Set Patient Expectations Research Articles

Preoperative Radiographic Assessment Predicts Incomplete Cytoreduction in Patients with Low Grade Mucinous Adenocarcinoma of the Appendix.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) for patients with low-grade mucinous adenocarcinoma (LGMA) is most effective when complete cytoreduction is achieved. We externally validated two radiographic scoring systems to predict resectability and assessed radiographic response to systemic chemotherapy (SCT). Patients with LGMA who received preoperative SCT followed by CRS/HIPEC from 2013 to 2016 were identified. CT scans were graded by six physicians using the simplified radiologic score (SRS) and simplified preoperative assessment of appendiceal tumor (SPAAT) systems. Positive and negative predictive values (PPV, NPV) were calculated by comparing to completeness of cytoreduction. Inter-rater agreement was assessed using the intraclass correlation coefficient (ICC). Twenty-four patients had preoperative SCT followed by CRS/HIPEC. Thirteen patients underwent incomplete CRS and 11 patients complete CRS. Scoring of the preoperative CT had a PPV of complete cytoreduction of 75% and 66.7% for SRS and SPAAT, respectively. NPV was 83.4% and 88.9% for SRS and SPAAT, respectively. ICC for the preoperative SRS and SPAAT score was 0.826 (95% confidence interval [CI]: 0.720-0.910] and 0.788 [0.667-0.888). Comparison of CT scans before and after SCT recorded an increase in calculated scores in 45.8% (SRS) and 50% (SPAAT) of patients. External validation of two radiographic scoring systems to predict complete cytoreduction showed that inter-rater agreement for both systems was good. Both scoring systems predicted incomplete cytoreduction. Applying a systematic approach to preoperative imaging review is recommended to improve treatment selection by minimizing morbidity associated with incomplete CRS and help to set patient expectations.

Mobility bridges a gap in care: Findings from an early mobilisation quality improvement project in acute care.

To qualitatively evaluate an early mobilisation quality improvement project implemented on a general medicine unit. Early mobility quality improvement projects show promising quantitative results yet have failed to collect data from patient and staff experience associated with physical activity during illness and the impact of this change in clinical practice. A mixed methods case study was used to evaluate a mobility quality improvement project. Quantitative results will be published separately. The qualitative evaluation used a phenomenological lens to explore the patient and staff experience. Semi-structured interviews with twelve participants (four patients and eight staff) were performed during the project. Data were analysed using open coding, direct interpretation and then categorised into an overarching and four supporting themes. Findings are reported per the Standards for Reporting Qualitative Research. Participants reported that early mobilisation bridged a gap in care. Staff understood the benefits of early mobility. Patients expressed how mobility aligned with personal preferences and their need to prepare for hospital discharge. Greater functional independence and higher mobility levels in patients on the unit reduced staff level of care. When patients were consistently presented with opportunities to be mobile and active, they expected mobility to be a part of their daily care plan. Findings suggest that early mobility quality improvement projects have the potential to transform clinical practice and improve the quality of care for patients in acute care. All members of the healthcare team, including the patient, recognise the importance of maintaining mobility and function during hospitalisation yet focus on these needs are often delayed or missed. Early mobility quality improvement projects help to set patient expectations and build a culture that promotes patient mobility and function during acute illness.

