Burden Incurred by Patients and Their Caregivers After Outpatient Surgery: A Prospective Observational Study

Abstract

Introduction

The burden of patients and their caregivers after outpatient surgery has not been fully examined. The number of outpatient surgeries has dramatically increased in the last several years, particularly in the orthopaedic sector. Patients undergoing outpatient orthopaedic procedures may be expected to have more postdischarge pain than those undergoing nonorthopaedic outpatient procedures. In light of this, assessment of patient and caregiver expectations and actual burden after discharge is of importance.

Questions/purposes

We assessed the impact of outpatient surgery on recovery of patients and their caregivers in the postoperative period by determining (1) expected versus actual time to resume daily activities, including work; (2) expected versus actual recovery at 7 and 30 days postoperatively; and (3) the number of caregivers that felt emotional or physical disturbances from caring for outpatients.

Methods

Forty-four adult patients undergoing outpatient surgical procedures and their primary caregivers were enrolled in this prospective survey study, of which 30% were orthopaedic patients. Surveys assessing postoperative recovery were given to patients at six time points, on Postoperative Days 0 to 3, 7, and 30. Surveys assessing the burden of informal caregiving were given to each patient’s primary caregiver at four time points, on Postoperative Days 1 to 3 and 7. The enrollment rate was 79% (44 enrolled of 56 approached) and the survey response rate was 100% for patients and 93% (41 of 44) for caregivers.

Results

We found that 16 of 44 patients (36%) needed more time than originally anticipated to resume their daily activities and three of 29 patients (10%) needed more time off from work than originally anticipated. Patients were approximately 66% and 88% fully recovered 7 and 30 days after surgery, respectively. The primary caregivers noted disturbances in emotional (nine of 43, 21%) and physical (17 of 43, 40%) aspects of their daily lives while providing care for patients. Our surveyed patients were from multiple surgical services; however, our results may be generalized to an orthopaedic population, although they may underestimate actual results for this population given their generally higher pain scores.

Conclusions

Patients may take longer to recover from outpatient surgery than previously recognized. As increased pain and prolonged recovery may be associated with increased caregiver burden, these data are of particular significance to the outpatient orthopaedic surgical population. Informal caregiving after outpatient surgery may be an unrecognized physical and psychologic burden and may have a significant societal impact.

Level of Evidence

Level II, prognostic study. See Instructions for Authors for a complete description of levels of evidence.

Introduction

In 1996, the National Center for Health Statistics reported orthopaedic procedures to be the third most commonly performed surgery in an ambulatory setting, reflecting the fact that up to 70% of all surgical procedures in the United States are performed on an outpatient basis [10]. Hospitals, insurers, and managed care organizations consider outpatient surgery an important cost containment strategy and have encouraged its growth and expansion [7]. It has been shown that patients undergoing orthopaedic procedures will experience more pain and greater delays in recovery than those undergoing nonorthopaedic procedures [2, 14]. As a result, the actual time to return to work may be delayed in patients undergoing outpatient orthopaedic procedures.

Because of the potential increase in pain and delay in recovery in orthopaedic surgical outpatients, people who care for these patients (ie, caregivers) may also experience physical, emotional, and financial burdens. Caregiver burden is of particular importance to patients undergoing orthopaedic surgery, considering that caregivers are increasingly being asked to perform a larger number of healthcare-related duties (eg, assistance for functional issues related to nonweightbearing or nonuse status of the operative limb, dressing changes, removal of catheters) [21]. As a result, caregivers may experience decreased quality of life when providing informal caregiving for patients undergoing ambulatory orthopaedic surgery.

Thus, for patients, undergoing outpatient orthopaedic procedures, the postdischarge patient and caregiver burdens may be especially important. Also of interest is whether patients and their caregivers expected the prolonged recovery and the associated level of burden. We believe that patient and caregiver expectations underestimate reality. Identifying this mismatch may allow us to minimize caregiver burden by improved patient/caregiver education or even decreasing patient symptoms such as pain. The extent of these burdens for outpatient surgery has not been fully evaluated; thus, we conducted a small prospective study to provide baseline data for a larger, possibly multicenter study in an orthopaedic surgical population.

To describe the burden of outpatient surgery on patients and their caregivers, we determined (1) the percentage of patients needing more time than anticipated to resume activities of daily living (ADLs), including work; (2) the extent of full recovery patients felt at 7 and 30 days after outpatient surgery; and (3) the percentage of caregivers identifying emotional or physical disturbances resulting from providing care.

