Original article Association between psychological health and wound complications after surgery P. Britteon1 , N. Cullum2 and M. Sutton1 1 Manchester Centre for Health Economics and 2 Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK Correspondence to: Mr P. Britteon, Manchester Centre for Health Economics, University of Manchester, Room 4.306 Jean McFarlane Building, Oxford Road, Manchester M13 9PL, UK (e-mail: [email protected]) Background: Surgical wound complications remain a major cause of morbidity, leading to higher costs and reduced quality of life. Although psychological health is widely considered to affect wound healing, the evidence on wound outcomes after surgery is mixed. Studies generally focus on small samples of patients undergoing a specific procedure and have limited statistical power. Methods: This study investigated the relationship between three different measures of anxiety and/or depression and seven adverse surgical outcomes using observational data collected before and after surgery between 2009 and 2011. A wide range of confounding factors was adjusted for, including patient demographics, physical co-morbidities, health-related behaviours, month of operation, procedure complexity and treating hospital. Results: The estimation sample included 176 827 patients undergoing 59 410 hip replacements, 64 145 knee replacements, 38 328 hernia repairs and 14 944 varicose vein operations. Patients with moderate anxiety or depression had an increased probability of wound complications after a hip replacement (odds ratio (OR) 1⋅17, 95 per cent c.i. 1⋅11 to 1⋅24). They were more likely to be readmitted for a wound complication (OR 1⋅20, 1⋅02 to 1⋅41) and had an increased duration of hospital stay by 0⋅19 (95 per cent c.i. 0⋅15 to 0⋅24) days. Estimated associations were consistent across all four types of operation and for each measure of anxiety and/or depression. Conclusion: Preoperative psychological health is a significant risk factor for adverse wound outcomes after surgery for four of the procedures most commonly performed in England. Paper accepted 30 November 2016 Published online 14 February 2017 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.10474 Introduction In 2015–2016, admissions for general surgery in England exceeded 1⋅1 million1 . Wound-related problems arising after surgery remain a major cause of morbidity, despite often being preventable. Surgical-site infection alone is thought to affect at least 5 per cent of patients undergoing surgery2 . Patients with wound complications face longer periods of recovery, leading to an increased risk of death, higher costs of treatment, and a significantly reduced quality of life3 . The adverse impact of wound complications may even negate the benefits of the surgery4 . Understanding the factors associated with wound complications can help to identify susceptible patients, deliver appropriate interventions and reduce their incidence. Although studies have generally focused on surgical issues, patient factors also have an important role5 . Factors associated with delayed wound healing include © 2017 BJS Society Ltd Published by John Wiley & Sons Ltd patient characteristics such as age and sex, health-related behaviours (such as smoking, alcohol consumption, poor diet), physical co-morbidities (obesity, diabetes, medications) and psychological health (stress, anxiety, depression)6 . In particular, there is increasing evidence that stress, anxiety and depression directly influence immune response, and hence wound healing7 . Several studies have investigated the impact of poor psychological health on wound healing and found similar negative effects8,9 . However, relatively few studies have focused specifically on the recovery of patients undergoing surgery10 , with most concentrating on outcomes after cardiac surgery11 . Findings from these studies are inconclusive10 . Wound healing takes many months, yet discharge usually occurs within a week of surgery. As such, incisional surgical wound complications nearly always persist outside of hospital where the opportunities for BJS 2017; 104: 769–776 770 wound observation and detailed data collection are lacking. Hence, analyses tend to be conducted for specific surgical procedures using small samples of patients10 . This increases the heterogeneity between studies and reduces the statistical power required to identify a significant effect. In this study, rich observational hospital- and patientreported information was combined for 176 827 patients undergoing four