Chapters Transcript Video Complex hernia repair and AWR - Patient quality of life - John P. Fischer, M.D. Well, good morning, everyone. Um, Kyle, what's up, brother? Uh, want a special special thanks to Gore for for doing this, it's It's been a while since we've been together, and it kind of feels great to be in person again. So So it's awesome to see folks and be here. Um, this talks about patient reported outcomes in hernia surgery, which I think is really important thing because I think that when you kind of boil it down when we're treating these complex patients, it's it's really about function and quality of life. I think more than anything else, I'm a plastic surgeon from Philadelphia. So what is a patient reported outcome? So I think it's really important to understand and appreciate that. And so a P. R o, uh, is any report of the patient's status of their health, and it comes directly from them, um, really with with no interpretation. So it's really kind of representation of how the patient is doing what they're experiencing and kind of how they responded to surgery. And so I think for me that the reason why I'm so passionate about P. R. O s, um, and quality of life um in hernia surgery, I think kind of is derived from a conference I was able to attend when I was a resident in D. C. Um, my chief year, actually, the bureau's conference. Um, it was a plastic surgery conference, but it really, I think, inspired me to want to measure P. R. O s in my complex hernia patients. And so I think it becomes an important representation of our work. And so I think that it's something I have to think about measuring. So So I think the question is, you know why Pierrot matters so much in a W. R. And here's here's kind of, I think, a great representation of why, um so this patient obviously has kind of an interesting defect. It's It's not a England attorney. It's actually a four time recurrent super pubic defect after a medical tram for left side of breast reconstruction. And so um, her surgical goal or her goal was to be able to wear jeans. And so, um, I think that that kind of is interesting, which which makes sense. Um, but it's also kind of in great alignment with the clinical goal, which is to to fix the hernia. And so I think when you have that type of alignment between patient defined goal and surgical goal, I think you can really achieve some awesome things in abdominal wall reconstruction. And I think that, um, she got what she wanted and she did really well, which is awesome. And so you can see her preoperative defect. You can see her post operative result and of course you can see her. I think most importantly, you know, wearing a pair of jeans postoperative, which is so important and it's so meaningful. And when you look at her quality of life, the foreign after surgery, I think it went up really, really high. And so this is not the truth for every patient. But I think in most of our patients it's it's really, really important, and so quality of life in my mind gives us another dimension with which we can measure the care that we're delivering for our patients. So we have clinical outcomes, we have costs and now we have kind of quality of life as a tool to be able to measure outcomes for patients really, really fun to do that. Um and so here's I think a good example, too, of kind of why function is so important. This guy had a 13 centimeter midline defect. Um, you know, he can't sit up retired guy, He can't sit up. And so when we hear from some of our I think world class faculty about component separations and techniques, I think we'll kind of get a greater appreciation for how much we can improve quality of life with these advanced techniques and bio materials. He did. We didn't open tar for him, reconstruct his abdominal wall, got his midline fashion back together, and you can see him fast forward. Um, you know, three years later, Uh, really, really nice result for him. I charge them extra for the six pack. Obviously, Um and, uh, you know, I think that that's kind of a plastic surgeon and me kind of coming out a little bit. Um, but I think it really speaks to the importance of getting a good result for these folks and, uh, trying to trying to improve quality of life through our operations. Um and so so p r o. M. Or patient. Reported outcome measures are basically the tools that we use to measure these p r O s, which are the representation of quality of life, which I think is really, really cool. So let's kind of get into, like, why it matters. Okay, so I have a large journey, Um, and so that's going to affect my abdominal wall function. And so So? So why does it affect function? Well, the abdominal wall is a complex unit that provides function for the torso, provides movement and stability. Um, and there's a dynamic interplay between the muscles of the abdominal wall. The rectus is involved in trunk reflection, the external oblique rotation and lateral flexion, the internal oblique kind of similar function. And the transverse abdominals, of course, is involved in a generation of abdominal pressure. So So these muscles kind of work in almost in synergy, like a like a well, um, well orchestrated set of muscles kind of giving you the function. You need to, you know, stand up. Sit down. You know, cough, laugh, all these different things and so important for for abdominal wall core function. And so when you develop a hernia, what happens is some of this function is disrupted. So I I kind of think it's It's so fascinating that, you know, the the hernia health state is disruption of that normal abdominal wall structure and function and what it leads to. So a midline hernia leads to simply simply put lateral displacement of the rectus of dominance. And and the core doesn't work as well. Um, uh, Jensen and colleagues