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Kim M, Vingan P, Boe LA, Tadros AB, Nelson JA, Stern CS. Nonresponse data in sexual well-being among breast reconstruction patients-who are we overlooking? J Surg Oncol 2024; 129:1192-1201. [PMID: 38583135 DOI: 10.1002/jso.27639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 02/17/2024] [Indexed: 04/08/2024]
Abstract
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.
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Affiliation(s)
- Minji Kim
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Perri Vingan
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lillian A Boe
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Audree B Tadros
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jonas A Nelson
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Carrie S Stern
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Ruff GL, Thomas J, Ashkenazi I, Grossman EL, Davidovitch RI, Schwarzkopf R. How Has the Total Hip Arthroplasty Patient Population Changed? A Ten-Year Analysis of Total Hip Arthroplasty Patients From 2013 to 2022: A Retrospective, Single-Center Study. J Arthroplasty 2024:S0883-5403(24)00553-9. [PMID: 38830434 DOI: 10.1016/j.arth.2024.05.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 05/25/2024] [Accepted: 05/27/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Over the past decades, utilization of total hip arthroplasty (THA) has steadily increased. Understanding the demographic trends of THA patients can assist in projecting access to care. This study sought to assess the temporal trends in THA patient baseline characteristics and socioeconomic factors. METHODS We retrospectively analyzed 16,296 patients who underwent primary elective THA from January 1, 2013, to December 31, 2022. Demographic data, including age, sex, race, body mass index (BMI), Charlson comorbidity index, insurance, and socioeconomic status, as determined by median income by patients' zip code, were collected. The trends of these data were analyzed using the Mann-Kendall test. RESULTS Over the past decade at our institution, patient age (2013: 62.1 years to 2022: 65.1 years, P = .001), BMI (2013: 29.0 to 2022: 29.5, P = .020), and mean Charlson comorbidity index (2013: 2.4 to 2022: 3.1, P = .001) increased. The proportion of Medicare patients increased from 48.4% in 2013 to 54.9% in 2022 (P = .001). The proportion of African American patients among the THA population increased from 11.3% in 2013 to 13.0% in 2022 (P = .012). Over this period, 90-day readmission and 1-year revision rates did not significantly change (2013: 4.8 and 3.0% to 2022: 3.4 and 1.4%, P = .107 and P = .136, respectively). The proportion of operations using robotic devices also significantly increased (2013: 0% to 2022: 19.1%; P < .001). CONCLUSIONS In the past decade, the average age, BMI, and comorbidity burden of THA patients have significantly increased, suggesting improved access to care for these populations. Similarly, there have been improvements in access to care for African American patients. Along with these changes in patient demographics, we found no change in 90-day readmission or 1-year revision rates. Continued characterization of the THA patient population is vital to understanding this demographic shift and educating future strategies and improvements in patient care.