of the most common surgical procedures in England. The impact of depression and anxiety on wound-related complications after surgery was analysed, controlling for a wide range of confounding prognostic factors. Methods Since April 2009, the national Patient Reported Outcome Measures (PROMs) programme has collected patient-reported information before and after surgery from National Health Service (NHS) patients aged 12 years or over undergoing one of four common elective procedures: unilateral hip replacement, unilateral knee replacement, inguinal hernia repair and varicose vein surgery. All providers of NHS care in England are required to offer patients undergoing these procedures a preoperative PROMs questionnaire (Q1) before their date of surgery. This usually occurs during the last outpatient assessment or on the day of admission. A postoperative PROMs questionnaire (Q2) is then mailed to the patient 6 months after the operation date for hip and knee replacement, and 3 months after operation for hernia repair and varicose vein surgery. One reminder is sent to patients who fail to respond. Patients are made aware that identifiable information is anonymized to all hospital staff, including surgeons. PROMs data from 1 April 2009 to 31 March 2011 were linked to administrative data from Hospital Episode Statistics (HES) containing detailed clinical and demographic information on all inpatient admissions in England. Psychological health Three alternative measures were used to characterize the psychological status of the patient: two reported by the patient before surgery and the third recorded by the hospital during the patient’s admission. Diagnosed depression Patients’ self-identified co-morbidities were selected from a list of 12 common serious conditions in the preoperative PROMs questionnaire (depression, high BP, problems caused by stroke, heart disease, lung disease, diabetes, © 2017 BJS Society Ltd Published by John Wiley & Sons Ltd P. Britteon, N. Cullum and M. Sutton kidney disease, diseases of the nervous system, liver disease, cancer, arthritis, leg pain when walking due to poor circulation). To minimize the use of medical terminology, patients were asked: ‘Have you been told by a doctor that you have any of the following?’. The study focused on patients identifying themselves as having been diagnosed with depression, the only psychological condition specified in the list. Although self-reported medical diagnoses are subject to recall bias, such measures have been shown to correlate moderately or strongly with medical records and are widely considered as valid instruments12,13 . Patient-reported anxiety or depression Responses to the EQ-5DTM (EuroQoL Group, Rotterdam, The Netherlands) reported by the patient before surgery were also considered. The EQ-5D™ measures health over five dimensions (anxiety or depression, mobility, self-care, usual activities, pain or discomfort). The study focused on the anxiety or depression dimension. Patients were offered three response categories: no problems, moderate problems or extreme problems. The EQ-5D™ is the generic health measure recommended by the National Institute for Health and Care Excellence. Hospital-recorded anxiety/depression Clinical information on the diagnosed psychological health status of patients recorded in HES was also considered. Since 2009, hospitals have reported mental or behavioural disorders of patients undergoing surgery as secondary diagnoses, according to Chapter V of ICD-10. Patients with a diagnosis of either an anxiety disorder (F41.X) or a depressive episode (F32.X) were identified. These codes represent the mental and behavioural disorders most commonly recorded by hospitals. Wound-related outcomes Patient-reported complication In the postoperative PROMs questionnaire, patients were asked: ‘Did you experience any of the following problems after your operation: allergy or reaction to drug; urinary problems; bleeding; and wound problems?’