Anaesthesia 2020, 75, 576–579
14980
Editorial
Regional anaesthesia and quality of recovery after surgery
D. Burns1 and A. Perlas2
1 Fellow, 2 Professor, Department of Anaesthesia and Pain Management, Toronto Western Hospital, University Health
Network, University of Toronto, ON, Canada
............................................................................................................................................................................................................................................................................................................
Correspondenc to: A. Perlas
Email: Anahi.perlas@uhn.ca
Accepted: 10 December 2019
Keywords: patient-centred outcomes; quality metrics; recovery from surgery
This editorial accompanies an article by Koning et al., Anaesthesia 2020; 75: 599–608.
Twitter: @PerlasAnahi, @donoghb
Recovery from surgery is a complex process dependent on
surgical, anaesthetic and patient factors, among others.
Traditionally, recovery has been measured primarily by
physiological parameters and adverse events such as
morbidity and mortality [1]. More recently, there has been a
shift of emphasis towards defining recovery from a patient’s
perspective, with self-reported measures of recovery
incorporating multiple postoperative domains [2]. This
reflects both a decrease in overall surgical morbidity and
mortality due to surgical and anaesthetic advances as well as
an increased focus on factors of importance to the patient [3].
In this issue of Anaesthesia, Koning et al. report on the
impact of an anaesthetic
bupivacaine and morphine added to general anaesthesia)
on the quality of recovery after robot-assisted radical
prostatectomy [4]. The primary outcome was the 15-item
Quality of Recovery (QoR-15) score and a statistically
significant improvement was reported in this study [5].
What is the QoR-15 and should we use
it more often?
The QoR-15 is a patient-reported outcome measurement of
postoperative quality of recovery, published and available
on a free-to-access basis [5]. This tool was developed by the
same group that produced the nine-item ‘QoR’ score in
1999 [6], and expanded on it with the longer and more
comprehensive QoR-40 in 2000, which demonstrated
superior validity and reliability [7]. Quality of Recovery-40
has been extensively used and validated in the intervening
period [8]. Five dimensions are included in QoR-40: pain;
physical comfort and physical independence (grouped as
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physical well-being); and psychological support and
emotional state (grouped as mental well-being). Quality of
Recovery-15 was in turn derived from QoR-40 as a simplified,
shorter version limited to one page which enhances its
feasibility and likelihood of completion. Quality of Recovery-
15 has equivalent psychometric properties to QoR-40 with an
estimated time to completion of 2.5 min vs. 10 min for QoR-
40 [5]. Each of the 15 questions included in this questionnaire
is answered on an 11-point numerical rating scale (0–10). The
resulting composite score (scaled from 0 to 150) is attained
by summing the values from each question to produce a
single number. The maximum score of 150 would represent a
intervention (intrathecal ‘perfect’ condition with no pain, no nausea or vomiting, no
sleep disruption, feeling of well-being, able to perform own
hygiene and no anxiety or sadness.
Quality of Recovery-15 has been validated in patients
undergoing surgery and general anaesthesia across a range
of minor, intermediate and major surgical procedures, thus
it represents an appropriate measure for quality of recovery
in the surgical context of robot-assisted radical
prostatectomy. This scoring system has been shown to be
reliable, consistent, responsive and clinically acceptable [5],
with translation and validation into multiple languages and
has undergone systematic review [9]. The QoR-15 score
(alongside the nine-item QoR score) has recently been
recommended by the standardised endpoints in peri-
operative medicine initiative as one of six endpoints which
should be considered for inclusion in clinical trials assessing
patient comfort and pain after surgery [10]. Furthermore,
the European Society of Anaesthesia (ESA) – European
Society of Intensive Care Medicine joint taskforce has
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Editorial
recommended QoR-15 as the standardised outcome
measure for quality of recovery [11]. The use of such
validated, standardised measures in clinical trials is deemed
necessary to enable accurate comparison of results across
studies. A limitation of composite scoring is that it assigns
equal value to different recovery parameters, so that, for
example, severe pain produces equal weighting to the
inability to look after personal hygiene [12]. The score is
intended for use in clinical trials and in quality assurance,
but not at the individual level to determine adequacy of
recovery.
