Similarities in postoperative recovery and health care contacts within 14 days in males and females with mhealth follow up

Transcription

1 Similarities in postoperative recovery and health care contacts within 14 days in males and females with mhealth follow up M. Jaensson 1 K. Dahlberg 1 U. Nilsson 1 1. Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden Corresponding author: Maria Jaensson School of Health Sciences Örebro University, Örebro Sweden Phone: Fax: maria.jaensson@oru.se Trial registry number NCT

2 ABSTRACT BACKGROUND. Earlier studies have reported that females are prone to experience a poorer recovery compared to men. One research group has developed a smartphone application (app) called RAPP (Recovery Assessment by Phone Points) that includes the Swedish Quality of Recovery questionnaire (SwQoR). OBJECTIVE. The aim of this study was to investigate sex differences in postoperative recovery and number of health care contacts within 14 postoperative days in a cohort of day surgery patients using RAPP. METHODS. This study was a secondary analysis from a single-blind randomized controlled trial. Conducted at four day surgery settings in Sweden from October 2015 to July Included were 494 patients (220 male and 274 female) undergoing day surgery. RESULTS. There were no significant sex differences in postoperative recovery or health care contacts. Subgroup analysis showed that females < 45 years of age reported significantly higher global scores in SwQoR (hence a poor recovery) on postoperative days 1-10 compared to females 45 years. Males < 45 years of age reported significantly higher global scores on postoperative day 2-6 compared to males 45 years. No significant sex differences were seen when comparing different age groups. CONCLUSIONS. This study indicates that there are sex similarities in postoperative recovery and health care contacts. However, subgroup analysis showed that age might be an independent factor for poorer recovery in both female and male. This knowledge can be used when informing patients what to expect after discharge. Key words sex; gender; mhealth; mobile phone; patient outcome assessment; postoperative complications; postoperative period

3 Introduction Previous research has shown that women seem to have a poorer quality of recovery than men [1, 2]. Even though women emerged faster from general anaesthesia [1-3], women reported higher pain scores in the post-anaesthesia care unit (PACU) and in the first three days after surgery, and they also experienced more postoperative nausea and vomiting as well as longer stays in the PACU compared to men [1]. Physical differences might explain these observed differences [1]. Also worth noting is that there may be gender role expectations resulting in men being less willing than women to report pain [4]. However a weakness is that previous studies reporting patients recovery only measure postoperative recovery 2-3 times postoperatively [1, 2, 5, 6, 7]. As well, there is no consensus regarding which day or days are most important to follow up. Furthermore, patients experience several barriers to self-management during their recovery [8]. This may be one reason for unplanned health care contacts [9] and according to one study, the most common reason was postoperative pain [10]. Another reason can be that follow up after anaesthesia and surgery is not performed routinely or as telephone call postoperative day (POD) one or two [11]. One way to perform follow up after surgery is to use mhealth solutions [12-14] to increase patients satisfaction [12, 14] and to facilitate postoperative follow up [12, 15]. To the best of our knowledge, evidence is lacking with respect to daily potential sex differences in postoperative recovery and number of health care contacts. Therefore, the aim of this study was to investigate whether there were any sex differences in postoperative recovery within 14 postoperative days (PODs) in a cohort of day surgery patients using a mhealth solution.

4 Methods Study design and participants This was a secondary analysis from a prospective single-blind multicentre randomized controlled trial performed at four different day surgery settings in Sweden. The study was carried out in accordance the study protocol [16] and was approved by the regional ethical review board in Uppsala (2015/262) [17]. The trial was registered with the US National Institutes of Health Clinical Trials Registry: NCT Participants received written information about the study before the planned surgery. Oral information was provided by the research nurse who also was responsible for participant inclusion on the same day as surgery, and for collecting oral and written consent from all participants. Inclusion criteria were undergoing day surgery, being able to understand the spoken and written Swedish language, having access to a smartphone, and being 18 years of age. Exclusion criteria were having memory impairment, visual impairment, or alcohol and/or drug abuse, or undergoing a surgical abortion. The secondary aim of the RCT was to investigate postoperative recovery. This paper presents only the patients who were randomly allocated to the intervention group [16]. In the intervention group, an app called RAPP (Recovery Assessment by Phone Points) which includes the Swedish web-version of the Quality of Recovery questionnaire (SwQoR) [13, 14, 18] was installed on the participant s own smart phone. The patient was instructed how to report postoperative recovery daily for 14 days, starting from postoperative day 1 after surgery. An additional function in the app was the possibility for the participant to be contacted by a nurse. Every day the app presented the question Do you want to be contacted by a nurse? (YES or NO). If requested, a registered nurse, from the department where the surgery had been performed, called within 24 hours (weekdays). Outcomes The primary endpoint for this study was postoperative recovery assessed by SwQoR. Reliability and validity tests have provided sufficient evidence that SwQoR is appropriate to use for day surgery patients [13, 14, 18, 19] and is clinically feasible for systematic follow-up over time during postoperative recovery [19]. The SwQoR includes 24 items measuring postoperative recovery to be reported on an 11-point response scale (0-10) ranging from 0=none of the time to 10 = all of the time [19]. Guided by the main study

