Veterans Enhanced Recovery Using Integrative Treatments Around Surgery

Pain and Pain Interference assessed among patients using the Defense veterans pain rating scale 2.0

The Defense and Veterans Pain Rating Scale 2.0 utilizes a numerical rating scale enhanced by functional word descriptors, color coding, and pictorial facial expressions matched to pain levels. Four supplemental questions measure how much pain: a) interferes with usual activity, b) interferes with sleep, c) affects mood and d) contributes to stress. The scale for each assessment ranges from 0-10. Three assessments will occur each day. The daily average values will be compared at each time point. Higher Scores represent worse outcomes.

Heart Rate Variability among Patients as assessed using time and frequency domain analysis of the heart rate.

Heart rate variability represents the change in the time interval in milliseconds between successive heartbeats. It is a measure of input to the heart from both sympathetic and parasympathetic branches of the nervous system. Increased heart rate variability is the better outcome.

Implementation of Treatment among Patients as assessed by the Acceptability of Intervention, Appropriateness of Intervention, and Feasibility of Intervention Measures.

The Acceptability of Intervention measure, Appropriateness of Intervention measure, and Feasibility of Intervention Measure will be used. Each of these three tools is a 4-item questionnaire that has been validated as a distinct and strong measure of implementation success. Scale values for each measure range from 1-5. The average of the three measures will be computed and compared at each time point. Higher scores represent better outcomes.

Fidelity of Treatment among Patients as assessed by a Fidelity Checklist

Fidelity, the degree to which an intervention was implemented as it was intended by the developers, will be measured using a fidelity instrument with three domains: adherence (adherence to each component of treatment, scale 1- 5), participant responsiveness (measured on the treatment expectation questionnaire scale 0-10), and dosage (scale 1-5). Higher scores are better. We will compare the average scores overall, and in each domain.

Amount of Opioid medication received by patients assessed in average daily oral morphine equivalents.

The amount of opioid analgesic medications received by patients as recorded in the electronic health record (inpatient setting) or as reported by patients (outpatient setting) will be summarized each day and reported in daily oral morphine equivalents. The total amount from postoperative day 0 to day 5, and the average daily oral morphine equivalents will be measured for comparisons. Higher amounts represent worse outcomes.

Quality of Recovery among patients as measured using the Quality-of-Recovery 40 tool.

The Quality-of-Recovery 40 tool is a 40-item questionnaire, with each question graded on a five-point Likert scale. Scores range from 40 (extremely poor quality of recovery) to 200 (excellent quality of recovery). Assessment will occur preoperatively on the day of surgery (baseline value) and each day from Postoperative Day 0 to 5. The difference between the baseline and the value each day will be compared.