Patient-Reported Outcomes: Time to Integrate Into Outcomes Reporting?

Premorbid functional status in patients requiring veno-arterial extracorporeal membrane oxygenation after cardiac surgery

Assessment of a patient's functional status prior to undergoing cardiac surgery may be a useful marker for predicting outcomes when postoperative veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is required. In this short communication, we present retrospective data on 83 patients at a single center who required V-A ECMO after cardiac surgery. Our results did not show a statistically significant association between premorbid functional status and mortality, though age was predictive of mortality. Future studies should explore other markers of functional status and relationships with additional outcomes.

Comparison of early patient-reported outcomes between uniportal thoracoscopic segmentectomy and wedge resection for peripheral small-sized non-small-cell lung cancer

BACKGROUND

Analysis of patient-reported outcomes (PROs) offers valuable insights into distinguishing the effects of closely related medical procedures from the patient's perspective. In this study we compared symptom burden in patients undergoing uniportal thoracoscopic segmentectomy and wedge resection for peripheral small-sized non-small cell lung cancer (NSCLC).

METHODS

This study included patients with peripheral NSCLC from an ongoing longitudinal prospective cohort study (CN-PRO-Lung 3) who underwent segmentectomy or wedge resection with tumor diameter ≤ 2 cm and consolidation tumor ratio (CTR) ≤ 0.5. PROs data were collected using the Perioperative Symptom Assessment for Lung Surgery questionnaire pre-operatively, daily post-surgery up to the fourth hospitalization day, and weekly post-discharge up to the fourth week. Propensity score matching and a generalized estimation equation model were employed to compare symptom severity. In addition, short-term clinical outcomes were compared.

RESULTS

In total, data of 286 patients (82.4%) undergoing segmentectomy and 61 patients (17.6%) undergoing wedge resection were extracted from the cohort. No statistically significant differences were found in the proportion of moderate-to-severe symptoms and mean scores for pain, cough, shortness of breath, disturbed sleep, fatigue, drowsiness, and distress during the 4-day postoperative hospitalization or the 4-week post-discharge period before or after matching (all p > 0.05). Compared with segmentectomy, wedge resection showed better short-term clinical outcomes, including shorter operative time (p = 0.001), less intraoperative bleeding (p = 0.046), and lower total hospital costs (p = 0.002).

CONCLUSIONS

The study findings indicate that uniportal thoracoscopic segmentectomy and wedge resection exert similar early postoperative symptom burden in patients with peripheral NSCLC (tumor diameter ≤ 2 cm and CTR ≤ 0.5).

CLINICAL TRIAL REGISTRATION

Not applicable.

Patients are pragmatic and physicians are perfectionists? Comparing success after liver transplantation among patients and physicians

Although both patients and physicians are key stakeholders in health care outcomes, patients and physicians often define success differently. The purpose of this study was to compare patient and physician perceptions of success 1 year after liver transplantation. This was a single-institution, qualitative study. We conducted in-person, semi-structured interviews with liver transplant recipients 1 year after transplantation and virtual interviews with transplant surgeons and hepatologists. Transcripts were coded and iteratively analyzed for themes using the principles of phenomenology. Twenty patients, 8 caregivers, 5 transplant surgeons, and 4 hepatologists were interviewed. Subject interviews averaged 57 (patient) and 27 (physician) minutes. Overall, patients and physicians had significant agreement in their definitions of success, which included avoidance of death, restoration of physical and mental function, return to society, acquisition of new health care knowledge, and open communication between the patient and the physician. Patients highlighted relief from worry about their future health status, and physicians highlighted decreased health care costs. Patients noted that a liver transplant did not have to be perfect, that is free from complications, to be successful. Physicians had a more stringent view and felt that any deviation from an ideal course reduced the relative success of a transplant. Detailed assessment of patient and physician responses reveals similar overall goals of regaining physical, mental, and emotional function. Complications are perceived differently by patients and physicians. Awareness of this discordance may serve to enhance relationships between transplant patients and their providers.

Surgeon Perceptions of the Integration of Patient-Reported Outcome Measures into Clinical Practice

INTRODUCTION

Patient-reported outcome measures (PROMs/PROM) are standardized, validated instruments used to measure the patient's perception of their own health status including their symptoms, functional wellbeing, and mental health. Although PROMs were initially developed as research tools, their use in clinical practice for shared decision-making and to assess the impact of disease and treatment on quality of life of individual patients has been increasing. There is a paucity of research exploring providers' perspectives on the clinical integration of PROMs. We sought to use a qualitative methodology to understand surgeons' perceptions of integrating PROMs into their clinical practices.

