# Comfort-Focused Assessment and Patient-Reported Experience After Regional versus General Anaesthesia: Post Hoc Analysis of a Cluster-Randomised Trial

Axel Maurice-Szamburski, Romain Rozier, Nicolas Fusco, Ludovic Meuret, Anderson Loundou, Pascal Auquier, Hélène Beloeil

► To cite this version:

Axel Maurice-Szamburski, Romain Rozier, Nicolas Fusco, Ludovic Meuret, Anderson Loundou, et al. Comfort-Focused Assessment and Patient-Reported Experience After Regional versus General Anaesthesia: Post Hoc Analysis of a Cluster-Randomised Trial. Anaesthesia Critical Care & Pain Medicine, 2025, pp.101660. 10.1016/j.accpm.2025.101660. hal-05390613

HAL Id: hal-05390613

https://hal.science/hal-05390613v1

Submitted on 3 Dec 2025

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_1.png" /></figure>

Distributed under a Creative Commons Attribution 4.0 International License
Journal Pre-proof

Comfort-Focused Assessment and Patient-Reported Experience After
Regional versus General Anaesthesia: Post Hoc Analysis of a
Cluster-Randomised Trial

Axel Maurice-Szamburski, Romain Rozier, Nicolas Fusco, Ludovic
Meuret, Anderson Loundou, Pascal Auquier, Hélène Beloeil

PII: S2352-5568(25)00192-4

DOI: https://doi.org/10.1016/j.accpm.2025.101660

Reference: ACCPM 101660

To appear in: Anaesthesia Critical Care & Pain Medicine

Accepted Date: 11 September 2025

<figure><img src="image_2.png" /></figure>

Please cite this article as: Maurice-Szamburski A, Rozier R, Fusco N, Meuret L, Loundou A, Auquier P, Beloeil H, Comfort-Focused Assessment and Patient-Reported Experience After Regional versus General Anaesthesia: Post Hoc Analysis of a Cluster-Randomised Trial, *Anaesthesia Critical Care and Pain Medicine* (2025), doi: https://doi.org/10.1016/j.accpm.2025.101660

This is a PDF of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability. This version will undergo additional copyediting, typesetting and review before it is published in its final form. As such, this version is no longer the Accepted Manuscript, but it is not yet the definitive Version of Record; we are providing this early version to give early visibility of the article. Please note that Elsevier's sharing policy for the Published Journal Article applies to this version, see: https://www.elsevier.com/about/policies-and-standards/sharing#4-published-journal-article. Please also note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

© 2025 Published by Elsevier Masson SAS on behalf of Société française d'anesthésie et de réanimation (SFAR).
# Title Page

## Comfort-Focused Assessment and Patient-Reported Experience After Regional versus General Anaesthesia: Post Hoc Analysis of a Cluster-Randomised Trial

Axel Maurice-Szamburski,¹ Romain Rozier,² Nicolas Fusco,³,⁴,⁵ Ludovic Meuret,⁶ Anderson Loundou,⁷ Pascal Auquier,⁷ and Hélène Beloeil.⁸

### Authors affiliations:

¹ Department of Anesthesiology and Intensive Care Medicine, Pasteur Nice University Hospital, Nice, France

² Department of Anesthesiology and Intensive Care Medicine, L'Archet Nice University Hospital, Nice, France

³ CHU Rennes, Anesthesia and Intensive Care Department, Rennes, France

⁴ Private Hospital, Anesthesia Department, Saint-Gregoire, France

⁵ Hypnosis Institute, Emergences Campus, F-35000 Rennes, France

⁶ CHU Rennes, Anesthesia and Intensive Care Department, CIC 1414, Rennes, France

⁷ Laboratoire de Santé Publique, 264 rue Saint Pierre, 13005, Marseille, France

⁸ University of Rennes, CHU Rennes, Inserm, OSS1242, CIC 1414, Anesthesia and Intensive Care Department, Rennes, France

### Corresponding author:

Axel Maurice-Szamburski

Mobile: +33 (0) 615 315 747

E-mail: amszamburski@gmail.com

Axel Maurice-Szamburski: AMS

Romain Rozier: RR

Nicolas Fusco: NF

Anderson Loundou: AL

Pascal Auquier: PA

Hélène Beloeil: HB
# Abstract

## Introduction

Postoperative pain management typically relies on numerical (NRS) or analogue rating scales. However, exclusive focus on nociception may overlook broader aspects of patient experience, especially under regional anaesthesia (RA). This post hoc analysis of the COMFORT trial (NCT05234216) examined whether replacing the NRS with a comfort-focused scale affects patient-reported experience, opioid use, and related outcomes.

