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Quality improvement

Assessing preoperative anxiety using a questionnaire and clinical rating

A prospective observational study

Laufenberg-Feldmann, Rita; Kappis, Bernd

Author Information
European Journal of Anaesthesiology: December 2013 - Volume 30 - Issue 12 - p 758-763
doi: 10.1097/EJA.0b013e3283631751



Psychological factors have been found to have a substantial impact on surgical recovery.1 Anxiety is of particular importance, as it affects different aspects of anaesthesiological perioperative situations, such as the preoperative visit, induction and maintenance of anaesthesia, postoperative demands and physical recovery.2–4 Studies in surgical patients have identified an association between preoperative anxiety and surgical recovery and outcome.5

For example, postoperative pain in the recovery room was predictable to some extent by using a short questionnaire about the patients’ preoperative anxiety.6

In epidemiological studies, anxiety disorders have a 12-month prevalence of about 15% and a 4-week prevalence of about 9%.7 In patients with chronic somatic diseases, prevalence rates are even higher and psychological comorbidity is frequently overlooked in medical care.8 Despite the influence of preoperative psychological factors (such as anxiety) on the results of surgery, these variables are not systematically assessed during the preoperative visit. Although it is self-evident that anxiety can only be detected if patients are asked about it, it is not common practice to explore these aspects because of time restrictions during the preoperative visit and the workload of the anaesthesiologist, or because patient concerns are underestimated or overlooked. However, several approaches exist to quantify anxiety levels. Questionnaires are suitable tools to ask patients about feelings of fear or somatic and cognitive symptoms associated with anxiety. Due to the correlation between preoperative anxiety and composite outcome, it seems reasonable to assess preoperative anxiety using a pragmatic, yet sensitive and specific instrument. One of the most commonly used questionnaires is the 40-item Spielberger's State-Trait Anxiety Inventory,9 although it is not specific for the preoperative situation. A more specific instrument is the State-Trait-Operation-Anxiety (STOA) tool,10 which is only available in German. In clinical settings, such as the preoperative visit, only short questionnaires are applicable because the time for contact between patient and anaesthesiologist is limited. One condensed instrument is the Amsterdam Preoperative Anxiety and Information Scale (APAIS)11 to assess preoperative anxiety and the patient's need for information.

The aims of this study were to identify the prevalence of preoperative anxiety and need for information, with regard to influencing factors such as age, sex, previous operation and grade of surgery, and to examine the level of agreement between patients’ self-rating and physicians’ ratings.


This study was designed as a part of our internal quality management. The State Ethical Care Committee (Ethikkommission der Landesärztekammer Rheinland-Pfalz, Mainz) had confirmed that no approval and no written informed consent were required for this non-interventional epidemiological study.

During a 3-week period (15/12/2010 to 06/01/2011), adult patients were recruited consecutively in the anaesthesia consultation office at the Department of Anaesthesiology, University Hospital Medical Centre, Mainz, Germany. Patients were referred from trauma/orthopaedic surgery, urology, general surgery, neurosurgery, transplantation surgery, and vascular surgery. The patients were given questionnaires (see below) prior to the interaction with the anaesthesiologist, which they completed during the waiting period. The questionnaires took approximately 15 min to complete. Exclusion criteria were patients less than 18 years of age, inadequate understanding of German language and mental disorders with significant cerebral dysfunction. Additionally, physicians were asked to provide their subjective ratings about patients’ anxiety and need for information immediately after having seen the patients in the anaesthesia consultation office. Overall 19 physicians completed the questionnaire (15.7% of senior staff members) and were blinded to the patients’ self-ratings. We classified the planned surgery into minor, intermediate and major surgery, following the NICE (National Institute for Health and Care Excellence) guidelines12 and the Moerman et al. criteria.11


Patients filled in three questionnaires. The first was a questionnaire on sociodemographic variables with respect to family status, level of educational background, current professional life and number of previous surgeries. These possible predictors of preoperative anxiety were outlined in previous studies.13,14 Patients also completed the APAIS11 and the inventory STOA.10

The APAIS, as shown in Table 1, is a six-item questionnaire developed in 1996. It is used in different countries, including the Netherlands, Japan, Canada, USA,6,15–17 and was translated into German by Berth et al.14 By using four items concerning preoperative anxiety and two items concerning the need for information, it is a time-saving, economical instrument. Patients judge their agreement with each statement on a 5-point Likert scale from ‘not at all’ (1 point) to ‘extremely’ (5 points). Sum scores range from 4 to 20 for the anxiety scale and from 2 to 10 for the need for information scale, respectively.

