An introduction to patient-reported outcome measures (PROMs) in trauma

Quality of life and return to work rates in the first two years following major burn injury

BACKGROUND

A better understanding of how major burns patients recover following injury is vital in assessing trauma care and informing healthcare and rehabilitation provision. We aimed to describe the longer-term health and return to work status of major burns patients and identify factors associated with positive outcomes i.e., reporting no problems with health-related quality of life, returning to work).

METHODS

This registry-based cohort study included adult (≥ 16 years) patients with a burn injury affecting ≥ 20 % total body surface area registered by the Victorian State Trauma Registry with a date of injury from July 1 2009 to June 30 2022. Patients were followed-up at six, 12, and 24 months post-injury, completing the 3-level or 5-level EuroQoL 5 dimensions questionnaire (depending on their date of injury) and return to work-related questions at each time point. Mixed effect regression models were used to predict factors associated with quality of life outcomes. Modified binary Poisson models were used to model the probability of experiencing no problems in each of the quality of life domains, and mixed effects linear regression was used to model the overall utility score.

RESULTS

Two hundred and eighty-seven patients were included; 63 (21.9 %) did not die but were completely lost to follow-up. The prevalence of reporting no problems at 24 months post-injury was 70.2 % for mobility, 77.8 % for self-care, 48.0 % for usual activities, 49.7 % for pain or discomfort, and 51.5 % for anxiety or depression. The predicted probability of reporting no problems in each of the EQ-5D health states was lowest at six-months and increased over time.

CONCLUSIONS

The prevalence of ongoing problems - particularly with usual activities, pain, and anxiety/depression - at 24 months post-injury is high, confirming that major burns are often an ongoing disorder. Greater investment in interventions designed to reduce these problems is needed.

Does injury type influence patient preference, response rates, and data completeness for online or telephone follow-up following injury?

INTRODUCTION

Collecting patient-reported outcomes in a systematic fashion is important to understand recovery trajectories and compare performance between different services and fields of care. These outcomes can be collected through a variety of means, but studies comparing different follow-up methods in patients with a variety of injury types are scarce. This study aimed to compare follow-up data from three injury registries to quantify patient preference for telephone versus online follow-up, determine factors associated with choosing online follow-up, and compare response rates based on the patient's preferred follow-up method.

METHODS

A registry-based cohort study of adult (≥16 years) patients registered one of three registries from January 2021 to December 2021 was undertaken. Patients who survived to discharge were contacted by telephone and offered the option of telephone or online self-completion at six- and 12-months post-injury using the EQ-5D-5L. The three injury cohorts and telephone/online groups were compared for differences in characteristics, follow-up rates, and data completeness. Multivariable logistic regression models were used to identify predictors of choosing online completion in the three cohorts.

RESULTS

Data were retrieved for 8,049 patients. A greater proportion of orthopaedic trauma patients initially opted for online follow-up (41.0 %) compared to major trauma (31.0 %) and burns (24.1 %) patients. Orthopaedic and major trauma patients had increased odds of choosing online follow-up compared to burns patients (adjusted odds ratio [95 % confidence interval] 2.9 [2.2-3.7] and 2.1 [1.6-2.7], respectively). A greater proportion of major trauma patients (69.3 %) and burns patients (64.3 %) completed both follow-ups compared to orthopaedic trauma patients (52.4 %). The overall completion rates for the EQ-5D-5L were high.

CONCLUSIONS

While follow-up preference and completion were higher for telephone-based follow-ups, the findings suggest a patient's preference for completing post-injury follow-ups differs according to the type of injury they sustained, and that allowing patients a choice of their preferred follow-up method is important. The variety of follow-up methods offered should therefore reflect the needs of different patient groups, which may allow for the development of algorithms or workflow processes. Directing certain patients towards a particular follow-up method could deliver higher and more efficient follow-up rates.

Minimum clinically important difference of 36-item short form health survey (SF-36) to assess post-surgery quality of life in knee osteoarthritis

BACKGROUND

Quality of life in patients receiving knee arthroplasty is crucial for rehabilitation. Even if the validity of the 36-Item Short Form (SF-36) was already confirmed, the Substantial Clinical Benefit (SCB) and Patient Acceptable Symptom Score (PASS) values of this score remain unknown for both Total Knee Arthroplasty (TKA) and Unicompartmental Knee Arthroplasty (UKA).

OBJECTIVE

The purpose of this research was to compute the Minimal Clinically Important Difference (MCID) of the SF-36 after UKA, and the SCB and PASS of SF-36 after TKA and UKA, in order to assess post-surgery quality of life in knee osteoarthritis.

METHODS

Overall, 59 patients (40 women and 19 men, mean age 60.3 ± 13.1 years) completed the questionnaire until six months follow-up. Of these patients, 22 underwent the TKA procedure, while 37 patients underwent the UKA procedure. The anchor question for computing the MCID and SCB thresholds was "How would you describe your health condition in relation to your previous state?". The PASS scores were determined using the ROC curve and the 75th percentile of the cumulative percentage curve of respondents who believe their symptoms are under control.

RESULTS

The MCID values of global SF-36, Physical Component Summary (PCS) and Mental Component Summary (MCS) after UKA were 11.3, 14.5 and 11.4, respectively. The SCB values of global SF-36, PCS and MCS after UKA were 23.5, 23.1 and 15, respectively. The PASS values of global SF-36, PCS and MCS after TKA were 71.2, 75 and 69.3, respectively. The PASS values of global SF-36, PCS and MCS after UKA were 70.4, 72.1 and 67.5, respectively.

CONCLUSION

The SF-36 score represents a valid score for quality of life in patients with knee osteoarthritis. Taken together, the results showed a statistically significant improvement between inception and latest follow-up after TKA and UKA.

