Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Public confidence in the auditing profession

The auditing profession is facing increased number of litigation recently due to corporate failures of their clients whom they audited and had received "clean" reports. How do the users of audited financial information perceive the profession and the work performed by the auditors with all the happenings to the profession? Is the profession able to maintain its credibility and usefulness now? This project serves to ascertain the level of public confidence users have in the auditing profession, the factors contributing to their confidence, and the recommendations deemed necessary to maintain or enhance the profession's image. Research was carried out in two ways: (1) A questionnaire survey was designed to determine public's perception of auditors' competence, integrity, independence, and the exercise of due audit care. It also ascertains whether there is an expectation gap and how in addition to litigation of auditors and high audit staff turnover impact users' confidence in the profession. (2) Literature review based on local and foreign written articles was carried out to supplement and compare findings from the survey. Respondents indicated a more than indifference confidence level of 3.67 (on a scale of 1 to 5) in the profession. Auditors' competence in understanding the clients' businesses received a low rating among all other factors and it is rather highly correlated to public confidence. Auditors' independence and the training by CPA firms reflected fairly good ratings. All these three factors had relatively higher correlations to the confidence level than the other factors. Hence, there must be measures to improve auditors' competence in understanding clients' business; and at a minimum, maintain the current standard of independence and training by CPA firms, so as not to decrease the level of confidence the public has in the profession. The project concluded that users wanted more stringent auditing standards. This would supposedly improve audit quality, thus maintaining or even increase their confidence in the profession. Other favourable recommendations included audit rotation by audit partners or CPA firms; having an independent body to appoint and pay the CPA firms; make audit committees compulsory for all companies; revise the current audit report; and peer review by other CPA firms.ACCOUNTANC