- Email: [email protected]
Returning to Work Following Minimally Invasive Hysterectomy
COMMENTARY
Returning to Work Following Minimally Invasive Hysterectomy Ari P. Sanders, MD;1,2 Hira Amir, MD;1 Carmen J. Fong, MD;3 Ally Murji, MD, MPH;1 M. Jonathon Solnik, MD1 1 Department of Obstetrics and Gynaecology, Mount Sinai Hospital & Women’s College Hospital, University of Toronto, Toronto, ON 2
Department of Obstetrics and Gynecology, Peter Lougheed Centre, University of Calgary, Calgary, AB
3
Department of Family Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON
A.P. Sanders
Abstract This commentary presents data collected from one patient population and reviews the literature on returning to work following minimally invasive hysterectomy (MIH). Although MIH can reduce postoperative pain, decrease hospital stays, and accelerate return to activities of daily living, it has not consistently translated into a quicker return to work (RTW) for patients. A retrospective case series was performed assessing RTW times of 31 patients following elective MIH at Mount Sinai Hospital in Toronto in 2018. The median RTW time was 21 days. Patients returned to work significantly faster when they were counselled about an expected convalescence of 2 to 4 weeks (median 16 days) compared with a more traditional 4- to 8-week recovery (median 56 days). Surgeon recommendation can strongly affect when a patient returns to work following MIH. Most patients can RTW within 2 to 3 weeks. However, recommendations should be patient-centred and consider job description.
lai avant le retour au travail de 31 patientes qui ont subi une HMI de e au Mount Sinai Hospital a Toronto en 2018. Le de lai planifie tait de 21 jours. Les patientes qui ont moyen du retour au travail e te conseille es au sujet d’une convalescence pre vue de 2 a 4 e es au travail semaines (moyenne de 16 jours) sont retourne es pour une pe riode beaucoup plus rapidement que celles conseille 8 semaines (moyenne de 56 de convalescence traditionnelle de 4 a jours). La recommandation du chirurgien peut avoir une grande la incidence sur le moment auquel une patiente retourne au travail a suite d’une HMI. La plupart des patientes peuvent effectuer un s 2 ou 3 semaines. Cependant, il est indique retour au travail apre es sur la patiente et tiennent que les recommandations soient axe compte de la nature de son travail. © 2019 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
Résumé J Obstet Gynaecol Can 2020;42(1):80−83 sente les donne es recueillies aupre s d’une Ce commentaire pre rature sur le retour population de patientes et passe en revue la litte s une hyste rectomie minimalement invasive (HMI). au travail apre duire la douleur postope ratoire, diminuer la dure e L’HMI peut re le rer le retour aux activite s du quotidien, d’hospitalisation et acce matiquement le retour rapide au travail mais ne permet pas syste tude re trospective de se rie de cas a e tudie le des patientes. Une e Key Words: Laparoscopy, minimally invasive surgery, hysterectomy, return to work, convalescence, recovery Corresponding author: Dr. Ari P. Sanders, Department of Obstetrics and Gynaecology, Mount Sinai Hospital & Women’s College Hospital, University of Toronto, Toronto, ON; Department of Obstetrics and Gynecology, Peter Lougheed Centre, University of Calgary, Calgary, AB. [email protected] Competing interests: The authors declare that they have no competing interests. Each author has indicated that they meet the journal’s requirements for authorship. Received on July 14, 2019
https://doi.org/10.1016/j.jogc.2019.08.007
INTRODUCTION
inimally invasive hysterectomy (MIH) has been shown to reduce postoperative pain, decrease hospital length of stay, and accelerate return to activities of daily living.1 However, this has not consistently translated into a quicker return to work (RTW) for patients following MIH.2,3 Prolonged RTW following surgery can decrease quality of life, decrease patient satisfaction, and increase psychological distress.2 It is also postulated that RTW delays may slow recovery times, increase deconditioning, and increase financial burdens on individuals, employers, and society. Although there are many medical and occupational factors determining RTW timing following MIH, surgeon recommendations and patient expectations likely play a significant role.