Rehabilitation to Improve Outcomes after Cervical Spine Surgery: Narrative Review

PURPOSE

The increasing elderly patient population is contributing to the rising worldwide load of cervical spinal disorders, which is expected to result in a global increase in the number of surgical procedures in the foreseeable future. Cervical rehabilitation plays a crucial role in optimal recovery after cervical spine surgeries. Nevertheless, there is no agreement in the existing research regarding the most suitable postsurgical rehabilitation program. Consequently, this review assesses the ideal rehabilitation approach for adult patients following cervical spine operations.

MATERIALS AND METHODS

This review covers activities of daily living and encompasses diverse treatment methods, including physiotherapy, specialized tools, and guidance for everyday activities. The review is organized under three headings: (1) historical perspectives, (2) patient-reported functional outcomes, and (3) general and disease-specific rehabilitation.

RESULTS

Rehabilitation programs are determined on the basis of patient-reported outcomes, performance tests, and disease prognosis. CSM requires strengthening of the neck and shoulder muscles that have been surgically invaded. In contrast, the CCI requires mobility according to the severity of the spinal cord injury and functional prognosis. The goal of rehabilitation for CCTs, as for CCIs, is to achieve ambulation, but the prognosis and impact of cancer treatment must be considered.

CONCLUSIONS

Rehabilitation of the cervical spine after surgery is essential for improving physical function and the ability to perform daily activities and enhancing overall quality of life. The rehabilitation process should encompass general as well as disease-specific exercises. While current rehabilitation protocols heavily focus on strengthening muscles, they often neglect the crucial aspect of spinal balance. Therefore, giving equal attention to muscle reinforcement and the enhancement of spinal balance following surgery on the cervical spine is vital.

European society for trauma and emergency surgery member-identified research priorities in emergency surgery: a roadmap for future clinical research opportunities

BACKGROUND

European Society for Trauma and Emergency Surgery (ESTES) is the European community of clinicians providing care to the injured and critically ill surgical patient. ESTES has several interlinked missions - (1) the promotion of optimal emergency surgical care through networked advocacy, (2) promulgation of relevant clinical cognitive and technical skills, and (3) the advancement of scientific inquiry that closes knowledge gaps, iteratively improves upon surgical and perioperative practice, and guides decision-making rooted in scientific evidence. Faced with multitudinous opportunities for clinical research, ESTES undertook an exercise to determine member priorities for surgical research in the short-to-medium term; these research priorities were presented to a panel of experts to inform a 'road map' narrative review which anchored these research priorities in the contemporary surgical literature.

METHODS

Individual ESTES members in active emergency surgery practice were polled as a representative sample of end-users and were asked to rank potential areas of future research according to their personal perceptions of priority. Using the modified eDelphi method, an invited panel of ESTES-associated experts in academic emergency surgery then crafted a narrative review highlighting potential research priorities for the Society.

RESULTS

Seventy-two responding ESTES members from 23 countries provided feedback to guide the modified eDelphi expert consensus narrative review. Experts then crafted evidence-based mini-reviews highlighting knowledge gaps and areas of interest for future clinical research in emergency surgery: timing of surgery, inter-hospital transfer, diagnostic imaging in emergency surgery, the role of minimally-invasive surgical techniques and Enhanced Recovery After Surgery (ERAS) protocols, patient-reported outcome measures, risk-stratification methods, disparities in access to care, geriatric outcomes, data registry and snapshot audit evaluations, emerging technologies interrogation, and the delivery and benchmarking of emergency surgical training.

CONCLUSIONS

This manuscript presents the priorities for future clinical research in academic emergency surgery as determined by a sample of the membership of ESTES. While the precise basis for prioritization was not evident, it may be anchored in disease prevalence, controversy around aspects of current patient care, or indeed the identification of a knowledge gap. These expert-crafted evidence-based mini-reviews provide useful insights that may guide the direction of future academic emergency surgery research efforts.

Defining the minimum clinically important difference (MCID) in the hospital anxiety and depression scale (HADS) in patients undergoing total hip and knee arthroplasty

INTRODUCTION

Total hip (THA) and knee (TKA) arthroplasty are effective procedures, but whose success depends on various factors, including patients' genetics, sociocultural environments, and psychological factors. Patient-reported outcome measures (PROMs) provide objective health status outcomes measurements, whose lowest significant variation is detected by the minimum clinically important difference (MCID).

HYPOTHESIS

We aimed to find the MCID scores for the Hospital Anxiety and Depression Scale (HADS), HADS-A, and HADS-D in a cohort of individuals undergoing THA or TKA.

PATIENTS AND METHODS

We enrolled 88 patients suffering from osteoarthritis (43 undergoing THA, and 45 TKA) by administering HADS, SF-12 and WOMAC at baseline and then with a 12-month prospective follow-up. The MCID for HADS, HADS-A, and HADS-D was calculated using the distribution-based approach, according to various techniques (0.5 standard deviation [0.5 SD]), the standard error of measurement (SEM), the effect size (ES), and the minimum detectable change (MDC).

RESULTS

The analysis of HADS, HADS-A, and HADS-D scores revealed clinically significant improvements in symptoms in patients who underwent THA and TKA. The MCID range values were determined to be between 2.7-8.5 for the HADS, 1.4-4.4 for the HADS-A, and 1.5-4.8 for the HADS-D in the group of patients undergoing THA, and 2.1-6.7 for the HADS, 1.2-3.8 for the HADS-A, and 1.1-3.6 for the HADS-D in the TKA group.

DISCUSSION

The study determined significant improvement in all scores applying MCID analysis, which can aid physicians in interpreting anxiety and depression scores and developing both preoperative and postoperative procedures to enhance outcomes for patients undergoing THA and TKA.

LEVEL OF EVIDENCE

I; well-designed cohort study.

