A cross-sectional prevention and rehabilitation programme for surgery
Per Rotbøll Nielsen
About the authors:
Multidiciplinary Pain Centre, Rigshospital, Capital Region of Denmark.
The PhD is published as a supplement to the journal and will be available for download at www.clinhp.org
The PhD described 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. Several units closed down afterwards, so in 2009 only 29% of departments reported 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.
Several studies have demonstrated the effect of smoking and alcohol cessation before an operation, while the possible effect of physical exercise was 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 regime that was designed to optimise 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 programme, alcohol intervention, physical exercise, nutritional supplements and pain management.
The randomised study was an open clinic trial taking place over an 18-months period with a primary efficacy end point of functionality assessed by the time of inclusion, which was 6 to 8 weeks prior to surgery, repeated on admission, postoperatively on day 1, 3 and again at discharge, as well as after 1, 3 and 6 months . The secondary objective was pain, side effects, postoperative complications, quality of life and patient satisfaction. Twenty-eight patients were randomised to prehabilitation and 32 to the department’s usual treatment. Patients in the intervention group had already at admission a significantly better functional level, 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 postoperative mobilisation during hospitalisation significantly earlier than the control group. This difference was visualised in the duration of hospitalisation; 5 days versus 7 days (P = 0.007).
At the control after one month, the patients in the intervention group had a better functionality, but after 3 and 6 months 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 postoperative complications (p = 0.002), and the randomisation to the control group was a predictor of prolonged hospitalisation (p = 0.004).
Patients’ experiences 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. No difference was found between the groups on postoperative pain management and at the time of discharge.
Health economic analysis of the costs and benefits of the two therapy forms 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 3,705 (app. EUR 496) 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 postoperative recovery, mainly because of the shorter hospital stay.