Early quality of recovery according to QoR-15 score is
associated with one-month postoperative complications
after elective surgery

Maëva Campfort, Cléor Cayla, Sigismond Lasocki, Emmanuel Rineau,
Maxime Léger

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To cite this version:

Maëva Campfort, Cléor Cayla, Sigismond Lasocki, Emmanuel Rineau, Maxime Léger. Early quality of recovery according to QoR-15 score is associated with one-month postoperative complications after elective surgery. Journal of Clinical Anesthesia, 2022, 78, pp.110638. 10.1016/j.jclinane.2021.110638. hal-04796458

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Original Contribution

# Early quality of recovery according to QoR-15 score is associated with one-month postoperative complications after elective surgery

Maëva Campfort, MD<sup>a, *</sup>, Cléor Cayla, MD<sup>a</sup>, Sigismond Lasocki, PhD, MD<sup>a</sup>, Emmanuel Rineau, PhD, MD<sup>a</sup>, Maxime Léger, MD<sup>a, b</sup>

<figure><img src="image_4.png" /></figure>

ARTICLE INFO

Keywords:

Patient-centred outcome

Perioperative care

Postoperative complications

Postoperative recovery

QoR-15

A B S T R A C T

**Study objective:** The QoR-15 scale is a validated tool to assess the quality of postoperative recovery (QoR). Our objective was to assess the association between the early QoR-15 values and the occurrence of one-month postoperative complications.

**Design:** We used the data from a prospective single-centre cohort study conducted in the Angers University Hospital from July 2019 to February 2020 that validated the French version of the QoR-15 (FQoR-15).

**Setting:** Preoperative room, ward, and home.

**Patients:** 363 French-speaking adult patients, undergoing elective surgery, were enrolled (217 (59,8%) men, median age 60 (range 44 to 71) years old), including 139 (38.3%) ambulatory surgeries.

**Intervention:** Patients completed the QoR-15 scale the day before, at 24 and 48 h after surgery.

**Measurements:** Postoperative complications were recorded according to the PostOperative Morbidity Survey (POMS) classification till 30 days after surgery. The QoR was classified as excellent (QoR-15 > 135), good (122 ≤ QoR-15 ≤ 135), moderate (90 ≤ QoR-15 ≤ 121) or poor (QoR-15 < 90). Days alive and out of hospital up to 30 days after surgery was also recorded.

**Main results:** According to the POMS classification, 176 (48.5%) patients had at least one complication up to 30 days after surgery. Among the 69 (19.0%) patients with a poor recovery at H24, 58 (84.1%) had at least one complication up to 30 days after surgery compared to 10 (23.8%) among the 42 (11.6%) in the excellent recovery group (p < 0.0001). The QoR-15 score at H24 allowed suitable discrimination of the occurrence of at least one complication up to 30 days after surgery (AUC 0.732 (95% CI 0.680 to 0.784)).

**Conclusion:** The early QoR-15 scale after surgery is moderately associated with the occurrence of postoperative complications up to 30 days after elective surgeries (i.e. it has predictive validity).

1. Introduction

Postoperative complications and impaired quality of recovery are linked [1,2]. Postoperative complications are common, with incidence of 5 to 43%, depending on the series [3–5]. They often result in longer hospital stay, increased costs, altered recovery and poorer patient's satisfaction. Thus, considering postoperative complications is an important point for perioperative-medicine trials but it does not seem to be sufficient to assess the overall postoperative recovery.

