Analysis of Health-Related Quality-of-Life Instruments Measuring the Impact of Bariatric Surgery

Analysis of Health-Related Quality-of-LifeInstruments Measuring the Impact ofBariatric SurgerySystematic Review of the Instruments Used and their ContentValidity

Raed Tayyem,1 Abdulmajid Ali,1 John Atkinson2 and Colin R. Martin3

1 General Surgery Department, The Ayr Hospital, Ayr, UK

2 University of the West of Scotland, Paisley Campus, Paisley, UK

3 University of the West of Scotland, Ayr Campus, Ayr, UK

Contents

Abstract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 731. Overview of Obesity and Health-Related Quality of Life (HR-QOL). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 742. Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

2.1 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 752.2 Potential Sources of Bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 762.3 Search Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

3. Content Validity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 774. Generic vs Obesity-Specific HR-QOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 775. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 786. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

Abstract The worldwide prevalence of obesity has been steadily rising, reachingalarming levels. Obesity, particularly morbid obesity, carries significanthealth risks to the lives of affected patients, including physical, psychological,and social co-morbidities. Bariatric surgery provides the only effective andsustainable approach to treat morbid obesity and reverse its adverse effects.

The reduction in well-being due to poor health in obesity may have adverseeffects on health-related quality of life (HR-QOL). There are numerous studiesreportingHR-QOL in bariatric patients; however, there is a paucity of studiesexamining the psychometric properties of the HR-QOL instruments used.The main aim of this review is to identify the instruments used in assessingHR-QOL in bariatric patients and evaluate their content validity. We believethat this is the first systematic review of its kind to look in depth at variousgeneric- and obesity-specific HR-QOL instruments that were used in bariatricsurgery, and to analyze their content validity.

A systematic and structured search of Ovid databases (1980–2009) wasconducted using terms synonymous with bariatric surgery, combined withterms synonymous withHR-QOL instruments. A total of 112 relevant studies

REVIEWARTICLEPatient 2011; 4 (2): 73-87

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were identified, detailing the use of eight generic, nine obesity-specific, andnumerous other condition-specific instruments.

A conceptual framework comprising 20 domains pertinent to bariatricsurgery and morbid obesity was proposed, against which the identifiedgeneric- and obesity-specific instruments were assessed. The results of thisassessment showed that neither the generic nor the specific instruments wereadequate instruments in terms of content validity.

Given the lack of adequate HR-QOL instruments in the rapidly developingfield of bariatric surgery, we suggest building a new bariatric-specific instru-ment informed by the proposed framework, which will then enable clinicians toassess the full impact of morbid obesity and bariatric surgery on HR-QOL.

1. Overview of Obesity andHealth-Related Quality of Life (HR-QOL)

Although there is no universally accepted defi-nition[1,2] or measurement[2] of quality of life (QOL),it is basically agreed that QOL is concerned with thefunctioning and well-being of the physical, mental,and social aspects of one’s life.[3,4]

QOL is multidimensional, and could be sub-divided into health-related (HR-QOL) and non-health- or environment-based domains. The aspectsof life measured by HR-QOL have the potentialto improve with treatment. On the other hand,the aspects of non-health QOL that can adverselyaffect health are unlikely to improve with ap-propriate medical care.[5]

Obesity is a chronic, complex, multifactorialcondition[6-8] associated with a body mass index(BMI) ‡30 kg/m2[9] and results in increased mor-bidity[10-12] and mortality.[13,14] Morbid obesitycharacterized by a BMI ‡40 kg/m2[15] will furtherincrease health risks,[16-18] including detrimentaleffects on HR-QOL.[19-21]

In the US, two-thirds of adults are overweight,one-third of adults are obese,[9] and approximately5% of the population are morbidly obese.[10] Obe-sity and associated medical conditions cost thehealth system in the US a staggering $US100billion per year,[15] which is roughly equal to 10%of overall medical expenditure.[22] The socioecono-mic impact of the obesity epidemic is similar tothat of poverty, smoking, or alcohol abuse.[23]

The prevalence of obesity is expected to doubleevery 5–10 years.[20] The UK has the fastest in-crease in obesity in Europe, which costs the UK

economy d7 billion and the NHS d2 billion peryear (estimated costs for the year 2006–7).[24]

