REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologia www.sba.com.brSCIENTIFIC
ARTICLE
Quality
of
recovery
after
anaesthesia
measured
with
QoR-40:
a
prospective
observational
study
Luís
Guimarães-Pereira
a,b,∗,
Maria
Costa
b,
Gabriela
Sousa
a,
Fernando
Abelha
a,baAnaesthesiologyDepartment,CentroHospitalarSãoJoão,Porto,Portugal bFaculdadedeMedicina,UniversidadedoPorto,Portugal
Received30June2014;accepted11November2014 Availableonline20October2015
KEYWORDS
Anaesthesia; Qualityofrecovery; Qualityoflife; QoR-40
Abstract
Background: QoR-40,a40-itemquestionnaireonqualityofrecoveryfromanaesthesia,hasbeen showntomeasurehealthstatusaftersurgery.Ouraimwastoevaluatetheincidenceofpoor qualityofrecoveryinourPostAnaesthesiaCareUnitandtocomparetheirQoR-40scoresbefore surgeryand3monthslater.
Methods:A prospective observational study was conducted in adult patients consecutively admittedfrom18Juneto12July2012.Thefollow-upperiodwas3months.Weexcludepatients submitted to cardiacsurgery, neurosurgery,obstetric surgeryand witha mini-mental state examinationtestscorelowerthan25.Theprimaryendpointwasqualityofrecoverymeasured withthevalidatedPortugueseforPortugalversionoftheQoR-40beforesurgery(T0),24hafter surgery(T1)and3monthsafter(T2).
Results:Atotalof114patientscompletedthestudy.MeanQoR-40scorewas169andpatients withpoorqualityofrecoverywereidentifiediftheirQoR-40scorewaslesserthan142.This occurredin26patients(24%).Globalmedianscoresforpatientswithpoorqualityofrecovery wereloweratT0(121vs.184,p<0.001),atT1(120vs.177,p<0.001)andatT2(119vs.189,
p<0.001).
Conclusion: Patientswithpoorqualityofrecoveryhadlowerqualityoflife.Thisfactmayallow earlierandmoreeffectiveinterventions,inordertoimprovequalityoflifeaftersurgery.Beside itsutilityaftersurgery,QoR-40maybeimportantpriortosurgerytoidentifypatientswhowill developapoorqualityofrecovery.
©2015SociedadeBrasileiradeAnestesiologia.Publishedby ElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense (http://creativecommons.org/licenses/by-nc-nd/4.0/).
∗Correspondingauthor.
E-mail:luis.alberto.p@hotmail.com(L.Guimarães-Pereira).
http://dx.doi.org/10.1016/j.bjane.2014.11.010
PALAVRAS-CHAVE
Anestesia; Qualidadede recuperac¸ão; Qualidadedevida; QoR-40
Qualidadedarecuperac¸ãopós-anestesiamedidacomQoR-40:umestudo observacionalprospectivo
Resumo
Justificativa:QoR-40, um questionáriocom 40 itenssobre aqualidade de recuperac¸ão da anestesia,mostrou medir oestadodesaúde apósacirurgia. Onossoobjetivo foiavaliara incidência demá qualidadeda recuperac¸ão em nossaSala de Recuperac¸ão Pós-anestesiae compararosescoresdoQoR-40antesetrêsmesesdepoisdacirurgia.
Métodos: Estudoobservacionalprospectivo,realizadocompacientesadultosadmitidos consec-utivamentede18dejunhoa12dejulhode2012.Operíododeacompanhamentofoidetrês meses.Excluímosospacientessubmetidosàcirurgiacardíaca,neurocirurgia,cirurgiaobstétrica eaquelescomescoreinferiora25nominiexamedoestadomental.Odesfechoprimáriofoia qualidadedarecuperac¸ãomedidacomaversãodoQoR-40,validadaparaaversãodoportuguês dePortugal,antesdacirurgia(T0),24horasapósacirurgia(T1)etrêsmesesapósacirurgia (T2).