Health-related quality of life following trauma: Prevalence of problems and factors associated with six-month outcomes in a New Zealand cohort

Injury is a leading cause of health loss in Aotearoa me Te Waipounamu (New Zealand; NZ). The NZ Trauma Registry was established in 2015 to monitor outcomes in those experiencing severe injury and to identify ways of improving the quality of care for these patients. Few NZ studies have assessed outcomes in trauma patients using patient-reported outcome measures (PROMs) despite increasing recognition that the impacts of injury are better understood through PROMs. Our aim was to estimate the prevalence of self-reported problems with health-related quality of life (HRQoL) outcomes six months post-injury, and identify factors associated with these, in a cohort of Māori (the Indigenous population of NZ) and non-Māori individuals who had experienced major trauma. HRQoL outcomes were measured according to the five dimensions of the EQ-5D-5L. This information, along with sociodemographic data, was collected via structured telephone interviews. Participants (n = 870), aged 16 years or more, were recruited following admission to a trauma hospital in one of three (of NZ's four) trauma regions. Multivariable models were developed using modified Poisson Regression to identify factors associated with outcomes for both Māori and non-Māori patients. The prevalence and severity of problems across each of the five EQ-5D-5L dimensions was similar for Māori and non-Māori except for Anxiety/Depression. The prevalence and severity of problems with Anxiety/Depression was greater for Māori. Factors associated with HRQoL problems at six-months were also largely similar for each cohort. Those commonly associated with outcomes were age, hospital length of stay, adequacy of household income, and participants' expectations regarding recovery from injury. Further research examining recovery expectations in trauma patients to determine which factors contribute to formulating recovery expectations, and the potential impact of recovery expectations on treatment and rehabilitation, would be of value. Should expectations, at least in part, influence HRQoL outcomes, then routinely collecting data on patients' recovery expectations, adequacy of household income and potential barriers to treatment and rehabilitation, could help inform post-hospital treatment plans, and identify those who may require additional support following discharge from hospital.

Wearable activity data can predict functional recovery after musculoskeletal injury: Feasibility of a machine learning approach

Delayed functional recovery after injury is associated with significant personal and socioeconomic burden. Identification of patients at risk for a prolonged recovery after a musculoskeletal injury is thus of high relevance. The aim of the current study was to show the feasibility of using a machine learning assisted model to predict functional recovery based on the pre- and immediate post injury patient activity as measured with wearable systems in trauma patients. Patients with a pre-existing wearable (smartphone and/or body-worn sensor), data availability of at least 7 days prior to their injury, and any musculoskeletal injury of the upper or lower extremity were included in this study. Patient age, sex, injured extremity, time off work and step count as activity data were recorded continuously both pre- and post-injury. Descriptive statistics were performed and a logistic regression machine learning model was used to predict the patient's functional recovery status after 6 weeks based on their pre- and post-injury activity characteristics. Overall 38 patients (7 upper extremity, 24 lower extremity, 5 pelvis, 2 combined) were included in this proof-of-concept study. The average follow-up with available wearable data was 85.4 days. Based on the activity data, a predictive model was constructed to determine the likelihood of having a recovery of at least 50 % of the pre-injury activity state by post injury week 6. Based on the individual activity by week 3 a predictive accuracy of over 80 % was achieved on an independent test set (F1=0,82; AUC=0,86; ACC=8,83). The employed model is feasible to assess the principal risk for a slower recovery based on readily available personal wearable activity data. The model has the potential to identify patients requiring additional aftercare attention early during the treatment course, thus optimizing return to the pre-injury status through focused interventions. Additional patient data is needed to adapt the model to more specifically focus on different fracture entities and patient groups.

Evaluating the Minimum Clinically Important Difference and Patient Acceptable Symptom State for the Womac Osteoarthritis Index after Unicompartmental Knee Arthroplasty

Patient-Reported Outcome Measures (PROMs) are standardized questionnaires that gather information on health-related quality of life directly from patients. Since a significant statistical mean change may not correspond to a clinical improvement, there is a need to calculate a considerable change in scores. This is done by the Minimum Clinically Important Difference (MCID) and Patient Acceptable Symptom State (PASS). The objective of this article is to report the MCID and the PASS values of the WOMAC (Western Ontario and McMaster University) osteoarthritis index for patients undergoing Unicompartmental Knee Arthroplasty (UKA). A total of 37 patients (25 females and 12 males; mean age 68 ± 8.1 years and mean BMI 28.7 ± 4) who underwent UKA were enrolled. All patients were assessed using the WOMAC and the Oxford Knee Score (OKS) questionnaires before and six months following the procedure. To measure the cut-off values for MCID, distribution methods and anchor methods were applied, while the PASS was assessed only via anchor approaches. The MCID related to the WOMAC average global score was 90.7 ± 7.6, the average pain dimension score was 93.2 ± 6.6, the average stiffness dimension score was 92.6 ± 17, and the average physical function dimension score was 89.7 ± 7.6. In terms of PASS, the normalized WOMAC was 82.8, the pain dimension was 87.5, the stiffness dimension was 93.7, and the functional dimension was 83.1. A 34.5 amelioration in the WOMAC score, from initial evaluation to final follow-up, using change in OKS > 5 as anchor, indicates that the patients' health state improved to a clinically significant degree. A value at least of 82.8 in WOMAC score after treatment denotes that the symptom state is deemed acceptable by most of the patients.

Cohort profile: The Trauma Outcomes Project, a prospective study of New Zealanders experiencing major trauma

PURPOSE

Patient-reported outcome measures (PROMs) are useful for trauma registries interested in monitoring patient outcomes and trauma care quality. PROMs had not previously been collected by the New Zealand Trauma Registry (NZTR). More than 2500 New Zealanders are admitted to hospital for major trauma annually. The Trauma Outcomes Project (TOP) collected PROMs postinjury from three of New Zealand's (NZ's) major trauma regions. This cohort profile paper aims to provide a thorough description of preinjury and 6 month postinjury characteristics of the TOP cohort, including specifically for Māori (Indigenous population in Aotearoa me Te Waipounamu/NZ).

PARTICIPANTS

Between July 2019 and June 2020, 2533 NZ trauma patients were admitted to one of 22 hospitals nationwide for major trauma and included on the NZTR. TOP invited trauma patients (aged ≥16 years) to be interviewed from three regions; one region (Midlands) declined to participate. Interviews included questions about health-related quality of life, disability, injury recovery, healthcare access and household income adequacy.

