Do Lumbar Decompression and Fusion Patients Recall Their Preoperative Status?: A Cohort Study of Recall Bias in Patient-Reported Outcomes

Assessment of the External Validity of Dialogue Support for Predicting Lumbar Spine Surgery Outcomes in a US Cohort

STUDY DESIGN

External validation using prospectively collected data.

OBJECTIVES

To determine the model performance of "Dialogue Support" (DS) in predicting outcomes after lumbar spine surgery.

SUMMARY OF BACKGROUND DATA

To help clinicians discuss risk versus benefit with patients considering lumbar fusion surgery, DS has been made available online. As DS was created using a Swedish sample, there is a need to study how well DS performs in alternative populations.

PATIENTS AND METHODS

Preoperative data from patients enrolled in the Quality Outcomes Database were entered into DS. The probability for each patient to report satisfaction, achieve success (leg pain improvement ≥3), or have no leg pain 12 months after surgery was extracted and compared with their actual 12-month postoperative data. The ability of DS to identify patients in the Quality Outcomes Database who report satisfaction, achieve success, or have no leg pain 12 months after surgery was determined using Receiver operating characteristic curve analysis, goodness-of-fit tests, and calibration plots.

RESULTS

There was a significant improvement in all outcomes in 23,928 cases included in the analysis from baseline to 12 months postoperative. Most (84%) reported satisfaction, 67% achieved success, and 44% were pain-free 12 months postoperative. Receiver operating characteristic analysis showed that DS had a low ability to predict satisfaction [area under the curve (AUC) = 0.606], success (AUC = 0.546), and being pain-free (AUC = 0.578) at 12 months postoperative; poor fit for satisfaction (<0.001) and being pain-free ( P = 0.004), but acceptable fit for success ( P = 0.052). Calibration plots showed underestimation for satisfaction and success, but acceptable estimates for being pain-free.

CONCLUSION

DS is not directly transferable to predict satisfaction and success after lumbar surgery in a US population. This may be due to differences in patient characteristics, weights of the variables included, or the exclusion of unknown variables associated with outcomes. Future studies to better understand and improve the transferability of these models are needed.

Recall Bias in Client-Reported Outcomes in Canine Orthopaedic Patients Using Clinical Metrology Instruments

OBJECTIVE

 The aim of this study was to determine the accuracy of client recollection of their dogs' preconsultation status using clinical metrology instruments such as the Liverpool Osteoarthritis in Dogs (LOAD) and Canine Brief Pain Inventory (CBPI) questionnaires in dogs presenting to a referral orthopaedic clinic.

STUDY DESIGN

 This is a longitudinal prospective cohort study of client-owned dogs presenting for investigations of lameness (n = 217). LOAD and CBPI questionnaires were completed by the owners at the first consultation (T0). Owners were contacted at 2 (T1), 6 (T2), and 12 (T3) months and asked to recall their dogs' T0 status by completing another LOAD and CBPI questionnaire. The agreement between the T0 and recalled LOAD and CBPI scores was determined using the two-way mixed effects intraclass correlation coefficient (ICC). The Wilcoxon signed-rank test was used to determine the difference between scores.

RESULTS

 For the LOAD scores, there was moderate agreement between T0 and T1 (ICC: 0.64) and T0 and T2 (ICC: 0.53) scores and poor agreement between T0 and T3 (ICC: 0.496). For the CBPI Pain Severity Scores, there was poor agreement between T0 and all three subsequent time points (ICC < 0.5). For the CBPI Pain Interference Scores, there was moderate agreement between T0 and T1 (ICC: 0.57) and T2 (ICC: 0.56) scores and poor agreement between T0 and T3 (ICC: 0.43).

CONCLUSION

 The LOAD and CBPI questionnaires are subject to recall bias. Studies reporting retrospectively acquired CMI data should be interpreted with caution.

Do Patients Accurately Recall Their Preoperative Symptoms After Elective Orthopedic Procedures?

