Psychosocial factors influencing the outcomes after major anatomical lung resections: a retrospective analysis of prospectively collected data

Introduction

The length of stay (LOS) in hospital is regularly investigated and displayed in most surgical and medical studies as a measure of quality of care. In surgical specialties, postoperative LOS represents a surrogate of procedural efficacy and safety, and most studies use it to compare operations or techniques demonstrating their superiority. However, the vast majority of studies take into consideration and investigate clinical factors, such as patients’ comorbidities and functional status, which might impair the postoperative course prolonging the LOS. Postoperative complications are intuitively and uniformly accepted as having a strong influence on LOS even in case of non-severe ones (1). Major efforts are therefore directed toward preventing complications. Recently, in thoracic surgery there has been a widespread application of enhanced recovery after surgery (ERAS) protocols, with publication of guidelines (2) that give recommendations for reducing LOS after lung surgery. These guidelines provide several suggestions to accelerate recovery after lung resection and prevent common complications, addressing the patient journey from referral to discharge. They propose improvements and protocols regarding nutrition, venous thrombosis prophylaxis, surgical technique, pain management and physiotherapy.

The association between psychosocial factors and post-operative outcomes is known, but not often considered in surgical series. Beyond the occurrence of postoperative complications, social support and the psychological background of patients have an impact on recovery and outcomes, and influence the LOS (3).

The aim of our study was to investigate the role of psychosocial factors on LOS after anatomical lung resection. Alongside clinical factors already known to influence hospitalization, adopting a broader perspective that considers individual and societal backgrounds may be valuable. Some insights might be useful to prevent over-occupation of health care facilities and to redistribute resources. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-1974/rc).

Methods

A prospectively maintained database on consecutive, elective anatomical lung resections was retrospectively culled for data on pre-operative, intraoperative and postoperative variables. The outcome of interest was the LOS (days between surgery and discharge from acute hospital). The internal database included data on patients who underwent anatomical lung resection at our institution between January 2020 and December 2023. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Ticino Cantonal Ethical Committee approved the study (No. 2020-01561) and informed consent was obtained from patients. Patients undergoing segmentectomy were excluded because of the limited extent of the resection. Surgeries were performed either using a 3-port thoracoscopic surgery or a muscle-sparing thoracotomy. Indications for oncological resections were discussed at multidisciplinary meetings. All patients received standard postoperative care including an electronic chest drain system, patient-controlled analgesia, nutritional support, thromboembolic prophylaxis, early mobilization and physiotherapy. Collected data included age, sex, body mass index (BMI), smoking status, Eastern Cooperative Oncology Group performance status (PS), forced expiratory volume in 1 second (FEV1), diffusion capacity of the lungs for carbon monoxide (DLCO), cardiovascular and metabolic comorbidities, surgical approach (as actual technique used), extent of resection (lobectomy, bilobectomy, pneumonectomy), histology. The following major cardiopulmonary complications were recorded: pneumonia, respiratory failure requiring at least 24 hours of mechanical ventilation, atelectasis requiring bronchoscopy, adult respiratory distress syndrome, acute myocardial ischemia, atrial fibrillation requiring medical therapy or electric cardioversion, pulmonary embolism, pulmonary edema, and stroke. These were defined according to the joint Society of Thoracic Surgeons (STS)-European Society of Thoracic Surgeons (ESTS) definitions (4). Additional complications including surgical and minor complications classified according to the Thoracic Morbidity and Mortality classification system (5) were also recorded.

Additionally, three psychosocial variables were included: “living alone”, “pre-operative stress”, and “hobbies and interests”. These data were routinely collected by ward nurses at admission with the aim to investigate mood and attitude, social support and socio-cultural background. The variable “living alone” was recorded as a binary parameter (living alone vs. living with at least one other person). Regarding psychological status, nurses received specific training supported by professional psychologists and social workers to investigate depression, anxiety, anger, worry and hostility. Each positive item was then summarized and recorded as a binary variable (“pre-operative stress”: yes/no). This psychological questionnaire is internally validated and approved across the seven sites of the Tessin Regional Hospital. An English version of the questionnaire is available as Appendix 1. The variable “hobbies and interest” was recorded as a free text, where nurses recorded patients’ extracurricular recreational activities including sports. For the purpose of the study, this item was then transformed into a binary variable.

