An equivalence study: Are patient-completed and telephone interview equivalent modes of administration for the EuroQol survey?

The effect of biomass smoke exposure on quality-of-life among Ugandan patients treated for tuberculosis: A cross-sectional analysis

More than half the global population burns biomass fuels for cooking and home heating, especially in low-middle income countries. This practice is a prominent source of indoor air pollution and has been linked to the development of a variety of cardiopulmonary diseases, including Tuberculosis (TB). The purpose of this cross-sectional study was to investigate the association between current biomass smoke exposure and self-reported quality of life scores in a cohort of previous TB patients in Uganda. We reviewed medical records from six TB clinics from 9/2019-9/2020 and conducted phone interviews to obtain information about biomass smoke exposure. A random sample of these patients were asked to complete three validated quality-of-life surveys including the St. Georges Respiratory Questionnaire (SGRQ), the EuroQol 5 Dimension 3 Level system (EQ-5D-3L) which includes the EuroQol Visual Analog Scale (EQ-VAS), and the Patient Health Questionnaire 9 (PHQ-9). The cohort was divided up into 3 levels based on years of smoke exposure-no-reported smoke exposure (0 years), light exposure (1-19 years), and heavy exposure (20+ years), and independent-samples-Kruskal-Wallis testing was performed with post-hoc pairwise comparison and the Bonferroni correction. The results of this testing indicated significant increases in survey scores for patients with current biomass exposure and a heavy smoke exposure history (20+ years) compared to no reported smoke exposure in the SGRQ activity scores (adj. p = 0.018) and EQ-5D-3L usual activity scores (adj. p = 0.002), indicating worse activity related symptoms. There was a decrease in EQ-VAS scores for heavy (adj. p = 0.007) and light (adj. p = 0.017) exposure groups compared to no reported exposure, indicating lower perceptions of overall health. These results may suggest worse outcomes or baseline health for TB patients exposed to biomass smoke at the time of treatment and recovery, however further research is needed to characterize the effect of indoor air pollution on TB treatment outcomes.

Comparison of short-term outcomes between people with and without a pre-morbid mental health diagnosis following surgery for traumatic hand injury: a prospective longitudinal study of a multicultural cohort

BACKGROUND

Following traumatic hand injury, few studies have compared outcomes between people with and without a pre-morbid mental health diagnosis. This study aimed to compare sub-acute outcomes in a multicultural patient cohort with surgically managed traumatic hand injury with and without a pre-morbid mental health diagnosis.

METHODS

A prospective, observational cohort study of people with traumatic hand injury presenting pre- surgically to a high-volume hand injury centre in a region of cultural and language diversity was conducted. Participants were assessed face-to-face (baseline) then via telephone (3-months post-surgery) and categorized according to a pre-morbid medically diagnosed mental health diagnosis. Baseline and follow-up assessments included global mental health, and the EuroQol (EQ) 'Health Today' analogue scale (0-100) and health domains. Return-to-work status, complications/symptomatic complaints, and hand function (QuickDASH) were also collected at follow-up. Adjusted analyses-accounting for covariates including cultural identity-were conducted to determine whether 3-month outcomes were associated with a pre-morbid mental health diagnosis.

RESULTS

From 405 eligible patients, 386 were enrolled (76% male, mean age 38.9 (standard deviation 15.6)); 57% self-identified as Australian and 22% had a pre-morbid mental health diagnosis. Common injuries regardless of pre-morbid mental health diagnosis were skin (40%), tendon (17%) and bone (17%) injuries. None were complex mutilating injuries. Seventy-eight per cent of the cohort was followed-up. In adjusted analyses, a pre-morbid mental health diagnosis was associated with lower odds for reporting 'good or better' global mental health (Odds Ratio (OR) 0.23 (95% Confidence Interval (CI) 0.18, 0.47), p < 0.001), 'no' anxiety or depression (OR 0.21 (0.11, 0.40), p < 0.001) and no pain (OR 0.56 (0.31, 0.98), p = 0.04)(EQ domains), and worse EQ 'Health Today' (10 points on average (95%CI -14.9, -5.1, p < 0.001). QuickDASH scores, rates of complications/symptomatic complaints and return-to-work profiles were similar.

CONCLUSIONS

Despite reporting worse mental and health-related quality-of-life outcomes post-surgery, people with a pre-morbid mental health diagnosis regardless of cultural identity experienced similar clinical and return-to-work outcomes. Future research assessing the value of screening for pre-morbid mental health conditions on post-surgical outcomes is required and should include people with more complex hand injuries.

Do the Revision Rates of Arthroplasty Surgeons Correlate With Postoperative Patient-reported Outcome Measure Scores? A Study From the Australian Orthopaedic Association National Joint Replacement Registry

BACKGROUND

Patient-reported outcome measures (PROMs) are a pragmatic and efficient means to evaluate the functional quality of arthroplasty beyond revision rates, which are used by most joint replacement registries to judge success. The relationship between these two measures of quality-revision rates and PROMs-is unknown, and not every procedure with a poor functional result is revised. It is logical-although still untested-that higher cumulative revision rates correlate inversely with PROMs for individual surgeons; more revisions are associated with lower PROM scores.

QUESTIONS/PURPOSES

We used data from a large national joint replacement registry to ask: (1) Does a surgeon's early THA cumulative percent revision (CPR) rate and (2) early TKA CPR rate correlate with the postoperative PROMs of patients undergoing primary THA and TKA, respectively, who have not undergone revision?

