The impact of health literacy in the care of surgical patients: a qualitative systematic review

Decision-making preferences and regret in rectal cancer patients undergoing restorative proctectomy: A prospective cohort study

BACKGROUND

How patients make treatment choices in rectal cancer is poorly understood and may affect long-term regret and satisfaction. The objective of this study is to characterize decision-making preferences and their effect on decisional regret in patients undergoing restorative proctectomy for rectal cancer.

METHODS

A prospective cohort study was conducted in a single academic specialist rectal cancer center from October 2018 to June 2022. Adult patients who underwent restorative proctectomy at least one year prior were recruited. Health literacy was assessed using the BRIEF instrument. Decision-making preferences regarding cancer treatment were assessed using the Control Preferences Scale. Decisional regret regarding their choice of restorative proctectomy was assessed using the Decision Regret Score. Bowel dysfunction was measured using the low anterior resection syndrome score.

RESULTS

Overall, 123 patients were included. Health literacy was categorized as adequate in 63%, marginal in 25%, and limited in 12%. Patients with adequate health literacy were more likely to prefer a collaborative decision-making role compared with those with low health literacy (86% vs 65%, P = .016). Patients with incongruence between preferred and actual decision-making roles were more likely to report high regret (56% vs 25%, P = .003). Patients with major low anterior resection syndrome were also more likely to experience high regret compared with patients with no/minor low anterior resection syndrome (44% vs 25%, P = .036).

CONCLUSION

A significant proportion of patients with rectal cancer undergoing restorative proctectomy do not have a decision-making role that is congruent with their preferences, and these patients experience a high degree of regret.

The effect of video-assisted learning on pre-operative knowledge and satisfaction for total knee arthroplasty surgery: a randomised-controlled study

INTRODUCTION

Traditionally, surgical procedures are explained through consultations between the surgeon and the patient to ensure informed consent. Patient education enhances engagement and knowledge, aiding informed decision-making. This study aimed to assess the effect of an educational video on preoperative patient knowledge and satisfaction in the context of total knee arthroplasty (TKA) as an adjunct to the consent process.

METHODS

A prospective randomized controlled study involving 100 patients in dedicated elective orthopedic units in UK-based hospitals was conducted. After consultation with a dedicated knee surgeon and a preoperative education day for TKA run by dedicated orthopedic nurse specialists, patients were randomized into one of two limbs (video vs no video) at a 1:1 ratio. The treatment group (video group) was shown a video about the principles and steps of the procedure, including the recovery time. Following this, a 10-point knowledge test was completed, and patients rated their satisfaction with the preoperative education on a scale of 0-10.

RESULTS

Patients in the video limb group had a significantly greater mean knowledge score and greater satisfaction with preoperative education than patients who did not view the video. The video group (n = 49) had a mean knowledge score of 8.73 +/- 0.159 compared to 7.68 +/- 0.281 for the nonvideo limb (n = 50) (p < 0.05). The video group had a mean satisfaction score of 9.00 +/- 0.123 compared to 8.40 +/- 0.121 for the nonvideo limb group (p < 0.05).

CONCLUSION

Video-assisted consent in total knee arthroplasty improves preoperative knowledge and patient satisfaction when used as an adjunct in the consent process. A simple, standardized video, either pre- or post-consultation could reinforce information that the patient receives in a simple effective manner, allowing for true informed consent.

Poverty and Its Impact on Surgical Care

In this article, the authors explore the intricate relationship between poverty and surgical care, underscoring its multifaceted nature and its profound impact on access and outcomes. Poverty extends beyond financial constraints to encompass barriers related to healthcare infrastructure, geographic isolation, education, mental health, and social determinants of health, resulting in persistent disparities in access to high-quality surgical care, especially for those in persistently impoverished areas and access-sensitive surgical conditions. Additionally, the authors delve into the complex intersection of poverty, race, and ethnicity, emphasizing the heightened risks faced by minority patients in surgical care.

Gender-affirming vaginoplasty online resources exceed patient health literacy: A readability analysis

Purpose

Ensuring that educational materials geared toward transgender and gender-diverse patients are comprehensible can mitigate barriers to accessing gender-affirming care and understanding postoperative care. This study evaluates the readability of online patient resources related to gender-affirming vaginoplasty.

Methods

Online searches for vaginoplasty were conducted in January 2023 using two search engines. The readability scores of the top ten websites and their associated hyperlinked webpages were derived using ten validated readability tests.

Results

A total of 40 pages were assessed from the vaginoplasty searches. The average reading grade level for all the webpages with relevant educational materials was 13.3 (i.e., college level), exceeding the American Medical Association's recommended 6th grade reading level.

Conclusion

Complex patient resources may impede patients' understanding of gender-affirming vaginoplasty. Online patient education resources should be created that are more accessible to patients with diverse reading comprehension capabilities.

Validation in the Greek Language of the Patients' Perception of the Surgical Safety Questionnaire

Introduction Adverse events in the operating room are considered unintended injuries or harm caused by healthcare rather than the patient's disease, leading to death, disability, or prolonged hospital stays. Methods A cross-sectional design was conducted following the random sampling method, on 200 surgical patients. A self-completed questionnaire was used, translated, and adapted into the Greek language. Results Most of the sample (57%) was male. The mean age was 67 years, and 52% were elementary school graduates. Upon analysis, significant correlations were observed between the two-administration (p<0.001) facts (intraclass correlation coefficient = 0.567), which reveal that the scale is stable through time. In addition, Cronbach's alpha had a value of 0.824 suggesting good internal consistency of the scale. Regarding the subscale, the first factor "safety regarding surgical procedure" was found 0.847, the second factor "effective communication and understanding" was 0.792, and finally the third factor "emotional security" was 0.506. A statistically significant difference found between the dimensions of safety in the operating room and the age of the patients was in the factor of emotional security, revealing that patients aged more than 70 were feeling more secure compared to younger patients (198) = 2.374, p=0.019. Conclusions The internal consistency of the Patients' Perspectives of Surgical Safety Scale (PPSS), weighted in a sample of the Greek population, is deemed satisfactory. The safety perceptions of surgical patients are at high levels.

Health literacy friendly organizations - A scoping review about promoting health literacy in a surgical setting

OBJECTIVE

This review aims to describe interventions that promote health literacy in a surgical setting and identify knowledge gaps for future research.

METHODS

A scoping review with a systematic search was performed in Medline, CINAHL, Scopus, and Web of Science between January 1, 2012, and January 23, 2024. All screening was conducted using the Covidence software. In total, the search yielded 6 281 articles.

RESULTS

Eighteen articles were included in the results. Studies were heterogeneous regarding the type of health literacy measured, type of surgery, and type of intervention. Most interventions were educational to improve knowledge, decision making or health literacy through digital media, group sessions or consent forms. Most interventions had a positive impact on health literacy.

CONCLUSIONS

Patients with limited health literacy may benefit from a variety of interventions. However, research in this area is sparse. Further research is needed into interventions that may be beneficial for patients.

PRACTICE IMPLICATIONS

Measure, evaluate and implement health literacy-friendly options to ensure people can make safe and sound decisions for their care. Researchers need to consider the type of health literacy investigated and the type of instrument used in the research.

Head-to-Head Comparison of ChatGPT Versus Google Search for Medical Knowledge Acquisition

OBJECTIVE

Chat Generative Pretrained Transformer (ChatGPT) is the newest iteration of OpenAI's generative artificial intelligence (AI) with the potential to influence many facets of life, including health care. This study sought to assess ChatGPT's capabilities as a source of medical knowledge, using Google Search as a comparison.

STUDY DESIGN

Cross-sectional analysis.

SETTING

Online using ChatGPT, Google Seach, and Clinical Practice Guidelines (CPG).

METHODS

CPG Plain Language Summaries for 6 conditions were obtained. Questions relevant to specific conditions were developed and input into ChatGPT and Google Search. All questions were written from the patient perspective and sought (1) general medical knowledge or (2) medical recommendations, with varying levels of acuity (urgent or emergent vs routine clinical scenarios). Two blinded reviewers scored all passages and compared results from ChatGPT and Google Search, using the Patient Education Material Assessment Tool (PEMAT-P) as the primary outcome. Additional customized questions were developed that assessed the medical content of the passages.

RESULTS

The overall average PEMAT-P score for medical advice was 68.2% (standard deviation [SD]: 4.4) for ChatGPT and 89.4% (SD: 5.9) for Google Search (p < .001). There was a statistically significant difference in the PEMAT-P score by source (p < .001) but not by urgency of the clinical situation (p = .613). ChatGPT scored significantly higher than Google Search (87% vs 78%, p = .012) for patient education questions.

