Ratings of global outcome at the first post-operative assessment after spinal surgery: how often do the surgeon and patient agree?

The Core Outcome Measures Index (COMI) comes of age: 18 years of efficient and effective patient-reported outcome measurement in the field of spinal disorders. Part 1. Development of the COMI, interpretation of scores, and use in research

In 1998, an international and multidisciplinary group of experts (from the fields of spine surgery, physiotherapy, occupational therapy, rheumatology, primary care medicine, internal medicine, health economics and epidemiology) proposed a short multidimensional series of core outcome items for use in patients with low back disorders. In 2005 and 2006, two independent research groups published studies validating these items when combined to form an outcome instrument that was subsequently coined the Core Outcome Measures Index for the back (COMI-back). It now exists in at least 22 languages, is used as the primary outcome measure in numerous research studies, and has been adopted by International and National Surgical and Non-Surgical Spine Registries. Its Minimal Clinically Important Change score (MCIC) for both improvement and worsening have been calculated. It has been shown to be as responsive an outcome measure as many other, long-standing legacy outcome measures (e.g. Oswestry Disability Index, ODI) and various condition-specific instruments used in assessing patients with specific pathologies such as spinal stenosis, spinal deformity, or spinal tumour. A cross-walk to convert COMI scores to ODI scores has been developed. Other musculoskeletal specialties have taken the COMI-back and modified the wording to reflect the joint being enquired about to produce COMI-neck, COMI-knee and COMI-hip versions; these have been subsequently validated for use in patients with the corresponding musculoskeletal disorders. Predictor studies using machine-learning methods and sophisticated statistical analyses have been carried out to predict post-surgical COMI scores, based on a minimal set of baseline characteristics. Part 1 of this review gives an overview of the development of the COMI and its success as a brief but responsive multidimensional outcome instrument over the last 18 years, whilst Part 2 serves to describe its content, scoring, language versions and applications.

Discrepancies between physician-assessed and patient-reported complications after cystectomy - a prospective analysis

PURPOSE

Despite the high incidence of perioperative complications following cystectomy, there is a lack of evidence regarding patients' perceptions. Moreover, discrepancies between established complication grading systems and the patient's perspective remain unexplored.

METHODS

We prospectively evaluated perioperative complications after cystectomy using the Clavien-Dindo Classification (CDC) and the Comprehensive Complication Index (CCI). The CDC and CCI were compared to patient-reported complication grades through Spearman correlation analysis. Discrepancies between physician-assessed and patient-reported complication grades were then evaluated. The study was registered at ClinicalTrials.gov (NCT05153694).

RESULTS

Between December 2021 and March 2024, 172 patients underwent open cystectomy at our department. Of those, 154 provided written consent to participate in the study, and 111 completed the post-discharge questionnaire. We found a moderate correlation between physician-assessed and patient-reported complication grades (CDC: r = 0.34, CCI: r = 0.39; p < 0.001). Patients with matching grades were defined as realists (50%). Those who reported lower complication grades than assessed by physicians were defined as optimists (38%), while those who reported higher grades were defined as pessimists (12%). Optimists rated the preoperative medical information better than pessimists ("very good": 79% vs. 38%, p = 0.006). We found no significant differences between optimists and pessimists regarding age, gender, tumor characteristics or educational level.

CONCLUSION

In our prospective study, the correlation between physician-assessed and patient-reported complication grades was only moderate. Only half of the cystectomy patients accurately perceived the severity of their complications. Our findings represent the first study to investigate patients' perspectives on complications in urology and underscore the importance of thorough preoperative medical information.

How well can the clinician appraise the patient's perception of the severity and impact of their back problem?

PURPOSE

A main concern of patients with back problems is pain and its impact on function and quality of life. These are subjective phenomena, and should be probed during the clinical consultation so that the physician can ascertain the extent of the problem. This study evaluated the agreement between clinicians' and patients' independent ratings of patient status on the Core Outcome Measures Index (COMI).

METHODS

This was an analysis of the data from 5 spine specialists and 108 patients, in two centres. Prior to the consultation, the patient completed the COMI. After the consultation, the clinician (blind to the patient's version) also completed a COMI. Concordance was assessed by % agreement, Kappa values, Bland-Altman plots, Spearman rank, Intraclass Correlation Coefficients and comparisons of mean values, as appropriate.

RESULTS

Agreement regarding the "main problem" (back pain, leg/buttock pain, sensory disturbances, other) was 83%, Kappa = 0.70 (95%CI 0.58-0.81). Moderate/strong correlations were found between the doctors' and patients' COMI-item ratings (0.48-0.74; p < 0.0001), although compared with the patients' ratings the doctors systematically underestimated absolute values for leg pain (p = 0.002) and dissatisfaction with symptom state (p = 0.002), and overestimated how much the patient's function was impaired (p = 0.029).

CONCLUSION

The doctors were able to ascertain the location of the main problem and the multidimensional outcome score with good accuracy, but some individual domains were systematically underestimated (pain, symptom-specific well-being) or overestimated (impairment of function). More detailed/direct questioning on these domains during the consultation might deliver a better appreciation of the impact of the back problem on the patient's daily life.

Spinal cord epidural stimulation for motor and autonomic function recovery after chronic spinal cord injury: A case series and technical note

Background:

Traumatic spinal cord injury (tSCI) is a debilitating condition, leading to chronic morbidity and mortality. In recent peer-reviewed studies, spinal cord epidural stimulation (scES) enabled voluntary movement and return of over-ground walking in a small number of patients with motor complete SCI. Using the most extensive case series (n = 25) for chronic SCI, the present report describes our motor and cardiovascular and functional outcomes, surgical and training complication rates, quality of life (QOL) improvements, and patient satisfaction results after scES.

Methods:

This prospective study occurred at the University of Louisville from 2009 to 2020. scES interventions began 2–3 weeks after surgical implantation of the scES device. Perioperative complications were recorded as well as long-term complications during training and device related events. QOL outcomes and patient satisfaction were evaluated using the impairment domains model and a global patient satisfaction scale, respectively.

Results:

Twenty-five patients (80% male, mean age of 30.9 ± 9.4 years) with chronic motor complete tSCI underwent scES using an epidural paddle electrode and internal pulse generator. The interval from SCI to scES implantation was 5.9 ± 3.4 years. Two participants (8%) developed infections, and three additional patients required washouts (12%). All participants achieved voluntary movement after implantation. A total of 17 research participants (85%) reported that the procedure either met (n = 9) or exceeded (n = 8) their expectations, and 100% would undergo the operation again.