Patients and Methods

This study was approved by the Johns Hopkins Medicine Institutional Review Board. Written informed consent was obtained from all patients enrolled in the study. Inclusion criteria included patients older than 18 years undergoing gynecologic (tubal ligation, dilation and curettage), orthopaedic (ACL repair), or otolaryngologic (tympanoplasty) outpatient surgery under general anesthesia and whose primary and only caregiver (ie, the primary person responsible for not only transport but also ADLs during patient recovery) was available during the preoperative period. This was a prospective observational study during the period of October 2000 through October 2003 (there was a hold on all clinical research from July 2001 through October 2002 due to a research death at our institution). Exclusion criteria included patients undergoing emergency surgery, patients with altered mental status or inability to comprehend questions, inability to contact the patient or their caregiver postoperatively, presence of more than one caregiver, or unavailability or unwillingness of the patient’s primary and only caregiver to participate in surveys. Fifty-six patients were approached and 12 declined, leaving 44 enrolled patients. Thirteen of the 44 (30%) had orthopaedic surgery. We were able to complete 100% (44 of 44) of patient surveys but only 93% (41 of 44) of caregiver surveys (Table 1). Our outpatient surgery center is a separate center within our main hospital (ie, not a freestanding surgery center).

Table 1.

Patient demographic data (n = 44 adult patients except where noted)

Variable	Value
Type of surgery
Gynecologic	25 (56.8%)
Orthopaedic	13 (29.5%)
Otolaryngologic	6 (13.6%)
Sex
Male	17 (38.6%)
Female	27 (61.4%)
Age (years)*	38.9 ± 13.0
Employment
Work > 20 hours/week	28 (63.6%)
Work < 20 hours/week	2 (4.5%)
Unemployed, looking for work	2 (4.5%)
Retired	3 (6.8%)
Homemaker	5 (11.4%)
Student	3 (6.8%)
Other	1 (2.3%)
Marital status (n = 43)
Married	31 (72.1%)
Single	9 (20.9%)
Divorced/separated	3 (7%)
Widowed	0 (0%)
Income (n = 43)
< USD 30,000	20 (46.5%)
> USD 30,000	23 (53.5%)
Race
White, non-Hispanic	21 (47.7%)
Black, non-Hispanic	19 (43.2%)
Hispanic	3 (6.8%)
Other	1 (2.3%)
Education (n = 38)
< 8 years	7 (18.4%)
9–12 years	6 (15.8%)
> 12 years	25 (65.8%)
Number of sick leave days/year allowed*	11.7 ± 9.2
Number of days arranged off from work*	4.6 ± 3.6
Number of hours/day spent on household duties*	3.4 ± 3.0

* Data are presented as mean ± SD; the remaining data are presented as number of patients.

After obtaining written informed consent, a study team member not involved in data analysis administered the preoperative surveys to both the patient and the patient’s primary caregiver. Surveys were self-administered and collected before the patient entered the operating room. Subsequently, five patient and four caregiver surveys were administered after completion of the surgical procedure. For patient surveys, a written postoperative survey was administered before discharge and during a series of telephone calls on Postoperative Day (POD) 1 to 3, 7, and 30. For caregiver surveys, a series of telephone calls was conducted on POD 1 to 3 and 7. Administration of the written questionnaires to the patient or caregiver took less than 20 minutes each to complete; the telephone surveys took less than 10 minutes each to complete.

The survey instruments were constructed to capture the extent of time away from employment and the presence and severity of postdischarge symptoms [30] that may have interfered with recovery and return to work for both the patients and their caregivers. The questions assessing the presence and severity of symptoms were based on those found in the outpatient surgery literature [13, 30]. Since the Fair Labor Standards Act does not require payment for time not worked, such as sick or vacation days [24], we incorporated questions regarding the nature (ie, paid or unpaid) of the days taken off. In addition, the question regarding the number of employees at the patient’s place of work relates to the fact that the Federal Family and Medical Leave Act applies to all government employers and to all private employers with at least 50 employees. It requires that employers provide up to 12 weeks of unpaid leave in specified situations [23]. The question on income status was based on the median household income of Baltimore City of approximately USD 30,000 from the US Census Bureau’s American Community Survey, based on samples from 2005 to 2009 [22]. Finally, caregivers may experience alterations in mental and physical well-being [3, 4] and questions assessing some of these changes were also included in their surveys.