METHODS

Elective primary THA and TKA procedures in patients with a primary diagnosis of osteoarthritis that were performed between August 2018 and December 2020 and registered in the Australian Orthopaedic Association National Joint Replacement Registry PROMs program were eligible. THAs and TKAs were eligible for inclusion in the primary analysis if 6-month postoperative PROMs were available, the operating surgeon was clearly identified, and the surgeon had performed at least 50 primary THAs or TKAs. Based on the inclusion criteria, 17,668 THAs were performed at eligible sites. We excluded 8878 procedures that were not matched to the PROMs program, leaving 8790 procedures. A further 790 were excluded because they were performed by unknown or ineligible surgeons or were revised, leaving 8000 procedures performed by 235 eligible surgeons, including 4256 (53%; 3744 cases of missing data) patients who had postoperative Oxford Hip Scores and 4242 (53%; 3758 cases of missing data) patients who had a postoperative EQ-VAS score recorded. Complete covariate data were available for 3939 procedures for the Oxford Hip Score and for 3941 procedures for the EQ-VAS. A total of 26,624 TKAs were performed at eligible sites. We excluded 12,685 procedures that were not matched to the PROMs program, leaving 13,939 procedures. A further 920 were excluded because they were performed by unknown or ineligible surgeons, or because they were revisions, leaving 13,019 procedures performed by 276 eligible surgeons, including 6730 (52%; 6289 cases of missing data) patients who had had postoperative Oxford Knee Scores and 6728 (52%; 6291 cases of missing data) patients who had a postoperative EQ-VAS score recorded. Complete covariate data were available for 6228 procedures for the Oxford Knee Score and for 6241 procedures for the EQ-VAS. The Spearman correlation between the operating surgeon's 2-year CPR and 6-month postoperative EQ-VAS Health and Oxford Hip or Oxford Knee Score was evaluated for THA and TKA procedures where a revision had not been performed. Associations between postoperative Oxford and EQ-VAS scores and a surgeon's 2-year CPR were estimated based on multivariate Tobit regressions and a cumulative link model with a probit link, adjusting for patient age, gender, ASA score, BMI category, preoperative PROMs, as well as surgical approach for THA. Missing data were accounted for using multiple imputation, with models assuming they were missing at random and a worst-case scenario.

RESULTS

Of the eligible THA procedures, postoperative Oxford Hip Score and surgeon 2-year CPR were correlated so weakly as to be clinically irrelevant (Spearman correlation ρ = -0.09; p < 0.001), and the correlation with postoperative EQ-VAS was close to zero (ρ = -0.02; p = 0.25). Of the eligible TKA procedures, postoperative Oxford Knee Score and EQ-VAS and surgeon 2-year CPR were correlated so weakly as to be clinically irrelevant (ρ = -0.04; p = 0.004 and ρ = 0.03; p = 0.006, respectively). All models accounting for missing data found the same result.

CONCLUSION

A surgeon's 2-year CPR did not exhibit a clinically relevant correlation with PROMs after THA or TKA, and all surgeons had similar postoperative Oxford scores. PROMs, revision rates, or both may be inaccurate or imperfect indicators of successful arthroplasty. Missing data may limit the findings of this study, although the results were consistent under a variety of different missing data scenarios. Innumerable factors contribute to arthroplasty results, including patient-related variables, differences in implant design, and the technical quality of the procedure. PROMs and revision rates may be analyzing two different facets of function after arthroplasty. Although surgeon variables are associated with revision rates, patient factors may exert a stronger influence on functional outcomes. Future research should identify variables that correlate with functional outcome. Additionally, given the gross level of function that Oxford scores record, outcome measures that can identify clinically meaningful functional differences are required. The use of Oxford scores in national arthroplasty registries may rightfully be questioned.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Health-related quality of life and associated factors among COVID-19 individuals managed with indian traditional medicine: A cross-sectional study from south India

Introduction

Coronavirus disease-2019 (COVID-19) had a multidimensional impact on human life. It affects the health-related quality of life (HRQoL) which is a perceived measure of physical and mental health. We estimated the EuroQol utility value for COVID-19 and the associated factors for those managed at Siddha COVID care centres in Tamil Nadu.

Methods

A cross-sectional study was conducted by a telephonic interview of 2000 randomly selected COVID-19 adults tested positive during June 2020 to Jan 2021. We collected sociodemographic, clinical and EQ-5D-5L profile. Mean EQ-5D-5L summary utility values and EQ-VAS scores were estimated. Multivariate regression was used to examine the factors associated with EQ-5D-5L. Study protocol was approved by the Institutional ethics committee of Government Siddha Medical College, Chennai (GSMC-CH-3401/ME-2/050/2021). The committee waived the written informed consent considering the pandemic situation of emerging infectious diseases.

Results

We interviewed 1047 participants. Of the total 68% were males with the median age (IQR) of 38 (29-51) years. The mean EQ-5D-5L utility score and EQ-VAS scores are 0.98 ± 0.05 and 92.14 ± 0.39 respectively. COVID-19 asymptomatic group reported a mean utility score of 0.99 ± 0.03 which is relatively more than the symptomatic group (0.97 ± 0.06),. EQ-VAS score was also reported high among the asymptomatic (95.45 ± 5.95) than the symptomatic (91.40 ± 8.69COVID-19.

Conclusion

The severity of illness and the comorbidity are significantly associated with a low HRQoL of COVID-19 patients.

Discharge to inpatient rehabilitation following arthroplasty is a strong predictor of persistent opioid use 90 days after surgery: a prospective, observational study

BACKGROUND

Total knee and hip arthroplasty are considered a clinically and cost-effective intervention, however, persistent pain post-surgery can occur, and some continue to take opioid medications long-term. One factor which has infrequently been included in prediction modelling is rehabilitation pathway, in particular, one which includes inpatient rehabilitation. As discharge to inpatient rehabilitation post-arthroplasty is common practice, we aimed to identify whether rehabilitation pathway (discharge to in-patient rehabilitation or not) predicts continued use of opioids at 3 months (90 days) post- total knee arthroplasty (TKA) and total hip arthroplasty (THA) whilst controlling for other covariates.

