Carolinas Comfort Scale as a Measure of Hernia Repair Quality of Life: A Reappraisal Utilizing 3788 International Patients

Ann Surg. 2018 Jan;267(1):171-176. doi: 10.1097/SLA.0000000000002027.


Objective: The goal of the present study was to reaffirm the psychometric properties of the CCS using an expansive, multinational cohort.

Background: The Carolinas Comfort Scale (CCS) is a validated, disease-specific, quality of life (QOL) questionnaire developed for patients undergoing hernia repair.

Methods: The data were obtained from the International Hernia Mesh Registry, an American, European, and Australian prospective, hernia repair database designed to capture information delineating patient demographics, surgical findings, and QOL using the CCS at 1, 6, 12, and 24 months postoperatively.

Results: A total of 3788 patients performed 11,060 postoperative surveys. Patient response rates exceeded 80% at 1 year postoperatively. Acceptability was demonstrated by an average of less than 2 missing items per survey. The formal test of reliability revealed a global Cronbach's alpha exceeding 0.95 for all hernia types. Test-retest validity was supported by the correlation found between 2 different administrations of the CCS using the kappa coefficient. Principal component analysis identified 2 components with a good distribution of variance, with the first component explaining approximately 60% of the variance, regardless of hernia type. Discriminant validity was assessed by comparing survey responses and use of pain medication at 1 month postoperatively and analysis revealed that symptomatic patients demonstrated significantly higher odds of requiring pain medication in all activity domains and for all hernia types.

Conclusions: The present study confirms that the CCS questionnaire is a validated, sensitive, and robust instrument for assessing QOL after hernia repair, which has become a predominant outcome measure in this discipline of surgery.

Publication types

  • Multicenter Study

MeSH terms

  • Australia
  • Europe
  • Hernia, Inguinal / surgery*
  • Hernia, Ventral / surgery*
  • Herniorrhaphy*
  • Humans
  • Patient Satisfaction*
  • Postoperative Period
  • Prospective Studies
  • Quality of Life*
  • Registries*
  • Reproducibility of Results
  • Surveys and Questionnaires
  • United States