M
Accepted on August 6, 2019 Available online on November 27, 2019
80
JANUARY JOGC JANVIER 2020
Currently, much of the counselling we provide to patients regarding postoperative recovery is anecdotal, based on
Returning to Work Following Minimally Invasive Hysterectomy
tradition, and lacking solid evidence. As a result, advice provided to patients can differ significantly from one practitioner to another. A study from the United Kingdom found that following abdominal hysterectomy, recommendations on when to RTW varied from 3 to 12 weeks postoperatively.4 Although similar results have been shown for other gynaecologic procedures, there is limited evidence following MIH. Comparisons are often drawn between laparoscopic hysterectomy and laparoscopic cholecystectomy. General surgeons in the United Kingdom were found to routinely recommend 2 to 3 weeks before returning to work after laparoscopic cholecystectomy.5 In contrast, general practitioners frequently advised 4 to 5 weeks off of work. Given that it is not uncommon for patients to present to a general practitioner during the postoperative period, this discrepancy in recommendations may alter patient expectations, cause confusion, prolong RTW times, and be used as a means to extend sick leave. From this, two important questions arise. First, how long do patients take to RTW following MIH, and second, how long should patients take to RTW following MIH? This commentary seeks to answer both questions through data collected from our own patient population and a review of the literature. HOW LONG DO PATIENTS TAKE TO RETURN TO WORK?
RTW timing following MIH is an area of limited research. Evidence would suggest that there is significant geographic variation in RTW timing, ranging from 3 to 12 weeks following MIH (Table). Furthermore, although some literature shows a significant reduction in RTW timing following MIH versus abdominal hysterectomy,1,6 results are not consistent across all studies.2,3
Given the wide variation in RTW timing, we sought to better understand how long our patients take to RTW following elective MIH. Thirty-one patients between the ages of 32 and 63, employed full-time or part-time, were surveyed retrospectively within 1 year of their surgical date. Procedures were performed between January and September, 2018, at a single academic institution, (Mount Sinai Hospital, Toronto) by one of three experienced gynaecologists with minimally invasive gynaecologic surgery fellowship training. Patients were discharged on the same day as their surgery in 23 of 31 (74%) cases. The longest in-hospital stay was 2 days (one patient). The median time to RTW at any capacity was 21 days (interquartile range [IQR] 14−55 days), and the median time to RTW at full capacity was 27 days (IQR 18−61 days) (Table). Patients were able to RTW by 1 week in 6 of 31 (19%) cases, by 2 weeks in 9 of 31 (29%) cases, and by 4 weeks in 16 of 31 (52%) cases. RTW times ranged from 6 to 246 days. Although limited by retrospective design and small sample size, the RTW times of our patients are consistent with others.3,6 Given significant geographic variations, however, the question remains: When should patients RTW following MIH? HOW LONG SHOULD PATIENTS TAKE TO RETURN TO WORK?
Drawing on comparisons with general surgery, evidence suggests that some patients may be able to RTW as soon as a median of 6 to 10 days following laparoscopic cholecystectomy.7 Our data would suggest that a similar period of convalescence may apply to certain patients following MIH. Increasing evidence also suggests that postoperative RTW
Table. Return to work times following hysterectomy Procedure; return to work time, days Author and reference 10
Year
Country
AH
VH
LH
—
—
2007
United Kingdom
Median 94 (range 23−292)
Garry et al.1
2004
United Kingdom and South Africa
Mean 95 § 60
Mean 70 § 34
Mean 79 § 44
Vonk Noordegraaf et al.2
2014
Netherlands
Median 69 (IQR 56−135)
Median 60 (IQR 22−101)
Median 60 (IQR 22−101)
Brummer et al.6
2009
Finland
Mean 32 § 5
Mean 29 § 8
Mean 22 § 6
Persson and Kjølhede3
2008
Sweden
Mean 34 § 11
Sanders et al. (current study)
2019
Canada
Clayton et al.
