All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain.
SYM16: The Value and Future of PROMs
in Hand Surgery
Moderator(s): Michael B. Gottschalk, MD and Eric R. Wagner, MD
Faculty: Warren C. Hammert, MD, Robin Neil Kamal, MD, Nikolas H. Kazmers, MD,
MSE, and Amy L. Ladd, MD
Session Handouts
Saturday, October 03, 2020
75TH VIRTUAL ANNUAL MEETING OF THE ASSH
OCTOBER 1-3, 2020
822 West Washington Blvd
Chicago, IL 60607
Phone: (312) 880-1900
Web: www.assh.org
Email: [email protected]
9/2/2020
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SYM16: The Value and Future of PROMs in Hand Surgery
Moderators:Michael B. Gottschalk, MD
Eric R. Wagner, MD
Faculty: Nikolas H. Kazmers, MD, MSE
Robin Neil Kamal, MDWarren C. Hammert, MD
Amy L. Ladd, MD
DISCLOSURES
Nikolas H. Kazmers, MD, MSE
Speaker has no relevant financial relationships with commercial interest to disclose.
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PROMs: Which Questionnaires Should we
be Asking?Nikolas H. Kazmers, MD MSE
Department of Orthopaedics
October 3, 2020
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DISCLOSURES
• No financial disclosures
• JHS Associate Editor
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OVERVIEW OF PROMS
• PROMs incorporate the patient’s perspective on how a condition, or its treatment, impact their wellbeing
• Adjunct to traditional study outcomes:– ROM & Strength– Complication rates– Radiographic parameters
• Union• Presence of arthritis
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OVERVIEW OF PROMS
• PROMs may be used to:– Measure the efficacy of, and response to,
medical care– Tailor treatments to improve outcomes– Determine the value of care
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OVERVIEW OF PROMS
• Instruments exist to measure:– Symptoms
• Carpal tunnel symptoms (BCTQ Symptom Severity Scale)
• Pain (VAS Pain)
– Patient Function• Physical• Emotional• Social
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PROMS IN HAND SURGERY
• “No single-consensus best measure”1
– Secondary to:• Broad spectrum pathology (bony, nerve, vascular,
etc)• Wide age range (pediatric through geriatric)
• However, a breadth of PROMs have been validated for hand and upper extremity applications
1. Hammert and Calfee; JHS 2020
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PROMS IN HAND SURGERY
• Two Categories of PROMs:1. Fixed-length scale metrics:
• Standardized, pre-determined list of questions that are the same for each patient
• May be specific to: – A domain (DASH, qDASH)– A disease (BCTQ)– A specific body part (PRWE)
2. Patient-Reported Outcomes Measurement Information System (PROMIS) Metrics• Short Forms• Computer Adaptive Testing (CAT)• Examples: Upper Extremity (UE), Physical Function (PF),
Pain Interference (PI), Depression, or Anxiety CATs
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PROMS: IMPORTANT CONCEPTS
Minimal Clinically Important Difference (MCID):• Represents a clinically-relevant change or difference in an outcome
score
• Useful for power calculations, or when interpreting outcomes studies for clinical relevance
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PROMS: IMPORTANT CONCEPTS
The Biopsychosocial Model:• Interplay between function and aspects of mental health
– Resilience, depression, anxiety, pain interference, coping
• These factors contribute to ~50% of the variability in patient-reported disability among hand surgery patients.1-2
– Critical to consider these factors when interpreting a patient’s function or improvement in function using PROMs data
1. Das De S; JBJS 20132. Menendez ME; JBJS 2013
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PROMS IN HAND SURGERY: FUNCTION
DASH: • Measures: Composite bilateral upper extremity disability• Responder burden: 38 questions, approximately 4.5
minutes• Scoring: Range 0-100 (a higher score represents greater
disability) • Additional details:
– MCID: Range of 10-11– Floor effect of 1%– Ceiling effect of 5%
• May demonstrate greater ceiling effects in an athletic population
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PROMS IN HAND SURGERY: FUNCTION
QuickDASH: • Measures: Composite bilateral upper extremity disability• Responder burden: 11 questions, or approximately 2 minutes• Scoring: Range 0-100 (a higher score represents greater disability) • Additional details:
– MCID: Range of 7-19– Highly correlated with the DASH– Responsive to patient-reported functional change– Sensitive to missing data (requires response to ≥ 10 questions)
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PROMS IN HAND SURGERY: FUNCTION
Patient-Rated Wrist Evaluation (PRWE): • Measures: Wrist function and pain• Responder burden: 15 questions• Scoring: Question scores range from 0-10 (10 is the worst pain, or worst
disability). Pain and function scores are weighted equally and converted to a score ranging from 0-100.
