Factors associated with satisfaction in patients undergoing elbow surgery: a prospective study.

HYPOTHESIS: Evidence on factors associated with patient satisfaction with elbow surgery is sparse; outcomes of surgery are not necessarily related to patient satisfaction. This study explored the hypothesis that condition-specific outcome measures would more closely reflect patient satisfaction than generic measures. MATERIALS AND METHODS: The prospective cohort comprised 104 consecutive patients/elbows undergoing elbow surgery. Preoperative and 6 month postoperative outcome questionnaires included the Oxford Elbow Score (OES), Disabilities of the Arm, Shoulder and Hand (DASH), and Short Form (SF)-36 general health survey. Clinical assessments used the standard Mayo Elbow Performance Score (MEPS). Patients who were "very pleased" with surgery were compared with others regarding which factors were associated with being "very pleased" at 6 months after surgery. RESULTS: By 6 months, 54% of patients were very pleased with their surgery. Preoperative scores were generally not associated with subsequent patient satisfaction. Postoperative scores and change scores for the OES Pain and Social-Psychological scales and the DASH were moderately to highly correlated with patient satisfaction (r(s), -0.43 to -0.72; all P < .001), whereas SF-36 and MEPS change scores were only correlated to a small extent (r < or = 0.34; all P < .05). A multivariable analysis revealed that patients' age, postoperative elbow pain, and change in elbow function each independently influenced the odds of patients being very pleased with surgery. DISCUSSION: Associations between outcome measures and patient satisfaction revealed likely differences between patients' and clinicians' perceptions of which aspects of outcome rated as important. CONCLUSIONS: Patient-reported results are more likely than clinically assessed outcome measures, and condition-specific are more likely than generic measures, to reflect patient-rated satisfaction with elbow surgery.

Perceived barriers to walking in the neighbourhood environment and change in physical activity levels over 12 months.

OBJECTIVES: To investigate whether, and to what extent, perceived barriers to neighbourhood walking (BTNW) may be associated with physical activity levels. DESIGN: Prospective survey with 12-month follow-up. SUBJECTS AND METHODS: 750 people attending walking schemes throughout England and Scotland; 551 completed the follow-up. independent variables were demographic characteristics, examples of possible "external" barriers to walking-for example, "worries about personal safety", and one item concerning ill health. The main outcome measures were "metabolic equivalent" (MET) hours' walking and overall physical activity in the preceding week. RESULTS: Baseline and follow-up demographic characteristics were similar and physical activity levels generally high. Leisure walking changed little over 12 months, while total physical activity levels reduced significantly from a mean (SD) of 71.26 (78.14) MET hours per week at baseline to 59.57 (181.40) at the 12-month follow-up (p<0.001). External BTNW cited between baseline and 12 months increased significantly from a mean (SD) of 1.24 (1.61) at baseline to 1.43 (1.72) at the 12-month follow-up (p<0.001); only "worries about personal safety" reduced. A significant association was found between citing a health-related BTNW and the total number of external BTNW that were reported at baseline. The strength of this association increased over 12 months. Neither changes in reporting external BTNW that occurred over 12 months (increased vs decreased, vs unchanged) nor changes in the presence of a health-related BTNW were significantly related to levels of leisure walking and overall physical activity (MET hours in the preceding week) over the same period. CONCLUSION: Among older people who attended walking schemes, having a health problem that restricted walking had a detrimental influence on people's perceptions about external BTNW, which increased over time. Actual levels of walking and overall physical activity levels did not appear to be significantly affected by this.

Minimally important change was estimated for the Manchester-Oxford Foot Questionnaire after foot/ankle surgery.

OBJECTIVES: To ascertain the smallest amounts of change for the three Manchester-Oxford Foot Questionnaire (MOXFQ) domains that are likely to be clinically meaningful and beyond measurement error for conditions affecting the foot/ankle. Estimates were compared with those from the Short-Form 36 (SF-36). STUDY DESIGN AND SETTING: A prospective observational study of 671 consecutive patients undergoing foot or ankle surgery at an orthopedic hospital. Before and 9 months after surgery, patients completed the MOXFQ and SF-36; transition items (anchor) asked about perceived changes in foot/ankle pain or problems since the surgery. RESULTS: Four hundred ninety-one patients completed pre- and postoperative questionnaires. Anchor-based minimal clinically important change (MCIC) values were ~13 points for each of the MOXFQ Walking/standing (W/S), Pain, and Social Interaction (S-I) domains [and greater than the standard error of measurement (SEM)]. MCIC values for all SF-36 domains fell within the SEM. Between-group MCIDs for the MOXFQ were W/S, 16.2; Pain, 9.9; S-I, 9.3. Distribution-based minimal detectable change (MDC90) values for the MOXFQ were ~11, ~12, and ~16 score points for the W/S, Pain, and S-I scales, respectively. CONCLUSION: This article provides information for aiding the interpretability of MOXFQ outcomes data and for planning future studies. The SF-36 is not recommended as a primary outcome for foot/ankle surgery.

