Barriers to completion of Patient Reported Outcome Measures

Completion of Patient-Reported Outcome Measures Improved With Use of a Mobile Application in Arthroplasty Patients: Results From a Randomized Controlled Trial

BACKGROUND

The collection of patient-reported outcome measures (PROMs) has historically been reported as costly and time-consuming, with low compliance rates that may impact reimbursement. Little research has reported the effects of mobile applications to support PROMs collection following arthroplasty.

METHODS

Secondary analysis of data from a multicenter randomized controlled trial was performed. Patients undergoing knee and hip arthroplasty were randomized to utilize a smartphone-based care management platform (app) for self-directed rehabilitation and completed joint-specific PROMs (Hip Dysfunction and Osteoarthritis Outcome Score, Joint Replacement or Knee Injury and Osteoarthritis Score, Joint Replacement) via the application at prescribed intervals or on paper during clinic visits. Control patients received practice standard of care, and completed PROMs via emailed hyperlink or during clinic visits following lower limb arthroplasty. Overall, 455 patients underwent knee arthroplasty procedures (245 control, 210 app group) and 380 underwent total hip arthroplasty (206 control, 174 app group). Compliance with expected PROMs completion was calculated through one year postoperatively.

RESULTS

Compliance was higher in the app group preoperatively in both knee (98.1 versus 86.9%, P < .0001) and hip cohorts (96.0 versus 88.4%, P = .008), and postoperatively, including at one year (knees, 72.2 versus 53.7%, P < .0001; hips, 71.1 versus 49.2%, P < .0001). On log-binomial regressions, intervention arm was the strongest predictor of completion of all PROMs, where app users undergoing knee (Relative Risk 2.039, 95% confidence interval (CI) 1.595 to 2.607, P < .000) and hip arthroplasty (2.268 95% CI 1.742 to 2.953, P < .0001) were more likely to be compliant at all timepoints. The majority of patients in the app group, including those over 65 years of age, completed PROMs using the application as opposed to paper methods.

CONCLUSIONS

A smartphone mobile application that engages patients during recovery after knee and hip joint arthroplasty improved compliance with completion of preoperative and postoperative PROMs compared to other electronic and paper methods.

Nonresponse data in sexual well-being among breast reconstruction patients-who are we overlooking?

BACKGROUND

Missing data can affect the representativeness and accuracy of survey results, and sexual health-related surveys are especially at a higher risk of nonresponse due to their sensitive nature and stigma. The purpose of this study was to evaluate the proportion of patients who do not complete the BREAST-Q Sexual Well-being relative to other BREAST-Q modules and compare responders versus nonresponders of Sexual Well-being. We secondarily examined variables associated with Sexual Well-being at 1-year.

METHODS

A retrospective analysis of patients who underwent breast reconstruction from January 2018 to December 2021 and completed any of the BREAST-Q modules postoperatively at 1-year was performed.

RESULTS

The 2941 patients were included. Of the four BREAST-Q domains, Sexual Well-being had the highest rate of nonresponse (47%). Patients who were separated (vs. married, OR = 0.69), whose primary language was not English (vs. English, OR = 0.60), and had Medicaid insurance (vs. commercial, OR = 0.67) were significantly less likely to complete the Sexual Well-being. Postmenopausal patients were significantly more likely to complete the survey than premenopausal patients. Lastly, autologous reconstruction patients were 2.93 times more likely to respond than implant-based reconstruction patients (p < 0.001) while delayed (vs. immediate, OR = 0.70, p = 0.022) and unilateral (vs. bilateral, OR = 0.80, p = 0.008) reconstruction patients were less likely to respond. History of psychiatric diagnosis, aromatase inhibitors, and immediate breast reconstruction were significantly associated with lower Sexual Well-being at 1-year.

CONCLUSION

Sexual Well-being is the least frequently completed BREAST-Q domain, and there are demographic and clinical differences between responders and nonresponders. We encourage providers to recognize patterns in nonresponse data for Sexual-Well-being to ensure that certain patient population's sexual health concerns are not overlooked.

Readability of Patient-Reported Outcomes in Spine Surgery and Implications for Health Literacy

STUDY DESIGN

Observational study.

OBJECTIVE

To evaluate the readability of commonly utilized patient-reported outcome measures (PROMs) in spine surgery.

SUMMARY OF BACKGROUND DATA

Although studies have evaluated patient education materials, discharge instructions, and informed consent forms in spine surgery, there is a dearth of literature on the readability of PROMs despite widespread health illiteracy. Without knowledge of PROM readability, it is unclear whether these measures are able to be understood by the average spine patient.

MATERIALS AND METHODS

We analyzed all commonly utilized nonvisual PROMs within the spinal literature and uploaded PROMs into an online readability calculator. The Flesch Reading Ease Score (FRES) and Simple Measure of Gobbledygook (SMOG) Index were collected. A FRES>79 or SMOG<7 was considered readable by the general population per American Medical Association and Centers for Disease Control guidelines. A stricter threshold recommended in health care (SMOG <6 or FRES>89) was then used to further review readability.

RESULTS

Seventy-seven PROMs were included. Based on FRES, the mean readability of all PROMs was 69.2 ± 17.2 (range, 10-96.4), indicating an average eighth to ninth-grade reading level. The mean readability score categorized by the SMOG Index was 8.12 ± 2.65 (range, 3.1-25.6), representing an eighth-grade reading level. Compared with the reading level of the general population, 49 (63.6%) PROMs are written above the United States literacy level, according to FRES. Using stricter definitions of readability, 8 PROMs were considered readable, including PROM Information System pain behavior (FRES: 96.4 and SMOG: 5.2), PROM Information System sleep disturbance (SMOG: 5.6), Neck Pain and Disability Scale (SMOG: 4.3), and Zung Depression Scale (SMOG: 3.1).

CONCLUSIONS

Most PROMs utilized in spine surgery require an average reading competency far above the average patient's comprehension. This may have a meaningful impact on understanding PROM instruments and may affect the accuracy of complete surveys and the rates of incompletion.

Implementing paper-based patient-reported outcome collection within outpatient integrative health and medicine

OBJECTIVE

To investigate the feasibility of pre- and post-encounter patient-reported outcome (PRO) measure collection within an outpatient integrative health and medicine (IHM) clinic and to characterize factors associated with successful completion.

METHODS

We conducted a retrospective review of 27,464 outpatient IHM encounters including 9,520 chiropractic; 8,237 acupuncture; 5,847 massage; 2,345 IHM consultation; and 1,515 osteopathic manipulation treatment encounters at four clinics offering IHM over 18 months. Patients were asked to complete paper questionnaires rating pain, anxiety, and stress from 0-10 immediately pre- and post-encounter. Generalized linear mixed effect regression models were used to examine the relationship between demographic, clinical, and operational covariates and completing (1) pre-encounter and (2) paired (i.e., pre and post) PROs.

RESULTS

Patients (N = 5587, mean age 49 years, 74% white, 77% female) generally presented for musculoskeletal conditions (81.7%), with a chief complaint of pain (55.1%). 21,852 (79.6%) encounters were among patients who completed pre-encounter PROs; 11,709/21,852 (53.6%) completed subsequent post-encounter PROs. Odds of PRO completion were more impacted by provider, operational, and clinical-level factors than patient factors. Covariates associated with increased odds of pre-encounter PRO completion included being female, having additional IHM encounters, and having a pain or anxiety complaint. Covariates associated with increased odds of paired PRO completion included being aged 31-40 vs. 51-60 years and having additional IHM encounters.

CONCLUSION

Implementing a paper-based PRO collection system in outpatient IHM is feasible; however, collecting post-encounter PROs was challenging. Future endeavors should leverage the electronic health record and patient portals to optimize PRO collection and engage patients and clinical providers.

Factors Associated With Loss to Follow-Up in Surgical Trials: A Systematic Review and Meta-Analysis

INTRODUCTION

Loss to follow-up (LTFU) distorts results of randomized controlled trials (RCTs). Understanding trial characteristics that contribute to LTFU may enable investigators to anticipate the extent of LTFU and plan retention strategies. The objective of this systematic review and meta-analysis was to investigate the extent of LTFU in surgical RCTs and evaluate associations between trial characteristics and LTFU.

METHODS

MEDLINE, Embase, and PubMed Central were searched for surgical RCTs published between January 2002 and December 2021 in the 30 highest impact factor surgical journals. Two-hundred eligible RCTs were randomly selected. The pooled LTFU rate was estimated using random intercept Poisson regression. Associations between trial characteristics and LTFU were assessed using metaregression.

RESULTS

The 200 RCTs included 37,914 participants and 1307 LTFU events. The pooled LTFU rate was 3.10 participants per 100 patient-years (95% confidence interval [CI] 1.85-5.17). Trial characteristics associated with reduced LTFU were standard-of-care outcome assessments (rate ratio [RR] 0.17; 95% CI 0.06-0.48), surgery for transplantation (RR 0.08; 95% CI 0.01-0.43), and surgery for cancer (RR 0.10; 95% CI 0.02-0.53). Increased LTFU was associated with patient-reported outcomes (RR 14.21; 95% CI 4.82-41.91) and follow-up duration ≥ three months (odds ratio 10.09; 95% CI 4.79-21.28).

CONCLUSIONS

LTFU in surgical RCTs is uncommon. Participants may be at increased risk of LTFU in trials with outcomes assessed beyond the standard of care, surgical indications other than cancer or transplant, patient-reported outcomes, and longer follow-up. Investigators should consider the impact of design on LTFU and plan retention strategies accordingly.

Patient Demographic Factors Impact KOOS JR Response Rates for Total Knee Arthroplasty Patients

The Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) is a validated patient-reported measure for assessing pain and function following total knee arthroplasty (TKA). This study investigates how patient demographic factors (i.e., age, sex, and race) correlate with KOOS JR response rates. This was a retrospective cohort study of adult, English-speaking patients who underwent primary TKA between 2017 and 2023 at an academic institution. KOOS JR completion status-complete or incomplete-was recorded within 90 days postoperatively. Standard statistical analyses were performed to assess KOOS JR completion against demographic factors. Among 2,883 total patients, 70.2% had complete and 29.8% had incomplete KOOS JR questionnaires. Complete status (all p < 0.01) was associated with patients aged 60 to 79 (71.8%), white race (77.6%), Medicare (81.7%), marriage (76.8%), and the highest income quartile (75.7%). Incomplete status (all p < 0.001) was associated with patients aged 18 to 59 (64.4%), Medicaid (82.4%), and lower income quartiles (41.6% first quartile, 36.8% third quartile). Multiple patient demographic factors may affect KOOS JR completion rates; patients who are older, white, and of higher socioeconomic status are more likely to participate. Addressing underrepresented groups is important to improve the utility and generalizability of the KOOS JR.

