Attending a patient education seminar before body-contouring surgery and its effect on total time admitted to hospital and postsurgical opioid use - a retrospective cohort study

doi:10.21203/rs.3.rs-3902694/v1

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Attending a patient education seminar before body-contouring surgery and its effect on total time admitted to hospital and postsurgical opioid use - a retrospective cohort study

https://doi.org/10.21203/rs.3.rs-3902694/v1

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Objective: To investigate whether attending a one-day patient education seminar before body-contouring surgery after massive weight loss surgery could affect postsurgical opioid use and the total time admitted to the hospital. Secondly, we wanted to see if other patient characteristics could influence the above variables.

Methods: We conducted a retrospective chart review of all patients undergoing body-contouring surgery at our department from April 2017 to December 2020. All patients had been invited to attend our patient education seminar prior to surgery, with around half accepting the invitation.

Results: We included a total of 276 patients. One hundred fifty patients had attended the patient education seminar and were compared to the one hundred and twenty-six who did not participate. Attending a patient education seminar prior to body-contouring surgery was associated with reduced total admission time after surgery. It did not affect the use of postoperative analgesics. Previous gastric bypass and previous body-contouring surgery were associated with a shorter duration of stay. Males reported higher use of analgesics compared to women. More extensive surgery, such as abdominoplasty and circular body lift, was associated with a longer stay duration than more minor procedures such as thighplasty, upper arm lift, and chest correction.

Conclusion: Our results indicate that attending a patient education seminar could reduce the total admission time in relation to their body-contouring surgery. As a result of this study, we have made participation in the patient education seminar mandatory before body-contouring surgery.

Practice implications: Healthcare personnel should be aware of the importance of proper pre-operative preparation and, if feasible, arrange a patient education seminar. They should also be aware of other factors that could affect hospital admission time, such as previous gastric bypass and previous body-contouring surgery. The area of surgery and gender of the patients could also affect the need for analgesics after surgery.

Patient education

Massive weight loss

Plastic surgery

Abdominoplasty

Brachioplasty

body-contouring surgery

OMEQs

analgesics

The implementation and development of patient education tools in populations of surgical patients are increasing. The benefits are, amongst others, more thorough and well-planned information for the patients. It also enables the healthcare professional to provide thoughtful, perioperative teaching within a limited timeframe[1].

Patient education aims to intervene in many different aspects of a patient's health, and its focus can be: scheduling education early; increased frequency of message exposure through several interventions and/or reinforcements; content frequently addressing postoperative management; the measurement of outcomes such as patients' cognitive, experiential and biophysiological aspects[2].

Studies have indicated improvements in physical and psychosocial recovery, reduction of anxiety and shorter time to meet functional milestones after surgery for patients attending preoperative patient education[3–5]. The evidence on the effect of patient education on outcomes after surgery is lacking and generally of low quality.

In the spring of 2017, we implemented a voluntary patient education seminar, where all patients with planned body-contouring surgery were invited to participate. Every six weeks, we would invite the patients scheduled for surgery in the near future. At the seminar, the patients would receive information about their admittance to the hospital, with a particular focus on the post-surgical period, regarding the expectation of outcome and post-operative pain. We believed that a well-planned seminar would benefit both patients as they would all get the same extensive information. It would also benefit the department and health care personnel as the patients would be better prepared for their surgery and aware of what to expect in terms of surgery and the level of postoperative pain.

Roughly half of the patients asked wanted to participate in our education seminar. In the two years since the beginning, around 150 patients attended. The healthcare personnel involved with these patients have had the impression that observed that the patients from the education seminar had a shorter duration of hospital stay and a lesser degree of pain after surgery compared to those who did not participate.

The primary aim of this retrospective chart review was to investigate if attending a one-day patient education seminar prior to body-contouring surgery after massive weight loss surgery could affect the use of analgesics and the total time admitted to the hospital. Secondly, we wanted to see if there were other patient characteristics that could influence the above variables.

The study was approved by the Danish data protection agency (journal number: 19/26453).

This study was reported in accordance with “The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement” [6].

Study design:

We performed a retrospective chart review of patients undergoing surgery after massive weight loss at our department. We use the national eligibility guidelines for corrective skin surgery after massive weight loss to assess patients before surgery. These are: patients have to have had a weight loss of at least 15 points on the BMI scale, have a normal BMI (< 25), age > 18 years and have been weight stable for at least six months and have an excess of skin corresponding to Danish scale grade 2 [7, 8].

