key: cord-0767404-6qhnb4eq
authors: Kumar, Prasoon; Sen, Ramesh Kumar; Aggarwal, Sameer; Jindal, Karan; Rajnish, Rajesh Kumar
title: Assessment and reliability of the World Health Organisation quality of life (WHO QOL-BREF) questionnaire in total hip replacement patients
date: 2020-07-28
journal: J Clin Orthop Trauma
DOI: 10.1016/j.jcot.2020.07.020
sha: 1f911419527325e8e2f5fbfe25bb107655d7a3fe
doc_id: 767404
cord_uid: 6qhnb4eq

BACKGROUND: Total hip replacement (THR) is a standard procedure for diseased or damaged hips for which several functional scoring tools are available to evaluate the outcomes. Majority of these scores were devised in western countries and their cross-cultural compatibility is rarely demonstrated. The World Health Organisation quality of life (WHOQOL-BREF) questionnaire is one of the best known multilingual instruments for such assessment which has 4 domains. Its reliability has never been demonstrated for THR and the present study was conceptualised for the same. METHODS: THRs done over 6 years were followed up retrospectively. Revision THRs and hemiarthroplasties were excluded. All the cases were done by a single senior arthroplasty surgeon. Clinical examination was done and questionnaires for WHO QOL-BREF and Harris Hip scores were given to the patients. RESULTS: The number of patients included in the study was 96 with 115 operated hips. The average age of these patients was 41.40 years ranging from 17 to 80 years. There was strong male preponderance in our series of patients with 90 THRs. The mean score of domain 1 was 70.8 (SD 21.6), domain 2: 72.4 (SD 18.8), domain 3: 74.7 (SD 16.8) and domain 4: 75.4 (SD 14.8), which showed significant functional improvement post THR in domain 2 (P = 0.0001), domain 3 (P = 0.0010) and domain 4(P = 0.0001), when compared to scores of general healthy population. Similarly, the scores were significantly improved in all domains as compared to cohorts of post-operative acetabular and hip fractures. The score was found to be a reliable tool with Cronbach's alpha of 0.912 and strong correlation was present with the standard Harris hip scores (p = 0.000). CONCLUSION: WHO QOL is a potent tool to assess the quality of life in patients undergoing THR. It can be used as a single index of measurement and it is simple, reproducible and reliable.

Functional outcomes and quality of life (QOL) scores are important instruments to assess the efficacy of any surgical intervention. [2, 5] Majority of these scores were devised in western countries and their cross-cultural compatibility is rarely demonstrated. [8] QoL assessment in postoperative patients is not routinely done, probably due to nonavailability of a suitable instrument. [8] The World Health Organisation QOL-BREF (WHO QOL-BREF) questionnaire is one of the best known multilingual instruments for assessment QOL. [11] This instrument is crossculturally valid and is reflected by four domains: Physical, psychological, social and environmental. [6, 7, 11] . It focuses on a patient's own assessment of overall well-being. Total hip replacement (THR) is a standard procedure for diseased or damaged hips.

[1] WHO QOL-BREF has been demonstrated to be a suitable instrument for comprehensively evaluating the QOL in some health care settings, however, its reliability and validity has not been assessed in THR patients and since there is an increasing trend toward using functional outcome and QOL scores beside the clinico-radiological assessments for outcome analysis, the present study was conceptualised with an aim to validate WHO QOL-BREF score to assess the quality of life in these patients.

A total of 135 patients underwent THR at our institution during the period of June 2007 to May 2013, by a single senior surgeon. All the patients were followed up and enrolled after informed consent in this retrospective study. Recruitment of the patients were done through the out patients department (OPD) of our institute and evaluated by an independent observer, other than the one who performed all the surgeries. Revision THRs and the cases of hemiarthroplasties were excluded from the study. Patients with missing records were also excluded.

Questionnaires for WHO QOL were given to all the included patients, and clinical examination was done to evaluate for deformities and measure the range of motion at the hip joints.

Patients with more than 20% missing values were excluded from the analysis according to the rule of the WHO QOL Group (the WHO QOL Group, 1995; World Health Organization, 1996). The obtained raw score was converted to transformed domain scores on a scale from 0 to 100, by using the SPSS software.

Analysis of functional outcome was done by using the HHS (0-100). The results are categorised as excellent 90-100, good 80-89, fair 70-79 and poor if <70. Follow up period ranged from 6 months to 5 years and it was homogenous.

The SPSS software (version 20, SPSS Inc., Chicago, IL, USA) was used. Unpaired t test was used to compare the WHO QOL score and the HHS. Spearman correlation coefficient was used to study the relation between the various domains of the WHO QOL score and HHS. P value of less than 0.05 was considered as statistically significant. Reliability of the score was evaluated using Cronbach alpha test. Tukey's HSD (Honest Significant difference) test was used for evaluation of the scores among the etiological groups.

