
==== Front
Medicine (Baltimore)
Medicine (Baltimore)
MD
Medicine
0025-7974
1536-5964
Lippincott Williams & Wilkins Hagerstown, MD

MD-D-23-03298
00062
10.1097/MD.0000000000039314
3
5700
Research Article
Observational Study
Factors associated with postoperative discharge readiness and continuing care needs in patients with lung cancer undergoing fast-track surgery: A prospective cohort study
Zhang Na BS 247215035@qq.com
a
Zhang Huan-Huan MS 1078121028@qq.com
a
https://orcid.org/0000-0003-4626-5912
Liu Yan BS a*
a National Cancer Center & National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical Sciences, Beijing, China.
* Correspondence: Yan Liu, National Cancer Center & National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical Sciences, No. 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China (e-mail: 15201119199@139.com).
13 9 2024
13 9 2024
103 37 e3931420 4 2023
03 4 2024
25 7 2024
Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal.

To investigate and analyze the characteristics and factors associated with readiness for hospital discharge and continuing care needs of postoperative patients with lung cancer undergoing fast-track surgery (FTS). FTS aims to reduce the body’s stress response to surgery and improve patient outcomes. The study included adult patients with confirmed lung cancer who underwent lung cancer surgery under FTS management and were discharged from the Cancer Institute and Hospital, Chinese Academy of Medical Sciences, between June 2020 and September 2020. Patients with severe illnesses, comorbidities, disturbance of consciousness, cognitive disorders, or communication impairments were excluded. One-hundred-and-eighty patients were included, and 167 (92.8%) indicated that they were discharge-ready. Multivariable regression analysis showed that age 60 years or older (β = 16.29, 95% confidence interval (CI): 4.11–28.46, P = .009) and living alone (β = 37.07, 95% CI: 16.30–45.84, P < .001) were associated with the discharge readiness scores. In addition, those who were able to take care of themselves (β = 43.57, 95% CI: 19.60–67.54, P < .001) and needed little assistance at home (β = 28.39, 95% CI: 5.52–51.26, P = .015) had higher discharge readiness scores than those who needed a lot of assisted care. Patients who were cared for at home by children (β = 40.32, 95% CI: 4.91–75.73, P = .026), parents (β = 56.68, 95% CI: 12.33–101.03, P = .013), or spouses (β = 35.92, 95% CI: 2.45–69.38, P = .036), had higher discharge readiness scores than nursemaid. The discharge readiness scores of patients requiring continuing care were 146.5 ± 39.3, while patients who had no need scored 179.8 ± 36.5 (P < .01). Most patients with lung cancer undergoing FTS are discharge-ready. Discharge readiness is influenced by living conditions and self-care ability. This study identified factors influencing discharge readiness, and that could be used to identify patients who could benefit from help to improve discharge readiness.

continuity of patient care
enhanced recovery after surgery
lung neoplasms
patient discharge
retrospective study
surgical procedures
OPEN-ACCESSTRUE
SDCT
==== Body
pmc1. Introduction

Lung cancer is the second most common cancer in the world and also the leading cause of death from malignant tumors globally, with an estimated 2,206,771 new cases in 2020 worldwide and 1,796,144 related deaths.[1] China has the most important burden of lung cancer in the world, accounting for 36.98% of the new cases and 39.21% of mortality.[2,3] Despite progress in therapies such as radiotherapy and immunotherapy, surgery remains the preferred curative treatment,[4] but complication rates after surgical treatment of patients are high, and up to 50% of the patients can have poor or delayed recovery, leading to poor outcomes, morbidity, increased hospitalization costs, and even death.[5]

Fast-track surgery (FTS) is a multidisciplinary approach that was introduced to accelerate recovery, reduce complications, and minimize hospital stay and costs after colorectal surgery, without increasing complications or hospital admissions.[6] FTS emphasizes removing the patient’s disease with minimal impacts on physiology by taking means to reduce the body’s stress response to surgery, translating into better patient outcomes.[7] For the past few years, the concept of FTS has been applied to lung cancer surgery, where it shortened hospitalization, accelerated postoperative rehabilitation, and ensured effective utilization of medical resources.[8,9] Lung cancer surgery faces specific challenges for FTS. Indeed, pneumonectomy is associated with high rates of complications (17–47%)[10,11] and reduces abruptly the lung capacity and functional reserves of the patients. Lung surgery is also associated with risks of arrhythmia, acute pulmonary edema, and acute respiratory failure.[12] FTS protocols vary among hospitals and departments, but all optimize preadmission, preoperative, intraoperative, and postoperative care components. For lung cancer, it mainly involves careful consideration of preoperative airway preparation, preoperative fasting, pain control, and postoperative management.[13] FTS shortens hospitalization and seems to be beneficial for the patient’s clinical outcomes after resection for primary lung cancer.[14]