METHODS

The study was nested within a prospective observational study capturing pre-operative, acute care and longer-term data from 1900 osteoarthritis (OA) patients who underwent primary TKA or THA. The larger study involved a part-random, part-convenience sample of 19 high-volume hospitals across Australia. Records with complete pre-and post-operative analgesic (35 days and 90 days) use were identified [1771 records (93% of sample)] and included in logistic regression analyses.

RESULTS

Three hundred and thirteen people (17.8%) reported ongoing opioid use at 90 days post-operatively. In the adjusted model, admission to inpatient rehabilitation after surgery was identified as an independent and significant predictor of opioid use at 90-days. Inpatient rehabilitation was associated with almost twice the odds of persistent opioid use at 90-days compared to discharge directly home (OR = 1.9 (1.4, 2.5), p < .001).

CONCLUSION

The inpatient rehabilitation pathway is a strong predictor of longer-term opioid use (90 days) post-arthroplasty, accounting for many known and possible confounders of use including sex, age, insurance status, major complications, smoking status and baseline body pain levels.

TRIAL REGISTRATION

The study was nested within a prospective cohort observational study capturing pre-operative, acute-care and longer-term data from patients undergoing primary TKA or THA for osteoarthritis (ClinicalTrials.gov NCT01899443).

Association between VTE and antibiotic prophylaxis guideline compliance and patient-reported outcomes after total hip and knee arthroplasty: an observational study

BACKGROUND

Surgical site infection (SSI) and venous thromboembolism (VTE) are associated with high burden and cost and are considered largely preventable following total knee or hip arthroplasty (TKA, THA). The risk of developing VTE and SSI is reduced when prophylaxis is compliant with evidence-based clinical guidelines. However, the association between VTE and antibiotic prophylaxis clinical guideline compliance and patient-reported outcome measures (PROMs) after THA/TKA is unknown. This study aims to explore whether care that is non-compliant with VTE and antibiotic guideline recommendations is associated with PROMs (Oxford Hip/Knee Score and EQ-5D Index scores) at 90- and 365-days after surgery.

METHODS

This prospective observational study included high-volume arthroplasty public and private sites and consenting eligible participants undergoing elective primary THA/TKA. We conducted multiple linear regression and linear mixed-effects modelling to explore the associations between non-compliance with VTE and antibiotic guidelines, and PROMs.

RESULTS

The sample included 1838 participants. Compliance with VTE and antibiotic guidelines was 35% and 13.2% respectively. In adjusted modelling, non-compliance with VTE guidelines was not associated with 90-day Oxford score (β = - 0.54, standard error [SE] = 0.34, p = 0.112) but was significantly associated with lower (worse) 365-day Oxford score (β = - 0.76, SE = 0.29, p = 0.009), lower EQ-5D Index scores at 90- (β = - 0.02 SE = 0.008, p = 0.011) and 365-days (β = - 0.03, SE = 0.008, p = 0.002).. The changes in Oxford and EQ-5D Index scores were not clinically important. Noncompliance with antibiotic guidelines was not associated with either PROM at 90- (Oxford: β = - 0.45, standard error [SE] = 0.47, p = 0.341; EQ-5D: β = - 0.001, SE = 0.011, p = 0.891) or 365-days (Oxford score: β = - 0.06, SE = 0.41, p = 0.880 EQ-5D: β = - 0.010, SE = 0.012, p = 0.383). Results were consistent when complications were included in the model and in linear mixed-effects modelling with the insurance sector as a random effect.

CONCLUSIONS

Non-compliance with VTE prophylaxis guidelines, but not antibiotic guidelines, is associated with statistically significant but not clinically meaningful differences in Oxford scores and EQ-5D Index scores at 365 days.

Measurement properties of the WHO Disability Assessment Schedule 2.0 for evaluating functional status after inpatient surgery

BACKGROUND

Expert recommendations propose the WHO Disability Assessment Schedule (WHODAS) 2.0 as a core outcome measure in surgical studies, yet data on its long-term measurement properties remain limited. These were evaluated in a secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) prospective cohort.

METHODS

Participants were adults (40 years of age or older) who underwent inpatient non-cardiac surgery. The 12-item WHODAS and EQ-5DTM-3L questionnaires were administered preoperatively (in person) and 1 year postoperatively (by telephone). Responsiveness was characterized using standardized response means (SRMs) and correlation coefficients between change scores. Construct validity was evaluated using correlation coefficients between 1-year scores and comparisons of WHODAS scores across clinically relevant subgroups.

RESULTS

The analysis included 546 patients. There was moderate correlation between changes in WHODAS and various EQ-5DTM subscales. The strongest correlation was between changes in WHODAS and changes in the functional domains of the EQ-5D-3L-for example, mobility (Spearman's rho 0.40, 95 per cent confidence interval [c.i.] 0.32 to 0.48) and usual activities (rho 0.45, 95 per cent c.i. 0.30 to 0.52). When compared across quartiles of EQ-5D index change, median WHODAS scores followed expected patterns of change. In subgroups with expected functional status changes, the WHODAS SRMs ranged from 'small' to 'large' in the expected directions of change. At 1 year, the WHODAS demonstrated convergence with the EQ-5D-3L functional domains, and good discrimination between patients with expected differences in functional status.

CONCLUSION

The WHODAS questionnaire has construct validity and responsiveness as a measure of functional status at 1 year after major surgery.