METHODS

Semistructured interviews were performed from November 2019 until August 2020. All interviews were recorded and transcribed verbatim. Thematic saturation was achieved after interviewing nine surgeons representing eight surgical specialties. Qualitative interview data were thematically analyzed using an inductive approach facilitated by Atlas.ti qualitative software.

RESULTS

Forty seven unique codes were identified that fit into 21 themes that revealed five novel insights. Key insights included: (1) PROM data can modify surgical practice on an individual and institutional level, (2) Surgeon's view PROM clinical integration as a potential method of advancing patient-centered care, (3) There are various institutional processes that must be in place, including strong leadership and an integrative platform, to enable successful clinical PROM integration, (4) Surgeons appreciate challenges of integrating PROMs into surgical practice including risks of incorrect use or interpretation, and (5) A PROM platform must be adaptable to the diversity within surgery and to unique physician workflows.

CONCLUSIONS

Surgeons perceived value from integrating PROMs into routine care to better inform patients during preoperative discussions and to help identify at-risk patients in the postoperative period. However, they also identified numerous barriers to the implementation of an integrated system for the routine use of PROMs in clinical practice and expressed concern about using PROMs to compare operative outcomes between surgeons. Based on this work, institutions that want to incorporate PROMs into surgical practice need a leadership team capable of supporting the change management necessary for effective integration and use a PROM platform that gives individual surgeons and surgical teams the ability to customize platforms for their unique practices.

Patient functional recovery after a 23-h surgery - a prospective, follow-up study

PURPOSE

We evaluated patients' functional outcomes 2 weeks after a 23-h surgery model in a tertiary care hospital.

METHODS

This prospective study comprised data on 993 consecutive adult patients who underwent a 23-h surgery. Patients were interviewed before surgery and at 14 days after surgery by telephone with a multidimensional structural survey including closed- and open-ended questions. Regarding functional outcomes, the patients were asked to assess their general wellbeing, energy levels and activities of daily living on a 5-point numeric rating scale (1 = poor to 5 = excellent). Data on patient characteristics, medical history, alcohol use, smoking status and pre-, peri- and postoperative pain and satisfaction with the care received were collected and analysed to determine whether these factors contributed to their recovery. The primary outcome measure was patient functional recovery at 14 days after surgery.

RESULTS

Most patients reported moderate to excellent functional outcomes: 93.6% (95% CI, 92.1--95.1) of the patients showed a score ≥ 3 on the 5-point numeric scale. One out of four patients (23%) scored all three domains as excellent. A weak inverse correlation was noted between functional recovery and most pain in the 23-h postanaesthesia care unit as well as pain at 2 weeks after surgery. A weak positive correlation was noted between functional recovery and patient satisfaction with the instructions at discharge.

CONCLUSIONS

Most patients showed ample functional recovery at 14 days after the 23-h surgery. Higher pain scores in the postanaesthesia care unit and 2 weeks after surgery predicted poor functional outcomes, and satisfaction with postoperative counselling predicted better outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04142203.

Association Between Patient Physical Function and Length of Stay After Thoracoscopic Lung Cancer Surgery

Patient-reported outcomes (PRO) are an ideal method for measuring patient functional status. We sought to evaluate whether preoperative PRO were associated with resource utilization. We hypothesize that higher preoperative physical function PRO scores, measured via the NIH-sponsored Patient Reported Outcome Measurement Information System (PROMIS), are associated with shorter length of stay (LOS). Preoperative physical function scores were obtained using NIH PROMIS in a prospective observational study of patients undergoing minimally invasive surgery for lung cancer. Poisson regression models were constructed to estimate the association between the length of stay and PROMIS physical function T-score, adjusting for extent of resection, age, gender, and race. Due to the significant interaction between postoperative complications and physical function T-score, the relationship between physical function and LOS was described separately for each complication status. A total of 123 patients were included; 88 lobectomy, 35 sublobar resections. Mean age was 67 years, 35% were male, 65% were Caucasian. Among patients who had a postoperative complication, a lower preoperative physical function T-score was associated with progressively increasing LOS (P  value = 0.006). In particular, LOS decreased by 18% for every 10-point increase in physical function T-score. Among patients without complications, T-score was not associated with LOS (P = 0.86). Preoperative physical function measured via PRO identifies patients who are at risk for longer LOS following thoracoscopic lung cancer surgery. In addition to its utility for preoperative counseling and planning, these data may be useful in identifying patients who may benefit from risk-reduction measures.