. Patients could have developed the complication at any time during the 3or 6-month follow-up after surgery, both during or after the hospital stay. The study focused on patients reporting a wound problem. The validity of patient-reported complications is well documented14 . Hospital-reported wound complication Clinical outcomes reported by the hospital in HES were also considered. Patients with a wound-related secondary www.bjs.co.uk BJS 2017; 104: 769–776 Psychological health and wound complications after surgery diagnosis recorded using the ICD-10 codes T81.3 (disruption of operation wound, not elsewhere classified) and T81.4 (infection following a procedure, not elsewhere classified) were identified. These codes were specifically designed to capture postoperative events when recorded as a secondary diagnosis. Wound-related readmission Patients readmitted to hospital after discharge where the primary diagnosis code of the readmission was recorded as T81.3 or T81.4 were identified. When recorded as a primary diagnosis, the ICD-10 codes T80–T88 are used to specify readmission to hospital from a previous complication of surgical care. For consistency with the patient-reported information, only readmissions within 3 months after surgery for hernia repair and varicose vein procedures, and within 6 months after surgery for hip and knee replacements, were considered. Length of hospital stay The patient’s duration of hospital stay during the admission in which the surgery took place was recorded. Duration of stay was defined as the number of days from admission to discharge from hospital using HES data. Statistical analysis Several factors confounding the relationship between psychological health and recovery from surgery were identified that had previously been adjusted for, or overlooked in the literature8 . These likely confounding factors were adjusted for using multiple logistic regression to calculate adjusted odds ratios (ORs) when outcomes were binary, and multiple linear regression when estimating the effect on duration of stay. The adjusted factors included patient age, sex and area-level income deprivation in 2010. An interaction term was used to allow adjustments for age to differ between male and female patients. Other health conditions were adjusted for using: the remaining conditions reported in the preoperative PROMs questionnaire; the remaining four EQ-5D™ physical dimensions; the patient’s duration of symptoms before surgery; and whether the patient had undergone previous surgery of the same type. Secondary diagnosis codes from HES were also used to adjust for indicators of obesity (E66.X), nutritional deficiencies (E40–E46, E50–E64), sleep disorders (F51.X, G47.X, R06.X, Z72.8, G25.8), smoking use (Z72.0, F17.2) and alcohol use (Z21.1, F10.2). Data on ethnicity, disability and whether the patient lived alone contained a large proportion of missing values and so were not included. © 2017 BJS Society Ltd Published by John Wiley & Sons Ltd 771 Finally, binary indicators were included to adjust for differences between hospitals, between primary procedures and between months. Separate models were estimated for each measure of psychological health. For most analyses, each of the four procedures was considered separately. However, because hospitals often did not code patients with wound-related complications, the analyses were not stratified by procedure type when estimating effects on hospital-reported outcomes, in order to maintain statistical power. Confidence intervals were calculated using cluster-robust standard errors to allow for the multilevel (patients within hospitals) structure of the data. Results Response rates to the preoperative PROM questionnaire between April 2009 and March 2011 varied between organizations and by procedure type: hip replacement (77⋅6 per cent), knee replacement (81⋅1 per cent), hernia repair (55⋅3 per cent) and varicose vein procedures (45⋅4 per cent)15,16 . The follow-up postoperative questionnaire was issued to 94⋅9 per cent of the patients who completed the preoperative questionnaire. Response rates to the postoperative questionnaire also varied across procedure type: hip replacement (83⋅7 per cent), knee replacement (82⋅9 per cent), hernia repair (73⋅3 per cent) and varicose vein procedures (64⋅3 per cent). Of patients who completed both questionnaires, 80⋅2 per cent could be linked to HES. Final response rates varied between 22⋅5 and 50⋅5 per cent across the four procedures. Some 178 622 patients completed both the preoperative and postoperative questionnaires, and could be linked to HES: 60 157 hip replacements, 64 887 knee replacements, 38 516 hernia repairs and 15 062 varicose vein operations. However, information on the area of residence needed to identify levels of income deprivation was missing for 1795 (1⋅0 per cent) of these patients. The final estimation sample contained 176 827 patients: 59 410 hip replacements, 64 145 knee replacements, 38 328 hernia repairs and 14 944 varicose vein operations. Estimation results Wound complications were frequently reported as an adverse outcome across all