Outcomes Research: A Methodologic Review

How to measure success in lower extremity reconstruction, which outcome measurements do we use a systematic review and metanalysis

Different factors have to be considered and weighted in the treatment algorithm of lower extremity reconstruction. A combination of both clinicians' and patients' perspectives is necessary to provide a conclusive picture. Currently, there aren't any standardized and validated measurement data sets for lower extremity reconstructions. This makes it necessary to identify the relevant domains. We, therefore, performed a systematic review and metanalysis of outcome measurements and evaluated their ability to measure outcomes after lower extremity reconstruction. A systematic review and metanalysis according to the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' protocol were performed for studies reporting at least one structured outcome measurement of lower extremity reconstruction. Both Patient (PROMs)- and Clinician reported outcome measurements (CROMs)were analyzed. Of the 2827 identified articles, 102 were included in the final analysis. In total 86 outcome measurements were identified, 34 CROMs, 44 PROMs and 8 (9.3%) outcome measurements that have elements of both. Twenty-four measure functional outcome, 3 pain, 10 sensations and proprioception, 9 quality of life, 8 satisfaction with the result, 5 measure the aesthetic outcome, 6 contours and flap stability and 21 contain multidomain elements. A multitude of different outcome measurements is currently used in lower extremity reconstruction So far, no consensus has been reached on what to measure and how. Validation and standardization of both PROMs and CROMs in plastic surgery is needed to improve the outcome of our patients, better meet their needs and expectations and eventually optimize extremity reconstruction by enabling a direct comparison of studies' results.

Nomograms based on pre-operative parametric for prediction of short-term mortality in acute myocardial infarction patients treated invasively

Objective Our aim was to develop and independently validate nomograms to predict short-term mortality in acute myocardial infarction (AMI) patients.

Results There were 1229 AMI patients enrolled in this study. In the training cohort (n=534), 69 deaths occurred during a median follow-up period of 375 days. The C-index for 1-year mortality in the training group and the validation cohort was 0.826 (95%CI: 0.780 - 0.872) and 0.775 (95%CI: 0.695 - 0.855), respectively. Integrated Discrimination Improvement (IDI) and net reclassification improvement (NRI) also showed a significant improvement in the accuracy of the new model compared with the Global Registry of Acute Coronary Events (GRACE) risk score. Furthermore, C-index of the prospective cohort (n=309) achieved 0.817 (95%CI: 0.754 - 0.880) for 30-day mortality and 0.790 (95%CI: 0.718 - 0.863) for 1-year mortality.

Conclusions Collectively, our simple-to-use nomogram effectively predicts short-term mortality in AMI patients.

Methods AMI patients who had undergone invasive intervention between January 2013 and Jan 2018 were enrolled. Cox regression analysis was used on the training cohort to develop nomograms for predicting 30-day and 1-year mortality. Model performance was then evaluated in the validation cohort and another independent prospective cohort.

Why should I do research? Is it a waste of time?

OBJECTIVES

To answer the questions 'Why should I do research? Is it a waste of time?' and present relevant issues.

METHODS

Medline was used to identify relevant articles published from 2000 to 2013, using the following keywords 'medicine', 'research', 'purpose', 'study', 'trial', 'urology'.

RESULTS

Research is the most important activity to achieve scientific progress. Although it is an easy process on a theoretical basis, practically it is a laborious process, and full commitment and dedication are of paramount importance. Currently, given that the financial crisis has a key influence in daily practice, the need to stress the real purpose of research is crucial.

CONCLUSION

Research is necessary and not a waste of time. Efforts to improving medical knowledge should be continuous.

Outcomes in microsurgery

The reporting of microsurgical outcomes has been variable. Historically, emphasis has been placed on flap and digit survival or failure in the case of free-tissue transfer or digit replantation, respectively. Outcomes have also been measured with indices such as range of motion or grip strength for digital replantations, the ability to eat or talk for head and neck microsurgery, and the ability to walk or return to work for lower extremity microsurgery. Although relevant, this type of reporting of outcomes may fail to capture the effectiveness of microsurgical intervention from the patient's, the third-party payer's, or society's perspective. Significant events have arisen in the past two decades, including the emphasis on outcomes research, recent recommendations to adopt evidence-based microsurgery, and the inclusion in academic training programs of the competency "manager" to the health care system. This necessitates rethinking the way we report outcomes in microsurgery. This article explains the need to (1) use health-related quality-of-life scales to measure the benefits of microsurgical interventions, (2) measure outcomes with high-quality clinical research designs, and (3) incorporate proper cost-effectiveness studies in our clinical research before adopting new technologies such as new free flaps or techniques.

