Set Patient Expectations Research Articles

Electronic Patient-Reported Symptoms After Ambulatory Cancer Surgery

Complex cancer procedures are now performed in the ambulatory surgery setting. Remote symptom monitoring (RSM) with electronic patient-reported outcomes (ePROs) can identify patients at risk for acute hospital encounters. Defining normal recovery is needed to set patient expectations and optimize clinical team responses to manage evolving problems in real time. To describe the patterns of postoperative recovery among patients undergoing ambulatory cancer surgery with RSM using an ePRO platform-the Recovery Tracker. In this retrospective cohort study, patients who underwent 1 of 5 of the most common procedures (prostatectomy, nephrectomy, mastectomy, hysterectomy, or thyroidectomy) at the Josie Robertson Surgery Center at Memorial Sloan Kettering Cancer Center from September 2016 to June 2022. Patients completed the Recovery Tracker, a brief ePRO platform assessing symptoms for 10 days after surgery. Data were analyzed from September 2022 to May 2023. Symptom severity and interference were estimated by postoperative day and procedure. A total of 12 433 patients were assigned 110 936 surveys. Of these patients, 7874 (63%) were female, and the median (IQR) age at surgery was 57 (47-65) years. The survey response rate was 87% (10 814 patients responding to at least 1 of 10 daily surveys). Among patients who submitted at least 1 survey, the median (IQR) number of surveys submitted was 7 (4-8), and each assessment took a median (IQR) of 1.7 (1.2-2.5) minutes to complete. Symptom burden was modest in this population, with the highest severity on postoperative days 1 to 3. Pain was moderate initially and steadily improved. Fatigue was reported by 6120 patients (57%) but was rarely severe. Maximum pain and fatigue responses (very severe) were reported by 324 of 10 814 patients (3%) and 106 of 10 814 patients (1%), respectively. The maximum pain severity (severe or very severe) was highest after nephrectomy (92 of 332 [28%]), followed by mastectomy with reconstruction (817 of 3322 [25%]) and prostatectomy (744 of 3543 [21%]). Nausea (occasionally, frequently, or almost constantly) was common and experienced on multiple days by 1485 of 9300 patients (16%), but vomiting was less common (139 of 10 812 [1%]). Temperature higher than 38 °C was reported by 740 of 10 812 (7%). Severe or very severe shortness of breath was reported by 125 of 10 813 (1%). Defining detailed postoperative symptom burden through this analysis provides valuable data to inform further implementation and maintenance of RSM programs in surgical oncology patients. These data can enhance patient education, set expectations, and support research to allow iterative improvement of clinical care based on the patient-reported experience after discharge.

Nephrologists’ perspectives on communication and decision-making regarding technique survival in peritoneal dialysis: an international qualitative interview study

ObjectivesPeritoneal dialysis (PD) allows patients increased autonomy and flexibility; however, both infectious and non-infectious complications may lead to technique failure, which shortens treatment longevity. Maintaining patients on PD remains a...

Social Media Posts About Carpal Tunnel Release: A Cross-Sectional Analysis of Patient and Surgeon Perspectives.

Social media provides an increasingly popular, unfiltered source of perspectives on healthcare. The objective of this study is to characterize the landscape of social media posts regarding carpal tunnel release (CTR). Content was queried from Instagram between February 2, 2019 to August 12, 2021 using the hashtags #carpaltunnelrelease and #carpaltunnelsurgery. The 1500 most-liked posts were analyzed. Poster demographics including age, gender, region, and symptom qualities and post characteristics including type, number, timing relative to surgery, tone, and satisfaction were collected. Categorical variables were compared utilizing chi-squared test. Univariate and multivariate regression were performed. The most popular post types included single photo (55.2%), multiple photos (18.8%), or single video (18.2%). Of all, 70.6% posts had fewer than 50 "likes." Patients accounted for 51.8% of posts, followed by surgeons (13.3%), other health care providers (11.7%), and physical therapists (8.8%). Women (66.7%) outnumbered men (33.3%). Fifty-five percent of posts were domestic. Posts mostly depicted postoperative care (85.6%). The most frequently mentioned symptoms were pain, burning, numbness, and tingling. Of all posts, 45.1% had a positive tone, 49.1% neutral, and 5.7% negative. Univariate analysis revealed that posters who were patients, underwent open CTR, and were female were more likely to post negative sentiments. Most posts regarding CTR are from patients, are postoperative, and are positive or neutral. Although rare, negative posts were more likely to originate from posters who are patients, female, or underwent open CTR. With this information, surgeons will be better prepared to address patient concerns, set patient expectations, and enter the social media themselves.

Risk Factors Associated With Poor Outcomes After Quadriceps Tendon Repair.