procedures (Table 1). Patients reported wound complications more frequently when undergoing varicose vein surgery (14⋅6 per cent) compared with hip replacements (9⋅4 per cent), knee replacements (12⋅0 per cent) and hernia repair (11⋅0 per cent). Very few patients undergoing hernia repair (0⋅03 per cent) and varicose vein surgery (0⋅01 per cent) were coded by the hospital www.bjs.co.uk BJS 2017; 104: 769–776 772 Table 1 P. Britteon, N. Cullum and M. Sutton Descriptive statistics of surgical outcomes and psychological factors by procedure group Patient-reported outcomes Wound complication Other complications Bleeding Allergy or reaction Urinary Hospital-reported outcomes Wound complication Wound-related readmission Length of stay (days) Day case 1 2 3 4 5 6 ≥7 Psychological factors Previously diagnosed depression Problems with anxiety or depression None Moderate Extreme Hospital-recorded anxiety or depression Hip replacement (n = 59 410) Knee replacement (n = 64 145) Hernia repair (n = 38 328) Varicose vein surgery (n = 14 944) 5605 (9⋅4) 7716 (12⋅0) 4226 (11⋅0) 2189 (14⋅6) 3260 (5⋅5) 6380 (10⋅7) 7168 (12⋅1) 4298 (6⋅7) 7899 (12⋅3) 6964 (10⋅9) 2163 (5⋅6) 1544 (4⋅0) 3132 (8⋅2) 2012 (13⋅5) 441 (3⋅0) 218 (1⋅5) 291 (0⋅5) 240 (0⋅4) 306 (0⋅5) 400 (0⋅6) 10 (0⋅0) 107 (0⋅3) 1 (0⋅0) 37 (0⋅2) 57 (0⋅1) 200 (0⋅3) 2552 (4⋅3) 10 365 (17⋅4) 13 613 (22⋅9) 11 006 (18⋅5) 7018 (11⋅8) 14 599 (24⋅6) 83 (0⋅1) 191 (0⋅3) 2209 (3⋅4) 11 290 (17⋅6) 15 621 (24⋅4) 11 860 (18⋅5) 7632 (11⋅9) 15 259 (23⋅8) 26 355 (68⋅8) 10 057 (26⋅2) 1176 (3⋅1) 333 (0⋅9) 153 (0⋅4) 74 (0⋅2) 38 (0⋅1) 142 (0⋅4) 13 177 (88⋅2) 1601 (10⋅7) 118 (0⋅8) 32 (0⋅2) 5 (0⋅0) 5 (0⋅0) 2 (0⋅0) 4 (0⋅0) 4073 (6⋅9) 4848 (7⋅6) 1595 (4⋅2) 1001 (6⋅7) 34 082 (57⋅4) 22 387 (37⋅7) 2941 (5⋅0) 1086 (1⋅8) 39 933 (62⋅3) 21748 (33⋅9) 2464 (3⋅8) 1287 (2⋅0) 32 316 (84⋅3) 5658 (14⋅8) 354 (0⋅9) 326 (0⋅9) 11 732 (78⋅5) 2925 (19⋅6) 287 (1⋅9) 143 (1⋅0) Values in parentheses are percentages. as having a wound-related complication. Wound-related complications were coded by the hospital more frequently for hip (0⋅5 per cent) and knee (0⋅5 per cent) replacements. Rates of readmission for a wound complication of previous surgery varied across procedures (from 0⋅2 to 0⋅6 per cent). Patients requiring joint replacement had a longer duration of stay than those undergoing hernia repair and varicose vein surgery, where the majority of patients were treated as a day case (68⋅8 and 88⋅2 per cent respectively). Patients having hip and knee replacement surgery were more likely to have experienced poor psychological health than those undergoing hernia repair and varicose vein surgery (Table 1). Those having hip and knee replacement reported higher rates of diagnosed depression (6⋅9 and 7⋅6 per cent respectively) and more frequently stated that they were moderately (37⋅7 and 33⋅9 per cent) or extremely (5⋅0 and 3⋅8 per cent respectively) anxious or depressed before surgery. Likewise, a greater proportion of patients undergoing hip (1⋅8 per cent) and knee (2⋅0 per cent) replacement were recorded by the hospital to have an anxiety disorder or depressive episode during their admission compared with patients undergoing hernia repair (0⋅9 per cent) and varicose vein surgery (1⋅0 per cent). The psychological health measures were positively correlated, as expected (Table 2). The proportion of patients © 2017 BJS Society Ltd Published by John Wiley & Sons Ltd Table 2 Alternative measures of psychological health Problems with anxiety or depression No. of patients Previously diagnosed depression Hospital-recorded anxiety or depression None Moderate Extreme 118 063 52 718 6046 1417 (1⋅2) 7710 (14⋅6) 2390 (39⋅5) 680 (0⋅6) 1678 (3⋅2) 484 (8⋅0) Values in parentheses are percentages. who had been diagnosed with depression increased with levels of reported problems with anxiety or depression from 1⋅2 per cent (none) to 14⋅6 per cent (moderate) to 39⋅5 per cent (extreme). Likewise, the proportion of patients diagnosed with an anxiety disorder or depressive episode by the hospital also increased with levels of reported problems with anxiety or depression from 0⋅6 per cent (none) to 3⋅2 per cent (moderate); only a small fraction of patients who had self-identified as having extreme problems with anxiety or depression (8⋅0 per cent) were identified with a depressive episode or anxiety disorder by the hospital. Patients with anxiety and/or depression were more likely to experience a wound problem after surgery (Table 3). The associations reduced but remained significant after www.bjs.co.uk BJS 2017; 104: 769–776 