Patient-reported outcome measures are a frequent tool used to assess orthopedic surgical outcomes. However, recall bias is a potential limitation of these tools when used retrospectively, as they rely on patients to accurately recall their preoperative symptoms. A database search of Cochrane Library, PubMed, Medline Ovid, and Scopus until May 2021 was completed in duplicate by two reviewers. Studies considered eligible for inclusion were those which reported on patient recall bias associated with orthopedic surgery. The primary outcome of interest investigated was the accuracy of patient recollection of preoperative health status. Any factors that were identified as affecting patient recall were secondary outcomes of interest. Of the 4,065 studies initially screened, 20 studies with 3,454 patients were included in the final analysis. Overall, there were 2,371 (69%) knee and hip patients, 422 (12%) shoulder patients, 370 (11%) spine patients, 208 (6%) other upper extremity patients, and 83 (2%) foot and ankle patients. Out of the eight studies that evaluated patient recall within three months postoperatively, seven studies concluded that patient recall is accurate. Out of the 13 studies that evaluated patient recall beyond three months postoperatively, nine studies concluded that patient recall is inaccurate. The accuracy of patient recall of preoperative symptoms after elective orthopedic procedures is not reliable beyond three months postoperatively.

Are the results of patient reported outcome measures after spine surgery influenced by recall of preoperative scores? A randomized controlled trial

BACKGROUND CONTEXT

Patient reported outcome measures (PROMs) are of utmost importance to clinical practice as they permit a patient-focused evaluation of surgical outcomes. However, recall bias can limit an adequate interpretation of PROMs.

PURPOSE

To assess the impact of recall bias of preoperative status on postoperative PROMs of patients submitted to surgery due to degenerative spine disease.

STUDY DESIGN / SETTING

Randomized controlled trial in a tertiary care neurosurgical unit in Portugal PATIENT SAMPLE: All patients submitted to surgery at our institution from January 2019 to April 2020 due to degenerative lumbar or cervical spine disease with valid PROMs questionnaires were enrolled, and 2 computer generated randomized groups were created.

OUTCOME MEASURES

The study´s primary endpoint was the median postoperative Core Outcome Measure Index (COMI) score.

METHODS

The intervention group was sent postoperative questionnaires including preoperative answers, while patients in the control group were sent the same PROMs without the preoperative answers.

RESULTS

Randomization was applied to 236 patients (118 for each group) and valid results were obtained for 147 patients (81 lumbar, 44 from the intervention group; and 66 cervical, 29 from the intervention group), from which 88 (60%) were females, with a median age of 58 years. Both groups shared similar baseline clinical characteristics and preoperative scores. Median postoperative COMI scores and interquartile ranges (IQR) were 4.20 (IQR: 2.30-6.00) and 5.45 (IQR: 3.75-7.40) for the intervention and control groups, respectively (Wilcoxon, p=.02). This difference was reached mainly due to cervical spine patients as median postoperative COMI score was 3.95 (IQR: 2.20-5.32) in the intervention group and 5.1 (IQR: 4.0-8.4) in the control group (Wilcoxon, p=.01). No significant difference was reached for lumbar patients.

CONCLUSIONS

Better PROMs scores were obtained for degenerative cervical spine patients to whom the preoperative results were provided. Therefore, providing preoperative scores to patients upon postoperative PROMs fulfilment might influence postoperative results. Further research is necessary to increase the reliability of PROMs in clinical practice.

Recall Bias in the Retrospective Collection of Common Patient-Reported Outcome Scores in Hip Arthroscopy

BACKGROUND

The use of patient-reported outcomes (PROs) is common practice in the treatment of patients undergoing hip arthroscopy. While the prospective collection of PROs is preferred, retrospective collection involving patient recall is not uncommon and may be subject to bias.

