Minimal Clinically Important Differences of Patient-Reported Outcomes Measurement Information System Physical Function in Patients With Tibial Shaft Fracture

OBJECTIVE

To calculate the minimal clinically important differences (MCIDs) of patient-reported outcomes measurement information system physical function (PROMIS PF) scores for patients with operatively treated tibial shaft fractures.

DESIGN

Retrospective Cohort Study.

SETTING

A Level 1 trauma center.

PATIENTS

All operatively treated tibial shaft fractures identified by Current Procedural Terminology codes.

INTERVENTION

Enrolled patients treated acutely with operative fixation of their tibia.

MAIN OUTCOME MEASUREMENTS

MCIDs were calculated by distribution-based and anchor-based methods, calculated from PROMIS PF scores completed at least at two-time points postoperatively. MCIDs were calculated at different time points including overall, 7-12 weeks, 3-6 months, and 6-24 months. MCIDs were calculated for different subgroups including open fractures, closed fractures, any complications, and no complications.

RESULTS

MCID for PROMIS PF scores was 5.7 in the distribution-based method and 7.84 (SD 18.65) in the anchor-based method. At 6-24 postoperatively, the months the distribution-based MCID was 5.95 from a postoperative baseline 27.83 (8.74) to 42.85 (9.61), P < 0.001. At 6-24 months, the anchor-based MCID was 10.62 with a score difference between the improvement group of 16.03 (10.73) and the no improvement group of 5.41 (15.75), P < 0.001. Patients with open fractures (distribution-based 6.22 and anchor-based 8.05) and any complications (distribution-based 5.71 and anchor-based 9.29) had similar or higher MCIDs depending on the methodology used than the overall cohort MCIDs.

CONCLUSION

This study identified distribution-based MCID of 5.7 and anchor-based MCID of 7.84 calculated from PROMIS PF scores in operative tibial shaft fractures. Distribution-based methods yielded smaller MCIDs than anchor-based methods. These MCID scores provide a standard to compare clinical and investigational outcomes.

The trajectory of patient-reported outcomes and minimal clinically important differences in isolated and polytraumatic pelvis and acetabular fractures

PURPOSE

Patient-reported minimal clinically important differences (MCID) provide a standard to compare clinical outcomes. The purpose of this study was to calculate the MCID of PROMIS Physical Function (PF), Pain Interference (PI), Anxiety (AX), and Depression (DEP) scores in patients with pelvis and/or acetabular fractures.

METHODS

All patients with operatively treated pelvic and/or acetabular fractures were identified. Patients were categorized as either only pelvis and/or acetabular fractures (PA) or polytrauma (PT). PROMIS PF, PI, AX, and DEP scores were evaluated at 3-month, 6-month, and 12-month intervals. Distribution-based MCID and anchor-based MCID were calculated for the overall cohort, PA, and PT groups.

RESULTS

The overall distribution-based MCIDs were PF (5.19), PI (3.97), AX (4.33), and DEP (4.41). The overall anchor-based MCIDs were PF (7.18), PI (8.03), AX (5.85), DEP (5.00). The percentage of patients achieving MCID for AX was 39.8-54% at 3 months and 32.7-56% at 12 months. The percentage of patients achieving MCID for DEP was 35.7-39.3% at 3 months and 32.1-35.7% at 12 months. The PT group had worse PROMIS PF scores than the PA group at all time points [post-operative, 3-month, 6-month, and 12-month scores, (28.3 (6.3) vs. 26.8 (6.8) P = 0.016), (38.1 (9.2) vs. 35.0 (8.7) P = 0.037), (42.8 (8.2) vs. 39 (9.6) P = 0.015), (46.2 (9.7) vs. 41.2 (9.7) P = 0.011)].

CONCLUSION

An overall MCID for PROMIS PF was 5.19-7.18, PROMIS PI 3.97-8.03, PROMIS AX of 4.33-5.85, and PROMIS DEP of 4.41-5.00. The PT group had worse PROMIS PF at all time points. The percentage of patients achieving MCID for AX and DEP plateaued at 3 months post-operatively.

LEVEL OF EVIDENCE

Level IV.

Socioeconomic and insurance-related disparities in disease-specific survival among patients with metastatic bone disease

BACKGROUND

Approximately 5% of cancer patients in the United States presented with metastatic bone disease (MBD) at diagnosis. Current study explores the disparities in survival for patients with MBD.

METHODS

Patients with the diagnosis of MBD at presentation for the five most common primary anatomical sites were extracted from Surveillance, Epidemiology, and End Results Census tract-level dataset (2010-2016). Kaplan-Meier and Cox Proportional Hazard models were used to evaluate survival, and prognostic factors for each cohort. Prognostic significance of socioeconomic status (SES) and insurance status were ascertained.