Psychological health and wound complications after surgery Table 3 773 Association between psychological factors and wound complications after surgery Patient-reported wound complication† Hip replacement Previously diagnosed depression No Yes Problems with anxiety or depression None Moderate Extreme Hospital-recorded anxiety or depression None Any Knee replacement Previously diagnosed depression No Yes Problems with anxiety or depression None Moderate Extreme Hospital-recorded anxiety or depression None Any Inguinal hernia repair Previously diagnosed depression No Yes Problems with anxiety or depression None Moderate Extreme Hospital-recorded anxiety or depression None Any Varicose vein procedure Previously diagnosed depression No Yes Problems with anxiety or depression None Moderate Extreme Hospital-recorded anxiety or depression None Any No. of patients* Unadjusted odds ratio Adjusted odds ratio 5040 (9⋅1) 565 (13⋅9) 1⋅00 (reference) 1⋅61 (1⋅47, 1⋅76) 1⋅00 (reference) 1⋅36 (1⋅24, 1⋅50) 2841 (8⋅3) 2393 (10⋅7) 371 (12⋅6) 1⋅00 (reference) 1⋅32 (1⋅25, 1⋅39) 1⋅59 (1⋅41, 1⋅79) 1⋅00 (reference) 1⋅17 (1⋅11, 1⋅24) 1⋅26 (1⋅10, 1⋅43) 5463 (9⋅4) 142 (13⋅1) 1⋅00 (reference) 1⋅46 (1⋅21, 1⋅75) 1⋅00 (reference) 1⋅32 (1⋅10, 1⋅59) 6897 (11⋅6) 819 (16⋅9) 1⋅00 (reference) 1⋅54 (1⋅42, 1⋅68) 1⋅00 (reference) 1⋅28 (1⋅17, 1⋅40) 4353 (10⋅9) 2947 (13⋅6) 416 (16⋅9) 1⋅00 (reference) 1⋅28 (1⋅22, 1⋅35) 1⋅66 (1⋅47, 1⋅88) 1⋅00 (reference) 1⋅13 (1⋅06, 1⋅19) 1⋅27 (1⋅12, 1⋅45) 7516 (12⋅0) 200 (15⋅5) 1⋅00 (reference) 1⋅35 (1⋅15, 1⋅59) 1⋅00 (reference) 1⋅24 (1⋅05, 1⋅45) 3966 (10⋅8) 260 (16⋅3) 1⋅00 (reference) 1⋅61 (1⋅41, 1⋅84) 1⋅00 (reference) 1⋅34 (1⋅16, 1⋅55) 3365 (10⋅4) 790 (14⋅0) 71 (20⋅1) 1⋅00 (reference) 1⋅40 (1⋅29, 1⋅52) 2⋅16 (1⋅67, 2⋅78) 1⋅00 (reference) 1⋅20 (1⋅10, 1⋅30) 1⋅66 (1⋅27, 2⋅17) 4177 (11⋅0) 49 (15⋅0) 1⋅00 (reference) 1⋅43 (1⋅07, 1⋅91) 1⋅00 (reference) 1⋅29 (0⋅98, 1⋅71) 1993 (14⋅3) 196 (19⋅6) 1⋅00 (reference) 1⋅46 (1⋅25, 1⋅70) 1⋅00 (reference) 1⋅27 (1⋅08, 1⋅51) 1611 (13⋅7) 510 (17⋅4) 68 (23⋅7) 1⋅00 (reference) 1⋅33 (1⋅19, 1⋅49) 1⋅95 (1⋅55, 2⋅46) 1⋅00 (reference) 1⋅21 (1⋅07, 1⋅36) 1⋅68 (1⋅25, 2⋅26) 2161 (14⋅6) 28 (19⋅6) 1⋅00 (reference) 1⋅42 (0⋅94, 2⋅16) 1⋅00 (reference) 1⋅13 (0⋅71, 1⋅79) Values in parentheses are *percentages and †95 per cent confidence intervals. Estimation sample: hip replacement, 59 410; knee replacement, 64 145; hernia repair, 38 328; varicose vein surgery, 14 944. Odds ratios were estimated by multiple logistic regression. adjustment for confounding factors. Following hip replacement, previously diagnosed depression increased the probability of wound complications (OR 1⋅36, 95 per cent c.i. 1⋅24 to 1⋅50). Likewise, patients undergoing hip replacement who had moderate problems of anxiety or depression were more likely to develop a wound complication than patients reporting no problems with anxiety or depression (OR 1⋅17, 1⋅11 to 1⋅24). The association with extreme problems of anxiety or depression was even stronger (OR 1⋅26, 1⋅10 1⋅43). These associations were similar in magnitude and significance for patients undergoing knee replacement, hernia repair and varicose vein surgery. Hospital-recorded anxiety or depression was significantly associated with the rate of surgical wound problems only for patients undergoing hip (OR 1⋅32, 1⋅10 to 1⋅59) or knee (OR 1⋅24, 1⋅05 to 1⋅45) replacement. © 2017 BJS Society Ltd Published by John Wiley & Sons Ltd www.bjs.co.uk BJS 2017; 104: 769–776 774 Table 4 P. Britteon, N. Cullum and M. Sutton Influence of psychological health on hospital-reported outcomes after surgery for all procedures Adjusted odds ratio Previously diagnosed depression No Yes Problems with anxiety or depression None Moderate Extreme Hospital-recorded anxiety or depression None Any Wound diagnosis Wound readmission Coefficient for length of stay (change in days) 1⋅00 (reference) 0⋅96 (0⋅69, 1⋅33) 1⋅00 (reference) 1⋅37 (1⋅11, 1⋅69) 1⋅00 (reference) 0⋅23 (0⋅14, 0⋅32) 1⋅00 (reference) 1⋅14 (0⋅96, 1⋅36) 1⋅18 (0⋅86, 1⋅63) 1⋅00 (reference) 1⋅20 (1⋅02, 1⋅41) 1⋅30 (0⋅92, 1⋅84) 1⋅00 (reference) 0⋅19 (0⋅15, 0⋅24) 0⋅49 (0⋅33, 0⋅65) 1⋅00 (reference) 0⋅92 (0⋅50, 1⋅73) 1⋅00 (reference) 1⋅08 (0⋅66, 1⋅78) 1⋅00 (reference) 0⋅44 (0⋅25, 0⋅62) Values in parentheses are 95 per cent confidence intervals. Estimation sample: 176 827. Odds ratios were estimated by multiple logistic regression, and coefficients by multiple linear regression. Diagnosed depression (OR 0⋅96, 0⋅69 to 1⋅33), reported moderate (OR 1⋅14, 0⋅96 to 1⋅36) and extreme (OR 1⋅18, 0⋅86 to 1⋅63) problems with anxiety or depression, and