Table 1
Table 1:
Preoperative anxiety and Information Scale (Amsterdam Preoperative Anxiety and Information Scale)

Physicians performing the preoperative anaesthesia assessment were requested to estimate patients’ anxiety and need for information by using an adapted version of the APAIS with some modifications in wording, for example from ‘I am worried about the procedure’ to ‘the patient is worried about the procedure’. The ratings were the same as in the patient version. Physicians were blinded to the patients’ ratings.

The inventory STOA is an instrument for the measurement of surgery-related state and trait anxiety, and was used for validation purposes. It consists of 30 items, each scored on a 4-point Likert Scale, resulting in two sum scores. The STOA, which is only available in German language, has been found to have highly satisfactory psychometric properties and a good predictive value for postoperative progress.18 Examples of STOA items are shown in Appendix 1,

Statistical analysis

Descriptive statistics are expressed as number (proportion) or mean ± SD. Differences between groups were examined using Student's t-test, Mann–Whitney U-test, cross-tables, χ2 test or repeated analyses of variance, as appropriate. Spearman rank correlation was used to examine the association between metric variables. Agreement between patients’ and physicians’ ratings was calculated using the Kappa coefficient. Data were examined using IBM Statistical Package for the Social Sciences version 17 (SPSS Inc., Chicago, Illinois, USA).

P < 0.05 was considered significant. As this observational study was designed as part of the internal quality management, a power analysis was not performed.


During the 3-week study period, 384 adult patients were seen in the anaesthesia consultation office. Of these, 217 (56.5%) met the inclusion criteria and agreed to participate. Twenty percent of patients screened for the study refused to participate. Patient characteristics are shown in Table 2. Data were incomplete in some cases due to missing single items. For the calculation of agreement between patients’ and physicians’ ratings, there were 151 complete data pairs. Patients were admitted from traumatology/orthopaedic surgery (35.7%), urology (21.2%), general surgery (18.4%) and neurosurgery (11.1%), with the remaining patients coming from different departments. In the present sample, 45% of the interventions were classified as ‘major surgery’, 41% were considered ‘intermediate surgery’ and 14% as ‘minor surgery’.

Table 2
Table 2:
Patients’ characteristics

Patient's anxiety and information demands

Sum scores were calculated for both anxiety and need for information. As proposed by Moerman et al.,11 a cut-off score of 11 for the anxiety scale was used to identify ‘anxiety cases’. Applying this cut-off we found 18.9% [31.8% of women and 10.6% of men (P < 0.005)] were ‘anxiety cases’. According to the sum scores of the APAIS, women presented with higher anxiety scores compared with men (9.1 vs. 6.9; P < 0.005). Both men and women reported to be more afraid of the surgical procedure than of the anaesthetic (sum scores 4.3 vs. 3.4; P < 0.005). The grade of the planned surgery (minor, intermediate, major) was significantly related to patients’ anxiety (P < 0.005). Patients with high anxiety levels were scheduled to undergo higher grades of surgery. There was no significant correlation between age and preoperative anxiety (r = 0.12). In addition, there were no effects of marital status, educational level and the number of previous surgeries on patients’ preoperative anxiety.

The sum scores of the need for information scale were used to classify patients into three groups as proposed by Moerman et al.11: ‘no/little information requirement’ (2 to 4 points); ‘average information requirement’ (5 to 7 points); and ‘high information requirement’ (8 to 10 points). In the present sample, 36% presented with no or little need for information, 41% with intermediate and 23% with high information requirements. Age was correlated with information requirements (r = 0.21, P = 0.002), indicating that older patients had higher demands. None of the following variables had an effect on the need for information scale: grade of surgery, sex, number of previous operations and educational level. The correlation of the two APAIS scales was r equal to 0.41. Reliability analyses show excellent internal consistency with Cronbach's alpha equal to 0.89 (anxiety scale) and 0.79 (need for information scale).

