology and obstetrics. This is mostly due to the fact that clinicians and patients prefer individualized counselling and person specific, more objective outcome assessment. To prevent using inadequate models, it is important to construct and perform prediction model studies correctly. Therefore, the TRIPOD statement (the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis) was developed. The aim of this review is to obtain an overview of the existing published prediction models for benign gynaecology and to investigate to what extent these studies meet the TRIPOD criteria. We performed a literature search in the databases PubMed, Embase and Cochrane Library from inception to August 2020. Searching the cross-references of the relevant studies within our search identified additional articles. Publications were included if the aim of the study was to develop a multivariable prediction model within the field of benign gynaecology. Two independent reviewers extracted the data. Analysis of the studies was performed by using a checklist derived from the TRIPOD criteria. Based on our search, 2487 studies were selected, including potential duplications. Eventually, a total of twenty-two studies were selected. 91% of these studies handled their predictors by univariable analysis before developing a multivariable prediction model. Fifteen studies described having missing data, but not all of them (9%) handled these missing data. Four different internal validation methods were used in twenty studies. Fifteen studies (68%) had prediction models with a C-index ≥ 0.7, which indicates a good model. Half of the studies (50%) did not measure the calibration, overall performance was described in two studies (9%). External validation was performed in 9% of the studies. The correct development of a prediction model within benign gynaecology and subsequent transparent reporting of the model development is important to facilitate clinical use. Without transparent reporting, wrong assumptions can be made leading to incorrect application of a specific prediction model. This overview shows that excepting carrying out an external validation, only one article met all the criteria. Therefore, we strongly recommend use of the TRIPOD criteria for developing and validating a prediction model (study). In addition, prior to publication, content experts should critically and statistically review the prediction model. If too many criteria are not met, refusing publication should be considered.

Utilizing Telemedicine for Delivery of Postoperative Care Following Minimally Invasive Gynecologic Surgery: A Randomized Controlled Trial

Objectives:

Determine if patient satisfaction is greater after delivering postoperative care via telemedicine following minimally invasive gynecologic surgery.

Materials and Methods:

University-based outpatient clinic; Randomized controlled trial (Canadian Task Force classification I). Females between 18 and 60 years of age scheduled to undergo laparoscopic hysterectomy or laparoscopic excision of endometriosis were invited to participate. Eligible patients were randomized to receive postoperative care either through a traditional office visit or via telemedicine. PSQ-18 satisfaction surveys were performed by phone after the visit.

Results:

Forty-one patients were analyzed out of which 25 were in the office group and 16 in the telemedicine group. Groups were homogenous to age (41.4 vs. 43.3 p. 48), body mass index (31.9 vs. 30.6 P = 0.52), distance in miles from home (12.7 vs. 12.4 P = 0.92), and parity (P = 0.51). PSQ-18 questionnaire was scored and each category was compared between the office and telemedicine groups. When comparing medians (interquartile range), the general satisfaction and time spent with doctor categories were significantly higher in the telemedicine group (4.0 [4.0, 4.5] vs. 4.5 [4.5, 5.0] P = 0.05), (4.0 [4.0, 4.5] vs. 4.5 [4.0, 5.0] P = 0.05). The remainder of the categories analyzed were not different between groups Technical Quality (4.0 [3.8, 4.5] vs. 4.5 [3.9, 5.0] P = 0.13), Interpersonal Manner (4.0 [4.0, 4.5] vs. 4.5 [4.0, 5.0] P = 0.34), Communication (4.5 [4.0, 4.5] vs. 4.5 [4.3, 5.0] P = 0.21), Accessibility and Convenience (4.0 [3.5, 4.5] v 4.0 [3.6, 4.5] P = 0.84). A chart review was performed, examining the first 30 days after surgery. One (4%) patient in the office group went to the ER after postoperative visit, and 0 in the telemedicine group (P = 0.42).

Conclusion:

Postoperative care via telemedicine after gynecologic surgery results in higher patient satisfaction.

Operationalizing Postdischarge Recovery From Laparoscopic Sacrocolpopexy for the Preoperative Consultative Visit

OBJECTIVE

The objective was to establish a threshold for postdischarge surgical recovery from laparoscopic sacrocolpopexy for the preoperative consultative visit to answer the "what is my recovery time?" question.

METHODS

Study participants (N = 171) with stage 2 or worse pelvic organ prolapse undergoing laparoscopic sacrocolpopexy who completed postoperative surveys at 4 time points. Postdischarge Surgical Recovery 13 (PSR13) scores were anchored to a Global Surgical Recovery (GSR) tool (if 100% recovery is back to your usual health, what percentage of recovery are you now?). Weighted mean PSR13 scores were calculated as a sum of the products variable when patients considered themselves 80 to less than 85, 85 to less than 90, 90 to less than 95, or 95 to 100 percent recovered on the GSR tool. The percentage of study participants recovered at postdischarge day 7, 14, 42, and 90 was calculated based on a comparison between the GSR scores and weighted mean PSR13 scores.

RESULTS

A PSR13 score of 80 or greater, corresponding to 85% or greater recovery, was seen in 55.6% (42 days) and 50.9% (90 days) of study participants, respectively, establishing this numeric threshold as representing "significant" postdischarge recovery after laparoscopic sacrocolpopexy. At 14 days after discharge, only 16.4% of the study population achieved this PSR13 score.

CONCLUSIONS

Most study subjects were "significantly" recovered at 42 days after laparoscopic sacrocolpopexy using a PSR13 score of 80 or greater as a numeric threshold. There is a need to determine the population percentage of recovered study subjects at 30, 60, and beyond 90 days from laparoscopic sacrocolpopexy.

Lack of Standardized Advice on Physical Strain Following Abdominal Surgery

BACKGROUND

In Germany as elsewhere, standardized recommendations are lacking on the avoidance of physical exertion to protect the abdom - inal wall in patients who have recently undergone abdominal surgery. It is unclear how much stress the abdominal wall can withstand and how long the patient should be exempted from work. The goal of this review is to determine whether there are any standardized, evidence-based recommendations for postoperative care from which valid recommendations for Germany can be derived.

