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Pennings JS, Oleisky ER, Master H, Davidson C, Coronado RA, Brintz CE, Archer KR. Impact of Racial/Ethnic Disparities on Patient-Reported Outcomes Following Cervical Spine Surgery: QOD Analysis. Spine (Phila Pa 1976) 2024; 49:873-883. [PMID: 38270397 PMCID: PMC11196202 DOI: 10.1097/brs.0000000000004935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/10/2024] [Indexed: 01/26/2024]
Abstract
STUDY DESIGN Retrospective analysis of data from the cervical module of a National Spine Registry, the Quality Outcomes Database. OBJECTIVE To examine the association of race and ethnicity with patient-reported outcome measures (PROMs) at one year after cervical spine surgery. SUMMARY OF BACKGROUND DATA Evidence suggests that Black individuals are 39% to 44% more likely to have postoperative complications and a prolonged length of stay after cervical spine surgery compared with Whites. The long-term recovery assessed with PROMs after cervical spine surgery among Black, Hispanic, and other non-Hispanic groups ( i.e . Asian) remains unclear. MATERIALS AND METHODS PROMs were used to assess disability (neck disability index) and neck/arm pain preoperatively and one-year postoperative. Primary outcomes were disability and pain, and not being satisfied from preoperative to 12 months after surgery. Multivariable logistic and proportional odds regression analyses were used to determine the association of racial/ethnic groups [Hispanic, non-Hispanic White (NHW), non-Hispanic Black (NHB), and non-Hispanic Asian (NHA)] with outcomes after covariate adjustment and to compute the odds of each racial/ethnic group achieving a minimal clinically important difference one-year postoperatively. RESULTS On average, the sample of 14,429 participants had significant reductions in pain and disability, and 87% were satisfied at one-year follow-up. Hispanic and NHB patients had higher odds of not being satisfied (40% and 80%) and having worse pain outcomes (30%-70%) compared with NHW. NHB had 50% higher odds of worse disability scores compared with NHW. NHA reported similar disability and neck pain outcomes compared with NHW. CONCLUSIONS Hispanic and NHB patients had worse patient-reported outcomes one year after cervical spine surgery compared with NHW individuals, even after adjusting for potential confounders, yet there was no difference in disability and neck pain outcomes reported for NHA patients. This study highlights the need to address inherent racial/ethnic disparities in recovery trajectories following cervical spine surgery.
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Affiliation(s)
- Jacquelyn S. Pennings
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Emily R. Oleisky
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN
| | - Hiral Master
- Vanderbilt Institute of Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Claudia Davidson
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN
| | - Rogelio A. Coronado
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN
| | - Carrie E. Brintz
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
- Osher Center for Integrative Health, Vanderbilt University Medical Center, Nashville, TN
| | - Kristin R. Archer
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN
- Osher Center for Integrative Health, Vanderbilt University Medical Center, Nashville, TN
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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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Miller JP, Hutton J, Doherty C, Vallesi S, Currie J, Rushworth K, Larkin M, Scott M, Morrow J, Wood L. A scoping review examining patient experience and what matters to people experiencing homelessness when seeking healthcare. BMC Health Serv Res 2024; 24:492. [PMID: 38643146 PMCID: PMC11031864 DOI: 10.1186/s12913-024-10971-8] [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: 07/25/2023] [Accepted: 04/09/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND Homelessness is associated with significant health disparities. Conventional health services often fail to address the unique needs and lived experience of homeless individuals and fail to include participatory design when planning health services. This scoping review aimed to examine areas of patient experience that are most frequently reported by people experiencing homelessness when seeking and receiving healthcare, and to identify existing surveys used to measure patient experience for this cohort. METHODS A scoping review was undertaken reported according to the PRISMA-ScR 2020 Statement. Databases were searched on 1 December 2022: MEDLINE, EMBASE, APA PsychINFO and CINAHL. Included studies focused on people experiencing homelessness, healthcare services and patient experience, primary research, published in English from 2010. Qualitative papers and findings were extracted and synthesized against a modified framework based on the National Institute for Health and Care Excellence