Aanesthetic Agents for Day Surgery - NIHR Health Technology ...

16 years of age. The study validated this
questionnaire and the initial results suggested
that patient satisfaction is most affected by age,
gender and type of surgical procedure. During
1991–92 the questionnaire was used in 1741
day-surgery patients undergoing day surgery
at 11 hospitals in England. Issues relating to
anaesthesia included in the questionnaire were:
satisfaction with 17 specific aspects of care (not
detailed), pain during the first 24 hours, time
taken convalescing, impact on activities of daily
living, effect of the operation on day-to-day life,
speed of recovery, readmission, and use of
ambulatory and domiciliary services. Response
rates ranged from 33% to 90% (mean 60%).
The procedures carried out were: dilatation
and curettage (D&C) (12.4%); removal of skin
growth (9.4%); cystoscopy (7.9%); dental
extraction (7.6%); laparoscopy (7.4%); and
varicose vein surgery (6.6%). Eighty-four per
cent of patients would recommend day surgery
in similar circumstances, reflecting the generally
high levels of satisfaction in this area.
The use of satisfaction as an outcome in clinical
or economic evaluations is problematic due to
the range of methods available to measure it, but
more specifically because an ‘index’ of satisfaction
is required for analysis. There is little evidence
of the development of this type of measure in
anaesthesia in general. One descriptive study was
found that developed a CV method in the form
of a willingness-to-pay tool. 21 The tool had been
developed in anaesthetic staff rather than patients,
because it was rejected by three ethics committees
as too politically sensitive. A further study looked
at 80 patients’ valuations to reduce the incidence
of PONV to zero. 176 The willingness-to-pay values
were found to be in the range US $56–100. The
study did not explore any of the methodological
issues associated with the development of valid
CV instruments. Elliott and co-workers 33 explored
the methodological development of a CV tool to
elicit patients’ preferences and willingness to pay
for alternative anaesthetic agents in day surgery.
The willingness-to-pay values for induction agents
were a mean of £208 for propofol and £105 for
sevoflurane. The mean willingness-to-pay value
for maintenance with propofol was £157.
In another descriptive study, Macario and coworkers
186 undertook a survey to try and quantify
patients’ preferences for postoperative anaesthesia
outcomes by asking them to rank ten
possible postoperative outcomes. Patients rated
the most undesirable as being vomiting, gagging
on the tracheal tube and incisional pain. The
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Health Technology Assessment 2002; Vol. 6: No. 30
authors felt that patient validation of different
outcomes was necessary for economic studies
in anaesthesia.
Baker and co-workers 167 used the Short Form with
36 items (SF-36) to measure health status in varicose
vein day surgery. The SF-36 scores indicated
that the operation caused increased pain and
reduced role function at 1 month. At 6 months
all dimensions except social function and
health perception were improved.
No other studies were found that evaluated the
use of utility measures, such as QALYs. However,
this is not surprising, as patient-based differences
between anaesthetic techniques are transient and
‘process-orientated’. Therefore, outcome-oriented
measures such as QALYs will not be sensitive to
these differences.
Qualitative studies are often useful in providing
an in-depth analysis of patient satisfaction. One
such study, using a grounded theory methodology,
explored patients’ experiences and views of day
surgery which would lead to improving the
quality of this service. This study highlighted
the need for adequate preparation and provision
of information for patients attending for
day surgery. 191
In summary, in the small number of studies found,
a wide range of methods was used, but reported in
little detail. They were mostly unvalidated, apart
from the CFQ and the Aldrete recovery score,
and were used in small groups of patients. Further
work is required to satisfy the criteria for the
evaluation of outcomes measures suggested
by Fitzpatrick and co-workers. 49
Results of studies
High levels of satisfaction with the day surgery
process overall were reported by patients.
Two studies reported a higher incidence of
‘dreams’ with propofol, 164,180 although one of
these studies 180 also used ketamine. Brandner
and co-workers 170 reported that patients ‘felt
happier’ with TIVA than with thiopentone
induction or isoflurane maintenance (p = 0.0038).
Gupta and co-workers 78 reported no mood
difference between patients maintained with
propofol or isoflurane. Larsen and co-workers 89
reported quicker psychomotor recovery with
isoflurane than with propofol (p < 0.05), as did
Nelskyla and co-workers 189 (p < 0.05). Philip and
co-workers 108 reported faster cognitive recovery
with sevoflurane than with isoflurane (p < 0.001).
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