Introduction .uk



Association between psychological health and wound complications after surgeryP. Britteon1, N. Cullum2 and M. Sutton11 Manchester Centre for Health Economics, University of Manchester2 School of Nursing, Midwifery and Social Network, University of ManchesterCorresponding authorName: Philip Britteon Address: University of Manchester, Room 4.306 Jean McFarlane Building, Oxford Road, Manchester, M13 9PLE-mail: philip.britteon@manchester.ac.ukFunding for researchNational Institute for Health Research (NIHR)Manuscript categoryOriginal articleBackground: Surgical wound complications remain a major cause of morbidity, leading to higher costs and reduced quality of life. Whilst psychological health is widely considered to affect wound healing, the evidence on wound outcomes after surgery is mixed. Studies generally focus on small samples of patients undergoing a specific procedure and have limited statistical power.Methods: We investigated the relationship between three different measures of anxiety and/or depression and seven adverse surgical outcomes using observational data collected before and after surgery between 2009 and 2011. We adjusted for a wide range of confounding factors including patient demographics, physical comorbidities, health-related behaviours, month of operation, procedure complexity, and treating hospital.Results: The estimation sample included 176827 patients undergoing 59410 hip replacements, 64145 knee replacements, 38328 hernia repairs, and 14944 varicose vein operations. Patients with moderate anxiety or depression were associated with an increased probability of developing a wound complication (OR 1.17, 95% CI: 1.11 to 1.24) within 6 months of a hip replacement. They were more likely to be readmitted from a wound complication (OR 1.20, 95% CI: 1.02 to 1.41) and faced increased length of stays by 0.19 days (95% CI: 0.15 to 0.24). Estimated associations were consistent across all four types of operation and for each measure of anxiety and/or depression.Conclusion: Preoperative psychological health is a significant risk factor for wound outcomes after surgery for four of the most commonly performed procedures in England. This finding warrants further exploration in order to understand the mechanisms and mediating factors required to identify effective interventions.IntroductionIn 2014/15, admissions for general surgery in England exceeded 1.7 millionADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Health and Social Care Information Centre (HSCIC)", "given" : "", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2015" ] ] }, "title" : "National Statistics Hospital Episode Statistics, Admitted Patient Care - England, 2014-15", "type" : "report" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "¹", "plainTextFormattedCitation" : "1", "previouslyFormattedCitation" : "¹" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }1. Wound related problems arising after surgery remain a major cause of morbidity, despite often being preventable. Surgical site infection alone is thought to affect at least 5% of patients undergoing surgeryADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "National Institute for Health and Care Excellence", "given" : "", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "NICE guidlines", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2008" ] ] }, "title" : "Surgical site infections: prevention and treatment", "type" : "report" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "²", "plainTextFormattedCitation" : "2", "previouslyFormattedCitation" : "²" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }2. Patients with wound complications face longer periods of recovery, leading to an increased risk of mortality, higher costs of treatment, and a significantly reduced quality of lifeADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Whitehouse", "given" : "James D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Friedman", "given" : "N Deborah", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kirkland", "given" : "Kathryn B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Richardson", "given" : "William J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sexton", "given" : "Daniel J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Infection Control and Hospital Epidemiology", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2002" ] ] }, "page" : "183-9", "title" : "The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost", "type" : "article-journal", "volume" : "23" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "³", "plainTextFormattedCitation" : "3", "previouslyFormattedCitation" : "³" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }3. The negative impact of wound complications may even negate the benefits of the surgeryADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Cullum", "given" : "N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Buckley", "given" : "H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dumville", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hall", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lamb", "given" : "K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Madden", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Morley", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O'Meara", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Saramago", "given" : "P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Goncalves", "given" : "P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Soares", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stubbs", "given" : "N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "NIHR J Libr. in press", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "0" ] ] }, "title" : "Wounds research for patient benefit: a five year programme of research", "type" : "report" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "⁴", "plainTextFormattedCitation" : "4", "previouslyFormattedCitation" : "⁴" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }4.Understanding the factors associated with the occurrence of wound complications can help to identify susceptible patients, deliver appropriate interventions and reduce their incidence. Whilst studies have generally focused on surgical issues, patient level factors also have an important role to playADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Buggy", "given" : "Donal", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Lancet", "id" : "ITEM-1", "issue" : "9227", "issued" : { "date-parts" : [ [ "2000" ] ] }, "page" : "355-357", "title" : "Can anaesthetic management influence surgical-wound healing?", "type" : "article-journal", "volume" : "356" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "⁵", "plainTextFormattedCitation" : "5", "previouslyFormattedCitation" : "⁵" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }5. Factors associated with delayed wound healing include patient characteristics such as age and sex; health-related behaviours (e.g., smoking, alcohol consumption, diet); physical comorbidities (obesity, diabetes, medications); and psychological health (e.g., stress, anxiety, depression)ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0022-0345", "author" : [ { "dropping-particle" : "", "family" : "Guo", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "DiPietrio", "given" : "LA", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Dental Research", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2010" ] ] }, "page" : "219-229", "title" : "Factors Affecting Wound Healing", "type" : "article-journal", "volume" : "89" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "⁶", "plainTextFormattedCitation" : "6", "previouslyFormattedCitation" : "⁶" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }6. In particular, there is increasing evidence that stress, anxiety, and depression directly influence immune response and hence, wound healingADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/S0140-6736(95)92899-5", "ISBN" : "0140-6736 (Print)\\n0140-6736 (Linking)", "ISSN" : "01406736", "PMID" : "7475659", "abstract" : "There is evidence that psychological stress adversely affects the immune system. We have investigated the effects of such stress, caused by caring for a relative with Alzheimer's disease, on wound healing. We studied 13 women caring for demented relatives (mean age 62\u00b73 [SE 2\u00b73] years) and 13 controls matched for age (60\u00b74 [2\u00b78] years) and family income. All subjects underwent a 3\u00b75 mm punch biopsy wound. Healing was assessed by photography of the wound and the response to hydrogen peroxide (healing was defined as no foaming). Wound healing took significantly longer in caregivers than in controls (48\u00b77 [2\u00b79] vs 39\u00b73 [3\u00b70] days, p<0\u00b705). Peripheral-blood leucocytes from caregivers produced significantly less interleukin-1\u03b2 mRNA in response to lipopolysaccharide stimulation than did controls' cells. Stress-related defects in wound repair could have important clinical implications, for instance for recovery from surgery. \u00a9 1995.", "author" : [ { "dropping-particle" : "", "family" : "Kiecolt-Glaser", "given" : "J. K.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Marucha", "given" : "P. T.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mercado", "given" : "A. M.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Malarkey", "given" : "W. B.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Glaser", "given" : "R.