—
—
Mean 28 § 15
—
Median 21 (IQR 14−55)
AH: abdominal hysterectomy; IQR: interquartile range; LH: laparoscopic hysterectomy; VH: vaginal hysterectomy.
JANUARY JOGC JANVIER 2020
81
COMMENTARY
timing can be significantly influenced by surgeon recommendation, preoperative counselling, and patient expectations.7−9 Despite this, many of our recommendations remain anecdotal and based on tradition. One factor driving postoperative recommendations is the concern that increased intra-abdominal pressure (IAP) with activity may impair healing. Outlined in a review by Minig et al. on building evidence for postoperative advice,9 this is problematic when discussing MIH for several reasons. First, MIH does not involve large abdominal incisions. Second, IAPs generated during lifting (mean 37.2−69.8 mm Hg) are significantly less than IAPs generated during daily physiologic functions involving a Valsalva manoeuvre or forceful cough (mean 77.1−112.3 mm Hg). Third, IAPs recorded during physiologic activity are far less than IAPs required (>250 mm Hg) to burst surgical wounds. Finally, 90% of wound dehiscence occurs between 4 and 15 days postoperatively. Therefore, activity-based restrictions may not offer significant protection. In fact, it is possible that postoperative activity-based restrictions may impair postoperative recovery through muscle atrophy, worsening fatigue, and generalized deconditioning. Earlier RTW following MIH should be encouraged. Our data are consistent with others3,6 who suggest most patients can RTW within 2 to 4 weeks following MIH. However, RTW times can likely be shortened further through optimization of patient expectations regarding their postoperative recovery. INTERVENTIONS TO SHORTEN RETURN TO WORK TIMING
Perioperative patient education has been shown to improve patient satisfaction, reduce postoperative pain and
psychological distress, and optimize patient expectations around surgery.8 Standardized patient recommendations and improved perioperative patient education may help to shorten RTW times through optimization of patient expectations. In fact, patients counselled on the importance of returning to work have been shown to return more quickly than their counterparts who received no counselling.10 This finding signifies that RTW times may be shortened by simple provision of recommendations, regardless of whether they are standardized. However, standardization of postoperative recommendations can help ensure that patients receive consistent advice across health care providers. This has been shown to shorten convalescence and sick leave further following surgical procedures.7 Additionally, platforms for patient engagement and education may facilitate shorter RTW times following surgery. Vonk Noordegraaf et al. created an eHealth platform for use following gynaecologic surgery that included personalized instructions, information for employers, and online forums for communication with other patients and physicians.8 Their eHealth platform significantly shortened RTW times, improved physical and mental quality of life scores, and decreased pain intensity scores. Our data confirm the significance of patient expectations and the role of surgeon recommendation in RTW times following MIH. Patients returned to work significantly faster when counselled about an expected convalescence of 2 to 4 weeks (median 16 [IQR 7−19.5] days) than when counselled about a more traditional 4- to 8-week recovery (median 56 [IQR 45−99.5] days; U = 17; P < 0.001) (Figure A). Importantly, the median RTW time of the 16
Figure. Median return to work times. Return to work times depicted as medians with interquartile ranges for (A) surgeon recommendation and (B) duties performed at work.
