Who Are We Missing: Does Engagement in Patient-Reported Outcome Measures for Breast Cancer Vary by Age, Race, or Disease Stage?

Exploring Completion Rates of the SNOT-22 Questionnaire

BACKGROUND

The 22-item Sinonasal Outcome Test (SNOT-22) is a widely used patient-reported outcome measure (PROM) for assessing chronic rhinosinusitis (CRS). However, incomplete surveys may impact its predictive utility.

AIMS

This study explores SNOT-22 completion rates, response trends, and potential factors influencing survey omissions aiming to optimize its predictive utility and practical application.

METHODS

SNOT-22 surveys were retrospectively collected from patients at various time points throughout their CRS treatment. Surveys with at least one question unanswered were included in the study. Completely unanswered surveys were excluded. Survey response dynamics and trends were analyzed and reported.

RESULTS

1,034 SNOT-22 surveys were collected, 18% of the surveys were incomplete. Questions on "Ear fullness" and "Embarrassed" were most unanswered, while "Need to blow nose" and "Nasal blockage" were least unanswered. Questions later in the survey showed a moderate positive correlation with missing responses. Mean scores per question were higher in incomplete than in complete surveys, though differences in SNOT-22 scores between partially and fully completed surveys weren't significant.

CONCLUSION

Our study found that a large number of SNOT-22 surveys were incomplete, higher than rates reported in similar PROMs. Mean scores did not differ significantly between partial and complete surveys, suggesting interpretation should prioritize individual responses over total scores. Potential barriers to survey completion include question wording, symptom relevance, and survey length. Future research should further investigate survey completion through qualitative methods and randomized question ordering to refine survey design.

Improving equitable collection and analysis of PROMIS Global health data over time following spine surgery: characterizing survey nonresponse and missing data

BACKGROUND CONTEXT

Patient-reported outcome measures (PROMs), the gold standard for outcome assessment in spine surgery, exhibit variability over time. Incomplete PROM collection, however, introduces nonresponse bias and limits the generalizability of time-based analyses of outcomes.

PURPOSE

This study compared PROM-respondents and nonrespondents in spine surgery to characterize survey nonresponse and improve equitable patient representation in time series PROM analyses.

STUDY DESIGN

Retrospective study.

PATIENT SAMPLE

Patients undergoing surgery at a large, tertiary care center in the United States between July 2009 and February 2023 for lumbar spinal stenosis without spondylolisthesis (LSS), lumbar spinal stenosis with spondylolisthesis (LSP), or cervical spondylotic myelopathy (CSM).

OUTCOME MEASURES

The primary outcome was completeness of available PROM records, which was defined as having Patient-Reported Outcomes Measurement Information System (PROMIS)-Global Health scores once within 2 years preoperatively and twice within 2 years postoperatively.

METHODS

Demographic variables of age, sex, race, marital status, employment, insurance, body mass index (BMI), smoking, and Area Deprivation Index (ADI) were obtained from the electronic medical record. These characteristics were compared by PROM-completeness within each pathology group. Comparative analyses between the PROM-complete and PROM-incomplete patients within each pathology group were conducted using the Satterthwaite t-test for continuous variables, Pearson's chi-square test for categorical variables, and Mann-Whitney U test for ordinal variables. Among patients with complete PROMs, availability of PROMIS-Global Health within 2 years pre- and postoperatively was plotted in bins of 84- and 168-days width to characterize the distribution of time points represented in PROM data for these patients. To visualize geographic variation in likelihood of representation in time series PROMs analyses, census block-level heatmaps were generated for each pathology group showing predicted probability of PROM-completeness by logistic regression with age, sex, race, marital status, employment status, insurance category, BMI, and smoking status as predictor variables.

RESULTS

About 4,938 patients (1,751 LSS, 1,711 LSP, 1,476 CSM) were analyzed. PROM-complete patients varied significantly from PROM-incomplete patients in demographic distributions. PROM-complete patients were more likely of White race, married, retired, and less likely to be current smokers. LSS and CSM PROM-complete patients were more likely to have Medicare insurance than PROM-incomplete patients.

CONCLUSION

Patients completing PROMs for spine surgery may differ from those who do not, with greater representation of White race, being married, retiree status, and Medicare insurance among those with complete PROMs. As PROMs are further incorporated into physician evaluation, value-based reimbursement, and predictive analytics for surgical outcomes, understanding survey nonresponse will be critical for generating equitable, individualized, and informed applications to support healthcare decisions.

Patient Reported Outcomes in Breast Cancer: A Plea for the Silent and Forgotten

BACKGROUND

There are an increasing number of reports addressing patient reported outcomes (PRO's) following breast conserving surgery (BCS) and mastectomy with reconstruction (MR), but few addressing mastectomy alone (MA). Patients' choice of procedure is often preference-based, making PRO's essential to inform decision making. The current research aims to evaluate PRO's associated with all three surgical procedures, along with patient participation rates.

