The effect of grade of anaesthetist on outcome after day surgery.

We conducted a retrospective survey to investigate if the grade of anaesthetist was a significant factor in determining outcome after day surgery in a district general hospital. All day surgery procedures performed between 1996 and 2006 were included except those under surgically administered local anaesthetic. The outcome measures assessed were unplanned admissions and symptoms reported after discharge. The overall admission rate was 2.6%, the admission rate for anaesthetic-related reasons was 1.5%, and 49% of patients reported some symptoms after discharge. Over the period studied the admission rate fell from 4.2% to 2.0%, admissions for anaesthetic-related reasons fell from 3.0% to 0.7% and reported symptoms fell from 67% to 37%. Consultants anaesthetists were associated with the lowest unplanned admission rate (consultants 2.3%, staff grade and associate specialists 3.1%, and trainees 3.3%), the lowest admission rate for anaesthetic reasons (consultants 1.2%, staff and associate specialists 2.0%, and trainees 1.8%), lower than expected specialty-weighted admissions and the lowest number of reported symptoms (consultants 47.3%, staff grade and associate specialists 52.6%, trainees 49.0%) (p < 0.001). We conclude that there was an improvement in outcome over the period of study and that the grade of anaesthetist is associated with outcome after day surgery.

A comparison of cyclizine and granisetron alone and in combination for the prevention of postoperative nausea and vomiting.

We conducted a randomised double-blinded study of 960 women undergoing day-case surgery to determine whether combination anti-emetic therapy of granisetron and cyclizine was more effective at decreasing the incidence of postoperative nausea and vomiting than these agents used alone. The women were randomly allocated to three groups to receive intravenous granisetron 1 mg, cyclizine 50 mg or both before induction of general anaesthesia. The incidence of postoperative nausea and vomiting was 77/322 (24%) in the granisetron group, 73/316 (23%) in the cyclizine group and 53/322 (17%) in those women given both drugs (p = 0.04). There was no difference in the requirement for rescue anti-emetic drugs. There were no differences in the anaesthetic techniques used in the three groups. We conclude that the risk of postoperative nausea and vomiting is less with cyclizine and granisetron given together than with either given alone.

Unplanned admission rates and postdischarge complications in patients over the age of 70 following day case surgery.

The elderly are a group of patients who would seem ideally suited to day surgery. However, age was initially regarded as a potential barrier to this process. We conducted a retrospective review of 1647 elderly patients (> 70 years of age) over a two-year period. Our results show a favourable outcome for these patients with low rates of unplanned admission and postoperative complications. Elderly patients seem to be at no increased risk of complications after day surgery, and show excellent satisfaction scores.

Outcome of ASA III patients undergoing day case surgery.

BACKGROUND: Day case surgery is becoming more acceptable, even for patients with complex medical conditions. Current recommendations suggest that patients who are graded as American Society of Anaesthesiologists physical status (ASA) III may be suitable for this approach. There is only a small amount of published data available to support this. We present a retrospective review of ASA III patients who had undergone day surgical procedures in our unit. METHODS: We carried out a retrospective case controlled review of 896 ASA III patients who had undergone day case procedures between January 1998 and June 2002 using the existing computerized patient information system. The system records admission rates, unplanned contact with healthcare services and post-operative complications in the first 24 h after discharge. RESULTS: We demonstrated no significant differences in unplanned admission rates, unplanned contact with health care services, or post-operative complications in the first 24 h after discharge between ASA III and ASA I or II patients. CONCLUSION: With good pre-assessment and adequate preparation ASA III patients can be treated safely in the day surgery setting.

Obesity and day-case surgery.

Day-case surgery is increasing in popularity and more patients with multiple medical problems are being considered as suitable for this approach. However, the current recommendations exclude morbidly obese patients (body mass index > 35 kg.m(-2)). We present a review of 258 morbidly obese patients who have received treatment in our day-surgery unit. Our experience does not show any significant increase in unplanned admission rates or postoperative complications. In conclusion, we feel that morbid obesity alone should not be an exclusion criterion for day-case surgery.

Doctor discontent. A comparison of physician satisfaction in different delivery system settings, 1986 and 1997.

