Background

The course of a postoperative recovery is important for both patient and healthcare services. Efforts to expedite and improve recovery in a safe and cost-effective manner are therefore highly desirable from the perspective of both parties. Telephone follow-up (TFU) has been suggested as a way to improve postoperative recovery and reduce the burden of the healthcare service. This thesis intends to investigate these issues. The overall purpose of the thesis was twofold: to evaluate the effects of nurse-led TFU contacts on the recovery after benign hysterectomy, and to make a health economic analysis of TFU. The specific aims of the thesis were a) to evaluate whether TFU, particularly when combined with structured-oriented coaching, facilitated postoperative recovery in terms of health-related quality of life (HRQoL), the duration of sick leave, and the occurrence of unplanned telephone contacts (uTCs) and unplanned visits (uVs) in the postoperative period, b) to determine if the TFUs affected postoperative symptoms and the consumption of analgesics, c) to analyze whether symptoms of anxiety and depression, and low stress-coping capacity had an impact on the effect of TFU on recovery and the occurrence of uTCs and uVs, and d) to provide a health economic evaluation of the TFU from the healthcare and societal perspectives. By addressing these aims, the intention of the thesis was to contribute with important knowledge to the existing sparse body of science concerning clinical outcomes after nurse-led TFUs and their impact on recovery outcomes after benign hysterectomy. 

Material and methods

A four-armed, semi-blinded, randomized controlled trial was conducted at the departments of obstetrics and gynecology in five public hospitals in the southeast health region of Sweden from October 2011 to May 2017. The study comprised 487 women between 18 and 60 years old who underwent abdominal or vaginal hysterectomy for benign gynecological conditions. The treatments to be investigated were different nurse-led TFU models and consisted of four groups: Group A had no planned follow-up contact with the healthcare service after discharge (control group); Group B had one planned, structured TFU session with the research nurse (RN) on the day after discharge; Group C had a planned, structured TFU session with the RN on the day after discharge and then once weekly for six weeks; and Group D had a planned, structured, oriented coaching TFU session with the RN on the day after discharge and then once weekly for six weeks. The specific content of the TFUs in Groups B and C, as well as the oriented coaching TFU model in Group D, were outlined in the study. Demographic and clinical data relevant to the study were collected prospectively. Sick leave duration, analgesic consumption, uTC, and uV were recorded from discharge until the six-week follow-up visit with the RN. HRQoL was measured by means of the EuroQoL-5 Dimension with three levels and the Short Form Health Survey with 36 items. Psychological distress was evaluated using the Hospital Anxiety and Depression Scale and the Stress-Coping Inventory. Postoperative symptoms were assessed using the Swedish Postoperative Symptoms Questionnaire. The health economics were evaluated using a cost minimization analysis. The estimation of hospital costs was based on the principles of the Cost Per Patient (CPP) method and the prices from the CPP list for 2022 from the University Hospital in Linköping were applied. 

Results

Regardless of the TFU model, women achieved baseline levels of HRQoL four weeks after surgery and no difference was seen between the intervention groups in the trajectory of recovery of HRQoL. The duration of sick leave was similar across all intervention groups, ranging from 26.8 to 28.1 days. There were no significant differences in the trajectory of the intensity of postoperative symptoms or analgesic consumption between the intervention groups. Approximately 46% of the women had uTC and 45% had uV. The oriented coaching TFU was associated with a 33% lower occurrence of uTC compared with other TFU models. Women who had uTC reported higher levels of pain intensity and sum scores of postoperative symptoms, especially when the uTC was followed by a uV. Symptoms of depression, anxiety, and low stress coping capacity did not affect the effects of the TFU models on recovery trajectories, although there were strong associations between symptoms of anxiety, depression and low stress-coping capacity and all recovery measures. In addition, uTCs were more frequent among women with anxiety. The total costs per patient more than doubled in the groups with repeated TFUs compared with the group with no TFU. The coaching TFU group had lower costs for informal care. 

Conclusions

Nurse-led TFU after benign hysterectomy in the form used in the present study did not expedite or improve the postoperative recovery concerning HRQoL, sick leave duration postoperative symptoms, or analgesic consumption. However, nurse-led TFU with structured coaching reduced the occurrence of uTC to healthcare providers, but not uVs. Symptoms of anxiety increased the occurrence of uTC and pain seemed to be a significant cause of both uTCs and uVs, The effect of the TFU on the recovery did not seem to be affected by the psychological state of proneness to anxiety, depression, or low stress-coping capacity. Nurse-led TFUs were cost-driving for the healthcare systems and can be seen as an inefficient use of healthcare resources.