PURPOSE

To assess the presence of recall bias between prospectively and retrospectively collected PRO scores in hip arthroscopy.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Patients who underwent hip arthroscopy between 2015 and 2021 and provided preoperative baseline responses for the International Hip Outcome Tool-12 (iHOT-12), the Hip disability and Osteoarthritis Outcome Score-Physical Shortform (HOOS-PS), and the modified Harris Hip Score (mHHS) were eligible for recruitment. After surgery, participants were asked to complete a study-specific survey and the same preoperative PROs retrospectively. Agreements between the prospective and retrospective scores were assessed, and associations between score discrepancies and patient characteristics were identified.

RESULTS

A total of 94 patients (43.3% participation rate) completed study requirements and were included for analysis. The mean ± standard deviation duration of symptoms before surgery was 25.3 ± 32.8 months, and the mean duration to recall (from the day of surgery) for the PROs was 29.6 ± 22.2 months. The iHOT-12 (intraclass correlation coefficient [ICC], 0.409; P < .001) and HOOS-PS (ICC, 0.415; P < .001) scores had low agreement between prospectively and retrospectively collected scores. The mHHS showed moderate agreement (ICC, 0.598; P < .001). The mean scores for the iHOT-12 (41.4 ± 22.6 vs 34.6 ± 16.3; P < .01), HOOS-PS (29.7 ± 18.5 vs 40.9 ± 17.1; P < .001), and mHHS (62.7 ± 16.5 vs 54.5 ± 14.8; P < .001) were all significantly different prospectively versus retrospectively. The average changes in score for the iHOT-12, HOOS-PS, and mHHS were -6.8, 11.2, and -8.2, respectively. Duration to recall and female sex were predictors of the difference between prospectively and retrospectively collected iHOT-12 data, while no predictors were significant for the HOOS-PS or mHHS.

CONCLUSION

The retrospective collection of PROs for hip arthroscopy procedures is subject to bias. On average, retrospective (recalled) PROs reflected worse pain/function than their prospectively recorded counterpoints; therefore, retrospective patient recall is an unreliable source of clinical data, and the prospective collection of iHOT-12, mHHS, and HOOS-PS data should be prioritized.

High recall bias in retrospective assessment of the pediatric International Knee Documentation Committee Questionnaire (Pedi-IKDC) in children with knee pathologies

PURPOSE

The increasing incidence of knee injuries among children is well known by sports physicians. Papers dealing with this topic have often collected patient-reported outcomes measures (PROMs) in a retrospective manner; this limitation could lead to a misinterpretation of the results, because pediatric patients might not remember their preoperative conditions adequately. This study aims to evaluate the reliability and the reproducibility of the IKDC pediatric score when administered retrospectively at a 12-month follow-up.

METHODS

From September 2018 and June 2019, all patients aged 7-18 scheduled for surgery due to different knee pathologies in a single center were considered eligible. Parents were contacted by phone for consent. An open-source platform was implemented to collect the responses: two surveys were created (Q1, Q2). They included general information and the Pedi-IKDC score. Q1 was completed prospectively, while Q2 was completed 12 months after surgery. The two questionnaires were identical, and patients were carefully advised to complete Q2 recalling their health status before surgery. ICC and the concordance correlation coefficient (ρ_c) were used to assess the reproducibility between the prospective and recalled scores.

RESULTS

Sixty-six patients responded to Q1 and Q2, and the mean age was 12.9 ± 2.2 years at Q1 and 14.1 ± 2.2 years at Q2. The mean time between Q1 and Q2 was 14.1 ± 2.1 months. Between prospective-IKDC and recall-IKDC, the ICC coefficient was "poor" at 0.32 (CI 0.09 to 0.5) and the ρ_c was "poor" at 0.4 (CI 0.29 to 0.51). Mean prospective-IKDC was 76.8 ± 23.52 mean recalled-IKDC was 60.4 ± 11.5 (P < 0.0001), while mean difference was -16.3 ± 2.09. Simple linear regression models showed that Δ-IKDC is independently associated with age at Q1 (R² = 0.2676; P0.0001)  and prospective-IKDC (R² = 0.653; P < 0.0001).

CONCLUSIONS

Retrospective collection of the Pedi-IKDC score is not reliable and has high recall bias. This should be avoided in children with knee conditions.

