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Quality of recovery after surgery for cancer treatment
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Rev Esp Anestesiol Reanim. 2018;xxx(xx):xxx---xxx
Revista Española de Anestesiología y Reanimación www.elsevier.es/redar
ORIGINAL ARTICLE
Quality of recovery after surgery for cancer treatment夽 R. Marinho a,∗ , J. Lusquinhos b , B. Carvalho a , J. Azevedo a , A. Santos a , F. Abelha a,b,c a
Department of Anesthesiology, Centro Hospitalar São João, Porto, Portugal Faculty of Medicine, University of Porto, Porto, Portugal c Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal b
Received 6 March 2018; accepted 22 April 2018
KEYWORDS Anesthesia recovery period; Patient satisfaction; Cancer; Questionnaires; Surgery
Abstract Introduction: Assessment of quality of recovery is important as an end-point for outcome research. This study aims to determine the incidence and determinants of poor quality of recovery (PQR) after surgery in patients scheduled for curative neoplastic surgery. Materials and methods: An observational prospective study was performed in consecutive patients undergoing surgery for cancer treatment. The quality of recovery 15 score (QoR-15) was applied on the day before surgery (T0) and 24 h after surgery (T1). PQR was defined for patients with a QoR-15 score lower than the mean QoR-15 score at T1 minus one standard deviation. Preoperative quality of life was assessed with EuroQol-5D. Frailty and disability were defined using Clinical Frailty Scale and World Health Organization Disability Assessment Schedule 2.0. Results: One hundred and thirty-eight patients were enrolled and 31 (15.9%) were identified as having PQR. At T0, patients with PQR presented lower scores on total QoR-15 (p = 0.03) and had more problems on EuroQol-5D in mobility (p = 0.014), self-care (p = 0.027) and usual activities domains (p = 0.019). The difference of QoR-15 score between T1 and T0 was higher in PQR patients (p < 0.001). PQR had more frequently Revised Cardiac Risk Index (RCRI) ≥ 2 (p = 0.012) and were more frequently frail (p = 0.03). PQR patients stayed longer in the hospital (p = 0.034). Conclusion: PQR patients had lower QoR-15 before surgery, poor quality of life, were more frequently frail and had high cardiac risk factors. PQR patients stayed longer in the hospital. © 2018 Sociedad Espa˜ nola de Anestesiolog´ıa, Reanimaci´ on y Terap´ eutica del Dolor. Published by Elsevier Espa˜ na, S.L.U. All rights reserved.
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Please cite this article as: Marinho R, Lusquinhos J, Carvalho B, Azevedo J, Santos A, Abelha F. Calidad de la recuperación después de la cirugía para el tratamiento del cáncer. Rev Esp Anestesiol Reanim. 2018. https://doi.org/10.1016/j.redar.2018.04.008 ∗ Corresponding author. E-mail address: ramiromarinho [email protected] (R. Marinho). 2341-1929/© 2018 Sociedad Espa˜ nola de Anestesiolog´ıa, Reanimaci´ on y Terap´ eutica del Dolor. Published by Elsevier Espa˜ na, S.L.U. All rights reserved.
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PALABRAS CLAVE Periodo de recuperación de la anestesia; Satisfacción del paciente; Cáncer; Cuestionarios; Cirugía
Calidad de la recuperación después de la cirugía para el tratamiento del cáncer Resumen Introducción: Evaluar la calidad de la recuperación es importante como objetivo de la investigación de resultados. El objetivo de este estudio fue determinar la incidencia y los factores determinantes de la mala calidad de la recuperación (MCR) después de la cirugía en pacientes sometidos a cirugías neoplásicas con intención curativa. Materiales y métodos: Estudio observacional prospectivo en pacientes consecutivos sometidos a cirugía para el tratamiento del cáncer. La puntuación Quality of Recovery 15 (QoR-15) se aplicó antes de la cirugía (T0) y 24 h después (T1). La MCR se definió para los pacientes con una puntuación QoR-15 inferior a la media en T1 menos una desviación estándar. La calidad de vida preoperatoria se evaluó con el cuestionario EuroQol-5D y se utilizaron las escalas Clinical Frailty Scale y World Health Organization Disability Assessement Schedule 2.0. Resultados: Se seleccionaron138 pacientes y se identificaron 31 (15,9%) con MCR. En T0, los pacientes con MCR presentaron puntuaciones totales más bajas en QoR-15 (p = 0,03) y más problemas en EuroQol-5D en cuanto a movilidad (p = 0,014), autocuidado (p = 0,027) y actividades cotidianas (p = 0,019). La diferencia de la puntuación QoR-15 entre T1 y T0 fue mayor en los pacientes con MCR (p < 0,001), quienes tenían con más frecuencia un Índice de Riesgo Cardiovascular Revisado (RCRI) ≥ 2 (p = 0,012), reflejaron fragilidad más frecuentemente (p = 0,03) y permanecieron más tiempo internados en el hospital (p = 0,034). Conclusión: Los pacientes con MCR tuvieron puntuaciones de QoR-15 más bajas antes de la cirugía, peor calidad de vida, más fragilidad, tenían más factores de riesgo cardíaco y permanecieron más tiempo internados en el hospital. © 2018 Sociedad Espa˜ nola de Anestesiolog´ıa, Reanimaci´ on y Terap´ eutica del Dolor. Publicado por Elsevier Espa˜ na, S.L.U. Todos los derechos reservados.