Obesity potentially carries detrimental effectson HR-QOL in three main aspects, includingphysical, psychological, and social aspects, as il-lustrated in a proposed graphical model of themechanism relatingHR-QOL and obesity (figure 1).Behavioral modification interventions and phar-macotherapy result in weight loss of 4–8%,[25,26]

which is not sustainable for more than a year,[27,28]

and will relapse and fail in 90% of patients within5 years.[29] Bariatric surgery, on the other hand,achieves significant and sustainable weight re-duction,[30,31] with resolution of obesity-relatedco-morbidities and reduction in mortality.[32-34]

Bariatric surgery – whether restrictive, malab-sorptive, or restrictive-malabsorptive – can be per-formed laparoscopically, safely, and effectively.[35,36]

Bariatric surgery has the potential to improvethe HR-QOL of obese patients. Results of studiesin which patients’ experiences and perspectiveshave been evaluated will help clinicians to betterunderstand what outcomes of bariatric surgeryare important to the patient. Consequently, re-sources can be directed towards treatments mostvalued by patients.[37] Surgeons usually makeimplicit subjective judgment of their patients’HR-QOL when performing bariatric procedures;however, few of them will use explicit HR-QOL in-struments.[38] In addition, where patient-recordedoutcomes such as HR-QOL have been measured assecondary endpoints of clinical trials, the results ofthese instruments have rarely been translated intoformal clinical assessment,[39] and they have rarelymodified the overall interpretation of the trial.[40]

74 Tayyem et al.

ª 2011 Adis Data Information BV. All rights reserved. Patient 2011; 4 (2)

Like any other psychometric instrument, anHR-QOL instrument should produce meaning-ful data with satisfactory psychometric proper-ties, including validity, reliability, specificity,sensitivity, and responsiveness to change. Con-tent validity is the extent to which items in aninstrument assess relevant aspects of the targetedconcepts.[37]

Few papers have tried to analyze the con-tent validity of obesity-specific HR-QOL in-struments.[41-43] The purpose of this systematicreview is to identify instruments used to assessHR-QOL in bariatric surgery and morbid obe-sity, which is a special subset of obesity, and toanalyze and explore their suitability with refer-ence to the proposed framework. As far as weknow, this is the first attempt at a systematicreview of the literature to analyze HR-QOL in-struments used in bariatric surgery and assesstheir content validity.

2. Literature Review

2.1 Methods

A comprehensive electronic search was per-formed of Ovid databases (Ovid MEDLINE,

EMBASE, PsycINFO, EBM Reviews: CochraneDatabase of Systematic Reviews – CDSR, andEBM Reviews: Cochrane Central Register ofControlled Trials – CCTR) for all relevant clin-ical studies including controlled trials writtenin the English language, reporting HR-QOL asone of the primary or secondary endpoints, andpublished between 1980 and October 2009. Acomprehensive description of the search meth-odology listing all search terms and inclusion andexclusion criteria is outlined in table I.1. An electronic search was conducted to includeall relevant studies by applying the followingterms in the citation, abstract and title fields:(i) terms synonymous with ‘bariatric surgery’;and (ii) terms synonymous with ‘HR-QOL’; and(iii) terms synonymous with ‘instrument’.2. Application of the inclusion parameters onthe database search result.3. Application of the exclusion parameters onthe database search result.4. Manual abstract screening.

Data extraction included the type of HR-QOLinstrument used and the number of different in-struments used (if more than one instrument wasused). Full articles were retrieved if their abstractswere not clear regarding the required data. Full

Obesity

Chronic inflammatory statePsychological

factorsSocialfactors

Behavioralfactors

Physical factors

Gut hormone modulation

Calcium and vitamin D

Socialco-morbidities

Physicalco-morbidities

Psychologicalco-morbidities

PoorHR-QOL

Fig. 1. Graphic model illustrating a proposed relationship between obesity and physical, psychological, and social co-morbidities. Thedemonstrated vicious cycle clearly carries detrimental effects on health-related quality of life (HR-QOL). The various factors contributing to thedevelopment of obesity are also shown in this model.

HR-QOL Instruments in Bariatric Surgery 75


articles of six abstracts were unavailable at the timeof writing.[44-49] Abstract screening and data ex-traction was carried out by a single reviewer (RT).