METHODS

We systematically searched the literature for evidence-based recommendations on exertion avoidance after abdominal surgery, as well as for information on the extent to which postoperative abdominal wall stress contributes to incisional hernia formation. We then created a questionnaire on recommendation practices and sent it to all of the chiefs of general and visceral surgery services that were listed in the German hospital registry (1078 chiefs of service as of June 2016).

RESULTS

All 16 of the included studies on postoperative exertion avoidance contained low-level evidence that could only be used to formulate weak recommendations ("can," rather than "should" or "must"). Some 50 000 incisional hernia repair procedures are performed in Germany each year, with a reported incidence of 12.8% in the first two years after surgery. The scientifically documented risk factors for incisional herniation are related to techniques of wound closure, the suture materials used, wound infections, and the patient risk profile. From the biological point of view, the abdominal wall regains full, normal resistance to exertional stress 30 days after a laparotomy with uncomplicated healing. Most incisional hernias (>50%) arise 18 months or more after surgery; they are more common in patients who have avoided exertion for longer periods of time (more than 8 weeks). Our questionnaire was returned by 386 surgical clinics. The responses showed that 78% of recommendations were based on personal experience only. The recommendations varied widely; exertion avoidance was recommended for as long as 6 months.

CONCLUSION

The dilemma of a deficient evidence base for postoperative exertion avoidance to protect the abdominal wall should be resolved with the much higher-quality evidence available from hernia research, which concerns the patient population with the biologically least favorable starting conditions. Based on our analysis of the available literature in light of the biomechanical principles of abdominal wall healing, we propose a new set of recommendations on postoperative exertion avoidance after abdominal surgery, with the goal of eliminating excessively protracted exertion avoidance and enabling a timely return to work.

Recovery expectancies impact postdischarge recovery 42 days after laparoscopic sacrocolpopexy

INTRODUCTION AND HYPOTHESIS

The aim of this retrospective cohort study was to determine if recovery expectancies were associated with actual postdischarge recovery after laparoscopic sacrocolpopexy.

METHODS

Study subjects (N = 167) undergoing laparoscopic sacrocolpopexy were asked to preoperatively predict the likelihood of a prolonged postdischarge recovery (> 42 days). Low, medium, and high recovery expectancy groups were created from responses to the likelihood of prolonged postdischarge recovery question. Previously established predictors of actual recovery 42 days after laparoscopic sacrocolpopexy included age, body mass index, Charlson co-morbidity index, short form (SF)-36 bodily pain scores, doctors' and others' health locus of control, and sick role investment. One parsimonious hierarchical linear and logistic regression model was constructed to determine if preoperative recovery expectancies were independently associated with PSR13 scores and "significant" postdischarge recovery after controlling for previously established predictors.

RESULTS

Study subjects with high recovery expectancies had higher PSR13 scores than subjects with low recovery expectancies (82.32 ± 15.34 vs 73.30 ± 15.30, mean difference 9.01, 95%CI 1.08-16.94). Study subjects with low recovery expectancies scored 7.7 points lower on the PSR13 scale (minimally important difference = 5), which translated into a 73% reduction in the likelihood of being "significantly" recovered 42 days after surgery, after controlling for previously established predictors.

CONCLUSIONS

A low recovery expectancy has a negative impact on actual recovery 42 days after laparoscopic sacrocolpopexy. Our findings are important because preoperative recovery expectancies are modifiable predictors, making them a candidate for an expectancy manipulation intervention designed to optimize recovery after pelvic reconstructive surgery.

Factors Influencing Postoperative Recovery and Time Off Work of Patients with Benign Indications for Surgery - Results of a Prospective Study

Objectives The study aimed to answer a number of questions: Which medical, psychological and sociodemographic factors affect the recovery of women after gynecological surgery for benign indications? Does patients' health-related quality of life improve after surgical intervention? How long are patients signed off work postoperatively? How do patients assess their own capacity to work? Method Study population: All women between the ages of 18 and 67 years who underwent gynecological surgery for benign indications at the Charité Campus Virchow Clinic over a 7-month period were consecutively enrolled in the study. Four standardized patient surveys (the first survey [T0] was carried out in hospital, T1 at 1 week, T2 at 6 weeks and T3 at 7 - 8 months after discharge by telephone interview) were carried out using evaluated questionnaires to record patients' recovery (Recovery Index), quality of life (RAND-36), satisfaction, complications, sociodemographic information and time off work with a medical sick note. Relevant medical and demographic data were also collected. Statistical analysis was carried out using univariate statistical tests for descriptive analysis and complex multifactorial statistical procedures to record observations over time. Results A total of 182 patients were included in this study (participation rate: 70%). Relevant prior operations (p = 0.01), in-hospital (p = 0.004) and postoperative complications (p < 0.001), preoperative psychological wellbeing (p = 0.01), physical functioning (p = 0.005) and postoperative anxiety (p = 0,006) had a significant impact on recovery (Recovery Index) and changed significantly over time (p < 0.001). The invasiveness of the surgery or sociodemographic parameters (including migration background) had no significant effect. Health-related quality of life (measured with the RAND-36 questionnaire) also improved postoperatively. More invasive surgical interventions were associated with longer sick leave times and, to a certain extent, with a poorer evaluation of patients' capacity to work. Conclusion Recovery after gynecological surgery is a multifactorial process. This survey of a patient population identified psychological and physical factors which influence recovery but did not find significant sociodemographic parameters affecting recovery. Irrespective of these findings, gynecological surgery for benign indications resulted in an improvement in health-related quality of life. Prospective studies need to investigate whether psychological interventions could reduce preoperative fear and thereby improve postoperative recovery.

