Measuring quality of recovery-15 after day case surgery Chazapis, M.; Walker, E.M.K.; Rooms, M.A. ...
British journal of anaesthesia,
February 2016, 20160201, 2016-Feb, 2016-02-00, Letnik:
116, Številka:
2
Journal Article
Recenzirano
Odprti dostop
‘Quality of recovery’ scores are patient-reported outcome measures evaluating recovery after surgery and anaesthesia. However, they are not widely used in the clinical or research setting. The ...Quality of Recovery-15 (QoR-15) is a recently developed, psychometrically tested and validated questionnaire.
We conducted a prospective study of all adult patients undergoing orthopaedic day case surgery over a period of six months (June 2013–November 2013). Patients completed the QoR-15 score preoperatively, and then were asked to repeat the score by telephone at 24 h, 48 h and seven days after surgery.
633 patients from a possible 714 (89%) completed the preoperative questionnaire and data from 437 patients who completed scores at all four time points were analysed. Most patients returned to their preoperative score by 48 h, and had exceeded it by seven days. Construct validity was supported by a negative correlation with duration of surgery and total inpatient opioid use. There was also excellent internal consistency (Cronbach’s alpha 0.80–0.83).
The QoR-15 is a clinically acceptable and feasible patient-centred outcome measure after day case surgery. The score demonstrated good validity, reliability and responsiveness. However, measurement of the QoR-15 score on the day of surgery may not provide a true baseline value. We suggest one follow-up call at 48 h would enable an adequate patient-centred assessment of postoperative recovery after day case orthopaedic surgery.
Patient-centred outcomes are increasingly used in perioperative clinical trials. The Standardised Endpoints in Perioperative Medicine (StEP) initiative aims to define which measures should be used in ...future research to facilitate comparison between studies and to enable robust evidence synthesis.
A systematic review was conducted to create a longlist of patient satisfaction, health-related quality of life, functional status, patient well-being, and life-impact measures for consideration. A three-stage Delphi consensus process involving 89 international experts was then conducted in order to refine this list into a set of recommendations.
The literature review yielded six patient-satisfaction measures, seven generic health-related quality-of-life measures, eight patient well-being measures, five functional-status measures, and five life-impact measures for consideration. The Delphi response rates were 92%, 87%, and 100% for Rounds 1, 2, and 3, respectively. Three additional measures were added during the Delphi process as a result of contributions from the StEP group members. Firm recommendations have been made about one health-related quality-of-life measure (EuroQol 5 Dimension, five-level version with visual analogue scale), one functional-status measure (WHO Disability Assessment Schedule version 2.0, 12-question version), and one life-impact measure (days alive and out of hospital at 30 days after surgery). Recommendations with caveats have been made about the Bauer patient-satisfaction measure and two life-impact measures (days alive and out of hospital at 1 yr after surgery, and discharge destination).
Several patient-centred outcome measures have been recommended for use in future perioperative studies. We suggest that every clinical study should consider using at least one patient-centred outcome within a suite of endpoints.
Understanding the patient perspective on healthcare is central to the evaluation of quality. This study measured selected patient-reported outcomes after anaesthesia in order to identify targets for ...research and quality improvement.
This cross-sectional observational study in UK National Health Service hospitals, recruited adults undergoing non-obstetric surgery requiring anaesthesia care over a 48 h period. Within 24 h of surgery, patients completed the Bauer questionnaire (measuring postoperative discomfort and satisfaction with anaesthesia care), and a modified Brice questionnaire to elicit symptoms suggestive of accidental awareness during general anaesthesia (AAGA). Patient, procedural and pharmacological data were recorded to enable exploration of risk factors for these poor outcomes.
257 hospitals in 171 NHS Trusts participated (97% of eligible organisations). Baseline characteristics were collected on 16,222 patients; 15,040 (93%) completed postoperative questionnaires. Anxiety was most frequently cited as the worst aspect of the perioperative experience. Thirty-five per cent of patients reported severe discomfort in at least one domain: thirst (18.5%; 95% CI 17.8-19.1), surgical pain (11.0%; 10.5-11.5) and drowsiness (10.1%; 9.6-10.5) were most common. Despite this, only 5% reported dissatisfaction with any aspect of anaesthesia-related care. Regional anaesthesia was associated with a reduced burden of side-effects. The incidence of reported AAGA was one in 800 general anaesthetics (0.12%)
Anxiety and discomfort after surgery are common; despite this, satisfaction with anaesthesia care in the UK is high. The inconsistent relationship between patient-reported outcome, patient experience and patient satisfaction supports using all three of these domains to provide a comprehensive assessment of the quality of anaesthesia care.
The Surgical Outcome Risk Tool (SORT) is a risk stratification instrument used to predict perioperative mortality. We wanted to evaluate and refine SORT for better prediction of the risk of ...postoperative morbidity.
We analysed prospectively collected data from a single-centre cohort of adult patients undergoing major elective surgery. The data set was split randomly into derivation and validation samples. We used logistic regression to construct a model in the derivation sample to predict postoperative morbidity as defined using the validated Postoperative Morbidity Survey (POMS) assessed at 1 week after surgery. Performance of this ‘SORT-morbidity’ model was then tested in the validation sample and compared against the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM).
