Quality of life and communication in orthognathic treatment

ABSTRACT

Objective: The primary aim was to determine what, if any, relationships exist between communication and quality of life in patients receiving orthognathic treatment since this has not been explored. A secondary aim was to compare the Quality of Life (QoL) of a pre-treatment sample with those at 2 years post-surgery.

Design: A cross-sectional questionnaire method was used.

Setting: Outpatient clinics providing orthognathic treatment at four UK hospital sites.

Participants: Two separate samples of pre-treatment (n = 73) and 2-year post-surgery (n = 78) patients participated in the study.

Methods: At clinic appointments, all eligible patients were invited to complete the Orthognathic Quality of Life Questionnaire (OQLQ), a previously validated condition-specific quality of life measure. At the same time, participants at the 2-year post-surgery stage also completed a second short questionnaire, the Communication Assessment Tool-Team (CAT-T), where they rated the quality of communication they had received during treatment.

Results: One hundred and fifty-one complete responses were received. The average age was 24.5 years (S.D. 9.77) and the majority (67%) were female in both groups. Statistically significant associations were found between QoL and quality of communication in the treated sample. Findings also showed a comparatively poorer QoL for the pre-treatment participants. This reduced QoL was more pronounced in females than males for all aspects except dentofacial appearance.

Conclusions: There was an improvement in QoL for patients at 2 years post-surgery compared to pre-treatment. There is an association between QoL and quality of communication as reported by participants at 2 years post-surgery. These novel findings are similar to outcomes in other patient settings such as oncology, but further investigation is required to establish the direction of cause and effect.

KEYWORDS:

• Communication
• orthognathic
• quality of life

Introduction

Orthognathic treatment success is recorded and reported in terms of clinical results, but with moves towards more holistic care for patients, there has been interest in the collection and publication of patient-reported outcome measures (PROMs). Satisfaction is one of the simplest patient-reported outcomes to measure and there has been a nationally agreed and validated orthognathic patient satisfaction questionnaire (Travess et al. 2004) promoted through the British Orthodontic Society (BOS) (Morris 2015). Indeed, most patients are highly satisfied after orthognathic treatment and would re-elect to have the surgery (Cunningham et al. 1995). However, where the aims are not only to improve function but also appearance, other areas of patients’ lives will be influenced too. Treating clinicians have anecdotally noted improvements in their patients’ psychological and social well-being and an expanding body of research supports this. Two systematic literature reviews covering published studies from 1966 to 2012 came to the same broad conclusions that there was proof that orthognathic surgery improved quality of life (QoL) in patients with dentofacial deformities (Hunt et al. 2001; Soh and Narayanan 2013). However, the psychosocial benefits are not clearly defined and there is a need for well-controlled longitudinal studies to establish these benefits and whether they are sustained in the long term, there has also been a lack of uniformity in the techniques used to evaluate QoL outcomes (Hunt et al. 2001). Review of the studies published since 2001 (Soh and Narayanan 2013) shows higher levels of evidence, better study design and increased use of validated instruments which generate quantifiable data, such as the Orthognathic Quality of Life Questionnaire (OQLQ), a condition-specific QoL tool validated for orthognathic treatment (Cunningham et al. 2000, 2002). Only one study has carried out longitudinal follow-up and more work is needed to understand the longer-term QoL outcomes for patients (Motegi et al. 2003). More recently, the OQLQ has been validated in other languages, such as Brazilian (de Araújo et al. 2013) and studies are becoming more widely reported from around the world, with interest being shown in the influences of ethnicity and culture, such as data gathered in Iran (Eslamipour et al. 2017). The relationships and influences between QoL and psychological well-being (depression and anxiety) have also been the focus of some studies (Brunault et al. 2016). There is a growing interest in the comparative outcomes of surgery-first versus the more traditional orthognathic approach as well (Pelo et al. 2017), but the reporting of longitudinal QoL outcome data greater than 12 months post-surgery is still to happen.