Ruptures of the quadriceps tendon present most frequently in older adults and individuals with underlying medical conditions. To examine the relationship between patient-specific factors and tear characteristics with outcomes after quadriceps tendon repair. Case-control study; Level of evidence, 3. A retrospective review was conducted on all patients who underwent quadriceps tendon repair between January 1, 2016, and January 1, 2021, at a single institution. Patients <18 years and those with chronic quadriceps tendon tears (>6 weeks to surgery) were excluded. Information was collected regarding patient characteristics, presenting symptoms, tear characteristics, physical examination findings, and postoperative outcomes. Poor outcome was defined as a need for revision surgery, complications, postoperative range of motion of (ROM) <110° of knee flexion, and extensor lag of >5°. A total of 191 patients met the inclusion criteria. Patients were aged 58.5 ± 13.2 years at the time of surgery, were predominantly men (90.6%), and had a mean body mass index (BMI) of 32.2 ± 6.3 kg/m2. Patients underwent repair with either suture anchors (15.2%) or transosseous tunnels (84.8%). Postoperatively, 18.5% of patients experienced knee flexion ROM of <110°, 11.3% experienced extensor lag of >5°, 8.5% had complications, and 3.2% underwent revision. Increasing age (odds ratio [OR], 1.03 [95% CI, 1.004-1.07]) and female sex (OR, 3.82 [95% CI, 1.25-11.28]) were significantly associated with postoperative knee flexion of <110°, and increasing age (OR, 1.08 [95% CI, 1.04-1.14]) and greater BMI (OR, 1.14 [95% CI, 1.05-1.23]) were significantly associated with postoperative extensor lag of >5°. Current smoking status (OR, 15.44 [95% CI, 3.97-65.90]) and concomitant retinacular tears (OR, 9.62 (95% CI, 1.67-184.14]) were associated with postoperative complications, and increasing age (OR, 1.05 [95% CI, 1.02-1.08]) and greater BMI (OR, 1.08 [95% CI, 1.02-1.14]) were associated with risk of acquiring any poor outcome criteria. Patient-specific characteristics-such as increasing age, greater BMI, female sex, retinacular involvement, and current smoking status-were found to be risk factors for poor outcomes after quadriceps tendon repair. Further studies are needed to identify potentially modifiable risk factors that can be used to set patient expectations and improve outcomes.

Proximal Interphalangeal Joint Fractures: Various Approaches to Fixation.

There are numerous operative and nonoperative options for the management of proximal interphalangeal joint fractures and fracture dislocations. The treatment of choice should be guided by the fracture pattern and joint stability. The authors highlight a contemporary option for open reduction and internal fixation techniques, but all the techniques presented are viable options under the right circumstances. It is also important to set patient expectations as most of these patients will note post-injury stiffness and potential functional limitations.

Leveraging web-based prediction calculators to set patient expectations for elective spine surgery: a qualitative study to inform implementation

BackgroundPrediction calculators can help set outcomes expectations following orthopaedic surgery, however effective implementation strategies for these tools are unknown. This study evaluated provider and patient perspectives on clinical implementation of web-based prediction calculators developed using national prospective spine surgery registry data from the Quality Outcomes Database.MethodsWe conducted semi-structured interviews in two health systems, Vanderbilt University Medical Center (VUMC) and Duke University Health System (DUHS) of orthopedic and neurosurgery health care providers (VUMC: n = 19; DUHS: n = 6), health care administrators (VUMC: n = 9; DUHS: n = 9), and patients undergoing elective spine surgery (VUMC: n = 16). Qualitative template analysis was used to analyze interview data, with a focus on end-user perspectives regarding clinical implementation of web-based prediction tools.ResultsHealth care providers, administrators and patients overwhelmingly supported the use of the calculators to help set realistic expectations for surgical outcomes. Some clinicians had questions about the validity and applicability of the calculators in their patient population. A consensus was that the calculators needed seamless integration into clinical workflows, but there was little agreement on best methods for selecting which patients to complete the calculators, timing, and mode of completion. Many interviewees expressed concerns that calculator results could influence payers, or expose risk of liability. Few patients expressed concerns over additional survey burden if they understood that the information would directly inform their care.ConclusionsInterviewees had a largely positive opinion of the calculators, believing they could aid in discussions about expectations for pain and functional recovery after spine surgery. No single implementation strategy is likely to be successful, and strategies vary, even within the same healthcare system. Patients should be well-informed of how responses will be used to deliver better care, and concerns over how the calculators could impact payment and liability should be addressed prior to use. Future research is necessary to determine whether use of calculators improves management and outcomes for people seeking a surgical consult for spine pain.

Does a public online IVF prediction tool help set patient expectations? A mixed methods evaluation study.