An experienced bariatric team (two bariatricsurgeons, a clinical psychologist, a bariatric spe-cialist nurse, and a bariatric dietician) in collab-oration with two university professors with interestin the subject created a preliminary conceptualframework relying on patients’ experiences andcriteria. The domains of the instruments identi-fied during the review were recorded. This helpedfurther refine and finalize the preliminary frame-work, as shown in figure 2.

2.2 Potential Sources of Bias

The methodology of this review followed astructured and comprehensive approach; however,one possible source of error could be publicationbias where studies with negative results are notpublished. Another source of bias is that a smallnumber of the full articles were not available.

2.3 Search Results

The search strategy was conducted in a system-atic and structured way to include all the relevantarticles. A total of 613 citations were obtained in

Table I. Search methodology showing the terms, inclusion criteria, and exclusion criteria used in the database search

Terms synonymous with bariatric

surgery

‘Bariatric surgery’ or ‘bariatric procedure’ or ‘bariatric operation’ or ‘bariatric’ or ‘obesity surgery’

or ‘gastric bypass’ or ‘gastroplasty’ or ‘sleeve gastrectomy’ or ‘gastric sleeve’ or ‘gastric band’ or

‘lap-band’ or ‘gastric balloon’ or ‘duodenal switch’ or ‘bilio-pancreatic diversion’

Terms synonymous with health-related

quality of life

‘Quality of life’ or ‘qol’ or ‘health related quality of life’ or ‘health-related quality of life’ or ‘hqol’ or

‘hrqol’ or ‘hrql’ or ‘health status’ or ‘well-being’ or ‘functional status’

Terms synonymous with instrument ‘Instrument*’ or ‘measure*’ or ‘question*’ or ‘tool*’ or ‘scale*’ where (*) denoted truncated term

Inclusion parameters Clinical trials, controlled clinical trials, or randomized controlled trials, year 1980–2009, and

‘morbid obesity’ or ‘morbidly obese’

Exclusion parameters Non-English publication and animal studies

Physicalaspects

Psychologicalaspects

Social aspects

Maritallife

Physicalactivity

Energyand

vitalityOther

symptoms

Familyrelationships

Work andemployment

Eatingactivity

Pain

Environmentand

accommodation

Friendship

Finance

Moodand

emotion

Sleep

Sexualactivity

Appearance

Mentalstatus

MobilityPhysicalhealth

Social activities andsocial relationships

HR-QOL

Self-esteem andself-respect

Fig. 2. Proposed conceptual framework demonstrating the potential domains of health-related quality of life (HR-QOL) that might be ad-versely affected by obesity.

76 Tayyem et al.


the first stage, 271 of which met the inclusioncriteria by the end of the second stage. It was sur-prising that, to date, less than 4% of all the publishedliterature regarding bariatric surgery for morbidobesity (7148 citations) included one or more in-struments to assess HR-QOL (271 citations).

During the third stage, 145 studies were ex-cluded and 126 abstracts were retrieved for fur-ther assessment. By the end of manual abstractscreening in the fourth stage, 14 studies were ex-cluded, leaving 112 studies for the review (figure 3).The majority of studies included in the review wererandomized controlled trials, non-randomized con-trolled clinical trials, and uncontrolled clinical trials.

Data extraction in the fifth stage revealed thatthe instrument type was not explicitly mentioned in22 studies, leaving 90 studies for the analysis. A totalof 42 differentHR-QOL instrumentswere identifiedin this systematic review, which were categorizedinto three groups: eight generic, nine obesity-specific,and 25 other condition-specific instruments.

Most of the studies used a single instrument tomeasureHR-QOL (70%), whereas 30% of the stud-ies used more than one instrument. Table II showsthat the most commonly used instrument categoryis other condition-specific instruments (36%), fol-lowed by obesity-specific instruments (34%). Thegeneric instruments were least used (30%).

Overall, the most commonly used instrumentswere theMAQOL (Moorehead-Ardelt Quality of

Life instrument; 21%), followed by the SF-36 (36-Item Short-Form Health Survey; 20%), GI-QLI(Gastrointestinal Quality of Life Index; 9%),Euroqol EQ-5D (5-Item European Quality ofLife; 5%), and IWQOL-Lite (Impact of Weighton Quality of Life-Lite version; 4%).