Recently, more interest have been given to patient-reported outcome scale that consider the overall patient recovery, taking into account parameters such as pain or gastrointestinal complications with patient-

centred items, and facilitate the comparison between different anaes-
thetic or surgical strategies [6,7]. In order to improve the global patient's
experience, the use of patient-centred outcomes is now recommended
for perioperative-medicine trials [8] and post-operative recovery scores
are more often used as primary or secondary endpoints in comparative
studies in the recent years [9]. The QoR-15 score is a validated tool to
assess the quality of postoperative recovery (QoR – Quality of Recovery)
[10]. It ranges from 0 to 150, with a higher score indicating a better
quality of recovery. Even if the minimal clinically important difference
(MCID) (i.e. the minimal change in score that would imply a meaningful
change in health status) of the QoR-15 has recently been revised to 6
[11,12], the clinical interpretation of their absolute values remains

<footnote><sup>a</sup> Département d'Anesthésie Réanimation, Centre Hospitalier Universitaire d'Angers, Angers, France</footnote>

<footnote><sup>b</sup> INSERM UMR 1246 - SPHERE, Nantes University, Tours University, Nantes, France</footnote>

<footnote>* Corresponding author at: Département d'Anesthésie Réanimation, CHU d'Angers, 4 rue Larrey, 49100 Angers, France.</footnote>

<footnote>E-mail addresses: maevacampfort@aol.com (M. Campfort), maxime.leger@chu-angers.fr (M. Léger).</footnote>
undefined.

In the current literature, the association between QoR-15 values and the occurrence of complications has mostly been evaluated at the same time frames (i.e., in the early postoperative period). Recently, Kleif and colleagues found that a worse severity class of recovery at H24 was associated with an increased risk of having postoperative complications up to 30 days after a laparoscopic appendectomy [13]. The association between the quality of recovery measured with the QoR-15 score and the occurrence of postoperative complications up to 30 days has not been evaluated for other surgeries.

Our main hypothesis was that QoR scores in the early postoperative period may help to identify patients who will have postoperative complications till 30 days after surgery.

We aimed to assess if the QoR-15 scale of patients at 24 and 48 h after surgery may help to predict the occurrence of postoperative complications in the first 30 postoperative days according to the Postoperative Morbidity Survey classification [14], in scheduled surgeries.

# 2. Materials & methods

## 2.1. Study population

Data from a prospective single-centre study performed in the Angers University Hospital, from July 2019 to February 2020, were used [15]. This previous study aimed to validate the French translation of the QoR-15, the FQoR-15. A French Ethical Research Committees have accepted the study (registration ID 2019-A011442-55) and the protocol was registered on [ClinicalTrials.gov](https://ClinicalTrials.gov) with the identifier NCT03967821. French-speaking adult patients undergoing elective surgery and who were able to understand and complete the form (alone or with the help of a member of the medical or nursing staff), were enrolled after being informed and having given their oral consent. Cognitive impairment, intracranial surgery and patients under legal guardianship were the main non-inclusion criteria. Demographic characteristics, anaesthesia and surgery details, and the occurrence of postoperative complications were collected by the two main investigators of the study (MC and ML).

## 2.2. QoR-15

Patients filled in the French version of the QoR-15 questionnaire before surgery (H0, baseline), at 24 h (H24) and 48 h (H48) after surgery, alone or with the help from a third person. In case of day-surgery, patients were contacted by phone to complete the questionnaire at H24 and H48. The QoR was classified according to the QoR-15 score as excellent (QoR-15 > 135), good (122 ≤ QoR-15 ≤ 135), moderate (90 ≤ QoR-15 ≤ 121) and poor (QoR-15 < 90) [13]. We were primarily interested in the assessment of the FQoR-15 at H24, and secondarily analysed the score measures at H48.

## 2.3. Postoperative complications and days alive at home

Postoperative complications were assessed till 30 days after the surgery, according to the Postoperative Morbidity Survey (POMS) classification, a validated and routinely easy-to-use tool described in 1999 by Bennett-Guerrero et al. to evaluate the incidence of postoperative complications [14,16–18]. The POMS classification uses a nine-domain score allowing an independent assessment of each organ failure (online Supporting Information Table A.1). For each patient with at least one POMS complication, we defined the most predominant complication according to its impact on the patient's general condition. “Days alive and out of hospital up to 30 days after surgery” (DAH₃₀) which has been shown to be a valid and readily quantifiable patient-centred outcome in perioperative trials was also recorded [19]. Data were collected from the patient medical record or from the phone call to the patient. If data were missing, we retrieved them retrospectively from the medical record. The ethical committee of the French Society of Anaesthesia and Intensive

Care has accepted the collection of these data and their analysis in June 2021 (IRB 00010254–2021-121).