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Affiliation(s)
- Garrett L Ruff
- Department of Orthopaedic Surgery, NYU Langone Health, New-York, New York
| | - Jeremiah Thomas
- Department of Orthopaedic Surgery, NYU Langone Health, New-York, New York
| | - Itay Ashkenazi
- Department of Orthopaedic Surgery, NYU Langone Health, New-York, New York; Division of Orthopaedic Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Eric L Grossman
- Department of Orthopaedic Surgery, NYU Langone Health, New-York, New York
| | - Roy I Davidovitch
- Department of Orthopaedic Surgery, NYU Langone Health, New-York, New York
| | - Ran Schwarzkopf
- Department of Orthopaedic Surgery, NYU Langone Health, New-York, New York
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3
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Boddu SP, Gill VS, Haglin JM, Brinkman JC, Deckey DG, Bingham JS. Lower Income and Nonheterosexual Orientation Are Associated With Poor Access to Care in Patients With Knee Osteoarthritis. Arthroplast Today 2024; 27:101353. [PMID: 38774403 PMCID: PMC11106826 DOI: 10.1016/j.artd.2024.101353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/20/2024] [Accepted: 02/14/2024] [Indexed: 05/24/2024] Open
Abstract
Background Social determinants of health are implicated in the experience of knee osteoarthritis, a key component of which is access to care and healthcare utilization. The objective of this study was to describe difficulties in access to care and healthcare utilization in the United States knee osteoarthritis population. Methods The publicly available All of Us Database was utilized to conduct a retrospective cohort study. Patients with a diagnosis of knee osteoarthritis were included and matched to a control group who did not have knee osteoarthritis. The association of knee osteoarthritis and patient-specific demographic features with self-reported domains of access to care was analyzed. Results Among 15,718 patients with knee osteoarthritis, 27.6% reported delayed care (n = 4343), 25.6% reported inability to afford care (n = 4015), 12.8% reported skipped medications (n = 2011), and 1.6% reported not seeing a healthcare provider in over 1 year (n = 247). Patients with knee osteoarthritis were more likely to be unable to afford care (odds ratio 1.21, P < .001) or skip medications (odds ratio 1.12, P = .004) in comparison to matched patients without knee osteoarthritis. Among the knee osteoarthritis cohort, low income and nonheterosexual orientation were both associated with increased rates of delayed care and an inability to afford care. Conclusions Patients with knee osteoarthritis report significant challenges with delayed care, affordability of care, and medication adherence. Among patients with knee osteoarthritis, patients who are younger age, female sex, low-income, low-education, nonheterosexual orientation, or have poor physical and mental health are at increased risk of having decreased access to treatment.
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Affiliation(s)
- Sayi P. Boddu
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
| | - Vikram S. Gill
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
| | - Jack M. Haglin
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | | | - David G. Deckey
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
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Ong CB, Buchan GBJ, Hecht CJ, Liu D, Petterwood J, Kamath AF. Use of a fluoroscopy-based robotic-assisted total hip arthroplasty system resulted in greater improvements in hip-specific outcome measures at one-year compared to a CT-based robotic-assisted system. Int J Med Robot 2024; 20:e2650. [PMID: 38856120 DOI: 10.1002/rcs.2650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 05/19/2024] [Accepted: 05/28/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND The purpose of this study was to compare one-year patient reported outcome measures between a novel fluoroscopy-based robotic-assisted (FL-RTHA) system and an existing computerised tomography-based robotic assisted (CT-RTHA) system. METHODS A review of 85 consecutive FL-RTHA and 125 consecutive CT-RTHA was conducted. Outcomes included one-year post-operative Veterans RAND-12 (VR-12) Physical (PCS)/Mental (MCS), Hip Disability and Osteoarthritis Outcome (HOOS) Pain/Physical Function (PS)/Joint replacement, and University of California Los Angeles (UCLA) Activity scores. RESULTS The FL-RTHA cohort had lower pre-operative VR-12 PCS, HOOS Pain, HOOS-PS, HOOS-JR, and UCLA Activity scores compared with patients in the CT-RTHA cohort. The FL-RTHA cohort reported greater improvements in HOOS-PS scores (-41.54 vs. -36.55; p = 0.028) than the CT-RTHA cohort. Both cohorts experienced similar rates of major post-operative complications, and had similar radiographic outcomes. CONCLUSIONS Use of the fluoroscopy-based robotic system resulted in greater improvements in HOOS-PS in one-year relative to the CT-based robotic technique.
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Affiliation(s)
- Christian B Ong
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Graham B J Buchan
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Christian J Hecht
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - David Liu
- Gold Coast Centre for Bone and Joint Surgery, Palm Beach, Queensland, Australia
| | - Joshua Petterwood
- Department of Orthopaedics, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Atul F Kamath
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Issa TZ, Lee Y, Mazmudar AS, Lambrechts MJ, Sellig M, Hilibrand AS, Vaccaro AR, Schroeder GD, Kepler CK. Readability of Patient-Reported Outcomes in Spine Surgery and Implications for Health Literacy. Spine (Phila Pa 1976) 2024; 49:811-817. [PMID: 37368975 DOI: 10.1097/brs.0000000000004761] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023]
Abstract
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.