FINDINGS TO DATE

TOP recruited 870 participants, including 119 Māori. At 6 months postinjury, most (85%) reported that the injury still affected them, 88% reported problems with≥1 of five EQ-5D-5L dimensions (eg, 75% reported problems with pain or discomfort, 71% reported problems with usual activities and 52% reported problems with mobility). Considerable disability (World Health Organization Disability Assessment Schedule, WHODAS II, score ≥10) was reported by 45% of participants. The prevalence of disability among Māori participants was 53%; for non-Māori it was 44%. Over a quarter of participants (28%) reported trouble accessing healthcare services for their injury. Participation in paid work decreased from 63% preinjury to 45% 6 months postinjury.

FUTURE PLANS

The 12 and 24 month postinjury data collection has recently been completed; analyses of 12 month outcomes are underway. There is potential for longer-term follow-up interviews with the existing cohort in future. TOP findings are intended to inform the National Trauma Network's quality improvement processes. TOP will identify key aspects that aid in improving postinjury outcomes for people experiencing serious injury, including importantly for Māori.

From numbers to meaningful change: Minimal important change by using PROMIS in a cohort of fracture patients

INTRODUCTION

use of the Patient-Reported Outcomes measurement Information System (PROMIS®) is slowly increasing in patients with a fracture. Yet, minimal important change of PROMIS in patients with fractures has been addressed in a very limited number of studies. As the minimal important change (MIC) is important to interpret PROMIS-scores, the goal is to estimate the MIC for PROMIS physical function (PF), PROMIS pain interference (PI) and PROMIS ability to participate in social roles and activities (APSRA) in patients with a fracture. Secondly, the smallest detectable change was determined.

MATERIALS AND METHODS

A longitudinal cohort study on patients ≥ 18 years receiving surgical or non-surgical care for fractures was conducted. Patients completed PROMIS PF V1.1, PROMIS PI V1.1 and PROMIS APSRA V2.0. For follow-up, patients completed three additional anchor questions evaluating patient-reported improvement on a seven point rating scale. The predictive modeling method was used to estimate the MIC value of all three PROMIS questionnaires.

RESULTS

Hundred patients with a mean age of 55.4 ± 12.6 years were included of which sixty (60%) were female. Seventy-two (72%) patients were recovering from a surgical procedure. PROMIS-CAT T-scores of all PROMIS measures showed significant correlations with their anchor questions. The predictive modeling method showed a MIC value of +2.4 (n = 98) for PROMIS PF, -2.9 (n = 96) for PROMIS PI and +3.2 (n = 91) for PROMIS APSRA.

CONCLUSION

By using the anchor based predictive modeling method, PROMIS MIC-values for improvement of respectively +2.4 points on a T-score metric for PROMIS-PF, -2.9 for PROMIS-PI and +3.2 for PROMIS APSRA give the impression of being meaningful to patients. These values can be used in clinical practice for managing patient expectations; to inform on treatment results; and to assess if patients experience significant change. This in order to encourage patient centered care.

Evaluating the Use of PROMs in Paediatric Orthopaedic Registries

Patient-reported outcome measures (PROMs) provide structured information on the patient's health experience and facilitate shared clinical decision-making. Registries that collect PROMs generate essential information about the clinical course and efficacy of interventions. Whilst PROMs are increasingly being used in adult orthopaedic registries, their use in paediatric orthopaedic registries is not well known. The purpose of this systematic review was to identify the frequency and scope of registries that collect PROMs in paediatric orthopaedic patient groups. In July 2023, six databases were systematically searched to identify studies that collected PROMs using a registry amongst patients aged under 18 years with orthopaedic diagnoses. Of 3190 identified articles, 128 unique registries were identified. Three were exclusively paediatric, 27 were majority paediatric, and the remainder included a minority of paediatric patients. One hundred and twenty-eight registries collected 72 different PROMs, and 58% of these PROMs were not validated for a paediatric population. The largest group of orthopaedic registries collected PROMs on knee ligament injuries (21%). There are few reported dedicated orthopaedic registries collecting PROMs in paediatric populations. The majority of PROMs collected amongst paediatric populations by orthopaedic registries are not validated for patients under the age of 18 years. The use of non-validated PROMs by registries greatly impedes their utility and impact. Dedicated orthopaedic registries collecting paediatric-validated PROMs are needed to increase health knowledge, improve decision-making between patients and healthcare providers, and optimise orthopaedic management.

Response rates in clinical quality registries and databases that collect patient reported outcome measures: a scoping review

BACKGROUND

Patient Reported Outcome Measures (PROMs) are being increasingly introduced in clinical registries, providing a personal perspective on the expectations and impact of treatment. The aim of this study was to describe response rates (RR) to PROMs in clinical registries and databases and to examine the trends over time, and how they change with the registry type, region and disease or condition captured.

METHODS

We conducted a scoping literature review of MEDLINE and EMBASE databases, in addition to Google Scholar and grey literature. All English studies on clinical registries capturing PROMs at one or more time points were included. Follow up time points were defined as follows: baseline (if available), < 1 year, 1 to < 2 years, 2 to < 5 years, 5 to < 10 years and 10 + years. Registries were grouped according to regions of the world and health conditions. Subgroup analyses were conducted to identify trends in RRs over time. These included calculating average RRs, standard deviation and change in RRs according to total follow up time.

RESULTS

The search strategy yielded 1,767 publications. Combined with 20 reports and four websites, a total of 141 sources were used in the data extraction and analysis process. Following the data extraction, 121 registries capturing PROMs were identified. The overall average RR at baseline started at 71% and decreased to 56% at 10 + year at follow up. The highest average baseline RR of 99% was observed in Asian registries and in registries capturing data on chronic conditions (85%). Overall, the average RR declined as follow up time increased.

