Measuring outcome in low priority .pdf
Original filename: Measuring outcome in low-priority.pdf
Title: PII: 0007-1226(94)90170-8
This PDF 1.3 document has been generated by Acrobat 3.0 Capture Plug-in / Acrobat 3.0 Import Plug-in , and has been sent on pdf-archive.com on 11/12/2016 at 17:30, from IP address 74.71.x.x.
The current document download page has been viewed 238 times.
File size: 542 KB (5 pages).
Privacy: public file
Measuring outcome in low-priority plastic surgery patients using Quality of
J. A. E. Hobbs
1 292 patients with a variety of “low-priority”
conditions completed the Health Measurement
Questionnaire self-report instrument (HMQ)
on admission for surgery, and again 6 months post-operation.
Comparison of the two questionnaires permitted the change in Quality of Life (QoL) to he measured.
Overall. of the respondents, 73 % gained benefit from surgery in terms of improvement in QoL. ‘The largest gains
were in the breast surgery group, hut there were individual patients in all groups who gained substantial improvement
The results suggest that the HMQ is a useful method of measuring benefit in patients admitted for Ion priority
plastic surgery procedures.
Since the intrlxiuction
of the market
toward\ the clearance of waiting
list\. 01- xduction
in patient waiting-time
for operCitic)n\. III the C;ISCnf the plastic surgrr); service. such
\\.:ilting ll\ts ~~l‘tt‘ncontain ;I large proportion
of soCalled “aesthc>tw” disorders. and these conditions are
tnvariabl~ assigned low priority in the fax of limited
surgical cap;icit> /resources.
of outcome for low priorit!plastic <urger>’ procedures have not been developed. it
15impossible to demonstrate
that patients benctit from
xuch procedures. In the fax of financial restrictions on
ilealth care proCsion.
such patients represent a soft
lsrgct for health care rationing.
The ain, of‘ this study U’S to attempt
benefit (or othcr~cisc) to patients admitted on ;I Plastic
Waiting List initiative
o\‘er ;I period of 6
month>. In \.iw of the Audit Commission’s
what mow attention
should he $ven to patients’ own
<opinions (>f their treatment withln the NHS.’ ;I patient
to assess quality of life
before. and h month\ after. operation was used as ;I
measure of outcome. The questionnaire
based on the Health Measurement
t HMQ) dcvcloped b! the Centre for Health Econr)mich. LiniverGt~ of I’ork.” The implications
data collected in term\ ofaudit and cost-utilitv analysis
/I;I\C hcen directed
Patients and methods
IIIC Health Measurement
(HMQ)’ is :I
which provides data on dis.Ibilit~ and distress. For the present study. the corn-
of the HMQ dealing with dixabllit\,
simplified on the basis that the study po~~Lllat~nn~~~,LIld
be unlikely to require detailed questlon~ PII mobilit>
and self-care (Fig. I ). The rules for scorinl; disahilit~
and distress are as given by Gudcx anti Kind.
of the qu~:~tionnaire
I2 visual analog scale\) to calculate an
additional separate score for each patient. the Cumulati\e Distress Score. This takes unto atrcount the
position of all marks on the visual analog xvles and
assigns ;i cumulative
value. On the basis of this score
each patient is assigned to a categor! ;I. h. c or d where
represents least distress and “d” niosi distress.
The scores from the two components of’ [he HMQ
translate into ;I single overall quality of life index using
the Rosser matrix.” The Rosser classification of health
state was developed
in the 1Y70’5 and a,nsists
disability and distress dimensions.
of these dimensions
may be valued and ~hc resulting
matrix of scores represents the value. or ” utility”. ol
being in ;I particular health state. where ;I XY~I-C‘of I .OO
reflects full health and 21score ofO.I)O represents death.
QoL index ~~btained
from this matrix from the postoperative
change in quality of life can be cailculated. This gi\e5 ;i
measure of the outcome of the operation.
The change in quality of life together Lzith the
patient’s life expectancy can be used to determine the
gain in Qualit>-Adjusted
Life \‘sars (QAL.\r’) for that
Usin g data on tos! ot’ in-patient
stay. theatre lime. laborator!
tests and drugs. an
can be calculated. This giws ;I
nie;lsure of cost-utility.
The suitability for LISA of the HMQ ;ii ;I ~K;ISLII’C’ ot
in the general
sho~vn.” Since there is no definitive
which potential instruments
to measure health status.
or quality of lift. can be assessed. NC ha\c attempt~~d to
completedform Will be keptseparatefrom your recordS
and is strictlyconfidential
HOW DOES YOUR CONDITION
LRST TWO MONTHS HAS YOUR CONDITION
RNY OF THESE FEELINGS
IF SO, HOW MUCH DISTRESS
of Plvstic Surew
the line with a frogs as ShOW" below)
tick one box in each section)
problem in walking about .................. cl
1 aa unable to walk WithOUt aids (crutchesetc)....... 0
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
difficultieswith washing or dressing ....
restrictionof my US"a1 actiuities ._......
