Judging the quality of life after surgical operations

Quality of life as an outcome measure in surgical oncology

Background

There is a growing interest in assessing the impact of a disease and the effect of a treatment on a patient's life, expressed as health-related quality of life (HRQoL). HRQoL assessment can provide essential outcome information for cancer surgery.

Methods

The core of this review is derived from a literature search of the Medline database.

Results

Three types of HRQoL instrument can be distinguished: generic, disease specific and symptom specific. There are criteria against which HRQoL instruments may be evaluated. The instrument chosen must be reliable, valid and sensitive to change.

Conclusion

HRQoL measurement may be useful in identifying the optimal surgical procedure. It may also be of help in deciding whether surgery in patients with limited life expectancy should still be considered. No HRQoL instrument fits all the recommended conditions or is suitable in all clinical situations. Using the appropriate instrument is essential to arrive at valid and clinically meaningful outcome measures.

Quality of life as an outcome variable in oncology and surgery

The major objective of all health interventions is to improve the quality of life. Assessment of the results of treatment for cancer has traditionally included tumour response, treatment toxicity, patient's physical performance status and length of survival. More recently, attempts have been made to incorporate quality of life assessment in oncology research and practice. The audit of surgical treatment includes the evaluation of process and outcome. Although prominence has often been given to the relatively readily identified negative features of operative mortality and complications, both positive and negative effects need to be assessed. Elective surgery may be intended to reduce the risk of future disease-specific mortality but it may be extremely difficult to establish whether this objective has been achieved. We therefore need to recognize that the main and legitimate aims of elective surgery are to relieve disability, discomfort and disfigurement. These are quality of life issues. Minimally invasive surgery and day surgery are examples of current practice where quality of life assessment is important in the thorough evaluation of their role. In this review the available methods of assessment of quality of life are examined and a case is made for their routine inclusion in the evaluation of treatment in oncology and surgery.

Quality-of-life measurement in surgical practice

Assessment of quality of life is gaining momentum in areas of medical practice where standard measures of outcome are not sensitive enough to determine treatment strategies. Such methods have not been widely adopted in the surgical specialties, although this is changing. The techniques used are easily understood but they have not been standardized and are subject to several confounding factors. Nevertheless, quality-of-life measurement may provide additional information in the research environment and surgical audit.

Subjective quality of life measures for evaluating medical intervention

Medical interventions are usually evaluated in terms of mortality and morbidity data, but there is recent interest in going beyond medical data to assess the impact of the therapy on the objective and subjective quality of the patient's life. Objective quality of life measures such as employment and functional status are relatively straightforward, but measuring subjective quality of life is a more complex task. This article reviews psychometric issues relevant to using subjective quality of life scales developed by Bradburn and by Campbell, Converse, and Rodgers for research with patient populations. The evidence indicates that these relatively brief scales assess both affective and cognitive aspects of subjective quality of life, that they are measuring something more stable than mood but less enduring than personality, and that they can be as sensitive as physiological measures in distinguishing among treatment groups. It is concluded that these scales offer a useful complement to more objective measures of patient status for research evaluating medical interventions.

[Evaluation of the performance of health services]

Recent literature (up to 1988) on health services assessment in general and especially on hospital service assessment is reviewed, with special attention to its conceptual and methodological aspects. The history of this process is also examined, from the first attempts by the American College of Surgeons, through the Joint Commission for Hospital Accreditation activities up to more recent efforts. The Diagnosis Related Group methodology is commented especially, as well as its more recent complement, the severity of illness indicators. Progress made in this field is briefly examined as in the light of the Brazilian situation. The origins of the growing international concern with this field are enumerated: soaring costs of health services; the recent growth in the number of medical malpractice suits; and the sharp increase in the complexity of health services. The sources of information used in the process, such as immediate observation (case-control type studies), medical records, and summary instruments already in use for payment or financial control purposes, are commented on. Mention is made of the deep influences of the assessment process on practice as in the case of the standardization of practices and procedures, staging of the pathological processes, trajectory-type studies; the utilization of tracer situations, and, finally, the most influential on practice of all these assessment instruments: the diagnosis and treatment protocols, already in wide use in some medical fields such as cancer treatment even in developing countries.