Resultados: Nototal,114pacientescompletaramoestudo.AmediadosescoresnoQoR-40foi de169,eospacientescommáqualidadederecuperac¸ãoforamidentificadosseosseusescores noQoR-40fossemmenoresque142.Issoocorreuem26pacientes(24%).Asmédiasdosescores globaisdospacientescommáqualidadederecuperac¸ãoforammenoresemT0(121vs.184,
p<0,001),T1(120vs.177,p<0,001)eT2(119vs.189,p<0,001).
Conclusão:Os pacientes com má qualidade de recuperac¸ão apresentaram uma pior quali-dadedevida. Essefatopodepermitirintervenc¸õesprecoces emaiseficazes paramelhorar aqualidadedevidaapósacirurgia.Alémdesuautilidadeapósacirurgia,oQoR-40podeser importanteantesdacirurgiaparaidentificarospacientesquedesenvolverãoumamáqualidade derecuperac¸ão.
©2015SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigoOpen Accesssobumalicenc¸aCCBY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Postoperativerecoveryisakeyoutcomeintheperspective ofanaesthesiologists.Itisdefinedasthepatientsreturnto thenormalstateafterasurgery,andhastraditionallybeen referredintermsofpainscores,durationofhospitalstay, andreturntonormalactivities.1Itinvolvesseveralfactors suchasregainofphysical,physiologicandsocialfunctions. Therefore,it is fundamental for the evaluation of health careandpatientsatisfactionaftersurgery.2
Regarding outcomes,inthe past whatconcernedmore the health professionals were the mortality and compli-cationrates. Sincethese parametershaveimproved, asa resultofsurgicaltechniquesenhancement,patient’s Qual-ityofLife(QoL)isnowmorethaneveracentralaspect.1,3,4 Satisfactionremains the best way to assess the outcome fromthepointofviewofthepatient.5Patientsatisfaction wasillustrated asthemost clinically relevant measureof outcome6andalsobecameafundamentalstepinprocesses ofhospitalaccreditation.7Therefore,itisvitaltoestimate patients’QualityofRecovery(QoR)fromtheirperspective, whichmightberelatedtoperceptionoftheirownQoL.
QoLisdefinedbythe WorldHealthOrganization asthe individualperception ofone’s position inlife, in the con-textof hisculture,objectives,expectations andworries.8 The complexity and subjectivity of this concept makes it difficult to evaluate and even more difficult to measure appropriately.9 Sothe question arises: howcanwe define andassesschangesintheQoLaftersurgery?
Avalid and reliable measure of QoR after anaesthesia andsurgery,theQoR-40,wasdevelopedbyMylesetal.10 It hasshownsuperiorcontentvalidityandconstructvalidity, when compared toother pre-existingquestionnaires, and didnotrevealanynegativeratings1Thisquestionnairewas specifically designed tomeasure a patient’s health status aftersurgeryandanaesthesiaandhasbeen proposedasa measure ofoutcome in clinical trials.10 Recently,a meta-analysis of seventeen studies with a sample size of 3459 patients concludedthat QoR-40 iswell suited tomeasure quality of postoperative recovery.11 A significant correla-tionbetweenQoR-40scoresandtheSF-36questionnairehas beendemonstrated.12---14 ApoorscoreonQoR-40was asso-ciated with a poor score on the SF-36. This supports the beliefthataPoorQualityofRecovery(PQR)canpredict a poorQoLaftersurgery.12Hence,QoR-40mightbeusedasa predictiveindextoidentifypatientswhosehealthstatusis abouttochange.
IfitwaspossibletoforeseeaPQR,moreeffectivesupport strategiescouldbeproposedforthesepatientsduringtheir hospitalstay.12 Furthermore,aPQR wasassociatedwitha prolongeddurationofstayinthehospital,readmissionand post-operative complications, indicating not only patient discomfortbutalsoconsumptionofeconomicresources.14
Methods
ThestudywasconductedintheinthePACUofCentro Hos-pitalarSãoJoão(CHSJ),inPorto,Portugal.Ethicalapproval (Ethical n◦ 127/2012) was providedon April 25, 2013, by the Ethical committee ofCHSJ (Comissão deÉtica para a SaúdedoHospitaldeSãoJoão---ChairpersonProfessorFilipe Almeida)andwritteninformedconsentwasobtainedfrom allpatients.
