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Acute Postoperative Pain Management at Home After Ambulatory Surgery: A French Pilot Survey of General Practitioners’ Views

2002; Lippincott Williams & Wilkins; Volume: 95; Issue: 5 Linguagem: Inglês

10.1097/00000539-200211000-00029

1526-7598

Sébastien Robaux, H. Bouaziz, Charles Cornet, J. M. Boivin, N. Lefèvre, M.C. Laxenaire,

Enhanced Recovery After Surgery

For the last two decades, day surgery has been increasing in importance in France. In 1980, surgery was provided on a daily basis for 5% of patients, whereas in 1996, 27% of all surgical procedures in France were performed on an ambulatory basis (1). This increasing amount of day-care surgery remains modest in France compared with others countries. Previous international studies have shown that the majority of day-care surgical patients and their general practitioners (GPs) were satisfied with this new ambulatory expansion care system (2,3). However, for the small number of outpatients who are not satisfied and who contact their GPs or the ambulatory unit, one of the most frequent causes is a problem related to pain management at home (4,5). Unfortunately, the literature is sparse concerning the impact of the burden of postoperative pain management on GPs after ambulatory surgery. The aim of this cross-sectional prospective pilot survey was to assess the views of GPs in North-East France concerning pain relief at home after ambulatory surgery. We also attempted to determine what their expectations or concerns were and what improvements are required in the future, by using an anonymous self-completion questionnaire. Methods At the beginning of the study, a short postal questionnaire was sent simultaneously on September 15, 2000, to the 2199 GPs of Lorraine, including those who were no longer practicing in that region of northeastern France. Every GP received a letter, which invited him or her to take part in the survey by filling out the questionnaire. The self-completion questionnaire was to be returned in a prepaid envelope before December 15, 2000. No phone or postal reminder was done by the investigators throughout the 3-mo period of the survey. The most important part of the questionnaire consisted of 10 multiple-choice questions (Appendix 1). The GPs were invited to comment on different aspects of day-care surgery according to their own experience of patients' aftercare at home. Results Response Rate Among the 2199 questionnaires sent out, 958 were returned, giving a response rate of 43.6%. Preoperative Information Received by GPs Regarding Day Surgery The first question showed to what degree GPs considered themselves notified by hospital physicians at the conclusion of preoperative consultations that one of their patients was scheduled for day surgery. The results are shown in Table 1.Table 1: Rate of Communication Necessary for Pain Management at Home Between the Ambulatory Units and GPsGPs' Concerns Relating to Day-Care Surgery The GPs' responses to Question 3 showed that 570 of them (59.5%) were concerned about being unaware of the exact nature of the operation at the discharge of a day-surgery patient. The potential risk of the patient needing a postdischarge intervention once home or of encountering inadequate acute postoperative pain control at home were major concerns to 711 (74.2%) and 621 (64.8%) GPs, respectively. Discharge Information Between Hospitals and GPs Concerning Pain Relief at Home The results of Question 4 showed that 54% and 20% of respondents believed they sometimes and never receive information from the hospital medical team about the postoperative analgesic protocol prescribed to their outpatients (Table 1). Table 1 demonstrates the results of Question 5: 72.7% of GPs asserted that they never receive instructions from hospital physicians concerning rescue analgesia if ever outpatients remain in pain at home. Results of Question 6 indicated that, according to 80.2% of respondents, the name and phone number of a designated specialist in the ambulatory unit (in case of inappropriate acute pain management) had not been communicated to them (Table 1). Modes of Communication The preferred modes of communication were a letter given to the outpatient at discharge in 70% of cases (667) or a postal letter in 12% (112). Other ways of communication (phone contact, fax, e-mail) were used in 48 h after for 249 (25.9%) of the GPs surveyed. Frequency and Cause of Pain Relief Failure According to the GPs Question 8 examined the frequency of home consultations by the GPs because of pain relief failure at home after ambulatory surgery. They reported to be visited by outpatients >1 time a week for 5.7% (55) of them, <1 time a week for 31.7% (304), <1 time a month for 48% (460), <1 time a year for 12% (115), and never for 2.5% (24) of them. Moreover, according to the results from Question 9, this failure was attributed to the absence or inadequacy of prescriptions for respectively 24% and 63% of respondents, inadequate follow-up of prescriptions (20%), lack of a designated physician (21%), and insufficient training of GPs (10%). GPs' Expectations in Pain Management After Ambulatory Surgery Question 10 showed that 618 (64.5%) of the family physicians would prefer to obtain exhaustive scientific information (guidelines, consensus-based conferences, etc.) to be able to manage acute postoperative pain themselves. Five hundred three (52.5%) would be interested in learning appropriate techniques for postambulatory surgery analgesia. Five hundred ninety-eight (62.4%) of the respondents would appreciate being able to contact, in the near future, a designated specialist of acute pain management 24 h a day. Discussion Our results show that there is a great lack of information and collaboration between GPs and the medical hospital team after ambulatory surgery in France. When this limited information is sent, the letter given to the outpatient at discharge remains the preferred means of communication; other methods such as phone, fax, or Internet are seldom used between the hospitals and GPs. This situation might be detrimental to the outpatient's pain management at home. Exaggerated concerns about pain control at home reported in our survey could be minimized if GPs could receive (in all phases of care) more instructive information about operations performed on an ambulatory basis in general, as well as more rapidly received details of routine