Usability of an Automated System for Real-Time Monitoring of Shared Decision-Making for Surgery: Mixed Methods Evaluation

BACKGROUND

Improving shared decision-making (SDM) for patients has become a health policy priority in many countries. Achieving high-quality SDM is particularly important for approximately 313 million surgical treatment decisions patients make globally every year. Large-scale monitoring of surgical patients' experience of SDM in real time is needed to identify the failings of SDM before surgery is performed. We developed a novel approach to automating real-time data collection using an electronic measurement system to address this. Examining usability will facilitate its optimization and wider implementation to inform interventions aimed at improving SDM.

OBJECTIVE

This study examined the usability of an electronic real-time measurement system to monitor surgical patients' experience of SDM. We aimed to evaluate the metrics and indicators relevant to system effectiveness, system efficiency, and user satisfaction.

METHODS

We performed a mixed methods usability evaluation using multiple participant cohorts. The measurement system was implemented in a large UK hospital to measure patients' experience of SDM electronically before surgery using 2 validated measures (CollaboRATE and SDM-Q-9). Quantitative data (collected between April 1 and December 31, 2021) provided measurement system metrics to assess system effectiveness and efficiency. We included adult patients booked for urgent and elective surgery across 7 specialties and excluded patients without the capacity to consent for medical procedures, those without access to an internet-enabled device, and those undergoing emergency or endoscopic procedures. Additional groups of service users (group 1: public members who had not engaged with the system; group 2: a subset of patients who completed the measurement system) completed user-testing sessions and semistructured interviews to assess system effectiveness and user satisfaction. We conducted quantitative data analysis using descriptive statistics and calculated the task completion rate and survey response rate (system effectiveness) as well as the task completion time, task efficiency, and relative efficiency (system efficiency). Qualitative thematic analysis identified indicators of and barriers to good usability (user satisfaction).

RESULTS

A total of 2254 completed surveys were returned to the measurement system. A total of 25 service users (group 1: n=9; group 2: n=16) participated in user-testing sessions and interviews. The task completion rate was high (169/171, 98.8%) and the survey response rate was good (2254/5794, 38.9%). The median task completion time was 3 (IQR 2-13) minutes, suggesting good system efficiency and effectiveness. The qualitative findings emphasized good user satisfaction. The identified themes suggested that the measurement system is acceptable, easy to use, and easy to access. Service users identified potential barriers and solutions to acceptability and ease of access.

CONCLUSIONS

A mixed methods evaluation of an electronic measurement system for automated, real-time monitoring of patients' experience of SDM showed that usability among patients was high. Future pilot work will optimize the system for wider implementation to ultimately inform intervention development to improve SDM.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2023-079155.

Equitable Integration of Patient-Reported Outcomes Into Clinical Practice-Opportunities, Challenges, and a Roadmap for Implementation

Patient-reported outcome measures (PROMs) provide a standardized assessment from the patient about their own health status. Although originally developed as research tools, PROMs can be used in clinical care to complement objective functional measures (eg, range of motion) and are increasingly integrated to guide treatment decisions and predict outcomes. In some situations, when PROMs are used during clinical care they can improve patient mortality, outcomes, engagement, well-being, and patient-physician communication. Guidance on how PROMs should be communicated with patients continued to be developed. However, PROM use may have unintended consequences, such as when used implemented without accounting for confounding factors (eg, psychological and social health) or in perpetuating healthcare disparities when used imprecisely (eg, lack of linguistic or cultural validation). In this review, we describe the current state of PROM use in orthopaedic surgery, highlight opportunities and challenges of PROM use in clinical care, and provide a roadmap to support orthopaedic surgery practices in incorporating PROMs into routine care to equitably improve patient health.

Multilingual Framework for Risk Assessment and Symptom Tracking (MRAST)

The importance and value of real-world data in healthcare cannot be overstated because it offers a valuable source of insights into patient experiences. Traditional patient-reported experience and outcomes measures (PREMs/PROMs) often fall short in addressing the complexities of these experiences due to subjectivity and their inability to precisely target the questions asked. In contrast, diary recordings offer a promising solution. They can provide a comprehensive picture of psychological well-being, encompassing both psychological and physiological symptoms. This study explores how using advanced digital technologies, i.e., automatic speech recognition and natural language processing, can efficiently capture patient insights in oncology settings. We introduce the MRAST framework, a simplified way to collect, structure, and understand patient data using questionnaires and diary recordings. The framework was validated in a prospective study with 81 colorectal and 85 breast cancer survivors, of whom 37 were male and 129 were female. Overall, the patients evaluated the solution as well made; they found it easy to use and integrate into their daily routine. The majority (75.3%) of the cancer survivors participating in the study were willing to engage in health monitoring activities using digital wearable devices daily for an extended period. Throughout the study, there was a noticeable increase in the number of participants who perceived the system as having excellent usability. Despite some negative feedback, 44.44% of patients still rated the app's usability as above satisfactory (i.e., 7.9 on 1-10 scale) and the experience with diary recording as above satisfactory (i.e., 7.0 on 1-10 scale). Overall, these findings also underscore the significance of user testing and continuous improvement in enhancing the usability and user acceptance of solutions like the MRAST framework. Overall, the automated extraction of information from diaries represents a pivotal step toward a more patient-centered approach, where healthcare decisions are based on real-world experiences and tailored to individual needs. The potential usefulness of such data is enormous, as it enables better measurement of everyday experiences and opens new avenues for patient-centered care.

Analysis of factors associated with patient-reported outcome (PRO) score completion rate one year after shoulder surgeries

Background

Patient-reported outcome measurements (PROMs) are important metrics for monitoring improvements following shoulder surgery. Despite the easy accessibility of electronic PROM surveys, completion rates vary, and factors predictive of survey completion for patients enrolled in medical survey follow-up after shoulder surgery remain largely unknown. The purpose of this study is to investigate survey completion rates for common shoulder procedures and identify factors predictive of PROM completion at one-year postoperatively. We hypothesize that the response rate to shoulder PROMs may vary by the shoulder procedure type after surgery.

Methods

Patients undergoing total shoulder arthroplasty (TSA), rotator cuff repair (RCR), and instability surgery (Latarjet procedure [LP], and arthroscopic Bankart repair [ABR]) from 2019 to 2021 were prospectively enrolled. Each patient was administered PROM surveys via email preoperatively and at 2-weeks, 6-weeks, 3-months, 6-months, and 12-months following surgery. Demographics and socioeconomic characteristics were collected from our institutional database. The primary outcome studied was survey completion rate by procedure. Multivariable logistic regression was performed to identify factors predictive of completing 12-month follow-up.

Results

A total of 514 (251 TSA, 194 RCR, and 69 instability surgery (35 LP, 34 ABR)) patients with an average age of 58 ± 15 years were included in this study. Overall, the 12-month survey completion rate for all procedures was 57.2%. TSA had the highest completion rate (64.9%), followed by RCR (52.1%), ABR (44.2%), and LP (42.9%). ABR and LP demonstrated more than a 50% drop in survey response at 2 weeks, and the RCR cohort demonstrated an increased attrition in survey response at the 6-month mark. Patients who completed the 12-month follow-up survey were older [61 ± 14 vs. 54 ± 17; P < .001], less frequently self-identified as Hispanic [13% vs. 23%; P = .009], less frequently single [32% vs. 44%; P = .008], and most frequently classified as the American Society of Anesthesiology [ASA] score II [65%, P = .001].

Conclusion

Postoperative PROM survey completion rates vary significantly among commonly performed shoulder procedures during the first year after surgery. Hispanic ethnicity and younger age were all predictive of a lower propensity, and the TSA procedure is predictive of higher odds for PROM survey completion at the 12-month follow-up.

Predictors of Postoperative Patient-Reported Outcome Measure Response Rates Among Patients With Rotator Cuff Repair

BACKGROUND

Patient-reported outcome measures (PROMs) contribute to evaluating and improving the quality of patient care. Patient outcomes after rotator cuff repair (RCR) have been researched; however, the relationship between PROM response rates and individual and health care correlates has not been thoroughly investigated.

PURPOSE

To examine differences in individual and health care factors among patients who had undergone RCR based on their PROM response rates.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Shoulder-specific and general PROMs were solicited via email and text message of all patients who underwent RCR between 2016 and 2020. Three subgroups were classified: (1) complete responders completed all 1-year postoperative PROMs, (2) partial responders answered enough questions to produce ≥1 usable score, and (3) nonresponders did not respond to a single measure. Correlates were assessed using analysis of variance and chi-square tests. Adjusted multinomial logistic regression models identified predictors of 1-year PROM response.

RESULTS

Of 2195 patients included at the 1-year follow-up, 34% were complete responders; 11%, partial responders; and 55%, nonresponders. Patients had a mean age of 61.8 years, 63% were men, and 90% were White. Pre- and postoperative PROM scores were similar across responder groups. In stepwise selection, 1-year responses (complete or partial) were associated with older age, later year of surgery, White race, and having workers' compensation insurance. The strongest predictor of PROM response was having workers' compensation insurance.

CONCLUSION

Patients with workers' compensation insurance compared with other insurance types responded to PROMs at disproportionately higher rates. This could distort postoperative PROM scores in the population studied because there are known differences among patients with this insurance status.

The Development and Validation of Data Elements and Process Steps for an Electronic Health Record for Hand Surgery Outreach Trips

Background  The surgical burden in low- and middle-income countries (LMICs) as reported by the number of surgical cases per capita is great. To improve global health and help address this burden, there has been a rise in surgical outreach to LMICs. In high-income countries, an electronic health record (EHR) is used to document and communicate data critical to the quality of care and patient safety. Despite this, there is little guidance or precedence on the data elements or processes for utilizing an EHR on outreach trips. We validated data elements and process steps for utilizing an EHR for hand surgery outreach trips. Methods  We conducted a literature review to identify data elements collected during surgical outreach trips. A future-state process map for the collection and documentation of data elements within an EHR was developed through literature review and semistructured interviews with experts in global outreach. An expert consortium completed a modified RAND/University of California at Los Angeles Delphi process to evaluate the importance and feasibility of each data element and process step. Results  In total, 65 data elements (e.g., date of birth) and 24 process steps (e.g., surgical site marking) were validated for use in an EHR for hand surgery outreach trips to LMICs. Conclusion  This validated portfolio of data elements/process steps can serve as the foundation for pilot testing of an EHR to document and communicate critical patient data on hand surgery outreach trips. Utilization of an EHR during outreach trips to LMICs may serve to improve the safety and quality of care provided. The validated data elements/process steps can serve as a guide for EHR development and implementation of other surgical specialties.