CHSJ is a tertiary hospital with 1124 beds in a major metropolitanareathatserves3,000,000people.A prospec-tivestudywasconductedinthe12-bedPACUovera4week periodfrom18Juneto12July2012.
Duringthisperiodoftime,everypatientadmittedtothe PACU,whowasabletoprovidewritteninformedconsentin advance,wasincludedinthestudy.Exclusioncriteriawere patientrefusal,inabilitytoprovideinformedconsent,age under18years,foreignlanguage,andknownneuromuscular disease.Ascoreunder25intheMini-MentalState Examina-tiontest(MMSE)determinesinabilityforprovidinginformed consent.Urgentoremergentsurgery,cardiacsurgery, neuro-surgeryandobstetricsurgerywerealsoexcludedforlogistic reasons,asthesepatientsgotootherpostoperativeunits.
Baselinedemographicdatawerecollectedfordescriptive purposes.
The validated QoR-40 Portuguese version was used to measurehealthstatusbeforesurgery(T0),24haftersurgery (T1)and3monthsaftersurgery(T2).QoR-40wasappliedby personalinterviewatT0andT1,andbytelephoneinterview atT2.
QoR-40 containsfivesub-scales: PhysicalComfort(PC), Emotional State (ES), Patient Support(PS), Physical Inde-pendence(PI),andPain(P). Eachitemisratedonascale of1---5,providingaminimumscoreof40andmaximumof 200.12
For each dimension of the QoR-40, impairment was defined if an individual score wasless than one standard deviationbelowthegroupmean.PQRwasdefinedby impair-mentintwoormoredimensions,orimpairmentoftheglobal QoR-40.12
The anaesthesiologist in charge wasblinded topatient involvement in the study. Anaesthesia was provided and monitoredaccordingtothecriteriaoftheanaesthesiologist incharge,butthisconductfollowedminimumdepartmental standards.Usually,thepatientwasextubated inthe oper-atingroomandtransferredtothePACU.
Therecordedpatients’characteristicswereage,gender, weight,height,bodymassindex,benzodiazepines adminis-trationbeforesurgery,chronicbenzodiazepinesuse,siteof surgery(intra-abdominal,musculoskeletal,headandneck), ASA physical status (ASA-PS), Revised Cardiac Risk Index (RCRI),15 duration of preoperative fluid fasting, type of anaesthesia,durationofsurgery,surgicalrisk,temperature atadmission,andLengthofStay(LoS)inthePACU.Surgical risk wasdefined according tothe Guidelines on Perioper-ative Cardiovascular Evaluation and Care for Noncardiac Surgery of the American College of Cardiology/American HeartAssociation.16
Dataforotherpreoperativeclinicalinformation regard-ing chronic obstructivepulmonary disease(COPD), hyper-tension and dyslipidemia were collected from routine clinicaldocumentation.
PainmeasuredwithVisualAnalogScale(VAS)was evalu-atedatPACUadmission.
Residual neuromuscular block (RNMB) was defined as TOF<0.9 and it was quantified at admission tothe PACU using acceleromyography of the adductor pollicis muscle (TOF-Watch®).17,18
The nursing delirium screening scale (Nu-DESC)19 was usedatPACUdischargeandinthewardthedayaftersurgery, andpatientswithaNu-DESCscoreof2ormorepointsatone evaluationwereconsidereddeliriumpositive.
Postoperativenauseaandvomiting(PONV)wasevaluated andmeasuredwithPONVIntensityscaledescribedbyMyles etal.20
Statisticalanalysis
Descriptive analysis of variables was used to summarize data.Ordinalandcontinuousdatafoundnottofollowa nor-maldistribution,basedontheKolmogorov---Smirnovtestfor normalityoftheunderlyingpopulation.The QoR-40values arepresented asmedian and 25 and 75 percentiles. Non parametrictestswereusedtocomparecontinuousvariables andChi-squareorFisher’sexacttesttocompareproportions between2groupsofsubjects.
