- Design
- National, prospective, multicentre observational cohort study with patient-reported follow-up at days 1, 3 and 7 (POPPY)
- Population
- 7,839 UK day-case surgical patients recruited, 7,331 responding at day 7
- Primary outcome
- Poor pain outcome (severity above 4/10) and functional impairment due to pain during the first 7 postoperative days
- Effect
- Poor pain outcome in 1,458/4,348 (33.5%); pain impaired function in 1,279/4,854 (26.3%) at day 7; risks raised with chronic pain, frailty, anxiety or depression treatment, surgical magnitude and head and neck surgery
Most surgery in the UK is day case, and follow-up usually stops when the patient goes home. POPPY, a national prospective observational study, followed them: 7,839 patients recruited, 7,331 responding at day 7, with pain severity, functional scores and quality of recovery captured at days 1, 3 and 7.
Pain scores fell over the week and function did not keep pace. A poor pain outcome - severity above 4 out of 10 - occurred in 1,458 of 4,348 (33.5%) during the first seven days, and pain was still impairing function in 1,279 of 4,854 (26.3%) at day 7.
The risk factors are the useful part because they are all known before the operation: treatment for anxiety or depression, pre-existing chronic pain, frailty, greater surgical magnitude, and head and neck surgery for pain outcomes; orthopaedic surgery, chronic pain and frailty for functional ones. Two protective associations run against intuition - increasing age was associated with a lower probability of a poor pain outcome, and so was opioid naivety.
This is observational, self-reported, and about a quarter of the recruited cohort did not contribute to some analyses, which will bias towards those well enough to respond - meaning the true figures are probably worse.
What it changes is the preoperative conversation and the follow-up plan. A frail patient with chronic pain on long-term opioids having a head and neck day case is not going to be comfortable on day 3, and telling them so - along with a specific analgesic plan and a named contact - is a better intervention than the leaflet they currently get. In Indian day-case practice, where follow-up is often a phone number rather than a service, identifying that subgroup before they leave matters more, not less.
- Flag chronic pain, frailty, current opioid use and anxiety or depression treatment at preassessment
- Give high-risk day-case patients a written escalation plan and a named contact, not a generic leaflet
- Warn patients that functional limitation commonly outlasts the pain score
- Do not reassure young patients on the basis of age - younger patients did worse here
- Consider a day-3 telephone review for the high-risk groups rather than a day-1 call
The statistics, in plain English
These are proportions from an observational cohort, not treatment effects, so they describe what happens rather than what any intervention would change. Note the shifting denominators - 4,348 for the pain outcome, 4,854 for function, against 7,331 responders - which means a substantial number of patients did not contribute to each analysis, and non-responders in pain studies tend to be doing worse than responders. The associations were identified across many candidate variables, so individual risk factors need replication before being used as selection criteria.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for anaesthesiology, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free