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Lancet", "id" : "ITEM-1", "issue" : "8984", "issued" : { "date-parts" : [ [ "1995" ] ] }, "page" : "1194-1196", "title" : "Slowing of wound healing by psychological stress", "type" : "article-journal", "volume" : "346" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "⁷", "plainTextFormattedCitation" : "7", "previouslyFormattedCitation" : "⁷" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }7.Several studies have investigated the impact of poor psychological health on wound healing and found similar negative effectsADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.jpsychores.2009.04.002", "ISBN" : "1879-1360 (Electronic)\\n0022-3999 (Linking)", "ISSN" : "00223999", "PMID" : "19686881", "abstract" : "Objective: The current review aims to synthesize existing knowledge about the relationship between psychological stress and wound healing. Methods: A systematic search strategy was conducted using electronic databases to search for published articles up to the end of October 2007. The reference lists of retrieved articles were inspected for further studies and citation searches were conducted. In addition, a meta-analysis of a subset of studies was conducted to provide a quantitative estimation of the influence of stress on wound healing. Results: Twenty-two papers met the inclusion criteria of the systematic review and a subsample of 11 was included in a meta-analysis. The studies assessed the impact of stress on the healing of a variety of wound types in different contexts, including acute and chronic clinical wounds, experimentally created punch biopsy and blister wounds, and minor damage to the skin caused by tape stripping. Seventeen studies in the systematic review reported that stress was associated with impaired healing or dysregulation of a biomarker related to wound healing. The relationship between stress and wound healing estimated by the meta-analysis was r=-0.42 (95% CI=-0.51 to -0.32) (P<.01). Conclusion: Attention now needs to be directed towards investigating potential moderators of the relationship, mediating mechanisms underpinning the association, as well as the demonstration of a causal link by the development of experimental interventions in healthy populations. ?? 2009 Elsevier Inc. All rights reserved.", "author" : [ { "dropping-particle" : "", "family" : "Walburn", "given" : "Jessica", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vedhara", "given" : "Kavita", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hankins", "given" : "Matthew", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rixon", "given" : "Lorna", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Weinman", "given" : "John", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Psychosomatic Research", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2009" ] ] }, "page" : "253-271", "publisher" : "Elsevier Inc.", "title" : "Psychological stress and wound healing in humans: A systematic review and meta-analysis", "type" : "article-journal", "volume" : "67" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1016/j.iac.2010.09.010", "ISBN" : "1557-8607 (Electronic)\\r0889-8561 (Linking)", "ISSN" : "08898561", "PMID" : "21094925", "abstract" : "Converging and replicated evidence indicates that psychological stress can modulate wound-healing processes. This article reviews the methods and findings of experimental models of wound healing. Psychological stress can have a substantial and clinically relevant impact on wound repair. Physiologic stress responses can directly influence wound-healing processes. Furthermore, psychological stress can indirectly modulate the repair process by promoting the adoption of health-damaging behaviors. Translational work is needed to develop innovative treatments able to attenuate stress-induced delays in wound healing. \u00a9 2011 Elsevier Inc.", "author" : [ { "dropping-particle" : "", "family" : "Gouin", "given" : "Jean Philippe", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kiecolt-Glaser", "given" : "Janice K.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Immunology and Allergy Clinics of North America", "id" : "ITEM-2", "issue" : "1", "issued" : { "date-parts" : [ [ "2011" ] ] }, "page" : "81-93", "title" : "The Impact of Psychological Stress on Wound Healing: Methods and Mechanisms", "type" : "article-journal", "volume" : "31" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "^8,9", "plainTextFormattedCitation" : "8,9", "previouslyFormattedCitation" : "^8,9" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }8,9. However, relatively few studies have focused specifically on the recovery of patients undergoing surgeryADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1371/journal.pone.0020306", "ISBN" : "1932-6203 (Electronic) 1932-6203 (Linking)", "ISSN" : "19326203", "PMID" : "21633506", "abstract" : "BACKGROUND: Numerous studies have examined the effect of psychological variables on surgical recovery, but no definite conclusion has been reached yet. We sought to examine whether psychological factors influence early surgical recovery.\\n\\nMETHODS: We performed a systematic search in PubMed, Scopus and PsycINFO databases to identify studies examining the association of preoperative psychological variables or interventions with objectively measured, early surgical outcomes.\\n\\nRESULTS: We identified 16 eligible studies, 15 of which reported a significant association between at least one psychological variable or intervention and an early postoperative outcome. However, most studies also reported psychological factors not influencing surgical recovery and there was significant heterogeneity across the studies. Overall, trait and state anxiety, state anger, active coping, subclinical depression, and intramarital hostility appeared to complicate recovery, while dispositional optimism, religiousness, anger control, low pain expectations, and external locus of control seemed to promote healing. Psychological interventions (guided relaxation, couple support visit, and psychiatric interview) also appeared to favor recovery. Psychological factors unrelated to surgical outcomes included loneliness, perceived social support, anger expression, and trait anger.\\n\\nCONCLUSION: Although the heterogeneity of the available evidence precludes any safe conclusions, psychological variables appear to be associated with early surgical recovery; this association could bear important implications for clinical practice. Large clinical trials and further analyses are needed to precisely evaluate the contribution of psychology in surgical recovery.", "author" : [ { "dropping-particle" : "", "family" : "Mavros", "given" : "Michael N.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Athanasiou", "given" : "Stavros", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gkegkes", "given" : "Ioannis D.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Polyzos", "given" : "Konstantinos A.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Peppas", "given" : "George", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Falagas", "given" : "Matthew E.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "PLoS ONE", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "2011" ] ] }, "title" : "Do psychological variables affect early surgical recovery?", "type" : "article-journal", "volume" : "6" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "¹⁰", "plainTextFormattedCitation" : "10", "previouslyFormattedCitation" : "¹⁰" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }10, with most focusing on outcomes after cardiac surgeryADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.surg.2015.03.050", "ISSN" : "0039-6060", "author" : [ { "dropping-particle" : "", "family" : "Ward", "given" : "Nicholas", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Roth", "given" : "J Scott", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lester", "given" : "Clark C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mutiso", "given" : "Lori", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Surgery", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2015" ] ] }, "page" : "420-427", "publisher" : "Elsevier Inc.", "title" : "Anxiolytic medication is an independent risk factor for 30-day morbidity or mortality after surgery", "type" : "article-journal", "volume" : "158" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "¹¹", "plainTextFormattedCitation" : "11", "previouslyFormattedCitation" : "¹¹" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }11. Findings from these studies are inconclusiveADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1371/journal.pone.0020306", "ISBN" : "1932-6203 (Electronic) 1932-6203 (Linking)", "ISSN" : "19326203", "PMID" : "21633506", "abstract" : "BACKGROUND: Numerous studies have examined the effect of psychological variables on surgical recovery, but no definite conclusion has been reached yet. We sought to examine whether psychological factors influence early surgical recovery.\\n\\nMETHODS: We performed a systematic search in PubMed, Scopus and PsycINFO databases to identify studies examining the association of preoperative psychological variables or interventions with objectively measured, early surgical outcomes.\\n\\nRESULTS: We identified 16 eligible studies, 15 of which reported a significant association between at least one psychological variable or intervention and an early postoperative outcome. However, most studies also reported psychological factors not influencing surgical recovery and there was significant heterogeneity across the studies. Overall, trait and state anxiety, state anger, active coping, subclinical depression, and intramarital hostility appeared to complicate recovery, while dispositional optimism, religiousness, anger control, low pain expectations, and external locus of control seemed to promote healing. Psychological interventions (guided relaxation, couple support visit, and psychiatric interview) also appeared to favor recovery. Psychological factors unrelated to surgical outcomes included loneliness, perceived social support, anger expression, and trait anger.\\n\\nCONCLUSION: Although the heterogeneity of the available evidence precludes any safe conclusions, psychological variables appear to be associated with early surgical recovery; this association could bear important implications for clinical practice. 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Wound healing takes many months yet discharge usually occurs within less than a week of surgery. As such, incisional surgical wound complications nearly always persist outside of hospital where the opportunities for wound observation and detailed data collection are few. Hence, analyses tend to be conducted for specific surgical procedures using small samples of patientsADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1371/journal.pone.0020306", "ISBN" : "1932-6203 (Electronic) 1932-6203 (Linking)", "ISSN" : "19326203", "PMID" : "21633506", "abstract" : "BACKGROUND: Numerous studies have examined the effect of psychological variables on surgical recovery, but no definite conclusion has been reached yet. We sought to examine whether psychological factors influence early surgical recovery.\\n\\nMETHODS: We performed a systematic search in PubMed, Scopus and PsycINFO databases to identify studies examining the association of preoperative psychological variables or interventions with objectively measured, early surgical outcomes.