Statistical analysis

The database was screened for missing data. Being a prospectively collected clinical database, data completeness was ensured, with the least complete variable being 98.8% of values. Normal distribution of continuous variables was tested by Shapiro-Wilk test (all continuous variables including LOS showed a skewed distribution). Variables were initially screened by univariable analysis to test their association with LOS. Mann-Whitney U test was used for two-group comparison and Spearman’s correlation was used to assess the relationship between continuous variables.

Variables with P<0.1 at univariable analysis were included as independent predictors in a multiple regression analysis (dependent variable: LOS). Subgroup analyses using the same tests were performed based on the presence of ≥1 complication.

All statistical analyses were performed using STATA software (StataCorp. 2017. Stata Statistical Software: Release 15. College Station, TX: StataCorp LLC).

Results

We included 193 patients in the analysis. Table 1 describes the general characteristics of the study population.

Median age [interquartile range (IQR)] was 69.4 [63.4–74.9] years. Most patients were current (44.0%) or former (39.9%) smokers. Sixty-four patients (33.2%) had a PS ≥1. Most of the procedures were lobectomies (n=185, 95.9%), followed by bilobectomies (n=6, 3.1%) and pneumonectomies (n=2, 0.5%). The most common surgical approach was video-assisted thoracoscopic surgery (VATS) (n=136, 70.5%), with a conversion rate of 23.5%. Therefore, thoracotomy was performed in 89 (46.1%) cases. A total of 34 (17.6%) patients experienced at least one cardiopulmonary complication, whereas the overall number of patients with complications, including minor ones, was 67 (34.7%). Most patients (n=175, 91%) were discharged home, while 18 (9%) were transferred to rehabilitation clinics. No patients were discharged to subacute care hospitals. Median LOS was 6 [4–9] days. 30-day mortality rate was 3%. Regarding the psychosocial factors collected, 36 (18.6%) patients lived alone, 51 (27.1%) had at least one positive item on the psychological questionnaire and 95 (49.5%) declared to have hobbies or cultural interests.

Univariable analysis showed a relationship between LOS and several clinical factors such as age, FEV1, DLCO, PS and thoracotomy approach. Additionally, intercostal tube duration and complications strongly influenced the outcome. Moreover, living alone and preoperative stress were associated with longer LOS. Table 2 shows the results of the univariable analysis.

Multiple regression analysis showed that reduced FEV1, higher PS status, intercostal tube duration, the presence of any complication and living alone were statistically significant predictors of LOS, F (9, 115) =7.39, P<0.001, R²=0.51. All five variables contributed significantly to the prediction, P<0.05. Table 3 displays the results of the analysis for the entire study population. Figure 1 represents the difference in LOS between patients who live alone versus those who live with others.

Figure 1 Box plot of LOS in patients who live alone versus patients who live together at least with one person in regards of the whole population. IQR, interquartile range; LOS, length of stay.

Subgroup analyses

A second set of analyses was performed based on the presence of any complication during the postoperative phase. In our population, LOS in patients who experienced complications was influenced only by FEV1 with a linear correlation [F (3, 53) =4.69, P=0.005, R²=0.20]. For the subgroup of patients with an uneventful postoperative course, higher PS, intercostal tube duration, thoracotomy approach, living alone and preoperative stress were statistically significant predictors of LOS, F (9, 74) =12.43, P<0.001, R²=0.60. All five variables contributed significantly to the prediction, P<0.05. Table 4 displays the results of the multiple regression analysis for the non-complicated group.

Figure 2 graphically illustrates the difference in LOS between patients who live alone versus those who live with others in the non-complicated group.

Figure 2 Box plot of LOS in patients who live alone versus patients who live together at least with one person in regards of the non-complicated group. IQR, interquartile range; LOS, length of stay.