guidelines for care for people experiencing homelessness, the Institute of Medicine Framework and Lachman's multidimensional quality model. People with lived experience of homelessness were employed as part of the research team. RESULTS Thirty-two studies were included. Of these, 22 were qualitative, seven quantitative and three mixed methods, from the United States of America (n = 17), United Kingdom (n = 5), Australia (n = 5) and Canada (n = 4). Health services ranged from primary healthcare to outpatient management, acute care, emergency care and hospital based healthcare. In qualitative papers, the domains of 'accessible and timely', 'person-centred', and values of 'dignity and respect' and 'kindness with compassion' were most prevalent. Among the three patient experience surveys identified, 'accessible and timely' and 'person-centred' were the most frequent domains. The least frequently highlighted domains and values were 'equitable' and 'holistic'. No questions addressed the 'safety' domain. CONCLUSIONS The Primary Care Quality-Homeless questionnaire best reflected the priorities for healthcare provision that were highlighted in the qualitative studies of people experiencing homelessness. The most frequently cited domains and values that people experiencing homelessness expressed as important when seeking healthcare were reflected in each of the three survey tools to varying degrees. Findings suggest that the principles of 'Kindness and compassion' require further emphasis when seeking feedback on healthcare experiences and the domains of 'safety', 'equitable', and 'efficiency' are not adequately represented in existing patient experience surveys.
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Affiliation(s)
| | - Jennie Hutton
- St Vincent's Hospital Melbourne, Melbourne, Australia.
- The University of Melbourne, Melbourne, Australia.
- Victorian Virtual Emergency Department, Northern Hospital, Melbourne, Australia.
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia.
| | | | | | - Jane Currie
- Queensland University of Technology, Brisbane, Australia
| | | | | | - Matthew Scott
- St Vincent's Hospital Melbourne, Melbourne, Australia
- Lived Experience Representative, Melbourne, Australia
| | - James Morrow
- Lived Experience Representative, Melbourne, Australia
| | - Lisa Wood
- The University of Notre Dame Australia, Perth, Australia
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Issa TZ, McCurdy MA, Lee Y, Lambrechts MJ, Sherman MB, Kalra A, Goodman P, Canseco JA, Hilibrand AS, Vaccaro AR, Schroeder GD, Kepler CK. The Impact of Socioeconomic Status on the Presence of Advance Care Planning Documents in Patients With Acute Cervical Spinal Cord Injury. J Am Acad Orthop Surg 2024; 32:354-361. [PMID: 38271675 DOI: 10.5435/jaaos-d-23-00763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 11/27/2023] [Indexed: 01/27/2024] Open
Abstract
INTRODUCTION Patients presenting with spinal cord injury (SCI) often times have notable deficits or polytrauma and may require urgent decision making for early management. However, their presentation may affect decision-making ability. Although advance care planning (ACP) may help guide spine surgeons as to patient preferences, the rate at which they are available and disparities in ACP completion are still not understood. The objective of this study was to evaluate disparities in the completion of ACP among patients with acute SCI. METHODS All patients presenting with cervical SCI to the emergency department at an urban, tertiary level I trauma center from 2010 to 2021 were identified from a prospective database of all consults evaluated by the spine service. Each patient's medical record was reviewed to assess for the presence of ACP documents such as living will, power of attorney, or advance directive. Community-level socioeconomic status was assessed using the Distressed Communities Index. Bivariable and multivariable analyses were performed. RESULTS We identified 424 patients: 104 (24.5%) of whom had ACP. Patients with ACP were older (64.8 versus 56.5 years, P = 0.001), more likely White (78.8% versus 71.9%, P = 0.057), and present with ASIA Impairment Scale grade A SCI (21.2% versus 12.8%, P = 0.054), although the latter two did not reach statistical significance. On multivariable logistic regression, patients residing in at-risk communities were significantly less likely to have ACP documents compared with those in prosperous communities (odds ratio [OR]: 0.29, P = 0.03). Although patients living in distressed communities were less likely to complete ACP compared with those in prosperous communities (OR 0.50, P = 0.066), this did not meet statistical significance. Female patients were also less likely to have ACP (OR: 0.43, P = 0.005). CONCLUSION Female patients and those from at-risk communities are markedly less likely to complete ACP. Attention to possible disparities during admission and ACP discussions may help ensure that patients of all backgrounds have treatment goals documented.
