Julia K. Moore

Anaesthesia for day case surgery: a survey of adult clinical practice in the UK

Background and objective: In October 2000, we conducted a national postal survey of consultant day case anaesthetists in the UK to explore the range and variation in the practice of anaesthetizing a patient for day case surgery (paediatrics, urology and orthopaedics). The survey was carried out as part of a larger study that comprised a major two-centre randomized controlled trial designed to investigate the costs and outcome of several anaesthetic techniques during day care surgery in paediatric and adult patients (cost-effectiveness study of anaesthesia in day case surgery). We report the findings of this national survey of adult urology and orthopaedic day case anaesthetic practice in the UK. Methods: The survey used a structured postal questionnaire and collected data on the duration of the surgical procedure; the use of premedication; the anaesthetic agents used for induction and maintenance; the fresh gas flows used for anaesthesia; the use of antiemetics; and the administration of local anaesthesia and analgesia. Results: The overall response rate for the survey was 74% (63% for urology, 67% for orthopaedics). The survey indicated the following practice in adult urology and adult orthopaedic day case surgery: 6 and 12% used premedication; propofol was the preferred induction agent (96 and 97%) and isoflurane the preferred maintenance agent (56 and 58%); 32 and 41% used prophylactic antiemetics; 86 and 93% used a laryngeal mask. Conclusions: This survey identifies the variation in current clinical practice in adult day surgery anaesthesia in the UK and discusses this variation in the context of current published evidence.

Clinical and economic choices in anaesthesia for day surgery: a prospective randomised controlled trial.

Summary We compared the cost‐effectiveness of general anaesthetic agents in adult and paediatric day surgery populations. We randomly assigned 1063 adult and 322 paediatric elective patients to one of four (adult) or two (paediatric) anaesthesia groups. Total costs were calculated from individual patient resource use to 7 days post discharge. Incremental cost‐effectiveness ratios were expressed as cost per episode of postoperative nausea and vomiting (PONV) avoided. In adults, variable secondary care costs were higher for propofol induction and propofol maintenance (propofol/propofol; p < 0.01) than other groups and lower in propofol induction and isoflurane maintenance (propofol/isoflurane; p < 0.01). In both studies, predischarge PONV was higher if sevoflurane/sevoflurane (p < 0.01) was used compared with use of propofol for induction. In both studies, there was no difference in postdischarge outcomes at Day 7. Sevoflurane/sevoflurane was more costly with higher PONV rates in both studies. In adults, the cost per extra episode of PONV avoided was £296 (propofol/propofol vs. propofol/ sevoflurane) and £333 (propofol/sevoflurane vs. propofol/isoflurane).

A comparison of parents and pediatric anesthesiologists’ preferences for attributes of child daycase surgery: a discrete choice experiment

Background:  Currently, there is little evidence relating to which attributes of pediatric daycase surgery are most important to parents; therefore, it is difficult for policy‐makers in the UK to incorporate parents’ preferences into pediatric daycase service provision. Additionally, few studies have considered anesthesiologists’ preferences in this area. Parents and anesthesiologists’ preferences for perioperative care of children undergoing daycase surgery may differ and this could affect levels of satisfaction with service provision. This study aimed to elicit and compare the relative importance of attributes of pediatric daycase surgery provision to parents and anesthesiologists using an established stated preference method, the discrete choice experiment. The attributes considered were: parental involvement in medical decision making; parental presence at induction of anaesthesia; quality of recovery from anaesthesia; staff attitude; postoperative pain and cost to the parents.

The effect of anaesthetic agents on induction, recovery and patient preferences in adult day case surgery: a 7-day follow-up randomized controlled trial.

Background and objective: To compare induction, pre‐ and post‐discharge recovery characteristics and patient preferences between four anaesthetic regimens in adult day‐surgery. Methods: Randomized controlled trial. In all, 1158 adults assigned to: propofol induction and maintenance, propofol induction with isoflurane/N2O, or sevoflurane/N2O maintenance, or sevoflurane/N2O alone. We prospectively recorded induction and pre‐discharge recovery characteristics, collected 7‐day post‐discharge recovery characteristics using patient diaries and patient preferences by telephone follow‐up. Results: Recruitment rate was 73% ‐ of the 425 refusals, 226 were not willing to risk a volatile induction. During induction, excitatory movements and breath holding were more common with sevoflurane only (P < 0.01). Injection pain and hiccup were more common with propofol induction (P < 0.01). In the recovery room and the postoperative ward, both nausea and vomiting were more common with sevoflurane only (P < 0.01). This difference disappeared within 48 h. There was no difference between groups in the mental state on awakening, recovery time, time to discharge or overnight admissions; then was also no difference in pain between the four groups for each of the seven postoperative days (P < 0.01), nor any differences in concentration or forgetfulness. Patients took 6.5 days (95% CI: 6.0‐7.0, n = 693) to resume normal activities. Patients who received sevoflurane only were more likely to recall an unpleasant induction and least likely to want the same induction method again (P < 0.01). Conclusion: Differences in outcome between the four regimens are transient; sevoflurane is not an ideal sole agent for adult day case anaesthesia and, in this setting, patients base their preferences for future anaesthetics on the method of induction.

A comparison of parents' and anaesthetists' preferences for attributes of child day case surgery: An application of discrete choice methodology

Background:  Currently, there is little evidence relating to which attributes of pediatric daycase surgery are most important to parents; therefore, it is difficult for policy‐makers in the UK to incorporate parents’ preferences into pediatric daycase service provision. Additionally, few studies have considered anesthesiologists’ preferences in this area. Parents and anesthesiologists’ preferences for perioperative care of children undergoing daycase surgery may differ and this could affect levels of satisfaction with service provision. This study aimed to elicit and compare the relative importance of attributes of pediatric daycase surgery provision to parents and anesthesiologists using an established stated preference method, the discrete choice experiment. The attributes considered were: parental involvement in medical decision making; parental presence at induction of anaesthesia; quality of recovery from anaesthesia; staff attitude; postoperative pain and cost to the parents.

Costing day case anesthesia: obtaining accurate patient-based costs for adults and children

OBJECTIVES This study proposes the method requirements for a valid costing study in anesthesia to allow differences to be identified between treatments and uses these method requirements to design and conduct a robust costing study. METHODS A prospective, patient-based costing study was carried out in adult and pediatric day surgery in the United Kingdom. The perspective was that of the National Health Service and the patient. Data were collected for each patient until 7 days after hospital discharge. RESULTS Data were collected for 1063 adults and 322 children undergoing day surgery between October 1999 and January 2001. Statistically significant differences were found only between variable costs, which accounted for 11.4 percent and 9.0 percent of adult and pediatric costs, respectively. There were no differences in length of stay, fixed costs, or semi-fixed costs. Differences were not found in total costs in adults but were found in children. By day 7, postdischarge primary and secondary care costs were not different between groups in either study. No differences were found in costs to patients or parents. CONCLUSIONS The use of prospective, patient-based cost data enabled the detection of differences in variable costs between difference anesthetic regimens in day surgery. The stochastic nature of the data provided a measure of variability around mean cost estimates. Practice patterns in the study reflected normal practice in the United Kingdom so the costing data have direct clinical relevance. The use of different anesthetic agents only affected variable costs and had no effect on larger cost drivers such as length of stay or staff input.