Patients' experiences of engaging with electronic Patient Reported Outcome Measures (PROMs) after the completion of radiation therapy for breast cancer: a pilot service evaluation

INTRODUCTION

Over 60 % of people who develop breast cancer will receive radiation therapy (RT) as part of their treatment. Side effects of RT may include inflammation, erythema, desquamation and fatigue. Electronic Patient Reported Outcomes Measures (ePROMs) enable patients to report side effects prior to their scheduled post-RT appointment. This pilot service evaluation aims to explore patients' perceptions regarding the value of the ePROM system, ease of its use and barriers to using the system, after breast irradiation.

METHODS

From July-November 2021, evaluation surveys were posted to 100 people who had received RT to their breast to explore their experience of using the ePROM. Ethical approval was obtained through Ulster University and the Western Health and Social Care Trust (WHSCT), Northern Ireland.

RESULTS

Fifty-two people responded to the survey, of which 27 respondents indicated that they had accessed the ePROM. Despite few participants experiencing significant side effects, the majority of participants recommended the ePROM indicating that it was an important source of support. Those who experienced significant side effects found the system to be prompt and effective. Barriers to accessing the ePROM included technical issues with the link, concerns about confidentiality and forgetting to access the link. Access to the ePROM increased with higher education levels.

CONCLUSIONS

This pilot service evaluation demonstrated that ePROMs are valued by patients and can provide rapid real-time access to support, offering individual care and reassurance. For patients with longer RT schedules (>10 fractions), the introduction of ePROMs during RT was viewed favourably by participants. All patients may benefit from the option of receiving ePROMs post-RT.

Young or Old Age and Non-White Race Are Associated With Poor Patient-Reported Outcome Measure Response Compliance After Orthopaedic Surgery

Purpose

To investigate orthopaedic patient compliance with patient-reported outcome measures (PROMs) and identify factors that improve response rates.

Methods

Our search strategy comprised a combination of key words and database-specific subject headings for the concepts of orthopaedic surgical procedures, compliance, and PROMs from several research databases from inception to October 11, 2022. Duplicates were removed. A total of 97 studies were included. A table was created for the remaining articles to be appraised and analyzed. The collected data included study characteristics, follow-up/compliance rate, factors that increase/decrease compliance, and type of PROM. Follow-up/compliance rate was determined to be any reported response rate. The range and average used for analysis was based on the highest or lowest number reported in the specific article.

Results

The range of compliance reported was 11.3% to 100%. The overall response rate was 68.6%. The average baseline (preoperative/previsit) response rate was 76.6%. Most studies (77%) had greater than 50% compliance. Intervention/reminder of any type (most commonly phone call or mail) resulted in improved compliance from 44.6% to 70.6%. Young and elderly non-White male patients had the lowest compliance rate. When directly compared, phone call (71.5%) resulted in a greater compliance rate than electronic-based (53.2%) or paper-based (57.6%) surveys.

Conclusions

The response rates for PROMs vary across the orthopaedic literature. Patient-specific factors, such as age (young or old) and race (non-White), may contribute to poor PROM response rate. Reminders and interventions significantly improve PROM response rates.

Clinical Relevance

PROMs are important tools in many aspects of medicine. The data generated from these tools not only provide information about individual patient outcomes but also make hypothesis-driven comparisons possible. Understanding the factors that affect patient compliance with PROMs is vital to our accurate understanding of patient outcomes and the overall advancement of medical care.

The role of socioeconomic factors as barriers to patient reported outcome measure completion following lumbar spine fusion

BACKGROUND CONTEXT

Although incorporating patient reported outcomes (PROMs) into practice allows healthcare systems to evaluate the value of care provided, research and policy reflecting PROMs can only be valid if they represent all patients. Few studies have evaluated socioeconomic barriers to PROM completion, and none have done so in a spine patient population.

PURPOSE

To identify patient barriers to PROM completion one year following lumbar spine fusion.

STUDY DESIGN/SETTING

Retrospective single-institution cohort study.

PATIENT SAMPLE

A total of 2,984 patients undergoing lumbar fusion between 2014 and 2020 OUTCOME MEASURES: Completion of Mental Component Score (MCS-12) and Physical Component Score (PCS-12) of Short Form-12 questionnaire 1 year postoperatively.

METHODS

A retrospective review was conducted of all patients undergoing 1-3-level lumbar fusion at a single urban tertiary center. PROMs were queried from our prospectively managed electronic outcomes database. Patients were considered to have complete PROMs if 1-year outcomes were available. Community-level characteristics were collected from patients' zip codes using the Economic Innovation Group Distressed Communities Index. Bivariate analyses were performed to assess factors associated with PROM incompletion along with multivariate logistic regression to control for confounders.

RESULTS

A total of 1,968 (66.0%) had incomplete 1-year PROMs. Patients with incomplete PROMs were more likely to be Black (14.5% vs 9.3%, p<.001), Hispanic (2.9% vs 1.6%, p=.027), reside in a distressed community (14.7% vs 8.5%, p<.001), and be active smokers (22.4% vs 15.5%, p<.001). On multivariate regression, Black race (OR: 1.46, p=.014, Hispanic ethnicity (OR: 2.19, p=.027), distressed community status (OR: 1.47, p=.024), workers' compensation status (OR: 2.82, p=.001), and active smoking (OR:1.31, p=.034) all were independently associated with PROM incompletion. Surgical characteristics, including primary surgeon, revision status, approach, and levels fused were not associated with PROM incompletion.

CONCLUSIONS

Social determinants of health impact completion of PROMs. Patients completing PROMs are overwhelmingly White, non-Hispanic, and reside in wealthier communities. Efforts should be taken to provide better education regarding PROMs and ensure closer follow-up of certain subgroups of patients to avoid furthering disparities in PROM research.

Evaluation of electronic patient-reported outcome assessment in inpatient cancer care: a feasibility study

PURPOSE

Patient-reported outcome (PRO) measures are increasingly important in evaluating medical care. The increased integration of technology within the healthcare systems allows for collection of PROs electronically. The objectives of this study were to Ashley et al. J Med Internet Res (2013) implement an electronic assessment of PROs in inpatient cancer care and test its feasibility for patients and Dawson et al. BMJ (2010) determine the equivalence of the paper and electronic assessment.

METHODS

We analyzed two arms from a study that was originally designed to be an interventional, three-arm, and multicenter inpatient trial. A self-administered questionnaire based on validated PRO-measures was applied and completed at admission, 1 week after, and at discharge. For this analysis - focusing on feasibility of the electronic assessment - the following groups will be considered: Group A (intervention arm) received a tablet version, while group B (control arm) completed the questionnaire on paper. A feasibility questionnaire, that was adapted from Ashley et al. J Med Internet Res (2013), was administered to group A.

RESULTS

We analyzed 103 patients that were recruited in oncology wards. ePRO was feasible to most patients, with 84% preferring the electronic over paper-based assessment. The feasibility questionnaire contained questions that were answered on a scale ranging from "1" (illustrating non achievement) to "5" (illustrating achieving goal). The majority (mean 4.24, SD .99) reported no difficulties handling the electronic tool and found it relatively easy finding time for filling out the questionnaire (mean 4.15, SD 1.05). There were no significant differences between the paper and the electronic assessment regarding the PROs.

CONCLUSION

Results indicate that electronic PRO assessment in inpatient cancer care is feasible.

Online Patient-Reported Outcome Measure Engagement Is Dependent on Demographics and Locality: Findings From an Observational Cohort

OBJECTIVE

Online patient-reported outcome measures (PROMs) enable remote collection of perceptions of health status, function, and well-being. We aimed to explore patterns of PROM completion in patients with early inflammatory arthritis (EIA) recruited to the National Early Inflammatory Arthritis Audit (NEIAA).

METHODS

NEIAA is an observational cohort study design; we included adults from this cohort with a new diagnosis of EIA from May 2018 to March 2020. The primary outcome was PROM completion at baseline, 3 months, and 12 months. Mixed effects logistic regression and spatial regression models were used to identify associations between demographics (age, gender, ethnicity, deprivation, smoking, and comorbidity), clinical commissioning groups, and PROM completion.

RESULTS

Eleven thousand nine hundred eighty-six patients with EIA were included, of whom 5331 (44.5%) completed at least 1 PROM. Patients from ethnic minority backgrounds were less likely to return a PROM (adjusted odds ratio [aOR] 0.57, 95% CI 0.48-0.66). Greater deprivation (aOR 0.73, 95% CI 0.64-0.83), male gender (aOR 0.86, 95% CI 0.78-0.94), higher comorbidity burden (aOR 0.95, 95% CI 0.91-0.99), and current smoker status (aOR 0.73, 95% CI 0.64-0.82) also reduced odds of PROM completion. Spatial analysis identified 2 regions with high (North of England) and low (Southeast of England) PROM completion.

CONCLUSION

We define key patient characteristics (including ethnicity) that influence PROM engagement using a national clinical audit. We observed an association between locality and PROM completion, with varying response rates across regions of England. Completion rates could benefit from targeted education for these groups.

Prediction Model for Postoperative Quality of Life Among Breast Cancer Survivors Along the Survivorship Trajectory From Pretreatment to 5 Years: Machine Learning-Based Analysis

BACKGROUND

Breast cancer is the most common cancer and the most common cause of cancer death in women. Although survival rates have improved, unmet psychosocial needs remain challenging because the quality of life (QoL) and QoL-related factors change over time. In addition, traditional statistical models have limitations in identifying factors associated with QoL over time, particularly concerning the physical, psychological, economic, spiritual, and social dimensions.

OBJECTIVE

This study aimed to identify patient-centered factors associated with QoL among patients with breast cancer using a machine learning (ML) algorithm to analyze data collected along different survivorship trajectories.

METHODS

The study used 2 data sets. The first data set was the cross-sectional survey data from the Breast Cancer Information Grand Round for Survivorship (BIG-S) study, which recruited consecutive breast cancer survivors who visited the outpatient breast cancer clinic at the Samsung Medical Center in Seoul, Korea, between 2018 and 2019. The second data set was the longitudinal cohort data from the Beauty Education for Distressed Breast Cancer (BEST) cohort study, which was conducted at 2 university-based cancer hospitals in Seoul, Korea, between 2011 and 2016. QoL was measured using European Organization for Research and Treatment of Cancer QoL Questionnaire Core 30 questionnaire. Feature importance was interpreted using Shapley Additive Explanations (SHAP). The final model was selected based on the highest mean area under the receiver operating characteristic curve (AUC). The analyses were performed using the Python 3.7 programming environment (Python Software Foundation).

