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From the Department of Anesthesiology and Pain Medicine, Walter C Mackenzie Health Sciences Center, University of Alberta, Edmonton, Alberta, Canada.
Address correspondence to: Dr. Peter Matthey, Department of Anesthesia, 3B2.32 Walter C Mackenzie Health Sciences Center, University of Alberta, Edmonton, Alberta T6G 2B7, Canada. Phone: 780-407-8861; Fax: 780-407-3200; E-mail: pmatthey{at}ualberta.ca
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Abstract |
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Methods: A province wide telephone survey was conducted in Alberta. General and regional anesthesia were defined, a scenario involving major knee surgery was described, and participants were asked to choose between regional and general anesthesia. Respondents used a seven-point scale to rate the importance of seeing an anesthesiologist preoperatively and were questioned about the timing of such a visit. Attitudes towards commonly perceived fears associated with anesthesia were also assessed.
Results: A total of 1,216 people were surveyed. Over 30% of respondents felt that it was very important to see an anesthesiologist preoperatively, with a total of over 60% attributing a high degree of importance to this. Fifty percent felt that this assessment should occur on the day prior to surgery. A preference for regional or general anesthesia was not expressed in the situation. Approximately 20% of respondents were very concerned about brain damage, waking up intraoperatively and memory loss. Twelve percent were concerned about dying intraoperatively. Nine percent expressed concern about postoperative pain, with 12% reporting being concerned about nausea and vomiting.
Conclusions: The general public considers anesthetic assessment on the day prior to surgery an important part of preoperative preparation. Fears of brain damage, death and intraoperative awareness associated with general anesthesia remain prevalent, suggesting that preoperative education of patients should address these concerns. The general population was less concerned about realistic fears such as nausea, vomiting and postoperative discomfort.
RATIONALIZATION of hospital services has resulted in a reduction in the number of in-patient surgical beds and the introduction of pre-admission clinics (PAC) and same day surgery. This has allowed significant savings to be made in both perioperative expenditure and unproductive bed utilization and occupancy. The pre-admission process has also resulted in an increased throughput of patients in the operating suite and decreased rates of case cancellation, with resultant increased operating suite efficiency.1,2 While this paradigm shift may be effective from a fiscal and resource management perspective; the response of the general public has not been assessed.
Anesthesiologists have traditionally seen patients the night before scheduled procedures. The same day admission process does not allow for this practice. Prior to the introduction of PAC this may have resulted in a large number of surgical cancellations, which would be inconvenient for patients and wasteful of limited hospital resources. Alberta has a large rural population so we realized that some patients might consider attendance at a PAC inconvenient and unnecessary, particularly because of the distances involved.
While we were in no doubt that it was important to see patients preoperatively, it was decided to seek public opinion on this issue. It was also hoped that a strong case for anesthetic presence in our PAC could be presented.
Several previous studies have surveyed patient fears concerning general anesthesia, usually on the preoperative night. It was felt that this survey instrument, the largest survey of public opinion on anesthesia related issues to date, would be an ideal tool to gain insight into the public's attitudes on these issues in a non-threatening environment.
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). Our topic was one component of the survey.
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General and regional anesthesia were defined and a case scenario involving the respondent requiring major knee surgery was described. Respondents were asked to use a seven-point scale to rate how important they felt it was to see an anesthesiologist preoperatively. They were also asked when they felt it was most appropriate to see the anesthesiologist. Other questions included whether they had a preference for regional or general anesthesia, and what their attitudes were to a number of common fears associated with general anesthesia. Responses to questions were of a closed nature to allow computerized collation of the data.
The population designated for interview was all persons 18 yr of age or older who, at the time of the survey, were living in a dwelling unit in Alberta that could be contacted by direct telephone dialling. Representative samples were chosen to cover the province: the cities of Edmonton and Calgary, and the remainder of the region. A minimum sample size of 400 or more for each area of the province was deemed necessary to permit analysis of each area as a separate entity. Respondents were selected by random dialling of numbers from a computer-generated database that is maintained by the PRL. This ensured that respondents had an equal chance of being contacted whether or not their household was listed in a telephone directory. Duplicate numbers, nursing homes and collective dwellings were excluded from the study. A single respondent was chosen from each household, and was asked to participate in the 30-min interview. Gender equality was obtained by using careful selection guidelines, as previous surveys had indicated that 60% of the time, the first household contact was female. These guidelines attempted to question a male member of the household, only selecting a female when the male was either unwilling to be interviewed or not available.
The survey instrument consisted of three components:
The questionnaire was pretested by trained interviewers on a total of 49 randomly selected households. Interviewer comments were reviewed (e.g., confusing wording, inadequate response categories, question order effect, etc.) and any necessary modifications to the final questionnaire were made prior to administering the survey.
Following the pretest, an electronic questionnaire was constructed for data collection. This was loaded into a Computer-Assisted Telephone Interviewing system, which randomly allocated telephone numbers to the interviewing stations. Both the questions and instructions were presented to the interviewer on the computer screen, and responses were entered directly into the computer. This helped ensure uniformity in interview approach.