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Affiliation(s)
- Tariq Z Issa
- Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Yunsoo Lee
- Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Aditya S Mazmudar
- Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Mark J Lambrechts
- Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Mason Sellig
- College of Medicine, Drexel University, Philadelphia, PA
| | - Alan S Hilibrand
- Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Alexander R Vaccaro
- Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Gregory D Schroeder
- Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Christopher K Kepler
- Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
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Tong Y, Rajahraman V, Gupta R, Schwarzkopf R, Rozell JC. Patient Demographic Factors Impact KOOS JR Response Rates for Total Knee Arthroplasty Patients. J Knee Surg 2024. [PMID: 38776975 DOI: 10.1055/s-0044-1787055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
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.
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Affiliation(s)
- Yixuan Tong
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Vinaya Rajahraman
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Rajan Gupta
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Joshua C Rozell
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
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Deans CF, Abdeen AR, Ricciardi BF, Deen JT, Schabel KL, Sterling RS. New CMS Merit-Based Incentive Payment System Value Pathway After Total Knee and Hip Arthroplasty: Preparing for Mandatory Reporting. J Arthroplasty 2024; 39:1131-1135. [PMID: 38278186 DOI: 10.1016/j.arth.2024.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 12/30/2023] [Accepted: 01/13/2024] [Indexed: 01/28/2024] Open
Abstract
This article discusses the implementation of a new Merit-Based Incentive Payment System Value Pathway (MVPs) applicable to elective total hip and total knee arthroplasty as created by Medicare and Medicaid Services (CMS) - the Improving Care for Lower Extremity Joint Repair MVP (MVP ID: G0058). We describe specific quality measures, surgeon-hospital collaborations, future developments with Quality Payment Program, and how lessons from early implementation will empower clinicians to participate in the refining of this MVP. The CMS has designed MVPs as a subset of measures relevant to a specialty or medical condition, in an effort to reduce the burden of reporting and improve assessment of care quality. Physicians and payors must be mindful of detrimental effects these measures in their current form may have on surgeons, institutions, and patients, including disincentivizing care for sicker or more vulnerable populations, and increased administrative costs. Early voluntary participation is crucial to gain valuable experience for the orthopedic community and in an effort to work alongside CMS to maximize care while minimizing cost for patients and burden for providers.
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Affiliation(s)
- Christopher F Deans
- Department of Orthopaedic Surgery & Rehabilitation, University of Nebraska Medical Center, Omaha, Nebraska; American Association of Hip and Knee Surgeons Health Policy Fellowship Program, Rosemont, Illinois
| | - Ayesha R Abdeen
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, Massachusetts
| | - Benjamin F Ricciardi
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York
| | | | - Kathryn L Schabel
- Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, Portland, Oregon
| | - Robert S Sterling
- Department of Orthopaedic Surgery, George Washington University, Washington, District of Columbia
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Ashkenazi I, Lawrence KW, Kaplan M, Arshi A, Rozell JC, Schwarzkopf R, Lajam CM. Demographic and Socioeconomic Trends of Patients Undergoing Total Knee Arthroplasty From 2013 to 2022-An Analysis From an Urban Orthopaedic Hospital. J Arthroplasty 2024:S0883-5403(24)00340-1. [PMID: 38614359 DOI: 10.1016/j.arth.2024.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 04/08/2024] [Accepted: 04/08/2024] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND As worldwide utilization of total knee arthroplasty (TKA) broadens, demographic trends can help make projections to inform access to care. This study aimed to assess the temporal trends in the socioeconomic and medical demographics of patients undergoing TKA. METHODS A retrospective review of 15,848 patients who underwent primary, elective TKA at an urban, New York City-based academic medical center between January 2013 and September 2022 was performed. Trends in patients' age, body mass index (BMI), socioeconomic status (SES) (based on median income by patients' ZIP code), race, and