We thank Vaghadia et al.  for their correspondence regarding the Postoperative Quality of Recovery Scale (PQRS).1They suggested that the use of subjective patient opinion might be more heavily emphasized among the multiple domains assessed in the PQRS. Interestingly, and presumably in support of this position, they quote two articles regarding the value of patient opinion in determining fitness for discharge—with opposing results! In the first of these articles, patients who underwent cholecystectomy would have delayed their discharge relative to the assessment of healthcare professionals2; in the second, the outpatients would have been discharged earlier than the health professional assessment.3This underlies the problem of excessive reliance on patient opinion and is one of the reasons our group chose to go forward with objective measurements. It is well-known, for example, that patients will not detect the same level of cognitive dysfunction compared with objective neuropsychological tests.4This was echoed in our study,1in which the patient perspective of cognitive recovery was twice that of the objective measures. One of the difficulties with excessive reliance on patient response in this domain is the influence of other factors on judgment, such as the desire to be discharged and the possibility of patients not having clarity of thought.

We identified that most current recovery assessment tools are based on subjective opinion or subjective recall of past events. This was considered a weakness, and we believe that the use of objective testing over repeated periods is the strength of the PQRS. Another strength is our concept of recovery (i.e. , “return to baseline values or better”). All patients undergo testing before surgery, which allows objective assessment of when they return to presurgery levels of function. We did include a subjective assessment domain called the “overall patient perspective.” This was included to allow better comparability with other recovery scales in the literature and questions aspects of return to function, satisfaction, and cognition. It only commenced from day 1 onward.

The PQRS is not just another “readiness for discharge tool” nor does it cater for specific surgery end points (e.g. , joint function or range of movement). If a particular operation, such as shoulder surgery, is only  to be assessed for home readiness, then other published scales may offer a better solution, as Vaghadia et al.  have commented. The strength of the PQRS is the objective assessment of multiple domains of recovery during the early, and late and long-term, periods. In the future, the PQRS may have broader application; at this stage, it is principally designed as a research or audit tool to assess how “what we do” affects the quality of recovery after anesthesia and surgery. It is far more complex than a simple tool to determine home readiness.

*University of Melbourne, Carlton, Australia. colin.royse@heartweb.com

1.
Royse CF, Newman S, Chung F, Stygall J, McKay RE, Boldt J, Servin FS, Hurtado I, Hannallah R, Yu B, Wilkinson DJ: Development and feasibility of a scale to assess postoperative recovery: The post-operative quality recovery scale. Anesthesiology 2010; 113:892–905
2.
Fleisher LA, Yee K, Lillemoe KD, Talamini MA, Yeo CJ, Heath R, Bass E, Snyder DS, Parker SD: Is outpatient laparoscopic cholecystectomy safe and cost-effective? A model to study transition of care. Anesthesiology 1999; 90:1746–55
3.
Vaghadia H, Cheung K, Henderson C, Stewart A, Lennox P: A quantification of discharge readiness after outpatient anesthesia: Patients' versus  nurses' assessment. S Afr J Anesth Analg 2003; 9:5–9
4.
Newman S, Klinger L, Venn G, Smith P, Harrison M, Treasure T: Subjective reports of cognition in relation to assessed cognitive performance following coronary artery bypass surgery. J Psychosom Res 1989; 33:227–33