\\n\\nRESULTS: We identified 16 eligible studies, 15 of which reported a significant association between at least one psychological variable or intervention and an early postoperative outcome. However, most studies also reported psychological factors not influencing surgical recovery and there was significant heterogeneity across the studies. Overall, trait and state anxiety, state anger, active coping, subclinical depression, and intramarital hostility appeared to complicate recovery, while dispositional optimism, religiousness, anger control, low pain expectations, and external locus of control seemed to promote healing. Psychological interventions (guided relaxation, couple support visit, and psychiatric interview) also appeared to favor recovery. Psychological factors unrelated to surgical outcomes included loneliness, perceived social support, anger expression, and trait anger.\\n\\nCONCLUSION: Although the heterogeneity of the available evidence precludes any safe conclusions, psychological variables appear to be associated with early surgical recovery; this association could bear important implications for clinical practice. Large clinical trials and further analyses are needed to precisely evaluate the contribution of psychology in surgical recovery.", "author" : [ { "dropping-particle" : "", "family" : "Mavros", "given" : "Michael N.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Athanasiou", "given" : "Stavros", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gkegkes", "given" : "Ioannis D.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Polyzos", "given" : "Konstantinos A.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Peppas", "given" : "George", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Falagas", "given" : "Matthew E.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "PLoS ONE", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "2011" ] ] }, "title" : "Do psychological variables affect early surgical recovery?", "type" : "article-journal", "volume" : "6" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "¹⁰", "plainTextFormattedCitation" : "10", "previouslyFormattedCitation" : "¹⁰" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }10. This increases the heterogeneity between studies and reduces statistical power required to identify a significant effect.In this study, we combined rich observational hospital- and patient-reported information for 176 827 patients undergoing four of the most common surgical procedures in England. We analysed the impact of depression and anxiety on wound-related complications after surgery, controlling for a wide-range of confounding prognostic factors.MethodsDataSince April 2009, the National Patient Reported Outcome Measures (PROMs) Programme has collected patient-reported information before and after surgery from NHS patients aged 12 or over undergoing one of four common elective procedures: unilateral hip replacement; unilateral knee replacement; inguinal hernia repair; and varicose vein surgery. All providers of NHS-care in England are required to offer patients undergoing these procedures a preoperative PROMs questionnaire (Q1) prior to their date of surgery. This usually occurs during their last outpatient assessment or on the day of admission. A post-operative PROMs questionnaire (Q2) is then mailed to the patient 6 months after the operation date for hip and knee replacement and 3 months after the operation date for hernia repair and varicose vein surgery. One reminder is sent to patients who fail to respond initially. Patients are made aware that identifiable information is anonymised to all hospital staff, including surgeons.We linked PROMs data from 1st April 2009 to 31st March 2011 to administrative data from Hospital Episode Statistics (HES) containing detailed clinical and demographical information on all inpatient admissions in England.Psychological health We used three alternative measures to characterise the psychological status of the patient; two reported by the patient before surgery and the third recorded by the hospital during the patient’s admission.Diagnosed depressionPatients self-identified comorbidities in their preoperative PROMs questionnaire; selecting from a list of 12 common serious conditions (depression, high blood pressure, problems caused by strokes, heart disease, lung disease, diabetes, kidney disease, diseases of the nervous system, liver disease, cancer, arthritis, and leg pain when walking due to poor circulation). To minimise the use of medical terminology, patients were asked: ‘Have you been told by a doctor that you have any of the following?’. We focused on patients identifying themselves as having been diagnosed with depression, the only psychological condition specified within the list. Whilst self-reported medical diagnoses are subject to recall bias, such measures have been shown to be moderately or strongly correlated with medical records and are widely considered as valid instrumentsADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.jclinepi.2008.05.002", "ISBN" : "1878-5921 (Electronic)\\r0895-4356 (Linking)", "ISSN" : "08954356", "PMID" : "18757178", "abstract" : "Objective: To explore the constructs underlying a self-report assessment of multimorbidity. Study Design and Setting: We conducted a cross-sectional survey of 352 HMO members aged 65 years or more with, at a minimum, diabetes, depression, and osteoarthritis. We assessed self-reported 'disease burden' (a severity-adjusted count of conditions) as a function of biopsychosocial factors, two data-based comorbidity indices, and demographic variables. Results: In multivariate regression, age, 'compound effects of conditions' (treatments and symptoms interfering with each other), self-efficacy, financial constraints, and physical functioning were significantly (p ??? 0.05) associated with disease burden. An ICD-9-based morbidity index did not significantly contribute to disease burden, and a pharmacy-data-based morbidity index was minimally significant. Conclusion: This measure of self-reported disease burden represents an amalgamation of functional capabilities, social considerations, and medical conditions that are not captured by two administrative data-based measures of morbidity. This suggests that (a) self-reported descriptions of multimorbidity incorporate biopsychosocial constructs that reflect the perceived burden of multimorbidity, (b) a simple count of diagnoses should be supplemented by an assessment of activity limitations imposed by these conditions, and (c) choice of the morbidity measurement instrument should be based on the outcome of interest rather than on the most convenient method of measurement. ?? 2009 Elsevier Inc. All rights reserved.", "author" : [ { "dropping-particle" : "", "family" : "Bayliss", "given" : "Elizabeth A.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ellis", "given" : "Jennifer L.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Steiner", "given" : "John F.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Clinical Epidemiology", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "2009" ] ] }, "title" : "Seniors' self-reported multimorbidity captured biopsychosocial factors not incorporated into two other data-based morbidity measures", "type" : "article-journal", "volume" : "62" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Katz", "given" : "Jeffrey N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Chang", "given" : "Lily C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sangha", "given" : "Oliver", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fossel", "given" : "Anne H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "David", "given" : "W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Medical Care", "id" : "ITEM-2", "issue" : "1", "issued" : { "date-parts" : [ [ "1996" ] ] }, "page" : "73-84", "title" : "Can Comorbidity Be Measured by Questionnaire Rather than Medical Record Review?", "type" : "article-journal", "volume" : "34" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "^12,13", "plainTextFormattedCitation" : "12,13", "previouslyFormattedCitation" : "^12,13" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }12,13.Patient reported anxiety or depressionWe also considered responses to the EQ-5DTM (EuroQoL Group, Rotterdam, The Netherlands) reported by the patient before surgery. The EQ-5D measures health over five dimensions (anxiety or depression, mobility, self-care, usual activities, pain or discomfort). We focused on the anxiety or depression dimension. Patients were offered three response categories: no problems; moderate problems; extreme problems. The EQ5D is the generic health measure recommended by The National Institute for Health and Care Excellence (NICE).Hospital recorded anxiety/depressionWe also considered clinical information on the diagnosed psychological health status of patients recorded in HES. Since 2009, hospitals have reported mental or behavioural disorders of patients undergoing surgery as secondary diagnoses, according to Chapter V of the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10). We identified patients to have been diagnosed with either an anxiety disorder (F41.X) or a depressive episode (F32.X). These codes were the most commonly recorded mental and behavioural disorders by hospitals. Wound-related outcomesPatient-reported complicationIn the postoperative PROMs questionnaire, patients were asked ‘Did you experience any of the following problems after your operation: allergy or reaction to drug; urinary problems; bleeding; and wound problems?’