In 1998, 41.5 million inpatient surgical procedures were performed on nearly 32 million persons in the United States (1,2). The average length of stay in short-term, nonfederal hospitals for individuals who had surgery was 5.1 days, and >160 million surgery-related days were spent in these hospitals. National health expenditures in 1999 were >$1.2 trillion (3). Hospital care accounted for 32.3% of this amount, whereas physician services were approximately 22.3% of national health expenditures.
Pain is an expected outcome of surgery (4). Many people experience suboptimally managed postoperative pain, however (4–10). Furthermore, current observational data support the existence of an “analgesic gap” in delivering adequate postoperative pain relief, despite evidence that aggressive postoperative pain control improves outcomes (8–10).
Postoperative pain is thought to affect both medical resource use and patients’ ability to resume the normal activities of their lives after discharge from the hospital to home (11). Acute pain is also thought to be a risk factor for developing chronic pain (12–14). In addition, assessment and treatment of pain, and patient education about pain are now part of new accreditation standards recently implemented by the Joint Commission on Accreditation of Healthcare Organizations (15).
Improving postoperative pain control is thought to result in more efficient use of health resources and to decrease overall costs; however, until better estimates of resource use, costs, and a clear understanding of the postoperative course of events are available, we cannot understand what needs to be improved, corrected, or left alone (4). Additionally, patients’ perceptions of their health, including their level of pain and their satisfaction with care, are considered to be important indicators of health care quality in general (16). We sought to describe postoperative pain and the frequency and severity of distress associated with postsurgical adverse effects from the patients’ perspective and to estimate direct medical resource use and costs incurred from the hospital perspective after total abdominal hysterectomy (TAH), total knee replacement (TKR), or total hip replacement (THR) surgery.
Data for this observational pilot study were obtained from patients admitted to the New England Medical Center, an urban regional medical center in Boston, MA, for TAH, THR, or TKR surgery from August 1999 through June 2000. These procedures were chosen based on the high frequency with which they are performed at New England Medical Center and their perceived painfulness. Enrollment was based on a convenience sample. Before surgery, the physical status of the patients was rated on the ASA physical status classification system. Only persons in classes 1, 2, or 3 were eligible to participate in the study. The Human Investigations Review Committee approved the study protocol, and all participants gave written informed consent. Study personnel did not directly participate in the patients’ medical care.
Data were collected in two stages. First, within 24 h before leaving the hospital, participants completed a survey about pain intensity and satisfaction with medical and nursing care. The survey was based on the American Pain Society Quality Improvement Patient Outcome Questionnaire (17). This questionnaire was developed by a multidisciplinary task force of the American Pain Society, and is designed to provide information about the patient’s experience with pain. Additional questions were added to elicit information about the occurrence and distress of postsurgical adverse effects. Second, estimates of direct and indirect costs and direct medical resource use were obtained from the hospital with currently used financial tracking software (Eclipsys, formerly known as TSI, Delray Beach, FL). A hospital perspective was adopted for this part of the analysis.
Costs and resource use were estimated for services provided by the hospital. These services were attributed to the following departments within the hospital: anesthesia, blood bank, laboratory, occupational and other therapy, operating room, pharmacy, physical therapy, postanesthesia care, radiation oncology, radiology, residents and interns, respiratory therapy, and routine room costs. Pharmacy costs include all drugs ordered for a specific person. Anesthetics and other drugs used by the anesthesiologist or surgeon are reported in costs for those departments, respectively, rather than the pharmacy. Attending physicians’ costs were not reported because these physicians are not employees of the hospital, and this information was not available because of confidentiality concerns. Although the hospital is not responsible for costs related to attending physician services, the mean Medicare physician reimbursement for the procedures of interest is reported as a proxy. Reimbursement amounts are based on the Current Procedural Terminology codes [58150, 58152, and 58200 for TAH, 27130 for THR, and 27447 for TKR (18)]. Cost estimates are reported in 1999 US dollars. All analyses were done by using Excel 97 (Microsoft, Redmond, WA).