Charlson comorbidity index were evaluated using the Mann-Kendall test. RESULTS In the last decade, mean patient age (65 to 68 years, P < .001) and Charlson comorbidity index (1.4 to 2.3, P < .001) increased significantly. The proportion of patients who had a BMI ≥ 30 and < 40 increased (43.8 to 51.2%, P = .002), while the proportion of patients who had a BMI ≥ 40 (13.7 to 12.1%, P = .015) and BMI < 30 (42.5 to 36.8%, P = .020) decreased. The distribution of patients' race and SES did not change from 2013 to 2022; Black (18.1 to 16.8%, P = .211) and low SES (12.9 to 11.3%, P = .283) patients consistently represented a minority of TKA patients. CONCLUSIONS Over the last decade, the average age and comorbidity burden of TKA patients at our institution have increased. This portends the need for higher levels of preoperative optimization and postoperative management for TKA patients. A decreased prevalence of BMI ≥40 could reflect optimization efforts. However, the consistently low prevalence of Black and low-SES patients suggests that recent payment models did not improve access to care for these populations. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Itay Ashkenazi
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York; Division of Orthopaedic Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Kyle W Lawrence
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York
| | - Mitchell Kaplan
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York
| | - Armin Arshi
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York
| | - Joshua C Rozell
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York
| | - Ran Schwarzkopf
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York
| | - Claudette M Lajam
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York
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Busigo Torres R, Yendluri A, Stern BZ, Rajjoub R, Restrepo Mejia M, Willson G, Chen DD, Moucha CS, Hayden BL, Poeran J. Is Limited English Proficiency Associated With Differences in Care Processes and Treatment Outcomes in Patients Undergoing Orthopaedic Surgery? A Systematic Review. Clin Orthop Relat Res 2024:00003086-990000000-01563. [PMID: 39031039 DOI: 10.1097/corr.0000000000003034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 02/16/2024] [Indexed: 07/22/2024]
Abstract
BACKGROUND Approximately 25 million people in the United States have limited English proficiency. Current developments in orthopaedic surgery, such as the expansion of preoperative education classes or patient-reported outcome collection in response to bundled payment models, may exacerbate language-related barriers. Currently, there are mixed findings of the associations between limited English proficiency and care processes and outcomes, warranting a cross-study synthesis to identify patterns of associations. QUESTIONS/PURPOSES In this systematic review, we asked: Is limited English proficiency associated with (1) differences in clinical care processes, (2) differences in care processes related to patient engagement, and (3) poorer treatment outcomes in patients undergoing orthopaedic surgery in English-speaking countries? METHODS On June 9, 2023, a systematic search of four databases from inception through the search date (PubMed, Ovid Embase, Web of Science, and Scopus) was performed by a medical librarian. Potentially eligible articles were observational studies that examined the association between limited English proficiency and the prespecified categories of outcomes among pediatric and adult patients undergoing orthopaedic surgery or receiving care in an orthopaedic surgery setting. We identified 10,563 records, of which we screened 6966 titles and abstracts after removing duplicates. We reviewed 56 full-text articles and included 29 peer-reviewed studies (outcome categories: eight for clinical care processes, 10 for care processes related to patient engagement, and 15 for treatment outcomes), with a total of 362,746 patients or encounters. We extracted data elements including study characteristics, definition of language exposure, specific outcomes, and study results. The quality of each study was evaluated using adapted Newcastle-Ottawa scales for cohort or cross-sectional studies. Most studies had a low (48%) or moderate (45%) risk of bias, but two cross-sectional studies had a high risk of bias. To answer our questions, we synthesized associations and no-difference findings, further stratified by adjusted versus unadjusted estimates, for each category of outcomes. No meta-analysis was performed. RESULTS There were mixed findings regarding whether limited English proficiency is associated with differences in clinical care processes, with the strongest adjusted associations between non-English versus English as the preferred language and delayed ACL reconstruction surgery and receipt of