Pain-related unscheduled contact with healthcare services after outpatient surgery

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1 Original Article doi: /anae Pain-related unscheduled contact with healthcare services after outpatient surgery L. D. Brix, 1 K. T. Bjørnholdt, 2 T. M. Thillemann 3 and L. Nikolajsen 4,5,6 1 PhD Student, Department of Anaesthesiology, 2 Senior House Officer, Department of Orthopaedic Surgery, Horsens Regional Hospital, Horsens, Denmark 3 Specialist Registar, Department of Orthopaedic Surgery, 4 Consultant, 5 Professor, Department of Anaesthesiology, 6 Danish Pain Research Center, Aarhus University Hospital, Aarhus, Denmark Summary This prospective, observational study explored the need for pain-related unscheduled contact with healthcare services after outpatient surgery. We hypothesised that 10% of outpatients would have pain-related unscheduled contact with healthcare services, and that the incidence would differ depending on the type of surgical procedure. In total, 905 patients who had undergone one of five common outpatient surgical procedures (knee or shoulder arthroscopy, surgical correction of hallux valgus, laparoscopic cholecystectomy or laparoscopic gynaecological procedures) completed an electronic questionnaire one week and eight weeks after surgery. Data from 732 patients (81%) were available for analysis. Within the first eight weeks after surgery, 150 patients (20.5%) had made unscheduled contact with healthcare professionals, in 247 cases due to pain that was most frequent in the first postoperative week. Risk factors were female sex, unemployment and laparoscopic cholecystectomy. The most frequent healthcare contact was with the general practitioner (46.4%), and the most frequent outcome was further information and guidance (41.2%). We have demonstrated that a minority of patients still needed to make contact with health services after outpatient surgery, most often due to inadequate pain management. This finding should be considered when planning postoperative monitoring and care, and developing postoperative patient education.... Correspondence to: L. D. Brix lonebrix@rm.dk Accepted: 21 February 2017 Keywords: ambulatory surgery; pain management; patient care; quality measures Introduction Today, 60 70% of all surgical procedures are performed as outpatient surgery, and this number is likely to increase in future in an ongoing effort to optimise the use of healthcare resources [1 3]. Outpatient surgery has many advantages over traditional inpatient surgery, including increased convenience for the patient and reduced stress of recovering at home [2]. Overall, the safety of outpatient surgery is well documented, with low rates of re-admissions and adverse events [4]. However, postoperative complications such as pain have been reported to occur frequently (20 80%), and pain treatment is often inadequate [5 7]. Pain is the most common reason for delayed discharge and unplanned hospital readmission after outpatient surgery, but the incidence of other The Association of Anaesthetists of Great Britain and Ireland

2 Brix et al. Unscheduled healthcare contact after outpatient surgery Anaesthesia 2017, 72, pain-related unscheduled healthcare contact is largely unexplored [8 13]. The aim of this study was to examine unscheduled pain-related contact with healthcare services, including risk factors for contact during the first eight weeks after five common elective outpatient surgical procedures. Based on the few recent studies available, we hypothesised that 10% of outpatients would have made pain-related unscheduled contact with healthcare services, and that the incidence would differ depending on the type of surgical procedure [14, 15]. Methods The study was a prospective, observational study with an 8-week follow-up period of patients who underwent one of five common ambulatory surgical procedures: knee or shoulder arthroscopy; surgical correction of hallux valgus; laparoscopic cholecystectomy; or laparoscopic gynaecological procedures (Fig. 1). After obtaining written, informed consent, 905 patients were enrolled at the day surgery unit at Horsens Regional Hospital, Denmark, from May 2014 to December Exclusion criteria were age < 18 years, psychiatric illness, or inability to communicate in Danish. The study was approved by the Danish Data Protection Agency. According to the Scientific Committee for the Central Denmark Region, the Biomedical Research Ethics Committee System Act did not apply to this study