We included all patients treated during the period of 1st of April 2017 to 31st December 2019 and expected a study size of approximately 250 patients. Records were retrieved using the relevant surgery codes from the electronic chart system.

The author SP performed the chart review and data collection using a pre-defined spreadsheet. SP collected data on gender, age, participation in the patient seminar, time from admittance to hospital to discharge, analgesics used from admittance to discharge and the area of surgery (lower circular lift, abdominoplasty, brachioplasty, thighplasty or mastopexy) and previous gastric bypass. We converted all analgesics into oral morphine equivalents (OMEQs) to facilitate comparison between the groups[9].

We allocated patients into two groups depending on whether or not they had attended our patient seminar.

Our primary outcomes were differences in total time admitted to the hospital and the amount of analgesics used in this period between our two study groups. For our secondary outcomes, we investigated whether previous gastric bypass, previous body-contouring surgery, gender or the area of the surgery could be independent indicators for the duration of hospital stay or the use of analgesics.

Description of the intervention/ Patient education seminar:

We based the design of the patient education seminar on a qualitative study investigating the psychological impact of body-contouring surgery[10]. Figure 1 depicts the outline of the day.

A specialist nurse was the leading figure throughout the day, with supplemental lectures from a surgeon and psychology students. Between 8–12 patients were invited to participate in preparation for their first body-contouring surgery. We did not specifically invite next of kin, but they were allowed to observe if they wanted to attend. The whole session lasted around two hours, but as the seminar is built on the principle of dialogue, it could vary some in duration depending on the group.

The seminar was planned as follows.

Nurse: Welcome session with a presentation of all participants, both healthcare personnel and patients. A subsequent run-through of the program of the day.

Nurse: Presentation of pre-operative preparations such as smoking cessation, shaving, fasting, medications, blood test, clinical photographs etc.

Surgeon: Session with a consultant plastic surgeon with a description of the different surgeries with a focus on techniques, outcomes and risks.

Nurse: Presentation of post-operative course at the hospital, with a special focus on pain levels, mobilisation, removal of drains and sutures and post-operative follow-up.

Nurse: Presentation of the BODY-Q with results. How can corrective surgery influence the quality of life?

Psychology: Session with two psychology students with the aim of facilitating a dialogue with the patients about the psychological aspects of undergoing major surgery. Examples could be bodily changes, self-esteem, maintaining weight loss and expectations with outcomes.

Statistical methods and data synthesis:

We used the independent t-test to test for differences in means between the group for continuous variables. We used a Pearson Chi-Squared for categorical data. A secondary analysis was performed using linear regression analyses where the differences were adjusted for gender, previous gastric bypass, are of surgery, age and previous skin corrective surgery.

We used Stata 16 for all calculations[11].

Baseline characteristics:

Baseline characteristics and primary outcomes can be found in Table 1. We included data from a total of 276 patients in our study. The mean age of the population was 42.3 and 44.4 years in the patient education group and control group, respectively, with a generally higher proportion of women than men. The distribution in age and gender were not significantly different between the groups. The area of surgery was mainly the abdomen with either an abdominoplasty or circular procedure. There was a higher proportion of circular body lifts amongst the patients attending the seminar. Around half of the patients had previously undergone a gastric bypass to facilitate their weight loss. We saw a tendency for the patients that had previously had body-contouring surgery to decline participation in the seminar. The distribution of areas of surgery, previous gastric bypass and previous body-contouring surgery were significantly different between the groups.

Primary outcomes:

We observed a shorter duration of stay amongst the patients that had attended the patient seminar with 32 hours compared to 34 hours. The difference was statistically significant when adjusting for the previously mentioned variables (p < 0.05). Regarding analgesics, we observed higher use of OMEQs in the groups not having attended with 46.7 OMEQs compared to 39.5 amongst those who had participated in the patient school. The difference was, however, not statistically significant.

Secondary outcomes:

The full results of the secondary outcomes can be seen in Table 2. For the secondary outcomes, we investigated whether the individual baseline characteristics could be indicators of longer duration of stay or increased use of analgesics.