Identifying Expectations of Delayed Return to Work in Patients with Prostate Cancer at the Beginning of a Cancer Rehabilitation Program

Purpose To investigate factors associated with expectations of delayed return to work (RTW) in patients with prostate cancer recently admitted to a cancer rehabilitation program. Methods In this multicenter study, data about expected time until RTW and potential correlates (personal, medical, psychosocial and work-related factors) were obtained from 822 employed cancer rehabilitation participants at the beginning of the program. Participants expecting early RTW (≤ 3 months) and delayed RTW (> 3 months) were compared. Hierarchical multivariate logistic regression was applied to study which factors are associated with expecting delayed RTW. Results In total, 171 cancer rehabilitation participants (21%) expected delayed RTW. Group comparison showed education, type of occupation, income, number of comorbid conditions, tumor stage according to the staging system of the Union for International Cancer Control (UICC), anxiety and depression, quality-of-life functioning scales, urinary and treatment-related symptoms, duration of sick leave, subjective work ability, perceived ability to return to the former job, intention to apply for a disability pension, effort-reward-imbalance and occupational stress to be associated in bivariate analysis with participants' expectations. Multivariate analysis revealed UICC tumor stage III (compared to stages I/II, OR 2.36), lower subjective work ability (OR 0.82), perceived inability to return to the former job (OR 1.88) and intention to apply for a disability pension (OR 1.94) to increase the likelihood of expecting delayed RTW. Conclusions Negative or non-beneficial RTW expectations, which are related to self-perception and behavioral intention, seem to be key factors for expecting delayed RTW. Interventions to early identify and adjust such expectations might empower cancer rehabilitation participants to develop appropriate expectations for work recovery.

Socio-economic and occupational outcomes of long-term survivors of gynaecological cancer: A French population-based study

OBJECTIVE

To describe socio-economic and professional outcomes in long-term survivors of cervical, endometrial or ovarian cancer, including return to work and problems related to obtaining loans and insurance.

METHODS

Women with cervical, endometrial or ovarian cancers diagnosed from 2006 to 2013 were selected through the French gynaecological cancer registry of Côte d'Or, in a cross-sectional survey. Using a questionnaire established with the help of sociologists and psychologists, social and cancer-related work issues were collected among women aged less than 60 years at the time of cancer diagnosis. The socio-economic status was also assessed, at the time of the survey using the EPICES questionnaire.

RESULTS

A total of 92 gynaecological cancer survivors (CS) participated in this survey. Gynaecological CS reported a decrease in income since cancer diagnosis, difficulties obtaining loans, and a decrease in ability to work, both in the short term after treatment and at the time of survey, on average 6 years after diagnosis. Fatigue, emotional and cognitive difficulties were the reasons cited to explain the decreased ability to work, both immediately after treatment and in the long term.

CONCLUSIONS

Gynaecological CS experienced many problems, such as decreased work capacity, decreased income and difficulty obtaining loans.

Gynecologic Surgical Outcomes Through the Patient's Eyes: Are Physicians Looking in the Same Direction?

Importance

Patient-centered care integrates the highest clinical standards with patient preferences surrounding their treatment. Increasing focus is being placed on the identification of patient-centered outcomes to optimize the impact of medical treatments on patient quality of life, as defined by patients themselves.

Objective

This article will review the central concepts of patient-centered outcomes in benign gynecologic surgery. This expert review will serve as a practical guide for surgeons to incorporate patient preferences into shared surgical decision making.

Evidence Acquisition

The current literature is examined, defining those outcomes identified by women undergoing gynecologic procedures as the most important factors in their decision making. Available literature on these patient-identified priorities is then reviewed with respect to gynecologic surgery in the preoperative, intraoperative, and postoperative periods.

Results

Each section of the article concludes with Clinical Pearls, where practical tools and key elements are summarized to assist providers with incorporating these concepts into practice.

Conclusions and Relevance

Many key outcomes have been identified by women undergoing benign gynecologic surgery in their decision-making process. Patient counseling should address clinically appropriate treatment modalities and include an exploration of patient expectations and preferences around nonclinical outcomes as well. This shared decision-making model will result in improved satisfaction with outcomes.

Returning to Work Following Minimally Invasive Hysterectomy

This commentary presents data collected from one patient population and reviews the literature on returning to work following minimally invasive hysterectomy (MIH). Although MIH can reduce postoperative pain, decrease hospital stays, and accelerate return to activities of daily living, it has not consistently translated into a quicker return to work (RTW) for patients. A retrospective case series was performed assessing RTW times of 31 patients following elective MIH at Mount Sinai Hospital in Toronto in 2018. The median RTW time was 21 days. Patients returned to work significantly faster when they were counselled about an expected convalescence of 2 to 4 weeks (median 16 days) compared with a more traditional 4- to 8-week recovery (median 56 days). Surgeon recommendation can strongly affect when a patient returns to work following MIH. Most patients can RTW within 2 to 3 weeks. However, recommendations should be patient-centred and consider job description.

Listening to the HysterSisters: A Retrospective Keyword Frequency Analysis of Conversations About Hysterectomy Recovery

Background

In the postoperative period, individual patient experiences vary widely and are based on a diverse set of input variables influenced by all stakeholders in and throughout the surgical process. Although clinical research has primarily focused on clinical and administrative datasets to characterize the postoperative recovery experience, there is increasing interest in patient-reported outcome measures (PROMs). The growth of online communities in which patients themselves participate provides a venue to study PROMs directly. One such forum-based community is HysterSisters, dedicated to helping individuals through the experience of hysterectomy, a major surgery which removes the uterus. The surgery can be performed by a variety of methods such as minimally invasive approaches or the traditional abdominal approach using a larger incision. The community offers support for “medical and emotional issues [...] from diagnosis, to treatment, to recovery.” Users can specify when and what type of hysterectomy they underwent. They can discuss their shared experience of hysterectomy and provide, among other interactions, feedback, reassurance, sympathy, or advice, thus providing a unique view into conversations surrounding the hysterectomy experience.

Objective

We aimed to characterize conversations about hysterectomy recovery as experienced by users of the HysterSisters online community.

Methods

A retrospective keyword frequency analysis of the HysterSisters Hysterectomy Recovery forum was performed.