Conclusion:

scES in this series was safe and achieved numerous benefits on motor and cardiovascular regulation and improved patient-reported QOL in multiple domains, with a high degree of patient satisfaction. The multiple previously unreported benefits beyond improvements in motor function render scES a promising option for improving QOL after motor complete SCI. Further studies may quantify these other benefits and clarify scES’s role in SCI patients.

Reliability and Validity of Adapted Russian Version of Hospital for Special Surgery Lumbar Spine Surgery Expectations Survey

Background: Patients' expectations are an important determinant in their decision to undergo lumbar spinal surgery-particularly their expectations of recovery after surgery. The Hospital for Special Surgery Lumbar Spine Surgery Expectations Survey (HSS-LSSES) is one tool used to assess this; however, the original version was only available in English. Objective: We sought to evaluate the reliability and validity of a translated and adapted Russian-language version of the HSS-LSSES. Methods: This was a prospective study of 91 patients with degenerative disc disease who underwent lumbar spine surgery with instrumented fixation at a single institution in Saint Petersburg, Russia. Patients were recruited between December 2019 and February 2021 and asked about their expectations of surgery with a translated and adapted Russian version of the HSS-LSSES. To analyze construct validity, participants also completed disease-specific and general quality-of-life scales (Oswestry Disability Index, European Quality of Life-5 Dimensions, and 36-item Short-Form Health Survey). Intraclass correlation coefficients (ICCs; 2-way random effects model, absolute agreement) were used to determine test-retest reliability of the total score of the Russian HSS-LSSES. Internal consistency was evaluated through the estimation of Cronbach's alpha between the test and retest response of the questionnaire. Results: The test-retest stability of the Russian HSS-LSSES evaluated through the estimation of ICC was found to have good stability. The instrument was shown to have high internal consistency. Conclusion: This study demonstrates that a translated and adapted Russian version of HSS-LSSES had good internal consistency, reliability, construct validity, and no floor and ceiling effects. Therefore, we recommend its use as a tool for evaluating Russian-speaking patients' expectations before lumbar spine surgery.

Outcomes at five to eight years of age for children with Hirschsprung's disease

OBJECTIVE

This study describes core outcomes of Hirschsprung's disease (HD) in a UK-wide cohort of primary school-aged children.

DESIGN

A prospective cohort study conducted from 1 October 2010 to 30 September 2012. Outcomes data were collected from parents and clinicians when children were 5-8 years of age, and combined with data collected at birth, and 28 days and 1 year post diagnosis.

SETTING

All 28 UK and Irish paediatric surgical centres.

PARTICIPANTS

Children with histologically proven HD diagnosed at <6 months of age.

MAIN OUTCOME MEASURES

NETS1HD core outcomes.

RESULTS

Data were returned for 239 (78%) of 305 children. Twelve children (5%) died prior to 5 years of age.Of the 227 surviving children, 30 (13%) had a stoma and 21 (9%) were incontinent of urine. Of the 197 children without a stoma, 155 (79%) maintained bowel movements without enemas/washouts, while 124 (63%) reported faecal incontinence. Of the 214 surviving children who had undergone a pull-through operation, 95 (44%) underwent ≥1 unplanned reoperation. 89 unplanned reoperations (27%) were major/complex.Of the 83 children with returned PedsQL scores, 37 (49%) had quality of life scores, and 31 (42%) had psychological well-being scores, that were ≥1 SD lower than the reference population mean for children without HD.

CONCLUSION

This study gives a realistic picture of population outcomes of HD in primary school-aged children in the UK/Ireland. The high rates of faecal incontinence, unplanned procedures and low quality of life scores are sobering. Ensuring clinicians address the bladder, bowel and psychological problems experienced by children should be a priority.

Concordance Between Patients' and Surgeons' Expectations of Lumbar Surgery

STUDY DESIGN

Longitudinal cohort.

OBJECTIVE

The aims of this study were to measure concordance between patients' and surgeons' preoperative expectations of lumbar surgery, and determine which member of the dyad more closely predicted fulfillment of expectations, defined as patient-reported status postoperatively.

SUMMARY OF BACKGROUND DATA

Concordant patient-surgeon expectations reflect effective communication and should foster better outcomes.

METHODS

Preoperatively patients and surgeons completed identical surveys measuring expectations for improvement in symptoms and physical/psychosocial function. Responses ranged from "complete improvement" to "do not have this expectation"; scores for each survey ranged from 0 to 100 (greatest expectations). Concordance between pairs of patient-surgeon scores was measured with the intraclass correlation coefficient (ICC). Postoperatively, fulfillment of expectations was measured from patient-reported amount of improvement received and was calculated as the proportion of patient-reported postoperative score relative to patient-reported preoperative score, and surgeon-reported preoperative score (range 0 [no expectations fulfilled] to >1.2 [expectations surpassed]). Clinical measures included patient-reported spine-related disability.

RESULTS

For 402 patient-surgeon pairs, mean survey scores were 73 ± 19 (patients) and 57 ± 16 (surgeons); 84% of patients had higher scores than surgeons, mainly due to expecting complete improvement, whereas surgeons expected a lot/moderate/little improvement. The ICC for the entire sample was .31 (fair agreement); for subgroups, the greatest difference in ICC was for patients with more spine-related disability (ICC = .10, 95% confidence interval [CI]:0.00-0.23) versus less disability (ICC = .46, 95% CI: 0.34-0.56). 96% of patients were contacted ≥2.0 years postoperatively. Proportions of expectations fulfilled were 0.79 (0-3.00) (patients) and 1.01 (0-2.29) (surgeons). Thus patients were less likely to anticipate subsequent postoperative status (odds ratio [OR] 0.34, 95% CI 0.25-0.45) versus surgeons who were more likely to anticipate patient-reported postoperative status (OR 2.98, 95% CI: 2.22-4.00).

CONCLUSION

Concordance between patients' and surgeons' expectations was fair; due mostly to patients expecting complete improvement whereas surgeons expected a lot/moderate/little improvement. Compared to patients' expectations, surgeons' expectations more closely coincided with patient-reported fulfillment of expectations 2 years postoperatively.Level of Evidence: 1.

Patient Expectations of Adult Spinal Deformity Correction Surgery

BACKGROUND

There is a growing interest in examining preoperative expectations as a potential predictor of postoperative outcome. However, it has never been studied in the setting of adult spinal deformity (ASD). This study aims to characterize patient expectations before ASD surgery and examine the relationship between preoperative expectation and postoperative patient-reported outcomes (PROs).

METHODS

Analysis of prospectively collected clinical and PRO data was performed on patients who underwent ASD surgery. Inclusion criteria were age >18 years, a diagnosis of ASD, >3 vertebral level instrumentation, and completed pre- and postoperative surveys. The preoperative expectation survey included expectations of surgical outcome, pain reduction, complications, and the duration of postoperative recovery. Relationships between patient expectations and PROs were assessed.

