Introduction

Spine disorders are a common cause of disability, and surgical intervention can positively impact pain, function, and quality of life for specific spinal conditions (Hoy et al., 2014). Beyond the spine-specific pathology, patient factors such as associated medical and psychosocial conditions, understanding of the treatment process, and the degree of patient engagement can influence surgical outcomes (Burgess et al., 2019; Harris et al., 2020; Skeppholm et al., 2017). Managing these variables in a diverse patient population can be complex and time-consuming but is an essential aspect of surgical treatment.

In the resource-constrained healthcare environment, it is essential that the effect of interventions on patient outcomes that measure both quality and cost of care be examined. Hospital length of stay (LOS), cost of care, rates of discharge to skilled nursing facilities (SNFs), 30-day return to the emergency department (ED), and 30-day readmissions are commonly used measures of cost and quality of surgical care. At the federal level, the Centers for Medicare & Medicaid Services (CMS) uses 30-day readmissions across six common conditions as the primary outcome measure for value-based payment through the Hospital Readmissions Reduction Program (HRRP) (CMS, 2020b). Other CMS value-based payment programs, including the bundled payments in care initiative (BPCI) and Comprehensive Care for Joint Replacement (CJR) models, incentivize participants to meet target quality metrics and reduce 90-day episode of care costs beneath a target threshold in order to share in the savings achieved (CMS, 2020a). Within these programs, LOS reductions, reduced SNF utilization, and reduced ED returns and readmissions have all been cited as key mechanisms for reducing episodic costs while maintaining quality, thus enhancing the value of surgical care (Clair et al., 2016; Kurtz et al., 2017; Luzzi et al., 2018; Lygrisse et al., 2020; Zuckerman et al., 2016). In patients undergoing spine surgery, a significant body of literature examining risk factors for adverse outcomes as measured by these endpoints highlights their importance as quality and resource utilization indicators within this patient population (Cho et al., 2020; Debono et al., 2019; Eastlack et al., 2018; Kalakoti et al., 2019; Mummaneni et al., 2019; Pugely et al., 2014).

Recent literature has highlighted the importance of patient activation and engagement as factors that may affect patient outcomes (Hibbard, 2017). Patient activation is defined as the ability of the individual to utilize the available information and actively engage in making their healthcare decisions (Hibbard et al., 2005). The knowledge, skills, and confidence to manage one's own health are associated with higher activation and engagement (Hibbard et al., 2005). Although psychosocial risk factors can negatively impact surgical outcomes including disease-specific disability, physical function, pain, and overall quality of life (Amaral et al., 2017; Chapin et al., 2017), some evidence suggests that higher levels of activation can buffer these factors when present (Block et al., 2019). Furthermore, higher levels of activation and engagement are associated with greater satisfaction with treatment following surgery (Harris et al., 2020).

At our institution, we committed resources to improve patient engagement through concierge-style coordination of patient resources and procedure-specific preoperative education. Office-based and hospital-based nurse navigators serve as a central point of contact to patients and aid the care team by providing surgical education as well as managing patient-specific issues to mitigate any identified medical, psychological, social, or behavioral risk factors. The aim of our study was to quantify the effect of a nurse navigator-led preoperative surgical education course on postoperative resource utilization and patient outcomes.

Methods

The institutional clinical research committee deemed this study institutional review board review exempt. A retrospective review of administrative databases was performed to identify consecutive patients who underwent posterolateral lumbar fusion (PLF) at a single institution from November 2017 to June 2019. All surgeries were performed by one of two board-certified orthopaedic spine surgeons.

