The impact of informal leader nurses on patient satisfaction.

BACKGROUND: The relationship between informal leaders, i.e., highly competent individuals who have influence over peers without holding formal leadership positions, and organisational outcomes has not been adequately assessed in health care. AIMS: We evaluated the relationships between informal leaders and experience, job satisfaction and patient satisfaction, among hospital nurses. METHODS: Floor nurses in non-leadership positions participated in an online survey and rated colleagues' leadership behaviours. Nurses identified as informal leaders took an additional survey to determine their leadership styles via the Multifactor Leadership QuestionnaireTM . Six months of patient satisfaction data were linked to the nursing units. RESULTS: A total of 3,456 (91%) nurses received peer ratings and 628 (18%) were identified as informal leaders. Informal leaders had more experience (13.2 ± 10.9 vs. 8.4 ± 9.7 years, p < 0.001) and higher job satisfaction than their counterparts (4.8 ± 1.2 vs. 4.5 ± 1.1, p = 0.007). Neither the proportion of informal leaders on a unit nor leadership style was associated with patient satisfaction (p = 0.53, 0.46, respectively). CONCLUSION: While significant relationships were not detected between patient satisfaction and styles/proportion of informal leaders, we found that informal leaders had more years of experience and higher job satisfaction. More work is needed to understand the informal leaders' roles in achieving organisational outcomes. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse informal leaders are unique resources and health care organisations should utilise them for optimal outcomes.

Factors Associated With Rehabilitation Outcomes After Traumatic Brain Injury: Comparing Functional Outcomes Between TBIMS Centers Using Hierarchical Linear Modeling.

OBJECTIVE: To examine differences in patient outcomes across Traumatic Brain Injury Model Systems (TBIMS) rehabilitation centers and factors that influence these differences using hierarchical linear modeling (HLM). SETTING: Sixteen TBIMS centers. PARTICIPANTS: A total of 2056 individuals 16 years or older with moderate to severe traumatic brain injury (TBI) who received inpatient rehabilitation. DESIGN: Multicenter observational cohort study using HLM to analyze prospectively collected data. MAIN OUTCOME MEASURES: Functional Independence Measure and Disability Rating Scale total scores at discharge and 1 year post-TBI. RESULTS: Duration of posttraumatic amnesia (PTA) demonstrated a significant inverse relationship with functional outcomes. However, the magnitude of this relationship (change in functional status for each additional day in PTA) varied among centers. Functional status at discharge from rehabilitation and at 1 year post-TBI could be predicted using the slope and intercept of each TBIMS center for the duration of PTA, by comparing it against the average slope and intercept. CONCLUSIONS: HLM demonstrated center effect due to variability in the relationship between PTA and functional outcomes of patients. This variability is not accounted for in traditional linear regression modeling. Future studies examining variations in patient outcomes between centers should utilize HLM to measure the impact of additional factors that influence patient rehabilitation functional outcomes.

Improving diabetes care and outcomes with community health workers.

BACKGROUND: Type II diabetes continues to be a major health problem in USA, particularly in minority populations. The Diabetes Equity Project (DEP), a clinic-based diabetes self-management and education program led by community health workers (CHWs), was designed to reduce observed disparities in diabetes care and outcomes in medically underserved, predominantly Hispanic communities. OBJECTIVE: The purpose of this study was to evaluate the impact of the DEP on patients' clinical outcomes, diabetes knowledge, self-management skills, and quality of life. METHODS: The DEP was implemented in five community clinics from 2009 to 2013 and 885 patients completed at least two visits with the CHW. Student's paired t-tests were used to compare baseline clinical indicators with indicators obtained from patients' last recorded visit with the CHW and to assess differences in diabetes knowledge, perceived competence in managing diabetes, and quality of life. A mixed-effects model for repeated measures was used to examine the effect of DEP visits on blood glucose (HbA1c), controlling for patient demographics, clinic and enrolment date. RESULTS: DEP patients experienced significant (P < 0.0001) improvements in HbA1c control, blood pressure, diabetes knowledge, perceived competence in managing diabetes, and quality of life. Mean HbA1c for all DEP patients decreased from 8.3% to 7.4%. CONCLUSION: Given the increasing prevalence of diabetes in USA and documented disparities in diabetes care and outcomes for minorities, particularly Hispanic patients, new models of care such as the DEP are needed to expand access to and improve the delivery of diabetes care and help patients achieve improved outcomes.