Results

Within the Hysterectomy Recovery forum, 33,311 unique users declared their hysterectomy date and type and posted during the first 12 weeks postsurgery. A taxonomy of 8 primary symptom groups was created using a seed list of keywords generated from a term frequency analysis of these threads. Pain and bleeding were the two most mentioned symptom groups and account for almost half of all symptom mentions (19,965/40,127). For symptoms categories such as pain and hormones and emotions, there was no difference in the proportion of users mentioning related keywords, regardless of the type of hysterectomy, whereas bleeding-related or intimacy-related keywords were mentioned more frequently by users undergoing certain minimally invasive approaches when compared with those undergoing abdominal hysterectomy. Temporal patterns in symptom mentions were noted as well. The majority of all posting activity occurred in the first 3 weeks. Across all keyword groups, individuals reporting minimally invasive procedures ceased forum use of these keywords significantly earlier than those reporting abdominal hysterectomy. Peaks in conversation volume surrounding particular symptom categories were also identified at 1, 3, and 6 weeks postoperatively.

Conclusions

The HysterSisters Hysterectomy Recovery forum and other such forums centered on users’ health care experience can provide novel actionable insights that can improve patient-centered care during the postoperative period. This study adds another dimension to the utility of social media analytics by demonstrating that measurement of post volumes and distribution of symptom mentions over time reveal key opportunities for beneficial symptom-specific patient engagement.

Interventions Developed with the Intervention Mapping Protocol in Work Disability Prevention: A Systematic Review of the Literature

Purposes Intervention mapping (IM) is a protocol for developing effective behavior change interventions. It has been used for 10 years to develop work disability prevention (WDP) interventions, but it is not known to what extent and with what success. The main objective of this study was to review the effectiveness of these interventions. Secondary objectives were to review their fidelity to the IM protocol, their theoretical frameworks and their content. Methods A search strategy was conducted in MEDLINE, Web of Science, PsycINFO, Pascal, Francis, and BDSP. All titles and abstracts were reviewed. A standardized extraction form was developed. All included studies were reviewed by two reviewers blinded to each other. Results Eight WDP interventions were identified aimed at return to work (RTW; n = 6) and self-management at work (n = 2). RTW interventions targeted workers with stress-related mental disorders (n = 1), low back pain (n = 1), musculoskeletal disorders (n = 1), cancer (n = 2) and gynecological surgery (n = 1). The fidelity to the IM protocol was weaker for the participatory planning group. Matrices of change, change methods, and applications were systematically reported. The main theoretical frameworks used were the attitude-social influence-self efficacy model (n = 4) and the theory of planned behavior (n = 2). Half of the interventions included a workplace component (n = 4). Two interventions were reported as effective, and one partially effective. Conclusion The IM protocol is used in WDP since 2007. The participative dimension appears underused. Few theoretical frameworks were used. Implications are to better consider the stakeholders involvement, and mobilize theoretical frameworks with greater attempts to intervene on the work environment.

Perioperative Outcomes for Stage I Non-Small Cell Lung Cancer: Differences Between Men and Women

BACKGROUND

Previous studies have highlighted important biologic and survival-related differences among men and women with non-small cell lung cancer (NSCLC). However, differences in perioperative or short-term outcomes have not been as well characterized. In this study, we investigated differences in the perioperative period and postoperative emergency department (ED) visits among men and women after lobectomy for stage I NSCLC.

METHODS

A retrospective review was performed of patients who underwent a lobectomy for clinical stage I NSCLC at a single institution from 2010 to 2015.

RESULTS

We identified 559 patients for inclusion, including 293 women (52%) and 266 men (48%). Women were more likely to present with clinical T1 status (p = 0.005) and to undergo a minimally invasive operation (p = 0.058). To reduce confounding, 206 case-matched pairs were identified. After matching, no differences were found in length of stay (p = 0.551) or pulmonary complications (p = 0.509); however, men experienced more cardiac complications (18% versus 7%, p = 0.001). Of importance, although rates of 30- and 90-day ED visits between sexes were similar (p = 0.531, p = 0.890, respectively) and no sex-related differences were found in presenting symptom on return to the ED (p = 0.478), women were more likely to be readmitted after presenting to the ED within 30 days (p = 0.038).

CONCLUSIONS

Women demonstrated an increased likelihood of being admitted after presenting to the ED within 30 days after discharge, indicating important differences between men and women in the short-term period after lobectomy. Further research will be required to further understand the cause for these differences.

Personalised perioperative care by e-health after intermediate-grade abdominal surgery: a multicentre, single-blind, randomised, placebo-controlled trial

BACKGROUND

Instructing and guiding patients after surgery is essential for successful recovery. However, the time that health-care professionals can spend with their patients postoperatively has been reduced because of efficiency-driven, shortened hospital stays. We evaluated the effect of a personalised e-health-care programme on return to normal activities after surgery.

METHODS

A multicentre, single-blind, randomised controlled trial was done at seven teaching hospitals in the Netherlands. Patients aged 18-75 years who were scheduled for laparoscopic cholecystectomy, inguinal hernia surgery, or laparoscopic adnexal surgery for a benign indication were recruited. An independent researcher randomly allocated participants to either the intervention or control group using computer-based randomisation lists, with stratification by sex, type of surgery, and hospital. Participants in the intervention group had access to a perioperative, personalised, e-health-care programme, which managed recovery expectations and provided postoperative guidance tailored to the patient. The control group received usual care and access to a placebo website containing standard general recovery advice. Participants were unaware of the study hypothesis and were asked to complete questionnaires at five timepoints during the 6-month period after surgery. The primary outcome was time between surgery and return to normal activities, measured using personalised patient-reported outcome measures. Intention-to-treat and per-protocol analyses were done. This trial is registered in the Netherlands National Trial Register, number NTR4699.

FINDINGS

Between Aug 24, 2015, and Aug 12, 2016, 344 participants were enrolled and randomly allocated to either the intervention (n=173) or control (n=171) group. 14 participants (4%) were lost to follow-up, with 330 participants included in the primary outcome analysis. Median time until return to normal activities was 21 days (95% CI 17-25) in the intervention group and 26 days (20-32) in the control group (hazard ratio 1·38, 95% CI 1·09-1·73; p=0·007). Complications did not differ between groups.

INTERPRETATION

A personalised e-health intervention after abdominal surgery speeds up the return to normal activities compared with usual care. Implementation of this e-health programme is recommended in patients undergoing intermediate-grade abdominal, gynaecological, or general surgical procedures.

FUNDING

ZonMw.

A Swedish population-based evaluation of benign hysterectomy, comparing minimally invasive and abdominal surgery

OBJECTIVE

The aim was to evaluate surgical routes for benign hysterectomy in a Swedish population, including abdominal and minimally invasive surgery.