CONCLUSION

ChatGPT fared better than Google Search when offering general medical knowledge, but it scored worse when providing medical recommendations. Health care providers should strive to understand the potential benefits and ramifications of generative AI to guide patients appropriately.

Cross-sectional and Correlational Examination of Patients' Preoperative Anxiety, Information Need, and Health Literacy in a Presurgical Consultation

PURPOSE

This study elucidates the preoperative anxiety (PA), information need (IN), and health literacy (HL) levels of an elective preoperative sample in Switzerland and examines the possible associations between PA and the patients' characteristics. By knowing these patient dimensions, which can influence perioperative outcomes, one can tailor individualized nursing interventions to improve patients' surgical experience.

DESIGN

This was a cross-sectional and correlational study.

METHODS

The sample consisted of 88 patients who underwent a preoperative consultation at a Swiss tertiary hosptial. Patients' PA and IN were assessed using the Anxiety Preoperative and Information Scale, and their HL was measured using the Functional, Communicative, and Critical Health Literacy Scale. Data on other patient characteristics were collected from the patients, physicians, and electronic patient records. Association tests, as well as univariate regressions, were performed on PA, IN, HL, and patient characteristics.

FINDINGS

Among participants, 40.91%, 78.41%, and 59% reported having PA, IN, and low HL, respectively. Finally, PA was associated with IN, HL, solitary living, and the American Society of Anesthesiology score.

CONCLUSIONS

A high proportion of patients scheduled for presurgical consultation were found to be anxious. They presented high IN and low HL. An examination of patients' PA-associated characteristics can help improve their surgical experience. More studies should examine PA-associated characteristics.

Evaluating the Readability of Patient Education Materials for Anterior Vertebral Body Tethering, Distraction-Based Methods, and Posterior Spinal Fusion for the Treatment of Pediatric Spinal Deformity

BACKGROUND

The Internet is an important source of information for patients, but its effectiveness relies on the readability of its content. Patient education materials (PEMs) should be written at or below a sixth-grade reading level as outlined by agencies such as the American Medical Association. This study assessed PEMs' readability for the novel anterior vertebral body tethering (AVBT), distraction-based methods, and posterior spinal fusion (PSF) in treating pediatric spinal deformity.

METHODS

An online search identified PEMs using the terms "anterior vertebral body tethering," "growing rods scoliosis," and "posterior spinal fusion pediatric scoliosis." We selected the first 20 general medical websites (GMWs) and 10 academic health institution websites (AHIWs) discussing each treatment (90 websites total). Readability tests for each webpage were conducted using Readability Studio software. Reading grade levels (RGLs), which correspond to the US grade at which one is expected to comprehend the text, were calculated for sources and independent t tests compared with RGLs between treatment types.

RESULTS

The mean RGL was 12.1 ± 2.0. No articles were below a sixth-grade reading level, with only 2.2% at the sixth-grade reading level. AVBT articles had a higher RGL than distraction-based methods (12.7 ± 1.6 vs 11.9 ± 1.9, P = 0.082) and PSF (12.7 ± 1.6 vs 11.6 ± 2.3, P = 0.032). Materials for distraction-based methods and PSF were comparable (11.9 ± 1.9 vs 11.6 ± 2.3, P = 0.566). Among GMWs, AVBT materials had a higher RGL than distraction-based methods (12.9 ± 1.4 vs 12.1 ± 1.8, P = 0.133) and PSF (12.9 ± 1.4 vs 11.4 ± 2.4, P = 0.016).

CLINICAL RELEVANCE

Patients' health literacy is important for shared decision-making. Assessing the readability of scoliosis treatment PEMs guides physicians when sharing resources and discussing treatment with patients.

CONCLUSION

Both GMWs and AHIWs exceed recommended RGLs, which may limit patient and parent understanding. Within GMWs, AVBT materials are written at a higher RGL than other treatments, which may hinder informed decision-making and patient outcomes. Efforts should be made to create online resources at the appropriate RGL. At the very least, patients and parents may be directed toward AHIWs; RGLs are more consistent.

LEVEL OF EVIDENCE: 3

Association of social determinants of health International Classification of Disease, Tenth Edition clinical modification codes with outcomes for emergency general surgery and trauma admissions

BACKGROUND

Patients with Acute Care Surgery needs (ie, emergency general surgery diagnosis or trauma admission) are at particularly high risk for nonmedical patient-related factors that can be important drivers of healthcare outcomes. These social determinants of health are typically ascertained at the geographic area level (ie, county or neighborhood) rather than at the individual patient level. Recently, the International Classification of Diseases Tenth Revision, Tenth Edition created codes to capture health hazards related to patient socioeconomic and psychosocial circumstances. We sought to characterize the impact of these social determinants of health-related codes on perioperative outcomes among patients with acute care surgery needs.

METHODS

Patients diagnosed between 2017 and 2020 with acute care surgery needs (ie, emergency general surgery diagnosis or a trauma admission) were identified in the California Department of Healthcare Access and information Patient Discharge database. Data on concomitant social determinants of health-related codes (International Classification of Diseases Tenth Revision, Tenth Edition Z55-Z65), which designated health hazards related to socioeconomic and psychosocial (socioeconomic and psychosocial, respectively) circumstances, were obtained. After controlling for patient factors, including age, sex, race, payer type, and admitting hospital, the association of socioeconomic and psychosocial codes with perioperative outcomes and hospital disposition was analyzed.

RESULTS

Among 483,280 with an acute care surgery admission (emergency general surgery: n = 289,530, 59.9%; trauma: n = 193,705, 40.1%) mean age was 56.5 years (standard deviation: 21.5) and 271,911 (56.3%) individuals were male. Overall, 16,263 (3.4%) patients had a concomitant socioeconomic and psychosocial diagnosis code. The percentage of patients with a concurrent social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis increased throughout the study period from 2.6% in 2017 to 4.4% in 2020. Patients that were male (odds ratio 1.89; 95% confidence interval 1.82, 1.96), insured by Medicaid (odds ratio 5.43; 95% confidence interval 5.15, 5.72) or self-pay (odds ratio 3.04; 95% confidence interval 2.75, 3.36) all had higher odds of having an social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis. Black race did not have a significant association with an social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis (odds ratio 0.99; 95% confidence interval 0.94, 1.04); however, Hispanic (odds ratio 0.44; 95% confidence interval 0.43, 0.46) and Asian (odds ratio 0.40; 95% confidence interval 0.36, 0.44) race/ethnicity was associated with a lower odds of having an social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis. After controlling for competing risk factors on multivariable analyses, the risk-adjusted probability of hospital postoperative death was 3.1% (95% confidence interval 2.8, 3.4) among patients with a social determinants of health diagnosis versus 5.9% (95% confidence interval 5.9, 6.0) (odds ratio 0.48; 95% confidence interval 0.44, 0.54) among patients without a social determinants of health diagnosis. Risk-adjusted complications were 26.7% (95% confidence interval 26.1, 37.3) among patients with a social determinants of health diagnosis compared with 31.9% (95% confidence interval 31.7, 32.0) (odds ratio 0.74; 95% confidence interval 0.71, 0.77) among patients without a social determinants of health diagnosis.

CONCLUSION

International Classification of Diseases Tenth Revision, Tenth Edition social determinants of health code use was low, with only 3.4% of patients having documentation of a socioeconomic and psychosocial circumstance. The presence of an International Classification of Diseases Tenth Revision, Tenth Edition social determinants of health code was not associated with greater odds of complications or death; however, it was associated with longer length of stay and higher odds of being discharged to a skilled nursing facility.

Influence of health literacy on health-related quality of life after total hip arthroplasty

INTRODUCTION

Personal knowledge about the own disease, a key component of health literacy (HL), may have a considerable impact on treatment outcomes. The purpose of this study was to investigate whether the patients' knowledge about the surgical procedure, risks, and aftercare, as well as the satisfaction with the preoperative level of information, has an influence on the health-related quality of life (HRQoL) after primary total hip arthroplasty (THA).

MATERIALS AND METHODS

A total of 176 patients (68.3 ± 10.3 years, 60.8% female) were evaluated. HRQoL was assessed prior to surgery as well as one and twelve months after THA using the 12-item Short Form Questionnaire. Following standardized surgical informed consent, HL was assessed preoperatively using a self-constructed quiz score, while information satisfaction was measured with a single-item rating scale. Sociodemographic and clinical characteristics, including pain (VAS), functionality (WOMAC), and psychological distress (PHQ-4), were also assessed at baseline. Multiple linear regression analyses were performed to examine whether HL, satisfaction with information, age, social class, WOMAC, VAS, and PHQ-4 predict HRQoL at one and twelve months post-surgery.