Nevertheless, a shorter hospitalization time reduces the time the patients have to learn about their disease and cope with functional limitations, and most patients are still recovering when discharged.[15–17] It can cause a lack of preparation and self-care knowledge for the patients and their families. It is entirely possible that some complications, even severe ones, occur on account of improper self-care after discharge from the hospital in the context of FTS.[18] In order to prevent that, a comprehensive evaluation of the patient’s physiological, psychological, and social statuses is used by medical workers to assess discharge readiness as an indicator of how well patients and/or their caregivers are prepared for leaving the hospital and as an estimate of their further rehabilitation capability.[19] Some studies suggested that early discharge did not increase readmission,[20,21] but the readiness for discharge of patients after surgery for lung cancer under FTS management is an important factor that needs further study.[22] It is important to understand what factors influence readiness for hospital discharge so that FTS methods can be further improved. There is a lack of data about the relationship between FTS and discharge readiness, and on the factors influencing discharge readiness in the FTS context.

This study aimed to investigate and analyze the characteristics and factors associated with readiness for hospital discharge and continuing care needs of postoperative patients with lung cancer undergoing FTS. The study hypothesis was that FTS yields a high rate of discharge readiness but that discharge readiness can be affected by several factors.

2. Methods

2.1. Study design and subjects

The prospective study considered for inclusion (convenience sampling) all consecutive patients who underwent lung cancer surgery and FTS management[23] and were discharged from the Cancer Institute and Hospital, Chinese Academy of Medical Sciences, between June 2020 and September 2020.

The inclusion criteria were ≥18 years of age, diagnosed with lung cancer by intraoperative frozen section pathology, managed with FTS during the perioperative period, and agreed to participate in this study and provided informed consent. The exclusion criteria were severe heart, lung, kidney, or other organ comorbidities (as patients with severe comorbidities are generally transferred to the intensive care unit after surgery, and the continuity of the study cannot be guaranteed), serious chronic diseases, disturbance of consciousness, cognitive disorder, verbal communication or character comprehension impairments, or missing data.

This study was approved by the Ethic Review Committee of Cancer Institute and Hospital, Chinese Academy of Medical Sciences (ethical approval number: NCC2017-YZ-009). The patients provided written informed consent for the use of their data.

2.2. Data collection

The general information questionnaire was designed to collect basic information from the patients, including age, sex, degree of education, occupation, marital status, place of residence, average monthly income of family members, payment means of medical expenses, and smoking history. Disease conditions such as preoperative comorbidities, tumor location, surgical approaches, postoperative complications, self-care ability, and primary caregivers were covered.

The self-rated Readiness for Hospital Discharge Scale (RHDS) was created by Weiss et al[19] The Chinese version of the RHDS was translated and validated by Zhao et al[24] and had wide domestic application.[25,26] Four dimensions and 23 items are included in the RHDS (Supplementary Materials, http://links.lww.com/MD/N413): personal physical condition (items #2–8), disease knowledge (items #9–16), coping capacity after discharge (items #17–19), and available social support (items #20–23). Item #1 is “Do you think you are ready to be discharged and return home according to the plan?” Item #1 is a yes/no question, while the other items are scored 0–10; therefore, item #1 was not included in the final score. For the other items, 0 indicates completely unprepared, while 10 indicates fully prepared. Items #3 and #6 are reverse-scored. The total score is the sum of each point, so a higher total score suggests better preparation for discharge. The original paper on the scale[19] did not provide a cutoff value. In the present study, Cronbach’s α coefficient was 0.8. The effect coefficient of items was 0.67 to 1.00 (0.92 on average).

Continuing care is a series of nursing activities aimed at ensuring the coordination and continuity of health services received by patients when transferring between different healthcare facilities or different levels of healthcare institutions. For example, the transfer from hospital to home, from home to nursing home, from hospital to rehabilitation institution, and other different care locations, with the most common being the transfer from hospital to home. The continuing care needs questionnaire was designed by 3 of the study’s authors. Five questions about the awareness level, demands, service crew, frequency, and forms & contents were designed with single- and multiple-choice questions. One author was a co-chief nurse with 23 years of experience, 1 was a supervisor nurse with 15 years of experience, and another was a nurse with 2 years of experience. The first draft was completed based on interviewing discharged postoperative patients with lung cancer. After guidance from experts and modification, the effect degree of the questionnaire was 0.90. The reliability survey was conducted on 30 patients for analysis, and Cronbach’s α coefficient was 0.846. The survey evaluated whether patients were aware of continuing care, pertinent demands, and preferred offers of personnel continuing care. Desired frequency, forms, and contents of continuing care were also included.

2.3. Survey procedure

No rewards were given to the participants, and they completed the questionnaire in a fully voluntary manner. Before starting the questionnaire, the patients were consulted about their wish to participate in the study, and their informed consent was obtained before starting the questionnaire. The survey was conducted by the investigators on the day of discharge and based on unified instructions. The investigators explained the study’s purpose to the patients, asked for their consent, and introduced the requirements for completing the questionnaires. The general information, RHDS, and continuing care need questionnaires were completed by the patients themselves. Any question raised while filling out the forms was answered by the investigators without delay. Ultimately, 180 questionnaires were distributed and returned (recovery rate of 100%).