CONCLUSION

A large variation and downward trend in PROMs RRs was observed in most of the registries identified in our review. Formal recommendations are required for consistent collection, follow up and reporting of PROMs data in a registry setting to improve patient care and clinical practice. Further research studies are needed to determine acceptable RRs for PROMs captured in clinical registries.

Establishing the Minimum Clinically Significant Difference (MCID) and the Patient Acceptable Symptom Score (PASS) for the Hospital Anxiety and Depression Scale (HADS) in Patients with Rotator Cuff Disease and Shoulder Prosthesis

Insufficiently treated shoulder pain may cause mental disturbances, including depression and anxiety. The Hospital Anxiety and Depression Scale (HADS) is a patient-reported outcome measure (PROM) that aims to identify depression and anxiety in patients in nonpsychiatric wards. The aim of this study was to identify the minimum clinically important difference (MCID) and patient acceptable symptom state (PASS) scores for the HADS in a cohort of individuals with rotator cuff disease. Using the HADS, participants' degrees of anxiety and depression were assessed at inception and at their final assessment 6 months after surgery. To calculate the MCID and the PASS, distribution and anchor approaches were employed. The MCID from inception to final assessment was 5.7 on the HADS, 3.8 on the HADS-A, and 3.3 on the HADS-D. A 5.7 amelioration on the HADS score, 3.8 on the HADS-A, and 3.3 on the HADS-D, from inception to final assessment, meant that patients had reached a clinically meaningful improvement in their symptom state. The PASS was 7 on the HADS, 3.5 on the HADS-A, and 3.5 on the HADS-D; therefore, for the majority of patients, a score of at least 7 on the HADS, 3.5 on the HADS-A, and 3.5 on the HADS-D at final evaluation was considered a satisfactory symptom state.

Structured approach with primary and secondary survey for major trauma care: an overview of reviews

BACKGROUND

A structured approach involves systematic management of trauma patients. We aim to conduct an overview of reviews about the clinical efficacy and safety of structured approach (i.e., primary and secondary survey) by guideline checklist compared to non-structured approach (i.e. clinical examination); moreover, routine screening whole-body computer tomography (WBCT) was compared to non-routine WBCT in patients with suspected major trauma.

METHODS

We systematically searched MEDLINE (PubMed), EMBASE and Cochrane Database of Systematic Reviews up to 3 May 2022. Systematic reviews (SRs) that investigated the use of a structured approach compared to a non-structured approach were eligible. Two authors independently extracted data, managed the overlapping of primary studies belonging to the included SRs and calculated the corrected covered area (CCA). The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

RESULTS

We included nine SRs investigating two comparisons in stable trauma patients: structured approach vs non-structured approach (n = 1) and routine WBCT vs non-routine WBCT (n = 8). The overlap of included primary studies was generally high across outcomes (CCA ranged between 20.85 and 42.86%) with some discrepancies in the directions of effects across reviews. The application of a structured approach by checklist may improve adherence to guidelines (e.g. Advanced Trauma Life Support) during resuscitation and might lead to a reduction in mortality among severely injured patients as compared to clinical examination (Adjusted OR 0.51; 95% CI 0.30-0.89; p = 0.018; low certainty of evidence). The use of routine WBCT seems to offer little to no effects in reducing mortality and time spent in emergency room or department, whereas non-routine WBCT seems to offer little to no effects in reducing radiation dose, intensive care unit length of stay (LOS) and hospital LOS (low-to-moderate certainty of evidence).

CONCLUSIONS

The application of structured approach by checklist during trauma resuscitation may improve patient- and process-related outcomes. Including non-routine WBCT seems to offer the best trade-offs between benefits and harm. Clinicians should consider these findings in the light of their clinical context, the volume of patients in their facilities, the need for time management, and costs.

Patient-reported outcome measures in spine surgery: A systematic review

Background

Steadily increasing expenditure in the United States health-care system has led to a shift toward a value-based model that focuses on quality of care and cost-effectiveness. Operations involving the spine rank among some of the most common and expensive procedures performed in operating rooms nationwide. Patient-reported outcomes measures (PROMs) are a useful tool for reporting levels of outcome and analyzing patient recovery but are both under-utilized and nonstandardized in spine surgery.

Methods

We conducted a systematic review of the literature using the PubMed database, focusing on the most commonly utilized PROMs for spine disease as well as spinal deformity. The benefits and drawbacks of these PROMs were then summarized and compared.

Results

Spine-specific PROMs were based on the class of disease. The most frequently utilized PROMs were the Neck Disability Index and the modified Japanese Orthopaedic Association scale; the Oswestry Disability Index and the Roland-Morris Disability Questionnaire; and the Scoliosis Research Society 22-item questionnaire (SRS-22) for cervicothoracic spine disease, lumbar spine disease, and spinal deformity, respectively.

Conclusion

We found limited, though effective, use of PROMs targeting specific classes of disease within spine surgery. Therefore, we advocate for increased use of PROMs in spine surgery, in both the research and clinical settings. PROM usage can help physicians assess subjective outcomes in standard ways that can be compared across patients and institutions, more uniquely tailor treatment to individual patients, and engage patients in their own medical care.

Association between perceived and objective hand-wrist function in distal radius fracture

The relationship between patient-reported outcome measures and objective measures is important for understanding patient expectations. The aim of this study was to investigate the relationship of each section of the Michigan Hand Outcomes Questionnaire (MHQ) to objective measurements in patients with distal radius fracture (DRF). Eighty-four patients who were treated operatively or non-operatively for DRF were included. Injury severity was assessed by the Modified Hand Injury Severity Score. Joint motion was assessed at 6 and 12 weeks and grip strength at 12 weeks after non-operative treatment or surgery. The MHQ was used to assess hand functionality. The relationships between measurements were analyzed by Spearman correlation analysis. Statistical significance was set at p &lt; 0.05. Fifty-one patients (60.7%) were women and 33 (39.3%) men. Mean age was 48.17 ± 12.26 (range, 20-64) years. Fifty-two (61.9%) patients were treated surgically and 32 (38.1%) non-operatively. Forearm pronation-supination and wrist flexion and ulnar deviation at week 6 and forearm pronation-supination, wrist extension and radial deviation at week 12 correlated with MHQ scores, unlike wrist extension and radial deviation at week 6 and flexion and ulnar deviation at week 12. Gross and fine grip strength at week 12 correlated with MHQ, except for the overall hand function, work performance and pain subsections. The MHQ subsections correlated with joint motion and grip strength in the early period after DRF. These findings clarified patient expectations in the early period.