RESULTS

The study included 6265 breast cancer survivors in the training data set and 432 patients in the validation set. The mean age was 50.6 (SD 8.66) years and 46.8% (n=2004) had stage 1 cancer. In the training data set, 48.3% (n=3026) of survivors had poor QoL. The study developed ML models for QoL prediction based on 6 algorithms. Performance was good for all survival trajectories: overall (AUC 0.823), baseline (AUC 0.835), within 1 year (AUC 0.860), between 2 and 3 years (AUC 0.808), between 3 and 4 years (AUC 0.820), and between 4 and 5 years (AUC 0.826). Emotional and physical functions were the most important features before surgery and within 1 year after surgery, respectively. Fatigue was the most important feature between 1 and 4 years. Despite the survival period, hopefulness was the most influential feature on QoL. External validation of the models showed good performance with AUCs between 0.770 and 0.862.

CONCLUSIONS

The study identified important factors associated with QoL among breast cancer survivors across different survival trajectories. Understanding the changing trends of these factors could help to intervene more precisely and timely, and potentially prevent or alleviate QoL-related issues for patients. The good performance of our ML models in both training and external validation sets suggests the potential use of this approach in identifying patient-centered factors and improving survivorship care.

Non-English Speakers and Socioeconomic Minorities are Significantly Less Likely to Complete Patient-Reported Outcome Measures for Total Hip and Knee Arthroplasty: Analysis of 16,119 Cases

BACKGROUND

The Comprehensive Care for Joint Replacement requires patient-reported outcome measure (PROM) completion for total knee/hip arthroplasty (TKA/THA) patients. A 90% completion rate to avoid penalties was planned for 2023 but has been delayed. Our analysis compares TKA/THA PROM completion and results across demographics. We hypothesized that minority groups would be less likely to complete PROMs.

METHODS

A retrospective review was performed from 2018 to 2021 of 16,119 patients who underwent primary elective TKA or THA at a single institution. Pairwise chi-squared tests, t-tests, analysis of variance, and multiple logistic regression analyses were used to compare PROM completion rates and scores across demographics and surgery type (TKA/THA).

RESULTS

Comparing patients who had (N = 7,664) and did not have (N = 8,455) documented PROMs, completion rates were significantly lower in patients who were women, Black, Hispanic, less educated, used Medicaid insurance, lived in lower income neighborhoods, spoke non-English languages, required an interpreter, and underwent TKA versus THA. After regression analyses, odds ratios for PROM completion remained significantly lower in non-English speakers, Hispanic and Medicaid patients, lower income groups, and patients undergoing TKA. For the 31.8% of patients who completed both preoperative/postoperative PROMs, women, Black, and non-English speaking patients had significantly lower PROM scores for most measures preoperatively and postoperatively despite similar or better improvements after surgery.

CONCLUSION

Patients undergoing TKA and non-English speaking, ethnic, and socioeconomic minorities are less likely to complete PROMs. Strategies to create, validate, and collect PROMs for these populations are needed to avoid exacerbation of healthcare disparities.

Evaluating the Performance of an Automated Patient-Reported Outcomes Collection Platform in a Postoperative Hand Surgery Population

PURPOSE

Reliable collection of postoperative patient-reported outcome measures (PROMs) is critical to understanding surgical outcomes and the value of care. Automated PROMs collection, triggered by the electronic medical record at the 1-year postoperative anniversary, may provide a simple way to acquire outcomes for patients who have been discharged from clinic. The purposes of this study were to (1) evaluate the percentage of responses with an automated PROMs collection platform and (2) identify whether such a system may introduce selection bias by comparing responders with nonresponders.

METHODS

Adult patients (aged ≥18 years) undergoing hand and upper-extremity surgeries between August 2017 and January 2019 were included. Preoperative Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores were collected using tablet computer. Postoperative QuickDASH scores were collected using a single electronic survey request 1 year after surgery via an email with a personalized REDCap link. Univariate and multivariable regression analyses were performed to identify factors that differed between responders and nonresponders.

RESULTS

A response rate of 27% (269 of 1010) was observed for the eligible postoperative patients. On multivariable analysis, the following were associated with greater odds of response: older age, Caucasian race (vs unknown), longer surgery duration, attending the first postoperative visit, and responding to the preoperative QuickDASH.

CONCLUSIONS

The poor response rate that was observed highlights that an automated single email postoperative contact for PROMs collection is insufficient-active follow-up via reminder emails and/or telephone calls is needed. Outcome researchers and clinicians must be aware of potential selection biases, such as age and race, that may exist with automated PROMs collection.

CLINICAL RELEVANCE

Single email postoperative contact to obtain postoperative PROMs is insufficient.

The implementation of the 2017 national policy on patient-reported outcomes in Denmark: An overview of developments after six years

Driven by the potential values of using more patient-centred approaches in health care, the Danish government, regions and municipalities have agreed to introduce a standardised use of patient-reported outcomes (PRO) in all healthcare sectors in Denmark. Expecting benefits in particular at the individual patient level, the work to implement the national PRO policy is carried out under the auspices of the Ministry of Health. This highly systematic and comprehensive work elevates the development of PRO to a national level and centres around three main elements: development and feasibility tests of standardised PRO instruments within specific clinical areas, the development and implementation of a PRO instrument repository and a national IT infrastructure for the sharing of data across healthcare sectors. The paper describes these elements together with reports on the current state of implementation after six years of activities. PRO instruments have been developed and tested within eight clinical areas and - as intended - they show promising value for patients as well as healthcare professionals with respect to individual patient care. It has taken time for the supporting IT infrastructure to become fully operational in practice and, likewise, the strengthening of the implementation in and across healthcare sectors has required - and continues to require - considerable efforts from all stakeholders.

Factors Associated With Loss to Follow-up During the First Year After Total Knee Arthroplasty

Despite increased pressure to capture patient-reported outcome measures for at least 1 year following total joint arthroplasty (TJA), follow-up rates during the first year after TJA are typically lower than desired and may result in biased findings if data are not missing at random. We conducted a retrospective review of medical records of primary total knee arthroplasty patients treated by a single surgeon at an urban academic private hospital. Main measures were demographics (sex, age, race, and insurance), body mass index, travel distance to clinic, and the Knee Injury and Osteoarthritis Outcome Score (KOOS). Multivariable regression analyses were performed to identify patient characteristics associated with attendance at follow-up visits and predictors of attendance at 6-month follow-up. Among the 205 study patients, follow-up visit attendance declined from a high of 95.7% at day 14 to lows of 69.2% at 6 months and 64.4% at 1 year. Attendance at the previously scheduled follow-up visit was a statistically significant predictor of attendance at 3-month (P=.0015), 6-month (P=.0002), and 1-year (P<.0001) follow-up visits, and travel distance was significantly associated with attending the 1-year follow-up visit (P=.042). Patients with the most favorable KOOS Symptom, Pain, and Function in daily living subscale scores at 3-month follow-up were significantly less likely to attend the 6-month follow-up visit than patients with the least favorable KOOS scores. Prospective studies are needed to identify the full range of factors that may contribute to high rates of loss to follow-up after TJA, which should be of concern to researchers, clinicians, and hospitals. [Orthopedics. 2023;46(2):93-97.].

The reliability of revision rates following primary shoulder arthroplasty as a quality indicator to rank hospital performance: a national registry analysis including 13,104 shoulders and 87 hospitals

BACKGROUND

To assess the extent of between-hospital variation in revision following primary shoulder arthroplasty (SA), both overall and for specific revision indications to guide quality improvement initiatives, and to assess whether revision rates are suitable as quality indicators to reliably rank hospital performance.

METHODS

All primary SAs performed between 2014 and 2018 were included from the Dutch Arthroplasty Register to examine 1-year revision and all primary SAs performed between 2014 and 2016 for 1- and 3-year revisions. For each hospital, the observed number (O) of revisions was compared with that expected (E) based on case-mix and depicted in funnel plots with 95% control limits to identify outlier hospitals. The rankability (ie, the reliability of ranking hospitals) was calculated as the percentage of total hospital variation due to true between-hospital differences rather than chance and categorized as low (<50%), moderate (50%-75%), and high (>75%).

RESULTS

A total of 13,104 primary SAs (87 hospitals) in 2014-2018 were included, of which 7213 were performed between 2014 and 2016. Considerable between-hospital variation was found in 1-year revision in 2014-2016 (median 1.6%, interquartile range 0.0%-3.1%), identifying 3 outlier hospitals having overall significantly more revisions than expected (O/E range 1.9-2.3) and for specific indications (cuff pathology and infection). Results for 2014-2018 were similar. For 3-year revision, 3 outlier hospitals were identified (O/E range 1.7-3.3). Rankabilities for all outcomes were low.

CONCLUSIONS

Considerable between-hospital variation was observed for 1- and 3-year revision rates following primary SA, where outlier hospitals could be identified based on large differences in revision for specific indications to direct quality improvement initiatives. However, rankabilities were low, meaning that much of the other (smaller) variation in performance could not be detected, rendering revisions unsuitable to rank hospital performances following primary SA.

Patients From Socioeconomically Distressed Communities Experience Similar Clinical Improvements Following Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective cohort.

OBJECTIVES

The aim was to compare patient-reported outcome measures (PROMs) following anterior cervical discectomy and fusion (ACDF) when categorizing patients based on socioeconomic status. Secondarily, we sought to compare PROMs based on race.

SUMMARY OF BACKGROUND DATA

Social determinants of health are believed to affect outcomes following spine surgery, but there is limited literature on how combined socioeconomic status metrics affect PROMs following ACDF.

MATERIALS AND METHODS

The authors identified patients who underwent primary elective one-level to four-level ACDF from 2014 to 2020. Patients were grouped based on their distressed community index (DCI) quintile (Distressed, At-Risk, Mid-tier, Comfortable, and Prosperous) and then race (White or Black). Multivariate regression for ∆PROMs was performed based on DCI group and race while controlling for baseline demographics and surgical characteristics.

RESULTS

Of 1204 patients included in the study, all DCI groups improved across all PROMs, except mental health component score (MCS-12) for the Mid-tier group ( P =0.091). Patients in the Distressed/At-Risk group had worse baseline MCS-12, visual analog scale (VAS) Neck, and neck disability index (NDI). There were no differences in magnitude of improvement between DCI groups. Black patients had significantly worse baseline VAS Neck ( P =0.002) and Arm ( P =0.012) as well as worse postoperative MCS-12 ( P =0.016), PCS-12 ( P =0.03), VAS Neck ( P <0.001), VAS Arm ( P =0.004), and NDI ( P <0.001). Multivariable regression analysis did not identify any of the DCI groupings to be significant independent predictors of ∆PROMs, but being White was an independent predictor of greater improvement in ∆PCS-12 (β=3.09, P =0.036) and ∆NDI (β=-7.32, P =0.003).

