Assessing Quality of Life After Surgery Paul D. Cleary, PhD, Sheldon Greenfield, MD, and Barbara J. McNeil, MD, PhD Department of Health Care Policy (P.D.C.; B.J.M.), Harvard Medical School, Boston, Massachusetts; and New England Medical Center (S.G.), Boston, Massachusetts.

ABSTRACT: Researchers and clinicians increasingly are recognizing the importance of as-

sessing a wide range of outcomes when evaluating the efficacy of medical therapies or procedures. We developed and evaluated a set of self-report scales that assessed both generic and condition-specific aspects of health-related quality of life before and after surgery. We report data from a study of patients having one of four types of surgery at six teaching hospitals in California and Massachusetts. The four surgical conditions studied were: total hip replacement, transurethral prostatectomy, cholecystectomy, and coronary artery bypass graft surgery. All the outcome scales, except for those assessing cognitive functioning and fatigue, had internal consistencies greater than 0.70. The pattern of correlations between the scales and other measures of health status are similar to those reported in other studies and provide evidence of their construct validity. The scales also appeared to be sensitive to differences between presurgical and postsurgical health-related quality of life. The results suggest that the scales used were easy to administer, reliable, valid, and offered important information about outcomes of surgery that is not provided by more traditional clinical indicators. KEY WORDS: Quality of life, functional status

INTRODUCTION Clinical trials traditionally have focused on n a r r o w l y defined outcomes. Over the past decade or so, however, there has b e e n increasing recognition of the importance of assessing a broad array of outcomes w h e n evaluating the efficacy of therapeutic agents or p r o c e d u r e s [1]. This trend is accelerated b y the fact that as the population ages, there has been an increasing emphasis on the t r e a t m e n t of chronic diseases which are more likely to have an impact on diverse aspects of a patient's life. Some clinical trials have u s e d qualityof-life assessments effectively [1-5], but the w i d e s p r e a d a d o p t i o n of such measures has b e e n h i n d e r e d by a relative lack of information about their usefulness in clinical trials [1, 6-8]. In this p a p e r w e describe several generic measures of quality of life that we are currently using in clinical research, and present data collected from samples of patients hospitalized for four different surgical p r o c e d u r e s using these scales. We describe the psychometric char-

Address reprint requests to: Paul D. Cleary, Harvard Medical School, Department of Health Care Policy, 25 Shattuck St., Parcel B, 1st Floor, Boston, MA 02115. Received July 11, 1990; revised March 25, 1991. ControlledClinicalTrials12:189S-203S(1991) © P. Cleary

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acteristics of these measures and present comparative data on their responsiveness to change subsequent to surgery. BACKGROUND

There are innumerable definitions of quality of life, and there is no deftnition that is applicable in all situations. It is possible, however, to specify several dimensions that capture many of the elements considered to make up quality of life [9-13]. Some of these elements, such as characteristics of an individual's social environment, may be only weakly related to health status [14-16]. Health is, however, one of the most important determinants of quality of life. The health-related components of quality of life include disease-specific symptoms, general health perception, somatic discomfort, physical, social, and role functioning, cognitive functioning, and psychologic well-being [6-8, 13, 14, 17-21]. The inclusion of some or all of these in qualityof-life assessments will d e p e n d on the procedure or therapy being evaluated in a given clinical trial. The breadth of coverage of health status measurement has increased in the rehabilitation and gerontologic literatures. Although researchers have long recognized the importance of assessing a broad range of health indicators, generally referred to as measures of functional status [22], early measures of quality of life focused almost exclusively on a few critical activities of daily living (e.g., ambulating, toileting, and transfers) and physical activities requiring more mobility (e.g., climbing stairs, walking longer distances, shopping, light housework and meal preparation). Over the past ten years, a wider range of measures of quality of life, including mental health, perceived physical health, and social and role functioning, in addition to physical functioning, have also been included [19]. Originally, measures of functioning were used primarily by clinicians, but recently they have increasingly been used as research tools [19, 23-26]. However, they have not been used widely in clinical trials [1,27], partially because they have been perceived as "soft" and unscientific [8]. As these perceptions change, however, limited information about the validity, psychometric properties, and relative efficiency of these measures may become the limiting factor in their application [1, 6, 7, 27]. In order for such scales to be useful in clinical trials, it is important that they be reliable and valid; they sl~ould be repeatable, sensitive to change over a range of severity, suitable for self-administration, and easy to complete [6--8, 27]. METHODS Patients

