Balancing fidelity and practicality in short version musculoskeletal patient reported outcome measures

Abstract

Background: Musculoskeletal patient reported outcome (PRO) measures are essential to clinical practice as they determine the status of a patient's health. While such measures are meant to improve the delivery of evidence based medicine, the design process often overlooks their clinical relevance and utility.

Discussion: The demand for greater efficiency through shorter, user friendly PRO measures is discussed. The aim is to reduce respondent, clinician and researcher burden while retaining precision instruments with validated psychometric properties. The reductive statistical methodology and techniques used to achieve these goals are highlighted. The general lack of important qualitative input from the clinician and patient in these processes is noted. This lack of input can be detrimental to the clinical practicality and cost efficiency of the final product. It may also raise problems of potential conflicts of interest. Four additional areas of practical concern with particular significance are outlined: questionnaire format, item number, time benefits and scoring methods.

Summary: It is important that developers of new and modified musculoskeletal PRO measures ensure that their instruments, whilst maximising the psychometric properties and methodological characteristics, satisfy the requirements of patient and clinician practicality while emphasising the essential principles of evidence based medicine.     

Is Laparoscopic Adjustable Gastric Banding a Day Surgery Procedure?

Background: Laparoscopic adjustable gastric banding is the least invasive bariatric operation. However, just isolated attempts to perform this procedure as a Day Case have been published. This study highlights some aspects that might contribute to safe patient discharge within 23 hours after LAGB. Methods: Prospective evaluation of 20 consecutive patients was carried out. Patients were indicated for laparoscopic Swedish adjustable gastric banding (SAGB, Obtech, Ethicon Endo-Surgery) in a private Bariatric center in the first 6 months of 2003. The effect of extensive pre- and immediate postoperative education and psychological support, and information on postoperative health consequences delivered through a multi-disciplinary bariatric team effort, was evaluated, regarding the influence of these facilitators in shortening the length of hospital stay. Results: Mean preoperative BMI of the 20 patients entering the study was 42.3. Mean operating-time was 91 minutes (58-112 min). Time spent on information and education of each patient was 60 minutes in total during the preoperative period. Average postoperative hospitalization was 21 hours. There were no intraoperative or early postoperative complications. Excess weight loss was 44% at 12 months after surgery. Conclusion: SAGB performed on a Day Case basis in selected patients who are subjected to intensive pre- and immediate postoperative dedicated education appears to be a feasible alternative.     

Comprendre le cancer du sein: guide d’information SOR SAVOIR PATIENT à destination des patientes et de leurs proches

In response to the evolution of the information-seeking behaviour of patients and concerns fromhealth professionals regarding cancer patient information, the French National Federation of Comprehensive Cancer Centres (FNCLCC) introduced, in 1998, an information and education program dedicated to patients and relatives, the SOR SAVOIR PATIENT program (SSP). The methodology of this program adheres to established quality criteria regarding the elaboration of patient information. Cancer patient information, developed in this program, is based on clinical practice guidelines produced by the FNCLCC and the twenty French cancer centres, the National League against Cancer, The National Cancer Institute, the French Hospital Federation, the National Oncology Federation of Regional and University Hospitals, the French Oncology Federation of General Hospitals, many learned societies, as well as an active participation of patients, former patients and caregivers. The SOR SAVOIR PATIENT information booklet “Comprendre le cancer du sein. (Understand breast cancer) is updated from the original edition published in 2000, first revised in 2002. The 2007 update includes the latest scientific data, especially in the areas of chemotherapy, hormonal therapy and monoclonal antibodies. The current guideline is aimed at helping patients with breast cancer and answering any questions they may have regarding the development and the diagnosis of breast cancer, the treatments available and current follow-up methods. The document also provides healthcare professionals with a valuable, concise source of validated information on breast cancer, thus facilitating communication between carers and patients. Information provided in the present article has been selected from the information handbook SOR SAVOIR PATIENT Comprendre le cancer du sein. It is based on the latest scientific data available on the treatment of primary breast cancers, especially chemotherapy, hormonal therapy and monoclonal antibodies.     

The Use of Multidisciplinary Teams to Evaluate Bariatric Surgery Patients: Results from a National Survey in the U.S.A.

Background: The degree to which U.S. bariatric surgeons use multidisciplinary methods to evaluate patients is unknown. Methods: We conducted a national survey of practising bariatric surgeons, mailed in 3 waves from September-December 2004, to describe and determine predictors of surgeons' approach to the multidisciplinary evaluation of prospective bariatric surgery patients. Multivariate analyses were performed to determine patterns and predictors of multidisciplinary methods. Results: The response rate was 62% (813/1,312). Although 95% of respondents reported using a multidisciplinary team, only 53% had a general physician, nutritionist, and mental health specialist (NIH-recommended team). Just 47% mandated primary care, nutrition, and mental health evaluations (NIH-recommended evaluations). Practice type, size, and location as well as membership in the American Society for Bariatric Surgery did not influence these outcomes. General surgery board certification reduced the odds of having an NIH-recommended team (OR = 0.56, 95%CI 0.35-0.92). Practicing bariatric surgery for >8 years decreased the odds of reported multidisciplinary team use (OR = 0.29, 95%CI 0.10-0.82) and requiring NIH-recommended evaluations (OR = 0.36, 95%CI 0.24-0.53). Medium volume surgeons had increased odds of reporting use of a team (OR = 2.96, 95%CI 1.22-7.18) and decreased odds of requiring NIH-recommended evaluations (OR = 0.65, 95%CI 0.44-0.92). Conclusion: Inconsistent and unpredictable patterns of multidisciplinary methods were found. Further research should explore the impact of different methods on outcomes. New policies should detail a minimum standard for the multidisciplinary evaluation of bariatric surgery patients. Health professionals across disciplines are needed to assist surgeons in evaluating prospective bariatric surgery patients.     