RESULTS

Twenty-seven patients who underwent operative management of ASD met the inclusion criteria. In their preoperative survey, 66% of patients expected highly successful surgery, whereas 22% had a moderate expectation of complications. Patients anticipated an average 71% reduction in back pain (range 42%-100%) and 68% reduction in leg pain (range 0%-100%). Patients who met their expectations of leg pain reduction had significantly greater satisfaction scores than those who did not. There were moderate-to-strong positive correlations between preoperative expectation and observed improvement in back pain, leg pain, and mental health.

CONCLUSIONS

While substantial variability in patient expectation exists for the surgical management of ASD, patients anticipated a positive outcome with a significant reduction in pain. Greater postoperative satisfaction was associated with patients who met the expected improvement in leg pain. Preoperative expectation was positively correlated with change in pain and mental health scores.

Postoperative Single-shot Epidural Fentanyl and Bupivacaine for Postoperative Analgesia After Lumbar Decompression: A Prospective, Double-blind Randomized Study

STUDY DESIGN

Randomized clinical trial.

OBJECTIVE

To evaluate the efficacy of the postoperative single-shot bolus of epidural Fentanyl and Bupivicaine in providing pain relief postlumbar decompression surgery.

SUMMARY OF BACKGROUND DATA

Despite lumbar decompression's success in alleviating symptoms of sciatica, radiculopathy, and neurogenic claudication, transient back and buttock pain has been a common complaint postoperatively. Providing good postoperative pain alleviation predicts patient's quality of recovery.

METHODS

We performed a randomized, double-blinded, clinical trial. Forty-five patients scheduled for lumbar decompression for a year's period who were randomly assigned to receive a postoperative bolus of 10-mL solution of 50 mcg of Fentanyl, 0.125% Bupivacaine, and 0.9% saline solution via an intraoperatively placed epidural catheter immediately after wound closure, before dressing application. Facial pain scale scores (from 0 to 10) were measured at three time points after surgery (fully awake at recovery room, transfer to ward, first postoperative day). Postoperative need for oral analgesics, time to independent ambulation, associated adverse events, and time to hospital discharge were also evaluated.

RESULTS

Pain scores were noted to be significantly lower at all time points in the epidural group (P < 0.001). In turn, they also received less on-demand oral pain medications than those in the control group (P = 0.000). The mean time to ambulation was 0.09 days in the epidural group and 0.91 days in the decompression-alone group (P = 0.000). Criteria for hospital discharge were usually met on Day 0 in the epidural and Day 1 in the control group (P = 0.000). Within the study period, only one infection was noted in the epidural group which necessitated additional lumbar spine surgery (4.3%). No adverse events or complications related to Fentanyl use were observed.

CONCLUSIONS

A postoperative bolus of Fentanyl and Bupivacaine is effective in reducing early postoperative pain without the related complications of opiod administration.

LEVEL OF EVIDENCE

2.

Global Treatment Outcome after Surgical Site Infection in Elective Degenerative Lumbar Spinal Operations

Background: Surgical site infection (SSI) is a serious complication after routine lumbar spinal operations, and its effect on global treatment outcome (GTO) is less reported. The aim of the current study was to measure the impact of SSI on outcome, which was evaluated with patient reported outcome measures (PROMs) and patients' subjective judgment (GTO). Methods: A total of 910 patients underwent primary a single- or two-level lumbar decompression or instrumented fusion surgical procedure. Patients completed Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and Core Outcome Measurement Index (COMI) at baseline and at two-year follow-up. The rate of improvement in PROMs was measured for the total cohort and the group of patients with SSI. Patients evaluated GTO on a five-point Likert scale. This study was approved by the Scientific and Research Ethics Committee of the Medical Research Council (number: 29970-3/2015/EKU) and the Institutional Review Board. Results: Regardless of the presence of SSI, significant improvement was measured in all PROMs without any difference in the rate of change between the clinical subgroups (non-SSI vs. SSI, dODI: p = 0.370, dCOMI: p = 0.383, dVAS: p = 0.793). In the total cohort, 87.3% of patients reported good outcome (N% = 87.3%). After an SSI, however, more patients (25.7%) reported poor outcome compared with those without the complication (chi-square test: value = 5.66; df = 1; p = 0.017; odds ratio = 2.49). Conclusions: Patients with successfully treated SSI can expect as good objective clinical result as patients without SSI while the subjective treatment outcome can be worse. The GTO could also be improved in complicated cases, however, with more extensive peri-operative patient education and information considering the patients' expectations, too.

Cross-cultural adaption and validation of the Swedish version of the Core Outcome Measures Index for low-back pain

Purpose

There is a wide selection of instruments and questionnaires available, but many are time consuming in their administration, for patients, practitioners and researchers alike. The Core Outcome Measures Index (COMI) is a short, self-administrated, multidimensional instrument translated into several languages that covers five domains recommended in the assessment of outcome in patients with low-back pain. The purpose of this study was to cross-culturally adapt the COMI from English to Swedish and to test the face and construct validity and reproducibility of its results in patients with low-back pain.

Methods

Participants (n = 102) were included from primary and secondary care. The participants reported moderate pain and disability levels. All participants filled in the COMI, the Oswestry Disability Index and the EQ5D at baseline. Forty-nine filled in the COMI again after 7 days for the reproducibility part of the study.

Results

The instrument was successfully forward and back-translated. In the validation process, there were low floor/ceiling effects, with the exception of the symptom-specific well-being (floor) and work disability (ceiling) items. The specific COMI domains and whole score correlated significantly with the chosen reference scale scores to the hypothesised extent (Rho 0.30–0.60 and > 0.60 respectively). COMI reached ICC 0.63 (95% CI 0.42–0.77) in the reproducibility test and the separate items, ICC 0.41–0.78.

Conclusions

The Swedish COMI shows acceptable psychometric properties and is thus suitable to use as a short instrument for measuring important domains in patients with low-back pain. A future study should investigate the instrument's sensitivity to measure change after treatment.

Graphic abstract

These slides can be retrieved under Electronic Supplementary Material.

Risk Factors for Negative Global Treatment Outcomes in Lumbar Spinal Stenosis Surgery: A Mixed Effects Model Analysis of Data from an International Spine Registry

OBJECTIVE

To determine risk factors for negative global treatment outcomes as self-assessed by patients undergoing surgical treatment for lumbar spinal stenosis (LSS).