METHODS

Patients with unilateral, nonrecurrent breast cancer were prospectively enrolled in the study (June 2020 to September 2023). Participants received the BREAST-Q (BQ) survey preoperatively (Q1), 2 to 6 weeks (Q2) and 1 year (Q3) postoperatively. Forced multiple regression analyses were performed to compare postoperative BQ scores.

RESULTS

199 patients were eligible, with 73.4% (146/199) participating in the study. While MA had lower satisfaction with breast scores than BCS (B = -11.6), they were equivalent to those of MR (B = -16.5), with similar pathologic and treatment related factors. Physical well being was similar between all three procedures, while psychosocial well being scores were lower following MR (B = -15.5), but not MA. Patient age, BMI, and tumor size variably impacted BQ scores, but preoperative BQ scores independently correlated with postoperative scores across all domains.

CONCLUSION

Patient response rates are consistent with the literature, but require improvement to ensure meaningful conclusions, generalizability of results, and comparisons between studies. Patients undergoing BCS reported the highest satisfaction and quality of life, with MA being noninferior to MR. Efforts to increase patient participation in PRO's are required, especially in those undergoing MA.

Access to results of patient reported outcome surveys did not improve longitudinal patient reported outcomes in breast cancer patients in a randomized controlled trial

BACKGROUND

We assessed the impact of breast cancer (BC) patients receiving their own patient-reported outcome (PRO) results on future PROs.

METHODS

Newly diagnosed female BC patients completed validated measures of satisfaction with breasts (SB), and psychosocial (PsyW), physical (PhW), and sexual wellbeing (SW) longitudinally during treatment. Patients were randomized to receive their PRO scores (Intervention) or not (Control). The primary outcome was difference in PRO scores from baseline to 1-year post-surgery. T- and chi2-tests compared baseline characteristics between groups. Linear mixed models assessed differences in PRO changes over time.

RESULTS

131 patients (70 intervention, 61 control) completed baseline and 1-year modules; groups were well-balanced. At 1-year, the intervention group had less improvement in PsyW compared to controls with a t-test (mean difference: 1.2 vs 8.3, p ​= ​0.04); this difference did not remain in mixed models (intervention group effect estimate (SE) 1.7 (2.1) vs control group 7.0 (2.2), p ​= ​0.08). Changes in SB, PhW, and SW did not differ.

CONCLUSIONS

Access to individual PRO scores throughout treatment did not improve BC patients' future PROs.

Living Flat: Stories from Women of Color After Mastectomy

BACKGROUND

There remain persistent racial and ethnic disparities in the receipt of post-mastectomy breast reconstruction for breast cancer. Yet, patient-reported outcomes and advocacy efforts around living flat overwhelmingly have focused on white women. We sought to characterize the lived experiences among women of color living flat after mastectomy for breast cancer.

PATIENTS AND METHODS

Our community-partnered study included a sociodemographic and health questionnaire followed by semistructured interviews. Using an interview guide designed in an interdisciplinary manner, we explored themes related to culture and community after mastectomy. Women ≥ 18 years old who underwent mastectomy without reconstruction for breast cancer were included. Interviews were performed by formally trained community-based research fellows and conducted virtually over video conferencing, recorded, and transcribed. Data were analyzed on NVivo using an integrated (inductive and deductive) team-based approach.

RESULTS

The final cohort included 20 women, 60% identified as Black, 20% as Asian, 10% as multiracial, 5% as Latina, and 5% as white. Key concepts included: (a) cancer stigma, (b) privacy around breasts, (c) finding support through shared experiences, (d) sacrifice of breast for life/health, (e) spirituality, (f) patients' familial roles and relationship to breast, and (g) societal expectations. Women described the intersection of cancer stigma and privacy around breasts influencing knowledge of family history and support during cancer treatment.

CONCLUSION

Among women of color, breast cancer stigma and spirituality are key contributors to quality of life after mastectomy without breast reconstruction, domains not routinely included in contemporary patient-reported outcome measures. Representation of diverse experiences is critical to achieving equity.

Enhancing representativeness of patient-reported outcomes in routine radiation oncology care: a quality improvement protocol to address non-response

INTRODUCTION

Non-response significantly undermines the representativeness of patient-reported outcome (PRO) data, thereby compromising its utility for facilitating high-value, equitable, patient-centred care in cancer clinics. Quality improvement studies are needed to assess the representativeness of PRO data collected in routine care, identify the underlying causes of non-response and develop novel methods to ensure data representativeness. Using a multilevel framework and a mixed-methods approach, we have three aims: (1) characterise the non-response of the Global-10 across clinic, provider and patient levels; (2) identify multilevel causes of non-response and potential strategies to improve representativeness in PRO collection; and (3) develop effective modifications to missing-data methods to enhance the representativeness of pre-existing PRO data.