and, therefore, the study did not need their approval. Regardless of the surgical procedure, all patients received oral dexamethasone 8 mg, paracetamol 1 g and ibuprofen 600 mg as premedication before anaesthesia. If ibuprofen was contraindicated, it was replaced by oral tramadol 50 mg. For prophylaxis of postoperative nausea and vomiting (PONV), intraoperative intravenous ondansetron 4 mg was administered. Anaesthesia was standardised and varied according to the surgical procedure. In the post-anaesthetic care unit (PACU), analgesia consisted of bolus doses of intravenous fentanyl lg (with a maximum of 300 lg) if pain intensity was 3 on an 11-point numerical rating scale (NRS), with 0 = no pain and 10 = worst possible pain. Postoperative nausea and vomiting was treated with further intravenous ondansetron 4 mg, droperidol mg and Assessed for eligibility (n = 1444) Excluded (n = 539) Not meeting inclusion criteria (n = 53): age (11), psychiatric illness (12), surgical reasons (3), language (27). Declined to participate (n = 238) Logistic reasons (n = 17) Was not asked (n = 224) Other reasons (n = 7): in prison (5), blind/dyslexic (2) Enrollment (n = 905) Knee arthroscopy Shoulder arthroscopy Surgical corr of hallux valgus cholecystectomy n = 194 n = 178 n = 170 n = 174 n = 189 gynaecological procedures Completed follow-up one week after surgery (n = 695) n = 152 (78.4%) n = 135 (75.8%) n = 136 (80.0%) n = 139 (79.9%) n = 133 (70.4%) Completed follow-up eight weeks after surgery (n = 569) n = 110 (56.7%) n = 122 (68.5%) n = 115 (67.6%) n = 111 (63.8%) n = 111 (58.7%) Figure 1 Flow chart. Data were available from 732 patients: 532 responded to both questionnaires, 163 patients responded to the first questionnaire, 37 patients only responded to the second questionnaire and 173 were nonresponders The Association of Anaesthetists of Great Britain and Ireland 871

3 Brix et al. Unscheduled healthcare contact after outpatient surgery metoclopramide 10 mg in that order. Patients were discharged directly from the PACU, and oral postoperative analgesia was started before hospital discharge. Before the day of surgery, all patients had been instructed to purchase paracetamol and ibuprofen for postoperative use as follows: paracetamol 1 g four times daily and ibuprofen mg three times daily. In addition, all patients, except uncomplicated cases of knee arthroscopy, were provided with ten morphine tablets of 10 mg. If ibuprofen was contraindicated, patients were also provided with 20 tramadol tablets 50 mg for use up to four times daily. At discharge, patients were provided with a two-page written instruction leaflet, including information about post-discharge complications such as fever, swelling, nausea, vomiting and pain. This also included a medicine list describing what doses and type of analgesics the patient should take and at what time they should be taken. The nurse explained the medicine list and the written instructions and emphasised the importance of taking analgesics as recommended. In case of questions or postoperative problems during the first 24 h after discharge, patients were advised to contact the day surgery unit at Horsens Regional Hospital or the nearest emergency department. After the first 24 h, patients were instructed to contact their general practitioner (GP) during daytime on weekdays; otherwise, they should contact the GP on call. Patients completed an electronic questionnaire one and eight weeks after surgery. The questionnaires were in Danish and were developed especially for the study as no suitable pre-existing questionnaire was available. Based on the literature and the experience of the authors, the questionnaires were drafted and assessed by research peers. After revision, the questionnaires were piloted in a group of ten outpatients at the first author s institution. After evaluation of the responses, the questionnaires were finalised. The electronic survey system Survey-Xact (Ramboll, Denmark), was used to distribute and handle the questionnaires. To achieve as high a response rate as possible, a text message (SMS) reminder was sent along with each questionnaire. Three days after the patient had received the questionnaire, the SMS reminder was repeated. Patients who did not answer at least one of the two questionnaires were not studied. In both electronic questionnaires, some of the questions had multiple response options, for example, multiple reasons for unscheduled healthcare contact as, for instance, pain and wound-related