METHODS

Patients from the Spine Tango registry undergoing first-time surgery for LSS were analyzed. The primary outcome was global treatment outcomes measured at the last available follow-up ≥3 months postoperatively using a single question rating how much the operation had helped the patient's back problem (negative = no change/operation made things worse). A 2-level logistic mixed effects model with the treating department as the random effect was used to assess factors associated with a negative outcome.

RESULTS

A total of 4504 patients from 39 departments in 10 countries were included. Overall, 14.4% of patients reported a negative global treatment outcome after an average follow-up of 1.3 years. In patients with dominant leg pain, negative outcome was associated with higher baseline back pain; in those with dominant back pain, it was associated with higher baseline back pain, ASA (American Society of Anesthesiologists) ≥3, lower age, not having rigid stabilization, not having disc herniation, and the vertebral level of the most severely affected segment (L5/S1 vs. L3/4). Four departments had significantly higher odds of a negative outcome, whereas 1 department had significantly lower odds. Three out of the 4 negative effects were related to 2 departments from 1 country.

CONCLUSIONS

LSS surgery fails to help at least 1 in 10 patients. High baseline back pain is the most important factor associated with a negative treatment outcome. Department-level and potentially country-level factors of unknown origin explained a nonnegligible variation in the treatment results.

Severity of Postoperative Complications From the Perspective of the Patient

Background:

Although provider-derived surgical complication severity grading systems exist, little is known about the patient perspective.

Objective:

To assess patient-rated complication severity and determine concordance with existing grading systems.

Methods:

A survey asked general surgery patients to rate the severity of 21 hypothetical postoperative events representing grades 1 to 5 complications from the Accordion Severity Grading System. Concordance with the Accordion scale was examined. Separately, descriptive ratings of 18 brief postoperative events were ranked.

Results:

One hundred sixty-eight patients returned a mailed survey following their discharge from a general surgery service. Patients rated grade 4 complications highest. Grade 1 complications were rated similarly to grade 5 and higher than grades 2 and 3 (P ≤ .01). Patients rated one event not considered an Accordion scale complication higher than all but grade 4 complications (P < .001). The brief events also did not follow the Accordion scale, other than the grade 6 complication ranking highest.

Conclusion:

Patient-rated complication severity is discordant with provider-derived grading systems, suggesting the need to explore important differences between patient and provider perspectives.

The Odom Criteria: Validated at Last: A Clinimetric Evaluation in Cervical Spine Surgery

BACKGROUND

The Odom criteria, established in 1958, are a widely used, 4-point rating scale for assessing the clinical outcome after cervical spine surgery. Surprisingly, the Odom criteria have never been validated, to our knowledge. The aim of this study was to investigate the reliability and validity of the Odom criteria for the evaluation of surgical procedures of the cervical spine.

METHODS

Patients with degenerative cervical spine disease were included in the study and divided into 2 subgroups on the basis of their most predominant symptom: myelopathy or radiculopathy. Reliability was assessed with interrater and test-retest design using quadratic weighted kappa coefficients. Construct validity was assessed by means of hypotheses testing. To evaluate whether the Odom criteria could act as a global perceived effect (GPE) scale, we assessed concurrent validity by comparing area under the curve (AUC) values of receiver operating characteristic (ROC) curves for the set of questionnaires.

RESULTS

A total of 110 patients were included in the study; 19 were excluded, leaving 91 in our analysis. Reliability assessments showed κ = 0.77 for overall interrater reliability and κ = 0.93 for overall test-retest reliability. Interrater reliability was κ = 0.81 for the radiculopathy subgroup and κ = 0.68 for the myelopathy subgroup. At least 75% of the hypotheses were met. The AUCs showed similar characteristics between the Odom criteria and GPE scale.

CONCLUSIONS

The Odom criteria met the predefined criteria for reliability and validity. Therefore, the Odom criteria may be used to assess surgical outcome after a cervical spine procedure, specifically for patients presenting with radicular symptoms. The results of previous studies that have been deemed less trustworthy because of the use of the Odom criteria should be reconsidered.

Responsiveness of the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire in lumbar surgery and its threshold for indicating clinically important differences

BACKGROUND CONTEXT

Introduced in 2007, the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) has been widely used, but its psychometric properties have not been well studied.

PURPOSE

The objective of this study was to assess the responsiveness of the JOABPEQ in lumbar surgery and its threshold for indicating clinically important differences.

STUDY DESIGN

This is a prospective study.

PATIENT SAMPLE

Two hundred three consecutive patients underwent lumbar surgeries between July 2013 and November 2015 in a single hospital. Of the 203 patients, 181 patients who completed 1 year of follow-up were included.

OUTCOME MEASURES

Before and after surgery, the patients were asked to complete the questionnaire, including JOABPEQ, the 8-Item Short Form Health Survey (SF-8), and EuroQol-5D (EQ-5D). The participants were divided into five anchoring groups, ranging from "much better" to "much worse," according to reports from both physicians and patients.

MATERIALS AND METHODS

The responsiveness of measures was compared among five domains of the JOABPEQ ("low back pain," "walking ability," "lumbar function," "social function," and "mental health"), two domains of the SF-8 (the physical component summary [PCS] and the mental component summary [MCS]), and the EQ-5D. The responsiveness was assessed by the paired t test, the effect size, and the standardized response mean. The Spearman rank correlation coefficient and the receiver operating characteristic (ROC) curve were assessed using the five anchoring groups as external criteria. The clinically important differences, based on the ROC curve, were assessed.

RESULTS

Walking ability was most responsive, followed by low back pain and the PCS. The MCS was least responsive, followed by mental health and lumbar function. Social function and the EQ-5D had intermediate-level responsiveness. The substantial clinically important differences occurred at 20 points for low back pain and lumbar function, 23 points for walking ability, 14 points for social function, and 8 points for mental health.

CONCLUSIONS

The JOABPEQ domains are responsive measures in patients who undergo lumbar surgery. For physical function, the threshold for substantial clinically important differences was approximately 20 points for the JOABPEQ.

Anesthetists and Surgeons Predict Postoperative Pain

PURPOSE

Nurses, surgeons and anesthetists are responsible for the management of postoperative pain. This study aimed to investigate surgeons', surgical residents', anesthesiologists', and anesthetic residents' predictions of patients' postoperative pain and satisfaction with pain management, compared to patients' postoperative ratings.

DESIGN

The bias and limits of agreement between physician and patient ratings of postoperative pain were compared.

METHODS

Doctors and patients completed a pain questionnaire (Numeric Rating Scale 11-point) regarding patients' overall pain, worst pain, and dissatisfaction with pain management during the first three days postoperatively.

FINDINGS

All doctors overestimated the degree of pain. Possible reasons include the efforts of the postoperative multidisciplinary team. Surgeons were the most accurate regarding patients' worst pain. The limits of agreement for doctor and patient ratings were very wide.

