Multimorbidity, healthcare utilization, and quality of life for older patients undergoing surgery: A prospective study.

Multimorbidity (≥2 chronic illnesses) is a worldwide healthcare challenge. Patients with multimorbidity have a reduced quality of life and higher mortality than healthy patients and use healthcare resources more intensively. This study investigated the prevalence of multimorbidity; examined the effects of multimorbidity on healthcare utilization; healthcare costs of multimorbidity; and compared the associations between the health-related quality of life (HRQoL) of older patients undergoing surgery and multimorbidity, the Charlson Comorbidity Index (CCI), the Simple Frailty Questionnaire (FRAIL), and the American Society of Anesthesiologists (ASA) physical status classifications. This prospective cohort study enrolled 360 patients aged > 65 years scheduled for surgery at a university hospital. Data were collected on their demographics, preoperative medical profiles, healthcare costs, and healthcare utilization (the quantification or description of the use of services, such as the number of preoperative visits, multiple-department consultations, surgery waiting time, and hospital length of stay). Preoperative-assessment data were collected via the CCI, FRAIL questionnaire, and ASA classification. HRQoL was derived using the EQ-5D-5L questionnaire. The 360 patients had a mean age of 73.9 ± 6.6 years, and 37.8% were men. Multimorbidity was found in 285 (79%) patients. The presence of multimorbidity had a significant effect on healthcare utilization (≥2 preoperative visits and consultations with ≥2 departments). However, there was no significant difference in healthcare costs between patients with and without multimorbidity. At the 3-month postoperative, patients without multimorbidity had significantly higher scores for HRQoL compared to those with multimorbidity (HRQoL = 1.00 vs 0.96; P < .007). While, patients with ASA Class > 2 had a significantly lower median HRQoL than patients with ASA Class ≤2 at postoperative day 5 (HRQoL = 0.76; P = .018), 1-month (HRQoL = 0.90; P = .001), and 3-months (HRQoL = 0.96; P < .001) postoperatively. Multimorbidity was associated with a significant increase in the healthcare utilization of the number of preoperative visits and a greater need for multiple-department consultations. In addition, multimorbidity resulted in a reduced HRQoL during hospital admission and 3-months postoperatively. In particular, the ASA classification > 2 apparently reduced postoperative HRQoL at day 5, 1-month, and 3-months lower than the ASA classification ≤2.

The effect of pediatric patient temperament on postoperative outcomes.

BACKGROUND: Research has improved practitioner awareness of the impact of individual characteristics on responses to painful procedures. However, there is little data relating preexisting temperament profiles and postsurgical/anesthesia outcomes in pediatric patients. In particular, it is not clear how best to identify which patients are at risk of poor postsurgical outcomes. AIM: In this prospective study, we examined relationships between preoperative measures of child temperament and postoperative pain/behavioral outcomes of children undergoing tonsillectomy/adenoidectomy surgeries. We sought to determine which temperament profiles were predictive of poor outcomes. METHODS: After IRB approval and informed consent, validated temperament surveys were administered to the parents of a cohort of children undergoing tonsillectomy/adenoidectomy surgery. These data were combined with preoperative, intraoperative, and postoperative outcome measures collected from the electronic medical record utilizing a large integrated anesthesia outcome database. The dataset was further augmented with surveys addressing remote postoperative behaviors. Analysis of the temperament data yielded four groups (positive, negative, excitable, and inhibitory). The probability of high perioperative pain, agitation, emesis, and postoperative behavior changes based on cluster membership was then assessed. RESULTS: A total of 260 patients undergoing tonsillectomy and/or adenoidectomy surgeries were enrolled in the study. ANOVA and chi-squared analyses indicated no statistically significant age, gender, or anesthesia technique differences across the four temperament clusters. Temperament cluster membership was not related to emesis, agitation, or behavioral changes. However, it was found to be predictive of high postoperative pain. Members of the excitable cluster (high positive and negative emotionality) were more likely to report high pain than those in positive cluster (high positive, low negative emotionality) (OR 7.97, 95% CI: 1.62-39.26; P < 0.05). Comparisons among other clusters were not significant. CONCLUSION: Our data indicate that preoperative temperament characteristics may differentially influence pediatric postoperative pain experience in children. Specifically, children with high levels of positive and negative emotionality may exhibit more postsurgical pain behaviors.

