Patient's knowledge and perception of preanesthesia check-up in rural India.

BACKGROUND: Preanesthesia assessment is an important aspect of patient care. If a patient shows lack of interest during preanesthesia check-up or tries to rush through, it may result in incomplete history and general physical examination, compromising patient care. AIM: The aim of this study was to assess the knowledge of patients presenting for elective surgery to Tertiary Care Hospital in Rural India regarding value and importance of preanesthesia check-up. SETTINGS AND
DESIGN: This observational study was conducted in a Tertiary Care Teaching Hospital in Rural India. 1000 patients posted for elective surgery coming to preadmission anesthesia consultation (PAC) clinic over a period of 3 months were included in this study.
METHODS: Patients were asked to fill a questionnaire consisting of 15 questions before start of preanesthesia assessment. Each question was provided with multiple possible choices, out of which patient had to choose the most appropriate according to him/her. Scoring was done, with each question answered correctly being given 1 mark while incorrect answer was awarded 0 marks. STATISTICAL ANALYSIS: Data were expressed as frequencies and percentage. Correlations studies were performed by unpaired t-test and one-way analysis of variance.
RESULTS: About 27.4% of patients knew that they had come to PAC clinic for preanesthesia assessment, the rest were not clear. Similarly, only 18.1% knew that only anesthesiologist can perform a preanesthesia examination. 16.5% patients said that they would discuss their fears or queries regarding anesthesia in PAC clinic while 58.6% said that they would share such feelings with the surgeon in ward.
CONCLUSION: Patients had insufficient knowledge about preanesthesia assessment and its role in improving the outcome of surgery.

INTRODUCTION

Many studies in past have demonstrated limited knowledge among general public and even patients about various aspects of anesthesia.[12345] However, patients' understanding of anesthesia and its importance is fast changing. More and more patients these days understand the role of anesthesiologist at the time of surgery and even during the postoperative period. However, preanesthesia check-up still remains a less cared aspect of anesthesia especially in rural India, where most patients believe it to be a waste of time. Such patients try to rush through the preanesthesia check-up resulting in incomplete history and general physical examination. Even preoperative investigations advised are often seen as unnecessary wastage of money and preoperative optimization is not taken seriously. This not only undermines the purpose of preadmission anesthesia consultation (PAC) clinic, but also increases peri-operative morbidity and mortality. The aim of this study was to assess the knowledge of patients presenting for elective surgery to a Tertiary Care Hospital in Rural India regarding value and importance of preanesthesia check-up.

METHODS

This observational study was conducted in a Tertiary Care Teaching Hospital in Rural India. 1000 patients posted for elective surgery coming to PAC clinic over a period of 3 months were included in this study. Written informed consent was obtained from all patients in their own language before starting this study. Patients were asked to fill a questionnaire consisting of 15 questions [Table 1]. Patients included in this study were aged between 18 and 60 years of age, both male and female. Patients with hearing problems, unable to speak and with altered mental status were excluded from the study. If any patient refused to answer the questionnaire he/she was also excluded from the study.

Table 1

Questionnaire

The questionnaire was available both in English and in Hindi (local language), and patients were explained how to fill the questionnaire before start of the study. In case patient was illiterate, questions were explained to the patients and their response was sought. The entire questionnaire was to be completed before start of preanesthesia check-up. Initial questions were about patient's characteristics like age, sex, education level, etc. Afterward, patients were asked about their views and understanding of preanesthesia check-up (question number 4–15) and its importance in patient care.

Each question was provided with multiple possible choices, out of which patient had to choose the most appropriate according to him/her. An option of don't know was also provided with most questions. Scoring was done for questions 4–15, with each question answered correctly being given 1 mark while incorrect answer was awarded 0 marks. Patients giving don't know as answer, were also awarded 0 marks.

Statistical analysis

Data were expressed as frequencies and percentage. Correlations studies were performed by unpaired t-test and one-way analysis of variance using SPSS® version 16 (Statistical Packages for the Social Sciences) for Windows by IBM to study the effect of variables like age, sex, literacy level, and previous visit to PAC clinic on patient's knowledge and understanding of preanesthesia check-up. P < 0.05 was considered statistically significant.