## 2.4. Statistical analyses

Data are presented as mean ± standard deviation, median [1st-3rd quartile] and number (%). For comparison between groups, we used the Chi-square test for categorical variables and the Student *t*-test for continuous variables. Associations between postoperative QoR-15 values (at H24 and H48) and occurrences of at least one postoperative complication at day 30 were visualized and compared with receiver operating characteristic curves (ROC curves). We performed an additional sensitivity analysis by considering only POMS complications occurring after H48 and up to day 30 after the surgery. We also analysed the association between the variation of score (between baseline values and postoperative values at 24 and 48 h after the surgery) and the occurrence of complication. In addition, to study the preoperative value of the score, we presented the ROC curve between these values and the occurrence of complications in the supportive information. The area under the curve (AUC) are presented with their confidence intervals at 95% (95% CI), computed with 2000 stratified bootstrap replicates. The optimal cut-off value of the QoR-15 to predict postoperative complications was defined by the threshold that maximizes the distance to the identity (diagonal) line. We determined the sensitivity and specificity corresponding to those thresholds, associated with their confidence intervals (also obtained by 2000 stratified bootstrap replicates). Since we analysed an existing database, we did not perform a sample size calculation. As an alternative, we presented the power of the AUC calculation of the QoR-15 score at H24 (primary endpoint of interest) of the occurrence of at least one POMS complication up to day 30 after the surgery, in comparison to the threshold of 0.5, with a type I error of 5%. With these parameters and the existing database (176 case subjects and 187 controls subjects), the power was 100% to show a difference.

All tests of significance were bilateral, and we rejected the null hypothesis if the *p*-value was less than 0.05. We performed all statistical analysis with R Studio software version 3.6.3.

# 3. Results

## 3.1. Baseline characteristics of the population

Among the 363 enrolled patients, 217 (59.8%) were men and the median age was 60 [44–71] years old. A wide panel of surgeries was represented, from cardiac surgery for 33 patients (9.1%) to gynaecological surgery for 15 patients (4,1%), with a large proportion of ambulatory surgeries (139 patients, 38.3%). The patient characteristics are presented in Table 1, and surgical procedures are detailed in online Supporting Information Table A.2. 311 patients (85.7%) had general anaesthesia, with or without regional anaesthesia, and 44 patients (12.1%) had regional anaesthesia alone.

## 3.2. QoR-15 score

The mean QoR-15 values at H24 and H48 were 109.5 ± 22.7 and 116.6 ± 21.9 respectively. According to the H24 QoR-15 value, 42 (11.6%) patients were classified in the excellent recovery group, 76 (20.9%) in the good recovery group, 176 (48.5%) in the moderate recovery group and 69 (19.0%) in the poor recovery group. Mean QoR-15 for each group at baseline, at H24 and at H48 are presented in Table 2. Changes over time in QoR-15 scores, from baseline to H48, are represented in Fig. 1.

## 3.3. Postoperative complications

According to the POMS classification, 176 (48.5%) experienced at least one POMS complication at 30 days (Table 2). The most frequent
<caption>**Table 1**</caption>

Patient's characteristics according to the QoR categories at H24: excellent (QoR-15 > 135), good (122 ≤ QoR-15 ≤ 135), moderate (90 ≤ QoR-15 ≤ 121) and poor (QoR-15 < 90).

