Two new studies published in Anaesthesia (the journal of the Association of Anaesthetists) analysing pain and other factors connected with day surgery in the UK show that around 1 in 8 patients having day-case surgery end up not going home and instead are admitted to hospital for various complications. Furthermore, one in 14 go on to develop chronic pain at the operative site after the procedure.
The studies are by Dr Martha Belete, Torbay and South Devon NHS Foundation Trust, Torbay, Devon, UK and Dr Adam Brayne, University Hospitals Plymouth NHS Trust, Plymouth, UK, and colleagues from the POPPY Consortium (Patient reported Outcomes, Postoperative Pain and pain relief after daY-case surgery). They are the first studies of this kind exploring chronic post-surgical pain after day-case surgery.
Day-case surgery is defined in the UK and Ireland as surgery that occurs on the same day a patient is admitted and discharged from hospital. Current UK NHS targets stipulate that 85% of eligible elective operations should be done as a day-case. There are several advantages of day-case surgery for patients and healthcare systems. Patients receive care that aims for rapid recovery and early mobilisation, reducing their risk of complications such as hospital acquired infection and venous thromboembolism (from lack of mobility in the hospital environment). Other benefits for the wider healthcare system include increased efficiency; reduced demands on inpatient beds; costs saving; and reductions in cancellations. The effect of day-case surgery on patients' experience of recovery and pain was unknown and the POPPY study was set up to study this.
Chronic post-surgical pain is surgical site pain that develops or increases in intensity after an operation, persists at 3 months and is not caused by another process. Before this study, it was not known how common this was after day-case surgery in the UK. Treatment options are very limited and ineffective. Patients suffering from chronic post-surgical pain are more likely to have a worse quality of life and mental health problems.
In the first study, a total of 9618 patients from 199 UK sites were screened, with 7839 eligible following exclusions. Unplanned admission following surgery was the most common reason for exclusion, affecting 1131/9618 (11.8%) patients. Unplanned admission was more likely with increasing surgical magnitude and for patients who were frail and/or had other medical problems. Some common operations such as prostate procedures (including prostate and cancer and benign prostate growth) had admission rates of higher than 50%.
Pain at the site of proposed surgery was reported by 3060/7839 (39%) patients and this was chronic pain in 2387/7839 (31%). Opioids were taken at least daily by 885/7839 (11%) patients.
The authors say: "In the UK, over one third of patients presenting for day-case surgery are in pain, which is mostly chronic in duration. One in four have access to opioid medications and a little over one in 10 are using opioids daily. More than one in 10 do not receive their planned surgery as a day-case and readmission rates for day-case surgery do not meet suggested targets."
In the second study, baseline data were collected on the day of surgery, and patients were followed up by mobile phone text message delivered questionnaires on day 1, day 3, day 7 and day 97. Chronic post-surgical pain was defined using pain severity scores at day 97. Statistical modelling was used to explore associations with chronic post-surgical pain.
At day 97, 3442 patients had responded from the total of 7839 recruited (eligible from the first study). The prevalence of chronic post-surgical pain was 7.2%, equivalent to one in 14 patients. The authors found the following were associated with chronic post-surgical pain: higher post-surgery pain scores in the first week after surgery; orthopaedic, breast and plastic surgical specialities; non-surgical site chronic pain at baseline; deprivation; and ethnicity. Patients with chronic post-surgical pain had a reduced quality of life scores compared with baseline.
Higher rates of chronic post-surgical pain after 3 months were seen for orthopaedic (13.4%), and breast (10%) surgeries. The wealthiest 20% of patients only represented 18% of chronic post-surgical pain cases despite being 26% of the total patient population whereas the poorest represented 17% of cases despite only being 14% of the patient population.
The authors say: "In the UK, given the active selection of patient suitability for day-case surgery, combined with modified surgical and anaesthetic techniques and enhanced recovery pathways, it could have been anticipated that the prevalence of chronic post-surgical pain in this cohort would be lower. By including representative, prospective data across all four nations, the findings of this study suggest that it is not. Therefore, as surgical workload increases, we can expect the numbers of patients with chronic post-surgical pain to increase."
On deprivation, they say: "The least deprived quintile is associated with a reduced risk of chronic post-surgical pain. Ill health often comes with financial, employment and social burdens that may be endured more easily by those with more financial security."
While previous studies have identified female sex as increasing the risk of chronic post-surgical pain, these new studies did not agree with that finding but did show that gynaecological and breast surgeries (almost all female patients) had higher rates of chronic post-surgical pain, suggesting these specialties -rather than actually being female - were behind the increased risk.
They conclude: "This is the first large UK multicentre, prospective observational study exploring chronic post-surgical pain after day-case surgery. Chronic post-surgical pain is common after day-case surgery and is associated with reduced quality of life."