• Additional details:– MCID: 11.5 – 14 points– Reliable, responsive, and valid in the setting of wrist trauma
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PROMS IN HAND SURGERY: FUNCTION
Michigan Hand Questionnaire (MHQ):• Measures:
– Six domains include hand function, daily activities, work activities, pain, appearance, and satisfaction.
– Measured separately for both hands.• Responder burden: 71 questions, approximately 15 minutes. • Scoring: Range 0-100 for the total combined score, and sub-domains. A
greater score represents greater function, with the exception of a higher pain score representing more pain.
• Additional details:– Useful if hand-specific outcomes, or a comparison between hands, are needed– MCID: Range of 8-13 for the total score. Highly variable depending on the domain,
disease process, and method of calculation. – A brief 12-question version exists
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PROMS IN HAND SURGERY: FUNCTION
Boston Carpal Tunnel Questionnaire (BCTQ): • Measures:
– The severity of symptoms (SSS), and functional status (FSS), of carpal tunnel syndrome patients
• Responder burden: 19 questions• Scoring: Scores for both dimensions range from 1-5 (greater score
represents greater symptom severity and disability). • Additional details:
– Recommended as a primary outcome measure for carpal tunnel syndrome trials.– MCID: 1.55 and 2.05 points for symptom and functional scales in diabetic patients, and 1.45
and 1.60 points for non-diabetics, respectively.
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PROMS IN HAND SURGERY: FUNCTION
PROMIS Physical Function (PF) CAT:• Measures: The ability to perform activities of daily living and instrumental
activities of daily living• Responder burden: Mean of 9 questions, or approximately 1 minute• Scoring: Scoring range is 0-100, with a population mean of 50 and
standard deviation of 10 (theoretically)
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PROMS IN HAND SURGERY: FUNCTION
PROMIS Physical Function (PF) CAT:• Additional details specific to hand and upper extremity
populations:– May be administered by phone, on paper, personal digital assistant with similar scores,
reliability, and validity (in medical patients)– Permissible to combine scores from v1.2 and v2.0– Ceiling effect 1.3%, and floor effect 0.5%. Other studies have not revealed a ceiling or
floor effect.– Upper extremity questions within the CAT question bank demonstrate a high ceiling
effect among orthopaedic surgery patients– Responsive to patient-reported functional change & highly correlated with the
QuickDASH
– MCID: • Thumb CMC OA: 3.5 – 3.9• Nonoperative DRF patients: 3.6 – 4.6• CTR: 4.6, or 1.8 to 2.8
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PROMS IN HAND SURGERY: FUNCTION
PROMIS Upper Extremity (UE) CAT:• Measures: The ability to perform activities of daily living and instrumental
activities of daily living specific to the upper extremity• Responder burden:
– Mean of 6 questions– Takes less time to complete than the QuickDASH (70 seconds)
• Scoring: Scoring range is 0-100, with a population mean of 50 and standard deviation of 10 (theoretically)
– Max score of 61 noted for v2.0
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PROMS IN HAND SURGERY: FUNCTION
PROMIS Upper Extremity (UE) CAT:• Additional details:
– Scores from v1.2 and v2.0 are NOT interchangeable– Ceiling effect: v1.2 10.8%, v2.0 6.9%– Floor effect: v1.2 1.6%, v2.0 1.0%– Responsive to patient-reported functional change & highly correlated with
the QuickDASH
– MCID v1.2:• General non-shoulder hand population: 2.1• CTR population: 3.4 (distribution-based) or 6.3 – 8.0 (anchor-based)
– MCID V2.0:• None published• 3.0 to 4.1 (ASSH 2020 abstract)
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PROMS IN HAND SURGERY: BIOPSYCHOSOCIAL FACTORS
PROMIS Pain Interference (PI) CAT:• Measures: The extent to which pain interferes with accomplishing goals
or engaging in activities, or the consequences of pain on relevant aspects of one’s life
• Responder burden: Variable question number, 30 seconds• Scoring: Scoring range is 0-100, with a population mean of 50 and
standard deviation of 10 (theoretically)• Additional Details:
– Advocated as the metric of choice to evaluate biopsychosocial factors for hand and upper extremity patients1
– May be dynamic (change over treatment course)
1. Kortlever; CORR 2015
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PROMS IN HAND SURGERY: BIOPSYCHOSOCIAL FACTORS
PROMIS Depression CAT:• Measures: Self-reported mood, views of self, social cognition, and
decreased positive affect and engagement. Somatic symptoms are not included.