CONCLUSIONS

Postoperative pain management is better than predicted.

Testing the construct validity of a health transition question using vignette-guided patient ratings of health

Background

A single-item transition question is often used to assess improvement or worsening in health, but its validity has not been tested extensively. The purpose of this study was to test the construct validity of a transition question by relating it to qualitative changes in patient’s self-rating of health guided by clinical vignettes.

Methods

We studied 169 patients with active rheumatoid arthritis (RA) before and after treatment escalation. At both assessments, patients scored their current health on a rating scale after first rating three vignettes describing mild, moderate, or severe RA. We classified patients into one of these three RA categories using a nearest-neighbor match. We then related the change in these self-rated categories between visits to responses to a transition question on visit 2.

Results

Sixty patients improved their RA vignette category after treatment, 86 remained in the same vignette category, and 23 worsened categories. On the transition question, 101 patients reported improvement, 48 reported no change, and 20 reported worsening, representing a modest association with changes in RA vignette categories (polychoric correlation r = 0.19). The association was stronger if patients who were in the mild RA category at both visits were also classified as improved if their self-rating changed from below to above their mild vignette rating (r = 0.23) and when incorporating the importance of changes on the transition question (r = 0.26).

Conclusion

Changes in health states, guided by clinical vignettes, support the construct validity of the transition question.

Why Does the Health-Related Quality of Life in Idiopathic Normal-Pressure Hydrocephalus Fail to Improve Despite the Favorable Clinical Outcome?

OBJECTIVE

Occasionally, a favorable clinical disease-specific outcome does not reflect into improved generic health-related quality of life (HRQoL) in patients with idiopathic normal-pressure hydrocephalus (iNPH) at 1 year after the installation of a cerebrospinal fluid shunt. Our aim was to identify factors causing this discrepancy.

METHODS

The 1-year HRQoL outcomes of 141 patients with iNPH were evaluated with the generic 15D instrument, in which the minimum clinically important change/difference on the 0-1 scale has been estimated to be ±0.015. A 12-point iNPH grading scale (iNPHGS) was used as a clinical disease-specific outcome measure, in which a 1-point decrease is considered to be clinically important. We identified 29 (21%) patients with iNPH from our prospective study whose HRQoL deteriorated or remained the same despite of a favorable iNPHGS outcome. We analyzed this discrepancy using patients' clinical variables and characteristics.

RESULTS

Multivariate binary logistic regression analysis indicated that a greater (worse) iNPHGS score at baseline (adjusted odds ratio [OR], 1.7; 95% confidence interval [CI] 1.3-2.3; P < 0.001), comorbid chronic pulmonary disease (40% vs. 20%; adjusted OR 17.8; 95% CI 3.6-89.9; P < 0.001), and any comorbid nonmetastatic tumor (62% vs. 17%; adjusted OR 11.5; 95% CI 1.5-85.3; P = 0.017) predicted discrepancy between iNPHGS and 15D outcomes.

CONCLUSIONS

Frail patients suffering from certain pre-existing comorbidities may not experience improvement in generic HRQoL despite of a favorable clinical disease-specific response. Acknowledging the comorbidity burden of the patient may help clinicians and the patients to understand the conflict between patient-reported and clinical outcomes.

[Not Available]

Zusammenfassung. Zur exakten Erfassung von Schmerzen, funktionellen Einschränkungen und gesundheitsbezogener Lebensqualität bei Patienten mit degenerativen Wirbelsäulenerkrankungen existiert eine Reihe validierter Messinstrumente. Neben der Beurteilung durch den Therapeuten sowie «subjektiven» patientenorientierten Messmethoden (PROMs) wurde in den vergangenen Jahren der «Timed Up and Go»(TUG)-Test systematisch untersucht und als krankheitsspezifisches Messinstrument validiert. Heute kann eine objektive funktionelle Einschränkung (OFI = Objective Functional Impairment) in wenigen Sekunden und kostenfrei mithilfe einer Smartphone-Applikation bestimmt werden. Die Bestimmung von Z- oder T-Werten, die TUG-Testergebnisse in Relation zur Populationsnorm setzen, ermöglichen eine alters- und geschlechtsadjustierte Ergebnisinterpretation. Diese Übersichtsarbeit fasst die aktuellen Erkenntnisse zu objektiven Messmethoden bei degenerativen Wirbelsäulenpathologien inklusive deren Vor- und Nachteile zusammen und vergleicht sie mit den bisherigen Beurteilungsmethoden für funktionelle Outcomes.

Women do not fare worse than men after lumbar fusion surgery: Two-year follow-up results from 4,780 prospectively collected patients in the Swedish National Spine Register with lumbar degenerative disc disease and chronic low back pain

BACKGROUND CONTEXT

Proper patient selection is of utmost importance in the surgical treatment of degenerative disc disease (DDD) with chronic low back pain (CLBP). Among other factors, gender was previously found to influence lumbar fusion surgery outcome.

PURPOSE

This study investigates whether gender affects clinical outcome after lumbar fusion.

STUDY DESIGN

This is a national registry cohort study.

PATIENT SAMPLE

Between 2001 and 2011, 2,251 men and 2,521 women were followed prospectively within the Swedish National Spine Register (SWESPINE) after lumbar fusion surgery for DDD and CLBP.

OUTCOME MEASURES

Patient-reported outcome measures (PROMs), visual analog scale (VAS) for leg and back pain, Oswestry Disability Index (ODI), quality of life (QoL) parameter EQ5D, and labor status and pain medication were collected preoperatively, 1 and 2 years after surgery.

METHODS

Gender differences of baseline data and PROM improvement from baseline were analyzed. The effect of gender on clinically important improvement of PROM was determined in a multivariate logistic regression model. Furthermore, gender-related differences in return-to-work were investigated.

RESULTS

Preoperatively, women had worse leg pain (p<.001), back pain (p=.002), lower QoL (p<.001), and greater disability than men (p=.001). Postoperatively, women presented greater improvement 2 years from baseline for pain, function, and QoL (all p<.01). Women had better chances of a clinically important improvement than men for leg pain (odds ratio [OR]=1.39, 95% confidence interval [CI]: 1.19-1.61, p<.01) and back pain (OR=1.20,95% CI:1.03-1.40, p=.02) as well as ODI (OR=1.24, 95% CI:1.05-1.47, p=.01), but improved at a slower pace in leg pain (p<.001), back pain (p=.009), and disability (p=.008). No gender differences were found in QoL and return to work at 2 years postoperatively.