5 the SwQoR has a possible global score ranging from 0 (excellent quality of postoperative recovery) to 240 (extremely poor quality of recovery) with cut off values of <31 at day 7 and (<21 at day 14 indicating good recovery) [17]. On POD 14 the participants answered a study-specific paper-based questionnaire including Yes/No questions (n = 5) and number of and reasons for all surgery-related health care contacts with: primary care, emergency department (ED), Sweden s 24-hour helpline 1177, outpatient hospital and contact via RAPP. A 14-day follow-up was chosen, as the majority of care contacts are reported to be made in the first 2 weeks after day surgery [20]. The following data was also recorded: sex, American Society for Anaesthesiologists (ASA) classification, type of surgery, type of anaesthesia, duration of surgery, and duration of time spent at the post-anaesthesia care unit (PACU). Statistical analysis The sample size calculation is presented else were and there was no priori sample size calculation regarding sex differences [16]. Descriptive statistics of baseline characteristics (age, sex, ASA classification, type of surgery, duration of stay at the PACU) were analysed with number, percentage or mean (SD). Missing answers in the returned questionnaires regarding health care contacts were considered as no contact (= 0). Continuous data were tested for normality using the Shapiro-Wilks test. In this study when analysing the overall level of recovery the global score was used. Guided from earlier studies [21-23], mean (SD) is used for SwQoR scores. To compare differences between males and females, chi-square, student s t-test, and Mann-Whitney U test were used, as appropriate. Different sub groups analyses were performed, analysing differences between types of surgery (general surgery / urology/gynaecology vs. orthopaedic and hand surgery), and age differences, (<45 years and 45 years, guided by the mean age in present study population). To determine differences between ages, the mean value was used as a cut-off value. To assess clinical significance, effect size was analysed using Cohens effect size (ES) ( = small effect, = moderate effect, >0.8= large effect) [24].

6 For statistical analyses, IBM SPSS statistics version 24 for Windows was used (IBM, Armonk, NY, US). A P-value <0.01 was considered statistically significant in all analyses. Results Patients were enrolled between October 2015, and July 2016 and patients were assessed for eligibility. In all, 770 patients were excluded before randomization, for different reasons, this is described elsewhere [17]. The remaining patients were randomized to either the RAPP or the control group. The RAPP group, included 513 patients, of whom 19 patients did not receive the intervention, leaving a total of 494 patients (n = 220 [44.5%] male and n = 274 female [55.5%]). Of these, 127 males and 215 females returned the questionnaire regarding health care contacts. There were no significant differences between males and females in age, ASA classification, duration of surgery or duration of time spent at the PACU. There were significant differences in type of surgery between males and females (P <.001) (Table 1). There were no significant differences between males and females on items of the SwQoR except on POD 1, in which females scored higher scores than males in dizziness ( P =. 002, ES.28), and on POD 4, in which females scored higher on more sleeping difficulties (P =.003, ES.30). On POD 12 males scored higher scores than females in reddened surgical wound (P =.006, ES.20). There were no significant differences in response rate over time between males and females (Table 2). The SwQoR global score decreased over time. Mean (SD) for males was 46 (34) on POD 1 and 17 (21) on POD 14. Corresponding numbers for females were 53 (36) on POD 1 and 22 (28) on POD 14. There were no significant differences in the global score between the sexes in postoperative recovery at any time point. Males had a global score below 30 at POD 5, and female had a global score below 30 at POD 8 (Figure 1). Age differences When analysing difference in items in the SwQoR between the sexes in different age groups, females (<45 years) scored significantly higher scores (i.e. poorer recovery) compared to males on the following items: nausea/vomiting on POD 1 (P =.003, ES.43) and, PODs 3-4 (P = , ES.43.53), anxiety on POD 1 (P =.006, ES.39),