METHODS AND ANALYSIS

Our primary data source is the Patient Reported Outcomes Measurement Information System Global-10, collected as part of routine care at the Radiation Oncology clinics within the Mass General Brigham (MGB) healthcare system. Other sources include (1) Harvard Catalyst for provider-specific data, (2) MGB administrative data, (3) public Centers for Medicare & Medicaid Services data and (4) the National Plan and Provider Enumeration System. We will conduct quantitative analyses to assess variations in Global-10 non-response across multilevel factors. Additionally, we will use qualitative interviews with patients and clinical professionals to understand the causes of non-response and to formulate strategies to expand the reach of PRO collection to underrepresented cancer patients, improve their completions and enhance overall data representativeness. Finally, we will integrate implementation science knowledge and findings from the first two aims into missing-data methods to manage non-response in the pre-existing Global-10 data and to evaluate their performance in preserving representativeness.

ETHICS AND DISSEMINATION

The study protocol was reviewed and approved by the Institutional Review Board at the Dana-Farber/Harvard Cancer Center (24-225). Written informed consent will be obtained from participants. Study findings will be disseminated through peer-reviewed publications and presentations at national and international conferences.

Value-based care as a solution to resolve the open debate on public healthcare outsourcing in Europe: What do the available data say?

Controversy surrounds the current debate regarding the effects of outsourcing health services, as recent studies claim that increased outsourcing leads to reduced costs at the expense of worse patient outcomes. The goal of the value-based model is to enable healthcare systems to create more value for patients, and evidence points to improvements in public health outcomes, patient experience, and health expenditure in systems incorporating components of value-based healthcare. Some emerging evidence indicates promising results for outsourced hospitals which follow a value-based model of healthcare delivery. Although additional future studies are still needed to confirm these benefits, value-based healthcare merits discussion as a new perspective on the public versus private management debate. In fact, we argue that outsourcing to value-based health providers could represent a valid alternative for public health management, encouraging greater competition within the healthcare sector while ensuring quality of care for both public and private sectors.

Nonresponse data in sexual well-being among breast reconstruction patients-who are we overlooking?

BACKGROUND

Missing data can affect the representativeness and accuracy of survey results, and sexual health-related surveys are especially at a higher risk of nonresponse due to their sensitive nature and stigma. The purpose of this study was to evaluate the proportion of patients who do not complete the BREAST-Q Sexual Well-being relative to other BREAST-Q modules and compare responders versus nonresponders of Sexual Well-being. We secondarily examined variables associated with Sexual Well-being at 1-year.

METHODS

A retrospective analysis of patients who underwent breast reconstruction from January 2018 to December 2021 and completed any of the BREAST-Q modules postoperatively at 1-year was performed.

RESULTS

The 2941 patients were included. Of the four BREAST-Q domains, Sexual Well-being had the highest rate of nonresponse (47%). Patients who were separated (vs. married, OR = 0.69), whose primary language was not English (vs. English, OR = 0.60), and had Medicaid insurance (vs. commercial, OR = 0.67) were significantly less likely to complete the Sexual Well-being. Postmenopausal patients were significantly more likely to complete the survey than premenopausal patients. Lastly, autologous reconstruction patients were 2.93 times more likely to respond than implant-based reconstruction patients (p < 0.001) while delayed (vs. immediate, OR = 0.70, p = 0.022) and unilateral (vs. bilateral, OR = 0.80, p = 0.008) reconstruction patients were less likely to respond. History of psychiatric diagnosis, aromatase inhibitors, and immediate breast reconstruction were significantly associated with lower Sexual Well-being at 1-year.

CONCLUSION

Sexual Well-being is the least frequently completed BREAST-Q domain, and there are demographic and clinical differences between responders and nonresponders. We encourage providers to recognize patterns in nonresponse data for Sexual-Well-being to ensure that certain patient population's sexual health concerns are not overlooked.

Missingness mechanisms and generalizability of patient reported outcome measures in colorectal cancer survivors - assessing the reasonableness of the "missing completely at random" assumption

BACKGROUND

Patient-Reported Outcome Measures (PROM) provide important information, however, missing PROM data threaten the interpretability and generalizability of findings by introducing potential bias. This study aims to provide insight into missingness mechanisms and inform future researchers on generalizability and possible methodological solutions to overcome missing PROM data problems during data collection and statistical analyses.

