Patient perceptions after the operative and nonoperative treatment of shoulder instability: A qualitative focus group study.

Background: Little evidence is available regarding patient perceptions of the treatment of shoulder instability. The aim of this study is to investigate patient perceptions regarding the operative and nonoperative treatment of anterior shoulder instability. Methods: Patients who presented to the emergency department or outpatient clinic between 2016 and 2020 were retrospectively selected using diagnosis and procedure codes. Online focus groups and semistructured interviews were conducted, systematically recorded and subsequently transcribed to MaxQDA 2007 for qualitative analysis. Coded transcripts of all focus groups were subjected to a grounded theory-based analysis. Results: Six focus groups and two semistructured interviews were hosted with 35 included patients. The mean age of included patients was 34.1 years (±11.5). Eight patients were female (23%), and 27 patients were male (77%). Fear of (recurrent) dislocation, preoperative counseling, communication between surgeon and physiotherapists and need for a consistent postoperative rehab protocol turned out to be important patient perceptions. The most crucial factor for discontent was a lack of communication from the surgeon. Discussion: This patient-centered focus group study revealed that fear of (recurrent) dislocation, preoperative counseling, communication between surgeons and physiotherapists and the need for a consistent postoperative rehabilitation protocol was the most frequently discussed themes.

Exploring patient satisfaction after operative and nonoperative treatment for midshaft clavicle fractures: a focus group analysis.

BACKGROUND: There is no consensus on the optimal treatment for displaced midshaft clavicle fractures. Several studies indicate superior patient satisfaction in favour of operative reconstruction. It is unknown what drives superior satisfaction in this treatment group. The aim of this study was to explore patient satisfaction and identify contributors to patient satisfaction after operative and nonoperative treatment for displaced midshaft clavicle fractures in adults using a focus group approach. METHODS: Four face-to-face and two web-based focus groups were hosted. A total of 24 participants who were treated nonoperatively (n = 14) or operatively (n = 10) agreed to participate. Participants were selected using purposive sampling, ensuring variation in gender, age, treatment complications and outcomes. A question script was developed to systematically explore patient expectations, attitudes and satisfaction with different dimensions of care. All focus groups were voice-recorded and transcribed at verbatim. Thematic analysis was conducted on all face-to-face and web-based transcripts. RESULTS: The main emerging themes across treatment groups were; need for more information, functional recovery, speed of recovery and patient-doctor interaction. There was no difference in themes observed between operative and nonoperative focus groups. The lack of information was the most important complaint in dissatisfied patients. CONCLUSION: Our study shows that informing patients about their injury, treatment options and expectations for recovery is paramount for overall patient satisfaction after treatment for a displaced midshaft clavicle fracture. LEVEL OF EVIDENCE: Level III, focus group study.

Plate fixation of clavicle fractures: comparison between early and delayed surgery.

BACKGROUND: The optimal treatment strategy for clavicle fractures remains a topic of debate. We evaluated our step-wise treatment protocol for patients with clavicle fractures to determine our success rate of conservative treatment. In addition, we evaluated the incidence of complications after clavicle plate fixation in patients undergoing acute surgery vs. delayed surgery. METHODS: This was a retrospective analysis in which we registered all patients aged 14 years or older with a clavicle fracture between January 2010 and May 2018 and at least 6 weeks' follow-up. Patients who underwent surgery were included from a prospectively maintained database. Functional outcomes were measured by Disabilities of the Arm, Shoulder and Hand and Constant-Murley scores 6 weeks after surgery. RESULTS: Conservative treatment was successful in 1627 of 1748 patients (93%). Primary fixation was performed in 73 patients (61%) and delayed fixation in 48 (39%). In 8 patients (6.6%), radiologic widening of the acromioclavicular (AC) joint was present after surgery, suggestive of AC injury. The incidence of complications was significantly higher among patients who underwent delayed fixation vs. those who underwent primary fixation: 15 of 48 patients (31.3%) vs. 9 of 73 patients (12.3%). CONCLUSION: Most patients with clavicle fractures have an excellent outcome using conservative management. Acute surgery can be performed in high-demand patients, resulting in high performance scores. Delayed surgery is associated with a higher risk of complications, although the outcome is generally good. Associated AC joint dislocation found on postoperative radiographs does not influence outcomes. Shared decision making is key, and patients should be well aware of the potential risks and benefits of surgery.