Does a public online IVF success prediction calculator based on real-world data help set patient expectations? The YourIVFSuccess Estimator aided consumer expectations of IVF success: one quarter (24%) of participants were unsure of their estimated IVF success before using the tool; one half changed their prediction of success after using the tool and one quarter (26%) had their expectations of IVF success confirmed. Several web-based IVF prediction tools exist worldwide but have not been evaluated for their impact on patient expectations, nor for patient perceptions of usefulness and trustworthiness. This is a pre-post evaluation of a convenience sample of 780 online users of the Australian YourIVFSuccess Estimatorhttps://yourivfsuccess.com.au/ between 1 July and 31 November 2021. Participants were eligible if they were over 18 years of age, Australian residents, and considering IVF for themselves or their partner. Participants filled in online surveys before and after using the YourIVFSuccess Estimator. The response rate of participants who completed both surveys and the YourIVFSuccess Estimator was 56% (n = 439). The YourIVFSuccess Estimator aided consumer expectations of IVF success: one quarter (24%) of participants were unsure of their estimated IVF success before using the tool; one half changed their prediction of success after using the tool (20% increased, 30% decreased), bringing their predictions in line with the YourIVFSuccess Estimator, and one quarter (26%) had their IVF success expectations confirmed. One in five participants claimed they would change the timing of IVF treatment. The majority of participants found the tool to be at least moderately trustworthy (91%), applicable (82%), and helpful (80%), and would recommend it to others (60%). The main reasons given for the positive responses were that the tool is independent (government funded, academic) and based on real-world data. Those who did not find it applicable or helpful were more likely to have had a worse-than-expected prediction, or to have experienced non-medical infertility (e.g. single women, LGBTQIA+), noting that at the time of evaluation the Estimator did not accommodate these patient groups. Those who dropped out between the pre- and post-surveys tended to have a lower education status or have been born outside of Australia or New Zealand, therefore there may be issues with generalizability. With consumers demanding increasing levels of transparency and participation in decisions around their medical care, public-facing IVF predictor tools based on real-world data are useful for aligning expectations about IVF success rates. Given differences in patient characteristics and IVF practices internationally, national data sources should be used to inform country-specific IVF prediction tools. The YourIVFSuccess website and evaluation of the YourIVFSuccess Estimator are supported by the Medical Research Future Fund (MRFF) Emerging Priorities and Consumer Driven Research initiative: EPCD000007. BKB, ND, and OF have no conflicts to declare. DM holds a clinical role at Virtus Health. His role did not influence the analysis plan or interpretation of results in this study. GMC is an employee of the UNSW Sydney, and Director of the UNSW NPESU. UNSW receives research funding on behalf of Prof Chambers from the MRFF to develop and manage the Your IVF Success website. Grant ID: MRFF Emerging Priorities and Consumer Driven Research initiative: EPCD000007. N/A.

Association of upper-limb neurological recovery with functional outcomes in high cervical spinal cord injury.

High cervical spinal cord injury (SCI) results in complete loss of upper-limb function, resulting in debilitating tetraplegia and permanent disability. Spontaneous motor recovery occurs to varying degrees in some patients, particularly in the 1st year postinjury. However, the impact of this upper-limb motor recovery on long-term functional outcomes remains unknown. The objective of this study was to characterize the impact of upper-limb motor recovery on the degree of long-term functional outcomes in order to inform priorities for research interventions that restore upper-limb function in patients with high cervical SCI. A prospective cohort of high cervical SCI (C1-4) patients with American Spinal Injury Association Impairment Scale (AIS) grade A-D injury and enrolled in the Spinal Cord Injury Model Systems Database was included. Baseline neurological examinations and functional independence measures (FIMs) in feeding, bladder management, and transfers (bed/wheelchair/chair) were evaluated. Independence was defined as score ≥ 4 in each of the FIM domains at 1-year follow-up. At 1-year follow-up, functional independence was compared among patients who gained recovery (motor grade ≥ 3) in elbow flexors (C5), wrist extensors (C6), elbow extensors (C7), and finger flexors (C8). Multivariable logistic regression evaluated the impact of motor recovery on functional independence in feeding, bladder management, and transfers. Between 1992 and 2016, 405 high cervical SCI patients were included. At baseline, 97% of patients had impaired upper-limb function with total dependence in eating, bladder management, and transfers. At 1 year of follow-up, the largest proportion of patients who gained independence in eating, bladder management, and transfers had recovery in finger flexion (C8) and wrist extension (C6). Elbow flexion (C5) recovery had the lowest translation to functional independence. Patients who achieved elbow extension (C7) were able to transfer independently. On multivariable analysis, patients who gained elbow extension (C7) and finger flexion (C8) were 11 times more likely to gain functional independence (OR 11, 95% CI 2.8-47, p < 0.001) and patients who gained wrist extension (C6) were 7 times more likely to gain functional independence (OR 7.1, 95% CI 1.2-56, p = 0.04). Older age (≥ 60 years) and motor complete SCI (AIS grade A-B) reduced the likelihood of gaining independence. After high cervical SCI, patients who gained elbow extension (C7) and finger flexion (C8) had significantly greater independence in feeding, bladder management, and transfers than those with recovery in elbow flexion (C5) and wrist extension (C6). Recovery of elbow extension (C7) also increased the capability for independent transfers. This information can be used to set patient expectations and prioritize interventions that restore these upper-limb functions in patients with high cervical SCI.

