Premeditation

in the United States: A Status Report

Bell,
MD*,

Zeev N. Kain, MD*& Linda C. Mayes, MDt& Charlotte Maura B. Hofstadter, PhD*, and Stephen Rimar, MD**
Departments of *Anesthesiology, tYale Medicine, New Haven, Connecticut Child Study Center, *Pediatrics,

Steven Weisman,
Yale University

MD*S,

and Psychology,

School of

We undertook a mailing survey study to assess the current practice of sedative premeditation in anesthesia. A total of 5396 questionnaires were mailed to randomly selected physician members of the American Society of Anesthesiologists. Forty-six percent (n = 2421) of those sampled returned the questionnaire after two mailings. The reported rate of sedative premeditation in the United States varied widely among age groups and geographical locations. Premedicant sedative drugs were least often used with children younger than age 3 years and most often used with adults less than 65 years of age (25% vs 75%, P = 0.001). Midazolam was the most frequently used premedicant both in adults and children (>75%). When analyzed based on geographical locations, use of sedative premedicants among adults was least frequent in the

Northeast region and most frequent in the Southeast region (50% vs 90%, P = 0.001). When the frequency of premedication was examined against health maintenance organization (HMO) penetration (i.e., HMO enrollment by total population) in the various geographical regions, correlation coefficients (Y) ranged from -0.96 to -0.54. Multivariable analysis revealed that HMO penetration is an independent predictor for the use of premeditation in adults and children. The marked variation among geographical areas in premedicant usage patterns underscores the lack of consensus among anesthesiologists about the need for premeditation. The data suggest that HMO participation may affect delivery of this component of anesthetic care. (Anesth Analg 1997;84:427-32)

anxiety correlates with various outcomes such as postoperative analgesic requirements, postanesthesia care unit and hospital stay, and delayed negative psychological effects (1,2). Considering the high incidence and the associated adverse outcomes (2-4), treatment may be indicated, and both pharmacological (i.e., premeditation) and psychological interventions are used to treat this problem (5,6). However, premedicant usage patterns are not well documented and have been described only in the British literature (7). From a public health policy point of view, it may be important to survey practice patterns in order to determine how often a premedication intervention is used to prevent an adverse outcome (e.g., preoperative anxiety). Indeed, survey research is widely used in the medical and surgical literature to report practice patterns (S-11). A recent editorial in the Journal of the American Medical Association has similarly advocated the concept of the practical standard of care (12). That is, the level of care reoperative Supported by a grant provided by Anesta Inc. Accepted for publication September 20, 19.96. Address correspondence and reprint requests to Zeev N. Kain, MD, Department of Anesthesiology, Yale University School of Medicine, 333 Cedar St., New Haven, CT 06510.
01997 by the International 0003.2999/97/$5.00 Anesthesia Research Society

actually being delivered to patients given the limitations of a particular system (e.g., health maintenance organization [HMO]) or geographical location (12). We therefore designed a repeated mailing survey to assess the current practice of preoperative sedation among anesthesiologists in the United States (US).

Methods
Respondents
A database containing the names of 5,396 (of 34,079 total) randomly selected anesthesiologists was provided to the investigators by the data processing unit of the American Society of Anesthesiology (ASA, Park Ridge, IL). Retired physicians, trainees, and physicians practicing anesthesia outside the US were excluded from the study. The study protocol was approved by our institutional review board.

Questionnaire
The initial version of the survey consisted of 82 questions regarding the characteristics of the respondents and their routine use of sedative premeditation for
An&h Analg 1997;84:427-32

427

428

KAIN ET AL PREMEDICATION

IN THE

US

STATUS

REPORT

ANESTH ANALG 1997;84:427-32

Attitudes toward premeditation practice were assessed using a series of statements to which the respondents were asked to answer in a five-point Likert scale ranging from most important to least important (13). Routes used for administration of premeditation (e.g., orally, intravenously) were assessed on a rank ordinal scale. We mailed questionnaires to the participants in the sample during October 1995. Although the survey was anonymous, return envelopes were coded to permit the identification of nonrespondents, to whom we sent additional surveys in December 1995. To measure potential nonresponse bias, we randomly selected a 10% (n = 300) subsample of the physicians who had not responded by December 1995 and mailed them an anonymous questionnaire containing 25 items from the initial survey.

