I am working on a protocol that would implement a surgeon’s “Toolbox” for use in elderly patients considering major surgery. It includes:
- NSQIP surgical risk calculator: provides individualized risk information to patients compared with the “average” patient.
- E-prognosis calculator: provides estimated mortality risk over 1, 5, and 10 years for your patient without surgery. Will function as a baseline.
- A brief tool to facilitate the discussion about surgical risks using a “best case/worst case” framework that we anticipate will enhance patient understanding of the expected postoperative course.
1. Considering the protocol you are developing: identify the process and outcome indicators associated with the program and briefly describe an approach to measuring each.
Process Indicators: Surgeon use of the toolbox.
- Qualitative measure: Measured by doing qualitative brief interviews with surgeons and asking: Are you using the tool box? If yes -> How are you using it? In which clinical scenarios? If not -> Are you interested in using it?
- Quantitative measure: I am working with the EMR developers to see how we can most efficiently measure this. A reasonable plan will be to monitor the clinic notes (documenting use of the calculators) and the after visit summary (with the calculator reports) that is given to each patient when they leave clinic and determine which patients over age 65 the tool box is being used in.
Initial outcome Indicators
- Improved patient knowledge of surgical options and expected postoperative course. Measure: patient interview/survey.
- Patient/surgeon satisfaction with the clinical encounter. Measure: patient/surgeon survey.
Intermediate outcome measures:
- Surgeons engage patients in decision making. Measure: Surgeon interview/survey
- Patients participate in decision making. Measure: Patient interview/survey.
Long-term Outcome Measures
- Surgeons value patient preferences. Measure: Surgeon interview/survey
- Operations performed that are in-line with best medical evidence and patient values. Measure: Patient survey
- Reduced decisional regret. Measure: Patient survey.
2. Define one or more “intermediate” outcome measures (reflecting changes in environment, organizational culture, systems of care, patient or public behavior, and/or clinician behaviors) that can inform you about the mechanism by which your intervention achieves its downstream effect on health inform you about the acceptability of your intervention.
The intermediate outcome indicators were 1) surgeons engage patients in decision making and 2) patient participation in decision making. I planned to measure this using patient and surgeon interviews/surveys. This will be particularly effective (although time intensive) for informing me about the mechanism of how the intervention achieves its downstream effects (long-term indicators) because the interviews can be tailored to get that information.