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Measuring quality of recovery-15 after day case surgery

Article in BJA British Journal of Anaesthesia · February 2016

DOI: 10.1093/bja/aev413

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 British Journal of Anaesthesia, 116 (2): 241–8 (2016)

doi: 10.1093/bja/aev413
Clinical Practice

Measuring quality of recovery-15 after day case surgery

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M. Chazapis1,2,3,4,*, E. M. K. Walker1,2,3,4, M. A. Rooms2,3, D. Kamming2,3
and S. R. Moonesinghe1,2,3,4,5
1
UCLH Surgical Outcomes Research Centre, Department of Applied Health Research, University College London,
UK, 2Centre for Anaesthesia, University College London, UK, 3Department of Anaesthesia and Perioperative
Medicine, University College Hospital, London, UK, 4National Institute for Academic Anaesthesia’s Health
Services Research Centre, Royal College of Anaesthetists, London, UK, and 5UCL Hospitals NIHR Biomedical
Research Centre, University College London Hospitals NHS Foundation Trust, London UK
*Corresponding author. E-mail: [email protected]

Abstract
Background: ‘Quality of recovery’ scores are patient-reported outcome measures evaluating recovery after surgery and
anaesthesia. However, they are not widely used in the clinical or research setting. The Quality of Recovery-15 (QoR-15) is a
recently developed, psychometrically tested and validated questionnaire.
Methods: We conducted a prospective study of all adult patients undergoing orthopaedic day case surgery over a period of six
months (June 2013–November 2013). Patients completed the QoR-15 score preoperatively, and then were asked to repeat the
score by telephone at 24 h, 48 h and seven days after surgery.
Results: 633 patients from a possible 714 (89%) completed the preoperative questionnaire and data from 437 patients who
completed scores at all four time points were analysed. Most patients returned to their preoperative score by 48 h, and had
exceeded it by seven days. Construct validity was supported by a negative correlation with duration of surgery and total
inpatient opioid use. There was also excellent internal consistency (Cronbach’s alpha 0.80–0.83).
Conclusions: The QoR-15 is a clinically acceptable and feasible patient-centred outcome measure after day case surgery. The
score demonstrated good validity, reliability and responsiveness. However, measurement of the QoR-15 score on the day of
surgery may not provide a true baseline value. We suggest one follow-up call at 48 h would enable an adequate patient-centred
assessment of postoperative recovery after day case orthopaedic surgery.

Key words: ambulatory surgical procedures E04.030; anesthesia E03.155; health care N05.700, quality assessment

Day case surgery is an expanding speciality. An increasing num- activities after surgery and anaesthesia is an important indicator
ber of patients are being considered suitable for more complex of a successful perioperative experience.4 Measuring the quality
surgery.1 The challenge is to maintain the quality of care and im- of recovery (QoR) from a patient’s perspective requires an assess-
prove patient outcomes within this type of healthcare delivery.2 ment of multiple patient-centred outcomes.4
Assessing postoperative patient recovery has traditionally fo- Multiple quality of recovery tools have been developed.5 6
cused on outcome measures of morbidity, mortality, physiologic- However, existing studies have focused predominantly on in-
al changes and re-hospitalization rates.3 These are important patient surgery rather than a day case setting. The QoR-15 is a re-
and should be measured, but these data represent only one as- cently developed and validated short-form postoperative QoR
pect of a patient’s recovery. A patient’s ability to resume normal score (Supplementary material).7 Fifteen questions assess five

Accepted: October 25, 2015

© The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
For Permissions, please email: [email protected]

241
242 | Chazapis et al.

between the QoR-15 at 24 h with age, gender, duration of

Editor’s key points
surgery and total opioid use (by calculating total morphine
• The QoR score is an established tool to measure quality of equivalents).
recovery after surgery, but there are no data on its use for (iii) Reliability – This describes consistency of questionnaire re-
day case surgery. sponses and was assessed using:
• This single-centre study evaluated the QoR score in adults 1. Internal consistency: This assesses the consistency of
undergoing day case orthopaedic surgery. results across items within a test.
• The QoR score was found to be feasible, reliable and 2. Inter-item correlation matrix: This assesses the correl-
consistent. ation of individual items within a test.
• However, scores taken within 24 h before surgery may not 3. Inter-dimension and Item-to-total dimension correla-
represent a ‘true’ baseline because of fatigue, anxiety or tions: These assess the correlation and consistency of
other factors. the individual dimensions within a test.