problems. The questionnaires also allowed patients to make comments. In the first electronic questionnaire, patients were asked to enter details about any contact with healthcare services regardless of the reason during the first postoperative week (number, type, cause(s) and result (s)). Patients were also asked to record their daily average pain intensity using the NRS every evening. Before their discharge from the PACU, patients had been provided with a written form containing some of the questions included in the electronic questionnaire (those concerning unscheduled contact and pain). After one week, patients were asked to transfer the answers to the electronic questionnaire. This was done to reduce recall bias. The questionnaire also included questions about baseline characteristics, including education, employment status, number of persons in the household, marital status, smoking and consumption of alcohol (Table 1). The second questionnaire included the same questions as the first questionnaire, except for the questions about baseline characteristics. Patients were asked to enter details about any contact with healthcare services, regardless of the reason, during postoperative weeks two to eight (number, type, cause(s) and result (s)), and the average pain intensity in week eight was recorded once on the NRS. The sample size was first calculated based on an expected prevalence of 10% for pain-related unscheduled contacts (5 15%, 95%CI), resulting in a required sample size of 570 patients, that is, 114 patients for each surgical procedure. To detect a difference of at least 10% between the surgical procedure with the lowest incidence and the surgical procedure with the highest incidence, the sample size was calculated by using two means of proportion in STATA software version 12.0 (StataCorp, TX, USA) with 80% power (a = 0.05, b = 0.2), resulting in a required sample size of 135 patients for each surgical procedure, that is, a total of 675 patients. Based on an expected response rate of 75%, it was decided to include at least 900 patients. Data were exported from Survey-Xact through Excel into STATA. Statistical analyses were performed The Association of Anaesthetists of Great Britain and Ireland

4 Brix et al. Unscheduled healthcare contact after outpatient surgery Anaesthesia 2017, 72, Table 1 Baseline characteristics from the first questionnaire one week after surgery (n = 695). Data except age and sex were only available for patients who completed the first questionnaire. Values are mean (SD) or number (proportion). Knee arthroscopy Shoulder arthroscopy Surgical correction of hallux valgus cholecystectomy gynaecological procedures Total n = 152 n = 135 n = 136 n = 139 n = 133 n = 695 Age; years 47.0 (13.9) 54.5 (11.0) 50.2 (13.9) 50.1 (14.0) 42.0 (11.7) 48.8 (13.6) Sex; Female 73 (48.0%) 63 (46.7%) 108 (79.4%) 103 (74.1%) 133 (100%) 480 (69.1%) Education Low level (< 13 y) 57 (37.5%) 55 (40.7%) 49 (36.0%) 43 (31.6%) 36 (27.1%) 240 (34.5%) High level ( 13 y) 80 (52.6%) 68 (50.4%) 78 (57.4%) 84 (59.7%) 92 (69.2%) 402 (57.8%) Missing 15 (9.7%) 12 (8.9%) 9 (6.6%) 12 (8.8%) 5 (3.8%) 53 (7.6%) Marital status Single/widowed 41 (26.9%) 19 (14.1%) 32 (23.5%) 24 (17.3%) 28 (21.1%) 144 (20.7%) Cohabitants/married 110 (72.4%) 113 (83.7%) 101 (74.3%) 113 (81.3%) 102 (76.7%) 539 (77.6%) Missing 1 (0.7%) 3 (2.2%) 3 (2.2%) 2 (1.4%) 3 (2.3%) 12 (1.7%) Employment Yes 108 (71.1%) 83 (61.5%) 95 (69.9%) 84 (60.4%) 108 (81.2%) 478 (68.8%) No 24 (15.8%) 22 (16.3%) 16 (11.8%) 26 (18.7%) 10 (7.5%) 98 (14.1%) Retiree 19 (12.5%) 27 (20.0%) 23 (16.9%) 27 (19.4%) 12 (9.0%) 108 (15.5%) Missing 1 (0.7%) 3 (2.2%) 2 (1.5%) 2 (1.4%) 3 (2.3%) 11 (1.6%) Smoking Non-smoker 112 (73.7%) 111 (82.2%) 108 (79.4%) 113 (81.3%) 97 (72.9%) 541 (77.8%) Current smoker 39 (25.7%) 21 (15.6%) 24 (17.6%) 24 (17.3%) 33 (24.8%) 141 (20.3%) Missing 1 (0.7%) 3 (2.2%) 4 (2.9%) 2 (1.4%) 3 (2.3%) 13 (1.9%) Alcohol consumption Low intake* 139 (91.4%) 122 (90.4%) 121 (89.0%) 128 (92.1%) 125 (94.0%) 635 (91.4%) High intake 12 (7.9%) 10 (7.4%) 11 (8.1%) 9 (6.5%) 5 (3.8%) 47 (6.8%) Missing 1 (0.7%) 3 (2.2%) 4 (2.9%) 2 (1.4%) 3 (2.3%) 13 (1.9%) Definitions of alcohol consumption based on the recommendations from the Danish Health Authority/WHO: * Low intake: 7 drinks/week (women) and 14 drinks/week (men). High intake: > 7 drinks/week (women) and > 14 drinks/week (men). with Student s t-test, chi-squared test or Wilcoxon rank-sum test as appropriate. Possible risk factors including: sex; age; operation; education