Team Approach: Clinical Outcome Collection, Done Practically

Does Patient Health Literacy Affect Patient Reported Outcome Measure Completion Method in Orthopaedic Patients?

Introduction

PROMIS® Computer Adaptive Testing (CAT) is a testing tool for tracking patient-reported outcome measures (PROM) with a goal to improve individual and population outcomes. Patients' health literacy (HL) may affect how they are able to complete PROM. We hypothesized that patients with low HL were less likely both to complete surveys and to do so via online patient portal (OPP).

Methods

A retrospective cohort study of 3926 orthopaedic patients in a rural state was performed. Completion rate and completion method both were subjected to log-binomial regressions with patient demographics and HL as predictor variables.

Results

PROM surveys were completed by 2166 (55.2%) of patients, including 512 completed via OPP and 1654 completed via in-clinic tablet (ICT). Compared to high HL patients, low HL patients had a 23% higher non-completion rate, and low HL completers were 63% less likely to use OPP. Age and gender had significant (P < 0.05) associations with completion method, but not completion rate, whereas Area Deprivation Index (ADI) had significant associations with both. Compared to White patients, Black patients had a 25% higher non-completion rate, and Black completers were 49% less likely to use OPP.

Discussion

Our analysis shows that health literacy, demographics, and socioeconomic status affect both whether and how patients fill out PROM surveys. Patients with low HL were less likely to complete PROM surveys, and less likely to use the OPP when they did.

Conclusion

Our results demonstrate that patients' health literacy, demographics, and socioeconomic status affect both whether they complete their PROMIS® CAT and what method they complete it with. Additional efforts should be made to understand these factors, accommodate patients, and facilitate accurate and complete PROM responses, especially in hospitals that serve diverse and socioeconomically disadvantaged patients.

A high proportion of patients demonstrate recall bias in the retrospective collection of patient-reported outcomes following hip arthroscopy

PURPOSE

The aim of this study is to assess agreement between retrospectively and prospectively collected patient-reported outcome measures (PROMs) following hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

METHODS

Patients undergoing hip arthroscopy from 2021 to 2023 for FAIS completed preoperative PROMs, including the modified Harris Hip Score (mHHS) and the Non-Arthritic Hip Score (NAHS). Post-operatively, patients were surveyed and asked to recall their preoperative hip function. Paired two-sample t tests were used to compare baseline and recalled baseline PROMs and the difference between scores was compared to previously published minimally clinically important difference (MCID) values. Intraclass correlation coefficients (ICCs) were calculated to test the reliability between scores based on a single-rater, two-way mixed-effects model. Multivariable regression, accounting for age, sex and preoperative baseline scores, was used to evaluate the relationship of time elapsed since surgery with recall accuracy.

RESULTS

A total of 116 patients (age: 37.6 ± 11.8 years; 61.2% female) were included. The mean time elapsed for recalled data was 13.1 months (range: 1-27 months). Overall, patients' recalled scores were significantly lower than those prospectively collected (mHHS: 52.9 ± 20.1 vs. 61.5 ± 18.5, p < 0.0001; NAHS: 54.7 ± 20.0 vs. 58.8 ± 19.1, p < 0.0001). Frequency distribution found 68.1% of recalled mHHS and 61.2% of NAHS scores to have a greater difference (between baseline and recalled scores) than the MCID. The ICC was moderate for both mHHS (ICC = 0.559, 95% confidence interval [CI] = [0.420-0.672], p < 0.001) and NAHS (ICC = 0.612, 95% CI = [0.484-0.714], p < 0.001). Multivariate regression analysis did not find time elapsed since surgery to be associated with the difference between baseline and recalled mHHS (n.s.) or NAHS (n.s.).

CONCLUSION

There are significant differences between retrospective and prospectively collected PROMs in patients undergoing hip arthroscopy that are not predicted by time to recall. These findings should impact the interpretation of the existing literature, support the routine collection of prospective data and inform patient counsel regarding their perceived post-operative outcomes.

LEVEL OF EVIDENCE

Level IV.

Automating Patient-Reported Outcome Measures Following Hand Surgery

PURPOSE

The purpose of this study was to assess the overall response rate of patients receiving electronic patient-reported outcome measures (ePROMs) following hand surgery and to determine the patient characteristics associated with responding.