Return to Sport and Exercise Following Repair of the Pectoralis Major Tendon

Objectives: Outcomes following repair of the pectoralis major muscle (PMM) is often prone to the ceiling effect due to the high functional demand of those that sustain this injury. A thorough evaluation of return to exercise and sport is beneficial to set patient expectations. Methods: A prospectively maintained institutional database was retrospectively reviewed for all patients undergoing PMM repair since 2010 with minimum 24-month follow-up. Patients were surveyed over phone with regard to preoperative and postoperative participation in sports, level of intensity, and maximum weight repetitions of barbell bench press, dumbbell bench press, dumbbell fly, and consecutive push-ups. American shoulder and elbow (ASES) and single assessment numeric evaluation (SANE) scores were also collected preoperatively and at final follow-up. Results: Forty-four patients (73.3%) were available for final follow-up. All patients were male. Mean follow-up was 51.1 ± 24.1 months. Mean age was 39.6 ± 8.8 and mean BMI was 28.6 ± 3.5. The dominant side was affected in 20/44 cases. The injury mechanism was reported to be during weightlifting in 59.1%, during sport in 20.5%, during work in 13.6%, and during accidental trauma in 6.8% of patients. There were statistically significant improvements in both ASES and SANE (p<0.001, respectively). Return to sport at any level was achieved by 43/44 (97.7%) patients, while 22/44 patients (50.0%) reported returning to sport at same or better intensity as pre-injury status. On average, there was a 23.3 ± 45.6% decrease in 1RM barbell bench press, 14.7 ± 62.3% decrease in 5RM barbell bench press, 24.3 ± 21.8% decrease in 1RM dumbbell bench press, 35.7 ± 32.1% decrease in 1RM dumbbell fly, and 15.6 ± 39.8% decrease in consecutive push-ups able to be performed (Figure 1). Seventeen patients (38.6%) reported degree of apprehension that affected their ability to lift weights. When accounting for all preoperative variables, history of surgery to the opposite shoulder (OR: 0.600, 95% CI: 0.389, 0.925) and acute repairs (OR: 0.745, 95% CI: 0.559, 0.993) were associated with decreased likelihood to return to sport at same or better level of intensity. Injury sustained during sport was associated with greater likelihood of returning to sport at same or better level (OR: 2.231, 95% CI: 0.389, 0.925) (Table 1). Conclusion: Patients undergoing repair of the PMM are expected to have significant improvements in function of the shoulder. Yet, roughly 50% achieve return to preoperative intensity of sport and there are significant reductions in ability to weightlift. Patients should be counseled to appropriately set expectation prior to surgery and rehabilitation. [Figure: see text][Table: see text]

Clinical and Radiographic Predictors of Acetabular Cartilage Lesions in Adolescents Undergoing Hip Arthroscopy

Background: Acetabular cartilage lesions are a known cause of poor outcomes after hip arthroscopy and are seen regularly among adolescents. However, studies identifying preoperative factors predictive of acetabular cartilage lesions have been limited to adult populations. Purpose: To assess clinical and radiographic predictors of acetabular cartilage lesions in a large cohort of adolescents undergoing hip arthroscopy. Study Design: Cohort study (Diagnosis); Level of evidence, 3. Methods: Patients undergoing hip arthroscopy for idiopathic femoroacetabular impingement or acetabular labral tears at a children’s hospital were reviewed. Demographic predictors were analyzed by use of univariate logistic regression with generalized estimating equations. A matched case-control analysis was subsequently performed to identify radiographic predictors of acetabular cartilage lesions through use of univariate and multivariable conditional logistic regression. Results: Four hundred two patients (446 hips) undergoing hip arthroscopy between 2010 and 2015 were analyzed. Median age was 16.7 years (range, 13.6-19.0) and 72% of patients were female. Ninety-five hips (21%) were found to have an acetabular cartilage lesion at the time of arthroscopic surgery. Age (odds ratio [OR], 1.7; 95% CI, 1.4-2.1), male sex (OR, 2.5; 95% CI, 1.7-5.0), and body mass index (OR, 1.07; 95% CI, 1.01-1.14) were found to be predictive of intraoperative acetabular cartilage lesions. In the matched case-control analysis, femoral alpha angle as calculated on a Dunn lateral radiograph was independently predictive of an intraoperative acetabular cartilage lesion (OR, 1.8; 95% CI, 1.2-2.6). Additionally, the presence of a crossover sign was independently associated with a decreased odds of an acetabular cartilage lesion (OR, 0.3; 95% CI, 0.1-0.7). On multivariate analysis, alpha angle (Dunn lateral) (OR, 2.0; 95% CI, 1.3-3.1) and crossover sign (OR, 0.2; 95% CI, 0.1-0.7) remained independently associated with the presence of an acetabular cartilage lesion. The presence of an acetabular labral tear was not predictive of an associated cartilage lesion (OR, 1.17; 95% CI, 0.39-3.47; P = .78). Conclusion: In an adolescent population undergoing hip arthroscopy, older age, male sex, and higher body mass index were predictive of acetabular cartilage lesions. From an imaging standpoint, increased alpha angle increased the likelihood of an acetabular cartilage lesion whereas the presence of a crossover sign decreased this likelihood. Predicting the presence of an acetabular cartilage lesion is important when considering a hip arthroscopy procedure to facilitate preoperative planning and to more accurately set patient expectations.

