A Systematic Review of Patient-reported Outcomes in Randomized Controlled Trials of Unplanned General Surgery

Reporting of health-related quality of life in emergency laparotomy trials: a systematic review and narrative synthesis

PURPOSE

Emergency laparotomy is associated with high morbidity for the surgical patient. Understanding patients' health-related quality of life after their surgery is important to enhance the informed consent process, and to enable the evaluation and improvement of surgical care. This review aims to summarise the use of health-related quality of life tools in clinical trials involving patients undergoing emergency laparotomy.

METHODS

A systematic review was undertaken of the scientific literature published in the MEDLINE® and PubMed databases between January 2011 and July 2021. A narrative synthesis approach was chosen to synthesise the diverse range of studies in a structured manner. All included papers were evaluated using the Cochrane Collaboration's tool for assessing risk of bias.

RESULTS

Eleven studies were selected for inclusion. Most of the studies had a low risk of bias. Two of the studies used health-related quality of life as the primary outcome measure. A variety of health-related quality of life measurement tools were used; the EQ-5D tool was the most popular questionnaire. Protocol adherence was dependent on the length of time which had elapsed after emergency surgery.

CONCLUSION

There are many perceived challenges to collecting health-related quality of life data in the emergency surgery setting. Many of these can be offset with progressive trial designs. There is a need for further research in the systematic development of patient-reported outcomes for use in emergency surgery.

Quality and reporting of patient-reported outcomes in elderly patients with hip fracture: a systematic review

OBJECTIVE

To assess how patient-reported outcomes (PROs) are reported and to assess the quality of reporting PROs for elderly patients with a hip fracture in both randomised controlled trials (RCTs) and observational studies.

DESIGN

Systematic review.

DATA SOURCES

Medline, Embase and CENTRAL were searched on 1 March 2013 to 25 May 2021.

ELIGIBILITY CRITERIA

RCTs and observational studies on geriatric (≥65 years of age) patients, with one or more PRO as outcome were included.

DATA EXTRACTION AND SYNTHESIS

Primary outcome was type of PRO; secondary outcome and quality assessment was measured by adherence to the Consolidated Standards of Reporting Trials (CONSORT) extension for patient-reported outcomes (CONSORT-PRO). Because of heterogeneity in study population and outcomes, data pooling was not possible.

RESULTS

3659 studies were found in the initial search. Of those, 67 were included in the final analysis. 83.6% of studies did not adequately mention missing data, 52.3% did not correctly report how PROs were collected and 61.2% did not report adequate effect size. PRO limitations were adequately reported in 20.9% of studies and interpretation of PROs was adequately reported in 19.4% of studies. Most Quality of Life (QoL) outcomes were measured by the EuroQol 5-Dimension 3-Levels, and pain as well as patient satisfaction by Visual Analogue Scale.

CONCLUSION

This study found that a high variety of PRO measures are used to evaluate geriatric hip fracture care. In addition, 47.8% of studies examining PROs in elderly patients with hip fracture do not satisfy at least 50% of the CONSORT-PRO criteria. This enables poorly conducted research to be published and used in evidence-based medicine and, consequently, shared decision-making. More efforts should be undertaken to improve adequate reporting. We believe extending the CONSORT-PRO extension to Strengthening the Reporting of Observational Studies in Epidemiology for observational studies would be a valuable addition to current guidelines.

Knowledge translation concerns for the CONSORT-PRO extension reporting guidance: a review of reviews

This review of reviews aimed to appraise the use of the CONSORT-PRO Extension as an evaluation tool for assessing the reporting of patient-reported outcome (PROs) in publications, and to describe the reporting of PRO research across reviews. We also outlined how variation in such evaluations impacts knowledge translation and may lead to potential misuse of the CONSORT-PRO Extension. We systematically searched Medline, Pubmed and CINAHL from 2013 to 2025 March 2021 for reviews of the completeness of reporting of PRO endpoints according to CONSORT-PRO criteria. Two reviewers extracted details of each review, the percentage of included studies that addressed each CONSORT-PRO item, and key recommendations from each review. Fourteen reviews met inclusion criteria, and only six of these used the full CONSORT-PRO checklist with minimal justified modifications. The remaining eight studies made significant or unjustified adjustments to the CONSORT-PRO Extension. Review studies also varied in how they scored multi-component CONSORT-PRO items. CONSORT-PRO items were often unreported in trial reports, and certain CONSORT-PRO items were reported less often than others. The reporting of statistical approaches to dealing with missing PRO data were poor in RCTs included in all 14 review articles. Studies reviewing PRO publications often omitted recommended CONSORT-PRO items from their evaluations, which may cause confusion among readers regarding how best to report their PRO research according to the CONSORT-PRO extension. Many trials published since CONSORT-PRO's release did not report recommended CONSORT-PRO items, which may lead to misinterpretation and consequently to research waste.

Emergency Laparotomy Follow-Up Study (ELFUS): prospective feasibility investigation into postoperative complications and quality of life using patient-reported outcome measures up to a year after emergency laparotomy

BACKGROUND

Emergency laparotomy carries a significant risk profile around the time of surgery. This research aimed to establish the feasibility of recruitment to a study using validated scoring tools to assess complications after surgery; and patient-reported outcome measures (PROMs) to assess quality of life and quality of recovery up to a year following emergency laparotomy (EL).