Introduction Quality of recovery after surgery is an important marker of the health status of patients.1---4 Traditionally, quality of recovery has been assessed through objective outcomes, such as comorbidity, mortality, physiological changes, length of hospital stay, and re-hospitalization rates. Nowadays, measuring the quality of recovery from the patient’s perspective is becoming more and more important.5,6 The quality of recovery-15 (QoR-15) scale is a 15-item patientcentered questionnaire with 5 dimensions of outcomes such as pain, physical comfort, physical independence, psychological support and emotional state.6 This score can be helpful to provide a patient-centered global assessments of postoperative recovery. QoR-15 is considered to fulfill requirements for outcome measurement instruments in clinical trials,3 and although recovery after surgery and anesthesia is a complex process, Qor-15 proved to be a valid tool for measuring quality of recovery.1 It is expected that patients deviate from their previous state and then recover over time.7 Postoperative recovery is multidimensional and can be defined as the return to, or even improvement over, the previous state. The undeniable importance of measuring patient satisfaction as a measure of quality of care can contribute to a balanced and wellstructured assessment of the configuration, method and outcome of health services.8 In our study, we used the Portuguese form of QoR-15 that was validated in 2013.9 This is a short form of the quality
of recovery-40 (QoR-40). Stark et al. showed that QoR-15 is valid, efficient, easy to administer, and takes less than 3 min to complete.6 With this score, health professionals can both predict patient recovery and also create a subgroup of patients to study poor quality of recovery (PQR). PQR has previously been correlated with variables that are associated with prolonged duration of hospital stay, readmission, post-anesthetic complications, chronic diseases, pain, and poor quality of life.10---14 This study aims to determine the incidence and determinants of PQR after surgery in patients scheduled for curative neoplastic surgery.
Material and methods Subjects and setting The Centro Hospitalar São João Ethics Committee approved this study and written informed consent was obtained from all participants the day before surgery. Centro Hospitalar São João, in Porto, is a 1124-bed tertiary hospital in a metropolitan area. This prospective study was conducted in the hospital’s 13-bed post-anesthesia care unit (PACU) between June and July 2016. We included patients with Portuguese nationality scheduled for neoplastic curative surgery for gynecologic, head and neck, gastrointestinal, urological, breast, and skin cancer. Patients were transferred to the PACU immediately after the intervention.
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Quality of recovery after surgery for cancer treatment Patients unable to provide informed consent, who were admitted to an intensive care unit immediately after surgery, or who were under 18 years of age were excluded.
Data collection Baseline demographic data were collected for descriptive purposes. Patient demographics, such as age, weight, height, body mass index, comorbidities, usual medication, education, American Society of Anesthesiology (ASA) physical status, and medical history, were recorded at T0. The validated Portuguese QoR-15 was used to measure health status before surgery (T0) and 24 h after surgery (T1). QoR-15 consists of 15 questions that assess the patient’s perceived quality of recovery, and each question is scored on an 11-point numeric scale from 0 and 10, with a total score ranging from 0 (poor recovery) to 150 (excellent recovery). All questions refer to the previous 24 h. Using a strategy similar to that outlined by Myles et al.,9,10 we defined PQR as a below-average QoR-15 score at T1 minus 1 standard deviation. Other questionnaires were administered the day before surgery, namely: - EuroQoL 5D (EQ-5D), evaluating Health Related Quality of Life in five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression.15 In the EQ-5D, mobility, daily activities, self-care problems, anxiety, and pain are categorized independently for the presence of problems. - The World Health Organization Disability Assessment Schedule 2.0 (WHODAS) measures disability. The 12-item WHODAS attributes numerical values to each item on a 5-point Likert scale: none = 0; mild = 1; moderate = 2; severe = 3; and extreme = 4. The total score (between 0 and 48) is then divided by 48 and multiplied by 100 to convert it to a percentage of the maximum disability score. We considered a score greater than or equal to 25% to indicate disability, based on the WHODAS and the World Health Organization International Classification of Functioning, Disability and Health.16 - Vulnerability was evaluated using the Clinical Frailty Scale, with frailty being defined as a score of ≥4 on this scale. The Clinical Frailty Scale is a subjective measurement of patient frailty based on their appearance and clinical history.17 - The Revised Cardiac Risk Index (RCRI) was evaluated according to the criteria developed by Lee et al., considering six variables: high-risk surgery, history of ischemic heart disease, history of congestive heart disease, preoperative insulin therapy, preoperative serum creatinine >2.0 mg/dL, and history of cerebrovascular disease.18 Data on type and time of anesthesia, time of surgery, drugs and fluids administrated during the procedures, and monitoring performed were obtained from the anesthesia ® management program PICIS . Prolonged surgery was defined as an intervention lasting more than 180 min. Major surgery was defined as an intervention that required a hospital stay of more than 2 days.
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Statistical methods Descriptive analyses of variables were used to summarize the data. The Mann---Whitney U-test was used to compare continuous variables between two groups, and the Chi-square or Fisher’s exact test was used to compare proportions between two groups. Differences were considered statistically significant when p < 0.05. Analysis was performed on the Statistical Package for Social Sciences (SPSS) version 22.0.
Results In total, 138 patients were enrolled in this study; 15.9% (n = 22) were identified as having PQR after neoplastic surgery and admission to the PACU. Table 1 shows the patient characteristics in terms of the site of surgery. Table 2 shows differences in the presence of PQR. Patients with PQR did not differ in terms of age, body mass index, gender, ASA physical status, type and duration of anesthesia, and length of stay in the PACU. The length of hospital stay was greater in patients with PQR (7 days vs. 8 days; p = 0.034). Patients with PQR had similar rates of comorbidities: coronary disease (10.3% vs. 22.7% p = 0.107), heart failure (7.8% vs. 18.2%; p = 0.130), diabetes mellitus (4.3% vs. 9.1%; p = 0.309), chronic kidney disease (3.4% vs. 13.6%; p = 0.081), cerebrovascular disease (0.9% vs. 0%; p = 0.841), and dyslipidemia (34.5% vs. 40.9; p = 0.781), but more frequently scored ≥2 on the RCRI (p = 0.012). No differences were observed when comparing different types of anesthesia (p = 0.695). PQR patients showed a greater difference between QoR15 score at T1 and QoR-15 score at T0 (45 vs. 11, p < 0.001). Table 3 shows the health status variables and the WHODAS and Frailty scores for patients with PQR. Problems with mobility (p = 0.014), self-care (p = 0.035), and activities of daily living (ADL) (p =0.019) were more frequent in patients with PQR, but rates of anxiety and pain (p = 0.488 and 0.368, respectively) were similar in both groups. PQR patients had similar rates of disability (p = 0.067), but a higher incidence of frailty (p =0.03). At T0, patients with PQR had lower mean overall QoR-15 scores (130 vs. 119, p = 0.03). Table 4 shows the pre-surgery mean QoR-15 scores for each question in patients with and without PQR.