## Methods

We analysed data from a cluster-randomised trial in 29 French centres. Adults undergoing elective non-cardiac surgery managed in the post-anaesthesia care unit (PACU) were included. The intervention (comfort scale) and comparator (pain NRS) were applied in the PACU. Patient-reported experience was measured with the EVAN-G/LR scales, self-completed on the ward/day-care unit ≥4 hours postoperatively. Participants were divided into RA and general anaesthesia subgroups.

## Results

Of 885 randomised patients, 786 had evaluable EVAN data. After regional anaesthesia (RA; n=305), comfort-focused assessment was associated with higher EVAN Pain (median 88 [IQR 75–94] vs. 75 [69–88]; *p*=0.034), Waiting (100 [75–100] vs. 75 [50–100]; *p*=0.012), and Global Index (81 [72–91] vs. 77 [68–90]; *p*=0.044). After general anaesthesia (GA; n=481), EVAN scores were similar between groups. Nefopam use was lower with the comfort approach in RA (7% vs. 18%; *p*=0.005). Antiemetic use was lower with the comfort approach in GA.

## Conclusion

Replacing the NRS with a comfort-focused approach did not improve global patient experience after surgery. In patients receiving regional anaesthesia, however, using a comfort scale was associated with better patient-reported experience in the EVAN “Pain” dimension, while no benefit was observed after general anaesthesia.

**Keywords:** Postoperative pain, Regional anaesthesia, Comfort scale, Patient experience, Multimodal analgesia
## Key Points

After regional anaesthesia, comfort-focused assessment was associated with higher EVAN Pain and Waiting dimensions scores, and a Global Index increase that did not reach the minimal clinically important difference.

The comfort scale did not change patient-reported experience or analgesic medication use after general anaesthesia, but antiemetic use was lower.

Nefopam administration decreased when the comfort scale was used after regional anaesthesia, suggesting a lower propensity to require adjuvant analgesia.

Comfort-oriented language may mitigate nocebo-related distress and enhance patient experience when patients are conscious during surgery.

## Introduction

Accurate postoperative pain assessment is essential for optimizing analgesic management, enhancing patient-reported experience, and improving overall satisfaction with perioperative care.[1,2] Conventional tools, such as the numerical rating scale (NRS), quantify pain intensity but neglect broader aspects that patients could value.[3,4]

Patient-reported experience measures (PREMs) and patient satisfaction are related but distinct constructs. PREMs assess how patients experience specific aspects of care, like the quality of information, healthcare providers' attention, waiting, or physical discomfort. Satisfaction is a more global appraisal that depends on expectations and can vary for reasons not related to care.

In anesthesia, the Bauer questionnaire is a validated patient satisfaction scale, recommended in the perioperative period.[5] The EVAN scales (EVAN-G and EVAN-LR) are validated PREMs that capture multiple dimensions of care, e.g., Pain, Information, Attention, Waiting, and
Comfort, alongside a global index, providing domain-level feedback beyond a single
satisfaction score.[6,7]

The COMFORT study was designed to compare a comfort-focused assessment, prompting caregivers to inquire about the patient's level of comfort following a dedicated algorithm, with the standard pain NRS in the postoperative setting.[8]. The primary results of the COMFORT trial showed no significant reduction in opioid consumption, but the trial also collected raw data on patient-reported experience using the EVAN scales.

Patient experience might be differentially affected by a comfort-focused approach depending
on the type of anesthesia. Patients undergoing regional anesthesia (RA) remain conscious
during their procedure and directly perceive intraoperative and immediate postoperative events,
including communication with staff. In this context, visual analog scale (VAS) ratings have
been shown to correlate more with the Comfort than with the Pain dimension of the EVAN,
suggesting that intensity scores may capture general stressing factors rather than nociception
[7]

In this article, we report a post hoc, exploratory subgroup analysis of the COMFORT trial in elective non-cardiac surgery, comparing a post-anesthesia care unit (PACU) comfort-focused assessment with the standard pain NRS. Patient-reported experience (EVAN-G/LR) was measured on the ward or day-care unit ≥4 hours postoperatively, and effects were examined separately for regional versus general anesthesia.

Our primary hypothesis was that a comfort-focused assessment improves patient-reported pain experience. Second, we anticipated a larger effect with regional anesthesia, whereas general anesthesia would attenuate the effect because patients are intraoperatively unconscious and often sedated or amnestic postoperatively.
Clarifying these effects may improve the precision and relevance of pain assessment methods
with a more patient-centered approach to perioperative care.