Functional Outcome Risk Score for Total Ankle Arthroplasty

Category: Ankle Introduction/Purpose: Postoperative functional outcomes are important measures as the orthopaedic community responds to pay-for-performance and bundled payments. Considering the 1000-fold growth of total ankle arthroplasty (TAA) procedures in the Medicare population in the past two decades, this procedure will likely undergo increasing scrutiny of quality under Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015(MACRA). While BMI, coronal plane deformity, age, and rheumatoid arthritis influence outcomes and rate of complications after TAA, there has been no single identifiable factor that predicts poor functional outcomes. The aim of this study is to identify independent patient factors that are associated with lower functional outcomes at two years after TAA and compound these predictive factors into an easily calculable score to preoperatively stratify patients undergoing modern TAA. Methods: 134 consecutive patients (136 ankles) with a mean age of 64 years (range, 31 to 79 years) and 70 (51%) men that had undergone TAA by a single surgeon from May 2011 to May 2015 were retrospectively enrolled. In addition to 2-year functional outcomes for each patient, 22 data point were collected including preoperative range of motion; baseline functional scores; and a comprehensive health history. FAAM ADL scores at 2-years were grouped into excellent (>90 points), good (75-90), or fair (<75). Univariable analyses tested for the association between demographics, medical history, functional outcomes, and procedure factors using chi-squared tests for categorical variables and either one-way ANOVAs or Kruskal Wallis tests for continuous variables. Model coefficients from a multivariable ordinal logistic regression analysis for the significant predictors of excellent, good, or fair outcomes were used to create a summed risk score to predict inferior 2-year outcome scores. Results: Ninety-one patients met the inclusion criteria. The only predictors associated with inferior functional outcomes were (1) baseline ADL score (2) no calcaneal osteotomy for coronal plane deformity (3) lateral or deltoid ligament reconstruction and (4) post-traumatic/chronic sprain etiology and BMI >30. From the multivariable ordinal logistic regression, baseline ADL scores less than 40 had a weight of 2 while an ADL score of 40-55 had a weight of 1. The remaining factors were weighted 3, 2, 1 for ligament reconstruction, no calcaneal osteotomy, and obese+sprain. Of the 23 patients with a calculated risk of 0-2, 18 did excellent and 2 did fair. Conversely, of the 22 patients with a calculated risk score of 4+, only 2 did excellent and 15 did fair (Table 1). Conclusion: Over twenty baseline and surgical factors were considered when creating a clinical scoring system that compounds the effect of risk factors on postoperative foot and ankle functional outcome measures at two years. Ligament reconstruction was the highest weighted factor(3-points), which suggests soft tissue stabilization needs to be considered in conjunction with boney correction. As previous literature supports, preoperative coronal plane deformity when corrected appropriately can lead to greater likelihood for superior outcomes when compared to patients without this deformity. This novel risk score takes into account 5 easily-obtainable factors and may help to better set patient expectations prior to TAA.

Factors Associated With Physician Loss in Anterior Cruciate Ligament Reconstruction Malpractice Lawsuits.