Discussion

Our study showed how psychosocial factors could prolong LOS after major lung resections. Especially in cases of uneventful postoperative courses, these non-clinical factors may play a significant role in discharge timing.

LOS is constantly analyzed and used as outcome measure in medical and surgical studies, and it is important for several reasons. First, LOS represents a quality metric that provides a surrogate for morbidity and mortality rates (6). Prolonged LOS might increase the awareness for quality improvement initiatives and it has been endorsed by the National Quality Forum. In thoracic surgery, great efforts have been made in trying to identify risk factors associated with longer LOS. Wright at al. analyzed the STS General Thoracic Surgery Database to search for predictors of prolonged LOS in lung cancer patients undergoing lobectomy (7). They developed a risk model that included age, male sex, American Society of Anesthesiology score, insulin-dependent diabetes, renal dysfunction, FEV1 and smoking. A clinical study was performed with the same aim by Hu et al. (8). The authors found that older age, male sex, ratio of residual volume to total lung capacity (RV/TLC) ≥45.0%, more invasive surgical approach, and extent of resection significantly influenced LOS. They also pointed out the second important aspect related to prolonged LOS: the economic burden. It is of great clinical and financial significance to allocate perioperative resources efficiently.

Recently, the widespread adoption of enhanced recovery protocols in thoracic surgery tried to provide pathways and guidelines that resulted in a reduction of postoperative complications and/or LOS (9-12). However, none of the aforementioned studies considered the potential role of non-clinical factors on the length of hospitalization.

Several works have investigated the effect of various social, psychological and cultural factors on surgical outcomes. Anxiety and stress have been found to be associated with postoperative complications and wound healing (13-16), affecting short-term surgical outcomes and recovery (17). The lack of social support and loneliness showed significant effect on LOS in different surgical fields (3). Reduced social support, depression and anxiety contribute to prolong LOS after lumbar surgery and influence discharge destination (18,19). In our study, we found that, along several clinical variables, some psychosocial factors influence LOS after major anatomical lung resection. Functional status, by mean of FEV1 and PS, has an impact on the length of hospitalization in the whole population. Other variables retained in the multiple regression are the presence of any complication, living alone and intercostal tube duration. The latter has a strong correlation with the air-leak duration and it is expression of a certain reluctance by patients and/or surgeons to manage chest drains on an outpatient basis. It might be also linked to the lack of social support: in our experience, patients who live alone are more prone to remain in the hospital if the chest drain cannot be removed.

Experiencing a complication during the postoperative course is surely one of the most important factors in determining LOS (1). This is why we wanted to perform a subgroup analysis based on the presence of any complication. In the group of patients with an uneventful postoperative course, the LOS was influenced by open approach, higher PS, intercostal tube duration, living alone and preoperative stress. Therefore, it is evident that, in the absence of complications, psychosocial factors play a pivotal role in determining the length of hospitalization. While in the complicated group only lower values of FEV1 affected the LOS, likely reflecting a more challenging recovery following an acute event, living alone and experiencing stressful feelings before the operation, played an important role on the perception of patients’ safety.

The results of our study lead to important considerations. LOS is a quality indicator of medical and surgical performance and, more generally, of the care delivered by a unit. However, it should be carefully interpreted, as it may be influenced by non-clinical factors unrelated to quality of medical care or illness severity, and not related to surgical procedures performance. For instance, Hall and colleagues demonstrated that variations in the transfer from acute services to long-term care hospitals has a significant impact on LOS in intensive care units (20). The patient’s discharge destination plays an important role in increased LOS, as discharge planning for facility placement can require more planning and coordination by hospital staff than a discharge directly home (21). The capability to allocate patients to the most appropriate level of care depends on several factors and it is largely variable between different health care systems, regions and hospitals. Moreover, the social support of each individual is also related to cultural factors that might influence the discharge timing. For orthopedic surgery, sex and ethnicity showed an association with LOS and discharge to a rehabilitation facility (22). In our experience, patients with similar clinical characteristics who underwent the same surgical procedures with overlapping clinical outcomes, exhibited a large variability in LOS. This is particularly evident for non-complicated patients who may prefer to remain in hospital “a few more days” to acquire more self-confidence. Individuals who live alone often experience feeling of anxiety and insecurity when discharged after major surgeries. We recorded a substantial difference between median LOS for non-complicated patients who lived alone compared to those who lived with partners or family (8 vs. 5 days).