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(iv) Responsiveness – This describes the questionnaire’s ability
to detect change at a group and individual level and was as-
domains of patient-reported health status: pain, physical com- sessed using:
fort, physical independence, psychological support and emotion- 1. Cohen effect size, calculated as the average change
al state. The 11-point numerical rating scale leads to a minimum scores (from pre-test to post-test) divided by the sd at
score of 0 (very poor recovery) and a maximum score of 150 (ex- baseline.10
cellent recovery). 2. Standardised response mean, calculated as the change
The aim of this study is to test the acceptability and feasibility of scores divided by the sd of the change scores.10
of using the QoR-15 score as a patient-reported outcomes meas-
ure after day case surgery and anaesthesia, and to identify when Statistical analysis
we should be administering the QoR-15 score.
The sample size of this study was guided by previous studies,
as power calculations cannot be reliably determined with correl-
Methods ation analysis.7 Data are presented as mean (), median (interquar-
After approval by the local research ethics committee and desig- tile range), number (%) or 95% CI. All percentages are rounded up to
nation as a service evaluation, we conducted a prospective, ob- the nearest integer.
servational, cohort study of all adult patients undergoing day Continuous data were tested for normality using the Shapiro-
case orthopaedic surgery over a period of six months (June Francia and Shapiro Wilk normality tests; No variables were nor-
2013–December 2013) in University College Hospital, London. Pa- mally distributed.
tients were sequentially recruited and written consent obtained. To compare the patients who completed all three of the post-
Day case surgery was defined as surgical procedures not requir- operative questionnaires against the patients that did not,
ing a planned overnight hospital stay. the distributions of gender, ASA, BMI, smoking, presence of
Patients were excluded if they had a known history of alcohol comorbidities, type of surgery (upper limb or lower limb), use of
or drug abuse, a psychiatric disturbance precluding complete co- regional anaesthesia, type of general anaesthesia, and analgesic
operation, poor English understanding, or they were aged less use were compared using χ2 tests. The distributions of age,
than 18 yr old. duration of surgery, and total opioid use, were compared using
Eligible patients were approached and given a patient infor- two sample Kolmogorov-Smirnov tests.
mation leaflet on the day of surgery. Patients filled in the pre- Associations were measured using Spearman rank correl-
operative QoR-15 questionnaire (Supplementary material) ation coefficient (ρ) presented to two decimal places. Statistical
before their surgery. This completed questionnaire was a base- significance was set at a P value of ≤0.05 and where necessary,
line measure of health status over the previous 24 h. The patients Bonferroni’s correction was used to adjust for multiple compari-
were then telephoned by research nurses, and repeated the same sons with a corrected P value (P′) of <0.05. The non-parametric
questionnaire at 24 h, 48 h and seven days after surgery. Wilcoxon rank sum test (Mann–Whitney U-test) (z) and Kruskal
Additionally, anaesthetic and recovery staff collected patient Wallis tests were also used to compare QoR-15 scores.
characteristics and perioperative data. This included: age; gen- Internal consistency was measured using Cronbach’s alpha.11
der; ethnicity; ASA physical status; BMI; extent, type, and dur- Inter-dimension and item-to-total dimension correlation coeffi-
ation of surgery; type of anaesthesia and analgesia use. cients and average inter-item covariances were also measured.
The QoR-15 was psychometrically evaluated using data col- Comparisons between the total QoR-15 scores at different time
lected from patients who responded at all four time intervals.8 9 points were made using Friedman’s non-parametric anova, fol-
This included: lowed by Wilcoxon’s matched pairs test in case of significance.
Bonferroni’s correction was used to adjust for multiple compari-
(i) Acceptability and Feasibility - These were assessed by the: sons with a corrected P value (P′) of <0.05.
1. Patient recruitment rate All statistical analyses were performed using STATA/IC for
2. Successful completion rate of the questionnaire at all Mac v12.1 (StataCorp LP, Texas, USA).
four time points
3. Time taken to complete the questionnaire in a subset of
patients (n=50)
Results
4. Which patients were more likely to respond or not re- Over the study period of six months, a total of 714 patients were
spond to the questionnaire at any of the postoperative eligible for inclusion. The study flowchart is presented in Fig. 1.
time points 633 evaluable patients completed the preoperative and at least
(ii) Validity – This describes accuracy of the questionnaire. one postoperative questionnaire giving a recruitment rate of
Construct validity was explored, investigating associations 89%. Clinical characteristics of included and excluded patients
 Quality of recovery-15 after day case surgery | 243