STUDY DESIGN

Prospectively collected data from the Swedish National GynOp Registry 2009-2015: 13 806 hysterectomy cases were included: abdominal (AH, n = 7485), vaginal (VH, n = 3767), conventional laparoscopic (LH, n = 1539) and robotically-assisted (RAH, n = 1015).

RESULTS

The VH group had the shortest operation time at 75 min, AH 97 min and RAH 104 min. LH was longest at 127 min (p < 0.005). The mean estimated blood loss was higher in the AH group (250 ml) compared to all minimally invasive surgery (MIS, 65-172 ml); p < 0.005). Conversion rates were 10% for LH, 4.8% for VH and 1.6% for RAH (p < 0.005). Hospitalization and patient-reported time to normal activities of daily living (ADL) were longer for AH compared to MIS (p < 0.005). Time to return to work was eight days longer in the AH group (35 days) compared with the MIS groups (p < 0.005). Complications were fewest in the VH group at 5.4% compared with AH 7.6% and RAH 8.7% (both p < 0.001), but did not significantly differ from the LH group at 6.6%. Overall patient satisfaction was reported to be 86-94% one year after surgery.

CONCLUSION

Women operated on for benign hysterectomy with minimally invasive methods in Sweden 2009-2015 had reduced length of hospitalization, as well as time to resuming normal ADL and return to work, compared to AH. Postoperative outcome measures were improved by minimally invasive methods and MIS should preferably be used.

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

OBJECTIVE

To evaluate the implementation and effectiveness of an internet-based perioperative care programme for patients following gynaecological surgery for benign disease.

DESIGN

Stepped-wedge cluster randomised controlled trial.

SETTING

Secondary care, nine hospitals in the Netherlands, 2011-2014.

PARTICIPANTS

433 employed women aged 18-65 years scheduled for hysterectomy and/or laparoscopic adnexal surgery.

INTERVENTIONS

An internet-based care programme was sequentially rolled out using a multifaceted implementation strategy. Depending on the implementation phase of their hospital, patients were allocated to usual care (n=206) or the care programme (n=227). The care programme included an e-health intervention equipping patients with tailored personalised convalescence advice.

MAIN OUTCOME MEASURES

The primary outcome was duration until full sustainable return to work (RTW). The degree of implementation of the care programme was evaluated at the level of the patient, healthcare provider and organisation by indicators measuring internet-based actions by patients and providers.

RESULTS

Median time until RTW was 49 days (IQR 27-76) in the intervention group and 62 days (42-85) in the control group. A piecewise Cox model was fitted to take into account non-proportionality of hazards. In the first 85 days after surgery, patients receiving the intervention returned to work faster than patients in the control group (HR 2.66, 95% CI 1.88 to 3.77), but this effect was reversed in the small group of patients that did not reach RTW within this period (0.28, 0.17 to 0.46). Indicators showed that the implementation of the care programme was most successful at the level of the patient (82.8%) and professional (81.7%).

CONCLUSIONS

Implementation of an internet-based care programme has a large potential to lead to accelerated recovery and improved RTW rates following different types of gynaecological surgeries.

TRIAL REGISTRATION NUMBER

NTR2933; Results.

A Perioperative eHealth Program to Enhance Postoperative Recovery After Abdominal Surgery: Process Evaluation of a Randomized Controlled Trial

BACKGROUND

Electronic health (eHealth) interventions have proven effective, but implementation in clinical practice is difficult. More research focusing on the implementation process of eHealth interventions is necessary.

OBJECTIVE

The objective of this study was to describe the process evaluation of a perioperative eHealth intervention, aiming to enhance recovery after laparoscopic abdominal surgery.

METHODS

A process evaluation was carried out alongside a multicenter randomized controlled trial. Patients aged between 18 and 75 years who were scheduled for a laparoscopic cholecystectomy, hernia inguinal surgery, or laparoscopic adnexal surgery were included. The eHealth intervention comprised a website and mobile phone app with the possibility to develop a personalized convalescence plan, a section with information about the surgical procedure and the recovery period, the possibility to ask questions via an electronic consultation (eConsult), and an activity tracker. The process evaluation was carried out using the model of Linnan and Steckler, measuring components such as reach, dose delivered, dose received, fidelity, and participants' attitudes. Implementation scores were calculated based on the average of the four components. Quantitative data were collected by means of an electronic questionnaire, a logistic database, a weblog, and medical files. Qualitative data were collected by conducting interviews with a subsample of the study participants.

RESULTS

A total of 344 of the 863 eligible patients were included in the study, which accounted for a reach of 39.9%, and 173 participants were randomized to the intervention group. The implementation scores of the different functions of the intervention ranged between 60% and 65%. The website, mobile phone app, and activity tracker were rated 7.3 to 7.6 on a scale of 1 to 10. Almost all participants who were interviewed about the eConsult function rated it as being of additional value if combined with the usual care but not as a replacement for usual care.

CONCLUSIONS

Although participants were overall satisfied with the intervention, the implementation scores of the different functions of the intervention were fair. More research is needed to evaluate the barriers and facilitators for implementation of this perioperative eHealth intervention in normal practice outside study setting.

TRIAL REGISTRATION

Netherlands Trial Registry NTR4699; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4699 (Archived by WebCite at http://www.webcitation.org/6vr02V4KK).

Laparoscopic hysterectomy for benign indications: clinical practice guideline

Purpose

Since the introduction of minimally invasive gynecologic surgery, the percentage of advanced laparoscopic procedures has greatly increased worldwide. It seems therefore, timely to standardize laparoscopic gynecologic care according to the principles of evidence-based medicine. With this goal in mind—the Dutch Society of Gynecological Endoscopic Surgery initiated in The Netherlands the development of a national guideline for laparoscopic hysterectomy (LH). This present article provides a summary of the main recommendations of the guideline.

Methods

This guideline was developed following the Dutch guideline of medical specialists and in accordance with the AGREE II tool. Clinically important issues were firstly defined and translated into research questions. A literature search per topic was then conducted to identify relevant articles. The quality of the evidence of these articles was rated following the GRADE systematic. An expert panel consisting of 18 selected gynecologists was consulted to formulate best practice recommendations for each topic.