After retrieving the questionnaires, the investigators verified the disease conditions of the patients, including tumor location and surgical approaches, by checking the medical records in the Hospital Information System.

2.4. Statistical methods

SPSS 17.0 (SPSS Inc., Chicago) was used to process and analyze the data. The normal distribution of the continuous data was evaluated using the Kolmogorov–Smirnov test, and all continuous data was normally distributed except the hospital stay. Continuous data were presented as means ± standard deviation. The hospital stay was presented as median (range). Categorical data were presented as n (%). Independent samples t test or one-way analysis of variance was used for univariable analysis, while a multivariable linear regression model was applied for multivariable analysis. Since there is no standard cutoff value for the binary classification of the preparation for discharge score,[19] linear regression was conducted instead of logistic regression. The differences were considered statistically significant when P < .05.

3. Results

3.1. General information and discharge readiness of the patients

This study enrolled 180 patients discharged after lung cancer surgery with FTS management. They were 55.3 ± 11.7 years of age. Their mean weight was 66.1 ± 11.4 kg. Among the 180 patients, 3 had a recurrent disease (1.7%; Table 1). The median hospital stay was 4.7 days.

Table 1 General information and discharge readiness scores of postoperative lung cancer patients (n = 180).

Variables	n (%)	Readiness scores (mean ± SD)	P	
Sex			.70	
 Male	66 (36.7)	160.8 ± 40.5		
 Female	114 (63.3)	158.1 ± 42.2		
Weight (kg)	66.14 ± 11.43			
Lung cancer				
 No recurrent disease	177 (98.3%)			
 Recurrent diseases	3 (1.7%)			
Age (yr)	55.3 ± 11.7		.06	
 <60	107 (59.4)	165.6 ± 35.2		
 ≥60	73 (40.6)	149.6 ± 47.9		
Marital status			.74	
 Married	165 (91.7)	159.0 ± 40.9		
 Single/divorced/widowed	15 (8.3)	160.1 ± 48.4		
Education			.73	
 Junior college and above	97 (53.9)	161.0 ± 38.0		
 High school and secondary school	42 (23.3)	153.9 ± 45.7		
 Junior high school and below	41 (22.8)	160.0 ± 45.2		
Places of residence after discharge			.33	
 Cities	164 (91.1)	158.5 ± 41.2		
 Countryside	16 (8.9)	165.8 ± 44.2		
Living condition			<.001*	
 Not alone	148 (82.2)	165.3 ± 38.4		
 Solitude	32 (17.8)	130.7 ± 43.9		
Occupation			.07	
 Workers/farmers	35 (19.4)	144.1 ± 40.2		
 Administrative/professional personnel	53 (29.4)	165.1 ± 37.2		
 Retired	51 (28.3)	163.6 ± 45.7		
 Others	41 (22.8)	158.7 ± 40.5		
Smoking history	152 (84.4)	158.9 ± 41.2		
Preoperative comorbidities			.31	
 No	117 (65.0)	161.6 ± 40.4		
Hypertension	29 (16.1)	155.8 ± 41.4		
 Diabetes	13 (7.2)	159.9 ± 37.1		
 Hypertension/diabetes	10 (5.6)	151.1 ± 53.9		
 Others	11 (6.1)	148.2 ± 49.5		
Tumor location			.20	
 Right lung	109 (60.6)	161.0 ± 43.5		
 Left lung	71 (39.4)	156.3 ± 38.2		
Surgical approaches				
 Thoracoscopic surgery	167 (92.8)			
 Thoracic surgery	13 (7.2)			
Postoperative complications	10 (5.6)	177.9 ± 41.7		
Self-care ability			.002*	
 Able to take care of oneself	56 (31.1)	172.3 ± 37.5		
 Little assistance	114 (63.3)	156.8 ± 38.9		
 Much assistance	10 (5.6)	111.5 ± 54.1		
Primary caregivers			.017*	
 Spouse	119 (66.1)	163.0 ± 38.6		
 Sons and daughters	43 (23.9)	152.3 ± 46.5		
 Parents	7 (3.9)	185.6 ± 28.0		
 Nannies	11 (6.1)	126.9 ± 40.4		
Average monthly income of family members (Yuan)			.94	
 <3000	37 (20.6)	157.5 ± 44.1		
 3000–4999	57 (31.7)	157.6 ± 40.5		
 5000–10,000	54 (30.0)	162.8 ± 38.0		
 >10,000	32 (17.8)	157.3 ± 46.9		
Payment means of medical expenses			.28	
 At public expense/medical insurance	148 (82.2)	161.3 ± 40.4		
 The new rural cooperative medical insurance	18 (10.0)	143.6 ± 46.6		
 Self-pay	14 (7.8)	155.9 ± 43.8		
* P < .05.