3. Content Validity

The provisional framework was thoroughlyre-edited during the literature search, resulting in20 potential domains of HR-QOL that might beadversely affected by obesity and improved bybariatric surgery. The identified domains weredistributed almost equally among the three mainaspects of the framework, with six domains in thephysical aspect, seven domains in the psychologicalaspect, and seven domains in the social aspect, asillustrated in the proposed conceptual framework(figure 2). This framework was used in analyzingthe content validity of the identified instruments.

Generic and obesity-specific instruments iden-tified in this review were compared against thedomains in the proposed conceptual framework.Table III compares the content validity of theHR-QOL instruments commonly used in bari-atric surgery against the domains in the proposedframework. Three generic instruments are notincluded because they are rather historical andnot in current use, and two obesity-specific in-struments are not included because they have notbeen used in clinical practice following their de-velopment and validation. Table III clearly showsthat the commonly used instruments are far fromperfect, because they are lacking important do-mains as informed by the proposed framework.

4. Generic vs Obesity-Specific HR-QOL

A condition-specific HR-QOL instrument ispreferable to a generic instrument when consid-ering a specific condition or disease, because acondition-specific instrument will provide a mea-surement that displays greater content validity,and a better attribution factor. The concept of theattribution factor can be explained by the fol-lowing example. When using generic instruments,obese patients will rate their health, sleep, social

Potentially relevant studies(n = 613)

Met inclusion criteria(n = 271)

Abstract reviewed for manualscreening (n = 126)

Irrelevant studies(n = 14)

Met exclusion criteria(n = 145)

Did not meet inclusioncriteria (n = 342)

Total number of studies includedin the systematic review

(n = 112)

Fig. 3. Flow diagram of the search results after the application ofthe search methodology.



activity, etc. without direct reference to their obe-sity, leaving their rating susceptible to externalinfluence from other conditions or factors. Con-versely, with obesity-specific instruments, onlythe impact of obesity on the various aspects of thepatients’ lives will be rated.[37]

Despite increased recognition of the advan-tages of condition-specific instruments and thelimitations of generic instruments, relatively fewobesity-specific instruments have been developedand are ready for use. Moreover, the use ofobesity-specific HR-QOL instruments in bariatricsurgery has still not become common practice asevident by the literature search, which showedthat <4% of all the published literature regarding

bariatric surgery for morbid obesity included oneor more instruments to assess the HR-QOL.

Table IV provides an annotated description ofHR-QOL instruments commonly used in bari-atric surgery.

5. Discussion

QOL is subjective, dynamic, and multidimen-sional. The multidimensional character can bedivided into health-related and non-health-relateddomains, as discussed in the introductory section.The subjectivity of QOL arises from the fact thatindividuals rate their own QOL from their uniqueperspective based on their own feelings, experi-

Table II. Types of health-related quality-of-life instruments and how often they were used in bariatric surgery

Instrument category Times used

Generic

36-Item Short-Form Health Survey (SF-36)[50-77] 28

5-Item European Quality of Life (EuroQoL EQ-5D)[54,56,68,78-81] 7

Miscellaneousa 7

Subtotal 42

Obesity-specific

Moorehead-Ardelt Quality of Life instrument (MAQOL)[51,52,56,57,64,65,79,82-103] 29

Impact of Weight on Quality of Life-Lite version (IWQOL-Lite)[67-70,104,105] 6

Swedish Obese Subjects Obesity Psychosocial Problem (SOS-OP) module[43,106,107] 3

Miscellaneousb 9

Subtotal 47

Other condition-specific

Gastrointestinal Quality of Life Index (GI-QLI)[51,64,108-117] 12

Visual Analog Scale (VAS)[53,118-121] 5

Symptom Check List – 90 Revised (SCC-90R)[92,122-124] 4

Miscellaneousc 30

Subtotal 51

Total 140

a Miscellaneous includes Nottingham Health Profile (NHP),[120,121] World Health Organization Quality Of Life (WHOQOL-BREF),[125]

Manchester Short Assessment of Quality of Life (MANSA),[126] Lancashire Quality of Life Profile,[122] Goldberg General Health

Questionnaire (GHQ-12),[79] and Gothenburg Quality of Life Scale.[127]

b Miscellaneous includes Obesity Specific Quality of Life (OSQOL) instrument,[43,128] Health Related Quality of Life (HRQL),[129,130] Obesity

and Weight-Loss Quality-of-Life (OWLQOL) instrument,[43,131] Obesity Adjustment Survey Short Form (OAS-SF),[132] Obesity Related

