The Impact of Nonpharmacological Interventions on Patient Experience, Opioid Use, and Health Care Utilization in Adult Cardiac Surgery Patients: Protocol for a Mixed Methods Study
Authors: Brescia Alexander A , Piazza Julie R , Jenkins Jessica N , Heering Lindsay K , Ivacko Alexander J , Piazza James C , Dwyer-White Molly C , Peters Stefanie L , Cepero Jesus , Brown Bailey H , Longi Faraz N , Monaghan Katelyn P , Bauer Frederick W , Kathawate Varun G , Jafri Sara M , Webster Melissa C , Kasperek Amanda M , Garvey Nickole L , Schwenzer Claudia , Wu Xiaoting , Lagisetty Kiran H , Osborne Nicholas H , Waljee Jennifer F , Riba Michelle , Likosky Donald S , Byrnes Mary E , Deeb G Michael 
Published: November 2020

Background
Despite pharmacological treatments, patients undergoing cardiac surgery experience severe anxiety and pain, which adversely affect outcomes. Previous work examining pediatric and nonsurgical adult patients has documented the effectiveness of inexpensive, nonpharmacological techniques to reduce anxiety and pain as well as health care costs and length of hospitalization. However, the impact of nonpharmacological interventions administered by a dedicated comfort coach has not been evaluated in an adult surgical setting.

Objective
This trial aims to assess whether nonpharmacological interventions administered by a trained comfort coach affect patient experience, opioid use, and health care utilization compared with usual care in adult cardiac surgery patients. This study has 3 specific aims: assess the effect of a comfort coach on patient experience, measure differences in inpatient and outpatient opioid use and postoperative health care utilization, and qualitatively evaluate the comfort coach intervention.

Methods
To address these aims, we will perform a prospective, randomized controlled trial of 154 adult cardiac surgery patients at Michigan Medicine. Opioid-naive patients undergoing first-time, elective cardiac surgery via sternotomy will be randomized to undergo targeted interventions from a comfort coach (intervention) versus usual care (control). The individualized comfort coach interventions will be administered at 6 points: preoperative outpatient clinic, preoperative care unit on the day of surgery, extubation, chest tube removal, hospital discharge, and 30-day clinic follow-up. To address aim 1, we will examine the effect of a comfort coach on perioperative anxiety, self-reported pain, functional status, and patient satisfaction through validated surveys administered at preoperative outpatient clinic, discharge, 30-day follow-up, and 90-day follow-up. For aim 2, we will record inpatient opioid use and collect postdischarge opioid use and pain-related outcomes through an 11-item questionnaire administered at the 30-day follow-up. Hospital length of stay, readmission, number of days in an extended care facility, emergency room, urgent care, and an unplanned doctor’s office visit will be recorded as the primary composite endpoint defined as total days spent at home within the first 30 days after surgery. For aim 3, we will perform semistructured interviews with patients in the intervention arm to understand the comfort coach intervention through a thematic analysis.

Results
This trial, funded by Blue Cross Blue Shield of Michigan Foundation in 2019, is presently enrolling patients with anticipated manuscript submissions from our primary aims targeted for the end of 2020.

Conclusions
Data generated from this mixed methods study will highlight effective nonpharmacological techniques and support a multidisciplinary approach to perioperative care during the adult cardiac surgery patient experience. This study’s findings may serve as the foundation for a subsequent multicenter trial and broader dissemination of these techniques to other types of surgery.

Trial Registration
ClinicalTrials.gov NCT04051021; https://clinicaltrials.gov/ct2/show/NCT04051021

International Registered Report Identifier (IRRID)
DERR1-10.2196/21350