How Do We Value Postoperative Recovery?

A Systematic Review of the Measurement Properties of Patient-Reported Outcomes After Abdominal Surgery

Julio F. Fiore Jr, PT, MSc, PhD; Sabrina Figueiredo, PT, MSc, PhD; Saba Balvardi, MS; Lawrence Lee, MD, PhD; Bénédicte Nauche, MLIS; Tara Landry, MLIS; Nancy E. Mayo, PhD; Liane S. Feldman, MD

Disclosures

Annals of Surgery. 2018;267(4):656-669. 

In This Article

Abstract and Introduction

Abstract

Objective: To appraise the level of evidence supporting the measurement properties of patient-reported outcome measures (PROMs) in the context of postoperative recovery after abdominal surgery.

Background: There is growing interest in using PROMs to support value-based care in abdominal surgery; however, to draw valid conclusions regarding patient-reported outcomes data, PROMs with robust measurement properties are required.

Methods: Eight databases (MEDLINE, EMBASE, Biosis, PsycINFO, The Cochrane Library, CINAHL, Scopus, Web of Science) were searched for studies focused on the measurement properties of PROMs in the context of recovery after abdominal surgery. The methodological quality of individual studies was evaluated using the consensus-based COSMIN checklist. Evidence supporting the measurement properties of each PROM was synthetized according to standardized criteria and compared against the International Society of Quality of Life Research minimum standards for the selection of PROMs for outcomes research.

Results: We identified 35 studies evaluating 22 PROMs [12 focused on nonspecific surgical populations (55%), 4 focused on abdominal surgery (18%), and 6 generic PROMs (27%)]. The great majority of the studies (74%) received only poor or fair quality ratings. Measurement properties of PROMs were predominantly supported by limited or unknown evidence. None of the PROMs fulfilled International Society of Quality of Life Research's minimum standards, hindering specific recommendations.

Conclusions: There is very limited evidence supporting the measurement properties of existing PROMs used in the context of recovery after abdominal surgery. This precludes the use of these PROMs to support value-based surgical care. Further research is required to bridge this major knowledge gap.

Introduction

Abdominal surgery accounts for the highest volume of in-hospital operations performed in North America and imposes substantial economic burden on healthcare systems.[1,2] For patients, abdominal surgery represents a major stressor resulting in a rapid health decline postoperatively, requiring weeks or months for full recovery (ie, getting back to "normal").[3] This health decline is primarily caused by a cascade of metabolic and hormonal events triggered by tissue trauma and may be further affected by postoperative complications and specific perioperative interventions (eg, opioid analgesia).[4] While recovering, patients withdraw from household, leisure, and economic activities and often require assistance.[5,6] As hospital stays are getting shorter, societal costs of surgery are increasingly impacted by recovery after hospital discharge.[6]

In recent years, costly and resource-intensive innovations in abdominal surgery (eg, laparoscopy, robotic surgery, perioperative care pathways, new pharmacological interventions) have been proposed to improve postoperative recovery.[7] For these to be adopted, they should increase the value of surgery—defined as "health outcomes achieved that matter to patients relative to the cost of achieving those outcomes."[8] Surgical recovery, however, is a latent outcome (ie, not directly observable or quantifiable) that is difficult to measure.[3] The process of recovery is highly dynamic and comprises multiple dimensions of health (eg, symptom experiences, functional status, and well-being); therefore, it cannot be easily captured by traditional metrics.[3] Studies on interventions aimed to improve recovery commonly rely on "proxy" measures such as length of stay and complication rates,[9] which are of interest for clinicians but do not reflect the complexity of the recovery process and fail to capture the perspective of patients.

As understanding patients' perspective is crucial for delivering high-value patient-centered care,[10] recent literature advocates that measurement of recovery includes the patients' voice through patient-reported outcomes (PROs; reports of health coming directly from the patient without interpretation by others[11]).[3,9,12] The main advantage of using PRO measures (PROMs) in the context of recovery is that they allow a broad assessment of health across various domains, engaging patients as the key stakeholders in the recovery process.[13] Also, PROMs generally take the form of questionnaires that can be completed at different time points, allowing a better understanding of the recovery trajectory beyond hospital discharge. In addition to bringing the patients' perspective into surgical research, PROMs can be a useful tool to improve delivery of care. For example, if collected routinely in daily practice, PRO data may inform clinician-patient communication about recovery expectations – return to normal activities[14] and fitness to undergo further treatment (eg, adjuvant oncologic therapies).[15] Furthermore, PROMs can help promoting postoperative self-management by empowering patients to track their own recovery trajectory in real-time and potentially identify complications at a point when they may be more easily treated.[16]

There is growing interest in using PROMs to support patient-centered decision making, measure provider performance and inform quality improvement initiatives in surgery;[17,18] however, to draw valid conclusions regarding PRO data, PROMs with robust measurement properties are required, that is with evidence supporting that they accurately measure aspects of health that are relevant to patients. The aim of this systematic review is to appraise the level of evidence supporting the measurement properties of PROMs in the context of postoperative recovery after abdominal surgery.

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