All patients received general anesthesia, but intraoperative anesthetic care was not standardized. Antiemetic and analgesic therapy was left to the discretion of the anesthesiologist caring for the patient. Postoperatively, patient discharge from the recovery room and hospital was based on standard institutional discharge criteria.

Results

Expected Versus Actual Time to Resume ADLs (Including Work)

Patients needed more time than anticipated to get back to work, and pain may have contributed to preventing them from resuming normal ADLs. We found that 16 of 44 patients (36%) needed more time than originally anticipated to resume their ADLs, with five of eight patients (63%) citing pain most frequently as the symptom preventing them from resuming normal ADLs (Table 2). Three of 29 patients (10%) needed more time off from work than originally anticipated, with one of the three (33%) taking unpaid days off.

Table 2.

Patient telephone survey: POD 0 to 3, 7, and 30

Question	Rating	Number of patients
		PACU*	POD 1	POD 2	POD 3	POD 7†	POD 30†
How much pain did you have over the past day?	None	3	2	8	12	15	24
	Mild	9	15	20	25	24	15
	Moderate	24	25	15	7	4	5
	Severe	1	2	0	0	0	0
	Unbearable	1	0	0	0	1	0
How much nausea (feeling sick to your stomach) have you had over the past day?	None	14	19	28	39	40	41
	Mild	14	23	14	5	3	3
	Moderate	10	2	1	0	1	0
	Severe	1	0	0	0	0	0
	Unbearable	0	0	0	0	0	0
How much vomiting have you had over the past day?	None	NA	34	40	43	43	44
	Mild	NA	9	3	1	0	0
	Moderate	NA	1	1	0	1	0
	Severe	NA	0	0	0	0	0
	Unbearable	NA	0	0	0	0	0
How much of a headache have you had over the past day?	None	20	18	26	24	27	38
	Mild	6	13	12	16	15	5
	Moderate	12	12	4	3	0	0
	Severe	1	1	1	1	2	1
	Unbearable	0	0	0	0	0	0
How much muscle ache have you had over the past day?	None	17	19	20	26	34	30
	Mild	9	15	15	11	8	9
	Moderate	12	8	8	6	1	4
	Severe	1	1	1	1	1	0
	Unbearable	0	0	0	0	0	0
How much tiredness have you had over the past day?	None	3	5	7	14	17	21
	Mild	7	5	14	19	18	19
	Moderate	8	25	19	11	7	4
	Severe	19	9	3	0	1	0
	Unbearable	2	0	0	0	1	0
How much of a sore throat have you had over the past day?	None	20	30	19	36	40	42
	Mild	17	12	23	6	3	2
	Moderate	1	1	2	0	1	0
	Severe	1	1	0	1	0	0
	Unbearable	0	0	0	0	0	0
On a scale of 0% to 100%, with 0% being totally disabled and 100% being fully recovered, how much are you back to full recovery at this moment?‡		18.4 ± 15.3	34.8 ± 23.3	45.8 ± 24.4	53.7 ± 23.8	66.3 ± 23	88.3 ± 14.9
If employed, did you need to take more time than anticipated to get back to work?§							Yes: 3 No: 26
If yes:
Did you need to take any additional/extra days off from work than originally scheduled?§							Yes: 3 No: 0
Were these paid or unpaid days?§							Paid: 2 Unpaid: 1
Did you need to take more time than anticipated to resume your routine daily activities?§							Yes: 16 No: 28
If yes, was there any particular symptom that prevented you from resuming your normal activities?§							Pain: 5 Fatigue: 1 Cellulitis: 1 Failed surgery: 1

* PACU survey was given immediately before discharge and worded exactly the same as surveys given on POD 1 to 3 with the exception that it was given in the present tense (ie, “How much pain do you have now?”); ^† POD 7 and 30 surveys were worded exactly the same as surveys given on POD 1 to 3 with the exception that time was extended (ie, “How much pain have you had since we last talked to you?”); ^‡ data are presented as mean ± SD; ^§ questions asked only on POD 30; POD = postoperative day; PACU = postanesthesia care unit; NA = not asked.