hospital-recorded anxiety or depression (OR 0⋅92, 0⋅50 to 1⋅73) were not significantly associated with hospital-reported wound complications (Table 4). Previously diagnosed depression, however, was significantly associated with readmission for a surgical wound complication (OR 1⋅37, 1⋅11 to 1⋅69). Likewise, patients reporting moderate (OR 1⋅20, 1⋅02 to 1⋅41) or extreme (OR 1⋅30, 0⋅92 to 1⋅84) anxiety or depression were more likely to be readmitted because of a surgical wound complication. Each psychological health measure was significantly associated with a longer mean duration of hospital stay: by 0⋅23 (95 per cent c.i. 0⋅14 to 0⋅32) days for previously diagnosed depression, 0⋅19 (0⋅15 to 0⋅24) and 0⋅49 (0⋅33 to 0⋅65) days for moderate and extreme problems with anxiety or depression respectively, and 0⋅44 (0⋅25 to 0⋅62) days for hospital-diagnosed anxiety or depression. Moderate problems with anxiety or depression were also associated with bleeding (OR 1⋅14, 1⋅05 to 1⋅24), allergy (OR 1⋅09, 1⋅04 to 1⋅16) and urinary (OR 1⋅21, 1⋅15 to 1⋅28) complications after hip replacement surgery (Table S1, supporting information). Extreme problems with anxiety or depression had larger associations than moderate problems with bleeding (OR 1⋅21, 1⋅04 to 1⋅41), allergy (OR 1⋅25, 1⋅11 to 1⋅41) and urinary (OR 1⋅48, 1⋅31 to 1⋅67) complications. Allergy complications after a hip replacement were not associated with previously diagnosed depression (OR 1⋅01, 0⋅91 to 1⋅12) or hospital-recorded anxiety or depression (OR 1⋅11, 0⋅91 to 1⋅37). Similar results were found for patients undergoing knee replacement and hernia repair. Discussion Large proportions of patients reported having moderate (29⋅8 per cent) or extreme (3⋅4 per cent) problems with © 2017 BJS Society Ltd Published by John Wiley & Sons Ltd anxiety or depression before surgery. Patients’ preoperative psychological health status was significantly associated with wound-related problems after surgery for hip replacement, knee replacement, hernia repair and varicose vein surgery. These associations were large and strong. They were consistent for three different anxiety and/or depression measures, and after adjusting for a wide range of confounding factors including patient demographics, physical co-morbidities, health behaviours, month of operation, procedure complexity and treating hospital. Anxiety and/or depression were not, however, associated with wound complications recorded by hospitals during the patients’ stay. Instead, anxiety and/or depression were significantly associated with surgical wound-related readmissions. Anxious and/or depressed patients were also more likely to stay in hospital longer. Although the increase in duration of stay was small at an individual level, the relative effect was sizeable given that the mean duration of stay for the sample of patients was only 4⋅51 days. Furthermore, anxiety and/or depression were strongly associated with urinary and bleeding complications after surgery, but only mildly associated with allergy and adverse drug reaction. This study adds to the existing evidence concerning the relationship between psychological health and wound healing. The results support smaller studies7,17 – 20 whose findings generally indicated a negative impact of anxiety or depression on wound healing, and other studies21 – 24 that were too underpowered to detect important associations as statistically significant. The associated increase in wound-related readmissions and duration of stay is especially large when the implications are considered at the population level. Furthermore, the findings were consistent with recent evidence in non-cardiac surgery that patients on anxiolytic drugs were more likely to develop a surgical wound complication after a broad range of general, vascular, urological and plastic surgery procedures11 . www.bjs.co.uk BJS 2017; 104: 769–776 Psychological health and wound complications after surgery Unlike past studies, individual information was used from a large, national sample of patients. This allowed adjustment for a wide range of confounding factors without losing the statistical power needed to identify significant associations. It was not possible to adjust for every potential confounding factor associated with the complex wound healing process (including exercise, wound severity, complications during surgery, quality of care after discharge, use of medication and education), but the combined use of PROMs and HES allowed adjustment for numerous factors omitted from previous studies, including