Table 1 Patients’ characteristics. Number (%) or median

Assessed for eligibility (n=714)
(interquartile range) unless otherwise stated

Included Patients who Excluded

Excluded (n=81)
® Not meeting inclusion criteria (n=49)
patients responded patients
® Declined to participate (n=16) (n=633) at all 4 time (n=81)
® Poor english comprehension (n=12) points (n=437)
® Readmitted to hospital (n=4)
Age, yr Range 18–88 (47) 18–85 (47) 18–74 (44)
Sex (M/F) (%M) 308/325 (49) 214/223 (49) 38/43 (47)
Recruited into study (n=633) BMI (kg m−2) n (%)
<20 17 (3) 12 (3) 2 (3)
20–25 208 (33) 169 (39) 25 (31)

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26–30 198 (31) 144 (33) 27 (33)
24 hr follow up
® Completed questionnaire (80% n=505) >30 99 (16) 73 (17) 12 (15)
® Did not receive allocated intervention (unable >40 9 (1) 8 (2) 1 (1)
to contact) (n=128) >50 8 (1) 6 (1) 0 (0)
not recorded 94 (15) 25 (6) 14 (17)
Ethnicity
British 365 (58) 269 (62) 40 (49)
48 hr follow up
Any other White 91 (13) 54 (12) 15 (19)
® Completed questionnaire (76% n=480) background
® Did not receive allocated intervention (unable Black 24 (4) 17 (4) 4 (5)
to contact) (n=153)
Any other Black 4 (1) 2 (0.5) 0 (0)
background
Asian 47 (7) 27 (6) 8 (10)
Mixed 16 (3) 11 (2.5) 1 (1)
7 day follow up Any other ethnic 42 (7) 27 (6) 4 (5)
® Completed questionnaire (82% n=518) background
® Did not receive allocated intervention (unable
to contact) (n=115) not recorded 44 (7) 30 (7) 9 (11)
Comorbidities
Hypertension 73 (12) 57 (13) 11 (14)
Atrial Fibrillation 8 (1) 7 (2) 1 (1)
Fig 1 Study Flowchart.
Angina 8 (1) 6 (1) 0 (0)
MI 7 (1) 7 (2) 2 (2)
COPD 12 (2) 7 (2) 1 (1)
are presented in Table 1. There were no significant differences Asthma 60 (9) 47 (11) 9 (11)
Renal disease 3 (0.5) 3 (0.7) 0 (0)
between the study patients and the excluded patients.
Neuropathy 13 (2) 9 (2) 2 (2)
437 (69%) patients completed all three postoperative QoR-15
Diabetes 32 (5) 23 (5) 7 (9)
questionnaires. The mean time taken to complete the post-
Malignancy 1 (0.2) 1 (0.2) 0 (0)
operative 24 h QoR-15 score in a subset of patients (n=50) was Smoker 97 (15) 76 (17) 12 (15)
2.6 (1–7) min. There were no differences in gender, ASA, age, ASA
BMI, smoking, or any of the recorded comorbidities other than I 365 (58) 257 (59) 49 (60)
hypertension (P=0.036) in those who completed all three of the II 214 (34) 144 (33) 24 (30)
postoperative questionnaires and those who did not. The study III 29 (5) 23 (5) 3 (4)
staff informally reported that patients were very happy to be con- IV 0 (0) 0 (0) 0 (0)
tacted, found the questions easy to understand and overall felt it not recorded 25 (4) 13 (3) 5 (6)
Type of Orthopaedic Surgery
was a positive experience.
Shoulder/Clavicle 130 (23) 100 (23) 16 (20)
Box plots of total QoR-15 scores at each study time point are
Upper Limb/Other 36 (7) 23 (5) 4 (5)
presented in Fig. 2. The percentage of patients achieving the Wrist/Hand 98 (16) 68 (16) 15 (19)
highest possible QoR-15 score at the different time points were: Upper Limb Total 264 (42) 191 (44) 35 (43)
ppreoperative (8%, n=34), 24 h (6%, n=25), 48 h (8%, n=36), and at Lower Limb/Other 50 (7) 33 (8) 4 (5)
seven days (17%, n=75). The data are negatively skewed; levels Knee 132 (21) 88 (20) 19 (23)
of skew are: −1.29 (24 h), −1.42 (48 h) and −2.4 (seven days). ACL repair 24 (4) 13 (3) 4 (5)
There was no significant relationship between ethnicity and Foot/Ankle 163 (26) 107 (2) 19 (23)
total QoR-15 scores at any of the four time points (using Spear- Lower Limb Total 369 (58) 241 (55) 46 (57)
Duration of surgery, 55 (5–240) 55 (5–240) 60 (5–160)
man correlation: pre-op QoR-15 score, rho=-0.0274, P′=0.5699;
min
QoR-15 score at 24 h, rho=0.0186, P′=0.7002; QoR-15 score at
Length of recovery 50 (5–320) 45 (5–260) 55 (5–310)
48 h, rho=−0.0381, P′=0.4295; QoR-15 score at seven days, rho=
stay, min
−0.0641, P′=0.1836.
For each patient their total QoR-15 scores at each of the three
postoperative time points were compared with their preoperative
scores using the Wilcoxon signed-rank test. There was a differ-
ence between the preoperative total QoR-15 scores and those preoperative total QoR-15 scores and those measured at 48 h
measured at 24 h (z=2.154, P=0.03) and seven days (z=−9.610, (z=−1.197, P=0.23).
P=<0.001). Indeed, the seven day scores exceeded the preo- Construct validity was tested by comparing the total QoR-15
perative ‘baseline’ scores. There was no difference between the scores and patient’s gender, age, duration of surgery and total
244 | Chazapis et al.