TherelatedsamplesWilcoxonsignedranktestwasused tocompare Qor-40 scores between the assessments. The Mann---WhitneyUtest wasusedtocompareQoR-40 scores betweenpatientswithPQRandthosewithoutPQR.Ap-value lessthan0.05wereconsideredsignificant.Allanalyseswere performedwithStatisticalPackagefor theSocialSciences softwareforWindowsVersion19.0(SPSSInc.,Chicago,IL, USA).
Results
From207patientsconsecutivelyadmittedinthePACU dur-ingthestudyperiod,27wereexcludedinitially:11patients werelessthan18yearsold,3patients didnotspeak Por-tuguese,2patientsunderwentneurosurgery,and11patients hadnoinformedconsentduetorefusalorinabilityto pro-vide it (MMSE<25). From the remaining 180 patients, 66 werelostduringthefollow-uporhadincomplete informa-tioncrucialtodataanalysis,andconsequentlyatotalof114 patientshadcompletedthestudy(63.3%).
AtT1,meanQoR-40scorewas169andpatientswithPQR wereidentifiediftheirQoR-40 scorewaslesserthan142, calculatedasmentionedpreviously.Thus,PQRoccurredin 26patients(24%).
Table1listspre-admissionpatient’scharacteristicsand postoperativevariables.There werenodifferences inthe pre-admission patient’s characteristics between patients withPQRandpatientswithoutPQR.PatientswithPQRand withoutPQRdidnotdifferinrespectofRNMB,Delirium,VAS forpainandLoS inPACU.However,patientswithPQRhad morefrequentlyPONV(42%vs.25%,p=0.038).
ThemedianQoR-40scoreforoursamplewas180atT0, 174atT1and182atT2.
Table2showsQoR-40scoresatT0,T1andT2,registered inpatientswithPQRandwithoutPQR.
Table1 Pre-admissionpatient’scharacteristicsandoutcomes.
All (n=114)
NoPQR (n=88)76%
PQR (n=26)24%
p
Ageinyears,median(IQR) 60(43---68) 60(42---68) 55(44---71) 0.685a
Agegroup,n(%) 0.603b
<65years 75(66) 59(67) 16(62)
>65years 39(34) 29(33) 10(38)
Gender,n(%) 0.937b
Male 49(43) 38(43) 11(42)
Female 65(57) 50(57) 15(58)
ASAphysicalstatus,n(%) 0.543c
I/II 87(76) 66(75) 21(81)
III/IV 27(24) 22(25) 5(19)
Bodymassindexinkg/m2,median(IQR) 26(24---30) 26(24---30) 29(24---32) 0.207a
Durationofanaesthesia(min),median(IQR) 120(90---180) 120(90---180) 120(84---189) 0.868a
Typeofanesthesia,n(%) 0.062a
General/combinedgenerallocoregional 94(82) 75(85) 19(73)
Locoregional 20(18) 13(15) 7(17)
Siteofsurgery 0.860c
Abdominal 52(46) 39(44) 13(50)
Musculoskeletal 49(43) 39(44) 10(39)
Headandneck 13(11) 10(11) 3(11)
TemperatureatPACUadmission,median(IQR) 35.5(34.9---36.0) 35.5(34.9---35.9) 35.7(35.2---36.0) 0.201a
Hypertension,n(%) 56(49) 46(52) 10(39) 0.216b
Hyperlipidemia,n(%) 40(35) 32(36) 8(31) 0.599b
COPD,n(%) 8(7) 5(6) 3(12) 0.263c
High-risksurgery,n(%) 28(25) 22(25) 6(23) 0.841b
Ischaemicheartdisease,n(%) 7(6) 5(6) 2(7) 0.503c