A total of 135 THR patients were called for follow up. The patients whose preoperative Xrays and other records were not available, and those with <6 months follow up were excluded from the study. Additionally there were 5 cases of revision THRs which were also excluded.

The number of patients included in the study was 96 with 115 hips operated. The average age of these patients was 41.40 years ranging from 17 to 80 years. There was strong male preponderance in our series of patients with 90 THRs. There were 47 THRs in non-traumatic avascular necrosis of hips, 35 for sequelae of trauma, 15 cases for primary osteoarthritis, 9

for rheumatoid arthritis, 6 for ankylosing spondylitis and 3 cases for tuberculosis hip sequelae Table 1 ] The comparison of scores among the various etiological groups was not significantly different (p>0.05). [ Table 2 ] Strong correlation was found on comparing this functional score with the HHS and the score was found to be reliable; Cronbach's alpha based on standardised items (4 domains of the WHO QOL-BREF and HHS) was 0.912.[ Table 3 ]

The aim of modern medicine is not just the treatment of the specific disease but to provide an overall upheaval of a patient's health. It involves the various aspects of well-being; physical, mental as well as social. The most reasonable method of assessing these domains is for the patient himself to assess the same by means of patient reported questionnaires. [2] WHO QOL scores are individualised scores that encompass every possible aspect of a patient's being, to evaluate the ultimate outcome of an intervention for a disease. It has shown cultural adaptability and validity in certain interventions like surgeries for acetabulum fractures and hip fractures. [4] In the present study we assessed the WHO QOL-BREF scores in THR patients, which is a very important and routinely done surgical procedure for diseased and painful hip joints. which showed significant improvements in the psychological, social and environmental domains, which were even better than scores in the average population. [7] The physical domain score is comparable to the general health population. These findings suggest that the overall quality of life, THR provides to its patients is remarkably good. The better results in the three domains may be explained by the fact that these surgeries are mostly done when the hip is increasingly damaged and the patients are debilitated to an extent where they cease to have a fruitful social and environmental life and have psychological deficits. So once their pain and debility diminishes post THR they report mental and social improvements which are relatively very highly significant. This point is also proven because the results in THR were also found to be better than groups of patients of hip fractures and acetabulum fractures who underwent fixations. [4, 12] However, there may be a possibility that the patients could have given better responses to the scoring to please the surgeon, which is a drawback of all patient reported outcomes. Psychological factors may lay a role in these outcome assessing modalities.

Harris Hip score is a validated tool for THR patients and we also calculated the same to correlate it with the quality of life scores in the study. [10] The positive correlation suggests that better the functional outcomes, better is the overall quality of life an intervention imparts to the patient. We also assessed the reliability of this score and found it to be significant and valid for use in THR patients. The fact that it also correlates significantly with a scoring tool (HHS) that has been previously validated and used in multiple studies for THR, adds to the overall strength and reliability for its clinical application.

The present study includes patients who were operated over 6 years and with adequate number of hips operated by a single surgeon (RKS); it provides a reliable assessment of the strength of WHO BREF QOL score in evaluating outcomes of THR patients. Despite its limitations of a retrospective design and short term follow up, the present study suffices the evidence in favour of this score being a good enough tool. These scores do not involve clinical examinations and the added advantage of such a patient reported outcome is that the actual presence of the patient is not even needed and the scoring can be done via a telephonic or video conversation. [2, 9] This saves time for both the patient and the assessor, latter could not even be a clinical practitioner, who in turn can devote the saved time in clinical practice.

[2] Additionally, this could specially help in follow ups of hip arthroplasty patients in these trying times of the Covid-19 pandemic, where routine OPDs are not functioning and the onus is on audio/video consultations. Although another patient reported and validated tool, the Modified Harris Hip score also does not need clinical examination, it only assesses pain and functional status of the patients; whereas a score like WHO QOL-BREF, encompasses every possible prognostic domain of well being, be it physical or socio-psychological. It is a more complete indicator for assessing outcomes in THR patients.

WHO QOL BREF score is a reliable tool to assess quality of life in total hip replacement patients which also correlates significantly with standard Harris hip scores. So, it may be used as a single index for quality of life and we recommend the same to evaluate the outcomes in total hip replacements as it is a simple, valid and reproducible method. 

Quality of life following total hip arthroplasty in patients with acetabular fractures, previously managed by open reduction and internal fixation

Reliability of Modified Harris Hip Score as a tool for outcome evaluation of Total Hip Replacements in Indian population

Displaced acetabular fractures managed operatively: Indicators of outcome

WHOQOL-BREF Hindi questionnaire: Quality of life assessment in acetabular fracture patients

Outcome measures following hip arthroplasty

Psychosocial aspect of quality of life of Polish women with breast cancer

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Use of telephone interviews to follow up patients after total hip replacement

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World Health Organization's. Quality of Life group: WHOQOL-BREF Introduction. Administration and Scoring. Field Trial version

Are hip-specific items useful in a quality of life questionnaire for patients with hip fractures?

Informed consent were obtained from all included patients