level; marital status; employment; smoking status; and alcohol consumption, were assessed by univariate logistic regression. A multivariate logistic regression model was used to test for association between unscheduled contacts and statistically significant risk factors. All p values are two-sided and those below 0.05 were considered significant. Results A total of 1444 patients were assessed for eligibility from May 2014 to December 2015, of which 53 were not studied based on study exclusion criteria. Of the remaining 1391 patients, 238 declined to participate, 224 were not asked, 17 were not studied due to logistic reasons and 7 due to other reasons (Fig. 1). Nine-hundred and five patients received an electronic questionnaire one and eight weeks after surgery. Data were available for 732 patients (81%). Analyses were performed on reported data and the characteristics of non-responders were examined. The 173 non-responders were equally distributed in the five surgical groups and were significantly younger (p < 0.001) than responders. By the end of the survey period, 298 patients (40.7%) reported a total of 530 unscheduled contacts with healthcare services. Out of the 732 patients, 150 (20.5%) reported 247 pain-related contacts, that is, one to seven contacts per patient within the first eight postoperative weeks (Table 2). The majority of the 247 pain-related contacts (91.2%) were made during daytime (from 7 a.m. to 5 a.m.); 97 contacts (39.3%) were in the first postoperative week and 150 contacts (60.7%) in weeks two to eight (Fig. 2). Pain-related unscheduled contacts with health services were most 2017 The Association of Anaesthetists of Great Britain and Ireland 873

5 Brix et al. Unscheduled healthcare contact after outpatient surgery frequent after laparoscopic cholecystectomy (27.9%) followed by shoulder arthroscopy (22.3%) (Table 2). The difference between the surgical procedure with the lowest incidence (laparoscopic gynaecological procedures) and the surgical procedure with the highest incidence (laparoscopic cholecystectomy) was 11.5%; 95%CI % (p = 0.02). Multiple logistic regression revealed a higher risk of pain-related unscheduled contacts after laparoscopic cholecystectomy (OR (95%CI) 2.0 ( )), for women (OR (95%CI) 1.7 ( )) and for unemployed status (OR (95%CI) 2.3 ( )). Pain-related unscheduled contacts with healthcare services were primarily made by telephone (67.1%), followed by visits (28.6%) and mail correspondence (4.3%) and were to: GP (46.4%); day surgery unit (26%); GP on call (10.1%); emergency department (9.2%); hospital department (9.2%); physiotherapist or occupational therapist (5.3%); and emergency dispatch service (0.3%). The main outcome of a pain-related unscheduled contact was further information and guidance (41.2%), followed by: prescription of analgesics (20.7%); referral to hospital departments and other places (13.1%); treatment of wound-related problems (5.7%); hospital admission (2.8%); home visit from a healthcare professional (2.3%); follow-up appointment (2.0%); prescription of antibiotics (0.6%); blood sampling (0.6%); re-operation (0.6%); and various other reasons (10.4%). Of those who did not make any painrelated unscheduled contact after discharge, 22.9% felt that it would have been beneficial. Of those who did, 48.7% felt that they would have benefited from further contact with healthcare professionals. As shown in Fig. 3, median postoperative pain intensity decreased for all types of surgery during the first postoperative week. Some patients still reported pain eight weeks after surgery. Of the 150 patients who made pain-related contacts, 78.7% reported that the information about pain and pain treatment given before hospital discharge was sufficient, and they felt well prepared to manage their pain at home. Patients recalled having received verbal (83.3%) and written information (90.7%). In reply to Did you follow the Table 2 Overview of reasons for unscheduled contacts. Values are number (proportion) or number. Surgical Knee arthroscopy Shoulder arthroscopy correction of hallux valgus cholecystectomy gynaecological procedures Total n = 158 n = 148 n = 145 n = 140 n = 141 n = 732 Unscheduled contacts 51 (32.3%) 61 (41.2%) 73 (50.3%) 69 (49.3%) 44 (31.2%) 298 (40.7%) (regardless of reason) Pain-related unscheduled 31 (19.6%) 33 (22.3%) 24 (16.6%) 39 (27.9%) 23 (16.3%) 150 (20.5%) contacts Number of unscheduled contacts Reasons* 645 Pain-related Pain (38.3%) Prescription for analgesics/ (11.5%) medication change Surgical-related complications Wound-related (26.7%) Signs of infection (5.7%) Abdominal discomfort Nausea and/or vomiting (8.1%) Diarrhoea and/or obstipation (2.8%) Mobilisation and other General advice of (4.0%) mobilisation Other (2.9%) * Patients could have more than one postoperative symptom per unscheduled contact. Other: malaise, fatigue, numb toe after regional anaesthesia The Association of Anaesthetists of Great Britain and Ireland

