QOL concerns in surgical patients: Assessment and intervention

Patient quality of life (QOL) is a vitally important clinical outcome measure in surgical practice.1 In this article, the authors describe efforts to assess patient concerns and interventions to address deficits in QOL. Surgical teams are interested in learning how to measure QOL interventions effectively and to assist their patients in preserving or improving their QOL in the perioperative time.

Drawbacks of rehabilitation programs

To improve perioperative QOL and functional recovery, patients often are asked to participate in rehabilitation programs, many of which involve physical or psychosocial interventions. The rationale for employing physical exercise programs is based on reports that exercise interventions can ameliorate deficits in QOL and fatigue, including cancer-related fatigue. It follows that positive changes in fitness could lead to a reduction of cancer-related fatigue and overall improved QOL.2

Traditional rehabilitation programs, such as aerobic exercise and smoking cessation programs, address issues that affect patient outcomes and are usually prescribed by a physician. Both in the preoperative setting and after a significant health event, such as a heart attack or major abdominal surgery, patients may have difficulty adhering to such programs.3

For example, one patient reported that although she increased her physical fitness significantly during rehabilitation, she had “no QOL” because the frequency and duration of the exercise program had entirely disrupted her social life. The patient went so far as to say she would have preferred that she had not survived, indicating that neither her emotional nor social needs had been met. Few patient-provider encounters provide enough time to explore these needs. There is increased attention to quality measures, such as pay-for-performance, that improve narrowly-defined patient outcomes, which results in conflicting goals between patients and providers and increases stressors on patients, providers, and other stakeholders.4

PROQOL

To address a similar problem associated with a different disease, chronic diabetes, the Beacon Patient-Reported Outcomes Quality of Life (PROQOL) Tool was launched by the Southeast Minnesota Beacon Program, Rochester, with funding from the Beacon program communities health information technology grant/award. PROQOL was developed with input from patient and health care providers and resulted in practical lessons learned for organizations interested in integrating the patient’s perspective into care management.

In this system, patient-reported outcomes are systematically measured and made available electronically to all health care providers, independent of location. Patients are able to report concerns related to less commonly discussed issues that may affect health management, such as social factors and personal relationships. The health care team develops a repository of “suggested actions” to respond to a broad set of issues that affect the patient’s health management within and without the formal health care system.5 Partnering with patients, caregivers, and other stakeholders, the original PROQOL tool used in the Beacon trial for diabetes can be modified to address issues common to other patients.6

The patients’ single biggest concern will trigger a list of suggested actions from the repository. The patient and provider then can select interventions that are likely to suite the patient’s needs (see figure 1A and 1B). Health care provider assessment may yield additional recommendations based on known modifiable risk factors for decreased QOL (such as lowered functional capacity/exercise and anemia) and postoperative complications, including immune-enhancing nutrition and smoking cessation.

PROQOL Domains

Patients select their single biggest concern from the domains shown (A). Based on the domain selected, the patient is then provided with a checklist to answer related to that specific domain (B). (Figures © Jeff Sloan, Mayo Clinic.)B.

Patients select their single biggest concern from the domains shown (A). Based on the domain selected, the patient is then provided with a checklist to answer related to that specific domain (B). (Figures © Jeff Sloan, Mayo Clinic.)

Different patients will have different concerns, such as physical or emotional health or work/financial concerns. Their specific concerns will connect them to the corresponding resources in the repository. For example, if a patient identifies cost of treatment as their biggest concern, suggested actions include a review of medications by the physician for more economical options, referral to the institutional financial resources, alerting the public health nurse to initiate case management, and identifying government programs for financial aid, community supportive resources such as the American Cancer Society resources, and Internet resources the patient can access independently. In this manner, the entire spectrum of stakeholders, both clinical and non-clinical, health care institutions, and community are mobilized to address the patient’s biggest concern.

As another example, if fatigue is identified as the main concern, the patient would be guided toward exercise modification, relaxation techniques, and potential screening for depression.

The PROQOL system hence identifies and addresses otherwise uncovered clinical problems in roughly 25 percent more patients than in standard care, which increases patient satisfaction with care, reduces complications, and improves QOL for both the patients and their caregivers.


References

  1. Bingener J, Sloan J, Boughey JC. Patient quality of life: Vitally important. Bull Am Coll Surg. 2014;99(5):46-48.
  2. Peddle CJ, Jones LW, Eves ND, et al. Effects of presurgical exercise training on quality of life in patients undergoing lung resection for suspected malignancy: A pilot study. Cancer Nursing. 2009;32:158-165.
  3. Carli F, Charlebois P, Stein B, et al. Randomized clinical trial of prehabilitation in colorectal surgery. Br J Surg. 2010;97(8):1187-1197.
  4. Ofri D. Doctor priorities vs. patient priorities. New York Times. Well blog. March 27, 2014.
    Available at: http://well.blogs.nytimes.com/2014/03/27/doctor-priorities-vs-patientpriorities/?_
    php=true&_type=blogs&_r=0. Accessed September 12, 2014.
  5. Ridgeway JL, Beebe TJ, Chute CG, et al. A brief Patient-Reported Outcomes Quality of Life (PROQOL) instrument to improve patient care. PLoS medicine. 2013;10:e1001548. doi:10.1371/journal.pmed.1001548.
  6. Sloan J, Gowan M, Hubbard J, Halyard M, Sloan E. Incorporating validated measures for patient-reported outcomes in clinical practice. Proceedings of the 3rd International Conference on Chemical, Ecology and Environmental Sciences (ICEES 2014) March 19–20, 2014. Abu Dhabi (UAE). Pp 92-97. Available at: http://psrcentre.org/images/extraimages/314010.pdf. Accessed September 8, 2014.

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