. Patients could have developed the complication at any time during the 3 or 6 month follow-up period after surgery, both during or after their stay in hospital. We focused on patients reporting a wound problem. The validity of patient-reported complications is well documentedADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1002/bjs.8830", "author" : [ { "dropping-particle" : "", "family" : "Grosse Frie", "given" : "K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Meulen", "given" : "J", "non-dropping-particle" : "van der", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Black", "given" : "N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "British Journal of Surgery", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2012" ] ] }, "page" : "1156-1163", "title" : "Relationship between patients \u2019 reports of complications and symptoms , disability and quality of life after surgery", "type" : "article-journal", "volume" : "99" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "¹⁴", "plainTextFormattedCitation" : "14", "previouslyFormattedCitation" : "¹⁴" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }14.Hospital-reported wound complicationWe also considered clinical outcomes reported by the hospital in HES. We identified patients recorded with a wound-related secondary diagnosis using the ICD-10 codes T81.3 (Disruption of operation wound, not elsewhere classified) and T81.4 (Infection following a procedure, not elsewhere classified). These codes were specifically designed to capture postoperative events when recorded as a secondary diagnosis. Wound-related readmissionWe also identified patients readmitted to hospital after discharge where the primary diagnosis code of the readmission was recorded as T81.3 or T81.4. When recorded as a primary diagnosis, the ICD-10 codes T80-T88 are used to specify readmission to hospital from a previous complication of surgical care. For consistency with the patient-reported information, we only considered readmissions occurring within 3 months after surgery for hernia repair and varicose vein procedures and within 6 months after surgery for hip and knee replacements.Length of stayFinally, we considered the patient’s length of stay during the hospital stay in which the surgery took place. We calculated the length of stay as the days from admission to discharge from hospital using HES data.Statistical AnalysisWe identified several factors confounding the relationship between psychological health and recovery from surgery that had previously been adjusted for or overlooked in the literatureADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.jpsychores.2009.04.002", "ISBN" : "1879-1360 (Electronic)\\n0022-3999 (Linking)", "ISSN" : "00223999", "PMID" : "19686881", "abstract" : "Objective: The current review aims to synthesize existing knowledge about the relationship between psychological stress and wound healing. Methods: A systematic search strategy was conducted using electronic databases to search for published articles up to the end of October 2007. The reference lists of retrieved articles were inspected for further studies and citation searches were conducted. In addition, a meta-analysis of a subset of studies was conducted to provide a quantitative estimation of the influence of stress on wound healing. Results: Twenty-two papers met the inclusion criteria of the systematic review and a subsample of 11 was included in a meta-analysis. The studies assessed the impact of stress on the healing of a variety of wound types in different contexts, including acute and chronic clinical wounds, experimentally created punch biopsy and blister wounds, and minor damage to the skin caused by tape stripping. Seventeen studies in the systematic review reported that stress was associated with impaired healing or dysregulation of a biomarker related to wound healing. The relationship between stress and wound healing estimated by the meta-analysis was r=-0.42 (95% CI=-0.51 to -0.32) (P<.01). Conclusion: Attention now needs to be directed towards investigating potential moderators of the relationship, mediating mechanisms underpinning the association, as well as the demonstration of a causal link by the development of experimental interventions in healthy populations. ?? 2009 Elsevier Inc. All rights reserved.", "author" : [ { "dropping-particle" : "", "family" : "Walburn", "given" : "Jessica", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vedhara", "given" : "Kavita", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hankins", "given" : "Matthew", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rixon", "given" : "Lorna", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Weinman", "given" : "John", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Psychosomatic Research", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2009" ] ] }, "page" : "253-271", "publisher" : "Elsevier Inc.", "title" : "Psychological stress and wound healing in humans: A systematic review and meta-analysis", "type" : "article-journal", "volume" : "67" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "⁸", "plainTextFormattedCitation" : "8", "previouslyFormattedCitation" : "⁸" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }8. We adjusted for likely confounding factors using multiple logistic regression to calculate adjusted odds ratios (ORs) when outcomes were binary and multiple linear regression when estimating the effect on length of stay. The adjusted factors included patients’ age, sex and area level income deprivation in 2010. We allowed the effects of age to differ between male and female patients. We adjusted for other health conditions using the remaining conditions reported in the preoperative PROMs questionnaire; the remaining 4 EQ-5D physical dimensions; the patient’s duration of symptoms before surgery; and whether the patient had undergone previous surgery of the same type. We used secondary diagnosis codes from HES to also adjust for indicators of obesity (E66.X), nutritional deficiencies (E40 to E46, E50 to E64), sleep disorders (F51.X, G47.X, R06.X, Z72.8, G25.8), smoking use (Z72.0, F17.2), and alcohol use (Z21.1, F10.2). Information on ethnicity, disability, and whether the patient lived alone contained a large proportion of missing values and hence, we did not include these factors. Finally, we included binary indicators to adjust for differences between hospitals, between primary procedures, and between months.Separate models were estimated for each measure of psychological health. For most analyses, we considered each of the four procedures separately. However, because hospitals did not frequently code patients with wound-related complications, we did not stratify analyses by procedure type when estimating effects on hospital-reported outcomes in order to maintain statistical power. Confidence intervals were calculated using cluster-robust standard errors to allow for the multilevel (patients within hospitals) structure of the data. ResultsEstimation sampleIn total, 480 421 patients who attended hospital between April 2009 and March 2011 were eligible for PROMs: 135 381 hip replacement, 148 134 knee replacement, 138 160 hernia repair, and 58 746 varicose vein procedures. Total recruitment and response rates to the preoperative PROMs questionnaire (linked and unlinked to HES) have been estimated by previous studies and vary by hip replacement (80%), knee replacement (80%), hernia repair (55%), and varicose vein (45%) proceduresADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1177/0141076815576700", "ISSN" : "0141-0768", "author" : [ { "dropping-particle" : "", "family" : "Gutacker", "given" : "N.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Street", "given" : "A.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gomes", "given" : "M.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bojke", "given" : "C.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of the Royal Society of Medicine", "id" : "ITEM-1", "issue" : "8", "issued" : { "date-parts" : [ [ "2015" ] ] }, "page" : "304-316", "title" : "Should English healthcare providers be penalised for failing to collect patient-reported outcome measures? A retrospective analysis", "type" : "article-journal", "volume" : "108" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "¹⁵", "plainTextFormattedCitation" : "15", "previouslyFormattedCitation" : "¹⁵" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }15. Completed preoperative PROM records that were linkable to HES existed for 261 922 of the eligible patients: 70 747 (52%) hip replacement, 75 040 (51%) knee replacement, 50 116 (36%) hernia repair, and 22 596 (38%) varicose vein procedures. Response rates to the postoperative questionnaire were higher and also varied across procedure type: hip replacement (86%), knee replacement (86%), hernia repair (77%), and varicose vein surgery (67%). In total, 178 622 patients completed both the preoperative and postoperative questionnaire between April 2009 and March 2011: 60 157 (44%) hip replacements; 64 887 (44%) knee replacements; 38 516 (28%) hernia repairs; and 15 062 (26%) varicose vein operations. However, information on the area of residence needed to identify levels of income deprivation was missing for 1 795 (1%) of these patients. The final estimation sample contained 176 827 patients: 59 410 (44%) hip replacements, 64 145 (43%) knee replacements, 38 328 (28%) hernia repairs, and 14 944 (25%) varicose vein operations.Estimation ResultsWound complications were the most commonly reported adverse outcome across all procedures except knee replacements (Table 1). Patients reported wound complications more frequently when undergoing varicose vein surgery (14.6%) compared with hip replacements (9.4%), knee replacements (12.0%), and hernia repair (11.0%). Very few patients undergoing hernia repair (0.03%) and varicose vein surgery (0.01%) were coded by the hospital as having a wound-related complication. Wound-related complications were coded by the hospital more frequently for hip (0.5%) and knee (0.5%) replacements. Readmission rates due to a wound complication of previous surgery varied across procedures (from 0.2% to 0.6%). Patients requiring joint replacements had longer lengths of stay than patients undergoing hernia repair and varicose vein surgery, where the majority of patients were seen as daycases (68.8% and 88.2% respectively).Patients undergoing hip and knee replacement surgery were more likely to have previously experienced poor psychological health than those undergoing hernia repair and varicose vein surgery (Table 1). Hip and knee replacement patients reported higher rates of diagnosed depression (6.9% and 7.6% respectively) and more frequently stated that they were moderately (37.7% and 33.9% respectively) or extremely (5.0% and 3.8% respectively) anxious or depressed before surgery. Likewise, a greater proportion of hip (1.8%) and knee (2.0%) replacement patients were recorded to have an anxiety disorder or depressive episode by the hospital during their admission compared to patients undergoing hernia repair (0.9%) and varicose vein surgery (1.0%). The psychological health measures were positively correlated, as expected (Table 2). The proportion of patients who had been previously diagnosed with depression increased with levels of reported problems with anxiety or depression from 1.2% (none) to 14.6% (moderate) to 39.5% (extreme). Likewise, the proportion of patients diagnosed with an anxiety disorder or depressive episode by the hospital also increased with levels of reported problems with anxiety or depression from 0.6% (none) to 3.2% (moderate) to 8.0% (extreme). Only a small fraction of patients who had self-identified as having extreme problems