Well-Being Scale (ORWELL 97) questionnaire,[133] and Bariatric Quality of Life Index (BQL).[51]

c Miscellaneous includes Psychosocial Stress and SymptomQuestionnaire (PSS-Q),[134,135] Incontinence Impact Questionnaire (IIQ-7),[136,137]

Urogenital Distress Inventory (UDI),[136,137] Kobashi Prolapse Symptom Inventory Quality of Life (PSI-QOL),[137] Oswestry Disability Index

(ODI),[53,118] Gastroesophageal RefluxDiseaseQuality of Life (GERD-QOL),[138,139] Beck Depression Inventory (BDI),[140,141] Cleveland Clinic

Foundation Fecal Incontinence Scale (CCF-FI),[142] Eating Disorder Inventory (EI),[143] Binge Eating Scale,[144] Eating Behavior Self-Efficacy

Scale Questionnaire,[145] Eating Disorder Examination questionnaire,[146] Stunkard and Messick Eating Inventory,[83] Three-Factor Eating

Questionnaire (TFEQ),[144,147] Questionnaire of Eating and Weight Patterns (QEWP),[147,148] Rosenberg Self-Esteem Scale (RSE),[149]

Roland Morris Disability Questionnaire,[118] Waddell Disability Index,[118] Apgar Family Function Questionnaire,[146] Hospital Anxiety

Depression Scale (HAD),[76] Pelvic Floor Disorder Questionnaire,[150] and International Consultation on Incontinence Questionnaire.[151]

78 Tayyem et al.


Table IV. Annotated description of health-related quality-of-life (HR-QOL) instruments commonly used in bariatric surgery

Instrument name Description

Moorehead-Ardelt Quality of Life instrument (MAQOL) Bariatric Analysis and Reporting Outcome System (BAROS) evaluates the

results of bariatric surgery by analyzing three domains: weight loss, changes

in co-morbidities, and HR-QOL.[82] The system has been used in many

countries since its introduction in the late 1990s.[83] The QOL instrument

used in BAROS is the validated[160] MAQOL instrument, which is a simple

quick six-item questionnaire[50]

Impact of Weight on Quality of Life (IWQOL) Has 74 items developed by Duke University to measure eight domains:

health, social interpersonal interaction, work, mobility, self-esteem, sexual

life, daily living activities, and comfort with food.[129,156] There are some

concerns regarding its reliability and validity.[22] The IWQOL has been

reduced to a 31-item psychometrically sound and clinically sensitive

instrument (IWQOL-Lite)[104]

Swedish Obese Subjects Obesity Psychosocial Problem

(SOS-OP) module

A special module composed of eight items and developed for use in the SOS

study.[130] The covered domains include physical activity, social activity,

appearance, and sexual functioning[159]

Obesity Specific Quality of Life (OSQOL) A validated 11-item instrument covering four domains: physical state, vitality

and desire to do things, relations with other people, and psychological

state[128,129]

Health Related Quality of Life (HRQL) A validated 55-item instrument looking at five domains: general well-being,

health distress and depression, self-esteem with three major levels of

functioning (self-regard, physical appearance, and work productivity),

physical activity, and social activities.[129,130] Unfortunately, this lengthy time-

consuming instrument is unreliable when administered serially in patients

with stable weights[22]

Obesity and Weight-Loss Quality-of-Life (OWLQOL)

instrument and Weight-Related Symptom Measure (WRSM)

Has two parts: part one records the patient’s feelings about their weight,

including 17 items, and part two records 20 items about weight-related

symptoms and how much they bother the patient.[131,157,158] Both have been

shown to display good internal consistency, test-retest reliability, and

convergent validity[129]

Obesity Adjustment Survey An instrument with a huge collection of 95 items from the Mental Health

Inventory, the Sickness Impact Profile, and the Eating Inventory, which was

condensed into a shorter 20-item survey[22,132]

Obesity Adjustment Survey Short Form (OAS-SF) A sensitive and valid measure of obesity, although it is limited as it only

measures the psychological distress aspect of HR-QOL[22,129,132]