Comparative effectiveness of traumatic brain injury rehabilitation: differential outcomes across TBI model systems centers.

OBJECTIVE: To measure patient functional outcomes across rehabilitation centers. SETTING: Traumatic Brain Injury Model System (TBIMS) centers. PARTICIPANTS: Patients with traumatic brain injury (TBI) admitted to 21 TBIMS rehabilitation centers (N = 6975, during 1999-2008). DESIGN: Retrospective analysis of prospectively collected data. MAIN MEASURES: Center-specific functional outcomes of TBI patients using Functional Independence Measure, Disability Rating Scale, and Glasgow Outcome Scale-Extended. RESULTS: There were large differences in patient characteristics across centers (demographics, TBI severity, and functional deficits at admission to rehabilitation). However, even after taking those factors into account, there were significant differences in functional outcomes of patients treated at different TBIMS centers. CONCLUSION: There are significant differences in functional outcomes of TBI patients across rehabilitation centers.

Development of a tool to measure user experience following electronic health record implementation.

OBJECTIVE: The aim of this study was to develop a survey tool to assess electronic health record (EHR) implementation to guide improvement initiatives. BACKGROUND: Survey tools are needed for ongoing improvement and have not been developed for aspects of EHR implementation. METHODS: The Baylor EHR User Experience (UX) survey was developed to capture 5 concept domains: training and competency, usability, infrastructure, usefulness, and end-user support. Validation efforts included content validity assessment, a pilot study, and analysis of 606 nurse respondents. The revised tool was sent to randomly sampled EHR nurse-users in 11 acute care facilities. RESULTS: A total of 1,301 nurses responded (37%). Internal consistency of the survey tool was excellent (Cronbach's α = .892). Survey responses including 1,819 open comments were used to identify and prioritize improvement efforts in areas such as education, support, optimization of EHR functions, and vendor change requests. CONCLUSION: The Baylor EHR UX survey was a valid tool that can be useful for prioritizing improvement efforts in relation to EHR implementation.

Impact of a transitional care program for heart failure patients at Baylor Scott & White Health: a pilot study.

Heart failure is a chronic health condition characterized by complex symptom management and costly hospitalizations. Hospitalization for the treatment of heart failure symptoms is common; however, many hospitalizations are thought to be preventable with effective self-management. This study describes the small, pilot implementation of a new, interventional, self-management heart failure program, "Engagement in Heart Failure Care" (EHFC), developed to assist heart failure patients with the management of disease symptoms following discharge from an inpatient hospital stay. EHFC was designed to engage patients in managing their symptoms and coaching them in skills that enable them to access medical and supportive care services across community, clinic, and hospital settings to help address both their current and future needs. The results of this pilot study suggest that EHFC's coaching model may have positive benefits on key health and well-being indicators of the patients enrolled.

The intensity and frequency of moral distress among different healthcare disciplines.

INTRODUCTION: The objectives of this study are to assess and compare differences in the intensity, frequency, and overall severity of moral distress among a diverse group of healthcare professionals. METHODS: Participants from within Baylor Health Care System completed an online seven-point Likert scale (range, 0 to 6) moral distress survey containing nine core clinical scenarios and additional scenarios specific to each participant's discipline. Higher scores reflected greater intensity and/or frequency of moral distress. RESULTS: More than 2,700 healthcare professionals responded to the survey (response rate 18.14 percent); survey respondents represented multiple healthcare disciplines across a variety of settings in a single healthcare system. Intensity of moral distress was high in all disciplines, although the causes of highest intensity varied by discipline. Mean moral distress intensity for the nine core scenarios was higher among physicians than nurses, but the mean moral distress frequency was higher among nurses. Taking into account both intensity and frequency, the difference in mean moral distress score was statistically significant among the various disciplines. Using post hoc analysis, differences were greatest between nurses and therapists. CONCLUSIONS: Moral distress has previously been described as a phenomenon predominantly among nursing professionals.This first-of-its-kind multidisciplinary study of moral distress suggests the phenomenon is significant across multiple professional healthcare disciplines. Healthcare professionals should be sensitive to situations that create moral distress for colleagues from other disciplines. Policy makers and administrators should explore options to lessen moral distress and professional burnout that frequently accompanies it.

From bedside to graveside: increased stress among healthcare chaplains.