with anxiety or depression (8.0%) were identified with a depressive episode or anxiety disorder by the hospital.Patients suffering from anxiety and/or depression were more likely to experience a wound problem after surgery (Table 3). The associations reduced but remained significant after adjustment for confounding factors. Following hip replacement, previously diagnosed depression increased the probability of wound complications (OR 1.36, 95%CI: 1.24 to 1.76). Likewise, hip replacement patients with moderate problems of anxiety or depression were more likely to develop a wound complication than patients reporting no problems with anxiety or depression (OR 1.17, CI: 1.11 to 1.24). The association with extreme problems of anxiety or depression was even larger (OR 1.26, CI: 1.10 1.43). These associations were similar in magnitude and significance for patients undergoing knee replacement, hernia repair, and varicose vein surgery. Hospital recorded anxiety or depression was significantly associated with the occurrence of surgical wound problems only for patients undergoing hip (OR 1.32, CI: 1.10 to 1.59) or knee (OR 1.24, CI: 1.05 to 1.45) replacements.Diagnosed depression (OR 0.96, CI: 0.69 to 1.33), reported moderate (OR 1.14, CI: 0.96 to 1.36) and extreme (OR 1.18, CI: 0.86 to 1.63) problems with anxiety or depression, and hospital recorded anxiety or depression (OR 0.92, CI: 0.50 to 1.73) were not significantly associated with hospital reported wound complications (Table 4). Previously diagnosed depression, however, was significantly associated with readmissions due to surgical wound complications (OR 1.37, CI: 1.11 to 1.69). Likewise, patients reporting moderate (OR 1.20, CI: 1.02 to 1.41) or extreme (OR 1.30, CI: 0.92 to 1.84) problems with anxiety or depression were more likely to be readmitted because of a surgical wound complication.Each psychological health measure was significantly associated with a longer average length of hospital stay: previously diagnosed depression (0.23 days, CI: 0.14 to 0.32); moderate (0.19 days, CI: 0.15 to 0.24) and extreme (0.49 days, CI: 0.33 to 0.65) problems with anxiety or depression; and hospital diagnosed anxiety or depression (0.44 days, CI: 0.25 to 0.62). Moderate problems with anxiety or depression were also associated with bleeding (OR 1.14, CI: 1.05 to 1.24), allergy (OR 1.09, CI: 1.04 to 1.16), and urinary (OR 1.21, CI: 1.15 to 1.28) problems after hip replacement surgery (Table 5). Extreme problems with anxiety or depression had larger associations than moderate problems with bleeding (OR 1.21, CI: 1.04 to 1.41), allergy (OR 1.25, CI: 1.11 to 1.41), and urinary (OR 1.48, CI: 1.31 to 1.67) problems. Allergy complications after a hip replacement were not associated with previously diagnosed depression (OR 1.01, CI: 0.91 to 1.12) or hospital recorded anxiety or depression (OR 1.11, CI: 0.91 to 1.37). Similar results were found for patients undergoing knee replacements and hernia repairs. DiscussionWe found that large proportions of patients reported having moderate (29.8%) or extreme problems with (3.4%) anxiety or depression prior to surgery. Patients’ preoperative psychological health status was significantly associated with wound-related problems after surgery for hip replacement, knee replacement, hernia repair, and varicose vein surgery. These associations were large and strong. They were consistent for three different anxiety and/or depression measures and when adjusting for a wide range of confounding factors including patient demographics, physical comorbidities, health behaviours, month of operation, procedure complexity, and treating hospital. Anxiety and/or depression were not associated with wound complications recorded by hospitals during the patients’ stay, however. Instead, anxiety and/or depression were significantly associated with surgical wound-related readmissions. Anxious and/or depressed patients were also more likely to stay in hospital for longer periods. Whilst the associated increase in length of stay was small in magnitude, the relative effect was sizeable given that the average length of stay for the sample of patients was only 4.51 days. Furthermore, anxiety and/or depression were strongly associated with urinary and bleeding complications after surgery but only mildly associated with reported allergy and drug reaction problems. We add to the existing evidence investigating the relationship between psychological health and wound healing. In particular, we build on the smaller evidence base focusing on wound outcomes after surgery. Our results support smaller studies whose findings generally indicated a negative impact of anxiety or depression on wound healingADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/S0140-6736(95)92899-5", "ISBN" : "0140-6736 (Print)\\n0140-6736 (Linking)", "ISSN" : "01406736", "PMID" : "7475659", "abstract" : "There is evidence that psychological stress adversely affects the immune system. We have investigated the effects of such stress, caused by caring for a relative with Alzheimer's disease, on wound healing. We studied 13 women caring for demented relatives (mean age 62\u00b73 [SE 2\u00b73] years) and 13 controls matched for age (60\u00b74 [2\u00b78] years) and family income. All subjects underwent a 3\u00b75 mm punch biopsy wound. Healing was assessed by photography of the wound and the response to hydrogen peroxide (healing was defined as no foaming). Wound healing took significantly longer in caregivers than in controls (48\u00b77 [2\u00b79] vs 39\u00b73 [3\u00b70] days, p<0\u00b705). Peripheral-blood leucocytes from caregivers produced significantly less interleukin-1\u03b2 mRNA in response to lipopolysaccharide stimulation than did controls' cells. Stress-related defects in wound repair could have important clinical implications, for instance for recovery from surgery. \u00a9 1995.", "author" : [ { "dropping-particle" : "", "family" : "Kiecolt-Glaser", "given" : "J. K.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Marucha", "given" : "P. T.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mercado", "given" : "A. M.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Malarkey", "given" : "W. B.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Glaser", "given" : "R.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Lancet", "id" : "ITEM-1", "issue" : "8984", "issued" : { "date-parts" : [ [ "1995" ] ] }, "page" : "1194-1196", "title" : "Slowing of wound healing by psychological stress", "type" : "article-journal", "volume" : "346" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1080/08870449608401983", "ISSN" : "0887-0446", "author" : [ { "dropping-particle" : "", "family" : "Stengrevics", "given" : "Susan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sirois", "given" : "Cheryl", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schwartz", "given" : "Carolyn E.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Friedman", "given" : "Richard", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Domar", "given" : "Alice D.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Psychology & Health", "id" : "ITEM-2", "issue" : "4", "issued" : { "date-parts" : [ [ "1996" ] ] }, "page" : "471-477", "title" : "The prediction of cardiac surgery outcome based upon preoperative psychological factors", "type" : "article-journal", "volume" : "11" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "DOI" : "10.1097/00006842-199805000-00025", "ISBN" : "0033-3174", "ISSN" : "0033-3174", "PMID" : "9625226", "abstract" : "OBJECTIVE: Impairment of wound healing is a well-recognized sequelae of conditions that alter immune function, including diabetes, jaundice, and advanced age. There is also growing evidence that psychological stress has adverse consequences for immune function. This study addressed the effects of a commonplace stressor on wound healing. METHOD: Two punch biopsy wounds were placed on the hard palate of 11 dental students. The first wound was timed during summer vacation, whereas the second was placed on the contralateral side 3 days before the first major examination of the term; thus, each student served as her or his own control. Two independent methods assessed healing (daily photographs and a foaming response to hydrogen peroxide). RESULTS: Students took an average of 3 days longer to completely heal the 3.5-mm wound during examinations, ie, 40% longer to heal a small, standardized wound. Production of interleukin 1beta (IL-1beta) messenger RNA (mRNA) declined by 68% during examinations, providing evidence of one possible immunological mechanism. These differences were quite reliable: No student healed as rapidly or produced as much IL-1beta mRNA during examinations as during vacation. CONCLUSIONS: These data suggest that even something as transient, predictable, and relatively benign as examination stress can have significant consequences for wound healing.", "author" : [ { "dropping-particle" : "", "family" : "Marucha", "given" : "P T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kiecolt-Glaser", "given" : "J K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Favagehi", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Psychosomatic medicine", "id" : "ITEM-3", "issue" : "3", "issued" : { "date-parts" : [ [ "1998" ] ] }, "page" : "362-365", "title" : "Mucosal wound healing is impaired by examination stress.", "type" : "article-journal", "volume" : "60" }, "uris" : [ "" ] }, { "id" : "ITEM-4", "itemData" : { "DOI" : "10.1097/01.PSY.0000088589.92699.30", "ISBN" : "1534-7796 (Electronic)\\r0033-3174 (Linking)", "ISSN" : "0033-3174", "PMID" : "14508033", "abstract" : "OBJECTIVE: Laboratory studies have demonstrated that psychological stress is associated with slower healing of small superficial wounds. The application of this finding to the clinical environment has not yet been undertaken. In order to do this, we investigated the relationship between psychological stress and wound repair in patients following routine surgery. METHODS: Forty-seven adults with an inguinal hernia were given a standardized questionnaire assessing psychological stress and worry about the operation before undergoing open incision repair. Wound fluid was collected from 36 participants over the first 20-hour postoperative period. Wound healing was assessed by levels of interleukin-1, interleukin-6, and matrix metalloproteinase-9 in the fluid. Other outcome measures included patient self-reports of recovery, as well as cytokine response to lipopolysaccharide stimulation of peripheral blood. RESULTS: Greater preoperative perceived stress significantly predicted lower levels of interleukin-1 in the wound fluid ({beta} = -0.44, p = 0.03). Greater worry about the operation predicted lower levels of matrix metalloproteinase-9 in the wound fluid ({beta} = -0.38, p = 0.03) as well as a more painful ({beta} = 0.51, p = 0.002), poorer ({beta} = -0.36, p = 0.04), and slower recovery ({beta} = 0.43, p = 0.01). CONCLUSIONS: Psychological stress impairs the inflammatory response and matrix degradation processes in the wound immediately following surgery. This finding generalizes previous laboratory research to surgical patients and expands the known influence of stress to connective tissue matrix remodelling processes. These results suggest that in clinical practice, interventions to reduce the patient's psychological stress level may improve wound repair and recovery following surgery.", "author" : [ { "dropping-particle" : "", "family" : "Broadbent", "given" : "E.