<table><thead><tr><th></th><th>Excellent<br>(n = 42)</th><th>Good<br>(n = 76)</th><th>Moderate<br>(n = 176)</th><th>Poor<br>(n = 69)</th><th>p</th></tr></thead><tbody><tr><td>Age (years)</td><td>58.4 ±<br>19.1</td><td>59.0 ±<br>17.5</td><td>58.5 ±<br>18.0</td><td>53.8<br>±<br>18.9</td><td>0.281</td></tr><tr><td>Women</td><td>15 (35.7)</td><td>38<br>(50.0)</td><td>69 (39.2)</td><td>24<br>(34.8)</td><td>0.231</td></tr><tr><td>Body Mass Index (kg.<br>m<sup>-1</sup>)</td><td>26.4 ±<br>5.3</td><td>26.2 ±<br>4.2</td><td>26.7 ±<br>5.5</td><td>25.9 ±<br>5.8</td><td>0.722</td></tr><tr><td>ASA status</td><td></td><td></td><td></td><td></td><td>0.844</td></tr><tr><td>1</td><td>13 (31.0)</td><td>23<br>(30.3)</td><td>52 (29.5)</td><td>18<br>(26.1)</td><td></td></tr><tr><td>2</td><td>20 (47.6)</td><td>41<br>(53.9)</td><td>83 (47.2)</td><td>33<br>(47.8)</td><td></td></tr><tr><td>3</td><td>9 (21.4)</td><td>11<br>(14.5)</td><td>37 (21.0)</td><td>15<br>(21.7)</td><td></td></tr><tr><td>4</td><td>0 (0.0)</td><td>1 (1.3)</td><td>4 (2.3)</td><td>3<br>(4.3)</td><td></td></tr><tr><td>Unit of admission</td><td></td><td></td><td></td><td></td><td>&lt;0.001</td></tr><tr><td>Ambulatory</td><td>27 (64.3)</td><td>36<br>(47.4)</td><td>61 (34.7)</td><td>15<br>(21.7)</td><td></td></tr><tr><td>Cardiac surgery</td><td>2 (4.8)</td><td>2 (2.6)</td><td>14 (8.0)</td><td>15<br>(21.7)</td><td></td></tr><tr><td>Gynaecologic surgery</td><td>0 (0.0)</td><td>1 (1.3)</td><td>6 (3.4)</td><td>1<br>(1.5)</td><td></td></tr><tr><td>Neurosurgery</td><td>2 (4.8)</td><td>0 (0.0)</td><td>17 (9.7)</td><td>2<br>(2.9)</td><td></td></tr><tr><td>Otorhinolaryngology</td><td>0 (0.0)</td><td>4 (5.3)</td><td>4 (2.3)</td><td>2<br>(2.9)</td><td></td></tr><tr><td>Orthopaedic surgery</td><td>3 (7.1)</td><td>7 (9.2)</td><td>28 (15.9)</td><td>6<br>(8.7)</td><td></td></tr><tr><td>Thoracic and<br>Vascular surgery</td><td>2 (4.8)</td><td>10<br>(13.2)</td><td>19 (10.8)</td><td>13<br>(18.8)</td><td></td></tr><tr><td>Urologic surgery</td><td>2 (4.8)</td><td>7 (9.2)</td><td>10 (5.7)</td><td>8<br>(11.6)</td><td></td></tr><tr><td>Visceral surgery</td><td>37 (10.2)</td><td>9<br>(11.8)</td><td>17 (9.7)</td><td>7<br>(10.1)</td><td></td></tr><tr><td>SORT Score</td><td>0.34 ±<br>0.73</td><td>0.84 ±<br>2.60</td><td>0.97 ±<br>2.19</td><td>1.26<br>±<br>3.81</td><td>0.358</td></tr><tr><td>Anaesthesia modalities</td><td></td><td></td><td></td><td></td><td>0.066</td></tr><tr><td>General anaesthesia</td><td>25 (59.5)</td><td>45<br>(59.2)</td><td>120<br>(68.2)</td><td>49<br>(71.0)</td><td></td></tr><tr><td>General anaesthesia<br>and regional<br>anaesthesia</td><td>8 (19.0)</td><td>17<br>(22.4)</td><td>33 (18.8)</td><td>14<br>(20.3)</td><td></td></tr><tr><td>Regional anaesthesia</td><td>5 (11.9)</td><td>13<br>(17.1)</td><td>21 (12.0)</td><td>5<br>(7.2)</td><td></td></tr><tr><td>Sedation</td><td>4 (9.5)</td><td>1 (1.3)</td><td>2 (1.1)</td><td>1<br>(1.4)</td><td></td></tr><tr><td>Operating time (min)</td><td>70 [45 to<br>95]</td><td>85 [64<br>to<br>111]</td><td>105 [70 to<br>150]</td><td>120<br>[79 to<br>213]</td><td>&lt;0.001</td></tr><tr><td>Time in PACU (min)</td><td>98 [89 to<br>120]</td><td>105<br>[80 to<br>134]</td><td>110 [90 to<br>135]</td><td>113<br>[66 to<br>135]</td><td>0.543</td></tr><tr><td>Hospital length of stay<br>(day)</td><td>0 [0 to 1]</td><td>1 [0 to<br>2]</td><td>2 [0 to 4]</td><td>4 [1<br>to 8]</td><td>&lt;0.001</td></tr></tbody></table>