The data analyzed in this paper were collected as part of a study of variations in case-mix, process of care, and outcomes in six acute care, universityaffiliated, teaching hospitals in California and Massachusetts. The study was designed to investigate whether patients receiving different types of care varied with respect to the outcomes measured, controlling for case-mix. In this paper, data are reported on the eligible patients w h o had one of four

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types of surgery: total hip replacement (THR); transurethral prostatectomy (TURP); cholecystectomy (CHOLE); and coronary artery bypass graft surgery (CABG). These procedures were chosen because they are relatively common and it was possible to identify an initial inception cohort of patients through operating room logs and discharge abstracts. In order to maximize the homogeneity of the patients to be studied, a set of inclusion and exclusion criteria were developed for each condition (Appendix A). In all cases patients had to be older than 18 years of age and were excluded if they had metastatic cancer, were undergoing chemotherapy, if they had an AIDS diagnosis, or if they were transplant patients. In addition, a patient could be included in the study only once.

Study Sites The hospitals from which study patients were selected are not-for-profit, university- affiliated, teaching hospitals. Hospitals were selected in this way to maximize homogeneity in the standards of care delivered. Three of the hospitals were located in California and three were located in Boston. The number of operating rooms in the study hospital ranged from 18 to 32 and the number of medical and surgical beds ranged from 325 to 859.

Procedures Data on case-mix and the process of care were abstracted from the medical records of each study patient. Information about sociodemographic characteristics, perceived health status, bed and work disability, health care utilization, disease-specific symptoms, social support and social activities, functioning prior and subsequent to hospitalization, satisfaction with care, perceived improvement, and employment status prior and subsequent to hospitalization were collected using a self-administered questionnaire. Questionnaires were sent to patients having a cholecystectomy or transurethral prostatectomy three months' postdischarge. CABG patients received follow-up questionnaires six months postdischarge and total hip replacement patients were assessed one year after they were discharged. These follow-up times were suggested by consulting physicians as the time period most likely to detect differences in outcome that are related to process of care. Follow-up data were collected using a variety of approaches [28]. Patients were first sent a letter explaining the study and a postcard that they could return if they did not want to participate in the study. If they did not send in the postcard they were sent a questionnaire. For respondents who still did not send in a questionnaire after a reminder, an attempt for a telephone interview was made.

Chart Reviews Information was collected from patient charts about sociodemographic characteristics, certain characteristics of the admission (e.g., floor, admission ICD-9 code, where admitted to), disease-specific severity measures, infor-

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P.D. Cleary et al. mation about the surgical procedure, the occurrence of inhospital complications, resource use, and comorbidity. Most of the items and coding schemes were straightforward. Some variables, such as comorbidity, required special procedures. Conditions other than the patients' target disease may have an impact on their overall disease management and outcome during the months following hospitalization [29]. In order to control for differences in comorbid conditions, such as insulin-dependent diabetes, mild renal failure, and angina, information on comorbidity was coded from the medical record of each patient using the approach developed by Greenfield and colleagues [30, 31]. The following three measures of comorbidity were assessed: 1. Severity of the patient's major health conditions 2. Complications from this condition 3. The patient's current functional status For the analyses presented here, we used a weighted sum of the number of comorbid conditions present. The weight was the severity score assigned by the medical record reviewer to each comorbid condition. For each condition, there are four possible values for the weight; 0 indicates least severe and 3 most severe. Diseases scored I included, for example, arthritic diseases, asthma, and gastrointestinal ulcers that are controlled with medications. Serious or uncontrolled conditions (with moderate to severe manifestations) are given a score of 2. A score of 3 is given for end-state disease.

Outcome Questionnaire The outcome questionnaire included questions about perceived general health, number of days that illness or injury kept the patient in bed all or most of the day in the preceding month, the number of days that illness or injury kept the patient from work or school during the preceding month, use of health services, symptoms related to the condition for which they were hospitalized, current social activities, activities of daily living, well-being, satisfaction with medical care and health, whether patients thought the operation made them feel better, whether their health was better or worse than expected, whether they felt "back to normal," employment, and role functioning, as well as indicators of socioeconomic status, such as education and income (Appendix B). The questionnaire also asked about former daily activities, well-being, employment, and role functioning. Barriers to the widespread use of functional status instruments include skepticism about their validity, lack of comparative data across conditions and settings, high costs of administration, find lack of information about their ability to detect important clinical changes [27]. These issues are especially salient in clinical trials in which time for the evaluation of patients is usually very limited and in which it is important that any differences in outcome between experimental and control groups be detected with as small a sample as possible. Most of the existing measures either must be administered by a clinician and/or are extremely long [19]. Furthermore, many of the available scales have not been clinically validated. In the study reported here, we used a measure that included physical, social, psychologic, and role functioning. The questionnaire could be used