RESULTS

The average HL quiz score was 23 ± 5.1 out of a possible 33 points. Social class index significantly influenced HL (p < 0.001). A weak correlation between HL and age (r = 0.23, p = 0.01) and no correlation between HL and psychological distress (p = 0.868) were observed. One month after THA, physical HRQoL was significantly predicted by the WOMAC index (p = 0.031) and subjective satisfaction with information (p = 0.022), but not by HL. After twelve months, only the WOMAC was a significant predictor (p < 0.001) of physical HRQoL.

CONCLUSION

Although subjective satisfaction with the patient's preoperative level of information had a significant effect on the physical HRQoL at one month after THA, the influence of osteoarthritis severity outweighed this effect after twelve months. HL had no direct influence on HRQoL. These results suggest that patient satisfaction, rather than knowledge, predicts HRQoL.

Association of ICD-10 Clinical Modification Codes for Social Determinants of Health with Surgical Outcomes and Hospital Charges Among Cancer Patients

INTRODUCTION

We sought to characterize the impact of social determinants of health (SDOH)-related codes on outcomes among patients with a cancer diagnosis.

METHODS

Patients diagnosed with lung, pancreas, colon, or rectal cancer between 2017 and 2020 were identified in the California Department of Healthcare Access and Information Patient Discharge Database. Data on concomitant SDOH-related codes (International Classification of Diseases, Tenth Revision [ICD-10] Z55-Z65) designating health hazards related to socioeconomic and psychosocial circumstances were obtained. The association of these SDOH codes with postoperative outcomes was evaluated.

RESULTS

Among 10,421 patients who underwent an operation from 2017 to 2020, median age was 66 years (interquartile range [IQR] 56-75) and nearly half of the cohort was male (n = 551,252.9%). In total, 102 (1%) patients had a concurrent ICD-10 SDOH diagnosis. After controlling for competing risk factors, the risk-adjusted probability of in-hospital death was 4.1% (95% confidence interval [CI] 1.0-7.2) among patients with an SDOH diagnosis compared with 2.9% (95% CI 2.5-3.2) among patients without an SDOH diagnosis (odds ratio [OR] 1.52, 95% CI 0.63-3.66; p = 0.258); postoperative complications were 27.0% (95% CI 20.0-34.1) compared with 24.9% (95% CI 24.1-25.6) among patients without an SDOH diagnosis (OR 1.15, 95% CI 0.73-1.82; p = 0.141), and length of stay was 10.6 days (95% CI 10.0-11.2) compared with 9.4 days (95% CI 9.3-9.5) among patients without an SDOH diagnosis. Patients with an SDOH diagnosis had a 5.19 (95% CI 3.23-8.34; p < 0.005) higher odds of being discharged to a skilled nursing facility versus patients without an SDOH diagnosis.

CONCLUSION

Uptake and utilization of ICD-10 SDOH was 1% among California patients with lung, pancreas, colon, or rectal cancer. Patients with a concomitant ICD-10 SDOH code had longer length of stay and had higher odds of being discharged to a skilled nursing facility.

The effect of health literacy on early postoperative recovery of patients undergoing outpatient surgery

BACKGROUND

The measurement of the health literacy level of patients undergoing outpatient surgery has become a major challenge in perioperative nursing of outpatient surgery.

OBJECTIVE

To analyze the effect of health literacy on early postoperative recovery of patients undergoing outpatient surgery by developing a health literacy assessment tool for this population.

METHODS

A scale for the assessment of health literacy was established based on Nutbeam's health literacy model. From April to September 2021, 264 patients were selected in the daytime operating rooms of six Class A tertiary hospitals in Kunming, Yunnan Province to investigate health literacy and early postoperative rehabilitation quality, and the influencing factors of the two variables were analyzed.

RESULTS

An assessment scale of health literacy of patients undergoing outpatient surgery was developed, including 3 dimensions and 24 items. The Cronbach's α coefficient of the total scale was 0.944, the split-half reliability was 0.902, and the content validity was 0.920. Exploratory factor analysis showed that the cumulative variance contribution rate was 66.37%, and the scale had good structural validity. Multiple linear regression analysis showed that age, functional health literacy, interactive health literacy, and critical health literacy could explain 60.4% of the variation (adjusted R2= 0.583) of postoperative recovery quality of patients undergoing outpatient surgery.

CONCLUSION

Health literacy of patients undergoing outpatient surgery is an important factor that affects the quality of early postoperative recovery. The health literacy assessment scale can assist medical staff in implementing personalized perioperative nursing and health education.

Readability Analysis of Online Breast Cancer Surgery Patient Education Materials from National Cancer Institute-Designated Cancer Centers Compared with Top Internet Search Results

BACKGROUND

The National Institutes of Health (NIH) recommends patient education materials reflect the average reading grade level of the US population. Due to the importance of shared decision-making in breast cancer surgery, this study evaluates the reading level of patient education materials from National Cancer Institute-designated cancer centers (NCI-DCC) compared with top Internet search results.

METHODS

Online materials from NCI-DCC and top Internet search results on breast cancer, staging, surgical options, and pre- and postoperative expectations were analyzed using three validated readability algorithms: Simplified Measure of Gobbledygook Readability Formula, Coleman-Liau index, and Flesch-Kincaid grade level. Mean readability was compared across source groups and information subcategories using an unpaired t-test with statistical significance set at p < 0.05. Mean readability was compared using a one-way analysis of variance.

RESULTS

Mean readability scores from NCI-DCC and Internet groups ranged from a 9th-12th grade level, significantly above the NIH recommended reading level of 6th-7th grade. There was no significant difference between reading levels from the two sources. The discrepancy between actual and recommended reading level was most pronounced for "surgical options" at a 10th-12th grade level from both sources.

CONCLUSIONS

Patient education materials on breast cancer from both NCI-DCC and top Internet search results were written several reading grade levels higher than the NIH recommendation. Materials should be revised to enhance patient comprehension of breast cancer surgical treatment and guide patients in this important decision-making process to ultimately improve health outcomes.

Availability and Readability Level of Online Patient Education Materials Provided by Cleft Lip and Palate Teams

OBJECTIVES

Evaluate the readability of online English and Spanish cleft lip and palate patient education materials.

DESIGN

Review of free online materials.

SETTING

English and Spanish language online patient education materials on cleft lip and palate were collected from American Cleft Palate-Craniofacial Association (ACPA) approved teams.

PARTICIPANTS

American Cleft Palate-Craniofacial Association (ACPA) approved teams.

INTERVENTIONS

English materials were analyzed using the Flesch-Kincaid, SMOG, and Coleman-Liau readability calculators. Spanish materials were analyzed using the Fry Graph, Fernandez Huerta, and INFLESZ calculators. A one-way analysis of variance (ANOVA) was used to test for variability between the readability tools.

OUTCOMES

Readability levels were examined for both sets of materials.

RESULTS

171 (90.5%) teams provided English language materials online, with an average readability score calculated as 10.5 ± 2.9 (10th-11th grade). A total of 44 (23.2%) teams listed Spanish language materials online, with average readability score of 7.9 ± 1.2 (8th grade). ANOVA demonstrated statistically significant variability between the readability assessment tools (P < .01).

CONCLUSION

Online cleft lip and palate patient education material provided by ACPA craniofacial teams were more available in English than in Spanish. Both sets of materials demonstrated readability levels above the recommended 6th-7th grade. Refining readability is associated with lowered healthcare costs and increased patient satisfaction.

Readability of Online Information on the Latarjet Procedure

Introduction A common complication of first-time or recurrent shoulder dislocations is bone loss at the humeral head and glenoid. Recurrent shoulder instability is often a result of bony defects in the glenoid following shoulder dislocations. In the setting of glenoid bone loss, surgical interventions are generally required to restore stability. The Latarjet procedure is a challenging operation and, due to its complexity, may be associated with operative complications. It can be difficult to explain the procedure to patients in a manner that is easily comprehensible, which may lead to confusion or being overwhelmed with information. Hence, it is important that the information available to patients is easily accessible and perceivable to allow for adequate health literacy. Health literacy is defined as the ability to make health decisions in the context of everyday life. Methods The search engines Google and Bing were accessed on a single day in the month of July 2023, searching the terms "Latarjet surgery" and "Latarjet procedure." For each term on both search engines, the first three pages were evaluated, resulting in a total of 114 websites for review. Out of these, 25 websites met the inclusion criteria and underwent further in-depth analysis through the online readability software, WEB FX. This software generated a Flesch Reading Ease Score (FRES) and a Reading Grade Level (RGL) for each website. Results In our study, the mean FRES was 50.3 (SD ±12.5), categorizing the data as 'fairly difficult to read.' The mean RGL score was 8.12 (SD ±2.35), which exceeds the recommended target. Conclusion In conclusion, the results of this study have demonstrated that the material available on the Internet about the Latarjet procedure is above the recommended readability levels for the majority of the population. Our findings align with similar studies assessing the readability of online patient information. Based on these findings, physicians should provide patients with vetted information to facilitate a better understanding of the procedure, thereby enabling patients to make more informed decisions regarding their health.