**Methods**

**Trial Design**

This study is an ancillary post hoc analysis of a clinical trial in which 885 patients were
randomized across 29 centers in France to determine whether using a comfort scale, rather than
a standard NRS, could reduce postoperative opioid consumption in the PACU (Figure 1). This
was an open-label pragmatic trial. Centers were cluster-randomized 1:1 (15 clusters per arm),
with an average cluster size of 25 patients per center in both arms. Due to the nature of the
intervention, participants and PACU staff were not blinded to the assessment tool used.
Participating centers were not required to implement or harmonize any patient-experience
improvement policy, and we did not collect data on such dedicated programs. The parent trial
was prospectively registered at ClinicalTrials.gov (registration number NCT05234216) on 10
February 2022. The first participant was enrolled on 9 May 2022, and the trial was conducted
from May 2022 to July 2022. Full registration details can be accessed at
https://clinicaltrials.gov/study/NCT05234216. The study protocol received ethical approval for
all participating centres from the French ethics committee Comité de Protection des Personnes
Est II de Besançon (chair: Dr Isabelle Martin, approval number SI 22.00140.000059-MS02,
dated 15 March 2022) and from the ethics committee of the Hospital Hôtel-Dieu (approval
number CEHDF 1897). This clinical investigation was reviewed and approved by the National
Institutional Review Board (ID-RCB 2021-A02839-32).

**Participants**
Informed consent, documented in the patient's records, was obtained from all participants before inclusion in the study. Eligible patients were French-speaking adults scheduled for elective non-cardiac surgery with postoperative management in the PACU, affiliated with a social security system, and having provided free oral informed consent. Participants were screened, approached, and recruited by study staff, who assessed eligibility, obtained written consent, and enrolled them. Non-inclusion criteria were as follows: patients unable to understand the assessment scales, patients using long-term opioids before the operation, patients with opioid or opioid-like addiction, pregnant and breastfeeding women, adults under legal protection, or deprived of liberty. Patients bypassing the PACU for ICU admission (e.g., cardiac surgery), or those who could not return to usual care after the PACU for a medical reason, were excluded.

Patients were managed according to standard anesthesia protocols aside from the pain assessment method. In regional anesthesia cases, patients received neuraxial or peripheral nerve blocks and remained responsive throughout the procedure. In general anesthesia cases, patients were fully unconscious with airway management as appropriate; some GA patients also received regional blocks for analgesia. For the subgroup analysis, patients were classified into the RA group if they underwent regional anesthesia as the primary anesthetic (with no general anesthesia induced), and into the GA group if they received general anesthesia (either with or without a regional block adjunct). Patients who had both GA and a regional technique were analyzed in the GA subgroup, since their intraoperative experience was that of a general anesthetic.

## Interventions
Centers were cluster-randomized in a 1:1 ratio to either the comfort or NRS (control) group, with centralized, computer-generated allocation. Prior to surgery, patients in both groups received standard preoperative assessment by the anesthesia team. The comfort scale was introduced and explained in a pre-trial online session led by the principal investigator of each center.

Analgesia, including for IV morphine titration, followed national recommendations for multimodal postoperative pain management and was implemented according to each center's routine practice and clinician judgment, with respect to contraindications.[9] Adequate PACU pain control targeted NRS ≤3/10.

## Timeline and Data Collection

The randomized intervention (comfort scale vs pain NRS) was implemented in the PACU. Patient-reported experience was collected after patient arrival in the surgical ward or day-care unit, using the EVAN questionnaire (EVAN-G for patients who underwent GA; EVAN-LR for patients who underwent RA). The EVAN was administered at least 4 hours after surgery in accordance with the instrument's validation studies.[6,7]

## Control Group: Pain NRS

In the control group, postoperative pain assessment used a verbal NRS, with patients being asked to rate their pain intensity on a 0–10 scale (0 = no pain, 10 = worst pain imaginable). Analgesic management was provided as needed based on reported pain scores and standard protocols for pain treatment.

## Intervention Group: Comfort Scale
PACU staff followed a standardized one-page flowchart to conduct the comfort-focused
assessment and were instructed to minimize the use of the word “pain” and to emphasize
positive framing. For example, if a patient’s comfort level was below a certain threshold
(indicating discomfort), the provider would explore various interventions to improve comfort
(Figure 2).