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for different conditions among hospitalized patients, it was easy to administer, and it was designed to be sensitive to clinical changes. The measures of social activities, functioning, and well-being were derived from widely used instruments [23, 24, 32, 33] and are similar to the Functional Status Questionnaire, used by Jette and colleagues in a number of studies [25]. These measures are applicable to a wide spectrum of patients, can be completed by the patient quickly, and were designed to be sensitive to the types of changes in quality of life that would result from surgery. The measures on which this instrument was based have been shown to have reliable subscales with construct and criteria validity [25, 34-36]. Copies and descriptions of the scales used are available from the senior author. Although the questionnaires collect a substantial amount of information, they were carefully designed to be easy to read and complete, and took approximately 30 minutes to complete. Among patients who agreed to participate in the study (approximately 91% of all patients contacted), about 88% returned a usable questionnaire. The response rate among participants was 81.3% for cholecystectomy patients, 88.6% for CABG patients, 93.7% for total hip replacement patients, and 91.1% for prostatectomy patients. ANALYSES

Sample characteristics are described by presenting means and standard deviations within each of the four conditions. Coefficient alpha, a measure of scale internal consistency [37], was used to describe the reliability of the scales. We assessed construct validity by calculating a Pearson product-moment correlation between each scale score and other variables that are known to be related to functioning. In order to assess the sensitivity of the different functional status scores over time, a paired-t statistic was calculated for the difference between the presurgical and postdischarge self-report of functioning. This measure provides an indication of the change in scores relative to the standard deviation of change scores [38, 39]. RESULTS

Selected sociodemographic, medical, and process of care data are presented for study patients in each of the four study conditions in Table 1. Because of the selection criteria used for each condition, participants were relatively healthy, as indicated by the low number of comorbid conditions and the high basic activities of daffy living (BADL) scores. The BADL score represents the average score on the three BADL questions, with a 4 given for the response "usually did with no difficulty" and 3 given for the response "usually did with some difficulty." Thus, the only group with any substantial limitation of basic activities of daffy living was the group of patients having a total hip replacement. Other patient characteristics varied by disease. Patients' average ages ranged from 46 to 69 years, the proportion male ranged from 26% to 100%, for three of the conditions between 7% and 8% were not Caucasian. Twenty-one percent of those having a cholecystectomy were nonwhite. The data in Table 2 indicate that the scales assessing BADL, intermediate

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P.D. Cleary et al. Table 1

Selected S o c i o d e m o g r a p h i c , Medical, a n d P r o c e s s of C a r e D a t a Condition

Variable Mean age Percent male Percent with a high school degree Percent with income greater than $40,000 Percent nonwhite ASA classification Comorbidity Previous BADLe Previous IADI./

CHOLE a (n = 476)

THR b (n = 335)

TURIx (n = 425)

CABGd (n = 361)

46.4 26% 85%

63.9 43% 66%

69.0 100% 87%

60.2 86% 57%

36%

42%

50%

36%

21% 1.8 0.59 3.7 3.4

7% 2.0 0.80 3.0 2.3

8% 2.1 1.02 3.9 3.6

8% 3.3 .92 3.7 3.1

~Cholecystectomy. bTotal hip replacement. ¢rransurethral prostatectomy. dCoronary artery bypass graft surgery. eBasic activities of daily living. /Intermediate activities of daily living.

Table 2

Reliability of Selected Q u e s t i o n n a i r e Scales Condition

Scale BADLe Previous Subsequent IADId Previous Subsequent Social activities Previous Subsequent Mental health Previous Subsequent Cognitive problems Previous Subsequent Fatigue Previous Subsequent

CHOLE a

THR b

TURP ~

0.80 0.78

0.82 0.75

0.76 0.76

0.72 0.69

0.92 0.88

0.88 0.85

0.82 0.83

0.84 0.71

0.92 0.85

0.88 0.88

0.91 0.84

0.87 0.76

0.82 0.77

0.80 0.74

0.77 0.74

0.80 0.82

0.69 0.71

0.59 0.42

0.64 0.41

0.75 0.67

0.83 0.66

0.81 0.66

0.69 0.71

0.74 0.64

~Cholecystectomy. bTotal hip replacement. ~Transurethral protatectomy. aCoronary artery bypass graft surgery. ~Basic activities of daily living. /Intermediate activities of daily living.