Congestiveheartdisease,n(%) 3(3) 2(2) 1(4) 0.544c
Cerebrovasculardisease,n(%) 1(3) 1(1) 0 0.772c
Renalinsufficiency,n(%) 9(8) 8(9) 1(4) 0.346c
Insulintherapyfordiabetes,n(%) 17(15) 16(18) 1(4) 0.059c
TotalRCRI,n(%) 0.676c
≤2 109(96) 83(95) 26(96)
>2 5(4) 4(5) 1(4)
Medicationwithbenzodiazepines 31(27) 22(25) 9(35) 0.333b
Benzodiazepinespremedication 43(38) 31(35) 12(36) 0.536b
Crystalloids,median(IQR) 1000(1000---2000) 1000(1000---2000) 1000(1000---2600) 0.889a
Colloids,n(%) 3(3) 2(2) 1(4) 0.579c
Erythrocytes,n(%) 2(2) 2(2) 0 0.569c
RNMB,n(%) 19(17) 16(18) 3(12) 0.715c
PONV,n(%) 34(30) 22(25) 12(42) 0.038b
Delirium,n(%) 18(16) 13(15) 5(19) 0.584c
VASforpainatPACUdischarge,median(IQR) 0(0---2) 0(0---2) 1(0---3) 0.599a
SICUlengthofstay(min),median(IQR) 114(85---146) 110(81---144) 120(110---188) 0.169a
PQR,PoorQualityofRecovery;IQR,interquartilerange;ASA,AmericanSocietyofAnesthesiologists;COPD,ChronicObstructivePulmonary Disease;RCRI,RevisedCardiacRiskIndex;PACU,PostAnesthesiaCareUnit;PONV,PostoperativeNauseaandVomiting;RNMB,Residual Neuromuscularblockade;VAS,VisualAnalogScale.
aMann---WhitneyUtest. b Pearson
2.
Table2 QoR-40scoresatT0,T1andT2inpatients.
All NoPQR PQR pa
(n=114) (n=88)76% (n=26)24%
T0
Global 180(157---190) 184(170---192) 121(117---139) <0.001 EmotionalState 36(27---42) 39(33---42) 24(22---28) <0.001 PhysicalComfort 54(48---57) 55(51---58) 29(28---38) <0.001 PsychologicalSupport 35(34---35) 35(34---35) 35(35---35) 0.115 PhysicalIndependence 25(23---25) 25(23---25) 25(23---25) 0.937 Pain 31(26---35) 33(29---35) 10(7---26) <0.001
T1
Global 174(151---183) 177(166---187) 120(107---134) <0.001 EmotionalState 38(30---42) 40(35---43) 23(20---28) <0.001 PhysicalComfort 51(43---55) 53(50---56) 30(25---41) <0.001 PsychologicalSupport 35(34---35) 35(34---35) 35(31---35) 0.166 PhysicalIndependence 21(15---25) 22(17---25) 14(12---22) 0.001 Pain 30(25---32) 31(28---33) 13(10---24) <0.001
T2
Global 182(161---196) 189(173---198) 119(115---175) <0.001 EmotionalState 38(29---44) 41(33---45) 22(21---37) <0.001 PhysicalComfort 57(47---60) 58(53---60) 28(28---53) <0.001 PsychologicalSupport 35(34---35) 35(34---35) 35(34---35) 0.794 PhysicalIndependence
Pain 32(26---34) 34(29---35) 10(7---30) <0.001
T0,beforesurgery;T1,24aftersurgery;T2,3monthsaftersurgery;PQR,PoorQualityofRecovery. Valuesareshowedinmedian(25---75%percentile).
a ObtainedwithMann---WhitneyUtest.
p<0.001),andalso,lowerscoresforES,PC,PIandP dimen-sions.
WhenanalysingtheinitialQoR-40scoresobtainedatT0, patientswithPQR(identifiedatT1)hadlowerglobal QoR-40scores(median:121vs.184,p<0.001),andalso,lower scoresforES,PCandPdimensions.