A Readability Analysis of Online Spondylolisthesis and Spondylolysis Patient Resources Among Pediatric Hospital Web Pages: A US-Based Study

INTRODUCTION

With the increasing use of the internet for health information, it is essential to prioritize resources that match the reading level of patients and parents. Limited health literacy is a notable issue in the United States, creating a financial burden and negatively affecting patient outcomes. This study aimed to assess the availability and readability of pediatric hospital web pages concerning two prevalent spine conditions in children, spondylolisthesis and spondylolysis, specifically examining whether the available resources meet the recommended sixth grade reading level.

METHODS

A total of 179 pediatric hospital web pages were assessed for their availability and readability of spondylolisthesis and spondylolysis patient information. The web pages' readability was assessed using five readability formulae. Descriptive statistics and Student t-tests were performed on the collected scores with significance set at P < 0.05.

RESULTS

Among the analyzed hospitals, 40.2% had no information on spondylolisthesis or spondylolysis, 20.1% mentioned treating these conditions, 7.8% had < 100 dedicated words, and only 31.8% had dedicated web pages with more than 100 words on these conditions. The average reading grade level for the evaluated web pages was 12.0, indicating a high school education level is required for comprehension. None of the web pages were written below the recommended sixth grade reading level.

DISCUSSION

The readability of the limited resources was markedly higher than the recommended reading level. In addition, this study emphasizes the need for enhanced accessibility and readability of online patient information from pediatric hospitals to improve parental comprehension and informed decision-making. Physicians should consider identifying online resources that they consider of high quality and acceptable readability to support better patient understanding and outcomes.

Total joint replacement in ambulatory surgery

Total joint arthroplasty is one of the most commonly performed surgical procedures in the United States, and projected numbers are expected to double in the next ten years. From 2018 to 2020, total hip and knee arthroplasty were removed from the United States' Center for Medicare and Medicaid Services "inpatient-only" list, accelerating this migration to the ambulatory setting. Appropriate patient selection, including age, body mass index, comorbidities, and adequate social support, is critical for successful ambulatory total joint arthroplasty. General anesthesia and neuraxial anesthesia are both safe and effective anesthetic choices, and recent studies in this population have found no difference in outcomes. Multimodal analgesia, including acetaminophen, nonsteroidal anti-inflammatory drugs, local infiltration analgesia, and peripheral nerve blocks, is the foundation for adequate pain control. Common reasons for "failure to launch" include postoperative urinary retention, postoperative nausea and vomiting, inadequate analgesia, and hypotension.

Persistence of Poverty and its Impact on Surgical Care and Postoperative Outcomes

OBJECTIVE

We sought to characterize the association between prolonged county-level poverty with postoperative outcomes.

BACKGROUND

The impact of long-standing poverty on surgical outcomes remains ill-defined.

METHODS

Patients who underwent lung resection, colectomy, coronary artery bypass graft, or lower extremity joint replacement were identified from Medicare Standard Analytical Files Database (2015-2017) and merged with data from the American Community Survey and the United States Department of Agriculture. Patients were categorized according to the duration of high poverty status from 1980 to 2015 [ie, never high poverty (NHP), persistent poverty (PP)]. Logistic regression was used to characterize the association between the duration of poverty and postoperative outcomes. Principal component and generalized structural equation modeling were used to assess the effect of mediators in the achievement of Textbook Outcomes (TO).

RESULTS

Overall, 335,595 patients underwent lung resection (10.1%), colectomy (29.4%), coronary artery bypass graft (36.4%), or lower extremity joint replacement (24.2%). While 80.3% of patients lived in NHP, 4.4% resided in PP counties. Compared with NHP, patients residing in PP were at increased risk of serious postoperative complications [odds ratio (OR)=1.10, 95% CI: 1.05-1.15], 30-day readmission (OR=1.09, 95% CI: 1.01-1.16), 30-day mortality (OR=1.08, 95% CI: 1.00-1.17), and higher expenditures (mean difference, $1010.0, 95% CI: 643.7-1376.4) (all P <0.05). Notably, PP was associated with lower odds of achieving TO (OR=0.93, 95% CI: 0.90-0.97, P <0.001); 65% of this effect was mediated by other social determinant factors. Minority patients were less likely to achieve TO (OR=0.81, 95% CI: 0.79-0.84, P <0.001), and the disparity persisted across all poverty categories.

CONCLUSIONS

County-level poverty duration was associated with adverse postoperative outcomes and higher expenditures. These effects were mediated by various socioeconomic factors and were most pronounced among minority patients.

Acceptability of surgical care in Uganda: a qualitative study on users and providers

OBJECTIVES

This study was conducted to assess acceptability of surgical care in Eastern Uganda and enable better allocation of resources, and to guide health policy towards increased surgical care seeking.

DESIGN

This qualitative study used semistructured in-depth interviews that were transcribed and analysed by coding according to grounded theory.

SETTING

The study was set in Eastern Uganda in the districts of Jinja, Mayuge, Kamuli, Iganga, Luuka, Buikwe and Buvuma.

PARTICIPANTS

Interviews were conducted with 32 past surgical patients, 16 community members who had not undergone surgery, 17 healthcare professionals involved in surgical treatment and 7 district health officers or their deputies.

RESULTS

The five intersecting categories that emerged were health literacy, perceptions, risks and fears, search for alternatives, care/treatment and trust in healthcare workers. It was also demonstrated that considering the user and provider side at the same time is very useful for a more extensive understanding of surgical care-seeking behaviour and the impact of user-provider interactions or lack thereof.

CONCLUSION

While affordability and accessibility are well defined and therefore easier to assess, acceptability is a much less quantifiable concept. This study breaks it down into tangible concepts in the form of five categories, which provide guidance for future interventions targeting acceptability of surgical care. We also demonstrated that multiple perspectives are beneficial to understanding the multifactorial nature of healthcare seeking and provision.

Health Literacy Awareness Among Orthopaedic Surgery Residents: A COERG Survey

Musculoskeletal health literacy (HL) is an emerging concept in orthopaedic patient care. Estimated rates of low musculoskeletal HL in patients surpass those of general HL. Studies in other specialties suggest that medical trainees are ill equipped to interact with low HL patients, often with detrimental patient outcomes. The purpose of this study was to (1) establish the current state of HL awareness among orthopaedic surgery trainees, (2) characterize the current state of HL training in orthopaedic surgery programs, and (3) evaluate the desire for formalized HL training among orthopaedic surgery trainees.

Methods

This study was endorsed by the Collaborative Orthopaedic Education Research Group board. A 17-item questionnaire was administered anonymously to orthopaedic residents through a secure online platform in the 2020 to 2021 academic year. All participation was voluntary.

Results

One hundred ninety-two residents (42%) from 19 orthopaedic programs completed the survey. Most residents felt "somewhat comfortable" with issues related to HL. Most residents reported no specific training in HL issues during residency (77.5%). Of the 43 residents (22.3%) who did receive formal training, most of these individuals felt that the training is effective (N = 42, 97.7%). Role playing/standardized patient encounters were reported as the most effective form of HL training. Residents felt it was somewhat important to receive formal HL training in residency (median = 4.0, interquartile range = 3.0-5.0), and there was a modest desire for formalized training (39%).

Discussion

This study is the first to characterize orthopaedic resident perceptions of HL issues in practice and training. Residents were somewhat confident in their understanding of HL concepts, and those who received formal training felt it was effective. However, there remains a low rate of formal orthopaedic resident training in HL issues, which may be an area for improvement in orthopaedic training paradigms.

Comparison Between ChatGPT and Google Search as Sources of Postoperative Patient Instructions

This qualitative study rates the level of understandability, actionability, and procedure-specific content in postoperative instructions generated from ChatGPT, Google Search, and Stanford University.