Alternative quality of recovery scores
Several alternative multidimensional quality of recovery
assessment scores are available. The Surgical Recovery
Index (SRI) [13], Postoperative Quality of Recovery Scale
(PQRS) [14] and Surgical Recovery Scale (SRS) [15] have also
been validated for inpatient surgical populations. In
selecting a suitable scoring system to examine the impact of
a regional anaesthetic intervention, pain should form part of
the assessment and the time-frame should be the early
postoperative period. In this respect, the Surgical Recovery
Index (SRI) with a first measurement at postoperative day 7
and the SRS with measurements at baseline, days 3, 7, 30
and 60 would not be ideally suited, as they may miss the
early recovery phase, the window during which regional
anaesthesia consistently has the greatest impact on
recovery. The PQRS tool is based on six domains of
recovery, including nociception, with a dichotomous
scoring system in which the postoperative return to a
patient’s previous baseline is assessed to determine
adequacy of recovery. This system provides flexibility in the
assessment of each domain separately and includes a
cognitive assessment with a range of timeframes from the
immediate postoperative period through days 1, 3 and at
3 months if required [14]. The PQRS score, therefore, could
also be considered to assess the effect of a regional
anaesthesia intervention.
Suitability of QoR-15
In this context, we commend Koning et al. for the use of
QoR-15 as a primary outcome measure for their study. As is
recommended, the questionnaire was conducted before
surgery to provide baseline data and then repeated at 24 h
after surgery [11]. The premise that improvement in
analgesia due to the study intervention would lead to a
significantly smaller decline in QoR-15 score would appear
to be a reasonable and indeed intuitive expectation. While
only two of the QoR-15 questions explicitly refer to pain,
other questions such as to what extent the patient had been
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Anaesthesia 2020, 75, 576–579
‘feeling comfortable and in control’ and to what extent they
‘had a good sleep’ might be expected to involve pain as a
factor.
How should we interpret QoR-15 in
clinical trials?
A question of paramount importance when interpreting the
results of a trial is what is the difference in score that would
be considered minimally clinically important; in other
words, significant enough to warrant the intervention?
Smaller differences below that threshold would be
considered clinically negligible and would not support the
intervention, irrespective of the result of statistical tests. In
the study by Koning et al., the difference in QoR-15 score
between the study and control groups was modest (5 points
on the scale of 0–150). As the authors have acknowledged,
this is less than the 8 points defined as the MCID [16], and on
this basis, we would question if it is accurate to describe the
outcome of this study as a positive result. Although
the difference of 5 points was statistically significant, the
magnitude of the difference is likely clinically negligible
[17].
When the five subdomains of QoR-15 were individually
analysed, the domain of ‘pain’ (two questions on the extent
of moderate pain and severe pain over the preceding 24 h)
was the only one of the five to yield statistical significance.
Within this domain, the effect size was relatively small with 6/
20 in the control group vs. 2/20 in the intervention group.
The postoperative morphine consumption via patient-
controlled intravenous analgesia was 1.5 mg in the study
group vs. 5 mg in the control group, again a small
difference of questionable clinical significance.
The striking finding is the relatively low pain scores
and opioid consumption recorded in the control group
receiving standard care in this centre. Consequently,
the scope for improvement in quality of recovery by an
intervention addressing acute pain would naturally be
expected to be limited. Although the study was
powered based on an estimated decline in QoR-15 at
postoperative day 1 (POD 1) of 35% in the control
group and 25% in the study group, the actual decline
in the control group was only about 12% (or 18
points). In fact, the score for the control group on
POD1 was 118, which coincidentally is the threshold
previously defined as the ‘patient acceptable symptom
state’ [16]. The ‘acceptable’ recovery score in the
control group by virtue of the efficacy of multimodal
analgesia has made further significant clinical
improvement from the addition of intrathecal morphine
challenging to achieve.
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Anaesthesia 2020, 75, 576–579
What types of interventions and what
surgical procedures have the greatest
impact on QoR-15?
In order to use QoR-15 to its maximum potential we need
to establish when its use as a research tool is most
appropriate. The impact of clinical trials is dependent on
the use of well-defined patient-centred outcome measures
that are potentially modifiable by the trial intervention [11].