Results

Ten topics were considered in this guideline, including amongst others, the different approaches for hysterectomy, advice regarding tissue extraction, pre-operative medical treatment and prevention of ureter injury. This work resulted in the development of a clinical practical guideline of LH with evidence- and expert-based recommendations. The guideline is currently being implemented in The Netherlands.

Conclusion

A guideline for LH was developed. It gives an overview of best clinical practice recommendations. It serves to standardize care, provides guidance for daily practice and aims to guarantee the quality of LH at an (inter)national level.

Using e-health in perioperative care: a survey study investigating shortcomings in current perioperative care and possible future solutions

Background

An e-health care program has previously shown to have a positive effect on return to work, quality of life and pain in patients who underwent gynaecological surgery. Plausibly, providing the care program to a population undergoing other types of surgery will be beneficial as well. The objectives of this study are to evaluate patients’ opinions, needs and preferences regarding the information and guidance supplied to patients during the perioperative period, to investigate whether e-health may be of assistance and to explore if gender specific needs exist.

Methods

A questionnaire was sent to all patients between 18 and 75 years (n = 362), who underwent various forms of abdominal surgery between August 2013 to September 2014 in a university hospital in the Netherlands. The questionnaire contained questions about the current situation in perioperative care and questions about patients’ preferences in an e-health care program. Gender differences were evaluated.

Results

Two hundred seven participants (57.2%) completed the survey. The majority of the participants were relatively satisfied with the perioperative care they received (68.6%). Most reported shortcomings in perioperative care concerning the supply of information regarding the resumption of activities and guidance during the recovery course. An e-health care program was expected to be of added value in perioperative care by 78% of the participants; a website was reported as most useful. In particular practical functions on a website focusing on the preparation to surgery and monitoring after surgery were appraised to be highly valuable. Overall, women had slightly more needs for extra information and support during the perioperative course than men.

Conclusions

In abdominal surgery, there is a need for an e-health care program, which should focus mainly on the supply of information about the resumption of activities as well as guidance in the postoperative course.

Assessing pre- and postoperative activity levels with an accelerometer: a proof of concept study

Background

Postoperative recovery after abdominal surgery is measured mostly based on subjective or self-reported data. In this article we aim to evaluate whether recovery of daily physical activity levels can be measured postoperatively with the use of an accelerometer.

Methods

In this multicenter, observational pilot study, 30 patients undergoing laparoscopic abdominal surgery (hysterectomy, adnexal surgery, cholecystectomy and hernia inguinal surgery) were included. Patients were instructed to wear an Actigraph wGT3X-BT accelerometer during one week before surgery (baseline) and during the first, third and fifth week after surgery. Wear time, steps taken and physical activity intensity levels (sedentary, light, moderate and vigorous) were measured. Patients were blinded for the accelerometer outcomes. Additionally, an activity diary comprising patients’ self-reported time of being recovered and a list of 18 activities, in which the dates of resumption of these 18 activities were recorded after surgery, was completed by the patient.

Results

Five patients were excluded from analyses because of technical problems with the accelerometer (n = 1) and protocol non-adherence (n = 4). Light, moderate, vigorous, combined moderate and vigorous intensity physical activity (MVPA), and step counts showed a clear recovery curve after surgery. Patients who underwent minor surgery reached their baseline step count and MVPA three weeks after surgery. Patients who underwent intermediate surgery had not yet reached their baseline step count during the last measuring week (five weeks after surgery). The results of the activity diaries showed a fair agreement with the accelerometer results (Cohens Kappa range: 0.273-0.391). Wearing the accelerometer was well tolerated and not regarded as being burdensome by the patients.

Conclusions

The accelerometer appeared to be a feasible way to measure recovery of postoperative physical activity levels in this study and was well tolerated by the patients. The agreement with self-reported physical recovery times was fair.

Electronic supplementary material

The online version of this article (doi:10.1186/s12893-017-0223-0) contains supplementary material, which is available to authorized users.

Substitution of Usual Perioperative Care by eHealth to Enhance Postoperative Recovery in Patients Undergoing General Surgical or Gynecological Procedures: Study Protocol of a Randomized Controlled Trial

Background

Due to the strong reduction in the length of hospital stays in the last decade, the period of in-hospital postoperative care is limited. After discharge from the hospital, guidance and monitoring on recovery and resumption of (work) activities are usually not provided. As a consequence, return to normal activities and work after surgery is hampered, leading to a lower quality of life and higher costs due to productivity loss and increased health care consumption.

Objective

With this study we aim to evaluate whether an eHealth care program can improve perioperative health care in patients undergoing commonly applied abdominal surgical procedures, leading to accelerated recovery and to a reduction in costs in comparison to usual care.

Methods

This is a multicenter randomized, single-blinded, controlled trial. At least 308 patients between 18 and 75 years old who are on the waiting list for a laparoscopic cholecystectomy, inguinal hernia surgery, or laparoscopic adnexal surgery for a benign indication will be included. Patients will be randomized to an intervention or control group. The intervention group will have access to an innovative, perioperative eHealth care program. This intervention program consists of a website, mobile phone app, and activity tracker. It aims to improve patient self-management and empowerment by providing guidance to patients in the weeks before and after surgery. The control group will receive usual care and will have access to a nonintervention (standard) website consisting of the digital information brochure about the surgical procedure being performed. Patients are asked to complete questionnaires at 5 moments during the first 6 months after surgery. The primary outcome measure is time to return to normal activities based on a patient-specific set of 8 activities selected from the Patient-Reported Outcomes Measurement Information System (PROMIS) physical functioning item bank version 1.2. Secondary outcomes include social participation, self-rated health, duration of return to work, physical activity, length of recovery, pain intensity, and patient satisfaction. In addition, an economic evaluation alongside this randomized controlled trial will be performed from the societal and health care perspective. All statistical analyses will be conducted according to the intention-to-treat principle.

Results

The enrollment of patients started in September 2015. The follow-up period will be completed in February 2017. Data cleaning and analyses have not begun as of the time this article was submitted.