Item #1 of the RHDS is not included in the total score but asks whether the patients are prepared for hospital discharge and returning home; 92.8% of the patients (167/180) indicated they were ready. The total RHDS score of discharge readiness was 159.1 ± 41.5 (maximum value of 220), with a mean score of 7.2 ± 2.0 (maximum value of 10) for each item. Higher scores indicate a higher discharge readiness. There is no recognized cutoff value for determining discharge readiness.[19] The scores of each dimension of the RHDS are shown in detail in Table S1, Supplemental Digital Content, http://links.lww.com/MD/N413.

3.2. Multivariable Linear Regression Analysis of Factors Related to Discharge Readiness

The multivariable linear regression analysis showed that age 60 years or older (β = 16.29, 95% confidence interval (CI): 4.11–28.46, P = .009) and living alone (β = 37.07, 95% CI: 16.30–45.84, P < .001) were associated with the discharge readiness scores (Table 2). In addition, those who were able to take care of themselves (β = 43.57, 95% CI: 19.60–67.54, P < .001) and needed little assistance at home (β = 28.39, 95% CI: 5.52–51.26, P = .015) had higher discharge readiness scores than those who needed a lot of assisted care. Patients who were cared for at home by children (β = 40.32, 95% CI: 4.91–75.73, P = .026), parents (β = 56.68, 95% CI: 12.33–101.03, P = .013), or spouses (β = 35.92, 95% CI: 2.45–69.38, P = .036), had higher discharge readiness scores than nursemaid (Fig. 1).

Table 2 Multiple linear regression analysis of factors affecting discharge readiness of postoperative lung cancer patients.

Variables	Univariable analysis	Multivariable analysis	Model fit	
Beta (95% CI)	P	Beta (95% CI)	P	
Sex					R2 = 0.210	
 Male	−2.67 (−15.35, 10.01)	.678			Adj R2 = 10.178	
 Female	Reference					
Age ≥ 60 (yr)	6.20 (3.77, 28.22)	.011*	16.29 (4.11, 28.46)	.009*		
Marital status						
 Married	Reference					
 Single/divorced/widowed	−1.04 (−23.16, 21.08)	.926				
Education	−1.19 (−8.66, 6.28)	.753				
 Junior college and above	Reference					
 High school and secondary school	7.08 (−8.08, 22.23)	.358				
 Junior high school and below	0.96 (−14.33, 16.24)	.902				
Places of residence after discharge						
 Cities	reference					
 Countryside	−11.35 (−33.86,11.16)	.321				
Living alone	7.68 (19.38, 49.69)	<.001*	37.07 (16.30, 45.84)	<.001*		
Occupation						
 Workers/farmers	−8.50 (−29.25, 12.26)	.420				
Administrative/professional						
 Personnel	7.04 (−14.28, 28.37)	.515				
 Retired	−9.27 (−29.38, 10.84)	.364				
 Others	Reference					
Smoking history	1.21 (−0.89, 3.30)	.257				
Preoperative comorbidities	5.82 (−7.21, 18.85)	.379				
Tumor location						
 Right lung	Reference					
 Left lung	−4.72 (−17.21, 7.77)	.457				
Postoperative complications	−20.15 (−46.34, 6.04)	.131				
Self-care ability						
 Able to take care of oneself	49.07 (23.91, 74.22)	.001*	43.57 (19.60,67.54)	<.001*		
 Little assistance	15.16 (2.14, 28.18)	.023*	28.39 (5.52, 51.26)	.015*		
 Much assistance	Reference		Reference			
Primary caregivers						
 Nursemaid	Reference		Reference			
 Sons and daughters	26.30 (−11.54, 64.15)	.172	40.32 (4.91, 75.73)	.026		
 Parents	63.00 (14.50, 111.50)	.011*	56.68 (12.33, 101.03)	.013*		
 Relative	7.00 (−39.90, 53.90)	.769	22.53 (−20.70, 65.77)	.305		
 Spouse	36.99 (0.43, 73.55)	.047*	35.92 (2.45, 69.38)	.036*		
Average monthly income of family members (Yuan)						
 <3000	Reference					
 3000–4999	−2.01 (−17.53, 17.13)	.982				
 5000–10,000	−5.23 (−22.88, 12.41)	.559				
 >10,000	0.20 (−19.69, 20.08)	.984				
Payment means of medical expenses						
At public expense/medical insurance	Reference					
The new rural cooperative medical insurance	17.84 (−2.49, 38.18)	.085				
Self-pay	7.57 (−16.89, 32.03)	.542				
* P < .05.

Figure 1. Multivariable linear regression analysis of factors related to discharge readiness.

3.3. Continuing care needs of the patients when discharged

Table S2, Supplemental Digital Content, http://links.lww.com/MD/N413 shows the responses to the questionnaire on continuing care needs. Overall, the results indicated that 53.3% of the patients were aware of continuing care, and 62.2% of the patients expressed a need for continuing care. In detail, 70% suggested continuing care should be available once a week, with a majority of 74.4% suggesting guidance through network platforms such as WeChat. The most commonly desired continuing care contents included rehabilitation training, medication guidance, self-observation of illness, and symptom management.