Regarding communication during orthognathic treatment, patient comprehension and retention of information has been found to be poor, particularly regarding the risks associated with treatment (Ikeda 2011). A small number of studies indicate that communication and information provision have significant influences on patient satisfaction. High treatment satisfaction has been associated with realistic expectations of outcome (Edgerton and Knorr 1971), realistic expectations of post-operative discomfort and recovery (Kiyak et al. 1982) and effective pre-operative preparation of the patient (Flanary and Alexander 1983). When patients have reported dissatisfaction, it has most commonly been due to the lack of explanation of side-effects following surgery itself (Cunningham et al. 1996). Literature from the oncology setting has revealed that unmet information needs can be linked to negative consequences, such as poorer psychological adjustment and well-being, including anxiety, depression and a reduced ability for self-care (Annunziata et al. 1998; Ong et al. 2000; McPherson et al. 2001; Molenaar et al. 2001). Enhancing information provision has been shown to result in improvements in information satisfaction, recall, decision-making and QoL. Moreover, information satisfaction has been demonstrated to be an important predictor of overall QoL and its components in terms of physical, emotional, social and functional well-being (Davies et al. 2008). In other patient populations, such as those undergoing myomectomy or hysterectomy (Hempowicz et al. 2013), brain tumour resection (Diaz et al. 2009) and pelvic reconstructive surgery (Kenton et al. 2007), there is evidence to demonstrate that preparedness, including informed consent for surgical procedures, is an important predictor of outcome relating to patient satisfaction, symptom improvement and QoL. Relationships between communication and QoL in orthognathic treatment have not been investigated previously and the current study aims to explore this in a United Kingdom (UK) population.

Material and methods

A cross-sectional questionnaire study was carried out at four UK hospital sites (Queen Victoria Hospital, East Grinstead; East Surrey Hospital, Redhill; Medway Maritime Hospital, Gillingham; Darent Valley Hospital, Dartford) between October 2014 and November 2015.

Two separate samples of pre-treatment and 2-year post-surgery patients attending orthognathic clinics were invited to join the study. Eligible patients were identified by the clinical team responsible for their care via electronic clinic lists and were approached consecutively during the study period. They received an invitation letter together with the patient information sheet and were given the opportunity to ask questions about the study before making a final decision whether to participate or not. Those willing to take part were provided with a consent form and the study questionnaire(s) by members of the clinical teams at each of the study sites.

Each participant was asked to complete the questionnaire(s) on a single occasion. Pre-treatment participants only completed the QoL questionnaire, whereas the 2-year post-surgery group was also asked to complete an additional questionnaire about the quality of communication they had received during the treatment. Participation took place in a designated quieter area of the waiting room or spare clinic/side-room if available. A pen, clipboard, the consent form and the questionnaire(s) were supplied together with a sealable envelope for the confidential return of the completed items.

The OQLQ was employed to measure QoL as there is good evidence for its validity, reliability and responsiveness (Cunningham et al. 2000; 2002). It is a self-reported questionnaire with 22 items divided into four domains: facial aesthetics, oral function, awareness of deformity and social aspects of the deformity. Items are rated on a 4-point Likert scale ranging from 1 ‘bothers you a little’ to 4 ‘bothers you a lot’. Higher scores indicate more concerns and poorer QoL, whereas lower scores indicate fewer concerns and better QoL.

To measure the quality of communication that patients experienced during treatment, the Communication Assessment Tool-Team (CAT-T) was used (Mercer et al. 2008). This is a reliable and validated instrument which was developed for assessing patient perceptions of healthcare staff performance in the areas of interpersonal and communication skills and has been applied in both hospital and community settings. It contains 15 items for respondents to rate medical staff on different dimensions of communication and interpersonal skills, e.g. ‘they talked in terms I could understand’. Scoring is done on a 5-point Likert scale (1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent). The authors of this instrument recommend results are summarised by calculating the proportion of items rated as ‘excellent’ rather than using mean scores.

Descriptive summary statistics were generated for the two questionnaires and SPSS Statistics (Version 22.0) was used to analyse these data. Differences between the two patient groups in QoL as measured by the OQLQ were examined using analysis of variance (ANOVA). Correlational analysis (non-parametric Spearman’s rho) was used to explore any relationships between QoL and patient-rated quality of communication in the treated patient sample only.

Results

One hundred and fifty-six patients attending orthognathic clinics completed questionnaires and evaluable data were available from 151 for analysis. Unfortunately, the study sites did not keep refusal records, but anecdotally they were said to be low. The average age of the whole sample was 24.5 years (S.D. 9.77) and the pre-treatment patients (n = 73) were significantly younger than the 2-year post-surgery group (n = 78), 21.2 years (S.D. 8.11) versus 27.6 years (S.D. 10.21), F (1,149) = 18.10, p < .001. Most were female (101/151, 67%) and this was regardless of treatment stage (pre-treatment 45/73, 62%; 2-year post-surgery 56/78, 72%).