Demographics are reported in Table 1. Ten persons in each surgical group participated in this study (total n = 30). The mean age of the persons who participated in this study was 55 yr (range 39–80 yr). Persons who underwent TKR were approximately 63 yr old, whereas the average age of persons in the THR group was 56 yr. All persons who underwent TAH were female, whereas 70% of the THR group was male, and 70% of the TKR group was female. Eighty percent of participants had private health insurance. On a five-point scale ranging from excellent to poor, 80% of TAH and THR participants reported excellent or very good health status, whereas 80% of persons undergoing TKR reported being in very good or good health. The most common comorbid conditions reported in participants’ charts were hypertension (30% of the TAH group) and arthritis or degenerative joint disease (40% of the THR group, 50% of the TKR group).
Patients’ estimates of their pain severity during hospitalization are shown in Table 2. All persons in the TAH group and 90% of persons in the THR and TKR groups reported having pain during their last day in the hospital. The mean worst pain (on a 0–10 analog scale) since surgery ranged from 7.6 (TKR) to 8.9 (TAH), and mean worst pain during the last 2 days of hospitalization ranged from 3.4 (THR) to 5.0 (TAH). Postoperative pain was most often reported to be worst on the first day after surgery among persons in the TAH or THR groups and on the second postoperative day for persons in the TKR group.
Information about pain relief, interference with activities, and patient satisfaction is shown in Table 3. Participants reported that medications relieved 60% (TKR) to approximately 78% (THR) of their pain. Despite obtaining good relief with medication, participants reported that postoperative pain interfered most with their ability to take part in general activities and sleep after TAH, and with their general activity and walking ability (THR and TKR).
All participants except one person who underwent TAH reported being told by a physician, nurse, or other health care professional that pain treatment is considered very important and that the patient should indicate if he or she is having pain. Seventy-two percent of participants reported that a physician had emphasized the importance of pain treatment to them, whereas 55% of persons indicated that a nurse had been involved. Physical therapists were involved for three persons who had THR, and an occupational therapist was involved for one person who had TKR. No person reported that a pharmacist had told study participants that pain relief was important. Ninety percent of persons who had either a THR or TKR were satisfied or very satisfied with their pain treatment. In contrast, 60% of persons who had a TAH were at least satisfied, and 40% were slightly dissatisfied with their pain treatment. Study participants generally waited for pain medication 30 min or less, although one person in the THR group asked for pain medication but never received it. In general, persons who asked for stronger or different pain medication waited an hour or less; however, one person in the TAH group waited 5–8 h, and one person each in the THR and TKR groups waited 3–4 h each.
Adverse effects reported are shown in Table 4. The three most distressing adverse effects reported by persons in the TAH group were hot flashes (n = 1), abdominal pain (n = 9), and constipation (n = 6). Among persons in the THR group, dry mouth (n = 7), sweating (n = 6), and difficulty sleeping (n = 9), difficulty breathing (n = 3), or difficulty concentrating (n = 3) caused the most distress. In the TKR group, difficulty breathing (n = 1), difficulty sleeping (n = 4), and vomiting (n = 3) were most distressing. The most commonly reported adverse effects (and their mean distress levels on a 0–5 analog scale) were abdominal pain (3.8) and dry mouth (3.1) for the TAH group, whereas difficulty sleeping (3.0) and dry mouth (3.0) were the most frequently reported adverse effects for persons in the THR and TKR groups, respectively.
Data about postoperative opioid and nonsteroidal antiinflammatory drug use are shown in Table 5. Only persons who underwent TKR surgery used epidural analgesia. Opioids via patient-controlled analgesia were the most common methods of providing pain relief on postoperative days 0, 1, and 2. Oral opioids were started by the first day after surgery and continued until the end of hospitalization for most patients. The use of nonsteroidal antiinflammatory drugs was relatively common for persons who underwent TAH surgery, but was infrequent in the other two surgical groups.
Direct and indirect cost estimates for services provided by the hospital are shown in Table 6. Operating room (including surgical hardware) and routine room costs accounted for approximately 62%–68% of costs. Pharmacy costs were 3.7% of the total for persons who had TAH, 1.9% of the THR costs, and 2.2% of TKR costs. The average length of stay was 2.8 days after TAH, and 3.9 days after THR or TKR.
As with all trauma, pain is an expected part of the surgical experience (4,19). Many published reports, however, have established that suboptimal treatment of pain occurs frequently (4,6–10). In the current study, we found that pain is a significant part of patients’ experience in the hospital. We also found that the average worst pain during the 48 hours before leaving the hospital was moderate to severe and that overall, the mean worst pain was severe for people in each of the surgical groups we studied.
