Introduction
The Coronary Revascularisation Outcome Questionnaire (CROQ) is a specialized instrument designed to meet this demand. Developed by Sara Schroter and Donna L. Lamping in 2004, the CROQ serves as a comprehensive tool for assessing health-related quality of life (HRQoL) in patients undergoing coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI). Since its publication in Heart, the CROQ has garnered more than 90 citations in scientific literature, reflecting its utility in both clinical trials and routine cardiac care (Schroter & Lamping, 2004).
This article delves into the CROQ‘s core features, practical applications, and overall clinical value for the cardiovascular field. Furthermore, it aims to provide researchers and clinicians with actionable insights for enhancing patient assessment and improving care in cardiology.
Key Features of the Coronary Revascularisation Outcome Questionnaire (CROQ)
Purpose and Use
The primary purpose of the CROQ is to evaluate health status and HRQoL specifically for patients undergoing coronary revascularisation. Unlike general health surveys, this instrument focuses on the unique recovery trajectory of cardiac patients. Consequently, clinicians and researchers can use it to identify post-procedural improvements or lingering functional deficits. By bridging the gap between clinical success and patient satisfaction, the CROQ facilitates a more nuanced understanding of surgical outcomes.
Target Population
Studies validate the CROQ for use in adult patients aged 18 and older who have been diagnosed with coronary artery disease and are candidates for, or recipients of, revascularisation procedures. This includes:
- Young Adults (18-24 years)
- Middle-Aged Adults (25-44 years)
- Older Adults (45–64 years)
- Seniors (65+ years)
Specifically, it targets populations undergoing CABG or PCI (PTCA), ensuring that the questions remain relevant to the specific challenges of these interventions
Structure
The CROQ features a modular design tailored to capture the patient’s health status at different clinical stages. The questionnaire is available in multiple versions with varying item counts:
- Pre-revascularisation versions (Pre-CABG / Pre-PTCA): This format consists of 32 items, in addition to one descriptive item that is not included in the scale scores.
- Post-revascularisation versions (Post-CABG): This is a comprehensive format that consists of 52 items.
- Post-revascularisation versions (Post-PTCA / PCI): This format consists of 47 items.
The questionnaire is systematically organized into core domains and procedure-specific subdomains to ensure clinical precision:
1. Core Domains (Included in both Pre- and Post-Revascularisation versions)
These four domains measure the patient’s baseline health status and consist of 32 core items and one descriptive item:
- Symptoms: This domain includes 7 items to assess cardiac-related symptoms.
- Physical Functioning: This domain uses 8 items to measure the ability to perform daily physical activities.
- Psychosocial Functioning: This domain evaluates emotional and social health through 14 items.
- Cognitive Functioning: This domain assesses cognitive abilities using 3 items.
2. Additional Domains (Included in Post-Revascularisation versions Only)
The post-procedure versions include the four core domains listed above, plus two additional subdomains:
- Satisfaction with Outcome: This domain features 6 items to measure satisfaction with the results of the procedure.
- Adverse Effects: This domain is tailored to the procedure, utilizing 11 items for CABG and 6 items for PCI to measure potential negative side effects.
Scoring Method
The scoring process for the CROQ is systematic and aligns with established health survey standards. Each item utilizes a 3- to 6-point Likert-type scale. To facilitate interpretation, the raw scores from the six scales are summed and transformed into a 0–100 scale, mirroring the method used in the SF-36.
In this system, a score of 100 represents the best possible outcome. It is important to note that each subscale is scored separately, as there is no standard overall total score. Furthermore, while higher scores indicate better outcomes, specific cut-off scores have not been defined in the literature; instead, the results are typically interpreted dimensionally.
Administration Format
Because the CROQ is a self-administered tool, it minimizes the burden on clinical staff. Patients can complete it via:
- Paper-based formats
- Digital (Online) platforms
They typically require 10 to 15 minutes to complete the questionnaire. While this is slightly longer than some screening tools, the depth of data provided justifies the additional time.
Application of the Coronary Revascularisation Outcome Questionnaire (CROQ)
The CROQ has broad utility in specialized cardiac settings:
- Monitoring: Clinicians use the post-revascularisation versions to track long-term recovery and the presence of adverse effects.
- Treatment Planning: By identifying specific deficits in physical or cognitive functioning, teams can tailor rehabilitation programs.
- Research: Because of its high responsiveness, the CROQ is an ideal outcome measure for clinical trials comparing different revascularisation techniques.
- Outcome Assessment: It serves as a primary tool for evaluating the success of CABG and PCI from the patient’s perspective.
Languages and availability
Researchers can access the CROQ in multiple languages, making it a versatile tool for multicultural clinical settings and international research collaborations. Available versions include:
- English (Original)
- Portuguese
- Japanese
- Greek
- Korean
- Italian
- and others
Regarding availability, the CROQ is proprietary and requires formal permission for use. While it is not an open-access tool, copies of the questionnaire and the necessary SPSS scoring programs can be obtained by contacting the lead author, Dr. Sara Schroter.
