Our study shows that outpatients in Zhejiang Hospital have relatively high levels of worries about day surgery, similar to previous studies in mainland China. 84.5% of respondents were worried about perioperative periods of day surgery, which was perceived as an innovative medical service in mainland China. Yu Deliang proposed that patients and families generally required a high level of professional nursing care during the postoperative period. However, such a high level of care may be absent in the outpatient setting, therefore, patients and their families undergoing day surgery may worry[9]. According to a survey in a Shanghai community, residents' perceptions of day surgery were poor, more than 70% of community residents had doubts about day surgery[11]. An investigation in West China Hospital showed that more than 60% of patients undergoing day surgery did not understand the concept of day surgery, including how it works and its values[12]. However, those studies did not explore which population is at risk of being worried. In our study, we identified several risk factors. Patients who were older and had more systemic diseases tend to worry more in the day surgery setting. This is consistent with a Swedish study showing that older patients had more concerns about anesthesia and surgery during day surgery. Also, lower levels of education and worse economic status lead to more worries. Therefore, we suggest hospitals establish a standardized process to screen out patients who may have more worries, and develop a personalized patient education system for this targeted patient population.
Moreover, we comprehensively investigated the specific reasons for patients’ concerns. Before receiving any day surgery, outpatients worried about both preoperative and postoperative periods, and the worries covered almost all possible aspects of preoperative preparation, transportation and accommodation, rehabilitation, healthcare payment, etc. That is, outpatients believed when they were not in the hospital, it was difficult to obtain professional guidance and relevant information in time, which suggested that an effective perioperative communication mechanism between doctors and patients was absent. Studies in France and America focusing on perioperative communication channels suggest that better doctor-patient communication is correlated with higher patient satisfaction and better outcomes[15-17]. Similarly, studies in mainland China also indicate that establishing a good communication channel could promote doctor-patient communication, hence reducing patients’ perioperative worries[18]. Nanjing Drum Tower Hospital applied extended nursing management during the perioperative period for patients undergoing laparoscopic day-surgery, based on the WeChat platform- one of the most popular instant messengers in mainland China, relieved the anxiety of patients effectively[19]. For those reasons, it is significant to establish a convenient, immediate and effective doctor-patient communication mechanism when patients are outside the hospital.
Patient acceptance of day surgery in our study is different from both domestic and foreign studies, the proportion of outpatients willing to undergo day surgery (scores 7-10) was 35.2%. While a study by Dai Yan in Sichuan Province showed that 94.5% of day-surgery patients are open to day surgery in 2016[12], yet a recent survey in 2019 revealed that 24.88% of residents in a Shanghai community accept day surgery[11]. These diversified results may derive from different samples in those studies and unbalanced development of day surgery across China. Furthermore, compared with western countries where day surgery is highly popular, Zhejiang outpatients’ acceptance of day surgery is fairly low.
The multivariate analysis revealed that patient acceptance of day surgery in this study was related to a variety of personal characteristics, suggesting that patients with younger age, higher education, no underlying disease, and better financial ability were more likely to accept the concept of day surgery. Better-educated patients were less worried but once they had any worries, patient acceptance would be affected more than those less-educated patients. These findings raised a possibility that with the improvement of national education level, physical quality and economic ability, Chinese patients would gradually be more open-minded about day surgery. Besides, surgery type also affected patient acceptance of day surgery. For example, orthopedic outpatients were relatively more reluctant to take operations as day surgery, we consider this may result from Chinese patients’ traditional thinking that patients should have a full recovery in the hospital, not in the day surgery setting, as orthopedic surgeries are perceived as extensive and complex in China. Given that Chinese people’s attitude towards day surgery has much to do with individual characteristics[20], age, education, comorbities, income and surgery type must be taken into consideration in patient education of day surgery to promote day surgery.
Our study implies that patient acceptance of day surgery was influenced by their perioperative worries and this association was related to patients’ characteristics. Accordingly, patient education must be tailored for specific populations and sufficient doctor-patient communication need to be guaranteed by strengthening perioperative systems of day surgery, focusing on providing patients timely, effective and professional guidance, so that to dispel worries of patients during the perioperative period, thereby increase patient acceptance of day surgery.
Limitations
The major drawback of the study lies in the sample taken from one center. Nevertheless, whether other patients like inpatients and patients who have experienced day surgery are of the same situation needs further investigation. Moreover, more researches are warranted not only in Zhejiang province but also across China to provide more evidence for present patient attitude towards day surgery in mainland China. Second, we used a subjective method to assess the patient acceptance of day surgery, similar to previous studies that also utilized various subjective evaluations. However, whether those subjective methods are reliable and valid need further proof. Third, future studies could investigate how to establish an effective doctor-patient communication mechanism to address patient worries during perioperative periods so that to increase patient acceptance of day surgery.