3.4. Multivariable logistic regression analysis of the factors related to discharge readiness continuing care needs

The discharge readiness scores of patients requiring continuing care were 146.5 ± 39.3, while patients who had no need scored 179.8 ± 36.5 (P < .01). The multivariable analysis suggested that those requiring “much assistance” in terms of self-care ability [odds ratio (OR) = 0.48 95%CI: 0.23–1.00, P = .050] and discharge readiness (OR = 1.03 95% CI: 1.01–1.04, P < .001) were independently associated with continuing care needs (Table 3 and Fig. 2).

Table 3 Logistic univariable and multivariable analysis of continuing care needs.

Variables	Univariable analysis	Multivariable analysis	Model fit	
OR (95% CI)	P	OR (95% CI)	P	
Gender					−2 Log likelihood = 202.205	
 Male	1.01 (0.54, 1.88)	.983			Nagelkerke R2 = 0.250	
 Female	Reference					
Age (yr)						
<60	Reference					
≥60	0.63 (0.34, 1.19)	.153				
Marital status						
 Married	Reference					
Single/divorced/widowed	1.49 (0.52, 4.32)	.461				
Education						
 Junior college and above	Reference					
 High school and secondary school	0.94 (0.44, 2.00)	.863				
 Junior high school and below	1.43 (0.59, 3.45)	.424				
Places of residence after discharge						
 Cities	Reference					
 Countryside	1.82 (0.61, 5.45)	.288				
Living condition						
 Not alone	Reference					
 Solitude	0.59 (0.26, 1.36)	.218				
Occupation						
 Workers/farmers	1.73 (0.52, 5.71)	.370				
Administrative/professional personnel	0.86 (0.24, 3.07)	.821				
 Retired	1.33 (0.41, 4.32)	.633				
 Others	Reference					
Smoking history	0.89 (0.40, 1.99)	.772				
Preoperative comorbidities	0.63 (0.32, 1.23)	.176				
Tumor location						
 Right lung	Reference					
 Left lung	1.47 (0.78, 2.75)	.230				
Postoperative complications	1.79 (0.50, 6.44)	.375				
Self-care ability						
 Able to take care of oneself	Reference		Reference			
 Little assistance	0.13 (0.02, 1.11)	.062	0.25 (0.02, 2.59)	.244		
 Much assistance	0.40 (0.20, 0.79)	.008*	0.48 (0.23, 1.00)	.050*		
Primary caregivers						
 Spouse	Reference					
 Sons and daughters	0.00 (0.00, 0.00)	.999				
 Parents	0.55 (0.24, 1.24)	.150				
 Nannies	2.86 (0.25, 32.39)	.397				
Average monthly income of family members (Yuan)						
 < 3000	1.06 (0.36, 3.13)	.915				
 3000–4999	1.33 (0.51, 3.46)	.555				
 5000–10,000	1.90 (0.73, 4.98)	.191				
 > 10,000	Reference					
Payment means of medical expenses						
 At public expense/medical insurance	0.61 (0.19, 1.99)	.416				
 The new rural cooperative medical insurance	0.39 (0.08, 1.78)	.221				
 Self-pay	Reference					
Discharge readiness	1.03 (1.02, 1.04)	<.001*	1.03 (1.01, 1.04)	<.001*		
* P < .05.

Figure 2. Multivariable logistic regression analysis of the factors related to discharge readiness continuing care needs.

4. Discussion

The results showed that living conditions and self-care ability were independently associated with the readiness for hospital discharge in the multivariable analysis. In addition, 53.3% of the patients were aware of continuing care, and 62.2% of patients expressed a need for it. The requirements were most commonly rehabilitation training, medication guidance, self-observation of disease condition, and symptom management. There was a significant difference in discharge readiness scores of patients with and without continuing care needs. These results suggest that the hospital discharge readiness of postoperative patients with lung cancer and FTS management was good and influenced by living conditions and self-care ability. Postoperative recovery might be accelerated with improved health education on hospital discharge and appropriate provision of continuing care.