The authors conducted a survey of Baylor Health Care System chaplains in an attempt to understand the stress they experience when leading funeral services of staff, staff family members, and patients. The intensity of stress experienced by these chaplains appears to be related to the cause of death, the deceased's age, and the relationship the deceased had with the chaplain. Further research is needed to corroborate these findings as well as to investigate how chaplains manage their own grief when they are involved in the grief experiences of patients and families.

The risk of subsequent joint arthroplasty after primary unilateral total knee arthroplasty, a 10-year study.

The purposes of this study were to determine the probabilities of subsequent lower extremity arthroplasty after index knee arthroplasty for osteoarthritis and to evaluate the demographic as well as radiographic factors that may predict progression to arthroplasty in the contralateral knee. Between 1984 and 1994, 646 patients, aged 40 to 75 years, with a primary cruciate-retaining knee were identified. The 10-year probability of having a contralateral knee after index knee was 36%. When grade 4 radiographic changes were present, the probability increased to 70%. Demographic factors played no role in the risk of future contralateral knee. The radiographic grade of the contralateral knee at the time of index surgery was found to correlate strongly with the future risk of contralateral total knee.

Health-related quality of life and patient satisfaction after global endometrial ablation for menorrhagia in women with bleeding disorders: a follow-up survey and systematic review.

OBJECTIVE: The purpose of this study was to describe health-related quality of life and satisfaction after global endometrial ablation in women with bleeding disorders and a systematic review of the literature. STUDY DESIGN: A follow-up survey was mailed to 36 patients with bleeding disorders and 110 reference patients (no coagulopathies) who underwent global endometrial ablation for menorrhagia. The survey included a generic (SF-12) and menorrhagia multi-attribute utility scale questionnaires. RESULTS: Ninety-six women (66%) responded. The total menorrhagia multiattribute utility scale score increased from 35-100 in bleeding disorder cohort (P = .03) and from 48-100 in the reference cohort (P < .001). Although postablation SF-12 mental domain scores were comparable in both cohorts (55 vs 55; P = .67), physical domain scores were lower in the bleeding disorder cohort (50 vs 56; P < .001). High satisfaction was reported by both cohorts (95% vs 84%; P = .60). CONCLUSION: Global endometrial ablation improved health-related quality of life for women with bleeding disorders and had high satisfaction rates.

Predictors of complications and outcomes of external hemipelvectomy wounds: account of 160 consecutive cases.

BACKGROUND: Hemipelvectomy has high wound complication rates. This study aimed to determine variables that may influence hemipelvectomy wound morbidity. METHODS: The records of 160 consecutive hemipelvectomy patients were reviewed with a focus on demographics, treatment, and surgical techniques. Multivariate analysis was used to determine risk factors for postoperative hemipelvectomy wound infection and flap necrosis. RESULTS: There were 31 standard, 62 modified, and 67 extended hemipelvectomy patients in whom 19 contiguous visceral, 62 spinal, 4 contralateral pelvic resections, and 1 contralateral hemipelvectomy were performed. Hospital mortality rate was 5%, and overall morbidity was 54%. Wound complications such as infection (39%) and flap necrosis (26%) were the most common. For modified, standard, and extended hemipelvectomies, rates of wound infection were 29%, 34%, and 51% (P = .036) and rates of flap necrosis were 16%, 25%, and 35% (P = .046), respectively. Longer operative time and increased complexity were associated with higher wound infection and flap necrosis rates. The hemipelvectomy flap design did not influence the frequency of wound infection (P = .173) or flap necrosis (P = .098). Common iliac vessel ligation was the most statistically significant predictor of flap necrosis and was associated with the 2.7-fold increase in flap necrosis rate (P = .001) in patients undergoing posterior flap hemipelvectomy. CONCLUSIONS: External hemipelvectomy has low mortality but high morbidity. Postoperative wound infection and flap necrosis are multifactorial events related to length and extent of operation. Level of vascular ligation strongly influenced flap necrosis rate for posterior flap hemipelvectomy.

Segmental vs. extended colectomy: measurable differences in morbidity, function, and quality of life.