METHODS

We identified 10,236 colorectal cancer survivors (CRCs) above 18y, diagnosed between 2014 and 2018 through the Danish Clinical Registries. We invited a random 20% (2,097) to participate in a national survey in May 2023. We distributed reminder e-mails at day 10 and day 20, and compared Initial Responders (response day 0-9), Subsequent Responders (response day 10-28) and Non-responders (no response after 28 days) in demographic and cancer-related characteristics and PROM-scores using linear regression.

RESULTS

Of the 2,097 CRCs, 1,188 responded (57%). Of these, 142 (7%) were excluded leaving 1,955 eligible CRCs. 628 (32%) were categorized as initial responders, 418 (21%) as subsequent responders, and 909 (47%) as non-responders. Differences in demographic and cancer-related characteristics between the three groups were minor and PROM-scores only marginally differed between initial and subsequent responders.

CONCLUSION

In this study of long-term colorectal cancer survivors, we showed that initial responders, subsequent responders, and non-responders exhibit comparable demographic and cancer-related characteristics. Among respondents, Patient-Reported Outcome Measures were also similar, indicating generalizability. Assuming Patient-Reported Outcome Measures of subsequent responders represent answers by the non-responders (would they be available), it may be reasonable to judge the missingness mechanism as Missing Completely At Random.

Remote Symptom Monitoring with Clinical Alerts Following Mastectomy: Do Early Symptoms Predict 30-Day Surgical Complications

BACKGROUND

Electronic patient-reported outcome measures (ePROMs) for real-time remote symptom monitoring facilitate early recognition of postoperative complications. We sought to determine whether remote, electronic, patient-reported symptom-monitoring with Recovery Tracker predicts 30-day readmission or reoperation in outpatient mastectomy patients.

METHODS

We conducted a retrospective review of breast cancer patients who underwent outpatient (< 24-h stay) mastectomy with or without reconstruction from April 2017 to January 2022 and who received the Recovery Tracker on Days 1-10 postoperatively. Of 5,130 patients, 3,888 met the inclusion criteria (2,880 mastectomy with immediate reconstruction and 1,008 mastectomy only). We focused on symptoms concerning for surgical complications and assessed if symptoms reaching prespecified alert levels-prompting a nursing call-predicted risk of 30-day readmission or reoperation.

RESULTS

Daily Recovery Tracker response rates ranged from 45% to 70%. Overall, 1,461 of 3,888 patients (38%) triggered at least one alert. Most red (urgent) alerts were triggered by pain and fever; most yellow (less urgent) alerts were triggered by wound redness and pain severity. The 30-day readmission and reoperation rates were low at 3.8% and 2.4%, respectively. There was no statistically significant association between symptom alerts and 30-day reoperation or readmission, and a clinically relevant increase in risk can be excluded (odds ratio 1.08; 95% confidence interval 0.8-1.46; p = 0.6).

CONCLUSIONS

Breast cancer patients undergoing mastectomy with or without reconstruction in the ambulatory setting have a low burden of concerning symptoms, even in the first few days after surgery. Patients can be reassured that symptoms that do present resolve quickly thereafter.

Examining Race and Patient-Reported Outcomes After Contralateral Prophylactic Mastectomy with Reconstruction

BACKGROUND

Little is known regarding racial differences in satisfaction and quality of life (QOL) after contralateral prophylactic mastectomy (CPM). In this study, we aim to characterize associations between race, and postoperative satisfaction and well-being, utilizing the validated BREAST-Q patient-reported outcome measure.

PATIENTS AND METHODS

Patients were eligible if they were diagnosed with stage 0-III unilateral breast cancer and underwent mastectomy with immediate reconstruction at our institution between 2016 and 2022. BREAST-Q surveys were administered in routine clinical care preoperatively and postoperatively to assess QOL. We assessed whether the relationship between race, and domains of satisfaction with breasts and psychosocial well-being differed by receipt of CPM compared with unilateral mastectomy at 6 months, 1 year, 2 years, and 3 years following reconstruction.

RESULTS

Of 3334 women, 2040 (61%) underwent unilateral mastectomy and 1294 (39%) underwent CPM. Compared with White and Asian women who received CPM, Black women who underwent CPM were more likely to have higher BMI (p < 0.001), undergo autologous reconstruction (p = 0.006), and receive postmastectomy radiation (PMRT) (p < 0.001). There was no association between race and domains of satisfaction of breasts or psychosocial well-being for women who underwent unilateral mastectomy (p = 0.6 and p > 0.9, respectively) or CPM (p = 0.8 and p = 0.9, respectively). PMRT was negatively associated with both satisfaction with breasts (p < 0.001) and psychosocial well-being (p = 0.007).

CONCLUSIONS

Differences in satisfaction with breasts and psychosocial well-being at 3-year follow-up were not associated with race but rather treatment variables, particularly the receipt of PMRT. Further investigations with a larger and more diverse population are needed to validate these findings.