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Petrie", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Alley", "given" : "P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Booth", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Psychosomatic Medicine", "id" : "ITEM-4", "issue" : "5", "issued" : { "date-parts" : [ [ "2003" ] ] }, "page" : "865-869", "title" : "Psychological Stress Impairs Early Wound Repair Following Surgery", "type" : "article-journal", "volume" : "65" }, "uris" : [ "" ] }, { "id" : "ITEM-5", "itemData" : { "DOI" : "10.1111/j.1601-5215.2009.00398.x", "ISBN" : "0924-2708", "ISSN" : "09242708", "PMID" : "25384630", "abstract" : "OBJECTIVE: This study used a prospective design and the technique of structural modelling to examine the complex interrelations between psychological factors, immune status and complications after major surgery.\\n\\nMETHODS: Twenty-nine women scheduled for elective cholecystectomy were studied prospectively. Information regarding medical history, health practices, life stressors, and coping strategies was obtained two weeks prior to admission. At this initial meeting, as well as three days after surgery, and at one month follow-up immunological tests were performed and the level of psychological distress was assessed. The study additionally included measures of post-operative complications, and infections and negative effect during follow-up.\\n\\nRESULTS: Pre-operative immune status emerged as a key variable exerting strong effects on subsequent immune function and, thereby producing significant, indirect effects on every recovery variable. Pre-operative distress was directly linked to increased mood disturbance at follow-up. Moreover, distress significantly influenced immune function both before and after surgery, which mediated a significant impact on most recovery variables. Active coping behaviour directly increased the risk of a complicated recovery.\\n\\nCONCLUSIONS: The study demonstrated that distress-induced changes in immune functioning have clinical relevance. Overall, the present findings suggest that recovery from surgery is facilitated in patients with a well-functioning immune system, a low-level of pre-operative distress and a passive coping disposition.", "author" : [ { "dropping-particle" : "", "family" : "Vollmer-Conna", "given" : "Ute", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bird", "given" : "Kevin D.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yeo", "given" : "Bryan W.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Truskett", "given" : "Philip G.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Westbrook", "given" : "Reginald F.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wakefield", "given" : "Denis", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Acta Neuropsychiatrica", "id" : "ITEM-5", "issue" : "4", "issued" : { "date-parts" : [ [ "2009" ] ] }, "page" : "169-178", "title" : "Psychological factors, immune function and recovery from major surgery", "type" : "article-journal", "volume" : "21" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "^7,16\u201319", "plainTextFormattedCitation" : "7,16\u201319", "previouslyFormattedCitation" : "^7,16\u201319" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }7,16–19 and the studies too under-powered to detect important associations as statistically significantADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISBN" : "0033-3174", "ISSN" : "0033-3174", "PMID" : "4803347", "abstract" : "Investigated the relationship between mode of coping with preoperative stress and recovery from surgery. 59 preoperative surgical patients were interviewed and classified into 3 groups based on the kind of coping behavior they exhibited: avoidance (n = 13), vigilance (n = 10), or both (n = 36). Subjects also completed the Sentence Completion Test, S. Epstein and W. D. Fenz's modified Repression-Sensitization scale, and the Schedule of Recent Experience. Results show that the vigilant group had the most complicated postoperative recovery, although only 2 recovery variables (days in hospital and minor complications) were significant (p < .01). Coping dispositions, anxiety, and life stress showed no clear relationships with recovery. (37 ref.) ((c) 1999 APA/PsycINFO, all rights reserved)", "author" : [ { "dropping-particle" : "", "family" : "Cohen", "given" : "F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lazarus", "given" : "R S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Psychosomatic medicine", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "1973" ] ] }, "page" : "375-389", "title" : "Active coping processes, coping dispositions, and recovery from surgery.", "type" : "article-journal", "volume" : "35" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "ISBN" : "0160-7715 (Print)\\n0160-7715 (Linking)", "ISSN" : "0160-7715", "PMID" : "7441729", "abstract" : "This study evaluated the effects of several psychological factors on postsurgical recovery while controlling for and also evaluating the effects of the physical trauma induced by the surgery. Subjects were 38 patients (18 males and 20 females) who were scheduled to have four third molars surgically removed. The psychological factors measured included anxiety and expectations about recovery, trait anxiety, coping behaviors, and health locus of control. Surgical trauma was rated after surgery, and the following aspects of recovery were monitored: postoperative pain, interference with normal function, swelling, and healing. Poorer postoperative recovery was significantly predicted by each of the psychological variables and by higher levels of surgical trauma. In addition, the effects of the psychological variables on recovery were shown to be largely independent of the trauma effects. The data suggest that (a) future studies which give patients more positive expectations and reduce their anxiety about recovery may improve their recovery and (b) the types of patients most in need of preoperative psychological support would be those who have higher trait anxiety, vigilant coping behaviors, or an internal locus of control.", "author" : [ { "dropping-particle" : "", "family" : "George", "given" : "J M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Scott", "given" : "D S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Turner", "given" : "S P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gregg", "given" : "J M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "J Behav Med", "id" : "ITEM-2", "issue" : "3", "issued" : { "date-parts" : [ [ "1980" ] ] }, "page" : "291-310", "title" : "The effects of psychological factors and physical trauma on recovery from oral surgery", "type" : "article-journal", "volume" : "3" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "DOI" : "", "ISBN" : "0033-3174", "ISSN" : "0033-3174", "PMID" : "3387507", "abstract" : "The aim was to determine the effects of stress on immune status and surgical outcome in 24 healthy men undergoing hernia repair. Stressful life events over the prior 6 mo and social support was assessed at time of admission. Physiological response to a cold pressor test was measured the day before surgery. Lymphocyte blastogenesis and neutrophil chemotaxis were measured before and 3 and 30 days after surgery in patients and controls. Surgical outcomes were assessed by length of stay, narcotics used, and complications. Data were analyzed in 2 x 2 factorial designs for multivariate analysis of covariance where one factor was life stress and the other was response to the cold pressor. Age and social support were covaried in comparing immune responses before surgery. High responders to life stress had significantly less response to PHA, and high responders to cold pressor stress had lower PWM responses. With preoperative immune status covaried, high responders to cold pressor stress had significantly lower PWM response after surgery, indicating some T-B cell interaction defect and more narcotics and complications. Data suggest that high psychological and physiological stress responses before surgery (that is itself an additional psychophysiologic stressor) lead to poorer outcomes even in otherwise healthy men undergoing relatively simple elective surgical procedures.", "author" : [ { "dropping-particle" : "", "family" : "Linn", "given" : "Bernard S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Linn", "given" : "Margaret W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Klimas", "given" : "Nancy G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Psychosomatic Medicine", "id" : "ITEM-3", "issued" : { "date-parts" : [ [ "1988" ] ] }, "page" : "230-244", "title" : "Effects of Psychophysical Stress on Surgical Outcome", "type" : "article-journal", "volume" : "50" }, "uris" : [ "" ] }, { "id" : "ITEM-4", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Contrada", "given" : "Richard", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Goyal", "given" : "Tanya M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cather", "given" : "Corinne", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rafalson", "given" : "Luba", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Idler", "given" : "Ellen L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Krause", "given" : "Tyrone J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Health Psychology", "id" : "ITEM-4", "issue" : "3", "issued" : { "date-parts" : [ [ "2004" ] ] }, "page" : "227-238", "title" : "Psychosocial Factors in Outcomes of Heart Surgery: The Impact of Religious Involvement and Depressive