• Responder burden: Variable question number• Scoring: Same
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PROMS IN HAND SURGERY: BIOPSYCHOSOCIAL FACTORS
PROMIS Anxiety CAT:• Measures: : Self-reported fear, anxious misery, hyperarousal, and somatic
symptoms related to arousal• Responder burden: Variable question number• Scoring: Same
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PROMS IN HAND SURGERY: BIOPSYCHOSOCIAL FACTORS
Legacy Instruments:• Brief Resilience Scale (BRS)• Pain Catastrophizing Scale (PCS)• Pain Inflexibility in Pain Scale (PIPS)• Pain Self-Efficacy Questionnaire (PSEQ)
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RECOMMENDATIONS FOR GENERAL CLINICAL USE
Function:• QuickDASH• PROMIS UE CAT v2.0
Biopsychosocial Factors:• PROMIS PI CAT• Legacy Scale (BRS, PCS, other)
Other questions to assist in the interpretation of changes in PRO scores over time:• Anchor question(s): “How much functional / pain improvement did you
experience since your last visit?”• Comorbidity question: “Do you have another body part, in addition to
what you are being seen for today, that is limiting the function of your upper extremities?”
• A question about new injuries, surgeries, or upper extremity diagnoses
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THANK YOU
DISCLOSURES
Robin N. Kamal, MD
Consulting Fees: Acumed
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The Value and Future of PROMS In Hand Surgery
Collection: How Should We be Collecting PROMs Efficiently?
Robin Kamal MD MBA
Assistant Professor I Medical Director
Department of Orthopaedic Surgery
Stanford University
The Value and Future of PROMS In Hand Surgery• Collection: How Should We be Collecting PROMs
Efficiently?
Delivering High Quality Care
• Structure
• Process
• Outcome
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Delivering High Quality Care
• Structure
• Process
• Outcome
Efficiency
• “the ratio of the useful work performed by a machine or in a process to the total energy expended”
• How do I get the most bang for my buck when collecting PROMS?
• First, how am I going to USE PROMS?
• What best supports that use?
How to Collect PROMs Efficiently (?)
1. Use PROMs that are meaningful to your patient
2. Use PROMs as communication aids
3. No consensus on which PROM to collect – balance reporting with patient care
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Making PROMs Patient Centered?
Assumptions:
1. When I collect PROMs, the questions mean something to patients
2. I can collect and show a patient a graph
3. Improving on a PROM is reassuring to the patient
4. The PROM reflects the patient’s goals/values
5. Patient and Surgeon agree the PROM is the correct measurement stick
“PROMs may differ little from traditional instruments unless they truly incorporate the patient’s perspective and not just the perspectives of clinicians and researchers. Efforts to develop new PROMs that provide a more patient‐centered outcome assessment should use qualitative and participatory methods to capture and incorporate patient perspectives and values”
“we should not infer that ‘patient reported’ means that the information so obtained actually reflects patient concerns”
• Survey adult cancer patients, oncologists, PROM researchers
• Randomized to receive• Different Line graphs (”better/worse,” “more/less,” and ”normed”)
• 629 patients (75% college/post), 139 clinicians, 249 researchers
• Patients: 56%, 41%, 39%
• Clinicians: 70%, 65%, 65%
Do Patients Understand PROMs?
Tolbert, MDM 2018
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Do PROMs Reflect the Patient’s Goals/Values?(QuickDASH versus the Patients Specific Functional Scale)
“Well, so many of those questions didn’t apply to my situation”
“The questionnaire is not specific, but it’s in the ballpark. There are so many things I can’t do, like my recreational activities, cooking, hair washing, dressing. It doesn’t really measure my progress”
“Yeah, you know they’re kind of vague”
“Those kinds of questions are always, you know, can be nebulous. They’re relative to the person, you know. One person’s pain you know is a great, great pain is someone else’s discomfort depending on how well they deal with pain”
Shapiro et al
How Do PROMs Compare?