CONCLUSIONS

All patients experienced clinical improvements regardless of DCI or race despite patients in Distressed communities and Black patients having worse preoperative PROMs. Being from a distressed community was not an independent predictor of worse improvement in any PROMs, but Black patients had worse improvement in NDI compared with White patients.

LEVEL OF EVIDENCE

3.

Compliance with Electronic Patient Reported Outcome Measure System Data Collection Is 51% Two-years After Shoulder Arthroscopy

Objective

To determine patient compliance in completing electronic patient-reported outcome measures (PROMs) following arthroscopic shoulder surgery and identify risk factors for noncompliance.

Methods

A retrospective review of compliance data was performed for patients who underwent arthroscopic shoulder surgery by a single surgeon in a private practice setting from June 2017 to June 2019. All patients were enrolled in Surgical Outcomes System (Arthrex) as a part of routine clinical care, and outcome reporting was integrated into our practice electronic medical record. Patient compliance with PROMs was calculated at preoperative, three-month, 6-month, 1-year, and 2-year follow-up time points. Compliance was defined as a complete patient response to each assigned outcome module in the database over time. Logistic regression for compliance at the one-year timepoint was performed to assess for factors associated with survey compliance.

Results

Compliance with PROMs was highest preoperatively (91.1%) and decreased at each subsequent time point. The largest decrease in compliance with PROMs occurred between the preoperative and 3-month follow-up time points. Compliance was 58% at 1 year and 51% at 2 years after surgery. Overall, 36% of patients were compliant at all individual time points. There were no significant predictors of compliance with regard to age, sex, race, ethnicity, or procedure.

Conclusions

Patient compliance with PROMs decreased over time with the lowest percentage of patients completing electronic surveys at the traditional 2-year follow-up for shoulder arthroscopy. In this study, basic demographic factors were not predictive of patient compliance with PROMs.

Clinical Relevance

PROMs are commonly collected after arthroscopic shoulder surgery; however, low patient compliance may affect their utility in research and clinical practice.

Predicting non-response in patient-reported outcome measures: results from the Swiss quality assurance programme in cardiac inpatient rehabilitation

BACKGROUND

Quality assurance programmes measure and compare certain health outcomes to ensure high-quality care in the health-care sector. The outcome of health-related quality of life is typically measured by patient-reported outcome measures (PROMs). However, certain patient groups are less likely to respond to PROMs than others. This non-response bias can potentially distort results in quality assurance programmes.

OBJECTIVE

Our study aims to identify relevant predictors of non-response during assessment using the PROM MacNew Heart Disease questionnaire in cardiac rehabilitation.

METHODS

This is a cross-sectional study based on data from the Swiss external quality assurance programme. All patients aged 18 years or older who underwent inpatient cardiac rehabilitation in 16 Swiss rehabilitation clinics between 2016 and 2019 were included. Patients' socio-demographic and basic medical data were analysed descriptively by comparing two groups: non-responders and responders. We used a random intercept logistic regression model to estimate the associations of patient characteristics and clinic differences with non-response.

RESULTS

Of 24 572 patients, there were 33.3% non-responders and 66.7% responders. The mean age was 70 years, and 31.0% were women. The regression model showed that being female was associated with non-response [odds ratio (OR) 1.22; 95% confidence interval (CI) 1.14-1.30], as well as having no supplementary health insurance (OR 1.49; 95% CI 1.39-1.59). Each additional year of age increased the chance of non-response by an OR of 1.02 (95% CI 1.02-1.02). Not being a first language speaker of German, French or Italian increased the chance of non-response by an OR of 6.94 (95% CI 6.03-7.99). Patients admitted directly from acute care had a higher chance of non-response (OR 1.23; 95% CI 1.10-1.38), as well as patients being discharged back into acute care after rehabilitation (OR 3.89; 95% CI 3.00-5.04). Each point on the cumulative illness rating scale total score increased the chance of non-response by an OR of 1.05 (95% CI 1.04-1.05). Certain diagnoses also influenced the chance of non-response. Even after adjustment for known confounders, response rates differed substantially between the 16 clinics.

CONCLUSION

We have found significant non-response bias among certain patient groups, as well as across different treatment facilities. Measures to improve response rates among patients with known barriers to participation, as well as among different treatment facilities, need to be considered, particularly when PROMs are being used for comparison of providers in quality assurance programmes or outcome evaluation.

Barriers and Facilitators of Outcome Collection During Hand Surgery Outreach: A Quality Improvement Study

BACKGROUND

Surgical outreach trips to low- and middle-income countries have been increasing. Outcome collection on these trips, however, has been inconsistent and often incomplete. We conducted a qualitative study of surgeons, administrators, and patients to identify the barriers and facilitators to outcome collection on hand surgery outreach trips to Hospital 175 in Ho Chi Minh City, Vietnam.

METHODS

A purposive sample of surgeons, administrators, and patients from Hospital 175 were interviewed about their beliefs regarding outcome collection. We used a semi-structured interview guide based on the Theoretical Domains Framework to systematically explore barriers and facilitators. Interviews were recorded, transcribed, and analyzed using content analysis. Beliefs underlying similar responses were identified and aggregated to describe barriers and facilitators of outcome measurement.

RESULTS

Twelve surgeons and administrative staff (3 visiting and 9 local) and 5 patients were interviewed before saturation was achieved. All stakeholders believed outcome collection on hand surgery outreach trips is important. Barriers identified were primarily related to environmental context and resources (eg, cost of returning) and memory, attention, and decision process (eg, difficulty in remembering patient follow-up intervals). The most commonly identified barriers address the distance patients live from the hospital/clinic, the resources required for them to return, and the lack of an organized system to assist in follow-up.

CONCLUSIONS

Multiple barriers to outcome collection exist at Hospital 175 in Vietnam. Understanding these barriers informs context-specific implementation approaches to collect outcomes on hand surgery outreach trips, which may improve the safety and quality of care provided.

Poor Patient Compliance Limits the Attainability of Patient-Reported Outcome Measure Completion Thresholds for the Comprehensive Care for Joint Arthroplasty Model

BACKGROUND

The Centers for Medicare and Medicaid Services (CMS) links patient-reported outcome measures (PROMs) with hospital reimbursement in some value-based models for total joint arthroplasty (TJA). This study evaluates PROM reporting compliance and resource utilization using protocol-driven electronic collection of outcomes for commercial and CMS alternative payment models (APMs).

METHODS

We analyzed a consecutive series of patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) from 2016 and 2019. Compliance rates were obtained for reporting hip disability and osteoarthritis outcome score for joint replacement (HOOS-JR.), knee disability and osteoarthritis outcome score for joint replacement (KOOS-JR.), and 12-item short form survey (SF-12) surveys preoperatively and postoperatively at 6-months, 1 year, and 2- years. Of 43,252 THA and TKA patients, 25,315 (58%) were Medicare-only. Direct supply and staff labor costs for PROM collection were obtained. Chi-square testing compared compliance rates between Medicare-only and all-arthroplasty groups. Time-driven activity-based costing (TDABC) estimated resource utilization for PROM collection.

RESULTS

In the Medicare-only cohort, preoperative HOOS-JR./KOOS-JR. compliance was 66.6%. Postoperative HOOS-JR./KOOS-JR. compliance was 29.9%, 46.1%, and 27.8% at 6 months, 1 year, and 2 years, respectively. Preoperative SF-12 compliance was 70%. Postoperative SF-12 compliance was 35.9%, 49.6%, and 33.4% at 6 months, 1 year, and 2 years, respectively. Medicare patients had lower PROM compliance than the overall cohort (P < .05) at all time points except preoperative KOOS-JR., HOOS-JR., and SF-12 in TKA patients. The estimated annual cost for PROM collection was $273,682 and the total cost for the entire study period was $986,369.

CONCLUSION

Despite extensive experience with APMs and a total expenditure near $1,000,000, our center demonstrated low preoperative and postoperative PROM compliance rates. In order for practices to achieve satisfactory compliance, Comprehensive Care for Joint Replacement (CJR) compensation should be adjusted to reflect the costs associated with collecting these PROMs and CJR target compliance rates should be adjusted to reflect more attainable levels consistent with currently published literature.

Preoperative Factors Associated with 2-Year Postoperative Survey Completion in Knee Surgery Patients

Patient-reported outcomes, such as the Patient-Reported Outcomes Measurement Information System (PROMIS) measures, have become increasingly valued as measures of treatment. The purpose of the study was to determine preoperative factors associated with survey compliance 2 years after elective knee surgery. Five hundred patients, age 17 years and older, undergoing knee surgery from August 2015 and March 2017 were administered questionnaires preoperatively and 2 years postoperatively. Questionnaires included the International Knee Documentation Committee (IKDC) score, Numeric Pain Scales (NPS), International Physical Activity Questionnaire (IPAQ), and six PROMIS Domains for physical function, pain interference, social satisfaction, fatigue, anxiety, and depression. Three hundred sixty-five patients (73.0%) completed both the preoperative and the 2-year surveys. A decreased likelihood of survey completion was significantly associated with black race, lower income, government-sponsored insurance, smoking, opioid use, fewer previous surgeries, lower expectations, lower PROMIS social satisfaction, higher PROMIS pain interference, and lower IPAQ physical activity. Multivariable logistic regression analysis confirmed that black race and lower IPAQ activity level were independent predictors of lower survey completion at 2-year follow-up with an area under the curve (AUC) of 0.62. A more robust multivariable model that included all variables with p < 0.05 in the bivariate analysis had an AUC of only 0.70. This study identified multiple preoperative factors that were associated with lower survey completion 2 years after elective orthopaedic knee surgery; however, all the factors measured in this study were not strong predictors of survey completion.

Handling missing data through prevention strategies in self-administered questionnaires: a discussion paper

BACKGROUND

Self-administered questionnaires are efficient and low-cost ways of collecting data with wide cohorts. Nonetheless, their use in studies can result in a high occurrence of missing data, which can affect the statistical power, representativeness and generalisability of the findings. Imputation methods have been considered efficient statistical techniques for managing missing data. However, they have also been associated with limits, such as the risk of under-estimation of the effect, lower statistical power and decrease of correlation among variables. Recent studies have highlighted the importance of using prevention strategies to avoid missing data before the data are analysed.

AIM

To identify strategies for preventing the occurrence of missing data and to discuss their effects, as well as their methodological and statistical considerations.