Two-way ANOVAS (treatment stage by gender) were carried out for each of the outcomes on the OQLQ measure; the factor of gender being entered since it has previously been reported as influencing QoL (Bortoluzzi et al. 2015). Repeat of these analyses was performed with age added as a co-variate as a weak effect has also previously been evidenced (Bortoluzzi et al. 2015), but this was not found to change the findings. The ANOVA for the total score of the OQLQ showed significant treatment stage by gender-interactive effects and this is graphically displayed in Figure 1. Since similar patterns to the outcome on the total OQLQ score were apparent for the sub-domains of social, facial aesthetic and oral function for brevity they are not presented. Follow-up one-way ANOVAS at each level of the two factors (treatment stage and gender) were separately carried out to confirm the final picture. For guidance, effect size is indicted by Eta² in the Figures and magnitudes of these values can be equated to general rules of thumb (i.e. small = 0.01 to <0.06, moderate = 0.06 to <0.14, large = >0.14). In the pre-treatment group of patients, females reported significantly more concerns in total (and specifically in the domains of social well-being, facial aesthetics and oral functioning) than the pre-treatment males. This gender disparity was not apparent in the 2-year post-surgery group and they had clearly reported significantly fewer concerns and therefore better QoL than the pre-treatment patients for all of the OQLQ summary scores.

Figure 1. Group means for OQLQ total by treatment stage and gender.

Regarding awareness of deformity, the picture was simpler with patients in the pre-treatment group having reported more concerns than those who were at the 2-year post-surgery stage with gender not found to be a significant influence on this aspect of QoL either as a main or interactive effect (Figure 2).

Figure 2. Group means for awareness of deformity by treatment stage and gender.

Table 1 displays a summary of the ratings 2-year post-surgery patients gave to the quality of communication that they received during their treatment (published results from other studies are provided for comparison).

Table 1. CAT-T: Percentage ‘Excellent’ results compared to other published data.

CAT-T item	Current study (n = 78)	Emergency department study^a (n = 226)	Inpatient study^b (n = 700)
The medical team
1. Greeted me in a way that made me feel comfortable	77	54	55
2. Treated me with respect	82	74	66
3. Showed interest in my ideas about health	67	59	58
4. Understood my health concerns	72	68	57
5. Paid attention to me (looked at me, listened carefully)	78	71	64
6. Let me talk without interruption	77	76	66
7. Gave me as much information as I wanted	73	61	56
8. Talked in terms I could understand	82	75	64
9. Checked to be sure I understood everything	74	66	57
10. Encouraged me to ask questions	68	50	53
11. Involved me in decisions as much as I wanted	68	55	52
12. Discussed next steps, including any follow-up plans	73	68	58
13. Showed me care and concern	76	73	64
14. Spent the right amount of time with me	74	69	57
Front desk staff
15. Treated me with respect	64	Not reported	Not reported

^aMcCarthy et al. (2013).

^bFerranti et al. (2010).

Results of the Spearman’s rho correlation analyses exploring the relationships between quality of communication and QoL in the treated patients are presented in Table 2. The OQLQ total score and summary scores for three of the domains (facial aesthetics, awareness of deformity, socials aspects) had statistically significant associations with the quality of communication ratings that patients provided. For these domains, patients with better QoL scores reported receiving better quality of communication, and those with poorer QoL rated their experience of communication less favourably.

Table 2. Associations between QoL and quality of communication.

Spearman’s rho		Quality of life (OQLQ)
		Total	Social aspects	Facial aesthetics	Oral function	Awareness of deformity
CAT-T total (n = 77)	Correlation coefficient	−.342^a	−.314^a	−.316^a	−.211	−.334^a

^aCorrelation is significant at the 0.01 level (two-tailed).