Are in Person and Telephone Interviews Equivalent Modes of Administrating the CAT, the FACIT-FS and the SGRQ in People With COPD?

Background: The COVID-19 pandemic brought numerous challenges, namely in routine assessment of people with chronic obstructive pulmonary disease (COPD). The COPD Assessment Test (CAT), the Functional Assessment of Chronic Illness-Fatigue-Subscale (FACIT-FS) and the St. George's respiratory questionnaire (SGRQ) are important patient-reported outcome measures used to assess people with COPD, but its face-to-face application has been compromised. The telephone interview offers a simple and effective alternative, yet uncertainty regarding its equivalence remains. This study aimed to establish the reliability and validity of the CAT, the FACIT-FS and the SGRQ administered by telephone interview in people with COPD.

Methods: Data from an observational prospective study including people with COPD were analyzed. Participants answered to the CAT, FACIT-FS and SGRQ questionnaires in person and by telephone, with a maximum interval of 48-h. Participants were randomly selected to answer first to the in-person questionnaire followed by telephone or vice versa. Reliability measures included internal consistency with Cronbach's alpha, test-retest reliability with the intraclass correlation coefficient (ICC_2,1), test-retest measurement error with the standard error of measurement (SEM) and agreement with the Bland and Altman 95% limits of agreement. Validity was assessed with the Spearman correlation (rho).

Results: Fifty-five people with COPD (44 men; 68.1 ± 7.9 years; FEV₁: 59.1 ± 20.3% predicted) were included. Similar internal consistency was observed between in person vs. telephone interview for the CAT (0.82 vs. 0.84), the FACIT-FS (0.83 vs. 0.84) and the SGRQ (0.92 vs. 0.93). Test-retest reliability was excellent, with an ICC_2,1 of 0.77 (95% CI: 0.65; 0.86), 0.86 (95% CI: 0.77; 0.92) and 0.94 (95% CI: 0.90; 0.96) for the CAT, FACIT-FS and SGRQ total scores, respectively. The SEM showed a low level of associated measurement error and the Bland and Altman plots illustrated a good level of agreement between both modes of administration, with no evidence of systematic bias. Robust positive correlations (rho 0.87–0.94, p < 0.001) were found for the CAT, FACIT-FS and SGRQ total scores applied by both methods.

Conclusion: The telephonic administration of the CAT, the FACIT-FS and the SGRQ are a valid and reliable alternative approach to in person interviews for monitoring symptoms and health-related quality of life in people with COPD. The telephone might be an important add-on for personalized assessment and management of COPD thru remote monitoring.

Validity and reliability of the Health-Related Quality of Life Instrument with 8 Items (HINT-8) in Korean breast cancer patients

OBJECTIVE

This study evaluated the validity and reliability of the Health-Related Quality of Life Instrument with 8 Items (HINT-8) in postoperative breast cancer patients in South Korea.

METHODS

The study included 300 breast cancer patients visiting a tertiary hospital. We measured health-related quality of life (HRQoL) using the HINT-8, the 5-level EQ-5D version (EQ-5D-5L), and the Functional Assessment of Cancer Therapy-Breast (FACT-B). Discriminatory ability, known-group validity, and convergent validity were assessed. Reliability was evaluated with the Cohen kappa, weighted kappa, and intraclass correlation coefficient (ICC).

RESULTS

The EQ-5D-5L indexes (p<0.001) and EQ visual analogue scale (VAS) scores (p<0.001) were significantly higher in subjects with no problems in each item of the HINT-8 than in those with problems. The FACT-B total scores were also higher in subjects without problems on the HINT-8. Older age, lower education level, and comorbidities were associated with a lower HINT-8 index. The HINT-8 index was correlated with the EQ-5D-5L index and the EQ VAS, with correlation coefficients of 0.671 (p<0.001) and 0.577 (p<0.001), respectively. The correlation coefficients between the HINT-8 and the FACT-B ranged from 0.390 to 0.714. The ICC was 0.690 (95% confidence interval, 0.580-0.780).

CONCLUSION

The HINT-8 showed appropriate validity for capturing HRQoL in postoperative breast cancer patients.

Validity of the Utrecht scale for evaluation of rehabilitation-participation restrictions scale in a hospital-based stroke population 3 months after stroke

Background:The Utrecht Scale for Evaluation of Rehabilitation-Participation Restrictions scale (USER-P-R) is a promising patient-reported outcome measure, but has currently not been validated in a hospital-based stroke population. Objective:To examine psychometric properties of the USER-P-R in a hospital-based stroke population 3 months after stroke onset. Methods:Cross-sectional study including 359 individuals with stroke recruited through 6 Dutch hospitals. The USER-P-R, EuroQol 5-dimensional 5-level questionnaire (EQ-5D-5 L), Patient Reported Outcomes Measurement Information System 10-Question Global Health Short Form (PROMIS-10), modified Rankin Scale (mRS) and two items on perceived decrease in health and activities post-stroke were administered in a telephone interview 3 months after stroke. The internal consistency, distribution, floor/ceiling effects, convergent validity and discriminant ability of the USER-P-R were calculated. Results:Of all participants, 96.9% were living at home and 50.9% experienced no or minimal disabilities (mRS 0-1). The USER-P-R showed high internal consistency (α = 0.90) and a non-normal left-skewed distribution with a ceiling effect (21.4% maximum scores). A substantial proportion of participants with minimal disabilities (mRS 1) experienced restrictions on USER-P-R items (range 11.9-48.5%). The USER-P-R correlated strongly with the EQ-5D-5 L, PROMIS-10 and mRS. The USER-P-R showed excellent discriminant ability in more severely affected individuals with stroke, whereas its discriminant ability in less affected individuals was moderate. Conclusions:The USER-P-R shows good measurement properties and provides additional patient-reported information, proving its usefulness as an instrument to evaluate participation after 3 months in a hospital-based stroke population.

