Routine Collection of Patient Reported Outcomes in Thoracic Surgery: A Quality Improvement Study

Acceptability, Perceptions, and Experiences Regarding Electronic Patient-Reported Outcomes After Laparoscopic Cholecystectomy: Protocol for a Mixed Methods Feasibility Study

BACKGROUND

Patient-reported outcomes (PROs) can be defined as any report of a patient's health taken directly from the patient. Routine collection of PRO data has been shown to offer potential benefits to patient-doctor communication. Electronic forms of PRO measures (PROMs) could be more beneficial in comparison to traditional PROMs in obtaining PROs from patients. However, it is currently unclear whether the routine collection of electronic PRO data could result in better outcomes for patients undergoing laparoscopic cholecystectomy (LC).

OBJECTIVE

This study aims to explore the perspectives of patients and surgeons on the use of electronic PROMs. Based on prior research, technical skill and experience level of the surgeon, long-term quality of life, patient involvement in decision-making, communication skills of the surgeon, cleanliness of the ward environment, and standards of nursing care are identified to be the most important factors for the patients.

METHODS

This is a mixed methods prospective study that will collect both quantitative (survey) and qualitative (interview) data. The study has two components. The first involves the distribution of an electronic presurvey to patients who received elective LC within 48 hours of their surgery (n=80). This survey will explore the perspective of patients regarding the procedure, hospital experience, long-term outcomes, and the perceived value of using PROMs. These patients will then be followed up after 1 year and given another survey. The second component involves the distribution of the same survey and the completion of structured interviews with general surgeons (n=10). The survey will ascertain what PROs from the participants are most useful for the surgeons and the interviews will focus on how the surgeons view routine PRO collection. A convenience sampling approach will be used. Surveys will be distributed through Qualtrics and interviews will be completed on Microsoft Teams.

RESULTS

Data collection began on February 14, 2023. As of February 12, 2024, 71 of 80 recruited patients have been given the presurvey. The follow-up with the patients and the general surgeon components of the study have not begun. The expected completion date of this study is in April 2025.

CONCLUSIONS

Overall, this study will investigate the potential of electronic PRO collection to offer value for patients and general surgeons. This approach will ensure that patient care is investigated in a multifaceted way, offering patient-centric guidance to surgeons in their approach to care.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/57344.

Patient factors related to patient engagement technology (PET) usage in thoracic surgery

BACKGROUND

We evaluated using Patient Engagement Technology (PET) to capture Patient Reported Outcomes (PROs) in thoracic surgery patients. METHODSY: atients using a PET received surveys including the Patient-Reported Outcomes Measurement Information System Global-10 (PROMIS-10) and a health literacy (HL) screen. The relationship of patient-level factors with survey completion was assessed through univariate and logistic regression analyses.

RESULTS

703 patients enrolled in a PET. 52 ​% were female and 83 ​% were white with a median age of 63.72 ​% had adequate HL. 81 ​% completed the PROMIS-10 survey. Univariate analysis found lower rates of PROMIS-10 completion in male patients and those with inadequate HL. Logistic regression analysis showed adequate HL (OR 1.76) and white race (OR 1.72) were associated with PROMIS-10 survey completion, while male gender (OR 0.65) had the opposite effect.

CONCLUSIONS

PETs are an effective means of collecting PROs, but use is affected by gender, race, and health literacy.

Feasibility of PROMIS using computerized adaptive testing during inpatient rehabilitation

BACKGROUND

There has been an increased significance on patient-reported outcomes in clinical settings. We aimed to evaluate the feasibility of administering patient-reported outcome measures by computerized adaptive testing (CAT) using a tablet computer with rehabilitation inpatients, assess workload demands on staff, and estimate the extent to which rehabilitation inpatients have elevated T-scores on six Patient Reported Outcomes Measurement Information System® (PROMIS®) measures.

METHODS

Patients (N = 108) with stroke, spinal cord injury, traumatic brain injury, and other neurological disorders participated in this study. PROMIS computerized adaptive tests (CAT) were administered via a web-based platform. Summary scores were calculated for six measures: Pain Interference, Sleep Disruption, Anxiety, Depression, Illness Impact Positive, and Illness Impact Negative. We calculated the percent of patients with T-scores equivalent to 2 standard deviations or greater above the mean.