management of postoperative pain. Different, more effective, communication, which would allow real-time transmission of information, such as phone, fax, or electronic mail, should be developed in France. We are convinced that GPs prefer to be more involved in acute pain management once the patient is at home. Unfortunately, according to our data, they believe that ambulatory units (surgeons, anesthesiologists, and nurses) do not transmit to them all the information required to control pain at home. Family physicians reported that they are not informed about the kind of take-home analgesic protocol that is given to their outpatients. Furthermore, in the case of inadequacy of pain relief, they reported that no designated specialist physician could be contacted to ask him or her how to improve analgesia or manage side effects. Our survey indicates that a designated acute pain specialist who could be contacted 24 hours a day could augment pain control. Although our survey was exhaustive and the questionnaire was sent to all of the GPs in our region, the main bias was the absence of a "nonresponse" analysis. A random selection of a representative sample or a system of "nonresponse" identification would perhaps have been useful. Furthermore, the practice zones (rural or urban) were not specified in the questionnaire. Therefore, it was impossible to establish the characteristics of the medical population who had replied, or not, to the questionnaire. Our results are in accordance with previous studies that have suggested that inadequate analgesia at home in outpatient adults (2,4,5) and in children (6,7) is a common reason for calling their doctor. These findings might have been underestimated by GPs as a result of a memory effect on recalling past pain suffered by their day patients. Because a minority of patients contact their family physician even though they suffer pain, GPs may have also underestimated the incidence of uncontrolled pain in our survey. Three similar surveys in North-East France (unpublished data), South France (8), and Central France (6) have recently been performed. The response rates for the first 2 surveys were 21% and 22.7%, respectively, and 48% for the last study, which was the only anonymous survey. In all of the studies, the results concerning the incidence of home consultations, uncontrolled pain, and the need for specific day surgery training for GPs were almost identical to our findings. The lack of communication between French physicians has also been previously reported (6,8,9). Therefore, our results, which are applicable to our region, confirm similar results found in the aforementioned studies performed in various parts of France. Based on this statement, it is likely that our results give a representation of the current situation in France. In fact, it is noteworthy that routine management of pain at home could not eliminate pain completely (10,11): for instance, some factors have been recognized as predictors of severe pain (12–14) and certain types of surgery have also been identified as having a high risk of pain (10,15,16). These data show that effective strategies for treating postoperative pain must be developed, and that individualized discharge analgesic protocols must be prescribed, keeping in mind the type of surgical procedures undertaken and the patient's profile and pain threshold. Furthermore, multi-modal analgesia and the use of new powerful analgesic strategies should be improved to reduce the incidence of pain at home. Unfortunately, our survey indicates that these effective strategies still remain under-prescribed in France and this statement could explain postoperative pain relief failure at home. Moreover, because approximately 30%–40% of outpatients (and sometimes more in children) may have moderate-to-severe pain after being discharged home, and because it may last several days (10,11,16,17), patient education is also required for optimal pain management after ambulatory surgery because successful postoperative pain control may depend on outpatients' demands (18–20). However, 19.8% of our respondents estimated that the failure of acute postoperative pain control at home could sometimes be explained by the lack of discipline and preparation of outpatients. Indeed, it is well known that despite severe pain, many patients do not always take their medication as prescribed and may even take their own analgesics. We cannot form conclusions regarding the appropriate use of analgesic drugs by patients at home, and the impact of this element on the incidence of persistent pain cannot be assessed in our study. This is why, to avoid pain, clear instructions are needed, such as advice on how to manage pain (which drugs, when, and how often) and what kinds of side effects to expect. Likewise, in the case of regional anesthesia, both patients and GPs should be warned that the effects of a single-dose local anesthetic will wear off suddenly and that the patients should take other analgesics before this occurs, particularly before going to bed on the first night after surgery. Because analgesia also needs to be tailored to the intensity of the pain, it is important to encourage patients and GPs to use pain assessment tools to optimize pain management at home: this self-pain evaluation allows patients, if pain relief is not effective, to take breakthrough analgesics if prescribed or contact their GP or the ambulatory unit to improve the analgesic protocol via a rescue analgesic prescription. Otherwise, in our current system, 64.8% of respondents reported that their main concern after discharge remains being unable to control pain in the event of unrelieved pain at home because they do not think they are adequately trained in acute postoperative pain management. Before further expansion of prophylactic analgesic modalities, we should consider the GPs' expectations in that field. Widespread professional education is required for doctors and nurses to instill in them the principles of these new modalities and to reassure them in their ability to manage pain at home after one-day surgery. In conclusion, this survey suggests that there are inadequacies in managing pain at home after ambulatory surgery. We thank Jean-Marc Virion, biostatistician, for his technical assistance in mass mailing and data collecting, and Kylie Brennan for proofreading the manuscript. We thank the general practitioners of Lorraine who responded to this survey.