CONCLUSIONS

Swedish women do not have worse results than men after spinal fusion surgery. Female patients present with worse pain and function preoperatively, but improve more than men do after surgery.

Proportion of Expectations Fulfilled: A New Method to Report Patient-centered Outcomes of Spine Surgery

STUDY DESIGN

Prospective lumbar and cervical surgery cohorts.

OBJECTIVE

Compare fulfillment of expectations with traditional global outcomes and provide evidence for its validity.

SUMMARY OF BACKGROUND DATA

New lumbar and cervical spine surgery Expectations Surveys can be used to measure fulfillment of expectations and their performance should be compared with existing outcomes.

METHODS

Three hundred thirty-six lumbar and 133 cervical spine surgery patients preoperatively completed valid 20-item Expectations Surveys measuring symptoms, function, and psychological well-being. Approximately 2 years postoperatively patients rated how much improvement they received for each item. The proportion of expectations fulfilled was compared with traditional outcomes, including global satisfaction and change in standard spine questionnaires, with correlation coefficients (r) and areas under receiver operator characteristic curves (AUC).

RESULTS

Ninety percent of lumbar patients had some expectations fulfilled (24% had all expectations fulfilled completely or exceeded). The mean proportion of expectations fulfilled was 0.66 and was associated with satisfaction (r = 0.73 (95% CI 0.68-0.78); AUC = 0.92 (95% CI 0.89-0.95) (P < 0.0001)). Based on the association with satisfaction, a clinically important proportion of expectations fulfilled for lumbar surgery is approximately 0.60 (sensitivity 0.90, specificity 0.79).Ninety-one percent of cervical patients had some expectations fulfilled (31% had all expectations fulfilled completely or exceeded). The mean proportion of expectations fulfilled was 0.78 and was associated with satisfaction (r = 0.62 (95% CI 0.50-0.72); AUC = 0.92 (95% CI 0.87-0.97) (P < 0.0001)). Based on the association with satisfaction, a clinically important proportion of expectations fulfilled for cervical surgery is approximately 0.62 (sensitivity 0.91, specificity 0.80).

CONCLUSION

The proportion of expectations fulfilled is a new patient-centered outcome that measures results of spine surgery. Unique features of this novel outcome are that it requires prospectively acquired pre- and postoperative data, provides details about in what ways patients believe surgery did and did not meet goals, and offers surgeons opportunities to address unfilled expectations directly.

LEVEL OF EVIDENCE

1.

Long-Term Results of Various Operations for Lumbar Disc Herniation: Analysis of over 39,000 Patients

OBJECTIVE

To determine the long-term follow-up of the various operations for lumbar disc herniation in a large patient population.

SUBJECTS AND METHODS

Patients who had operations for lumbar disc herniation (microdiscectomy, endoscopic microdiscectomy and the 'classical operation', i.e. laminectomy/laminotomy with discectomy) were collected from the world literature. Patients who had follow-ups for at least 2 years were analyzed relative to the outcome. The outcome was graded by the patients themselves, and the operative groups were compared to one another.

RESULTS

39,048 patients collected from the world literature had had lumbar disc operations for disc herniations. The mean follow-up period was 6.1 years, and 30,809 (78.9%) patients reported good/excellent results. Microdiscectomy was performed on 3,400 (8.7%) patients. The mean follow-up was 4.1 years with 2,866 (84.3%) good/excellent results, while 1,101 (3.6%) patients had endoscopic microdiscectomy. There, the mean follow-up was 2.9 years with 845 (79.5%) good/excellent results. The classical operation was performed on 34,547 (88.5%) patients with a mean follow-up period of 6.3 years, and 27,050 (78.3%) patients had good/excellent results. These results mirror those with discectomy and the placement of prosthetic discs.

CONCLUSIONS

The analysis of 39,048 patients with various operations for lumbar disc herniation revealed the same pattern of long-term results. Patients who had microdiscectomy, endoscopic microdiscectomy or the classical operation (laminectomy/laminotomy with discectomy) all had approximately 79% good/excellent results. None of the operative procedures gave a different outcome. l.

A Review and Analysis of the YODA Trials: What Can We Glean Clinically?

Medtronic's biologic, Infuse (rhBMP-2), was approved by the FDA in 2002. Since its approval, a whirlwind of controversy developed culminating in an investigation by the Senate Finance committee. These events led to a landmark agreement between Medtronic and Yale University to perform a comprehensive and unbiased analysis of all patient related data. The project was named the Yale Open Data Access (YODA). The purpose of this article is to evaluate the results of the YODA project and determine what is clinically meaningful.

Usefulness of minimum clinically important difference for assessing patients with subaxial degenerative cervical spine disease: statistical versus substantial clinical benefit

BACKGROUND

The measurement of the therapeutic outcome of cervical spine surgeries commonly relies on four main patient reported outcomes (PROs): Neck Disability Index (NDI), Visual Analog Scale (VAS) for pain, and Short Form-36 (SF-36) Physical (PCS) and Mental (MCS) Component Summary. However, the clinical impact of such scores and how they could effectively measure therapeutic efficacy remains unclear. In this context, the concept of minimum clinically important difference (MCID) is developing into the standard by which to evaluate treatments, patient satisfaction and cost-effectiveness.

METHODS

Eighty-eight consecutive patients undergoing surgery for subaxial degenerative cervical spine disease were selected from a prospective blinded database. PROs (NDI, PCS, MCS and VAS) were collected preoperatively, and together with blinded Surgeon Ratings (SR) at 3 months and 6 months post-surgery. Four anchor-based approaches were used to calculate different MCIDs. Three anchors (VAS, HTI (Health Transition Item of the SF-36) and SR) were used to evaluate surgery outcome. The best clinically and statistically relevant MCID was chosen.

RESULTS

On average, all patients presented with a statistically significant improvement (p < 0.001) postoperatively for NDI (27.42 to 19.42), PCS (33.02 to 42.03), MCS (44 to 50.74) and VAS (2.85 to 1.93). The four MCID anchor-based approaches yielded a range of values for each PRO: 2.23-16.59 for PCS, 0.11-16.27 for MCS and 2.72-12.08 for NDI. When compared to the VAS and HTI anchors, the area under the ROC curve was greater for SR. This finding suggests that SR may be a more reliable anchor for MCID calculation.

CONCLUSION

The MDC (minimum detectable change) approach together with the SR anchor appears to be the most appropriate MCID method. It offers the greatest area under the ROC curve (threshold above the 95 % CI), and the choice of the anchor did not significantly affect this result. MCID values for this dataset were 5.6 for PCS, 5.12 for MCS and 2.41 for NDI.

The assessment of complications after spine surgery: time for a paradigm shift?

