The QoR-40 was translated into the Thai language and culturally adapted to a Thai population. The resulting Thai QoR-35 was then tested for validity (a measure of accuracy) and reliability (a measure of consistency). Our primary hypothesis for testing validity was that Thai QoR-35 could discriminate recovery status between inpatients and outpatients. The results showed a significant difference in Thai QoR-35 scores between inpatients and outpatients and between baseline and two postoperative time points. Convergent validity showed a high correlation between Thai QoR-35 and VAS-R. The high correlation coefficient of Thai QoR-35 indicated good reliability. All 96 patients fully participated in all aspects of the study, with most subjects completing the Thai QoR-35 within 5 min. These parameters indicated the good acceptability and practicability of QoR-35.
The ability to measure quality of care has direct benefit to patients and facilitates auditing and improving health care-related services and protocols. Although the Aldrete scoring system has been widely adopted as an anesthesia recovery score, it addresses only the physiologic dimension and does not evaluate overall recovery outcomes. A credible instrument for measuring quality of recovery should be studied and accepted as valid and reliable, however, and the Aldrete scoring system has never been validated. At present, there is no generally accepted gold standard for measuring quality of recovery.
Other quality of recovery scores, including the Quality of Recovery 9 (QoR-9) and QoR-40 [4, 10], the 24-h Functional Ability Questionnaire (24hFAQ) [11], and the Postoperative Quality Recovery Scale (PQRS) [12] have been recently studied and validated. The 24hFAQ was developed to measure final recovery and satisfaction 24 h after surgery. It consists of 21 questions and mainly focuses on cognitive, physical, and satisfaction domains. The 24hFAQ, however, was validated only in an outpatient setting, so its application in an inpatient surgical population might be questioned.
Royse and colleagues [12] attempted to develop the Postoperative Quality Recovery Scale (PQRS), which also incorporates physiologic assessment. Although the PQRS was administered in a wide range of populations and in several languages, the investigators found that a considerable number of patients (including young children) within the studied populations could not or refused to complete the test, particularly during the early postoperative period. In contrast, none of the patients in the present study refused to participate, with nearly all patients completing the questionnaire within 5 min.
Chan and colleagues [13] conducted a psychometric test on the Chinese version of the QoR-9 and found nearly perfect agreement between the Chinese and English versions. The QoR-9 is a simple instrument that contains only nine questions, but it lacks detail. The QoR-40 elicits more patient information with minimal training, need for assistance, and time needed to complete the questionnaire. In addition to the QoR-40 being widely tested, it is a highly significant predictor of quality of life at late recovery. It is also appropriate for use in research and for quality assurance testing [4–8]. It is for these reasons that we chose to translate the QoR-40 in our study.
Unlike the study by Chan et al. [13], we modified the original QoR-40 by deleting five questions based on the professional advice of 25 experienced anesthesiologists. The following five questions were excluded from the translated version: Q4: able to write; Q12: feeling in control; Q33: sore mouth; Q37: feeling angry; Q39: feeling alone. These questions were excluded to improve the cultural suitability of the test, thereby adapting the test to the lifestyle of the Thai people. The Thai family structure is an extended family, with patients being attended to by family members who stay with them and/or take care of them at home and/or at the hospital. Regarding a sense of control, many Thai patients do not desire or seek control in a health crisis setting. Rather, they prefer to give up control and have someone take responsibility for their care when they are ill. In addition, Thai people rarely outwardly express anger, they normally avoid conflict, and they prefer listening to reading and writing. Among the Thai patient population and based on our postoperative data, sore mouth is not a common problem. Each of the deleted items is not appropriate for the Thai culture and lifestyle.
Our study demonstrated the feasibility, practicability, applicability, validity, and reliability of the Thai QoR-35. This QoR-35 may be generalizable to other Asian populations that have close or similar cultures and lifestyles. This tool and its potential transferability to other countries could expand the opportunity for multi-country collaborative research and quality audits, which may be the strength of our study. There are, however, some limitations to it as well. First, we tested the Thai QoR-35 in a small number of patients and followed those patients for only 24 h PO. Additional studies with larger study populations that follow patients for longer than 24 h after surgery should be undertaken. Second, further studies are needed to evaluate the utility of the QoR-35 across a wide range of ages, surgical types, and Asian populations.
