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Anesth Analg 1999;88:1280
© 1999 International Anesthesia Research Society

AMBULATORY ANESTHESIA

Patient Preferences for Early Discharge After Laparoscopic Cholecystectomy

Harold P. Lehmann, MD, PhD*, Lee A. Fleisher, MD{dagger},{ddagger},§, Janet Lam, AB{dagger}, Barbara A. Frink, RN, PhD||, and Eric B. Bass, MD{ddagger},§

Departments of *Pediatrics, {dagger}Anesthesiology and Critical Care Medicine, {ddagger}Medicine, and §Health Policy and Management and Division of Biomedical Information Sciences, ||Schools of Medicine and Nursing, Johns Hopkins School of Medicine, Baltimore, Maryland

Address correspondence and reprint requests to Lee A. Fleisher, MD, The Johns Hopkins Hospital, 600 North Wolfe St., Carnegie 280, Baltimore, MD 21287. Address e-mail to lfleishe{at}welchlink.welch.jhu.edu


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Appendix 1
 References
 
Patients may have concerns about their ability to manage postoperative symptoms at home after ambulatory surgery. We assessed patients' attitudes toward postoperative care at home or in the hospital after laparoscopic cholecystectomy. Thirty-eight patients undergoing elective laparoscopic cholecystectomy were pre- and postoperatively (within a week each) presented with scenarios describing symptoms of differing severity in either a home or hospital setting and were asked to rank and rate the relative desirability of the scenarios using rating scale, standard gamble, and willingness-to-pay techniques. Preoperatively, 16 (42%), 21 (55%), and 30 (79%) patients ranked pain of mild, moderate, and severe levels, respectively, as worse than the respective levels of nausea and vomiting. Of 24 patients, 19 (79%) preferred home care to hospital care for mild symptoms, and 12 of 22 patients (55%) preferred home care to hospital care for moderate symptoms. The average ratings were 20, 53, and 90 for mild, moderate, and severe symptoms, respectively, where 0 = no symptoms and 100 = the worst symptoms possible. Patients who preferred care outside the home indicated that they were willing to pay a mean of $142 (maximum $410) as a maximal copayment to have postoperative care in the hospital and a mean of $255 to receive care in a medical hotel-like facility. Postoperative assessment correlated highly with the preoperative assessment (correlation coefficient >0.6 for rating, standard gamble, and willingness-to-pay assessments). We conclude that patients vary in their attitudes toward where they would like to receive postoperative care. Attitudes assessed preoperatively may predict their attitudes postoperatively.

Implications: Patients preferred to be at home for mild postoperative symptoms but in the hospital for worse postoperative symptoms. Preferences did not change with different methods of asking and were the same pre- and postoperatively. If patients made choices for their care before their procedure, they would still be happy with those decisions postoperatively.


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Appendix 1
 References
 
With the current economic constraints on the healthcare system, there is increasing pressure to decrease the length of hospital stays. These forces have led to the rapid expansion of outpatient surgery. In many cases, the decision to perform surgery on an outpatient basis is based more on economic grounds than on the desires of the patients. However, there are some clinical scenarios in which patient preferences have had an important impact on policies regarding hospital length of stay. For example, in-hospital postpartum care was being shortened until public opinion resulted in legislation that mandated minimal allowable lengths of stay.

Increasingly, laparoscopic cholecystectomy is viewed as a procedure that can be performed on an ambulatory basis (1–3). The main factors that limit the ability to perform outpatient laparoscopic surgery on a routine basis are postoperative pain, nausea, and vomiting. How patients feel about such postoperative symptoms is likely to have a major impact on their preferences regarding inpatient versus home care after laparoscopic surgery. However, no work has been performed to determine whether patients' views about such factors can be reliably assessed preoperatively.

The purpose of this study was to assess patients' preferences regarding the location of postoperative care with regard to symptom severity and to compare different measures of these preferences before and after surgery to assess the consistency of their preferences.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Appendix 1
 References
 
After institutional review board approval, we studied consecutive patients scheduled for outpatient laparoscopic cholecystectomy who had not undergone prior surgery; there were no dropouts. Using a pre-/postprocedure design of patients and their preferences regarding postoperative care, we assessed baseline characteristics and preferences within 1 wk preoperatively, and preference assessments were repeated within 1 wk postoperatively. Patients were interviewed by telephone preoperatively and in person postoperatively using the same set of questions.