Are responders to patient health surveys representative of those invited to participate? An analysis of the Patient-Reported Outcome Measures Pilot from the Australian Orthopaedic Association National Joint Replacement Registry

Background

Patient-reported outcome measures (PROMs) are commonly used to evaluate surgical outcome in patients undergoing joint replacement surgery, however routine collection from the target population is often incomplete. Representative samples are required to allow inference from the sample to the population. Although higher capture rates are desired, the extent to which this improves the representativeness of the sample is not known. We aimed to measure the representativeness of data collected using an electronic PROMs capture system with or without telephone call follow up, and any differences in PROMS reporting between electronic and telephone call follow up.

Methods

Data from a pilot PROMs program within a large national joint replacement registry were examined. Telephone call follow up was used for people that failed to respond electronically. Data were collected pre-operatively and at 6 months post-operatively. Responding groups (either electronic only or electronic plus telephone call follow up) were compared to non-responders based on patient characteristics (joint replaced, bilaterality, age, sex, American Society of Anesthesiologist (ASA) score and Body Mass Index (BMI)) using chi squared test or ANOVA, and PROMs for the two responder groups were compared using generalised linear models adjusted for age and sex. The analysis was restricted to those undergoing primary elective hip, knee or shoulder replacement for osteoarthritis.

Results

Pre-operatively, 73.2% of patients responded electronically and telephone follow-up of non-responders increased this to 91.4%. Pre-operatively, patients responding electronically, compared to all others, were on average younger, more likely to be female, and healthier (lower ASA score). Similar differences were found when telephone follow up was included in the responding group. There were little (if any) differences in the post-operative comparisons, where electronic responders were on average one year younger and were more likely to have a lower ASA score compared to those not responding electronically, but there was no significant difference in sex or BMI. PROMs were similar between those reporting electronically and those reporting by telephone.

Conclusion

Patients undergoing total joint replacement who provide direct electronic PROMs data are younger, healthier and more likely to be female than non-responders, but these differences are small, particularly for post-operative data collection. The addition of telephone call follow up to electronic contact does not provide a more representative sample. Electronic-only follow up of patients undergoing joint replacement provides a satisfactory representation of the population invited to participate.

Economic Burden and Impact on Quality of Life of Herpes Zoster in Spanish Adults Aged 50 Years or Older: A Prospective Cohort Study

Introduction

The economic burden of herpes zoster (HZ), including its most common complication, postherpetic neuralgia (PHN), and its impact on health-related quality of life (HRQL) is not well described in Spain. The aim of this study was to estimate HZ-related healthcare costs and impact on HRQL in Spanish adults aged 50 years or older.

Methods

A prospective, observational study was performed with patients with HZ recruited through four general practitioner networks in Spain (NCT01521286). HRQL data were collected using the EuroQoL-5 Dimension (EQ-5D) questionnaire; HZ-related pain and associated interference with activities of daily living (ADL) were assessed using the Zoster Brief Pain Inventory (ZBPI) questionnaire at days 0 (HZ rash onset), 15, 30, 60, and 90; patients with PHN were assessed up until day 270. Medical resource utilization was recorded throughout study follow-up. Work loss for patients/caregivers was also assessed. Costs were calculated from both the payer and societal perspectives.

Results

A total of 545 patients with Hz were included, of whom 25 developed PHN. During days 0–30 post HZ diagnosis, the mean EQ-5D utility score was 0.738, equating to a utility loss of 0.138. Sleep was the ADL most affected component. The mean costs for HZ in the overall cohort were €240 and €296 from the payer/societal perspective, respectively; €187/€242 for patients with HZ without any HZ-related complications; and €571/€712 for patients who developed PHN. The majority of costs were incurred during days 0–30.

Conclusions

In Spain, HZ and HZ-related complications such as PHN reduce patient HRQL and increase the economic burden for both payers and society in general.

Trail Registration

ClinicalTrials.gov identifier NCT01521286.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01717-7.

Telephone consultation for myasthenia gravis care during the COVID-19 pandemic: Assessment of a novel virtual myasthenia gravis index

INTRODUCTION/AIMS

The aim of the study was to determine the association between the virtual Myasthenia Gravis Impairment Index (vMGII) with other patient-reported outcomes (PROs) of myasthenia gravis (MG) and its usefulness in telephone consultations with MG patients.

METHODS

This was a retrospective case series in which vMGII score along with virtual Single Simple Question (vSSQ), virtual Patient-Acceptable Symptom State PASS (vPASS) response, and patient disease status based on Myathenia Gravis Foundation of America postintervention status were collected during telephone consultation along with the MGII, SSQ, and PASS responses during the preceding in-person clinic visits.

RESULTS

In 214 patients, the mean difference of vMGII between the vPASS "Yes" and "No" groups was -14.2 ± 1.4 (95% confidence interval, -16.9 to -11.3; P < .001) with mean vMGII for vPASS "Yes" group being 6.4 ± 7.7 and vPASS "No" being 20.5 ± 11.5. A vMGII of 11.5 or higher predicted vPASS "yes" response with a sensitivity of 78.7% and specificity of 81.4%. A strong negative correlation was found between the vMGII and vSSQ (r = -.667; P < .001). The mean vMGII was 0.48 ± 1.42 for patients in remission, and 9.31 ± 10.93 for improved, 9.32 ± 8.79 for stable, and 22.58 ± 14.04 for worsened groups (P < .001). These associations were the same as those obtained during the preceding in-person clinic visit and the direction of change in MGII scores also indicated change in disease status.