When analysing QoR-40scores obtainedatT2,patients withPQR(identifiedatT1)remainedwithlowerglobal QoR-40scores,comparedwiththosewithoutPQR(median:119
vs.189,p<0.001),andalso,lowerscoresforES,PCandP. Patients without PQR showed an improvement in PC dimensionbetweenT0andT2(median:55vs.58,p=0.004), buttherewerenodifferencesintheotherscores(Table3). Ontheotherhand,inpatientswithPQRtherewereno dif-ferencesintheQoR-40scoresbetweenT0andT2(Table4).
Discussion
The main findings of this study were as follow: the inci-denceofPQRwas24%;PQR waspositivelyassociatedwith PONV;patientswithPQRhadlowerQoR-40scorespriorto surgeryand3monthsaftersurgery;andpriorhealthstatus wasrestoredafter3monthsofsurgeryinbothgroups.
The incidence of PQR 24h after surgery in our study (24%)isinaccordancewiththecurrentliterature,13although thereisalackofstudieswiththesamemethodologyafter non-cardiacsurgery.11,21
Our results did not find any association with PQR and pre-admissionpatient’s characteristics andpost-operative variables such as RNMB, Delirium, VAS for pain and LoS in PACU. However, we cannot conclude that these
Table3 QoR-40globalscoreandscoresforeachQoR-40dimensioninpatientswithoutPQR.
Beforesurgery 3monthsaftersurgery pa
Global 184(170---192) 189(173---198) 0.306
EmotionalState 39(33---42) 41(33---45) 0.110
PhysicalComfort 55(51---58) 58(53---60) 0.004
PsychologicalSupport 35(34---35) 35(34---35) 0.905 PhysicalIndependence 25(23---25) 25(24---25) 0.747
Pain 33(29---35) 34(29---35) 0.886
QoR-40,qualityofrecoveryscore;PQR,poorqualityofrecovery. Valuesareshowedinmedian(25---75%percentile).
Table4 QoR-40globalscoreandscoresforeachQoR-40dimensioninpatientswithPQR.
Beforesurgery 3monthsaftersurgery pa
Global 121(117---139) 119(115---175) 0.306
EmotionalState 24(22---28) 22(21---37) 0.935
PhysicalComfort 29(28---38) 28(28---53) 0.108
PsychologicalSupport 35(35---35) 35(34---35) 0.309 PhysicalIndependence 25(23---25) 25(24---25) 0.502
Pain 10(7---26) 10(7---30) 0.311
QoR-40,qualityofrecoveryscore;PQR,poorqualityofrecovery. Valuesareshowedinmedian(25to75%percentile).
aObtainedwithWilcoxonsignedranktest.
variablesarenotimportantforaPQR,andinfuturestudies alargersamplemayallowmoredefiniteconclusionsabout theimportanceofthesevariablesforthedevelopmentofa PQR.
InourstudytherewasanassociationbetweenPQRand PONV. As expected, the incidenceof PONV washigher in patientswithPQR,becauseQoR-40hasthreeitemsrelated tonauseaandvomiting;thiswasalreadystudiedbyMyles etal.18 thatconcludedthatpatientswithPONVhadlower QoR-40scores,eveniftheyremovethosethreeitemsfrom QoR-40. On the other hand, the numberof patients with PONVincomparisonwithpatientswithout PQRwashigher thanweexpected,sincePONViswellweightedinthe ques-tionnaire. Thiscould beexplainedby thefact thatPONV, onitsown,isnotenoughtodetermineaPQRandthereare othercontributorsforit.
Ourstudy suggests that patients whohad PQR maybe identifiedpriortosurgery,becausethesepatientshadlower global QoR-40 scores measured at T0. The ES, PC and P dimensionsmightbethemostimportantdimensionsto dis-tinguishthesepatientsfromthosewhowillnothaveaPQR. Thisisimportantbecauseassoonasthesepatientsare iden-tifiedthesoonereffortsmightbetakentoprovideimportant measurescapableofimprovingtheQoRand,consequently, QoL.Importantmeasures toimprovescores inES,PCand Pdimensions couldbeimplementedinpatientspreviously identified,suchas morecarefulfollow-up, more efficient comfortmeasuresandmoreeffectiveanalgesicregimens.
