Running head: PREOPERATIVE EDUCATION Preoperative Education for Patients Undergoing Spine Surgery Anna Janet Trejo Arizona State University 1 PREOPERATIVE EDUCATION 2 Abstract Low back pain is a worldwide health problem. Preoperative education is essential to provide patients with information across the continuum of care. Gaps exist among healthcare organizations regarding deficiencies in properly educating patients about their surgical experience. The lack of proper preoperative education can negatively impact reimbursement for healthcare systems, providers, and patient outcomes. In a large metropolitan tertiary care center providing spine surgery, an evidence-based project was implemented. A self-developed pre and post intervention surveys was given assessing patients’ knowledge and surgical expectations after surgery. A tri-fold education pamphlet was given to the participants with information that included detailed information regarding expectations before and after surgery. Descriptive statistics were used to describe the sample and outcome variable. An increase in knowledge in expectations after surgery was noted from pre-intervention (mean 1.83, SD .408) to postintervention (mean 1.67, SD .816) with a Cohen’s D of 0.248 although this was not statistically significant. However, the change in average length of stay (LOS) was significant. The average LOS for the project participants dropped from 4.54 days to 2.833 days which is within the Centers for Medicare and Medicaid Services (CMS) guidelines of 2.92 days for this surgical population. In conclusion, an increased in patients’ knowledge regarding expectations following surgery and decreased LOS was seen for the project participants. Keywords: spine surgery patients, patient expectation assessment, length of stay, patient education, preparation for surgery, clinical assessment tools PREOPERATIVE EDUCATION 3 Preoperative Education for Patients Undergoing Spine Surgery Proper patient education is recognized extensively in healthcare as an essential component of improving patient outcomes (Marcus, 2014). A gap exists in organizations surrounding patient education specifically in specialty procedures and surgical procedures. According to Agency for Healthcare Research and Quality, (n.d.), 30% of patients being discharged are less likely to be readmitted or visit the ED when they have a clear understanding of their after-hospital care instructions. A lack of knowledge of proper care can be potentially dangerous and causes extra expenditures for the patient and the healthcare system. Background and Significance According to HealthyPeople (2018), low back pain is the second leading cause of absenteeism from work, the third most common cause of surgical intervention and the fifth most common reason for hospitalization. Treatment of low back pain is costly to Americans; it is estimated people spend at least 50 billion dollars each year (HealthyPeople, 2018). Additionally, about 80% of Americans experience low back pain in their lifetime (HealthyPeople, 2018). It is estimated that each year about 15-20% of the population will develop prolonged back pain, 2-8% will have chronic back pain, 3-4% will be temporarily disabled and 1% are permanently disabled due to back pain (HealthyPeople, 2018). Herniated disks, spinal stenosis, degenerative disk disease, and spinal instability are the leading causes of lumbar spine surgery (Hartley, Neubrander, & Repede, 2012). Treatment options include managing pain, rest, physical therapy and surgical intervention. Patients who elect to have spine surgery many times face minimal preparation time. Current patient education practice has conventionally failed to educate patients on their care before and after surgery. PREOPERATIVE EDUCATION 4 Patient education is limited due to the decrease in allotted LOS in the hospital (Hartley et al., 2012). Preoperative teaching that is practical increases patient self-care knowledge, reduces pain, decreases anxiety, and adequately prepares the patient for post-operative care in their homes (Hartley et al., 2012). Factors that contribute to an increase in LOS are essential to identify in the preoperative phase to adequately prepare for those factors to improve postoperative outcomes. Gruskay, Fu, Bohl, Webb, & Grauer, (2015) determined some of the major factors contributing to an increase in LOS were age, American Society of Anesthesiologist (ASA) score, history of heart disease, and discharge to a nursing facility. Moreover, the Joint Commission (JC) emphasizes the importance of providing patient education. JC’s purpose is to improve the health care of the public, to evaluate healthcare organizations and ensure the care provided is of highest quality and value (The Joint Commission, 2018). JC certifies and accredits more than 21,000 health care organizations and programs in the United States (The Joint Commission, 2018). This organization focuses on patient safety and quality of care. Additionally, JC addresses patient’s rights and education, prevention of medication errors, management of infection control, verification that hospital personnel such as doctors, nurses, and other hospital staff are competent and qualified. Furthermore, JC ensures emergency preparedness plans are in place, they collect data to measure hospital performance and utilizes the data to make improvements (The Joint Commission, 2018). Consequently, hospitals must provide the proper training and education based on the patient’s needs and abilities. Organizations must assess the patient’s learning needs and utilize instruction and education methods customized to the patient’s level of understanding. Patient education is essential and directly influences the patient’s outcomes and promotes healthy PREOPERATIVE EDUCATION 5 behaviors (The Joint Commission, 2012). Individualized preoperative patient education is vital to ensure organizations comply with JC guidelines and are meeting patients’ needs and expectations while providing excellent patient care. In a large metropolitan hospital system providing spine surgery, currently, there is no process in place that is dedicated to patient education in this service line. Numerous modalities have been trialed with no definitive or consistent patient education method. General preoperative instruction is given to patients, but no specific procedure/surgical education is provided. Moreover, patients’ expectations of the surgical process are deficient. The organization's stakeholders have identified patient education as a major gap with abundant room for improvement. Additionally, the stakeholders of the organization raised concern after evaluating comparison data from other facilities looking at the same population of patients and how some health centers are meeting the reimbursable number of days set by Centers for Medicare and Medicaid Services CMS (CMS, 2017). CMS guides the reimbursement for medical treatments. Facilities who adhere to these guidelines receive maximum compensation. An analysis of the LOS data, explicitly examining DRG 460 non-complicated spine fusion surgeries in comparison to other local hospitals performing the same operations revealed that the facility was not meeting the target for reimbursement set by CMS. Data from fiscal year 2016 showed a total of 432 spine fusions were performed with a mean LOS of 4.54 days compared to CMS reimbursable of 2.92 days. Many reasons contribute to the issue. The organization determined a tremendous gap surrounding patient education as one of the factors contributing to this downfall. Surgical teams must first assess expectations, then moderate these patient-driven expectations with true trajectory of care potentials. Presently, no pre-surgical expectation assessment for patients is PREOPERATIVE EDUCATION 6 place to develop an individualized education plan. In addition, when teaching was provided, a lapse in time occurred where patients vaguely recalled the teaching Problem Statement and PICO The lack of education impacts patients, providers, and health systems. Educating patients correctly on what to expect preoperatively, post-operatively, inpatient and at discharge is crucial to meeting expectations and setting precedence for patients so that they have a clear understanding of their surgery process. This gap negatively impacts providers and health systems due to a loss in reimbursement by CMS due to an increase in LOS. Numerous factors contribute to the gap. Some of the factors are related to poor understanding of spine surgery outcomes, recovery standards, mobility, pain management, and patient responsibilities regarding the expectation for their care on the continuum focusing on the preoperative phase. This inquiry has led to the clinically relevant PICO question: in adult spine surgery patients (P), how does a surgery expectation assessment plus standardized patient education (I) compare to current practice (C) affect preparation for surgery, perceived surgical experience, and length of stay (O). Search Sources and Process A review of the literature was undertaken to address the PICO question. The search strategy was based on the electronic databases: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Library. Descriptors were combined with the Boolean connector AND, OR, and MeSH in English to broaden study results. Keywords searched: expectation assessment, patient education, surgery, instruments to measure outcomes, surgery expectation assessment, spine surgery, outcome assessment, back surgery, standardized education, standardized patient teaching, readiness for surgery, effect on length of stay, PREOPERATIVE EDUCATION 7 preparation for surgery, patient expectation assessment, LOS, ERAS, and clinical assessment tools. Inclusion criteria included full-text studies published from 2013 to 2018, adult patients, spine surgery, patient expectations, preoperative education, surgery expectation, outcomes, and LOS. Exclusion criteria included studies published before 2013, clinical studies, clinical guidelines, editorials, commentaries, and reviews addressing emergency or urgent spine surgeries. PubMed was the first database searched (Appendix A) for this literature review. An abundance of studies was obtained and reviewed. A total of 42 studies contained all components of the PICO question for consideration. The initial search of this database utilizing expectation assessment AND surgery AND patient education yield seven studies. A refinement in search strategy containing keywords: surgery expectation assessment AND spine surgery yielded 32 studies for evaluation. CINAHL was the second database searched (Appendix B). This database provided a wide range of studies as well. The initial search with this database yield two articles with keywords: patient expectation assessment AND surgery. One article with keywords: expectation assessment AND surgery AND patient reported outcomes. After refining the search utilizing keywords: clinical assessment tools AND spine surgery AND patient satisfaction, 24 studies were retrieved for review. Lastly, the Cochrane Library database was searched (Appendix C). This database provided the most studies incorporating all three components of the PICO question. The initial search yield 49 studies utilizing keywords: measurement instruments and surgery expectation assessment and surgery. Forty studies using keywords: standardized patient education and spine PREOPERATIVE EDUCATION 8 surgery and LOS. 214 studies utilizing keywords: surgery expectation assessment and surgery and clinical outcomes. Most of the studies retrieved from this database were of good quality articles and relevant to the PICO question. A total of 50 studies related to adult spine surgery, preoperative patient expectations and education, patient preparation and LOS were selected for review. A few of the articles were discarded due to not meeting inclusion criteria. A total of ten final studies were