Patient-reported complications after elective joint replacement surgery Are they correct?
University College Hospital, 235 Euston Road, London NW1 2BU, UK. The Bone & Joint Journal
(Impact Factor: 3.31).
08/2012; 94(8):1120-5. DOI: 10.1302/0301-620X.94B8.29040
Using general practitioner records and hospital notes and through direct telephone conversation with patients, we investigated the accuracy of nine patient-reported complications gathered from a self-completed questionnaire after elective joint replacement surgery of the hip and knee. A total of 402 post-discharge complications were reported after 8546 elective operations that were undertaken within a three-year period. These were reported by 136 men and 240 women with a mean age of 71.8 years (34 to 93). A total of 319 reported complications (79.4%; 95% confidence interval 75.4 to 83.3) were confirmed to be correct. High rates of correct reporting were demonstrated for infection (94.5%) and the need for further surgery (100%), whereas the rates of reporting deep-vein thrombosis (DVT), pulmonary embolism, myocardial infarction and stroke were lower (75% to 84.2%). Dislocation, peri-prosthetic fractures and nerve palsy had modest rates of correct reporting (36% to 57.1%). More patients who had knee surgery delivered incorrect reports of dislocation (p = 0.001) and DVT (p = 0.013). Despite these variations, it appears that post-operative complications may form part of a larger patient-reported outcome programme after elective joint replacement surgery.
Available from: Karina MM Reynolds
- "Currently, there is limited literature on the additional value of patient-reported complications following surgery. We are only aware of three studies (Dushey et al, 2011; Alazzawi et al, 2012; Greenbaum et al, 2012) examining concordance of clinical and patient-reported complications, in elective hip and knee replacement surgery. These suggest variable rates of correct reporting for different complications with good concordance for clearly defined complications such as deep vein thrombosis (DVT) and pulmonary embolism (PE) and poor concordance for those less clearly defined such as 'major bleeding'. "
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Most studies use hospital data to calculate postoperative complication rates (PCRs). We report on improving PCR estimates through use of patient-reporting.
A prospective cohort study of major surgery performed at 10 UK gynaecological cancer centres was undertaken. Hospitals entered the data contemporaneously into an online database. Patients were sent follow-up letters to capture postoperative complications. Grade II–V (Clavien–Dindo classification) patient-reported postoperative complications were verified from hospital records. Postoperative complication rate was defined as the proportion of surgeries with a Grade II–V postoperative complication.
Patient replies were received for 1462 (68%) of 2152 surgeries undertaken between April 2010 and February 2012. Overall, 452 Grade II–V (402 II, 50 III–V) complications were reported in 379 of the 1462 surgeries. This included 172 surgeries with 200 hospital-reported complications and 231 with 280 patient-reported complications. All (100% concordance) 36 Grade III–V and 158 of 280 (56.4% concordance) Grade II patient-reported complications were verified on hospital case-note review. The PCR using hospital-reported data was 11.8% (172 out of 1462; 95% CI 11–14), patient-reported was 15.8% (231 out of 1462; 95% CI 14–17.8), hospital and verified patient-reported was 19.4% (283 out of 1462; 95% CI 17.4–21.4) and all data were 25.9% (379 out of 1462; 95% CI 24–28). After excluding Grade II complications, the hospital and patient verified Grade III–V PCR was 3.3% (48 out of 1462; 95% CI 2.5–4.3).
This is the first prospective study of postoperative complications we are aware of in gynaecological oncology to include the patient-reported data. Patient-reporting is invaluable for obtaining complete information on postoperative complications. Primary care case-note review is likely to improve verification rates of patient-reported Grade II complications.
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ABSTRACT: The incidence of vascular injuries associated with total hip arthroplasty (THA) is low. However, several vascular structures are at risk of injury within the pelvis. These include the external iliac, femoral, and obturator vessels. Both reaming of the acetabulum and drilling of the acetabular screw holes may place these structures at risk. If left untreated, injuries to these vessels may be associated with severe morbidity and mortality. In this report, an acute vascular complication that had an unusual presentation is highlighted. A 72-year-old woman presented to the emergency department following a road traffic accident in which she sustained a combined fracture of the right acetabulum and femoral head. Her treatment involved a combination of THA and pelvic open reduction and internal fixation. The immediate perioperative recovery period was uncomplicated. However, the patient developed a deep venous thrombus in her right calf 7 days after surgery. Further investigation revealed a second thrombus, occluding the right common femoral vein. Surgical exploration revealed that a screw placed during the initial surgery was pressing against the vessel and occluding it. The discrepancy in incidence between the development of deep venous thrombosis and vascular compression or injury means that the association between the 2 events is unlikely to be made. The author highlights this unusual presentation to improve early recognition and prompt management of similar cases. The importance of adequate preoperative planning and intraoperative imaging with a C-arm is also stressed.
Available from: Joanne Greenhalgh
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The use of patient-reported outcome measures (PROMs) to provide healthcare professionals with peer benchmarked feedback is growing. However, there is little evidence on the opinions of professionals on the value of this information in practice. The purpose of this research is to explore surgeon’s experiences of receiving peer benchmarked PROMs feedback and to examine whether this information led to changes in their practice.
This qualitative research employed a Framework approach. Semi-structured interviews were undertaken with surgeons who received peer benchmarked PROMs feedback. The participants included eleven consultant orthopaedic surgeons in the Republic of Ireland.
Five themes were identified: conceptual, methodological, practical, attitudinal, and impact. A typology was developed based on the attitudinal and impact themes from which three distinct groups emerged. ‘Advocates’ had positive attitudes towards PROMs and confirmed that the information promoted a self-reflective process. ‘Converts’ were uncertain about the value of PROMs, which reduced their inclination to use the data. ‘Sceptics’ had negative attitudes towards PROMs and claimed that the information had no impact on their behaviour. The conceptual, methodological and practical factors were linked to the typology.
Surgeons had mixed opinions on the value of peer benchmarked PROMs data. Many appreciated the feedback as it reassured them that their practice was similar to their peers. However, PROMs information alone was considered insufficient to help identify opportunities for quality improvements. The reasons for the observed reluctance of participants to embrace PROMs can be categorised into conceptual, methodological, and practical factors. Policy makers and researchers need to increase professionals’ awareness of the numerous purposes and benefits of using PROMs, challenge the current methods to measure performance using PROMs, and reduce the burden of data collection and information dissemination on routine practice.
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