Pain-free surgery or pain-free parking: measuring patient satisfaction with perioperative care is humbling for the anesthesiologist.

To the Editor: Barnett et al.1 are to be thanked and congratulated for their attempted synthesis of efforts to quantify patient satisfaction with anesthesia care. The authors did not include the Surgical Consumer Assessment of Healthcare Providers and Systems® (CAHPS) in their assessment, which deserves discussion.2 Surgical CAHPS is the newest member of the CAHPS family and is the only tool measuring patient satisfaction with surgical (or anesthesia) care which is endorsed (in whole or in part) by the National Quality Forum, the main clearinghouse for performance measurement in health care.* Surgical CAHPS was designed by the American College of Surgeons with the Agency for Healthcare Research and Quality to be psychometrically rigorous. The instrument incorporates information from multiple care streams and providers of perioperative care—surgeon, nurse, anesthesiologist, hospital, and clinic. Although four of the seven selected measures ask about the “surgeon,” none ask about anesthesia care. When adopting and endorsing Surgical CAHPS as a publicly reportable performance measure (NQF #1741), the National Quality Forum included fewer than half of the questions making up the tool. Psychometric properties were ignored. Our specialty and the care we provide for patients were also ignored. Although four of the seven selected components ask about the “surgeon,” none ask about anesthesia care. Rather than feel “snubbed,” perhaps we anesthesiologists may find a pause point to imagine care from the perspective of the patient. For a “person” who becomes a “patient,” the lines separating surgery, nursing, anesthesia, and pain-free hospital parking can easily blur. This, of course, is why using a psychometrically rigorous instrument can be important, especially for targeting specific areas for improvement. But in practice, applying lengthy instruments for each component of perioperative care may induce survey fatigue in our patients and compromise the results of such surveys. More importantly, our patients are frequently unaware that we are physicians or that anesthesia care matters, as the American Society of Anesthesiologists’ “Physician Anesthesiologist” campaign points out.† As physicians practicing medicine, our goal is not to meet quarterly anesthesia satisfaction benchmarks but to earn patient loyalty by assuring that our patients are cared for—period.3 Embracing this concept would cement our role as perioperative physicians and align our goals with those of surgeons, nurses, hospitals, and, most importantly, our patients. Regarding the percentage change in ELV after lavage, the trend at different positive end-expiratory pressure levels with ELV was more uniform than end-expiratory lung volume, which may reflect that the former is a functional volume parameter and not a measure of anatomical volume. Furthermore, the ELV value is the only lung volume assessment available at bedside for the clinician, and any recruitment maneuver will be based on the changes in this index. Accordingly, the aim of the clinician will be to re-establish its former value by recruitment maneuver, which eliminates the risk of lung overdistension. It is noteworthy that the lavage-induced decreases in ELV follow a more uniform pattern than end-expiratory lung volume. There is no doubt that measurement of different lung functional parameters is necessary to reinforce the detection of airway closure and/or reopening. Accordingly, it is very hard to promote one single measure in clinical practice to guide ventilation strategy. Measuring ELV may contribute to better understand the changes observed in respiratory mechanics, but it cannot be considered as a single parameter to detect loss in lung volume. Particularly, changes in pulmonary blood volume may interfere with its absolute value as discussed in the article, which is more obvious at low positive end-expiratory pressure levels. Nevertheless, this method is under improvement and continuous development by our research team. We are currently investigating the relation between ELV and structural global and regional changes in the lungs to improve the algorithm.