82
JANUARY JOGC JANVIER 2020
Returning to Work Following Minimally Invasive Hysterectomy
patients receiving recommendations to RTW by 2 weeks following their MIH was 16 days, and 14 of 16 (88%) reported this duration of leave to be “about right” or “more than required.” There was no effect of age, employment type, job satisfaction, or household characteristics on RTW timing. Although employer RTW recommendations varied between 1 and 12 weeks, 50% of employers relied on patient reporting of surgeon recommendation to guide sick leave provision. Patients took significantly longer to RTW when jobs involved heavy lifting (median 56 [IQR 22−118] days), compared with those with regular duties (median 18.5 [IQR 10−44.3] days; U = 43.5; P < 0.05) (Figure B). Examples of job roles involving heavy lifting included nurses, daycare workers, and housekeepers. This finding further indicates that recommendations regarding surgical convalescence must consider other patient-specific factors. FINANCIAL IMPLICATIONS
Delayed postoperative recovery can impart substantial costs to patients, employers, and society.7,8 Depending on the type of medical leave coverage, patients often receive a fraction of their total salary, which can result in significant financial challenges in certain scenarios. Meanwhile, sick leave may subject employers to production loss or the need to hire temporary workers. Prolonged surgical convalescence can also have societal implications (e.g., through increased financial stress on an already strained Canadian Employment Insurance Program [EI]). Our survey found that financial coverage was provided through the following means: employer’s medical insurance provider (11 of 31; 35%), banked sick leave days (6 of 31; 19%), EI (5 of 31; 16%), no coverage (5 of 31; 16%), and other means (4 of 31; 13%). Interestingly, those patients who had no financial coverage during their recovery returned to work in a median 25 days after MIH even though 4 of 5 patients received recommendations to RTW at 6 weeks. Conversely, the patients who received coverage through EI returned to work in a median 49 days even though 2 of 5 patients received recommendations to RTW by 2 weeks. This highlights the financial challenges postoperative recovery can place both on individuals with no medical insurance coverage and on EI programs when RTW times are prolonged. Decreasing RTW times by 2 to 4 weeks can
help to relieve significant financial stressors on individuals, employers, and society. CONCLUSION
Shorter RTW times have been associated with increased patient satisfaction, improved quality of life, and decreased postoperative pain scores.8 However, additional prospective studies with cost analyses are required to better understand the effects of shorter RTW times on quality of life and financial outcomes. RTW times can be shortened by optimizing patient expectations through perioperative counselling and preparation, standardized RTW recommendations, and platforms for patient engagement and education.7,8,10 Our data suggest that surgeon recommendation can significantly influence RTW timing following MIH and that most patients can RTW within 2 to 3 weeks of an MIH. Recommendations should be standardized to encourage patients to RTW by 2 to 3 weeks following MIH. However, recommendations should also be patient-centred and consider job description. REFERENCES 1. Garry R, Fountain J, Brown J, et al. EVALUATE hysterectomy trial: a multicentre randomised trial comparing abdominal, vaginal and laparoscopic methods of hysterectomy. Health Technol Assess 2004;8:1–154. 2. Vonk Noordegraaf A, Anema J, Louwerse MD, et al. Prediction of time to return to work after gynaecological surgery: a prospective cohort study in the Netherlands. BJOG 2014;121:487–97. 3. Persson P, Kjølhede P. Factors associated with postoperative recovery after laparoscopic and abdominal hysterectomy. Eur J Obstet Gynecol Reprod Biol 2008;140:108–13. 4. Clayton M, Verow P. Advice given to patients about return to work and driving following surgery. Occup Med (Lond) 2007;57:488–91. 5. Majeed AW, Brown S, Williams N, et al. Variations in medical attitudes to postoperative recovery period. BMJ 1995;311:296. 6. Brummer TH, Jalkanen J, Fraser J, et al. FINHYST 2006−national prospective 1-year survey of 5,279 hysterectomies. Hum Reprod 2009;24:2515–22. 7. Bisgaard T, Klarskov B, Rosenberg J, et al. Factors determining convalescence after uncomplicated laparoscopic cholecystectomy. Arch Surg 2001;136:917–21. 8. Vonk Noordegraaf A, Anema JR, van Mechelen W, et al. A personalised eHealth programme reduces the duration until return to work after gynaecological surgery: results of a multicentre randomised trial. BJOG 2014;121:1127–35. 9. Minig L, Trimble EL, Sarsotti C, et al. Building the evidence base for postoperative and postpartum advice. Obstet Gynecol 2009;114:892–900. 10. Clayton M, Verow P. A retrospective study of return to work following surgery. Occup Med (Lond) 2007;57:525–31.