Statistic and Analytic Approaches

Upon data analysis, frequency classified by six US geographic
Rating of Importance

of premeditation regions:

was

Figure 1. Opinions Survey. The respondents were asked to rate 23 factors in four categories influencing their premeditation practice. Rating was performed using a scale of 1 (not important) to 5 (very important).

both adults and children (see Figure 1). During the pilot phase of the study, the questionnaire was pretested by 250 anesthesiologists and subsequently revised based on analysis of their responses. The final version of the survey instrument was limited to 73 questions in three sections: 1. Frequency and type of premeditation drugs (sedative/hypnotic/analgesic and anticholinergics) used. 2. Opinions and general practices regarding premedication and parental presence during induction of anesthesia. 3. Demographics of the respondent. The survey questions reported in this article pertain only to the sedative/hypnotic/analgesic groups of drugs. Several types of scales were used in the study, all of which are commonly used in survey research (13). The frequency of premeditation practice was assessed by presenting a statement to which the respondents were asked to estimate the percentage of patients for whom they used premedicant sedatives.
1 The questionnaire investigators. is available in its entirety from the

1. Northeast: Connecticut, New Hampshire, Pennsylvania, Delaware, Vermont, Rhode Island, Maine, New Jersey, Washington, DC, Maryland, Massachusetts, and New York. 2. Southeast: Alabama, South Carolina, Tennessee, Florida, Virginia, Georgia, West Virginia, North Carolina, and Kentucky. 3. South Central: Arkansas, Mississippi, Texas, Kansas, Missouri, Louisiana, and Oklahoma. 4. North Central: Illinois, Minnesota, North Dakota, Indiana, Ohio, South Dakota, Iowa, Wisconsin, Michigan, and Nebraska. 5. Southwest: Arizona, Nevada, California, New Mexico, Colorado, Hawaii, and Utah. 6. Northwest: Alaska, Washington, Idaho, Wyoming, Montana, and Oregon. Demographic data regarding HMO enrollment was obtained from InterStudy (Saint Paul, MNj2. The data were stratified based on the US geographic regions described above. The association between the frequency of premeditation and HMO penetration (i.e., HMO enrollment by total population) was examined using Pearsons correlation coefficient (u). Multivariable linear regression models were used to determine whether this association was independent of other demographic variables. Data were analyzed with the use of SPSS version 6.1.1 (SPSS Inc., Chicago, IL). Demographic data are summarized as the mean and standard deviation for
Data were obtained from InterStudy Competative Edge: Industry Report 6.1, Table 16 Combined enrollment as a percentage of state population as of July 1, 1995.

ANESTH ANALG 1997;84:427-32

PREMEDICATION

IN THE

KAIN ET AL. Us: STATUS REPORT

429

continuous data and frequency for categorical data. For each item in the questionnaire, we computed the frequency or mean response with standard errors and 95% confidence intervals. We compared means between subgroups using the unpaired samples t-test and one-way analyses of variance. Categorical items were analyzed by frequency distribution and 2 analysis. In the case of skewed data, medians and ranges are reported, and nonparametric tests such as the Mann-Whitney U-test and the Kruskal-Wallis H-test were used for analysis. Stepwise multivariable linear regression models were used to assessthe independent effects of demographics and practice characteristics on the frequency of premeditation. The final models were limited to the significant predictors of the variable of interest and were performed for outcomes of frequency. Significance level was determined at P < 0.05.