DISCUSSION

vMGII is an effective measure to assess an MG patient's disease status in telephone consultations and relates well with other PRO measures. The vMGII remains reliable for assessing MG disease status even with removal of the physical examination component.

Comparison of patient reported outcomes following clavicle operative fixation using supraclavicular nerve sparing and supraclavicular nerve sacrificing techniques- A cohort study

INTRODUCTION

Supraclavicular nerve injury is one of the common complications after clavicle open reduction internal fixation (ORIF) affecting up to 55% of patients. There is debate about whether sparing supraclavicular nerves improves functional outcomes and patient satisfaction. The purpose of this study was to compare numbness, patient-reported outcomes and surgical time in patients undergoing clavicle ORIF using supraclavicular nerve sparing and supraclavicular nerve sacrificing techniques.

PATIENTS AND METHODS

We conducted a retrospective cohort study with prospective survey of 108 patients with clavicular fractures treated with ORIF at a level 1 trauma centre. Patients were divided into two groups: 1) ORIF with supraclavicular nerve sparing techniques and 2) ORIF with supraclavicular nerve sacrificing techniques. Questionnaires were conducted and subjective numbness around supraclavicular nerve distribution was our primary outcome measure. Secondary outcome measures included the Quick Disability of the Arm, Shoulder and Hand (QuickDASH) score, a numeric rating scale for pain and satisfaction with treatment and surgical time.

RESULTS

An overall response rate of 92% was achieved with an average follow-up of 16 months. There were 20 patients in the supraclavicular nerve sparing group and 79 patients in the supraclavicular nerve sacrificing group. 76% of all patients experienced numbness post-operatively and 91% of these patients experienced persistent numbness at final follow-up. There was no significant difference between the groups for age, gender, time to follow-up and mechanism of injury. Patients in the supraclavicular nerve sparing group had significantly less numbness at final follow-up (35% vs 86%, P < 0.001; OR=0.21 95%CI 0.11-0.40). There was no significant difference in the QuickDASH score nor the NRS for pain and function. Sparing supraclavicular nerves did not result in a significantly longer operation.

CONCLUSIONS

Our study demonstrates that identification and protection of the supraclavicular nerves result in significantly less numbness following clavicle ORIF but does not affect patient reported functional outcomes.

Design and rationale of a routine clinical care pathway and prospective cohort study in older patients needing intensive treatment

BACKGROUND

Treatment decisions concerning older patients can be very challenging and individualised treatment plans are often required in this very heterogeneous group. In 2015 we have implemented a routine clinical care pathway for older patients in need of intensive treatment, including a comprehensive geriatric assessment (CGA) that was used to support clinical decision making. An ongoing prospective cohort study, the Triaging Elderly Needing Treatment (TENT) study, has also been initiated in 2016 for participants in this clinical care pathway, to study associations between geriatric characteristics and outcomes of treatment that are relevant to older patients. The aim of this paper is to describe the implementation and rationale of the routine clinical care pathway and design of the TENT study.

METHODS

A routine clinical care pathway has been designed and implemented in multiple hospitals in the Netherlands. Patients aged ≥70 years who are candidates for intensive treatments, such as chemotherapy, (chemo-)radiation therapy or major surgery, undergo frailty screening based on the Geriatric 8 (G-8) questionnaire and the Six-Item Cognitive Impairment Test (6CIT). If screening reveals potential frailty, a CGA is performed. All patients are invited to participate in the TENT study. Clinical data and blood samples for biomarker studies are collected at baseline. During follow-up, information about treatment complications, hospitalisations, functional decline, quality of life and mortality is collected. The primary outcome is the composite endpoint of functional decline or mortality at 1 year.

DISCUSSION

Implementation of a routine clinical care pathway for older patients in need of intensive treatment provides the opportunity to study associations between determinants of frailty and outcomes of treatment. Results of the TENT study will support individualised treatment for future patients.

TRIAL REGISTRATION

The study is retrospectively registered at the Netherlands Trial Register (NTR), trial number NL8107 . Date of registration: 22-10-2019.

Implementing early mobilisation after knee or hip arthroplasty to reduce length of stay: a quality improvement study with embedded qualitative component

BACKGROUND

Models of care for managing total knee or hip arthroplasty (TKA, THA) incorporating early mobilisation are associated with shorter acute length-of-stay (LOS). Few studies have examined the effect of implementing early mobilisation in isolation, however. This study aimed to determine if an accelerated mobilisation protocol implemented in isolation is associated with a reduced LOS without undermining care.

METHOD

A Before-After (quasi-experimental) study was used. Standard practice pre-implementation of the new protocol was physiotherapist-led mobilisation once per day commencing on post-operative Day 1 (Before phase). The new protocol (After phase) aimed to mobilise patients four times by end of Day 2 including an attempt to commence on Day 0; physiotherapy weekend coverage was necessarily increased. Poisson regression modelling was used to determine associations between study period and LOS. Additional outcomes to 12 weeks post-surgery were monitored to identify unintended consequences of the new protocol. Time to first mobilisation (hours) and proportion mobilising Day 0 were monitored to assess protocol compliance. An embedded qualitative component captured staff perspectives of the new protocol.