Bariatric Quality of Life Index (BQL) A 30-item measure of well-being in bariatric surgery patients, which is a

validated instrument ready for clinical use[51]

Obesity Related Well-Being Scale (ORWELL 97)

questionnaire

A simple, valid,[129] and reliable measure of obesity HR-QOL that can be

used in current clinical practice. It consists of measuring two subscales:

ORWELL 97-1, which is related to psychological status and social

adjustment, and ORWELL 97-2, which is related to physical symptoms and

impairment[133]

36-Item Short-Form Health Survey (SF-36) One of the most commonly used generic HR-QOL instruments, which has

been used in thousands of studies.[22] It is used in health economics as a

variable in the QALY calculation to determine the cost effectiveness of a

health treatment. A shorter validated version, the SF-12, composed of 12

items, is also available for use. The SF-36 instrument has been throughmany

years of development and refinement, producing well validated and reliable

results. The SF-36 is a multipurpose health survey, which consists of 36

validated items distributed among eight scaled domains:[152] vitality, physical

functioning, bodily pain, general health perceptions, physical role functioning,

emotional role functioning, social role functioning, and mental health

Continued next page

80 Tayyem et al.


ences, and priorities. Individuals’ assessment oftheir own QOL will change over time, dependingon their priorities, experiences, and circumstancesat a given time, which explains the dynamic prop-erty of QOL.[37] The concept of subjectivity anddynamicity of QOL may explain why patients’ andclinicians’ ratings of the same objective situationhave been found to differ significantly, with therating rarely well matched.[161]

To maintain adherence to treatment and to de-velop new treatments that may be more acceptableto patients, it is crucial to understand howconditionsand interventions can affect QOL in a way pertinentto patients. An HR-QOL instrument can be usedto generate quality-adjusted life-years (QALYs),which would be utilized in estimating the costeffectiveness of the treatment.HR-QOLassessmentcan also aid in the process of decision making whencomparing different treatment options.[3]

In bariatric surgery, objective measurement ofweight loss has been the standard common prac-tice; however, subjective assessment of HR-QOLhas been less standardized. Several generic andobesity-specific HR-QOL instruments have beendeveloped and used in bariatric surgery. Al-though some of their psychometric properties

have been satisfactory, their content validity asshown in this review has not. Content validity is afundamental concept of an instrument’s validity,as there is no point saying that an instrument hasexcellent reliability, sensitivity, and responsive-ness if it does not measure what it is supposed tomeasure, i.e. the target concept or domain.

During this study, a conceptual frameworkwith 20 domains was constructed. This frameworkcould provide better insight into the problems ofobesity, and equally importantly, a window to ex-plore the patient experience after the operation –whether that experience be good, as anticipated(e.g. weight loss, resolution of co-morbidities), orbad (e.g. complications).

Obesity-specific HR-QOL instruments identi-fied during the literature search did not includeall the domains of the conceptual framework.Generic instruments, although considerably lon-ger than the obesity-specific instruments, containedirrelevant domains and still missed some of thedomains of the conceptual framework. Therefore,the currently available instruments, whether genericor obesity-specific, may underestimate the fullimpact of obesity on HR-QOL. This has beenacknowledged by previous researchers, as they

Table IV. Contd

Instrument name Description

5-Item European Quality of Life (EuroQoL EQ-5D) Another commonly used validated health survey. It is a short generic

instrument composed of five items including mobility, self-care, usual

activities, pain/discomfort, and anxiety/depression. It provides a single index

value that can be used in clinical and economical evaluation of healthcare[153]

Nottingham Health Profile (NHP) A validated HR-QOL instrument that has been used in bariatric surgery. It

consists of 38 items covering six domains: energy, pain, emotional reaction,

sleep, social isolation, and physical mobility. A major advantage of this

instrument is that it has been validated against a large population, which

makes it possible to compare results with a reference population. Another

advantage is that the instrument results can be reduced to one single value

that can be used as a utility index[22]

World Health Organization Quality of Life (WHOQOL 100) Assesses generic HR-QOL over a 2-week recall period. It includes 100 items,

which have been reduced to 26 validated items in the WHOQOL-BREF

instrument; covers four domains of physical health, mental health, social

relationships, and environment[154]

