The engaged patient: patient activation can predict satisfaction with surgical treatment of lumbar and cervical spine disorders

Association between patient activation and delayed discharge in elective laparoscopic cholecystectomy: A prospective cohort analysis

BACKGROUND

Improving patient activation may be an effective way to reduce healthcare costs and improve patient outcomes after surgery.

OBJECTIVE

To determine whether preoperative patient activation is associated with delayed discharge (i.e., length of stay >24 h) after elective laparoscopic cholecystectomy. Postoperative symptoms, unscheduled access to healthcare facilities within seven days of surgery, unplanned hospital readmissions, and postoperative complications were analyzed as secondary outcomes.

DESIGN

This cohort study was a secondary analysis of the DeDiLaCo study (Delayed Discharge after day-surgery Laparoscopic Cholecystectomy) collecting data of patients undergoing elective laparoscopic cholecystectomy during 2021 in Italy. Data was analyzed from June 2022 to April 2023.

SETTING

90 Italian surgical centers participating in the study.

PARTICIPANTS

4708 adult patients with an instrumental diagnosis of gallbladder disease and undergoing laparoscopic cholecystectomy. Patient activation was assessed using the Italian translation of Patient Activation Measure in the preoperative setting.

RESULTS

Of 4532 cases analyzed the median (IQR) Patient Activation Measure score was 80.3 (71.2-92.3). Participants were on average 55.5 years of age and 58.1 % were female. Two groups based on the activation level were created: 270 (6 %) had low activation, and 4262 had high activation. The low activation level was associated with the likelihood of delayed discharge (odds ratio [OR] 1.47, 95 % CI, 1.11-1.95; P = .008), higher symptom burden (OR 1.99, 95 % CI 1.49-2.66, P < .0001), and unplanned healthcare utilization within seven days after hospital discharge (OR 1.85, 95 % CI, 1.29-2.63; P = .001). There was no difference between the high and low activation groups in the incidence of postoperative complications (OR 1.28, 95 % CI, 0.95-1.73; P = .10) and hospital readmission after discharge (OR 0.95, 95 % CI, 0.30-3.05; P = .93).

CONCLUSIONS

Our results suggest that patients with low activation have 1.47 times the risk of delayed discharge compared with patients with higher activation, almost twice the risk of the onset of postoperative symptoms, and 1.85 times the risk of unscheduled use of hospital services. Screening for patient activation in the preoperative setting could not only identify patients not suitable for early discharge, but more importantly, help physicians and nurses develop tailored interventions.

What Is the Association Between Agency and Levels of Capability and Comfort in Musculoskeletal Care? A Systematic Review

BACKGROUND

People who take active responsibility for their health demonstrate agency. Agency in the context of chronic illness management with disease-modifying treatments is commonly linked to adherence and confidence in care seeking. In musculoskeletal health, agency is commonly observed in the accommodation of conditions related to aging and reflected in studies of people not seeking care. The development of agency measures originates from the realm of medical management of chronic illness rather than that of musculoskeletal disease, which is often optional or discretionary. With growing interest in the universal adoption of agency as a performance measure for quality payment programs, there is a need to better understand how agency is measured across musculoskeletal conditions, and how agency may be a modifiable correlate of capability, comfort, mindset, and circumstances.

QUESTIONS/PURPOSES

We systematically reviewed the evidence regarding agency among people seeking musculoskeletal specialty care and asked: (1) Are greater levels of agency associated with greater levels of comfort and capability? (2) Are greater levels of agency associated with better mental and social health?

METHODS

Following the PRISMA guidelines, we performed searches on May 22, 2023, with searches spanning September 1988 (in PubMed and Web of Science) and September 1946 (in Ovid Medline) to May 2023. We included original clinical studies addressing the relationship between agency and levels of comfort, capability, mindset, and circumstances (by utilizing patient-reported agency measures [PRAMs], patient-reported outcome measures [PROMs], and mental and social health measures) involving adult patients 18 years or older receiving specialist care for musculoskeletal conditions. We identified 11 studies involving 3537 patients that addressed the primary research question and three studies involving 822 patients that addressed the secondary question. We conducted an evidence quality assessment using the Methodological Index for Non-Randomized Studies (MINORS) and found the overall evidence quality to be relatively high, with loss to follow-up and lack of reporting of sample size calculation the most consistent study shortcomings. The measures of capability varied by anatomical region. The Patient Activation Measure (a validated 10- or 13-item survey originally designed to assess a patient's level of understanding and confidence in managing their health and ability to engage in healthcare related to chronic medical illness) was used as a measure of agency in 10 studies (one of which also used the Effective Consumer Scale) and attitudes regarding one's management of musculoskeletal disorders in one study. We registered this systematic review on PROSPERO (Reg CRD42023426893).