CABG

d

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activities of daily living (IADL), and mental health all had good internal consistency, generally being close to or greater than 0.70. The scales assessing cognitive problems and fatigue, both consisting of two questions, had lower reliability, with the scale of cognitive problems having an alpha as low as 0.41 and fatigue being as low as 0.64. The short scale of fatigue had slightly better reliability, in general, and may be useful for some very general evaluations or comparisons. Table 3 presents the correlations between several single item measures of health status and the scale assessing IADL, all measured at the follow-up visit. The correlations were moderately large and comparable to the associations observed in similar studies [33, 40]. The magnitude and pattern of correlations were comparable for BADL scores and for the scale assessing social activities, except that the correlations between BADL and other measures of disability were lower for TURP patients. This probably is due to the fact that TURP patients had the highest levels of presurgical basic functioning and the least variability on the BADL scale. The t scores representing the difference between preadmission and postdischarge function, divided by the standard error of the difference, are presented in Table 4. The scores on most of the scales suggest statistically significant improvements after surgery for all patient groups, with some important differences among both scales and procedures. Graphs showing the changes between the pre- and post-surgical assessments are presented in Figures 1 and 2. The procedure having the largest relative impact on BADL scores was total hip replacement, with smaller improvements reported by CABG and cholecystectomy patients. There was no significant impact of proctectomy on BADL. The patterns for the IADL scores was slightly different. Once again, the THR patients showed the largest improvement, but the IADL scale was more sensitive to change among CABG patients than was the BADL score. For each of the scales analyzed, the t score was highest for THR patients. The t scores were second highest, with a few exceptions, for CABG patients. For all patients, the scale of confusion was the least likely to show any changes after surgery and with the exception of the work performance scores, the scales indicated the least change in TURP patients.

Table 3

Construct Validity Correlations Between Subsequent Intermediate Activity of Daily Living Score and Other Health-Related Measures Condition Variable CHOLEa THR b TURI~ CABGd General assessment of 0.35e 0.48e 0.54e 0.47e health Bed disability days 0.44~ 0.32e 0.38" 0.38" Restricted activity days 0.48e 0.43e 0.3ff 0.40~

°Cholecystectomy. bTotal hip replacement. ~Transurethral protatectomy. dCoronary artery bypass graft surgery. ep < .01.

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Table 4

Condition Variable

CHOLE

THR

TURP

BADL e IADL f Mental health Work performance Housework Social activities Fatigue Confusion

3.4~ 1.9 5. lg 1.7 4.4g 2.6~ 3.6g 1.3

17.5g 18.13 9.4a 5.73 11.0g 13.4g 10.6~ 2.0g

-0.7 - 1.1 3.13 2.73 1.5 0.2 -0.8 0.15

CABG 6.8g 12.3g 8.13 0.8 2.8g 7.4~ 8.0~ - 1.2

"Cholecystectomy. bTotal hip replacement. ~Fransurethral protatectomy. aCoronary artery bypass graft surgery. ~Basic activities of daily living. flntermediate activities of daily living. gp < .05.

4.0

3.5

3.0

:>.5

_

I

PRIOR ?. O A

POST PROSTATECTOMY TOTAL HIP REPLACEMENT CHOLECYSTECTOMY CORONARY ARTERY BYPASS SURGERY Figure 1

Changes in basic activities of daily living

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Assessing Quality of Life After Surgery

4.0

f~

-,,

w

3.5

w

3.0

2.5

2.0

_

1

PRIOR

(>

POST PROSTATECTOMY TOTAL HIP REPLACEMENT CHOLECYSTECTOMY CORONARY ARTERY BYPASS SURGERY

Figure 2 Changes in intermediate activities of daily living.

Table 5

Correlations B e t w e e n C h a n g e Scores a n d Perceived I m p r o v e m e n t in Health" Condition

Variable

CHOLE

THR

TURP

CABG

BADL IADL Mental health Work performance Housework Social activities Fatigue Confusion

0.20 0.22 0.25 0.20 0.27 0.31 0.30 0.21

0.37 0.38 0.20 0.14 0.37 0.38 0.28 0.18

0.14 0.25 0.20 0.08 0.09 0.25 0.28 0.18

0.32 0.48 0.29 0.34 0.52 0.31 0.34 0.17

aFor all correlations, p < 0.01. bCholecystectomy. ~Total hip replacement. aTransurethral protatectomy. eCoronary artery bypass graft surgery. fBasic activities of daily living. ~Intermediate activities of daily living.