Clinical outcomes and predictors of patient satisfaction in displaced midshaft clavicle fractures in adults: Results from a retrospective multicentre study.

BACKGROUND: The optimal treatment of displaced midshaft clavicle fractures (Robinson Type 2B1 & 2B2) in adults remains controversial. Little is known about patient satisfaction with treatment for this type of injury. The purpose of this study was to compare clinical outcomes and explore predictors of patient satisfaction after nonoperative and direct-operative treatment of displaced midshaft clavicle fractures in adults. METHODS: A retrospective multicentre study was conducted. Clinical data were retrieved from electronic patient charts. A questionnaire informing on current subjective function (QuickDASH), pain levels (VAS), health-related quality of life (Eq-5D-5L), impact on employment and satisfaction with treatment results was sent to all patients. Univariate and multivariate linear regression was performed to identify predictors of satisfaction. RESULTS: A total of 278 patients were identified (nonoperative n=150, direct-operative n=128). 67% of eligible patients returned the questionnaire. Median questionnaire follow-up was 2.1 years. No differences were found between groups for QuickDASH, Eq-5D-5L or pain VAS scores. Impaired union was observed in 13.2% of nonoperative cases vs. 2.3% in the direct-operative group. Patients in the nonoperative group could resume work after a median of 30.0days, compared to 13.5days in the direct-operative group. Patient satisfaction was higher in the direct-operative group, 8/10 vs. 7/10 for overall treatment results respectively. Patients' rating for the level of shared decision-making was the main predictor of overall satisfaction. CONCLUSION: Direct-operative management led to higher patient satisfaction, despite similar long-term patient reported outcomes with nonoperative treatment. Patients' rating for the level of shared decision-making was the main predictor of overall satisfaction. This study highlights the need to enhance communication to facilitate shared decision-making.

Inclusion of the benefits of enhanced cross-protection against cervical cancer and prevention of genital warts in the cost-effectiveness analysis of human papillomavirus vaccination in the Netherlands.

BACKGROUND: Infection with HPV 16 and 18, the major causative agents of cervical cancer, can be prevented through vaccination with a bivalent or quadrivalent vaccine. Both vaccines provide cross-protection against HPV-types not included in the vaccines. In particular, the bivalent vaccine provides additional protection against HPV 31, 33, and 45 and the quadrivalent vaccine against HPV31. The quadrivalent vaccine additionally protects against low-risk HPV type 6 and 11, responsible for most cases of genital warts. In this study, we made an analytical comparison of the two vaccines in terms of cost-effectiveness including the additional benefits of cross-protection and protection against genital warts in comparison with a screening-only strategy. METHODS: We used a Markov model, simulating the progression from HPV infection to cervical cancer or genital warts. The model was used to estimate the difference in future costs and health effects of both HPV-vaccines separately. RESULTS: In a cohort of 100,000 women, use of the bivalent or quadrivalent vaccine (both at 50% vaccination coverage) reduces the cervical cancer incidence by 221 and 207 cases, corresponding to ICERs of €17,600/QALY and €18,900/QALY, respectively. It was estimated that the quadrivalent vaccine additionally prevents 4390 cases of genital warts, reducing the ICER to €16,300/QALY. Assuming a comparable willingness to pay for cancer and genital warts prevention, the difference in ICERs could justify a slightly higher price (~7% per dose) in favor of the quadrivalent vaccine. CONCLUSIONS: Clearly, HPV vaccination has been implemented for the prevention of cervical cancer. From this perspective, use of the bivalent HPV vaccine appears to be most effective and cost-effective. Including the benefits of prevention against genital warts, the ICER of the quadrivalent HPV vaccine was found to be slightly more favourable. However, current decision-making on the introduction of HPV is driven by the primary cervical cancer outcome. New vaccine tenders could consider the benefits of cross-protection and the benefits of genital warts, which requires more balanced decision-making.