RESULTS

In general, the relationships between PRAMs and PROMs are weak to moderate in strength using the Cohen criteria, with 10 of 11 studies demonstrating an association between levels of agency and levels of comfort and capability. The three studies addressing mental health found a weak correlation (where reported) between levels of agency and levels of symptoms of depression and anxiety.

CONCLUSION

The finding that agency in patients seeking care for musculoskeletal conditions is associated with greater comfort, capability, and mental health supports the prioritization of agency modification during musculoskeletal specialty care. This might include behavioral health and cognitive debiasing strategies along with strategies and services promoting self-management. Our work also points to an opportunity to develop agency measures better suited for discretionary care that more directly assess the cultivation of healthy mindsets, behaviors, and accommodative attitudes toward the discomfort and incapability experienced during aging.

LEVEL OF EVIDENCE

Level II, prognostic study.

Predictors of post-discharge pain and satisfaction with pain management after laparoscopic bariatric surgery: a prospective cohort study

BACKGROUND

Pain management after bariatric surgery remains challenging given the risk for analgesia-related adverse events (e.g., opioid use disorder, marginal ulcers). Identifying modifiable factors associated with patient-reported pain outcomes may improve quality of care. We evaluated the extent to which patient and procedural factors predict 7-day post-discharge pain intensity, pain interference, and satisfaction with pain management after bariatric surgery.

METHODS

This prospective cohort study included adults undergoing laparoscopic bariatric surgery at two university-affiliated hospitals and one private clinic. Preoperative assessments included demographics, Pain Catastrophizing Scale (score range 0-52), Patient Activation Measure (low [< 55.1] vs. high [≥ 55.1]), pain expectation (0-10), and Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29) anxiety and depression scales. At 7 days post-discharge, assessments included PROMIS-29 pain intensity (0-10) and pain interference scales (41.6-75.6), and satisfaction with pain management (high [10-9] vs. lower [8-0]). Linear and logistic regression were used to assess the association of pain outcomes with potential predictors.

RESULTS

Three hundred and fifty-one patients were included (mean age = 44 ± 11 years, BMI = 45 ± 8 kg/m2, 77% female, 71% sleeve gastrectomy). At 7 days post-discharge, median (IQR) patient-reported pain intensity was 2.5 (1-5), pain interference was 55.6 (52.0-61.2), and 76% of patients reported high satisfaction with pain management. Pain intensity was predicted by preoperative anxiety (β + 0.04 [95% CI + 0.01 to + 0.07]) and pain expectation (+ 0.15 [+ 0.05 to + 0.25]). Pain interference was predicted by preoperative anxiety (+ 0.22 [+ 0.11 to + 0.33]), pain expectation (+ 0.47 [+ 0.10 to + 0.84]), and age (- 0.09 [- 0.174 to - 0.003]). Lower satisfaction was predicted by low patient activation (OR 1.94 [1.05-3.58]), higher pain catastrophizing (1.03 [1.003-1.05]), 30-day complications (3.27 [1.14-9.38]), and age (0.97 [0.948-0.998]).

CONCLUSION

Patient-related factors are important predictors of post-discharge pain outcomes after bariatric surgery. Our findings highlight the value of addressing educational, psychological, and coping strategies to improve postoperative pain outcomes.

The Impact of Nurse Navigator-Led Preoperative Education on Hospital Outcomes Following Posterolateral Lumbar Fusion Surgery

Beyond the spine-specific pathology, patient factors such as associated medical and psychosocial conditions, understanding of the treatment process, and the degree of patient activation-defined as the ability of the individual to utilize the available information and actively engage in making their healthcare decisions-can influence outcomes after posterolateral lumbar fusion (PLF) surgery. A retrospective observational cohort study of 177 patients undergoing PLF at a single institution was conducted. Patient demographics, medical and psychosocial risk factors, and outcomes were compared between patients who attended a nurse navigator-led group preoperative education course and those who did not. Patients attending the course were younger, more likely to undergo one-level fusion, less likely to undergo 5- or more-level fusion, and had less comorbidity burden as measured by the hierarchical condition categories score. No differences in psychosocial risk factors were observed between groups. Course attendees had a significantly shorter length of stay (2.12 vs. 2.60 days, p = .042) and decreased average hospital cost (U.S. $10,149 vs. U.S. $14,792, p < .001) than those who did not attend; no differences in other outcomes were observed. After controlling for differences in risk factors, patients enrolled in a preoperative education course demonstrated a statistically significant reduction in hospital cost (β=-4,143, p < .001). Preoperative education prior to PLF surgery may reduce hospital cost, possibly through increased patient activation. Given the relatively high prevalence of psychosocial risk factors in this and similar patient populations, optimizing patient activation and engagement is important to achieve high value care. Based on our findings, nurse navigator-led preoperative education appears to be valuable in this patient population and should be included in enhanced recovery protocols.