Measuring functional outcomes in major trauma: can we do better?

PURPOSE

There is relatively limited large scale, long-term unified evidence to describe how quality of life (QoL) and functional outcomes are affected after polytrauma. The aim of this study is to review validated measures available to assess QoL and functional outcomes and make recommendations on how best to assess patents after major trauma.

METHODS

PubMed and EMBASE databases were interrogated to identify suitable patient-reported outcome measures (PROMs) for use in major trauma, and current practice in their use globally.

RESULTS

Overall, 81 papers met the criteria for inclusion and evaluation. Data from these were synthesised. A full set of validated PROMs tools were identified for patients with polytrauma, as well as critique of current tools available, allowing us to evaluate practice and recommend specific outcome measures for patients following polytrauma, and system changes needed to embed this in routine practice moving forward.

CONCLUSION

To achieve optimal outcomes for patients with polytrauma, we will need to focus on what matters most to them, including their needs (and unmet needs). The use of appropriate PROMs allows evaluation and improvement in the care we can offer. Transformative effects have been noted in cases where they have been used to guide treatment, and if embedded as part of the wider system, it should lead to better overall outcomes. Accordingly, we have made recommendations to this effect. It is time to seize the day, bring these measures even further into our routine practice, and be part of shaping the future.

Use of Wearable Technology to Measure Activity in Orthopaedic Trauma Patients: A Systematic Review

BACKGROUND

Patient-Reported Outcome Measures (PROMs) are widely used for measurement of functional outcomes after orthopaedic trauma. However, PROMs rely on patient collaboration and suffer from various types of bias. Wearable Activity Monitors (WAMs) are increasingly used to objectify functional assessment. The objectives of this systematic review were to identify and characterise the WAMs technology and metrics currently used for orthopaedic trauma research.

METHODS

PubMed and Embase biomedical literature search engines were queried. Eligibility criteria included: Human clinical studies published in the English language between 2010 and 2019 involving fracture management and WAMs. Variables collected from each article included: Technology used, vendor/product, WAM body location, metrics measured, measurement time period, year of publication, study geographic location, phase of treatment studied, fractures studied, number of patients studied, sex and age of the study subjects, and study level of evidence. Six investigators reviewed the resulting papers. Descriptive statistics of variables of interest were used to analyse the data.

RESULTS

One hundred and thirty-six papers were available for analysis, showing an increasing trend of publications per year. Accelerometry followed by plantar pressure insoles were the most commonly employed technologies. The most common location for WAM placement was insoles, followed by the waist. The most commonly studied fracture type was hip fractures followed by fragility fractures in general, ankle, "lower extremity", and tibial fractures. The rehabilitation phase following surgery was the most commonly studied period. Sleep duration, activity time or step counts were the most commonly reported WAM metrics. A preferred, clinically validated WAM metric was not identified.

CONCLUSIONS

WAMs have an increasing presence in the orthopaedic trauma literature. The optimal implementation of this technology and its use to understand patients' pre-injury and post-injury functions is currently insufficiently explored and represents an area that will benefit from future study.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO ID:210344.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-022-00629-0.

Outcome measures used in clinical research evaluating prehospital blood component transfusion in traumatically injured bleeding patients: A systematic review

BACKGROUND

Trial outcomes should be relevant to all stakeholders and allow assessment of interventions' efficacy and safety at appropriate timeframes. There is no consensus regarding outcome measures in the growing field of prehospital trauma transfusion research. Harmonization of future clinical outcome reporting is key to facilitate interstudy comparisons and generate cohesive, robust evidence to guide practice. The objective of this study was to evaluate outcome measures reported in prehospital trauma transfusion trials.

METHODS

Data Sources, Eligibility Criteria, Participants, and InterventionsWe conducted a scoping systematic review to identify the type, number, and definitions of outcomes reported in randomized controlled trials, and prospective and retrospective observational cohort studies investigating prehospital blood component transfusion in adult and pediatric patients with traumatic hemorrhage. Electronic database searching of PubMed, Embase, Web of Science, Cochrane, OVID, clinical trials.gov, and the Transfusion Evidence Library was completed in accordance with Preferred Reporting Items for Meta-analyses guidelines.Study Appraisal and Synthesis MethodsTwo review authors independently extracted outcome data. Unique lists of salutogenic (patient-reported health and wellbeing outcomes) and nonsalutogenic focused outcomes were established.

RESULTS

A total of 3,471 records were identified. Thirty-four studies fulfilled the inclusion criteria: 4 military (n = 1,566 patients) and 30 civilian (n = 14,398 patients), all between 2000 and 2020. Two hundred twelve individual non-patient-reported outcomes were identified, which collapsed into 20 outcome domains with varied definitions and timings. All primary outcomes measured effectiveness, rather than safety or complications. Sixty-nine percent reported mortality, with 11 different definitions. No salutogenic outcomes were reported.

CONCLUSION

There is heterogeneity in outcome reporting and definitions, an absence of patient-reported outcome, and an emphasis on clinical effectiveness rather than safety or adverse events in prehospital trauma transfusion trials. We recommend stakeholder consultation and a Delphi process to develop a clearly defined minimum core outcome set for prehospital trauma transfusion trials.

LEVEL OF EVIDENCE

Scoping systematic review, level III.