Expected Versus Actual Recovery at 7 and 30 Days Postoperatively

Although we did not obtain data on preoperative expectations of recovery, we did find that the time to full recovery (100%) was on average not achieved even at even 30 days postoperatively, and symptoms of pain, tiredness, and muscle aches may have contributed to a delay in full recovery. Pain was reported to be moderate, severe, or unbearable in 26 of 38 (68%) on POD 0, 27 of 44 (61%) on POD 1, 15 of 43 (35%) on POD 2, and seven of 44 (16%) on POD 3 (Table 2). When the patients were contacted on POD 7, they were approximately 66% back to full recovery, with pain (five of 44, 11%) and tiredness (nine of 44, 20%) again as symptoms most frequently rated as moderate through unbearable. When called on POD 30, patients were still only approximately 88% back to full recovery. At POD 30, moderate pain was experienced by five of 44 patients (11%) while tiredness and muscle aches were still rated as moderate by four of 44 (9%).

Emotional and Physical Disturbances of Caregivers From Caring for Outpatients

Caregivers did experience physical and mental burdens resulting from providing care for surgical outpatients. On average, caregivers were responsible for approximately 65% of the daily duties of their households, which consumed an average of 4.4 hours/day (Table 3). Four of 43 caregivers (9%) also had someone else in their family who had a condition or illness requiring their care. In addition, 26 of 40 caregivers (65%) also cared for at least one child, with eight of 40 (20%) caring for three or four children. On POD 1, caregivers spent approximately 17 hours with the patient, with general supervision, transportation, and cooking consuming the most time assessed (Table 4). Caregivers felt that caring for these patients was a physical strain (17 of 26, 40%), was associated with disturbances in sleep (18 of 43, 42%), resulted in changes in personal plans (16 of 43, 37%), caused emotional adjustments (nine of 43, 21%), and was confining (20 of 43, 47%) (Table 5). Caregivers took an average of 1.9 days of work off and two of 41 caregivers (5%) reported needing to take more time off from work than originally anticipated. Eleven of 43 (26%) caregivers believed that they sacrificed moderately or a great deal to care for the patients.

Table 3.

Caregiver preoperative survey (n = 44 caregivers except where noted)

Variable	Value
Employment
Work > 20 hours/week	33 (75%)
Work < 20 hours/week	1 (2.3%)
Unemployed, looking for work	1 (2.3%)
Retired	5 (11.4%)
Homemaker	2 (4.5%)
Student	1 (2.3%)
Other	1 (2.3%)
Marital status (n = 43)
Married	29 (65.9%)
Single	8 (18.6%)
Divorced/separated	4 (9.3%)
Widowed	2 (4.7%)
Income (n = 40)
< USD 30,000	16 (40%)
> USD 30,000	24 (60%)
Race (n = 43)
White, non-Hispanic	21 (48.8%)
Black, non-Hispanic	20 (46.5%)
Hispanic	0 (0 %)
Other	2 (4.7%)
Education (n = 42)
< 8 years	1 (2.4%)
9–12 years	13 (31 %)
> 12 years	28 (66.7%)
Employer data
Are there more than 50 people employed at your place of work?	Yes: 23 No: 11
Does your workplace allow you to take sick leave days?	Yes: 29 No: 5
Are these sick leave days paid or unpaid days?	Paid: 28 Unpaid: 4
Are the days you are using for the patient paid or unpaid days?	Paid: 19 Unpaid: 8
Number of sick leave days/year allowed*	10.6 ± 11.6
Number of days arranged off from work*	1.9 ± 1.8
Household data
Number of hours/day spent on household duties*	4.3 ± 5.2
Number of children you care for
0 children	14
1 child	6
2 children	12
3 children	5
4 children	3
What percentage (from 0% to 100%) of your own daily household duties (cooking, cleaning, running errands, buying groceries, transportation of children, etc) are you responsible for?*	65 ± 33
Number of hours/day spent on household duties*	4.4 ± 5.3
Does anyone in your family have a condition or illness that requires your care?	Yes: 4 No: 39
Do you anticipate that you will have problems with any of the following items that other people have found to be difficult in helping out after somebody comes home from the hospital?
Sleep will be disturbed	Yes: 14 No: 28
It is inconvenient	Yes: 9 No: 33
It will be a physical strain	Yes: 38 No: 4
It will be confining	Yes: 10 No: 32
There will be family adjustments	Yes: 11 No: 31
There will be changes in personal plans	Yes: 18 No: 24
There will be other demands on my time	Yes: 18 No: 24
There will be emotional adjustments	Yes: 11 No: 31
Some behavior will be upsetting	Yes: 8 No: 34
It will be upsetting to find the person needing your care will change from his/her former self	Yes: 7 No: 35
There will be work adjustments	Yes: 18 No: 24
It will be a financial strain	Yes: 4 No: 38
I will feel completely overwhelmed	Yes: 6 No: 36

* Data are presented as mean ± SD; the remaining data are presented as number of caregivers.