RESULTS

The five most common anatomical-sites with MBD at presentation included "lung" (n = 59 739), "prostate" (n = 19 732), "breast" (n = 16 244), "renal and urothelium" (n = 7718) and "colon" (n= 3068). Lower SES was an independent risk factor for worse disease-specific survival (DSS) for patients with MBD originating from lung, prostate, breast and colon. Lack of insurance was an independent risk factor for worse DSS for MBD patients with primary tumors in lung and breast.

CONCLUSIONS

MBD patients from the five most common primary sites demonstrated SES and insurance-related disparities in disease-specific survival. This is the first and largest study to explore SES and insurance-related disparities among patients specifically afflicted with MBD. Our findings highlight vulnerability of patients with MBD across multiple primary sites to financial toxicity.

Sex, racial/ethnic and socioeconomic disparities in patients with metastatic bone disease

BACKGROUND

We have analyzed sex, race/ethnicity or socioeconomic disparities in the incidence of metastatic bone disease (MBD).

METHODS

Patients with the diagnosis of MBD at presentation for five most common primary anatomical sites was extracted from Surveillance, Epidemiology, and End Results Census tract-level dataset. Mean incidence of MBD for different sex, racial/ethnic and socioeconomic groups were compared.

RESULTS

The five most common anatomical sites with MBD at presentation include "lung: (n = 59 739), "prostate" (n = 19 732), "breast" (n = 16 244), "renal" (n = 7718) and "colon" (n = 3068). There was an increase in incidence of MBD among cancers originating from prostate (annual percentage change [APC] 4.94), renal (APC 2.55), and colon (APC 3.21) (p < 0.05 for all). Non-Hispanic Blacks had higher incidence of MBD for prostate and breast primary sites (p < 0.001). Non-Hispanic American Indian Alaskan Native had higher incidence of MBD for cancers originating from renal (p < 0.001) and colon (p = 0.049). A higher incidence of MBD was seen in lower socioeconomic status (SES) groups for the selected sites (p < 0.001).

CONCLUSIONS

These findings suggest that there are multiple sex-related, racial/ethnic and SES disparities in the incidence of MBD from the 5 most common primary sites. Higher incidence seen among lower SES suggests delay in diagnosis and limited access to screening modalities.

The effect of neoadjuvant chemotherapy on quality of life for patients with muscle invasive bladder cancer (MIBC) undergoing cystectomy

e18614

Background: To examine the relationship between neoadjuvant chemotherapy (NAC) clinical risk factors, and patient reported quality of life in patients with MIBC undergoing cystectomy. Methods: cT2-T4, N0, M0 MIBC patients who underwent radical cystectomy were identified from a prospectively maintained institutional outcomes database. PROMIS-Ca surveys (physical function (PF), pain interference, fatigue, depression, and anxiety domains) were administered at consultation and follow-up as part of routine clinical care. Patients were stratified as receiving NAC vs. none and surveys were anchored to date of cystectomy. Non-parametric kernel regressions with variance-covariance matrix bootstrapping were used to estimate the mean effect of covariates on each domain T-score with 95% confidence intervals. Covariates were: body mass index, smoking history, age, Charlson comorbidity score, pT and pN stage, urinary diversion-type, and survey time relative to the cystectomy date. T-score changes over time were modeled by including univariable parameters with a P<=0.1 in a multivariable model (MVA) for each domain and predicting the marginal means at date of cystectomy, 6 and 12 months postop. Results: The median age was 68 (IQR 60-73) years. NAC was received by 69/134 patients (40 Gem/Cis, 24 MVAC, 5 unknown). On univariate analyses NAC significantly reduces PF (mean change in t-score, 95%CI; -2.4, -3.7 to -0.8, p=0.001), trends toward more pain (0.94, -0.20 to 1.78, p=0.074), but does not influence fatigue, depression or anxiety. Other covariates with p<0.05 reducing PF were BMI (-0.31, -0.53 to -0.03), pT4 vs pT1-2 (-0.31, -0.53 to -0.03), Charlson 1 vs 0 (-0.31, -0.53 to -0.03), age (-0.31, -0.53 to -0.03), and days from surgery (-0.31, -0.53 to -0.03). Table shows how t-scores predicted from the MVA change over time. Conclusions: MIBC patients have mild to moderate impairment in physical function, fatigue, and pain before and after cystectomy, suggesting a need for increased focus on rehabilitation and wellness programs. Although the univariable analysis implies there may be differences in PF and Pain for those receiving NAC vs none, future studies with increased power are needed to properly adjust for the interplay of other significant covariates.[Table: see text]

Risk factors for readmission of orthopaedic surgical patients

BACKGROUND

Reducing hospital readmissions has become a priority in the development of policies aimed at patient safety and cost reduction. Evaluating the incidence of rehospitalization of orthopaedic surgical patients could help to identify targets for more efficient perioperative care. We addressed two questions: What is the incidence of thirty-day readmission for orthopaedic patients at an academic hospital? Can any risk factors for readmission be identified among rehospitalized patients?

