Defining a Research Agenda for Patient-Reported Outcomes in Surgery: Using a Delphi Survey of Stakeholders.

Importance: Identifying timely and important research questions using relevant patient-reported outcomes (PROs) in surgery remains paramount in the current medical climate. The inaugural Patient-Reported Outcomes in Surgery (PROS) Conference brought together stakeholders in PROs research in surgery with the aim of creating a research agenda to help determine future directions and advance cross-disciplinary collaboration. Objective: To create a research agenda to help determine future directions and advance cross-disciplinary collaboration on the use of PROs in surgery. Design, Setting, and Participants: An iterative web-based interface was used to create a conference-based, modified Delphi survey for registrants at the PROS Conference (January 29-30, 2015), including surgeons, PRO researchers, payers, and other stakeholders. In round 1, research items were generated from qualitative review of responses to open-ended prompts. In round 2, items were ranked using a 5-point Likert scale; attendees were also asked to submit any new items. In round 3, the top 30 items and newly submitted items were redistributed for final ranking using a 3-point Likert scale. The top 20 items by mean rating were selected for the research agenda. Main Outcomes and Measures: An expert-generated research agenda on PROs in surgery. Results: Of the 143 people registered for the conference, 137 provided valid email addresses. There was a wide range of attendees, with the 3 most common groups being plastic surgeons (28 [19.6%]), general surgeons (19 [13.3%]), and researchers (25 [17.5%]). In round 1, participants submitted 459 items, which were reduced through qualitative review to 53 distinct items across 7 themes of PROs research. A research agenda was formulated after 2 successive rounds of ranking. The research agenda identified 3 themes important for future PROs research in surgery: (1) PROs in the decision-making process, (2) integrating PROs into the electronic health record, and (3) measuring quality in surgery with PROs. Conclusions and Relevance: The PROS Conference research agenda was created using a modified Delphi survey of stakeholders that will help researchers, surgeons, and funders identify crucial areas of future PROs research in surgery.

The medical orthopaedic trauma service: an innovative multidisciplinary team model that decreases in-hospital complications in patients with hip fractures.

OBJECTIVES: The purpose of the study is to evaluate the influence of a multidisciplinary model of care on the incidence of postoperative complications after a hip fracture. DESIGN: Retrospective cohort series. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Three hundred six patients with pertrochanteric femur fracture (OTA classification: 31-B1, 31-B2, 31-B3, 31-A1, 31-A2, 31-B3, 32-A1, and 32-A2). INTERVENTION: A multidisciplinary, collaborative model of perioperative care: the Medical Orthopaedic Trauma Service (MOTS). MAIN OUTCOME MEASURES: Incidence of in-patient complications, length of in-patient hospitalization, readmission rate after hospital discharge, and postdischarge mortality at 90 days and 1 year. RESULTS: Although there was no change in length of hospitalization, there was a significantly decreased overall incidence of in-patient complications and a decreased incidences of new-onset urinary tract infection and arrhythmias in the MOTS cohort. These differences persisted after controlling for age, comorbidity, gender, ethnicity, type of fracture, and number of days from admission to surgery with a logistic regression model. Subgroup analysis of patients with an American Society of Anesthesiologists physical status classification of 1 or 2 revealed a significantly decreased 90 day readmission rate with the MOTS model, but this did not persist in a regression model (P = 0.07). CONCLUSIONS: A multidisciplinary, collaborative model of care for patients with hip fractures decreases the incidence of postoperative in-patient complications and may influence hospital readmission rates. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Quality of life in cervical cancer survivors: patient and provider perspectives on common complications of cervical cancer and treatment.