METHODS

A Health Insurance Portability and Accountability Act-compliant, web-based system was developed to automatically distribute ePROMs to patients undergoing hand surgery at five institutions with 22 surgeons. Patients who were at least 18 years old were eligible. The PROMs used were the visual analog scale (VAS) for pain and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH). After surgery, ePROMs along with a satisfaction questionnaire were electronically sent three, six, 12, 24, and 52 weeks after surgery.

RESULTS

A total of 6458 patients were eligible. Of these, 80% were enrolled voluntarily. Among these, 70% completed ePROMs for at least one postoperative time point, whereas 30% did not complete any. Among responders, 28% completed all five time points, whereas 72% completed four or fewer time points. Incomplete responders were more likely to be insured by workers' compensation when compared to complete responders. Incomplete responders exhibited higher baseline QuickDASH scores and similar baseline VAS compared to complete responders. During the follow-up, incomplete responders demonstrated worse VAS and QuickDASH scores at all time points. Finally, in comparison with complete responders, incomplete responders were less likely to be satisfied with their surgery at all time points.

CONCLUSIONS

This study demonstrates that automated email-based ePROM systems may be an effective method for survey distribution. Particularly for simple, outpatient surgeries, this study illustrates the potential for clinical use of the data obtained from these systems.

CLINICAL RELEVANCE

Patient-reported outcome measures continue to have an expanding role in health care with the rise of valued-based systems. Electronic PROMs are a relatively unexplored medium that may offer a viable alternative to more effectively collecting these valuable patient metrics.

Patient and family views of team functioning in primary healthcare teams with nurse practitioners: a survey of patient-reported experience and outcomes

BACKGROUND

Nurse practitioners (NPs) have been added to primary healthcare teams to improve access to care. Team processes, including communication and decision-making, explicate how patients and families view team functioning. Yet, important gaps exist in our understanding of patient-reported experience and outcomes at the level of the healthcare team. We aimed to examine the influence of individual, team, and organizational characteristics, and role clarity on outcomes of care mediated by team processes in primary healthcare teams that include NPs.

METHODS

A cross-sectional survey across six sites representing practices with NPs in Québec, Canada, was conducted between March 2018 and April 2019 as part of a multiple-case study. Patients and families (n = 485; response rate: 53%) completed a validated questionnaire, which included a patient-reported experience measure (PREM) and a patient-reported outcome measure (PROM) of team functioning (Cronbach alpha: 0.771 (PROM) to 0.877 (PREM)). We performed logistic regression and mediation analyses to examine relationships between the individual, team, and organizational characteristics, role clarity, and outcomes of care mediated by team processes.

RESULTS

Patients and families expressed positive perceptions of team functioning (mean 4.97/6 [SD 0.68]) and outcomes of care (5.08/6 [0.74]). Also, high team processes (adjusted odds ratio [AOR] 14.92 [95% CI 8.11 to 27.44]) was a significant predictor of high outcomes of care. Role clarity (indirect effect coefficient ab = 6.48 [95% CI 3.79 to 9.56]), living in an urban area (-1.32 [-2.59 to -0.13]), patient as respondent (-1.43 [-2.80 to -0.14]), and income (1.73 [0.14 to 3.45]) were significant predictors of outcomes of care mediated by team processes.

CONCLUSIONS

This study provides key insights on how primary healthcare teams with NPs contribute to team functioning, using a validated instrument consistent with a conceptual framework. Results highlight that high role clarity, living in a non urban area, family as respondent, and adequate income were significant predictors of high outcomes of care mediated by high team processes. Additional research is needed to compare teams with and without NPs in different settings, to further explicate the relationships identified in our study.

Meaningful Clinical Applications of Patient-Reported Outcome Measures in Orthopaedics

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Patient-reported outcome measures (PROMs) comprise valuable data, when combined with traditional clinical information, for patient-centered health outcome assessment.

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While PROMs form the foundation of orthopaedic clinical research, they are invaluable tools for clinical care.

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PROMs play a critical role in shared decision-making with patients, as they are quantitative measures of patient health (function, pain, and satisfaction).

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PROMs should be incorporated into routine postoperative care for effective clinical monitoring and understanding of the response to surgery.

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PROMs can be additionally utilized for meaningful clinical research, predictive analytics, and value-based care delivery pathways.