METHODS

This is a retrospective cohort study examining 3264 orthopaedic surgical admissions during two fiscal years from the hospital's quality-improvement database. Cases of patients with unplanned readmission within thirty days were subjected to univariate and multivariate analysis to determine the odds ratio (OR) for readmission. Further descriptive analysis was performed with use of electronic medical record data from the cohort of readmitted patients.

RESULTS

The estimated cumulative incidence of unplanned thirty-day readmissions was 4.2% (i.e., 138 of the 3261 patients who were eligible for the study). Multivariate analysis indicated that marital status of "widowed" significantly increased the risk of readmission (OR, 1.846; 95% confidence interval [CI], 1.070 to 3.184; p = 0.03). Race significantly increased the odds of readmission in patients identified as African-American (OR, 2.178; 95% CI, 1.077 to 4.408; p = 0.03), or American Indian or Alaskan Native race (OR, 3.550; 95% CI, 1.429 to 8.815; p = 0.006). The risk of readmission was significant at p &lt; 0.10 (OR 1.547; 95% CI, 0.941 to 2.545; p = 0.09) for patients with Medicaid insurance. Any intensive care unit stay gave the highest OR of readmission (OR, 2.356; 95% CI, 1.361 to 4.079; p = 0.002) for all demographic groups. Mean length of hospital stay was significantly longer, 5.9 days in the unplanned readmission group compared with 3.6 days for non-readmitted patients (OR, 1.038; 95% CI, 1.014 to 1.062; p = 0.002). Chart review of readmitted patients showed that 102 readmissions (73.9%) were classified as surgical; of these, thirty-five readmission events (34.3%) were for infection at the surgical site.

CONCLUSIONS

Longer length of hospital stay or admission to the intensive care unit significantly increased the likelihood of thirty-day readmission, regardless of demographics or discharge disposition. Marital status, Medicaid insurance status, and race may indicate how a patient's social and economic resources can impact his or her risk of being readmitted to the hospital.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Risk factors for cardiac complications after spine surgery

Study design: Registry study using prospectively collected data

Objective: To determine risk factors for cardiac complications in spine surgery.

Methods: The Spine End Results Registry 2003–2004 is an exhaustive database of 1,592 patients who underwent spine surgery at the University of Washington Medical Center or Harborview Medical Center. Detailed information regarding patient demographic, medical comorbidity, surgical invasiveness and adverse outcomes were prospectively recorded. The primary outcome of measure was the occurrence of a cardiac complication in the perioperative period. Relative risk (RR) and 95% confidence intervals were calculated for each of the categorical variables. Multiple log-binomial regression analysis was performed to investigate the independent factors associated with cardiac complication.

Results: The incidence of cardiac complication after spine surgery was 6.7%. There were 136 cardiac complications in 107 patients after spine surgery. Age, diabetes, previous cardiac history, elevated adjusted Charlson comorbidity score, revision surgery, combined anterior-posterior approaches, and surgical invasiveness were statistically significant risk factors for cardiac complication after spine surgery.

Conclusions: The results of the present study suggest numerous statistically significant risk factors for cardiac complications after spine surgery. These results may aid the clinician with preoperative risk stratification and patient counseling.

Risk factors for pulmonary complications after spine surgery

STUDY DESIGN

 Registry study with prospectively collected data Objective:  To determine risk factors for pulmonary complications in spine surgery.

METHODS

 The Spine End RESULTS Registry 2003-2004 is an exhaustive database of 1,592 patients who underwent spine surgery at the University of Washington Medical Center or Harborview Medical Center. Detailed information regarding patient demographic, medical comorbidity, and comorbidities, surgical invasiveness and adverse outcomes were prospectively recorded. The primary outcome measure was the occurrence of a pulmonary complication following surgery. Univariate relative risks and 95% confidence intervals for each of the risk factors were determined. Multivariate log binomial regression analysis was performed to investigate the association between each risk factor and a pulmonary complication, while controlling for other important risk factors.

RESULTS

 Altogether, there were 199 pulmonary complications after spine surgery. The cumulative incidence of a respiratory complication after spine surgery was 9% (144 patients). Multivariate analysis suggested gender, chronic obstructive pulmonary disease, congestive heart failure, diabetes, age, diagnosis, surgical invasiveness and surgery in the thoracic spine are significant risk factors for pulmonary complications after spinal surgery.