PURPOSE: The colon coordinates fecal elimination while reabsorbing excess fluid. Extended colonic resection removes synchronous and prevents metachronous disease but may adversely alter bowel function and health-related quality of life to a greater degree than segmental resection. This study examined the short-term morbidity and long-term function and quality of life after colon resections of different extents. METHODS: Patients undergoing extended resections (n = 201, subtotal colectomy with ileosigmoid or total abdominal colectomy with ileorectal anastomosis) and segmental colonic resections (n = 321) during 1991 to 2003 were reviewed for perioperative outcomes and surveyed for bowel function and quality of life using an institutional questionnaire and a validated quality of life instrument (response rate: 70 percent). RESULTS: The most common indication for extended resections was multiple polyps, and for segmental resections, single malignancy. The complication-free rate was 75.4 percent after segmental resections, 42.8 percent after ileosigmoid anastomosis, and 60 percent after ileorectal anastomosis. Median daily stool frequency was two after segmental resections, four after ileosigmoid anastomosis, and five after ileorectal anastomosis, despite considerable dietary restrictions (55.6 percent) and medication use (19.6 percent daily) after ileorectal anastomosis. Significant proportions of patients felt restricted from preoperative social activity (31.5 percent), housework (20.4 percent), recreation (31.5 percent), and travel (42.6 percent) after ileorectal anastomosis. The overall quality of life after segmental resection, ileosigmoid anastomosis, and ileorectal anastomosis was 98.5, 94.9, and 91.2, respectively. CONCLUSIONS: Measurable compromises in long-term bowel function and quality of life were observed after extended vs. segmental resections. The relative differences in patient-related outcomes should be deliberated against the clinical benefits of extended resection for the individual patient.

The impact of missing data and how it is handled on the rate of false-positive results in drug development.

In drug development, a common choice for the primary analysis is to assess mean changes via analysis of (co)variance with missing data imputed by carrying the last or baseline observations forward (LOCF, BOCF). These approaches assume that data are missing completely at random (MCAR). Multiple imputation (MI) and likelihood-based repeated measures (MMRM) are less restrictive as they assume data are missing at random (MAR). Nevertheless, LOCF and BOCF remain popular, perhaps because it is thought that the bias in these methods lead to protection against falsely concluding that a drug is more effective than the control. We conducted a simulation study that compared the rate of false positive results or regulatory risk error (RRE) from BOCF, LOCF, MI, and MMRM in 32 scenarios that were generated from a 2(5) full factorial arrangement with data missing due to a missing not at random (MNAR) mechanism. Both BOCF and LOCF inflated RRE were compared to MI and MMRM. In 12 of the 32 scenarios, BOCF yielded inflated RRE compared with eight scenarios for LOCF, three scenarios for MI and four scenarios for MMRM. In no situation did BOCF or LOCF provide adequate control of RRE when MI and MMRM did not. Both MI and MMRM are better choices than either BOCF or LOCF for the primary analysis.

Barriers and Benefits to the Use of Patient-Reported Outcome Measures in Routine Clinical Care: A Qualitative Study.

Patient-reported outcomes (PROs) provide information on how health care affects patient health and well-being and represent a patient-centered approach. Despite this potential, PROs are not widely used in clinical settings. Semi-structured focus groups were conducted with 3 stakeholder groups (patients, providers, and health care administrators) to determine the top 5 perceived barriers and benefits of PRO implementation. The Delphi technique was employed to obtain consensus and rank order responses. Patients perceived survey length to be important, whereas providers and administrators perceived time to collect data and patient health literacy, respectively, as the greatest barriers to PRO implementation. The greatest perceived benefits were the ability to track changes in clinical symptoms over time, improved quality of care, and better disease control among patients, providers, and administrators, respectively. These results may guide the development of novel frameworks for PRO implementation by addressing perceived barriers and building on the perceived benefits to encourage adoption of PROs.

Publication bias for CAM trials in the highest impact factor medicine journals is partly due to geographical bias.

OBJECTIVE: To assess the presence of publication bias and its relation to geographical bias in clinical trials involving complementary and alternative medicine (CAM) published in the highest impact factor general medicine journals. STUDY DESIGN AND SETTING: All CAM clinical trials published in the four highest impact factor general medicine journals, Lancet and British Medical Journal (European), and New England Journal of Medicine and Journal of American Medical Association (U.S.), between 1965 and 2004 were abstracted using Medline. Three reviewers abstracted data from the individual studies. In a multivariate analysis, factors predictive of a positive study were assessed. RESULTS: A total of 259 studies met the inclusion criteria. CAM trials published in the European journals were significantly more likely to be positive compared to those published in the U.S. journals (76% vs. 50%, odds ratio [OR]=3.15, P<0.0001). Studies originating outside of the United States were significantly more likely to be positive compared to the U.S. studies (75% vs. 49%, P<0.0001). Adjusting for location and other variables in a multivariate model, the OR for European vs. U.S. journals to publish a positive CAM trial was 1.95 (P=0.11). CONCLUSION: Publication bias related to CAM trials among the highest impact factor general medicine journals is partly due to geographical bias.