The SORT-morbidity model was constructed using a derivation sample of 1056 patients and validated in a further 527 patients. SORT-morbidity was well calibrated in the validation sample, as assessed using calibration plots and the Hosmer–Lemeshow test (χ2=4.87, P=0.77). It showed acceptable discrimination by receiver operating characteristic curve analysis area under the receiver operating characteristic curve (AUROC)=0.72, 95% confidence interval: 0.67–0.77. This compared favourably with POSSUM (AUROC=0.66, 95% confidence interval: 0.60–0.71), whilst being simpler to use. Linear shrinkage factors were estimated, which allow the SORT-morbidity model to predict a range of alternative morbidity outcomes with greater accuracy, including low- and high-grade morbidity, and POMS at later time points.
SORT-morbidity can be used before surgery, with clinical judgement, to predict postoperative morbidity risk in major elective surgery.
The UK Department of Health Enhanced Recovery Partnership Programme collected data on 24 513 surgical patients in the UK from 2009–2012. Enhanced Recovery is an approach to major elective surgery ...aimed at minimizing perioperative stress for the patient. Previous studies have shown Enhanced Recovery to be associated with reduced hospital length of stay and perioperative morbidity.
In this national clinical audit, National Health Service hospitals in the UK were invited to submit patient-level data. The data regarding length of stay and compliance with each element of Enhanced Recovery protocols for colorectal, orthopaedic, urological and gynaecological surgery patients were analysed. The relationship between Enhanced Recovery protocol compliance and length of stay was measured.
From 16 267 patients from 61 hospital trusts, three out of four surgical specialties showed Enhanced Recovery, compliance being weakly associated with shorter length of stay (correlation coefficients −0.18, −0.14, −0.25 in colorectal, orthopaedics and gynaecology respectively). At a cut-off of 80% compliance, good compliance was associated with two, one and three day reductions in median length of stay respectively in colorectal, orthopaedic and urological surgeries, with no saving in gynaecology.
This study is the largest assessment of the relationship between Enhanced Recovery protocol compliance and outcome in four surgical specialties. The data suggest that higher compliance with an Enhanced Recovery protocol has a weak association with shorter length of stay. This suggests that changes in process, resulting from highly protocolised pathways, may be as important in reducing perioperative length of stay as any individual element of Enhanced Recovery protocols in isolation.
Emergency laparotomies are performed commonly throughout the world, but one in six patients die within a month of surgery. Current international initiatives to reduce the considerable associated ...morbidity and mortality are founded upon delivering individualised perioperative care. However, while the identification of high-risk patients requires the routine assessment of individual risk, no method of doing so has been demonstrated to be practical and reliable across the commonly encountered spectrum of presentations, co-morbidities and operative procedures. A systematic review of Embase and Medline identified 20 validation studies assessing 25 risk assessment tools in patients undergoing emergency laparotomy. The most frequently studied general tools were APACHE II, ASA-PS and P-POSSUM. Comparative, quantitative analysis of tool performance was not feasible due to the heterogeneity of study design, poor reporting and infrequent within-study statistical comparison of tool performance. Reporting of calibration was notably absent in many prognostic tool validation studies. APACHE II demonstrated the most consistent discrimination of individual outcome across a variety of patient groups undergoing emergency laparotomy when used either preoperatively or postoperatively (area under the curve 0.76–0.98). While APACHE systems were designed for use in critical care, the ability of APACHE II to generate individual risk estimates from objective, exclusively preoperative data items may lead to better-informed shared decisions, triage and perioperative management of patients undergoing emergency laparotomy. Future endeavours should include the recalibration of APACHE II and P-POSSUM in contemporary cohorts, modifications to enable prediction of morbidity and assessment of the impact of adoption of these tools on clinical practice and patient outcomes.
Previous studies have suggested that there may be long-term harm associated with postoperative complications. Uncertainty exists however, because of the need for risk adjustment and inconsistent ...definitions of postoperative morbidity.
We did a longitudinal observational cohort study of patients undergoing major surgery. Case-mix adjustment was applied and morbidity was recorded using a validated outcome measure. Cox proportional hazards modelling using time-dependent covariates was used to measure the independent relationship between prolonged postoperative morbidity and longer term survival.
Data were analysed for 1362 patients. The median length of stay was 9 days and the median follow-up time was 6.5 yr. Independent of perioperative risk, postoperative neurological morbidity (prevalence 2.9%) was associated with a relative hazard for long-term mortality of 2.00 P=0.001; 95% confidence interval (CI) 1.32–3.04. Prolonged postoperative morbidity (prevalence 15.6%) conferred a relative hazard for death in the first 12 months after surgery of 3.51 (P<0.001; 95% CI 2.28–5.42) and for the next 2 yr of 2.44 (P<0.001; 95% CI 1.62–3.65), returning to baseline thereafter.
Prolonged morbidity after surgery is associated with a risk of premature death for a longer duration than perhaps is commonly thought; however, this risk falls with time. We suggest that prolonged postoperative morbidity measured in this way may be a valid indicator of the quality of surgical healthcare. Our findings reinforce the importance of research and quality improvement initiatives aimed at reducing the duration and severity of postoperative complications.
PDF