selected for this literature review (Appendix D). The studies chosen consisted of five systematic reviews (SR), one meta-analysis (MA), one retrospective case study (RCS), one randomized control trial (RCT), one cross-sectional study, and one integrative review. It is important to note, even though integrative reviews sometimes deliver vague information; this integrative review had a welldeveloped method and research design. The selected ten studies met inclusion criteria and were individually reviewed and organized in an evidence evaluation table (Appendix D). Overall, the strength of the ten studies selected for this review was of high quality and relevance. A total of six level I evidence studies consisting of five SR and one MA; one level II evidence RCT study; one level III evidence cross-sectional study; and two level IV evidence studies consisting of one randomized case study and one integrative review. Due to the nature of the study phenomena, no qualitative studies were found. Reliable, tested and valid measurement tools well known in the science of research were utilized in many of the studies to capture patients’ expectations and outcomes (Appendix D). Most of the articles reviewed discussed the importance of addressing pre-operative expectation; post-operative expectation; patient-reported outcomes such as patient satisfaction, understanding plan of care, and reduce pain and anxiety; variables affecting LOS and patient education (Appendix E). PREOPERATIVE EDUCATION 9 Validity and reliability among all the studies were measured through the utilization of evidence-based tools for evaluation of outcomes (Appendix D & E). All the studies implemented interventions, critically appraised current data and provided information regarding the use of valid measurement tools to assess studies. Two articles identified some bias however it was offset by the incorporation of validity scales such as Glombiewski-Gutterman-Koenig (GGK) quality score. Across all studies, careful consideration was taken utilizing descriptive statistics to extract high-quality data. Four of the studies reproduced low-quality data. However, the instruments of measurement and data collection were of valid and reliable value due to the positive results obtained from the intervention and outcome (Appendix D). Most of the studies reported heterogeneity; this precluded the use of a meta-analytical technique to estimate the strength of associations. The limited initial retrieval of studies searching specifically for adult spine surgery patients prevented the homogeneity of studies, and thus it was necessary to expand the search to other surgeries. Due to the heterogeneity, most of the studies used a quantitative method to assess, quantify and report preoperative expectations and patient-reported outcomes. Diverse use of validated methods of measurement were used across all studies. Most of the interventions assessed were preoperative patient expectations, post-operative expectations and patient-reported outcomes (Appendix E). The most common outcomes reported were correlations between preoperative expectations and postoperative outcomes. Evidence Synthesis Louw, Butler, Diener, & Puentedura, (2013) developed a neuroscience educational (NE) booklet that addresses pain, anxiety, stress in musculoskeletal conditions and disability. The development of this brochure along with one-on-one educational sessions for patients before PREOPERATIVE EDUCATION 10 spine surgery delivered the best outcome. A heterogonous sample of studies reviewed discovered the benefits of utilizing the written material in adjunct with in-person meetings to decrease pain, decreased perceived disability and increased physical activity. The authors stated further studies needed to occur to test for efficacy of the NE booklet. One year after the introduction of NE booklet as described above, a multicenter randomized controlled trial was conducted. This study focused on the effects of NE in pain. The results obtained from this trial revealed no significant difference between the NE groups to the control group. However, in regards to preparation for the surgical procedure and surgical experience the results were significantly better for the NE group than the control group. Also, 45% of healthcare expenditure was reduced in the NE group than the control group in a one-year follow-up (Louw, Diener, Landers, & Puentedura, 2014). A three-year follow-up in a randomized controlled trial found no significant difference in patient outcomes in regards to pain between the NE group and the control group. However, the implementation of NE at the threeyear mark resulted in the favorable views of the patients’ surgical experiences and reduced further healthcare needs than the control group. Educating patients regarding surgical expectations to reduce health expenditures produces lasting behavior changes following surgery (Louw, Diener, Landers, Zimney, & Puentedura, 2016). Enhanced recovery after surgery (ERAS) is an evidence-based model of care, with the goal to prepare patients for surgery, reduce the impact of surgery, and to enhance the recovery process (Wainwright, Immins, & Middleton, 2016). ERAS currently is being used in colorectal operations and hip and knee replacement with excellent outcomes. A critical concept of ERAS is decreasing patient’s stress response to surgery; this will, in turn, allow for faster recovery and shorter LOS. Although this model has not been implemented for primary spine surgery; it has the PREOPERATIVE EDUCATION 11 potential to have a positive impact in the care of spine surgery patients. The demand for major spine surgery is on the rise. ERAS seems promising in addressing the variation in LOS, postoperative pain, and functional recovery. The use of the components of ERAS individually such as patient education, physiotherapy, pain management, and interventions to minimize blood loss are beneficial. The incorporation of ERAS pathway in major spine surgery focusing on adopting the evidence-based practice, improving clinical procedures, enhancing logistics will enable prompt patient recovery, hence reducing hospital cost and LOS (Wainwright et al., 2016). Preoperative education is essential to improve patient outcomes (The Joint Commission, 2012). The deliverance of education requires a multidisciplinary approach taking into account the patient’s educational learning styles, culture, and literacy to be able to assess, communicate and incorporate appropriate methods based on learning needs (Marcus, 2014). Reiter, (2014) discusses the benefits of patient education for both patients and practitioners. Patient education is essential to ensure sufficient understanding of the expectations before, during and after surgery. Reiter, (2014) reinforces the importance in assessing and individualizing the plan of care for the patient. Not all patients learn the same way; they may have a different perception regarding recovery. For example, one may believe it is better to rest after surgery while another may not think in resting at all. It is essential to develop a plan that addresses individuals learning styles and that the education is reinforced on the continuum (Reiter, 2014). Preoperative education has been shown to reduce anxiety, pain and improve patient outcomes. A randomized controlled trial with block design was conducted in a medical center in Taiwan. The study explored the impact of using an educational intervention versus a standard patient education on pain and anxiety. The education intervention involved a booklet explaining PREOPERATIVE EDUCATION 12 the disease process, the operative environment, surgical procedures and post-operative care. Patients received 30 minutes of education by a nurse practitioner or an experienced nurse in the field which incorporated the use of videos and pictures to capture the learning needs of the patients. The control group consisted of standard education information. Patients in the control group received 15 minutes verbal information regarding the steps and cautions before the operation based on a checklist. The study revealed that a preoperative educational intervention was more effective in reducing anxiety and pain (Lee et al., 2017). Providing correct and adequate information to patients is essential to decrease anxiety and ensure patients are knowledgeable regarding their surgical care. The importance of evaluating individual education needs is vital. The delivery of education is beneficial when the practitioner has a good understanding of patient’s knowledge. Wongkietkachorn, Wongkietkachorn, & Rhunsiri, (2017) conducted a multicenter, single-blind, randomized controlled trial to compare a needs-based patient education with traditional patient education in reducing preoperative anxiety. The study resulted in favorable outcomes regarding decreasing anxiety, reduced education time and increased patient satisfaction with the needs-based patient education approach. Gruskay, Fu, Bohl, Webb, & Grauer, (2015) conducted a multivariate analysis using a retrospective case series at a tertiary care center. The purpose of the study was to analyze the factor affecting LOS in posterior lumbar fusion patients. The results of the study concluded that the older the patient’s age and the more pervasive the disease, longer hospital stays occurred. There was no correlation with comorbidities as a predictor of more extended hospital stays. Intraoperative events did not affect LOS, but postoperative events did. Postoperative events included anemia requiring blood transfusions, hardware complications requiring re-operation, PREOPERATIVE EDUCATION 13 altered mental status, and pneumonia (Gruskay et al., 2015). The results from this study are beneficial for improving patient education and setting expectations in the preoperative phase to improve outcomes. A systematic review looked at determining the impact of expectations on satisfaction and patient-reported outcomes (PRO) for patients undergoing elective spine surgery. Pre-existing expectations have been acknowledged to influence these events. The databases examined were MEDLINE, EMBASE, CINAHL, and Cochrane Library for studies that explored the relationship between expectations and satisfaction/PROs in spine surgeries. Three domains reviewed: 1. “does the magnitude of preoperative expectations impact patient satisfaction and/or PRO after surgery? 2. Does the underlying spinal pathology influence this relationship? 