DISCUSSION

The article discusses prevention strategies related to the administration format and follow-up and reminders. Strategies such as the use of electronic tablets, email and telephone reminders are associated with lower rates of missing data in self-administered questionnaires. However, methodological and statistical limits, including the absence of a comparison group and statistical validation of the reported results, limits the capacity to establish robust consensus.

CONCLUSION

Prevention strategies represent relevant and feasible avenues for handling missing data in a wide range of clinical, nursing and epidemiological research. More projects based on robust design are needed to ensure accurate and reliable data are collected from patients, families, communities and clinicians.

IMPLICATIONS FOR PRACTICE

It is important for clinicians and nurses to understand the phenomenon of missing data and the strategies available to prevent missing data, to collect data representing the patients' and families' perspectives and experiences.

Capturing patient-reported outcomes: paper versus electronic survey administration

Objective: To compare the capture rates and costs of paper patient-reported outcomes (pPRO) administered in-clinic and electronic PROs (ePRO) collected through emails and texts. Design: Retrospective review. Setting: Level 1 trauma center. Patients/Participants: The pPRO program enrolled 2164 patients for postsurgical follow-up in 4 fracture types: ankle, distal radius, proximal humerus, and implant removal from 2012 to 2017. The ePRO program enrolled 3096 patients in 13 fracture types from 2018 to 2020. Among the patients enrolled in the ePRO program, 1296 patients were matched to the 4 original fracture types and time points. Main Outcome Measures: PRO capture rates in 4 fracture types by matched time point and estimated cost of each program per enrolled patient. Results: At first follow-up, pPRO provided a higher capture rate than ePRO for 3 of 4 fracture types except for implant removal (P < 0.05). However, at 6-month and 1-year follow-ups, ePRO demonstrated statistically significant higher capture rates when compared with pPRO for all applicable modules (P < 0.05). The average cost for the pPRO program was $171 per patient versus $56 per patient in the ePRO program. Patients were 1.19 times more likely to complete ePRO compared with pPRO (P = 0.007) after controlling for age, sex, fracture type, and time point. Conclusion: The electronic PRO service has improved long-term capture rates compared with paper PROs, while minimizing cost. A combined program that includes both in-clinic and out of clinic effort may be the ideal model for collection of PROs. Level of Evidence: Level 3.

Sociodemographic Factors Are Associated with Patient-Reported Outcome Measure Completion in Orthopaedic Surgery: An Analysis of Completion Rates and Determinants Among New Patients

Patient-reported outcome measures (PROMs) and, specifically, the Patient-Reported Outcomes Measurement Information System (PROMIS), are increasingly utilized for clinical research, clinical care, and health-care policy. However, completion of these outcome measures can be inconsistent and challenging. We hypothesized that sociodemographic variables are associated with the completion of PROM questionnaires. The purposes of the present study were to calculate the completion rate of assigned PROM forms and to identify sociodemographic and other variables associated with completion to help guide improved collection efforts.

Methods

All new orthopaedic patients at a single academic medical center were identified from 2016 to 2020. On the basis of subspecialty and presenting condition, patients were assigned certain PROMIS forms and legacy PROMs. Demographic and clinical information was abstracted from the electronic medical record. Bivariate analyses were performed to compare characteristics among those who completed assigned PROMs and those who did not. A multivariable logistic regression model was created to determine which variables were associated with successful completion of assigned PROMs.

Results

Of the 219,891 new patients, 88,052 (40%) completed all assigned PROMs. Patients who did not activate their internet-based patient portal had a 62% increased likelihood of not completing assigned PROMs (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.58 to 1.66; p < 0.001). Non-English-speaking patients had a 90% (OR, 1.90; 95% CI, 1.82 to 2.00; p < 0.001) increased likelihood of not completing assigned PROMs at presentation. Older patients (≥65 years of age) and patients of Black race had a 23% (OR, 1.23; 95% CI, 1.19 to 1.27; p < 0.001) and 24% (OR, 1.24; 95% CI, 1.19 to 1.30; p < 0.001) increased likelihood of not completing assigned PROMs, respectively.

Conclusions

The rate of completion of PROMs varies according to sociodemographic variables. This variability could bias clinical outcomes research in orthopaedic surgery. The present study highlights the need to uniformly increase completion rates so that outcomes research incorporates truly representative cohorts of patients treated. Furthermore, the use of these PROMs to guide health-care policy decisions necessitates a representative patient distribution to avoid bias in the health-care system.

Level of Evidence

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Patient registries in orthopedics and orthobiologic procedures: a narrative review

There has been increasing evidence and growing popularity of orthobiologic treatments, such as platelet-rich plasma, bone marrow aspirate concentrate, and microfragmented adipose tissue. However, real-world data, including patient-reported pain and function outcomes, remains sparse for these procedures. Thus, collecting patient-reported outcome measures is important to evaluate the safety and efficacy of these treatments and hopefully improve patient care. Patient reported outcome measures can systematically be collected through patient registries. This narrative review serves to describe the data collection platforms and registries that obtain patient-reported outcome measures on orthobiologic procedures and provide a discussion on the benefits and limitations of registries. An internet search of the list of orthopedic registries available was conducted, and registries that collect patient-reported outcome measures for orthobiologic procedures were identified. Additional information regarding these various registries was collected by directly contacting these vendors. Publications from these registries, including case series, observational studies, and annual reports, were also reviewed. Providing this review will inform clinicians of a digital tool that can increase the efficiency of collecting outcome measures for orthobiologics and aid physicians in choosing a data collection platform.

Experiences of Norwegian child and school health nurses with the "Starting Right™" child health assessment innovation: a qualitative interview study

Background

Although child health services are well established in Norway, the use of information technology for the systematic collection of evidence-based child- and proxy-reported health measures may be beneficial in the early identification of child development problems. The Norwegian “Starting Right™” health service innovation consists of parent- and child-reported online structured health assessments tools, including practical routines for child and school health assessments. The aim of this study was to explore the experiences of child and school health nurses with the Starting Right innovation.

Methods

We used a qualitative design and conducted three focus group interviews with 18 child and school health nurses from three child health centres one year after the implementation of the innovation.

Results

The experiences of professionals with the Starting Right innovation were captured by three themes: (1) the digital innovation could be used to obtain a good overview of a child’s health and development; (2) interpreting the questionnaires was a challenge; and (3) implementing the new digital innovation was time-consuming.

Conclusions

Overall, the child and school health nurses experienced that the Starting Right innovation was useful for providing a comprehensive overview of child development and health. The challenges related to interpreting the parents’ scores and follow-up of children, as well as providing the questionnaires in relevant foreign languages, should be addressed to allow all children and families to be reached.

Digital patient-reported outcomes in inflammatory bowel disease routine clinical practice: the clinician perspective

Background

Use of digital health services, such as digital patient-reported outcomes, depends on many different human factors as well as digital design solutions. One factor is clinicians’ attitude towards the system, their reasoning behind the using system and their perceptions of patients’ ability to engage with digital health systems. This study aimed to explore hospital clinicians’ attitudes towards digital patient-reported outcomes used in the routine care and treatment of inflammatory bowel disease, and to explore the potential role of clinicians’ attitudes in influencing patients’ use of digital patient-reported outcomes.

Results

Twelve clinicians using digital patient-reported outcome assessments in the care of inflammatory bowel disease were interviewed about their experiences of, and perspectives on, using this service. Most participants supported the use of digital patient-reported outcome assessments in the care of most patients. Participants reported that most patients found the digital solution easy to use. They perceived digital patient-reported outcomes to have three main purposes: prioritising resources; improving patients’ quality of life; and improving quality of care. The patient-clinician relationship was of great importance to participants. Participants varied in their intention to use digital PRO, as some viewed the system as a positive but optional add-on for patients, whilst others intended to use the system with all eligible patients.

Conclusion

Clinicians’ general support of using digital patient-reported outcomes might facilitate their use among patients with inflammatory bowel disease. The participants saw benefits in doing so for patients, clinicians and the wider health service. Clinicians’ attitudes towards the use of digital PRO in the care of their patients may influence patients’ uptake of health service.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00462-x.

Substantial clinical benefit and patient acceptable symptom states of the Forgotten Joint Score 12 after primary knee arthroplasty

Background and purpose - Knowing how to interpret values obtained with patient reported outcome measures (PROMs) is essential. We estimated the substantial clinical benefit (SCB) and patient acceptable symptom state (PASS) for Forgotten Joint Score 12 (FJS) and explored differences depending on methods used for the estimates. Patients and methods - The study was based on 195 knee arthroplasties (KA) performed at a university hospital. We used 1 item from the Knee injury and Osteoarthritis Outcome Score domain quality of life and satisfaction with surgery, obtained 1-year postoperatively, to assess SCB and PASS thresholds of the FJS with anchor-based methods. We used different combinations of anchor questions for SCB and PASS (satisfied, satisfied with no or mild knee difficulties, and satisfied with no knee difficulties). A novel predictive approach and receiver-operating characteristics curve were applied for the estimates. Results - 70 and 113 KAs were available for the SCB and PASS estimates, respectively. Depending on method, SCB of the FJS (range 0-100) was 28 (95% CI 21-35) and 22 (12-45) respectively. PASS was 31 (2-39) and 20 (10-29) for satisfied patients, 40 (31-47) and 38 (32-43) for satisfied patients with no/mild difficulties, and 76 (39-80) and 64 (55-74) for satisfied patients with no difficulties. The areas under the curve ranged from 0.82 to 0.88. Interpretation - Both the SCB and PASS thresholds varied depending on methodology. This may indicate a problem using meaningful values from other studies defining outcomes after KA. This study supports the premise of the FJS as a PROM with good discriminatory ability in patients undergoing KA.

Patient-reported outcome measures can advance population health, but is access to instruments and use equitable?

Patient reported outcome measures (PROM) can engage patients and clinicians to improve health outcomes. Their population health impact may be limited by systematic barriers inhibiting access to completion. In this analysis we evaluated the association between individual parent/child characteristics and clinic factors with parental completion of a locally developed PROM, the Early Healthy Lifestyles (EHL) questionnaire. Participants included parent-child dyads who presented at 14 pediatric clinics for regularly scheduled well-child visits (WCV) prior to age 26 months. EHL items include feeding practices, diet, play time, screen exposure, and sleep. Completion was categorized at patient- (i.e., parent-child dyad) and clinic-levels. Parents completed the 15-item EHL in the patient portal before arrival or in the clinic; ninety-three percent of EHL questionnaires were completed in the clinic vs. 7% in the patient portal. High-completers completed EHL for half of WCVs; low-completers completed at least once; and non-completers never completed. Clinics were classified by EHL adoption level (% high completion): High-adoption: >50%; Moderate-adoption: 10%-50%; and Low-adoption: <10%. Individual-level factors had negligible impact on EHL completion within moderate/low EHL adoption sites; high-adoption sites were used to evaluate infant and maternal factors in association with EHL completion using hierarchical logistic regression. Noncompletion of EHL was significantly associated (p < 0.05) with infant use of public insurance (OR = 1.92 [1.42, 2.59]), >1 clinic site for WCV (OR = 1.83 [1.34, 2.50]), non-White birth mother (OR = 1.78 [1.28, 2.47]), and body weight <2,500 grams or gestational age <34 weeks (OR = 1.74 [1.05, 2.90]). The number of WCVs, a proxy for clinic size, was evaluated but was not associated with completion. Findings indicate potential disparities between populations exposed to, completing, and benefitting from these tools.