I hdue SoIperestrictionof my usual actiuities -.a...
I aa unable
(based on HMQ).
show that the questionnaire
based on the HMQ was
valid for use in our study group by comparing it with
and recognised instruments
the assumption that these themselves are both “valid”
measures). These were the Nottingham
(NHP),’ and the Hospital Anxiety and Depression
Score (HAD).” For 41 patients who completed
between the HMQ and
NHP resulted in a correlation
coefficient of 0.638
(p < O.Ol), on grouped data using the Pearson Product
for anxiety and depression
HMQ. and the HAD score were 0.480 (p < 0.01) for
anxiety. and 0.425 (p < 0.01) for depression.
(2) Ptrtirttf populfttiott .stidiecl
The HMQ was completed
(700 female, 99 male, median
admitted between July and December I99 1 and treated
by two surgeons at the Wessex Centre for Plastic and
Surgery. The questionnaire
was accompanied by a letter emphasising that information
the effect of their condition
on everyday life was
sought. It was made clear that the completed questionnaire would not be seen by medical staffand would
be processed by an independent
research analyst. Six
these same patients were sent.
by post. a second HMQ. 2 13 completed questionnaires
(145 females, 68 males. median age 30 years) were
returned by the end of the study period. representing a
total of 73 %. Details of the operative procedures are
shown in Table I. Of the respondents.
day-case surgery whilst the mean length of stay for the
was 3.57 days (maximum
stay 15 days).
77 % of the respondents
had waited 2 years or longer
for their operation.
and 26% had been waiting for
more than 5 years. Further
of nonrespondents was precluded by the limited period of the
Prominent ear c0rrectl0n
Breast (including reduction
Minor skin lesion
represents miscellaneous conditions includinr 4 facial
dermabrasiona. 3 liposuction~ and 7 palmar fasciectom:er.)
An attempt to test the reliability of the HMQ on ;L
group of patients who were not operated
on (i.c~.not yet called for surgery) proved impossible to
administer. Because of the many variables involved in
of patients from the
Waiting List according to personal circumstances.
were unable to approximate
M~~xur~ng Outcome in Lo\v-Priority Plastic Surpcry Patient5 Using Qualit! (if Lik Indices
~khich the two Questionnaires
control group nt‘patitxts who did not undergo surgery.
ti) c ‘~mtidu~/rc Ili.v/wrs (‘~~tcywic~s. The pre- and postoperativ,: C’umulative Distress Categories associated
are shown in Table 2. The
breast and ~lbdominal surgery patients had the greatest
distress preryxrativellr_. In the breast group. 13 out 01‘
40 patients were in the two most distrc5st3.l categories
(c and d) before operation.
After surger! 3 of the 40
in these two categorica.
cases the respective tigurcs
out of73 in categories c and d before surger!’ and ? out
of 73 after surgery. These groups of patients therefore
of distrec\ after surper-v. The rhinopliisty
patients had less distress. but the least distressed were
exckion of minter s!i~n 01
c)ucllif.~~ oj /,ifc lttrlicv.~.The changes III QoL indices
as ;I result of surgery. associated Lvith tile dif?‘crcnt
are shobvn in Figure 2. The \ ;llues used to
calculate the change in QoL arc c!cri\,eJ front the
Rosser matrix (see reference 2 for ;I full esplanati,~n 01
Overall. 71.X”,. c>f respondents
achieved iin increase in quality of life. ?I.(,“/,, h;id
quality of life arid 3.6 ” o hd
quality of life. The largest changes in QoL inde\ arc
seen in pitticnts who underwent
surgery for breast
and for abdominal
The Qol. changes
associated with rhinoplasty
procedures MNc notctd to
be small. The smallest changes were seen In minor- skin
In total 12 patients ac%ie\,ed negative scores. including 3 rhinoplasty.
2 breast. 2 dermubrasion. 2 scar revisions. and one each of prominent
and minor skin Iesio~tl
Overall improvement In OOL eccodng to wndltion.
(,) C’tr/cl//f/fio/l 01 0.4 L 1. gt/i/l.\ c//u/ ~Y/\/-lr’/;lifk’.\ .45suming perioperative
mortality to be zero. by incorporating the lit expectancy ofeach patient (discounted
at 5 “b per year after the ape of 50 years). it W,IS possible
to calculate the QALY (Quality-Adjusted
gain for each procedure. These arc’ shown III Tahk 3.
The highest QALY gains are shown in p:.itients who
surgery for breast conditions.