3. What is the impact of unmet expectations on satisfaction?” (Witiw et al., 2018, p. 19). The results revealed high preoperative expectations resulted in higher satisfaction and PROs after surgery in lumbar disc herniation but not for lumbar spinal stenosis; patient expectations exceeded actual outcomes, resulting in a discrepancy in expectation-actuality; and the higher the discrepancy, the lower the satisfaction. The findings emphasized the importance of setting realistic expectations before surgery to achieve good outcomes and patient satisfaction (Witiw et al., 2018). Customized education strategies are essential to meet the individual needs of the patients at every stage in their lives. A randomized study by Rhodes et al., (2015) studied the effects of an interventional preoperative education for scoliosis surgery (PEOSS) on anxiety levels of patients undergoing posterior spinal fusion (PSF). The study also looked at the outcomes of this intervention on LOS, patient/caregiver satisfaction, pain medication usage and caregiver anxiety. The study resulted in increased anxiety throughout the surgical process in adolescents in both the PREOPERATIVE EDUCATION 14 control group and the interventional group. However, the patient satisfaction was higher in the interventional group. Based on this study results it is appropriate to conclude that educational strategies that are age-appropriate produce better outcomes (Rhodes et al., 2015). Patients with a history of heart disease had shorter LOS in the study by Gruskay et al., (2015), this is a significant finding as these patients have an extensive preoperative workup and are closely monitored. This extensive preoperative workup along with effective preoperative education may benefit spine surgery patients. Understanding patient’s expectations preoperatively and postoperatively are crucial to determining patient’s preparedness. An explicit discussion regarding reasonable expectations may change patient’s perceptions and expectations and will enable the provider and the patient to have a plan of care that is suitable and understandable. This approach will result in higher patient satisfaction (Soroceanu, Ching, Abdu, & McGuire, 2012). Preoperative expectations and education may have positive results in addressing pain relief, anxiety, and post-operative care thus reducing LOS (Soroceanu et al., 2012). The evidence retrieved from the studies showed an overall moderate positive correlation between pre-operative expectations and post-operative expectations; although the degree of impact varied from low to moderate in one study and positive results reported in the other studies measuring this relationship (Appendix E). A study looking at education positively influenced patient outcomes when standardized education was delivered. The evidence showed the positive correlation between patient expectations and patient-reported outcomes; this had a direct effect on LOS and patient satisfaction. The utilization of valid and reliable measurement tools measuring interventions and outcomes is essential to guide research and achieve high-quality results and reduce bias. Based on the evidence presented one can conclude understanding patient PREOPERATIVE EDUCATION 15 expectations across the continuum in surgical care is vital. The positive results utilizing validated measurement tools to guide research, a standardized patient education to understand patient’s expectations to reduce LOS, improving patients’ understanding of post-operative care and improving patient satisfaction is essential to quality outcomes. Purpose The purpose of this project is to improve patients understanding of their surgery, enhance the patient experience, reduce variability in the quality of education provided to patients and reduce cost. Evidence-Based Practice Model and Conceptual/Theoretical Model Evidence-based practice is essential to improve the quality of patient care and reduce healthcare costs (Brown, 2014). Many EBP models exist to aid nurses, and healthcare providers incorporate the best evidence into clinical practice. A model that is well known and used in a clinical setting to effectively implement a practice change at the unit or organization level is the Iowa Model of Evidence-Based Practice (Titler et al., 2001). The Iowa Model of Evidence-Based Practice to Promote Quality of Care (Appendix F) guided this project. The Iowa Model serves as a conceptual framework that guides and organizes implementation to ensure changes are appropriate to attain high-quality outcomes for the organization. This framework was used to guide the project by identifying the problem (inadequate preoperative teaching), the stakeholders (patients undergoing spine surgery DRG 460 non-complicated spine surgery, excluding cervical) to address the issue (pre and post questionnaire and provide a tri-fold pamphlet providing preoperative education) and evaluate the process (post questionnaire and LOS) (White & Spruce, 2015). PREOPERATIVE EDUCATION 16 The expectation-actuality discrepancy (E-AD) conceptual model (Mannion et al., 2009) (Appendix G) describes the interrelated concepts and predicts events and situations by defining relationships among variables. This model explains that as the difference between what a patient expects from surgery and what they experience widens, satisfaction lessens (Witiw et al., 2018). This conceptual model aligns with the project in utilizing descriptive analysis looking at cause and effect. This model is most useful in determining the patient’s expectations regarding their spine surgery and determine where the knowledge deficits are. Methods An evidence-based project was implemented in an urban tertiary care center specializing in neurologic surgery. Permission was obtained from the organization’s Investigation Review Board (IRB) and Arizona State University IRB. English speaking participants over the age of 18 years who were scheduled for elective thoracic and lumbar spine surgery (specifically DRG 460 surgeries) and presented to the preoperative department for preoperative testing were recruited to participate. Participants were provided the purpose of the project verbally and in written format. Consent to participate in the project was implied upon completion of the preintervention survey. The pre-intervention survey consisted of questions to assess the participants learning preference and method of surgery education already received, knowledge about their spine surgery, preparedness, expectations after surgery, current back pain, LOS and at home care (Appendix H). The functional and demographics surveys consisted of questions regarding age, gender, ethnicity, level of education, the use of assistive devices for ambulation, length of time experiencing back pain, anticipated length of stay after surgery (Appendix I). After the preintervention surveys were completed, a tri-fold education pamphlet (Appendix J) was given to these participants with information that includes detailed information regarding expectations PREOPERATIVE EDUCATION 17 before and after surgery. The intervention not only provided education but also outlined and set expectations for participants before, immediately after surgery and help at home. A post-intervention survey was collected on post-operative day two before the participant was discharged home following their surgery. The post-intervention survey consisted of questions assessing a change in knowledge regarding expectations after surgery, effectiveness of the intervention, management of pain and help at home (Appendix K). The pre-intervention and post-intervention surveys were self-developed questionnaires based on Bandura, (2016) selfefficacy questionnaires and in conjunction with project site mentor. The survey instruments were evaluated by ASU faculty and project site mentor for content validity. The pre and post surveys were assigned a randomized number by the project coordinator to allow for paired analysis and to protect the identity of the participants. No identifiable information was on the surveys. The survey results were kept confidential and stored in REDCap software. Data was entered in SPSS software for data analysis. Due to the small sample size, only descriptive statistics were used. The effect size was calculated using the Cohen’s D. Results There was a total of 6 participants consisting of 5 females and 1 male. All the participants were Caucasian with ages ranging from 30 to 69 and an average age of 58 years. Most of the participants reported walking to the preoperative center with 1 reporting the use of an assistive device for ambulation. All the participants reported suffering from back pain for an average of 98 days. An average of 3 days was the anticipated LOS reported by the participants (Appendix L). Due to the small sample size (N=6) no statistical analysis was performed (Appendix M). To determine the effect size a Cohen’s D was calculated. An increase in knowledge in expectations after surgery was noted from pre-intervention (mean 1.83, SD .408) to PREOPERATIVE EDUCATION 18 post-intervention (mean 1.67, SD .816) with a Cohen’s D of 0.248 although this was not statistically significant (Appendix N). However, the difference in the average LOS was significant for this sample. The average LOS for the project facility was 4.54 days, LOS for project participants was 2.833 days meeting CMS guidelines of 2.92 days for this sample. Discussion One of the limitations of the project was it only included Caucasian and English-speaking participants. A diverse population perhaps may show a different impact due to differences in expectations from other people from other cultures. A small sample size prohibited from performing statistical analysis. Additionally, slight differences in wording on the pre and post surveys prevented additional analysis of the data. Moreover, the project had one outlier resulting from a participant’s prolonged LOS of six days due to complications which impacted the overall LOS for the project participants. A larger sample size may result in a better understanding of the impact of the educational pamphlet and patients’ expectations. Implications of the project are a standardized preoperative education for this surgical population may improve patients’ knowledge about expectations following surgery which may result in decreasing LOS and decrease in costs. Conclusion An increased in patients’ knowledge regarding expectations following surgery was seen in the project participants. LOS for project participants fell within the CMS guidelines for patients who underwent non-complicated thoracic or lumbar spine surgery. As the literature review suggested, a standardized patient education to improve patients’ understanding and expectations of their surgical care is vital to decrease LOS. The results of the project were presented to the project facility. Furthermore, incorporation of the educational pamphlet as part PREOPERATIVE EDUCATION 19 of the preoperative process will be adopted at the project facility for all patients undergoing spine surgery. A brief report of the project was submitted to the Journal of Nurse Practitioners for publication consideration. PREOPERATIVE EDUCATION 20 References AHRQ. (n.d.). Preventing avoidable readmissions. Retrieved from: https://www.ahrq.gov/professionals/quality-patient-safety/patient-safetyresources/resources/impptdis/index.html Bandura, A. (2006). Guide for constructing self-efficacy scales. Self-efficacy beliefs of adolescents (pp. 307-337). Retrieved from http://www.uky.edu/~eushe2/BanduraPubs/BanduraGuide2006.pdf Brown, C. G. (2014). The Iowa model of evidence-based practice to promote quality care: An illustrated example in oncology nursing. CJON, 18(2), 157-159. http://dx.doi.org/10.1188/14.CJON.157-159 Centers for Medicare & Medicaid Services. (2017). Medicare provider utilization and payment data. Retrieved from: https://www.cms.gov/Research-Statistics-Data-andSystems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/index.html Gruskay, J. A., Fu, M., Bohl, D. D., Webb, M. L., & Grauer, J. N. (2015). Factors affecting length of stay after elective posterior lumbar spine surgery: a multivariate analysis. The Spine Journal, 15, 1188-1195. https://doi.org/10.1016/j.spinee.2013.10.022 Hartley, M., Neubrander, J., & Repede, E. (2012). Evidence-based spine preoperative education. International Journal of Orthopaedic and Trauma Nursing, 16, 65-75. https://doi.org/10.1016/j.ijotn.2011.12.003 HealthyPeople. (2018). Arthritis, osteoporosis, and chronic back conditions. Retrieved from: https://www.healthypeople.gov/2020/topics-objectives/topic/Arthritis-Osteoporosis-andChronic-Back-Conditions PREOPERATIVE EDUCATION 21 Lee, C., Liu, J., Lin, S., Hsu, T., Lin, C., & Lin, L. (2017). Effects of educational intervention on state anxiety and pain in people undergoing spinal surgery: A randomized controlled trial. Pain Management Nursing, 19(2), 163-171. https://doi.org/DOI: 10.1016/j.pmn.2017.08.004 Louw, A., Butler, D. S., Diener, I., & Puentedura, E. J. (2013). Development of a preoperative neuroscience educational program for patients with lumbar radiculopathy. American Journal of Physical Medicine and Rehabilitation, 92, 446-452. https://doi.org/10.1097/PHM.0b013e3182876aa4 Louw, A., Diener, I., Landers, M. R., & Puentedura, E. J. (2014). Preoperative pain neuroscience education for lumbar radiculopathy: a multicenter randomized controlled trial with 1-year follow-up. Spine, 39(18), 1449-1457. https://doi.org/ DOI: 10.1097/BRS.0000000000000444 Louw, A., Diener, I., Landers, M. R., Zimney, K., & Puentedura, E. J. (2016). Three-year followup of a randomized controlled trial comparing preoperative neuroscience education for patients undergoing surgery for lumbar radiculopathy. Journal of Spine Surgery, 2, 289298. https://doi.org/10.21037/jss.2016.12.04 Mannion AF, Junge A, Elfering A, Dvorak J, Porchet F, Grob D. (2009). Great expectations: really the novel predictor of outcome after spinal surgery? Spine 34: 1590–1599 Marcus, C. (2014). Strategies for improving the quality of verbal patient and family education: a review of the literature and creation of the EDUCATE model. Health Psychology and Behavioral Medicine, 2, 482-495. https://doi.org/doi: 10.1080/21642850.2014.900450 PREOPERATIVE EDUCATION 22 Reiter, K. (2014). A look at best practices for patient education in outpatient spine surgery. Association of Perioperative Registered Nurses, 99, 376-384. https://doi.org/10.1016/j.aorn.2014.01.008 Rhodes, L., Nash, C., Moisan, A., Scott, D. C., Barkoh, K., Warner, W. C., ... Kelly, D. M. (2015). Does preoperative orientation and education alleviate anxiety in posterior spinal fusion patients? A prospective, randomized study. Journal of Pediatric Orthopaedics, 35, 276-279. https://doi.org/doi: 10.1097/BPO.0000000000000260 Soroceanu, A., Ching, A., Abdu, W., & McGuire, K. (2012). Relationship between preoperative expectations, satisfaction, and functional outcomes in patients undergoing lumbar and cervical spine surgery. Spine, 37(2), E103-E108. https://doi.org/10.1097/BRS.0b013e3182245c1f The Joint Commission. (2012). Joint Commission standards 2012. Retrieved from: http://www.mghpcs.org/eed_portal/Documents/PatientEd/JC_Standards_PatientEd.pdf The Joint Commission. (2018). About the Joint Commission. Retrieved from: https://www.jointcommission.org/about/jointcommissionfaqs.aspx?CategoryId=10#2274 Titler, M.G., Klieber, C., Rakel, B., Budreau, G., Everett, L.Q., Steelman, V., Buckwalter, K.C., Tripp-Reimer, T., & Goode C. (2001). The Iowa model of evidence-based practice to promote quality care. Critical Care Nursing Clinics of North America. 13(4), 497-509. Wainwright, T. W., Immins, T., & Middleton, R. G. (2016). Enhanced recovery after surgery (ERAS) and its applicability for major spine surgery. Best Practice & Research Clinical Anaesthesiology, 30(1), 91-102. https://doi.org/10.1016/j.bpa.2015.11.001 PREOPERATIVE EDUCATION 23 White, S., & Spruce, L. (2015). Perioperative nursing leaders implement clinical practice guidelines using the Iowa model of evidence-based practice. AORN, 102(1), 50-59. http://dx.doi.org/doi:10.1016/j.aorn.2015.04.001 Witiw, C. D., Mansouri, A., Mathieu, F., Nassiri, F., Badhiwala, J. H., & Fessler, R. G. (2018). Exploring the expectation-actuality discrepancy: a systematic review of the impact of preoperative expectations on satisfaction and patient reported outcomes in spinal surgery. Neurosurgical Review, 41, 19-30. https://doi.org/10.1007/s10143-016-0720-0 Wongkietkachorn, A., Wongkietkachorn, N., & Rhunsiri, P. (2017). Preoperative needs-based education to reduce anxiety, increase satisfaction, and decrease time spent in day surgery: A randomized controlled trial. World Journal of Surgery, 42(3), 666-674. https://doi.org/10.1007/s00268-017-4207-0 PREOPERATIVE EDUCATION 24 Appendix A Search Strategy 1 PubMed PREOPERATIVE EDUCATION 25 Appendix B Search Strategy 2 CINAHL PREOPERATIVE EDUCATION 26 Appendix C Search Strategy 3 The Cochrane Library PREOPERATIVE EDUCATION 27 Appendix D Table 1 Evaluation Table Citation Auer et al., (2016) Patients’ expectations predict surgery outcome: a meta-analysis Funded by German Research Foundation No conflicts or biases identified Europe Conceptual Framework Inferred to be Transactional Model of Stress and Coping Design/Method Sample/Setting Design: MA N=21 Purpose: To assess the association between patients’ pre-surgical expectations and post-surgical QOL Data collected from MEDLINE, CENTRAL, and PsychINFO Inclusion Criteria: patients undergoing surgical procedure age-ranging from 1865 years, using a prospective design, expectations measure before sx and QOL after sx. English and German articles Exclusion criteria: CSS, case reports, letters, review, and comments were excluded, articles published in other languages other than German and English, articles published before 1980 or after Dec. 2013 Major Variables & Definitions IV1: Pre-surgical expectation IV2: Postsurgical QOL DV1: Expectation and overall QOL DV2: Expectation and physical QOL DV3: Expectation and mental QOL Measurement Analysis Data was extracted based on databases described in sample/setting. MOOSE recommendations were followed as a review protocol. All analysis was conducted by using a software called CMA, Pearson’s r -GSE -IPQ-R -LOT & LOT-R -Positive expectation scale -SEQOL Researchers had experience with expectations, psychological factor involving surgeries and MA Extracted data based on study characteristics CI-95% Findings DV1: 11 studies, 0.126 (95% CI, 0.079 to 0.172 P for heterogeneity=0 .63; random effects model) DV2: 12 studies, 0.208 (95% CI, 0.113 to 0.299; P heterogeneity <0.001; random-effects model) DV3: 12 studies, indicating low to moderate associations between presurgery patients’ expectations and postsurgery QOL Decision for Use Level I Strengths: robust effect size. The study provided with significant effect size of the relationship between patients’ expectations and postsurgical QOL Good analytical process to decrease bias Weaknesses: the lack of control of the influence of presurgical QOL on the effect sizes. Poor homogeneity of the studies Conclusion: Presurgical expectations have a strong association with postsurgical QOL. Focusing on CG-control group, CI-confidence interval, CMA-comprehensive meta-analysis, CSS- cross-sectional studies, DV-dependent variable, E-AD-expectationactuality discrepancy, ES-expectation survey, FO-functional outcome, GRADE-Grades of Recommendations Assessment, Development and Evaluation, GSEGeneral Self-Efficacy Scale, IG-intervention group, IPQ-R-Illness Perception Questionnaire-revised, IR-integrative review, IV-independent variable, LOT & LOT-R-Life Orientation Test and Life and Life Orientation Test-Revised, LSS- lumbar spine surgery, LSSES-lumbar spine surgery expectations survey, MAmeta-analysis, MODEMS-Musculoskeletal outcomes data evaluation and management, MOOSE- meta-analysis of observational studies in epidemiology, Nnumber of studies, n-total population, NASS-North American Spine Society, ODI-Oswetry Disability Index, PCS- Prospective Cohort Study, PE-preoperative expectations, PLF-posterior lumbar fusion, POS-postoperative satisfaction, PRO-patient-reported outcomes, QOL-quality of life, RCT-randomized control trial, RCS-retrospective case studies, ROM- range of motion, SF-36-Short form health survey, SEIQ OL-DW-schedule for the evaluation of individual quality of life-direct weight, SEQOL-Self-evaluation of quality of life, SR-systematic review, SS- spine surgery, STAI-State-trait anxiety inventory, sx-surgery (ies), TJBF-Thoracolumbar junction burst fracture, VAS-visual analog scale PREOPERATIVE EDUCATION 28 presurgical expectations has the possibility of rendering surgeries more effectively Citation Ellis et al., (2015) The relationship between preoperative expectations and the short-term postoperative satisfaction and functional outcome in lumbar spine surgery: A systematic review Funded by Division of Orthopaedics, Montreal General Hospital No conflicts or biases identified Canada Conceptual Framework Inferred to be Social Cognitive Theory Design/Method Sample/Setting Design:SR N= 13 Purpose: To examine the relationship between the patient’s PE and short-term POS and FO in LSS Data collected from: Medline, Embase, and Cochrane 1996- Nov. 15, 2014 Inclusion criteria: Case control Cohort, RCT MA study population IV Outcome measured Exclusion criteria: non-lumbar spine studies Major Variables & Definitions IV: what is the short-term relationship between PE and POS and FO in LSS DV: Positive expectations significantly correlated with short-term POS and FO Measurement Searched conducted utilizing the database mentioned under sample/setting. Predefined search algorithm that identified the influence of PE on postoperative satisfaction and FO Two independent reviewers and a third independent mediator Methodological assessment Dichotomous, multiple choice, open ended questions PE assessment tool Functional assessment such as VAS, ODI, SF-36 Analysis Methodological quality assessment tool ODI and SF-36 CI-95% Findings DV: this review demonstrated a positive correlation between PE and postoperative satisfaction and FO in LSS. Decision for Use Level I Strengths: good quality an article review. Measurement tools along with tables with assessment questions and tools were helpful. Good discussion offering suggestions for better research process to obtain better and specific data Weaknesses: lack of homogeneity The use of many measurement tools to study the phenomenon created difficulty in making generalizations. Studies varied in regards to demographics, surgical indication, type of surgery and follow up time CG-control group, CI-confidence interval, CMA-comprehensive meta-analysis, CSS- cross-sectional studies, DV-dependent variable, E-AD-expectationactuality discrepancy, ES-expectation survey, FO-functional outcome, GRADE-Grades of Recommendations Assessment, Development and Evaluation, GSEGeneral Self-Efficacy Scale, IG-intervention group, IPQ-R-Illness Perception Questionnaire-revised, IR-integrative review, IV-independent variable, LOT & LOT-R-Life Orientation Test and Life and Life Orientation Test-Revised, LSS- lumbar spine surgery, LSSES-lumbar spine surgery expectations survey, MAmeta-analysis, MODEMS-Musculoskeletal outcomes data evaluation and management, MOOSE- meta-analysis of observational studies in epidemiology, Nnumber of studies, n-total population, NASS-North American Spine Society, ODI-Oswetry Disability Index, PCS- Prospective Cohort Study, PE-preoperative expectations, PLF-posterior lumbar fusion, POS-postoperative satisfaction, PRO-patient-reported outcomes, QOL-quality of life, RCT-randomized control trial, RCS-retrospective case studies, ROM- range of motion, SF-36-Short form health survey, SEIQ OL-DW-schedule for the evaluation of individual quality of life-direct weight, SEQOL-Self-evaluation of quality of life, SR-systematic review, SS- spine surgery, STAI-State-trait anxiety inventory, sx-surgery (ies), TJBF-Thoracolumbar junction burst fracture, VAS-visual analog scale PREOPERATIVE EDUCATION 29 Conclusions: The review positively correlated with short-term postoperative satisfaction, and FO. Citation Gruskay et al., (2015) Factors affecting length of stay after elective posterior lumbar spine surgery: a multivariate analysis No funding was received for this study Potential bias on skewed cases towards one-level procedures USA Conceptual Framework Inferred to be Social Cognitive Theory Design/Method Sample/Setting Design: RCS N=103 Purpose: understanding the variables affecting LOS after open elective PLF Location: Tertiary care center Between Jan. 2010 and June 2012 Inclusion criteria: -Preoperative factors: patient demographics including, gender, age, BMI, smoker, nonsmoker, ETOH, opiate or illicit drug use, marital status, and employment status -Previous surgeries -Levels instrumented -ASA score -Major comorbidities -Intraoperative factors -Postoperative factors Exclusion criteria: patients treated with anterior/posterior approach Patients treated with minimally invasive Major Variables & Definitions IV1: patient demographics IV2: previous sx IV3: levels instrumented IV4: ASA score IV5: intraoperative factors IV6: postoperative factors DV1: no single comorbidity