These findings are consistent with current observations that document continuing “analgesic gaps” during present-day postoperative pain management, such as after discontinuing patient-controlled analgesia, or when patients start physical therapy (8,9). Furthermore, although analgesics provided impressive pain relief, postoperative pain interfered with patients’ ability to function in ways that are important to them and to their caregivers. The ability to function is an important indicator of when a person may be safely discharged from the hospital, and length of stay is a significant determinant of total costs from a hospital perspective. The patient’s perspective of his or her health status and ability to function is also thought to be an important indicator of costs and resource use (20).
Most participants experienced moderate-to-severe pain during their hospital stay, yet participants were generally satisfied or very satisfied with their pain treatment and with the responses of nurses and physicians to their reports of pain. By itself, however, satisfaction with care is a crude measure of quality. Prior reports have documented high patient satisfaction with care despite suboptimal pain control (21). These results may reflect prior personal experiences (or that of friends and family), knowledge, expectations of postsurgical pain, and the relative change in pain from before surgery to postsurgical levels. For example, someone with chronic painful osteoarthritis of the knee may expect a significant decrease in pain as a long-term outcome of knee replacement, and may, therefore, be more willing to accept suboptimal postoperative pain care. We also found that caregivers told most participants that reports of pain are important. This finding was corroborated by reports of short waiting time for analgesics. Although physicians and nurses provide most direct patient care at this facility, there is room for other caregivers, including pharmacists, to be more proactively involved in pain treatment.
Adverse effects were relatively common among participants in this study, despite prophylactic treatment for some events. Although adverse events caused some distress, treatment was typically straightforward, such as giving antiemetic medications to treat or prevent nausea or vomiting. Although the adverse effects that participants experienced were uncomplicated, they were important sources of distress to the patient. Furthermore, patients were sometimes given medications to treat or prevent these adverse events, indicating that these events are associated with resource use and costs. Because many of the adverse events that were reported by participants in this study were often associated with opioid use, a multimodal approach to postoperative analgesia may be useful to help decrease the rate and severity of side effects (22). In addition, other researchers have found that avoiding common adverse events like nausea and vomiting is important to patients (23,24).
Most of the costs incurred by persons in this study were attributable to being in the hospital and surgery-related. Notably, we found that costs from the hospital perspective for TKR were approximately $11,350, about 39% less than that reported by other researchers using 1993 dollars (25). This discrepancy may be attributed in part to changes in care over the past several years, and decreases in the length of stay after these surgeries, as well as different systems of delivering medical care.
The average length of stay for study participants was approximately three days for TAH and approximately four days for THR and TKR. On average, pharmacy costs accounted for <5% of TAH costs and fewer than 3% for patients who underwent THR or TKR. Although drugs used by the anesthesia service during surgery are included in anesthesia-related costs, this finding emphasizes that attempts to restrict overall expenditures based on decreasing drug costs are unlikely to have a significant effect on overall costs.
There are several limitations of this study. First, generalizability is limited for several reasons. This study was designed to provide baseline estimates of medical resource use, costs, and postoperative pain, and for hypothesis generation. This project was a pilot study and only 10 persons from each surgical group were included. These estimates provide a useful foundation for these purposes, but these data cannot be used to compare the surgical groups. Participants were recruited based on a convenience sample, and the surgical groups were chosen based on the high frequency with which TAH, THR, and TKR are performed at this hospital, as well as the perceived painfulness of these procedures. Persons who undergo other surgical procedures or who have other comorbid conditions, such as cancer, may experience different levels of pain and adverse effects. In addition, this study was performed at an urban regional medical center in the Northeastern United States, and estimates of costs and resource use may not extend to facilities in other parts of the United States, or to other countries.
Our findings provide detailed, current information about patients’ pain experience after three common inpatient surgeries and the costs associated with these procedures. These data are a foundation for additional studies to evaluate the cost effects of newer analgesic therapies. In addition, our study highlights the potential for improved pain management, the distress that side effects evoke in patients, and the importance of a patient-centered perspective when measuring the success of postoperative care (16).
