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Predictors of Quality of Life at 3 Months after Treatment for Aneurysmal Subarachnoid Hemorrhage
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.314581
Keywords: Aneurysm, disability, quality of life, subarachnoid hemorrhage
Aneurysmal subarachnoid hemorrhage (SAH) is a life-threatening condition. Despite improvements in preoperative/postoperative care, surgical techniques, and endovascular methods, the case fatality remains high, and post-event resumption to normal life is a challenging task. Survivors add a lot of burden to the healthcare system in one or another form. Less than half of the survivors return to the same job and have difficulty in being a functional part of society and their families.[1] The outcome of SAH has been quantified in the form of various quality of life (QOL) tools in different studies across the world.[2] Assessment of QOL after aneurysmal SAH gives an idea regarding the functional and psychological impairments associated with SAH and its treatments. This may also reflect on the utility and significance of the therapeutic interventions. Though several studies on mortality and outcome after SAH is available from India, ours is the first study from India dealing with QOL. This study aimed to assess the overall outcome and QOL of the patients with aneurysmal SAH and identify the predictive factors determining the QOL.
This is a prospective observational study of patients admitted in our hospital with history, clinical findings, and imaging diagnosis of aneurysmal SAH during the period between October 2017 and March 2018. Prior approval from our institute's ethics committee was taken. On hospital admission, the neurological condition was assessed using the Glasgow coma scale (GCS) and World Federation of Neurosurgical Societies (WFNS) scale. The amount of SAH was assessed using the modified Fisher scale. Patients were evaluated at discharge with the GCS, and neurological deficits if any were noted at the time of discharge. At discharge, patients and caregivers were informed about the follow-up assessment and the nature of the questionnaires. All the follow-up interviews for assessment of functional outcome and QOL were conducted by a single-blinded interviewer at 3 months after treatment to avoid the bias. The interview was done telephonically with validated tools as described below. Patients were interviewed preferably in their native language with the help of appropriate translators. Questions on the resumption of previous activities such as employment and activities daily life were also noted. Outcome assessment tools The following instruments were used to assess functional outcome and QOL. These tools have been validated for use in patients with SAH and these are also validated for telephonic interviews. Short form (SF)- 36 The SF-36 measures QOL on eight scales: physical functioning(PF), role limitations-physical(RP), bodily pain (BP), general health(GH), vitality(VT), social functioning (SF), role limitations-emotional(RE), and mental health(MH).[3] The direct score in the different dimensions is based on a scale that ranges from 0 (worse) to 100 (better). Barthel index (BI) The BI is a measure of disability ranging in 5-point increments from 0 (totally dependent and bedridden state) to 100 (fully independent).[4] Modified Rankin Scale (mRS) To assess functional outcome and disability we used the modified Rankin Scale (mRS). The mRS is a 6-point handicap scale that focuses on restrictions in lifestyle with 6 being death and zero being normal. The mRS above 3 indicates moderate to severe disability.[5] Quality of life after brain injury – Overall scale (QOLIBRI-OS) The QOLIBRI was developed for the assessment of outcome after traumatic brain injury. QOLIBRI-OS consists of six items with one item selected from each domain of QOL (physical condition, cognition, function in daily life, personal and social life, and current situation and prospects). Responses to each item are scored 1 (not at all) to 5 (very), and the sum of all items is converted to a percentage, with 0% representing the lowest score and 100% the best score.[6] This is relatively a novel tool for the assessment of QOL in SAH. All the above mentioned tools have been validated in previous studies for reliability by telephonic interview.[7],[8],[9] Statistical analysis To calculate the impairment of QOL in the eight dimensions as described in SF 36, the normative data (mean and standard deviation) for our population was derived from the study by Sinha, et al.[10] Impairment was denoted as one standard deviation below the mean. Linear regression was performed separately with each of the dimensions of SF 36 as the dependent variable and the established predicting factors as the independent variable. The variables studied were age, gender, GCS at presentation, WFNS grade on admission, modified fisher grade on admission, location of the aneurysm, size of the aneurysm, preoperative external ventricular drainage, treatment modality, a course in the ward, angiographic vasospasm, clinical vasospasm, residual aneurysm neck on a postoperative angiogram, and GCS at discharge. The P value below 0.05 was considered statistically significant. Spearman coefficient was used to calculate the correlation coefficient between the various tools used for QOL. Statistical analyses were conducted using the data analysis toolkit in Microsoft Excel (Office 365, 2015 version).