was predictive of longer LOS DV2: older age and widespread systemic disease had longer LOS DV3: Intraoperative events did not affect LOS DV4: Heart disease had short LOS due to more extensive preoperative Measurement Multivariate stepwise regression CI: 95% Analysis Findings Bivariate independent samples t tests were performed for all variable comparing the normal stay cohort with the extended stay cohort. DV1: of this cohort 79% had LOS of 4 days or less. No specific comorbidity was found to be associated with LOS in this multivariate analysis DV2: age p=.038, and ASA sore p=.001 DV3: no intraoperative factors were found to be associated with a longer LOS DV4: p=.005, significantly associated with a decrease in LOS DV5: average LOS 5.1±2.3 vs. 2.9±0.9 days for patients Multivariate linear stepwise regression was performed with LOS. A series of iterative analyses were performed, excluding predictors by declining p value until only variable, with p<.2 remained as the final model covariates. Final regression was performed with these variable, with p<.05 indicating statistical significance Decision for Use Level IV Strengths: this study had a good study design. It thoroughly described the phenomenon studied and illustrated the findings utilizing confidence interval to measure effect. Weaknesses: Study was retrospective. Conducted in one facility. Some data was skewed towards one-level procedures. To minimize the potential for bias a regression analysis was performed. Conclusion: Understanding the factors that impact CG-control group, CI-confidence interval, CMA-comprehensive meta-analysis, CSS- cross-sectional studies, DV-dependent variable, E-AD-expectationactuality discrepancy, ES-expectation survey, FO-functional outcome, GRADE-Grades of Recommendations Assessment, Development and Evaluation, GSEGeneral Self-Efficacy Scale, IG-intervention group, IPQ-R-Illness Perception Questionnaire-revised, IR-integrative review, IV-independent variable, LOT & LOT-R-Life Orientation Test and Life and Life Orientation Test-Revised, LSS- lumbar spine surgery, LSSES-lumbar spine surgery expectations survey, MAmeta-analysis, MODEMS-Musculoskeletal outcomes data evaluation and management, MOOSE- meta-analysis of observational studies in epidemiology, Nnumber of studies, n-total population, NASS-North American Spine Society, ODI-Oswetry Disability Index, PCS- Prospective Cohort Study, PE-preoperative expectations, PLF-posterior lumbar fusion, POS-postoperative satisfaction, PRO-patient-reported outcomes, QOL-quality of life, RCT-randomized control trial, RCS-retrospective case studies, ROM- range of motion, SF-36-Short form health survey, SEIQ OL-DW-schedule for the evaluation of individual quality of life-direct weight, SEQOL-Self-evaluation of quality of life, SR-systematic review, SS- spine surgery, STAI-State-trait anxiety inventory, sx-surgery (ies), TJBF-Thoracolumbar junction burst fracture, VAS-visual analog scale PREOPERATIVE EDUCATION 30 techniques More than three levels of instrumentation Trauma cases workup DV5: postoperative complications had a longer LOS Pearson bivariate cross-correlation analysis was performed with all IV. with no complications (p<.001) Two-sided p values <.05 were considered statistically significant SPSS software was used for all statistical analysis Citation Lee et al., (2017) Effects of educational intervention on state anxiety and pain in people undergoing spinal surgery: a randomized controlled trial Funded by the Department of Rehabilitation Sciences, Hong Kong Polytechnic University Conceptual Framework Inferred to be Transactional Model of Stress and Coping Design/Method Design: RCT with block design Purpose: To investigate the effects of education on anxiety and pain for patients undergoing spinal surgery Sample/Setting N=86 n=43 (IG) n=43 (CG) Location: Medical Center in central Taiwan-Chung Shan Medical University Hospital April to Dec. 2012 Inclusion criteria: age >20 years Voluntary participation Able to understand Taiwanese Mandarin Major Variables & Definitions IV: booklet rich in information 30 minutes of education by NP or nurse along with videos and pictures IV2: Standard preoperative teaching consisting of 15 minutes of teaching DV1: no significant Measurement STAI VAS Patient monitors for physical indicators CI:95% Analysis Findings Sample size was calculated using G*Power 3.1.5: large effect size (Cohen’s d=.8) on a two-sided independent t test with an α error of .05 and an allocation ratio of 1 for the two groups. DV1: age p=.57, gender(male) p=.82, type of surgery p=.96, smoking p=.73, education level p=.55, marital status p=.90, drinking p=.90, employed p=.60, diagnosis p=1.00, LOS p=.06 DV2: anxiety ANCOVA SPSS for all analyses LOS is crucial to help surgeons in treatment choice, preoperative counseling. This study identified age, ASA scores, history of heart disease, and discharge to subacute/nursing facility are associated with increased LOS. Perhaps a more extensive workup and close medical management is warranted for all patients to decrease LOS as discovered in this study of patients with heart disease having shorter LOS Decision for Use Level II Strengths: Wellconstructed study. Provided with important facts regarding importance of preoperative education and outcomes. Good data analysis tools Weaknesses: All participants were CG-control group, CI-confidence interval, CMA-comprehensive meta-analysis, CSS- cross-sectional studies, DV-dependent variable, E-AD-expectationactuality discrepancy, ES-expectation survey, FO-functional outcome, GRADE-Grades of Recommendations Assessment, Development and Evaluation, GSEGeneral Self-Efficacy Scale, IG-intervention group, IPQ-R-Illness Perception Questionnaire-revised, IR-integrative review, IV-independent variable, LOT & LOT-R-Life Orientation Test and Life and Life Orientation Test-Revised, LSS- lumbar spine surgery, LSSES-lumbar spine surgery expectations survey, MAmeta-analysis, MODEMS-Musculoskeletal outcomes data evaluation and management, MOOSE- meta-analysis of observational studies in epidemiology, Nnumber of studies, n-total population, NASS-North American Spine Society, ODI-Oswetry Disability Index, PCS- Prospective Cohort Study, PE-preoperative expectations, PLF-posterior lumbar fusion, POS-postoperative satisfaction, PRO-patient-reported outcomes, QOL-quality of life, RCT-randomized control trial, RCS-retrospective case studies, ROM- range of motion, SF-36-Short form health survey, SEIQ OL-DW-schedule for the evaluation of individual quality of life-direct weight, SEQOL-Self-evaluation of quality of life, SR-systematic review, SS- spine surgery, STAI-State-trait anxiety inventory, sx-surgery (ies), TJBF-Thoracolumbar junction burst fracture, VAS-visual analog scale PREOPERATIVE EDUCATION 31 Chinese or Taiwanese No hearing or vision impairments No bias identified Exclusion criteria: Other languages Hearing or vision impairment Patients’ less than 20 years old Taiwan Citation Mancuso et al., (2013) Development and testing of an expectations survey for patients undergoing lumbar spine surgery. No funding received for this study No bias was identified Conceptual Framework Inferred to be Health Belief Model Design/Method Design: CSS Purpose: To develop and test a patient-derived expectations survey Sample/Setting N=118 (Phase I) N=56 (Phase II, III) Inclusion criteria: patients with diverse lumbar spine diagnoses Exclusion criteria: other diagnoses difference in demographic or clinical characteristics DV2: Anxiety and pain were significantly lower in the IG than CG Major Variables & Definitions IV1: Phase Iinterviews with patients with open-ended questions about expectations and assembly of draft survey IV2: Phase IIAdministered the survey twice to assess test-retest reliability IV3: Phase IIIselection of final item based on concordance of responses and clinical relevance, and development of and pain were significantly lower in the IG than the CG 30 minutes before sx (t=3.45 and 2.30; p=.001 and .024, respectively) The day after surgery: (t=2.68 and 4.81; p=.009 and <.001, respectively) Measurement Surveys developed in III phases. Analysis Phase I: 118 preoperative patients with diverse lumbar spine diagnoses, 583 expectations were gathered, 31 categories were selected for draft survey Phase II: 56 patients completed the survey twice, 4 days apart Phase III: 21 final items including symptoms relief, return to basic mobility, resuming Findings DV1: The mean scores for both administration in Phase II were 66 and 65 points, the Cronbach alpha coefficients for both administration were 0.90 and 0.92, and the intraclass correlation coefficient between scores was 0.86 DV2: The scores revealed recruited from the same hospital. This prevents for generalization due to similar demographic information Conclusion: Preoperative education is effective in informing patients undergoing spinal surgery which can lead to reduction in pain and anxiety postoperatively Decision for Use Level III Strengths: This article provided good information regarding patient expectations and used a reliable scale to measure patient’s perspectives Weaknesses: the authors did not include the questions offered to them, a table outlining the process would have been helpful to capture similarities across the different CG-control group, CI-confidence interval, CMA-comprehensive meta-analysis, CSS- cross-sectional studies, DV-dependent variable, E-AD-expectationactuality discrepancy, ES-expectation survey, FO-functional outcome, GRADE-Grades of Recommendations Assessment, Development and Evaluation, GSEGeneral Self-Efficacy Scale, IG-intervention group, IPQ-R-Illness Perception Questionnaire-revised, IR-integrative review, IV-independent variable, LOT & LOT-R-Life Orientation Test and Life and Life Orientation Test-Revised, LSS- lumbar spine surgery, LSSES-lumbar spine surgery expectations survey, MAmeta-analysis, MODEMS-Musculoskeletal outcomes data evaluation and management, MOOSE- meta-analysis of observational studies in epidemiology, Nnumber of studies, n-total population, NASS-North American Spine Society, ODI-Oswetry Disability Index, PCS- Prospective Cohort Study, PE-preoperative expectations, PLF-posterior lumbar fusion, POS-postoperative satisfaction, PRO-patient-reported outcomes, QOL-quality of life, RCT-randomized control trial, RCS-retrospective case studies, ROM- range of motion, SF-36-Short form health survey, SEIQ OL-DW-schedule for the evaluation of individual quality of life-direct weight, SEQOL-Self-evaluation of quality of life, SR-systematic review, SS- spine surgery, STAI-State-trait anxiety inventory, sx-surgery (ies), TJBF-Thoracolumbar junction burst fracture, VAS-visual analog scale PREOPERATIVE EDUCATION 32 scoring rubric USA Citation Nepomuceno et al., (2016) Instruments used in the assessment of expectation toward a spine surgery: an integrative review No funding was received for this Conceptual Framework Inferred to be Health Belief Model Design/Method Sample/Setting Design: IR N=25 Purpose: To identify and describe instruments used to assess patients’ expectations toward spine surgery Databases searched PubMed, CINAHL, LILACS, and PsycINFO published between 1998 and 2015 Inclusion criteria: primary studies -published in full evaluating adult and/or elderly patients’ DV1:21 items were retained for final survey addressing symptom relief, return to basic mobility, resumption of activities, and improvement in psychosocial well-being DV2: A rubric score calculated based on the number of expectations and amount of improvement expected ranging from 0-100 points, the higher the score the higher the expectations Major Variables & Definitions IV1: formulation of guiding question IV2: literature search for proposed theme IV3: categorization of studies IV4: evaluation of studies IV5: discussion and interpretation activities, improvement of psychosocial well being Measurement Formulation of steps to guide