JANUARY JOGC JANVIER 2020
83
Returning to Work Following Minimally Invasive Hysterectomy Ari P. Sanders, MD;1,2 Hira Amir, MD;1 Carmen J. Fong, MD;3 Ally Murji, MD, MPH;1 M. Jonathon Solnik, MD1 1 Department of Obstetrics and Gynaecology, Mount Sinai Hospital & Women’s College Hospital, University of Toronto, Toronto, ON 2
Department of Obstetrics and Gynecology, Peter Lougheed Centre, University of Calgary, Calgary, AB
3
Department of Family Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON
A.P. Sanders
Abstract This commentary presents data collected from one patient population and reviews the literature on returning to work following minimally invasive hysterectomy (MIH). Although MIH can reduce postoperative pain, decrease hospital stays, and accelerate return to activities of daily living, it has not consistently translated into a quicker return to work (RTW) for patients. A retrospective case series was performed assessing RTW times of 31 patients following elective MIH at Mount Sinai Hospital in Toronto in 2018. The median RTW time was 21 days. Patients returned to work significantly faster when they were counselled about an expected convalescence of 2 to 4 weeks (median 16 days) compared with a more traditional 4- to 8-week recovery (median 56 days). Surgeon recommendation can strongly affect when a patient returns to work following MIH. Most patients can RTW within 2 to 3 weeks. However, recommendations should be patient-centred and consider job description.
lai avant le retour au travail de 31 patientes qui ont subi une HMI de e au Mount Sinai Hospital a Toronto en 2018. Le de lai planifie tait de 21 jours. Les patientes qui ont moyen du retour au travail e te conseille es au sujet d’une convalescence pre vue de 2 a 4 e es au travail semaines (moyenne de 16 jours) sont retourne es pour une pe riode beaucoup plus rapidement que celles conseille 8 semaines (moyenne de 56 de convalescence traditionnelle de 4 a jours). La recommandation du chirurgien peut avoir une grande la incidence sur le moment auquel une patiente retourne au travail a suite d’une HMI. La plupart des patientes peuvent effectuer un s 2 ou 3 semaines. Cependant, il est indique retour au travail apre es sur la patiente et tiennent que les recommandations soient axe compte de la nature de son travail. © 2019 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
Résumé J Obstet Gynaecol Can 2020;42(1):80−83 sente les donne es recueillies aupre s d’une Ce commentaire pre rature sur le retour population de patientes et passe en revue la litte s une hyste rectomie minimalement invasive (HMI). au travail apre duire la douleur postope ratoire, diminuer la dure e L’HMI peut re le rer le retour aux activite s du quotidien, d’hospitalisation et acce matiquement le retour rapide au travail mais ne permet pas syste tude re trospective de se rie de cas a e tudie le des patientes. Une e Key Words: Laparoscopy, minimally invasive surgery, hysterectomy, return to work, convalescence, recovery Corresponding author: Dr. Ari P. Sanders, Department of Obstetrics and Gynaecology, Mount Sinai Hospital & Women’s College Hospital, University of Toronto, Toronto, ON; Department of Obstetrics and Gynecology, Peter Lougheed Centre, University of Calgary, Calgary, AB. [email protected] Competing interests: The authors declare that they have no competing interests. Each author has indicated that they meet the journal’s requirements for authorship. Received on July 14, 2019
https://doi.org/10.1016/j.jogc.2019.08.007
INTRODUCTION
inimally invasive hysterectomy (MIH) has been shown to reduce postoperative pain, decrease hospital length of stay, and accelerate return to activities of daily living.1 However, this has not consistently translated into a quicker return to work (RTW) for patients following MIH.2,3 Prolonged RTW following surgery can decrease quality of life, decrease patient satisfaction, and increase psychological distress.2 It is also postulated that RTW delays may slow recovery times, increase deconditioning, and increase financial burdens on individuals, employers, and society. Although there are many medical and occupational factors determining RTW timing following MIH, surgeon recommendations and patient expectations likely play a significant role.