Table 4.

Caregiver telephone survey: POD 1 to 3

Question	POD 1	POD 2	POD 3
How many hours did you spend with the patient yesterday?*	16.6 ± 7.1	13.3 ± 7.7	12.5 ± 6.6
Which of the following items did you do for Mr/Ms X yesterday?
Laundry	Yes: 7 No: 37	Yes: 18 No: 26	Yes: 14 No: 30
Time performing task (minutes)*	12.3 ± 30.6	26.7 ± 35.6	18.4 ± 32.5
Cooking	Yes: 36 No: 8	Yes: 37 No: 7	Yes: 30 No: 14
Time performing task (minutes)*	57.4 ± 50.4	54.9 ± 42.4	39.9 ± 41.8
Shopping	Yes: 17 No: 27	Yes: 16 No: 28	Yes: 10 No: 34
Time performing task (minutes)*	25.8 ± 41.4	26.9 ± 46.8	13.6 ± 41.8
Cleaning	Yes: 21 No: 23	Yes: 14 No: 30	Yes: 16 No: 28
Time performing task (minutes)*	32.4 ± 62.4	27.6 ± 69.7	20.1 ± 38.5
Other household chores	Yes: 21 No: 23	Yes: 14 No: 30	Yes: 16 No: 28
Time performing task (minutes)*	34.2 ± 46.6	23.9 ± 40.7	21.1 ± 31.4
Transportation	Yes: 35 No: 9	Yes: 2 No: 42	Yes: 5 No: 39
Time performing task (minutes)*	70 ± 74.5	2 ± 10	13.4 ± 47.7
Taking medication	Yes: 32 No: 12	Yes: 18 No: 26	Yes: 13 No: 31
Time performing task (minutes)*	18.9 ± 16.7	10.2 ± 13.2	9.2 ± 20.5
General supervision	Yes: 42 No: 2	Yes: 38 No: 6	Yes: 8 No: 36
Time performing task (minutes)*	378.4 ± 398.1	298.0 ± 340.1	199.1 ± 199.8
Personal care†	Yes: 18 No: 26	Yes: 15 No: 29	Yes: 9 No: 35
Time performing task (minutes)*	19.5 ± 41.1	15 ± 26.1	8.5 ± 21.8
Did you give up any leisure or recreational activities today so that you could care for the patient?	Yes: 14 No: 30	Yes: 9 No: 32	Yes: 6 No: 37
Did you give up any educational opportunities (like classes) today so that you could care for the patient?	Yes: 3 No: 41	Yes: 0 No: 40	Yes: 0 No: 42
Did you give up any employment opportunities (like interviewing for a new job) today so that you could care for the patient?	Yes: 10 No: 33	Yes: 3 No: 38	Yes: 3 No: 38

* Data are presented as mean ± SD; the remaining data are presented as number of caregivers; ^† eg, bathing, grooming, dressing, assisting to bathroom; POD = postoperative day.

Table 5.