Table 1. Characteristics of 2421 United States Anesthesiologists Who Responded to the Survey of Premeditation Use Characteristic Age (yr) Mean + SD Range Years in practice Mean -C SD Range Gender (%) Male Female Subspecialty training (a) Yes No Type of hospital (%) Community University Ambulatory center Other No. of beds in hospital Mean t SD Range % of practice Outpatients Inpatients Same-day admit
a Site of primary practice

Value 44 8 30-76 13 +- 9 1-51 77 23 52 48 76 17 5 2 346 ? 212 45 - 1100 53 23 24

Results
Of the 5396 anesthesiologists surveyed, 121 were found to be ineligible for the survey: 7 anesthesiologists had retired, 111 had left no forwarding address, and 3 had died. Of the remaining physicians, 2421 (46%) returned the questionnaire after two mailings. The demographic and professional characteristics of the respondents are shown in Table 1. Their mean age was 44 years, and most (77%) were men. Respondents had practiced anesthesia from 1 to 51 yr (mean 13 + 9), and 52% of the respondents had completed anesthesia subspecialty training (e.g., pediatrics).

Premeditation

Usage

The reported prevalence of premeditation in the preoperative holding area varies widely among the different age groups and geographical locations in the US (Figure 2). Premedicants were used the least often for children younger than age 3 yr and most often for adults less than 65 yr of age (25% vs 75%, P = 0.001). Analysis by geographical regions revealed that premedicants were used least often in the Southwest and Northeast regions and most often in the Southeast region (P = 0.001) (Figure 2). When the frequency of premeditation was examined against HMO penetration in the various geographical regions, correlation coefficients (Y) ranged from -0.96 to -0.54 (Table 2). Interestingly, the strength of the correlation decreased with the age of patients, with the highest correlation (-0.96) observed with children aged 4-7 yr and the lowest with adults more than 65 yr (Table 2). A multivariable analysis in which premeditation in children

was the outcome and predictors included HMO penetration, percentage of time the respondent spends providing pediatric anesthesia, number of years in practice, type and number of beds in the hospital of the respondent, and geographical region revealed that HMO penetration, percentage of time the respondent spends providing pediatric anesthesia, and geographical region are independent predictors for the usage of premeditation in children (Table 3). Similarly, for adults, this association between premeditation and HMO penetration was independent of geographical region, number of years in practice, specialty training, type of hospital and number of beds in the respondents hospital (Table 3). Among adults, the most commonly used sedative premedicant was midazolam, followed by diazepam (7%) and lorazepam (2%) (Figure 3). Similarly, for children, midazolam was used by more than 80% of the respondents; the remaining respondents used mostly ketamine (4%) and transmucosal fentanyl(3%). The majority of respondents premeditate adult patients in the preoperative holding area using an intravenous route (>70%) followed by the intramuscular route (18%) and the oral route (10%) (P = 0.001). In contrast, the majority of respondents (80%) premedicate pediatric patients in the preoperative holding area

430

JSAlN ET AL. IREMEDICATION

IN THE Us: STATUS

REPORT

ANESTH ANALG 1997;84:427-32

Figure 2. Frequency

of premeditation practice in the United States (medians; range for all values was 0%-100%).

Swtheast North Central South Central USA Geographical Realon

.%ut hwest

6mo-3yrs

Patient

Population

Table 2. The Premedication

Association

Between

Health

Maintenance

Organization

(HMO) Frequency

Regional

Penetration ( %)b

and Frequency

of

HMO penetration* (a) South Central Southeast North Central Northwest Northeast Southwest r value*
a Penetration b Medians. * Between refers HMO to the number

of premeditation Children 8-15 yrs 50 75 65 40 24 25 -0.85

region,

Children 6 mo-3 yrs 50 50 23 20 25 5 -0.91

members by total popul&ion

Children 4-7 yrs 50 60 50 20 25

10

Adults <65 yrs 60 90 75 60 50 50 -0.73

Adults >65 yrs 40 70 50 50 30 40 -0.54

11 12 17 25 27 33
of HMO

-0.96
in that geographical

penetration

(%) and

frequency

of premeditation

(%) in the appropriate

age groups.