Psychometric validation of the Korean version of PROMIS 29 Profile V2.1 among patients with lower extremity problems

Background

Patients with lower extremity problems (LEP) commonly experience functional loss, pain, decreased range of motion, inadequacy in daily living activities, and structural change in radiographic evaluations. However, the traditional patient-reported outcome measurement which focused on symptoms, had a limited scope of applicability. This study aimed to validate the psychometric properties of the Korean version of PROMIS-29 Profile v2.1 (K-PROMIS-29 V2.1), a multi-dimensional measure for assessing generic profile health-related quality-of-life (HRQoL) in a sample of patients with lower extremity problems (LEP).

Methods

Participants were recruited from the orthopedic outpatient clinics at the Samsung Medical Center in Seoul, South Korea from September to October 2018. Participants completed a survey questionnaire that included the K-PROMIS-29 V2.1 and the SF-36v2. Principal component analysis (PCA) and confirmatory factor analysis (CFA) and Pearson’s correlations were used to evaluate the reliability and validity of the K-PROMIS-29 V2.1.

Results

A total of 299 participants were enrolled in the study and 258 (86%) completed the study questionnaire. The mean age (SD) of the participants was 56.6 (14.5) and 32.3%, 29.8, and 25.2% of the study participants visited outpatient clinics for foot, knee, and hip problems respectively. The Cronbach’s alpha coefficients of 7 sub-domains in K-PROMIS-29 V2.1 ranged from 0.80 to 0.95, indicating satisfactory internal consistency. In CFA, the goodness-of-fit indices were high (CFI = 0.937 and SRMR = 0.061). High to moderate correlations were found between comparable subscales of the K-PROMIS-29 V2.1 and subscales of the SF-36v2 (r = 0.55–0.70).

Conclusions

The K-PROMIS-29 V2.1 is a reliable and valid measure for assessing a broad range of health-related quality-of-life domains in patients with LEP. It would reflect the real-life symptoms experienced by patients with LEP.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-021-00374-1.

Collection of the International Hip Outcome Tool-12 Using a Smartphone Application Format Is Faster and Preferred When Compared With the Paper Version: A Pilot Study of rHip

Purpose

To evaluate the agreeability between the mobile application-based International Hip Outcome Tool-12 (iHOT-12) survey with the paper version, as well as compare the time it takes patients each of the versions, and patient preferences between the two.

Methods

Patients seen with symptomatic femoroacetabular impingement syndrome were prospectively enrolled in February 2019 and completed both the paper and application-based iHOT-12, in randomized order. Outcomes scores and time to completion were recorded for each version, and patients were also asked which they preferred. Intraclass correlation coefficient was calculated to assess for absolute agreement between the 2 versions. Bland–Altman plots were constructed to evaluate the agreeability between paper and application-based iHOT-12 scores. Bland–Altman plots were evaluated to identify systematic bias and data stratification was performed to identify sequence bias between the application and paper-based collection modalities.

Results

Twenty-nine patients (aged15-56 years) completed both the paper and application-based versions of the iHOT-12. Between the application-based and paper versions, the intraclass correlation coefficient was 0.98, and Bland–Altman analysis showed agreement without bias between versions. There was no sequence bias. Accounting for completion order, the application-based iHOT-12 was faster for patients when compared to the paper version (61.4 ± 20.3 vs 71.9 ± 23.6 seconds, P = .02). Twenty-two patients reported a version preference where 19 of 22 (86%) chose application-based (P < .001).

Conclusions

The application-based iHOT-12 demonstrated absolute agreement with the paper iHOT-12, and is faster for patients to complete. Patients preferred using the application-based iHOT-12 over the paper-based version. Application-based PROs allow for collection of patient data at more frequent time points, which may be helpful in tracking the recovery progress of patients and predicting outcomes.

Clinical Relevance

As electronic-based outcome surveys become more common, it is important to know how the results may differ from traditional paper-based surveys.

Collection and Reporting of Patient-reported Outcome Measures in Arthroplasty Registries: Multinational Survey and Recommendations

BACKGROUND

Patient-reported outcome measures (PROMs) are validated questionnaires that are completed by patients. Arthroplasty registries vary in PROM collection and use. Current information about registry collection and use of PROMs is important to help improve methods of PROM data analysis, reporting, comparison, and use toward improving clinical practice.

QUESTIONS/PURPOSES

To characterize PROM collection and use by registries, we asked: (1) What is the current practice of PROM collection by arthroplasty registries that are current or former members of the International Society of Arthroplasty Registries, and are there sufficient similarities in PROM collection between registries to enable useful international comparisons that could inform the improvement of arthroplasty care? (2) How do registries differ in PROM administration and demographic, clinical, and comorbidity index variables collected for case-mix adjustment in data analysis and reporting? (3) What quality assurance methods are used for PROMs, and how are PROM results reported and used by registries? (4) What recommendations to arthroplasty registries may improve PROM reporting and facilitate international comparisons?

METHODS

An electronic survey was developed with questions about registry structure and collection, analysis, reporting, and use of PROM data and distributed to directors or senior administrators of 39 arthroplasty registries that were current or former members of the International Society of Arthroplasty Registries. In all, 64% (25 of 39) of registries responded and completed the survey. Missing responses from incomplete surveys were captured by contacting the registries, and up to three reminder emails were sent to nonresponding registries. Recommendations about PROM collection were drafted, revised, and approved by the International Society of Arthroplasty Registries PROMs Working Group members.

RESULTS

Of the 25 registries that completed the survey, 15 collected generic PROMs, most frequently the EuroQol-5 Dimension survey; 16 collected joint-specific PROMs, most frequently the Knee Injury and Osteoarthritis Outcome Score and Hip Disability and Osteoarthritis Outcome Score; and 11 registries collected a satisfaction item. Most registries administered PROM questionnaires within 3 months before and 1 year after surgery. All 16 registries that collected PROM data collected patient age, sex or gender, BMI, indication for the primary arthroplasty, reason for revision arthroplasty, and a comorbidity index, most often the American Society of Anesthesiologists classification. All 16 registries performed regular auditing and reporting of data quality, and most registries reported PROM results to hospitals and linked PROM data to other data sets such as hospital, medication, billing, and emergency care databases. Recommendations for transparent reporting of PROMs were grouped into four categories: demographic and clinical, survey administration, data analysis, and results.

CONCLUSION

Although registries differed in PROM collection and use, there were sufficient similarities that may enable useful data comparisons. The International Society of Arthroplasty Registries PROMs Working Group recommendations identify issues that may be important to most registries such as the need to make decisions about survey times and collection methods, as well as how to select generic and joint-specific surveys, handle missing data and attrition, report data, and ensure representativeness of the sample.

CLINICAL RELEVANCE

By collecting PROMs, registries can provide patient-centered data to surgeons, hospitals, and national entities to improve arthroplasty care.

Patient-level barriers and facilitators to completion of patient-reported outcomes measures

PURPOSE

To identify patient-level barriers and facilitators to completion of patient-reported outcomes measures (PROMs) in a hand and upper extremity clinic in Baltimore, Maryland.

METHODS

We conducted 12 h of direct observation of PROM completion (October-November, 2020). Ethnographic observation memos were qualitatively analyzed for barriers and facilitators using rapid thematic analysis. Informed by observation findings, we conducted 17 semi-structured interviews with mixed-literacy patients, caregivers, and clinic staff to understand the patient experience when completing PROMs (November 2020-March 2021). We identified initial themes through inductive and deductive framework analysis and validated findings through subsequent interviews with member-checking.

RESULTS

We identified nine patient-level factors that influence PROM completion: platform design, print literacy, health literacy, technology literacy, language proficiency, physical functioning, vision, cognitive functioning, and time.

CONCLUSIONS

There are multiple distinct patient-level factors that affect PROM completion. Failure to consider these factors in PROM design and implementation may lower completion rates or prevent accurate completion, undermining PROM validity. Because certain factors affect minority populations at disproportionate rates, this may also contribute to existing health disparities.

Patient-Reported Outcome Measurement Information System (PROMIS) in Orthopaedic Trauma Research

This review describes the development, advantages and disadvantages, and applications of the Patient-Reported Outcome Measurement Information System (PROMIS) in orthopaedic trauma. PROMIS is a useful tool for quantifying outcomes in orthopedic trauma. It allows measurement of outcomes across multiple domains while minimizing administration time. PROMIS also reliably identifies clinical, social, and psychological risk factors for poor outcomes across a variety of orthopaedic injuries and disease states. However, PROMIS lacks specificity for certain anatomic regions and validation for mental health outcomes. It also is limited by ceiling effects in certain active patient populations. Orthopaedic traumatologists should be familiar with PROMIS, as its use is increasing and it is a valuable tool that can aid in clinical decision making.

Disparities Limit the Effect and Benefit of a Web-Based Clinic Intake System

With increasing value being placed on patient-centered care and the focus on efficiency and workflow in health care delivery, the authors have implemented a web-based system for demographic, medical history, and patient-reported outcomes data collection for every clinical visit at their specialty upper-extremity center. They evaluated initial success and disparities in use after 12 months. The authors evaluated questionnaire parameters from 2018 patients, focusing primarily on the new patient intake form. They analyzed form-completion time relative to appointment time and form-completion percentage at various times before the appointment. The authors grouped patients by age, sex, race, income, education, employment status, transportation access, self-reported pain, and quality-of-life scores. Waiting room time was evaluated. Of new patients, 94% used the web-based platform to complete the intake form. Of the 4898 completed forms, 69.7% were done more than 1 hour before appointment time, indicating that a personal device was used. When grouped by patient characteristics and controlling for all demographic factors, patients who were male, non-White, and older than 40 years; had lower family income; and had a high school education or less were significantly associated with later form completion. Of the 1136 patients for whom the authors had adequate waiting room time data, late form completion significantly increased odds of waiting more than 15 minutes to be placed into an examination room. These data indicate that the authors are reliably capturing important patient information before appointment time. This could improve clinical workflow and overall quality of care and also identify limits in access and online system use, providing opportunities to improve capture by developing targeted interventions for specific patient populations. [Orthopedics. 2021;44(3):e434-e439.].