## Outcome Measures

The primary outcome was the multidimensional postoperative patient experience measured by the EVAN questionnaires (“Evaluation du Vécu de l’Anesthésie”). The EVAN is a validated patient-reported outcome measure specifically designed to assess perioperative satisfaction and experience with anesthesia (Supplemental appendix S1). The questionnaire is self-administered and typically completed in 3–5 minutes in validation studies. [7,10]

Two versions of the EVAN scale exist: EVAN-G for general anesthesia (26 items) and EVAN-LR for regional anesthesia (19 items). Both versions share a similar conceptual framework and dimensional structure, originally derived from patient interviews and psychometric validation, yielding a Global Index (overall satisfaction score) and multiple dimension scores (Attention, Information, Pain, Comfort, Waiting). Each item is answered on a 5-point Likert scale and then standardized to a 0–100 scale per dimension and overall, with higher scores indicating better experience/satisfaction.

The EVAN was self-completed on the ward or day-care unit at least 4 hours after the surgery.

A 5-point difference was defined as the minimal clinically important difference, based on the EVAN validation studies and supporting evidence from the existing literature.[11–15]

Secondary outcomes included opioid consumption (mg of morphine equivalent) and the use of nonsteroidal anti-inflammatory drugs (NSAIDs), nefopam, and antiemetic medication in the PACU.
**Statistical Analysis**

Primary analyses were prespecified as exploratory and stratified by anesthetic technique (RA
vs. GA). Continuous variables are reported as mean (SD) or median [IQR], depending on the
distribution identified by the Shapiro-Wilk test. Age is specifically reported as mean [IQR].
Because the primary endpoint (EVAN scale) did not follow a normal distribution, group
comparisons were performed using the Mann-Whitney U test.

Secondary outcomes (opioid consumption in milligrams, NSAID use [yes/no], nefopam use [yes/no], and antiemetic medication use [yes/no]) were compared using Pearson's chi-square test. All tests were two-sided, with *P*<0.05 considered to indicate a statistically significant difference. Given the post hoc, exploratory nature of this ancillary analysis, comparisons were performed at the patient level without accounting for the cluster randomization by center.

Analyses were performed using the v30.0.0 of SPSS (IBM Corp., Armonk, NY, USA).

**Results**

Among the 885 patients randomized in the COMFORT trial, 860 were included in the intention-
to-treat. EVAN was missing for 54 (12.5%) in the comfort arm vs. 20 (4.7%) in the NRS arm,
respectively, yielding 786 patients for the post hoc analysis (Figure 1). Their baseline
characteristics are presented in Table 1.

**Primary outcome: EVAN Scores**
All EVAN scores reported below were collected on the ward/day-care unit, at least 4 hours after surgery.

## Regional Anaesthesia

A total of 305 patients undergoing regional anesthesia were included, with 163 assigned to the NRS group and 142 to the Comfort group. The comfort scale was associated with higher satisfaction scores on the Pain dimension compared with the NRS (median [IQR]: 88 [75–94] vs. 75 [69–88], P=0.034).

Satisfaction was also higher in the Comfort group for the Waiting dimension (100 [75–100] vs. 75 [50–100], P=0.012), along with the global index of patient experience (81 [72–91] vs. 77 [68–90], P=0.044). Table 2 summarises the remaining EVAN scale dimensions.

## General Anaesthesia

A total of 481 patients undergoing general anesthesia were included, with 244 in the NRS group and 237 in the Comfort group. EVAN scale dimension scores and the global index were similar between groups (Table 2). The satisfaction for the Pain dimension was 75 [69–88] in both groups (P=0.367), and the global index was 73 [65–85] vs. 76 [67–85] (P=0.303). No differences were detected for Attention, Information, Comfort, or Waiting.

## Secondary outcomes

### Regional Anaesthesia

Among patients who underwent regional anesthesia, opioid consumption was low and similar in both groups (3.2 [5.1] vs. 2.6 [4.9]; P=0.179), as was NSAID use (7% vs. 4%; P=0.207, Table 3). Nefopam use was more frequent in the NRS group compared to the comfort group (18% vs. 7%; P=0.005). Antiemetic medication use did not differ between groups (10% vs. 9%; P=0.844).
## General Anaesthesia

In the general anesthesia subgroup, opioid consumption did not differ significantly between the NRS and Comfort groups (3.5 [5] vs. 3 [4.1], P=0.325, Table 3). No differences were observed in the proportions of patients receiving NSAIDs (5% vs. 4%; P=0.714) or nefopam (12% vs. 9%; P=0.431). Antiemetic use was higher in the NRS group than in the Comfort group (18% vs. 10%; P=0.006).

