Quality of Perception and Quality of Care in Ambulatory Laparoscopic Cholecystectomy. Methodological Considerations and Questionnaires

Dear Editor,

We have read the article published in this journal by A. Sala Hernández et al.¹ referring to quality control and the overall satisfaction of ambulatory laparoscopic cholecystectomy (ALC) procedures. In this study, the authors used a satisfaction scale (Figure 1) to evaluate the scientific-technical quality and the quality perceived by patients, mistakenly attributing the origin of said survey to the MAS Unit at the Hospital La Fe. This survey was not the original work of the authors nor of the MAS Unit of the Hospital La Fe. Therefore, it should be referenced in the study as ‘taken from’, ‘modified from’ or ‘adapted from’, and the corresponding bibliographical reference, as it was previously published for the first time in 2002 by our group² as a specific modification of the SUCMA 14 questionnaire.³ In addition, this survey was subsequently used in the doctoral thesis of Dr. J.A. Bueno Lledó in a sample of 363 cases.⁴ Moreover, the authors could have used its current name, ICAD15, which was published when it was validated in a prospective series of 148 consecutive cases, administered by a nurse specialized in pre-, intra- and postoperative control.⁵ The SUCMA 14 is a very similar questionnaire but validated for different MAS procedures in other areas of general surgery that does not contain relevant items for ALC and was used to guide our initial survey design used in the first publication on quality and ALC in our country.² ICAD15 was published in the Cirugía Mayor Ambulatoria(CMA) journal⁵ and analyzed a prospective group of 148 consecutive patients demonstrating the high relevance of specialized nursing in MAS and specifically in ALC by significantly improving all items of perceived and scientific technical quality in the group of 627 consecutive patients analyzed.

The new survey modality published in the CMA journal thus corresponds to the refined ICAD15 questionnaire that is expanded with a greater number of perceived quality/satisfaction questions. ICAD15 includes many more items related to the scientific-technical quality and side effects of the procedure than SUCMA 14 and fewer items related to perceived quality. The difference is that ICAD15 is a process-specific questionnaire (in this case ALC) validated in 3 series of patients, with a total sample of 627 patients who had undergone ALC.^2,5

If you initiate a search of the literature using Google (non-academic), the first articles that are found after entering the authors’ study title are precisely entries referring to the doctoral thesis of Dr. Lledó (departamento de cirugía evaluación de la colecistectomía…/ https://www.tdx.cat/bitstream/handle/10803/9604/bueno.pdf) and the article published in the CMA journal (www.asecma.org/Documentos/Articulos/OR%20Marmaneu.pdf). Further along, the initial article from 2002 appears.

While the lack of reference to the ICAD15 survey published in MAS could be considered ‘grey’ literature, we must admit that forgetting the reference of the satisfaction survey in Dr. Lledó’s doctoral thesis and its origin in the study we previously published in 2002 entail a deficient search of the literature in a subject area that is very restricted in the number of publications (in our country) and highly specific.

Finally, a severe methodological defect: conducting a survey of this nature after 14±8 months (it should be assumed that there is a transcription error and actually refers to days) ends up generating results that are difficult to support, at best. The long-term memory of patients would not be able to reliably respond to a large majority of the items included in the survey, because a large part of it is based on technical scientific items. Plus, as we know, time erases and buffers all things, which is usually what happens with patients in their kindness and tolerance. This is a survey that must be carried out between 72 h and 5 days after surgery and in person, if possible, since telephone surveys are sure to distort reality, generating either false negatives or false positives for any of the dichotomous questions.

On a final note, in the study in which the ICAD15⁵ is published, the results tables demonstrate the relevance of including a nurse specialized in the pre, peri and postoperative care of a complex CMA procedure like ALC.