QALY gain calculation
younger patients may gain significantI!
on the lifespan
of the calculation
itnd show 4gniticant
gains even though the QoL change ma; be 10~. This i:,
apparent in the prominent
ear correction category of
patients. where QALY gains greater than I.0 were
shown in 33 “i, of patients ( I h of 4X).
was calculated using the following
by the Hospital
Resource Management Department:
51 ?I per da\; inp;ltient
El.50 per min in theatre plus fi9.50 lor consumabks.
and flX for histology. Other costs for medication\
British Journal of Plastic Surgcrp
Cost-utility for procedures
were negligible in comparison. The values for the most commonly
procedures are shown in Table 4.
There is a variety of questionnaires
which attempt to
measure health status or quality of life,‘,’ and examples
of the clinical use of these questionnaires
more numerous.” ‘XMany of these instruments.
have been introduced in an attempt to measure Health
Status or Quality of Life as an indicator of outcome,
attract criticism with regard to their validity and
reliability. For example, the use of the SF-36 Health
has recently provoked
Although the use of the HMQ has also
attracted criticism,‘” I’ the validity of the responses to
has been investigated
in 407 respondents
of the general population”
and in 41 patients from our own study group by
comparison with two long-established
The HMQ was chosen for use in the present study in
the hope of achieving good patient compliance. A trial
showed that it takes only a few minutes to complete
the need for personal interview.
About 8 “/o of patients to whom the questionnaire
given on admission
failed to complete it correctly.
These patients were eliminated from the study.
With due consideration
for the limitations ofa short
the study showed overall benefit to a majority
in terms of
improved QoL. In addition the HMQ-derived
of life scores were found to be helpful for the detection
outcomes. These included patients
with loss of quality of life and patients with unchanged
quality of life following surgery. All patients who were
i.e. had negative
scores, and those
patients who showed preoperative disability or distress
but achieved zero QoL gain, were reviewed for audit
purposes (33 patients). These patients were offered a
with the surgeon
if desired. Three patients made no response. In four
and scar revision) it was considered that 6 months was too early to make a final
because of the time required
Of the remainder.
reasons for unfavourable outcome
considered to be areas where improvement
The very limited time period over which this study
was supported did not allow time to follow up nonresponders (17 9/o of patients who were sent a post-
It is possible that this group
may contain a disproportionate
number of patients
who failed to benefit from surgery.
patients ( 16 9” of the total) were operated upon who had no preoperative
disability as assessed by this questionnaire.
in terms of wastage of resources. It is evident that whatever castings are used,
the cost-utility ratios in Table 4 could most efficiently
be improved by selecting the patients for surgery who
were likely to achieve the highest gains in quality of
life. It is likely to prove difficult to predict accurately
which individual patients will achieve highest gains in
QoL as a result of surgery. It is suggested that a more
assessment by the admitting
surgeon, perhaps based on disease progression,
and physical and social disability, may help to reduce the number of patients
placed on the waiting list.
The use of the HMQ permitted measurement
only of change in quality of life, but also gain in
QALY’s (see reference 2 for a full discussion of the use
of the QALY). There are particular criticisms of the
use of QALY’s related to the imposition
values on subjective (patient-derived)
data. The QALY
values are biased towards young patients with normal
life expectancies. who will tend to show higher values.
QALY’s do not allow for the possibility that a small improvement
in the quality of life of
a patient in a perceived poor state of health might be
more desirable to society than a greater improvement
in a patient in a less severe state. The ‘SAVE’ (saved
young life equivalent) has been proposed as a way of
for this discrepancy.‘!’
It is interesting to note that a comparison
of costper-QALY between low priority plastic surgery and
or specialties, notwithstanding
shows the cost-effectiveness
providing this service for carefully selected patients.
These values can only be compared if derived using the
same means (such as the HMQ and the Rosser
In conclusion. the study shows that the HMQ can be
used to measure the benefit, or otherwise. of surgery to
low priority plastic surgery patients. The consideration
of benefit is obviously
central to the problems encountered in the cost-effective allocation of resources
in the market-oriented
prevailing in the
NHS. It should be emphasised that, in this study. there
in most groups who achieved large
gains in Quality of Life, suggesting that careful patient
selection is more important
than the exclusion
procedures from the service delivered.
We are grateful to the patienta Ibr their cooperntlon
We wish to thank Mr J. Michael Porter FRCS, and
Miss Margaret O’Donnell FRCS for their assistance with adm~nIstration of questionnaires.
I. Minding the Quality:
Document 011 the role OI
the Audit Commission in Quality Assurance in Htlalth Care.
Section. Audit Commission.
Plastic Surgery Patients
Using Qu311t\ of Life Indiws
Wade DT. The “0”
.?(I.3 I I.%