METHODS

We used our local National Emergency Laparotomy Audit (NELA) register to identify potential participants at a single NHS centre in England. Complications were assessed at 5, 10 and 30 days after EL. Patient-reported outcome measures were collected at 1, 3, 6 and 12 months after surgery using EQ5D and WHODAS 2.0 questionnaires.

RESULTS

Seventy of 129 consecutive patients (54%) agreed to take part in the study. Post-operative morbidity survey data was recorded from 63 and 37 patients at postoperative day 5 and day 10. Accordion Complication Severity Grading data was obtained from 70 patients. Patient-reported outcome measures were obtained from patients at baseline and 1, 3, 6 and 12 months after surgery from 70, 59, 51, 48, to 42 patients (100%, 87%, 77%, 75% and 69% of survivors), respectively.

CONCLUSIONS

This study affirms the feasibility of collecting PROMs and morbidity data successfully at various time points following emergency laparotomy, and is the first longitudinal study to describe quality of life up to a year after surgery. This finding is important in the design of a larger observational study into quality of life and recovery after EL.

Laparoscopic versus open colorectal surgery in the acute setting (LaCeS trial): a multicentre randomized feasibility trial

BACKGROUND

Approximately 30 000 people undergo major emergency abdominal gastrointestinal surgery annually, and 36 per cent of these procedures (around 10 800) are carried out for emergency colorectal pathology. Some 14 per cent of all patients requiring emergency surgery have a laparoscopic procedure. The aims of the LaCeS (laparoscopic versus open colorectal surgery in the acute setting) feasibility trial were to assess the feasibility, safety and acceptability of performing a large-scale definitive phase III RCT, with a comparison of emergency laparoscopic versus open surgery for acute colorectal pathology.

METHODS

LaCeS was designed as a prospective, multicentre, single-blind, parallel-group, pragmatic feasibility RCT with an integrated qualitative study. Randomization was undertaken centrally, with patients randomized on a 1 : 1 basis between laparoscopic or open surgery.

RESULTS

A total of 64 patients were recruited across five centres. The overall mean steady-state recruitment rate was 1·2 patients per month per site. Baseline compliance for clinical and health-related quality-of-life data was 99·8 and 93·8 per cent respectively. The conversion rate from laparoscopic to open surgery was 39 (95 per cent c.i. 23 to 58) per cent. The 30-day postoperative complication rate was 27 (13 to 46) per cent in the laparoscopic arm and 42 (25 to 61) per cent in the open arm.

CONCLUSION

Laparoscopic emergency colorectal surgery may have an acceptable safety profile. Registration number: ISRCTN15681041 ( http://www.controlled-trials.com).

Feasibility of collecting retrospective patient reported outcome measures (PROMs) in emergency hospital admissions

INTRODUCTION

Outcome of emergency admissions is usually limited to mortality with little attempt to capture the views of health status of survivors. This is because of the challenge of determining patient reported outcome measures (PROMs) for the period before their emergency admission. The aim was to assess the feasibility of collecting retrospective PROMs to capture the pre-admission health status of patients admitted as emergencies.

METHODS

Prospective study of two cohorts: patients undergoing primary coronary angioplasty for acute ST elevation myocardial infarction (STEMI) in five hospitals and emergency laparotomy (EL) for gastro-intestinal conditions in 11 hospitals. Three rates were calculated: proportion of patients eligible for inclusion; proportion of eligible patients invited to participate; proportion of invitees who participated. Staff views were thematically analysed to understand factors that affected recruitment.

RESULTS

About 85% of patients were eligible of whom most were invited to participate (84% EL; 79% STEMI). The proportions of invitees agreeing to participate differed between STEMI (92%) and EL (72%), probably reflecting greater post-intervention morbidity in the latter. Variation between hospitals was observed in the proportion deemed eligible (EL 72-97%; STEMI 63-100%), proportion invited (EL 60-93%; STEMI 71-96%) and the proportion of invitees agreeing to participate (EL 55-92%; STEMI 67-100%). While this might reflect case-mix differences between hospitals, it suggests there is scope for less well performing hospitals to improve their recruitment processes. The extent to which this initial feasibility study was able to assess selection bias was limited to the age and sex of patients. There was no bias evident for EL patients but for STEMI, younger men were more likely to participate.

CONCLUSION

It appears to be feasible to collect retrospective PROMs from patients admitted unexpectedly as emergencies for the two conditions studied. The relevance of these findings to other causes of emergency admissions needs to be established. In addition, these findings justify the case for a large, multi-site study that could explore unresolved concerns about selection bias, particularly those arising from the clinical characteristics of patients. It would also enable estimates of the extent of variation in PROMs between hospitals to determine the usefulness of using PROMs in emergency admissions.

Surgery After an Initial Episode of Uncomplicated Diverticulitis: Does Time to Resection Matter?

BACKGROUND

The aim of this study was to determine whether time to surgery after an initial episode of uncomplicated diverticulitis is associated with undergoing an emergent versus an elective resection.