Symptoms", "type" : "article-journal", "volume" : "23" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "^20\u201323", "plainTextFormattedCitation" : "20\u201323", "previouslyFormattedCitation" : "^20\u201323" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }20–23. The associated increase in wound-related readmissions and length of stay is especially large when considering the implications of the finding at a population level. Furthermore, the findings were consistent with recent evidence focusing on non-cardiac surgery that found anxiolytic users were more likely to develop a surgical wound complication after a broad range of general, vascular, urological and plastic surgery proceduresADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.surg.2015.03.050", "ISSN" : "0039-6060", "author" : [ { "dropping-particle" : "", "family" : "Ward", "given" : "Nicholas", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Roth", "given" : "J Scott", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lester", "given" : "Clark C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mutiso", "given" : "Lori", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Surgery", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2015" ] ] }, "page" : "420-427", "publisher" : "Elsevier Inc.", "title" : "Anxiolytic medication is an independent risk factor for 30-day morbidity or mortality after surgery", "type" : "article-journal", "volume" : "158" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "¹¹", "plainTextFormattedCitation" : "11", "previouslyFormattedCitation" : "¹¹" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }11.Unlike past studies, we were able to exploit individual information on a large, national sample of patients. This allowed us to adjust for a wide range of confounding factors without losing the statistical power needed to identify significant associations. Whilst we were unable to adjust for every potential confounding factor associated with the complex wound healing process (including exercise, wound severity, complications during surgery, quality of care after discharge, use of medication, and education), the combined use of PROMs and HES allowed us to adjust for numerous factors overlooked by previous studies including EQ-5D scores, health behaviours, and comorbidityADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.jpsychores.2009.04.002", "ISBN" : "1879-1360 (Electronic)\\n0022-3999 (Linking)", "ISSN" : "00223999", "PMID" : "19686881", "abstract" : "Objective: The current review aims to synthesize existing knowledge about the relationship between psychological stress and wound healing. Methods: A systematic search strategy was conducted using electronic databases to search for published articles up to the end of October 2007. The reference lists of retrieved articles were inspected for further studies and citation searches were conducted. In addition, a meta-analysis of a subset of studies was conducted to provide a quantitative estimation of the influence of stress on wound healing. Results: Twenty-two papers met the inclusion criteria of the systematic review and a subsample of 11 was included in a meta-analysis. The studies assessed the impact of stress on the healing of a variety of wound types in different contexts, including acute and chronic clinical wounds, experimentally created punch biopsy and blister wounds, and minor damage to the skin caused by tape stripping. Seventeen studies in the systematic review reported that stress was associated with impaired healing or dysregulation of a biomarker related to wound healing. The relationship between stress and wound healing estimated by the meta-analysis was r=-0.42 (95% CI=-0.51 to -0.32) (P<.01). Conclusion: Attention now needs to be directed towards investigating potential moderators of the relationship, mediating mechanisms underpinning the association, as well as the demonstration of a causal link by the development of experimental interventions in healthy populations. ?? 2009 Elsevier Inc. All rights reserved.", "author" : [ { "dropping-particle" : "", "family" : "Walburn", "given" : "Jessica", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vedhara", "given" : "Kavita", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hankins", "given" : "Matthew", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rixon", "given" : "Lorna", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Weinman", "given" : "John", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Psychosomatic Research", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2009" ] ] }, "page" : "253-271", "publisher" : "Elsevier Inc.", "title" : "Psychological stress and wound healing in humans: A systematic review and meta-analysis", "type" : "article-journal", "volume" : "67" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "⁸", "plainTextFormattedCitation" : "8", "previouslyFormattedCitation" : "⁸" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }8. Large administrative datasets such as HES, however, may have contained incomplete information on patient conditions if hospitals did not report the required information for coding. As a result, our estimates may have only partly adjusted for obesity, smoking use, alcohol use, nutritional deficiencies, and sleep disorders. Adjustment for each hospital-reported condition had a little or no effect on the estimated association between anxiety and/or depression and outcomes after surgery when already adjusting for information in PROMs, however. As with the majority of health questionnaires, PROMs data was not available for all eligible patients identified in HES. There exist three main reasons as to why information on PROMs may have been missing: (i) patients may have chosen to opt out of the survey; (ii) the hospital may have failed to administer the preoperative questionnaire; or (ii) the required information may have been insufficient to link the PROMs record to the HES episodeADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1002/hec", "ISBN" : "1099-1050; 1057-9230", "ISSN" : "1099-1050", "PMID" : "19816948", "author" : [ { "dropping-particle" : "", "family" : "Gomes", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gutacker", "given" : "N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bojke", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Street", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Health economics", "id" : "ITEM-1", "issue" : "11", "issued" : { "date-parts" : [ [ "2015" ] ] }, "page" : "1300-1317", "title" : "Addressing missing data in Patient-Reported Outcome Measures (PROMS): Implications for the use of PROMS for comparing provider performance", "type" : "article-journal", "volume" : "19" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "²⁴", "plainTextFormattedCitation" : "24" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }24. To reduce missingness, we assumed that patients responding ‘yes’ to any of the four postoperative complications in PROMs (wound, bleeding, allergy, and urinary) did not experience other problems if they left these answers blankADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1002/bjs.8830", "author" : [ { "dropping-particle" : "", "family" : "Grosse Frie", "given" : "K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Meulen", "given" : "J", "non-dropping-particle" : "van der", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Black", "given" : "N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "British Journal of Surgery", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2012" ] ] }, "page" : "1156-1163", "title" : "Relationship between patients \u2019 reports of complications and symptoms , disability and quality of life after surgery", "type" : "article-journal", "volume" : "99" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "¹⁴", "plainTextFormattedCitation" : "14", "previouslyFormattedCitation" : "¹⁴" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }14. Irrespective to this, however, results may have not been representative of the population if responders differed from non-responders in terms of unadjusted factors correlated with anxiety and/or depression and the outcome of interestADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1002/hec", "ISBN" : "1099-1050; 1057-9230", "ISSN" : "1099-1050", "PMID" : "19816948", "author" : [ { "dropping-particle" : "", "family" : "Gomes", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gutacker", "given" : "N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bojke", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Street", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Health economics", "id" : "ITEM-1", "issue" : "11", "issued" : { "date-parts" : [ [ "2015" ] ] }, "page" : "1300-1317", "title" : "Addressing missing data in Patient-Reported Outcome Measures (PROMS): Implications for the use of PROMS for comparing provider performance", "type" : "article-journal", "volume" : "19" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "²⁴", "plainTextFormattedCitation" : "24", "previouslyFormattedCitation" : "²⁴" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }24. Re-estimation of the association between hospital-recorded anxiety or depression and hospital-reported outcomes using the full eligible sample allowed us to investigate the potential direction of any response bias. The magnitude of the association between anxiety and/or depression on outcomes after surgery was larger or the same for the sample of non-responding patients suggesting a downward or no response bias. Either way, this is supportive of our findings, suggesting that observed associations would persist for the full population.Patients suffering from depression or anxiety may have been more likely to report complications regardless of the surgical outcome, inflating the estimated associations. Contradictory to this, we found a significant association of anxiety and/or depression with readmissions recorded by hospitals as related to surgical wounds. Furthermore, consideration of the other patient reported complication indicators revealed no impact of psychological health on allergy or drug reaction problems, as would be clinically expected. More so, the fact that associations increased incrementally with levels of problems with anxiety or depression gives further weight to the findings.Hospital recorded anxiety or depression may have arisen as a consequence of the postoperative wound complication thereby inflating the estimated associations. Utilising PROMs data allowed us to measure patients’ psychological health prior to surgery and overcome this issue. Additionally, patient-reported outcomes were recorded 