opioid use. There was no difference between pre-op total QoR-15 Reliability indices measured using Cronbach’s alpha (α) for
scores in men and women [132(17) vs 129(18), respectively, the 437 patients for whom data were available at all time points,
P=0.06] or at 48 h [133(16) vs 131(17), P=0.27] and seven days [140 were high (>0.80) for all time points: α=0.83 for total preoperative
(12) vs 137(15), P=0.07]. Men had higher total QoR-15 scores at 24 h QoR-15 scores, α=0.81 at 24 h, α=0.80 at 48 h and α=0.83 at seven
[130(18) vs 126(19), P=0.02]. There was a negative correlation be- days. The inter-item correlation matrix at 24 h is shown in Table 2.
tween age and the preoperative total QoR-15 score, which was Inter-dimension and item-to-total dimension correlation coeffi-
statistically significant, ρ=−0.17, P′=<0.001; but this was not pre- cients at 24 h are included in Table 3.
sent at any of the postoperative time points. Responsiveness was calculated using the Cohen effect size
There were negative correlations between the total QoR-15 and standardized response means (SRM), included in Table 4
score and length of surgery, at 24 h (ρ=−0.13, P′=0.006) at 48 h for the three postoperative time points. Cohen effect sizes of
(ρ=−0.13, P′=0.009), and 7 days (ρ=−0.13, P′=0.007). There was a 0.2, 0.5 and 0.8 correspond to small, medium and large changes
negative relationship between the total QoR-15 score and total in quality of recovery scores. In this population, the total QoR-

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inpatient opioid use at 24 h (ρ=−0.16, P′=0.002), 48 h (ρ=−0.12, 15 score had a Cohen effect size of 0.31 at 24 h, 0.30 at 48 h and
P′=0.02), but not at seven days (ρ=−0.09, P′=0.06). 0.37 at seven days. Standardized response means of the total
QoR-15 score were 0.21 at 24 h, 0.22 at 48 h and 0.33 at seven days.

Discussion
Box plots of QoR 15 scores at each time point
We have found the QoR-15 to be a clinically acceptable and feas-
150 ible outcome measure after day case surgery. It demonstrates
good validity, reliability and responsiveness. We suggest one fol-
low-up call at 48 h would enable an efficient and clinically useful
Total QoR 15 score

patient-centred assessment of postoperative recovery.

100 This is the largest study using the QoR-15 questionnaire to
date; furthermore, only 21 patients evaluated in the original
QoR-15 study underwent day case surgery. Few psychometric
evaluations of QoR scores in the day surgery setting exist. Idvall
and colleagues12 psychometrically evaluated 399 patients, who
50
fully completed a modified 29-item QoR-40 after day case sur-
gery. Bost and colleagues13 assessed the 8-item Short-Form
Pre-op 24 hours 48 hours 7 days Health Survey (SF-8) and the QoR-40 in 154 patients after day
case anterior cruciate ligament repair surgery.
The high recruitment and response rate indicate that the QoR-
Fig 2 Box plots demonstrating median and IQR of total QoR-15 scores (437
patients) at each perioperative time point: preoperative, 24 h, 48 h and
15 is an acceptable and feasible outcome measure for day case
seven days after surgery. Whiskers demonstrate 5th and 95th percentiles. patients. Acceptability of patient-based outcome measures is im-
portant to ensure high return rates and results in less bias from