Main factors predicting somatic, psychological, and cognitive patient outcomes after significant injury: a pilot study of a simple prognostic tool

Background

There are still insufficient data on the complexity and predictability of patient-related outcomes following trauma. The aim of this study was to assess longer-term outcomes in patients with significant injury and to develop a simple scoring method to identify patients at high risk of subsequent deficits 1–2 years after injury.

Methods

We conducted a prospective cohort study of survivors of significant injury (New Injury Severity Score, NISS greater than or equal to 8), with analysis of patients’ 1- to 2-year health-related quality of life (HRQoL) and their functional outcomes based on Short Form-36 (SF-36), Trauma Outcome Profile (TOP), and Quality Of Life after Brain Injury (QOLIBRI). Documented variables suspected or known from the literature to be possible factors associated with outcome were first analysed by univariate analysis, and significant variables were entered into a stepwise logistic regression analysis. Scores predicting longer-term impaired outcome were constructed from risk factors resulting from multivariate analysis.

Results

Depending on the patient-reported outcome measure (PROM) used, up to 30 per cent of 1052 study patients (mean NISS 18.6) indicated somatic, 27 per cent psychological, and 54 per cent cognitive deficits. The investigated sociodemographic, injury-related, treatment, and early hospital outcome variables demonstrated only low associations with longer-term outcome in univariate analysis that were highest for preinjury pain or function (R = 0.4) and outcome at hospital discharge (R = 0.3). After logistic regression, the study variables explained a maximum variance of 23 per cent for somatic, 11 per cent for psychological, and 14 per cent for cognitive longer-term outcomes. The resulting Aarau trauma prognostic longer-term outcome scoring (ATPLOS) system, developed by checking eight risk factors, had a specificity of up to 80 per cent, and importantly may facilitate early detection of patients at risk of a poorer longer-term outcome.

Conclusion

Despite the high rate of deficits recorded for survivors of significant injury, particularly in loss of cognitive function, the multiple variables analysed only led to a limited characterization of patient-related longer-term outcomes. Until more is known about additional individual influencing factors, the proposed scoring system may serve well for clinical evaluation.

Registration number

NCT 02165137 (http://www.clinicaltrials.gov)

Correlation of Patient-Reported Outcomes Measurement Information System Questionnaires With the Brief Michigan Hand Questionnaire in Patients With 5 Common Hand Conditions

PURPOSE

We evaluated the concurrent validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) Global Mental Health (GMH), Global Physical Health (GPH), Upper Extremity (UE), Pain Interference (PI), and Self-Efficacy for Managing Medications and Treatment (SE-MMT) by analyzing correlation to the brief Michigan Hand Questionnaire (bMHQ) in patients with 5 common hand conditions: carpal tunnel syndrome, Dupuytren contracture, trigger finger, thumb carpometacarpal osteoarthritis, and wrist ganglion cysts.

METHODS

Our cohort included 11,782 unique visits representing 4,401 patients. Patient demographics, PROMIS Computer Adaptive Test questionnaires, and bMHQ were collected prospectively at all visits for all patients. Spearman rank correlation was used to evaluate the relationship between the PROMIS and bMHQ scores. Multivariable linear regression models were used to evaluate the relationship between questionnaires and patient demographics.

RESULTS

The PROMIS UE and PI showed strong correlations to the bMHQ. The PROMIS GPH showed moderate correlation to the bMHQ. The PROMIS GMH and SE-MMT were weakly correlated with the bMHQ. These results for the overall group were consistent across subgroup analysis for each condition, and regression models confirmed these correlation findings when controlling for demographic variables. The bMHQ had the smallest ceiling and floor effects compared with the PROMIS questionnaires. The PROMIS UE, PI, and SE-MMT took significantly less time to complete than the bMHQ.

CONCLUSION

Correlations between the PROMIS questionnaires and the bMHQ were similar regardless of condition.

CLINICAL RELEVANCE

Given their moderate-to-strong correlations with the bMHQ and consistency across conditions, the PROMIS UE and PI may be adequate replacements for the bMHQ for evaluating these domains in both clinical and research applications in patients with these common upper extremity pathologies. The PROMIS GPH, GMH, and SE-MMT, in conjunction with the bMHQ, may provide more information regarding patient's physical and mental health and ability to manage medications and treatment without substantially increasing patient burden. Clinicians and researchers can use these findings to guide questionnaire selection based on the clinical or research question(s) of interest.

Developing a core outcome set for traumatic brachial plexus injuries: a systematic review of outcomes

OBJECTIVE

To identify what outcomes have been assessed in traumatic brachial plexus injury (TBPI) research to inform the development of a core outcome set for TBPI.

DESIGN

Systematic review.

METHOD

Medline (OVID), EMBASE, CINAHL and AMED were systematically searched for studies evaluating the clinical effectiveness of interventions in adult TBPIs from January 2013 to September 2018 updated in May 2021. Two authors independently screened papers. Outcome reporting bias was assessed. All outcomes were extracted verbatim from studies. Patient-reported outcomes or performance outcome measures were extracted directly from the instrument. Variation in outcome reporting was determined by assessing the number of unique outcomes reported across all included studies. Outcomes were categorised into domains using a prespecified taxonomy.

RESULTS

Verbatim outcomes (n=1491) were extracted from 138 studies including 32 questionnaires. Unique outcomes (n=157) were structured into 4 core areas and 11 domains. Outcomes within the musculoskeletal domain were measured in 86% of studies, physical functioning in 25%, emotional functioning in 25% and adverse events in 33%. We identified 63 different methods for measuring muscle strength, 16 studies for range of movement and 63 studies did not define how they measured movement. More than two-thirds of the outcomes were incompletely reported in prospective studies.

CONCLUSION

This review of outcome reporting in TBPI research demonstrated an impairment focus and heterogeneity. A core outcome set would ensure standardised and relevant outcomes are reported to facilitate future systematic review and meta-analysis.

PROSPERO REGISTRATION NUMBER

CRD42018109843.