3 to 6 months after surgery. This allowed us to also capture complications that developed after discharge from hospital. However, we were only able to identify whether a patient developed a wound problem and not when it developed nor the nature of the problem. Furthermore, our findings are based on information from 2009/10 and 2010/11. Future work should investigate if the observed associations between preoperative depression and/or anxiety and wound outcomes still exist.In summary, these results highlight a relationship between psychological health and adverse wound outcomes after surgery. This relationship warrants further exploration in order to understand the mechanisms and opportunities for intervention. The study also emphasises the importance of psychological state of the patient prior to surgery. Only 8.0% of patients reporting extreme problems with anxiety or depression were recorded with a psychological disorder diagnosis by the hospital, highlighting the common concern that psychological disorders are often overlooked in surgeryADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISBN" : "9780957583115", "abstract" : "There is compelling evidence that people with mental illness or a learning disablity die earlier than the general population. This says something of course not only about the services available to support these problems, but also how we as a society, treat people with mental illness or a learning disability. This must change.", "author" : [ { "dropping-particle" : "", "family" : "British Medical Association", "given" : "", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issue" : "May", "issued" : { "date-parts" : [ [ "2014" ] ] }, "title" : "Recognising the importance of physical health in mental health and intellectual disability. Acheiving parity of outcomes", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "²⁵", "plainTextFormattedCitation" : "25", "previouslyFormattedCitation" : "²⁵" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }25. Our findings emphasise the importance of a holistic preoperative assessment that addresses psychological as well as physical health, given the significant impact of anxiety/depression on wound-related readmissions and complications. The delivery of more holistic care that integrates both physical and mental aspects of healthcare services may help reduce the incidence of wound complicationsADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISBN" : "9780957583115", "abstract" : "There is compelling evidence that people with mental illness or a learning disablity die earlier than the general population. This says something of course not only about the services available to support these problems, but also how we as a society, treat people with mental illness or a learning disability. This must change.", "author" : [ { "dropping-particle" : "", "family" : "British Medical Association", "given" : "", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issue" : "May", "issued" : { "date-parts" : [ [ "2014" ] ] }, "title" : "Recognising the importance of physical health in mental health and intellectual disability. Acheiving parity of outcomes", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "²⁵", "plainTextFormattedCitation" : "25", "previouslyFormattedCitation" : "²⁵" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }25.Table 1 Descriptive statistics of surgical outcomes and psychological factors by procedure group?Hip ReplacementKnee ReplacementHernia RepairVaricose Vein Surgery?n%n%n%n%Patient-Reported Outcomes Wound complication56059.4771612.0422611.0218914.6 Other complications Bleeding32605.542986.721635.6201213.5 Allergy or reaction638010.7789912.315444.04413.0 Urinary716812.1696410.931328.22181.5Hospital-Reported Outcomes Wound complication2910.53060.5100.010.0 Wound-related readmission2400.44000.61070.3370.2 Length of stay (days) Day case570.1830.12635568.81317788.2 12000.31910.31005726.2160110.7 225524.322093.411763.11180.8 31036517.41129017.63330.9320.2 41361322.91562124.41530.450.0 51100618.51186018.5740.250.0 6701811.8763211.9380.120.0 7 or more1459924.61525923.81420.440.0Psychological Factors Previously diagnosed depression40736.948487.615954.210016.7 Problems with anxiety or depression None3408257.43993362.33231684.31173278.5 Moderate2238737.72174833.9565814.8292519.6 Extreme29415.024643.83540.92871.9 Hospital recorded anxiety or depression10861.812872.03260.91431.0Estimation sample59410?64145?38328?14944??Table 2 Alternative measures of psychological health?Previously diagnosed depression?Hospital recorded anxiety or depression?n%?n%Problems with anxiety or depression????? None14171.26800.6 Moderate771014.616783.2 Extreme239039.5?4848.0?Table 3 Association between psychological factors and wound complications after surgery?Patient-Reported Wound Complicationn%RawAdjusted?Odds ratioCI?Odds ratioCIHip ReplacementPreviously diagnosed depression???????? No50409.11.001.00 Yes56513.91.61(1.47 1.76)1.36(1.24 1.50)Problems with anxiety or depression None28418.31.001.00 Moderate239310.71.32(1.25 1.39)1.17(1.11 1.24) Extreme37112.61.59(1.41 1.79)1.26(1.10 1.43)Hospital recorded anxiety or depression None54639.41.001.00 Any14213.1?1.46(1.21 1.75)1.32(1.10 1.59)Knee ReplacementPreviously diagnosed depression???????? No689711.61.001.00 Yes81916.91.54(1.42 1.68)1.28(1.17 1.40)Problems with anxiety or depression None435310.91.001.00 Moderate294713.61.28(1.22 1.35)1.13(1.06 1.19) Extreme41616.91.66(1.47 1.88)1.27(1.12 1.45)Hospital recorded anxiety or depression None751612.01.001.00 Any20015.5?1.35(1.15 1.59)?1.24(1.05 1.45)Inigual Hernia RepairPreviously diagnosed depression???????? No396610.81.001.00 Yes26016.31.61(1.41 1.84)1.34(1.16 1.55)Problems with anxiety or depression None336510.41.001.00 Moderate79014.01.40(1.29 1.52)1.20(1.10 1.30) Extreme7120.12.16(1.67 2.78)1.66(1.27 2.17)Hospital recorded anxiety or depression None417711.01.001.00 Any4915.0?1.43(1.07 1.91)1.29(0.98 1.71)Varicose Vein ProcedurePreviously diagnosed depression???????? No199314.31.001.00 Yes19619.61.46(1.25 1.70)1.27(1.08 1.51)Problems with anxiety or depression None161113.71.001.00 Moderate51017.41.33(1.19 1.49)1.21(1.07 1.36) Extreme6823.71.95(1.55 2.46)1.68(1.25 2.26)Hospital recorded anxiety or depression None216114.61.001.00 Any2819.6?1.42(0.94 2.16)?1.13(0.71 1.79)Unadjusted odds ratios are shown for raw model.Adjusted odds ratios are shown for adjusted model.Values in parentheses are 95 per cent confidence intervals. Estimation sample: hip replacement (59410), knee replacement (64145), hernia repair (38328), varicose vein surgery (14994)Table 4 Influence of psychological health on hospital-reported outcomes after surgery?Hospital-Reported OutcomesWound DiagnosisWound ReadmissionLength of stayORCI?ORCI?Coef.CIAll ProceduresPreviously diagnosed depression???????? No1.001.00 Yes0.96(0.69 1.33)1.37(1.11 1.69)0.23(0.14 0.32)Problems with anxiety or depression None1.001.00 Moderate1.14(0.96 1.36)1.20(1.02 1.41)0.19(0.15 0.24) Extreme1.18(0.86 1.63)1.30(0.92 1.84)0.49(0.33 0.65)Hospital recorded anxiety or depression None1.001.00 Any0.92(0.50 1.73)1.08(0.66 1.78)?0.44(0.25 0.62)Adjusted odds ratios are shown.Coefficients are change in days.Values in parentheses are 95 per cent confidence intervals.Estimation sample: 176 827 patientsTable 5 Influence of psychological health on other patient-reported outcomes after surgery?Other Patient-Reported ComplicationBleedingAllergyUrineORCI?ORCI?ORCIHip ReplacementPreviously diagnosed depression???????? No1.001.001.00 Yes1.26(1.12 1.41)1.01(0.91 1.12)1.34(1.22 1.47)Problems with anxiety or depression None1.001.001.00 Moderate1.14(1.05 1.24)1.09(1.04 1.16)1.21(1.15 1.28) Extreme1.21(1.04 1.41)1.25(1.11 1.41)1.48(1.31 1.67)Hospital recorded anxiety or depression None1.001.001.00 Any1.32(1.06 1.64)?1.11(0.91 1.37)?1.50(1.26 1.78)Knee ReplacementPreviously diagnosed depression???????? No1.001.001.00 Yes1.14(1.01 1.28)0.98(0.89 1.07)1.17(1.06 1.29)Problems with anxiety or depression None1.001.001.00 Moderate1.08(1.01 1.16)1.13(1.08 1.18)1.14(1.08 1.21) Extreme1.11(0.94 1.30)1.21(1.06 1.39)1.25(1.09 1.42)Hospital recorded anxiety or depression None1.001.001.00 Any0.89(0.73 1.10)?0.91(0.77 1.08)?1.28(1.07 1.53)Inigual Hernia RepairPreviously diagnosed depression???????? No1.001.001.00 Yes1.43(1.19 1.71)1.29(1.03 1.60)1.67(1.44 1.95)Problems with anxiety or depression None1.001.001.00 Moderate1.19(1.07 1.33)1.38(1.20 1.60)1.51(1.38 1.66) Extreme1.46(1.00 2.14)1.63(1.02 2.61)1.44(1.04 2.02)Hospital recorded anxiety or depression None1.001.001.00 Any1.37(0.92 2.03)?1.01(0.58 1.76)?1.40(1.02 1.92)Varicose Vein ProcedurePreviously diagnosed depression???????? No1.001.001.00 Yes1.43(1.18 1.73)0.58(0.36 0.92)1.51(0.94 2.41)Problems with anxiety or depression None1.001.001.00 Moderate1.28(1.12 1.47)1.13(0.89 1.44)1.63(1.23 2.17) Extreme1.25(0.88 1.78)1.20(0.70 2.07)2.08(0.79 5.47)Hospital recorded anxiety or depression None1.001.001.00 Any1.09(0.66 1.79)?0.20(0.026 1.46)?0.50(0.095 2.65)Adjusted odds ratios are shown for adjusted model.Values in parentheses are 95 per cent confidence intervals. Estimation sample: hip replacement (59410), knee replacement (64145), hernia repair (38328), varicose vein surgery (14994)ReferencesADDIN Mendeley Bibliography CSL_BIBLIOGRAPHY 1 Health and Social Care Information Centre (HSCIC). National Statistics Hospital Episode Statistics, Admitted Patient Care - England, 2014-15. 2015. 2 National Institute for Health and Care Excellence. Surgical site infections: prevention and treatment. NICE Guid. 2008. 3 Whitehouse JD, Friedman ND, Kirkland KB, Richardson WJ, Sexton DJ. The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost. Infect Control Hosp Epidemiol. 2002; 23: 183–189. 4 Cullum N, Buckley H, Dumville J, Hall J, Lamb K, Madden M, et al. Wounds research for patient benefit: a five year programme of research. NIHR J Libr. Press. 5 Buggy D. Can anaesthetic management influence surgical-wound healing? 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Psychosocial Factors in Outcomes of Heart Surgery: The Impact of Religious Involvement and Depressive Symptoms. Heal Psychol. 2004; 23: 227–238. 24 Gomes M, Gutacker N, Bojke C, Street A. Addressing missing data in Patient-Reported Outcome Measures (PROMS): Implications for the use of PROMS for comparing provider performance. Health Econ. 2015; 19: 1300–1317. 25 British Medical Association. Recognising the importance of physical health in mental health and intellectual disability. Acheiving parity of outcomes. 2014. ................
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