LEVEL OF EVIDENCE

III.

Lumbar intervertebral disc degeneration, end-plates and paraspinal muscle changes in children and adolescents with low-back pain

The prevalence of low-back pain (LBP) in adolescents ranges from 7 to 72%. We aimed to define the radiologic characteristics of the lumbar spine in children and adolescents with LBP with/without leg pain. Two hundred and fourteen children and adolescents, who were born between 2001 and 2009 and had lumbar spine MRI for LBP with/without leg pain, were evaluated in terms of intervertebral disc degeneration (IVDD), end-plates and paraspinal muscle changes on lumbar spine MRIs. Severe IVDD was detected at all lumbar levels except for L2-L3. Modic changes were present in 4.2% of the patients. Modic changes were more common in patients with severe IVDD than in those with mild-to-moderate IVDD. Severe IVDD was significantly associated with Modic changes at the corresponding L1-L2 and L3-L4 disc levels. Girls had significantly more fatty infiltration in the paraspinal muscles when compared to boys. The risk of having severe IVDD concomitant with Modic changes was high [odds ratio (OR), 8.6]. The OR was 20.7 for predicting the presence of severe IVDD at any level if Modic changes presented particularly at the L3-L4 level. The ORs of Modic changes presented at any lumbar level at the background of fat-infiltrated multifidus at L3-L4 and L4-L5 levels were 8.3 and 9.1, respectively. Fatty infiltration in the paraspinal muscles and IVDD were closely associated with Modic changes in children and adolescents with LBP. Lumbar IVDD in children and adolescents could be the result of a mechanical pathology.

A Narrative Literature Review of Bias in Collecting Patient Reported Outcomes Measures (PROMs)

There is a growing interest in the collection and use of patient reported outcomes because they not only provide clinicians with crucial information, but can also be used for economic evaluation and enable public health decisions. During the collection phase of PROMs, there are several factors that can potentially bias the analysis of PROM data. It is crucial that the collected data are reliable and comparable. The aim of this paper was to analyze the type of bias that have already been taken into consideration in the literature. A literature review was conducted by the authors searching on PubMed database, after the selection process, 24 studies were included in this review, mostly regarding orthopedics. Seven types of bias were identified: Non-response bias, collection method related bias, fatigue bias, timing bias, language bias, proxy response bias, and recall bias. Regarding fatigue bias and timing bias, only one study was found; for non-response bias, collection mode related bias, and recall bias, no agreement was found between studies. For these reasons, further research on this subject is needed in order to assess each bias type in relation to each medical specialty, and therefore find correction methods for reliable and comparable data for analysis.

Two-Year Recall Bias After ACL Reconstruction Is Affected by Clinical Result

Recall bias is a systematic error caused by inaccuracy in reporting past health status and can be a substantial methodological flaw in the retrospective collection of data. Little is known about recall bias following anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to evaluate patients’ recall bias regarding preinjury knee function at 2 years after ACLR.

Patient-Reported Outcomes Following Lumbar Decompression Surgery: A Review of 2699 Cases

STUDY DESIGN

Retrospective case series.

OBJECTIVE

Despite numerous advances in the technology and techniques available to spinal surgeons, lumbar decompression remains the mainstay of degenerative lumbar spine surgery. It has proven efficacy in trials, but only limited evidence of advantage over conservative management in large scale systematic reviews. We collated data from a large surgically managed cohort to evaluate the patient-reported outcomes.

METHODS

We performed a retrospective analysis of a prospectively populated database. Patient demographics, surgical details, and patient outcomes (Spine Tango core outcome measures index [COMI]-Low Back) were collected for 2699 lumbar decompression surgeries.