A total of 143 patients with a final diagnosis of aneurysmal SAH were admitted to our center during the period between October 2017 and March 2018. The demographic, clinical, and imaging findings of these patients are given in [Supplementary Table 1]. Out of the 143 patients enrolled in the study, five patients died in the hospital and 14 patients died after discharge. Eighteen patients could not be contacted and were considered as lost to follow-up. A total of 106 (85.5%) out of 124 survivors completed the follow-up questionnaires. The assessment was done at 3 months after treatment. The clinical and imaging findings of these patients are given in [Table 1]. The mean age at presentation was 48.9 ± 11.1 years with an equal number of males and females. Majority of the patients presented with WFNS grade 1 (84.9%). On imaging, the majority had modified Fisher grade 3 (79.3%) hemorrhage. The commonest location of the aneurysm was anterior communicating artery (ACOMA) (39.4%) followed by the middle cerebral artery (MCA) (21.3%).
Functional outcome One hundred and one out of 106 patients (95.28%) resumed their activities of daily life, however, 43 out of the 106 (40.56%) patients could not resume their previous work/employment. The disability grades as scored using mRS, BI, and QOLIBRI OS scales are shown in [Table 2]. Five patients out of 106 (4.7%) had moderate to severe disability on the mRS scale, and rest had mild/minimal or no disability. Similar findings were observed when evaluated with the Barthel index, severe disability was present in three patients out of 106 (2.8%) while the rest had mild or no physical disability. When patients were evaluated with the QOLIBRI-OS, 15 patients (14.1%) had a score of less than 52 implying low or impaired health-related QOL.
The analyses for the determination of QOL using the eight components of SF 36 is depicted in [Figure 1]. The main QOL domains affected were mental health (86/106, 81.10%), vitality (64/106, 60.30%), general health perception (63/106, 59.40%), and physical functioning (60/106, 56.60%). The least affected domains were physical role 16.9% (18/106), emotional role 20.7% (22/106), and body pain 17.9% (19/106).
Correlation of outcome assessment tools Spearman's correlation coefficients were calculated between the scores of different functional outcomes and QOL measurement tools as shown in [Table 3]. The correlation score of 1 indicates a perfect direct correlation whereas a score of -1 indicates a perfect inverse correlation. Inverse correlation can occur because the best outcome in a tool like SF 36/Barthel gets the highest score, whereas the scoring for mRS is inverse with the best outcome being given a score of zero. A correlation coefficient closer to 0 is a poor correlation. The SF 36 showed moderate correlation with all other scales, highest being with QOLIBRI-OS followed by BI. The mRS showed a negative correlation with all other scales. The BI had a relatively poor correlation with other scales.
Predictors for quality of life The results of the linear regression analysis are presented in [Table 4]. Only significant predictors are depicted in [Table 4] other predictors are listed in [Supplementary Table 2]. The results obtained after linear regression analysis show that the statistically significant predictors for the majority of the dimensions of SF-36 were GCS at presentation and discharge, and the course in the ward. Certain dimensions of SF 36 were also affected by factors such as treatment modality, clinical vasospasm, and preoperative EVD. The treatment modality predicted body pain and the physical functioning domain of QOL. The presence of clinical vasospasm also predicted body pain and the physical functioning domain of QOL. Age, gender, location of the aneurysm, or its size were not statistically significant predictors of a poor QOL in our study.