7 dizziness on POD 1 (P =.002, ES.43) and, PODs 3-5 (P = , ES ), sleeping difficulties POD 4 (P =.005, ES.48) and POD 8 (P =.008, ES.36) and headache POD 9 (P =.002, ES.61) and POD 13 (P =.008, ES.39). Females 45 years also scored higher scores on the items having difficulty returning to work or usual home activities on POD 1 (P =.01, ES.38) and having difficulty taking care of my personal hygiene on POD 2 (P=.01, ES.30). Males scored significantly higher scores (i.e. poor recovery) on the items having trouble breathing (P =.001, ES.45), sore throat (P =.01, ES.34), and fever (P =.007, ES.24) on POD 10. Also, men scored higher values in reddened surgical wound (P =.01, ES.24) on POD 12 compared to females. When analysing global score in SwQoR and age differences (<45 years and 45 years), males and females showed somewhat similar recovery profiles. Younger males (<45 years) reported significantly higher global scores (i.e. poorer recovery) on PODs 2-6 (P =.001 to P =.006) compared to males 45 years (Figure 2). Females <45 years reported significantly higher global scores (i.e. poorer recovery) on PODs 1-10 compared to females 45 years (P-values ranging from <.001 to.011) (Figure 3). A higher proportion of females 45 years had undergone orthopaedics and hand surgery (n = 98 [65%] vs. n = 53 [35%]) and general surgery, gynecology (n=48[52%] vs. n=44 [48%]) than younger females. For males, the proportions for surgery were somewhat the same: a higher proportion of older males ( 45 years) had undergone general surgery or urology (n = 42 [67%] vs. n = 22 [33%]) than younger males. The numbers for orthopaedics and hand surgery were 43% (n = 53) vs. 57% (n = 71) between older and younger males, respectively. Finally, a higher proportion of younger females 68% (n = 19) and males 71% (n = 22) had ear, nose, and throat surgery: eye surgery: or dental surgery compared to the older age group in females, 32% (n = 9) and males 29% (n = 9). When comparing global scores in SwQoR and sex in the two age groups, <45 years and 45 years, there were no significant differences between sexes at any time during the PODs There were no statistical differences between sexes in healthcare contacts. Both males and females had most of their healthcare contacts via RAPP, 21/43 (49%) and 40/110 (36%), respectively (Table 3).

8 Discussion This study evaluates patients postoperative recovery during the first 14 PODs using RAPP, a mhealth solution. To our knowledge, this type of follow-up has never been performed previously. The focus of this study was sex differences, and the results showed no significant differences in postoperative recovery, either in global score of SwQoR during the first 14 PODs or in health care contacts. In individual items there were only sex differences in 3 out of 24 items, dizziness and sleeping difficulties on POD 1 and reddened surgical wound on POD 12. The absence of difference between men and women in this study is in line with an Icelandic study using Quality of Recovery 40 (QoR-40), investigating 427 men and women undergoing day surgery [5]. These results and ours are, however, in contrast with a number of studies showing sex differences, reporting women to be prone to poor postoperative recovery [1-3, 25]. The underlying mechanism for the absence of sex differences in the present study is not clear, and there may be several possible explanations. To mention a few there could be cultural differences, or our findings may be a result of awareness of possible sex difference and implementation of evidence- based medicine guidelines in clinical practice, such as preventing postoperative symptoms like nausea, pain and so forth. It may be that using mhealth is more beneficial for women. If so, this is consistent with a study investigating a telehealth intervention, showing that women in the intervention group had lower incidence of depression, fatigue, sleeping difficulties and pain after coronary artery bypass surgery [26]. The possibility of reporting the postoperative recovery process on a daily basis has been shown to significantly decrease scores in SwQoR on individual items and to lower global scores compared to a control group [17]. Another explanation may be that the intervention itself increased the feeling of selfefficacy: thus, it may have lessened any potential difference between men and women. Also, the patients could at any time press the button if they wished to be contacted by a nurse. This may have given a sense of security. However, Hyde [27] stated, in her review about gender differences and similarities, that gender differences in emotional experience are small, or in many cases, trivial, and that there still exists a stereotype that portrays women as the emotional ones, and that there are large gender differences in emotions such as fear and anxiety. In the present study similarities were also found between sexes in number of health care contacts, which is in line with an earlier study