Hip and Knee Total Joint Arthroplasty Online Resources for Patients and Health Care Professionals: A Canadian Environmental Scan

Purpose:

To appraise the quality of publicly available online Canadian resources for patients with hip or knee osteoarthritis considering total joint arthroplasty (TJA) and health care professionals participating in TJA decision-making processes.

Method:

An environmental scan. Two independent authors appraised: a) patient resources against the International Patient Decision Aids Standards (IPDAS) criteria and the Patient Education Material Evaluation Tool (PEMAT); and b) health care professional resources against six appropriateness criteria for TJA and eight elements of shared decision-making. Analysis was descriptive.

Results:

Of 84 included resources, 71 were for patients, 11 for health care professionals, and 2 for both. For patient resources, the median number of IPDAS defining criteria met was 2 of 7, median PEMAT understandability score was 83%, and median PEMAT actionability score was 60%. For health care professional resources, the median number of appropriateness criteria was 3 of 6, and the median number of shared decision-making elements was 3 of 8.

Conclusions:

Only four of 73 patient resources were structured to help patients consider their options and reach a decision based on their preferences. Health care professional resources were limited to traditional criteria for determining TJA appropriateness (evidence of osteoarthritis, use of conservative treatments) and poorly met key elements of shared decision-making.

Orthopaedic trauma patient non-adherence to follow-up visits at a level 1 trauma center serving an urban and rural population

OBJECTIVE

To assess key demographic and psychosocial variables that may be associated with non-adherence to clinic visits following orthopaedic trauma injuries to patients in an urban and rural population.

METHODS

This retrospective review included all operative and non-operative patients presenting to a Level I academic trauma center serving an urban and rural population in the Midwest following an orthopaedic injury. The study tracked patient attendance to scheduled orthopaedic trauma follow-up clinic visits after a scheduled visit in the clinic following a trauma-related injury.

RESULTS

Data were obtained for 5816 unique orthopaedic trauma patients who had 21,066 post-treatment follow-up visits scheduled. 1627 "no-show" appointments were recorded. Factors associated with no-shows included male sex, age between 26 and 35 years, self-reported race other than white, employment listed as disabled, household income below $25,000, education less than a high school level, uninsured, Medicaid insured, and relationship status reported as single.

CONCLUSIONS

In the present study, key demographic and psychosocial factors were significantly associated with patient adherence to scheduled follow-up appointments after treatment for orthopaedic trauma. Identifying patients at higher risk for nonadherence will allow healthcare teams to educate patients, providers, and staff, link patients to resources to enhance adherence, and work with their institutions to develop and implement protocols for improving adherence to follow-up appointments.

Economic and educational disparities are associated with an increased risk of revision surgery following shoulder arthroplasty

BACKGROUND

There is limited literature exploring how nonmedical factors such as social determinants of health (SDOHs) are associated with postoperative outcomes following shoulder arthroplasty.

METHODS

A retrospective cohort review of the Pearl Diver Database was used to capture patients undergoing either primary anatomic total or reverse shoulder arthroplasty from the fourth quarter of 2015 to the third quarter of 2019 with at least 1 year of active longitudinal follow-up. Patients with proximal humeral fractures, stress fractures, or septic arthritis were excluded. The included patients were then divided into 2 cohorts based on the presence of current SDOHs or a history of SDOHs. The SDOH cohort comprised 4 non-mutually exclusive categories: economic, educational, social, and environmental disparities. Subsequently, a control cohort was matched at a 1:1 ratio to the SDOH cohort. Primary outcome measures were assessed using a logistic regression and consisted of the following 90-day postoperative complications: minor and major medical complications and infection. Emergency department (ED) visits and readmissions for any cause were also assessed. Additionally, the following 1-year outcomes were assessed: aseptic loosening, instability, and revision arthroplasty. Surgical costs and 90-day postoperative costs were collected using averaged insurance reimbursements for both the control and SDOH cohorts.

RESULTS

There were 5190 patients in each cohort. Economic disparities made up the largest portion of the SDOH cohort (n = 4631, 89.2%), followed by social (n = 741, 14.3%), environmental (n = 417, 8.0%), and educational (n = 99, 1.9%) disparities. Compared with the control cohort, SDOHs were associated with an increased risk of major complications (2.3% vs. 1.4%; odds ratio [OR], 1.55; 95% confidence interval [CI], 1.29-1.87; P < .001), minor complications (5.7% vs. 3.8%; OR, 1.62; 95% CI, 1.21-1.95; P = .001), readmissions (4.3% vs. 2.8%; OR, 1.56; 95% CI, 1.26-1.84; P < .001), and ED visits (15.2% vs. 11.0%; OR, 1.45; 95% CI, 1.29-1.63; P < .001) within 90 days following surgery. Additionally, SDOHs were associated with an increased risk of aseptic loosening (1.1% vs. 0.6%; OR, 1.85; 95% CI, 1.20-2.65; P = .006), instability (4.0% vs. 2.2%; OR, 1.80; 95% CI, 1.43-2.28; P < .001), and ipsilateral revision (9.2% vs. 7.6%; OR, 1.24; 95% CI, 1.08-1.43; P < .001) at 1 year postoperatively compared with the control cohort.

CONCLUSION

SDOHs are associated with increased rates of adverse outcomes following shoulder arthroplasty including revision surgery, ED visits, length of stay, and overall cost compared with matched controls without SDOHs. Specifically, economic and educational disparities are associated with increased rates of adverse outcomes following surgery including revision surgery, ED visits, length of stay, and overall cost.

Evaluating first year residents' communication skills: a health literacy curriculum needs assessment

BACKGROUND

High quality communication skills are necessary for competent and ethical practice. When patients present with low health literacy, physicians' skills may be lacking, which can put patients' safety and satisfaction at risk. The authors' developed and executed a simulation-based needs assessment following conflicting internal reports about the communications skills of new residents.

METHODS

The current study recruited first year residents (N = 30) during the 2019 first post-graduate year (PGY-1) orientation at a southeastern university hospital simulation center. The residents completed an Objective Structured Clinical Examination (OSCE) which focused on obtaining informed consent from a patient's health care proxy who presented with limited literacy and health literacy and poor communication skills. After completing the OSCE, the residents, simulated patients (SP), and independent observers assessed the residents' performance.

RESULTS

Residents assessed their performance higher when compared with the ratings from independent observers and patient raters. Residents who spent more time with SPs were given higher ratings by the SPs and independent observers. Finally, residents' ratings of themselves had a positive correlation with their reported confidence, but no correlation between self-confidence and the ratings provided by SPs or observers.

CONCLUSION

PGY-1 residents demonstrate a continued need for health literacy and informed consent education, despite faculty believing that these skills were covered enough in medical school. These residents also demonstrated limited self-assessment ability or skills below the expectations of health literacy experts. Curriculum changes included improving the focus on health literacy, communication skills, and additional practice opportunities throughout their internship year.

Is Preferred Language Other Than English Associated With Delayed Surgery After ACL Injury in Children and Adolescents?

BACKGROUND

Previous studies have investigated the impact of social determinants of health, such as the type of healthcare insurance and household income, on children and adolescents with ACL tears. However, despite the increasing incidence of ACL injury in young patients and a substantial proportion of families who may prefer languages other than English, the relationship between language and clinical care remains unclear.

QUESTIONS/PURPOSES

To investigate the relationship between language and the care of children and adolescents with ACL tears, we asked: (1) Is a preferred language other than English (PLOE) associated with a delay between ACL injury and surgery? (2) Is a PLOE associated with a greater odds of a patient experiencing a meniscal tear and undergoing a meniscectomy than in those who prefer English?

METHODS

We treated 591 patients surgically for ACL injuries between 2011 and 2021. Of those, we considered patients aged 18 years or younger who underwent primary ACL reconstruction for this retrospective, comparative study. Five percent (31 of 591) of patients were excluded because the date of injury was not clearly documented, 2% (11 of 591) were revision reconstructions, and 1% (6 of 591) underwent procedures that were intentionally delayed or staged, leaving 92% (543 of 591) for analysis. The mean age was 16 ± 2 years, and 51% (276 of 543) of patients were boys. The family's preferred language was noted, as were demographic data, time between injury and surgery, and intraoperative findings. A language other than English was preferred by 21% (113 of 543) of patients. Of these, 94% (106 of 113) preferred Spanish. In a univariate analysis, we used independent-samples t-tests, Mann-Whitney U-tests, and Fisher exact tests, as appropriate. Purposeful-entry multivariable regression analyses were used to determine whether PLOE was associated with increased time to surgery, concomitant meniscus injury, or performance of meniscectomy while adjusting for confounding variables. Variables were included in multivariable models if they met the threshold for statistical significance in univariate testing (p < 0.05).