Table 1 Characterization malignancy/surgery.
of
the
site
of
Site of cancer/surgery
Absolute frequency (n = 138)
Gynecologic cancer Cancer of the head and neck Gastrointestinal cancer Urologic cancer Breast cancer Skin cancer
8 10 46 41 31 2
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Patient characteristics and surgery parameters.
Variables Age, mean (IQR) Age in years, n (%) <65 ≥65 Gender, n (%) Male Female ASA physical status, n (%) I/II III/IV Major surgery, n (%) BMI in kg/m2 , mean (IQR) Comorbidities/medication, n (%) Coronary disease Heart failure Diabetes mellitus Chronic renal failure Cerebrovascular disease Benzodiazepine therapy Dyslipidemia RCRI, n (%) <2 ≥2 Type of anesthesia, n (%) General Regional Combined general and regional Analgesia and sedation Duration of anesthesia (min), mean (IQR) Longer surgery, n (%) PACU length of stay (min), mean Hospital length of stay (days), mean QoR mean difference (T0---T1)
Without PQR (n = 116)
With PQR (n = 22)
66 (53---73)
63 (56---77)
56 (48) 60 (52)
13 (59) 9 (41)
48 (41) 68 (59)
12 (55) 10 (45)
p 0.859a 0.352b
0.182b
0.136b 82 34 42 25.6 12 9 5 4 1 22 40
(71) (29) (78) (22.8---29.1) (10) (8) (4) (3) (1) (19) (35)
12 10 14 25.0 5 4 2 3 0 4 9
103 (89) 13 (11)
(55) (45) (22) (23.1---26.7) (23) (18) (9) (14) (0) (15) (41)
0.016b 0.376a 0.107b 0.130c 0.309c 0.081c 0.841c 0.599c 0.781b 0.033b
15 (68) 7 (32) 0.695b
79 (68) 8 (7) 28 (24) 1(1) 150 (120---200) 71(61) 133 (90---212) 7 (2---8) 11
17 (77) 2 (9) 3 (14) 0 (0) 195 (115---243) 12 (55) 168 (108---956) 8 (6---13) 45
0.091a 0.090a 0.154a 0.034a <0.001a
ASA, American Society of Anesthesiologists; BMI, body mass index; PACU, post anesthetic care unit; PQR, poor quality of recovery; QoR, quality of recovery; RCRI, Revised Cardiovascular Risk Index; T0, before surgery; T1, 24 h after surgery; a Mann---Whitney U-test. b Chi-square test. c Fisher-test.
Scores differed between these groups at T0 in respect of four questions: ‘‘Able to communicate with family and friends’’ (p = 0.031). ‘‘Able to return to work or usual home activities’’ (p = 0.014). ‘‘Feeling comfortable and in control’’ (p = 0.025). ‘‘Having a feeling of general well-being’’ (p = 0.01). Patients with PQR had lower mean overall QoR-15 scores at T0. At T1 (Table 5), PQR patients had worse overall QoR-15 scores and worse score for each item, except for question 7 ‘‘Getting support from the hospital, doctors and nurses’’ (p = 0.133).
Discussion The major contributions of this study were the evaluation of the frequency of PQR, and the finding that PQR was more frequent in patients with a higher cardiovascular risk. We
also found that surgery has a greater impact on quality of recovery in PQR patients and that these patients already had a worse quality of life and were more frail. Interestingly, this group showed lower QoR-15 scores before surgery and also a greater mean decrease in the total score between T0 and T1. In their systematic review, Klein et al.3 concluded that the QoR-15, being a patient-reported outcome questionnaire measuring quality of recovery after surgery, fulfills the consensus-based requirements for use as a reliable instrument. In another systematic review, Myles19 recommended measuring patient comfort outcomes in the perioperative period, suggesting that the QoR-15 provides a patientcentered global assessment of a patient’s postoperative recovery. On the basis of this evidence, we used QoR15 to identify patients with PQR, assuming that this tool is able to discriminate patients with worse quality of recovery.
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Quality of recovery after surgery for cancer treatment Table 3
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Health status tests and PQR.
Variables
No PQR (n = 116)
PQR (n = 22)
p
WHODAS, mean (IQR) Disability, n (%) Yes No Frailty, n (%) Yes No EQ-5D, n (%) Mobility Yes No Self-Care Yes No ADL Yes No Anxiety Yes No Pain Yes No
6.3 (4.2---18.8)
12.5 (7.8---33.3)
0.008a 0.067b
22 (19) 94 (81)
8 (36.4) 14 (63.6)
31 (26.7) 85 (73.3)
11 (50) 11 (50)
28 (24.1) 88 (75.9)
11 (50) 11 (50)
0.030b
0.014b
0.035b 15 (12.9) 101 (87.1)
7 (31.8) 15 (68.2) 0.019b
29 (25) 87 (75)
11 (50) 11 (50) 0.488c
91 (78.4) 25 (21.6)
18 (81.8) 4 (18.2)
41 (35.3) 75 (64.7)
10 (45.4) 12 (54.5)
0.368b
ADL, activities of daily living; PQR, poor quality of recovery; WHODAS, World Health Organization Disability Assessment Schedule. a Mann---Whitney U-test. b Chi-square test. c Fisher test.
Table 4
QoR-15 items at T0.
QoR-15 at T1, mean (IQR) Able to breathe easily Been able to enjoy food Feeling rested Have had a good sleep Able to look after personal and hygiene unaided Able to communicate with family and friends Getting support from hospital, doctors and nurses Able to return to work or usual home activities Feeling comfortable and in control Having a feeling of general well-being Moderate pain Severe pain Nausea or vomiting Feeling worried or anxious Feeling sad or depressed Total score (IQR)
Without PQR 10 10 8 7 10 10 10 10 10 9 10 10 10 5 7 130
(10---10) (10---10) (5---10) (5---10) (10---10) (10---10) (10---10) (7---10) (8---10) (6---10) (10---10) (10---10) (10---10) (2---8) (5---10) (69---150)
IQR, interquartile range; PQR, poor quality of recovery; QOR, quality of recovery. a Mann---Whitney U-test.
