PhD Thesis by Per Rotbøll Nielsen
This PhD thesis aims to describe postoperative pain, the effect of implementation of pain management principles and accelerated multimodal pre-and postoperative treatment among surgery patients. Nationally the postoperative pain services were implemented rather fast to surgical and anaesthesiological departments in the period 2000-2009. Afterwards, several units closed down, so in 2009 only 29% of departments reported that they still had an acute pain service.
In contrast to this, and probably in the view of the recent increase of knowledge and evidence on surgical pathophysiology, surgical patient and postoperative rehabilitation, it was found that the number of departments that have implemented accelerated patient pathways had significantly increased over the same period. Clinical Health Promotion Centre, WHO-CC • Bispebjerg Hospital og Tværfaglig Smertecenter 7612, Rigshospitalet Side 7 Tværfagligt forebyggelses- og rehabiliteringsprogram ved operation Several studies have demonstrated the effect of smoking and alcohol cessation before an operation, while a possible effect of physical exercise were still unclear, and literature reviews on elective hip and knee replacement therapy failed to demonstrate evidence. For patients with lumbar spine surgery no randomised trials had been published.
With accelerated patient pathways as a basis and in combination with prehabilitation a new treatment regimen that was designed to optimize the patient through improved organ function prior to surgery, was tested in a randomised study. The aims were to reduce hospitalisations and to improve recovery. Prehabilitation included thorough pre-intervention information, a smoking cessation program, alcohol intervention, physical exercise, nutritional supplements and pain management.
The randomized study was an open clinic trial that took place over a 18-months period with a primary efficacy endpoint of functionality assessed by the time of inclusion, which was 6 to 8 weeks prior to surgery, repeated on admission, postoperatively on day one three and again at discharge, as well as after one, three and six months . The secondary objective was pain, side effects, postoperative complications, quality of life and patient satisfaction. Twenty-eight patients were randomized to prehabilitation and 32 to the department's usual treatment. Patients in the intervention group had significantly better functional level already at admission, measured with the Roland Morris score than the control group. They also had less pain postoperatively - measured as current and minimum pain, but not in terms of the overall pain. Patients in the intervention group achieved the milestones of post-operative mobilization during hospitalisation significantly earlier than the control group. This difference was visualised in the duration of hospitalization; 5 days versus 7 days (P = 0.007).
At the control after one month patients in the intervention group a better functionality, but after three-and six-month no significant difference existed. There was no significant difference between the groups in complication rate. A multivariate analysis showed that the intensity of the pre-operative nociceptive pain was a predictor of post-operative complications (P = 0.002), and the randomization to the control group was a predictor of prolonged hospitalization (p = 0.004).
Patients' experience showed that the intervention group was significantly more satisfied with respect to the entire process, oral and written information, linkage between information and treatment as well as the quality of rehabilitation, while no difference was found between the groups on and post-operative pain management at discharge.
Health economic analysis of the costs and benefits of the two therapies were performed. The aim of the economic analysis was to evaluate quality of life data and cost data for the patients. The analysis showed that prehabilitation course was DKK 3705.00 cheaper per patient than care in the control group. The direct cost per patient was higher, because of the prehabilitation, but the cost was lower for post-operative recovery, mainly because of the shorter hospital stay.