CORR Insights®: Patients Place More of an Emphasis on Physical Recovery Than Return to Work or Financial Recovery

Where Are We Now?

Patient-reported outcome (PRO) data are a hot topic in orthopaedics. Some of the emphasis is being pushed on us by outside forces (good or bad), and there is some recognition that traditionally reported outcome measures (for example, operating room time and radiographic alignment) are more important to surgeons than to patients. In my own work on the outcome after distal tibial plafond fractures, many patients with good-looking radiographs were unhappy with their outcome while others with a residual radiographic deformity were happy and functioning better than their radiographically attractive counterparts [1, 3, 12]. It is clear that patients place an importance on different parameters than surgeons do regarding outcomes after orthopaedic trauma and orthopaedic interventions for a variety of pathologic findings. In addition, value-based payments are increasingly based on PROs, but some research suggests that there is a general lack of good PRO measures (PROMs) that are validated, consistent, comparable, and have face validity [9]. PROMs that are not well validated or that do not measure the endpoints we seek may result in misleading conclusions.

In the article “Patients Place More of an Emphasis on Physical Recovery Than Return to Work or Financial Recovery” [8], O’Hara et al. found that patients identified physical recovery as the highest priority during the first year after treatment, although return to work and financial recovery became progressively more important over time. The study identified the importance of regularly asking patients about their changing priorities in sequential office follow-up visits during fracture recovery. These findings were independent of the occurrence of complications or patient socioeconomic factors, such as preinjury employment status. After reading this article, I plan to ask and document patients’ general and financial concerns, particularly after the initial treatment, and then inquire about changing concerns over the course of their recovery during the first year.

Some of the current limitations to accurately measuring satisfaction (a form of PROs) objectively and quantitatively are well outlined by Ring and Leopold [11]. They emphasized the need for face validity (that is, the measure must reproducibly and accurately reflect the spectrum of a patient’s response to treatment). A useful PRO must minimize the confounding impact of psychological comorbidities. Useful PROs must also measure parameters that are truly important to the patient and that are not merely convenient. For example, patients might want antibiotics for colds and an MRI for their first episode of lumbago (low back pain), but those treatments are not effective and they waste healthcare resources. The narcotic epidemic was partially a response to third-party intervention into the doctor-patient relationship and emphasis on “the fourth vital sign-pain” and right to “freedom from all pain” concept [5]. Fenton et al. [2] reported increased patient satisfaction with increased prescriptions, cost of care, and in-patient location. They also reported an increased death rate, indicating that sometimes giving patients what they want is not good for them.

PROs in orthopaedic trauma were discussed at the 2013 Orthopaedic Trauma Association’s annual meeting and recently (November 2020) updated in a webinar called “Utilizing Patient Reported Outcome (PRO) Measures in Orthopaedic Trauma: What Have We Learned and Where are We Headed?” [9]. PROMs are increasingly being reported in orthopaedic studies, and they affect orthopaedic surgeons in terms of reimbursement schemes and credentialing. Unfortunately, there is little validation or standardization of these measures, which limits their utility.

Where Do We Need To Go?

It is clear that there are gaps in existing knowledge and we need good input data from PROMs if desired results are to be achieved. Current PROMs can be improved by developing and using validated scales and techniques that are comparable and consistent. That will make it possible to compare apples and oranges using standardized scales of objective, quantifiable parameters such as weight and caloric content. PROMs must be flexible, reflecting changing patient priorities as identified by this study [8]. Studies using PROMs also need to account for the variability introduced by psychological comorbidities and be sensitive to situations where there is discrepancy between what patients want and what they need. PROMs must be scientifically sound, and studies using those PROMs must consider known confounding effects.

Although PROMs have mostly been applied to specific interventions such as the particular treatment of a particular fracture, there is potential benefit in applying the same concepts to systems-based measurements such as the patient’s evaluation of their overall experience with a doctor or orthopaedic clinic.

One controversial topic on this theme is whether providers or healthcare regulators should be the ones to develop, record, and use these measures. Obviously, the perspective of the developer, recorder, or user will be reflected in the nature of the measure. A provider is likely to use a PROM to choose between treatment options for future patients. Regulators and payors will likely use PROMs to make reimbursement and contractual allowance decisions.

How Do We Get There?

Future studies should compare existing PRO tools in patients treated for common conditions and injuries in order to identify which tools most accurately, sensitively, and easily capture the most-important elements of recovery from musculoskeletal conditions. Validated scales should be identified and promoted for consistent and comparable results between studies. PROMs that are not scientifically sound should be identified and replaced. The American Orthopaedic Foot and Ankle Association has recently started this process [4, 10]. Once validated PROMs are identified, a large number of common orthopaedic interventions should be studied to quantify the value provided by these interventions. Fracture treatment is a great place to start because fractures are common and readily identified by bone segment [7]. Furthermore, a small number of different treatments are used for most fractures, and fracture healing usually occurs over a short period of time (2-6 months), enabling good data acquisition and meaningful comparisons.

As in O’Hara et al.’s study [8] in this month’s Clinical Orthopaedics and Related Research®, the changing priorities of patients over time should be identified for a wide variety of conditions, and common patterns should be identified. Techniques need to be developed to allow a given PROM to reflect the patient’s changing priorities over time. Adjusting the weighting given to particular questions or sections is an attractive technique to achieve this goal.

In addition to an analysis of the response to an intervention, system-wide evaluations should be performed. Press Ganey and Consumer Assessment of Healthcare Providers and Systems evaluations of hospital systems are in widespread use [6]. Although far from perfect, these tools can be used for this new purpose to provide useful feedback and guidance. Instead of measuring the response to treatment of a fracture, they can measure patient responses to their overall interaction with the orthopaedic clinic. The process of receiving care from an orthopaedic practice can be assessed to potentially provide valuable information to the practice, payors, regulators, patients, and society. Additionally, the American Board of Orthopaedic Surgeons will increasingly incorporate standard PROMs into their board-certification credentialing and maintenance of certification process.