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Measuring outcome in low priority .pdf


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IBRITISH

JOURNAL

TIC

OF

SURGERY

I1

Measuring outcome in low-priority plastic surgery patients using Quality of
Life indices
I<.13.C‘nle.
V Shakespeare.

P. Shakespeare

and

J. A. E. Hobbs

S1 .2lA/.4R
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
in Qol..
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
unto

hwlth

Patients

in Britain

cxt-t‘ provision.

( ‘hartcr.

and

of the market
the

advent

system
of

the

rn~~ch effort

and msn~
rcsource~
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.
Since meit5uremcnts
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
to measure
benefit (or othcr~cisc) to patients admitted on ;I Plastic
Surger!
Waiting List initiative
o\‘er ;I period of 6
month>. In \.iw of the Audit Commission’s
proposal
what mow attention
should he $ven to patients’ own
<opinions (>f their treatment withln the NHS.’ ;I patient
~c11~-;twsw~ent questionnaire
to assess quality of life
before. and h month\ after. operation was used as ;I
potential
measure of outcome. The questionnaire
was
based on the Health Measurement
Questionnaire
t HMQ) dcvcloped b! the Centre for Health Econr)mich. LiniverGt~ of I’ork.” The implications
of the
data collected in term\ ofaudit and cost-utilitv analysis
wrc Invt3tigatcd
/I;I\C hcen directed

Patients and methods

IIIC Health Measurement
Questionnaire
(HMQ)’ is :I
\elf-report
instrument
which provides data on dis.Ibilit~ and distress. For the present study. the corn-

w;lb
ponent
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.
We Iww
~isc‘d
the
distress component
of the qu~:~tionnaire
(in\,olving
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
Lb 1.
3
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
of
disability and distress dimensions.
Each cwnbination
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.
By subtracting
the prroprrati\r
QoL index ~~btained
from this matrix from the postoperative
Index. the
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
particular
patlent.
Usin g data on tos! ot’ in-patient
stay. theatre lime. laborator!
tests and drugs. an
overall cost-per-QALY
can be calculated. This giws ;I
nie;lsure of cost-utility.
The suitability for LISA of the HMQ ;ii ;I ~K;ISLII’C’ ot
health
status
in the general
population
has been
sho~vn.” Since there is no definitive
reference against
which potential instruments
to measure health status.
or quality of lift. can be assessed. NC ha\c attempt~~d to
117

British Journal

118
[PLERSE
SELF
The

COMPLETE

BEFORE

ASSESSMENT

YOUR

OUER THE
EXPERIENCE

OPERATION]

PUESTIONNRIRE

completedform Will be keptseparatefrom your recordS
and is strictlyconfidential

HOW DOES YOUR CONDITION
(please

AFFEdT

YOU IN

EUERYDAY

LRST TWO MONTHS HAS YOUR CONDITION
RNY OF THESE FEELINGS
?

IF SO, HOW MUCH DISTRESS
(aark
your
positionon

LIFE?

HAUE

THEY

CAUSED

of Plvstic Surew

EUER
YOU

LED

YOU

TO

7

the line with a frogs as ShOW" below)
No distress
Extreme
Distress
-3

,tcll

tick one box in each section)
MOBILITY

I

have

no

I

alp confined

problem in walking about .................. cl
1 aa unable to walk WithOUt aids (crutchesetc)....... 0
to

I ha”e

no problem

I

sme

have

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

bed

SELF

CRRE

with

self

to

wash

or

dress

USUPL
(HOUSEWORK.
have

no

care

OR DRESSING)

mySelF

_.................

Dissatisiactio”
with

0

RCTIUITIES

WORK.

STUDY.

SHOPPING,

Feeling
anxious
or worried

Dissatisfaction
with weiqht

_........-......s...

difficultieswith washing or dressing ....