CONCLUSIONS

 The results of the present study suggest numerous statistically significant risk factors for pulmonary complications after spine surgery. These results may aid the clinician with preoperative risk stratification and patient counseling. [Table: see text] The definiton of the different classes of evidence is available on page 73.

Two-incision minimally invasive vs standard total hip arthroplasty: comparison of component position and hospital costs

Forty-nine patients undergoing 2-incision total hip arthroplasty were matched by age, gender, body mass index, and comorbidity to patients undergoing a standard lateral Hardinge approach. Hospital costs and charges were compared along with length of stay, component position, and complication rates. Component position and complication rates were identical for the 2 groups. However, hospital costs and charges were significantly lower for the 2-incision group, as was length of stay.

Systems-based safety intervention: reducing falls with injury and total falls on an orthopaedic ward

BACKGROUND

In-hospital falls can result in substantial morbidity and mortality and were declared "never events" by the Centers for Medicare & Medicaid Services in 2008. Interventions that were intended to reduce the incidence of falls based on patient risk factors have not been successful in the acute inpatient setting. We hypothesized that a systems-based fall-prevention program targeting high-risk situations would result in fewer falls with injury.

METHODS

Falls that occurred in the prospective postintervention period were reviewed in real time with use of a clinical database that could be accessed by all physicians, nurses, aides, and therapists. Analysis of the hospital setting, patient factors, and circumstances associated with all falls occurring on the hospital's orthopaedic ward were evaluated during the preintervention study period. On the basis of the findings from this audit, four systems-based interventions were implemented. Prospective analysis of these interventions was then conducted. All falls were tracked by means of the clinical database and reviewed by the study investigators. The rates of falls with injury and total falls in the preintervention and postintervention periods were compared.

RESULTS

The preintervention study period (May 1, 2007, to September 28, 2008) represented 11,082 patient days, during which time the fall with injury rate and total fall rate were 1.17 and 4.24, respectively, per 1000 patient days. The postintervention study period (September 29, 2008, to May 1, 2010) represented 12,267 patient days, during which time the fall with injury rate and the total fall rate were 0.41 and 2.53, respectively, per 1000 patient days. The reductions in the rates of falls with injury (p = 0.036) and total falls (p = 0.024) were significant.

CONCLUSION

Utilization of a continuous quality improvement model to develop a systems-based fall-prevention program can be effective in reducing falls with injury and total falls in an acute inpatient setting. Despite a thoughtful, multidisciplinary, intensive approach to the problem, falls did occur. We believe that it is unrealistic to consider all falls to be preventable.

Risk assessment in high grade sarcoma patients during neoadjuvant chemotherapy using multiple tracer PET

20006

Background: Patients with high grade soft tissue sarcomas are treated with neoadjuvant chemotherapy. Sarcomas have biological features that may predict for poor outcome. Some of these features are tumor proliferation rate, level of tumor hypoxia, and upregulation of tumor drug resistance mechanisms. Methods: We have a group of specific PET imaging agents to quantify the level of activity of these tumor processes. Patients with soft tissue sarcomas receive [C-11]Thymidine (TdR) to assess cellular proliferation, [O-15] Water to quantify tumor blood flow and to serve as the input function for quantification of the other tracers, [C-11]Verapamil to assess drug resistance mechanism activity, and [F-18]Fluoromisonidazole) FMISO to quantify changes in tumor hypoxic volume in response to treatment. These studies are performed in a single PET imaging session prior to neoadjuvant chemotherapy, after the second of four cycles of therapy and in the week prior to resection. Results: An example of this complex study result, is demonstrated by a recent patient with a high grade soft tissue sarcoma. The tumor showed increased TdR uptake, a moderate hypoxic volume, and [C-11] verapamil uptake prior to initiation of neoadjuvant adriamycin based chemotherapy. After 2 cycles of therapy, there was a significant decrease in the maximum level and volume of TdR uptake and a large reduction in tumor hypoxic volume. Conclusions: These data would imply a high risk soft tissue sarcoma due the presence of increased cellular proliferation, a significant hypoxic volume and the absence of p-glycoprotein activity determined by the presence of [C-11]Verapamil uptake. However, early response is also suggested by the findings above. Patient outcome will be assessed and correlated with these tumor parameters to further understand what tumor biological risk factors can be quantified non-invasively and repeated throughout the clinical course in soft tissue sarcoma patients. Supported by NIH NCI PO1 42045–18 and S10 RR017229–01

[Table: see text]

No significant financial relationships to disclose.