health-related quality of life, health behaviours and co-morbidity8 . Large administrative data sets such as HES may contain incomplete information on patient conditions if hospitals do not report the required information for coding. As a result, the present estimates may have only partly adjusted for obesity, smoking, alcohol use, nutritional deficiency and sleep disorders. Nevertheless, adjustment for each hospital-reported condition had little or no effect on the estimated association between anxiety and/or depression and outcomes after surgery. PROMs data were not available for all eligible patients identified in HES. There are three main reasons why information on PROMs may have been missing: the hospital may have failed to administer the preoperative questionnaire; patients may not have participated in, or responded to, the survey; or the required information may have been insufficient to link the PROMs record to the HES episode25 . To reduce missingness, it was assumed that patients responding ‘yes’ to any of the four postoperative complications in PROMs (wound, bleeding, allergy, urinary) did not experience other problems if they left these answers blank14 . Nevertheless, the present results may not have been representative of the full population of patients if responders differed from non-responders in terms of unadjusted factors correlated with anxiety and/or depression and the outcome of interest25 . Re-estimation of the association between hospital-recorded anxiety or depression and hospital-reported outcomes using the full eligible sample allowed an investigation of the potential direction of any response bias. The magnitude of the association between anxiety and/or depression on outcomes after surgery was larger, or the same, for the sample of non-responding patients, suggesting no, or a downward bias in the sample analysed. This is supportive of the findings, suggesting that observed associations would persist in the full population. Patients suffering from depression or anxiety may have been more likely to report complications regardless of the surgical outcome, inflating the estimated associations. However, there was a significant association between © 2017 BJS Society Ltd Published by John Wiley & Sons Ltd 775 anxiety and/or depression with readmissions recorded by hospitals related to surgical wounds. Furthermore, consideration of the other patient-reported complication indicators revealed no impact of psychological health on allergy or drug reaction problems, as would be expected. The fact that associations increased incrementally with levels of anxiety or depression gives further weight to the findings. Hospital-recorded anxiety or depression may have arisen as a consequence of the postoperative wound complication, thereby inflating the estimated associations. Using PROMs data allowed measurement of patients’ psychological health before surgery, which overcame this issue. Additionally, patient-reported outcomes were recorded 3–6 months after surgery. Complications that developed after discharge from hospital were therefore captured. However, it was only possible to identify that a patient developed a wound problem, not when it developed or the nature of the problem. These findings are based on information from 2009–2010 and 2010–2011 (the latest available). Future work should investigate whether the observed associations between preoperative depression and/or anxiety and wound outcomes still exist. These results highlight a relationship between psychological health and adverse wound outcomes after surgery. This relationship warrants further exploration in order to understand the mechanisms and potential opportunities for intervention. The study also emphasises the importance of the psychological state before surgery, and the fact psychological disorders are often overlooked. Preoperative assessment should address psychological as well as physical health, given the significant impact of anxiety/depression on wound-related complications and readmissions. Acknowledgements This report is independent research supported by the National Institute for Health Research (NIHR Research Methods Programme, Fellowships and Internships, NIHR-RMFI-2014-05-29). The views expressed in this publication are those of the author(s) and not necessarily those of the National Health Service, the National Institute for Health Research or the Department of Health. Disclosure: The authors declare no conflict of interest. References 1 NHS Digital. Hospital Admitted Patient Care Activity, 2015–16; 2016. http://www.content.digital.nhs.uk/ catalogue/PUB22378 [accessed 20 December 2016]. 