published a wonderful article in annals of surgery. Um, and and it shows that it's that lateral displacement that leads to distorted function. And you may ask yourself, Well, is it Is it proportional like there's a bigger Hurney usually lead to more disruption and function. The answer is absolutely yes. The bigger the hernia, the more disruption and core function and poor health. And so so what happens? Well, when those muscles are out of alignment and everything is pulled away, you know, you get, uh, you get fibrosis. Uh, the abdominal wall becomes less compliant and less able to work. And, you know, I think one of the emerging tools that we use that I think, you know, um, talk. Other people have had pioneered the use of chemo to innovation, the abdominal wall almost reversing this before we operate on folks, so we'll hear about that probably later on. So this correlates perfectly with symptom Atala ji. And so when you look at patients who have a large hernia incision, all hernia lowers physical functioning in terms of score and body image, so patients feel like they don't have their core strength. Can't do activities, have a lower body image so really, really important, but also what you're doing for your patients? Your techniques and your repairs and your reconstructions are improving. Quality of life, decreasing pain, improving depression. Um, and I think what's awesome is it's independent of surgical techniques, so you can do your external oblique release. You can do it robotically. You can do it open. As long as you reconstruct and rehabilitate the abdominal wall, there's gonna be a major improvement in quality of life, which is awesome. And of course, I think recurrence kind of kind of, because the other side of that coin, you know, with recurrent kind of you have, um, some loss of that function decrease in satisfaction and, um, obviously some associated issues with pain, mesh sensation and lower quality of life. Here is this article that I was referring to I think you know, everyone has their favorites, like favorite kid favorite article of literature. Um, you know, uh, this article is awesome. It's my favorite article on quality of life. And so why? I think it's so important. It tells a very clear story about quality of life in hernia surgery. And that story is simple is that if you can successfully put the fashion back together and reconstruct the abdominal wall, there is a quantifiable, statistically significant improvement in trunk reflection and trunkful extension, and that directly leads to an improvement in physical, health related quality of life. Simply put, you fix a hernia. You're making a person better and and quantifiable. And so it's a wonderful prospective observational cohort study. And so the reason in my mind why we need P. R. O s and and the use of proms in a WRs because we fix a lot of different types of stuff, uh, types of hernias and we have a wide range of approaches. And so I think in the end, you know that the outcomes that we care about they're not binary, it's not yes or no that you get a complication. It should be you know yes or no? Did we? You know, measurably improved quality of life, and and you can see the different types of problems that you know, many of us treating it in a given in a given week in practice and so very, very diverse types of defects. And so we really want to think kind of beyond just binary clinical outcomes. And so it becomes part of this, I think, concept about value. And so when we talk about the idea of value, at least in medicine, we're talking about the output or the quality of the kind of the care that we're delivering relative to the cost. And so I would make the argument to you that for these complex hernias, if we're not quantifying the quality of life improvements that were imparting with our surgeries that were not completely measuring the numerous, uh, measuring the numerator in terms of how we're defining our value and so really, really important that I think that we measure quality of life in these patients. And so another great kind of benefit, um, of P. R. O s in my mind is that it's a great way to just make sure that we're in alignment with our clinical outcomes because oftentimes, at least as a plastic surgeon, I feel like I've done a good job. The operation made sense, and it looks right. But the patient may not be happy, and so so what we're doing is we're trying to kind of be in that green dot We're trying to get alignment between the P r O, what the patient experiences and what we're seeing. And so, I think, another great reason to consider using quality of life measures in clinical practice. And I think here's a couple of cases of of, I think, kind of where that might make sense. You know, three very challenging defects. Most of these patients, uh, two or three of these patients had complications. And so, um, what I think is kind of cool about these cases is that, um, you know, even though they had complications, they had major improvement in quality of life. But if we weren't measuring quality of life, we wouldn't have an in depth understanding of how much you know. The operation impacted them as individuals. And so I mentioned this before, but proms basically a tool to measure quality of life. We want it to be specific to the problem at hand. We wanted to, I think matter to the patient that we're using it upon. And it has to be what's called psychometric Lee valid, which basically means that it's been statistically tested to be able to be usable in that disease state. And here's kind of the way I would think about it is, is if you have a patient outcome and you use a P R O M prom, you can basically take what seems like a binary outcome, and you can transform it and kind of look at it in a different way. You can really, I