• Standardized instrument versus Patient Specific Instrument
Shapiro et al
Can PROMs be Used to Facilitate Communication?
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• “This study has identified goals important to patients with low back pain, these were varied, and most did not correspond with current clinical measures”
1) Maybe PROMs = Goals?
• Can we efficiently collect what’s important to patients ‐ goals?
• Can those goals be used to assess outcomes?
• Can those goals be used as a PROM?
• Randomized controlled trial
• 96 patients
• Goal elicitation sheet (tell us 2 goals of care today)
• Led to improved perceived involvement in care
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PSFS
• Track goals longterm
• +Communication
• Most musculoskeletal conditions
2) PROM Scores Stable
• 112 Patients
• What happens when you do the tasks on the instrument?
• (PROM Scores Improve)
Shapiro et al, CORR, 2019
PROM Scores are NOT Stable – Mindset Matters
• PROM scores may not reflect activity levels or objective function
• Instead, they may reflect the mindset of a patient
• Process to use PROM scores to trigger a conversation
• Address psychosocial factors?
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3) No consensus on which PROM to Collect and How
• Top 10: Primary TKA, Primary THA, Revision TKA, Revision THA, Fix FN Fx, Arthroplasty FN Fx, Total Shoulder, Carpal Tunnel, Rotator Cuff, Knee Arthroscopy
• No “cross cutting” PROM common conditions
• Generic vs Disease Specific
• Mental Health?
• Systematic review of upper extremity PROMS
• Assessed Reliability, Validity, and Responsiveness of instruments for Hand/Wrist Trauma
• Only 2 instruments underwent this testing for this population(DASH, PRWE)
• Which PROM do I use?
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Efficiency in PROM collection comes from how we use the Data
“it is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.”
‐ William Osler
Conclusions
• Pick PROMs that are meaningful to your patients
• Use PROMs as communication tools
• Incorporate PROMs that are meaningful into longitudinal tracking when picking what to collect
Thank [email protected]
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Symposium 16 – The Value of PROM’s in Hand Surgery
2020 ASSH Annual Meeting
October 3, 2020
PROMIS: How to use it clinically
Warren C. Hammert, MD
University of Rochester
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DisclosureI have no financial relationships relevant to this presentation to disclose
Challenges
You can not manage what you can not measure
If you want to know how your patients are doing…..
Just ask them
Specific InstrumentsHand surgery uses multiple instruments•Symptom/Condition specific – OA index, CTQ•Region specific – MHQ, DASH,PRWHE
Confusing for research as there is not one agreed upon instrument
Papers on the same topic may use different instruments
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PROMIS: A New Breed of PRO
Patient Reported Outcome Measurement Information System
•15-year, $150 million effort by NIH
•New psychometric methods to improve the PRO
•Large bank of questions - computer adaptive
•Each instrument asks on average 4-5 questions
•Biopsychosocial approach
PROMIS
•Domain specific not disease specific•Standardized across domains
•1-100 with 50=mean score for US population•t-score (10pts = 1 standard deviation)
• Follow patients throughout Health Care System• Produces validated data quickly “Smart Testing”
•Computer Adapted Technology•Item Response Theory
Bio- Psycho- Social
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IRT/ CATUses a statistical model based on item response theory (IRT) to determine scores
IRT gives computer software the information it needs to select the best follow up question given the response to an initial question
Using CAT, the patient only needs to answer 4-8 questions per instrument
Average PROMIS instrument can be given in under a minute
What Domains to Collect? Physical Function
Upper Extremity
Pain Interference
Depression
Anxiety
PASS question
Anchor Question – How are you now compared to:• First visit• Most recent visit
Total, Sept 20192.4 million scores
252K unique patients12 million questions
Start, Feb 2015
Patient Reported Outcome Collections
2.4 minutes
Median time to complete assessment
12 questions
98.2%completed
PROMISAdult
Domains2.0 million scores (84%)
Physical Function
Pain Interference
Depression
PROMISPediatric /
Parent Proxy Domains174,469 scores (7%)
Non‐PROMIS210,584 scores (9%)
PROMIS CATs
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Outcomes areNot just for research anymore
Set Up/ Delivery
Administered via tablet (or paper forms)
Sync and stored in EMR (RED Cap for Research)
Stored and delivered to patients via applications like My Chart
Set Up
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PROMISHow do we use the data clinically?