RESULTS

During the first phase, we collected data from 19 of 49 patients; of the remainder, 61% were not available or had cognitive or expressive language impairments. In the second phase of the study, 40 of 59 patients participated to complete the assessment. The mean PROMIS T-scores were in the low 50 s, indicating an average symptom level, but 19-31% of patients had elevated T-scores where the patients needed clinical action.

CONCLUSIONS

The study demonstrated that PROMIS assessment using a CAT administration during an inpatient rehabilitation setting is feasible with the presence of a research staff member to complete PROMIS assessment.

Routine Implementation of Patient-Reported Outcomes Assessment Into Thoracic Surgery Practice

BACKGROUND

Patient-reported outcomes (PROs) assessment is a necessary component of surgical outcome assessment and patient care. This study examined the success of routine PROs assessment in an academic-based thoracic surgery practice.

METHODS

PROs, measuring pain intensity, physical function, and dyspnea, were routinely obtained using the National Institutes of Health-sponsored Patient-Reported Outcomes Measurement Information System (PROMIS) on all thoracic surgery patients beginning in April 2018 through January 2021. Questionnaires were administered electronically through a web-based platform at home or during the office visit. Completion rates and barriers were measured.

RESULTS

A total of 9725 thoracic surgery office visits occurred during this time frame. PROs data were obtained in 6899 visits from a total of 3551 patients. The mean number of questions answered per survey was 22.4 ± 2.2. Overall questionnaire completion rate was 65.7%. A significant decline in survey completion was noted in April 2020, after which adjustments were made to allow for questionnaire completion through a mobile health platform. Overall monthly questionnaire completion rates ranged from 20% (April 2020) to 90% (October 2018). Mean T scores were dyspnea, 41.6 ± 12.3; physical function, 42.7 ± 10.5; and pain intensity, 52.8 ± 10.3.

CONCLUSIONS

PROs can be assessed effectively in a thoracic surgery clinic setting, with minimal disruption of clinical activities. Future efforts should focus on facilitating PROs collection from disadvantaged patient populations and scaling implementation across programs.

Feasibility of collecting computer-facilitated patient-reported tobacco use, interest, and preferences for smoking cessation in an outpatient thoracic surgery and oncology setting

INTRODUCTION

Effective strategies are needed to facilitate collection of tobacco use information and integrate smoking cessation treatment into the routine care of all high-risk patient populations to improve clinical outcomes. The objective of this study was to establish the feasibility of collecting computer-facilitated patient-reported tobacco use, identify patient interest and preferences for smoking cessation in an outpatient thoracic surgery and oncology setting with higher prevalence of tobacco use than the general population.

METHODS

A brief patient-administered tobacco screening survey was handed out on an iPad in the waiting room of a thoracic surgery and oncology practice setting to sequential patients with varying diagnoses. Tobacco use, household exposure to tobacco, and interest and preferences for smoking cessation treatment were recorded. Descriptive statistics and Pearson’s chi-squared test were used for analysis.

RESULTS

Of the 599 surveys administered, 594 (99%) were completed. Self-reported smoking status included 36.4% (n=218) never smokers, 53.3% (n=319) former smokers, and 10.4% (n=62) current smokers. Among current smokers, 45.2% (n=28) were interested in receiving smoking cessation treatment. Preferences for treatment included: 21.4% (n=6) who wanted Quitline only, 25% (n=7) medication alone, and 53.6% (n=15) combined Quitline plus medication. Current smokers (55.7%, n=34) were more likely to live in households with tobacco exposure compared to those with former (11.4%, n=36) or never smokers (8.3%, n=18) (p<0.0001).

CONCLUSIONS

Implementing a computer-facilitated system to screen for current smoking and provide smoking cessation services was feasible in the outpatient thoracic surgery and oncology setting. Almost half of the smokers indicated an interest in receipt of smoking cessation treatment. Household exposure was more frequent among current smokers, therefore routine screening for secondhand smoke exposure from other household members is an important consideration in developing smoking cessation treatment plans to mitigate health risks among vulnerable patient populations.