think, visualize all these different aspects of how the patient is doing, whether it's function, satisfaction, pain or well being. And so we're basically transforming binary outcomes to multidimensional outcomes. And so the benefits, I think, are obvious. I think in the future, in particular for hernia. I think there's going to be, um, almost incentives or maybe even mandates about proms and measuring quality of life. But only can they be used for therapeutic choices, disease management reimbursement. But I think it's a great way to um, I think advocate for our patients to make sure that we're doing the right operation for the right patient for the right reason at the right time. So really, really important. A quick word about generic versus disease specific. So a generic instrument like the SF 36 of the SF 12 basically measures how a patient is holistically doing, whereas a disease specific measure is focused on a specific type of problem or disease state very sensitive to change most appropriate for surgical interventions. I think the most well published and most importantly the literature is the Carolina comfort scale that Doctor Hereford developed. Um, most widely used in current practice. Um, it focuses on mesh and pain. Um and, um, I think really, really important. Multiple articles in the published literature on This is a great example of a head to head comparison of the Carolina comfort scale from Dr Henry Ford's Group compared to the S S 36 in the Journal of the American College of Surgeons, showing that it was more responsive, um, in terms of measuring positive outcomes in hernia patients and so again, a great example of why a disease specific P R O measure is superior to a generic measure and why it's so important to be able to discriminate positive outcomes in these patients again. Publishing Jacks Another really, really nice article by Mike Rosen's group called the Hercules Publishing Jacks. This is an instrument that was kind of designed by a group of surgeons. 16 questions that it really captures some important things about abdominal wall function, quality of life, activities of daily living and so really, really nice instrument used in clinical practice. And here is just a great article that I think kind of captures all of this, which is a systematic review of the literature and plastic and reconstructive surgery by Parag Pinot Meow Nahabedian and colleagues. It looked at 22 studies, and basically what it showed is what we kind of already know, which is that a good repair globally improves quality of life for our patients. It improves functionality kind of awesome that improves social function and satisfaction, and recurrence leads to decreased quality of life. And one of the conclusions of their article, which kind of inspired some of research, is that adoption of an abdominal wall procedure specific quality of life to us. Very important. And so So we kind of thought about this and we looked at the Carolina conference call with Hercules and based upon those, I think to really, really important, um, instruments, we kind of created our own, and we kind of share that with you in just a few minutes. Um, here, in my mind, is a great reason why if you're doing research, you should think about using P. R. O. S is a great randomized control trial for those that do laparoscopic hernia. This compares whether or not you should close the fashion. So bridging single crown fixation compared to bridging double Crown fixation compared to close fashion double crown fixation, no different. All right, so the clinical outcomes are the same. But what I think is striking is that there was a statistically significant improvement in quality of life and the patients that had their fashion clothes, which I think is just awesome. Basically, this article, if you didn't measure quality of life, you would have said, Well, I don't have to close the fashion, but this tells me you probably should, because you're gonna give your patients more function if you can so I think really, really important and giving us, I think, an example of why quality of life in addition to, you know, kind of using in our clinical practice to help us do better, I think can inform research. So really, really important. Great article by Michael Yang's group that I think shows that in patients who undergo hernia repair, um, you can you can get these patients to almost what a non hernia patient quality of life would be. So a good repair, really, I think can restore normalcy almost, which is amazing. We thought about this a lot of 10, and I guess inspired probably by Dr. Henry Ford's research. I think, um, we we kind of did this really, really cool set of studies. We work with some qualitative researchers. What that means is basically people that, um, do research, uh, that that is kind of qualitative and not quantitative in nature. So a lot of kind of conceptual research, Um and so what we did is we got a bunch of stakeholders together, So patients, patient family, nurses, doctors, um, a lot of cool people and we tried to generate an instrument. Um, it was a bunch of focus groups. Psychometric validation, a prospective study. And it's been integrated into epic in our health system. And it's called the Abdominal Hernia que, Uh, eight questions pre op 16 post up with with a significant focus on function and quality of life. And so we were fortunate to have this published in the annals of surgery. And it's It's an open access instrument so you can go and just type this in into Pop Met, and you can download the article and in the article is A is a hyper link. To download the instrument you can. You can use it if you want, but I think what's cool about this this instrument, because it really is an extension of Dr Jennifer. Dr Rosen's work is that it captures what I