Asothershadproposedinanalogousstudies,11PQR mea-sured24h after surgerycan predict apoor QoL 3months aftersurgery.QoR-40isrelatedwithQoLaftersurgery.11In ourstudy,patientswithPQRdefinedatT1,maintainlower QoR-40scores3monthsaftersurgery.Thatiswhywe sug-gestthatimprovingmeasuresinpatientswithPQRmightbe abletoimprovetheQoL3monthsaftersurgery.Othershave describedarelationshipbetweenQoR-40aftersurgeryand QoLupto3years,12soQoR-40maybeconsideredanindirect tooltomeasureQoL.
PatientswithPQR,identified24haftersurgery,maintain lowerQoRuntilatleast3monthsaftersurgery, especially inES,PCandPdimensions.
The PS and PI dimensions at T0 and T2 showed no differences in both patients with PQR and without it, which suggeststhat these dimensions maynot contribute todevelopaPQRandforthelowQoRafter3months.
Globally,the results show that prior health status was restoredafter 3 months of surgery in both groups. When
we comparedscores beforesurgeryand 3monthsafter it for patients without PQR, therewasonly improvement in one dimension, which was PC. This maysuggest that the moreaccuratedimensiontomeasureimprovementinthese patientscouldbePC,butmorestudiesareneededtoconfirm it.
Somemightbewaitingforanimprovementinpriorhealth status,representedbyanincreaseinpatient’sglobal QoR-40scores3monthsaftersurgery.However,bothgroupsdid not showan increase in theirglobal QoR-40 scores, when wecomparedthepriortosurgeryscoresand3monthsafter surgery scores. We believe that there are different rea-sonsforthis,accordingtoeachgroup.PatientswithoutPQR didnotimprovetheirglobalQoR-40scoreafter3months, whichcanbeexplainedbythefactthattheyhadhigh QoR-40 scores previously. On the other hand, in patients with PQR, the globalQoR-40 score andscores for each QoR-40 dimensiondidnotimprovealso;however,theirpriorscores werenotashighasinpatientswithoutPQR,andsomecould expecttoraiseit.Ourinterpretationisthatthesepatients had aprior bad heath status thatcannot be improved by surgeryforseveralreasonssuchasmultipleco-morbidities, oncologicsurgeryandpessimismabouttheirhealthstatus.
Inordertoreducebiaswewerestrictabouttiming mea-surementssinceitwasessentialinadynamicprocesssuchas postoperativerecovery.Alsoby selectingaheterogeneous surgical populationwe ought tobe abletomeasuregreat extremesofcomfortandmobility.11Inthisstudyitwasthe investigatorthatadministeredthequestionnaire,whatmay beseenasamoreefficientuseofresources.22
Limitationsofthestudy
One of the limitations of our study wasthe loss of some patientsduringthefollow-upleadingtoarateof patients thatcompletedthestudyas63.3%.
Some mayconsider that we should have useda previ-ouslyvalidatedtooltomeasureQoL,asSf-36questionnaire; however, we assumed the relationship between QoR-40 andQoL, whichwaspreviouslydescribed.11---13 QoR-40 and SF-36containsimilarscopesanddimensionsthatwillassist their association and also because they represent similar psychosocialaspects,theyoughttobecorrelated.12,13
suggeststhatbesideitsutilityaftersurgery,QoR-40maybe usedpriortosurgerytoidentifypatientswhowilldevelop aPQR.Moreover,recognizingthemostaffecteddimensions couldhelptoimplementactionsinordertoachieveabetter QoR,andconsequentlyabetterQoLaftersurgery.However, morestudiesareneededinordertovalidatethistoolprior tosurgery.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
Acknowledgments
Assistancewiththestudy:Theauthorwouldliketothankall theCentroHospitalardeSãoJoãoHospitalPost-Anaesthesia CareUnitstafffortheirassistancewiththestudy.
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