Agreement between retrospectively and contemporaneously collected patient-reported outcome measures (PROMs) in hip and knee replacement patients.

PURPOSE: To investigate the relationship between retrospectively and contemporaneously collected patient-reported outcome measures (PROMs) and the influence on this relationship of patients' age and socio-economic status and the length of time. METHODS: Patients undergoing hip or knee replacement in four hospitals who had completed a pre-operative questionnaire were invited to recall their pre-operative health status shortly after surgery. The questionnaires included a disease-specific (Oxford Hip Score; Oxford Knee Score) and generic (EQ-5D-3L) PROM. Consistency and absolute agreement between contemporary and retrospective reports were investigated using intraclass correlations (ICCs). Differences were visualised using Bland-Altman plots. Linear regression analysis explored whether retrospective can predict contemporary PROMs. RESULTS: Patients' recalled health statuses were similar to their contemporaneous reports, with no significant systematic bias. Absolute agreement for disease-specific PROMs was very strong (ICC 0.82) and stronger than for the generic PROM (ICC 0.60, 0.62). Agreement was consistently strong across the range of severity of a patient's condition, age and socio-economic status. Patients' age and socio-economic status had no significant influence on size of difference and direction of recall, although reliability of recall was slightly worse among the over-75s versus under-60s for hips (Oxford Hip Score ICC 0.88 vs. 0.78). Mean retrospective PROMs for groups or populations of patients can reliably predict what mean contemporary reports of PROMs would have been. CONCLUSION: Retrospective PROMs can be used to obtain a baseline assessment of health status when contemporary collection is not feasible or cost effective. Research is needed to determine the feasibility of retrospective PROMs in emergency admissions.

Can Patient Reported Outcomes (PROs) from Population Surveys Provide Accurate Estimates of Pre-Admission Health Status of Emergency Hospital Admissions?

INTRODUCTION: The use of PROs for assessing the outcomes of emergency hospital admissions requires a means of estimating patients' pre-admission health status. A possible alternative to asking patients to recall how their health was before the incident causing admission is to use estimates derived from matched samples from population surveys. Our aims were to explore the impact of different methods of matching and to compare the results with estimates based on retrospective reporting. METHODS: First, elective hip arthroplasty patients were matched to respondents to the General Practice Patient Survey using age, sex, socio-economic status and number of comorbidities. The impact of restricting matching for locality and specific co-morbidities was explored. Second, the best matching method was applied to emergency admissions for laparotomy and for percutaneous coronary intervention (PCI) after acute myocardial infarction. Data were stratified by patient characteristics. Differences in mean EQ-5D scores between the patients and matched population respondents were tested using t tests. RESULTS: Modifying the most basic form of matching by also taking locality and the specific comorbid conditions into account made no significant difference to the mean EQ-5D score for hip arthroplasty patients. Even using the most detailed matching possible, patients' mean EQ-5D score was significantly different to that of the general population for all three cohorts. The difference was greatest for elective hip arthroplasty (0.22 v 0.64), less so for emergency laparotomy (0.56 v 0.72) and least for PCI (0.79 v 0.71). This reflects hip arthroplasty patients having a long-standing condition characterised by pain and limited mobility, whereas the other two cohorts may have enjoyed reasonable health until an unexpected acute episode led to their emergency admission. CONCLUSION: Routine PRO data acquired from population surveys cannot be used as an accurate alternative to retrospectively reported PROMs by patients during their emergency admission episode.

Using patient-reported outcome measures for primary percutaneous coronary intervention.