Table 2 Inter-item Correlation Matrix for the QoR-15 at 24 h postoperatively (437 patients). Quality of recovery (QoR)-15 items: 1=able to
breathe easily; 2=been able to enjoy food; 3=feeling rested; 4=have had a good sleep; 5=able to look after personal toilet and hygiene unaided;
6=able to communicate with family or friends; 7=getting support from hospital doctors and nurses; 8=able to return to work or usual home
activities; 9=feeling comfortable and in control; 10=having a feeling of general well-being; 11=moderate pain; 12=severe pain; 13=nausea or
vomiting; 14=feeling worried or anxious; 15=feeling sad or depressed. Inter-item Correlation Matrix for the QoR-15 at 24 h postoperatively
(437 patients)

QoR-15 question number Total 1 2 3 4 5 6 7 8 9 10 11 12 13 14

QoR-15
score

1. Breathing 0.33 —
2. Food 0.59 0.18 —
3. Rest 0.64 0.17 0.43 —
4. Sleep 0.64 0.11 0.38 0.63 —
5. Hygiene 0.48 0.17 0.24 0.23 0.23 —
6. Communication 0.34 0.24 0.19 0.13 0.18 0.22 —
7. Support 0.18 0.02 0.08 0.003 0.14 −0.02 0.12 —
8. Return to work 0.62 0.10 0.26 0.27 0.31 0.37 0.15 0.02 —
9. Feeling in control 0.71 0.18 0.38 0.44 0.40 0.23 0.19 0.05 0.42 —
10. Well-being 0.70 0.24 0.42 0.49 0.40 0.20 0.21 0.07 0.34 0.72 —
11. Moderate pain 0.50 0.07 0.09 0.21 0.20 0.16 0.09 0.05 0.32 0.35 0.23 —
12. Severe pain 0.64 0.21 0.33 0.35 0.38 0.25 0.19 0.11 0.30 0.38 0.31 0.18 —
13. Nausea/vomiting 0.41 0.17 0.41 0.14 0.17 0.09 0.22 0.13 0.15 0.14 0.12 0.13 0.26 —
14. Anxiety 0.60 0.26 0.24 0.26 0.21 0.17 0.20 0.09 0.23 0.38 0.47 0.22 0.38 0.21 —
15. Depressed 0.52 0.18 0.16 0.24 0.19 0.22 0.19 0.05 0.18 0.31 0.45 0.15 0.30 0.10 0.67
 Quality of recovery-15 after day case surgery | 245

Table 3 Inter-dimension and item-to-total dimension correlation coefficients. Inter-dimension and item-to-total dimension correlation
coefficients calculated at 24 h, 48 h and seven days after surgery (437 patients)

QoR-15 Question 24 h Inter- 24 h Item- 24 h Inter- 48 h Inter- 48 h Item-to- 48 h Inter- seven days seven days seven days
Number dimension to-total item dimension total item Inter- Item-to-total Inter-item
correlation dimension Cronbach correlation dimension Cronbach dimension dimension Cronbach
coefficient correlation alpha coefficient correlation alpha correlation correlation alpha
coefficient coefficient coefficient coefficient

1. Breathing 0.33 0.28 0.81 0.31 0.26 0.80 0.29 0.25 0.83
2. Food 0.59 0.50 0.80 0.57 0.50 0.79 0.57 0.52 0.81
3. Rest 0.64 0.56 0.80 0.63 0.55 0.78 0.63 0.56 0.81
4. Sleep 0.64 0.54 0.80 0.62 0.52 0.79 0.67 0.59 0.80

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5. Hygiene 0.48 0.37 0.81 0.52 0.42 0.79 0.55 0.47 0.81
6. Communication 0.34 0.31 0.81 0.37 0.35 0.80 0.29 0.27 0.83
7. Support 0.18 0.11 0.82 0.18 0.09 0.81 0.17 0.07 0.83
8. Return to work 0.62 0.48 0.80 0.64 0.49 0.79 0.67 0.53 0.81
9. Feeling in control 0.71 0.64 0.79 0.69 0.61 0.78 0.80 0.75 0.80
10. Well-being 0.70 0.63 0.79 0.68 0.61 0.78 0.77 0.71 0.80
11. Moderate pain 0.50 0.34 0.81 0.54 0.37 0.81 0.50 0.31 0.84
12. Severe pain 0.64 0.53 0.80 0.60 0.48 0.79 0.64 0.54 0.81
13. Nausea/Vomiting 0.41 0.30 0.81 0.41 0.32 0.80 0.31 0.23 0.83
14. Anxiety 0.60 0.51 0.80 0.56 0.46 0.79 0.69 0.63 0.80
15. Depressed 0.52 0.44 0.80 0.53 0.45 0.79 0.70 0.63 0.80
Test scale 0.81 0.80 0.83