Facilitators and barriers for implementing patient-reported outcome measures in clinical care: An academic center's initial experience

Objectives The aim of this study was to explore the perspectives of healthcare providers and researchers in a large academic hospital on facilitators and barriers for implementing patient-reported outcome measures (PROMs) in clinical care. Methods A customized web-based questionnaire was developed and disseminated to healthcare providers and researchers across multiple medical departments involved in a value-based health care initiative in the hospital. Questionnaire statements were rated using a 5-point Likert scale ranging from "strongly agree" to "strongly disagree". In addition, 8 open-ended questions were included allowing respondents to mention additional facilitators and barriers for implementing PROMs. Descriptive statistics were used to summarize the results. Results In total, 61 participants from both surgical and non-surgical departments completed the survey. Most respondents (51%) were medical specialists and the median employment duration was 14 years. Frequently reported facilitators were the presence of a PROM coordinator in the (outpatient) clinic (85%), the integration of PROMs in the electronic health record (81%), and the intrinsic motivation of members involved in the implementation (N=9 open responses). Commonly reported barriers were language barriers (76%), IT issues (N=17 open responses), and time constraints (N=14 open responses). Conclusions For the successful implementation of PROMs in clinical practice, it is imperative that healthcare organizations consider supporting motivated healthcare professionals, involving PROMs coordinators, and investing in an adequate IT infrastructure, and removal of language barriers.

Electronic forms for patient reported outcome measures (PROMs) are an effective, time-efficient, and cost-minimizing alternative to paper forms

BACKGROUND

Patient reported outcome measures (PROMs) provide valuable insight on patients' well-being and facilitates communication between healthcare providers and their patients. The increased integration of the technology within the healthcare setting presents the opportunity to collect PROMs electronically, rather than on paper. The Childhood Health Assessment Questionnaire (CHAQ) and Quality of My Life (QoML) are common PROMs collected from pediatric rheumatology patients. The objectives of this study are to (a) determine the equivalence of the paper and electronic forms (e-form) of CHAQ and QoML questionnaires; (b) identify potential benefits and barriers associated with using an e-form to capture PROMs; and (c) gather feedback on user experience.

METHODS

Participants completed both a paper and an e-form of the questionnaires in a randomized order, following which they completed a feedback survey. Agreement of the scores between the forms were statistically analyzed using the intraclass correlation coefficient (ICC) (95 % Confidence Interval (CI)) and bias was assessed using a Bland-Altman plot. Completion and processing times of the forms were compared using mean and median measures. Quantitative analysis was performed to assess user experience ratings, while comments were qualitatively analyzed to identify important themes.

RESULTS

196 patients participated in this project. Scores on the forms had high ICC agreement > 0.9. New patients took longer than returning patients to complete the forms. Overall, the e-form was completed and processed in a shorter amount of time than the paper form. 83 % of survey respondents indicated that they either preferred the e-form or had no preference. Approximately 10 % of respondents suggested improvements to improve the user interface.

CONCLUSIONS

E-forms collect comparable information in an efficient manner to paper forms. Given that patients and caregivers indicated they preferred completing PROMs in this manner, we will implement their suggested changes and incorporate e-forms as standard practice for PROMs collection in our pediatric rheumatology clinic.

Age and Gender Confound PROMIS Scores in Spine Patients With Back and Neck Pain

STUDY DESIGN

This was a single-center retrospective review.

OBJECTIVES

To explore how age and gender affect PROMIS scores compared with traditional health-related quality of life (HRQL) in spine patients.

METHODS

Patients presenting with a primary complaint of back pain (BP) or neck pain (NP) were included. Legacy HRQLs were Oswestry Disability Index (ODI), Neck Disability Index (NDI), and Visual Analogue Scale (VAS). PROMIS Physical Function (PF), Pain Intensity (Int), and Pain Interference (Inf) were also administered to patients in a clinical setting. Patients were grouped by chief complaint, age (18-44, 45-64, 65+ years) and gender. Two parallel analyses were conducted to identify the effects of age and gender on patient-reported outcomes. Age groups were compared after propensity-score matching by VAS-pain and gender. Separately, genders were compared after propensity-score matching by age and VAS-pain.

RESULTS

A total of 484 BP and 128 NP patients were matched into gender cohorts (n = 201 in each BP group, 46 in each NP group). Among BP patients, female patients demonstrated worse disability by ODI (44.15 vs 38.45, P = .005); PROMIS-PF did not differ by gender. Among NP patients, neither legacy HRQLs nor PROMIS differed by gender when controlling for NP and age. BP and NP patients were matched into age cohorts (n = 135 in each BP group and n = 14 in each BP group). Among BP patients, ANOVA revealed differences between groups when controlling for BP and gender: ODI (P < .001), PROMIS-PF (P = .018), PROMIS-Int (P < .001) PROMIS-Inf (P < .001). Among NP patients, matched age groups differed significantly in terms of NDI (P = .032) and PROMIS-PF (P = .022) but not PROMIS-Int or PROMIS-Inf.

CONCLUSIONS

Age and gender confound traditional HRQLs as well as PROMIS domains. However, PROMIS offers age and gender-specific scores, which traditional HRQLs lack.

Patient-Reported Outcomes Measurement Information System Scores Are Inconsistently Correlated With Legacy Patient-Reported Outcome Measures in Shoulder Pathology: A Systematic Review

PURPOSE

To evaluate the current literature regarding Patient-Reported Outcomes Measurement Information System (PROMIS) and its correlation to legacy patient-reported outcomes measures (PROMs) in 5 domains: (1) rotator cuff disease, (2) shoulder instability, (3) shoulder arthroplasty, (4) proximal humerus fractures, and (5) glenohumeral arthritis. The secondary purpose is to evaluate the floor and ceiling effects, the number of questions, and time needed to complete PROMIS and legacy PROMs in shoulder care.

METHODS

A systematic review of the available literature on PROMIS scores in shoulder care was performed. This review was accomplished per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines.

RESULTS

A total of 11 studies that reported data on 1485 patients met inclusion criteria. There was a strong correlation between general function PROMs and the PROMIS PF for patients with rotator cuff disease, shoulder instability, shoulder arthroplasty, and proximal humerus fractures. In addition, there was a strong correlation between PROMIS UE and legacy PROMs in patients with rotator cuff injury and shoulder instability. PROMIS instruments asked fewer questions than legacy PROMs (9.46 vs 12.99, respectively), took less time to complete (88.21 vs 96.53 seconds, respectively), had less floor effects in both PROMIS PF and UE (0.17% and 0.62% vs 2.89%, respectively), and had lower ceiling effects for PROMIS PF but not PROMIS UE assessments (0.17% and 6.37% vs 1.89%, respectively).

CONCLUSIONS

This systematic review demonstrated PROMIS instruments have varying correlations with legacy PROMs measures for patients with rotator cuff disease, shoulder instability, shoulder arthroplasty, and glenohumeral arthritis. PROMIS instruments do measure clinical outcomes faster and with fewer questions. Other than PROMIS UE v1.2 ceiling effects, PROMIS instruments have lower rates of floor and ceiling effects.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II-IV studies.

The Acceptability and Efficacy of Electronic Data Collection in a Hospital Neurodevelopmental Clinic: Pilot Questionnaire Study

Background

There is a growing need for cost-efficient and patient-centered approaches to support families in hospital- and community-based neurodevelopmental services. For such purposes, electronic data collection (EDC) may hold advantages over paper-based data collection. Such EDC approaches enable automated data collection for scoring and interpretation, saving time for clinicians and services and promoting more efficient service delivery.

Objective

This pilot study evaluated the efficacy of EDC for the Child Development Unit, a hospital-based diagnostic assessment clinic in the Sydney Children’s Hospital Network. Caregiver response rates and preference for EDC or paper-based methods were evaluated as well as the moderating role of demographic characteristics such as age, level of education, and ethnic background.

Methods

Families were sent either a paper-based questionnaire via post or an electronic mail link for completion before attending their first on-site clinic appointment for assessment. A total of 62 families were provided a paper version of the questionnaire, while 184 families were provided the online version of the same questionnaire.

Results

Completion rates of the questionnaire before the first appointment were significantly higher for EDC (164/184, 89.1%) in comparison to paper-based methods (24/62, 39%; P<.001). Within the EDC group, a vast majority of respondents indicated a preference for completing the questionnaire online (151/173, 87.3%), compared to paper completion (22/173, 12.7%; P<.001). Of the caregiver demographic characteristics, only the respondent’s level of education was associated with modality preference, such that those with a higher level of education reported a greater preference for EDC (P=.04).

Conclusions

These results show that EDC is feasible in hospital-based clinics and has the potential to offer substantial benefits in terms of centralized data collation, time and cost savings, efficiency of service, and resource allocation. The results of this study therefore support the continued use of electronic methods to improve family-centered care in clinical practices.

Validity of five foot and ankle specific electronic patient-reported outcome (ePRO) instruments in patients undergoing elective orthopedic foot or ankle surgery

BACKGROUND

Patient-reported outcomes (PROs) are widely accepted measures for evaluating outcomes of surgical interventions. As patient-reported information is stored in electronic health records, it is essential that there are valid electronic PRO (ePRO) instruments available for clinicians and researchers. The aim of this study was to evaluate the validity of electronic versions of five widely used foot and ankle specific PRO instruments.

METHODS

Altogether 111 consecutive elective foot/ankle surgery patients were invited face-to-face to participate in this study. Patients completed electronic versions of the Foot and Ankle Ability Measure (FAAM), the Foot and Ankle Outcome Score (FAOS), the modified Lower Extremity Function Scale (LEFS), the Manchester-Oxford Foot Questionnaire (MOXFQ), and the Visual Analogue Scale Foot and Ankle (VAS-FA) on the day of elective foot and/or ankle surgery. Construct validity, coverage, and targeting of the scales were assessed.

RESULTS

Based on general and predefined thresholds, construct validity, coverage, and targeting of the ePRO versions of the FAAM, the FAOS, the MOXFQ, and the VAS-FA were acceptable. Major issues arose with score distribution and convergent validity of the modified LEFS instrument.

CONCLUSIONS

The ePRO versions of the FAAM, the FAOS, the MOXFQ, and the VAS-FA provide valid scores for foot and ankle patients. However, our findings do not support the use of the modified LEFS as an electronic outcome measure for patients with orthopedic foot and/or ankle pathologies.