What is the optimal time point to assess patient-reported recovery after hip and knee replacement? A systematic review and analysis of routinely reported outcome data from the English patient-reported outcome measures programme.

BACKGROUND: It is unclear if there is a clinically important improvement in the six to 12-month recovery period after hip and knee replacement. This is an obvious gap in the evidence required by patients undergoing these procedures. It is also an issue for the English PROMs (Patient-Reported Outcome Measures) Programme which uses 6-month outcome data to compare the results of hospitals that perform hip and knee replacements. METHODS: A systematic review of studies reporting the Oxford Hip Score (OHS) or Oxford Knee Score (OKS) at 12 months after surgery was performed. This was compared with six-month outcome data collected for 60, 160 patients within the English PROMs programme. A minimally important difference of one standard error of the measurement, equivalent to 2.7 for the OHS and 2.1 for the OKS, was adopted. RESULTS AND DISCUSSION: Six studies reported OHS data for 10 different groups containing 8,308 patients in total. In eight groups the change scores reported were at least 2.7 points higher than the six-month change observed in the PROMs programme (20.2 points). Nine studies reported OKS data for 13 different groups containing 4,369 patients in total. In eight groups the change scores reported were at least 2.1 points higher than the six-month change observed in the PROMs programme (15.0 points). CONCLUSIONS: There is some evidence from this systematic review that clinically important improvement in the Oxford hip and knee scores occurs in the six to 12 month recovery period. This trend is more apparent for hip than knee replacement. Therefore we recommend that the English Department of Health study the impact on hospital comparisons of using 12- rather than six-month outcome data.

The Sino-Nasal Outcome Test (SNOT): can we make it more clinically meaningful?

OBJECTIVE: To test whether subscales should be used when analyzing the Sino-Nasal Outcome Test (SNOT). STUDY DESIGN AND SETTING: Prospective cohort study involved 87 acute NHS hospitals in England and Wales. RESULTS: With the use of exploratory factor analysis we found evidence for the existence of four unique constructs within the SNOT. Two constructs address symptoms (rhinologic and ear/facial) and two address aspects of health-related quality of life (psychological issues and sleep function). Subscales of the SNOT that correspond to these constructs provided clinically meaningful information over and above that provided by the SNOT total score on the type of surgical benefits gained by patients with different sino-nasal conditions. CONCLUSION: The SNOT is not unidimensional and a SNOT total score will mask variation in the true underlying constructs. SIGNIFICANCE: The SNOT would have greatly improved clinical use if it was scored with appropriate subscales. Such a measure would allow us to tease out the differential impact of sino-nasal conditions, in addition to allowing greater understanding of treatment effects.

Understanding perspectives on major system change: A comparative case study of public engagement and the implementation of urgent and emergency care system reconfiguration.

OBJECTIVES: Major changes have been made to how emergency care services are configured in several regions in the Republic of Ireland. This study investigated the hypothesis that engagement activities undertaken prior to these changes influenced stakeholder perspectives on the proposed changes and impacted on the success of implementation. METHODS: A comparative case-study approach was used to explore the changes in three regions. These regions were chosen for the case study as the nature of the proposals to reconfigure care provision were broadly similar but implementation outcomes varied considerably. Documentary analysis of reconfiguration planning reports was used to identify planned public engagement activities. Semi-structured interviews with 74 purposively-sampled stakeholders explored their perspectives on reconfiguration, engagement activities and public responses to reconfiguration. Framework analysis was used, integrating inductive and deductive approaches. RESULTS: Approaches to public engagement and success of implementation differed considerably across the three cases. Regions that presented the public with the reconfiguration plan alone reported greater public opposition and difficulty in implementing changes. Engagement activities that included a range of stakeholders and continued throughout the reconfiguration process appeared to largely address public concerns, contributing to smoother implementation. CONCLUSIONS: The presentation of reconfiguration reports alone is not enough to convince communities of the case for change. Genuine, ongoing and inclusive engagement offers the best opportunity to address community concerns about reconfiguration.

Health-related quality of life after polypectomy with and without additional surgery.

OBJECTIVE: The objective of this study was to compare the health-related quality of life of patients undergoing simple polypectomy with that of patients undergoing polypectomy with additional surgery. STUDY DESIGN: This was a prospective, multicenter cohort study of adults undergoing sinonasal surgery. METHODS: Eight hundred forty-four patients received simple polypectomy and 1,004 patients received polypectomy with additional surgery. Health-related quality of life was compared at 12 and 36 months after surgery using the Sino-Nasal Outcome Test (SNOT-22). Total SNOT-22 scores may range from zero to 110 with lower scores representing better outcomes. We used linear regression to adjust postoperative SNOT-22 scores for baseline characteristics. When comparing the difference between the two surgical techniques, positive SNOT-22 scores represent a better outcome for those undergoing additional surgery. RESULTS: There were only small differences between the two groups at 12 months (difference in SNOT-22 -0.5; 95% confidence interval [CI]=-2.3-1.3; P=.58) and 36 months after surgery (difference -2.1; 95% CI=-4.4-0.2; P=.08). The additional surgery group had a slightly higher risk of excessive perioperative bleeding (8.6% vs. 6.0%; P=.04) but a slightly lower risk of revision surgery within 36 months (10.4% vs. 13.3%; P=.12). CONCLUSIONS: Nasal polypectomy with additional surgery seems to have no benefit over simple polypectomy in terms of health-related quality of life improvement for patients with nasal polyposis.

Mathematical coupling may account for the association between baseline severity and minimally important difference values.

OBJECTIVE: To generate anchor-based values for the "minimally important difference" (MID) for a number of commonly used patient-reported outcome (PRO) measures and to examine whether these values could be applied across the continuum of preoperative patient severity. STUDY DESIGN AND SETTING: Six prospective cohort studies of patients undergoing elective surgery at hospitals in England and Wales. Patients completed questionnaires about their health and health-related quality of life before and after surgery. MID values were calculated using the mean change score for a reference group of patients who reported they were "a little better" after surgery minus the mean change score for those who said they were "about the same." Pearson's correlation was used to examine the association between baseline severity and change scores in the reference group. Baseline severity was expressed in two ways: first in terms of preoperative scores and second in terms of the average of pre- and postoperative scores (Oldham's method). RESULTS: Of the 10 PRO measures examined, eight demonstrated a moderate or high positive association between preoperative scores and MID values. Only two measures demonstrated such an association when Oldham's measure of baseline severity was used. CONCLUSION: In general, there is little association between baseline severity and MID values. However, a moderate association persists for some measures, and it is recommended that researchers continue to test for this relationship when generating anchor-based MID values from change scores.