M
Accepted on August 6, 2019 Available online on November 27, 2019
80
JANUARY JOGC JANVIER 2020
Currently, much of the counselling we provide to patients regarding postoperative recovery is anecdotal, based on
Returning to Work Following Minimally Invasive Hysterectomy
tradition, and lacking solid evidence. As a result, advice provided to patients can differ significantly from one practitioner to another. A study from the United Kingdom found that following abdominal hysterectomy, recommendations on when to RTW varied from 3 to 12 weeks postoperatively.4 Although similar results have been shown for other gynaecologic procedures, there is limited evidence following MIH. Comparisons are often drawn between laparoscopic hysterectomy and laparoscopic cholecystectomy. General surgeons in the United Kingdom were found to routinely recommend 2 to 3 weeks before returning to work after laparoscopic cholecystectomy.5 In contrast, general practitioners frequently advised 4 to 5 weeks off of work. Given that it is not uncommon for patients to present to a general practitioner during the postoperative period, this discrepancy in recommendations may alter patient expectations, cause confusion, prolong RTW times, and be used as a means to extend sick leave. From this, two important questions arise. First, how long do patients take to RTW following MIH, and second, how long should patients take to RTW following MIH? This commentary seeks to answer both questions through data collected from our own patient population and a review of the literature. HOW LONG DO PATIENTS TAKE TO RETURN TO WORK?
RTW timing following MIH is an area of limited research. Evidence would suggest that there is significant geographic variation in RTW timing, ranging from 3 to 12 weeks following MIH (Table). Furthermore, although some literature shows a significant reduction in RTW timing following MIH versus abdominal hysterectomy,1,6 results are not consistent across all studies.2,3
Given the wide variation in RTW timing, we sought to better understand how long our patients take to RTW following elective MIH. Thirty-one patients between the ages of 32 and 63, employed full-time or part-time, were surveyed retrospectively within 1 year of their surgical date. Procedures were performed between January and September, 2018, at a single academic institution, (Mount Sinai Hospital, Toronto) by one of three experienced gynaecologists with minimally invasive gynaecologic surgery fellowship training. Patients were discharged on the same day as their surgery in 23 of 31 (74%) cases. The longest in-hospital stay was 2 days (one patient). The median time to RTW at any capacity was 21 days (interquartile range [IQR] 14−55 days), and the median time to RTW at full capacity was 27 days (IQR 18−61 days) (Table). Patients were able to RTW by 1 week in 6 of 31 (19%) cases, by 2 weeks in 9 of 31 (29%) cases, and by 4 weeks in 16 of 31 (52%) cases. RTW times ranged from 6 to 246 days. Although limited by retrospective design and small sample size, the RTW times of our patients are consistent with others.3,6 Given significant geographic variations, however, the question remains: When should patients RTW following MIH? HOW LONG SHOULD PATIENTS TAKE TO RETURN TO WORK?
Drawing on comparisons with general surgery, evidence suggests that some patients may be able to RTW as soon as a median of 6 to 10 days following laparoscopic cholecystectomy.7 Our data would suggest that a similar period of convalescence may apply to certain patients following MIH. Increasing evidence also suggests that postoperative RTW
Table. Return to work times following hysterectomy Procedure; return to work time, days Author and reference 10
Year
Country
AH
VH
LH
—
—
2007
United Kingdom
Median 94 (range 23−292)
Garry et al.1
2004
United Kingdom and South Africa
Mean 95 § 60
Mean 70 § 34
Mean 79 § 44
Vonk Noordegraaf et al.2
2014
Netherlands
Median 69 (IQR 56−135)
Median 60 (IQR 22−101)
Median 60 (IQR 22−101)
Brummer et al.6
2009
Finland
Mean 32 § 5
Mean 29 § 8
Mean 22 § 6
Persson and Kjølhede3
2008
Sweden
Mean 34 § 11
Sanders et al. (current study)
2019
Canada
Clayton et al.