Data are number (%), mean ± standard deviation or median with [interquartile range].

The SORT is a preoperative risk prediction tool which estimates the risk of death within 30 days of inpatient non-cardiac surgery (online calculator: http://www.sortsurgery.com).

QoR, Quality of Recovery; PACU, postanaesthetic care unit; SORT, Surgical Outcome Risk Tool.

complications were significant pain (i.e., requiring parenteral opioid or a rescue locoregional analgesia) for 63 (17.4%) patients, pulmonary complications for 39 (10.7%) patients and infectious complications for 22 (6.1%) patients. Among the population, 152 (42.3%) patients had at least one postoperative complication at H24, 49 (14.2%) at H48. The

<caption>**Table 2**</caption>

QoR-15 evolution and occurrence of postoperative complication according to the QoR categories at H24: excellent (QoR-15 > 135), good (122 ≤ QoR-15 ≤ 135), moderate (90 ≤ QoR-15 ≤ 121) and poor (QoR-15 < 90).

<table><thead><tr><th></th><th>Excellent<br>(n = 42)</th><th>Good<br>(n = 76)</th><th>Moderate<br>(n = 176)</th><th>Poor<br>(n = 69)</th><th>p</th></tr></thead><tbody><tr><td>QoR-15 baseline<br>value</td><td>138.4 ±<br>9.8</td><td>132.5 ±<br>13.9</td><td>122.7 ±<br>16.8</td><td>113.2 ±<br>21.0</td><td>&lt;0.001</td></tr><tr><td>QoR-15 value at H24</td><td>141.6 ±<br>4.0</td><td>128.0 ±<br>3.9</td><td>108.0 ±<br>8.2</td><td>73.4 ±<br>13.5</td><td>&lt;0.001</td></tr><tr><td>QoR-15 value at H48</td><td>139.3 ±<br>10.7</td><td>131.5 ±<br>12.8</td><td>114.7 ±<br>15.6</td><td>91.6 ±<br>21.6</td><td>&lt;0.001</td></tr><tr><td>Difference in QoR-15<br>score between the<br>baseline and H24<br>values</td><td>-1.0<br>[-11.3 to<br>4.8]</td><td>7.5<br>[-2.0<br>to<br>15.0]</td><td>16.0 [3.8<br>to 27.0]</td><td>[26.0<br>to<br>56.0]</td><td>&lt;0.001</td></tr><tr><td>Difference in QoR-15<br>score between the<br>baseline and H48<br>values</td><td>-1.0<br>[-11.8 to<br>5.8]</td><td>2.0<br>[-7.3<br>to 9.0]</td><td>8.0 [-5.0<br>to 17.3]</td><td>[7.0 to<br>36.0]</td><td>&lt;0.001</td></tr><tr><td>At least one POMS<br>complication at<br>day 30</td><td>10 (23.8)</td><td>24<br>(31.6)</td><td>84 (47.7)</td><td>58<br>(84.1)</td><td>&lt;0.001</td></tr><tr><td>Predominant POMS<br>complication at<br>day 30</td><td></td><td></td><td></td><td></td><td>0.099</td></tr><tr><td>Cardiologic</td><td>0 (0.0)</td><td>0 (0.0)</td><td>3 (1.7)</td><td>5 (7.2)</td><td></td></tr><tr><td>Surgical</td><td>2 (4.8)</td><td>1 (1.3)</td><td>6 (3.4)</td><td>5 (7.2)</td><td></td></tr><tr><td>Significant Pain</td><td>5 (11.9)</td><td>10<br>(13.2)</td><td>39 (22.2)</td><td>9<br>(13.0)</td><td></td></tr><tr><td>Gastrointestinal</td><td>0 (0.0)</td><td>5 (6.6)</td><td>8 (4.5)</td><td>6 (8.7)</td><td></td></tr><tr><td>Haematological</td><td>1 (2.4)</td><td>0 (0.0)</td><td>1 (0.6)</td><td>1 (1.4)</td><td></td></tr><tr><td>Infectious</td><td>1 (2.4)</td><td>4 (5.3)</td><td>5 (2.8)</td><td>(17.4)</td><td></td></tr><tr><td>Neurological</td><td>0 (0.0)</td><td>0 (0.0)</td><td>0 (0.0)</td><td>1 (1.4)</td><td></td></tr><tr><td>Respiratory</td><td>4 (9.5)</td><td>8<br>(10.5)</td><td>17 (9.6)</td><td>10<br>(14.5)</td><td></td></tr><tr><td>Renal/Urinary</td><td>1 (2.4)</td><td>1 (1.3)</td><td>2 (1.1)</td><td>2 (2.9)</td><td></td></tr></tbody></table>

Data are number (%), mean ± standard deviation or median with [interquartile range].

QoR, Quality of Recovery; POMS, PostOperative Morbidity Survey classification.

summary table of POMS complications at H24 and H48 is presented in online Supporting Information Table A.3.

Considering only complications occurring after H48 and up to day 30 after the surgery, 63 (17.4%) patients had at least one POMS complication. The most frequent POMS complications were infectious complications for 22 (6.1%) patients and surgical complications for 15 (4.1%) patients.

### 3.4. Association between QoR-15 score and postoperative complications

Among the population, 58 (84.1%) patients in the poor recovery group at H24 experienced at least one complication at 30 days after surgery versus 10 (23.8%) in the excellent recovery group (p < 0.0001) (Table 2). These results are comparable for the QoR-15 score classifications at H48 and the occurrence of complications at 30 days (online Supporting Information Table A.4).

The QoR-15 score at H24 was quite associated with the occurrence of at least one complication up to 30 days after surgery with an AUC of 0.73, (95% CI 0.68 to 0.78) (Fig. 2). The optimal threshold according to Youden index was 104.5, specificity 83% (95% CI 57 to 93), sensitivity 56% (95% CI 42 to 80). The association was similar between the QoR-15 score at H48 and the occurrence of postoperative complications up to day 30 after surgery with an AUC of 0.69, (95% CI 0.63 to 0.74). The threshold according to Youden index was 119.5, specificity 69% (95% CI 56 to 77), sensitivity 65% (95% CI 56 to 76) (online Supporting Information Fig. A.1).