OBJECTIVE: This study's objective was to quantify the impact (utility) of common complications of early cervical cancer treatment on quality of life (QOL). Utilities assigned by survivors were compared to those assigned by providers. METHODS: 30 survivors of early cervical cancer identified from our Tumor Registry and 10 gynecologic oncology providers were interviewed. Participants evaluated complications (health states) using the standard gamble (SG) and visual analogue scale (VAS). Each participant was randomly assigned to rate 5 of 13 health states. Mixed-effects linear models were used to generate confidence intervals for utility means, and evaluate the effect of group (survivors versus providers). Higher utilities indicate the health state is closer to perfect health. RESULTS: Survivors and providers mean ages were similar (44 and 40). Mean time from diagnosis was 6.7 years. 28 of 30 survivors had no evidence of disease. 56% of survivors had complications. Using SG, providers consistently assigned utilities 7% higher than survivors (p=0.035) for all health states except "ileostomy", which survivors rated higher than providers. Survivors assigned the lowest utility to small bowel obstruction (SBO) (fixable without an ostomy) and ureteral obstruction (UO). Survivors rated SBO 16% and UO 21% lower than providers. Personal history of complications or higher stage did not have a consistent effect on QOL adjustments. DISCUSSION: Providers assign higher utilities than survivors to health states. Providers and survivors diverge on which complications impact QOL the most. Data on patient preferences should be considered when weighing treatment options with similar survival but different associated complications.

Does a multidisciplinary team decrease complications in male patients with hip fractures?

BACKGROUND: Men with hip fractures are more likely to experience postoperative complications than women. The Medical Orthopaedic Trauma Service program at New York Presbyterian Hospital utilizes a multidisciplinary team approach to care for patients with hip fractures. The service is comanaged by an attending hospitalist and orthopaedic surgeon, with daily walking rounds attended by the hospitalist, orthopaedic resident, physical therapist, social worker, and a dedicated Medical Orthopaedic Trauma Service physician assistant. QUESTIONS/PURPOSES: We asked whether a multidisciplinary service for patients with hip fracture decreases (1) the incidence of inpatient complications in men, (2) the length of hospitalization, and (3) 90-day and 1-year mortality. PATIENTS AND METHODS: We retrospectively reviewed the charts of 74 men who had surgery for a nonperiprosthetic femoral neck, intertrochanteric, or subtrochanteric fracture for two 7-month periods before and after implementation of the Medical Orthopaedic Trauma Service. Age, ethnicity, comorbidity status, time to surgery, and postoperative complication data were collected. Regression modeling was used to evaluate the likelihood of postoperative complications, length of hospitalization, and 90-day and 1-year mortality while controlling for age, Charlson Comorbidity Index score, fracture type, and time from admission to surgery. RESULTS: We observed a decrease in the likelihood of experiencing at least one inpatient complication in male patients after implementation of the Medical Orthopaedic Trauma Service (odds ratio = 0.264). There was no difference in length of hospitalization, 90-day mortality, or 1-year mortality. CONCLUSIONS: Multidisciplinary collaboration for patients with hip fractures can decrease the likelihood of experiencing inpatient complications in male patients. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Improvement of outcomes after coronary artery bypass II: a randomized trial comparing intraoperative high versus customized mean arterial pressure.

BACKGROUND AND AIM OF THE STUDY: The objective of this randomized trial was to compare the efficacy of two strategies of hemodynamic management during cardiopulmonary bypass (CPB) on morbidity, mortality, cognitive complications and deterioration in functional status. METHODS: Patients scheduled to undergo primary elective CABG were eligible. In one group, mean arterial pressure target during CPB was 80 mmHg ("high" MAP group); in the other group, MAP target was determined by patients' pre-bypass MAP ("custom" MAP group). The principal outcomes were mortality, major neurologic or cardiac complications, cognitive complications or deterioration in functional status. RESULTS: Of 412 enrolled patients, 36% were women, with overall mean age of 64.7 +/- 12.3 years. Duration of bypass was identical for the two randomization groups. Overall complication rates were similar: 16.5% of the high group and 14.6% of the custom group experienced one or more neurologic, cardiac or cognitive complications. When only cardiac and neurologic morbidity and mortality were considered, the rates were 11.7% and 12.6%, in the high and custom groups, respectively. The aggregate outcome rate, including functional deterioration, was 31.6% in the high group and 29.6% in the custom group. CONCLUSIONS: There were no statistically significant differences between the high MAP group and the custom MAP group for the combined outcome of mortality cardiac, neurologic or cognitive complications, and deterioration in the quality of life.