think are the important components of a successful repair, which is the physical aspect of how the patient is doing. And so if you kind of look at this closely, um, you know, in the last two weeks, my hernia has made my sleep worse, or in the last two weeks, my hernia has limited how much I can get done by myself, so important things about the patient's quality of life. But of course I had to have to interject the plastic surgery element to this. The appearance component. Kind of. How does the patient feel about the way they look and appear? Uh, you know, in public, um, and then the same questions are mirrored afterwards, but it also kind of includes a measure of how good of a job the surgical team did, which I think can be a very humbling thing to to measure in real life. And so I think it's kind of like an inventory of how good of a job we did. Simple scoring system one is not good for her is really good. And so here's, um here's some discrete data, just kind of on a patient. This is actually in the chart, uh, in epic. And so, de, um, you know, good repair can really kind of bump someone score up significantly, and so so many people often say, Well, how are you using the score to know if you're doing a good job at the moment? We're not, but I think that capturing this data is going to enable us to figure out maybe who not to operate on who's not improving, but who's getting lots of complications. Um, and I talked with Dr Henry. Heard a lot about this. I think this is going to be an important aspect of how we kind of capture outcomes for patients, and we prospectively validated this. And we're fortunate enough I can't believe it to have this publishing annals of surgery again. A second paper, prospective study, all kind of cut to the chase. But, you know, it is very reliable. Um, as measured statistically, um, and also longitudinal E. Um, you know, it compares very favorably. We didn't compare it to the the Carolina comforts because we knew it would be inferior. So you just compared to the Hercules and it actually had a better net change in quality of life, which is good. So the effect size was better in terms of measuring the significance of, you know, the repair in terms of of the patients P. R. O. And what's the coolest thing is when we kind of compare our instrument to the Hercules to the generic instruments, which I think is really cool. And this was kind of mirrored after Dr Hanford's work is that the HQ was the only instrument or measure that was able to discriminate Negative clinical outcomes that was able to detect, uh, statistically significantly, if someone had a complication, if someone had a readmission, if someone had a recurrence was very, very cool that it might be a tool we could use. That may be a signal to measure and look out for in terms of someone having a complication. So so really, really interesting. And I think again, just to kind of wrap it up about the the HQ really, really useful in our practice. Prospective process, we validate very, very cool instrument. And, uh, yeah, so in summary, um, I think what I think is most important to take home is it intentional? Hernia impacts patients in very diverse ways, but it affects their quality of life, their function, their activities of daily living. And I think the use of multidimensional proms or patient reported outcome measures are really, really important when we're doing complex operations on these folks. Um, and the HQ is validated tools to measure that. Um, and I personally feel that I think measuring, I think is not going to hurt us. you know, sometimes it can make us make us feel like we're not doing that good of a job, but it's only gonna make us better. Um, so a w our outcomes are not binary. Their multidimensional, um, and prof help us align our clinical perception of outcomes with what the patient is experiencing. And I think it gives us a common direction and path forward. I think it's a great opportunity to just learn to better and add value to the way we're taking care of our honey of patients. So thank you so much. Thank you again to to Gore for being here and, uh, look forward. Any questions? Thank you for fantastic talk to start off the morning. Does anyone in the audience have any questions? I'm gonna start off with a question. So how does your, um, your app compared to the Carolina app? Yeah. So I think it's a great question. So I think that, um, So the Carolina conference call, really I think is, um is a tool that you can use, I think for any type of hernia which I think is nice, you can use it for inguinal hernia. You can use a provincial hernia, and it's it's very focused on mashing pain. And so so are are kind of instrument, I think is an extension of that in the sense that we're really focused. Um, you know, on quality of life activities of daily living. And I think just kind of how the patient is, thank you very much how the patient is doing overall. And so we kind of we kind of use probably some of the lessons learned from developing that act to kind of extend ours. Um, and I think that we kind of also mirrored it after some of the work from Andrea Pusic, who was a surgeon at M s, K C C and now is in Boston, Um, about kind of satisfaction with the surgical team, which I think is really, really important. Kind of how good of a job that we do in terms of the care of the patient. And so that's kind of how we kind of developed, which is which is kinda cool. Thanks, John. I guess my other question is, what do you do when you and the patient, um probably don't agree on what the the actual outcome or the quality outcome is, and so you feel like you may have and really achieved your PR. But the patient feels like they did not achieve their goal with the operation they have. Yeah, I think that's that's challenging. Fortunately, doesn't