Considering the POMS complications occurring between H48 and day 30 after the surgery, QoR-15 score at H24 was still well associated
<figure><img src="image_5.png" /><figcaption>Fig. 1. Trajectories of recovery according to the QoR groups at baseline (H0), 24 h (H24) and 48 h (H48) after the surgery.</figcaption></figure>

<figure><img src="image_6.png" /><figcaption>Fig. 2. ROC curve between QoR-15 values at H24 and the occurrence of at least one postoperative complication up to day 30 after surgery according to the POMS classification.</figcaption></figure>

with the occurrence of at least one complication with an AUC of 0.70 (95% CI 0.62 to 0.78) (online Supporting Information Fig. A.2), and an optimal threshold of 102.5 (specificity 79% (95% CI 54 to 91); sensitivity 60% (95% CI 40 to 81)). This association remained well calibrated for the QoR-15 value at H48 with an AUC of 0.67 (95% CI 0.59 to 0.75)) (online Supporting Information Fig. A.3), and an optimal threshold of 104.5 (specificity 76% (95% CI 55 to 94); sensitivity 60% (95% CI 32 to 79)).

Variation of QoR-15 score between baseline and postoperative values (at H24 and H48) remain associated with score categories at H24, with the poor recovery quality group showing the largest difference from the preoperative value (Table 2). Similarly, score variations are associated with the occurrence of complications at day 30, with a median difference of 19.0 [−36.0 to 32.0] in the complications group versus 10.0 [−37.0 to 21.5] in the control group (p < 0.001) for the

baseline/H24 differences. The median difference was 10.0 [−56.0 to 24.3] in the complications group versus 5.0 [−29.0 to 14.0] in the control group (p < 0.02) for the baseline/H48 differences. However, score variations have less discrimination power with AUCs of 0.61 (95% CI 0.56 to 0.67) and 0.57 (95% CI 0.51 to 0.63) for baseline/H24 and baseline/H48 variations, respectively (online Supportive Information Figs. A.4 and A.5).

The preoperative values of QoR-15 score were also associated with the occurrences of POMS complication till day 30, with a mean value of 119.9 ± 18.9 in the complications group versus 129.3 ± 16.4 in the control group (p < 0.02). The discrimination was acceptable between the baseline QoR-15 score and the occurrence of postoperative complications up to day 30 after surgery with an AUC of 0.65, (95% CI 0.60 to 0.71). The threshold according to Youden index was 136, specificity 45% (95% CI 38 to 83), sensitivity 79% (95% CI 41 to 86) (online Supporting Information Fig. A.6). Considering the POMS complications occurring between H48 and day 30 after the surgery, QoR-15 score at baseline was still associated with the occurrence of at least one complication with an AUC of 0.66 (95% CI 0.59 to 0.74) (online Supporting Information Fig. A.7).

### 3.5. Association between QoR categories and the DAH₃₀

A poor recovery according to the QoR-15 score at H24 was associated with a significantly lower DAH₃₀ (p < 0.001) (Table 3). Results were similar at H48 with a lower DAH₃₀ for patients with a poor or a moderate

**Table 3**

Days at home up to 30 days after surgery according to the QoR categories at H24: excellent (QoR-15 > 135), good (122 ≤ QoR-15 ≤ 135), moderate (90 ≤ QoR-15 ≤ 121) and poor (QoR-15 < 90).

<table><thead><tr><th></th><th>Excellent (n = 42)</th><th>Good (n = 76)</th><th>Moderate (n = 176)</th><th>Poor (n = 69)</th><th>p</th></tr></thead><tbody><tr><td>DAH<sub>30</sub></td><td>28 [27 to 29]</td><td>28 [27 to 29]</td><td>27 [25 to 29]</td><td>24 [18 to 27]</td><td>&lt;0.001</td></tr></tbody></table>

Data are median with [interquartile range].

DAH₃₀, Days at home up to 30 days after surgery.
recovery (p < 0.001) (online Supporting Information Table A.4).

## 4. Discussion

This study is the first to show a significant association between QoR-15 severity categories at 24 h after surgery and the occurrence of postoperative complications till one-month after surgery.