Background:Anterior cruciate ligament (ACL) reconstruction is among the most common orthopaedic procedures, with its incidence doubling over the past decade. To date, no studies have analyzed litigation after ACL reconstruction.Purpose:To characterize the causes of malpractice litigation after ACL reconstruction.Study Design:Cross-sectional study.Methods:A retrospective review of malpractice lawsuits after ACL reconstruction was performed using VerdictSearch, a large legal claims database encompassing nearly 180,000 legal cases, from February 1988 to May 2015. Settlement rates and physician loss rates were calculated along with 95% CIs for each complication type, and analysis of variance was used to compare all indemnity payments.Results:Of a total 30 lawsuits, 5 (16.7%) settled out of court. The 3 most common complications leading to litigation were prolonged pain (n = 5, 16.7%), infection (n = 5, 16.7%), and malpositioned graft (n = 5, 16.7%). Of the 25 cases that went to court, 8 (32.0%) ended in favor of the plaintiff (physician loss). Damage to a neurovascular structure resulted in the highest indemnity payment (mean, $2,012,926 ± $1,076,530; P = .021). Lawsuits for which pain or loss of range of motion was the only complication were significantly more likely to end in a physician victory (P = .04) and lower indemnity payments ($87,500 vs $678,715, respectively). Cases that involved a surgical technical error were more likely to result in a physician loss (P = .01), with malpositioned grafts having a significantly higher loss rate than average (75% vs 32%, respectively).Conclusion:After ACL reconstruction, physicians are more likely to win malpractice suits if pain or limited range of motion is the only complaint and less likely to win if a surgical error was alleged. These findings may help to set patient expectations and provide adequate guidance during the informed consent process.

Transitional care services: a quality and safety process improvement program in neurosurgery.

OBJECTIVE Readmissions increasingly serve as a metric of hospital performance, inviting quality improvement initiatives in both medicine and surgery. However, few readmission reduction programs have targeted surgical patient populations. The objective of this study was to establish a transitional care program (TCP) with the goal of decreasing length of stay (LOS), improving discharge efficiency, and reducing readmissions of neurosurgical patients by optimizing patient education and postdischarge surveillance. METHODS Patients undergoing elective cranial or spinal neurosurgery performed by one of 5 participating surgeons at a quaternary care hospital were enrolled into a multifaceted intervention. A preadmission overview and establishment of an anticipated discharge date were both intended to set patient expectations for a shorter hospitalization. At discharge, in-hospital prescription filling was provided to facilitate medication compliance. Extended discharge appointments with a neurosurgery TCP-trained nurse emphasized postoperative activity, medications, incisional care, nutrition, signs that merit return to medical attention, and follow-up appointments. Finally, patients received a surveillance phone call 48 hours after discharge. Eligible patients omitted due to staff limitations were selected as controls. Patients were matched by sex, age, and operation type-key confounding variables-with control patients, who were eligible patients treated at the same time period but not enrolled in the TCP due to staff limitation. Multivariable logistic regression evaluated the association of TCP enrollment with discharge time and readmission, and linear regression with LOS. Covariates included matching criteria and Charlson Comorbidity Index scores. RESULTS Between 2013 and 2015, 416 patients were enrolled in the program and matched to a control. The median patient age was 55 years (interquartile range 44.5-65 years); 58.4% were male. The majority of enrolled patients underwent spine surgery (59.4%, compared with 40.6% undergoing cranial surgery). Hospitalizations averaged 62.1 hours for TCP patients versus 79.6 hours for controls (a 16.40% reduction, 95% CI 9.30%-23.49%; p < 0.001). The intervention was associated with a higher proportion of morning discharges, which was intended to free beds for afternoon admissions and improve patient flow (OR 3.13, 95% CI 2.27-4.30; p < 0.001), and decreased 30-day readmissions (2.5% vs 5.8%; OR 2.43, 95% CI 1.14-5.27; p = 0.02). CONCLUSIONS This neurosurgical TCP was associated with a significantly shorter LOS, earlier discharge, and reduced 30-day readmission after elective neurosurgery. These results underscore the importance of patient education and surveillance after hospital discharge.

Preoperative predictors for outcomes after total hip replacement in patients with osteoarthritis: a systematic review