A scoring system for the foot and ankle that is acceptable, reliable, valid and responsive.

We read with interest the recent paper by Groarke et al. (Quality of life in individuals with chronic foot conditions: a cross sectional observational study. The Foot (2012) doi:10.1016/i.foot.2011.11.007). The paper ended by stating that 'there is no scoring system for the foot and ankle that is valid, repeatable and reliable'. This statement is misleading. The authors could have made reference to the patient-reported Manchester-Oxford Foot Questionnaire (MOXFQ). The MOXFQ has been subjected to more rigorous testing of its measurement properties than is the case for most instruments, and has been demonstrated to be acceptable, reliable, valid and responsive in the context of foot or ankle surgery.

Factors associated with patient satisfaction with foot and ankle surgery in a large prospective study.

BACKGROUND: There is minimal published research on outcomes and satisfaction with foot and ankle surgery. OBJECTIVE: To investigate patient-reported outcomes and satisfaction, and investigate which factors influence satisfaction at 9 months following foot or ankle surgery. METHODS: Prospective study of 671 adult patients having foot or ankle surgery. Pre-and post-surgery, patients self-completed MOXFQ, SF-36 and EQ-5D questionnaires. Using ratings to a satisfaction item, patients who were 'very pleased' with the outcome were compared with everyone else, using multiple logistic regression, regarding their pre-, peri- and post-operative characteristics. RESULTS: Of 628 eligible patients, 491 (73%) completed pre-and post-operative questionnaires. Following adjustment, satisfaction with surgery was influenced by patients' perceptions of their foot/ankle's appearance (OR 0.12, 95% CIs 0.06-0.23, p<0.001); wearable range of shoes (OR 0.36, 95% CIs 0.17-0.79, p=0.01); continued foot/ankle pain (OR 0.06, 95% CIs 0.03-0.14, p<0.001); impairment in Social-Interaction (MOXFQ SI scale) (OR 0.98, 95% CIs 0.96-0.99, p=0.009). The final explanatory model explained 67% of the variance in patient satisfaction. CONCLUSIONS: Foot appearance, wearable shoe range, the (full) alleviation of pain and the ability/confidence to interact socially are crucial to peoples' satisfaction with their foot or ankle surgery.

Comparative responsiveness and minimal change for the Oxford Elbow Score following surgery.

PURPOSE: To assess the responsiveness and minimal change for the Oxford Elbow Score (OES) using anchor- and distribution-based approaches. METHODS: A prospective observational study of 104 patients undergoing elbow surgery at a specialist orthopaedic hospital was carried out. Patients completed the OES and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaires (both scored on a 0 to 100 scale) pre- and 6 months post-surgery. Transition items (used as anchors) assessed perceived changes following surgery. Indicators of responsiveness were the effect size; the anchor-based minimal clinically important difference (MCID) and best cut-point on the receiver operator characteristic (ROC) curve; and the distribution-based minimal detectable change (MDC). RESULTS: The three elbow-specific OES scales (Function, Pain, Social-Psychological) produced generally larger effect sizes (0.79, 1.14 and 1.18, respectively) than the upper-limb-specific DASH scale (0.76). Clear associations were observed between transition items and all OES and DASH scores (all r > |0.35|). The MCIDs for the OES Function scale and the DASH were similar (approximately 10), but were larger for the OES Pain and Social-Psychological scales (approximately 18), reflecting their lower (i.e. poorer) baseline scores and larger effect sizes. The MCIDs were, however, only consistently larger than the MDCs for the OES Pain domain. The OES Function scale and the DASH performed similarly on ROC analysis, but with the OES Pain and Social-Psychological scales demonstrating superior efficiency. CONCLUSIONS: For elbow surgery, the 12-item three-scale OES is highly responsive to 6-month post-operative outcomes, with its performance being generally better than that of the 30-item one-scale DASH. Study estimates of minimal change for the OES may be useful for informing sample size calculations and interpreting outcomes in future clinical trials.

Perceived barriers to walking in the neighborhood environment: a survey of middle-aged and older adults.

The authors investigated whether low levels of walking among older adults in the UK were associated with demographic and health characteristics, as well as perceived environmental attributes. Survey data were obtained from self-administered standard questionnaires given to 680 people age 50+ (mean age 64.4 yr) attending nationally led walking schemes. Items concerned with demographic characteristics and perceived barriers to neighborhood walking were analyzed using multiple logistic regression. Citing more than 1 environmental barrier to walking, versus not, was associated with significantly reduced levels of (leisure) walking (MET/hr) in the preceding week (Z = -2.35, p = .019), but physical activity levels overall did not differ significantly (Z = -0.71, p = .48). Citing a health-related barrier to walking significantly adversely affected overall physical activity levels (Z = -2.72, p = .006). The authors concluded that, among older people who favor walking, health problems might more seriously affect overall physical activity levels than perceived environmental barriers.