RESULTS

The median time between injury and ACL reconstruction was shorter in families who preferred English compared with those with a PLOE (69 days [IQR 80] versus 103 days [IQR 107)]; p < 0.001). After controlling for potentially confounding variables like insurance and age, we found that patients whose families had a PLOE had greater odds of undergoing surgery more than 60 days after injury (OR 2.2 [95% CI 1.3 to 3.8]; p = 0.005) and more than 90 days after injury (OR 1.8 [95% CI 1.1 to 2.8]; p = 0.02). After controlling for insurance, age, and other factors, PLOE was not associated with surgical delay beyond 180 days, concomitant meniscal tears, or performance of meniscectomy.

CONCLUSION

In this study of children and adolescents undergoing primary ACL reconstruction, patients whose families prefer a language other than English experienced a longer delay between injury and surgery. In areas with a large proportion of families with a PLOE, partnerships with primary care clinicians, emergency departments, schools, athletic teams, and community organizations may improve efficiency in the care of children with ACL injuries. Clinicians proficient in other languages, reliable interpreter services, and translated references and resources may also be impactful. Our results suggest a need for further research on the experiences, needs, and long-term outcomes of these patients, as well as the association of preferred language with results after surgery.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Socioeconomic status influences participation in cancer prehabilitation and preparation for surgical recovery: A pooled retrospective analysis using a validated area-level socioeconomic status metric

BACKGROUND

Prehabilitation employs exercise, nutrition, and psychological interventions to optimize physiological status in preparation for surgery. First, we described the extent to which material deprivation index score (MDIS) influenced prehabilitation participation. Second, we evaluated the extent to which prehabilitation influenced recovery as compared to control.

METHODS

Pooled patient records from prospective multimodal prehabilitation studies in oncologic surgery were retrospectively examined. Patient postal codes were linked to their MDIS, a validated area-level socioeconomic status (SES) metric, as quintiles 1-5 (1 = highest SES). Functional capacity was evaluated with the 6-min walking test (6MWT) at baseline, before, and 8 weeks post-surgery. Influence of prehabilitation on length of hospital stay (LOS) was explored using generalized linear models with a negative binomial distribution adjusted for age, sex, surgical population, and MDIS.

RESULTS

Recruitment records were available from 2014 onwards, yielding 1013 eligible patients for prehabilitation participation with MDIS data. Fewer patients with a low SES enrolled (Q1:62% vs. Q5:47%; P = 0.01) and remained in prehabilitation studies (Q1: 59% vs. Q5: 45%; P = 0.07). Prehabilitation study records were available from 2008 onward, yielding 886 enrolled patients with MDIS data (n = 510 prehabilitation, n = 376 control). Preoperative 6MWT similarly improved by > 20 m in response to prehabilitation across SES strata (P < 0.05). Postoperative 6MWT could not be evaluated due to substantial missing data. Prehabilitation had a significant protective influence on LOS, as compared to control, in unadjusted and adjusted models [adjusted IRR:0.77 (95% CI:0.68 to 0.87; P < 0.001].

CONCLUSION

Findings suggest that prehabilitation is effective across all SES; however, participation across SES quintiles was not equal. Barriers to participation must be identified and addressed. Once these barriers are addressed, prehabilitation may reduce surgical disparities among SES.

Readability of Online Patient Education Materials for Total Joint Arthroplasty: A Systematic Review

BACKGROUND

As the demand for total joint arthroplasty continues to grow, patients increasingly turn to internet sources for accessible orthopaedic health information. We sought to evaluate the readability of online hip and knee arthroplasty patient education materials (PEMs).

METHODS

Our systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-P guidelines (PROSPERO registration of the study protocol: CRD42022358872, September 19th, 2022). PubMed, EBSCOhost, Medline, and Google Scholar electronic databases were utilized to identify all studies evaluating online PEMs related to total joint arthroplasty between January 1, 2000, and August 1, 2022. The quality of studies was assessed with the Joanna Briggs Institute scale.

RESULTS

Our initial search yielded 360 publications which were then screened for appropriate studies aligned with our review's purpose. A total of eleven cross-sectional studies were included. The total sample size across the studies consisted of 662 PEMs. Five studies evaluated professional or academic orthopaedic websites, six evaluated PEMs through web engines, and three evaluated apps or commercial websites. Most included studies found PEMs to be well above the recommended 6th-grade reading level.

CONCLUSION

Arthroplasty PEMs produced by orthopaaedic websites, web searches, and apps have readability scores well above the recommended levels. Given the importance of health literacy on patient outcomes and satisfaction, work needs to be done to improve the readability of these materials.

Area Deprivation Index is Associated with Variation in Quality of Life and Psychosocial Well-being Following Breast Cancer Surgery

BACKGROUND

Neighborhood-level factors have been shown to influence surgical outcomes through material deprivation, psychosocial mechanisms, health behaviors, and access to resources. To date, no study has examined the relationship between area-level deprivation (ADI) and post-mastectomy outcomes.

METHODS

A cross-sectional survey of adult female breast cancer patients who underwent lumpectomy or mastectomy between January 2018 to June 2019 was carried out. Patient-specific characteristics and ADI information were abstracted and correlated with postoperative global- (SF-12) and condition-specific (BREAST-Q) quality-of-life performance via multivariable regression. Patients were classified into three ADI terciles: 0-39 (low deprivation), 40-59 (moderate deprivation), and 60-100 (high deprivation).

RESULTS

A total of 564 consecutive patients were identified, being mostly white (75%) with mean age of 60.2 ± 12.4 years, median body mass index of 27.8 [interquartile range (IQR) 24.3-32.2) kg/m², median Charlson Comorbidity Index of 3 (IQR 2-5), and mean ADI of 42.3 ± 25.7. African American and Hispanic patients and those with high BMI were more likely to reside in highly deprived neighborhoods (p = 0.003 and p < 0.001). In adjusted models, patients in highly deprived neighborhoods had significantly lower mean SF-12 physical (44.9 [95% CI, 43.8-46.0] versus 44.9 [95% CI, 43.7-46.1] versus 46.3 [95% CI, 45.3-47.3], p = 0.03) and BREAST-Q psychosocial well-being scores (63.5 [95% CI, 59.32-67.8] versus 69.3 [95% CI, 65.1-73.6] versus 69.7 [95% CI, 66.4-73.1], p = 0.01) relative to moderate- and low-deprivation groups.

CONCLUSIONS

Patients residing in the most deprived neighborhoods were identified to have worse psychological well-being and quality-of-life. The ADI should be incorporated into the shared decision-making process and perioperative counseling to engender value-based and personalized care, especially for vulnerable populations.

Racial disparities in minimally invasive esophagectomy and gastrectomy for upper GI malignancies

BACKGROUND

Esophageal cancer and gastric cancer are two important causes of upper GI malignancies. Literature has shown that minimally invasive esophagectomies (MIE) and gastrectomies (MIG), have shorter length of stay and fewer complications. However, limited literature exists about the association between race and access to MIE and MIG. This study aims to identify the racial disparities in the different approaches to esophagectomy and gastrectomy. We further evaluate the relationship between the race and postoperative complications.

METHODS

This IRB-approved retrospective study utilized data from the American College of Surgeons National Quality Improvement Program. All recorded cases of MIE, MIG, open gastrectomy, and esophagectomy between 2012 and 2019 were isolated. Propensity score matching and univariate analysis was performed to assess the independent effect of black self-identified race on access and outcomes. p < 0.05 was required to achieve statistical significance.

RESULTS

7891 cases of esophagectomy and 5,132 cases of gastrectomy cases were identified. Using Propensity and logistic regression, we identified that black self-reported race is an independent predictor of open approach to gastrectomy (OR 1.6871943, 95% CI 1.431464-1.989829, p < 0.001). Black self-reported race was not predictive of operative approach among esophagectomy patients (OR 0.7942576, 95% CI 0.5698645-1.124228, p = 0.183). In contrast, black self-reported is an independent predictor of postoperative complications among esophagectomy patients only. Esophagectomy patients of black self-reported race were more likely to experience any complication (OR 1.4373437, 95% CI 1.1129239-1.8557096, p = 0.00537), severe complications (OR 1.3818966, 95% CI 1.0653087-1.7888454, p = 0.0144), and death (OR 2.00779762, 95% CI 1.08034921-3.56117535, p = 0.0211) within 30 days of their surgeries.