Introduction: Routine measurement of the outcome of myocardial infarction is usually limited to immediate morbidity and mortality. Our aim was to determine the response to patient-reported outcome measures (PROMs) 3 months later, identify response bias and explore the feasibility of comparing outcome with their recalled view of their prior health state. Methods: Patients admitted with ST-segment-elevation myocardial infarction (STEMI) to five percutaneous coronary intervention centres were invited to complete a retrospective questionnaire containing the EQ-5D-3L and short form Seattle Angina Questionnaire (SAQ-7). Response rate for a 3-month mailed follow-up questionnaire and potential response biases were assessed. Patients' outcomes were compared with their baseline using χ2 and paired t-test to assess for differences. Results: Of 392 patients contacted, 260 (66.3%) responded. Responders were more likely to be older, female, more affluent and have a higher EQ-5D at baseline. Three months after surgery, patients' SAQ-7 and angina symptom subscale returned to their baseline score. The physical limitation subscale score was worse than at baseline (79.9 vs 73.2, p=0.002), whereas the quality-of-life subscale was better (66.6 vs 73.9; p<0.001). The EQ-5D-3L index score was similar at 3 months to baseline (0.82 vs 0.79). Evidence of bias arising from responders being in better general health at baseline needs further investigation and, if confirmed, needs to be taken into account in interpreting PROMs data. Conclusion: It is feasible to use PROMs routinely to assess the impact of emergency admissions of patients with STEMI. A larger demonstration project with more sites is needed to confirm these findings.

Feasibility of collecting retrospective patient reported outcome measures (PROMs) in emergency hospital admissions.

INTRODUCTION: Outcome of emergency admissions is usually limited to mortality with little attempt to capture the views of health status of survivors. This is because of the challenge of determining patient reported outcome measures (PROMs) for the period before their emergency admission. The aim was to assess the feasibility of collecting retrospective PROMs to capture the pre-admission health status of patients admitted as emergencies. METHODS: Prospective study of two cohorts: patients undergoing primary coronary angioplasty for acute ST elevation myocardial infarction (STEMI) in five hospitals and emergency laparotomy (EL) for gastro-intestinal conditions in 11 hospitals. Three rates were calculated: proportion of patients eligible for inclusion; proportion of eligible patients invited to participate; proportion of invitees who participated. Staff views were thematically analysed to understand factors that affected recruitment. RESULTS: About 85% of patients were eligible of whom most were invited to participate (84% EL; 79% STEMI). The proportions of invitees agreeing to participate differed between STEMI (92%) and EL (72%), probably reflecting greater post-intervention morbidity in the latter. Variation between hospitals was observed in the proportion deemed eligible (EL 72-97%; STEMI 63-100%), proportion invited (EL 60-93%; STEMI 71-96%) and the proportion of invitees agreeing to participate (EL 55-92%; STEMI 67-100%). While this might reflect case-mix differences between hospitals, it suggests there is scope for less well performing hospitals to improve their recruitment processes. The extent to which this initial feasibility study was able to assess selection bias was limited to the age and sex of patients. There was no bias evident for EL patients but for STEMI, younger men were more likely to participate. CONCLUSION: It appears to be feasible to collect retrospective PROMs from patients admitted unexpectedly as emergencies for the two conditions studied. The relevance of these findings to other causes of emergency admissions needs to be established. In addition, these findings justify the case for a large, multi-site study that could explore unresolved concerns about selection bias, particularly those arising from the clinical characteristics of patients. It would also enable estimates of the extent of variation in PROMs between hospitals to determine the usefulness of using PROMs in emergency admissions.

Feasibility of collecting and assessing patient-reported outcomes for emergency admissions: laparotomy for gastrointestinal conditions.