Caregiver telephone survey: POD 7

Question	Number of caregivers
If employed, did you need to take more time off from work than originally anticipated?	Yes: 2 No: 39
If yes:
Did you need to take any additional/extra days off from work than originally scheduled?	Yes: 1 No: 9
Were these paid or unpaid days?	Paid: 2 Unpaid: 0
How much did taking care of the patient interfere with your daily routine?	Not at all: 20 A little: 17 Moderately: 5 A great deal: 1
In thinking of what you could have done if you didn’t have to care for the patient, how much do you feel you sacrificed?	Not at all: 20 A little: 12 Moderately: 8 A great deal: 3
Did taking care of the patient place any burden on your own immediate family?	Yes: 3 No: 37
Would you please tell us whether any of the following items that other people have found to be difficult after somebody comes home from the hospital applied to you while taking care of the patient?
Sleep was disturbed	Yes: 18 No: 25
It was inconvenient	Yes: 8 No: 35
It was a physical strain	Yes: 17 No: 26
It was confining	Yes: 20 No: 23
There were family adjustments	Yes: 16 No: 27
There were changes in personal plans	Yes: 16 No: 27
There were other demands on my time	Yes: 7 No: 36
There were emotional adjustments	Yes: 9 No: 34
Some behavior was upsetting	Yes: 7 No: 36
It was upsetting to find the person needing your care will change from his/her former self	Yes: 4 No: 39
There were work adjustments	Yes: 4 No: 39
It was a financial strain	Yes: 0 No: 43
I felt completely overwhelmed	Yes: 1 No: 42

POD = postoperative day.

Discussion

Extensive efforts have been made to understand the burdens felt by caregivers of elderly, pediatric, and chronically ill populations [8, 27, 31]. In 2012, an article published in the Journal of the American Medical Association recognized that “support of family in [the] health care process could advance the triple aim of better health, higher-quality care, and reduced costs for patients” [29]. However, there has been little to no examination of caregiver burden after ambulatory surgery. This may be especially important in patients undergoing orthopaedic surgery, as many of those procedures are performed on an outpatient basis. Furthermore, patients undergoing orthopaedic surgery have been found to experience more pain and more difficulty with physical activity in comparison to outpatients of other surgical specialties [2, 14]. Thus, obtaining preliminary information on the impact of ambulatory surgery on patients and their caregivers is of particular relevance to orthopaedic surgeons. We therefore determined (1) the percentage of patients needing more time than anticipated to resume ADLs, including work; (2) the extent of full recovery patients felt at 7 and 30 days after outpatient surgery; and (3) the percentage of caregivers identifying emotional or physical disturbances resulting from providing care.

There are several limitations to our study. Our survey instruments have not been validated. Although there are no validated caregiver instruments available for assessment in the postoperative period after outpatient surgery, validated instruments are available to assess caregiver burden in other more chronic settings [5, 12, 25, 33]. However, it is not clear whether use of these more established validated caregiver instruments (eg, Zarit Burden Interview) would be appropriate in this acute setting. Due to the lack of validation of our instruments, patients may have interpreted our questions differently from expected (eg, defining anticipated recovery). We plan to either use validated instruments or validate a revised version of our survey in future studies; however, the primary purpose of this preliminary study was examination of feasibility, not validation. In addition, only 20% (13 of 44) of our sample size was limited to patients undergoing orthopaedic procedures; thus, the generalizability of our results as a whole to this population is uncertain. Our dataset was not complete, as there were a few nonresponders. Due to the lack of a sufficient sample size, our findings may or may not be generalizable to a broader population or even a population outside the state of Maryland. Also, due to our small sample size, we did not believe it was appropriate to perform subgroup analysis (ie, by sex of patient or caregiver, symptoms, type of surgery, income level). Subsequent larger studies may have sufficient sample sizes to allow subgroup analysis, which would be useful to determine the specific impact of various factors on the fiscal burdens and anticipated needs of caregivers. In addition, the anesthesia regimen was not standardized and it is possible that different perioperative anesthetic regimens may influence patient recovery (eg, symptoms such as pain and fatigue) and thus caregiver burden. We did not have information regarding the details of the postdischarge analgesic usage, which may be useful in determining whether improving postdischarge pain would facilitate patient recovery and consequently diminish caregiver burden. Pain as a postdischarge symptom may not be specific and may in one sense be a surrogate marker for the surgical procedure/technique, a factor that the anesthesiologist cannot control for intraoperatively. Finally, we did not survey the patients with regard to expected recovery time, and as such, we were not able to compare what they expected to our findings; however, we did find that some patients had not achieved full recovery by 30 days postoperatively.

We found that patients’ and caregivers’ expectations of required time away from work did not match reality. Approximately 10% of patients and 5% of caregivers needed to take more time off from work than originally anticipated. While we do not have any similar prior data to determine the cost of these additional days, we do know that absenteeism due to health problems costs USD 153 billion in the United States alone [28]. Based on the 34.7 million patients who underwent outpatient procedures in 2006 [6], the total cost of additional days off for the 10% of surgical outpatients and 5% of their caregivers would be approximately USD 302 million (based on minimum wage of USD 7.25/hour for an 8-hour day) to USD 1.8 billion (based on the Gallop estimated cost of a missed day at USD 341) [28] (ie, 34.7 million × 15% × wage).