BACKGROUND CONTEXT

Recent years have witnessed a shift in the assessment of spine surgical outcomes with a greater focus on the patient's perspective. However, this approach has not been widely extended to the assessment of complications.

PURPOSE

The present study sought to quantify the patient-rated impact/severity of complications of spine surgery and directly compare the incidences of surgeon-rated and patient-reported complications.

STUDY DESIGN

Prospective study of patients undergoing surgery for painful degenerative lumbar disorders, being operated in the Spine Center of an orthopedic hospital.

PATIENT SAMPLE

A total of 2,303 patients (mean [standard deviation] age, 61.9 [15.1] years; 1,136 [49.3%] women and 1,167 [50.7%] men).

PATIENTS

Core Outcome Measures Index, self-rated complications, bothersomeness of complications, global treatment outcome, and satisfaction. Surgeons: Spine Tango surgery and follow-up documentation forms registering surgical details and complications.

METHODS

PATIENTS completed questionnaires before and 3 months after surgery. Surgeons documented complications before discharge and at the first postoperative follow-up, 6 to 12 weeks after surgery.

RESULTS

In total, 615 out of 2,303 (27%) patients reported complications, with "bothersomeness" ratings of 1%, not at all; 22%, slightly; 26%, moderately; 34%, very; and 17%, extremely bothersome. PATIENTS most commonly reported sensory disturbances (35% of those reporting a complication) or ongoing/new pain (27%) followed by wound healing problems (11%) and motor disturbances (8%). The surgeons documented complications in 19% of patients. There was a minimal overlap regarding the presence or absence of complications in any given patient.

CONCLUSIONS

Most complications reported by the patient are perceived to be at least moderately bothersome and are, hence, not inconsequential. Surgeons reported lower complication rates than the patients did, and there was only moderate agreement between the ratings of the two. As with treatment outcome, complications and their severity should be assessed from both the patient's and the surgeon's perspectives.

Comparison between patient and surgeon perception of degenerative spine disease outcomes--a prospective blinded database study

BACKGROUND

Few have studied the correlation between patients' and spine surgeons' perception on outcomes, or compared these with patient-reported outcome scores. Outcomes studies are increasingly important in evaluating costs and benefits to patients and surgeons, and in developing metrics for payer evaluation and health care policy-making.

OBJECTIVE

To compare patients' and surgeons' assessment of spine treatment outcome in a prospective blinded patient-driven spine surgery outcomes registry, and to correlate perceived outcomes ratings to validated outcomes scores.

METHODS

Patients filled out surveys at baseline, 3 months and 6 months postoperatively, including Visual Analog Scale (VAS), and Neck Disability Index (NDI) or Oswestry Disability Index (ODI). Outcome was rated independently by patients and surgeons on a 7-point Likert-type scale.

RESULTS

Two-hundred and sixty-five consecutive adult patients were surgical candidates. Of these, 154 (58.1 %) opted for surgery, with 69 (44.8 %) cervical and 85 (55.2 %) lumbar patients. One hundred and thirty-five (87.7 %) had both patient and surgeon postoperative ratings. Surgeons' and patients' ratings correlated strongly (Spearman rho = 0.53, p < 0.0001, 45.9 % identical, 88.2 % +/- 1 grade). The surgeon rated outcomes were better than patients in 29.8 % and worse in 21.15 %. Patient rating correlated better with the most recent NDI/ODI and pain scores than with incremental change from baseline. In multivariate analysis, age, location (cervical vs lumbar), pain ratings, and functional scores (NDI, ODI) did not have significant impact on the discrepancy between patient and surgeon ratings.

CONCLUSIONS

Patients' and surgeons' global outcome ratings for spinal disease correlate highly. Patients' ratings correlate better with most recent functional scores, rather than incremental change from baseline.

Cross-cultural adaptation and validation of the Norwegian version of the Core Outcome Measures Index for low back pain

PURPOSE

The Core Outcome Measures Index (COMI) is a short multidimensional scale covering all domains recommended to be included as outcome measures for patients with low back pain (LBP). The purpose of the present study was to translate and cross-culturally adapt the COMI into Norwegian and to test clinimetric properties of the Norwegian COMI version in patients with non-specific LBP recruited from various clinical settings.

METHODS

Ninety patients with non-specific LBP from primary care and hospital settings participated in the validation part and 61 also in the reproducibility part of the study (1 week apart). Acceptability, data quality, reproducibility and construct validity were investigated.

RESULTS

The questionnaire was well accepted and with little missing data and end effects. Reliability in terms of intraclass correlations (ICC) was satisfactory for the COMI index [0.89 (95 % CI 0.82-0.94)] and most single-core items. Agreement was acceptable for the COMI index [standard error of measurement (SEM(agreement)) 0.80, minimal detectable change (MDC(individual)) 2.21], but exceeded the minimal standard of acceptability in some of the individual core items. Construct validity was acceptable for the COMI index.

CONCLUSION

The Norwegian version of the COMI index shows acceptable clinimetric properties in our patient population, but some of the sub-items had shortcomings. Our study, however, support the usefulness of the COMI index as an applicable stand-alone global scale when a light respondent burden is advisable.

Effect of deep wound infection following lumbar arthrodesis for degenerative disc disease on long-term outcome: a prospective study: clinical article

OBJECT

Deep wound infections are one of the most common and serious complications of spinal surgery. The impact of such infections on long-term outcomes is not well understood. The purpose of this study was to evaluate the functional status and satisfaction in patients who suffered a deep wound infection after undergoing lumbar arthrodesis for symptomatic degenerative disc disease.

METHODS

The authors conducted a prospective study in 13 patients with a clinical and radiological diagnosis of symptomatic degenerative lumbar stenosis and instability; after undergoing decompression and instrumentation-augmented arthrodesis, the patients suffered a deep wound infection (infection group). A 3:1 (39-patient) matched cohort was selected for comparison (control group). All surgeries were performed during the same period and by a single surgeon. The postoperative infections were all treated in a similar manner and the instrumentation was not removed. Both groups were followed up and assessed with validated outcome instruments: Numerical Rating Scale of pain, Oswestry Disability Index, 36-Item Short Form Health Survey, Beck Depression Inventory, and Hospital Anxiety and Depression Scale. Patient satisfaction was also determined.

RESULTS

The median follow-up duration was 22 months (range 6-108 months). The mean patient age was 62 ± 10 years, and 59.6% of the patients were female. There was no significant difference between the groups in pain, functional disability, quality of life, or depression and anxiety. However, 53.8% of the patients with infection were not satisfied with the procedure at the final evaluation, compared with 15.4% of the patients without a deep wound infection (p = 0.003).