The availability of rehabilitation structures is another important aspect that should be considered. Patients undergoing lung resection might benefit from an in-hospital rehabilitation program that includes respiratory physiotherapy (23). Thoracic surgery wards delivering high quality of care usually provide a physiotherapy support during the hospital stay; however, this is limited to acute care and does not replace comprehensive rehabilitation. Thus, another highlight from this study is the need for more extensive implementation of long-term and rehabilitation facilities that might help a correct recovery of thoracic surgery patients. In our cohort of patients, discharge to home was far more common than discharge to a rehabilitation facility. It is possible that a greater proportion of patients could benefit from post-acute rehabilitation and experience a shorter LOS if more facilities were available. Investing resources in this area might improve appropriateness of patient allocation and increase the availability and turnover of surgical beds.

The association between LOS and pre-operative stress has been demonstrated in our series within the uncomplicated subgroup: it is undoubtedly true that psychological support is mandatory in certain categories of patients. Most anatomical lung resections are usually performed for malignant diseases and the association between lung cancer surgery and psychological disorders has been demonstrated (24). Moreover, for non-small cell lung cancer, there is an association between marital status and survival in some series, explained by the possible psychological and social support that a spouse could experience within marriage (25). For cancer patients, the relationship between mental status and social support is certainly complex. Guidelines suggest that distress should be recognized, monitored, documented and treated promptly (26). They also identify admission to/discharge from hospital as periods of increased vulnerability (26). Assessment, counseling and support, including adequate reimbursement and insurance coverage, should be implemented at all stages of disease. Experiencing negative feelings before and during the hospital stay might slow down recovery and ultimately impact on outcomes. Psychological support in form of psycho-oncology counselling and pharmaceutical interventions are currently offered at our cancer center to patients with advanced stage disease who undergo multimodality treatments. However, no established interventions are provided to patients with less advanced malignant diseases, or with benign conditions such as infectious diseases or emphysema, which have a different impact on patients’ mental status.

Limitations

This is a retrospective, single-institution study with a relatively limited number of patients. The nature of the analysis carries an inherent bias and it might not be easily extended to other Countries. Moreover, the questionnaire investigating psychological status is only internally validated and might be not widely applicable. Although the questionnaire was designed with reference to several validated tests investigating different aspects of possible psychological status, it does not provide extensive, detailed or semi-quantitative measurements. It is meant to serve as a guide for the nursing staff to highlight potential discomfort during the hospital stay. Future improvements might require a more in-depth analysis of psychological aspects at different time points throughout the clinical journey. However, given these considerations and accounting for cultural and economic differences, all health-care systems worldwide face discharge-related issues and this study can provide an useful trace to improve various aspects of care.

Most evidence on the impact of psychosocial factors on surgical outcomes come from studies performed in orthopedic specialties. To our knowledge, this is the first paper analyzing this aspect of the quality of care in lung resections. Further studies are warranted to better investigate the role of psychosocial elements and potential interventions to mitigate their effect.

Conclusions

In conclusion, our results provide some interesting insights for constructive discussions and interventions. Psychosocial factors might influence the LOS metric, and this should be taken into account when collecting, analyzing and interpreting this metric, keeping in mind that it might not merely correspond to quality of care. Secondly, more attention should be paid by surgeons and healthcare providers in investigating and possibly correcting negative psychological feelings in patients. At the management level, more extensive investments in social support and rehabilitation facilities should be soaked for a more efficient allocation of healthcare resources.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-1974/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-1974/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-1974/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-1974/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ticino Cantonal Ethical Committee, Switzerland (No. 2020-01561) and informed consent was obtained from patients.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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