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6.13 Quality of life assessment in amputees
Aortafemoral patients. Such an approach was considered as simple and costeffective. In our population, all elderly patients with evidence of occlusive I?A.D. were considered as the only high-risk group in developing abdominal aortic aneurysm. However, regarding screening for occlusion (P.A.D.) we suggested the screening of three main high-risk groups of elderly patients with either: diabetes mellitus, ischaemic heart disease or chronic renal failure.
6.13 Quality of Life Assessmentin Amputees G.1. HICKEN, L. AR0 and EM. AMELZ, Toronto, Ontario, Canada Objective: To study quality of life and its assessment in amputees. Method: Fifty-nine patients underwent major lower limb amputation for irreversible critical ischemia over a 52 month period. Thirty-six of these were successfully contacted and asked to complete a previously validated health-related quality of life questionnaire with five equally weighted dimensions (QL-Index), a single linear scale to rate their own quality of life (QOL), a similar scale to rate the specific impact of the amputation (Amp-Diff). All three scales scored out of 10 with higher scores indicating a favourable response. Results: Twenty-seven (75%) of 36 amputees (15 BKA, seven AKA, five Bilateral) returned the completed questionnaire. There was a significant difference between the mean QL-Index, QOL, and Amp-Diff scores (respectively 7.56/10,5.43/10 and 4.19/10) (P c 0.003) -0.005) with overall quality of life as measured by the QL-Index scoring highest, the impact of amputation on QOL scoring lowest. Amputation type did not appear to influence the quality of life (P > 0.05). Conclusion: When measured with a generic instrument (QLIndex) an amputee’s quality of life appears good. However, this may represent an overestimation because a patient’s own self assessment of quality of life (QOL), and impact of amputation on that life (Amp-Diff) score significantly lower. To accurately assess the impact of disability on quality of life in distinct patient groups a disease specific instrument must be used to avoid underestimation of this impact. Efforts must be made to develop such an instrument.
6.14 Initial Item Selection for a Disease-specificQuality of Life Questionnaire for Intermittent Claudication G.]. HZCKEN, L. ARO, A. LOSSING and EM. AMELI, Toronto, Ontario, Canada Objective: To create an instrument to objectively measure the specific impact of intermittent claudication (IC) on quality of life (QOL) that would help standardize patient assessment, assist with research and improve the relevance of audit. Method: After eight surgeons were consulted, and many QOL instruments reviewed, a questionnaire was compiled to assess the specific impact of IC on QOL. This was used alongside a known generic QOL (MOS SF-36). The surgeons’ opinion of the severity of claudication was sought. The patients’ and surgeons’ answers and SF-36 were scored and correlated. Any questions not understood by patients were noted. The vascular laboratory results were recorded.
CARDIOVASCULAR SURGERY
SEPTEMBER 1997
Disease
Results: There were 36 claudicants interviewed. Fifteen questions from the questionnaire were easily understood and when totaled, had good correlation (r = 0.5468) with the surgeon’s score, and internal consistency of 0.9018 (Cronbaths Alpha). The SF-36 scores correlated poorly with the surgeon (r = 0.3210). Both the patient’s and the surgeon’s scores correlated poorly with the vascular laboration results. Conclusion: We have identified specific questions which have face, content and criterion-related validity for objectively assessing the impact of IC on QOL. These questions may be used in a clinically practical QOL for patients with IC, Generic QOL instruments do not accurately reflect the surgeon’s assessment of the specific impact of IC on QQL and therefore should be used with caution when planning the management of these patients. Vascular laboratory measurements do not predict the impact of IC on QOI..
6.15 Outcome in Vascular Surgery: how Good is POSSUM? L.D. WIlESlNGHE, J.S. LEEDS, N. PRATER, D.C. BERRIDGE and D.J.A. SCOTT York, UK Introduction: In today’s climate of health care reforms, purchasing is increasingly driven by the analysis of outcomes. Simple comparative audit has its limitations, notably the failure to assess case-mix in vascular practice. POSSUM (Physiological, Operative Scoring System enti Meration) has been used to overcome some of these problems. Aim: To assess the accuracy of POSSUM (P) and Portsmouth modified POSSUM (PMP) in predicting the mortality and morbidity of vascular operations. Patients and methods: Two hundred and fourcy-SIX consecutive operations (83 aortic aneurysms (AA), 56 ruptured; 46 carotid endarterectomies (CE); 63 femoropophreal (FP) and 54 femorodistal (FD) bypasses) were prospectively scored for P and PMP values (median patient age 72 years, IQR 65-71; 168 men). Thirty day mortality and morbidity results were collected. The observed and predicted values were compared by Chi-square analysis. In addition, mortality was analysed according to four subgroups defined by the predicted risk of death (O-20%. 21-.Si)%, 51-X0%, Sl-100%). Overall Obs Mortality P Mortality PMP Mortality Obs Morbidity P Morbidity
14 24” 14 74 65
27 39” 24 85 80
(, 9.; .?.* 36 4’1
y-9 x 5x 5s
13 22 ” 14 66 60
Results: The table below shows the morbidity and mortality (%) with an asterisk (“) indicating significant difference from the observed (Obs) value at the 5% level. P overestimated the likelihood of death in each subgroup of predicted mortality, whereas PMP was inaccurate in only the 51-80% subgroup. Conclusion: POSSUM is a good predictor of morbidity in vascular surgical procedures. The PMP score appears to be a good predictor of mortality and could be used to compare vascular units and present important information to purchasers and providers of health care.