6 Brix et al. Unscheduled healthcare contact after outpatient surgery Anaesthesia 2017, 72, unscheduled contacts (%) Postoperative week Figure 2 Distribution of the 247 pain-related unscheduled healthcare contacts within the first eight postoperative weeks. verbal/written information, 81.3%/84% answered yes. In reply to Did you take the medication as recommended?, 63.3% answered yes, 8% answered no because they took more analgesics than recommended due to pain and/or daily use of analgesics before surgery, and 22.6% answered no because they took less analgesics due to no pain, poor tolerance with the analgesics, and/or did not want to take analgesics. Discussion We found that 20.5% of all patients had made painrelated unscheduled contact with healthcare services within the first eight postoperative weeks, which was twice as high as hypothesised. Comparison with other studies is complex due to varying follow-up periods and different definitions of unscheduled contact after discharge. The incidence of pain-related unscheduled contacts found in this investigation is higher than found by others [14, 15]. For instance, Brattwall et al. found the incidence of pain-related unscheduled contacts with healthcare professionals within the first week after surgery to be 4.2% [14]. However, Beuregaard et al. found that as many as one patient in four needed contact with a healthcare professional due to pain in the first postoperative week, which is more similar to our findings [5]. The high pain-related and overall incidence of unscheduled healthcare contact in our study could be attributed to a wider definition of unscheduled contact, since many earlier studies have had only one main focus, for example, hospital return visits. The high pain scores reported in our study are consistent with those reported by Gerbershagen and colleagues on the first postoperative day after minor surgical procedures [16]. They suggest that patients undergoing minor surgical procedures have high pain scores because they often receive no or low doses of opioids [16]. In our study, 62.7% of patients reported taking analgesic medication as recommended and, for three of the five surgical procedures, patients still reported pain eight weeks after surgery. Nevertheless, the majority of patients reported having followed the instructions for pain management at home. It is not possible to state from our study whether a more rigorous pain management plan or higher doses of opioids would have had an impact on pain intensity, nor whether it makes a difference if the information is given just before discharge, since this may have an impact on the patients ability to retain and recall the verbal information [17]. Type of surgical procedure (laparoscopic cholecystectomy), female sex and unemployment were found to be risk factors for pain-related unscheduled contact with healthcare services. This should be taken into account when planning post-discharge information, care and treatment. It is interesting that laparoscopic cholecystectomy generated the highest number of pain-related unscheduled contacts since both our study and previous studies have shown that orthopaedic surgical procedures result in higher postoperative pain intensity over time and longer recovery than general and gynaecological surgical procedures [18, 2017 The Association of Anaesthetists of Great Britain and Ireland 875