The present study showed that fewer patients were severely disabled, 4.7% according to mRS, and 2.8% according to BI. There was a good correlation between different outcome scales for assessing disability as well as QOL. Though significant BI had a relatively weaker correlation with other outcome measures. A similar observation was described in the study by Kim, et al.[11] Though fewer patients were severely disabled, many patients had deterioration in QOL. Almost one-third of our patients had QOL scores below the mean for the normal population. The main QOL domains affected were mental health, vitality, general health perception, and physical functioning. The least affected domains included physical role, emotional role, and body pain. This observation is quite different from other studies. The other studies reported that the physical role domain was commonly affected [Table 5].[12],[13],[14xs] The reason for this difference could be the sociocultural and socioeconomic differences in both the study populations. Most of our patients are from low socioeconomic status, and they have a pressing need for economic gains from physical labor hence physical role did not determine the QOL among them. The physical function improves over time. In the study by Hop, et al. a significant improvement in the physical domain was observed from 4 to 18 months, however, the mental health component continued to be lower than the mean.[15] The mental health domain was the most affected in our study, with more than two-thirds of the patients being affected by it. Depression, anxiety, and emotional instability in SAH have been quite extensively reported in the study by Katati, et al. as well as in a metanalysis by Noble, et al.[2],[12] In the study by Dey, et al., significant neurocognitive and neuropsychological impairment was observed even in good grade SAH, further contributing to a deterioration in mental health and QOL.[16] Mental health is the most important factor related to poor QOL in these patients hence along with physical rehabilitation, psychological counseling should also be an integral part of follow-up visits in these patients.
The second important aim of this study was to try to identify the factors that can predict the QOL after aneurysmal SAH. The results obtained after linear regression analysis show that the statistically significant predictors for all the dimensions of the SF-36 are neurological status at presentation (GCS), neurological status (GCS) measured at discharge, and the course in the ward. Cedzich, et al. reported similar results but with GOS at discharge, affecting the QOL scores.[17] Similar to their study, our study also concluded that the radiological severity of SAH as measured by the modified Fisher scale was not a statistically significant predictor of poor QOL.[17] Age, gender, location of the aneurysm, or its size were not statistically significant predictors of poor QOL. This was similar to the results reported by Nobel, et al. and Passier, et al.[2],[18] in their metanalyses but not in agreement with the results by Katati, et al. which reported gender as the most important variable.[12] The other variables in our study which were statistically significant predictors for some of the dimensions of SF 36 were treatment modality and clinical vasospasm. There is a considerable variation in the significance of the predictors of QOL as seen in the metanalysis by Noble, et al.[2] Most of the studies in the metanalyses showed that the traditional risk factors such as age, sex. the severity of the bleed, location, and size of the aneurysm were not statistically significant in predicting a poor QOL.[2] In the metanalysis by Noble, et al. physical disability was the main factor for poor QOL.[2] The predictors vary in the multiple studies due to different sample sizes, variable statistical analyses models, nonuniform follow-up periods, and variable measurement tools. We did not find any new determinants of the outcome as compared to existing literature. However, we have shown that GCS rather than WFNS was a determinant of outcome. The modified WFNS, which considers only GCS has been proposed.[19] In the original article by the developer of modified WFNS they found that in the modified WFNS scale, a significant difference between any neighboring grades was observed both in the mean GOS and mRS scores. However, the developers have not correlated modified WFNS with QOL. As we have shown that GCS (the only component in modified WFNS) correlates with QOL in patients with SAH this can be considered as a novel finding. The limitation of this study was the small sample size and a shorter duration of follow-up. The outcome was assessed only at 3 months after treatment. Patients are likely to recover over time.[20] This manuscript is a result of a time-bound research project with no funding hence we could not generate a large sample size, and do a longitudinal study. However, such a pilot study will motivate other researchers to do a similar study in their centers, and validate our findings. The pattern of improvement in QOL over time needs to be studied in the future in the Indian population.
Though a fewer patient has severe disability after SAH, a majority of them have a deteriorated QOL. The mental health domain is worst affected followed by physical health and social functioning. The main determinant of QOL in SAH is GCS at presentation and GCS at discharge. Ethical approval All procedures performed in studies involving human participants were under the ethical standards of the institutional ethics committee (NIMHANS/IEC (BS & NS DIV) 8th Meeting, 2017. Dated 12-Sep-2017) Declaration of patient consent Informed consent was obtained from all individuals as participants included in the study. No identifying information about participants is available in the article. All as home as at the end. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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