## Discussion

In this post hoc analysis of the COMFORT trial, replacing a pain NRS with a comfort-focused assessment in the PACU was associated with higher patient-reported experience in the Pain and Waiting dimensions among patients who received regional anesthesia, whereas no differences were observed after general anesthesia.

These findings are consistent with the hypothesis that experience after regional anesthesia is more sensitive to the way caregivers communicate and explore postoperative discomfort. A comfort-oriented algorithm invites patients to report non-nociceptive sources of distress (anxiety, positioning, cold, nausea)[16,17] and may reduce the alarm of repeated “pain” language.[18–20] This approach could also improve the patient perception of responsiveness and attention, which is consistent with the higher Waiting score. The lower nefopam use in the regional anesthesia subgroup is consistent with fewer non-specific systemic analgesia escalations when discomfort is identified and addressed directly.

By contrast, postoperative discomfort after GA may be dominated by nociception and systematic multimodal analgesia.[21] In this context, the lack of effect of a comfort-focused
assessment is consistent with the multifactorial nature of patient experience, which depends on
multiple providers and components across the perioperative period, [22] and a single PACU
intervention may contribute only modestly to the overall EVAN profile measured several hours
later in the ward or day care unit. [23]

The EVAN scale is a patient-reported experience measure (PREM) in anesthesia with a multidimensional split and a global index. The 4-point increase in the EVAN Global Index after regional anesthesia falls below the prespecified minimal clinically important difference of 5 points.[10,11,15] The observed changes in Pain and Waiting dimensions may still matter, but these results should not be taken as evidence of a clinically important improvement in the overall patient experience. Together with unchanged opioid consumption, our data suggest that a comfort-focused assessment modifies how patients perceive their postoperative care after regional anesthesia rather than altering their analgesic needs. This approach conforms with recent expert recommendations advocating for more patient-centered assessments. [24]

This ancillary, post hoc subgroup analysis has limitations. Although centers were cluster-
randomized, site-level variation (e.g., intraoperative management, presence of patient-
experience programs) may persist. We did not adjust for clustering by center, which may
underestimate variance. Subgroups by anesthetic technique were not randomized and may differ
in unmeasured ways. The intervention was confined to the PACU. Eleven per cent of
questionnaires were missing or incomplete and were imbalanced between groups. Finally, the
pre-trial explanation of the comfort scale may have influenced patient expectations.

Replacing the NRS with a comfort-focused approach did not improve global patient
experience after surgery. In patients receiving regional anesthesia, however, using a comfort
scale was associated with better patient-reported experience in the EVAN “Pain” dimension,
while no benefit was observed after general anesthesia.

*Funding statement:* Pasteur Nice University Hospital, Nice, France. The committee allowing grants had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data or approval of the manuscript.

**Ethical Statement**

The original trial was prospectively registered at ClinicalTrials.gov (registration number NCT05234216) on 10 February 2022. The first participant was enrolled on 9 May 2022, and the trial was conducted from May 2022 to July 2022. Full registration details can be accessed at https://clinicaltrials.gov/study/NCT05234216. The study protocol received ethical approval for all participating centers from the French ethics committee Comité de Protection des Personnes Est II de Besançon (chair: Dr Isabelle Martin, approval number SI 22.00140.000059-MS02, dated 15 March 2022) and from the ethics committee of the Hospital Hôtel-Dieu (approval number CEHDF 1897). This clinical investigation was reviewed and approved by the National Institutional Review Board (ID-RCB 2021-A02839-32).

**Acknowledgements**

The authors have no conflicts of interest to declare.

No generative AI was used in writing this manuscript.

Presentations of preliminary data: none declared.

*Data availability:* Original data are available upon request from Léa Beaulieu, Data Manager, Clinical Pharmacology Department, CHU Rennes, Service de Pharmacologie Clinique, 2 Rue Henri Le Guilloux, 35033 Rennes Cedex 9, France (email: [Lea.BEAULIEU@chu-rennes.fr](mailto:Lea.BEAULIEU@chu-rennes.fr)); telephone: +33 2 99 28 65 70; fax: +33 2 99 28 37 22).
**AMS**: Analysis and interpretation of data; drafting and revising and agreement to be accountable for all aspects of the work thereby ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. **RR**: Analysis, interpretation of data and agreement to be accountable for all aspects of the work. **NF**: Conception and design, acquisition of data and agreement to be accountable for all aspects of the work thereby ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

**AL**: Analysis, interpretation of data and agreement to be accountable for all aspects of the work. **PA**: Analysis, interpretation of data and agreement to be accountable for all aspects of the work. **HB**: Conception and design, acquisition of data, analysis and interpretation of data; drafting and revising and agreement to be accountable for all aspects of the work thereby ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

## References

[1] Boulding W, Glickman SW, Manary MP, Schulman KA, Staelin R. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. Am J Manag Care 2011;17:41-8.