Thumb Arthritis - UE
Thumb Arthritis- PI
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Patients with higher levels of depression or PI recovered slower and not to the same extent following elective hand surgery
Compared PROMIS to MHQ and Boston CTQ questionnaires
UE and PI correlated well with MHQ total and BCTQ symptom severity
PF poor correlation
Minimum Clinically Important Difference
Varies depending on method of calculation
Distribution method
Anchor method
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PROMIS Data
Changes in PROMIS scores and MCID are helpful in designing research studies and following groups
For individuals, following trends and directions of scores rather then using MCID to determine success of a procedure
PROMIS LimitationsOther conditions can affect scores/ outcomes
May not be sensitive or specific enough for common hand conditions
UE has ceiling and floor effect
ConclusionWe currently do not have one ideal outcome measure
PROMIS comparable to other UE instruments
Continued research to determine MCID,…
Values, such as MCID, likely better for groups than to evaluate an individual
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Thank You
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Amy L. Ladd, MD
Intellectual Property: Loci OrthopaedicsContracted Research: NIHOwnership Interests: Loci, Intuitive Surgical, Stryker
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Single Assessment Numeric Evaluation (SANE)
Is the future of PROMs in the HandSimilar to its Evolution in the Shoulder?
Amy L Ladd MDCo-authors: Jacob D Gire MD, Jayme C B Koltsov PhD, Nicole A Segovia
PhD, Deborah E Kenney MS, OTR, Jeffrey Yao MD
Disclosures
Intellectual Property: Loci Orthopaedics
Contracted Research: NIH
Ownership Interests: Loci, Intuitive Surgical, Stryker
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Questions
• What is the1-question SANE?
• How does it compare to other instruments?
• Is it good enough?
SANE
O N E Q U E S T I O N I N S T R U M E N T
Single Assessment Numeric Evaluation
-1-What is the SANE?
• Shoulder literature• Williams, Arciero Am J Sp Med 1999
• 294 PubMed references 8.30.20• 49 publications 2020 so far
• No robust validation studies until 2020• Lack of comparison to instruments, ceiling, clinical utility
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-2-Hand surgery – how does it compare?
SANE - Single assessment numeric evaluation
Methods
Retrospective review of all patients with outcome measures
Included those that underwent one of the seven most common hand surgery procedures
Isolated, unilateral with preop and/or postop outcome data
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Included hand procedures
1. Carpal tunnel release
2. Trigger finger release
3. Carpometacarpal arthroplasty
4. Wrist arthroscopy
5. Distal radius fixation
6. First dorsal compartment release
7. Cubital tunnel release
Abbreviated questionnaires & computer adaptive testing (CAT)
PROMIS-UE
QuickDASH
Compared to validated instruments
Results
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Convergent validity
Moderate to strong correlation between SANE score, QuickDASH, and PROMIS upper extremity at all time points (R 0.63 - 0.82, p<.001)
Coverage
ResponsivenessN Median IQR Range ES SRM p‐value
SANE
Baseline 165 50 30 ‐ 70 0 ‐ 95
Follow
Up151 75 60 ‐ 90 0 ‐ 100 1.0 0.9 < 0.001
Change 103 20 7 ‐ 40 ‐40 ‐ 90
QuickDASH
Baseline 132 45 32 ‐ 57 11 ‐ 91
Follow
Up122 23 11 ‐ 39 0 ‐ 70 1.1 1.1 < 0.001
Change 86 ‐18 ‐29 ‐ ‐8 ‐66 ‐ 23
PROMIS‐UE
Baseline 165 34 29‐38 15 ‐ 56
Follow
Up153 37 34‐42 24 ‐ 56 0.8 0.7 < 0.001
Change 104 5 0‐11 ‐8 ‐ 33
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-3-Is it good enough?
• For clinical assessment
• To show patients
• For cost and efficiency
-3-Is it good enough?
• For clinical and research trials
• For multiple conditions affecting same limb
• For specific task assessment
Safe conclusions - SANE
Reasonable measure to evaluate outcomes common hand procedures
Demonstrates comparable psychometric properties to the PROMIS-UE and QuickDASH outcome scores.