RESULTS

Five hundred twenty consecutive patients (n = 278, Before; n = 242, After) were included. The new protocol was associated with no change in unadjusted LOS, a small reduction in adjusted LOS (8.1%, p = 0.046), a reduction in time to first mobilisation (28.5 (10.8) vs 22.6 (8.1) hrs, p < 0.001), and an increase in the proportion mobilising Day 0 (0 vs 7%, p < 0.001). Greater improvements were curtailed by an unexpected decrease in physiotherapy staffing (After phase). There were no significant changes to the rates of complications or readmissions, joint-specific pain and function scores or health-related quality of life to 12 weeks post-surgery. Qualitative findings of 11 multidisciplinary team members highlighted the importance of morning surgery, staffing, and well-defined roles.

CONCLUSION

Small reductions in LOS are possible utilising an early mobilisation protocol in isolation after TKA or THA although staff burden is increased likely undermining both sustainability and the magnitude of the change. Simultaneous incorporation of other changes within the pathway would likely secure larger reductions in LOS.

Is retrospective assessment of health-related quality of life valid?

BACKGROUND

Health-related quality of life (HRQoL) is a commonly used health outcome. For many acute conditions (e.g. fractures), retrospective measurement of HRQoL is necessary to establish pre-morbid health status. However, the validity of retrospective measurement of HRQoL following an intervening significant health event has not been established. The aim of this study was to test the validity of retrospective measurement (recall) of HRQoL by using a test-retest design to measure reliability and agreement between prospective and retrospective patient-reported HRQoL before and after an intervening health event (elective orthopaedic surgery).

METHOD

Participants were recruited from the pre-admission clinic of a metropolitan hospital. Participants were assessed for their HRQoL using the EQ-5D-5L at two time-points; prospectively at 2 weeks prior to their date of surgery and then retrospectively (recalling their pre-operative health) following elective hip or knee joint replacement surgery. Prospective measurements were compared with retrospective measurements for the five domain scores (nominal data) using intra-class correlation and for the EQ-Index score and EQ-Visual Analogue Scale (VAS) score (continuous data), using Pearson's correlation. Agreement was tested in continuous variables using Lin's coefficient of concordance (p_c) and Bland-Altman plots.

RESULTS

One hundred seventy-four patients consented to participate. Eighty-eight paired prospective and retrospective scores were collected and there was a median between-test period of 15 days. At a group level, the prospective measurements were similar to the retrospective measurements; the modes and means of the five domain scores were not different and the mean differences (MD) between the scores for EQ-Index (MD = 0.02, on a scale of 0-1) and EQ-VAS (MD = 0.53, on a scale of 1-100) were negligible. However, the correlation of paired scores was varied; the range of domain score correlations was 0.52 to 0.74, the concordance was substantial for the EQ-Index scores (p_c = 0.76, 95% CI = 0.66, 0.84) and moderate for the EQ-VAS scores (p_c = 0.46, 95% CI = 0.28, 0.61).

CONCLUSION

Agreement between prospective and retrospective measurements was high at a group level and moderate to substantial at an individual level. Retrospective measurement of HRQoL using the EQ-5D-5L in an orthopaedic clinical context is a valid alternative to using reference data to estimate baseline or pre-morbid health status.

Associations between pre-surgical daily opioid use and short-term outcomes following knee or hip arthroplasty: a prospective, exploratory cohort study

Background

Retrospective studies have found that daily opioid use pre-arthroplasty predicts worse longer-term service, clinical and patient-reported outcomes. Prospective studies are needed to confirm these observations. This prospective, exploratory study aimed to determine: the proportion of total knee or hip arthroplasty (TKA, THA) patients who use opioids regularly (daily) pre-surgery; if opioid use pre-surgery is associated with acute and sub-acute outcomes to 12-weeks post-surgery.

Methods

Consecutive patients undergoing primary TKA or THA were prospectively enrolled pre-surgery and followed-up by telephone to 12-weeks post-surgery. Acute-care (oral morphine equivalent dosage (OMED), length of stay, discharge to inpatient rehabilitation, complications) and 12-week outcomes (Oxford Knee or Hip Score, Euroqol ‘today’ health score, current use of opioids, and complications including readmissions) were monitored. Unadjusted and adjusted Odds Ratios (ORs) (95% Confidence Interval, CI), Rate Ratios and β coefficients (standard error) were calculated.

Results

Five Hundred Twenty-One patients were included (TKA n = 381). 15.7% (95%CI 12.6 to 18.9) used opioids regularly pre-surgery. 86.8% (452/521) were available for follow-up at 12-weeks. In unadjusted analyses, pre-surgical opioid use was significantly associated with higher average acute daily OMED [β 0.40 (0.07), p <  0.001], presence of an acute complication [OR 1.75 (1.02 to 3.00)], and ongoing use of opioids at 12-weeks [OR 5.06 (2.86 to 8.93)]. After adjusting for covariates, opioid use pre-surgery remained significantly associated with average acute daily OMED [β 0.40 (0.07), p <  0.001] and ongoing use at 12-weeks [OR 5.38 (2.89 to 9.99)].

Conclusion

People who take daily opioids pre-surgery have significantly greater odds for greater opioid consumption acutely and ongoing use post-surgery. Adequately powered prospective studies are required to confirm whether pre-surgical opioid use is or is not associated with poorer joint and quality of life scores or a complication in the short-term.

An online intervention for improving stroke survivors' health-related quality of life: study protocol for a randomised controlled trial

Background

Recurrent stroke is a major contributor to stroke-related disability and costs. Improving health-risk behaviours and mental health has the potential to significantly improve recovery, enhance health-related quality of life (HRQoL), independent living, and lower the risk of recurrent stroke. The primary aim will be to test the effectiveness of an online intervention to improve HRQoL among stroke survivors at 6 months’ follow-up. Programme effectiveness on four health behaviours, anxiety and depression, cost-effectiveness, and impact on other hospital admissions will also be assessed.