[2] Manary MP, Boulding W, Staelin R, Glickman SW. The patient experience and health outcomes. N Engl J Med 2013;368:201-3. https://doi.org/10.1056/NEJMp1211775.

[3] Gordon DB. Acute pain assessment tools: let us move beyond simple pain ratings. Curr Opin Anaesthesiol 2015;28:565-9. https://doi.org/10.1097/ACO.0000000000000225.

[4] Karcioglu O, Topacoglu H, Dikme O, Dikme O. A systematic review of the pain scales in adults: Which to use? Am J Emerg Med 2018;36:707-14. https://doi.org/10.1016/j.ajem.2018.01.008.

[5] Moonesinghe SR, Jackson AIR, Boney O, Stevenson N, Chan MTV, Cook TM, et al. Systematic review and consensus definitions for the Standardised Endpoints in Perioperative Medicine initiative: patient-centred outcomes. Br J Anaesth 2019;123:664-70. https://doi.org/10.1016/j.bja.2019.07.020.

[6] Auquier P, Pernoud N, Bruder N, Simeoni M-C, Auffray J-P, Colavolpe C, et al. Development and validation of a perioperative satisfaction questionnaire. Anesthesiology 2005;102:1116-23. https://doi.org/10.1097/00000542-200506000-00010.

[7] Maurice-Szamburski A, Bruder N, Loundou A, Capdevila X, Auquier P. Development and validation of a perioperative satisfaction questionnaire in regional anesthesia. Anesthesiology 2013;118:78-87. https://doi.org/10.1097/ALN.0b013e31827469f2.
[8] Fusco N, Meuret L, Bernard F, Musellec H, Martin L, Léonard M, et al. Effect of a comfort scale compared with a pain numerical rate scale on opioids consumption in postanaesthesia care unit: the COMFORT study. Br J Anaesth 2024;133:839–45. https://doi.org/10.1016/j.bja.2024.06.029.

[9] Aubrun F, Nouette-Gaulain K, Fletcher D, Belbachir A, Beloeil H, Carles M, et al. Revision of expert panel’s guidelines on postoperative pain management. Anaesth Crit Care Pain Med 2019;38:405–11. https://doi.org/10.1016/j.accpm.2019.02.011.

[10] Auquier P, Pernoud N, Bruder N, Simeoni M-C, Auffray J-P, Colavolpe C, et al. Development and validation of a perioperative satisfaction questionnaire. Anesthesiology 2005;102:1116–23. https://doi.org/10.1097/00000542-200506000-00010.

[11] Maurice-Szamburski A, Auquier P, Viarre-Oreal V, Cuvillon P, Carles M, Ripart J, et al. Effect of sedative premedication on patient experience after general anesthesia: a randomized clinical trial. JAMA 2015;313:916–25. https://doi.org/10.1001/jama.2015.1108.

[12] Maurice-Szamburski A, Grillo P, Cuvillon P, Gazeau T, Delaunay L, Auquier P, et al. Comparison of continuous with single-injection regional analgesia on patient experience after ambulatory orthopaedic surgery: a randomised multicentre trial. Br J Anaesth 2022;129:435–44. https://doi.org/10.1016/j.bja.2022.05.039.

[13] Maurice-Szamburski A, Bringuier S, Auquier P, Capdevila X. From pain level to pain experience: redefining acute pain assessment to enhance understanding of chronic postsurgical pain. Br J Anaesth 2024;133:1021–7. https://doi.org/10.1016/j.bja.2024.08.003.

[14] Maurice-Szamburski A, Rozier R, Gridel V, Radev V, Badia E, Loundou A, et al. Factors associated with poor pain experience after surgery. Reg Anesth Pain Med 2025:rapm-2024-106095. https://doi.org/10.1136/rapm-2024-106095.

[15] Kowark A, Keszei AP, Schneider G, Pilge S, Schneider F, Obert DP, et al. Preoperative Midazolam and Patient-Centered Outcomes of Older Patients: The I-PROMOTE Randomized Clinical Trial. JAMA Surg 2024;159:129–38. https://doi.org/10.1001/jamasurg.2023.6479.