BackgroundThis systematic review examines which patient related factors influence functional and clinical outcomes after total hip arthroplasty (THA) in patients with hip osteoarthritis (OA).MethodsWe performed a systematic review according to the PRISMA guidelines. We searched databases and trial registries for prospective studies including OA patients who underwent primary THA. Studies with preoperative measurements on predictors, with at least 1 year follow-up were included. Risk of bias and confounding was assessed for two domains: follow-up rate and looking at independent effects.ResultsThirty-five studies were included (138,039 patients). Only nine studies (29 %) had low risk of bias for all domains thus suggesting an overall low quality of evidence. Studies were heterogeneous in the predictors tested and in the observed directions of the associations. Overall, preoperative function (13 studies (37 %), 2 with low risk of bias) and radiological OA (6 studies (17 %), 1 with low risk of bias) were predictors with the most consistent findings. Worse preoperative function and more severe radiological OA were associated with larger postoperative improvement. However, these patients never reached the level of postoperative functioning as patients with better preoperative function or less severe radiological OA. For age, gender, comorbidity, pain and quality of life the results of studies were conflicting. For BMI, some studies (n = 5, 2 with low risk of bias) found worse outcomes for patients with higher BMI. However, substantial improvement was still achieved regardless of their BMI.ConclusionThere is not enough evidence to draw succinct conclusions on preoperative predictors for postoperative outcome in THA, as results of studies are conflicting and the methodological quality is low. Results suggest to focus on preoperative function and radiological osteoarthritis to decide when THA will be most effective. The present mapping of current evidence on the relationship between patient related factors and outcomes provides better information compared to individual studies and may help to set patient expectations before surgery. In addition, these findings may contribute to discussions on how to achieve the best possible postoperative outcome for specific patient groups.Trial registrationThis systematic review was registered in Prospero, registration number RD42014009977.Electronic supplementary materialThe online version of this article (doi:10.1186/s12891-016-1070-3) contains supplementary material, which is available to authorized users.

Decipher Genomic Classifier Measured on Prostate Biopsy Predicts Metastasis Risk

To evaluate the ability of the Decipher genomic classifier in predicting metastasis from analysis of prostate needle biopsy diagnostic tumor tissue specimens. Fifty-seven patients with available biopsy specimens were identified from a cohort of 169 men treated with radical prostatectomy in a previously reported Decipher validation study at Cleveland Clinic. A Cox multivariable proportional hazards model and survival C-index were used to evaluate the performance of Decipher. With a median follow up of 8 years, 8 patients metastasized and 3 died of prostate cancer. The Decipher plus National Comprehensive Cancer Network (NCCN) model had an improved C-index of 0.88 (95% confidence interval [CI] 0.77-0.96) compared to NCCN alone (C-index 0.75, 95% CI 0.64-0.87). On multivariable analysis, Decipher was the only significant predictor of metastasis when adjusting for age, preoperative prostate-specific antigen and biopsy Gleason score (Decipher hazard ratio per 10% increase 1.72, 95% CI 1.07-2.81, P = .02). Biopsy Decipher predicted the risk of metastasis at 10 years post radical prostatectomy. While further validation is required on larger cohorts, preoperative knowledge of Decipher risk derived from biopsy could indicate the need for multimodality therapy and help set patient expectations of therapeutic burden.

Patient versus clinician symptom reporting during chemoradiation for rectal cancer.

646 Background: Pelvic radiotherapy with concurrent 5-fluorouracil based chemotherapy (chemoradiation) is a component of standard therapy for patients with T3/T4 or node-positive rectal cancer. Chemoradiation can be associated with significant acute gastrointestinal toxicity. This study sought to retrospectively compare patient and clinician reports of acute symptoms experienced by rectal cancer patients receiving chemoradiation. Methods: The charts of 199 rectal cancer patients who received chemoradiation from 11/06 to 2/11 were reviewed. Clinicians assessed toxicity weekly using Common Terminology for Clinical Adverse Event (CTCAE) version 3.0. Patient-reported outcomes (PROs) were collected weekly, in clinic, beginning 9/09 using the 7-item Bowel Problems Scale. 197 patients had at least one clinician assessment or PRO and were eligible for this study. Patient and clinician assessments were compared among a subgroup of 65 patients (paired group) who had at least one patient and clinician assessment on the same date using descriptive statistics. Agreement between patient and clinician assessments was evaluated by Cohen’s kappa coefficient. Results: Characteristics were well-balanced between all rectal patients and the paired group, with the exception of the use of intensity modulated radiotherapy (IMRT). IMRT has been used increasingly over time, and IMRT was therefore used in a larger proportion of the paired group versus all patients (77% vs. 51%, respectively). Diarrhea and proctitis were reported more often by patients than clinicians throughout treatment. Uncorrected agreement for diarrhea and proctitis was 82% and 72%, respectively. Corrected for chance, Cohen’s kappa was .64 for diarrhea, indicating moderate agreement, and .22 for proctitis, indicating only slight agreement. Conclusions: Our findings suggest a discrepancy between clinician and patient symptom reports. Further study is warranted to discern potential benefits of including PROs in prospective studies, and to find whether PROs can help clinicians set patient expectations, and/or enhance communication for optimal symptom management.