neuraxial versus general anesthesia for other non-Spanish versus English primary language in patients undergoing THA or TKA. Limited English proficiency was also associated with increased hospitalization costs for THA or TKA but not opioid prescribing in pediatric patients undergoing surgery for fractures. For care processes related to patient engagement, limited English proficiency was consistently associated with decreased patient portal use and decreased completion of patient-reported outcome measures per adjusted estimates. The exposure was also associated with decreased virtual visit completion for other non-Spanish versus English language and decreased postoperative opioid refill requests after TKA but not differences in attendance-related outcomes. For treatment outcomes, limited English proficiency was consistently associated with increased hospital length of stay and nonhome discharge per adjusted estimates, but not hospital returns. There were mixed findings regarding associations with increased complications and worse postoperative patient-reported outcome measure scores. CONCLUSION Findings specifically suggest the need to remove language-based barriers for patients to engage in care, including for patient portal use and patient-reported outcome measure completion, and to identify mechanisms and solutions for increased postoperative healthcare use. However, interpretations are limited by the heterogeneity of study parameters, including the language exposure. Future research should include more-precise and transparent definitions of limited English proficiency and contextual details on available language-based resources to support quantitative syntheses. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Rodnell Busigo Torres
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Avanish Yendluri
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brocha Z Stern
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rami Rajjoub
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mateo Restrepo Mejia
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gloria Willson
- Levy Library, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Darwin D Chen
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Calin S Moucha
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brett L Hayden
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jashvant Poeran
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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10
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Baxter SN, Brennan JC, Johnson AH, Chapa L, Robbins S, Turcotte JJ, King PJ. Non-White Race and Concomitant Orthopedic Conditions Are Risk Factors for Failure to Achieve Clinically Relevant Improvement After Total Knee Arthroplasty. J Arthroplasty 2024; 39:927-934. [PMID: 37852453 DOI: 10.1016/j.arth.2023.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 09/26/2023] [Accepted: 10/02/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Data from the American Joint Replacement Registry demonstrate that 1-year minimal clinically important difference (MCID) achievement rates after total knee arthroplasty (TKA) are substantially lower when using general patient reported outcome measures, such as Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), than joint specific measures. The purpose of this study was to evaluate patient characteristics and outcomes associated with MCID achievement after TKA using the PROMIS-PF measure. METHODS A retrospective review of 263 patients undergoing TKA with preoperative and 1-year postoperative PROMIS-PF scores from March 12, 2020 to February 8, 2022 was performed. Three multivariate models were built to evaluate predictors of MCID achievement. Preoperative predictors evaluated included demographics, comorbidities, history of spine and knee surgery, and baseline PROMIS-PF. Postoperative clinical outcomes evaluated included lengths of stay, discharge statuses, complications, and utilizations of other orthopaedic services. RESULTS There were 109 patients (41%) who achieved an MCID at 1-year postoperatively. Non-white patients had 2.17 times lower odds of achieving MCID. No clinical outcomes assessed were independently predictive of MCID achievement. During the 1-year postoperative period, 63% of patients sought care for another orthopaedic condition. Patients requiring postoperative injections on another joint had a 2.27 times lower odds of achieving MCID. Those seen for spine conditions postoperatively had a 2.44 lower odds of achieving MCID. CONCLUSIONS Race, postoperative injections, and treatment for spine conditions after TKA were independent predictors of failure to achieve MCID. These results may guide preoperative patient consultation and risk-adjustment in future studies using PROMIS-PF as an endpoint for evaluation of TKA outcomes.