the review and data extraction Analysis LSSES, internal consistency Cronbach’s alpha=0.92, after surgery correlation coefficient of 86% (Cohen’s kappa=0.86) ES, good internal consistency (Cronbach’s alpha=0.93), the higher the scores the higher the expectations Findings DV1: LSSES and ES are the current and only measurement instruments DV2: the use of VAS to measure how much the patients hope to improve after spine surgery phases Conclusion: Good information measuring the physical and psychosocial expectations. The incorporation of measurement score is important to capture the and record patient expectations. Decision for Use Level IV Strengths: good review processes and method. The findings were categorized and based on measurement tools and instruments to assess patient expectations. CG-control group, CI-confidence interval, CMA-comprehensive meta-analysis, CSS- cross-sectional studies, DV-dependent variable, E-AD-expectationactuality discrepancy, ES-expectation survey, FO-functional outcome, GRADE-Grades of Recommendations Assessment, Development and Evaluation, GSEGeneral Self-Efficacy Scale, IG-intervention group, IPQ-R-Illness Perception Questionnaire-revised, IR-integrative review, IV-independent variable, LOT & LOT-R-Life Orientation Test and Life and Life Orientation Test-Revised, LSS- lumbar spine surgery, LSSES-lumbar spine surgery expectations survey, MAmeta-analysis, MODEMS-Musculoskeletal outcomes data evaluation and management, MOOSE- meta-analysis of observational studies in epidemiology, Nnumber of studies, n-total population, NASS-North American Spine Society, ODI-Oswetry Disability Index, PCS- Prospective Cohort Study, PE-preoperative expectations, PLF-posterior lumbar fusion, POS-postoperative satisfaction, PRO-patient-reported outcomes, QOL-quality of life, RCT-randomized control trial, RCS-retrospective case studies, ROM- range of motion, SF-36-Short form health survey, SEIQ OL-DW-schedule for the evaluation of individual quality of life-direct weight, SEQOL-Self-evaluation of quality of life, SR-systematic review, SS- spine surgery, STAI-State-trait anxiety inventory, sx-surgery (ies), TJBF-Thoracolumbar junction burst fracture, VAS-visual analog scale PREOPERATIVE EDUCATION 33 study expectations towards spine sx treatment, because of degenerative disease, using tools, published in any language, regardless of date of publication, and with a quantitative approach No bias identified Exclusion criteria: secondary studies and clinical guidelines Case studies Pilot study in preclinical stage Methodological studies Urgent/emergency ss Studies evaluation expectation of quality of healthcare services or from healthcare professionals Brazil Citation Schouten et al., (2016) Expectations of recovery and Conceptual Framework Inferred to be Social Cognitive Theory Design/Method Design: SR Purpose: The purpose of the Sample/Setting N=38 N=4 (expert opinion cases) of results IV6: synthesis agreement coefficient of 90% (Cohen’s kappa=0.90) DV1: instruments already submitted to psychometric validation DV2: modified clinical scores to assess patients’ expectations DV3: scales created by authors themselves without an adequate description of the development methodology or any evident of validation Major Variables & Definitions IV1: TJBF managed nonsurgically IV2: TJBF NASS-Cronbach’s alpha =0.88, testretest reliability Cohen’s kappa =0.95 MODEMSCronbach’s alpha=0.71, testretest reliability Cohen’s kappa=0.91 DV3: the incorporation of NASS, MODEMS, SEIQL-DW/ VAS, evaluation of other constructs such as health related QOL, anxiety, depression, patient satisfaction with surgical outcome are crucial SEIQL-DW/VASreliability test-retest Cohen’s kappa =0.76 Measurement Case Questionnaire Analysis GRADE Percentages for expert opinion analysis Findings DV1: -TJBF nonsurgically: GRADE quality: low Excellent review process and useful information to use for future research Weaknesses: no actual study to test the instruments was performed. Conclusion: the review of measurement instruments was excellent to guide future research in regards to patient expectations Decision for Use Level I Strengths: the review was well CG-control group, CI-confidence interval, CMA-comprehensive meta-analysis, CSS- cross-sectional studies, DV-dependent variable, E-AD-expectationactuality discrepancy, ES-expectation survey, FO-functional outcome, GRADE-Grades of Recommendations Assessment, Development and Evaluation, GSEGeneral Self-Efficacy Scale, IG-intervention group, IPQ-R-Illness Perception Questionnaire-revised, IR-integrative review, IV-independent variable, LOT & LOT-R-Life Orientation Test and Life and Life Orientation Test-Revised, LSS- lumbar spine surgery, LSSES-lumbar spine surgery expectations survey, MAmeta-analysis, MODEMS-Musculoskeletal outcomes data evaluation and management, MOOSE- meta-analysis of observational studies in epidemiology, Nnumber of studies, n-total population, NASS-North American Spine Society, ODI-Oswetry Disability Index, PCS- Prospective Cohort Study, PE-preoperative expectations, PLF-posterior lumbar fusion, POS-postoperative satisfaction, PRO-patient-reported outcomes, QOL-quality of life, RCT-randomized control trial, RCS-retrospective case studies, ROM- range of motion, SF-36-Short form health survey, SEIQ OL-DW-schedule for the evaluation of individual quality of life-direct weight, SEQOL-Self-evaluation of quality of life, SR-systematic review, SS- spine surgery, STAI-State-trait anxiety inventory, sx-surgery (ies), TJBF-Thoracolumbar junction burst fracture, VAS-visual analog scale PREOPERATIVE EDUCATION functional outcomes following thoracolumbar trauma: an evidence-based medicine process to determine what surgeons should be telling their patients Funding by Medtronic No identifiable bias USA 34 study was to define the expected functional outcomes following common thoracolumbar injuries Databases searched: MEDLINE and EMBASE from 1980Oct. 2010 Inclusion criteria: thoracolumbar sx Neurological intact Functional outcomes Exclusion criteria: lack of functional outcome measures Failure to separate results for patients with/without neurological injury Inability to distinguish data for thoracolumbar or low lumbar injuries treated with posterior instrument stabilization IV3: Thoracolumbar junction flexiondistraction injury treated with posterior instrumented stabilization IV4: Low lumbar burst fracture managed nonsurgically IV5: 5 question questionnaires about expected outcome and questionnaire to surgeons regarding information given to patients DV1: pain free DV2: regaining pre-injury ROM DV3: return to activities and work DV4: consistent accurate information, realistic expectations Final follow up 38% were painfree, predicted from survey responders 61% -TJBF posterior instrumentation , GRADE: low, 45% pain free at follow up, predicted by survey 62% -Thoracolumbar junction flexiondistraction injury treated with posterior instrumentation GRADE: very low pain free 48%, surveys predicted 56% -Low lumbar burst fracturenonsurgically, GRADE: very low, pain free 26%, survey predicted 59% DV2: -TJBF non-surgically no studies assessed ROM recovery across all cases, experts survey response was 68% at the 1year mark -TJBF posterior instrumentation constructed. Good data extraction pertaining to the desired information Specific case scenarios evolved with the specificity representing an effort to reduce variability and enhance generalization Weaknesses: expert opinions were used exclusively for many of the study domains. The follow up interval exceeded the 12month time point may have introduced bias. The outcome predictors are limited to quality and quantity of the research available Conclusion: overall good review with good data analysis in regards to functional outcomes CG-control group, CI-confidence interval, CMA-comprehensive meta-analysis, CSS- cross-sectional studies, DV-dependent variable, E-AD-expectationactuality discrepancy, ES-expectation survey, FO-functional outcome, GRADE-Grades of Recommendations Assessment, Development and Evaluation, GSEGeneral Self-Efficacy Scale, IG-intervention group, IPQ-R-Illness Perception Questionnaire-revised, IR-integrative review, IV-independent variable, LOT & LOT-R-Life Orientation Test and Life and Life Orientation Test-Revised, LSS- lumbar spine surgery, LSSES-lumbar spine surgery expectations survey, MAmeta-analysis, MODEMS-Musculoskeletal outcomes data evaluation and management, MOOSE- meta-analysis of observational studies in epidemiology, Nnumber of studies, n-total population, NASS-North American Spine Society, ODI-Oswetry Disability Index, PCS- Prospective Cohort Study, PE-preoperative expectations, PLF-posterior lumbar fusion, POS-postoperative satisfaction, PRO-patient-reported outcomes, QOL-quality of life, RCT-randomized control trial, RCS-retrospective case studies, ROM- range of motion, SF-36-Short form health survey, SEIQ OL-DW-schedule for the evaluation of individual quality of life-direct weight, SEQOL-Self-evaluation of quality of life, SR-systematic review, SS- spine surgery, STAI-State-trait anxiety inventory, sx-surgery (ies), TJBF-Thoracolumbar junction burst fracture, VAS-visual analog scale PREOPERATIVE EDUCATION 35 : survey response 57% -Thoracolumbar junction flexiondistraction injury treated with posterior instrumentation : survey predicted 44% -Low lumbar burst fracturenonsurgically: survey predicted 65% DV3: TJBF non-surgically: 71% returned to work, survey predicted 46% TJBF posterior instrumentation : 32% return to work, survey predicted 35% -Thoracolumbar junction flexiondistraction injury treated with posterior instrumentation : 29-32% returned to work, survey predicted 2948% -Low lumbar burst fracturenonsurgically: 60-90% CG-control group, CI-confidence interval, CMA-comprehensive meta-analysis, CSS- cross-sectional studies, DV-dependent variable, E-AD-expectationactuality discrepancy, ES-expectation survey, FO-functional outcome, GRADE-Grades of Recommendations Assessment, Development and Evaluation, GSEGeneral Self-Efficacy Scale, IG-intervention group, IPQ-R-Illness Perception Questionnaire-revised, IR-integrative review, IV-independent variable, LOT & LOT-R-Life Orientation Test and Life and Life Orientation Test-Revised, LSS- lumbar spine surgery, LSSES-lumbar spine surgery expectations survey, MAmeta-analysis, MODEMS-Musculoskeletal outcomes data evaluation and management, MOOSE- meta-analysis of observational studies in epidemiology, Nnumber of studies, n-total population, NASS-North American Spine Society, ODI-Oswetry Disability Index, PCS- Prospective Cohort Study, PE-preoperative expectations, PLF-posterior lumbar fusion, POS-postoperative satisfaction, PRO-patient-reported outcomes, QOL-quality of life, RCT-randomized control trial, RCS-retrospective case studies, ROM- range of motion, SF-36-Short form health survey, SEIQ OL-DW-schedule for the evaluation of individual quality of life-direct weight, SEQOL-Self-evaluation of quality of life, SR-systematic review, SS- spine surgery, STAI-State-trait anxiety inventory, sx-surgery (ies), TJBF-Thoracolumbar junction burst fracture, VAS-visual analog scale PREOPERATIVE EDUCATION 36 returned to work, survey predicted 97% DV4: difficult to measure due to paucity in data Citation Waljee et al., (2014) Patient expectations and patient-reported outcomes in surgery: A systematic review Funded by the National Institute of Arthritis and Musculoskeletal and Skin disease and National Institute on Aging and a Midcareer Investigator Award in Patient-Oriented Research No bias identified Conceptual Framework The ExpectancyDiscrepancy Model The Assimilation Model The AssimilationContrast Model Design/Method Sample/Setting Design: SR N=60 Purpose: Is to systematically review the available literature describing the relationship between patient expectations and PROs Database searched: Ovid Medline literature published before Nov. 1, 2012 Inclusion criteria: primary data consisting of adult patients -patient expectations regarding sx procedure were measured pre and post operatively -PROs measure pre and post op -relationship between patient expectations and PROs specifically examined Exclusion criteria: not published in English -studies not including primary data -editorials, commentaries, and review papers Major Variables & Definitions IV1: fulfillment of expectations IV2: Positive expectations related to improved post op PROS IV3: Positive expectations related to worse post op PROs IV4: No correlation between expectations and post op PROs DV1: Patient expectations DV2: Patient expectations and PROs Measurement Literature review based on inclusion and exclusion criteria for data extraction Analysis Descriptive statistics Findings DV1: 17% used previously validated surveys, 25% used qualitative methods, 45% used ad hoc surveys, an 13% used modified outcome surveys DV2: 40% found the fulfillment of expectations correlated with improved PROs, 20% of patient expectations were not correlated with PROs postoperatively Decision for Use Level I Strengths: studies reviewed revealed positive expectations were associated with improved PROs Expectancydiscrepancy theory was discussed in an effort to understand the mechanism by which patient expectations could influence postoperative experiences Overall good information retrieved from this review Weaknesses: Heterogeneity existed in methods used to assess and report PE and postoperative PROS CG-control group, CI-confidence interval, CMA-comprehensive meta-analysis, CSS- cross-sectional studies, DV-dependent variable, E-AD-expectationactuality discrepancy, ES-expectation survey, FO-functional outcome, GRADE-Grades of Recommendations Assessment, Development and Evaluation, GSEGeneral Self-Efficacy Scale, IG-intervention group, IPQ-R-Illness Perception Questionnaire-revised, IR-integrative review, IV-independent variable, LOT & LOT-R-Life Orientation Test and Life and Life Orientation Test-Revised, LSS- lumbar spine surgery, LSSES-lumbar spine surgery expectations survey, MAmeta-analysis, MODEMS-Musculoskeletal outcomes data evaluation and management, MOOSE- meta-analysis of observational studies in epidemiology, Nnumber of studies, n-total population, NASS-North American Spine Society, ODI-Oswetry Disability Index, PCS- Prospective Cohort Study, PE-preoperative expectations, PLF-posterior lumbar fusion, POS-postoperative satisfaction, PRO-patient-reported outcomes, QOL-quality of life, RCT-randomized control trial, RCS-retrospective case studies, ROM- range of motion, SF-36-Short form health survey, SEIQ OL-DW-schedule for the evaluation of individual quality of life-direct weight, SEQOL-Self-evaluation of quality of life, SR-systematic review, SS- spine surgery, STAI-State-trait anxiety inventory, sx-surgery (ies), TJBF-Thoracolumbar junction burst fracture, VAS-visual analog scale PREOPERATIVE EDUCATION 37 Many of the studies were observational USA Citation Witiw et al., (2018) Exploring the expectationactuality discrepancy: a systematic review of the impact of preoperative expectations on satisfaction and patient reported outcomes in spinal surgery Funded by the Canadian Institutes of Health Research Conceptual Framework Expectation-Actuality Discrepancy Design/Method Design: SR Prospective observational cohorts Purpose: to examine the impact of expectations on satisfaction and PRO for patients undergoing elective SS Sample/Setting N=19 Databases searched: MEDLINE, EMBASE, CINAHL, and Cochrane Library from inception to July 2015 Inclusion criteria: adults over 18 -degenerative spinal pathology -deformity -chronic back pain -preop assessment of patient satisfaction -post op assessment of patient satisfaction -post op assessment of PROs -PCT -RCT -RCS Major Variables & Definitions IV1: Is there an association between a patients’ PE and their post op satisfaction/PRO s? IV2: Does the underlying spinal pathology influence the relationship between expectations and satisfaction/PRO s? IV3: Does the difference between expected outcome and actual outcome influence satisfaction? Measurement Analysis Findings Literature review based on inclusion and exclusion criteria for data extraction Numeric rating scales VAS Dichotomous scales Likert scales DV1: positive association between expectations and satisfaction 2 reviewers DV2: studies found that the closer patients’ expectations were to their actual outcomes the higher the satisfaction DV3: the lower the E-AD the higher the satisfaction Conclusion: good information regarding their findings and next steps. Future studies should be geared toward examining patient expectations and the relationship between patient perception and postoperative recovery Decision for Use Level I Strengths: good information with good literature review that provided with a variety of assessment tools to measure PE and patient expectations Weaknesses: as with other systematic reviews in this topic the heterogeneity precluded the use of meta-analytical methods Conclusion: Relevant information to use CG-control group, CI-confidence interval, CMA-comprehensive meta-analysis, CSS- cross-sectional studies, DV-dependent variable, E-AD-expectationactuality discrepancy, ES-expectation survey, FO-functional outcome, GRADE-Grades of Recommendations Assessment, Development and Evaluation, GSEGeneral Self-Efficacy Scale, IG-intervention group, IPQ-R-Illness Perception Questionnaire-revised, IR-integrative review, IV-independent variable, LOT & LOT-R-Life Orientation Test and Life and Life Orientation Test-Revised, LSS- lumbar spine surgery, LSSES-lumbar spine surgery expectations survey, MAmeta-analysis, MODEMS-Musculoskeletal outcomes data evaluation and management, MOOSE- meta-analysis of observational studies in epidemiology, Nnumber of studies, n-total population, NASS-North American Spine Society, ODI-Oswetry Disability Index, PCS- Prospective Cohort Study, PE-preoperative expectations, PLF-posterior lumbar fusion, POS-postoperative satisfaction, PRO-patient-reported outcomes, QOL-quality of life, RCT-randomized control trial, RCS-retrospective case studies, ROM- range of motion, SF-36-Short form health survey, SEIQ OL-DW-schedule for the evaluation of individual quality of life-direct weight, SEQOL-Self-evaluation of quality of life, SR-systematic review, SS- spine surgery, STAI-State-trait anxiety inventory, sx-surgery (ies), TJBF-Thoracolumbar junction burst fracture, VAS-visual analog scale PREOPERATIVE EDUCATION 38 Exclusion criteria: -pediatric patients -trauma, infection, tumor -spinal cord stimulator -percutaneous injections -non-operative management -Retrospective assessment of expectations -less than 3 months follow up -studies with less than 10 patients No bias identified USA Citation Zywiel et al., (2013) Measuring expectations in orthopaedic surgery: a systematic review Funded by Smith & Nephew, Inc., Biomet Conceptual Framework Inferred to be Social Cognitive Theory Design/Method Sample/Setting Design: SR N=66 Purpose: to define and understand patients’ expectations in orthopaedic sx Databases searched: OVID Medline and EMBASE Inclusion criteria: -underwent othopaedic sx for musculoskeletal conditions -assessment of their expectations at any point during the study -limited studies that assesses patient expectations -full text articles -English DV1: high PE appear to be associated with higher satisfaction and PROs after surgery for focal lumbar disc herniation, but not for LSS DV2: PE frequently exceed actual outcome creating an E-AD DV3: highquality studies suggest a larger E-AD portends lower satisfaction Major Variables & Definitions IV1: what validated instruments for the assessment of patient expectations of orthopaedic sx have been used in published studies to date? IV2: How were these expectation measures develop and validate? IV3: What unvalidated instruments on with key assessment tools to measure outcomes Measurement Literature review based on inclusion and exclusion criteria for data extraction Analysis Qualitative review Findings DV1: the validated tools used patient interviews or open-ended self-response questions as a definitive assessment tools, data was categorized and grouped for analysis DV2: one unvalidated tool lacked the adequate Decision for Use Level I Strengths: good information regarding the abundance of measurement tools to assess patient expectations Observation was made on the essence of reducing variability to extract useful data to best measure phenomena Weaknesses: may CG-control group, CI-confidence interval, CMA-comprehensive meta-analysis, CSS- cross-sectional studies, DV-dependent variable, E-AD-expectationactuality discrepancy, ES-expectation survey, FO-functional outcome, GRADE-Grades of Recommendations Assessment, Development and Evaluation, GSEGeneral Self-Efficacy Scale, IG-intervention group, IPQ-R-Illness Perception Questionnaire-revised, IR-integrative review, IV-independent variable, LOT & LOT-R-Life Orientation Test and Life and Life Orientation Test-Revised, LSS- lumbar spine surgery, LSSES-lumbar spine surgery expectations survey, MAmeta-analysis, MODEMS-Musculoskeletal outcomes data evaluation and management, MOOSE- meta-analysis of observational studies in epidemiology, Nnumber of studies, n-total population, NASS-North American Spine Society, ODI-Oswetry Disability Index, PCS- Prospective Cohort Study, PE-preoperative expectations, PLF-posterior lumbar fusion, POS-postoperative satisfaction, PRO-patient-reported outcomes, QOL-quality of life, RCT-randomized control trial, RCS-retrospective case studies, ROM- range of motion, SF-36-Short form health survey, SEIQ OL-DW-schedule for the evaluation of individual quality of life-direct weight, SEQOL-Self-evaluation of quality of life, SR-systematic review, SS- spine surgery, STAI-State-trait anxiety inventory, sx-surgery (ies), TJBF-Thoracolumbar junction burst fracture, VAS-visual analog scale PREOPERATIVE EDUCATION No bias identified Canada 39 Exclusion criteria: review articles -published abstracts -no full text in English -Short surveys, notes, letters, editorials -non-applicable content the assessment of patient expectations have been used in published studies to date? DV1: 7 validated instruments were identified DV2: details of reliability and validity testing were available for all but one of the instruments. DV3: 40 unvalidated expectation tools were identified. 