non-responders.14 This highlights the QoR-15’s clinical useful- and allow targeted intelligent interventions to aid their recovery.
ness, not only for patients, but also for staff using the QoR-15 We suggest one follow-up call at 48 h would enable an adequate
for research and quality improvement purposes.14 patient-centred assessment of postoperative recovery after day
The QoR-15’s brevity means it can be read and completed case orthopaedic surgery.
quickly, as opposed to other longer QoR scores.8 15 16 Currently, The original paper assessed 21 day case surgery patients who
one of the most well-regarded and widely used QoR scores in sur- were contacted by telephone the day after their surgery.7 Their
gery is the QoR-40.4 Myles and colleagues6 developed and psy- mean QoR-15 scores and kurtosis were consistent with a normal
chometrically evaluated this comprehensive 40-item score. distribution. This is opposed to our analysis where we saw an in-
However it is a lengthy questionnaire, with most patients taking creasingly negative skew to the data, reflecting either better pa-
around 10 min to complete it. By contrast, in our study, the mea- tient recovery or lower surgical severity. Floor or ceiling effects
sured subset of patients was able to complete the QoR-15 ques- are present if greater than 15% of subjects achieve the highest
tionnaire in an average of 2.6 min. This is slightly longer than or lowest possible scores.17 This was not seen in the preoperative,
the original development and validation paper,7 but this could re- 24 h or 48 h scores, however a ceiling effect was observed seven
flect that the QoR-15 questionnaire in our study was not self- days postoperatively, with 17% of patients achieving the highest
administered. score. This is an expected effect, as patients will hopefully con-
Most patients’ QoR-15 scores had returned to their preopera- tinue to recover from their surgery over time. In the longer
tive values by 48 h and exceeded them by seven days. This indi- term, the increasing percentage of patients achieving the highest
cates the preoperative score may not be a true baseline score. possible score is a patient-reported outcome measure of surgical
Focusing in on individual items of the score, the results indicate success.
that patients are tired, anxious and in pain in the 24 h before sur- The QoR-15 demonstrated strong construct validity. It was
gery. These circumstances may not provide an ideal baseline for able to discriminate between the genders, as it has previously
comparison. A measurement taken during preoperative assess- been shown that women have a worse postoperative recovery.2 18
ment, or at the time of surgical booking could provide a truer A negative association was demonstrated between the QoR-15
baseline score, with possibly lower scores for anxiety and tired- and duration of surgery and total opioid use. The negative asso-
ness. However, preoperative pain measures may be unchanged, ciation with total opioid use may reflect the severity of the sur-
as pain may be the reason for the surgery. A QoR-15 measure- gery, as a bigger, more painful operation may lead to a slower
ment after complete recovery may be a better comparator, but recovery post-discharge.
this assumes that patients will have a complete recovery. Internal consistency was measured using Cronbach’s α coeffi-
Measuring the QoR-15 at three postoperative time points is cient. The results were high and satisfied published recommen-
feasible, but is very time and resource heavy, requiring dedicated dations (0.70–0.90).19 These results are comparable with the
staff. The data suggest most patients return to their preoperative validation paper of the QoR-15,7 the longer form QoR-406 and ex-
scores by 48 h after surgery, despite this score not being a true ceed those of the modified 28-item QoR 40.12 Internal consistency
baseline. If a patient has not approximated their preoperative was also measured using inter-item correlation. Each item was
score by 48 h, this may indicate a deviation from their expected internally consistent (coefficient values 0.79–0.83) and correlated
recovery. Enhanced recovery after surgery is based on adherence well with the total QoR-15 score.
to protocols and the care pathway, and managing deviations ap- The responsiveness was assessed using Cohen effect size and
propriately.16 Measurement of the QoR-15 at 48 h may aid identi- standardized response means.20 The Cohen effect size was 0.37,
fication of patients who are not recovering as well as expected, suggesting a moderate ability to detect change. This is a lower
246 | Chazapis et al.