RESULTS

Lumbar decompression was shown to be successful at improving leg pain (mean improvement in visual analogue scale [VAS] at 3 months = 4) and to a lesser extent, back pain (mean improvement in VAS at 3 months = 2.61). Mean improvement in COMI score was 3.15 for all-comers. Minimal clinically important improvement (MCID) in COMI score (-2 points) was achieved in 73% of patients by 2-year follow-up. Primary surgery was more effective than redo surgery: odds ratio 0.547 (95% CI 0.408-0.733, P < .001). The benefits across all outcomes were maintained for the 2-year follow-up period. Patients can be classified according to their outcome as "early responders"; achieving MCID by 3 months (61% primary vs 41% redo), "late responders"; achieving MCID by 2 years (15% vs 20%) or nonresponders (24% vs 39%).

CONCLUSIONS

Lumbar decompression is effective in improving quality of life in appropriately selected patients. Patient-reported outcome measures collected routinely and collated within a registry are a powerful tool for assessing the efficacy of lumbar spine interventions and allow accurate counseling of patients perioperatively.

Do Cervical Spine Surgery Patients Recall Their Preoperative Status?: A Cohort Study of Recall Bias in Patient-reported Outcomes

STUDY DESIGN

This is a prospective cohort study.

OBJECTIVE

To characterize the accuracy of patient recollection of preoperative symptoms after cervical spine surgery.

SUMMARY OF BACKGROUND DATA

Recall bias is a well-known source of systematic error. The accuracy of patient recall after cervical spine surgery remains unknown.

METHODS

Consecutive patients undergoing cervical spine surgery for myelopathy or radiculopathy were enrolled. Neck and arm numeric pain scores and Neck Disability Indices were recorded preoperatively. Patients were asked to recall their preoperative status at either short (<1 y) or long-term (≥1 y) follow-up. Actual and recalled scores were compared using paired t tests and relations were quantified using the Pearson correlation coefficients. Multivariable linear regression was used to identify factors impacting recollection.

RESULTS

In total, 73 patients with a mean age of 58.2 years were included. Compared with their preoperative scores, patients showed significant improvement in neck pain [mean difference (MD)=-2.9; 95% confidence intervals (CIs), -3.5 to -2.3], arm pain (MD, -3.4; 95% CI, -4.0 to -2.8), and disability (MD, -12.4%; 95% CI, -16.9 to -7.9). Patient recollection of preoperative status was significantly more severe than actual for neck pain (MD, +1.5; 95% CI, 0.8-2.2), arm pain (MD, +2.3; 95% CI, 1.6-3.0), and disability (MD, +5.8%; 95% CI, 2.4-9.2). Moderate correlation between actual and recalled scores with regard to neck (r=0.41), arm (r=0.50) pain, and disability (r=0.67) was seen. This was maintained across age, sex, and time between date of surgery and recollection. Over 30% of patients switched their predominant symptom from neck-to-arm pain or vice versa on recall of their preoperative symptoms.

CONCLUSIONS

Relying on patient recollection does not provide an accurate measure of preoperative status after cervical spine surgery. Prospective and not retrospective collection of patient-reported outcomes remain the gold standard to measure and interpret outcomes after cervical spine surgery. Recall bias has the potential to affect patient satisfaction and requires further study.

Sleep Tracking and Exercise in Patients With Type 2 Diabetes Mellitus (Step-D): Pilot Study to Determine Correlations Between Fitbit Data and Patient-Reported Outcomes

Background

Few studies assessing the correlation between patient-reported outcomes and patient-generated health data from wearable devices exist.

Objective

The aim of this study was to determine the direction and magnitude of associations between patient-generated health data (from the Fitbit Charge HR) and patient-reported outcomes for sleep patterns and physical activity in patients with type 2 diabetes mellitus (T2DM).

Methods

This was a pilot study conducted with adults diagnosed with T2DM (n=86). All participants wore a Fitbit Charge HR for 14 consecutive days and completed internet-based surveys at 3 time points: day 1, day 7, and day 14. Patient-generated health data included minutes asleep and number of steps taken. Questionnaires assessed the number of days of exercise and nights of sleep problems per week. Means and SDs were calculated for all data, and Pearson correlations were used to examine associations between patient-reported outcomes and patient-generated health data. All respondents provided informed consent before participating.

