Pre-packed take-home analgesics in ambulatory surgery

[Evaluation of the impact of prescription analgesic during the anaesthesia consultation on the incidence of postoperative pain at home in ambulatory orthopaedic surgery]

INTRODUCTION

Postoperative pain at home in ambulatory surgery is a major problem. To improve its management, the French society of anaesthesia emphasizes the importance of writing prescriptions for analgesic during the preanaesthetic consultation. The objective of this study was to assess the impact of this prescription on the incidence of postoperative pain at home in ambulatory orthopaedic surgery.

PATIENT AND METHODS

We conducted a prospective evaluation in the ambulatory surgery unit of Rouen University Hospital. We were able to identify two periods of 1 year with implementation of a systematic prescription of analgesics during the postoperative period (P1) or during the preanaesthetic consultation (P2). The evaluation of this measurement was made by a telephone survey conducted the day after surgery. The main parameter was the incidence of postoperative pain at home defined by the occurrence of a pain greater to 3/10 on a numerical scale (FR). Secondary parameters were demographic and anaesthetic data, the incidence of moderate pain (FR ≤ 3), treatment adherence and patient satisfaction.

RESULTS

We included 638 patients and 531 were analysed: 28% of patients had an EN greater than 3 the day following surgery. There is no difference between the two periods (30% for P1 versus 27% for P2). The analysis of subgroups showed that in the general anaesthesia group, 30% of patients had an EN greater than 3 for P1 versus 18% for P2 (P<0.01). Furthermore, 55% of patients expressed moderate pain (FR ≤ 3) for P1 versus 22% for P2 (P<0.01). Moreover, 89% of patients reported having an adequate analgesic treatment. The overall observance was 64%, 53% for P1 versus 75% for P2 (P<0.01).

DISCUSSION

The systematic prescription of analgesics during the preanaesthetic consultation does not decrease the intensity of moderate to severe pain. On the other hand, this procedure seems to be positive for the people who underwent a general anaesthesia.

Reminder packaging for improving adherence to self-administered long-term medications

BACKGROUND

Current methods of improving medication adherence for health problems are mostly complex, labour-intensive, and not reliably effective. Medication 'reminder packaging', which incorporates a date or time for a medication to be taken in the packaging, can act as a reminder to improve adherence. This review of reminder packaging is an update of our 2006 Cochrane review.

OBJECTIVES

The objective of this review was to determine the effects of reminder packaging aids for self-administered medication/s taken for at least one month, on adherence and other outcomes.

SEARCH STRATEGY

We updated searches of the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library Issue 9, 2010), MEDLINE, EMBASE, CINAHL and PsycINFO from the database start dates to September 2010. We searched Current Controlled Trials to identify trials in progress. We performed a cited reference search on the Science Citation Index to identify papers that had cited the original systematic review.We also searched the Internet, contacted packaging manufacturers, and checked abstracts from the Pharm-line database and reference lists from relevant articles. We did not apply any language restrictions.

SELECTION CRITERIA

We selected randomised controlled trials with at least 80% follow up. We intended to do a sensitivity analysis of those studies that analysed their data on an intention-to-treat basis. Included studies compared a reminder packaging device with no device, for participants taking self-administered medications for at least one month.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed studies for inclusion, assessed quality, and extracted data from included studies. Where considered appropriate, data were combined for meta-analysis, or were reported and discussed in a narrative.

MAIN RESULTS

We included twelve studies containing data on 2196 participants; four of these studies were newly included in this 2011 update of our 2006 Cochrane review.Six intervention groups in four trials provided data on the percentage of pills taken. Reminder packaging increased the percentage of pills taken (mean difference (MD) 11% (95% confidence interval (CI) 6% to 17%)). Notable heterogeneity occurred among these trials (I(2) = 96.3%). Two trials provided data for the proportion of self-reported adherent patients, reporting a reduction in the intervention group which was not statistically significant (odds ratio = 0.89 (95% CI 0.56 to 1.40)). We conducted meta-analysis on data from two trials assessing the effect of reminder packaging on blood pressure measurements. We found that reminder packaging significantly decreased diastolic blood pressure (MD = -5.89 mmHg (95% CI -6.70 to -5.09; P < 0.00001; I(2) = 0%). No effect was seen on systolic blood pressure (mean change -1.01, 95% CI -2.22 to 0.20; P = 0.1, I(2) = 0%). We also conducted meta-analysis on extracted data from two trials that looked at change in glycated haemoglobin. We found that reminder packaging significantly reduced glycated haemoglobin levels (MD -0.72; 95% CI -0.83 to -0.60; P < 0.00001; I(2) = 92%), although there was considerable heterogeneity.No appropriate data were available for meta-analysis of remaining clinical outcomes, which included serum vitamin C and E levels, and self-reported psychological symptoms (one trial each). We reported remaining data narratively. In one study the presence of a reminder packaging aid was found to be preferred by patients with low literacy levels.

AUTHORS' CONCLUSIONS

Reminder packing may represent a simple method for improving adherence for patients with selected conditions. Further research is warranted to improve the design and targeting of these devices.

Clinical practice and routines for day surgery in Sweden: results from a nation-wide survey

BACKGROUND

Day surgery has expanded considerably during the last decades. Routines and standards have developed but differ between and within countries.

METHODS

We studied the practice of day surgery in Sweden by an extensive questionnaire survey sent to all 92 hospitals.

RESULTS

The proportion of day surgery vs. in-hospital procedures was overall 43%, with 43% in adults and 46% in children. Orthopaedic (33%), general (29%) and gynaecological (17%) surgery were the most common ambulatory procedures. Most patients (>90%) underwent pre-operative assessment by an anaesthesiologist. Patient self-assessment questionnaires were common (86%). Risk stratification for post-operative nausea and vomiting was used by 70% of the departments. Anxiolytic pre-medication was uncommon. Most anaesthesiologists (95%) used pre-operative oral analgesics to initiate post-operative analgesia, the most common being paracetamol (95%), NSAIDs (73%) and coxibs (15%). A balanced general anaesthesia technique was preferred. Post-operatively, 93% of the units routinely assessed patients' pain. Analgesic combinations of paracetamol, NSAIDs and weak opioids were used by 94% of the units. Most hospitals (80%) had standardised discharge criteria based on clinical assessment, and many required a patient escort at home for 24 h post-operatively. Assessments of unplanned admission, re-admission and post-operative complications were not performed routinely. Follow-up telephone calls within 1-2 days were performed regularly in about 40% of the units, or in selected patients only (37%). Pain was the most frequent complaint on follow-up.

CONCLUSIONS

In Sweden, a high degree of standardised regime for day surgical practice was found. Post-operative pain is the most common complaint after discharge.