Nurse Navigator Intervention: Preoperative

The nurse navigator preoperative interventions consist of a standardized assessment of psychosocial risk factors and a preoperative educational course. For nonurgent elective surgeries, initial contact with the patient and discussion of the psychosocial risk factors occur approximately 4 weeks preoperatively and patients are scheduled to attend the education course approximately 2-3 weeks preoperatively. The components of the psychosocial assessment are shown in Table 1. The psychosocial risk factors included on the instrument were selected by consensus between the surgical teams (surgeon and physician assistant), nurse navigators, and the joint and spine unit staff during a structured performance improvement event. After a literature search was conducted to identify psychosocial factors previously demonstrated to influence postoperative outcomes after spine surgery, the group selected the final eight elements included in the instrument based on clinical experience, as these were deemed to be the most prevalent and impactful risk factors in our patient population. This instrument is not designed to be a comprehensive assessment of social determinants of health that may influence outcomes. Specific interventions are then initiated on the basis of the presence of various risk factors. Smokers are scheduled for a smoking cessation consult preoperatively, with follow-ups as necessary. If a patient lives alone or use an assistive device, they are enrolled in a home-based physical therapy program (Menon et al., 2020) that evaluates the safety and risk factors within the patient's home. Patients without a current primary care provider (PCP) are sent to the hospital preanesthesia testing center for preoperative medical clearance. Counseling regarding the importance of preventive care is conducted, and postoperative appointments with a PCP are coordinated by the navigator if the patient agrees to utilize this service. If patients do not have transportation to appointments, the nurse navigator will coordinate curb-to-curb pickup and drop-off with the county department of transportation or volunteer transportation services. Patients who are currently under the care of a pain management physician or have a documented diagnosis of anxiety disorder receive additional counseling regarding the risks of developing opioid dependence after surgery and additional coaching related to alternative pain management techniques including multimodal analgesia, cryotherapy, and mindfulness. This intervention is performed on the basis of evidence that long-term preoperative opioid use and anxiety are risk factors for developing opioid dependence after spine surgery (Armaghani et al., 2013; Esfahani et al., 2018; Kalakoti et al., 2018). In addition, navigators document whether a patient appears subjectively anxious about the upcoming surgery based on clinical judgment. Indicators used to deem patients subjectively anxious include abnormally high levels of fear about the upcoming surgery, significantly increased calls and questions over normal levels observed in patients, or other symptoms such as patient-reported irritability, dread, or problems with sleeping. This information is used to preemptively inform the care team that a patient may need additional attention and coaching around the time of surgery. A handoff between the office-based and hospital-based nurse navigators is then performed, and the patient is contacted within 3 days of surgery by the hospital-based navigator to answer any final questions about the upcoming surgical process.

Table 1. Nurse Navigator Psychosocial Assessment Instrument

Nurse Navigator Intervention: Acute Care Hospitalization

During the acute care admission, the hospital-based nurse navigator rounds on high-risk patients (defined as patients with multiple comorbidities, multiple psychosocial risk factors, or multilevel fusion surgery) to ensure appropriate postdischarge care and early follow-up. On these rounds, patient and family questions are addressed, discharge destination decisions are made in collaboration with the patient, family, care managers, and surgical and medical providers, and post-acute resource needs are addressed (e.g., confirm patients have all durable medical equipment, discharge medications). All patients receive a phone call within 48 hours after discharge to answer questions and address issues of concern. After 48 hours postoperatively, the office-based nurse navigator resumes the role as the patient's primary point of contact to guide them through follow-up visits and the recovery process. Although patients are instructed to contact the office-based navigator after the immediate postoperative period, both navigators remain available to respond to patient questions and concerns. If nurse navigators are alerted to a nonemergent complication postoperatively, they directly coordinate urgent follow-up with either the surgical team or a spine program nurse practitioner with dedicated urgent postoperative access clinic time.

Preoperative Group Education

The cornerstone of nurse navigator intervention is a preoperative group education course that all patients are highly encouraged to attend. Course components include a checklist of tasks to complete prior to surgery, overview of the surgery and hospital experience, information regarding physical rehabilitation, pain management, and postoperative care. Key points of emphasis include setting realistic expectations around postoperative pain and introducing patients to alternative methods of pain management, along with the identification and education of a caregiver to provide postoperative support. Furthermore, patients are counseled on the risks and benefits of SNFs and introduced to alternative support structures that can support home discharge, such as home-based physical therapy. At the conclusion of the group session, one-to-one follow-up is conducted to address patient-specific concerns. An outline of the topics covered in the class is provided in Appendix 1.

Chart Review: Independent Variables

Patients were classified according to preoperative course participation. Data on psychosocial risk factors were prospectively collected via phone by the nurse navigator prior to surgery and entered into the electronic health record (EHR). These responses, along with patient demographics and outcome measures, were extracted from the EHR. The Centers for Medicare & Medicaid Services hierarchical condition categories (HCC) risk score was used as a measure of comorbidity burden for risk adjustment. The HCC model, which was designed for risk adjustment of Medicare Advantage plan payments, uses demographic factors, condition categories (defined by diagnoses), and interaction terms (combinations of conditions and/or demographic factors) of Medicare beneficiaries to develop a risk score where the average Medicare beneficiary has a score of 1.0 (CMS, 2018). A prior work at our institution demonstrated that the HCC score is a valid instrument for risk stratification and prediction of readmission and reoperation after elective inpatient spine surgery (Turcotte et al., 2019). In addition, the number of levels fused was recorded, as multilevel fusion has been associated with longer LOS and higher postoperative complication rates than with single-level procedures (Kobayashi et al., 2019; Veeravagu et al., 2014).