OBJECTIVE: To examine the differences in physician satisfaction associated with open- versus closed-model practice settings and to evaluate changes in physician satisfaction between 1986 and 1997. Open-model practices refer to those in which physicians accept patients from multiple health plans and insurers (i.e., do not have an exclusive arrangement with any single health plan). Closed-model practices refer to those wherein physicians have an exclusive relationship with a single health plan (i.e., staff- or group-model HMO). DESIGN: Two cross-sectional surveys of physicians; one conducted in 1986 (Medical Outcomes Study) and one conducted in 1997 (Study of Primary Care Performance in Massachusetts). SETTING: Primary care practices in Massachusetts. PARTICIPANTS: General internists and family practitioners in Massachusetts. MEASUREMENTS: Seven measures of physician satisfaction, including satisfaction with quality of care, the potential to achieve professional goals, time spent with individual patients, total earnings from practice, degree of personal autonomy, leisure time, and incentives for high quality. RESULTS: Physicians in open- versus closed-model practices differed significantly in several aspects of their professional satisfaction. In 1997, open-model physicians were less satisfied than closed-model physicians with their total earnings, leisure time, and incentives for high quality. Open-model physicians reported significantly more difficulty with authorization procedures and reported more denials for care. Overall, physicians in 1997 were less satisfied in every aspect of their professional life than 1986 physicians. Differences were significant in three areas: time spent with individual patients, autonomy, and leisure time (P < or =.05). Among open-model physicians, satisfaction with autonomy and time with individual patients were significantly lower in 1997 than 1986 (P < or =.01). Among closed-model physicians, satisfaction with total earnings and with potential to achieve professional goals were significantly lower in 1997 than in 1986 (P < or =.01). CONCLUSIONS: This study finds that the state of physician satisfaction in Massachusetts is extremely low, with the majority of physicians dissatisfied with the amount of time they have with individual patients, their leisure time, and their incentives for high quality. Satisfaction with most areas of practice declined significantly between 1986 and 1997. Open-model physicians were less satisfied than closed-model physicians in most aspects of practices.

The quality of physician-patient relationships. Patients' experiences 1996-1999.

BACKGROUND: Our objective was to examine how patients of primary care physicians are responding to a changing health care environment. The quality of their relationship with their primary care physicians and their experience with organizational features of care were monitored over a 3-year period. METHODS: This was a longitudinal observational study (1996-1999). Participants completed a self-administered questionnaire at baseline and at follow-up. The questionnaires included measures of primary care quality from the Primary Care Assessment Survey (PCAS). We included insured adults employed by the Commonwealth of Massachusetts who remained with one primary care physician throughout the study period (n=2383). The outcomes were unadjusted mean scale score changes in each of the 8 PCAS over the 3 years and associated standardized difference scores (effect sizes). The 8 PCAS scales measured relationship quality (4 scales: communication, interpersonal treatment, physician's knowledge of the patient, patient trust) and organizational features of care (4 scales: financial access, organizational access, visit-based continuity, integration of care). RESULTS: There were significant declines in 3 of the 4 relationship scales: communication (effect size [ES] = -0.095), interpersonal treatment (ES = -0.115), and trust (ES = -0.046). Improvement was observed in physician's knowledge of the patient (ES = 0.051). There was a significant decline in organizational access (ES = -0.165) and an increase in visit-based continuity (ES = 0.060). There were no significant changes in financial access and integration of care indexes. CONCLUSIONS: The declines in access and 3 of the 4 indexes of physician-patient relationship quality are of concern, especially if they signify a trend.

Switching doctors: predictors of voluntary disenrollment from a primary physician's practice.

BACKGROUND: Our objective was to evaluate 8 interpersonal and structural features of care as predictors of patients' voluntary disenrollment from their primary care physician's practice. METHODS: We performed a longitudinal observational study in which participants completed a validated questionnaire at baseline (1996) and follow-up (1999). The questionnaire measured 4 elements of the quality of physician-patient relations (communication, interpersonal treatment, physician's knowledge of the patient, and patient trust) and 4 structural features of care (access, visit-based continuity, relationship duration, and integration of care). Study participants were insured adults who reported having a regular personal physician at baseline and who completed both baseline and follow-up questionnaires (n=4108). The outcome measured was voluntary disenrollment from the primary physician's practice between baseline and follow-up. RESULTS: One fifth of the patients voluntarily left their primary physician's practice during the study period. When tested independently, all 8 scales significantly predicted voluntary disenrollment (P <.001), with somewhat larger effects associated with the 4 relationship quality measures. In multivariable models, a composite relationship quality factor most strongly predicted voluntary disenrollment (odds ratio [OR]=1.6; P<.001), and the 2 continuity scales also significantly predicted disenrollment (OR=1.1; P<.05). Access and integration did not significantly predict disenrollment in the presence of these variables. CONCLUSIONS: These findings highlight the importance of relationship quality in determining patients' loyalty to a physician's practice. They suggest that in the race to the bottom line medical practices and health plans cannot afford to ignore that the essence of medical care involves the interaction of one human being with another.