Favorable readiness for discharge is significant for enhancing postoperative recovery and a positive disease outcome. This study suggested that 92.8% of the patients were adequately prepared for hospital discharge and returning home, similar to a survey on discharge readiness of medical and surgical patients conducted by Weiss et al,[19] showing that 93.0% of the patients were properly prepared. The total score of discharge readiness was 159.1 ± 41.5, and the mean item score was 7.2 ± 2.6, which was close to the report data on discharge readiness of postoperative lung cancer patients with FTS management provided by Sun et al,[27] in which the total score was 163.4 ± 14.4 and mean score was 7.4 ± 0.7. Consequently, we can speculate that the discharge readiness of postoperative lung cancer patients with FTS management is better than the average level, which could translate into good patient outcomes (i.e., no readmission, patient satisfaction, and controlled complications), but that aspect was not examined in the present study since participation ended with discharge. Factors like improved minimally invasive surgery and efficiently organized health education events contributed to this outcome. Nevertheless, cognition of personal physical condition, disease knowledge, and coping capacity should be increased for the patients. In addition, available social support requires further improvement. In line with the literature,[27,28] the mean score of personal physical condition (6.88 ± 2.50) was lower than the scores of the other dimensions. The personal physical condition includes sickness, physical strength, vitality, stress, emotions, and self-care ability. The low score of this dimension indicated that the patients still had symptoms of discomfort when discharged and required further rehabilitation, both physically and psychologically. This result highlights that the patients must be discharged with appropriate pain control and instructions or prescriptions for rehabilitation and counseling when necessary. In FTS management, postoperative lung cancer patients are discharged before they fully recover their physical strength or vitality, although the discharge indications were satisfactory. Attention should be paid to the caregivers and ensure that they understand the care processes they are to give. Moreover, a certain period is needed to allow the patients to recover from the negative psychological stress caused by cancer, and a shorter hospital stay reduces the time available for learning about the disease. Accordingly, the physical recovery of postoperative lung cancer patients undergoing FTS needs more attention,[29] and so does their awareness of the disease knowledge. In view of the actual status of patients when discharged, specific instructions should be given to increase their coping capacity. Meanwhile, continuous attention must be paid to the available social support situation to boost the discharge readiness of patients as far as possible. Even if the present study generally agrees with the scarce literature on the subject, differences among studies can be due to the differences in study populations, local practices and policies, and national guidelines. In addition, the exact FTS protocols are different among hospitals due to the differences in management, resources, and surgeons’ preferences.

This study identified factors related to the total discharge readiness scores of lung cancer patients, such as age, living conditions, self-care ability, and type of primary caregiver. The findings were consistent with the literature.[27,29] Solitary patients had distinctly lower discharge readiness than others. After all, lung cancer, along with surgical treatment, can have various degrees of physiological and psychological impact on the patients, and solitary patients receive less support from families, friends, or society. Those factors can help identify patients who are not discharge-ready or could be at risk of negative outcomes when discharged. Special consideration should be given to such patients.

The discharge readiness scores of patients who lacked self-care ability and needed much assistance were considerably lower than those who needed no or little assistance. When discharged, those patients had not recovered completely, and most of them had some sort of discomfort, like aches in wounds and coughing. Sufficient time is required for pulmonary rehabilitation, so living independently is not possible. In dire need of disease knowledge and support from families and society, patients with poor self-care were physically indisposed and lacked coping capacity after discharge. It suggests that a more comprehensive understanding of both the physiological and psychological conditions of the patients and the available social support is needed. Medical teams must emphasize patients who live alone and have poor self-care ability to give a thorough and personalized educational service with respect to health management after discharge and encourage families to continue to support and help patients. Education should cover all aspects of postoperative care, including wound care, pain control, emotional and mental state, the signs and symptoms to watch and that could prompt readmission, rehabilitation exercises, and follow-ups to attend. Such education should be provided to all patients but with a special emphasis on patients living alone. In the meantime, patients and their family members should be taught to take full advantage of community health services, which are extremely important in improving the quality of their discharge readiness.[27]

Continuing care involves a new nursing pattern after discharge undertaken by telephone, the Internet, and home visits to maintain the patients’ health. Through a series of actions, it ensures that the patients are cooperatively and continuously nursed during hospitalization and in their transition home. Continuing care increases their cognition of diseases and self-management capability, thereby improving the therapeutic effects and living quality of patients after discharge.[30,31] According to the present study, the awareness rate of continuing care was 53.3%, and 62.2% of the patients expressed the need for continuing care provided by nurses and doctors. Patients with lung cancer have a great need for continuing care since pulmonary rehabilitation, and pain management require guidance from professionals.[32]

The shorter hospital stays of the patients undergoing FTS reduced their time learning about self-care. Most cases are still in the recovery phase when discharged, so there is a possibility of complications and a decline in living quality after discharge, leading to greater demands for continuing care. However, because the provision of such continuing care is currently fairly new in China, some problems arose. Some medical workers are short of relevant knowledge, and the implementation of continuing care as a single and complete continuing care system for patients after discharge has not been completely established.[33,34] These issues can influence the awareness of the patients. Medical teams should attach more importance to continuing care, increase information and education levels, enhance the professional quality of nursing staff, and intensify doctor-nurse cooperation, thus bringing elevated awareness and recognition of continuing care to patients and their families.

No unified regulations on methods and contents of continuing care for postoperative lung cancer patients after discharge have been issued so far.[32] According to the present study, 70% of the patients expected to have continuing care once a week. Their preferred methods of implementation were through WeChat, telephone, and home visits, including rehabilitation training, medication guidance, self-observation of illness, and symptom management common requirements. It indicated that postoperative lung cancer patients who underwent FTS have diversified demands for continuing care. In addition, the discharge readiness scores of patients requiring continuing care were lower than in patients who had no such need in this study. This implies that patients with lower discharge readiness are in more prominent need of continuing care. To decrease the incidence of complications after discharge and improve the quality of life of patients, medical teams should comprehensively understand the conditions of different patients, develop personalized continuing care plans, and give appropriate guidance.