Discussion

This study clearly demonstrates that patients considered eligible for orthognathic treatment have an overall reduced QoL compared to patients that have received orthognathic treatment. They have specific concerns regarding their oral function and social aspects of their life, and they have increased concerns about dentofacial appearance and awareness of their condition. These results are similar to other published studies (Hunt et al. 2001; Soh and Narayanan 2013). Of note is the fact that this reduced QoL was more pronounced in females than males in relation to all aspects except dentofacial appearance; other recently published studies have found similar gender disparities (Bortoluzzi et al. 2015; Palomares et al. 2016; Stagles et al. 2016). Comparison of the pre-treatment patients with the 2-year post-surgery group in the current study revealed a strong effect of treatment. The treated patients reported significantly better overall QoL and better scores in all of the sub-domains, again this is in agreement with previous findings (Hunt et al. 2001; Soh and Narayanan 2013). In the 2-year post-surgery group, there were no statistically significant differences in QoL between males and females.

Regarding quality of communication, the 2-year post-surgery group rated their experiences as excellent, and compared to the limited published studies in the literature they had received better quality of communication (Ferranti et al. 2010; McCarthy et al. 2013). The lowest ratings for quality of communication were in the following dimensions: front desk staff communicating respectfully with patients, treating clinicians showing interest in patients’ own ideas about health, clinicians encouraging patients to ask questions and involving patients in decision-making as much as they wanted.

Any relationship between QoL and quality of communication ratings was explored with the 2-year post-surgery group. Despite the fact that in the majority of instances, the rating given by patients for quality of communication was the top score of 5 = ‘excellent’ correlational analyses found significant, but moderate associations between QoL and quality of communication. Patients with better QoL scores gave higher ratings to the quality of communication they had received and conversely those with poorer QoL had rated their experience of communication as worse. This type of relationship is evident in other patient settings (Annunziata et al. 1998, Ong et al. 2000, McPherson et al. 2001, Molenaar et al. 2001, Kenton et al. 2007, Davies et al. 2008; Diaz et al. 2009; Hempowicz et al. 2013). Though a small number of studies of orthognathic treatment have indicated communication and information provision have significant influences on patients’ satisfaction (Edgerton and Knorr 1971; Flanary and Alexander 1983; Cunningham et al. 1996), this is the first time that the association of communication with QoL has been shown. While these findings are potentially of interest, further investigations are required to establish the direction, if any, of cause and effect. At present, it is not possible to state whether poor communication has contributed to reducing aspects of some of the patients’ QoL in the orthognathic setting, or if having a reduced QoL led to some orthognathic patients experiencing worse communication, and thus gave lower quality ratings when asked about it.

Limitations of the study

We acknowledge the main limitation of this study is the cross-sectional design which was necessary given the budget restraints and time available for the work; a prospective longitudinal study would be ideal. There is potential for the study sample to be biased since it excludes patients who did not attend their clinic appointments; it is possible this group could have a different quality of life and different experiences of communication. Refusals to participate in the current study were not accurately recorded which is a weakness and means that comment cannot be made as to the representativeness of the study sample in relation to all patients attending the orthognathic clinics at the time of the study. There is potential bias with having asked patients to retrospectively give a rating to the quality of communication that they have experienced particularly as it spans a long treatment period for recall. However, the 2-year post-surgery time point was chosen as published evidence shows improvements in QoL resulting from treatment are still emergent before this. The results from the CAT-T communication measure are exploratory, particularly because it is a generic measure of communication quality and has not previously been validated for the orthognathic population.

Conclusions

• an association was found between QoL and quality of communication as reported by the 2-year post-surgery participants

• the female pre-treatment participants reported more concerns on the OQLQ in total (and for facial aesthetics, oral function, social well-being), indicting poorer QoL, than the males in this group

• fewer concerns were reported on the OQLQ (indicating a better QoL) by both females and males in the 2-year post-surgery group compared to the pre-treatment participants

Acknowledgements

We would like to thank all the respondents who found time to complete the questionnaires, Mr Daniel Burford and Miss Natasha Wright who invited patients in their busy clinics to participate, and Sarah Dawe for R&D Department support. Ethics approval: Ethical approval for the study was granted by NRES Committee London-Chelsea (REC Ref: 14/LO/1402). Permission was granted to use the various questionnaires in the current study for research purposes. Informed consent was obtained from all individual participants included in the study.

Disclosure statement

No potential conflict of interest was reported by the authors.

ORCID

Susan Catt http://orcid.org/0000-0002-9898-2289

Sofia Ahmad http://orcid.org/0000-0003-2166-4212

Additional information

Funding

The Queen Victoria Hospital NHS Foundation Trust Charitable Fund financed this study.