With PQR 10 10 7 7 10 10 10 7 8 7 10 10 10 5 5 119
(10---10) (10---10) (4---10) (4---10) (9---10) (5---10) (10---10) (2---10) (5---10) (5---9) (5---10) (10---10) (10---10) (1---9) (2---9) (69---150)
Pa 0.693 0.799 0.307 0.753 0.106 0.031 0.053 0.014 0.025 0.010 0.195 0.862 0.819 0.341 0.900 0.030
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Table 5
QoR score per question at T1.
Able to breathe easily Been able to enjoy food Feeling rested Have had a good sleep Able to look after personal and hygiene unaided Able to communicate with family and friends Getting support from hospital, doctors and nurses Able to return to work or usual home activities Feeling comfortable and in control Having a feeling of general well-being Moderate pain Severe pain Nausea or vomiting Feeling worried or anxious Feeling sad or depressed Total score (IQR)
No PQR 10 8 8 7 7 10 10 6 8 8 10 10 10 9 8 119
(9---10) (4---10) (6---10) (3---10) (3---10) (10---10) (9---10) (2---9) (7---10) (6---10) (7---10) (10---10) (7---10) (6---10) (6---10) (43---150)
PQR 9 2 5 5 2 9 10 2 5 5 3 5 5 3 5 78
(7---10) (0---5) (4---6) (3---7) (0---5) (6---10) (9---10) (0---5) (4---8) (4---6) (0---5) (1---10) (1---10) (2---6) (2---7) (43---150)
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QoR-15 at T1, mean (IQR)
<0.001 <0.001 <0.001 0.010 <0.001 <0.001 0.133 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
IQR, interquartile range; PQR, poor quality of recovery; QOR, quality of recovery. a Mann---Whitney U-test.
R. Marinho et al.
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Quality of recovery after surgery for cancer treatment We used the same definition of PQR as previous studies,9,10 and the incidence of PQR was similar that reported in a previous Portuguese study.9 In contrast to other studies, we found no differences in age, gender, body mass index, ASA physical status, or type of anesthesia,9,20,21 and there was no evidence of poorer recovery in patients with comorbidities such as cerebrovascular disease, coronary disease, cardiac failure, dyslipidemia, or chronic kidney disease. Although we found no statistically significant differences regarding these comorbidities, there is a clear tendency toward more comorbidities in PQR patients, so we presume that our limited sample size prevented us from detecting these differences. We found no evidence that the type of anesthesia used impacts the quality of recovery; furthermore, duration of anesthesia was not related to PQR, although patients with PQR had longer hospital stays. In contrast, Lyckner et al.22 found that the QoR-15 correlates well with comorbidity, as well as with the type and duration of surgery. Similar results were reported by Stark et al.6 using the 40-item version of the QoR. The authors found that duration of surgery correlated negatively with length of stay in the post-anesthesia care unit and duration of hospital stay. PQR patients had higher cardiovascular risk factors according to the RCRI. They showed a higher incidence of frailty, but not of disability, despite their higher WHODAS scores. In a study that concluded that PQR can predict poor quality of life, Myles et al.9,10 found that QoR-40 and SF-36 had good internal consistency. This may explain why patients with PQR had worse scores on the EuroQoL. In this study, PQR patients showed a higher incidence of problems with mobility, ADL, and self-care, but levels of anxiety and pain were similar in both groups. Although there is evidence of an association between frailty and adverse postoperative outcomes, such as mortality and complications,19,23 our results show that poor outcomes can be predicted shortly after surgery if PQR is observed. To assess individual recovery, we calculated the difference between QoR-15 score at T0 and T1. Almost all patients had a worse postoperative vs. preoperative score. It was helpful to observe that patients with PQR showed a greater mean decrease in QoR-15 score from T0 to T1. This suggests that surgery had a greater impact on patients with PQR. Total QoR-15 scores at T0 and T1 differed significantly in patients with PQR. The finding of lower values suggests a greater probability of randomly finding a lower score in PQR patients, even in certain comparisons with the same mean score. Moreover, an analysis of scores for each question at T0 showed that there were only four questions with significant differences, namely those related to general well-being, ability to communicate and perform usual activities. Additionally, at T1 we observed lower scores in each question in patients with PQR, except for ‘‘Getting Support from Hospital, Doctors and Nurses’’. This study had several limitations. The QoR-15 questionnaire is a valid, robust evaluation of postoperative recovery6 from the patient’s perspective, and this is its greatest advantage. Nonetheless, although the patient’s perspective is useful when assessing recovery, some aspects of recovery are
7 not included in the QoR-15, such as physiological parameters and cognitive recovery.15 The size of our sample was not previously calculated, and the final size was limited, which may have affected our ability to find significant differences. Cancer surgery includes a wide range of interventions of differing magnitude and severity, so our sample was necessarily heterogeneous.
Conclusions Patients with PQR had lower QoR-15 scores before surgery and poorer self-assessed quality of life. These patients presented more problems on the EQ-5D, a higher incidence of frailty, higher WHODAS scores, greater cardiac risk factors, and longer hospital stays. PQR patients had a greater mean decrease in overall QoR15 scores when comparing preoperative and postoperative scores. The QoR-15 can be used preoperatively to identify patients with PQR so that earlier and more effective support strategies can be implemented to improve postoperative recovery.
Conflicts of interest The authors have no conflicts of interest to declare.