[16] van Dorp TIB, Kwant M, Lameijer H. Could we use the comfort score instead of the numeric rating pain score? A proof of concept pilot study. Am J Emerg Med 2023;68:64–7. https://doi.org/10.1016/j.ajem.2023.01.015.

[17] Petersen GL, Finnerup NB, Colloca L, Amanzio M, Price DD, Jensen TS, et al. The magnitude of nocebo effects in pain: a meta-analysis. Pain 2014;155:1426–34. https://doi.org/10.1016/j.pain.2014.04.016.

[18] Bushnell MC, Ceko M, Low LA. Cognitive and emotional control of pain and its disruption in chronic pain. Nat Rev Neurosci 2013;14:502–11. https://doi.org/10.1038/nrn3516.

[19] Raja SN, Carr DB, Cohen M, Finnerup NB, Flor H, Gibson S, et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain 2020;161:1976–82. https://doi.org/10.1097/j.pain.0000000000001939.

[20] Arrow K, Burgoyne LL, Cyna AM. Implications of nocebo in anaesthesia care. Anaesthesia 2022;77 Suppl 1:11–20. https://doi.org/10.1111/anae.15601.

[21] Wager TD, Atlas LY. The neuroscience of placebo effects: connecting context, learning and health. Nat Rev Neurosci 2015;16:403–18. https://doi.org/10.1038/nrn3976.

[22] Skivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM, et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. BMJ 2021;374:n2061. https://doi.org/10.1136/bmj.n2061.
[23] Meyer MJ, Hyder JA, Cole DJ, Kamdar NV. The Mandate to Measure Patient Experience: How Can Patients “Value” Anesthesia Care? Anesth Analg 2016;122:1211-5. https://doi.org/10.1213/ANE.0000000000001198.

[24] Choi S, Yoon S-H, Lee H-J. Beyond measurement: a deep dive into the commonly used pain scales for postoperative pain assessment. Korean J Pain 2024;37:188-200. https://doi.org/10.3344/kjp.24069.
<figure><img src="image_3.png" /><figcaption>**Figure 2**</figcaption></figure>
<figure><img src="image_4.png" /></figure>

<figure><img src="image_5.png" /></figure>
<table><caption>**Table 1.** Subject Characteristics</caption><thead><tr><th>Characteristic</th><th>General Anaesthesia (n=481)</th><th>Regional Anaesthesia (n=305)</th></tr></thead><tbody><tr><td>Age, yr</td><td>55 (41 – 69)</td><td>59 (49 – 72)</td></tr><tr><td>Sex, female (%)</td><td>277 (58)</td><td>152 (50)</td></tr><tr><td>Body mass index (SD)</td><td>26.7 (6.1)</td><td>27.5 (5.8)</td></tr><tr><td>Tobacco use (%)</td><td>97 (20)</td><td>58 (19)</td></tr><tr><td>Alcohol use (%)</td><td>29 (6)</td><td>12 (4)</td></tr><tr><td>Antidepressants (%)</td><td>42 (9)</td><td>23 (8)</td></tr><tr><td>Anxiolytics (%)</td><td>45 (9)</td><td>21 (7)</td></tr><tr><td>ASA class (%)</td><td></td><td></td></tr><tr><td>I</td><td>145 (31)</td><td>98 (32)</td></tr><tr><td>II</td><td>233 (50)</td><td>144 (47)</td></tr><tr><td>III</td><td>85 (18)</td><td>63 (21)</td></tr><tr><td>IV</td><td>2 (&lt;1)</td><td>0 (&lt;1)</td></tr><tr><td>Type of surgery (%)</td><td></td><td></td></tr><tr><td>Orthopaedics</td><td>115 (24)</td><td>215 (71)</td></tr><tr><td>Abdominal</td><td>237 (49)</td><td>58 (19)</td></tr><tr><td>ENT, oral surgery</td><td>35 (7)</td><td>0 (-)</td></tr><tr><td>Vascular</td><td>9 (2)</td><td>3 (1)</td></tr><tr><td>Lung</td><td>4 (1)</td><td>19 (6)</td></tr><tr><td>Other</td><td>81 (17)</td><td>10 (3)</td></tr><tr><td>Surgical procedure risk (ACC/AHA, %)</td><td></td><td></td></tr><tr><td>Low</td><td>142 (29)</td><td>95 (31)</td></tr><tr><td>Intermediate</td><td>302 (63)</td><td>194 (64)</td></tr><tr><td>High</td><td>37 (8)</td><td>16 (5)</td></tr><tr><td>Anaesthesia duration (min)</td><td>147 (85)</td><td>145 (94)</td></tr><tr><td>Surgery duration (min)</td><td>91 (73)</td><td>90 (81)</td></tr><tr><td>Outpatient surgery (%)</td><td>122 (25)</td><td>105 (34)</td></tr></tbody></table>