7 Brix et al. Unscheduled healthcare contact after outpatient surgery Average pain intensity, NRS Knee arthroscopy Shoulder arthroscopy Surgical correction of hallux valgus cholecystectomy gynaecological procedures Day of surgery 2nd postoperative day 4th postoperative day 6th postoperative day 1st postoperative day 3rd postoperative day 5th postoperative day 7th postoperative day 8th postoperative week Figure 3 Pain intensity in the 1 st to the 8th postoperative week. Vertical boxes indicate median pain intensity on a numeric rating scale (NRS) from 0 = no pain at all to 10 = worst pain imaginable. Box edges indicate 25th and 75th percentiles and Whiskers indicate 5th and 95th percentiles. 19]. Our findings are supported by the findings of another study which found a high incidence of GP visits (12.5%) during the first postoperative week after laparoscopic cholecystectomy. The main reason for GP visits was the need for further analgesia and anti-emetics [13]. In accordance with other studies, pain intensity and recovery also differed among the three orthopaedic surgical procedures [20]. The reason why female sex was a predictor for pain-related unscheduled contacts in our study could be that women are more prone to seek help from healthcare professionals than men [21, 22]. A possible explanation for unemployment as a risk factor could be the lack of a social network. Unemployment has also been found to be an important determinant of GP utilisation [21, 22]. Our study has certain limitations. Response rate decreased from the 1st to the 8th week. However, the overall response rate of 81% can be regarded as satisfactory when compared with the mean response rate of approximately 62% in mail surveys published in medical journals [23]. Second, data may be skewed by the absence of non-responders who were mainly younger. Third, a non-validated questionnaire was used. The results should be interpreted keeping in mind the study design. Fourth, the required sample size for each procedure was only reached at one week and not at eight weeks. Finally, data on pre-operative pain in the surgical area and elsewhere, opioid tolerance, and psychological and peri-operative factors, for example, type of anaesthesia, were not collected in our study. This is a limitation since these factors are likely The Association of Anaesthetists of Great Britain and Ireland

8 Brix et al. Unscheduled healthcare contact after outpatient surgery Anaesthesia 2017, 72, to influence postoperative pain intensity and, thus, the number of pain-related unscheduled contacts [6]. Although some methodological issues exist, our study is unique in the large number of participants who were included, the different types of surgical procedures, and the long follow-up period for outpatient surgery. Recommendations from the International Association for Ambulatory Surgery regarding outcome indicators and follow-up time suggest an extension of the follow-up time from the previously recommended 24 h to 14 days and up to 28 days [24]. In concordance with these recommendations, our study showed that the majority of pain-related contacts were within the first four postoperative weeks. This confirms that the first four postoperative weeks can be seen as the target follow-up time after outpatient surgery. We also found external validity to be strengthened by the fact that the study was carried out in a routine clinical setting with standard protocols and discharge criteria reflecting daily practice. However, despite the large sample size, our results should be generalised with caution, as the findings are from a single centre. Our results give further support to the view that, despite the growing popularity of outpatient surgery and its increasing complexity, unscheduled contact with health services may be under-reported and is a problem for even the most common operation types. Pain is the most prominent postoperative reason for unscheduled contact and the high incidence calls for future studies to examine interventions that could reduce this. The number of both pain-related and non-pain-related unscheduled contacts with healthcare services may also represent indicators of outcome quality in outpatient surgery. Acknowledgements The authors thank the patients who participated in the study, the staff at the Day Surgery Unit at Horsens Regional Hospital and Helle O. Andersen (Danish Pain Research Centre, Aarhus, Denmark) for language revision. This work was supported by the Family Hede Nielsen Foundation, the Gurli and Hans Engell Friis Foundation, the Aase and Ejnar Danielsen Foundation [grant number ], and the Health Research Fund of Central Denmark. No competing interests declared. References 1. Steiner CA, Maggard-Gibbons M, Raetzman SO, Barrett ML, Sacks GD, Owens PL. Return to acute care following ambulatory surgery. Journal of the American Medical Association 2015; 314: Stessel B. Prevalence and predictors of quality of recovery at home after day surgery. Medicine (Baltimore) 2015; 94: e Rosen HI, Bergh IH, Oden A, Martensson LB. Patients experiences of pain following day surgery at 48 hours, seven days and three months. 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