Reliability and Validity
Researchers recognize the CROQ as a highly reliable and valid instrument. Statistical analysis shows that Cronbach’s alpha is generally above 0.70, with many subscales exceeding 0.80, indicating excellent internal consistency. To support its clinical application, several studies have confirmed its psychometric robustness.
- The original validation study link: Study link.
- Validation of the responsiveness evaluation (post-op): study Link.
- Psychometric validation of the Coronary Revascularisation Outcome Questionnaire (CROQv2) in the context of the NHS Coronary Revascularisation PROMs Pilot: Link.
- Validation of the Portuguese version. Study link.
- Validation of the Japanese version: Study link.
- Validation of the Greek version: Study link.
- Validation of the Korean version: Study link.
- Validation of the Italian version: Study link.
Limitations and Considerations
Despite its strengths, the CROQ has a few limitations:
- Length: Some patients may find the 52-item post-revascularisation questionnaire lengthy, potentially leading to survey fatigue.
- Self-report: As with any PROM, respondents may be influenced by social desirability bias or subjective interpretation of their symptoms.
Other Versions And Related Questionnaires
The CROQ is available in multiple modular versions designed to capture the patient’s status at different clinical stages:
- Pre-revascularisation (Pre-CABG and Pre-PTCA).
- Post-revascularisation (Post-CABG and Post-PCI).
- the Updated Version (CROQv2).
Additionally, several related questionnaires can be used alongside the CROQ to provide a more comprehensive assessment of cardiac health:
- MacNew Heart Disease Questionnaire.
- Seattle Angina Questionnaire (SAQ).
- CADE-Q SV (Coronary Artery Disease Education Questionnaire).
Additional Resources
- The original validation Study link.
- You can access the questionnaire as a PDF through this Link.
- For inquiries, contact at sschroter@bmj.com the lead author of the questionnaire.
- For additional resources on cardiac PROMs, consult Oxford University Press.
Frequently Asked Questions (FAQ)
- Who can use the CROQ?
Clinicians, researchers, and healthcare providers use the CROQ for patients aged 18 and older with coronary artery disease undergoing revascularisation.
- How long does it take to complete the CROQ?
Patients typically take 10 to 15 minutes to complete the CROQ, which makes it feasible for use in clinical and research settings.
- How is the CROQ administered?
Healthcare teams can administer the questionnaire via paper or digital formats, offering flexibility in usage across different hospital environments.
- Is there any cost to using the CROQ?
The CROQ requires permission for use. Copies of the CROQ and the scoring programs can be obtained directly from the author.
A Word from ResRef about the Coronary Revascularisation Outcome Questionnaire (CROQ)
The CROQ is a highly responsive, scientifically validated instrument, filling a critical gap in cardiac assessment by providing a “patient-reported perspective” on recovery that is often overlooked in clinical data, making it valuable for monitoring care outcomes.
References
- Schroter S, Lamping DL. Coronary revascularisation outcome questionnaire (CROQ): development and validation of a new, patient based measure of outcome in coronary bypass surgery and angioplasty. Heart. 2004 Dec;90(12):1460-6. Link.
- Schroter S, Lamping DL. Responsiveness of the coronary revascularisation outcome questionnaire compared with the SF-36 and Seattle Angina Questionnaire. Qual Life Res. 2006 Aug;15(6):1069-78. Link.
- Schroter S, Miles R, Green S, Jackson M. Psychometric validation of the Coronary Revascularisation Outcome Questionnaire (CROQv2) in the context of the NHS Coronary Revascularisation PROMs Pilot. BMJ Open. 2017 Feb 28;7(2):e015915. Link.
- Assis ARV, Maximo E Melo L, Santos VB, Lopes JL. Quality of life in people with coronary artery disease: translation and cross-cultural adaptation of a questionnaire. Rev Bras Enferm. 2021 Sep 6;75(1):e20200647. English, Portuguese. Link.
- Seki S, Kato N, Ito N, Kinugawa K, Ono M, Motomura N, Yao A, Watanabe M, Imai Y, Takeda N, Inoue M, Hatano M, Kazuma K. Translation and validation study of the Japanese versions of the Coronary Revascularisation Outcome Questionnaire (CROQ-J). Eur J Cardiovasc Nurs. 2011 Mar;10(1):22-30. Link.
- Takousi MG, Schmeer S, Manaras I, Olympios CD, Fakiolas CN, Makos G, Troop NA. Translation, adaptation and validation of the Coronary Revascularization Outcome Questionnaire into Greek. Eur J Cardiovasc Nurs. 2016 Apr;15(2):134-41. Link.
- Kim M, Seo J, Hwang JY, Park KS. Reliability and validity of the Korean version of the coronary revascularization outcome questionnaire. Health Qual Life Outcomes. 2017 Feb 15;15(1):37. Link.
- Fattirolli F, Marchionni N, Höfer S, Giannuzzi P, Angelino E, Fioretti P, Miani D, Oldridge N. The Italian MacNew heart disease health-related quality of life questionnaire: a validation study. Intern Emerg Med. 2015 Apr;10(3):359-68. Link.