To estimate the validity of the APAIS, the correlation coefficients for each of the APAIS scores with the State-scale of the STOA were calculated. Satisfactory values for the APAIS anxiety scale were identified (r = 0.76), but not for the need for information scale (r = 0.33).

Physicians’ ratings

The correlation between patient self-reporting and the rating of the physician who performed the preoperative assessment was analysed. A comparison of the mean levels of self-evaluation and physicians’ rating revealed a difference between both groups. Physicians attributed greater importance to the patients’ anxiety than the patients themselves, while they had a tendency to underestimate the patients’ need for information. Calculating a t-test for paired samples, we found these differences to be significant. The agreement between self-report and physicians’ ratings was calculated as correlation coefficients. We found the APAIS anxiety scale with r equal to 0.40 (P < 0.01; Fig. 1), and the APAIS need for information scale r equal to 0.17 (P < 0.05).

Fig. 1
Fig. 1:
No captions available.

Using an ordinal scale with five levels, the weighted kappa-coefficient κ for each item of the questionnaire was calculated. This coefficient, which takes into account that a mismatch by only one level is less divergent than a mismatch by two or more levels, is used to quantify the agreement between two ratings with a range from 0 to 1. A coefficient of 0 represents no agreement at all, whereas a coefficient of 1 represents perfect agreement.20 Agreements for most variables were ‘poor’, with only one ‘fair’ agreement (item 1: ‘worried about anaesthesia’; Table 3).

Table 3
Table 3:
Weighted κ, indicating the level of agreement between physicians’ and patients’ ratings


Many patients experience anxiety about surgery and anaesthesia. However, the individual need for information may not correlate with the degree of preoperative anxiety. Routine use of screening may help anaesthesiologists explore anxiety and need for information. A short questionnaire can help to focus on the patients’ needs in the preoperative meeting and within a tight time schedule.

This study demonstrates that perioperative anxiety is common in patients undergoing elective surgery. This suggests that preoperative anxiety should be addressed as part of their preoperative management in order to improve outcome. Using the APAIS, a short, reliable and valid instrument, physicians can assess patients’ anxiety and need for information in a preoperative anaesthesia office setting.

This study comprises a sample of patients undergoing different types of surgery. The first trial with the German version of the APAIS was conducted in 68 orthopaedic patients.14 The distribution of sex and age in that trial was similar to that in our study. Our sample is typical for a university medical centre (Table 2). The larger proportion of men is due to the recruitment of patients at a centre that includes urological patients and excludes gynaecological patients.

Anxiety and need for information

In our sample, 18.9% of the patients exceed the cut-off as defined by Moerman et al.,11 and could be considered as ‘anxiety cases’. The mean scores for the APAIS anxiety scale correspond to the results reported by Goebel et al.21 in patients with intracranial tumours. Sex-related differences were similar to previously published cohorts,22,23 and can be explained by psychosocial factors, such as sex-specific perception and behaviour patterns. Patients reported more concerns related to surgery than to anaesthesia. Different factors, such as violation of physical integrity, fear of extension of the planned procedure, outcome of surgery (functional disability), better imagination of surgical strategies in comparison with anaesthesia techniques and others may lead to this perception.

In this study, preoperative anxiety was assessed prior to the preoperative assessment (while patients were waiting for the consultation). In this situation, fear of anaesthesia may be reduced by a positive feeling about the anaesthesiologist who performs the preoperative discussion. Possible individual motivations inducing anxiety were not taken into consideration, and the possible effects of the presurgical visit remain, therefore, speculative. This result reflects that, apart from anaesthesia-specific questions, patients’ concerns related to surgery should also be addressed and evaluated by the anaesthesiologist. As expected, a positive correlation between extent of surgery and the patients’ anxiety was identified. However, the severity of the medical condition was not evaluated. We may expect greater fear in patients with cancer than in comparatively healthy patients undergoing similar surgery.