We also found that actual full recovery was delayed at 7 and 30 days. Patients reported approximately 66% and 88% recovery at 7 and 30 days after surgery, respectively. The presence of postdischarge symptoms, particularly pain and fatigue, was the most commonly cited symptom preventing patients from resuming normal activities. This finding is consistent with the results of a systematic review summarizing the incidence of postdischarge symptoms after outpatient surgery [30]. This is of concern because of the relatively high prevalence of postoperative pain in patients undergoing orthopaedic procedures. McGarth et al. [15] surveyed postoperative pain at 24 hours in patients undergoing ambulatory surgery. In terms of the percentage of patients reporting severe to moderate pain, orthopaedic and hand procedures ranked third and fourth, only surpassed by neurologic and general surgery. Moderate to severe pain was reported in more than 50% of patients who underwent shoulder arthroscopies, elbow/hand procedures, ankle procedures, and knee arthroscopies [19]. Rawal et al. [18] substantiated these finding by conducting a prospective study in patients who underwent ambulatory orthopaedic and hand surgeries and found that 41% of patients undergoing orthopaedic surgery and 37% of patients undergoing hand surgery experienced moderate to severe pain. McGarth et al. [15] found that about 12% of patients with moderate to severe pain reported not receiving adequate instructions regarding prescribed analgesics and 14% of them reported receiving inadequate information on adjusting their analgesic regimen despite receiving verbal and printed discharge instructions regarding pain management. The pain became so troublesome that almost 10% of those patients requested advice from the on-call nurse [15]. In general, patients would be more adequately prepared for their recovery period at home by encouraging client-centered, interdisciplinary communication among health practitioners, adopting a flexible approach to discharge planning, which is tailored to individual needs of postsurgical patients (particularly in relation to advice and information related to recovery), and encouraging and supporting adequate health literacy for self-management.

Lastly, we found that caregivers noted disturbances in mental- and physical-related aspects of their daily lives while providing care for patients. These findings are similar to caregiver studies, the vast majority of which have examined burdens in chronic disease states [8, 27, 31], where caregivers experienced mental and physical disturbances in their daily lives while providing care, which may diminish their quality of life [19, 33].

One area that may adversely affect caregiver health is quality of discharge information. In general, discharge information was found to be inconsistent and variable and provided by a variety of healthcare professionals [16]. A retrospective analysis of patients undergoing ambulatory surgery revealed that patient satisfaction scores were higher and less medical attention was sought in the patients receiving improved patient information [32]. Caregivers also sought more homecare and discharge information [1]. Expectations of recovery did not appear to match reality and future studies may focus on educating patients and caregivers on the recovery period preoperatively. Realistic expectations will allow better planning and likely result in fewer last minute changes and less burden. Therefore, there is potential for cost reduction with improved patient and caregiver homecare education.

In summary, we found evidence that informal caregiving after outpatient surgery may constitute a significant burden for caregivers and their patients. The presence of postdischarge pain may have prevented some patients from resuming normal activities including a delay in returning to work. These data are of special value to the orthopaedic subset of patients due to the commonly severe nature of postoperative pain and the perception of poor patient and family education on pain management with or without regional anesthesia. If subsequent larger studies confirm our findings, then additional trials will be needed to determine whether perioperative interventions (eg, postdischarge analgesic regimens to decrease pain, nausea, or fatigue) [9, 11, 17] can be successfully used to improve the postdischarge profile of outpatients [20] (eg, minimizing postdischarge complications, hastening functional recovery) to minimize the burden to both patients and their caregivers. Healthcare providers may also need to provide realistic expectations of recovery to both the patients and their caregivers. A recent study demonstrated the potential for predicting what recovery at home from ambulatory surgery may be like, thus allowing physicians to set patient and caregiver expectations before discharge [26]. Considering that an increasing number of surgical procedures, particularly in the field of orthopaedics, are being performed on an outpatient basis, especially on older patients with an increasing number of comorbidities, additional studies are needed to create a validated survey to assess caregiver burden, confirm our findings, and examine the extent of caregiver burden for different procedures and settings.