Serum paracetamol concentrations in adult volunteers following rectal administration.

Paracetamol is usually given in adults at a dose of 10-20 mg kg(-1) orally or rectally. Work in children suggests that doses of 40 mg kg(-1) are needed to provide therapeutic concentrations when this drug is used by the rectal route. We have investigated the dose of rectal paracetamol needed to achieve serum concentrations within the accepted therapeutic range of 10-20 microg ml(-1) in adults. Ten healthy adult volunteers received increasing doses of rectal paracetamol (15, 25, 35, and 45 mg kg(-1)). Following suppository administration, serum paracetamol concentrations were measured half hourly to 4 h then hourly to 8 h. Sustained concentrations within our therapeutic range were achieved with 35 and 45 mg kg(-1). Maximum measured concentrations were 12.5 (10-16), 16.5 (14-20), and 20 (17.5-23) microg ml(-1), median (inter-quartile range) after 25, 35, and 45 mg kg(-1), respectively. We conclude that doses of 35-45 mg kg(-1) of rectal paracetamol are needed to achieve sustained therapeutic plasma concentrations in healthy adult volunteers.

Part-time physicians. Physician workload and patient-based assessments of primary care performance.

OBJECTIVE: To examine the relationship between the number of hours physicians work and patients' assessment of the physician. DESIGN: Cross-sectional study with physician and patient surveys. SETTING: Primary care practices in Massachusetts. PARTICIPANTS: A random sample of 6810 Massachusetts state employees in 15 different health plans. MAIN OUTCOME MEASURES: Eleven summary scales measuring 7 essential elements of primary care. Information was derived from the Primary Care Assessment Survey, a validated patient-completed questionnaire. RESULTS: Physicians were classified into 3 groups according to their reported hours of work: "overtime" (> 65 h/wk), "full time" (40-65 h/wk), and "part time" (< 40 h/wk). There was no statistically significant difference between the 3 groups of physicians in 10 of the 11 measures of primary care performance. Physicians who worked more than 65 hours per week were found to score significantly higher in the visit-based continuity of care category than physicians working fewer hours. Physicians working more than 65 hours per week were also found to be significantly less satisfied with the amount of time they had for family and personal life than the other 2 groups. CONCLUSIONS: Part-time physicians perform as well as full-time physicians in most aspects of primary care, including all interpersonal aspects of care, as reported by patients. Patients of physicians working more than 65 hours per week experienced higher levels of visit-based continuity of care than patients of physicians working fewer hours, but this appears to carry a cost to those physicians in the area of personal and professional satisfaction. Subsequent research should examine the relationship between physician workload and technical aspects of care.

Organizational and financial characteristics of health plans: are they related to primary care performance?

BACKGROUND: Primary care performance has been shown to differ under different models of health care delivery, even among various models of managed care. Pervasive changes in our nation's health care delivery systems, including the emergence of new forms of managed care, compel more current data. OBJECTIVE: To compare the primary care received by patients in each of 5 models of managed care (managed indemnity, point of service, network-model health maintenance organization [HMO], group-model HMO, and staff-model HMO) and identify specific characteristics of health plans associated with performance differences. METHODS: Cross-sectional observational study of Massachusetts adults who reported having a regular personal physician and for whom plan-type was known (n = 6018). Participants completed a validated questionnaire measuring 7 defining characteristics of primary care. Senior health plan executives provided information about financial and nonfinancial features of the plan's contractual arrangements with physicians. RESULTS: The managed indemnity system performed most favorably, with the highest adjusted mean scores for 8 of 10 measures (P<.05). Point of service and network-model HMO performance equaled the indemnity system on many measures. Staff-model HMOs performed least favorably, with adjusted mean scores that were lowest or statistically equivalent to the lowest score on all 10 scales. Among network-model HMOs, several features of the plan's contractual arrangement with physicians (ie, capitated physician payment, extensive use of clinical practice guidelines, financial incentives concerning patient satisfaction) were significantly associated with performance (P<.05). CONCLUSIONS: With US employers and purchasers having largely rejected traditional indemnity insurance as unaffordable, the results suggest that the current momentum toward open-model managed care plans is consistent with goals for high-quality primary care, but that the effects of specific financial and nonfinancial incentives used by plans must continue to be examined.