Interviewing took place over a three-week period, primarily during weekend or evening hours. Interviewers were instructed to make a minimum of ten call back attempts before declaring a number as a "no contact" if their first attempt in establishing contact was unsuccessful. Upon making contact the interviewer introduced himself/herself, verified the telephone number, and then asked screening questions for selecting the respondent. Respondents were advised that their participation was voluntary, their responses would be kept completely confidential and that they could terminate the 30-min interview at any time. Ten percent of respondents were re-contacted by supervisors for interviewing validation. A team of specially trained interviewers made call backs to reluctant householders to further explain the purpose of the survey and to re-request an interview. This increased the response rate by approximately nine percent.
The data were tabulated and cleaned using the Statistical Package for the Social Sciences (SPSS) 6.1 for Windows. The cleaning process included wildcode, discrepant value, and consistency checks to eliminate any inconsistencies or invalid responses to questions. As the final sample sizes obtained for the three areas surveyed were not proportional to the Alberta population they represent, weighting was necessary in order to combine the samples for a provincial survey (Table II). A comparison of this survey's age distributions with that of the Statistics Canada 1994 Preliminary Postcensal Estimates demonstrated that the samples adequately reflected the populations from which they were drawn (Table III).
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). Non-participation was due to incomplete interviews, refusals, language problems and no contacts. Demographic data including education, employment data, income and gender are shown in Table V. The median age of respondents was 40.3 yr. There were no differences in percentages of males and females selected. Eighty percent of those interviewed had had an anesthetic, other than dental anesthesia, previously.
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). Fifty-one percent of the total respondents felt that such a visit should occur on the day prior to surgery, while 33.6% thought that they should be seen on the operative day. The remaining 15.5% felt that it was not necessary to be seen by an anesthesiologist.
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Nineteen percent of respondents were very concerned about brain damage, while waking up during general anesthesia and memory loss were reported as significant concerns by 17.3% and 17.2 % of those interviewed respectively. Twelve percent were very concerned about dying intraoperatively. Very few of the respondents were very concerned about postoperative pain (8.8%) or nausea and vomiting (11.8%).
The results of enquiries concerning other perioperative fears are summarized in Table VI.
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Discussion |
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The results of this survey support Lonsdale's finding, in a study comparing Scottish and Canadian populations, that patients rated meeting the anesthesiologist preoperatively as their highest priority.3 Conway et al. also found that preoperative consultation increased patient satisfaction with the standard of perioperative care, and decreased anxiety about anesthesia.
A study by Shevde et al. found that 69% of patients had a preference for general anesthesia over regional anesthesia.4 However; this study questioned a number of patients undergoing a wide variety of surgical procedures on the preoperative day. Furthermore as his study population was 62% female, and they found that women tended to express higher levels of concern on a number factors concerning anesthesia, these factors may have contributed to the higher percentage of patients expressing a preference for general anesthesia. The current survey result of 49.3% probably reflects the fact that we chose a single case scenario that was readily amenable to a regional anesthetic technique and that our study population was 50% female.
Previous studies have shown that the incidences of many common fears about anesthesia vary widely between patient populations chosen and the type of survey instrument used (Table VII).5–7 The number of respondents stating that they would be very concerned about intraoperative death was lower than that reported in three other large studies which reported the incidence as varying from 34% to 43.4%. However, when scores for patients expressing any degree of concern about intraoperative death are combined, the incidence of 47% was noticeably higher.
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The risk of awareness would appear to be a major concern among members of the general public. Nearly 40% of the respondents stated that they would have some degree of concern about this. This clearly represents a failure on the part of anesthesiologists to adequately educate the public, as large clinical surveys indicate an incidence of explicit awareness of <0.3% for general surgery.8,9
In conclusion, the general public places a high priority on meeting with their anesthesiologist preoperatively. This meeting affords patients the opportunity to voice any specific fears and anxieties that they may have about their anesthetic. It also allows the anesthesiologist discuss the choice of anesthetic technique and analgesic options with patients, get appropriate informed consent, and reassure them about real and perceived, though rare, risks involved in the administration of anesthesia.
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References |
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2
Conway JB, Goldberg J, Chung F. Preadmission anaesthesia consultation clinic. Can J Anaesth 1992; 39: 1051–7.
3 Lonsdale M, Hutchinson GL. Patients' desire for information about anaesthesia; Scottish and Canadian attitudes. Anaesthesia 1991; 46: 410–2.[Medline]
4
Shevde K, Panagopoulos G. A survey of 800 patients' knowledge, attitudes, and concerns regarding anesthesia. Anesth Analg 1991; 73: 190–8.
5 Klafta JM, Roizen MF. Current understanding of patients' attitudes toward and preparation for anesthesia: a review. Anesth Analg 1996; 83: 1314–21.[Abstract]
6 Hume MA, Kennedy B, Asbury AJ. Patient knowledge of anaesthesia and peri-operative care. Anaesthesia 1994; 49: 715–8.[Medline]
7 McCleane GJ, Cooper R. The nature of pre-operative anxiety. Anaesthesia 1990; 45: 153–5.[Medline]
8 Heier T, Steen PA. Awareness in anaesthesia: incidence, consequences and prevention. Acta Anaesthesiol Scand 1996; 40: 1073–86.[Medline]
9 Sandin RH, Enlund G, Samuelsson P, Lennmarken C. Awareness during anaesthesia: a prospective case study. Lancet 2000; 355: 707–11.[Medline]
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