Patient-reported outcomes to evaluate surgery

Validation of the SF-36 as a measure of postoperative recovery after colorectal surgery

INTRODUCTION

Surgery is evolving, and new techniques are introduced to improve "recovery." Postoperative recovery is complex, and evaluating the effectiveness of surgical innovations requires assessment of patient-reported outcomes. The Short-Form-36 (SF-36), a generic health-related quality of life questionnaire, is the most commonly used instrument in this context. The objective of this study was to contribute evidence for the validity of the SF-36 as a metric of postoperative recovery.

METHODS

Data from 128 patients undergoing planned colorectal surgery at one university hospital between 2005 and 2010 were analyzed. In the absence of a gold standard, the responsiveness and construct validity (known groups and convergent) of the SF-36 were evaluated. Standardized response means were computed for the former and non-parametric tests were used to assess the statistical significance of the changes observed. Multiple linear regression was used to determine whether the SF-36 discriminates between patients with versus without complications and between laparoscopic and open surgery (known groups); correlations between the SF-36 and the 6-min walk test, a measure of functional walking capacity (convergent) was investigated with Spearman's rank correlation.

RESULTS

The SF-36 was sensitive to clinically important changes. Scores on six of eight domains and the physical component summary score deteriorated postoperatively (SRM 0.86 for the PCS, p < 0.01) and improved to baseline thereafter. Patients with complications had significantly lower scores on five SF-36 domains (with differences from -9 (-18, -1), p = 0.04 to -18 (-32, -2), p = 0.03), and scores on all subscales were lower than those in a healthy population (p < 0.01 to p = 0.04). The SF-36 did not differentiate between laparoscopic and open surgery. Physical functioning scores correlated with 6MWT distance at 1 and 2 months (Spearman's r = 0.31 and 0.36, p < 0.01).

CONCLUSIONS

The SF-36 is responsive to expected physiological changes in the postoperative period, demonstrates construct validity, and thus constitutes a valid measure of postoperative recovery after planned colorectal surgery. The SF-36 did not, however, discriminate between recovery after laparoscopic and open surgery.

Outcomes reported in high-impact surgical journals

Background

With advances in operative technique and perioperative care, traditional endpoints such as morbidity and mortality provide an incomplete description of surgical outcomes. There is increasing emphasis on the need for patient-reported outcomes (PROs) to evaluate fully the effectiveness and quality of surgical interventions. The objective of this study was to identify the outcomes reported in clinical studies published in high-impact surgical journals and the frequency with which PROs are used.

Methods

Electronic versions of material published between 2008 and 2012 in the four highest-impact non-subspecialty surgical journals (Annals of Surgery, British Journal of Surgery (BJS), Journal of the American College of Surgeons (JACS), Journal of the American Medical Association (JAMA) Surgery) were hand-searched. Clinical studies of adult patients undergoing planned abdominal, thoracic or vascular surgery were included. Reported outcomes were classified into five categories using Wilson and Cleary's conceptual model.

Results

A total of 893 articles were assessed, of which 770 were included in the analysis. Some 91·6 per cent of studies reported biological and physiological outcomes, 36·0 per cent symptoms, 13·4 per cent direct indicators of functional status, 10·6 per cent general health perception and 14·8 per cent overall quality of life (QoL). The proportion of studies with at least one PRO was 38·7 per cent overall and 73·4 per cent in BJS (P &lt; 0·001). The proportion of studies using a formal measure of health-related QoL ranged from 8·9 per cent (JAMA Surgery) to 33·8 per cent (BJS).

Conclusion

The predominant reporting of clinical endpoints and the inconsistent use of PROs underscore the need for further research and education to enhance the applicability of these measures in specific surgical settings.

Using patient-reported outcome measures for improved decision-making in patients with gastrointestinal cancer - the last clinical frontier in surgical oncology?

The genomic era has introduced concepts of “personalized medicine” and “targeted therapy” in the field of oncology. Medicine has become increasingly complex with a plethora of potential dilemmas in diagnosis, treatment, and management. The focus on classical outcomes for clinical decision-making is now increasingly being replaced by patient-reported outcome measures (PROMs). PROMs should increasingly now be in the center of patient-centered decision-making, based on valid, reliable, and clinically useful measures delivered directly by the patient to the caregiver. Surgeons’ ability to interpret and apply PROMs and quality of life results must improve by education and further research, and has an unreleased potential to contribute to a better understanding of the patients’ well-being. A number of caveats must be addressed before this can be brought to fruition; standardization for valid items; appropriate use of instruments; correct timing of the application; missing data handling, compliance, and respondent drop-outs are but a few issues to be addressed. Based on the apparent lack of use in both research and clinical work, it should call for an educational effort to address this among surgeons caring for patients with cancer.

Health-related quality of life following ambulatory surgery procedures: assessment by RAND-36

Background

Increasing numbers of elective surgical procedures are performed as day-cases. The impact of ambulatory surgery on health-related quality of life in the recovery period has seldom been described.

Methods

We assessed health-related quality of life in 143 adult outpatients scheduled for arthroscopic procedures of the knee and shoulder joints, laparoscopic cholecystectomy and inguinal hernia repair using the RAND 36-Item Health Survey preoperatively and one week after patients had returned to work or comparable normal daily routines.

Results

Postoperatively all patient groups reported significant improvements in bodily pain and vitality. Physical functioning improved significantly in orthopedic and inguinal hernia patients. However, in the orthopedic groups, postoperative scores for physical health were still relatively lower compared to the general population reference values.

Conclusions

Ambulatory surgery has a positive impact on health-related quality of life. Assessment of the recovery process is necessary for recognition of potential areas of improvement in care and postoperative rehabilitation.

Quality of life in pulmonary surgery: choosing, using, and developing assessment tools

There is mounting recognition that, to aid surgical decision making, treatment efficacy needs to be measured in a variety of ways, with health-related quality of life now widely regarded as an important outcome in pulmonary surgical populations. The aim of this review is to provide a comprehensive overview of the key issues to consider if an investigator wishes to incorporate health-related quality of life assessment into trials and studies of pulmonary surgery, drawing on recent studies of lung cancer surgery as an example.

Added value of health-related quality of life measurement in cancer clinical trials: the experience of the NCIC CTG

Health-related quality-of-life (HRQoL) data are often included in Phase III clinical trials. We evaluate and classify the value added to Phase III trials by HRQoL outcomes, through a review of the National Cancer Institute of Canada Clinical Trials Group clinical trials experience within various cancer patient populations. HRQoL may add value in a variety of ways, including the provision of data that may contrast with or may support the primary study outcome; or that assess a unique perspective or subgroup, not addressed by the primary outcome. Thus, HRQoL data may change the study's interpretation. Even in situations where HRQoL measurement does not alter the clinical interpretation of a trial, important methodologic advances can be made. A classification of the added value of HRQoL information is provided, which may assist in choosing trials for which measurement of HRQoL outcomes will be beneficial.