Outcome measurement in hand surgery: What is important to patients?
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Date
2024
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Habilitation Thesis
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Abstract
Background: In recent years, the use of patient-reported outcome measures (PROMs) in the evaluation of orthopaedic interventions of the hand has become indispensable. Before a PROM can be used, it should be tested for its measurement properties. In the past, the measurement properties of several PROMs for patients with hand disorders have not been fully investigated. Besides the traditional measurement properties of reliability, validity and responsiveness, the concepts of Minimal Important Change (MIC) and Patient Acceptable Symptom State (PASS) are becoming increasingly popular for assessing treatment effects from the patient's perspective. The MIC is the smallest change in a PROM that patients perceive as being important. The PASS is the value beyond which patients consider themselves well.
Objectives: The research questions addressed in this thesis were: (1) to assess the measurement properties of PROMs commonly used in hand surgery; (2) to establish MIC and PASS thresholds; (3) and to define clinically relevant preoperative thresholds for PROMs at which patients have the greatest chance of achieving a MIC and PASS after surgery.
Methods: The measurement properties of reliability, validity and responsiveness were assessed for the Michigan Hand Outcomes Questionnaire (MHQ), the brief MHQ, the Unité Rhumatologique des Affections de la Main (URAM) scale and the EuroQol EQ-5D-5L. Five clinical studies evaluated patients with thumb carpometacarpal osteoarthritis, Dupuytren's disease, carpal tunnel syndrome, arthroscopic rotator cuff repair and total shoulder arthroplasty. Furthermore, the MIC and PASS were determined for several outcome measures in different patient populations. Prediction models were developed to define preoperative thresholds above which patients have the highest chance of achieving a MIC or PASS one year after surgery.
Results: All PROMs showed good measurement properties in patients with different hand and upper extremity conditions. Based on these results, recommendations could be made on which outcome measure to choose in hand surgery. Furthermore, the MIC and PASS could be determined for several outcome measures. A set of recommendations for surgeons regarding the optimal timing of surgery in the course of hand osteoarthritis could be defined.
Conclusions: This work will help hand surgeons and researchers to define the most appropriate PROM to monitor their patients or to assess the outcome in clinical trials. The defined MIC and PASS values are useful tools for interpreting the outcome of individual patients in clinical routine, for appraising study results and for sample size calculations. In routine clinical practice, the surgeon can assess whether the treatment has had a subjectively important effect on the patient and whether the patient is satisfied despite potential residual symptoms. For the interpretation of study results, knowledge of the MIC and PASS is crucial to look beyond p-values, which do not consider the magnitude of a treatment effect. The determined thresholds may support surgeons in the preoperative process of deciding for or against a surgical intervention, and in explaining the probability of achieving sufficient postoperative symptom relief to the patient.
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Examiner : Ferguson, Stephen
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ETH Zurich
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02070 - Dep. Gesundheitswiss. und Technologie / Dep. of Health Sciences and Technology