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Relevance to clinical practice
SANE score allows patients to self rate their outcome and response to treatment over time
SANE score incorporates other factors that lead to a patient feeling “normal”
Single item lacks granularity of a function specific measure such as QuickDASH or PROMIS upper extremity
Thank you
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Michael B. Gottschalk
Associate Professor
Emory Department of Orthopedics
Director of Clinical Research
Hand Division Chief
Upper Extremity Hand Fellowship Director
Patient Reported Outcomes (PROs)
• Definition:
•“Any response directly from the patient about a patient’s health condition without interpretation from a physician” – National Health Council
• What are they not?
•Objective measurements (e.g. 30 day readmission, %90 day mortality, antibiotic stewardship, OR utilization, RVU benchmarks
Why Collect PROs?
• Quality / Value
• Research
• Registries
• Billing
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Why do physicians not collect them?
• Difficult to collect (need a WORKING system to store, analyze, and report them; may cost time/money to practice and inconvenience to patient)
• Can’t determine which outcome measure to use
• Like “Press Ganey”, need patient buy in/responses
• Concern that PRO’s may be used for reimbursement/payment
Patient Centered Practice
• Can review patient progress
PROMs are Powerful
• Predictive analytics for patients yet to undergo surgery (e.g. SCB, PASS, MCID)
• Contrasting two surgeries to each other (value comparison outcome/cost of procedure)
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Revenue Generator
• Remote patient monitoring (99091)
• What do you need to bill for PROs
Patient Consent
Active feedback loop in real time
Reconsent within every year
Used no more than once every 30 days and not within global period; must document time spent and consent
Thank you for your time!
Introducing the Emory Upper Extremity Fellowship Inaugural Year 2021
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PROMS: What is the Value to the Patient???
PROMS: What is the Value to the Patient???
Eric R. Wagner, MD MSDivision of Upper Extremity Surgery
Department of Orthopaedic SurgeryDirector of Upper Extremity Research
Emory University, Atlanta GA
Eric R. Wagner, MD MSDivision of Upper Extremity Surgery
Department of Orthopaedic SurgeryDirector of Upper Extremity Research
Emory University, Atlanta GA
Value and PROM Collection MentorValue and PROM Collection Mentor
Value: Michael PorterValue: Michael Porter
Surgeon
Patient
Hospital
Value =Outcome(patient satisfaction,
complications)
Costs
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Value: HospitalValue: Hospital
Value (Hospital)
=IncomeOutcomes
Costs
Surgeon
Patient
Hospital
VolumeComplicationsReoperationsUtilization, Costs
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
1‐14 15‐31 32‐57 58+ 1‐16 17‐53 54+
Quartile SSLR
90‐Day Revision Rate
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
1‐14 15‐31 32‐57 58+ 1‐5 6‐25 26‐47 48‐71 72‐105 106+
Quartile SSLR
Increased Cost (> Median)
Value: SurgeonValue: Surgeon
Value (Surgeon)
=Income
Outcomes
Time
Surgeon
Patient
Hospital
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Why Measure??Why Measure??
1. To Improve Outcomes
2. To Improve Personal Skills
3. To Innovate
4. To Reduce Costs
5. To Gain Advantage over Competition
1. To Improve Outcomes
2. To Improve Personal Skills
3. To Innovate
4. To Reduce Costs
5. To Gain Advantage over Competition
Experts: Why Measure??Experts: Why Measure??
Experts: Why Measure??Experts: Why Measure??
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Expert??Expert??
Learning CurveLearning Curve
1979
Learning CurveLearning Curve
*40*>20
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Value: PatientValue: Patient
Incidence
Patient
Value
Value (Patient) =
Cost
Outcomes
Return to Work/Play
Value to the PatientValue to the Patient
Value to the PatientValue to the Patient
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Value to the PatientValue to the Patient
Value Driven Outcomes Tool
Value Driven Outcomes Tool
Improved Quality and Costs
Improved Quality and Costs
Value to the PatientValue to the Patient
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Primary TSA
Primary RSA
Revision RSAASES
SSV
VAS
How Fast Will I Recover???How Fast Will I Recover???
What is My Risk of Complications??What is My Risk of Complications??
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Why NOT Measure??Why NOT Measure??
1. Lack of Time
2. Blissful Ignorance
3. Lack of Resources
4. Don’t know what or how to measure
1. Lack of Time
2. Blissful Ignorance
3. Lack of Resources
4. Don’t know what or how to measure
Why NOT Measure??Why NOT Measure??
Value to the PatientsValue to the Patients
Value =Outcome(patient satisfaction,
complications)
Costs
PROMs
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Value to the PatientsValue to the Patients
Thank you for your time!
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