5. Limitations

Although a prospective study to investigate factors related to discharge readiness after FTS has value in determining areas in need of improvement, there was no comparison group, so a direct comparison with patients who did not undergo FTS was not possible. The sample size was relatively small. The prospective study considered for inclusion (convenience sampling) all consecutive patients who underwent lung cancer surgery and FTS management and were discharged from the study center, but inclusion and exclusion criteria were applied to control for confounders, possibly introducing a selection bias. This study started and was completed during the COVID-19 pandemic. Lung cancer still occurred during the pandemic, and the patients had to be treated. Nevertheless, COVID-19 might have influenced the willingness to go to the hospital and the anxiety level of the patients, but no comparator was available since all study patients were discharged during the pandemic. Finally, the outcomes after discharge were not available. Larger multicenter studies would provide more evidence to support these results.

6. Relevance for clinical practice

The hospital discharge readiness of postoperative patients with lung cancer undergoing FTS was good and influenced by living conditions and self-care ability. The results indicate that selected patients with lung cancer can undergo FTS and achieve good outcomes. FTS could be used to improve the outcomes in selected patients. Patients living alone and those with limited self-care ability should receive special attention. Cognition of personal physical condition, disease knowledge, and coping capacity should be increased for the patients.

In summary, the discharge readiness of lung cancer patients after FTS was good but could be improved by addressing issues related to living conditions and self-care ability. Such patients have high demands for continuing care yet lack the necessary knowledge. Based on the conditions and needs of different patients, medical workers should pay attention to those who live alone or have poor self-care abilities. Enhancing health education after discharge and providing appropriate continuing care services for patients might assist them with accelerated rehabilitation and recovery.

Author contributions

Conceptualization: Na Zhang.

Data curation: Na Zhang, Huan-Huan Zhang.

Formal analysis: Na Zhang.

Funding acquisition: Yan Liu.

Investigation: Huan-Huan Zhang.

Methodology: Huan-Huan Zhang.

Writing – original draft: Na Zhang, Huan-Huan Zhang, Yan Liu.

Writing – review & editing: Na Zhang, Huan-Huan Zhang, Yan Liu.

Supplementary Material

Abbreviations:

CI confidence interval

FTS fast-track surgery

OR odds ratio

RHDS readiness for hospital discharge scale.

NZ and H-HZ contributed equally to this work.

This study was approved by the Ethic Review Committee of Cancer Institute and Hospital, Chinese Academy of Medical Sciences (ethical approval number: NCC2017-YZ-009). The research conforms to the provisions of the Declaration of Helsinki (as revised in Brazil 2013). All participants gave informed consent for the research, and their anonymity was preserved.

The authors have no funding and conflicts of interest to disclose.

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Supplemental Digital Content is available for this article.

How to cite this article: Zhang N, Zhang H-H, Liu Y. Factors associated with postoperative discharge readiness and continuing care needs in patients with lung cancer undergoing fast-track surgery: A prospective cohort study. Medicine 2024;103:37(e39314).
==== Refs
References

