Healthcare initiatives to support the course of early post-discharge recovery after elective degenerative spine surgery

Introduction
 The overall aim of this PhD project was to improve the course of early post-discharge recovery after elective spine surgery by identifying the patients’ and healthcare professionals’ needs and wishes in the early postdischarge recovery phase. Subsequently, we designed and developed an mHealth pathway using an existing app and an accompanying organizational intervention to meet the identified needs and wishes. Finally, we aimed to test and evaluate the effect, usability, and satisfaction with the solution.

Methods
Participatory Design (PD), performed in three phases, was the methodological framework of this PhD thesis. The study was conducted at a single spine centre, which is part of a medium-sized hospital in Denmark. 

PD Phase 1: Identifying needs and wishes. Field observations using a rapid ethnographic method were conducted to understand the patient’s journey for degenerative lumbar spinal surgery. In Study 1, we quantitatively assessed patients’ quality of recovery (QoR-15) scores, preoperatively and at 3 time points post-discharge. After descriptive analysis, we conducted with-in-subject longitudinal repeated measures and explored individual QoR-15 items via a heatmap. Additionally, Study 2, a qualitative study was carried out using solicited patient diaries and focus groups with nurses from the surgical ward, with data analyzed through systematic text condensation. Findings from field observations, Studies 1 and 2 formed the basis for Workshop 1, where relevant stakeholders were engaged to enrich the findings. 

PD Phase 2: Designing and developing a new solution. In Study 3, we conducted a systematic review following the PRISMA guidelines. The literature search was conducted in March 2022 (updated in May 2023) in MEDLINE (Ovid), EMBASE (Ovid), CINAHL (Ebsco), PsycINFO (Ovid), and Scopus. Utilizing thematic analysis, we categorized the characteristics of care interventions supporting surgical treated spine patients in their early post-discharge recovery. The findings of Study 3, alongside those of Workshop 1, served as the foundation for Workshop 2, which focused on idea generation. Workshop 2 was followed by a design and development process and finally, a third workshop focusing on organization and workflow related to the solution.

PD Phase 3: Testing and evaluating the new solution: In study 4, we employed a quasi-experimental design utilizing two cohorts for pre- and post-test comparisons to evaluate the effectiveness, usability, and patient satisfaction of evaluating an mHealth pathway. This pathway included an ePRO-based post-discharge nurseled intervention. The primary outcome measure was the assessment of the patients’ quality of recovery using the QoR-15 questionnaire. Secondary outcome measures included patient-perceived usability utilizing the Danish version of the System Usability Scale, which was analyzed descriptively. Feedback comments were analyzed quantitatively and qualitatively using an inductive coding strategy and content analysis. Finally, we conducted a prospective cohort study to evaluate the clinicians’ assessment of the intervention.

Results

Study 1: Data from 46 patients were analyzed. The mean QoR-15 sum score at baseline was 105.4 ± 18.3. The mean QoR-15 sum scores were 108.1 ± 19.2 on post-discharge day 1, 118.5 ± 17.4 on day 7, and 120.7 ± 20.9 on day 14. The QoR-15 score improved significantly from day 1 to day 7. Eight of the 15 items influenced the overall QoR-15 score. 

Study 2: From 8 patient diaries and 2 focus groups, 3 themes were identified: 1) Postoperative clarity: Recognizing and coping with pain and symptoms; 2) Innovative post-discharge communication between patients and healthcare professionals; and 3) The significance of family support. 

Study 3: A total of 14 articles met the eligibility criteria. The included studies were published between 2008 and 2022 and included 1,399 unique patients with mean reported ages of 42.3 to 62.3 years. The reported interventions were divided into two categories: “Early active rehabilitation” and “Telemonitoring”. As for pain, function, quality of life, and activity, the telemonitoring interventions seemed mainly to be in favor of the interventions. Study 4: The analysis of the QoR-15 included data from a total of 150 patients, consisting of 77 women and 73 men, with 104 patients in the intervention group and 46 in the comparison group, who completed the QoR-15 score at baseline and at all three post-discharge time points. A total of 110 out of 154 possible respondents (71.4%) participated in the SUS survey. The mean SUS score was 84.68 (SD 12.86). Thirty-nine patients provided feedback comments. The analysis identified 48 statements, which were classified into five themes; (1) Usability and functionality of the mHealth solution, (2) Feedback on the QoR15 questionnaire, (3) Safety and sense of support, (4) Missing functions and suggestions for improvements, and (5) Patient satisfaction. Usability from the clinicians’ perspectives: Twenty-two of the possible 27 respondents (81.5%) completed the questionnaire. The mean SUS score was 74.55 (SD 15.17). 

Conclusion

The findings suggested that the intervention does not affect the patients’ quality of recovery measured by the QoR-15. However, feedback from patients highlights the importance of usability, safety, and support in enhancing their recovery experience. Healthcare professionals were also predominantly positive regarding usability. Moving forward, integrating mHealth into healthcare systems could potentially improve the overall recovery process for patients undergoing elective spine surgery. Additionally, the study proposes a series of improvement suggestions that could be beneficial for future research in this field.