Validation of the Pediatric Sedation State Scale.

OBJECTIVES: Development and validation of the Pediatric Sedation State Scale (PSSS) is intended to specifically meet the needs of pediatric procedural sedation providers to measure effectiveness and quality of care. METHODS: The PSSS content was developed through Delphi methods utilizing leading pediatric sedation experts and published guidelines on procedural sedation in children. Video clips were created and presented to study participants, who graded the state of patients during procedures by using the PSSS to evaluate inter- and intrarater reliability by determining the intraclass correlation coefficient. We also compared the PSSS to the Observational Scale of Behavioral Distress-revised during 4 clinically relevant phases of a laceration repair procedure. RESULTS: Six sedation states were defined for the PSSS. Each state was assigned a numerical value with higher numbers for increasing activity states. We included behaviors associated with adequate and inadequate sedation and adverse events associated with excessive sedation. Analysis of interrater and intrarater reliability revealed an intraclass correlation coefficient of 0.994 (95% confidence interval: 0.986-0.998) and 0.986 (95% confidence interval: 0.970-0.995), respectively. Criterion validity was confirmed with respect to the Observational Scale of Behavioral Distress-revised (Spearman r = 0.96). Construct validity was indicated by significant differences in PSSS scores (P < .001) between 4 phases of a procedure, each having a different degree of painful or distressing stimuli. CONCLUSIONS: The PSSS is a 6-point scale that is a valid measure of the effectiveness and quality of procedural sedation in children within the limits of the testing method used in this study.

Creation of an integrated outcome database for pediatric anesthesia.

Outcome analysis is essential to health care quality improvement efforts. Pediatric anesthesia faces unique challenges in analyzing outcomes. Anesthesia most often involves a one-time point of care interaction where work flow precludes detailed feedback to care givers. In addition, pediatric outcome evaluations must take into account patients' age, development, and underlying illnesses when attempting to establish benchmarks. The deployment of electronic medical records, including preoperative, operative, and postoperative data, offers an opportunity for creating datasets large and inclusive enough to overcome these potential confounders. At our institution, perioperative data exist in five distinct environments. In this study, we describe a method to integrate these datasets into a single web-based relational database that provides researchers and clinicians with regular anesthesia outcome data that can be reviewed on a daily, weekly, or monthly basis. Because of its complexity, the project also entailed the creation of a 'dashboard,' allowing tracking of data trends and rapid feedback of measured metrics to promote and sustain improvements. We present the first use of such a database and dashboard for pediatric anesthesia professionals as well as successfully demonstrating its capabilities to perform as described above.

Prospective study of hypotension after spinal anesthesia for cesarean section at Siriraj Hospital: incidence and risk factors, Part 2.

BACKGROUND: The incidence of hypotension after spinal anesthesia is highest in cesarean section. The authors' first retrospective study identified three risk factors that included two non-modifiable (patient's height and low baseline systolic blood pressure) and one modifiable risk factor (sensory analgesia equal to or higher than TS) associated with hypotension. OBJECTIVE: To create a prospective record of the event in the patients who received successful spinal anesthesia for cesarean section. MATERIAL AND METHOD: A prospective data collection, together with questionnaires that were completed by the responsible anesthetic team at the end of the operation for each consecutive patient. All parameters were coded and recorded in SPSS11.5. To assess the association between two categorical variables in a univariable analysis, chi-square test was used along with odds ratio (OR) and its 95% confidence interval (CI). Mutivariable analysis via multiple logistic regressions was employed to determine the effect of each independent variable. RESULTS: Eight hundred and seven full-term pregnant women received successful spinal anesthesia for cesarean section at Siriraj Hospital from July 1 to December 31, 2004. Hypotension was defined as lowest systolic < 100 mmHg and the pressure was lower to equal to or more than 20% of baseline. Incidence of hypotension was 65.1%. Age > 35 yr BMI > 35 were two non-modifiable risk factors that increased the incidence of hypotension in the crude odds ratio (OR) 1.62 and 2.83 respectively with narrow 95% confidence interval. The level of sensory analgesia equal to or higher than T5 was the only one modifiable risk factor that increased the incidence of hypotension with crude OR 1.55 and narrow 95% CI. CONCLUSION: Limitation of the dose of local anesthetic agent or addition of some opioids could reduce the incidence and severity of hypotension after spinal anesthesia for cesarean section.