Piloting a tool for informed consent comprehension in a cardiovascular clinical trial in South Africa: An IMPI-2 pilot trial substudy (ICC Study)

Background. Informed consent is a key requirement in research. However, the comprehension of information presented is rarelyevaluated prior to or during the research. Ensuring that participants understand the key issues in trials is important, not just forethical reasons, but also because it can help set patient expectations. We evaluated the feasibility of using the University of California Brief Assessment of Capacity to Consent (UBACC) questionnaire to guide informed consent comprehension in the pilot study for the second Investigation of the Management of Pericarditis in Africa (IMPI-2) trial. IMPI-2 is a randomised control trial (RCT) on the use of alteplase-facilitated pericardial drainage, compared with routine care among patients with large pericardial effusion. We used an abbreviated version of the UBACC to evaluate participant comprehension of key elements of the consent documentation and to guide discussions.Method. Comprehension was assessed using a 10-item UBACC at baseline, 6 weeks, 3 months and 6 months follow-up to reiterate the information about the trial. Each response was scored from 0 to 3 and the sum at each visit was recorded to represent comprehension. A UBACC score ≥25 was considered adequate comprehension. Bivariate logistic regression was performed to evaluate comprehension over time. A multivariate analysis was conducted to identify predictors of UBACC score.Results. The Informed Consent Comprehension (ICC) Study included 71 participants with a median age of 42 years; 45% were females and 49% had at least a secondary level of education. Level of comprehension improved with time; the odds of passing the evaluation at baseline compared with 6 months was higher (odds ratio (OR) 1.39, 95% confidence interval (CI) 1.17 - 1.65, p&lt;0.001). Not using interpreters and having a secondary level of education were associated with higher comprehension. Despite knowing that they were participating in research, many participants still did not accept that the trial drug may have no effect.Conclusion. It is feasible to use the UBACC questionnaire for informed consent comprehension evaluation in RCTs. Repeated learning during follow-up improves comprehension over time, while a low level of education and use of interpreters reduces comprehension.

Derivation and Validation of a Clinical Prediction Rule for Upper Limb Functional Outcomes After Traumatic Cervical Spinal Cord Injury

Traumatic cervical spinal cord injury (SCI) can result in debilitating paralysis. Following cervical SCI, accurate early prediction of upper limb recovery can serve an important role in guiding the appropriateness and timing of reconstructive therapies. To develop a clinical prediction rule to prognosticate upper limb functional recovery after cervical SCI. This prognostic study was a retrospective review of a longitudinal cohort study including patients enrolled in the National SCI model systems (SCIMS) database in US. Eligible patients were 15 years or older with tetraplegia (neurological level of injury C1-C8, American Spinal Cord Injury Association [ASIA] impairment scale [AIS] A-D), with early (within 1 month of SCI) and late (1-year follow-up) clinical examinations from 2011 to 2016. The data analysis was conducted from September 2021 to June 2022. The primary outcome was a composite of dependency in eating, bladder management, transfers, and locomotion domains of functional independence measure at 1-year follow-up. Each domain ranges from 1 to 7 with a lower score indicating greater functional dependence. Composite dependency was defined as a score of 4 or higher in at least 3 chosen domains. Multivariable logistic regression was used to predict the outcome based on early neurological variables. Discrimination was quantified using C statistics, and model performance was internally validated with bootstrapping and 10-fold cross-validation. The performance of the prediction score was compared with AIS grading. Data were split into derivation (2011-2014) and temporal-validation (2015-2016) cohorts. Among 2373 patients with traumatic cervical SCI, 940 had complete 1-year outcome data (237 patients [25%] aged 60 years or older; 753 men [80%]). The primary outcome was present in 118 patients (13%), which included 92 men (78%), 83 (70%) patients who were younger than 60 years, and 73 (62%) patients experiencing AIS grade A SCI. The variables significantly associated with the outcome were age (age 60 years or older: OR, 2.31; 95% CI, 1.26-4.19), sex (men: OR, 0.60; 95% CI, 0.31-1.17), light-touch sensation at C5 (OR, 0.44; 95% CI, 0.44-1.01) and C8 (OR, 036; 95% CI, 0.24-0.53) dermatomes, and motor scores of the elbow flexors (C5) (OR, 0.74; 95% CI, 0.60-0.89) and wrist extensors (C6) (OR, 0.61; 95% CI, 0.49-0.75). A multivariable model including these variables had excellent discrimination in distinguishing dependent from independent patients in the temporal-validation cohort (C statistic, 0.90; 95% CI, 0.88-0.93). A clinical prediction score (range, 0 to 45 points) was developed based on these measures, with higher scores increasing the probability of dependency. The discrimination of the prediction score was significantly higher than from AIS grading (change in AUC, 0.14; 95% CI, 0.10-0.18; P < .001). The findings of this study suggest that this prediction rule may help prognosticate upper limb function following cervical SCI. This tool can be used to set patient expectations, rehabilitation goals, and aid decision-making regarding the appropriateness and timing for upper limb reconstructive surgeries.