13 were based on existing clinical outcome tools and the others were studyspecific, customdeveloped tools description of the development methodology or evidence of any testing or validation DV3: the use of high-quality, standardized instruments for the measurement of patient expectations is crucial have failed to identify other instruments used for other types of surgical procedures possibly relevant in spine surgery population Conclusion: Good guidance to follow when developing measurement tools and instruments to obtain quality data. CG-control group, CI-confidence interval, CMA-comprehensive meta-analysis, CSS- cross-sectional studies, DV-dependent variable, E-AD-expectationactuality discrepancy, ES-expectation survey, FO-functional outcome, GRADE-Grades of Recommendations Assessment, Development and Evaluation, GSEGeneral Self-Efficacy Scale, IG-intervention group, IPQ-R-Illness Perception Questionnaire-revised, IR-integrative review, IV-independent variable, LOT & LOT-R-Life Orientation Test and Life and Life Orientation Test-Revised, LSS- lumbar spine surgery, LSSES-lumbar spine surgery expectations survey, MAmeta-analysis, MODEMS-Musculoskeletal outcomes data evaluation and management, MOOSE- meta-analysis of observational studies in epidemiology, Nnumber of studies, n-total population, NASS-North American Spine Society, ODI-Oswetry Disability Index, PCS- Prospective Cohort Study, PE-preoperative expectations, PLF-posterior lumbar fusion, POS-postoperative satisfaction, PRO-patient-reported outcomes, QOL-quality of life, RCT-randomized control trial, RCS-retrospective case studies, ROM- range of motion, SF-36-Short form health survey, SEIQ OL-DW-schedule for the evaluation of individual quality of life-direct weight, SEQOL-Self-evaluation of quality of life, SR-systematic review, SS- spine surgery, STAI-State-trait anxiety inventory, sx-surgery (ies), TJBF-Thoracolumbar junction burst fracture, VAS-visual analog scale PREOPERATIVE EDUCATION 40 Appendix E Table 2 Synthesis Table Author Year Auer et al. Ellis et al. 2016 2015 Gruskay et al. 2015 Lee et al. 2017 Mancuso et al. Nepomuceno et al. 2013 2016 Schouten et al. Waljee et al. Witiw et al. Zywiel et al. 2016 2014 2018 2013 X X X X 38 60 19 66 Study Design Systematic Review Meta-Analysis X X Retrospective Case Studies X Randomized Control Trial X Cross-sectional studies X Integrative Review X Sample N 21 13 103 86 118 (phase I) 25 56 (phase II) 4 (expert opinion cases) Surgery Type Spine X X X X X X X Orthopedic Surgical procedure X X ↑-low effect; ↑↑-moderate effect; ↑↑↑-high effect; +-positive effect X PREOPERATIVE EDUCATION Author 41 Auer et al. Ellis et al. 2016 2015 Pre-surgical expectation X X Post-surgical expectation X X Year Gruskay et al. 2015 Lee et al. Mancuso et al. Nepomuceno et al. 2017 2013 2016 X X X Schouten et al. 2016 Waljee et al. Witiw et al. Zywiel et al. 2014 2018 2013 X X X X X X Independent Variables Variables affecting length of stay X X Preoperative education Patient reported outcomes X X X Expectation ↑-↑↑ ↑↑↑ Experience ↑-↑↑ ↑↑↑ Outcomes ↑↑↑ ↑↑ ↑↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ + + + LOS ↑↑↑ ↑↑↑ Preoperative teaching Satisfaction + + + ↑-low effect; ↑↑-moderate effect; ↑↑↑-high effect; +-positive effect ↑↑ PREOPERATIVE EDUCATION 42 Appendix F The Iowa Model of Evidence-Based Practice to Promote Quality Care Reference Titler, M.G., Klieber, C., Rakel, B., Budreau, G., Everett, L.Q., Steelman, V., Buckwalter, K.C., Tripp-Reimer, T., & Goode C. (2001). The Iowa model of evidence-based practice to promote quality care. Critical Care Nursing Clinics of North America. 13(4), 497-509. PREOPERATIVE EDUCATION 43 Appendix G Expectation-Actuality Discrepancy Conceptual Model Reference Mannion AF, Junge A, Elfering A, Dvorak J, Porchet F, Grob D. (2009). Great expectations: really the novel predictor of outcome after spinal surgery? Spine 34: 1590–1599 PREOPERATIVE EDUCATION 44 Appendix H Pre-Intervention Survey You are invited to participate in an evidence-based project about education of spine surgery. The purpose of the project is to improve patient knowledge/preparation for their spine surgery. This survey should take about 10-20 minutes to complete. Participation is voluntary, and responses will be kept confidential. You have the option to not respond to any questions that you choose. Participation or nonparticipation will not impact your relationship with St. Joseph’s Hospital and Medical Center and Barrow Neurological Institute. Submission of the survey will be interpreted as your informed consent to participate and that you affirm that you are at least 18 years of age. If you have any questions about the project, please contact Janet Trejo, via email at aptrejo1@asu.edu or cell number 602-919-8699. If you have any questions regarding your rights as a research subject, contact the SJHMC Institutional Review Board (IRB) at 602-4068051. Pre Educational Intervention Survey Instructions (Please circle all that apply) 1. How were you given information about your spine surgery? 1. In person and/or by telephone 2. Written information 3. Medical Memory or CD or Video 4. Interactive website (EMMI) 5. Other______________________ (write-in) 2. What is the best way for you to remember new information? 1. Instruction in person 2. Written information 3. On-line instruction or Video PREOPERATIVE EDUCATION 45 4. Attending a class 5. Other, please explain ______________________ (write-in) 3. How knowledgeable do you feel about what to expect after your surgery? 1. Very knowledgeable 2. Somewhat knowledgeable 3. Not very knowledgeable 4. Not very knowledgeable at all 4. How knowledgeable are you about the surgery process and recovery of your spine surgery? 1. Very knowledgeable 2. Somewhat knowledgeable 3. Not very knowledgeable 4. Not very knowledgeable at all 5. Do you feel ready and prepared for your spine surgery? 1. Very ready 2. Somewhat ready 3. Not very ready 4. Not ready at all 6. Rate your current back pain (please circle a number) PREOPERATIVE EDUCATION 46 7. How confident are you that you will be able to walk from the hospital stretcher to your inpatient bed after surgery? 1. Very confident 2. Somewhat confident 3. Not very confident 4. Not very confident at all 8. How many days do you expect to stay in the hospital after your surgery? 1. 2 days 2. 3 days 3. 4 days 4. 5 days 9. How confident are you that you will be discharged to your home rather than a rehabilitation facility after surgery? 1. Very confident 2. Somewhat confident 3. Not very confident 4. Not very confident at all PREOPERATIVE EDUCATION 47 10. How confident are you that you will have someone to help you at home after discharge? 1. Very confident 2. Somewhat confident 3. Not very confident 4. Not very confident at all Please add comments and suggestions: PREOPERATIVE EDUCATION 48 Appendix I Functional and Demographics Survey You are invited to participate in an evidence-based project about education of spine surgery. The purpose of the project is to improve patient knowledge/preparation for their spine surgery. This survey should take about 10-20 minutes to complete. Participation is voluntary, and responses will be kept confidential. You have the option to not respond to any questions that you choose. Participation or nonparticipation will not impact your relationship with St. Joseph’s Hospital and Medical Center and Barrow Neurological Institute. Submission of the survey will be interpreted as your informed consent to participate and that you affirm that you are at least 18 years of age. If you have any questions about the project, please contact Janet Trejo, via email at aptrejo1@asu.edu or cell number 602-919-8699. If you have any questions regarding your rights as a research subject, contact the SJHMC Institutional Review Board (IRB) at 602-4068051. Spine Surgery Preop Educational Intervention Participant Demographics Please answer the following questions to the best of your abilities Fill in the blank or circle the best answer 1. How old are you? _________________(years) 2. What is your gender? Male 3. What is your ethnic group? 1. Caucasian Female PREOPERATIVE EDUCATION 49 2. Hispanic 3. African American 4. Asian 5. Native American 6. Other _____________________ (write-in) 4. What is your highest level of education? 1. No school 2. Some high school 3. High school graduate 4. Some college 5. College graduate 6. Graduate degree 5. Did you walk from the parking garage to the preoperative center today? Yes No 6. How long have you had back pain? ___________ (months) 7. Do you use any assistive devices for walking? Yes No 8. How many days do you expect to spend in the hospital? ____________ PREOPERATIVE EDUCATION 50 Appendix J Intervention PREOPERATIVE EDUCATION 51 PREOPERATIVE EDUCATION 52 Appendix K Post-Intervention Survey You are invited to participate in an evidence-based project about education of spine surgery. The purpose of the project is to improve patient knowledge/preparation for their spine surgery. This survey should take about 10-20 minutes to complete. Participation is voluntary, and responses will be kept confidential. You have the option to not respond to any questions that you choose. Participation or nonparticipation will not impact your relationship with St. Joseph’s Hospital and Medical Center and Barrow Neurological Institute. Submission of the survey will be interpreted as your informed consent to participate and that you affirm that you are at least 18 years of age. If you have any questions about the project, please contact Janet Trejo, via email at aptrejo1@asu.edu or cell number 602-919-8699. If you have any questions regarding your rights as a research subject, contact the SJHMC Institutional Review Board (IRB) at 602-4068051. Post Educational Intervention Survey 1. How knowledgeable do you feel about the expectations after your surgery? 1. Very knowledgeable 2. Somewhat knowledgeable 3. Not very knowledgeable 4. Not very knowledgeable at all 2. Did the educational pamphlet improve your understanding of your spine surgery? 1. Highly improved 2. Moderately improved 3. Somewhat improved PREOPERATIVE EDUCATION 53 4. Not at all improved 3. How educated did you feel after the educational pamphlet about the surgical expectations after your surgery? 1. Very knowledgeable 2. Somewhat knowledgeable 3. Not very knowledgeable 4. Not very knowledgeable at all 4. Did the educational pamphlet improve your knowledge regarding your postoperative or hospital care? 1. Highly improved 2. Moderately improved 3. Somewhat improved 4. Not all improved 5. Did you find the educational pamphlet easy to understand? 1. Very easy 2. Moderately easy 3. Somewhat easy 4. Not at all easy 6. Did you find the educational pamphlet effective and relevant to your spine surgery experience? 1. Very effective 2. Moderately effective 3. Somewhat effective 4. Not at all effective PREOPERATIVE EDUCATION 54 7. How confident are you that you will have someone to help you at home after discharge? 5. Very confident 6. Somewhat confident 7. Not very confident 8. Not very confident at all 8. How confident are you that you will be able to manage your post-operative pain at home? 1. Very confident 2. Somewhat confident 3. Not very confident 4. Not very confident at all Please add comments and suggestions: PREOPERATIVE EDUCATION 55 Appendix L Table 3 Functional and Demographics Statistics Survey questions Mean Age 58.17 Gender 1.83 Ethnic group 1.00 Other ethnic group .00 Highest level of 4.33 education Walked from the .33 parking garage to the preoperative center Length of time with 98.67 back pain Use of assistive .33 devices for walking Days expected to stay 3.0 in the hospital Note SD=Standard deviation; n=number of participants SD 14.607 .408 .000 .000 1.033 n 6 6 6 6 6 .516 6 93.264 6 .516 6 1.673 6 PREOPERATIVE EDUCATION 56 Appendix M Table 4 Pre and Post Intervention Statistics Pre-intervention Survey Mean (SD) question Pre 1.83(.408) intervention (knowledge about what to expect after surgery) How 1.83 (.408) knowledgeable are you about the surgery process and recovery Do you feel 1.17 (.408) ready and prepared n 6 6 6 Able to walk from stretcher to inpatient bed 2.00 (1.095) 6 Days expected to stay in the hospital 2.00 (.894) 6 Discharged home rather than a rehabilitation facility 1.17 (.408) 6 Survey Question Post intervention (knowledge about expectations after surgery) Education pamphlet improve your understanding How educated did you feel after the educational pamphlet Educational pamphlet improve your knowledge about post operative care Did you find the educational pamphlet easy to understand Did you find the educational pamphlet effective and Post-intervention Mean (SD) n 1.67 (.816) 6 1.83 (.408) 6 1.67 (.516) 6 2.00 (.632) 6 1.67 (.816) 6 1.67 (.816) 6 PREOPERATIVE EDUCATION 57 Preintervention (help at home after discharge) 1.00 (.000) 6 relevant Post intervention (help at home after discharge) 1.00 (.000) 6 PREOPERATIVE EDUCATION 58 Appendix N Table 5 Pre and Post Intervention Effect Size Pre-intervention Survey Mean n question (SD) Pre 1.83 6 intervention (.408) (knowledge about what to expect after surgery) Pre1.00 6 intervention (.000) (help at home after discharge) Note: SD=standard deviation; n=number of participants Survey question Post intervention (knowledge about expectations after surgery) Post intervention (help at home after discharge) Post-intervention Mean n (SD) 1.67 6 (.816) 1.00 (.000) 6 Cohen’s D 0.248 0