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18. Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100:1043---9. 19. Daniel Guerron A, Portenier DD. Patient selection and surgical management of high-risk patients with morbid obesity. Surg Clin North Am. 2016;96:743---62. 20. Kleif J, Vilandt J, Gogenur I. Recovery and convalescence after laparoscopic surgery for appendicitis: a longitudinal cohort study. J Surg Res. 2016;205:407---18. 21. Lyckner S, Boregard IL, Zetterlund EL, Chew MS. Validation of the Swedish version of Quality of Recovery score-15: a multicentre, cohort study. Acta Anaesthesiol Scand. 2018;62:893---902. 22. Abelha F, Castro M, Landeiro N, Neves M, Santos C. Quality of life and independence in activities of daily living after discharge from a surgical ICU. Crit Care Med. 2005;33: A88. 23. Tan KY, Kawamura YJ, Tokomitsu A, Tang T. Assessment for frailty is useful for predicting morbidity in elderly patients undergoing colorectal cancer resection whose comorbidities are already optimized. Am J Surg. 2012;204: 139---43.
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Rev Esp Anestesiol Reanim. 2018;xxx(xx):xxx---xxx
Revista Española de Anestesiología y Reanimación www.elsevier.es/redar
ORIGINAL ARTICLE
Quality of recovery after surgery for cancer treatment夽 R. Marinho a,∗ , J. Lusquinhos b , B. Carvalho a , J. Azevedo a , A. Santos a , F. Abelha a,b,c a
Department of Anesthesiology, Centro Hospitalar São João, Porto, Portugal Faculty of Medicine, University of Porto, Porto, Portugal c Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal b
Received 6 March 2018; accepted 22 April 2018
KEYWORDS Anesthesia recovery period; Patient satisfaction; Cancer; Questionnaires; Surgery
Abstract Introduction: Assessment of quality of recovery is important as an end-point for outcome research. This study aims to determine the incidence and determinants of poor quality of recovery (PQR) after surgery in patients scheduled for curative neoplastic surgery. Materials and methods: An observational prospective study was performed in consecutive patients undergoing surgery for cancer treatment. The quality of recovery 15 score (QoR-15) was applied on the day before surgery (T0) and 24 h after surgery (T1). PQR was defined for patients with a QoR-15 score lower than the mean QoR-15 score at T1 minus one standard deviation. Preoperative quality of life was assessed with EuroQol-5D. Frailty and disability were defined using Clinical Frailty Scale and World Health Organization Disability Assessment Schedule 2.0. Results: One hundred and thirty-eight patients were enrolled and 31 (15.9%) were identified as having PQR. At T0, patients with PQR presented lower scores on total QoR-15 (p = 0.03) and had more problems on EuroQol-5D in mobility (p = 0.014), self-care (p = 0.027) and usual activities domains (p = 0.019). The difference of QoR-15 score between T1 and T0 was higher in PQR patients (p < 0.001). PQR had more frequently Revised Cardiac Risk Index (RCRI) ≥ 2 (p = 0.012) and were more frequently frail (p = 0.03). PQR patients stayed longer in the hospital (p = 0.034). Conclusion: PQR patients had lower QoR-15 before surgery, poor quality of life, were more frequently frail and had high cardiac risk factors. PQR patients stayed longer in the hospital. © 2018 Sociedad Espa˜ nola de Anestesiolog´ıa, Reanimaci´ on y Terap´ eutica del Dolor. Published by Elsevier Espa˜ na, S.L.U. All rights reserved.
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Please cite this article as: Marinho R, Lusquinhos J, Carvalho B, Azevedo J, Santos A, Abelha F. Calidad de la recuperación después de la cirugía para el tratamiento del cáncer. Rev Esp Anestesiol Reanim. 2018. https://doi.org/10.1016/j.redar.2018.04.008 ∗ Corresponding author. E-mail address: ramiromarinho [email protected] (R. Marinho). 2341-1929/© 2018 Sociedad Espa˜ nola de Anestesiolog´ıa, Reanimaci´ on y Terap´ eutica del Dolor. Published by Elsevier Espa˜ na, S.L.U. All rights reserved.
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PALABRAS CLAVE Periodo de recuperación de la anestesia; Satisfacción del paciente; Cáncer; Cuestionarios; Cirugía
Calidad de la recuperación después de la cirugía para el tratamiento del cáncer Resumen Introducción: Evaluar la calidad de la recuperación es importante como objetivo de la investigación de resultados. El objetivo de este estudio fue determinar la incidencia y los factores determinantes de la mala calidad de la recuperación (MCR) después de la cirugía en pacientes sometidos a cirugías neoplásicas con intención curativa. Materiales y métodos: Estudio observacional prospectivo en pacientes consecutivos sometidos a cirugía para el tratamiento del cáncer. La puntuación Quality of Recovery 15 (QoR-15) se aplicó antes de la cirugía (T0) y 24 h después (T1). La MCR se definió para los pacientes con una puntuación QoR-15 inferior a la media en T1 menos una desviación estándar. La calidad de vida preoperatoria se evaluó con el cuestionario EuroQol-5D y se utilizaron las escalas Clinical Frailty Scale y World Health Organization Disability Assessement Schedule 2.0. Resultados: Se seleccionaron138 pacientes y se identificaron 31 (15,9%) con MCR. En T0, los pacientes con MCR presentaron puntuaciones totales más bajas en QoR-15 (p = 0,03) y más problemas en EuroQol-5D en cuanto a movilidad (p = 0,014), autocuidado (p = 0,027) y actividades cotidianas (p = 0,019). La diferencia de la puntuación QoR-15 entre T1 y T0 fue mayor en los pacientes con MCR (p < 0,001), quienes tenían con más frecuencia un Índice de Riesgo Cardiovascular Revisado (RCRI) ≥ 2 (p = 0,012), reflejaron fragilidad más frecuentemente (p = 0,03) y permanecieron más tiempo internados en el hospital (p = 0,034). Conclusión: Los pacientes con MCR tuvieron puntuaciones de QoR-15 más bajas antes de la cirugía, peor calidad de vida, más fragilidad, tenían más factores de riesgo cardíaco y permanecieron más tiempo internados en el hospital. © 2018 Sociedad Espa˜ nola de Anestesiolog´ıa, Reanimaci´ on y Terap´ eutica del Dolor. Publicado por Elsevier Espa˜ na, S.L.U. Todos los derechos reservados.