CONCLUSIONS

Patients with successfully treated postoperative deep wound infections do not have a difference in functional outcome compared with patients who underwent an identical operation but did not suffer a complicating infection. Patients who suffered an infection were more likely to be unsatisfied with the procedure than patients who did not.

The extent to which common health-related quality of life indices capture constructs beyond symptoms and function

PURPOSE

This study proposes to identify for 5 widely used generic HRQL and QOL measures the extent to which function and global feelings of well-being are represented in their content.

METHODS

The 5 indices were the EQ-5D, the HUI, the SF-36, SF-12, and the WHOQOL-Bref. A total of 15 raters with a variety of health and research backgrounds mapped the items. Raters independently identified all codes that could possibly map to the item and indicated the code that best reflected the underlying intent of the item, using the standardized mapping rules and methodology. A Delphi process aided consensus for each of the items. The consensus rounds involved reconsideration of item codes for which 70% of raters did not agree on the "best" code. These consensus rounds were terminated when item codes reached the threshold of 70% agreement or when it became evident from that consensus would not be reached.

RESULTS

Function was a predominant construct for the 5 indices, with the proportion of items capturing function ranging from a low of 27% for the WHOQOL-Bref to a high of 92% for the SF-12. Less than 50% of items within the indices mapped to the granularity of function as described by the ICF.

CONCLUSIONS

This paper demonstrates an additional method to validate the content of health-related indices to supplement the qualitative methods of consulting with experts and patients.

Life dissatisfaction in the pre-operative and early recovery phase predicts low functional ability and coping among post-operative patients with lumbar spinal stenosis: a 2-year prospective study

PURPOSE

We examined the significance of life dissatisfaction in pre-operative and early recovery phases with respect to functional ability, pain and coping on 2-year follow-up of patients with lumbar spinal stenosis (LSS).

METHODS

Patients (n=90, mean age, 62 years, men 40%) with symptomatic LSS underwent decompressive surgery. Data collection took place with the same set of questionnaires before surgery and 3 months, 6 months and 2 years postoperatively. Life dissatisfaction was assessed with the four-item life satisfaction (LS) scale. In addition, a life dissatisfaction burden, comprising the sum of preoperative, 3-month and 6-month LS scores, was calculated. Physical functioning (Oswestry disability index), pain (VAS and pain drawing) and coping (sense of coherence, SOC) were assessed. Logistic regression analysis was used to examine life dissatisfaction as a predictor of the 2-year functional ability, pain and coping (SOC).

RESULTS

In these analyses, pain was not predicted by either pre-operative life dissatisfaction or life dissatisfaction burden. However, both disability and poor coping on 2-year follow-up were independently associated with both pre-operative and early recovery phase life dissatisfaction.

CONCLUSIONS

Our results show the importance of both pre-operative and early post-operative well-being regarding subsequent functioning. Thus, monitoring of the subjective well-being throughout the pre-operative and post-operative period may indicate those patients at risk of poorer post-operative recovery.

Comparison of patient and surgeon ratings of outcome 12 months after spine surgery

Object

The contemporary assessment of spine surgical outcome primarily relies on patient-centered reports of symptoms and function. Such measures are considered to reduce bias compared with traditional surgeon-based outcome ratings. This study examined the agreement between patients' and surgeons' ratings of outcome 1 year after spine surgery.

Methods

The study involved 404 patients (mean age 56.6 ± 16.4 years; 259 women, 145 men) and their treating surgeons. At baseline and 12 months postoperatively patients completed the Core Outcome Measures Index (COMI) rating pain, function, quality of life, and disability. At 12 months postoperatively, they also rated the global outcome of surgery and their satisfaction with treatment. The surgeon, blinded to the patient's evaluation, rated the global outcome of surgery as excellent, good, fair, or poor.

Results

Seventy-six percent of the patients who were considered by the surgeon to have an excellent or good outcome achieved the minimum clinically important difference (MCID) of a 2.2-point reduction on the COMI; 24% achieved less than the MCID. There was a significant correlation between the surgeons' and patients' global outcome ratings (Spearman ρ = 0.56; p < 0.0001). The degree of absolute agreement between them was significantly influenced by surgeon seniority: senior surgeons “overrated” the outcome in 24.5% of cases (compared with patients' ratings) and “underrated” it in 17.5% of cases. Junior surgeons overrated in 7.8% of cases and underrated in 43.8% of cases (p < 0.0001). Surgeon overrating occurred significantly more frequently for patients with a poor self-rated outcome (measured as global outcome, COMI score, or satisfaction with treatment). In a multivariate model, the independent variables “senior surgeon” and “patient dissatisfaction with care” were the most significant unique predictors of surgeon overrating of the global outcome (p < 0.0001; adjusted R2for the model = 0.16).

Conclusions

Overall, agreement between surgeon and patient was reasonably good. The majority of patients who were rated as excellent/good by the surgeons had achieved the MCID in the prospectively measured COMI score. Discrepancies in outcome ratings were influenced by surgeon seniority and patient satisfaction. For a balanced view of the surgical result, outcomes should be assessed from the perspectives of both the patient and the surgeon.

Money matters: exploiting the data from outcomes research for quality improvement initiatives

In recent years, there has been an increase in studies that have sought to identify predictors of treatment outcome and to examine the efficacy of surgical and non-surgical treatments. In addition to the scientific advancement associated with these studies per se, the hospitals and clinics where the studies are conducted may gain indirect financial benefit from participating in such projects as a result of the prestige derived from corporate social responsibility, a reputational lever used to reward such institutions. It is known that there is a positive association between corporate social performance and corporate financial performance. However, in addition to this, the research findings and the research staff can constitute resources from which the provider can reap a more direct benefit, by means of their contribution to quality control and improvement. Poor quality is costly. Patient satisfaction increases the chances that the patient will be a promoter of the provider to friends and colleagues. As such, involvement of the research staff in the improvement of the quality of care can ultimately result in economic revenue for the provider. The most advanced methodologies for continuous quality improvement (e.g., six-sigma) are data-driven and use statistical tools similar to those utilized in the traditional research setting. Given that these methods rely on the application of the scientific process to quality improvement, researchers have the adequate skills and mind-set to embrace them and thereby contribute effectively to the quality team. The aim of this article is to demonstrate by means of real-life examples how to utilize the findings of outcome studies for quality management in a manner similar to that used in the business community. It also aims to stimulate research groups to better understand that, by adopting a different perspective, their studies can be an additional resource for the healthcare provider. The change in perspective should stimulate researchers to go beyond the traditional studies examining predictors of treatment outcome and to see things instead in terms of the "bigger picture", i.e., the improvement of the process outcome, the quality of the service.