Baseline data included age, gender, race, surgeon, marital status, total number of children, the identity of the caretaker (who would take primary care of the patient at home postoperatively), occupation, spouse's occupation, father's occupation, education, health insurance, and confirmation of surgical procedure.

Patients' preferences regarding postoperative care were assessed using four different measurement techniques: ranking of preferred clinical scenarios, rating of clinical scenarios on a linear analog scale, assessment of potential clinical scenarios using a standard gamble technique, and assessment of clinical scenarios using a willingness-to-pay technique (4).

For ranking, patients were given concrete descriptions of typical postoperative symptoms, including mild, moderate, and severe nausea/vomiting and mild, moderate, and severe abdominal pain (see Appendix 1 for definitions as presented to the patients). The two potential postoperative care settings—at the hospital or at home—were also defined. Patients were first asked where they would prefer to have their postoperative care for mild or moderate pain, or for mild or moderate nausea/vomiting. For those preferring the hospital for the postoperative care of such symptoms, a willingness-to-pay assessment was performed (see below). For the remaining majority of patients, ranking, rating, and standard-gamble assessments were performed. Severe symptoms were defined as those requiring hospitalization.

Using a rating-scale technique, patients were asked to assign a numerical score (0 = no symptoms to 100 = severe symptoms—the worst symptoms the patient could imagine) to mild, moderate, and severe symptoms independent of care setting.

The patients were then asked to assess their preference regarding different scenarios using a standard reference gamble format (5). In this paradigm (Fig. 1), patients who preferred care at home for mild symptoms were asked to choose between two hypothetical scenarios. One was care in the hospital with mild symptoms, and the second was a lottery, or gamble, between mild symptoms at home (more preferred) and severe symptoms at home (less preferred). Patients were then asked at what chance of severe symptoms at home (and the complementary chance of mild symptoms at home) they were indifferent between care at home and care in the hospital. This point of indifference was determined by starting with a high probability of severe symptoms, getting agreement that the hospital would be preferred, then presuming a very low probability of severe symptoms, and getting agreement that home would be preferred. The higher probability was then lowered and the lower probability raised until patients were indifferent to care at home or in the hospital. The point of indifference—the probability of mild symptoms at home (pMild)—represents the preference score for mild symptoms under treatment at the hospital. A similar gamble was performed for moderate symptoms in the hospital versus a chance of moderate or severe symptoms at home.



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  		Figure 1. Standard reference gamble to quantify preference for treatment of mild symptoms in the hospital. When the patient is indifferent between the left- and right-hand choices, the probability of mild symptoms at home (pMild) provides the quantification. pSevere = the probability of severe symptoms at home. pMild + pSevere = 1.

 
For patients preferring care in the hospital, an assessment of willingness to pay (WTP) (6) was made by asking how much patients would pay out of pocket to switch from the home care scenario to hospital or medical hotel care. The payments were assessed in three ways: the amount patients would expect to co-pay to stay in the hospital, the maximum they would pay to stay in the hospital, and the amount they would pay for a medical hotel stay (for those patients who would prefer to be home). "Co-pay" was defined as out-of-pocket expenses beyond what insurance would pay. The expression "hotel stay" was defined as a medical hotel in which minimal nursing care was available.

Demographic data, ranks, ratings, standard gamble scores (pMild), and WTP values were summarized by counts or means, as appropriate. Comparisons between pre- and postoperative assessments were evaluated by {chi}2 (rankings) or by t-tests (ratings, standard gamble, WTP; normality confirmed by normal quantile plots) and by Spearman's correlation.

We performed a consistency check between assessed pMild and pModerate before preferring an in-patient stay by setting the utility of mild symptoms in the hospital as greater (or less) than the utility of moderate symptoms in the hospital and confirming that the assessed probabilities were consistent with either hypothesis.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Appendix 1
 References
 
Table 1 displays data regarding the demographics of this patient sample, which comprised a group of middle-aged and middle-class patients, mostly women, with high school or greater education and with caretaking responsibilities for their children or spouse. The education helped in their completing the assessment tasks, and the caretaking responsibilities may have influenced patients' preferences for site of postoperative care.