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P.D. Cleary et al. Table 5 presents the correlations between patients' perceived improvement in health and change scores for the different quality-of-life measurements. These correlations were generally moderate, with the highest associations tending to be among THR and CABG patients.

DISCUSSION The scales used in this study to assess changes in quality of life after surgery are very similar to a number of scales that have been developed and used by other researchers [19]. A necessary, although not sufficient, condition for a valid instrument is that it needs to be reliable. Using internal consistency as a measure of reliability, the scales described here performed quite well. Nunnally [37] has suggested that a reliability of 0.70 is adequate for scales. Using this criterion, all of the scales used had acceptable reliability and many had extremely high internal consistency, with a few exceptions. The scales with the worst internal consistency were the scales of cognitive problems and fatigue. The low reliability of these scales undoubtedly is due, in part, to the fact that they had only two items. Valid neurologic and neuropsychologic assessment requires objective measures and an independent assessment. Given that such assessments are not likely to be included in many clinical trials, there is need to develop better scales for these two outcome measures. Cognitive impairment and fatigue are often mentioned by patients as consequences of medical treatment and there is a need for short, easy-toadminister scales for these outcomes. Another important feature of this study is that it includes information on presurgical and postsurgical functioning, so that it was possible to evaluate the sensitivity to different subscales to change in conditions of patients. As might be expected, by far the greatest improvements in BADL and IADL occurred among patients having a total hip replacement, although CABG patients also showed large improvements. Interestingly, the only scale, aside from confusion, that showed no change for CABG patients was work performance. This is consistent with other findings in the literature [41], although it is not fully understood w h y CABG surgery does not have a more beneficial impact on employment. The smallest changes in functioning occurred among TURP and cholecystectomy patients. This is probably due to the fact that patients in both groups had good functioning prior to surgery (Table 1). Cholecystectomy patients did show significant improvements in the measures of mental health, housework, social activities, and fatigue. Patient reports about prehospitalization conditions were based on recall periods that varied between three months and one year, depending on the condition. Although this is a potential source of bias, the different pattern of results among conditions, validity studies of comparable measures [34], and analyses of data from medical patients among w h o m data were collected at two points in time suggest that such recall data is quite accurate. The moderate correlations between reported improvements in health and change scores (Table 5) suggest that asking a set of questions about specific activities provides information that is not captured by a simple global assessment by the patient. The scale of IADL tended to have the strongest

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association with perceived improvement, although both social activities and fatigue had relatively high correlations with perceived improvement, espedally in the conditions in which patients had relatively good physical functioning (TURP and cholecystectomy). This is to be expected, since in the absence of changes in physical functioning, perceived improvement is likely to be assessed on the basis of other activities or subjective states such as fatigue. The main conclusion is that these scales are easy to administer to patients and can detect important changes related to medical treatment. They were most successful in detecting change among patients with low functioning prior to surgery (CABG and THR). The lack of sensitivity to change in CHOLE and TURP patients may be because those patients had relatively little change in quality of life, because our instruments did not focus on the appropriate dimensions of quality of life, or both. It would be desirable to have an absolute standard against which to evaluate the change indicated by these scales [3840], but we had no such standard in this study. Moreover, in certain respects, the patient's perception of improvement in functioning may be one ultimate standard. These data provide useful information about the level of functioning in a variety of domains prior and subsequent to surgery. As such knowledge is accumulated, it will be possible to specify more accurately, a priori, which types of measures are likely to detect change in particular groups of patients. For example, among TURP patients it may not be useful to include general functioning patients unless the patients have severe symptoms prior to surgery [42]. On the other hand, for the other conditions studied, these short self-administered scales were able to detect statistically significant changes. Although we agree with Deyo and Patrick [27] that more comparisons with traditional clinical scales are needed, we also think that the high compliance rates, internal consistency, construct validity, and sensitivity to changes argue for more widespread use of scales of this type when evaluating medical interventions. The work reported in this manuscript was supported by grants from the RobertWoodJohnson Foundation and the John A. Hartford Foundation. The authors acknowledge the participation of Steven A. Schroeder, Lewis Wexler, Albert G. Mulley, Stephen G. Pauker, Rachel Miller, Thomas Mitchell, Lucia Sommers, Elizabeth Martin, Vicki Reder, Isabelle Durand, and Steven B. Boswellin the design and conduct of the study.

