Patients Place More of an Emphasis on Physical Recovery Than Return to Work or Financial Recovery

Abstract

Background Value-based healthcare models aim to incentivize healthcare providers to offer interventions that address determinants of health. Understanding patient priorities for physical and socioeconomic recovery after injury can help determine which services and resources are most useful to patients. Questions/purposes (1) Do trauma patients consistently identify a specific aspect/domain of recovery as being most important at 6 weeks, 6 months, and 12 months after an injury? (2) Does the relative importance of those domains change within the first year after injury? (3) Are differences in priorities greater between patients than for a given patient over time? (4) Are different recovery priorities associated with identifiable biopsychosocial factors? Methods Between June 2018 and December 2018, 504 adult patients with fractures of the extremities or pelvis were surgically treated at the study site. For this prospective longitudinal study, we purposefully sampled patients from 6 of the 12 orthopaedic attendings’ postoperative clinics. The participating surgeons surgically treated 243 adult patients with fractures of the extremities or pelvis. Five percent (11 of 243) of patients met inclusion criteria but missed their appointments during the 6-week recruitment window and could not be consented. We excluded 4% (9 of 243) of patients with a traumatic brain injury, 1% (2) of patients with a spinal cord injury, and 5% (12) of non-English-speaking patients (4% Spanish speaking [10]; 1% other languages [2]). Eighty-six percent of eligible patients (209 of 243) were approached for consent, and 5% (11 of 209) of those patients refused to participate. All remaining 198 patients consented and completed the baseline survey; 83% (164 of 198 patients) completed at least 6 months of follow-up, and 68% (134 of 198 patients) completed the 12-month assessment. The study participants’ mean age was 44 ± 17 years, and 63% (125 of 198) were men. The primary outcome was the patient’s recovery priorities, assessed at 6 weeks, 6 months, and 12 months after fracture using a discrete choice experiment. Discrete choice experiments are a well-established method for eliciting decisional preferences. In this technique, respondents are presented with a series of hypothetical scenarios, described by a set of plausible attributes or outcomes, and asked to select their preferred scenario. We used hierarchical Bayesian modeling to calculate individual-level estimates of the relative importance of physical recovery, work-related recovery, and disability benefits, based on the discrete choice experiment responses. The hierarchical Bayesian model improves upon more commonly used regression techniques by accounting for the observed response patterns of individual patients and the sequence of scenarios presented in the discrete choice experiment when calculating the model estimates. We computed the coefficient of variation for the three recovery domains and compared the between-patient versus within-patient differences using asymptotic tests. Separate prognostic models were fit for each of the study’s three recovery domains to assess marginal changes in the importance of the recovery domain based on patient characteristics and factors that remained constant over the study (such as sex or preinjury work status) and patient characteristics and factors that varied over the study (including current work status or patient-reported health status). We previously published the 6-week results. This paper expands upon the prior publication to evaluate longitudinal changes in patient recovery priorities. Results Physical recovery was the respondents’ main priority at all three timepoints, representing 60% ± 9% of their overall concern. Work-related recovery and access to disability benefits were of secondary importance and were associated with 27% ± 6% and 13% ± 7% of the patients’ concern, respectively. The patients’ concern for physical recovery was 6% (95% CrI 4% to 7%) higher at 12 months after fracture that at 6 weeks postfracture. The mean concern for work-related recovery increased by 7% (95% CrI 6% to 8%) from 6 weeks to 6 months after injury. The mean importance of disability benefits increased by 2% (95% CrI 1% to 4%) from 6 weeks to 6 months and remained 2% higher (95% CrI 0% to 3%) at 12 months after the injury. Differences in priorities were greater within a given patient over time than between patients as measured using the coefficient of variation (physical recovery [245% versus 7%; p < 0.001], work-related recovery [678% versus 12%; p < 0.001], and disability benefits [620% versus 33%; p < 0.001]. There was limited evidence that biopsychosocial factors were associated with variation in recovery priorities. Patients’ concern for physical recovery was 2% higher for every 10-point increase in their Patient-reported Outcome Measure Information System (PROMIS) physical health status score (95% CrI 1% to 3%). A 10-point increase in the patient’s PROMIS mental health status score was associated with a 1% increase in concern for work-related recovery (95% CrI 0% to 2%). Conclusion Work-related recovery and accessing disability benefits were a secondary concern compared with physical recovery in the 12 months after injury for patients with fractures. However, the importance of work-related recovery was elevated after the subacute phase. Priorities were highly variable within a given patient in the year after injury compared with between-patient differences. Given this variation, orthopaedic surgeons should consider assessing and reassessing the socioeconomic well-being of their patients throughout their continuum of care. Level of Evidence Level II, therapeutic study.

Patients value their own pain over braking safety when deciding when to return to driving: a discrete choice experiment on lower extremity injuries

“…It is possible that some patients were counseled on returning to driving prior to completing the survey. While this study was not designed to assess the impact of these external factors, previous research has demonstrated that patient recovery preferences remain relatively robust during the first 12 months after injury [25] . We did not collect data on the type or severity of the lower extremity fracture and are, therefore, unable to investigate preference variation based on these factors.…”

“…While this study was not designed to assess the impact of these external factors, previous research has demonstrated that patient recovery preferences remain relatively robust during the first 12 months after injury. [ 25 ] We did not collect data on the type or severity of the lower extremity fracture and are, therefore, unable to investigate preference variation based on these factors. Our study excluded non-English speaking patients, which may limit the generalizability of the results.…”

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

“…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.…”

“…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.…”

“…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.…”