—
—
Mean 28 § 15
—
Median 21 (IQR 14−55)
AH: abdominal hysterectomy; IQR: interquartile range; LH: laparoscopic hysterectomy; VH: vaginal hysterectomy.
JANUARY JOGC JANVIER 2020
81
COMMENTARY
timing can be significantly influenced by surgeon recommendation, preoperative counselling, and patient expectations.7−9 Despite this, many of our recommendations remain anecdotal and based on tradition. One factor driving postoperative recommendations is the concern that increased intra-abdominal pressure (IAP) with activity may impair healing. Outlined in a review by Minig et al. on building evidence for postoperative advice,9 this is problematic when discussing MIH for several reasons. First, MIH does not involve large abdominal incisions. Second, IAPs generated during lifting (mean 37.2−69.8 mm Hg) are significantly less than IAPs generated during daily physiologic functions involving a Valsalva manoeuvre or forceful cough (mean 77.1−112.3 mm Hg). Third, IAPs recorded during physiologic activity are far less than IAPs required (>250 mm Hg) to burst surgical wounds. Finally, 90% of wound dehiscence occurs between 4 and 15 days postoperatively. Therefore, activity-based restrictions may not offer significant protection. In fact, it is possible that postoperative activity-based restrictions may impair postoperative recovery through muscle atrophy, worsening fatigue, and generalized deconditioning. Earlier RTW following MIH should be encouraged. Our data are consistent with others3,6 who suggest most patients can RTW within 2 to 4 weeks following MIH. However, RTW times can likely be shortened further through optimization of patient expectations regarding their postoperative recovery. INTERVENTIONS TO SHORTEN RETURN TO WORK TIMING
Perioperative patient education has been shown to improve patient satisfaction, reduce postoperative pain and
psychological distress, and optimize patient expectations around surgery.8 Standardized patient recommendations and improved perioperative patient education may help to shorten RTW times through optimization of patient expectations. In fact, patients counselled on the importance of returning to work have been shown to return more quickly than their counterparts who received no counselling.10 This finding signifies that RTW times may be shortened by simple provision of recommendations, regardless of whether they are standardized. However, standardization of postoperative recommendations can help ensure that patients receive consistent advice across health care providers. This has been shown to shorten convalescence and sick leave further following surgical procedures.7 Additionally, platforms for patient engagement and education may facilitate shorter RTW times following surgery. Vonk Noordegraaf et al. created an eHealth platform for use following gynaecologic surgery that included personalized instructions, information for employers, and online forums for communication with other patients and physicians.8 Their eHealth platform significantly shortened RTW times, improved physical and mental quality of life scores, and decreased pain intensity scores. Our data confirm the significance of patient expectations and the role of surgeon recommendation in RTW times following MIH. Patients returned to work significantly faster when counselled about an expected convalescence of 2 to 4 weeks (median 16 [IQR 7−19.5] days) than when counselled about a more traditional 4- to 8-week recovery (median 56 [IQR 45−99.5] days; U = 17; P < 0.001) (Figure A). Importantly, the median RTW time of the 16
Figure. Median return to work times. Return to work times depicted as medians with interquartile ranges for (A) surgeon recommendation and (B) duties performed at work.