Introduction Quality of recovery after surgery is an important marker of the health status of patients.1---4 Traditionally, quality of recovery has been assessed through objective outcomes, such as comorbidity, mortality, physiological changes, length of hospital stay, and re-hospitalization rates. Nowadays, measuring the quality of recovery from the patient’s perspective is becoming more and more important.5,6 The quality of recovery-15 (QoR-15) scale is a 15-item patientcentered questionnaire with 5 dimensions of outcomes such as pain, physical comfort, physical independence, psychological support and emotional state.6 This score can be helpful to provide a patient-centered global assessments of postoperative recovery. QoR-15 is considered to fulfill requirements for outcome measurement instruments in clinical trials,3 and although recovery after surgery and anesthesia is a complex process, Qor-15 proved to be a valid tool for measuring quality of recovery.1 It is expected that patients deviate from their previous state and then recover over time.7 Postoperative recovery is multidimensional and can be defined as the return to, or even improvement over, the previous state. The undeniable importance of measuring patient satisfaction as a measure of quality of care can contribute to a balanced and wellstructured assessment of the configuration, method and outcome of health services.8 In our study, we used the Portuguese form of QoR-15 that was validated in 2013.9 This is a short form of the quality
of recovery-40 (QoR-40). Stark et al. showed that QoR-15 is valid, efficient, easy to administer, and takes less than 3 min to complete.6 With this score, health professionals can both predict patient recovery and also create a subgroup of patients to study poor quality of recovery (PQR). PQR has previously been correlated with variables that are associated with prolonged duration of hospital stay, readmission, post-anesthetic complications, chronic diseases, pain, and poor quality of life.10---14 This study aims to determine the incidence and determinants of PQR after surgery in patients scheduled for curative neoplastic surgery.
Material and methods Subjects and setting The Centro Hospitalar São João Ethics Committee approved this study and written informed consent was obtained from all participants the day before surgery. Centro Hospitalar São João, in Porto, is a 1124-bed tertiary hospital in a metropolitan area. This prospective study was conducted in the hospital’s 13-bed post-anesthesia care unit (PACU) between June and July 2016. We included patients with Portuguese nationality scheduled for neoplastic curative surgery for gynecologic, head and neck, gastrointestinal, urological, breast, and skin cancer. Patients were transferred to the PACU immediately after the intervention.
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Quality of recovery after surgery for cancer treatment Patients unable to provide informed consent, who were admitted to an intensive care unit immediately after surgery, or who were under 18 years of age were excluded.
Data collection Baseline demographic data were collected for descriptive purposes. Patient demographics, such as age, weight, height, body mass index, comorbidities, usual medication, education, American Society of Anesthesiology (ASA) physical status, and medical history, were recorded at T0. The validated Portuguese QoR-15 was used to measure health status before surgery (T0) and 24 h after surgery (T1). QoR-15 consists of 15 questions that assess the patient’s perceived quality of recovery, and each question is scored on an 11-point numeric scale from 0 and 10, with a total score ranging from 0 (poor recovery) to 150 (excellent recovery). All questions refer to the previous 24 h. Using a strategy similar to that outlined by Myles et al.,9,10 we defined PQR as a below-average QoR-15 score at T1 minus 1 standard deviation. Other questionnaires were administered the day before surgery, namely: - EuroQoL 5D (EQ-5D), evaluating Health Related Quality of Life in five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression.15 In the EQ-5D, mobility, daily activities, self-care problems, anxiety, and pain are categorized independently for the presence of problems. - The World Health Organization Disability Assessment Schedule 2.0 (WHODAS) measures disability. The 12-item WHODAS attributes numerical values to each item on a 5-point Likert scale: none = 0; mild = 1; moderate = 2; severe = 3; and extreme = 4. The total score (between 0 and 48) is then divided by 48 and multiplied by 100 to convert it to a percentage of the maximum disability score. We considered a score greater than or equal to 25% to indicate disability, based on the WHODAS and the World Health Organization International Classification of Functioning, Disability and Health.16 - Vulnerability was evaluated using the Clinical Frailty Scale, with frailty being defined as a score of ≥4 on this scale. The Clinical Frailty Scale is a subjective measurement of patient frailty based on their appearance and clinical history.17 - The Revised Cardiac Risk Index (RCRI) was evaluated according to the criteria developed by Lee et al., considering six variables: high-risk surgery, history of ischemic heart disease, history of congestive heart disease, preoperative insulin therapy, preoperative serum creatinine >2.0 mg/dL, and history of cerebrovascular disease.18 Data on type and time of anesthesia, time of surgery, drugs and fluids administrated during the procedures, and monitoring performed were obtained from the anesthesia ® management program PICIS . Prolonged surgery was defined as an intervention lasting more than 180 min. Major surgery was defined as an intervention that required a hospital stay of more than 2 days.
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Statistical methods Descriptive analyses of variables were used to summarize the data. The Mann---Whitney U-test was used to compare continuous variables between two groups, and the Chi-square or Fisher’s exact test was used to compare proportions between two groups. Differences were considered statistically significant when p < 0.05. Analysis was performed on the Statistical Package for Social Sciences (SPSS) version 22.0.
Results In total, 138 patients were enrolled in this study; 15.9% (n = 22) were identified as having PQR after neoplastic surgery and admission to the PACU. Table 1 shows the patient characteristics in terms of the site of surgery. Table 2 shows differences in the presence of PQR. Patients with PQR did not differ in terms of age, body mass index, gender, ASA physical status, type and duration of anesthesia, and length of stay in the PACU. The length of hospital stay was greater in patients with PQR (7 days vs. 8 days; p = 0.034). Patients with PQR had similar rates of comorbidities: coronary disease (10.3% vs. 22.7% p = 0.107), heart failure (7.8% vs. 18.2%; p = 0.130), diabetes mellitus (4.3% vs. 9.1%; p = 0.309), chronic kidney disease (3.4% vs. 13.6%; p = 0.081), cerebrovascular disease (0.9% vs. 0%; p = 0.841), and dyslipidemia (34.5% vs. 40.9; p = 0.781), but more frequently scored ≥2 on the RCRI (p = 0.012). No differences were observed when comparing different types of anesthesia (p = 0.695). PQR patients showed a greater difference between QoR15 score at T1 and QoR-15 score at T0 (45 vs. 11, p < 0.001). Table 3 shows the health status variables and the WHODAS and Frailty scores for patients with PQR. Problems with mobility (p = 0.014), self-care (p = 0.035), and activities of daily living (ADL) (p =0.019) were more frequent in patients with PQR, but rates of anxiety and pain (p = 0.488 and 0.368, respectively) were similar in both groups. PQR patients had similar rates of disability (p = 0.067), but a higher incidence of frailty (p =0.03). At T0, patients with PQR had lower mean overall QoR-15 scores (130 vs. 119, p = 0.03). Table 4 shows the pre-surgery mean QoR-15 scores for each question in patients with and without PQR.