Global endometrial ablation for menorrhagia in women with bleeding disorders.

OBJECTIVE: To evaluate the efficacy of global endometrial ablation in women with bleeding disorders who presented with menorrhagia. METHODS: A records-linkage system was used to construct a retrospective cohort of 41 women with bleeding disorders (coagulopathy) and a reference group of 111 randomly selected women without bleeding disorders from a pool of 943 women who underwent global endometrial ablation (with thermal balloon ablation technology or bipolar radiofrequency ablation technology) for menorrhagia at Mayo Clinic (Rochester, Minnesota) from January 1995 through December 2005. Demographic data, type of global endometrial ablation therapy and reablation, and hysterectomy data were extracted from the database. RESULTS: There was no significant difference in baseline age, parity, body mass index, uterine size, type of global endometrial ablation therapy, or duration of follow-up between the groups. Two women (5%) in the coagulopathy group had hysterectomy or reablation, compared with 8 (7%) in the reference group (Fisher exact test, P=.728). A Kaplan-Meier plot showed no difference in the time to treatment failure between the groups (log-rank test, P=.534). Procedural-related complications were generally minor and infrequent (9 of 152 [6%]). Complications were equally distributed in the coagulopathy (4 of 41) and reference groups (6 of 111) (Fisher exact test, P=.267). CONCLUSION: Global endometrial ablation is an effective treatment choice for women with coagulopathy presenting with menorrhagia.

Mixing web and mail methods in a survey of physicians.

OBJECTIVE: To assess the effects of two different mixed-mode (mail and web survey) combinations on response rates, response times, and nonresponse bias in a sample of primary care and specialty internal medicine physicians. DATA SOURCES/STUDY SETTING: Primary data were collected from 500 physicians with an appointment in the Mayo Clinic Department of Medicine (DOM) between February and March 2005. STUDY DESIGN: Physicians were randomly assigned to receive either an initial mailed survey evaluating the Electronic Medical Record (EMR) with a web survey follow-up to nonrespondents or its converse-an initial web survey followed by a mailed survey to nonrespondents. Response rates for each condition were calculated using standard formula. Response times were determined as well. Nonresponse bias was measured by comparing selected characteristics of survey respondents to similar characteristics in the full sample frame. In addition, the distributions of results on key outcome variables were compared overall and by data collection condition and phase. PRINCIPAL FINDINGS: Overall response rates were somewhat higher in the mail/web condition (70.5 percent) than in the web/mail condition (62.9 percent); differences were more pronounced before the mode switch prior to the mailing to nonrespondents. Median response time was 2 days faster in the web/mail condition than in the mail/web (median=5 and 7 days, respectively) but there was evidence of under-representation of specialist physicians and those who used the EMR a half a day or less each day in the web/mail condition before introduction of the mailed component. This did not translate into significant inconsistencies or differences in the distributions of key outcome variables, however. CONCLUSIONS: A methodology that uses an initial mailing of a self-administered form followed by a web survey to nonrespondents provides slightly higher response rates and a more representative sample than one that starts with web and ends with a mailed survey. However, if the length of the data collection period is limited and rapid response is important, perhaps the web survey followed by a mailed questionnaire is to be preferred. Key outcome variables appear to be unaffected by the data collection method.

Attitudes of general dentists regarding the acceptance of gifts and unconventional payments from patients.