Thickened liquids: do they still have a place in the dysphagia toolkit?

PURPOSE OF REVIEW

The use of commercially or naturally thickened liquids is a well-established treatment for patients with dysphagia to fluids, the aim of which is to improve swallow safety by minimizing risk of aspiration. Although the most recent systematic reviews conclude that this treatment lacks evidential support and leads to patient-reported worsening health and quality of life, thickened liquids continue to be used with patients with dysphagia across clinical settings. This review briefly summarizes the evidence and considers potential reasons for the apparent mismatch between the evidence and clinical practice.

RECENT FINDINGS

Continuing practice with thickened liquids is influenced by a range of factors, including gaps in clinical knowledge, inadequate patient involvement, a culture of common practice and a reliance on invalid surrogate studies or research lacking a credible association between thickened liquids and clinically meaningful endpoints.

SUMMARY

While awaiting further research, clinical decision-making about thickened liquids can be improved by considering the evidence of clinically meaningful endpoints, promoting shared decision-making with patients and underpinning practice with knowledge about the complex relationship between dysphagia, aspiration and pneumonia.

Beyond morbidity and mortality: The practicality of measuring patient-reported outcomes in trauma

BACKGROUND

The 2016 Zero Preventable Deaths report highlighted the need for comprehensive injury data to include long term outcomes such as societal and workforce re-entry. Currently, postinjury quality of life is poorly understood. We hypothesized that routine measurement of patient-reported outcomes is feasible as a part of post-discharge follow-up, and that trauma patients would report that their injury had a detrimental impact on health-related quality of life (HRQoL) after discharge.

METHODS

After instruction, patients self-administered the PROMIS-29 instrument in our outpatient office (11/2019-4/2020). We surveyed 7 domains: Participation in Social Roles/Activities, Anxiety, Depression, Fatigue, Pain Interference, Physical Function, and Sleep Disturbance. Results are reported as means (SD) and compared to the U.S population by t-score (mean score=50). Higher scores in negatively-worded domains (e.g. "Depression") are worse; vice versa for positively-worded domains (e.g. "Physical Function"). Repeated scores among patients returning for a second visit were analyzed using paired t-tests.

RESULTS

103 patients completed the PROMIS-29. Mean (SD) age was 42.3 (17.3) years, 75% were male, and 42% suffered a penetrating injury. Median length of stay was 3 days and median time from injury to clinic visit was 18 days. Mean scores were worse than population means in every domain. Pain Interference (mean 63.5, 95%CI [61.8-65.3]) and Physical Function (38.0 [36.2-39.8]) were particularly affected. Among patients returning for a second visit (n=10; median time between clinic visits: 17.5 days), there were no significant differences in domain scores over time.

CONCLUSION

Trauma patients are at high risk for poor quality of life outcomes in the short term following injury. Our results highlight the need for early recognition and multidisciplinary treatment following injury.

Financial toxicity is associated with worse physical and emotional long-term outcomes after traumatic injury

BACKGROUND

Increasing health care costs and high deductible insurance plans have shifted more responsibility for medical costs to patients. After serious illnesses, financial responsibilities may result in lost wages, forced unemployment, and other financial burdens, collectively described as financial toxicity. Following cancer treatments, financial toxicity is associated with worse long-term health-related quality of life (HRQoL) outcomes. The purpose of this study was to determine the incidence of financial toxicity following injury, factors associated with financial toxicity, and the impact of financial toxicity on long-term HRQoL.

METHODS

Adult patients with an Injury Severity Score of 10 or greater and without head or spinal cord injury were prospectively followed for 1 year. The Short-Form-36 was used to determine overall quality of life at 1 month, 2 months, 4 months, and 12 months. Screens for depression and posttraumatic stress syndrome were administered. The primary outcome was any financial toxicity. A multivariable generalized estimating equation was used to account for variability over time.

RESULTS

Five hundred patients were enrolled, and 88% suffered financial toxicity during the year following injury (64% reduced income, 58% unemployment, 85% experienced stress due to financial burden). Financial toxicity remained stable over follow-up (80-85%). Factors independently associated with financial toxicity were lower age (odds ratio [OR], 0.96 [0.94-0.98]), lack of health insurance (OR, 0.28 [0.14-0.56]), and larger household size (OR, 1.37 [1.06-1.77]). After risk adjustment, patients with financial toxicity had worse HRQoL, and more depression and posttraumatic stress syndrome in a stepwise fashion based on severity of financial toxicity.

CONCLUSION

Financial toxicity following injury is extremely common and is associated with worse psychological and physical outcomes. Age, lack of insurance, and large household size are associated with financial toxicity. Patients at risk for financial toxicity can be identified, and interventions to counteract the negative effects should be developed to improve long-term outcomes.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level III.

Patient-Reported Outcome Measures and Patient Activation: What Are Their Roles in Orthopedic Trauma?

The rise of patient-reported outcome (PRO) measurement across medicine has been swift and now extends to the world of orthopedic trauma. However, PRO measures (PROMs) applied to trauma patients pose special considerations; measuring "episodes of care" is less straightforward, injuries are heterogeneous in their severity, and the patient's initial visit is "postinjury." Obtaining baseline scores and assessing the impact of a traumatic event on mental health are key considerations. Currently, few, if any, trauma registries include PROs; though general and condition-specific PROMs plus the patient empowerment measure of Patient Activation represent meaningful inputs for the clinical decision-making process. To be useful in trauma care, PROMs should be psychometrically sound and validated, be used for capturing function, screen for mental state and substance use, and give the clinician a sense of the patient's "activation" (engagement in their own health). Although the implementation of routine PRO collection can seem daunting, clinicians can use a multitude of electronic resources to access validated measures and simplify the implementation process. Computer-adaptive testing has evolved to help minimize patient burden, and PROM collection must maximize efficiency. Once established as part of your practice, PROs become an important tool to track recovery, identify mental health issues, engage in the prevention of future injury, and enable care of the whole patient.