Table 1 Characterization malignancy/surgery.
of
the
site
of
Site of cancer/surgery
Absolute frequency (n = 138)
Gynecologic cancer Cancer of the head and neck Gastrointestinal cancer Urologic cancer Breast cancer Skin cancer
8 10 46 41 31 2
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Patient characteristics and surgery parameters.
Variables Age, mean (IQR) Age in years, n (%) <65 ≥65 Gender, n (%) Male Female ASA physical status, n (%) I/II III/IV Major surgery, n (%) BMI in kg/m2 , mean (IQR) Comorbidities/medication, n (%) Coronary disease Heart failure Diabetes mellitus Chronic renal failure Cerebrovascular disease Benzodiazepine therapy Dyslipidemia RCRI, n (%) <2 ≥2 Type of anesthesia, n (%) General Regional Combined general and regional Analgesia and sedation Duration of anesthesia (min), mean (IQR) Longer surgery, n (%) PACU length of stay (min), mean Hospital length of stay (days), mean QoR mean difference (T0---T1)
Without PQR (n = 116)
With PQR (n = 22)
66 (53---73)
63 (56---77)
56 (48) 60 (52)
13 (59) 9 (41)
48 (41) 68 (59)
12 (55) 10 (45)
p 0.859a 0.352b
0.182b
0.136b 82 34 42 25.6 12 9 5 4 1 22 40
(71) (29) (78) (22.8---29.1) (10) (8) (4) (3) (1) (19) (35)
12 10 14 25.0 5 4 2 3 0 4 9
103 (89) 13 (11)
(55) (45) (22) (23.1---26.7) (23) (18) (9) (14) (0) (15) (41)
0.016b 0.376a 0.107b 0.130c 0.309c 0.081c 0.841c 0.599c 0.781b 0.033b
15 (68) 7 (32) 0.695b
79 (68) 8 (7) 28 (24) 1(1) 150 (120---200) 71(61) 133 (90---212) 7 (2---8) 11
17 (77) 2 (9) 3 (14) 0 (0) 195 (115---243) 12 (55) 168 (108---956) 8 (6---13) 45
0.091a 0.090a 0.154a 0.034a <0.001a
ASA, American Society of Anesthesiologists; BMI, body mass index; PACU, post anesthetic care unit; PQR, poor quality of recovery; QoR, quality of recovery; RCRI, Revised Cardiovascular Risk Index; T0, before surgery; T1, 24 h after surgery; a Mann---Whitney U-test. b Chi-square test. c Fisher-test.
Scores differed between these groups at T0 in respect of four questions: ‘‘Able to communicate with family and friends’’ (p = 0.031). ‘‘Able to return to work or usual home activities’’ (p = 0.014). ‘‘Feeling comfortable and in control’’ (p = 0.025). ‘‘Having a feeling of general well-being’’ (p = 0.01). Patients with PQR had lower mean overall QoR-15 scores at T0. At T1 (Table 5), PQR patients had worse overall QoR-15 scores and worse score for each item, except for question 7 ‘‘Getting support from the hospital, doctors and nurses’’ (p = 0.133).
Discussion The major contributions of this study were the evaluation of the frequency of PQR, and the finding that PQR was more frequent in patients with a higher cardiovascular risk. We
also found that surgery has a greater impact on quality of recovery in PQR patients and that these patients already had a worse quality of life and were more frail. Interestingly, this group showed lower QoR-15 scores before surgery and also a greater mean decrease in the total score between T0 and T1. In their systematic review, Klein et al.3 concluded that the QoR-15, being a patient-reported outcome questionnaire measuring quality of recovery after surgery, fulfills the consensus-based requirements for use as a reliable instrument. In another systematic review, Myles19 recommended measuring patient comfort outcomes in the perioperative period, suggesting that the QoR-15 provides a patientcentered global assessment of a patient’s postoperative recovery. On the basis of this evidence, we used QoR15 to identify patients with PQR, assuming that this tool is able to discriminate patients with worse quality of recovery.
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Quality of recovery after surgery for cancer treatment Table 3
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Health status tests and PQR.
Variables
No PQR (n = 116)
PQR (n = 22)
p
WHODAS, mean (IQR) Disability, n (%) Yes No Frailty, n (%) Yes No EQ-5D, n (%) Mobility Yes No Self-Care Yes No ADL Yes No Anxiety Yes No Pain Yes No
6.3 (4.2---18.8)
12.5 (7.8---33.3)
0.008a 0.067b
22 (19) 94 (81)
8 (36.4) 14 (63.6)
31 (26.7) 85 (73.3)
11 (50) 11 (50)
28 (24.1) 88 (75.9)
11 (50) 11 (50)
0.030b
0.014b
0.035b 15 (12.9) 101 (87.1)
7 (31.8) 15 (68.2) 0.019b
29 (25) 87 (75)
11 (50) 11 (50) 0.488c
91 (78.4) 25 (21.6)
18 (81.8) 4 (18.2)
41 (35.3) 75 (64.7)
10 (45.4) 12 (54.5)
0.368b
ADL, activities of daily living; PQR, poor quality of recovery; WHODAS, World Health Organization Disability Assessment Schedule. a Mann---Whitney U-test. b Chi-square test. c Fisher test.
Table 4
QoR-15 items at T0.