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Affiliation(s)
- Tariq Z Issa
- From the Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA (Issa, McCurdy, Lee, Sherman, Kalra, Goodman, Canseco, Hilibrand, Vaccaro, Schroeder, and Kepler), the Feinberg School of Medicine, Northwestern University, Chicago, IL (Issa), and the Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO (Lambrechts)
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Issa TZ, Lee Y, Henry TW, Trenchfield D, Schroeder GD, Vaccaro AR, Kepler CK. Values derived from patient reported outcomes in spine surgery: a systematic review of the minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:3333-3351. [PMID: 37642774 DOI: 10.1007/s00586-023-07896-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 08/05/2023] [Accepted: 08/08/2023] [Indexed: 08/31/2023]
Abstract
PURPOSE While patient reported outcome measures (PROMs) define value in spine surgery, several values such as minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) help guide the interpretation of PROMs and identify thresholds of clinical significance. Significant variation exists in reported values and their calculation, so the primary objective of this study was to systematically review the spine surgery literature for metrics of clinical significance derived from PROMs. METHODS We conducted a query of PubMed/MEDLINE and Scopus databases from inception to January 1, 2023, for studies that derived quantitative metrics (e.g., SCB, MCID, PASS) from PROMs in the setting of spine surgery with minimum 1-year follow-up. Details regarding the specific PROMs were collected including which PROM was measured, whether anchor- or distribution-based methods were utilized, the specific calculations, and the recommended value for a given PROM based on all evaluated calculations. RESULTS Thirty-seven studies of 21,780 patients were included. The most commonly evaluated PROM-derived value was the MCID (n = 28), followed by PASS (n = 6) and SCB (n = 4). Twenty-one studies only utilized anchor-based calculations, 15 utilized both anchor-based and distribution-based methods, and one only utilized distribution-based calculations. The most commonly evaluated legacy PROMs were the Oswestry Disability Index (ODI) (N = 11, MCID range 4-20) and visual analog scale back pain (N = 5, MCID range 0.5-4.6). All 10 studies that derived SCB or PASS utilized the receiver operating characteristic methods. Among the six studies deriving a PASS value, four only evaluated ODI, identifying PASS ranging from 5 to 22. CONCLUSION While calculated measures of clinical significance such as MCID, PASS, and SCB exist, significant heterogeneity exists in the current literature. Current shortcomings include a wide variability of reported value thresholds across the literature, and limited applicability to more heterogenous patient populations than the targeted cohorts included in published investigations. Continued investigations that apply these methods to heterogenous, large-scale populations can help increase generalizability and validity of these measures. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Tariq Z Issa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 125 S 9th St, Suite 1000, Philadelphia, PA, 19107, USA.
| | - Yunsoo Lee
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 125 S 9th St, Suite 1000, Philadelphia, PA, 19107, USA
| | - Tyler W Henry
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 125 S 9th St, Suite 1000, Philadelphia, PA, 19107, USA
| | - Delano Trenchfield
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 125 S 9th St, Suite 1000, Philadelphia, PA, 19107, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 125 S 9th St, Suite 1000, Philadelphia, PA, 19107, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 125 S 9th St, Suite 1000, Philadelphia, PA, 19107, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 125 S 9th St, Suite 1000, Philadelphia, PA, 19107, USA
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