Pain is an important dimension of the postoperative experience for most people, and many patients continue to experience moderate-to-severe pain after surgery. Adverse events are relatively common. Despite the experiences of pain and adverse events, most patients in the present study, as in earlier studies, report being satisfied or very satisfied with their pain treatment and the response of their care providers to reports of pain. Patient satisfaction is an important guide to the success of postoperative care; however, satisfaction alone is a poor indicator of whether analgesia was adequate. These findings identify major contributors to postsurgical costs from a hospital perspective, and the kinds of analgesic medications often used from admission to discharge from the hospital. The results of this study also suggest ways to improve the treatment of postoperative pain, a goal that has assumed substantial importance in recent years.
The authors gratefully acknowledge Eric S. Johnson, MPH, PhD, Jan Smith, and Judy Weinstock for their help.
2. Popovic JR, Kozak LJ. National hospital discharge survey: annual summary, 1998. Vital Health Stat 2000; 13: 1–194.
3. Heffler S, Levit K, Smith S, et al. Health spending growth up in 1999: faster growth expected in the future. Health Aff 2001; 20: 193–203.
4. Carr DB, Jacox AK, Chapman CR, et al. Acute pain management: operative or medical procedures and trauma. Clinical practice guideline no. 1. AHCPR pub. no. 92-0032. Rockville, MD: Agency for Healthcare Policy and Research, Public Health Service, US Department of Health and Human Services, Feb. 1992.
5. American Society of Anesthesiologists. Practice guidelines for acute pain management in the perioperative setting: a report by the American Society of Anesthesiologists Task Force on Pain Management, Acute Pain Section. Anesthesiology 1995;82:1071–81.
6. Marks RM, Sachar EJ. Undertreatment of medical inpatients with narcotic analgesics. Ann Intern Med 1973; 78: 173–81.
7. Donovan M, Dillon P, McGuire L. Incidence and characteristics of pain in a sample of medical-surgical inpatients. Pain 1987; 30: 69–78.
8. Ng A, Hall F, Atkinson A, et al. Bridging the analgesic gap. Acute Pain 2000; 3: 194–9.
9. Chen PP, Chui PT, Ma M, Gin T. A prospective survey of patients after cessation of patient-controlled analgesia. Anesth Analg 2001; 92: 224–7.
10. Carr EC. Exploring the effect of postoperative pain on patient outcomes following surgery. Acute Pain 2000; 3: 183–93.
11. Gottschalk A, Smith DS, Jobes DR, et al. Preemptive epidural analgesia and recovery from radical prostatectomy: a randomized controlled trial. JAMA 1998; 279: 1076–82.
12. Song SO, Carr DB. Pain and memory. Pain: Clinical Updates. Spring 1999; 7: 1–4.
13. Perkins FM, Kehlet H. Chronic pain as an outcome of surgery: a review of predictive factors. Anesthesiology 2000; 93: 1123–33.
14. Wall PD. The prevention of postoperative pain. Pain 1988; 33: 289–90.
16. Walker JD. Enhancing physical comfort. In: Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL, eds. Through the patient’s eyes: understanding and promoting patient-centered care. San Francisco: Jossey-Bass Publishers, 1993: 119–53.
17. American Pain Society Quality of Care Committee. Quality improvement guidelines for the treatment of acute pain and cancer pain. JAMA 1995; 274: 1874–80.
18. Kirschner CG, Anderson CA, Dalton JA, et al. Current procedural terminology 2000. Chicago, IL: American Medical Association, 1999:104, 108, 215.
19. Carr DB, Goudas LC. Acute pain. Lancet 1999; 353: 2051–8.
20. Strassels SA, Smith DH, Sullivan SD, et al. The costs of treating COPD in the United States. Chest 2001; 119: 344–52.
21. Miaskowski C, Nichols R, Brody R, Synold T. Assessment of patient satisfaction using the American Pain Society’s Quality Assurance Standards on acute and cancer-related pain. J Pain Symptom Manage 1994; 9: 5–11.
22. Goudas LC, Carr DB. Postoperative opioid analgesia: reconsider, don’t reject. J Clin Anesth 1996; 8: 439–40.
23. Gan TJ, Sloan F, Dear GD, et al. How much are patients willing to pay to avoid postoperative nausea and vomiting? Anesth Analg 2001; 92: 393–400.
24. Macario A, Weinger M, Carney S, Kim A. Which clinical anesthesia outcomes are important to avoid? The perspective of patients. Anesth Analg 1999; 89: 652–8.
25. Macario A, Vitez TS, Dunn B, et al. Hospital costs and severity of illness in three types of elective surgery. Anesthesiology 1997; 86: 92–100.