82
JANUARY JOGC JANVIER 2020
Returning to Work Following Minimally Invasive Hysterectomy
patients receiving recommendations to RTW by 2 weeks following their MIH was 16 days, and 14 of 16 (88%) reported this duration of leave to be “about right” or “more than required.” There was no effect of age, employment type, job satisfaction, or household characteristics on RTW timing. Although employer RTW recommendations varied between 1 and 12 weeks, 50% of employers relied on patient reporting of surgeon recommendation to guide sick leave provision. Patients took significantly longer to RTW when jobs involved heavy lifting (median 56 [IQR 22−118] days), compared with those with regular duties (median 18.5 [IQR 10−44.3] days; U = 43.5; P < 0.05) (Figure B). Examples of job roles involving heavy lifting included nurses, daycare workers, and housekeepers. This finding further indicates that recommendations regarding surgical convalescence must consider other patient-specific factors. FINANCIAL IMPLICATIONS
Delayed postoperative recovery can impart substantial costs to patients, employers, and society.7,8 Depending on the type of medical leave coverage, patients often receive a fraction of their total salary, which can result in significant financial challenges in certain scenarios. Meanwhile, sick leave may subject employers to production loss or the need to hire temporary workers. Prolonged surgical convalescence can also have societal implications (e.g., through increased financial stress on an already strained Canadian Employment Insurance Program [EI]). Our survey found that financial coverage was provided through the following means: employer’s medical insurance provider (11 of 31; 35%), banked sick leave days (6 of 31; 19%), EI (5 of 31; 16%), no coverage (5 of 31; 16%), and other means (4 of 31; 13%). Interestingly, those patients who had no financial coverage during their recovery returned to work in a median 25 days after MIH even though 4 of 5 patients received recommendations to RTW at 6 weeks. Conversely, the patients who received coverage through EI returned to work in a median 49 days even though 2 of 5 patients received recommendations to RTW by 2 weeks. This highlights the financial challenges postoperative recovery can place both on individuals with no medical insurance coverage and on EI programs when RTW times are prolonged. Decreasing RTW times by 2 to 4 weeks can
help to relieve significant financial stressors on individuals, employers, and society. CONCLUSION
Shorter RTW times have been associated with increased patient satisfaction, improved quality of life, and decreased postoperative pain scores.8 However, additional prospective studies with cost analyses are required to better understand the effects of shorter RTW times on quality of life and financial outcomes. RTW times can be shortened by optimizing patient expectations through perioperative counselling and preparation, standardized RTW recommendations, and platforms for patient engagement and education.7,8,10 Our data suggest that surgeon recommendation can significantly influence RTW timing following MIH and that most patients can RTW within 2 to 3 weeks of an MIH. Recommendations should be standardized to encourage patients to RTW by 2 to 3 weeks following MIH. However, recommendations should also be patient-centred and consider job description. REFERENCES 1. Garry R, Fountain J, Brown J, et al. EVALUATE hysterectomy trial: a multicentre randomised trial comparing abdominal, vaginal and laparoscopic methods of hysterectomy. Health Technol Assess 2004;8:1–154. 2. Vonk Noordegraaf A, Anema J, Louwerse MD, et al. Prediction of time to return to work after gynaecological surgery: a prospective cohort study in the Netherlands. BJOG 2014;121:487–97. 3. Persson P, Kjølhede P. Factors associated with postoperative recovery after laparoscopic and abdominal hysterectomy. Eur J Obstet Gynecol Reprod Biol 2008;140:108–13. 4. Clayton M, Verow P. Advice given to patients about return to work and driving following surgery. Occup Med (Lond) 2007;57:488–91. 5. Majeed AW, Brown S, Williams N, et al. Variations in medical attitudes to postoperative recovery period. BMJ 1995;311:296. 6. Brummer TH, Jalkanen J, Fraser J, et al. FINHYST 2006−national prospective 1-year survey of 5,279 hysterectomies. Hum Reprod 2009;24:2515–22. 7. Bisgaard T, Klarskov B, Rosenberg J, et al. Factors determining convalescence after uncomplicated laparoscopic cholecystectomy. Arch Surg 2001;136:917–21. 8. Vonk Noordegraaf A, Anema JR, van Mechelen W, et al. A personalised eHealth programme reduces the duration until return to work after gynaecological surgery: results of a multicentre randomised trial. BJOG 2014;121:1127–35. 9. Minig L, Trimble EL, Sarsotti C, et al. Building the evidence base for postoperative and postpartum advice. Obstet Gynecol 2009;114:892–900. 10. Clayton M, Verow P. A retrospective study of return to work following surgery. Occup Med (Lond) 2007;57:525–31.
JANUARY JOGC JANVIER 2020
83