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  		Table 1. Demographic Characteristics
 
Although most patients thought that mild and moderate nausea/vomiting were worse than their painful counterparts, most patients thought that severe pain was worse than severe nausea/vomiting (Fig. 2). These preferences did not change postoperatively, after they had experienced some of the outcomes. We did not ask patients which symptoms they had personally experienced.



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  		Figure 2. Number of patients (of a total of 26) ranking nausea and vomiting (NV) as worse than pain. Patients who reported that the symptoms are equivalent are not reported. The largest such group was in the Severe category (15% of respondents).

 
More people preferred to be hospitalized for moderate symptoms than for mild symptoms (Table 2). This suggestion is borne out by a more detailed analysis of the 22 patients for whom we had both pre- and postoperative rankings. Only 23% of these patients wanted to be treated in the hospital for mild symptoms, whereas 43% preferred hospitalization for moderate symptoms ({chi}2 statistic [1 df] of 8; P = 0.0013). Furthermore, the assessments did not change postoperatively compared with preoperative preferences.


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  		Table 2. Site of Treatment Preferences
 
Ratings for symptoms deemed worse increased quantitatively with higher verbal categories (Table 3). This observation was tested by performing a within-subject analysis of variance, which confirmed that the patients rated moderate symptoms as worse than mild symptoms (P < 0.0001) and that the ratings were the same pre- and postoperatively. The correlation between pre- and postoperative ratings was 0.79 for mild symptoms (P = 0.0006) and 0.77 (P = 0.004) for moderate symptoms.


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  		Table 3. Ratings of Symptom Severity
 
The standard gambles provided another quantitative assessments of patients' perceptions. Table 3 shows the responses of 12 patients who preferred treatment at home versus in the hospital for mild and moderate symptoms. Unlike the results with the rating scale, there is a large overlap of mild and moderate scores. The correlation of pre- and postoperative assessments was 0.69 (P = 0.005). In terms of consistency of the responses between mild and moderate, we found that all the responses were consistent under the hypothesis that the underlying utility of moderate symptoms in the hospital is less than the utility of mild symptoms at the hospital. Thus, patients understood the assessment method.

As a further consistency check to determine whether individual patients changed their standard gamble responses between assessments for mild and moderate symptoms, we performed a repeated-measures analysis of variance of subject versus time versus severity, which showed a statistically significant effect for subject only. That is, subjects' responses were idiosyncratic, were unchanged after the surgical procedure, and did not necessarily differ between severe and moderate symptoms. The mean difference between assessments for mild and for moderate preoperatively was 5, with a standard deviation of 22, so the mean is statistically indistinguishable from 0, meaning that there is effectively no difference between moderate and severe assessments.

Because patients were most unfamiliar with the standard gamble assessment, it was important to compare their pre- and postoperative responses. In the evaluation of mild symptoms, these assessments had a correlation coefficient of 0.69 (P = 0.005). For moderate symptoms, the correlation coefficient was only 0.13 (not significantly different). Finally, the overlap in confidence intervals between pre- and postoperative scores suggests that the ratings and the standard gambles were statistically indistinguishable in the two time periods.

The third quantitative assessment was WTP. Analysis of variance applied to each outcome in Table 4 confirmed that there were no apparent differences pre- and postoperatively. The large standard deviations convey the large range of values assessed from these patients. A within-subject multiple regression analysis confirmed that each of the three WTP questions addressed a different aspect of the patients' tradeoffs regarding out-of-pocket costs, symptoms, and location of care and confirms that different patients are willing to pay very different amounts for these different services.