9 investigating predisposing factors for ED visits that found that no sex differences in ED visits after surgery [28]. The postoperative recovery assessment in this study was performed using the patients own mobile phones. The benefit of using e-assessment with a mobile phone is familiarity with the technology, which makes it easy to use[14]. Previous research has shown that barriers against using mobile technology can be dependent on, amongst all, gender, indicating that women have higher levels of anxiety and technophobia than men [29]. Therefore, the use of an app in relationship to genders and postoperative recovery needs to be investigated further. Postoperative pain has been reported to be a common symptom during recovery at home [10]. SwQoR measures how often (none of the time to all of the time) a symptom, feeling, or an impaired ability occurs and not how severe a feeling or symptom is. It is not to be confused with a numeric rating scale measuring, for example postoperative pain. In this study both men and women patients reported pain from the surgical wound to be present most of the time, especially on the first PODs. One study investigating patients symptom management techniques after orthopaedic day surgery reported that patients managed postoperative pain using different strategies, including pain medications and, ice to relieve pain and induce numbness, and also reducing of food and drink so they wouldn t have to get up and move [8]. In respect of that result, it is likely that the sense of feeling relaxed/comfortable as well as having a feeling of general wellbeing, and difficulty in taking care of one s personal hygiene and in returning to work or usual home activities may, in fact, be interrelated with the patients postoperative pain in this study. The present study showed that women 45 years reported significantly better postoperative recovery (hence, lower global scores on SwQoR). The effect of menstrual cycles phase and its effect on overall postoperative recovery have been investigated, showing that premenopausal women reported higher pain scores and had poorer recovery according to scores [1]. This study also shows that men 45 years reported significantly lower global scores (i.e. better recovery) on PODs 2-6. On the other hand,

10 both younger women and men reported poorer recovery (i.e. higher global score in SwQoR) in the first week after discharge. It may be argued that the cut-off used in this study is not appropriate. Different age cut-offs have been used when investigating younger and older patients, for example < 52 years [3] or < 65 years [30]. This study s result is somewhat in line with a large-scale study including day surgery patients which found that elderly patients (i.e. >65 years) had lower incidence of any postoperative event (for example, pain, postoperative nausea and vomiting, shivering and agitation) measured at the PACU and in the ambulatory surgical unit (adjusted odds ratio, 0.43). However, the elderly patients had mostly undergone ophthalmologic surgery which causes minimal postoperative pain [30]. The role of age, sex, and postoperative recovery needs further investigate on. It is possible that this study s results depend on the presence of generation gaps, attitudes and gender role expectations. Maybe there is less gender role expectations in this Swedish sample. Fifty-eight per cent of the women and 48 % of the men were 45 years. As a result of these differences, an analysis on type of surgery was performed, in case the younger population was confounded by the distribution of type of surgery. The analysis showed significant differences between the groups. Hence, there is a possibility that type of surgery may have confounded the results. This study has some limitations. The non-existing significant differences between genders could be due to the small sample size, and there might be a type II error. The sample size was calculated for the primary outcome, cost effectiveness for RAPP [9, 16]. However, the sample size in this study is almost the same as in other studies reporting gender differences [1, 2]. Another limitation we acknowledge is that the patients did not report any baseline values in SwQoR. Patient-reported outcome (PRO) after surgery and anaesthesia is of great interest for health care professionals as well as for the patient. The question is not why, but when and how PRO s should be measured. There are also some concerns regarding how to compare results between different studies. Therefore, this study s result must be interpreted with caution and the results between studies are difficult to compare. Different instruments [5, 6, 31] and different data collection methods are used in different studies. Other available instruments for example QoR-40 [22] and the postoperative quality recovery scale (PQRS) [32] or post-discharge surgical