happen that often. Um, I think the good news is, is I think that, like, there's never really been a scenario where we've had a successful clinical result in my mind, and we've had a really, really bad kind of improvement in P. R. O S. And so so usually there's not too much misalignment with those, but I think what happens, you know, kind of irrespective of I think you know what the Pierro says is sometimes in practice, we have patients who we do a really complex repair, and they have some other issue, and I think that it becomes challenging. And that was kind of, I think, inspiration for trying to kind of quantify what the patient is experiencing with the Pierrot. And so I feel like I personally have a lot to learn about that, and I think that, you know, at least as a plastic surgeon, you know, it happens all the time like You know, I do like quite a bit of cosmetic surgeon. You have a really, really nice results. And the patient is fixated on some issue or isn't happy in some way. And I think that, you know, I think kind of always trying to focus on positives and really, I think kind of reinforcing the improvements that have been achieved. I think it's kind of my approach and kind of really kind of keeping it positive. And then I think letting kind of time kind of just pass in terms of, you know, kind of seeing how things settle out and seeing how things improve our time. I think it's been just really, really the way I've addressed that. Thank you. Oh, yeah, Just because their role for this from so that's that's an awesome question. So, uh so So So the question was, is there a role? Um, in terms of medical legal, And I guess the short answer is probably no. But I think that in my mind, you know, in my mind, um, I guess if if you're doing some complex stuff and, um and so and I think that you're embarking on a complex reconstruction and I think that the way that you're rationalizing the clinical decision to pursue surgery is that they have a very kind of low quality of life and function. If you have that quantified in clinical documentation, I feel like that is very valuable. Um and so um, I think that that could be very important and I haven't thought about it or looked at it through that lens. I think it's a really insightful comment. Um, and I think that, you know, if you if we all so so part of part of kind of the research opportunity that is ahead of us, I think is to one figure out maybe who the complex patients are that don't get a benefit but have a lot of complications and costs and maybe say we shouldn't be operating on these people and the other maybe is even in these very challenging cases, that we have a lot of complications and there's a lot of costs. But it's a huge improvement in quality of life is maybe it's worth the gamble in those patients and so I think that that's probably where this is going. But I feel like if we're not measuring this and thinking about this across multiple dimensions, we're not gonna be able to truly understand how good we're doing. So great question. I mean, this is the describe, yes, quality of life story into the future. You can't get through this and is what Qualified surgeons, right. This is I like I like that discriminator. Like the Terminator. Uh huh. Question. Just curious. A 300 setting extra. Oh, God. Realization These So? So maybe that's the answer is so the answer is absolutely yes. But then then the follow up question which you may or may not ask, is kind of When do you give these like? So if you're giving this in the office right after you're done doing that, is it going to bias their results? So super interesting question. So So I think that the short answer is also to that question is probably yes. And so So what we've done is, you know, would be great to kind of, like cheat a little bit, but no, no, we don't. So we actually So when patients get scheduled for a consult, we kind of find a way. That epic just sends them the format so it actually kind of happens behind closed doors, which is awesome. And so you kind of get a real sample of kind of how they're doing. And then after a surgery, when their case gets completed, there's a program inside of Epic that kind of just automates, you know, sending it to them. Um, we certainly have the ability to give patients this in the office and just type it into the computer. Actually, we kind of work with epic, too kind of make it like, you know, when the Emma puts in the vital signs or you put whoever puts in the vital signs like you type in the temperature of the blood pressure like you can, like, type the scores in and it actually puts in discrete data in the in the note just kind of became too cumbersome. So we have a kind of automated for the whole health system now, and so it's kind of cool in that regard. I think that Yeah, so? So if you're talking to the patient, then you give it to him right after it's probably gonna bias. So we kind of thought through that exactly what you're saying and we kind of have a workaround now just as automated, which I think is important. Yes. Yeah. And so the other thing, too, is so I didn't say this. Also, I should probably stop talking. But, um is that, um is that I think that quality of life measurement is the key to getting insurance approval for a diagnosis. Repairs. I'll just leave it at that. I think that, like in the end, like we all should be able to fix functionally significant diet synthesis. And I think it insurance bill. And I think that's the key for it. And there's a ton of diocese out there. I would tell you later, when your waiter comes by and says Help, Yeah, I was like, I was like, How could a job? I didn't fill this. Fill this out and do a good job if Alright, cool. Alright. Thank you. Thank you very much. John Published December 15, 2021 Created by