Corporate social responsibility:a potential lifesaver?

Corporate social responsibility (CSR) has become a familiar concept for those working in the private sector and is now making a slow entry into the consciousness of the NHS, the UK’s biggest employer with a budget of over £100 billion (NHS Choices, 2011). Some elements of CSR fit well into any modern organisation, for example, addressing the need to reduce waste and use of fossil fuels. Similarly, it is easy to understand the potential strength of locally sourcing the £11 billion annual supplies and services (Coote, 2002). The NHS Supply Chain produced their first report in 2008 (NHS Supply Chain, 2008) and some hospital trusts are producing CSR reports, although these are sometimes a synthesis of policies relating to other corporate targets (Royal United Hospital, 2010) or merely address environmental concerns (NHS London, 2011). With regard to the ethical behaviours of CSR, the NHS might be expected to have a head start given that professionals employed by the NHS are governed by strict ethical codes of behaviour from external bodies (e.g. General Medical Council, Nursing and Midwifery Council) and there are no fee-perservice agreements with employees. Previously there was no need for hospitals to be competitive, but the current funding arrangements where primary care trusts commission services from hospitals mean that secondary care providers, whether NHS or privately funded, compete for contracts. In business, CSR has been shown to be successful in ‘building a better image and reputation’ and in demonstrating ‘differentiation from competitors’ (Formbrun and Stanley, 1990) and these benefits might easily lead to similar competitive advantage in a predominantly public sector market. However, using taxpayers’ money to fund activities other than those for which you have been commissioned seems, at first glance, to be unacceptable. Surely any money left over after fulfilling taxpayers’ needs should be returned to taxpayers? Could there be any justification of health service workers contributing to their local communities in the same way during working time as workers in commercial enterprises, for example, hearing children read, litter collecting or helping in a night shelter? Hospitals are nowadays beset with targets, the results of which are published and publicised. Just as anxious parents pore over OFSTED reports when choosing schools for their offspring, patients can hardly avoid reading about the successes and failures of their local hospitals before choosing where to have surgery. But does all this information change the decisions patients make? Patients have to take into account the travel convenience of choosing local services. A Kings Fund study (2010) found that 69% of patients always choose their local provider and 20% choose the local provider in all hypothetical circumstances, however bad the performance characteristics given. Therefore, the information in the public domain is more likely to set patient expectations than to cause them to choose an alternative hospital. Mondloch et al (2001) undertook a systematic review of the evidence for expectations affecting health outcomes and found that ‘15 out of 16 studies showed that positive expectations were associated with better health outcomes’. Therefore it is likely that patients who have faith in their local hospital are more likely to have a good outcome. Conversely, patients who have low expectations of their hospital may actually do worse. If we accept this argument, then the hospital public relations department has a role in direct clinical care. After an error has occurred, Fiona Martin is Specialist Registrar, Anaesthetics, Peninsula Deanery

How Often are Patient and Surgeon Recovery Expectations for Total Joint Arthroplasty Aligned? Results of a Pilot Study

Surgeons strive to set patient expectations for recovery following total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, some patients report dissatisfaction after surgery due to unmet expectations. We compared patients' and surgeon's recovery expectations prior to primary THA and TKA. Sixty eight patients scheduled to undergo primary total hip replacement (THR) or total knee replacement (TKR) surgery were enrolled. Before surgery, patients filled out a validated recovery expectations questionnaire that quantified expectations of postoperative pain relief, function, and well-being with a value from 0 to 100 (higher being more optimistic). The surgeon independently completed the same questionnaire for each patient. Overall score and item-specific comparisons were conducted. Correlations were explored between agreement level, demographics, patient-reported health status measures, and patients' assessments of the risk of complications associated with surgery. Most patients undergoing THR or TKR had higher expectations for recovery than their surgeon. Applying the clinically meaningful difference in expectations (≥7 points), 52.5% of the TKA patients' expectations exceeded those of the surgeon, while 22.5% expected less than their surgeon and 60.7% of THA patients' expectations exceeded those of the surgeon, while 21.4% expected less than their surgeon. THA patients with either lower or higher expectations than their surgeon had lower physical and mental health status scores. TKA patients with lower expectations compared to their surgeon had a higher expectation of complications. More than 50% of the patients had higher expectations than their surgeon and this was driven by expectations of high-level activities and extreme range of motion. Further investigations are needed to understand these differences so as to enhance patient preoperative education.