We found previous gastric bypass to be statistically significantly associated with a shorter duration of stay after surgery (30 vs 36 hours, p = < 0.05). Forty-four patients had previously undergone body-contouring surgery, and these patients had a statistically significant longer duration of stay (35 vs 24 hours, p = 0.05). Males had significantly higher use of analgesics than females (58.5 vs 39.8 OMEQs, p = 0.05). When comparing the different areas of surgery, we found differences in OMEQs after surgery, with statistically significant higher use of analgesics amongst patients undergoing abdominoplasty and circular body lift than thighplasty, upper arm lift and surgery to the chest.

This study presents data on the effects of a preoperative education seminar before body-contouring surgery. In our population, we observed a shorter duration of stay amongst patients having attended our patient education seminar. Surprisingly we did not observe any difference in the use of analgesics. We also found that previous gastric bypass and previous body-contouring surgery, and area of surgery were individual factors influencing the length of stay after surgery. Men also had higher use of analgesics compared to women.

The results of the primary outcomes are mostly in line with our pre-study thesis. The difference in total time admitted to the hospital was only two hours. One could discuss whether this is of clinical relevance. When considering that the group attending the education seminar consisted of a population undergoing a higher proportion of circular body lifts and abdominoplasty, the effect of the patient school on time admitted is probably higher as these are more invasive procedures. We believed that attending the patient's school would affect the use of analgesics. This was not the case with our data. The amount of analgesics used is generally low amongst our patients, and it could, therefore, be challenging to obtain a statistically significant result.

For the secondary outcomes, we found that previous gastric bypass was associated with a shorter duration of stay. As these patients have previously undergone major surgery, we believe that these patients are more prepared for what the surgery entails and what to expect from the post-operative course. Males had statistically significantly higher use of post-operative analgesics compared to women. This is in line with previous studies, though the level of evidence is low in the field[12]. The area of surgery influenced the total time admitted to the hospital. We observed that patients with surgeries on the abdomen or circular procedures had a significantly more extended hospital stay than those on the thighs, upper arms or chest. This aligns with our hospital's current guidelines that recommend admitting the patient for observation after major surgery.

The strength of this study lies in the comprehensive material used to design the patient education seminar and the detailed program ensuring cohesiveness of the individual meetings. The number of patients is also high compared to other studies on the subject.

The most significant limitation of this study is its retrospective study design. The data is not 100% reliable, especially regarding the medications used between postoperative monitoring and discharge. During this period, the patients are admitted to the plastic surgery ward, where we aim for the patients to self-administer their pain medications if possible as it prepares them for their discharge. Though their prescribed dosage of medications is distributed to them and recorded, we cannot rule out that there have been instances where the patients have not taken the full amount prescribed. There is, therefore, a risk of overestimation of the analgesics used.

In this study period, the health care personnel reported that the patients who had attended the seminar seemed more prepared for their surgeries and had fewer complaints after. Therefore, at the beginning of 2021, we made it mandatory to participate in the seminar before body-contouring surgery. We do, however, lack information on the patient-reported effect of these seminars and using patient-reported outcomes measures to assess this in the future would be interesting. Therefore, the next step would be a prospective trial both investigating patient satisfaction and the level of educational output.

This study found that attending a patient education seminar prior to body-contouring surgery reduced the total admission time after surgery. It did not affect the use of postoperative analgesics. Previous gastric bypass and previous body-contouring surgery were associated with a shorter duration of stay. Males reported higher use of analgesics compared to women. More extensive surgery, such as abdominoplasty and circular body lift, was associated with a longer stay duration than more minor procedures such as thighplasty, upper arm lift, and chest correction. This is in line with our clinical experience, and as a result, we have now made participation in the patient education seminar mandatory before undergoing body-contouring surgery.

Author Contribution

All authors contributed to the study's conception and design. MS and SP performed material preparation, data collection and analysis. MS wrote the first draft of the manuscript, and all authors commented on the following versions. All authors read and approved the final manuscript.

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Tables 1 and 2 are available in the Supplementary Files section.

No competing interests reported.

Tables.docx

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Attending a patient education seminar before body-contouring surgery and its effect on total time admitted to hospital and postsurgical opioid use - a retrospective cohort study

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Version 1

Abstract

Figures

Introduction

Methods

Study design:

Description of the intervention/ Patient education seminar:

Statistical methods and data synthesis:

Results

Baseline characteristics:

Primary outcomes:

Secondary outcomes:

Discussion

Conclusion

Declarations

Author Contribution

References

Tables

Additional Declarations

Supplementary Files

Status:

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