1 amunable

I

(YGSHIHG

cl

Feeling
depressed

ET0

restrictionof my US"a1 actiuities ._......

appearance

Embarrassment
unce,rtainty
about Future
mger or

resentment
Guilt

I hdue SoIperestrictionof my usual actiuities -.a...
I

haue

swwe

I aa unable

to

restriction

of

perform

my usual

SOCIRL
(PLERSE

RN0

qy usual

PERSOHAL

RNSWER

(ILL

LonelinPss
actiuities ....

actiultles

__...__...

LOSS

Of

Self-confidence

RELRTIONS
QUESTIONS)

Fig. I
Figure I--Self

Assessment

Qtwtuuuire

(based on HMQ).

show that the questionnaire
based on the HMQ was
valid for use in our study group by comparing it with
two well-established
and recognised instruments
(on
the assumption that these themselves are both “valid”
measures). These were the Nottingham
Health Profile
(NHP),’ and the Hospital Anxiety and Depression
Score (HAD).” For 41 patients who completed
all
three instruments
comparison
between the HMQ and
NHP resulted in a correlation
coefficient of 0.638
(p < O.Ol), on grouped data using the Pearson Product
Moment
coefficient.
The correlations
between the
components
for anxiety and depression
from the
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
on admission
by 392
patients
(700 female, 99 male, median
age 29)
admitted between July and December I99 1 and treated
by two surgeons at the Wessex Centre for Plastic and
Maxillofacial
Surgery. The questionnaire
was accompanied by a letter emphasising that information
about
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
months postoperatively
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.
34 underwent
day-case surgery whilst the mean length of stay for the
remainder
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
follow-up
of nonrespondents was precluded by the limited period of the
study.
Table 1

Operations

performed
.%‘I
,

P lw&rc~
Prominent ear c0rrectl0n
Breast (including reduction
Rhinoplasty
Abdominoplasty
Minor skin lesion
Scar revision
Or her

48
and augmentation)

JO
36
23
21
I4
31

(“Other”
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
comparable
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
the management
of admission
of patients from the
Waiting List according to personal circumstances.
we
were unable to approximate
the conditions
under

M~~xur~ng Outcome in Lo\v-Priority Plastic Surpcry Patient5 Using Qualit! (if Lik Indices
~khich the two Questionnaires
were administered
in ;I
control group nt‘patitxts who did not undergo surgery.

Results

ti) c ‘~mtidu~/rc Ili.v/wrs (‘~~tcywic~s. The pre- and postoperativ,: C’umulative Distress Categories associated
lvith diflkcnt
conditions
are shown in Table 2. The
breast and ~lbdominal surgery patients had the greatest
distress preryxrativellr_. In the breast group. 13 out 01‘

I ICI

40 patients were in the two most distrc5st3.l categories
(c and d) before operation.
After surger! 3 of the 40
patients
remained
in these two categorica.
III the
abdominoplasty
cases the respective tigurcs
weI-c
IF
out of73 in categories c and d before surger!’ and ? out
of 73 after surgery. These groups of patients therefore
achia.ed substantial
alleviation
of distrec\ after surper-v. The rhinopliisty
and prominent
ar corrcztion
patients had less distress. but the least distressed were
the PiltiUlth
undergoing
exckion of minter s!i~n 01
SLlbCL~til~leOU~
lesions.
c)ucllif.~~ oj /,ifc lttrlicv.~.The changes III QoL indices
as ;I result of surgery. associated Lvith tile dif?‘crcnt
conditions.
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
these CillCUliltiOllS).
Overall. 71.X”,. c>f respondents
achieved iin increase in quality of life. ?I.(,“/,, h;id
unchanged
quality of life arid 3.6 ” o hd
reduced
quality of life. The largest changes in QoL inde\ arc
seen in pitticnts who underwent
surgery for breast
conditions.
especially reduction
and aLIirmentation.
and for abdominal
conditions.
The Qol. changes
associated with rhinoplasty
procedures MNc notctd to
be small. The smallest changes were seen In minor- skin
lesion corrections.
In total 12 patients ac%ie\,ed negative scores. including 3 rhinoplasty.
2 breast. 2 dermubrasion. 2 scar revisions. and one each of prominent
ear. abdominoplasty
and minor skin Iesio~tl
h)

Overall improvement In OOL eccodng to wndltion.

i.
;