442 PAID-A Randomized Controlled Trial: Distribution of an Informational Brochure to Patients in the ED Waiting Room Does Not Improve Overall Patient Satisfaction

442 PAID-A Randomized Controlled Trial: Distribution of an Informational Brochure to Patients in the ED Waiting Room Does Not Improve Overall Patient Satisfaction

Estimating Survival in Patients with Operable Skeletal Metastases: An Application of a Bayesian Belief Network

BackgroundAccurate estimations of life expectancy are important in the management of patients with metastatic cancer affecting the extremities, and help set patient, family, and physician expectations. Clinically, the decision whether to operate on patients with skeletal metastases, as well as the choice of surgical procedure, are predicated on an individual patient's estimated survival. Currently, there are no reliable methods for estimating survival in this patient population. Bayesian classification, which includes Bayesian belief network (BBN) modeling, is a statistical method that explores conditional, probabilistic relationships between variables to estimate the likelihood of an outcome using observed data. Thus, BBN models are being used with increasing frequency in a variety of diagnoses to codify complex clinical data into prognostic models. The purpose of this study was to determine the feasibility of developing Bayesian classifiers to estimate survival in patients undergoing surgery for metastases of the axial and appendicular skeleton.MethodsWe searched an institution-owned patient management database for all patients who underwent surgery for skeletal metastases between 1999 and 2003. We then developed and trained a machine-learned BBN model to estimate survival in months using candidate features based on historical data. Ten-fold cross-validation and receiver operating characteristic (ROC) curve analysis were performed to evaluate the BNN model's accuracy and robustness.ResultsA total of 189 consecutive patients were included. First-degree predictors of survival differed between the 3-month and 12-month models. Following cross validation, the area under the ROC curve was 0.85 (95% CI: 0.80–0.93) for 3-month probability of survival and 0.83 (95% CI: 0.77–0.90) for 12-month probability of survival.ConclusionsA robust, accurate, probabilistic naïve BBN model was successfully developed using observed clinical data to estimate individualized survival in patients with operable skeletal metastases. This method warrants further development and must be externally validated in other patient populations.

Hearing preservation in acoustic neuroma surgery: the impact of different patient selection criteria.

The aim of the present study was to assess whether applying the various selection criteria for hearing preservation surgery on the same group of patients with acoustic neuroma leads to significantly different numbers of patients being considered suitable for this kind of surgery. We used different selection criteria for hearing conservation surgery based on a range of studies in the published literature. We applied these criteria to a consecutive group of patients presenting to our unit with acoustic neuroma. We then calculated the numbers of patients deemed suitable for hearing preservation surgery as a function of these different selection criteria. Studies with published selection criteria, total numbers of patients, and numbers of patients suitable for hearing preservation surgery were found in the literature. These selection criteria were applied to our patient data. A chi2 statistical analysis was used to assess whether applying different selection criteria to the same group of patients (the subjects of the present study) resulted in different numbers of patients suitable for hearing preservation surgery. The numbers of patients suitable for hearing preservation showed wide variation, ranging from 8 (10%) to 45 (56%) patients (of the total number of 80 patients in the present study). The chi2 statistical analysis revealed that the various selection criteria did have an effect on the numbers of patients suitable for hearing preservation surgery, and the statistical significance reached the level of P<.001. Different selection criteria lead to significantly different numbers of patients being considered suitable for hearing preservation surgery. Consensus and agreed selection criteria would help set patient expectations, refine candidate selection, and facilitate the comparison of outcomes across centers.