In the present sample, 23% of the patients had a strong need for information regarding surgery and anaesthesia. Although the desire for information and anxiety are closely related, the degree of information that patients want to obtain on a specific procedure may be determined by other factors. However, in this study, only age was significantly correlated with need for information, which means that older patients require more information.

Patients use different coping strategies to reduce their anxiety.24 In addition to personal experience with surgery and anaesthesia, individual coping styles determine how patients act in stressful situations. A helpful differentiation of coping strategies is made by the psychological constructs ‘monitoring’ and ‘blunting’, as described by Miller and Mangan,25 or the more recent concept of ‘vigilance’ and ‘cognitive avoidance’.26 Vigilant people (‘monitors’) are more oriented towards the stressful aspects of a challenging situation, which may appear as seeking for information during the premedication visit, such as intensified questioning or anxious observation. People using avoidance strategies (‘blunters’) tend to avert their attention from stress-related information or use cognitive strategies, which cannot be easily observed. This individual way to manage difficult situations should be taken into consideration during communication with the patient in order to avoid a possible increase in anxiety. Moreover, legal aspects, such as the duty to inform, have to be considered when providing information to the patient.

Physicians’ ratings

In this study, the anxiety scale scores revealed an overestimation of patients’ anxiety by the physicians. A possible reason, which is in accordance with results from other studies,27,28 may be that physicians focus their attention more on the patient's physical condition and tend to overlook the importance of psychological factors. Missing a diagnosis is probably more important than to mistake someone as an ‘anxiety case’. Another reason may be the anticipation of the patient's fear based on their own experience and knowledge about specific risks of surgery and anaesthesia. However, the patients’ need for information was slightly underestimated in the physicians’ ratings.

The agreement of physicians’ rating and patients’ self-reporting concerning preoperative anxiety is not well characterised. Shafer et al.27 assessed patients’ preoperative anxiety about the surgery and the anaesthesia by a visual analogue scale (VAS). Surgery and anaesthesia residents were asked to rate the same VAS from the point of view of the patient, and not from their own perspective. In a sample of 100 patients in a Veterans Affairs Hospital, the residents were not able to predict patients’ anxiety, tending to overestimate it. Only in a small sample (46 patients), with more severe diagnosis and more cases undergoing major surgery, was a significant correlation between patients’ and physicians’ rating (Kendall's tau coefficient = 0.47) found.

Even in an outpatient setting with patients in an after-care programme following treatment of cancer, it was not possible for general practitioners to precisely assess patients’ distress.29 Detection of a patient's emotional state is difficult, and may be even more so when the physician has not met the patient before, such as in a preoperative visit. Although it would be easier for anaesthesiologists to ask directly about a patient's anxiety and need for information, the value of these concerns is frequently underestimated. Additionally, at a preoperative visit, contact with the patient is usually time-limited, and because of the individual work load of the anaesthesiologist questions about emotions such as anxiety may be avoided.

The limitations of our study are the missing considerations of possible relevant factors such as underlying disease (malignant vs. non-malignant disease), and type of anaesthesia. As we have no record of the characteristics of our dropouts, there may be a bias in the recruitment. However, the sample characteristics are similar to those in comparable clinical trials. Finally, we used a non-validated, modified APAIS version for the physicians’ ratings. This may have influenced the level of agreement between the two ratings.


The APAIS can be used to provide a systematic assessment during the preoperative visit. As a screening instrument, it provides relevant information on the presence of preoperative anxiety and need for information, and may allow individual treatment of anxious patients. Given the relationship between preoperative anxiety and postoperative outcome, it seems justified to incorporate this approach into the preoperative consultation.

Acknowledgements relating to this article

Assistance with the study: the authors would like to thank all members of the study team of the Anaesthesiology Department who participated in the study.

Financial support and sponsorship: none.

Conflicts of interest: none.

Presentation: none.


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