CONCLUSION

Our analysis revealed a significant racial disparity in access to MIG and a higher incidence of post-operative complications amongst esophagectomy patients. Minimally invasive techniques are underutilized in racial minorities. The findings herein warrant further investigation to eliminate barriers and disparities.

Low health literacy is associated with worse postoperative outcomes following hepato-pancreato-biliary cancer surgery

BACKGROUND

Low health literacy (HL) can lead to worse health outcomes for patients with chronic diseases and could also lead to worse postoperative outcomes. This retrospective cohort study investigates the association between HL and postoperative textbook outcome (TO) after hepato-pancreato-biliary (HPB) cancer surgery.

METHODS

Patients that consented and underwent surgery for a premalignant andmalignant HPB tumor were included. Preoperatively, HL was measured by the brief health literacy screen (BHLS). Patients were categorized as having low or adequate HL. Primary outcome was TO (length of hospital stay (LOS) ≤ 75th percentile; and no severe complication; and no readmission and mortality within 30 days after discharge). Secondary outcomes were LOS and emergency department (ED) visits within 30 days after discharge.

RESULTS

In total, 137 patients were included, of whom thirty-six patients had low HL. In patients with low HL (vs. adequate HL), rate of TO was lower (55.6% vs. 72.3%; p = 0.095), LOS was significantly longer (13.5 vs. 9 days; p = 0.007) and there was only a slight difference in ED visits (14.3% vs. 11.0%; p = 0.560). Patients with low HL had a significant lower chance of achieving TO (OR 0.400, 95%-CI 0.169-0.948; p = 0.037).

CONCLUSION

Low HL leads to worse postoperative outcome after HPB cancer surgery. Better preoperative education and guidance of patients with low HL could lead to better postoperative outcomes. Therefore, HL could be the next modifiable risk factor before major surgery.

Social Determinants of Health Disparities are Associated with Increased Costs, Revisions, and Infection in Patients Undergoing Arthroscopic Rotator Cuff Repair

PURPOSE

The purpose of this study was to use a national claims database to assess the impact of pre-existing social determinants of health disparities (SDHD) on postoperative outcomes following rotator cuff repair (RCR).

METHODS

A retrospective review of the Mariner Claims Database was used to capture patients undergoing primary RCR with at least 1 year of follow-up. These patients were divided into two cohorts based on the presence of a current or previous history of SDHD, encompassing educational, environmental, social, or economic disparities. Records were queried for 90-day postoperative complications, consisting of minor and major medical complications, emergency department (ED) visits, readmission, stiffness, and 1-year ipsilateral revision surgery. Multivariate logistic regression was employed to assess the impact of SDHD on the assessed postoperative outcomes following RCR.

RESULTS

58,748 patients undergoing primary RCR with a SDHD diagnosis and 58,748 patients in the matched control group were included. A previous diagnosis of SDHD was associated with an increased risk of ED visits (OR 1.22, 95% CI 1.18-1.27; P < .001), postoperative stiffness (OR 2.53, 95% CI 2.42-2.64; P < .001), and revision surgery (OR 2.35, 95% CI 2.13-2.59; P < .001) compared to the matched control group. Subgroup analysis revealed educational disparities had the greatest risk for 1-year revision (OR 3.13, 95% CI 2.53-4.05; P < .001).

CONCLUSIONS

The presence of a SDHD was associated with an increased risk of revision surgery, postoperative stiffness, emergency room visits, medical complications, and surgical costs following arthroscopic RCR. Overall, economic and educational SDHD were associated with the greatest risk of 1-year revision surgery.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Patients' expectations and experiences of provided surgery-related patient education: A descriptive longitudinal study

AIMS

The aim of this study was to explore the educational expectations and experiences of surgical patients.

DESIGN

Prospective, longitudinal, descriptive and two-centre study. Data were collected with questionnaires at the hospital and 6 weeks and 6 months postsurgery.

METHODS

Patients undergoing elective surgery and hospitalized overnight from January to July 2016 answered questions about the content of received pre-operative and pre-discharge education, topics they wanted more information on, sources of information, satisfaction with and usefulness of the information and if their recovery was as expected.

RESULTS

Patients (N = 697, 49% male, mean age 64.1 [SD 12.6] years) perceived the provided education as useful and satisfactory but less so after discharge. Most common topics which they expected more education about were postoperative complications, pain management, fatigue, lack of stamina and expected recovery time. Most patients received information through face-to-face teaching (79.7%) and in writing (78.4%). Expectations on recovery were related to patients' satisfaction with the education and how useful they evaluated it.

Statistical Literacy in the Orthopaedic Trauma Population

OBJECTIVE

To evaluate the baseline level and demographic predictors of statistical literacy in orthopaedic patients who sustained traumatic injuries.

DESIGN

Prospective observational.

SETTING

Level 1 trauma center.

PATIENTS

One hundred ninety-eight patients presenting to the orthopaedic trauma clinic.

INTERVENTION

Berlin Numeracy Test (BNT) and General Health Numeracy Test-6 (GHNT-6).

RESULTS

When assessed using the BNT, 67% of patients had results that placed them into the lowest quartile of objective numeracy skills. Only 3.5% of patients had results that scored in the top quartile. Our multivariate ordinal regression model demonstrated lower education level ( P = 0.01), and older age ( P = 0.03) were significant predictors of poor performance on the BNT. The mean score on the GHNT-6 was 36% (SD 30%).

CONCLUSIONS

In a cohort of traumatically injured patients, poor statistical literacy was common, occurring in more than two-thirds of patient surveyed. Older age and lower levels of education were predictive of poor BNT performance and should be considered when discussing surgical options, associated risks, and likelihood of potential complications.

The role of digital health interventions to improve health literacy in surgical patients: a narrative review in arthroplasty

BACKGROUND

Arthroplasty is a high-volume but costly treatment option for advanced osteoarthritis. Health literacy and patient education are modifiable factors that can improve patient outcomes in arthroplasty. Digital technologies show potential as an instrument for providing patients with reliable information. This narrative review aimed to identify the current evidence for how effective digital health interventions (DHIs) are in targeting health literacy and related constructs (including knowledge, decision-making and self-efficacy) in arthroplasty.

METHODS

Six databases were searched for published studies comprising health literacy and related constructs, arthroplasty, and DHIs. The main outcome measure was health literacy. Two reviewer-authors independently screened studies according to predefined inclusion criteria and performed data extraction. Data was analysed and summarized in tabular and narrative form.

RESULTS

Two thousand seven-hundred and sixty-four titles and abstracts were screened. One hundred and sixty-seven papers underwent full-text analysis. No studies used health literacy as an outcome measure; therefore, the outcome measure was broadened to include its constructs, and the full-text analysis was repeated. Thirteen studies were included. No study following a structured design for their DHI. Eleven studies demonstrated participant improvement in constructs of health literacy, including knowledge, decision-making and self-management.

CONCLUSION

Current evidence suggests digital technology may provide new means of educating patients and improving aspects of their health literacy. More research digital technology with a structured approach, framework and standardized measures is required. Well-designed digital technology may become a useful adjunct to future patient care.

Translator use not associated with longer time to pain medication in initial evaluation of low-severity geriatric trauma

OBJECTIVES

Determine whether geriatric victims of blunt trauma who preferred to communicate in a language other than English waited longer for pain medication or received more imaging studies than English-speaking patients with the same age and injuries. Secondary outcomes were the type of medication administered and number of imaging studies.

METHODS

We conducted a retrospective analysis of all trauma activations to a single academic urban medical center from January 2019 to October 2019. We included all hemodynamically stable patients older than 65, with head or torso trauma after a low energy injury, and on at least one medication that was an anti-coagulant, anti-platelet, or chemotherapeutic.

RESULTS

We identified 1,153 unique patients (17, 379 radiologic studies) performed from January 2019 to October 2019, with a median of 5 (4-6) radiologic studies per patient. We excluded 419 patients for whom the language used was not reported (n = 7), no imaging was not reported (n = 16), or no medication was recorded as given (n = 409), leaving 734 patients for further analysis. Of those 734 patients, 460 preferred to communicate in English, 84 in Mandarin Chinese, 64 in Spanish, 37 in Cantonese Chinese, and 35 in Korean, and 29 in Russian. Across all languages patient age and Injury Severity Score (ISS) were comparable. Those who preferred to communicate in Spanish, Russian, or Korean were more likely to be female than those who preferred English, Mandarin, or Cantonese, but this tendency was not statistically significant (χ²-test; p = 0.051, 0.15 after Bonferroni correction). We did not find a statistically significant association between preferred language and time to medication, fraction of opioids used as first-line pain medication, or number of imaging studies performed. Across all patients, the most common medications administered were acetaminophen (524/734, 71%), any opioid (111/734, 15%), followed by local infiltration or nerve block with lidocaine (49/734, 6.7%).