Conclusions

We hypothesize that patients receiving the intervention program will resume their normal activities sooner than patients in the control group and costs will be lower.

ClinicalTrial

Netherlands Trial Registry NTC4699; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4699 (Archived by WebCite at http://www.webcitation.org/6mcCBZmwy)

The Effect of Perioperative E-Health Interventions on the Postoperative Course: A Systematic Review of Randomised and Non-Randomised Controlled Trials

BACKGROUND

E-health interventions have become increasingly popular, including in perioperative care. The objective of this study was to evaluate the effect of perioperative e-health interventions on the postoperative course.

METHODS

We conducted a systematic review and searched for relevant articles in the PUBMED, EMBASE, CINAHL and COCHRANE databases. Controlled trials written in English, with participants of 18 years and older who underwent any type of surgery and which evaluated any type of e-health intervention by reporting patient-related outcome measures focusing on the period after surgery, were included. Data of all included studies were extracted and study quality was assessed by using the Downs and Black scoring system.

FINDINGS

A total of 33 articles were included, reporting on 27 unique studies. Most studies were judged as having a medium risk of bias (n = 13), 11 as a low risk of bias, and three as high risk of bias studies. Most studies included patients undergoing cardiac (n = 9) or orthopedic surgery (n = 7). All studies focused on replacing (n = 11) or complementing (n = 15) perioperative usual care with some form of care via ICT; one study evaluated both type of interventions. Interventions consisted of an educational or supportive website, telemonitoring, telerehabilitation or teleconsultation. All studies measured patient-related outcomes focusing on the physical, the mental or the general component of recovery. 11 studies (40.7%) reported outcome measures related to the effectiveness of the intervention in terms of health care usage and costs. 25 studies (92.6%) reported at least an equal (n = 8) or positive (n = 17) effect of the e-health intervention compared to usual care. In two studies (7.4%) a positive effect on any outcome was found in favour of the control group.

CONCLUSION

Based on this systematic review we conclude that in the majority of the studies e-health leads to similar or improved clinical patient-related outcomes compared to only face to face perioperative care for patients who have undergone various forms of surgery. However, due to the low or moderate quality of many studies, the results should be interpreted with caution.

A modified Delphi method toward multidisciplinary consensus on functional convalescence recommendations after abdominal surgery

Background

Evidence-based information on the resumption of daily activities following uncomplicated abdominal surgery is scarce and not yet standardized in medical guidelines. As a consequence, convalescence recommendations are generally not provided after surgery, leading to patients’ insecurity, needlessly delayed recovery and prolonged sick leave. The aim of this study was to generate consensus-based multidisciplinary convalescence recommendations, including advice on return to work, applicable for both patients and physicians.

Method

Using a modified Delphi method among a multidisciplinary panel of 13 experts consisting of surgeons, occupational physicians and general practitioners, detailed recommendations were developed for graded resumption of 34 activities after uncomplicated laparoscopic cholecystectomy, laparoscopic and open appendectomy, laparoscopic and open colectomy and laparoscopic and open inguinal hernia repair. A sample of occupational physicians, general practitioners and surgeons assessed the recommendations on feasibility in daily practice. The response of this group of care providers was discussed with the experts in the final Delphi questionnaire round.

Results

Out of initially 56 activities, the expert panel selected 34 relevant activities for which convalescence recommendations were developed. After four Delphi rounds, consensus was reached for all of the 34 activities for all the surgical procedures. A sample of occupational physicians, general practitioners and surgeons regarded the recommendations as feasible in daily practice.

Conclusion

Multidisciplinary convalescence recommendations regarding uncomplicated laparoscopic cholecystectomy, appendectomy (laparoscopic, open), colectomy (laparoscopic, open) and inguinal hernia repair (laparoscopic, open) were developed by a modified Delphi procedure. Further research is required to evaluate whether these recommendations are realistic and effective in daily practice.

Results of Postdischarge Nursing Telephone Assessments: Persistent Symptoms Common Among Pulmonary Resection Patients

BACKGROUND

After hospital discharge, patients may have questions or complaints that surface or remain inadequately addressed. However, the dominant concerns and indications for further intervention among recently discharged patients after pulmonary resection have not been well described. The aims of this study were to characterize dominant concerns of pulmonary resection patients after discharge and to elucidate any relevant risk factors for their development.

METHODS

A single-institution, retrospective review was conducted of all patients who underwent pulmonary resection over a 12-month period and included records of standardized, nurse-initiated follow-up phone calls to discharged patients. Records of postdischarge telephone calls were reviewed, and data collected pertaining to complaints requiring counseling over the phone or escalation to higher care level. Demographic, operative, and hospital data were examined by multivariate analyses to assess predictors of need for counseling or escalation of care.

RESULTS

In all, 523 patients underwent pulmonary resection during the study, and 245 (46.8%) had nursing-documented telephone conversations at 4.6 days (±0.18) days after discharge. Among those reached, 81 (33.1%) had problems requiring counseling during the call; 31 (12.7%) reported concerns requiring escalation of care, handled by subsequent telephone call for 7 (22.6%), clinic appointment for 22 (71.0%), or emergency room referral for 2 (6.5%). Age, sex, race, and residential proximity to the hospital did not predict need for counseling nor escalation of care.

CONCLUSIONS

Patient complaints after pulmonary resection were frequent, with most problems resolved by telephone counseling. Despite highly prevalent concerns, predictors of need for counseling or care escalation were not identified, suggesting ongoing utility in the practice of telephoning all patients. Further, this study serves as a needs assessment, highlighting the importance of patient education and discharge planning.

Measures of patients' expectations about recovery: a systematic review

INTRODUCTION

Patients' expectations regarding their prognosis has been shown to affect recovery. We completed a systematic review to identify measures that assess patients' expectations of recovery.

METHODS

Eligible studies explored the association between patients' expectations of recovery, and return to work or claim resolution. We searched electronic databases (MEDLINE and PSYCInfo) from inception to June 21, 2014, bibliographies of eligible studies, relevant systematic reviews and our personal files. Reviewers determined study eligibility and study quality, and completed data extraction.