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  		Table 4. Assessments of Willingness to Pay
 
To look for relationships among the WTP responses in another way, we performed correlations among these variables. Pairwise correlations yielded a correlation coefficient of 0.64 (P = 0.018) for the relationship between the maximal WTP for hospital care and WTP for medical hotel care and a correlation of 0.83 (P < 0.0001) for the relationship between maximal WTP for co-pay and WTP for medical hotel care. The coefficient for co-pay and hotel care did not reach statistical significance, which suggests that the WTP for co-pay and the WTP for medical hotel care assessed two different dimensions of concern.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Appendix 1
 References
 
In this sample of middle-aged, middle-class patients undergoing laparoscopic cholecystectomies, we discerned a number of trends regarding patients' perceptions of postoperative symptoms and their preferences regarding their care. Mild and moderate nausea/vomiting after surgery were perceived as being worse than mild and moderate pain, respectively. Patients showed a preference for postoperative care at home for mild and moderate symptoms, although preference for hospital care increased with increasing symptom severity. Patients' standard gamble assessments for mild symptoms agreed with their symptom ratings. The standard gamble assessments for moderate symptoms were consistent with the ratings of moderate symptoms. Finally, in the WTP assessments, the elicited maximum was half of the charge ($400) that they were told to expect, which indicates an expectation to co-pay. The actual amount they were willing to co-pay was approximately 25% of that maximum, close to the 20% they often must pay for medical procedures. The average they were willing to pay for a medical hotel matches the amount of an expensive hotel stay.

Because the pre- and postoperative assessments were unchanged with almost every assessment method, our results suggest that preoperative planning can include a preference assessment. A formal assessment such as we have performed would be helpful when local probabilities of mild, moderate, or severe symptoms were known and patients' assessments could be compared with these likelihoods. We would expect that, for patients who state a preference for home care, ambulatory surgery would not be perceived as a premature discharge, but rather as a plan consonant with their preferences. However, patients who state a preference for hospital care cannot be blithely ignored. The tradeoff in permitting some patients to stay must be assessed by each institution.

Our patients' ranking of mild and moderate nausea/vomiting as worse than mild and moderate pain support previous investigations demonstrating the importance of postoperative nausea/vomiting and pain. In economic terms, postoperative nausea/vomiting is estimated to cost the medical system approximately $400 per patient experiencing these symptoms (7). Because the incidence of such symptoms may influence a patient's willingness to be discharged early after surgery, prophylactic treatment may be justified.

The different assessment methods have their strengths and weaknesses. Each assessment method we used elicited different aspects of patient preferences: ranking gets at raw preference, and rating elicits attitudes toward degree of outcomes. Standard gambles attempt to assess whether those ratings change when patients are faced with outcomes that have conflicting risks; no change was noted for mild symptoms in our study. Finally, WTP forces subjects to trade off medical and economic outcomes.

There have been a number of attempts to quantify patients' perceptions of morbid conditions (8,9). These assessments have focused on function and chronic morbidity and have not assessed patients' preferences regarding procedures or location of care, both of which are short-term health states. In general, preference assessment for short-term outcomes is difficult if one of the outcomes entails even a small chance of a severe outcome, such as death or stroke, because then the minor outcomes must be placed on a scale where 0 represents that severe outcome. The interpretation of the standard gamble then becomes what chance of death the patient is willing to take to avoid the short-term outcome. Because the answer may be on the order of one in a million, the utility depends on the fifth or sixth decimal place, which is not very convincing or certain. We obviated this concern by using severe postoperative symptoms as our worst outcome in our scale, and the assessments ran the gamut.

Beyond the details of these perceptions and preferences, we demonstrated some important facts that are important to future investigators. Patient responses did not change postoperatively, which means that preoperative assessments might be predictive of postoperative perceptions. Patients were also generally consistent in their responses, and they used the methods appropriately.

The standard gamble must be refined further. A second gamble is needed to assess the probability that would lead to a utility measure of moderate symptoms treated at home. This measure would be helpful in assisting patients to decide whether to risk postoperative care at home, because moderate symptoms are more likely than severe symptoms. However, if the likelihood is below their threshold for switching care to hospital care, then patients should feel that their best decision is to be cared for at home.

Several recent studies of chronic illness have addressed formal approaches to assessing patient preferences. Nease et al. (10) demonstrated that the utility values that angina patients assigned to their pain differed from the severity suggested by "objective" functional inventories. Rutten-van Mölken et al. (11) assessed health states of patients with fibromyalgia or ankylosing spondylitis by using rating scale and standard gamble and documented standard gamble ratings higher than rating scale ratings and greater stability in the assessed numbers over time. Ramsey et al. (12) compared standard gamble responses with a health status inventory in the context of life before and after lung transplantation and demonstrated that different assessment measures assess different dimensions of patients' experiences.