INTRODUCTION: Audit of emergency surgery is usually limited to immediate clinical outcomes relating to outcomes during the acute hospital episode with little attempt to capture patients' views of their longer-term outcomes. Our aim was to determine the response rate to patient-reported outcome measures (PROMs) for patients who underwent an emergency laparotomy for gastrointestinal conditions, identify response bias and explore the feasibility of comparing outcomes with their prior health based on their recalled view collected during their admission. METHODS: Patients undergoing emergency laparotomy in 11 hospitals were recruited to complete a retrospective questionnaire containing the EQ-5D-3L and Gastrointestinal Quality of Life Index (GIQLI). Response rate for 3-month mailed follow-up questionnaire and potential response biases were assessed. Patients' outcomes were compared with their baseline using χ2 and paired t-test to assess for differences. RESULTS: Of 255 patients contacted at 3 months, 190 (74.1%) responded. Responders were more likely to be older, female and more affluent. Patients' health improved significantly as regards the GIQLI (93.3 vs 97.9; p=0.048) and the subscale on symptoms (51.9 vs 59.6; p<0.001). No significant change in subscales on emotion or physical aspects or for overall health status (EQ-5D: 0.58 vs 0.64; p=0.06). According to the social subscale, patients had deteriorated (11.0 vs 9.8; p<0.0006). Differences in change scores by patient characteristics were slight, suggesting minimal response bias. CONCLUSION: This approach offers the opportunity for assessing the impact of treatment, from the patient's perspective and the potential to evaluate emergency laparotomy care using PROMs.

Retrospectively patient-reported pre-event health status showed strong association and agreement with contemporaneous reports.

OBJECTIVE: The unpredictability of the occurrence of illnesses and injuries leading to most emergency admissions to hospital makes it impossible prospectively to collect preadmission patient-reported outcome measures (PROMs). Our aims were to review the evidence for using retrospective PROMs to determine pre-event health status and the validity of using general population norms instead of retrospective PROMs. STUDY DESIGN AND SETTING: Searches of Medline, PsycINFO, Embase, Global Health, and Health Management information. Six studies met the inclusion criteria for the first aim, and 11 studies addressed the second aim. Narrative syntheses were conducted. RESULTS: Strong associations were found between retrospective and contemporary PROMs in 21 of 30 comparisons (correlation coefficients over 0.68) and 20 of 24 showed strong agreement for continuous measures (intraclass correlations over 0.75). Categorical measures revealed only fair to moderate levels of agreement (kappa 0.3-0.6). Associations were stronger for indices than for individual items and for shorter time intervals. The direction of differences was inconsistent. Retrospective PROMs reported by elderly patients were similar to the general population but younger adults had been healthier. CONCLUSION: Retrospective collection offers a means of assessing PROMs in unexpected emergency admissions. However, further research is needed to establish the best policy for their use.

Co-regulatory potential of vascular endothelial growth factor-A and vascular endothelial growth factor-C in thyroid carcinoma.

Vascular endothelial growth factor (VEGF) promotes growth of blood or lymphatic vessels. The aim of the current study is to identify relationships between VEGF-A and VEGF-C, and their impact in angiogenesis and metastases in thyroid cancers. VEGF-A and VEGF-C mRNA and protein expression was investigated in 136 thyroid cancers (123 papillary thyroid carcinomas and 13 undifferentiated thyroid carcinomas) and 40 matched lymph node metastases with papillary thyroid carcinoma using reverse transcription polymerase chain reaction and immunohistochemistry. VEGF-A and VEGF-C mRNA expression was significantly different between conventional papillary thyroid carcinoma, follicular variant of papillary thyroid carcinoma, and undifferentiated thyroid carcinomas (P = 1 × 10(-6) and 1 × 10(-5), respectively). In undifferentiated carcinoma, VEGF-A and VEGF-C protein overexpression was noted in all cases. VEGF-A and VEGF-C mRNA overexpression was noted in 51% (n = 62) and 27% (n = 33) of the papillary thyroid carcinomas, whereas VEGF-A and VEGF-C protein overexpression was also identified in 70% (n = 86) and 62% (n = 76) of the carcinomas. VEGF-A mRNA was significantly higher in cancers with lymph node metastases compared with nonmetastatic cancers (P = .001), whereas most metastatic cancers underexpressed VEGF-C (P = .0002), with a similar trend for protein. The expression of VEGF-A and VEGF-C correlated with each other at both mRNA and protein levels (P = .00004 and .003, respectively). In summary, VEGF-A and -C expressions correlate with the pathological parameters and metastatic status of thyroid carcinomas. The significant correlations between the expressions of these genes add weight to hypotheses concerning VEGF-A and -C interaction in cancer progression.