To assess the association between QoR and postoperative complications, we used the categorization of postoperative recovery stages described by Kleif et al. in 2018 [13]. Although this classification was initially described with patients undergoing laparoscopic surgery for suspected appendicitis only, it was correlated with postoperative complications according to the Clavien-Dindo classification [20]. Our study highlights that this QoR-15 classification (organized in four categories: poor, moderate, good and excellent recoveries) were evenly associated with the occurrence of postoperative complications according to the POMS classification within 30 days after the surgery. Compared to the Clavien-Dindo classification, the POMS classification allows for the evaluation of medical complications in addition to surgical complications and has now been well validated in major elective surgery [16–18]. The POMS classification is a simple method of detecting and quantifying postoperative complications that prevent hospital discharge. Our analysis allowed us to extend the association of the QoR-15 score with the occurrence of complications on a large panel of surgeries, with concordant results whether or not ambulatory surgery was included. In our study, the complications rate was 48.5%, which is consistent with others studies [5]. A large panel of complications occurred, and each domain of the POMS classification was represented. Beyond the good predictive capacity of the QoR-15 score at H24 to predict the occurrence of at least one POMS complication within 30 days after surgery, we have secondarily demonstrated that the assessment of the score at H48 is well calibrated to the occurrence of complications. Even when considering only complications occurring after H48 and up to 30 days after surgery, measurement of the QoR-15 score at H24 or H48 adequately predicted the occurrence of complications.

When we look at the preoperative QoR-15 score, it remains adequate to predict the occurrence of postoperative complications, while the variation between the preoperative QoR-15 score and the values at H24 and H48 presented less interesting predictive parameters. One should keep in mind that of QoR measurement scales were mainly developed to be assessed postoperatively [21].

Beyond these results, the analysis of patients' temporal evolution and trajectories, according to their early postoperative QoR-15 scores, confirmed that those with impaired recovery in the postoperative phase had low baseline values [22]. Identification of patients with abnormally low preoperative QoR-15 scores could improve perioperative management. For example, Yoon and colleagues supposed that the development of ERAS (Enhanced Recovery After Surgery) protocol, could improve the QoR-15 score for patients undergoing VATS lung resection [23], they will conduct a study to assess whether this hypothesis is confirmed.

The use of QoR categorization into four classes optimizes the clinical interpretation of an absolute score value. Implementing this classification in routine postoperative management could identify the patients most at risk of experiencing a postoperative complication. In addition, a poorer postoperative QoR is also associated with a longer length of stay. QoR-15 may also be used as an early warning for post-operative complications; indeed, a QoR-15 score below 105 at 24 h after surgery reliably predicted the occurrence of a complication till one month after. Because this score is easy to perform (done in 2–3 min and may be self-administered by the patients themselves), it could be included in standard follow-up to improve patient's care. It may also be implemented in app to allow systematic follow-up [24].

The systematic use of the score to evaluate the quality of postoperative recovery makes it possible to compare therapeutic interventions but could also be considered as a tool to improve patient's care.

Our study had some limitations. First, we assessed the complications until 30 days after surgery only, while postoperative complications could occur even up to three months after surgery, especially in case of major surgeries or implantation of prosthetic material [25]. Secondly, we chose the POMS classification to assess the postoperative events. This classification does not consider the severity of the complication, which did not allow us to estimate the correlation between the severity class of recovery and the complication severity. Thirdly, since this is a single-centre study, the external validity of the study is limited. Still note that the rate of postoperative complications in our cohort was similar to that found elsewhere [5,13], as were the values of QoR-15 score [26,27].

## 5. Conclusion

In this study, the early use of the QoR-15 score after surgery and its classification in severity groups were well associated with postoperative complications at 30 days according to the POMS classification.

## Assistance with the article

None.

## Funding source

None.

## Declaration of Competing Interest

ML was the developer of a validated version of the French translation of the QoR-15 (FQoR-15). No other competing interests declared.

## Acknowledgements

None.

## Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.jclinane.2021.110638.

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