6

(,) 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
Life \‘txr)
gain for each procedure. These arc’ shown III Tahk 3.
The highest QALY gains are shown in p:.itients who
underwent
surgery for breast conditions.
Since the
QALY gain calculation
incorporates
life Icupectancy.
younger patients may gain significantI!
on the lifespan
component
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).
Cost-per-QALY
was calculated using the following
costing
provided
by the Hospital
Resource Management Department:
51 ?I per da\; inp;ltient
Stity.
El.50 per min in theatre plus fi9.50 lor consumabks.
and flX for histology. Other costs for medication\
and

British Journal of Plastic Surgcrp

110
Table 4

Cost-utility for procedures
,1;0.

Prom. car5
Abdomino.
Rhinopl.
Br. red.
Br. aug.

48
23
36
14
12

laboratory
investigations
were negligible in comparison. The values for the most commonly
performed
procedures are shown in Table 4.
Discussion
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
are becoming
more numerous.” ‘XMany of these instruments.
which
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
Survey Questionnaire
has recently provoked
much
discussion.”
Although the use of the HMQ has also
attracted criticism,‘” I’ the validity of the responses to
this questionnaire
has been investigated
in 407 respondents
representative
of the general population”
and in 41 patients from our own study group by
comparison with two long-established
questionnaires.
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
unaided.
without
the need for personal interview.
About 8 “/o of patients to whom the questionnaire
was
given on admission
failed to complete it correctly.
These patients were eliminated from the study.
With due consideration
for the limitations ofa short
self-assessment
questionnaire,
the study showed overall benefit to a majority
of patients
in terms of
improved QoL. In addition the HMQ-derived
quality
of life scores were found to be helpful for the detection
of unsatisfactory
outcomes. These included patients
with loss of quality of life and patients with unchanged
quality of life following surgery. All patients who were
disadvantaged.
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
further appointment
for consultation
with the surgeon
if desired. Three patients made no response. In four
cases (dermabrasion
and scar revision) it was considered that 6 months was too early to make a final
assessment
because of the time required
for scar
maturation.
Of the remainder.
reasons for unfavourable outcome
included
poor patient
selection
(7
patients),
insufficient
correction
of deformity
(6
patients)
or complication
(3 patients).
These were
considered to be areas where improvement
might be
made.
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-

operative questionnaire).
It is possible that this group
may contain a disproportionate
number of patients
who failed to benefit from surgery.
Thirty-three
patients ( 16 9” of the total) were operated upon who had no preoperative
distress or
disability as assessed by this questionnaire.
This has
significant
implications
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
structured
preoperative
assessment by the admitting
surgeon, perhaps based on disease progression,
pain.
psychological
morbidity
and physical and social disability, may help to reduce the number of patients
inappropriately
placed on the waiting list.
The use of the HMQ permitted measurement
not
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
of external
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.
Furthermore,
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
compensating
for this discrepancy.‘!’
It is interesting to note that a comparison
of costper-QALY between low priority plastic surgery and
other conditions
or specialties, notwithstanding
the
above reservations,
shows the cost-effectiveness
of
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
matrix).‘”
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
environment
prevailing in the
NHS. It should be emphasised that, in this study. there
were individuals
in most groups who achieved large
gains in Quality of Life, suggesting that careful patient
selection is more important
than the exclusion
of
procedures from the service delivered.
Acknowledgements
We are grateful to the patienta Ibr their cooperntlon
uith thla
investigation.
We wish to thank Mr J. Michael Porter FRCS, and
Miss Margaret O’Donnell FRCS for their assistance with adm~nIstration of questionnaires.

References
I. Minding the Quality:

A Consultation
Document 011 the role OI
the Audit Commission in Quality Assurance in Htlalth Care.
Publication
Section. Audit Commission.
Nicholson
Houw.

Mcasurlng

Oulconx

in Low-Priority

Plastic Surgery Patients

Using Qu311t\ of Life Indiws
+

Ih.

in Q4Lj.b
;I cautlonnry
note
Wade DT. The “0”
in OALYa.

BMJ
BMJ

IYYI
IYYI

7oJ- f&
.?(I.3 I I.%

7111


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