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February 2000
Which Clinical Anesthesia Outcomes Are Important to Avoid? The Perspective of Patients.
Alex Macario, MD, MBA, Matthew Weinger, MD, Stacie Carney, BA, and Ann Kim, BA.
Anesth Analg. 1999; 89:652-8.
Commentary by Beverly Philip, M.D.
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[ see abstract below ]
 We seek to provide high quality anesthesia. However, the recipients of our care, the patients, must define this. Quality of anesthesia arises from the patients' subjective assessment of their desire for different health states, expressed as preferences for specific clinical anesthesia outcomes. Patient preferences for clinical outcomes are difficult to discern without informing patients about the expected outcomes of the procedure, and asking them about their specific preferences in a structured manner. The goals of this study were to address this need by asking patients to 1) rank order their preferences from most to least important for avoiding specific clinical anesthesia outcomes, and 2) quantify any variability in how surgical patients perceive common anesthesia side effects.
This study took place at Stanford University Medical Center. The authors reviewed the anesthesia literature and selected nine items for study. They developed 25-45 word descriptions of the clinical outcomes, which represented a range of clinical possibilities: nausea, recall without pain, gag on endotracheal tube, shivering, vomiting, residual weakness, somnolence, sore throat, pain, and normal. The authors used two separate techniques to study patient preferences. In one, patients were asked to rank ten possible postoperative outcomes, from most undesirable to most desirable. In the second method, patients used a relative value scale, in which they assigned 100 hypothetical dollars across the outcomes: more dollars were to be assigned to the less desirable outcomes.
195 surveys were distributed and 101 patients returned a fully completed questionnaire, which were analyzed. The patient population had a mean age of 45 years, 61% were female, 60% were married, 81% were Caucasian, 90% had more than high school education, and 69% had a household income greater than $50,000. The ranking of the adverse anesthesia outcomes from worst to least was:
- vomiting
- gagging on endotracheal tube
- pain
- nausea
- recall without pain
- residual weakness
- shivering
- sore throat
- somnolence
- normal
All patients rated normal outcome as the most desirable. The relative value method of evaluating anesthesia outcomes produced the same ordering of results, except for an interchange of 'recall without pain' with 'nausea'. There was appreciable inter-individual variability among patient preferences for different anesthesia outcomes, but previous experience with a certain anesthesia outcome was not related to a patient's ranking of outcomes. For example, patients who had experienced nausea ranked nausea similarly to those patients who had not experienced nausea. Patients were also asked to list any other outcomes that they had experienced after surgery and anesthesia, and no single clinical outcome was suggested by more than one respondent.
Clinicians may make anesthetic regimen decisions based partly on what they believe is important medically and partly on their perceptions of what a typical patient would want to have as an ideal outcome after anesthesia. Because of the variability in how patients responded, it is difficult to know which clinical anesthesia outcomes will be of greatest concern to any particular patient. Therefore, it may be useful to actively discuss with patients the clinical outcomes that are most important to them and then tailor the anesthetic to address these preferences. Knowing how patients prioritize clinical anesthesia outcomes will help anesthesiologists to customize care.
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ABSTRACT
Which clinical anesthesia outcomes are important to avoid? The perspective of patients.
AUTHORS: Macario A; Weinger M; Carney S; Kim A.
SOURCE: Anesth Analg. 1999 Sep;89(3):652-8.
ABSTRACT:
Healthcare quality can be improved by eliciting patient preferences and customizing care to meet the needs of the patient. The goal of this study was to quantify patients' preferences for postoperative anesthesia outcomes. One hundred one patients in the preoperative clinic completed a written survey. Patients were asked to rank (order) 10 possible postoperative outcomes from their most undesirable to their least undesirable outcome. Each outcome was described in simple language. Patients were also asked to distribute $100 among the 10 outcomes, proportionally more money being allocated to the more undesirable outcomes. The dollar allocations were used to determine the relative value of each outcome. Rankings and relative value scores correlated closely (r2 = 0.69). Patients rated from most undesirable to least undesirable (in order): vomiting, gagging on the tracheal tube, incisional pain, nausea, recall without pain, residual weakness, shivering, sore throat, and somnolence (F-test < 0.01).
IMPLICATIONS: Although there is variability in how patients rated
postoperative outcomes, avoiding nausea/vomiting, incisional pain, and gagging
on the endotracheal tube was a high priority for most patients. Whether
clinicians can improve the quality of anesthesia by designing anesthesia
regimens that most closely meet each individual patient's preferences for
clinical outcomes deserves further study.
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