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Affiliation(s)
- Samantha N Baxter
- Luminis Health Orthopedics, Anne Arundel Medical Center, Annapolis, Maryland
| | - Jane C Brennan
- Luminis Health Orthopedics, Anne Arundel Medical Center, Annapolis, Maryland
| | - Andrea H Johnson
- Luminis Health Orthopedics, Anne Arundel Medical Center, Annapolis, Maryland
| | - Lauren Chapa
- Luminis Health Orthopedics, Anne Arundel Medical Center, Annapolis, Maryland
| | - Shayla Robbins
- Luminis Health Orthopedics, Anne Arundel Medical Center, Annapolis, Maryland
| | - Justin J Turcotte
- Luminis Health Orthopedics, Anne Arundel Medical Center, Annapolis, Maryland
| | - Paul J King
- Luminis Health Orthopedics, Anne Arundel Medical Center, Annapolis, Maryland
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11
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Tang E, Yantsis A, Ho M, Hussain J, Dano S, Aiyegbusi OL, Peipert JD, Mucsi I. Patient-Reported Outcome Measures for Patients With CKD: The Case for Patient-Reported Outcomes Measurement Information System (PROMIS) Tools. Am J Kidney Dis 2024; 83:508-518. [PMID: 37924931 DOI: 10.1053/j.ajkd.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 08/30/2023] [Accepted: 09/04/2023] [Indexed: 11/06/2023]
Abstract
Chronic kidney disease (CKD), kidney failure, and kidney replacement therapies are associated with high symptom burden and impaired health-related quality of life (HRQOL). Symptoms change with disease progression or transition between treatment modalities and frequently go unreported and unmanaged. Tools that reliably monitor symptoms may improve the management of patients with CKD. Patient-reported outcome measures (PROMs) assess symptom severity; physical, psychological, social, and cognitive functioning; treatment-related side effects; and HRQOL. Systematic use of PROMs can improve patient-provider communication, patient satisfaction, clinical outcomes, and HRQOL. Potential barriers to their use include a lack of engagement, response burden, and limited guidance about PROM collection, score interpretation, and workflow integration. Well-defined, acceptable, and effective clinical response pathways are essential for implementing PROMs. PROMs developed by the Patient-Reported Outcomes Measurement Information System (PROMIS) address some challenges and may be suitable for clinical use among patients with CKD. PROMIS tools assess multiple patient-valued, clinically actionable symptoms and functions. They can be administered as fixed-length, customized short forms or computer adaptive tests, offering precise measurement across a range of symptom severities or function levels, tailored questions to individuals, and reduced question burden. Here we provide an overview of the potential use of PROMs in CKD care, with a focus on PROMIS.
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Affiliation(s)
- Evan Tang
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Alyssa Yantsis
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Matthew Ho
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Junayd Hussain
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Sumaya Dano
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Olalekan L Aiyegbusi
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham (OLA), Birmingham, United Kingdom; National Institute for Health Research Applied Research Centre West Midlands, Birmingham, United Kingdom
| | - John D Peipert
- Department of Medical Social Sciences, Northwestern University, Chicago, Illinois
| | - Istvan Mucsi
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada.
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12
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Shapiro LM, Katz P, Stern BZ, Kamal RN. Equitable Integration of Patient-Reported Outcomes Into Clinical Practice-Opportunities, Challenges, and a Roadmap for Implementation. J Am Acad Orthop Surg 2024; 32:187-195. [PMID: 38194644 DOI: 10.5435/jaaos-d-23-00798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 11/08/2023] [Indexed: 01/11/2024] Open
Abstract
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.