RESULTS

Patient characteristics

A total of 1000 patients aged 18–60 years, coming to preanesthesia clinic answered the questionnaire. 32.6% of the patients were <30 years of age while 27.5% were between 30 and 45 years of age and rest were between 45 and 60 years of age. 647 (64.7%) were males and remaining 353 (35.3%) were females [Table 2]. As far as literacy levels were concerned 29.8% of the patients were illiterates, 9.6% had studied up to primary school, 37.5% finished secondary school, 18.4% were graduates, and remaining 4.7% were postgraduates. When asked about a previous visit to PAC clinic, 36.8% of the patients had visited PAC clinic previously, the rest were coming for the 1st time.

Table 2

Patient variables

Patients' knowledge and perception of preanesthesia check-up

On being asked, why they had come to PAC clinic, only 27.4% of patients answered for preanesthesia assessment, while 47.8% said that they were following surgeon's instructions, rest 23.5% believed that they would be getting date for surgery there, and 1.3% patients didn't know the exact reason [Table 3]. In reply to question what is done in a preanesthesia clinic, 43.1% believed that only preanesthetic assessment is done; only 3.2% said that both preanesthetic assessment and optimization is done in PAC clinic, rest 34.5% thought some test would be performed to check fitness for surgery and 19.2% were not sure.

Table 3

Patients’ response to questionnaire

Similarly, only 18.1% [Table 3] of the patients knew that only anesthesiologist can perform a preanesthesia examination, and only 15.6% thought that preanesthesia examination helps to reduce surgery and anesthesia-related risk. On being asked the significance of preoperative morbid conditions, only 36.7% believed that they are to be told before surgery, 21.3% said that such conditions are required to be optimized before surgery and only 31% knew that presence of such conditions might affect the outcome of anesthesia and surgery. As far as habits like drinking and smoking are concerned only 23.7% said that these conditions might affect anesthesia or surgery.

When patients were asked if preanesthesia examination is required only for surgery, 36.9% of patients agreed. Similarly, only 16.5% patients said that they would discuss their fears or queries regarding anesthesia in PAC clinic while 58.6% said that they would share such feeling with the surgeon in ward. Only 20.3% patients said that they follow PAC advice for their own good. 26.5% said they would follow preanesthesia advice only till surgery, 31.1% said that they would do so only if the surgeon advises same while 22.1% were not sure.

Correlation between patient variables and patient knowledge

Impact of age, sex, education level, and previous experience of PAC was statistically analyzed. No significant correlation was found between age [Table 4] and sex [P - 0.3644, Table 5] of the patients and their knowledge of PAC. However, education level [Table 6] significantly influenced patient knowledge as illiterate patients and patients educated till primary level had significantly lesser knowledge than graduates and postgraduates. Though total score achieved by patients educated up to secondary schools was higher than those who had only attended primary school but no statistically significant difference was found (P - 0.48). Similarly, patients who had previously visited PAC clinic [Table 7] achieved significantly higher mean score than patients coming for the 1st time (P < 0.0001).

Table 4

Effect of patient's age on knowledge regarding pre anaesthesia check up

Table 5

Effect of patient's gender on knowledge regarding pre anaesthesia check up

Table 6

Effect of patient's level of education on knowledge regarding pre anaesthesia check up

Table 7

Effect of patient's previous PAC visit on knowledge regarding pre anaesthesia check up

DISCUSSION

Anesthesia as a profession has evolved from merely being a supportive specialty to surgery to one involved in wholesome and complete care of patients, not only in operation theaters but also in intensive care units and pain clinics. In spite of this, knowledge among the general public,[12] patients,[345] paramedical staff,[6] and even surgeons[7] regarding various aspects of anesthesia is limited. Picture is even depressing in developing countries where only 50–60% of the patients consider anesthesiologist to be a doctor[8] as compared to 90–99% patients in developed countries.[910] This not only frustrates anesthesiologists[11] but also affects the patient care and hampers further development of the specialty. Though many reasons can be attributed to this, one of the major reasons is that the patient first goes to a surgeon for their disease and is later referred to an anesthesiologist.[12]