CONCLUSIONS

A retrospective analysis of patients with low-risk blunt trauma found no relationship between preferred language, time to pain medication, use of opioids or number of imaging studies.

Overcoming Health Literacy Barriers by Developing Standardized Surgical Discharge Instructions

INTRODUCTION

Approximately one-third of surgical patients exhibit low health literacy, and 39% of our patients are primary Spanish speakers. We first evaluated the current content of our arteriovenous fistula/graft discharge instruction (DCI) templates. Using the Plan-Do-Study-Act cycle quality improvement methodology, we then aimed to optimize the readability and formally translate new DCI and evaluate usage and inappropriate bouncebacks following implementation.

METHODS

Current arteriovenous fistula/graft template content was reviewed by the literacy department for readability and vascular faculty for completeness and accuracy. The literacy department edits were categorized by word choice, added/removed content, format change, and grammatical errors. Two vascular surgeons rated completeness and accuracy on a Likert scale (1-5). Retrospective chart review was performed for telephone calls and emergency department bouncebacks for 3 mo flanking new DCI implementation.

RESULTS

Of the 10 templates, all were in English and word count ranged from 192 to 990 words. Despite each template including all necessary subcategories, the median number of edits per 100 words was 9.2 [7.0-9.5]. Approximately half of the edits (5.4 [5.1-5.5]) were word choice edits. Overall, experts rated completeness at 3.9 [3.2-4.2] and accuracy at 4.0 [3.7-4.1]. Highest template utilization occurred during post-implementation months 1 (90%) and 3 (100%) with orientation sessions. There was a significant increase in concordant Spanish DCI use (P < 0.01) and no inappropriate bouncebacks after implementation.

CONCLUSIONS

Our study demonstrated notable variability in the content and readability of our vascular access instruction templates. New DCI had strong usage and language concordance; continued use may decrease bouncebacks.

Characterizing the impact of verbal communication and health literacy in the patient-surgeon encounter

BACKGROUND

Patients with limited health literacy (HL) have difficulty understanding written/verbal information. The quality of verbal communication is not well understood. Therefore, our aim was to characterize patient-surgeon conversations and identify opportunities for improvement.

METHODS

New colorectal patient-surgeon encounters were audio-recorded and transcribed. HL was measured. Primary outcomes were rates-of-speech, understandability of words, patient-reported understanding, and usage of medical jargon/statistics. Secondary outcomes included length-of-visit (LOV), conversation possession time, patient-surgeon exchanges, and speech interruptions.

RESULTS

Significant variations existed between surgeons in rates-of-speech and understandability of words (p < 0.05). Faster rates-of-speech were associated with significantly less understandable words (p < 0.05). Patient-reported understanding varied by HL and by surgeon. Conversation possession time and usage of medical jargon/statistics varied significantly by surgeon (p < 0.05) in addition to patient-surgeon exchanges and interruptions. Patients with limited HL had shorter LOV.

CONCLUSIONS

Significant variations exist in how surgeons talk to patients. Opportunities to improve verbal communication include slowing speech and using more understandable words.

How could perioperative anxiety be addressed via surgical team communication approaches? Findings from a scoping review

OBJECTIVES

Surgical patients and their families experience high rates of perioperative anxiety, which determine a negative impact on their surgery-related outcomes. Understanding what communicational aspects positively impact perioperative anxiety may help promote more efficient, patient-centered communication approaches which could address this issue. The aim of this scoping review was to synthesize published research on communication between surgical employees and adult patients and their relatives, and its role in managing perioperative anxiety.

METHODS

A scoping review approach was used across four international databases to search for publications detailing communicational interventions and approaches employed in surgical contexts and their impact on surgical patients' and their caregivers' perioperative anxiety levels. Results were narratively synthesized.

RESULTS

Twenty-two studies were included in this scoping review, which were grouped according to their communication intervention into one of five categories: technology-assisted interventions, interpersonal communication, educational programs, tools for facilitating exchange of information and theory-derived communication strategies. Records reported mixed results in terms of reducing perioperative anxiety. Facilitating and hindering factors in interpersonal communication in this context were further synthesized.

CONCLUSION

A multitude of communicational approaches and their effect on anxiety have been investigated within surgical settings, with varying results. Existing evidence suggests that it is vital to address surgical patients' anxiety through personalized empathetic communication, tailored to an individual's case, preferences, and needs. Key aspects of patient-healthcare professional communication which may impact perioperative anxiety were identified and may be utilized in future trainings for communication skills among surgical teams.

Testing of a Risk-Standardized Complication Rate Electronic Clinical Quality Measure (eCQM) for Total Hip and/or Total Knee Arthroplasty

Supported by the Centers for Medicare & Medicaid Services (CMS), Brigham and Women's Hospital (BWH) has retooled the existing claims-based measures NQF1550 and NQF3493 into an electronic clinical quality measure (eCQM) to assess the risk-standardized complication rate (RSCR) following elective primary total hip (THA) and knee arthroplasty (TKA) at the clinician group level. This novel eCQM includes risk-adjustment for social determinants of health, includes all adult patients from all payers, leverages electronic health records (EHRs) rather than claims-based data, and includes both inpatient and outpatient procedures and complications which offers benefits compared to existing metrics. Following testing in two geographically different healthcare systems, the overall risk-standardized complication rate within 90 days following THA and TKA at the two sites was 3.60% (Site 1) and 3.70% (Site 2). This measure is designed for use in the Merit-Based Incentive Payment System (MIPS).

Development of four electronic clinical quality measures (eCQMs) for use in the Merit-based Incentive Payment System (MIPS) following elective primary total hip and knee arthroplasty

The Centers for Medicare & Medicaid Services (CMS) supported Brigham and Women's Hospital (BWH) Center for Patient Safety, Research, and Practice to retool one existing National Quality Forum (NQF) endorsed clinical quality measure (CQM) measure into an electronic clinical quality measure (eCQM) and develop three new eCQMs related to orthopedic care. This manuscript details the iterative process of measure development through environmental scans and stakeholder feedback prior to testing at two geographically different sites. The four measures under development are the: Risk Standardized Complication Rate (RSCR), Risk Standardized Venous Thromboembolism and Major Bleeding Rate (VTE/Bleeding), Risk Standardized Prolonged Opioid Prescribing Rate (POP), and the Risk Standardized Inpatient Respiratory Depression Rate (IRD).

Public understanding of female genital anatomy and pelvic organ prolapse (POP); a questionnaire-based pilot study

INTRODUCTION AND HYPOTHESIS

Health literacy underpins informed consent and shared decision-making. In gynaecology, this includes understanding of normal anatomy and urogenital disease. This study evaluated public knowledge of external female genital anatomy and pelvic organ prolapse (POP).

METHODS

A questionnaire study asked participants for their demographics and to label a female external genitalia diagram and included free-text questions on POP, its symptoms and treatment. Questionnaires were distributed at general outpatient (OPD) and urogynaecology (UG) departments at a UK teaching hospital. Differences in the number of correct anatomy labels between participant genders were assessed via chi-squared tests and, within female participants, multivariable linear and logistic regressions assessed associations with increasing correct anatomical labels and an understanding (versus no understanding) of POP, respectively.

RESULTS

Within 191 (n = 160 OPD, n = 31 UG), 9/103 (9%) labelled all anatomical structures correctly. Females had more correct labels (median 1, IQR 0,3) versus males (median 0, IQR 0,1), P = 0.022). Higher education (vs. < secondary) and white ethnicity were associated with greater numbers of correct labels [coefficient (95% CI): 1.05 (0.14, 1.96), P = 0.024, 1.45 (0.58, 2.33), P = 0.001 respectively]. Fifty-three per cent understood POP. POP understanding increased with increasing age, white ethnicity (OR: 4.38, 95% CI: 1.36, 14.08, P = 0.013) and more correct anatomy labels (OR: 1.43, 95% CI 1.14, 1.79, P = 0.002). Of those who understood POP, only 35% identified "bulge" as a symptom and 7% physiotherapy as a treatment option.

CONCLUSION

There was poor public understanding of external female genital anatomy and POP, which may have significant implications for health-seeking, shared decision-making and informed consent.