Laryngology Outcomes Following Implantable Vagus Nerve Stimulation

Vagus nerve stimulation (VNS) devices have gained widespread acceptance for treatment of resistant epilepsy and depression. The increasing number of procedures has resulted in an increasing number of iatrogenic injuries to the vagus nerve, which can have a significant effect on vocalization and quality of life. To determine the relative frequency of laryngeal adverse effects reported to the US Food and Drug Administration (FDA) after VNS implantation and to analyze associated VNS device problems. This retrospective cross-sectional analysis queried the FDA Manufacturer and User Facility Device Experience database of adverse events in the US between 1996 and 2020. The primary outcome was the percent of adverse events reported to the FDA that included patients who received VNS with laryngeal adverse effects and the associated proportion of device problems after VNS surgery. A total of 12 725 iatrogenic vagus nerve issues were documented after VNS implantation, with apnea (n = 395; 3.1%) being the most common patient problem. Overall, 187 reports of laryngeal adverse effects associated with VNS devices were identified and represented the eighth most common iatrogenic vagus nerve problem reported to the FDA. Laryngeal adverse effects included 78 reports of voice alteration and 57 reports of paresis/paralysis. The VNS device problems frequently associated with laryngeal adverse effects were high impedance (n = 15, 8.02%), incorrect frequency delivery (n = 10, 5.35%), and battery problems (n = 11, 5.88%). The number of laryngeal adverse effect reports per year peaked in 2012 with 43 cases. This cross-sectional study found that although the literature demonstrates that vocal changes occur with nearly all VNS devices, the FDA receives adverse event reports of voice changes. Our results emphasize a potential need to improve patient counseling prior to VNS surgery to better set patient expectations regarding vocal changes and to prevent unnecessary patient concern. In addition, reports of vocal fold paresis/paralysis potentially suggest that patients may benefit from preoperative laryngeal assessment to differentiate preexisting vocal fold paralysis from that caused by VNS surgery.

Patient Perspectives after Trapeziectomy and Ligament Reconstruction Tendon Interposition: A Qualitative Analysis.

The authors aimed to explore patients' perioperative experience after trapeziectomy and ligament reconstruction tendon interposition through semistructured patient interviews to identify deficiencies in preoperative patient counseling. The authors conducted semistructured interviews with 14 patients who had undergone ligament reconstruction tendon interposition either 10 to 14 weeks or 9 to 12 months postoperatively at the time of their interview. The semistructured interview guide was developed by a fellowship-trained hand surgeon and a qualitative research specialist to discuss each patient's perioperative experience. Inductive and deductive qualitative coding strategies were used to develop a codebook. All transcripts were then double-coded and discussed to develop recurrent major themes from the patient interviews. The authors' interviews identified three major themes discussed consistently on the patient perioperative experience. First, despite specific counseling about a 3- to 6-month postoperative rehabilitation period, patients were still surprised at the length of the recovery process in regaining function, range of motion, and strength. Second, patients repeatedly outlined that surgery on the dominant hand imparted specific limitations that made the postoperative course difficult. Third, patients discussed the importance of hand therapy both in rehabilitation and in guiding patient postoperative expectations. Preoperative counseling is of vital importance to set patient expectations in terms of overall expected outcomes, but also regarding early limitations, expectations, and overall recovery length. These themes have influenced how we counsel our patients about recovery after thumb carpometacarpal surgery and may help other surgeons identify areas for improvement in their discussions with patients.

Fluctuation of visual analog scale pain scores and opioid consumption before and after total hip arthroplasty.

BACKGROUNDPatients who undergo orthopedic procedures are often given excess opioid medication. Understanding the relationship between pain and opioid consumption following total hip arthroplasty (THA) is key to creating safe and effective opioid prescribing guidelines. AIMTo evaluate the association between the quantity of opioid consumption in relation to pain scores both pre-and postoperatively in patients undergoing primary THA.METHODSWe retrospectively reviewed patients who underwent primary THA from November 2018-May 2019 and answered both the visual analog scale (VAS) pain and opioid medication questionnaires pre-and postoperatively. Both surveys were delivered daily for 7-days before surgery through the first 30 postoperative days. Survey results were divided into preoperative, postoperative days 1-7, postoperative days 8-14, and postoperative days 15-30 for analysis. Mean opioid pill consumption and VAS pain scores in each time period were determined and compared to patients’ preoperative status using hierarchical Poisson and linear regressions, respectively.RESULTSThere were 105 patients included. Mean VAS pain scores were the highest preoperatively 7.41 ± 1.72. However, VAS pain scores significantly declined in each successive postoperative category compared to preoperative scores: postoperative day 1-7 (5.07 ± 1.79; P < 0.001), postoperative day 8-14 (3.60 ± 1.64; P < 0.001), and postoperative day 15-30 (3.15 ± 1.63; P < 0.001). Mean opioid pill consumption preoperatively was 0.68 ± 1.29 pills. Compared to preoperative opioid consumption, opioid use was significantly greater between postoperative days 1-7 (1.51 ± 1.58; P = 0.001) and postoperative days 8-14 (1.00 ± 1.27; P = 0.043). Opioid consumption declined below preoperative levels between postoperative days 15-30 (0.35 ± 0.72; P = 0.160) which correlates with a VAS pain score of 3.15. CONCLUSIONAll patients experienced significant benefit and pain relief from having undergone THA. Average postoperative opioid consumption decreased below preoperative consumption between postoperative days 15-30, which was associated with a VAS pain score of 3.15. These results can be used to appropriately guide opioid prescribing practices and set patient expectations regarding pain management following THA.