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APPENDIX A: DISEASE-SPECIFIC ELIGIBILITY CRITERIA Coronary Artery Bypass Graft Patient's DRG is 107 Primary operation is Coronary Artery Bypass Graft NOT if preoperative LOS > 3 days NOT if formally transferred from another acute care hospital (via ambulance) NOT if admitted t h r o u g h emergency room (chart has emergency room record) NOT if admitted directly to CCU or ICU NOT if on W nitroglycerin (or similar medication) pre-operatively NOT if history of prior CABG NOT if history of MI within 1 m o n t h of admission

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P.D. Cleary et al. Cholecystectomy Patient's DRG is 197 or 198 Primary operation is a total cholecystectomy without common duct exploration TURP without cancer: Any operation is a transurethral prostatectomy Patient does NOT have any of the following diagnosis: Malignant neoplasm of prostate Malignant neoplasm of testis Malignant neoplasm of penis and other male genital organs Malignant neoplasm of bladder Total Hip Replacement Primary operation is unilateral (NOT bilateral) total hip replacement Secondary operation is NOT total hip replacement Patient does NOT have a diagnosis of rheumatoid arthritis Patient does NOT have a diagnosis of Paget's disease (of the bone) Operation is NOT a revision or reoperation

APPENDIX B

Perceived Health. The measures of disability and health services use were derived from the Health Interview Survey or other commonly used questions, and the symptoms measures were developed on the basis of reviews of the literature on each condition and the advice of medical experts at each of the hospitals. Patients were asked to rate their health as excellent, good, fair, or poor and whether their health was better, worse, or the same as prior to hospitalization. Patients were also asked about bed disability days, work limitation days, and the number of days in the preceding month during which they cut down on normal activities. Health Care Use. Patients were asked how many times since their hospitalization they had seen a medical doctor, how many times they had seen a doctor for the same problem that they were hospitalized for, and how many times a nurse had come to their home. Symptoms. Patients were asked about condition specific symptoms using questions developed specifically for this study. Copies of these symptom scales are available from the first author. Functioning. The measure of basic activities of daily living (BADL) was a threeitem scale that asked about self-care (eating, dressing, bathing), transfers (moving in and out of a chair) and ambulation (walking indoors). The items were derived from widely used instruments (e.g. 23; 24; 32; 33) and are identical to the Functional Status Questionnaire. For each of the functioning items, patients were asked how hard it was or how much physical effort it took to do the activity. The response options were usually did with no difficulty, usually did with some difficulty, usually did with much difficulty, usually did not do because of health, and usually did not do because of other reasons.

Assessing Quality of Life After Surgery

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The Intermediate Activities of Daily Living (IADL) scale contained six items covering activities requiring more physical effort. The Social Activities scale contained three items referring to social interaction (e.g., visiting with relatives or friends). The Mental Health scale contained five items and was identical to the mental health scale used in the Functional Status Questionnaire and the shortform survey from the Medical Outcome Study [25, 33]. The questions asked how often in the preceding month the patient had felt certain ways (e.g., calm and peaceful; very nervous). The response categories were all of the time, most of the time, a good bit of the time, some of the time, a little of the time, none of the time. The measures of fatigue and cognitive functioning had not been used before. They are derived from the types of questions asked in the Sickness Impact Profile and were very simple attempts to assess these areas in a very short questionnaire. They included questions such as: During the past month, how much of the time did you feel fatigued or tired? and Did you have difficulty doing activities involving concentration and thinking? For persons who were working, there were four questions about work performance. For homemakers, there were two questions about health-related difficulties.

Satisfaction.

Patients were asked whether they were very satisfied, somewhat satisfied, neither satisfied nor dissatisfied, somewhat dissatisfied, or very dissatisfied with the information they were given about surgery, the way their pain was treated, and their hospital stay in general. They were also asked whether their hospital stay was much too long, somewhat too long, just right, somewhat too short, or much too short. Patients were asked whether their operation made them feel better with seven response options ranging from much better to much worse and whether they were happy they had the operation, with four response options ranging from very happy to not happy at all. Finally, they were asked whether their health was better or worse than they expected it to be and whether they felt that they were "back to normal."

Assessing quality of life after surgery.

Researchers and clinicians increasingly are recognizing the importance of assessing a wide range of outcomes when evaluating the efficacy of medical t...
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