Table

3. Multivariable Outcome(s)

Analysis

Predicting

the Practice of Premedication Predictor(s) % of practice devoted to children HMO penetration Geographical region HMO penetration Years in practice Number of beds in hospital P 0.07 -0.11 -0.05 -1.70 -0.07 -0.10 t 3.04 -4.42 -2.21 -7.50 -3.20 -4.60 Sig T 0.002 0.000 0.030 0.000
0.001

% of children

premeditated

% of adults premedicatedb

0.000

HMO = health maintenance organization. a Outpatient children 6 mo-3 yrs. premeditated b Outpatient adults under 65 years premeditated

in the preoperative the preoperative

holding holding

area area

ANESTH ANALG 1997;84427-32

PREMEDICATION

IN THE

KAIN ET AL. Us: STATUS REPORT

431

q
[7

M~dazolam Dmepam Fentanyl Mependme (IV)

q q
0

Ketamme Fentanyl other (Orale

Outpt

=pt

outpt

Inpt

Outpt

Inpt

Outpt

Inpt

6mo-3yrs

4-7yrs

< 65yrs Patient Population

> 65yrs

Figure

3. Types

of premedicants

used

in the preoperative

holding

area.

using the oral route followed by the intranasal route (8%), the intramuscular route (6%), and the rectal route (3%) (P = 0.001). The respondents were also asked to rate 23 factors influencing their premeditation practice (Table 3). For example, when asked about the reasons for using sedative premeditation, decreased anxiety and increased cooperation were rated as most important; modulation of sympathetic response and analgesia were the least important (P = 0.001). Comparative analysis of the questionnaires that were received after the first mailing versus those received after the second mailing revealed no significant differences between the two groups. Similarly, the nonresponse survey indicated that the nonresponders did not differ significantly from the responders either in demographic characteristics or in their premeditation patterns.

Discussion
The marked variation among geographical areas in premedicant usage patterns underscores the lack of consensus among anesthesiologists about the need for premeditation. Geographic variation in various aspects of medical care is well documented (14). For example, Welch et al. (14) described geographic variation in expenditure for physicians services in the US. Similarly, our survey examined geographic variation in premedicant usage patterns. Interestingly, we found that when these data were correlated with HMO penetration, the geographic variations in usage

of premeditation coincided with penetration by HMOs. It is important to remember, however, that we have measured for association and not for causation. One possible explanation for this association is that hospitals located in areas that are highly penetrated with HMOs are driven to greater efficiency and lower costs. Since premeditation may be associated with additional nursing staff, increased pharmacy costs, and possible delays in the operating room schedule and recovery after short surgical procedures, some hospitals may not encourage its use. The higher correlation observed in the younger age groups may further support this explanation. First, unlike adults who are premeditated intramuscularly, most younger children are premeditated orally in a process that requires at least 15-20 min. Second, short surgical procedures (e.g. placement of pressure-equalizing tubes) are far more common in the pediatric population. Therefore, premeditating children may theoretically result in longer operating room delays than those caused by premeditating adults. Overall, more anesthesiologists in the US use sedative premedicants for adults undergoing outpatient surgery than their colleagues in Great Britain (89% vs 53%, P = 0.001) (7). Similarly, more British anesthetists indicated that they never premeditate children undergoing outpatient surgery with sedative premedicants (37% vs 20%, P = 0.001) (7). In contrast, preoperative psychological preparation programs and parental presence during induction of anesthesia are more common in Great Britain (15,16). The reasons for these practice differences may include a stronger demand