Putting Patients First: Patient Experience in the Perioperative Setting

Background Information One of our hospital's mottos is “We Put Patients First”. Being a “patient-forward” hospital requires us to anticipate patient's needs and wants, as well as correct the inevitable road bumps that can occur. Although this is part of our everyday practice, one way to prove this is through patient surveys. However, providing high quality care during a pandemic has left many feeling overwhelmed and underappreciated. Hospital led attempts at morale boosting exercises fall short. As staff, we're aware that patient experience is linked to staff morale. Objectives of Project: Our objective is to boost patient experience while also boosting staff morale. Staff is encouraged to put so much focus on patient and family experience that it feels more scripted than genuine. We aim to keep the care staff has for patients intrinsic. Process of Implementation Group discussions were held to identify factors of patient dissatisfaction. Common patient questions and concerns were acknowledged. All perioperative staff initiated interventions to set patient and family expectations, including reinforcement of visitation policies and regular patient progress updates. Extensive procedural education was also provided in the preoperative unit. A Press Ganey (PG) eSurvey flyer was placed in every preoperative patient bay to encourage feedback, if said survey was emailed to them. “Thank an Employee” signage was predominantly displayed in both perioperative units, as well as in postop discharge envelopes. Statement of Successful Practice Two PG data points are our focus: “Nurses’ Response to Concerns/Questions” and “How Well the Staff Work Together to Care for You”. Feedback shows that nurses are more responsive (4.8 point increase) after three months. They also feel that staff doesn't work well together (1.6 point decrease), which can be attributed to continuing staff shortages. The number of glowing emails are also on the rise, which are disseminated during weekly huddles. Implications for Advancing the Practice of Perianesthesia Nursing Working in a hospital setting requires staff to have a combination of empathy, sympathy, and compassion. By allowing staff to be proactive and alleviate common known patient issues, these innate virtues are allowed to shine. By giving the patients a forum to freely express themselves, their appreciation can be reflected back to the staff, improving the experience of all involved. One of our hospital's mottos is “We Put Patients First”. Being a “patient-forward” hospital requires us to anticipate patient's needs and wants, as well as correct the inevitable road bumps that can occur. Although this is part of our everyday practice, one way to prove this is through patient surveys. However, providing high quality care during a pandemic has left many feeling overwhelmed and underappreciated. Hospital led attempts at morale boosting exercises fall short. As staff, we're aware that patient experience is linked to staff morale. Objectives of Project: Our objective is to boost patient experience while also boosting staff morale. Staff is encouraged to put so much focus on patient and family experience that it feels more scripted than genuine. We aim to keep the care staff has for patients intrinsic. Group discussions were held to identify factors of patient dissatisfaction. Common patient questions and concerns were acknowledged. All perioperative staff initiated interventions to set patient and family expectations, including reinforcement of visitation policies and regular patient progress updates. Extensive procedural education was also provided in the preoperative unit. A Press Ganey (PG) eSurvey flyer was placed in every preoperative patient bay to encourage feedback, if said survey was emailed to them. “Thank an Employee” signage was predominantly displayed in both perioperative units, as well as in postop discharge envelopes. Two PG data points are our focus: “Nurses’ Response to Concerns/Questions” and “How Well the Staff Work Together to Care for You”. Feedback shows that nurses are more responsive (4.8 point increase) after three months. They also feel that staff doesn't work well together (1.6 point decrease), which can be attributed to continuing staff shortages. The number of glowing emails are also on the rise, which are disseminated during weekly huddles. Working in a hospital setting requires staff to have a combination of empathy, sympathy, and compassion. By allowing staff to be proactive and alleviate common known patient issues, these innate virtues are allowed to shine. By giving the patients a forum to freely express themselves, their appreciation can be reflected back to the staff, improving the experience of all involved.

Conversion Total Knee Arthroplasty.

Conversion total knee arthroplasty (TKA) represents a heterogeneous group of procedures and most commonly includes TKA performed after ligamentous reconstruction, periarticular open reduction and internal fixation (ORIF), high tibial osteotomy (HTO), and unicompartmental knee arthroplasty (UKA). Relative to patients undergoing primary TKA, patients undergoing conversion TKA often have longer operative times and higher surgical complexity, which may translate into higher postoperative complication rates. There is mixed evidence on implant survivorship and patient-reported outcome measures when comparing conversion TKA and primary TKA, with some studies noting no differences between the procedures and others finding decreased survivorship and outcome scores for conversion TKA. By gaining an improved understanding of the unique challenges facing patients undergoing conversion TKA, clinicians may better set patient expectations, make intraoperative adjustments, and guide postoperative care.