Methods/design

An open-label randomised controlled trial is planned. A total of 530 adults will be recruited across one national and one regional stroke registry and block randomised to the intervention or minimal care control group. The intervention group will receive access to the online programme Prevent 2nd Stroke (P2S); the minimal care control group will receive an email with Internet addresses of generic health sites designed for the general population. The primary outcome, HRQoL, will be measured using the EuroQol-5D. A full analysis plan will compare between groups from baseline to follow-up.

Discussion

A low-cost per user option to supplement current care, such as P2S, has the potential to increase HRQoL for stroke survivors, and reduce the risk of second stroke.

Trial registration

Australian and New Zealand Clinical Trials Registry, ID: ACTRN12617001205325p. Registered on 17 August 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3604-0) contains supplementary material, which is available to authorized users.

Population norms for the EQ-5D-3L: a cross-country analysis of population surveys for 20 countries

This study provides EQ-5D population norms for 20 countries (N = 163,838), which can be used to compare profiles for patients with specific conditions with data for the average person in the general population in a similar age and/or gender group. Descriptive EQ-5D data are provided for the total population, by gender and by seven age groups. Provided index values are based on European VAS for all countries, based on TTO for 11 countries and based on VAS for 10 countries. Important differences exist in EQ-5D reported health status across countries after standardizing for population structure. Self-reported health according to all five dimensions and EQ VAS generally decreased with increasing age and was lower for females. Mean self-rated EQ VAS scores varied from 70.4 to 83.3 in the total population by country. The prior living standards (GDP per capita) in the countries studied are correlated most with the EQ VAS scores (0.58), while unemployment appeared to be significantly correlated in people over the age of 45 only. A country's expenditure on health care correlated moderately with higher ratings on the EQ VAS (0.55). EQ-5D norms can be used as reference data to assess the burden of disease of patients with specific conditions. Such information, in turn, can inform policy-making and assist in setting priorities in health care.

The effectiveness of inpatient rehabilitation after uncomplicated total hip arthroplasty: a propensity score matched cohort

Background

Inpatient rehabilitation is an expensive option following total hip arthroplasty (THA). We aimed to determine if THA patients who receive inpatient rehabilitation report better hip and quality of life scores post-surgery compared to those discharged directly home.

Methods

Prospective, propensity score matched cohort involving 12 private hospitals across five Australian States. Patients undergoing THA secondary to osteoarthritis were included. Those receiving inpatient rehabilitation for reasons other than choice or who experienced significant health events within 90-days post-surgery were excluded. Comparisons were made between those who did and did not receive inpatient rehabilitation for patient-reported hip pain and function (Oxford Hip Score, OHS) and ‘today’ health rating (EuroQol 0–100 scale). Rehabilitation provider charges were also estimated and compared.

Results

Two hundred forty-six patients (123 pairs, mean age 67 (10) yr., 66% female) were matched on 19 covariates for their propensity to receive inpatient rehabilitation. No statistically nor clinically significant between-group differences were observed [OHS median difference (IQR): 0 (− 3, 3), P = 0.60; 0 (− 1 to 1), P = 0.91, at 90 and 365-days, respectively; EuroQol scale median difference 0 (− 10, 12), P = 0.24; 0 (− 10, 10), P = 0.49; 5 (− 10, 15), P = 0.09, at 35-, 90- and 365-days, respectively]. Median rehabilitation provider charges were 10-fold higher for those who received inpatient rehabilitation [median difference $7582 (5649, 10,249), P <  0.001]. Sensitivity analyses corroborated the results of the primary analyses.

Conclusion

Utilization of inpatient rehabilitation pathways following THA appears to be low value healthcare. Sustainability of inpatient rehabilitation models may be enhanced if inpatient rehabilitation is reserved for those most impaired or who have limited social supports.

Trial registration

ClinicalTrials.gov Identifier: NCT01899443.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2134-3) contains supplementary material, which is available to authorized users.

The value of inpatient rehabilitation after uncomplicated knee arthroplasty: a propensity score analysis

OBJECTIVE

To compare the effectiveness of rehabilitation after total knee arthroplasty (TKA) in models with or without an inpatient rehabilitation component.

DESIGN, SETTING AND PARTICIPANTS

A propensity score-matched cohort of privately insured patients with osteoarthritis who underwent primary, unilateral TKA in one of 12 Australian hospitals between August 2013 and January 2015 were included. Those discharged to an inpatient facility because of poor progress or who experienced significant complications within 90 days of surgery were excluded.

INTERVENTION

Discharge after surgery to an inpatient rehabilitation facility or home.

MAIN OUTCOME MEASURES

Patient-reported knee pain and function (Oxford Knee Score; at 90 and 365 days after surgery) and health rating (EuroQol "today" health scale; at 35, 90 and 365 days). Inpatient and community-based rehabilitation provider charges were also assessed.

RESULTS

258 patients (129 pairs) from a sample of 332 were matched according to their propensity scores for receiving inpatient rehabilitation; covariates used in the matching included age, sex, body mass index, and markers of health and impairment. The only significant difference in outcomes was that EuroQol health scores were better on Day 35 for patients not undergoing inpatient rehabilitation (median difference, 5; IQR, -10 to 19; P = 0.01). Median rehabilitation provider charges were significantly higher for those discharged to inpatient therapy (total costs: median difference, $9500; IQR, $7000-11 497; P < 0.001; community therapy costs: median difference, $749; IQR, $0-1980; P < 0.001).

CONCLUSIONS

Rehabilitation pathways incorporating inpatient rehabilitation did not achieve better joint-specific outcomes or health scores than alternatives not including inpatient rehabilitation. Given the substantial cost differences, better value alternatives should be considered for patients after uncomplicated TKA.