It stands to reason that more invasive surgical procedures
affecting major organ systems, with high levels of
postoperative pain and functional limitation, will have the
greatest postoperative declines in QoR-15, and in turn will
be more susceptible to improvement from an effective
intervention. Indeed, Myles et al. have reported 24-h mean
postoperative scores of 127, 114 and 106 for minor,
intermediate and major surgery, respectively [16]. At the
same time, major regional anaesthesia interventions with
substantial positive impact on several aspects of
physiology (e.g. thoracic epidural analgesia for major
laparotomy) [18] are more likely to improve postoperative
outcomes than more minor regional anaesthesia
interventions aimed at improving analgesia as part of a
multimodal regimen (e.g. an adductor canal block for total
knee arthroplasty).
In terms of future clinical trial designs, it may be prudent
to undertake a pilot study to determine an accurate baseline
Q0R 15 in the control (standard care) group. If a small
postoperative decline is noted with the current standard of
care, it may be unlikely that any intervention will produce an
improvement in individual domains of recovery large
enough to yield a positive result (of at least 8 points). In
addition, an isolated intervention that in itself is expected to
provide a small, incremental benefit (e.g. postoperative
paracetamol), although unlikely to improve QoR 15 in and
of itself, may be a useful component of a larger multimodal
strategy. Mature multimodal analgesic regimens that
include regional anaesthesia and systemic analgesics are
gold-standard therapy for many surgical procedures, and
when taken as a group, have been proven to effectively treat
pain and reduce side-effects [19]. It remains necessary to
assess if the addition of an analgesic intervention to a ‘best-
practice’ multimodal technique further improves pain
control or allows replacement of another analgesic
intervention to improve cost effectiveness and/or safety
[20]. However, it is unlikely that if studied in isolation each
individual component of the regimen would result in a
significant improvement to a complex outcome such as
QoR-15.
This begs the question of how worthwhile new
interventions are in clinical scenarios where an ‘acceptable’
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Editorial
baseline quality of recovery already exists. As with any
treatment, the potential benefits must be weighed against
the clinical risks as well as cost and resource requirements,
within a cost effectiveness framework. In the context of
marginal gains in patient outcomes, this presents a
challenge as we strive to innovate and improve standards of
care. In certain outcomes, such as the goal of reducing
opioid consumption, some benefits of novel techniques and
treatments may not necessarily be reflected in the QoR-15
score if recovery from the patient’s perspective is not altered
significantly.
In retrospect, had pain score been examined as a
primary instead of secondary outcome in this study it is a
reasonable assumption that statistical significance would
also have been demonstrated. It would be overly
speculative to comment on whether any difference in this
outcome might have been clinically significant in this
instance. Regardless, a clearly defined and accepted
clinically important difference (i.e. two points in an eleven
point numerical rating scale) should be demonstrated to
support positive findings in a pain score outcome [21].
Traditional outcome measures such as pain or opioid
consumption represent a more conservative option for
investigators, whereas a positive finding on a
multidimensional quality of recovery scale would carry
greater clinical weight. For this reason, we support a greater
use of QoR15 for major regional anaesthetic techniques
expected to result in significant pain relief, improvement in
sleep quality and overall sense of well-being after a
relatively invasive and painful surgical procedure (e.g.
continuous brachial plexus analgesia for total shoulder
replacement). For a minor regional anaesthesia intervention
expected to provide an incremental improvement for a
minimally invasive surgical procedure (e.g. a chest wall
block as part of a multimodal regimen for minor breast
surgery), more traditional outcome measures such as pain
relief and opioid consumption are still reasonable
outcomes to study.
In summary, the study by Koning et al. highlights the
value of the QoR-15 in providing a standardised, validated
measure of postoperative recovery. In this respect, the
described intervention demonstrated a marginal
improvement in pain management specifically and quality
of recovery more broadly, but not to a clinically meaningful
extent across the study population. In general terms, the
impact on quality of recovery will be most evident with
important anaesthetic interventions targeted at major
surgical procedures that usually result in severe pain,
nausea and vomiting and significant functional limitation.
Quality of Recovery-15 provides a levelling mechanism,
© 2020 Association of Anaesthetists

Editorial
creating an objective measurement to compare
improvements in one or more individual domains within the
broader context of patient-centred outcomes. In this
standardised manner, the relative value of new
interventions may be more readily interpreted by the wider
anaesthetic community.
Acknowledgements
AP has a current research grant from Fisher and Paykel and
she receives protected academic time from the Department
of Anesthesia, University Health Network, Toronto. No other
competing interests declared.
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