RESULTS

Of 14,509 unique citations, 46 studies were eligible with majority of the studies (n = 27; 59 %) rated as low quality, primarily due to substantial missing data and inappropriate adjustment for age, gender and illness severity in their regression models. We identified 5 measures and 41 individual items assessing recovery expectations. Three of seven (43 %) studies using a measure to assess recovery expectations reported psychometric properties, with only one reporting both reliability and construct validity. Only two measures (Expectations of Recovery Scale and the Work-related Recovery Expectations Questionnaire) were externally validated in different populations. Overall, 44 (96 %) studies found that patient recovery expectations was a significant predictor of return to work or sick leave/disability claim resolution.

CONCLUSIONS

Very few studies assessing recovery expectations use a psychometrically valid measure. Current evidence suggests that patients with lower recovery expectations are less likely to resolve their disability claim or return to work versus patients with higher recovery expectations. Further validation of existing measures for assessing patient recovery expectations, or development of a new measure that addresses the limitations of existing ones, is required.

The impact of different surgical modalities for hysterectomy on satisfaction and patient reported outcomes

Background

There is an ongoing debate regarding the cost-benefit of different surgical modalities for hysterectomy. Studies have relied primarily on evaluation of clinical outcomes and medical expenses. Thus, a paucity of information on patient-reported outcomes including satisfaction, recovery, and recommendations exists.

Objective

The objective of this study was to identify differences in patient satisfaction and recommendations by approach to a hysterectomy.

Methods

We recruited a large, geographically diverse group of women who were members of an online hysterectomy support community. US women who had undergone a benign hysterectomy formed this retrospective study cohort. Self-reported characteristics and experiences were compared by surgical modality using chi-square tests. Outcomes over time were assessed with the Jonkheere-Terpstra trend test. Logistic regression identified independent predictors of patient satisfaction and recommendations.

Results

There were 6262 women who met the study criteria; 41.74% (2614/6262) underwent an abdominal hysterectomy, 10.64% (666/6262) were vaginal, 27.42% (1717/6262) laparoscopic, 18.94% (1186/6262) robotic, and 1.26% (79/6262) single-incision laparoscopic. Most women were at least college educated (56.37%, 3530/6262), and identified as white, non-Hispanic (83.17%, 5208/6262). Abdominal hysterectomy rates decreased from 68.2% (152/223) to 24.4% (75/307), and minimally invasive surgeries increased from 31.8% (71/223) to 75.6% (232/307) between 2001 or prior years and 2013 (P<.001 all trends). Trends in overall patient satisfaction and recommendations showed significant improvement over time (P<.001).There were differences across the surgical modalities in all patient-reported experiences (ie, satisfaction, time to walking, driving and working, and whether patients would recommend or use the same technique again; P<.001). Significantly better outcomes were evident among women who had vaginal, laparoscopic, and robotic procedures than among those who had an abdominal procedure. However, robotic surgery was the only approach that was an independent predictor of better patient experience; these patients were more satisfied overall (odds ratio [OR] 1.31, 95% CI 1.13-1.51) and on six other satisfaction measures, and more likely to recommend (OR 1.64, 95% CI 1.39-1.94) and choose the same modality again (OR 2.07, 95% CI 1.67-2.57). Abdominal hysterectomy patients were more dissatisfied with outcomes after surgery and less likely to recommend (OR 0.36, 95% CI 0.31-0.40) or choose the same technique again (OR 0.29, 95% CI 0.25-0.33). Quicker return to normal activities and surgery after 2007 also were independently associated with better overall satisfaction, willingness to recommend, and to choose the same surgery again.

Conclusions

Consistent with other US data, laparoscopic and robotic hysterectomy rates increased over time, with a concomitant decline in abdominal hysterectomy. While inherent shortcomings of this retrospective Web-based study exist, findings show that patient experience was better for each of the major minimally invasive approaches than for abdominal hysterectomy. However, robotic-assisted hysterectomy was the only modality that independently predicted greater satisfaction and willingness to recommend and have the same procedure again.

The cost effectiveness of a tailored, web-based care program to enhance postoperative recovery in gynecologic patients in comparison with usual care: protocol of a stepped wedge cluster randomized controlled trial

Background

The length of recovery after benign gynecological surgery and return to work frequently exceeds the period that is recommended or expected by specialists. A prolonged recovery is associated with a poorer quality of life. In addition, costs due to prolonged sick leave following gynecological surgery cause a significant financial burden on society.

Objective

The objective of our study was to present the protocol of a stepped wedge cluster randomized controlled trial to evaluate the cost effectiveness of a new care program for patients undergoing hysterectomy and/or adnexal surgery for benign disease, compared to the usual care.

Methods

The care program under study, designed to improve convalescence and to prevent delayed return to work, targets two levels. At the hospital level, guidelines will be distributed among clinical staff in order to stimulate evidence-based patient education. At the patient level, additional perioperative guidance is provided by means of an eHealth intervention, equipping patients with tailored convalescence advice, and an occupational intervention is available for those patients at risk of prolonged sick leave. Due to the stepped wedge design of the trial, the care program will be sequentially rolled out among the 9 participating hospitals, from which the patients are recruited. Eligible for this study are employed women, 18-65 years of age, who are scheduled for hysterectomy and/or laparoscopic adnexal surgery. The primary outcome is full sustainable return to work. The secondary outcomes include general recovery, quality of life, self-efficacy, coping, and pain. The data will be collected by means of self-reported electronic questionnaires before surgery and at 2, 6, 12, 26, and 52 weeks after surgery. Sick leave and cost data are measured by monthly sick leave calendars, and cost diaries during the 12 month follow-up period. The economic evaluation will be performed from the societal perspective. All statistical analyses will be conducted according to the intention-to-treat principle.

Results

The enrollment of the patients started October 2011. The follow-up period will be completed in August 2014. Data cleaning or analysis has not begun as of this article’s submission.

Conclusions

We hypothesize the care program to be effective by means of improving convalescence and reducing costs associated with productivity losses following gynecological surgery. The results of this study will enable health care policy makers to decide about future implementation of this care program on a broad scale.

Trial Registration

Netherlands Trial Register: NTR2933; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2933 (Archived by WebCite at http://www.webcitation.org/6Q7exPG84).