Manchester Short Assessment of Quality of Life (MANSA) Used to assess HR-QOL, developed by Priebe et al.[126] in 1999. It is a brief

instrument for assessing HR-QOL, focusing on satisfaction with life as a

whole and with life domains.[126] It has 14 specific life domains looking at

employment, financial situation, family relationships, accommodation,

sexuality, mental health, and physical health. It has satisfactory psychometric

properties, including validity and reliability[155]

QALY = quality-adjusted life-year; QOL = quality of life.



administered more than one HR-QOL instru-ment in their studies, which is time consumingand difficult for both the patient and the clini-cian. Moreover, the use of multiple instrumentsmay increase the number of irrelevant items,and still not pick up all the domains of theframework.[37]

The findings from the current review contrastwith those of Stucki et al.,[43] although this isunsurprising since that review focused on thecontent of obesity-specific measures within therealm of generic utilization in a broad range ofpopulations encountering health concerns due toobesity. The current review focuses specificallyon the content and application of HR-QOLmeasures within the context of bariatric surgery.Furthermore, whereas the elegant review ofStucki et al.[43] compared instrument content withthe International Classification of Functioning,Disability and Health (ICF), the current reviewdeveloped a conceptual framework against whichboth generic and disease-specific measures wereassessed. Unsurprisingly, therefore, the con-clusions from both studies are different in that theuse of the conceptual framework within the cur-rent review emphasizes the requirement for anovel HR-QOL tool to be developed specificallyfor use within the bariatric clinical setting, giventhat the current instruments available would ap-pear inadequate. This contrasts with Stuckiet al.,[43] since the content comparisons were in-trinsically and fundamentally related to and de-termined by orientation to the ICF.

This review may represent the first step tobuilding a valid and true ‘bariatric’-specific instru-ment, as opposed to the majority of the currentlyavailable instruments, which are ‘obesity’-specificinstruments and might be unable to fully assessthe bariatric patient pre- and post-operatively.One potential limitation of the review concernsthe conceptual framework developed by the au-thors. It may be seen from this introduction thatthe authors present a conceptual frameworkstrictly focused on obesity and QOL. The devel-opment of a preliminary framework before goingto the literature could potentially introduce twotypes of bias: initial bias, as the framework couldbe influenced by the experience and knowledge of

the researcher, and ongoing bias as, once theframework is developed, it will influence the re-searcher’s thinking and may result in some issuesbeing overestimated and others being ignored.Whereas this is contextually sensitive to the pur-poses of the review, such an orientation may in-evitably introduce a degree of bias within the lit-erature search, since the focus of these elements isnecessarily circumscribed within the overarch-ing domain of bariatric surgery. This has beenaddressed by revisiting and refining the con-ceptual framework during the literature review.The assertions made, therefore, must be viewedas specific and not general.

6. Conclusion

Various aspects of the morbidly obese pa-tient’s life can be adversely affected, althoughmuch remains to be understood to be able tomeasure it scientifically and accurately. In thissystematic review of the literature, we foundthat most of the literature in bariatric surgeryeither did not report HR-QOL outcome, or theHR-QOL outcome was not given the appro-priate weight and importance. Whenever a HR-QOL instrument was used, the generic and othercondition-specific instruments were used notice-ably more frequently than the obesity-specificinstruments.

Over the years, several generic and obesity-specific instruments have been developed and usedin bariatric surgery; however, all had limitations.Content validity, which is a vital element when itcomes to deciding the type of instrument to beused, has been unsatisfactory and substandard forall the instruments we identified. Obese patientsneed to be given the opportunity to decide the se-verity of impairment of their HR-QOL, based ontheir own experience and criteria. Only then canthe full impact of morbid obesity and bariatricsurgery be assessed. We propose a conceptualframework detailing all the pertinent domains thatmight be affected, which can be used to develop anew bariatric-specific instrument. Such an instru-ment would display excellent content validity andcover all the potential aspects that might be af-fected by morbid obesity or bariatric surgery.

82 Tayyem et al.


Acknowledgments

No sources of funding were used to conduct this review orprepare this manuscript. The authors have no conflicts of in-terest that are directly relevant to the content of this review.

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Correspondence: Professor Colin R. Martin, University ofthe West of Scotland, Ayr Campus, Beech Grove, Ayr,KA8 0SR, UK.E-mail: [email protected]



Analysis of Health-Related Quality-of-Life Instruments Measuring the Impact of Bariatric Surgery

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