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6.13 Quality of Life Assessmentin Amputees G.1. HICKEN, L. AR0 and EM. AMELZ, Toronto, Ontario, Canada Objective: To study quality of life and its assessment in amputees. Method: Fifty-nine patients underwent major lower limb amputation for irreversible critical ischemia over a 52 month period. Thirty-six of these were successfully contacted and asked to complete a previously validated health-related quality of life questionnaire with five equally weighted dimensions (QL-Index), a single linear scale to rate their own quality of life (QOL), a similar scale to rate the specific impact of the amputation (Amp-Diff). All three scales scored out of 10 with higher scores indicating a favourable response. Results: Twenty-seven (75%) of 36 amputees (15 BKA, seven AKA, five Bilateral) returned the completed questionnaire. There was a significant difference between the mean QL-Index, QOL, and Amp-Diff scores (respectively 7.56/10,5.43/10 and 4.19/10) (P c 0.003) -0.005) with overall quality of life as measured by the QL-Index scoring highest, the impact of amputation on QOL scoring lowest. Amputation type did not appear to influence the quality of life (P > 0.05). Conclusion: When measured with a generic instrument (QLIndex) an amputee’s quality of life appears good. However, this may represent an overestimation because a patient’s own self assessment of quality of life (QOL), and impact of amputation on that life (Amp-Diff) score significantly lower. To accurately assess the impact of disability on quality of life in distinct patient groups a disease specific instrument must be used to avoid underestimation of this impact. Efforts must be made to develop such an instrument.
6.14 Initial Item Selection for a Disease-specificQuality of Life Questionnaire for Intermittent Claudication G.]. HZCKEN, L. ARO, A. LOSSING and EM. AMELI, Toronto, Ontario, Canada Objective: To create an instrument to objectively measure the specific impact of intermittent claudication (IC) on quality of life (QOL) that would help standardize patient assessment, assist with research and improve the relevance of audit. Method: After eight surgeons were consulted, and many QOL instruments reviewed, a questionnaire was compiled to assess the specific impact of IC on QOL. This was used alongside a known generic QOL (MOS SF-36). The surgeons’ opinion of the severity of claudication was sought. The patients’ and surgeons’ answers and SF-36 were scored and correlated. Any questions not understood by patients were noted. The vascular laboratory results were recorded.
CARDIOVASCULAR SURGERY
SEPTEMBER 1997
Disease
Results: There were 36 claudicants interviewed. Fifteen questions from the questionnaire were easily understood and when totaled, had good correlation (r = 0.5468) with the surgeon’s score, and internal consistency of 0.9018 (Cronbaths Alpha). The SF-36 scores correlated poorly with the surgeon (r = 0.3210). Both the patient’s and the surgeon’s scores correlated poorly with the vascular laboration results. Conclusion: We have identified specific questions which have face, content and criterion-related validity for objectively assessing the impact of IC on QOL. These questions may be used in a clinically practical QOL for patients with IC, Generic QOL instruments do not accurately reflect the surgeon’s assessment of the specific impact of IC on QQL and therefore should be used with caution when planning the management of these patients. Vascular laboratory measurements do not predict the impact of IC on QOI..
6.15 Outcome in Vascular Surgery: how Good is POSSUM? L.D. WIlESlNGHE, J.S. LEEDS, N. PRATER, D.C. BERRIDGE and D.J.A. SCOTT York, UK Introduction: In today’s climate of health care reforms, purchasing is increasingly driven by the analysis of outcomes. Simple comparative audit has its limitations, notably the failure to assess case-mix in vascular practice. POSSUM (Physiological, Operative Scoring System enti Meration) has been used to overcome some of these problems. Aim: To assess the accuracy of POSSUM (P) and Portsmouth modified POSSUM (PMP) in predicting the mortality and morbidity of vascular operations. Patients and methods: Two hundred and fourcy-SIX consecutive operations (83 aortic aneurysms (AA), 56 ruptured; 46 carotid endarterectomies (CE); 63 femoropophreal (FP) and 54 femorodistal (FD) bypasses) were prospectively scored for P and PMP values (median patient age 72 years, IQR 65-71; 168 men). Thirty day mortality and morbidity results were collected. The observed and predicted values were compared by Chi-square analysis. In addition, mortality was analysed according to four subgroups defined by the predicted risk of death (O-20%. 21-.Si)%, 51-X0%, Sl-100%). Overall Obs Mortality P Mortality PMP Mortality Obs Morbidity P Morbidity
14 24” 14 74 65
27 39” 24 85 80
(, 9.; .?.* 36 4’1
y-9 x 5x 5s
13 22 ” 14 66 60
Results: The table below shows the morbidity and mortality (%) with an asterisk (“) indicating significant difference from the observed (Obs) value at the 5% level. P overestimated the likelihood of death in each subgroup of predicted mortality, whereas PMP was inaccurate in only the 51-80% subgroup. Conclusion: POSSUM is a good predictor of morbidity in vascular surgical procedures. The PMP score appears to be a good predictor of mortality and could be used to compare vascular units and present important information to purchasers and providers of health care.
33