METHODS

In this retrospective, administrative claims database study, we identified patients at least 18 y old in the 2005-2011 California State Inpatient Database who had an initial episode of uncomplicated diverticulitis and then underwent a bowel resection within 2 y. After characterizing the distribution in time to surgery among all patients, we used a multivariable logistic regression to determine whether time to surgery was associated with undergoing an emergent resection. Next, we assessed differences in three outcomes between elective and emergent resections: at least one of eight postoperative complications, extended length of stay (defined as the top decile of hospitalizations), and 30-d inpatient readmissions. Analyses adjusted for time between initial hospitalization and resection, number of inpatient hospitalizations for diverticulitis before the resection, clinical factors, and hospital clustering.

RESULTS

We identified 4478 patients with an initial episode of uncomplicated diverticulitis followed by a bowel resection within the subsequent 2 y. One-fifth (21.1%) underwent an emergent resection. The median time from the initial episode to resection was 3.8 mo (IQR: 2.3-8.1 mo) for elective resections and 5.1 mo (IQR: 2.3-12.4 mo) for emergent resections. The adjusted odds of undergoing an emergent relative to an elective resection increased by 7% (aOR 1.07 [1.02-1.11]) for every 3 passing mo. Emergent resections were associated with greater adjusted odds of complications (adjusted odds ratio [aOR] 1.75 [95%-CI 1.43-2.15]), extended LOS (aOR 4.52 [3.31-6.17]), and 30-d readmissions (aOR 1.49 [1.09-2.04]).

CONCLUSIONS

Among patients who experienced an initial episode of uncomplicated diverticulitis and eventually underwent a resection, the odds of having an emergent relative to elective surgery increased with every 3 passing mo. These findings may inform the management of uncomplicated diverticulitis for high-risk patients eventually needing surgery.

Standards of reporting: the use of CONSORT PRO and CERT in individuals living with osteoporosis

The Consolidated Standards of Reporting Trials for Patient-Reported Outcomes (CONSORT PRO) and the Consensus on Exercise Reporting Template (CERT) have been developed to improve the quality and transparency of reporting standards in scientific research. The purpose of this study was to provide evidence for the adoption of CONSORT PRO and CERT by researchers examining the link between exercise and quality of life in individuals living with osteoporosis. A systematic search was conducted to identify randomized control trials published in English evaluating exercise interventions on quality of life in individuals living with osteoporosis. Reporting standards were assessed using CONSORT PRO and CERT. A total of 127 studies were identified with 23 meeting inclusion criteria. "Good" evidence for eight (42.1%) CONSORT PRO and two (12.5%) CERT items was found. Adherence to CONSORT PRO was not related to the year of publication, journal impact factor, or study quality. Adherence to CONSORT PRO and CERT reporting standards is inadequate in the literature examining exercise interventions on quality of life in individuals living with osteoporosis. Sufficient reporting is paramount to knowledge translation, interpretation by interventionists, and clinician confidence in understanding if (and how) exercise is associated with quality of life outcomes in this cohort. Concerns associated with failure to include this information are highlighted.

New outcome measures in perioperative care

Improvements in outcome measurement are needed to produce quality improvement in perioperative care. However, problems with the collection and use of outcome data persist in research and clinical practice. This is being addressed by several national programmes and initiatives to standardize and integrate outcome measurement. The use of different outcome measures is changing and there has been a transition towards patient-focused measures. Traditional measures of quality in perioperative care include mortality, morbidity and resource utilization measures. Patient-focused measures include patient-reported outcome measures and measures of patient experience. Each of these has advantages and disadvantages in different situations. The routine collection, analysis and dissemination of data relating to perioperative outcome is beneficial to patients, clinicians, hospitals, commissioners, regulators and researchers.

Methodological overview of systematic reviews to establish the evidence base for emergency general surgery

BACKGROUND

The evidence for treatment decision-making in emergency general surgery has not been summarized previously. The aim of this overview was to review the quantity and quality of systematic review evidence for the most common emergency surgical conditions.

METHODS

Systematic reviews of the most common conditions requiring unplanned admission and treatment managed by general surgeons were eligible for inclusion. The Centre for Reviews and Dissemination databases were searched to April 2014. The number and type (randomized or non-randomized) of included studies and patients were extracted and summarized. The total number of unique studies was recorded for each condition. The nature of the interventions (surgical, non-surgical invasive or non-invasive) was documented. The quality of reviews was assessed using the AMSTAR checklist.

RESULTS

The 106 included reviews focused mainly on bowel conditions (42), appendicitis (40) and gallstone disease (17). Fifty-one (48·1 per cent) included RCTs alone, 79 (74·5 per cent) included at least one RCT and 25 (23·6 per cent) summarized non-randomized evidence alone. Reviews included 727 unique studies, of which 30·3 per cent were RCTs. Sixty-five reviews compared different types of surgical intervention and 27 summarized trials of surgical versus non-surgical interventions. Fifty-seven reviews (53·8 per cent) were rated as low risk of bias.

CONCLUSION

This overview of reviews highlights the need for more and better research in this field.