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Affiliation(s)
- Lauren M Shapiro
- From the Department of Orthopaedic Surgery, University of California-San Francisco, San Francisco, CA (Shapiro), the Department of Medicine, University of California-San Francisco, San Francisco CA (Katz), the Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine, New York, NY (Stern), the VOICES Health Policy Research Center, and Department of Orthopaedic Surgery, Stanford University, Redwood City, CA (Kamal)
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13
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Youssef M, Rubens M, Sedarous M, Babajide O, Adekunle D, Mahmud M, Roque MV, Okafor PN. The Impact of Patients' Primary Language on Inpatient Gastrointestinal Bleeding Outcomes. Am J Gastroenterol 2024; 119:556-564. [PMID: 37787427 DOI: 10.14309/ajg.0000000000002545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 09/22/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND The impact of English proficiency on gastrointestinal bleeding (GIB) outcomes remains unclear. In this analysis, we compare inpatient GIB outcomes between patients with English as their primary language (EPL) and those with a primary language other than English (PLOE). METHODS Using the 2019 State Inpatient Databases for New Jersey, Maryland, and Michigan, we created an analysis cohort of GIB hospitalizations using International Classification of Diseases, 10th Revision codes. Patients were stratified by primary language (EPL vs PLOE) and type of bleeding (variceal upper GI bleeding [VUGIB], nonvariceal upper GI bleeding [NVUGIB], and lower GI bleeding (LGIB)]. Regression analyses were used to compare mortality, 30-day readmissions, and length of stay. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were reported. P < 0.05 was considered statistically significant. RESULTS In the cohort, 5.5%-10% of the patients spoke a primary language other than English. Endoscopy utilization was lower among patients with PLOE vs EPL for NVUGIB (17.2% vs 21.2%, P < 0.001) and LGIB (26.3% vs 29.2%, P = 0.027). Patients with PLOE had higher odds of dying of VUGIB (aOR 1.45, 95% CI 1.16-2.48) and LGIB (aOR 1.71, 95% CI 1.22-2.12). Patients with PLOE were also more likely to be readmitted after NVUGIB (aOR 1.75, 95% CI 1.64-1.81). However, after controlling for the percentage of patients with PLOE discharged from each hospital, the disparities in mortality and readmissions were no longer detected. DISCUSSION Disparities exist in GIB outcomes among patients with PLOE, but these gaps narrow at hospitals with higher percentages of patients with PLOE. Cultural and linguistic competence may improve outcomes in this vulnerable group.
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Affiliation(s)
- Michael Youssef
- Division of Internal Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Muni Rubens
- Office of Clinical Research, Baptist Health South Florida, Miami, Florida, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
- Research Department, Universidad Espíritu Santo, Samborondon, Ecuador
| | - Mary Sedarous
- Division of Gastroenterology, Kingston Health Sciences Centre, Queen's University, Kingston General Hospital, Kingston, Ontario, Canada
| | - Oyedotun Babajide
- Department of Gastroenterology and Hepatology, New York City Health and Hospitals Metropolitan/New York Medical College, New York, New York, USA
| | - Deborah Adekunle
- Division of Internal Medicine, St. Luke's Hospital, Chesterfield, Missouri, USA
| | - Muftah Mahmud
- Division of Internal Medicine, Midwestern University, Verde Valley Internal Medicine Program, Cottonwood, Arizona, USA
| | - Maria Vazquez Roque
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Philip N Okafor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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Issa TZ, Lee Y, Toci GR, Lambrechts MJ, Kalra A, Pipa D, Canseco JA, Hilibrand AS, Vaccaro AR, Schroeder GD, Kepler CK. The role of socioeconomic factors as barriers to patient reported outcome measure completion following lumbar spine fusion. Spine J 2023; 23:1531-1539. [PMID: 37209966 DOI: 10.1016/j.spinee.2023.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/19/2023] [Accepted: 05/02/2023] [Indexed: 05/22/2023]
Abstract
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.
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Affiliation(s)
- Tariq Z Issa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA; Feinberg School of Medicine, Northwestern University, 420 E Superior St, Chicago, IL 60611, USA.
| | - Yunsoo Lee
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Gregory R Toci
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Mark J Lambrechts
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Andrew Kalra
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - David Pipa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
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