Chart Review: Outcome Measures

The primary outcome measures for this study were hospital LOS days and the cost of hospitalization. Cost was measured as the total cost of providing care (not charges) during the acute care hospitalization based on an institutional cost accounting system (Costflex Systems Inc., Mobile, AL). Cost allocations were made using activity-based costing methods (Costflex, 2020; Keel et al., 2017). Secondary outcomes were rates of SNF utilization, 30-day returns to the ED, and readmissions. These outcomes were chosen on the basis of their ability to be used both as indicators of care quality and for their influence on the value of care provided. Each of the primary and secondary endpoints is used at our institution as key performance indicator and has been frequently cited as a measure of the quality and value of spine surgery in previously published studies.

Statistical Analysis

Pearson's chi-square test was used to analyze the differences between groups in categorical variables (discharge to SNF, 30-day return to ED, 30-day readmissions), with Fisher's exact test used when appropriate. Independent-samples t tests with two-sided significance were used to analyze continuous variables (LOS days and hospital cost). A value of p <= .05 was treated as statistically significant. Multivariate logistic and linear regressions were performed to assess the impact of preoperative course attendance on patient outcomes after controlling for risk factors that yielded a value of p < .1 on univariate analysis. All statistical tests were performed using SPSS (Version 24.0; IBM Inc., Somers, NY).

Results

A total of 177 patients underwent PLF surgery. One hundred four (59%) patients attended the preoperative course, whereas 73 (41%) did not attend. On univariate analysis, patients attending the course were younger, had less comorbidity burden as measured by the HCC score, were more likely to undergo one-level fusion, and less likely to undergo five- or more-level fusion. The percentage of one-level fusions (no course: 56.2% vs. course: 71.2%, p = .040) and HCC risk score were found to be statistically significant (no course: 0.68 vs. course: 0.53, p = .033). Age, performance of one-level fusion, performance of five- or more-level fusion, and HCC score were included in the multivariate model, given their p < .1 values. Notably, no differences in the rates of any of the eight psychosocial risk factors were observed between patients who attended the course and those who did not (see Table 2).

Table 2. Demographic and Psychosocial Risk Factors by Course Attendance

Univariate analysis of outcomes demonstrated that patients who attended the preoperative course had a significantly shorter LOS (2.12 vs. 2.60 days, p = .042) and decreased average hospital cost (U.S. $10,149 vs. U.S. $14,792, p < .001). No difference in the rate of discharge to SNF was observed between patients who attended the course (10.6%) and those who did not (16.4%, p = .254). Similar rates of 30-day postoperative ED returns (overall rate 9.0%) and readmissions (overall rate 3.4%) were found between groups (see Table 3). After controlling for age, comorbidities, and the number of levels fused, patients enrolled in preoperative course did not demonstrate statistically significant reductions in LOS days ([beta]=-.265, p = .224), discharge to SNF (OR = 0.939, p = .900), 30-day ED returns (OR = 0.864, p = 0.789), or 30-day readmissions (OR = 1.376, p = .721). However, after controlling these factors, patients enrolled in preoperative course demonstrated a statistically significant reduction in hospital cost ([beta]=-4,143, p < .001).

Table 3. Univariate Analysis of Outcomes by Course Attendance

Discussion

The results of our study suggest that a nurse navigator-led preoperative group education program may enhance the value of posterolateral fusion. Building on the evidence from enhanced recovery after surgery (ERAS) pathways (Elsarrag et al., 2019; Ljungqvist et al., 2017) in spine surgery and the successful implementation of preoperative education in other orthopaedic subspecialties (Causey-Upton et al., 2020; Tait et al., 2015), the use of group education appears to hold value in mitigating cost and LOS in this patient population.

The benefits of preoperative education have been well described in other orthopaedic subspecialties. In a systematic review of nearly 3,000 patients undergoing hip and knee arthroplasty, those receiving preoperative education demonstrated improvements in LOS and functional assessments over those not participating in educational programs (Moyer et al., 2017). For patients undergoing spine surgery, less evidence of the effect preoperative education has on patient outcomes exists, although prior studies have demonstrated a correlation between education and patient satisfaction with surgery (Papanastassiou et al., 2011). In a systematic review of patients undergoing elective spine surgery, there was limited, fair-quality evidence regarding the benefits of preoperative education (Burgess et al., 2019). The benefits of education included enhanced patient knowledge, feelings of better preparation, reduced negative thinking, and increased levels of physical activity after the intervention. In contrast to these benefits, no differences in quality of life, return to work, physical indicators, or postoperative complications were reported in the seven studies included (Burgess et al., 2019).