Changes in health-related quality of life outcomes in older patients with kidney cancer: A longitudinal cohort analysis with matched controls

BackgroundCurrent evidence regarding health-related quality of life (HRQoL) changes among patients with kidney cancer (KC) is limited. We characterized HRQoL changes from before (baseline) to after (follow-up) diagnosis of KC in older Americans relative to matched controls, and identified sociodemographic and clinical factors associated with HRQoL changes in older patients with KC. Materials and MethodsThis longitudinal, population-based, retrospective cohort study used data from Surveillance, Epidemiology and End Results linked with Medicare Health Outcomes Survey, 1998–2013. Participants aged ≥65 years with baseline and follow-up survey data were identified. Those with primary KC (n = 186) were matched to adults without cancer (n = 558). HRQoL (physical component summary and mental component summary [MCS]) changes in KC patients were compared using generalized linear mixed-effects models to those of controls. Regression models were used to identify baseline factors associated with HRQoL changes. ResultsThe adjusted least squares mean (95% confidence interval) reduction in physical component summary from baseline to follow-up was greater in KC patients vs. controls (−4.1 [−5.6, −2.7] vs. −2.3 [−3.1, −1.4], P = 0.025). While the reduction in MCS was similar in both groups (−2.4 [−3.9, −0.8] vs. −1.5 [−2.4, −0.6], P = 0.338). Lower income and distant stage KC predicted greater declines in MCS among KC patients. ConclusionKC significantly affects overall general health in older patients, with sociodemographic factors and distant KC predicting greater reductions in HRQoL. Findings may help clinicians set patient expectations about their HRQoL post-diagnosis and increase clinician awareness of risk factors for HRQoL deterioration.

High Acuity of Postoperative Consults to Emergency General Surgery at an Urban Safety Net Hospital

BackgroundEmergency general surgery (EGS) has high rates of morbidity, mortality, and readmission. Therefore, it might be expected that an EGS service fields many consultations for postoperative patients. However, with the known overutilization of emergency department visits for nonurgent conditions, we hypothesized most postoperative consults received by an EGS service would be nonurgent and could be appropriately managed as an outpatient. MethodsWe reviewed all EGS consults at a single urban safety net hospital over a 12-month period, screening for patients who had undergone surgery in the previous 12 mo. This included consultations from the emergency room and inpatient setting. Demographics, admission status, procedures performed, and other details were abstracted from the chart and Vizient reports. Consultation questions were categorized and then reviewed by an expert panel to determine if conditions could have been managed as an outpatient. ResultsThe EGS service received a total of 1112 consults, with 99 (9%) for a postoperative condition. Overall, 85% of postoperative consults were admitted after consultation, 19% underwent surgery and 21% underwent a procedure with gastroenterology or interventional radiology. Expert review classified slightly over one-third (36%) of consults as nonurgent. ConclusionsMost postoperative consults seen at our urban safety net hospital represent true morbidity that required admission, intervention, or surgery. Despite this high acuity, one-third of postoperative consults could have been managed as an outpatient. Efforts to improve discharge instructions and set patient expectations could limit unnecessary postoperative emergency department visits.

What Are Typical Outcomes Associated with Physical Therapy for Foot &amp; Ankle Patients?

Category:OutcomesIntroduction/Purpose:It is unclear whether patients attending physical therapy, post-op or for conservative care, achieve clinically important differences (CID) on the patient reported outcome information system (PROMIS) scales. Key PROMIS outcomes physical function (PF) and pain interference (PI) match well with treatments provided in physical therapy. Physical therapy may also influence depression (Dep). Documentation of PROMIS outcomes associated with physical therapy are useful to help set patient expectations. The purpose of this analysis was to document expected PROMIS PF, PI, and Dep outcomes after physical therapy for foot and ankle diagnoses by 1) reporting average improvement and 2) examining whether severity of symptoms (PROMIS Scales) at the start of physical therapy are associated with a 0.5 standard deviation (CID) improvement at the end of therapy.Methods:PROMIS scales were available at the start and end of physical therapy treatment for 377 patients with foot and ankle ICD10 codes. Clinical categories(>n=20) of patients were identified for 6 groups(n=309): Achilles Rupture(n=24), Fracture(n=34), Ankle Pain(n=105), Foot Pain(n= 50), Ankle Sprain(n=51), and Achilles Non-Rupture(n=45). ANOVA models followed by pairwise comparisons were used to assess differences between start and end scores for all patients (n=377) and across diagnoses (n=309). Minimal CID was defined as improvement of t-score 3-5 and CID as above 5 (0.5 SD) consistent with published data. PROMIS scales were also converted to 0.5 standard deviation(SD) increments to document proportions of patients with symptoms relative to normal of the US population at start and end of physical therapy. Chi-square analysis was used to examine the association of PROMIS symptoms PF and PI at the start and end of care in 0.5 SD increments.Results:Across ALL patients the largest improvements occurred in PF (6.5, p<0.01) followed by PI (3.9, P<0.01) and Dep (2.4, p<0.01). When evaluating diagnostic categories, all categories improved for PI (p<0.01), PF (p<0.05) and for Dep except for Ankle Pain (p=0.22). For PF, improvements ranged from 6.6 for Ankle Sprain to 3.3 for Achilles Non-Rupture. For PI improvements ranged from 11.1 for Achilles rupture to 4.6 for Achilles Non-Rupture. For both PF and PI there was a significant association of starting PF (p<0.01) and PI (p<0.01) score and end PF and PI scores. Patients with worse PF or PI in the midrange (55-65) at the start showed a higher percentage of patients achieving a 0.5 increment improvement at the end of therapy.Conclusion:Although many factors influence these outcomes, physical therapy for foot and ankle patients was associated with strong positive, clinically meaningful outcomes for a majority of patients as assessed during the episode of care. As expected improvements were greater for PF and PI as compared to Dep. Providers should consider more severe symptoms as a possible indication for physical therapy referral.