A comparison of intramuscular tenoxicam with intramuscular morphine for pain relief following tonsillectomy in children.

A double blind trial was conducted to evaluate the analgesic efficacy of intramuscular tenoxicam for pain relief following tonsillectomy in children. Fifty children, aged 3-10 years, were randomly allocated to receive intramuscular tenoxicam 0.75 mg.kg-1 or intramuscular morphine sulphate 0.2 mg.kg-1 after induction of anaesthesia. Although the tenoxicam group required significantly more postoperative morphine.(mean 57.8 micrograms.kg-1 compared with 26.9 micrograms.kg-1, P = 0.025), the total morphine dose was significantly reduced after tenoxicam (57.8 micrograms.kg-1 compared with 226.9 micrograms.kg-1, P < 0.0001). There was no difference between the quality of analgesia after discharge from recovery. The incidence of postoperative vomiting was significantly reduced after tenoxicam (20%) compared with morphine (71%).

Consent to clinical trials in anaesthesia.

In order to evaluate satisfaction with, and recollection of, the consent process, we sent a postal questionnaire to 204 patients who had taken part in one of six clinical trials. Three trials were multicentre commercial studies and three were 'in house'. The readability of the different patient information sheets was compared. Seventy-seven per cent of patients responded, of whom 82% remembered having an information sheet. Most (99%) thought this was easy to read and understand. Five patients claimed that they had felt pressurised to take part in the trials. Nearly all patients (97%) realised that participation was voluntary and that other treatment would not be affected; 83% knew they could have changed their minds. There were no differences in the response patterns between the patients taking part in the different trials although the patient information sheets produced by pharmaceutical companies were longer and more complex than the 'in hospital' variety. We conclude that increasing the amount and complexity of information does not alter patient satisfaction. Taken overall, patients were content with the way they were approached when asked for consent for clinical trials.

Morphine consumption in patients receiving rectal paracetamol and diclofenac alone and in combination.

Paracetamol and diclofenac have different mechanisms of action, and the combination may be more effective than each drug used alone in treating postoperative pain. In a double-blind, controlled design, we studied 60 patients undergoing elective abdominal gynaecological surgery, who received suppositories of paracetamol 1.5 g, diclofenac 100 mg or a combination of the two before the start of surgery. Patients received morphine in the intraoperative period, and cumulative morphine use from a patient-controlled analgesia system was recorded to measure the analgesic effect of the suppositories. Morphine consumption was greatest in the group that received paracetamol alone and lowest in the group given the combination (P < 0.01). There was no difference in the incidence of morphine-related side effects between the groups. We conclude that a diclofenac-paracetamol combination reduced the amount of morphine used compared with paracetamol alone.

Infusions of subhypnotic doses of propofol for the prevention of postoperative nausea and vomiting.

We studied the antiemetic effects of a low dose infusion of propofol for 24 h after major gynaecological surgery in a double-blind, randomised, controlled trial. Fifty women of ASA physical status 1 or 2 undergoing major gynaecological surgery received an infusion of 1% propofol or intralipid at 0.1 ml.kg-1.h-1 for 24 h after surgery. Pain was managed using morphine delivered by a patient-controlled analgesia pump. The degree of postoperative nausea and vomiting was assessed by the nurses using a four-point ordinal scale, by the patients using a visual analogue scale and by the amount of rescue antiemetic given by the nurses. There were no differences between the two groups in any of the measures of postoperative nausea and vomiting during the first 48 h after surgery. Postoperative nausea and vomiting in the control group was less on the second day compared with the first postoperative day, but not in the propofol group. There were no side effects from the propofol infusion.