QoR-15 at T1, mean (IQR) Able to breathe easily Been able to enjoy food Feeling rested Have had a good sleep Able to look after personal and hygiene unaided Able to communicate with family and friends Getting support from hospital, doctors and nurses Able to return to work or usual home activities Feeling comfortable and in control Having a feeling of general well-being Moderate pain Severe pain Nausea or vomiting Feeling worried or anxious Feeling sad or depressed Total score (IQR)
Without PQR 10 10 8 7 10 10 10 10 10 9 10 10 10 5 7 130
(10---10) (10---10) (5---10) (5---10) (10---10) (10---10) (10---10) (7---10) (8---10) (6---10) (10---10) (10---10) (10---10) (2---8) (5---10) (69---150)
IQR, interquartile range; PQR, poor quality of recovery; QOR, quality of recovery. a Mann---Whitney U-test.
With PQR 10 10 7 7 10 10 10 7 8 7 10 10 10 5 5 119
(10---10) (10---10) (4---10) (4---10) (9---10) (5---10) (10---10) (2---10) (5---10) (5---9) (5---10) (10---10) (10---10) (1---9) (2---9) (69---150)
Pa 0.693 0.799 0.307 0.753 0.106 0.031 0.053 0.014 0.025 0.010 0.195 0.862 0.819 0.341 0.900 0.030
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Table 5
QoR score per question at T1.
Able to breathe easily Been able to enjoy food Feeling rested Have had a good sleep Able to look after personal and hygiene unaided Able to communicate with family and friends Getting support from hospital, doctors and nurses Able to return to work or usual home activities Feeling comfortable and in control Having a feeling of general well-being Moderate pain Severe pain Nausea or vomiting Feeling worried or anxious Feeling sad or depressed Total score (IQR)
No PQR 10 8 8 7 7 10 10 6 8 8 10 10 10 9 8 119
(9---10) (4---10) (6---10) (3---10) (3---10) (10---10) (9---10) (2---9) (7---10) (6---10) (7---10) (10---10) (7---10) (6---10) (6---10) (43---150)
PQR 9 2 5 5 2 9 10 2 5 5 3 5 5 3 5 78
(7---10) (0---5) (4---6) (3---7) (0---5) (6---10) (9---10) (0---5) (4---8) (4---6) (0---5) (1---10) (1---10) (2---6) (2---7) (43---150)
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QoR-15 at T1, mean (IQR)
<0.001 <0.001 <0.001 0.010 <0.001 <0.001 0.133 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
IQR, interquartile range; PQR, poor quality of recovery; QOR, quality of recovery. a Mann---Whitney U-test.
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Quality of recovery after surgery for cancer treatment We used the same definition of PQR as previous studies,9,10 and the incidence of PQR was similar that reported in a previous Portuguese study.9 In contrast to other studies, we found no differences in age, gender, body mass index, ASA physical status, or type of anesthesia,9,20,21 and there was no evidence of poorer recovery in patients with comorbidities such as cerebrovascular disease, coronary disease, cardiac failure, dyslipidemia, or chronic kidney disease. Although we found no statistically significant differences regarding these comorbidities, there is a clear tendency toward more comorbidities in PQR patients, so we presume that our limited sample size prevented us from detecting these differences. We found no evidence that the type of anesthesia used impacts the quality of recovery; furthermore, duration of anesthesia was not related to PQR, although patients with PQR had longer hospital stays. In contrast, Lyckner et al.22 found that the QoR-15 correlates well with comorbidity, as well as with the type and duration of surgery. Similar results were reported by Stark et al.6 using the 40-item version of the QoR. The authors found that duration of surgery correlated negatively with length of stay in the post-anesthesia care unit and duration of hospital stay. PQR patients had higher cardiovascular risk factors according to the RCRI. They showed a higher incidence of frailty, but not of disability, despite their higher WHODAS scores. In a study that concluded that PQR can predict poor quality of life, Myles et al.9,10 found that QoR-40 and SF-36 had good internal consistency. This may explain why patients with PQR had worse scores on the EuroQoL. In this study, PQR patients showed a higher incidence of problems with mobility, ADL, and self-care, but levels of anxiety and pain were similar in both groups. Although there is evidence of an association between frailty and adverse postoperative outcomes, such as mortality and complications,19,23 our results show that poor outcomes can be predicted shortly after surgery if PQR is observed. To assess individual recovery, we calculated the difference between QoR-15 score at T0 and T1. Almost all patients had a worse postoperative vs. preoperative score. It was helpful to observe that patients with PQR showed a greater mean decrease in QoR-15 score from T0 to T1. This suggests that surgery had a greater impact on patients with PQR. Total QoR-15 scores at T0 and T1 differed significantly in patients with PQR. The finding of lower values suggests a greater probability of randomly finding a lower score in PQR patients, even in certain comparisons with the same mean score. Moreover, an analysis of scores for each question at T0 showed that there were only four questions with significant differences, namely those related to general well-being, ability to communicate and perform usual activities. Additionally, at T1 we observed lower scores in each question in patients with PQR, except for ‘‘Getting Support from Hospital, Doctors and Nurses’’. This study had several limitations. The QoR-15 questionnaire is a valid, robust evaluation of postoperative recovery6 from the patient’s perspective, and this is its greatest advantage. Nonetheless, although the patient’s perspective is useful when assessing recovery, some aspects of recovery are
7 not included in the QoR-15, such as physiological parameters and cognitive recovery.15 The size of our sample was not previously calculated, and the final size was limited, which may have affected our ability to find significant differences. Cancer surgery includes a wide range of interventions of differing magnitude and severity, so our sample was necessarily heterogeneous.
Conclusions Patients with PQR had lower QoR-15 scores before surgery and poorer self-assessed quality of life. These patients presented more problems on the EQ-5D, a higher incidence of frailty, higher WHODAS scores, greater cardiac risk factors, and longer hospital stays. PQR patients had a greater mean decrease in overall QoR15 scores when comparing preoperative and postoperative scores. The QoR-15 can be used preoperatively to identify patients with PQR so that earlier and more effective support strategies can be implemented to improve postoperative recovery.
Conflicts of interest The authors have no conflicts of interest to declare.
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