Preoperative Mental Health Scores and Achieving Patient Acceptable Symptom State Are Predictive of Return to Work After Arthroscopic Rotator Cuff Repair.

Background:The incidence of rotator cuff repairs has risen dramatically over the past 10 years, most notably in the working-class population. Return to work (RTW) is a valuable outcome measure to set patient expectations before surgery.Purpose:To establish the rate of RTW after rotator cuff repair with respect to stratified levels of occupational demand (sedentary, light, moderate, and heavy) and to identify clinical factors significantly associated with postoperative RTW.Study Design:Cohort study; Level of evidence, 3.Methods:Patients who received rotator cuff repair between 2014 and 2017 were queried from a prospectively maintained institutional registry. Work status was evaluated from clinical and physical therapy notes, and RTW was stratified based on duty level. The minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) values were calculated for American Shoulder and Elbow Surgeons (ASES) score and subjective Constant score through use of an anchor-based approach. Patient demographic factors, preoperative ASES scores, Constant scores, and health-related quality of life scores, as well as change in postoperative scores exceeding the thresholds for MCID, SCB, and PASS, were analyzed to determine significant associations with RTW without restriction.Results:In total, 89 patients with documented pre- and postoperative work status underwent surgery. Rates of RTW for sedentary, light, moderate, and heavy duties were 100%, 84.0%, 77.4%, and 63.3%, respectively, within return at less than 7 postoperative months on average. RTW was associated with achieving PASS (P = .004) but not achieving MCID and SCB (P = .429 and .452, respectively). Injury to a patient’s dominant side had reduced odds (0.057; 95% CI, 0.004-0.763; P = .030) for RTW at full duty. Tear characteristics and type of insurance were not associated with RTW. Preoperative Veterans RAND Mental Component Score (>53.3; area under the curve, 70.4%) was predictive of returning to work.Conclusion:A vast majority of patients undergoing rotator cuff repair can expect to return to work within 8 months of surgery. Preoperative mental health scores can predict future return to work, which supports the concept that mental health status plays an important role in the outcomes after rotator cuff repair surgery.

68. Early patient-reported outcomes can be used to identify patients at risk for poor 1-year outcomes in adult spinal deformity

BACKGROUND CONTEXT The progression of patient-reported outcomes (PRO) scores postoperatively in adult spinal deformity (ASD) is not well understood. Estimating when outcomes plateau and when minimum clinically important differences (MCIDs) are achieved could result in early identification of patients at risk for poor outcomes, and allow for early intervention. It may also help set patient expectations on when they will experience the benefits of surgery. This study examines the relationship between early and 1-year postoperative PROMIS outcomes scores. It further evaluates whether early assessments can predict failure to achieve PROMIS minimal clinically important differences (MCIDs) at 1 year. PURPOSE To determine whether failure to achieve MCIDs at 3 months leads to lower likelihood to achieve them after 1 year. STUDY DESIGN/SETTING Retrospective review. PATIENT SAMPLE Seventy-eight ASD patients. OUTCOME MEASURES PROMIS domains, achievement of MCIDs. METHODS Surgical ASD patients from 2015-2018 with 3-month and 1-year postoperative follow-up were evaluated. PROMIS scores were obtained preoperatively, at all follow-up appointments. PROMIS domains assessed were pain interference, physical function, anxiety, depression, fatigue, sleep disturbance and satisfaction with participation in social roles. First, we correlated assessments at 3 months to those at 1 year. Then, to determine whether failure to achieve MCIDs at 3 months postoperatively resulted in a lower likelihood to achieve them after 1 year, we performed a logistic regression for each PROMIS domain, adjusting for age, gender, race and preoperative scores. MCIDs used for this purpose, specifically computed for the ASD population, were: pain interference, -6.4; physical function, 4.8; anxiety, -6.5; depression, -5.7; fatigue, -6.4; sleep disturbance, -5.6; satisfaction with participation in social roles, 6.0. RESULTS Seventy-eight ASD patients (mean age 59.2 years) undergoing surgery for ASD were included. There were moderate correlations between 3-month and 1-year assessments in all domains (0.45 CONCLUSIONS Patients who fail to achieve PROMIS MCIDs by 3 months postoperatively are unlikely to achieve them after 1 year in domains of pain interference, physical function, anxiety and depression. Thus, early assessments allow identification of patients at risk for poor outcomes and present an opportunity for early intervention. They can also be used to set patient expectations after surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.