Physical Therapy Exercise Intervention Based on Classification Using the Patient Response Method: A Systematic Review of the Literature

Abstract

It has been suggested that inclusion into a study that categorizes patients in mutually exclusive, clinometric classifications should improve the outcome of an exercise based randomized clinical trial. This review examined the evidence regarding the effectiveness of physical therapist-directed therapeutic exercises when patients were classified using the patient response method. This systematic literature review restricted article inclusion to English-only articles that classified homogenous samples of low back pain patients using the patient response based method, demonstrated physical therapist-directed exercise interventions, and used specific outcome criteria for assessment of patient improvement. The PEDro scale was used to rate the methodological quality of the studies. Of 82 articles reviewed only 5 articles were accepted. All 5 met the PEDro standards for a high-quality study. Of the 5 articles, 4 demonstrated that physical therapy exercise intervention based on the patient response method of classification were significantly better than the pragmatic control comparisons; the remaining article indicated that exercise was less effective than manipulation. There appears to be a trend toward positive outcomes with physical therapy exercise intervention in trials restricted to the patient response method of classification; however, few studies have investigated this phenomenon.     

Predicting Patient Satisfaction: A Study of Two Emergency Departments

To identify perceptions that predict overall patient (dis)satisfaction with Emergency Department (ED) care, we studied responses to a survey mailed to all discharged patients over a 6-month period (Academic Hospital), and to a telephone interview of a random sample of discharged patients over a 1-year period (Community Hospital). The survey and interview both assessed overall satisfaction, as well as satisfaction with perceived waiting times, information delivery, and expressive quality of physicians, nurses, and staff. Data for 1176 patients (training sample) and 1101 patients (holdout sample) who rated overall satisfaction as either very good or very poor (Academic Hospital), and for 856 patients (training sample) and 431 patients (holdout sample) who rated overall satisfaction as either excellent or poor (Community Hospital), were retained for analysis. For both hospitals, nonlinear tree models efficiently achieved overall classification accuracy exceeding 98% in training analysis and 95% in holdout analysis (all p < .0001). The findings suggest that overall patient (dis)satisfaction with care received in the ED is nearly perfectly predictable on the basis of patient-rated expressive qualities of ED staff, particularly physicians and nurses. Interventions designed to reinforce positive (and extinguish negative) expressive health-care provider behaviors may cut the number of extremely dissatisfied patients in half.     

Femoral fracture rates after discharge from the hospital to the community

Previous studies found that the risk of a femoral fracture in residents newly admitted to nursing homes was highest during the first months after admission and declined thereafter. Many nursing home admissions are preceded by a hospitalization. Therefore, the present study aimed to analyze if a similar risk pattern of fall‐related fractures could also be observed in community‐dwelling people at home after discharge from the hospital. Routine data of more than 690,000 German people aged 65 years and older with more than 2 million hospital discharges were used to calculate fracture rates in the first 6 months after hospitalization, for people discharged to live in the community. Incidence rates of femoral fractures as a function of time since discharge from hospital were analyzed. Analyses were stratified by sex, age, the need for care, and diagnostic groups. For femoral fractures the incidence was highest during the first months after discharge and declined thereafter. This pattern was observed in women and men, in different age‐groups, in different diagnostic groups, and in people with and without the need for care. For example, rates for femoral fractures in women declined from 17.4 to 11.0 per 1000 person years over the first 6 months after admission, and in men over the same time period from 8.2 to 4.5 per 1000 person‐years, respectively. We conclude that the first weeks at home after discharge from the hospital are associated with an increased risk for femoral fractures. © 2013 American Society for Bone and Mineral Research.     

Patients Postoperatively Forget Aspects of Preoperative Patient Education

Background: Preoperative patient education is critically important to the success of any bariatric operation. In our clinic, we perform extensive preoperative education and informed consent. Part of the informed consent process includes a preoperative true/false quiz. This study tests the hypothesis that postoperative patients do not recall key components of their preoperative education. Methods: Preoperatively, all patients were required to take the true/false quiz and retake it, if necessary, until they received all the questions correct. All patients were given their preoperative informed consent quiz again at least 1 month after laparoscopic gastric bypass, during their postoperative clinic visit. Patients >1 year postoperatively from surgery were compared to patients <1 year postoperatively. Results: 63 patients were included in this study. Originally, 46% of patients did not get all the questions correct the first time; mean score on the quiz preoperatively was 95%. Patients took the test an average of 8 months after surgery. Postoperatively, 46% of patients did not get all the questions correct; mean score on the quiz was 96%. The 2 most common incorrect answers were: "Obesity surgery is basically an aid to dieting: it does not mean that you will lose weight no matter what you eat or do (True)" and "Diabetes, high blood pressure, back pain and similar ailments always get better after obesity surgery (False)". Patients >1 year postoperative were more likely not to get all the questions correct (80% vs 36%; P<0.01; two-tailed Fisher's exact test). Conclusions: Patients do not remember basic preoperative education facts after their bariatric surgery. Despite maximal efforts in verifying preoperative education, patients often forget this critical information after bariatric surgery. Patients 1 year after surgery forget more information.