Results

The participants were predominantly middle-aged (mean 54.3, SD 13.3 years), white (80/86, 93%), and female (50/86, 58%). Use of oral T2DM medication correlated with the number of mean steps taken (r=.35, P=.001), whereas being unaware of the glycated hemoglobin level correlated with the number of minutes asleep (r=−.24, P=.04). On the basis of the Fitbit data, participants walked an average of 4955 steps and slept 6.7 hours per day. They self-reported an average of 2.0 days of exercise and 2.3 nights of sleep problems per week. The association between the number of days exercised and steps walked was strong (r=.60, P<.001), whereas the association between the number of troubled sleep nights and minutes asleep was weaker (r=.28, P=.02).

Conclusions

Fitbit and patient-reported data were positively associated for physical activity as well as sleep, with the former more strongly correlated than the latter. As extensive patient monitoring can guide clinical decisions regarding T2DM therapy, passive, objective data collection through wearables could potentially enhance patient care, resulting in better patient-reported outcomes.

Can We Assess the Success of Surgery for Degenerative Spinal Diseases Using Patients' Recall of Their Preoperative Status?

BACKGROUND

Patients' recall of their preoperative status is seldom used to assess surgical outcomes because of concerns about inaccuracy and bias. The present study aimed to measure the significance of this recall bias and its repercussion on patients' recollection of their preoperative status.

METHODS

Patients submitted to surgery due to degenerative spine diseases over a 1-year period (n = 198) were included in this study. Each patient completed the EuroQol Five-Dimensional Questionnaire (including a visual analog scale), Core Outcome Measures Index (COMI) for neck (including neck pain and shoulder/arm pain numeric rating scale [NRS]), COMI back (including back pain and buttock/leg pain NRS), Neck Disability Index, and Oswestry Disability Index preoperatively. At 1 year after surgery, the patients were asked to complete 2 sets of the same questionnaires, one set regarding their postoperative status and the other set regarding their recall of their preoperative status.

RESULTS

There was poor to moderate agreement between recalled and collected preoperative scores for all patient-reported outcome measures. Patients' recollection of their preoperative status was accurate for patients who underwent cervical spine surgery, but not for those who underwent lumbar spine surgery. Patients satisfied with the outcome after lumbar spine surgery recalled significantly worse scores compared with the actual preoperative scores.

CONCLUSIONS

Using patients' recall of their preoperative status may lead to overestimation of the effectiveness of surgery, particularly for lumbar spine surgery. The self-assessed effectiveness of surgery interferes with the recollection of baseline status.

Sources of distress among patients undergoing surgery for colorectal cancer: a qualitative study

BACKGROUND

Distress is common among cancer and surgical patients and can lead to worse outcomes if untreated. The objective of this study was to explore sources of distress among colorectal cancer patients undergoing surgery.

MATERIALS AND METHODS

This was a qualitative study using in-depth, semistructured, one-on-one interviews in an academic setting. Patients were recruited if they had a pathologically confirmed diagnosis of colon or rectal cancer. Purposive sampling was used to recruit patients who were about to undergo (preoperative), or had recently undergone (postoperative), curative resection for colorectal cancer.

RESULTS

All participants (n = 24) reported experiencing distress during treatment. Participants identified sources of distress preoperatively (negative emotional reaction to diagnosis, distress from preconception of cancer diagnosis, and distress interacting with healthcare system). Sources of distress during in-hospital recovery included negative emotional reaction to having a surgery and negative emotions experienced in the hospital. Postoperative sources of distress included mismatch of expectations and experience of recovery, dealing with distressing physical symptoms and complications after surgery, and distress worrying about recurrence. Participants identified other sources of distress that were not time-specific (distress related to social support network, from disruption of life, and worrying about death).

CONCLUSIONS

Our results highlight a potential role for a comprehensive screening program to identify which patients require assistance with addressing sources of distress during the surgical experience. Understanding how sources of distress may vary by time will help us tailor interventions at different time points of the surgical experience.