Table 4 Responsiveness of the total QoR-15 score. Individual item mean QoR-15 scores, Cohen effect sizes and Standardized Response
Means (SRM) at 24 h, 48 h and seven days after surgery, compared with preoperative values (437 patients)

Mean scores (±) Mean change from % Change Cohen effect size SRM
pre-op score (95% CI) from pre-op

QoR-15 score pre-op

1. Breathing 9.6 (1.0) NA NA NA NA
2. Food 9.6 (1.2) NA NA NA NA
3. Rest 8.2 (2.1) NA NA NA NA
4. Sleep 7.8 (2.2) NA NA NA NA
5. Hygiene 9.7 (1.1) NA NA NA NA
6. Communication 9.9 (0.6) NA NA NA NA

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7. Support 9.4 (1.7) NA NA NA NA
8. Return to work 8.5 (2.7) NA NA NA NA
9. Feeling in control 8.8 (2.0) NA NA NA NA
10. Well-being 8.6 (2.0) NA NA NA NA
11. Moderate pain 6.6 (3.4) NA NA NA NA
12. Severe pain 8.1 (3.0) NA NA NA NA
13. Nausea/vomiting 9.4 (2.1) NA NA NA NA
14. Anxiety 7.6 (2.7) NA NA NA NA
15. Depressed 8.6 (2.5) NA NA NA NA
QoR-15 Score at 24 H
1. Breathing 9.8 (0.9) 0.2 (0.05 to 0.3) 2.0 +0.2 +0.1
2. Food 9.1 (2.1) −0.6 (−0.8 to −0.4) 6.3 −0.5 −0.3
3. Rest 8.4 (2.4) 0.2 (−0.08 to 0.5) 2.4 +0.1 +0.07
4. Sleep 7.7 (2.8) −0.1 (−0.4 to 0.2) 1.3 −0.05 −0.03
5. Hygiene 8.8 (2.3) −0.9 (−1.1 to −0.7) 9.3 −0.8 −0.4
6. Communication 9.9 (0.5) 0.02 (−0.05 to 0.1) 0.2 +0.03 +0.03
7. Support 9.8 (1.2) 0.4 (0.2 to 0.6) 4.3 +0.2 +0.2
8. Return to work 5.2 (3.6) −3.2 (−3.6 to −2.8) 37.6 −1.2 −0.8
9. Feeling in control 8.5 (2.3) −0.3 (−0.5 to −0.01) 3.4 −0.2 −0.1
10. Well-being 8.8 (2.1) 0.2 (−0.06 to 0.4) 2.3 +0.1 +0.07
11. Moderate pain 6.2 (3.4) −0.4 (−0.9 to −0.002) 6.1 −0.1 −0.09
12. Severe pain 8.6 (2.9) 0.5 (0.1 to 0.8) 6.2 +0.2 +0.1
13. Nausea/vomiting 9.1 (2.3) −0.2 (−0.5 to 0.05) 2.1 −0.1 −0.08
14. Anxiety 9.0 (2.2) 1.3 (1.1 to 1.6) 17.1 +0.5 +0.4
15. Depressed 9.3 (1.9) 0.7 (0.4 to 0.9) 8.1 +0.3 +0.3
QoR-15 Score at 48 H
1. Breathing 9.9 (0.8) 0.2 (0.1 to 0.3) 2.1 +0.2 +0.2
2. Food 9.3 (1.7) −0.3 (−0.5 to −0.1) 3.1 −0.3 −0.2
3. Rest 8.8 (2.0) 0.6 (0.3 to 0.8) 7.3 +0.3 +0.2
4. Sleep 8.5 (2.3) 0.6 (0.4 to 0.9) 7.7 +0.3 +0.2
5. Hygiene 9.0 (1.9) −0.7 (−0.9 to −0.5) 7.2 −0.6 −0.4
6. Communication 9.9 (0.4) 0.04 (−0.03 to 0.1) 0.4 +0.07 +0.05
7. Support 9.7 (1.4) 0.3 (0.09 to 0.5) 3.2 +0.2 +0.1
8. Return to work 5.8 (3.4) −2.7 (−3.0 to −2.3) 31.8 −1.0 −0.7
9. Feeling in control 8.8 (2.1) 0.005 (−0.2 to 0.2) 0.06 +0.003 +0.002
10. Well-being 9.0 (1.9) 0.3 (0.1 to 0.5) 3.5 +0.2 +0.2
11. Moderate pain 6.3 (3.3) −0.3 (−0.7 to 0.1) 4.5 −0.09 −0.07
12. Severe pain 8.6 (2.7) 0.5 (0.2 to 0.9) 6.2 +0.2 +0.1
13. Nausea/vomiting 9.5 (1.5) 0.2 (−0.06 to 0.4) 2.1 +0.1 +0.07
14. Anxiety 9.1 (2.0) 1.5 (1.2 to 1.8) 19.7 +0.6 +0.5
15. Depressed 9.4 (1.8) 0.8 (0.5 to 1.0) 9.3 +0.3 +0.3
QoR-15 Score at seven days
1. Breathing 9.9 (0.6) 0.3 (0.2 to 0.4) 3.1 +0.3 +0.3
2. Food 9.7 (1.1) 0.08 (−0.06 to 0.2) 0.8 +0.07 +0.05
3. Rest 9.4 (1.5) 1.1 (0.9 to 1.3) 13.4 +0.5 +0.5
4. Sleep 9.1 (1.9) 1.2 (1.0 to 1.4) 15.4 +0.5 +0.5
5. Hygiene 9.4 (1.6) −0.3 (−0.4 to −0.1) 3.1 −0.3 −0.2
6. Communication 10.0 (0.3) 0.07 (0.02 to 0.1) 0.7 +0.1 +0.1
7. Support 9.7 (1.4) 0.3 (0.1 to 0.5) 3.2 +0.2 +0.1
8. Return to work 7.3 (3.0) −1.2 (−1.5 to −0.9) 14.1 −0.4 −0.3
9. Feeling in control 9.4 (1.5) 0.6 (0.4 to 0.8) 6.8 +0.3 +0.3