Despite the relative paucity of evidence supporting nurse navigator-led education, many spine centers, including our own, invest significant resources to conduct formal education programs and develop care pathways. Another study evaluating the value of providing individualized education before lumbar spine surgery found that this intervention led to a 45% reduction in 1-year cost of care (experimental: U.S. $2,678.57; control: U.S. $4,833.48; p = .007) (Louw et al., 2014). Although this study differed from our own in its use of one-to-one education provided by physical therapists, in comparison with our use of nurse navigators to provide group education supplemented with one-to-one support, it provides the strongest prior evidence supporting the assertion that increased patient education may translate to decreased cost of care. In our study, after controlling for age, comorbidities, and the number of levels fused, patients attending preoperative education incurred a hospital cost U.S. $4,143 lower than those not attending. Despite our finding that patients attending the preoperative course did not have a statistically significant reduction in LOS after controlling for other factors ([beta]=-.265, p = .224), we posit that cost reductions were primarily driven by the decreased LOS in this group, which was significantly shorter than patients not attending class prior to risk adjustment (2.12 vs. 2.60 days, p = .042). The difference between the risk-adjusted and raw LOS highlights the multitude of factors that influence this outcome. Although we hypothesize that these trends in LOS reduction resulted in cost savings from decreased labor required to care for these patients, we are unable to confirm this and it is possible that cost differences in devices and implants used or pharmacological treatments used drove the majority of these savings. Although our findings do not confirm a causal relationship between preoperative education and cost savings, they do add to the evidence supporting the potential return on investment in nurse navigator-led group education.

The concept of patient activation and empowerment is our theoretical basis for linking preoperative education course attendance with decreased cost and potential LOS reductions. Preoperative education empowers patients and their families to understand the scope of surgery, the recovery process, and how their actions influence postoperative quality of life. Educating patients and families prior to surgery prepares them with strategies to address the increased emotional, physical, and psychological demands they will face in the early postoperative period (Menon et al., 2020). The mechanism by which patients may prepare themselves to deal with these challenges is through the cultivation of adaptability to changes in their health status after surgery (Elsarrag et al., 2019). The efficacy of this approach has been measured by patients' propensity to engage in efficacious health behaviors. This increased engagement has been associated with improved treatment protocol compliance, which leads to enhanced functional recovery and better outcomes after spine surgery (Ljungqvist et al., 2017). Unfortunately, the retrospective design of our current study precluded our ability to quantify levels of patient empowerment, thus preventing us from evaluating the association between preoperative education and empirical evidence of engagement. This presents a significant opportunity for future research, and the potential to build upon our results by evaluating whether the proposed linkage between education, empowerment, and clinical outcomes can be confirmed.

Although our primary focus was on the impact of preoperative education on patient outcomes after spine surgery, the collection of data quantifying the prevalence of psychosocial risk factors in this patient population is a unique aspect of the study. The negative impact that psychological conditions, particularly anxiety and depression (Abtahi et al., 2015; Anderson et al., 2015, 2006; Skeppholm et al., 2017), and poor social conditions and lifestyle choices (Anderson et al., 2006; Schwartz et al., 2011; Vereckei et al., 2013) have on patients with spine conditions is described across multiple studies (Amaral et al., 2017). However, benchmarks for the second-order results of these underlying conditions, such as whether a patient lives alone, has a PCP, or has transportation for follow-up appointments, remain sparse. The findings that in our population of patients undergoing PLF, 18% live alone, only 51% have a dedicated PCP, and only 48% have transportation available for follow-up appointments are important targets for future population health improvement initiatives. Interestingly, no differences in the prevalence of these risk factors were observed between patients who attended preoperative education course and those who did not. This suggests that increased preoperative education may help mitigate the influence of social factors that can lead to delayed transition to lower levels of care at the time of hospital discharge, therefore preventing increased LOS and cost.

This study does have multiple limitations. First, its retrospective observational design exposes it to selection bias, and it is possible that our patient population does not represent the broader population of patients undergoing PLF. This is particularly important when considering psychosocial factors that are highly variable across geographic areas, socioeconomic levels, and cultures. Second, although our study attempted to statistically control for relevant variables that influence hospital outcomes, it is probable that other unmeasured confounding factors exist. Third, although this study was designed to compare outcomes between patients who did and did not attend a preoperative education course, we were unable to control for variability in the level of other individualized nurse navigation services used between groups, which confounds our results. To establish a causal relationship between preoperative nurse navigator-led education and improved clinical outcomes, randomized controlled studies are warranted. Finally, our study is limited in its evaluation of only hospital outcomes and cost. One notable outcome missing from our study is patient satisfaction, which we were unable to collect at the individual level and compare between groups based on institutional data collection and reporting methodologies. To evaluate the true utility of preoperative education, patient-reported outcomes (including measures of patient activation and engagement, patient satisfaction, physical and mental function, and global health status) must be assessed. In addition, cost, considered from a societal perspective, must be assessed over a longer time horizon to evaluate the economic impact of preoperative education beyond the acute care hospitalization. Significant opportunities for follow-up studies evaluating the effectiveness of different variations of patient education programs on patient-reported, clinical, and financial outcomes in patients undergoing spine surgery exist.

Conclusion

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.

References