Quality-adjusted life-year as a surgical outcome measure: a primer for plastic surgeons.

Historically, surgical outcomes have been measured by rates of mortality and morbidity. Fortunately, in plastic surgery, mortality is rarely an issue unless one is practicing in high-risk settings such as burn units or war zones. The improvement of presurgical morbidity, however, is very relevant to our specialty, and great effort should be made to measure it as precisely as possible. The success of plastic surgery interventions has traditionally been measured by beforeand-after photographs in cosmetic surgery, pinch and grip strength and range of motion in hand surgery, percentage of successful flaps or replanted digits in microsurgery, and so forth. Although such outcomes are important, they serve only as proxies for the ultimate goal of optimal physical, mental, and social well-being of the patient. Would one seriously consider a face-lift result satisfactory if the patient required psychiatric support after her operation despite a much improved postoperative photograph? Likewise, would an improvement of 0.5 kg in grip strength after a novel hand procedure be considered successful if the patient was still unable to return to work? What about a meticulously executed flap to reconstruct a through-and-through defect of the mandible in a head and neck cancer where the patient died 6 months later from cancer recurrence?1 Plastic surgeons have recognized for some time now that there can be a discrepancy between their interpretation of a successful surgical outcome and the patient’s expectation. A rapid expansion of outcomes research has occurred over the past two decades in many medical specialties. This has been fueled, at least in part, by the practice of evidence-based medicine. Evidence-based medicine integrates individual clinical expertise with the best available clinical evidence from systematic research.2,3 Outcomes research sets out to measure a patient’s quality of life. The broader term “quality of life” can be defined as “the adequacy of people’s material circumstances and their feelings about these circumstances.”4,5 This encompasses indicators of life satisfaction; personal wealth and possessions; level of safety; level of freedom; spirituality; health perceptions; and physical, psychological, social, and cognitive well-being.4,5 Health-related quality of life, a subcomponent of quality of life, includes all areas specific to health, that is, physical, emotional, psychological, social, cognitive, and role functioning, in addition to abilities, relationships, perceptions, life satisfaction, and well-being. It refers to patients’ appraisals of their current level of functioning and satisfaction with it, compared with what they perceive to be ideal.6,7 There are several different methods available to measure a patient’s health-related quality of life. In the past two decades, a number of validated and reliable scales have been introduced to measure improvement in quality of life of plastic surgical interventions. One particular health-related quality-of-life outcome measure, although infrequently used in plastic surgery, is the quality-adjusted life-year. The quality-adjusted life-year was originally introduced as a measure of health effectiveness for cost-effectiveness analysis to assist decision makers in allocating scarce resources across competing health care programs.8–10 Health care spending in the United States is the highest in the world, averaging $7026 per person per year.11 However, the U.S. health care system ranks 37th among the 191 countries.12 Although nationwide efforts to decrease this unsustainable growth have had limited success so far, this issue will be dealt with sooner From the Department of Clinical Epidemiology and Biostatistics and the Surgical Outcomes Research Center, McMaster University, and the Department of Surgery, Division of Plastic and Reconstructive Surgery, St. Joseph’s Healthcare. Received for publication July 23, 2009; accepted October 29, 2009. Copyright ©2010 by the American Society of Plastic Surgeons