Continued
 Quality of recovery-15 after day case surgery | 247

Table 4 Continued

Mean scores (±) Mean change from % Change Cohen effect size SRM
pre-op score (95% CI) from pre-op

10. Well-being 9.3 (1.6) 0.7 (0.5 to 0.9) 8.0 +0.4 +0.4
11. Moderate pain 7.5 (3.0) 0.9 (0.5 to 1.3) 13.6 +0.3 +0.2
12. Severe pain 9.2 (2.1) 1.1 (0.8 to 1.4) 13.6 +0.4 +0.3
13. Nausea/vomiting 9.8 (1.1) 0.4 (0.2 to 0.6) 4.3 +0.2 +0.2
14. Anxiety 9.5 (1.5) 1.8 (1.6 to 2.1) 23.7 +0.7 +0.7
15. Depressed 9.5 (1.6) 0.8 (0.6 to 1.1) 9.3 +0.3 +0.3

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value than the original validation paper, but this could reflect the Acknowledgements
lower severity of procedures undertaken in our ambulatory sur-
We would like to thank the following contributors who collected
gery population. For individual dimensions, the effect sizes var-
data: R. Aziz., E.J. Bettini., D. Blackwood., D. Brunnen., L. Cairns.,
ied, being greatest for the physical independence questions, and
R. Coe., R. Gordon-Williams., P. Gorur., M. Hoy., E.I. Mcllroy.,
lowest for the pain dimension. For all individual items, Cohen
J. Patel., D. Wagstaff., D. Wyndham., D. Zeloof.
effect size values ranged from small to large scales of responsive-
ness. The most responsive was question eight, on the ability to
return to work or usual activities, followed by question five, on
Declaration of interest
ability to maintain personal toilet and hygiene unaided. The
least responsive items varied between the three time points, None declared.
and included the items on ‘feeling comfortable and in control’
and ‘the ability to communicate with family and friends’. This
raises the possibility of removing these two questions from the
Funding
QoR-15 score for day case surgery. However, they address import- National Institute for Health Research UCL/UCLH Biomedical Re-
ant discrete parts of a patient’s recovery and wellbeing, and pa- search Centre (where S.R.M. is a member of the Faculty), through
tients scoring low in these items must be identified. support for the UCL/UCLH Surgical Outcomes Research Centre,
Our study has some limitations. It was conducted in a single University College Hospital, London. S.R.M. receives funding for
university-affiliated hospital in London, UK, therefore generaliz- her role as Deputy Director of the NIAA Health Services Research
ability outside this setting is unknown; however, our patient co- Centre and as a Health Foundation Improvement Science Fellow
hort was representative of diverse ethnicity, age, gender and (2015-18). M.C. was supported through a grant awarded by the
comorbidities. The study cohort was limited to orthopaedic day National Institute for Academic Anaesthesia’s Health Services
case surgery, therefore, formal assessment in other procedural Research Centre.
cohorts may be of interest. Finally, the follow-up questionnaires
were not self-administered, which may have led to administra-
tion bias. To address some of these limitations, we suggest that References
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