11 recovery scale (PSR) [33] and they were developed to be used with inpatients [32], outpatients [33], or both in-and outpatients [21]. Wording of items differs: usually there is a mix of positively and negatively worded items in an instrument [34]. In SwQoR all items are negatively worded [18] and this construction is consistent with visual analogue scales, anchored by two extreme values [35]. The SwQoR global score is also anchored by two values, 0 (excellent recovery) and 240 (poor recovery). The QoR-40 [21] and PQRS [32] were developed to be analysed in dimensions. SwQoR evaluates the patient s recovery on an item level, in the belief that the patient needs to be cared for according to which individual item indicating distress is disturbing. However, having said this, the possibility of analysing global scores may offer an insight in the overall recovery process. And possibly get a surrogate measure for quality in the recovery process. This study indicates to that there are similarities in postoperative recovery and health care contacts between men and women. However, subgroup analysis shows that age may be an independent factor for poorer recovery in women and men. This knowledge can be used when informing female patients what to expect after discharge. Acknowledgement Authors contribution and authorship Study design: UN, MJ Study coordination: UN, KD Data analysis: UN, MJ, KD Writing and approval of final manuscript: UN, MJ, KD Declaration of conflicts of interest The author UN and the Örebro University Enterprise AB hold shares in RAPP-AB. Funding This study was founded by FORTE (the Swedish Research Council for Health Working Life and Health Care), (grant No ) and (the Swedish Research Council (Vetenskapsrådet), (grant No References 1. Buchanan FF, Myles PS, Cicuttini F. Effect of patient sex on general anaesthesia and recovery. British journal of anaesthesia 2011;106(6): PMID:

12 2. Myles PS, McLeod AD, Hunt JO, Fletcher H. Sex differences in speed of emergence and quality of recovery after anaesthesia: cohort study. BMJ (Clinical research ed) 2001;322(7288): PMID: Buchanan FF, Myles PS, Leslie K, Forbes A, Cicuttini F. Gender and recovery after general anesthesia combined with neuromuscular blocking drugs. Anesthesia and analgesia 2006;102(1): PMID: Robinson ME, Riley JL, 3rd, Myers CD, Papas RK, Wise EA, Waxenberg LB, et al. Gender role expectations of pain: relationship to sex differences in pain. The journal of pain : official journal of the American Pain Society 2001;2(5): PMID: Sveinsdottir H, Borgthorsdottir T, Asgeirsdottir M, Albertsdottir K, Asmundsdottir L. Recovery After Same-Day Surgery in Patients Receiving General Anesthesia: A Cohort Study Using the Quality of Recovery-40 Questionnaire. Journal of Perianesthesia Nursing 2016;31(6): PMID: Chazapis M, Walker EM, Rooms MA, Kamming D, Moonesinghe SR. Measuring quality of recovery-15 after day case surgery. British journal of anaesthesia 2016;116(2): PMID: Idvall E, Berg K, Unosson M, Brudin L, Nilsson U. Assessment of recovery after day surgery using a modified version of quality of recovery-40. Acta anaesthesiologica Scandinavica 2009;53(5): PMID: Odom-Forren J, Reed DB, Rush C. Postoperative Distress of Orthopedic Ambulatory Surgery Patients. AORN journal 2017;105(5): PMID: Dahlberg K, Philipsson A, Hagberg L, Jaensson M, Hälleberg-Nyman M, Nilsson U. Costeffectiveness of a systematic e-assessed follow-up of postoperative recovery after day surgery: a multicentre randomized controlled trial. British journal of anaesthesia 2017;119(5): PMID: Mattila K, Toivonen J, Janhunen L, Rosenberg PH, Hynynen M. Postdischarge symptoms after ambulatory surgery: first-week incidence, intensity, and risk factors. Anesthesia and analgesia 2005;101(6): PMID: Stomberg MW, Brattwall M, Jakobsson JG. Day surgery, variations in routines and practices a questionnaire survey. Int J Surg 2013;11(2): PMID: Semple JL, Sharpe S, Murnaghan ML, Theodoropoulos J, Metcalfe KA. Using a mobile app for monitoring post-operative quality of recovery of patients at home: a feasibility study. JMIR mhealth and uhealth 2015;3(1):e18. PMID: Jaensson M, Dahlberg K, Eriksson M, Grönlund Å, Nilsson U. The Development of the Recovery Assessments by Phone Points (RAPP): A Mobile Phone App for Postoperative Recovery Monitoring and Assessment. JMIR mhealth and uhealth 2015;3(3):e86. PMID: Dahlberg K, Jaensson M, Eriksson M, Nilsson U. Evaluation of the Swedish Web-Version of Quality of Recovery (SwQoR): Secondary Step in the Development of a Mobile Phone App to Measure Postoperative Recovery. JMIR research protocols 2016;5(3):e192. PMID:

13 Armstrong KA, Coyte PC, Brown M, Beber B, Semple JL. Effect of Home Monitoring via Mobile App on the Number of In-Person Visits Following Ambulatory Surgery: A Randomized Clinical Trial. JAMA surgery 2017;152(7): PMID: Nilsson U, Jaensson M, Dahlberg K, Odencrants O, Grönlund Å, Hagberg L, et al. RAPP, a systematic e-assessment of postoperative recovery in patients undergoing day surgery: study protocol for a mixed-methods study design including a multicentre, twogroup, parallel,single-blind randomised controlled trial and qualitative interview studies. BMJ Open 2016;6(1) :e PMID: Jaensson M, Dahlberg K, Eriksson M, Nilsson U. Evaluation of postoperative recovery in day surgery patients using a mobile phone application: a multicentre randomized trial. British journal of anaesthesia 2017;119(5): PMID: Jaensson M, Nilsson U. Impact of changing positively worded items to negatively worded items in the Swedish web-version of the Quality of Recovery (SwQoR) questionnaire. Journal of evaluation in clinical practice 2016;23(3): PMID: Nilsson U, Dahlberg K, Jaensson M. The Swedish Web Version of the Quality of Recovery Scale Adapted for Use in a Mobile App: Prospective Psychometric Evaluation Study. JMIR mhealth and uhealth 2017;5(12):e188. PMID: Engbaek J, Bartholdy J, Hjortso NC. Return hospital visits and morbidity within 60 days after day surgery: a retrospective study of 18,736 day surgical procedures. Acta anaesthesiologica Scandinavica 2006;50(8): PMID: Myles PS, Weitkamp B, Jones K, Melick J, Hensen S. Validity and reliability of a postoperative quality of recovery score: the QoR-40. British journal of anaesthesia 2000;84(1): PMID: Stark PA, Myles PS, Burke JA. Development and psychometric evaluation of a postoperative quality of recovery score: the QoR-15. Anesthesiology 2013;118(6): PMID: Gornall BF, Myles PS, Smith CL, Burke JA, Leslie K, Pereira MJ, et al. Measurement of quality of recovery using the QoR-40: a quantitative systematic review. British journal of anaesthesia 2013;111(2): PMID: Fayers PM, Machin D. Quality of life. The assessment, analysis and reporting of patientrepored outcomes.: John Wiley & Sons Ltd; Myles PS, Hunt JO, Moloney JT. Postoperative 'minor' complications. Comparison between men and women. Anaesthesia 1997;52(4): PMID: Zimmerman L, Barnason S, Hertzog M, Young L, Nieveen J, Schulz P, et al. Gender differences in recovery outcomes after an early recovery symptom management intervention. Heart Lung 2011;40(5): PMID: Hyde JS. Gender similarities and differences. Annu Rev Psychol 2014;65: PMID:

14 28. Menendez ME, Ring D. Emergency Department Visits After Hand Surgery Are Common and Usually Related to Pain or Wound Issues. Clinical orthopaedics and related research 2016;474(2): PMID: Gilbert D, Lee-Kelley L, Barton M. Technophobia, Gender Influences and Consumer DecisionMaking for Technology-Related Products. European Journal of Innovation Management 2003;6(4): Chung F, Mezei G, Tong D. Adverse events in ambulatory surgery. A comparison between elderly and younger patients. Canadian journal of anaesthesia = Journal canadien d'anesthesie 1999;46(4): PMID: Berg K, Kjellgren K, Unosson M, Arestedt K. Postoperative recovery and its association with health-related quality of life among day surgery patients. BMC Nurs 2012;11(1):24. PMID: Royse CF, Newman S, Chung F, Stygall J, McKay RE, Boldt J, et al. Development and feasibility of a scale to assess postoperative recovery: the post-operative quality recovery scale. Anesthesiology 2010;113(4): PMID: Berg K, Idvall E, Nilsson U, Arestedt KF, Unosson M. Psychometric evaluation of the postdischarge surgical recovery scale. Journal of evaluation in clinical practice 2010;16(4): PMID: Podsakoff PM, MacKenzie SB, Lee JY, Podsakoff NP. Common method biases in behavioral research: a critical review of the literature and recommended remedies. J Appl Psychol 2003;88(5): PMID: Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken) 2011;63 Suppl 11:S PMID:

15 Table 1. Demographic data, type of surgery and anaesthesia and duration of surgery and anaesthesia Age mean(sd) ASA I,II,III n(%) Type of surgery# n(%) Male Female P-value 220(44.5) 274(55.5) 44.13(15.09) 45.49(14.87).31 a 115(52)/61(28)/6(3) 127(46)/86(31)/5(1.8).45 c <.001 c Orthopaedics 75(34) 85(31) General 60(27) 66(24) Hand 50(22.3) 66(24) ENT 28(12.7) 24(8.8) Gynaecology 26(9.5) Eye 3(1.4) 2(0.7) Urology 3(1.4) Dental 2(0.7) Duration of surgery, 43.61(30.20) 37.92(28.90).16 b min mean (SD) Duration of time spent at PACU, hours mean (SD) 2.28(1.66) 2.35(1.82).67 a PACU= postanaesthesia care unit a Analysed with independent T-test, b Analysed with Mann-Whitney U- test, c Analysed with Chi-square test Missing values: men n=38, women n=56 # Missing values: men n=1, women n=3

16 Table 2. Response rate for SwQoR Postoperative day Response rate, male n (%) (85) 243 (89) (79) 232 (85) (77) 224 (82) (70) 226 (82) (69) 212(77) (68) 207 (76) (64) 201 (73) (62) 199 (73) (62) 189 (69) (58) 182 (66) (58) 178 (65) (53) 187 (68) (59) 191 (70) (53) 167 (61) There was no significant differences at any time Response rate, female n(%) Table 3. Comparison of unplanned health care contacts (n= 342)

17 Male (n=127) # Female (n=215) # P-value Primary health care Number of persons, n (%) 4/127 (3) 12/215 (6).30 b Number of contacts a c ED Number of persons, n (%) 4/127 (3) 8/215 (4).78 b Number of contacts a c 1177 Number of persons, n (%) 6/127 (5) 22/215 (10).07 b Number of contacts a c Outpatient hospital visits Number of persons, n (%) 7/127 (6) 16/215 (7).49 b Number of contacts a c Phone call to the day surgery department 1 1 Requesting contact via RAPP Number of persons, n (%) 17/127 (13) 37/215 (17).35 b Number of contacts a c Sum unplanned contacts Number of persons, n (%) 25/127 (20) 67/215 (31).021 b Number of contacts a c ED = emergency department; 1177 = Sweden s 24-hour helpline; RAPP = Recovery Assessment by Phone Points. # Missing questionnaires men=93, women=59 a Unless otherwise specified, one contact per person was made. b Chi-square test. c Mann-Whitney U-test.

18 60 SwQoR global score Postoperative day Female Male Figure 1. Presenting global score (mean) for SwQoR for males and females (Higher score= poorer recovery) SwQoR=Swedish web version of Quality of Recovery questionnaire

19 60 SwQoR global score Postoperative day < 45 years 45 years Figure 2. Presenting the difference in global score ( mean) for SwQoR depending on age for males. (Higher score= poorer recovery). Postoperative days 2 to 6 showed statistically significant differences, p-values between and SwQoR=Swedish web version of Quality of Recovery questionnaire

20 70 SwQoR global score Postoperative day <45 years 45 years Figure 3. Presenting the difference in global score for SwQoR depending on age for females. (Higher score= poorer recovery). Postoperative days 2 to10 showed statistically significant differences, p-values between <0.001 and SwQoR=Swedish web version of Quality of Recovery questionnaire