The literature is consistent with our study in showing that preference assessments in standard gambles capture patients' attitudes toward risk itself, thereby giving different numbers than rating scales (11). Bowe (13) has shown how it is precisely patients' risk aversiveness to medical outcomes that accounts for the generally higher values assessed via standard gambles.

In conclusion, we demonstrated that patient preferences can be assessed in an elective preoperative setting, that they correlate strongly with postoperative preferences, that standard gamble assessment captures attitudes about risk different from that assessed by using other methods, and that patients expect a co-pay but would be loathe to pay more for semi-home care than for an expensive hotel room.


   Appendix 1
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Appendix 1
References
 
Definitions of Health States
Mild pain: Pain in the abdomen from the surgery. It is relieved by taking medicines by mouth.

Mild nausea/vomiting: You would be able to drink and eat with minimal nausea and you might have an episode of vomiting, but then you would feel better.

Moderate pain: Pain that is stimulated with minimal activity. Oral medications dull the pain but do not completely alleviate it; you would be able to tolerate the pain if you were lying in bed.

Moderate nausea/vomiting: Discomfort upon drinking and vomiting upon eating. You would experience intermittent vomiting.

Severe pain: The worst pain you have ever experienced which is not dulled by oral medication or alleviated by rest. You would be required to return to the hospital within 24 h of the onset of symptoms.

Severe nausea/vomiting: The worst nausea/vomiting that you can imagine; you would vomit everything taken by mouth, would have lightheadedness from dehydration, and would have a constant feeling of nausea. You would be required to return to the hospital within 24 h of the onset of symptoms


   Acknowledgments
 
This work was supported by National Library of Medicine Grant R29 LM05647.

Our thanks to the nurses in the General Clinic Research Center of Johns Hopkins Medicine.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Appendix 1
 References
 

  1. Baird DR, Wilson JP, Mason EM, et al. An early review of 800 laparoscopic cholecystectomies at a university-affiliated community teaching hospital. Am Surg 1992;58:206–10.[Web of Science][Medline]
  2. Biswas TK, Leary C. Postoperative hospital admission from a day surgery unit: a seven-year retrospective survey. Care 1992;20:147–50.
  3. Lillemoe K, Lin J, Talamini M, et al. Laparoscopic cholecystectomy as a "true" outpatient procedure: initial experience in 130 consecutive patients. J Gastrointest Surg. In press.
  4. Froberg DG, Kane RL. Methodology for measuring health-state preferences. II. Scaling methods. J Clin Epidemiol 1989;42:459–72.[Web of Science][Medline]
  5. Sox HC, Blatt MA, Higgins MC, Marton KI. Medical decision making. Stoneham, MA:Butterworth-Heinemann, 1988.
  6. O'Brien B, Viramontes JL. Willingness to pay: a valid and reliable measure of health state preference? Med Decis Making 1994;14:289–97.
  7. Carroll NV, Miederhoff PA, Cox FM, Hirsch J. Costs incurred by outpatient surgical centers in managing postoperative nausea and vomiting. J Clin Anesth 1994;6:364–9.[Web of Science][Medline]
  8. Gold MR, Siegel JE, Russell LB, eds. MCW: cost-effectiveness in health and medicine. New York: Oxford University, 1996.
  9. Torrance GW. Utility approach to measuring health-related quality of life. Chron Dis 1987;40:593–600.
  10. Nease RF, Kneeland T, O'Connor GT, et al. Variations in patient utilities for outcomes of the management of chronic stable angina. JAMA 1995;273:1185–90.[Abstract/Free Full Text]
  11. Rutten-van Mölken M, Bakker CH, Doorslaer EV, van der Linden S. Methodological issues of patient utility measurement. Med Care 1995;33:922–37.[Web of Science][Medline]
  12. Ramsey SD, Patrick DL, Lewis S, et al. Improvement in quality of life after lung transplantation: a preliminary study. J Heart Lung Transplant 1995;14:870–7.[Web of Science][Medline]
  13. Bowe TR. Measuring patient preferences: rating scale versus standard gamble. Med Decis Making 1995;15:283–8.[Free Full Text]
Accepted for publication March 1, 1999.




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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press