BACKGROUND: Professional boundaries ensure that a dentist's focus remains on the patient's welfare. Such boundaries may be compromised by accepting gifts from patients. METHODS: General dentists attending a continuing dental education conference completed an anonymous questionnaire about professional boundaries and acceptance of gifts from patients. The authors compared subjects' responses to questionnaire items and calculated descriptive statistics. RESULTS: Of the 333 dentists attending the conference, 219 (65.8 percent) submitted a completed or partially completed survey. Of the respondents, 81.2 percent endorsed receiving gifts, 82.5 percent thought accepting inexpensive gifts was acceptable, 79.7 percent would accept a dinner invitation from a patient, 52.1 percent would accept a $1,000 discount from a business owned by a patient and 59.0 percent would fabricate a set of dentures in exchange for house-painting services. More than one-third of respondents stated they would not accept a gift worth $25 to $100, and 51.1 percent would not accept a gift worth more than $100. There were no statistically significant differences in responses stratified by sex, age and years in practice, with the exception that female dentists were significantly less likely to accept a dinner invitation. Logistic regression models revealed that younger dentists and dentists with fewer years in practice were less likely to respond "agree" or "strongly agree" to accepting gifts worth $25 to $100, and female dentists were less likely to respond "agree" or "strongly agree" to accepting a dinner invitation. CONCLUSION: A majority of dentists endorsed accepting gifts from patients, which may put them at risk of violating boundaries with patients. Practice Implications. Our findings suggest that general dentists should establish policies regarding the receipt of gifts from patients and inform them of such policies.

A single-center experience with inflammatory breast cancer, 1985-2003.

HYPOTHESIS: "Up-front" surgery improves survival in inflammatory breast cancer (IBC). DESIGN: Retrospective cohort, 1985-2003. SETTING: Tertiary referral center. PATIENTS: Consecutive patients with a primary occurrence of IBC. MAIN OUTCOME MEASURES: All-cause and disease-free survival. RESULTS: One-hundred fifty-six patients were identified with IBC; 28 patients with metastatic disease were excluded from further analysis. The mean age of the remaining 128 patients was 53 years; 57% of women were postmenopausal. One hundred twenty-two patients had clinically apparent IBC. Tumors were palpable in 83 patients (mean diameter, 9.1 cm). Neoadjuvant chemotherapy was the initial therapy in 106 patients, while surgery was the initial therapy in 22 patients. The overall median survival was 37 months, with a median disease-free interval of 23 months. The 5-year survival was 42%, with a disease-free survival of 21%. Univariate analysis of recurrence identified previous hormone therapy (relative risk [RR], 0.50; P = .03), menopause (RR, 0.55; P = .01), and palpable adenopathy (RR, 1.57; P = .04) as significant factors. Univariate survival analysis highlighted previous hormone therapy (RR, 0.48; P = .04), radiotherapy (RR, 0.39; P = .02), sequence of therapy (P = .001), family history (RR, 0.47; P = .01), and palpable adenopathy (RR, 2.22; P<.001) as being important. Multivariate analysis of recurrence identified menopausal status as the key factor. Adenopathy at the initial examination was associated with decreased length of survival, while radiotherapy was associated with better survival. CONCLUSIONS: Survival from IBC remains poor. Although adenopathy and radiotherapy affected survival by multivariate analysis, the sequence of therapy was not associated with improved outcome.

Patient and physician-assessed shoulder function after arthroplasty.

BACKGROUND: We found no information in the literature regarding the relationship between patient and physician-derived outcome assessments with a shoulder questionnaire. In this study, we examined a group of patients who were assessed with patient and physician-administered questionnaires following shoulder arthroplasty. METHODS: From August 2003 to February 2004, sixty-seven consecutive patients who had been followed for a minimum of six months after shoulder arthroplasty were evaluated with a self-administered and an identical physician-directed shoulder questionnaire that assessed clinical and functional outcomes at the time of routine follow-up. An assessment of the agreement between physicians and patients as well as the factors that affected agreement was performed. RESULTS: The intraclass correlation indicated almost perfect physician-patient agreement (>0.80) on items related to overall pain, pain at night, pain with activity, stability, and active elevation and substantial agreement (intraclass correlation, 0.66 and 0.69) between the physician and patient assessments of pain without activity and strength. While the differences were small, on the average physician ratings for pain were lower (indicating less pain) than patient ratings for pain, physicians rated stability and strength as being closer to normal, and they reported less active elevation. There was substantial agreement between the physician and patient assessments of outcome with the modified Neer system (intraclass correlation = 0.75), with 87% agreement if excellent and satisfactory outcomes were combined. CONCLUSIONS: A patient-derived questionnaire can provide a high level of agreement with surgeon assessments of outcome following shoulder surgery. Patient-administered methods should continue to be evaluated as a means of assessment of these patients.