[1] Sung H Ferlay J Siegel RL . Global Cancer Statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021;71 :209–49.33538338
[2] Sun KX Zheng RS Zhang SW . Report of cancer incidence and mortality in different areas of China, 2015. China Cancer. 2019;28 :1–11.
[3] He S Li H Cao M . Trends and risk factors of lung cancer in China. Chin J Cancer Res. 2020;32 :683–94.33446992
[4] Qin M Qian Y Chen Y . Advances in pulmonary rehabilitation for lung cancer patients. J Nurs Sci. 2019;34 :101–4.
[5] Chen FF Zhang D Wang YL Xiong B . Video-assisted thoracoscopic surgery lobectomy versus open lobectomy in patients with clinical stage Ⅰ non-small cell lung cancer: a meta-analysis. Eur J Surg Oncol. 2013;39 :957–63.23845704
[6] Ansari D Gianotti L Schröder J Andersson R . Fast-track surgery: procedure-specific aspects and future direction. Langenbecks Arch Surg. 2013;398 :29–37.23014834
[7] Nanavati AJ Prabhakar S . Fast-track surgery: Toward comprehensive perioperative care. Anesth Essays Res. 2014;8 :127–33.25886214
[8] Xia Y Chang S Ye J Xue J Shu Y . [Application effect of fast track surgery for patients with lung cancer: a meta-analysis]. Zhongguo Fei Ai Za Zhi. 2016;19 :827–36.27978868
[9] Zhao JH Sun JX Gao P . Fast-track surgery versus traditional perioperative care in laparoscopic colorectal cancer surgery: a meta-analysis. BMC Cancer. 2014;14 :607–31.25148902
[10] Aberle DR Adams AM Berg CD . National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365 :395–409.21714641
[11] Dancewicz M Kowalewski J Peplinski J . Factors associated with perioperative complications after pneumonectomy for primary carcinoma of the lung. Interact Cardiovasc Thorac Surg. 2006;5 :97–100.17670525
[12] Deslauriers J Ugalde P Miro S . Adjustments in cardiorespiratory function after pneumonectomy: results of the pneumonectomy project. J Thorac Cardiovasc Surg. 2011;141 :7–15.21168011
[13] Li S Che G Shen C Zhou K . Current situation and consideration on the enhanced recovery protocols in lung cancer surgery. J Thorac Dis. 2018;10 ((Suppl 33 ):S3855–8.30631497
[14] Rogers LJ Bleetman D Messenger DE . The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer. J Thorac Cardiovasc Surg. 2018;155 :1843–52.29352586
[15] Liao J Wang Y Dai W . Profiling symptom burden and its influencing factors at discharge for patients undergoing lung cancer surgery: a cross-sectional analysis. J Cardiothorac Surg. 2022;17 :229.36057613
[16] Tang L Yu H Dai W . Symptom trajectories informing patient care after lung cancer surgery: a longitudinal patient-reported outcome study. Ann Surg Oncol. 2023;30 :2607–17.36658248
[17] Wei X Yu H Dai W . Patient-reported outcomes of video-assisted thoracoscopic surgery versus thoracotomy for locally advanced lung cancer: a longitudinal cohort study. Ann Surg Oncol. 2021;28 :8358–71.33880671
[18] Liu S Li J . Analysis on differences of readiness for hospital discharge of patients with lung cancer assessed by patients and nurses. Chin Nurs Res. 2017;21 :120–3.
[19] Weiss ME Piacentine LB Lokken L . Perceived readiness for hospital discharge in adult medical-surgical patients. Clin Nurse Spec. 2007;21 :31–42.17213738
[20] Chevrollier GS Nemecz AK Devin C . Early discharge does not increase readmission rates after minimally invasive anatomic lung resection. Innovations (Phila). 2019;14 :218–26.30871400
[21] Rosen JE Salazar MC Dharmarajan K Kim AW Detterbeck FC Boffa DJ . Length of stay from the hospital perspective: practice of early discharge is not associated with increased readmission risk after lung cancer surgery. Ann Surg. 2017;266 :383–8.27564681
[22] King M Kerr A Dixon S . Multicentre review of readmission rates within 30 days of discharge following lung cancer surgery. Br J Nurs. 2019;28 :S16–22.
[23] Dong Q Zhang K Cao S Cui J . Fast-track surgery versus conventional perioperative management of lung cancer-associated pneumonectomy: a randomized controlled clinical trial. World J Surg Oncol. 2017;15 :20.28086896
[24] Zhao H Feng X Yu R Gu D Ji X . Validation of the Chinese version of the readiness for hospital discharge scale on patients who have undergone laryngectomy. J Nurs Res. 2016;24 :321–8.27846104
[25] Cheng J Huang L Chen L . The readiness for hospital discharge and influencing factors in patients with Chronic Heart Failure. Chinese Nursing Management. 2018;18 :1352–7.
[26] Zhou Y Yan Q . Status quo and influencing factors of discharge readiness in patients with enterostomy. Nurs Res. 2019;33 :1827–32.
[27] Sun S Li Y Li J . Analysis on the current situation and influencing factors of the hospital discharge readiness of lung cancer patients after operation in the mode of enhanced recovery after surgery. Tianjin J Nurs. 2019;27 :674–7.
[28] Qiu L Hong Y Shi X . Status and influencing factors of the hospital discharge readiness of elder postoperative lung cancer patients. J Nurs Train. 2018;33 :1994–7.
[29] Yang J He YH Jiang LL Zhou ZG Li K . [Analysis of the status quo and influencing factors of short-term quality of life after discharge in colorectal cancer patients following enhanced recovery after surgery pathway]. Zhonghua Yi Xue Za Zhi. 2019;99 :1707–11.31216816
[30] Coats V Maltais F Simard S . Feasibility and effectiveness of a home-based exercise training program before lung resection surgery. Can Respir J. 2013;20 :e10–6.23616972
[31] Yang H . Evaluation of comfort care utilized in lung cancer patients with chemotherapy. Chin J Pract Nurs. 2012;28 :64–5.
[32] Kong Q Sha Y . Research development of continuing care for lung cancer patients after discharge. J Nurs Train. 2018;33 :1565–8.
[33] Li MH Chen SW Li YD . Prevalence of unruptured cerebral aneurysms in Chinese adults aged 35 to 75 years: a cross-sectional study. Ann Intern Med. 2013;159 :514–21.24126645
[34] Zhang L Ye Y Liu M . The application and research progress of transitional care in discharged cancer patients. Chin Nurs Manag. 2012;12 :91–4.