432

KAIN ET AL. PREMEDICATION

IN THE US: STATUS

REPORT

ANESTH ANALG 1997;84:427-32

and less concern about the legal implications of parental presence in Great Britain (7,17,18). Different anesthesia induction techniques for children may also affect the reported attitudes; while in the US, mask induction is still the most common practice, the introduction of a eutectic mixture of local anesthetics in Great Britain caused many anesthesiologists to use intravenous induction techniques. Our study has two methodological limitations. First, this study targeted only anesthesiologists who are members of the ASA. It is possible that this group is not representative of anesthesiologists as a whole, although it is estimated that 90% of US anesthesiologists are ASA members (19). Second, this survey was limited to anesthesiologists, and because nurse anesthetists occasionally provide anesthetic care without the supervision of an anesthesiologist, it is possible that the data presented in this study do not represent their practice. In conclusion, the marked variation among geographical areas in premedicant usage patterns underscores the lack of consensus among anesthesiologists regarding the need for premeditation. Interestingly, we found that premedicant usage patterns coincided with HMO penetration. Finally, more anesthesiologists in the US use sedative premedicants for both children and adults undergoing surgery than their colleagues in Great Britain.
The authors would like to thank review of this manuscript. Paul G. Barash, MD, for his critical

References
1. Johnston recovery. M. Pre-operative Adv Psychosom emotional states and post-operative Med 1986;15:1-22.

2. Kain Z, Mayes L, OConnor T, Cicchetti D. Preoperative anxiety in children: predictors and outcomes. Arch Pediatr Adolesc Med 1996;150;1238-45. 3. Badner N, Nielson W, Munk S, et al. Preoperative anxiety: detection and contributing factors. Can J Anaesth 1990;37:444-7. 4. Moerman N, van Dam F, Muller M, Oosting H. The Amsterdam Preoperative Anxiety and Information Scale (APAIS). Anesth Analg 1996;82:445-51. 5. Kain Z, Mayes L. Anxiety in children during the perioperative period. In: Borestein M, Genevro J, eds. Child development and behavioral pediatrics. NJ: Lawrence Erlbaum Associates, 1996: 85-103. 6. Lichtor J, Zacny J. Psychological preparation and preoperative medication. In: Miller RD, ed. Anesthesia. 4th ed. New York: Churchill Livingstone, 1994:1015-44. 7. Mirakhur RK. Preanaesthetic medication: a survey of current usage. J R Sot Med 1991;84:481-3. 8. Putnam F, Loewenstein R. Treatment of multiple personality disorder: a survey of current practices. Am J Psychiatry 1993; 150:1048-52. 9. Campbell J, Condon V. Catheter removal of blunt esophageal foreign bodies in children: survey of the Society for Pediatric Radiology. Radiology 1989;19:361-5. 10. Wellington N, Rieder M. Attitudes and practices regarding analgesia in newborn circumcision. Pediatrics 1993;92:541-3. 11. Tait R, Tuttle D. Prevention of occupational transmission of human immunodeficiency virus and hepatitis B virus among anesthesiologists: a survey of anesthesiology practice. Anesth Analg 1994;79:623-8. 12. Argy 0. Standards of care. JAMA 1996;275:1296. 13. Alreck I, Settle R. The survey research handbook. 2nd ed. Chicago: Irwin, 1995:113-42. 14. Welch I, Miller M, Welch G, et al. Geographic variation in expenditures for physicians services in the United States. N Engl J Med 1993;328:621-7. 15. Mathews A, Ridgeway V. Psychological preparation for surgery. In: Steptoe A, Mathews A, eds. Health care and human behavior. London: Academic Press, 1984:231-59. 16. Kain Z, Ferris C, Mayes L, Rimar S. Parental presence during induction of anesthesia: practice differences between the US and Great Britain. Paediatr Anaesth 1996;6:187-93. 17. Holt S. Paediatric anaesthesia. Br J Anaesth 1985;291:673. 18. Roberts W. Paediatric anaesthesia. Br J Anaesth 1985;291:543. 19. Gaba M, Howard S, Jump B. Production pressure in the work environment. Anesthesiology 1994;81:488-500.