Long-term patient-reported outcomes after non-small cell lung cancer resection

OBJECTIVES

Patient-reported outcomes (PROs) are critical tools for evaluating patients before and after lung cancer resection. In this study, we assessed patient-reported pain, dyspnea, and functional status up to 1 year postoperatively.

METHODS

This study included patients who underwent surgery for non-small cell lung cancer at a single institution (2017-2020). We collected PROs using the National Institutes of Health Patient Reported Outcome Measurement Information System (PROMIS). Data were prospectively collected and merged with our institutional Society of Thoracic Surgeons data. Using multivariable linear mixed effect models, we compared PROMIS scores for preoperative and several postoperative visits.

RESULTS

From 2017 until 2020, 334 patients underwent lung cancer resection with completed PROMIS assessments. Pain interference, physical function, and dyspnea severity scores were worse 1 month after surgery (P < .001). Pain interference and physical function scores returned to baseline by 6 months after surgery. However, dyspnea severity scores remained persistently worse up to 1 year after surgery (1-month difference, 8.8 ± 1.9; 6-month difference, 3.6 ± 2.2; 1-year difference, 4.9 ± 2.8; P < .001). Patients who received a thoracotomy had worse physical function and pain interference scores 1 month after surgery compared with patients who received a minimally invasive operation; however, there were no differences in PROs by 6 months after surgery.

CONCLUSIONS

PROs are important metrics for assessing patients before and after lung cancer resection. Patients may report persistent dyspnea up to 1 year after resection. Additionally, patients undergoing thoracotomy initially report worse pain and physical function but these impairments improve by 6 months after surgery.

Pilot Study of Patient Reported Outcomes in Patients with Esophageal Cancer following Esophagectomy

BACKGROUND

Patient-reported outcomes are critical measures of patient well-being following esophagectomy. In this pilot study, we assessed PROs before and after esophagectomy using the Patient Reported Outcomes Measurement Information System (PROMIS) to assess patient recovery following surgery.

METHODS

We prospectively collected PROMIS dyspnea severity, physical function, and pain interference measures from patients with esophageal cancer undergoing esophagectomy (2017-2020). We merged these data with our institutional Society of Thoracic Surgery esophagectomy database. We used linear mixed-effect multivariable models to assess changes in PROMIS scores (least square mean [LSM] differences) between pre-operative and post-operative timepoints (1-month, 6-month).

RESULTS

The study included 112 patients undergoing esophagectomy. Pain interference, physical function, and dyspnea severity scores were significantly worse 1 month following surgery. While physical function and dyspnea severity scores returned to baseline 6 months after surgery, pain interference scores remained persistently worse (LSM difference 2.7 ± 2.5, p=0.036). PROMIS scores were further assessed among patients undergoing transhiatal esophagectomy compared to transthoracic esophagectomy. Physical function and dyspnea severity scores were similar between the groups at each time point. However, pain interference scores were persistently better among patients undergoing THE at both 1 month (LSM difference 6.5 ± 5.1, p=0.013) and 6 months after surgery (LSM difference 5.2 ± 3.9, p=0.008).

CONCLUSIONS

This pilot study assessing PROMIS scores after esophagectomy for cancer reveals that pain is a persistently reported symptom up to 6 months following surgery, particularly among patients receiving transthoracic esophagectomy.

Dissemination and Implementation Science in Cardiothoracic Surgery: A Review and Case Study

Dissemination and implementation (D&I) science is the practice of taking evidence-based interventions (EBI) and sustainably incorporating them in routine clinical practice. As a relatively young field, D&I techniques are underutilized in cardiothoracic surgery. This review offers an overview of D&I science from the context of the cardiothoracic surgeon. First, we provide a general introduction to D&I science and basic terminology that is used in the field. Second, to illustrate D&I techniques in a real-world example, we discuss a case study for implementing lung protective management (LPM) strategies for lung donor optimization nationally. Finally, we discuss challenges to successful implementation that are unique to cardiothoracic surgery and give several examples of EBIs that have been poorly implemented into surgical practice. We also provide examples of successful D&I interventions - including de-implementation strategies - from other surgical subspecialties. We hope that this review offers additional tools for cardiothoracic surgeons to explore when introducing EBIs into routine practice.