It is a well-established fact that preanesthesia assessment is an important aspect of patient care. Preanesthetic evaluation includes history taking, proper physical examination and laboratory investigations. The aim of preanesthetic check-up is to optimize a patient before surgery, so as to reduce the risk of anesthesia and surgery as far as possible and improve outcome. Furthermore, it provides an opportunity for the patient to discuss any queries or fears regarding anesthesia. Hence, if a patient shows a lack of interest during PAC or tries to rush through it, the task of anesthesiologist becomes more difficult. This may result in patient being inadequately optimized before surgery. And it is a well-established fact that both the patient's preoperative physical status and surgical procedure affects morbidity and mortality during surgery.[13]

In our study, no statistically significant correlation was found between gender of the patient and knowledge of preanesthesia check-up. Similar results were obtained by Gurunathan and Jacob[2] in a study regarding public's perception of the anesthesiologist in India. Similarly in a study by Sagün et al.[12] though women showed higher knowledge of anesthesia, results were not statistically significant. Impact of education and previous surgical experience on the knowledge of anesthesia was studied by Baaj et al.[8] and both were found to be directly related. Similar results were obtained in our study.

As a result of increased patient load, lack of patient knowledge regarding PAC and more and more day care surgeries being performed, the incidence of inadequate preanesthesia check-up is increasing resulting in increased morbidity and mortality. Kluger et al. examined the Australian Incident Monitoring Study database and showed that out of 6271 reports, 478 had incorrect preoperative assessment while 248 had inadequate preoperative preparation.[14] They found that inadequate preanesthetic management resulted in six-fold increase in mortality. Lack of proper communication was one of the important factors identified in that study. Though PAC can be performed in the evening, a day before surgery but the lack of proper equipment in ward and inadequate time left for optimization may limit its utility. Hence, preoperative visit by the patient to anesthesia clinic should be emphasized. Also this has been shown to be a cost-effective method of patient care by reducing the expense of indoor admissions.[15]

Hence, patients should understand that complete and through preanesthetic assessment and optimization goes a long way to improve operative outcome. Not only patients, the general public should be educated about the value of various aspects of anesthesia. Furthermore, misconceptions like preanesthesia examination only delay surgeries should be strongly discouraged. On the other hand, if patients understand the purpose of PAC and cooperate fully during preoperative optimization, unnecessary delays and cancelations on the day of surgery could be avoided.

Further patients may be having certain fears or questions, all of which surgeon cannot answer. These include fear of pain or awareness during surgery, queries regarding type of anesthesia that can be offered and postoperative pain. Chew et al.[5] in a study showed that patients were more afraid of postoperative pain, and their main fear of surgery was that they may not be able to come out of anesthesia. Similarly in a study by Ahsan-Ul-Haq et al., 40% of the patients were afraid of surgery while 60% were afraid of anesthesia.[16] These concerns can be more appropriately addressed in PAC clinic. Proper understanding and interest among surgical patients would help in better communication between patient and anesthesiologist. This will result in higher patient satisfaction and reduced preoperative anxiety.[17] Furthermore, it will help to establish anesthesiologists as preoperative physicians in the minds of patients resulting in the further development of specialty.

Our study had certain limitations. First, the relationship between lack of PAC related knowledge and inadequate preanesthesia optimization was not studied. Second, the impact of lack of such knowledge on operative outcome was not assessed. Third, this study does not suggest possible measures that can be taken to improve patient's knowledge regarding preanesthesia check-up. Hence, further studies may be required to fully address this problem and improve patient care.

CONCLUSION

Patients have inadequate knowledge about preanesthesia assessment and its role in improving the outcome of surgery. Hence, efforts should be made by not only anesthesiologists but also by surgeons involved in patient care to emphasize the importance of PAC clinic, to decrease peri-operative morbidity and mortality.