Age is reported as mean [Q1–Q3]. Other continuous variables are reported as mean (SD), while categorical variables are expressed as frequency (%). ACC/AHA, American College of Cardiology/American Heart Association; ENT: ear, nose and throat; GA, general anaesthesia; NRS, numerical rating scale; RA, regional anaesthesia; SA, spinal anaesthesia. *The ASA criteria for physical status include a classification for normal health (I), mild systemic disease (II), severe systemic disease (III), and severe systemic disease that is a constant threat to life (IV).
<table><caption>**Table 2.** Comparisons of EVAN Scores by Groups and Type of Anaesthesia.</caption><thead><tr><th>Dimensions</th><th>NRS group (n=163)</th><th>Comfort Group (n=142)</th><th>P-Value</th></tr></thead><tbody><tr><td><strong>Regional Anaesthesia</strong></td><td></td><td></td><td></td></tr><tr><td>Attention</td><td>81 (70-95)</td><td>86 (75-95)</td><td>0.487</td></tr><tr><td>Information</td><td>70 (50-90)</td><td>75 (55-95)</td><td>0.295</td></tr><tr><td>Pain</td><td>75 (69-88)</td><td>88 (75-94)</td><td>0.034*</td></tr><tr><td>Comfort</td><td>70 (55-85)</td><td>75 (60-88)</td><td>0.107</td></tr><tr><td>Waiting</td><td>75 (50-100)</td><td>100 (75-100)</td><td>0.012*</td></tr><tr><td>Global Index</td><td>77 (68-90)</td><td>81 (72-91)</td><td>0.044*</td></tr></tbody><tbody><tr><td><strong>General Anaesthesia</strong></td><td></td><td></td><td></td></tr><tr><td>Attention</td><td>80 (75-90)</td><td>83 (75-90)</td><td>0.861</td></tr><tr><td>Information</td><td>65 (50-85)</td><td>65 (50-85)</td><td>0.926</td></tr><tr><td>Pain</td><td>75 (69-88)</td><td>75 (69-88)</td><td>0.367</td></tr><tr><td>Comfort</td><td>70 (60-80)</td><td>70 (60-80)</td><td>0.225</td></tr><tr><td>Waiting</td><td>75 (50-100)</td><td>75 (50-100)</td><td>0.314</td></tr><tr><td>Global Index</td><td>73 (65-85)</td><td>76 (67-85)</td><td>0.303</td></tr></tbody></table>

Data are presented in medians and interquartile ranges. NRS, numerical rating scale. *P-value for Mann Whitney U-test. EVAN, Evaluation du Vécu de l'Anesthésie (range 0–100; higher scores indicate better experience). EVAN administered on the ward/day-care unit 4h after surgery (post-PACU)

<table><caption>**Table 3.** Secondary Outcomes in the Post Anaesthesia Care Unit</caption><thead><tr><th rowspan="2"></th><th colspan="3">General Anaesthesia</th><th colspan="3">Regional Anaesthesia</th></tr><tr><th>NRS group (n=244)</th><th>Comfort Group (n=237)</th><th>P-value</th><th>NRS group (n=163)</th><th>Comfort Group (n=142)</th><th>P-value</th></tr></thead><tbody><tr><td>Opioid consumption in mg (SD)</td><td>3.5 (5)</td><td>3 (4.1)</td><td>0.325</td><td>3.2 (5.1)</td><td>2.6 (4.9)</td><td>0.179</td></tr><tr><td>NSAID, yes (%)</td><td>12 (5)</td><td>10 (4)</td><td>0.714</td><td>11 (7)</td><td>5 (4)</td><td>0.207</td></tr><tr><td>Nefopam, yes (%)</td><td>28 (12)</td><td>22 (9)</td><td>0.431</td><td>29 (18)</td><td>10 (7)</td><td>0.005*</td></tr><tr><td>Antiemetic medication, yes (%)</td><td>45 (18)</td><td>23 (10)</td><td>0.006*</td><td>16 (10)</td><td>13 (9)</td><td>0.844</td></tr></tbody></table>

Data presented as mean (SD) or number (%). NRS, numerical rating scale; NSAID, non-steroidal anti-inflammatory drug. *P-value for Pearson's chi-square test.