Associations of depression and sociodemographic characteristics with patient activation among those presenting for spine surgery

Purpose

To investigate the associations of sociodemographic characteristics and PROMIS domain scores with patient activation among patients presenting for spine surgery at a university-affiliated spine center.

Methods

Patients completed a survey collecting demographic and social information. Patients also completed the Patient-Reported Outcomes Measurement Information System (PROMIS) and Patient Activation Measure questionnaires. The associations of PROMIS scores and sociodemographic characteristics with patient activation were assessed using linear and ordinal logistic regression (patient activation stage as ordinal).

Results

A total of 1018 patients were included. Most respondents were white (84%), married (73%), and female (52%). Patients were distributed among the 4 activation stages as follows: stage I, 7.7%; stage II, 12%; stage III, 26%; and stage IV, 55%. Mean (±standard deviation) patient activation score was 70 ± 17 points. Female sex (adjusted coefficient [AC] = 4.3; 95% confidence interval [CI] 2.1, 6.4) and annual household income >$80,000 (OR = 3.7; 95% CI 0.54, 6.9) were associated with higher patient activation scores. Lower patient activation scores were associated with worse PROMIS Depression (AC = -0.31; 95% CI -0.48, -0.14), Fatigue (OR = -0.19; 95% CI -0.33, -0.05), Pain (OR = 0.22; 95% CI 0.01, 0.43), and Social Satisfaction (OR = 0.33; 95% CI 0.14, 0.51) scores.

Conclusion

Depression and socioeconomic status, along with PROMIS Pain, Fatigue, and Social Satisfaction domains, were associated with patient activation. Patients with a greater burden of depressive symptoms had lower patient activation; conversely, women and those with higher income had greater patient activation.

Level of evidence

Level 1.

Appropriate Opioid Use After Spine Surgery: Psychobehavioral Barriers and Patient Knowledge

OBJECTIVE

To identify spine patients' barriers to appropriate postoperative opioid use, comfort with naloxone, knowledge of safe opioid disposal practices, and associated factors.

METHODS

We preoperatively surveyed 174 spine patients about psychobehavioral barriers to appropriate opioid use, comfort with naloxone, and knowledge about opioid disposal. Multivariable logistic regression identified factors associated with barriers and knowledge (α = 0.05).

RESULTS

Common barriers were fear of addiction (71%) and concern about disease progression (43%). Most patients (78%) had neutral/low confidence in the ability of nonopioid medications to control pain; most (57%) felt neutral or uncomfortable with using naloxone; and most (86%) were familiar with safe disposal. Anxiety was associated with fear of distracting the physician (adjusted odds ratio [aOR], 3.8; 95% confidence interval [CI], 1.1-14) and with lower odds of knowing safe disposal methods (aOR, 0.18; 95% CI, 0.04-0.72). Opioid use during the preceding month was associated with comfort with naloxone (aOR, 4.9; 95% CI, 2.1-12). Patients with a higher educational level had lower odds of reporting fear of distracting the physician (aOR, 0.30; 95% CI, 0.09-0.97), and those with previous postoperative opioid use had lower odds of concern about disease progression (aOR, 0.25; 95% CI, 0.09-0.63) and with a belief in tolerating pain (aOR, 0.34; 95% CI, 0.12-0.95).

CONCLUSIONS

Many spine patients report barriers to appropriate postoperative opioid use and are neutral or uncomfortable with naloxone. Some are unfamiliar with safe disposal. Associated factors include anxiety, lack of recent opioid use, and no previous postoperative use.

Chronic Patients' Activation and Its Association with Stress, Anxiety, Depression, and Quality of Life: A Survey in Southeast Iran

A better perception of the factors associated with patient activation, as a way to improve self-management, is the most important step in planning patient-centered education for chronic disease management. Therefore, the present study is aimed at investigating the relationship between activation, stress, anxiety, depression, and quality of life (QOL) in patients with chronic diseases. This correlational study was performed on 293 chronic patients admitted to coronary care units (CCUs) in one of the hospitals in Rafsanjan. The Patient Activation Measure (PAM), Quality of Life-BREF (WHOQOL-BREF), and Depression, Anxiety, and Stress Scale-21 Items (DASS-21) were used to collect data. The data were then analyzed using SPSS 22. A significant positive correlation was observed between general QOL and PAM (P < 0.001). In addition, a significant negative correlation was found between PAM, stress (P = 0.032), and depression (P = 0.025). The results of multivariate linear regression indicated that only physical and psychological subscales of QOL significantly predicted PAM (B = 0.24; 95% confidence interval; P value < 0.05). Owing to the fact that some subscales of QOL have a determinant role in the PAM of chronic patients, healthcare providers are recommended to plan and implement the necessary interventions to improve the QOL and the health outcomes of chronic patients.