Minimizing population health loss due to scarcity in OR capacity: validation of quality of life input

Abstract

Objectives: A previously developed decision model to prioritize surgical procedures in times of scarce surgical capacity used quality of life (QoL) primarily derived from experts in one center. These estimates are key input of the model, and might be more context-dependent than the other input parameters (age, survival). The aim of this study was to validate our model by replicating these QoL estimates.

Methods: The original study estimated QoL of patients in need of commonly performed procedures in live expert-panel meetings. This study replicated this procedure using a web-based Delphi approach in a different hospital. The new QoL scores were compared with the original scores using mixed effects linear regression. The ranking of surgical procedures based on combined QoL values from the validation and original study was compared to the ranking based solely on the original QoL values.

Results: The overall mean difference in QoL estimates between the validation study and the original study was - 0.11 (95% CI: -0.12 - -0.10). The model output (DALY/month delay) based on QoL data from both studies was similar to the model output based on the original data only: The Spearman's correlation coefficient between the ranking of all procedures before and after including the new QoL estimates was 0.988.

Discussion: Even though the new QoL estimates were systematically lower than the values from the original study, the ranking for urgency based on health loss per unit of time delay of procedures was consistent. This underscores the robustness and generalizability of the decision model for prioritization of surgical procedures.

Keywords: Decision modeling; Prioritization; Quality of life; Surgery; Validation; Value based health care.

Fig. 1

The quality of life estimates derived from the original and the validation study, stratified for preoperative and postoperative state. Abbreviations: AAA, abdominal aneurysm of the aorta; AP, angina pectoris; ASD, atrial septum defect; AV, aortic valve; AVR, aortic valve replacement; CABG, coronary artery bypass graft; COPD, chronic obstructive pulmonary disease; ESHF, end-stage heart failure; ESLD, end-stage liver disease; ESRD, end-stage renal disease; EVAR, endovascular aortic repair; F2, Fontaine 2; F3-4, Fontaine 3-4; HCC, hepatocellular carcinoma; HIPEC, hyperthermic intraperitoneal chemotherapy; LVAD, left ventricle assist device; MI, muscle invasive; NSCLC, non-small cell lung carcinoma; obstr, obstruction; PAD, peripheral arterial disease; PCI, percutaneous coronary intervention; pit, pituitary; sev, severe; TAVI, transcatheter aortic valve implantation; TUR, transurethral resection;UUT, upper urinary tract; VATS, video-assisted thoracoscopy

Fig. 2

Bland-Altman plot of the orginal and validated quality of life estimates, stratified for the preoperative and postoperative state. The Bland-Altman Bias and 95% limits of agreement are shown (dashed horizontal lines).The mean quality of life estimate on the x-axis represents the overal mean quality of life estimates for the preoperative health state based on data from both the origional study and the validation study. The y-axis represents the difference in mean quality of life estimates between the origninal data and the validation data

Fig. 3

Standard deviation of Quality of life (QoL) estimates for the different surgical procedures and hospitals. Abbreviations: AAA, abdominal aneurysm of the aorta; AP, angina pectoris; ASD, atrial septum defect; AV, aortic valve; AVR, aortic valve replacement; CABG, coronary artery bypass graft; COPD, chronic obstructive pulmonary disease; ESHF, end-stage heart failure; ESLD, end-stage liver disease; ESRD, end-stage renal disease; EVAR, endovascular aortic repair; F2, Fontaine 2; F3-4, Fontaine 3-4; HCC, hepatocellular carcinoma; HIPEC, hyperthermic intraperitoneal chemotherapy; LVAD, left ventricle assist device; MI, muscle invasive; NSCLC, non-small cell lung carcinoma; PAD, peripheral arterial disease; PCI, percutaneous coronary intervention; QoL, quality of live, TAVI, transcatheter aortic valve implantation; UUT, upper urinary tract; VATS, video-assisted thoracoscopy

Fig. 4

Comparing of the ranking of the procedure based on the original quality of life estimates (x-axis), versus the ranking based on the original and validation study scores (y-axis). Rho is the Spearman correlation coefficient between the original and validation study

Fig. 5

The difference in urgency of surgical procedures between the original and the updated quality of life estimates. Only the diseases which now include the new quality of life estimates from the validation study are shown. Abbreviations: AAA, abdominal aneurysm of the aorta; AP, angina pectoris; ASD, atrial septum defect; AV, aortic valve; AVR, aortic valve replacement; CABG, coronary artery bypass graft; COPD, chronic obstructive pulmonary disease; ESHF, end-stage heart failure; ESLD, end-stage liver disease; ESRD, end-stage renal disease; EVAR, endovascular aortic repair; F2, Fontaine 2; F3-4, Fontaine 3-4; HCC, hepatocellular carcinoma; HIPEC, hyperthermic intraperitoneal chemotherapy; LVAD, left ventricle assist device; MI, muscle invasive; NSCLC, non-small cell lung carcinoma; PAD, peripheral arterial disease; PCI, percutaneous coronary intervention; TAVI, transcatheter aortic valve implantation; UUT, upper urinary tract; VATS, video-assisted thoracoscopy