2 National Institute for Health and Care Excellence (NICE). Surgical Site Infections: Prevention and Treatment. NICE: London, 2008. www.bjs.co.uk BJS 2017; 104: 769–776 776 P. Britteon, N. Cullum and M. Sutton 3 Whitehouse JD, Friedman ND, Kirkland KB, Richardson WJ, Sexton DJ. The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost. Infect Control Hosp Epidemiol 2002; 23: 183–189. 4 Cullum N, Buckley H, Dumville J, Hall J, Lamb K, Madden M et al. Wounds research for patient benefit: a 5-year programme of research. Programme Grants Appl Res 2016; 4: 91–100. 5 Buggy D. Can anaesthetic management influence surgical-wound healing? Lancet 2000; 356: 355–357. 6 Guo S, DiPietrio L. Factors affecting wound healing. J Dent Res 2010; 89: 219–229. 7 Kiecolt-Glaser JK, Marucha PT, Mercado AM, Malarkey WB, Glaser R. Slowing of wound healing by psychological stress. Lancet 1995; 346: 1194–1196. 8 Walburn J, Vedhara K, Hankins M, Rixon L, Weinman J. Psychological stress and wound healing in humans: a systematic review and meta-analysis. J Psychosom Res 2009; 67: 253–271. 9 Gouin JP, Kiecolt-Glaser JK. The impact of psychological stress on wound healing: methods and mechanisms. Immunol Allergy Clin North Am 2011; 31: 81–93. 10 Mavros MN, Athanasiou S, Gkegkes ID, Polyzos KA, Peppas G, Falagas ME. Do psychological variables affect early surgical recovery? PLoS One 2011; 6: e20306. 11 Ward N, Roth JS, Lester CC, Mutiso L, Lommel KM, Davenport DL. Anxiolytic medication is an independent risk factor for 30-day morbidity or mortality after surgery. Surgery 2015; 158: 420–427. 12 Bayliss EA, Ellis JL, Steiner JF. Seniors’ self-reported multimorbidity captured biopsychosocial factors not incorporated into two other data-based morbidity measures. J Clin Epidemiol 2009; 62: 550–557. 13 Katz JN, Chang LC, Sangha O, Fossel AH, David W. Can comorbidity be measured by questionnaire rather than medical record review? Med Care 1996; 34: 73–84. 14 Grosse Frie K, van der Meulen J, Black N. Relationship between patients’ reports of complications and symptoms, disability and quality of life after surgery. Br J Surg 2012; 99: 1156–1163. 15 Health and Social Care Information Centre. Finalised Patient Reported Outcome Measures (PROMs) in England: April 2009 – March 2010; 2011. http://content.digital.nhs.uk/ catalogue/PUB02429/fina-prom-data-2009-10-rep.pdf [accessed 13 October 2016]. 16 Health and Social Care Information Centre. Finalised Patient Reported Outcome Measures (PROMs) in England: April 2010 to March 2011; 2012. http://content.digital.nhs.uk/catalogue/ PUB07049/fina-prom-eng-apr-10-mar-11-pre-post-rep1.pdf [accessed 13 October 2016]. 17 Stengrevics S, Sirois C, Schwartz CE, Friedman R, Domar AD. The prediction of cardiac surgery outcome based upon preoperative psychological factors. Psychol Health 1996; 11: 471–477. 18 Marucha PT, Kiecolt-Glaser JK, Favagehi M. Mucosal wound healing is impaired by examination stress. Psychosom Med 1998; 60: 362–365. 19 Broadbent E, Petrie J, Alley P, Booth R. Psychological stress impairs early wound repair following surgery. Psychosom Med 2003; 65: 865–869. 20 Vollmer-Conna U, Bird KD, Yeo BW, Truskett PG, Westbrook RF, Wakefield D. Psychological factors, immune function and recovery from major surgery. Acta Neuropsychiatr 2009; 21: 169–178. 21 Cohen F, Lazarus RS. Active coping processes, coping dispositions, and recovery from surgery. Psychosom Med 1973; 35: 375–389. 22 George JM, Scott DS, Turner SP, Gregg JM. The effects of psychological factors and physical trauma on recovery from oral surgery. J Behav Med 1980; 3: 291–310. 23 Linn BS, Linn MW, Klimas NG. Effects of psychophysical stress on surgical outcome. Psychosom Med 1988; 50: 230–244. 24 Contrada R, Goyal TM, Cather C, Rafalson L, Idler EL, Krause TJ. Psychosocial factors in outcomes of heart surgery: the impact of religious involvement and depressive symptoms. Health Psychol 2004; 23: 227–238. 25 Gomes M, Gutacker N, Bojke C, Street A. Addressing missing data in patient-reported outcome measures (PROMS): implications for the use of PROMS for comparing provider performance. Health Econ 2015; 19: 1300–1317. Supporting information Additional supporting information may be found in the online version of this article: Table S1 Influence of psychological health on other patient-reported outcomes after surgery (Word document) © 2017 BJS Society Ltd Published by John Wiley & Sons Ltd www.bjs.co.uk BJS 2017; 104: 769–776