Cytoreductive partial nephrectomy does not undermine cancer control in metastatic renal cell carcinoma: a population-based study

OBJECTIVES

We examined the population-based rates of cancer-specific survival in patients with metastatic renal cell carcinoma (MRCC) treated with either partial (PN) or radical cytoreductive nephrectomy (RN).

METHODS

Patients diagnosed with MRCC and treated with either PN or RN were identified within nine SEER cancer registries. Matched and unmatched Kaplan-Meier survival analyses, as well as multivariable Cox regression models compared the effect of RN (n = 1997, 97.8%) vs. PN (n = 46, 2.2%) on cancer-specific survival (CSS). Covariates consisted of age, gender, community type (rural vs urban), race, Surveillance, Epidemiology, and End Results (SEER) registry, tumor size and year of diagnosis.

RESULTS

In multivariable unmatched Cox regression analyses, no statistically significantly difference was found in CSS between the two groups (hazard ratio [HR] 1.40, P = .16). Similarly, no difference in CSS was found in the matched analyses (HR 1.35, log rank P = .34).

CONCLUSION

Cytoreductive PN does not appear to undermine survival in patients with MRCC.

Role of nomograms for prostate cancer in 2007

Nomograms have been developed to predict prostate cancer (PCa) related outcomes. We report what has been achieved and what can be expected in 2007 and in the future. We reviewed the literature to provide guidelines in terms of criteria, limitations and clinical value of nomograms in 2007. Further, we report a set of recent PCa nomograms, where certain criteria are listed which were used to develop each nomogram. Our findings suggest a demand for an update of nomograms as well as head-to-head comparisons to determine the best-suited model in select fields of PCa outcomes. In 2007 and the future, an increasing number of nomograms will address important endpoints such as PSA recurrence, local and distant metastases, or androgen-independent PCa-specific survival. Our results suggest that nomograms represent valid risk stratification models to achieve most accurate predictions. In 2007 and the future, more specific and refined nomograms will be available which address relevant clinical end points. Moreover, novel markers in PCa outcomes will be quantified using the nomogram approach.

Prostate cancer-specific survival in men treated with hormonal therapy after failure of radical prostatectomy

OBJECTIVES

We hypothesized that prostate cancer-specific survival (PCaSS) could be accurately predicted in men in whom radical prostatectomy (RP) failed and who received hormonal therapy (HT) after RP failure.

METHODS

Between 1954 and 1994, 752 consecutive patients underwent RP without neoadjuvant therapy. Of those, 114 patients (15.2%) received HT at RP failure and represent the focus of this analysis. Cox regression models and a nomogram targeted PCaSS. The main predictor was timing of HT initiation: at prostate-specific antigen (PSA) versus local versus distant recurrence. Covariates included age at HT, pathologic T stage, surgical margin status and Gleason sum at RP, use of adjuvant or salvage radiation, and time from RP to HT.

RESULTS

Mean and median follow-up periods were 5.1 and 3.9 yr; 70 deaths were recorded, of which 45 (39.8%) were due to PCa. At 1, 5, 10, and 15 yr, the estimates of PCaSS were, respectively, 97.1%, 68.3%, 49.3%, and 30.2% (median, 9.8 yr). Younger men and those with HT initiated at the time of distant recurrence had lower PCaSS. A nomogram predicting PCaSS at 2, 3, 4, and 5 yr after RP was developed and demonstrated 66% accuracy after 200-bootstrap internal validation.

CONCLUSION

Despite RP failure, half the patients can expect to survive for 10 yr. The nomogram can help in discriminating between those with better versus worse PCaSS, better than relying on most educated guesses.