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Commentary and Perspective   |    
As a Last Resort, Ask the PatientCommentary on an article by Judith F. Baumhauer, MD, MPH, et al.: “Age and Sex Differences Between Patient and Physician-Derived Outcome Measures in the Foot and Ankle”
Patrick B. Ebeling, MD1
1 Twin Cities Orthopedics, Burnsville, Minnesota
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The author received no payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. Neither the author nor his institution has had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, the author has not had any other relationships, or engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.


Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Feb 06;95(3):e17 1. doi: 10.2106/JBJS.L.01541
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As physicians, we have always sought ways to evaluate ourselves. We strive both to know that we are providing optimum care for our patients and to satisfy ourselves that we are being the best clinicians we can be. Traditionally, a wide variety of physician-derived outcome measures have been employed to answer these questions. Unfortunately, these instruments have often failed to capture the complex relationship between success, as we define it, and satisfaction, as defined by our patients.
Increasingly, patient satisfaction is assuming a more prominent position in the world of outcomes measurement. With the emergence of online rating sites such as Healthgrades, Angie’s List, and RateMDs, the public evaluation of our practice is, more than ever, a reflection of patient satisfaction. In addition, in the changing landscape of health care, patient satisfaction is becoming increasingly tied to reimbursement. Over the next year, for example, 30% of Medicare payments to hospitals will be based on a patient-satisfaction questionnaire, and patient satisfaction seems certain to play a role in pay-for-performance models.
As the practice environment changes around us, we cannot dismiss the possibility that we could lose control of how our outcomes are measured. Although physician-derived instruments have, to date, failed to fully capture the factors that patients identify as important, we remain in the best position to develop the next generation of more complete measurement tools. We must apply good science to our unique knowledge and experience and take a leadership role in shaping the future of outcomes measurement.
In “Age and Sex Differences Between Patient and Physician-Derived Outcome Measures in the Foot and Ankle,” Dr. Baumhauer and her colleagues demonstrate the type of important work that will begin to shape that future. Starting with an open-ended pilot question and building their survey instrument with use of the patients’ own words, they developed a survey built entirely on factors deemed important by their patients. They then administered their survey to nearly 800 patients over a three-month period to further stratify which of the factors their patients considered to be most important. They further evaluated their data by stratifying by age and sex and, finally, by comparing their rank list with two commonly used physician-derived outcome scales.
I applaud Dr. Baumhauer and her colleagues for what is an important and timely contribution to the orthopaedic literature. As they would undoubtedly agree, there is further work ahead to produce a validated, widely applicable outcomes instrument. As noted in the paper, this survey was developed by, and applies most directly to, their patient population. Regional and demographic differences in the factors that patients identify as important could be substantial and, in order to best capture patient satisfaction, sex or region-specific instruments may be necessary. In addition, some work could, and should, be done to determine whether factors that foot and ankle surgeons traditionally have considered to be important may, in fact, capture factors identified by patients. As an example, this group of patients identified several factors (weakness, the need for a brace, the need for walking aids, and fear of falling) that could, at least in part, be proxies for stability, a factor that is included in physician-derived instruments. I expect that the best measurement tool, like the best surgical outcomes, will grow out of a joint effort between our patients and us.
It seems certain that the demand placed on us to provide patient-satisfaction data will only increase. The face of that data and, more specifically, the collection of factors that will define patient satisfaction remain to be determined. I, and all of us in this field, will benefit greatly from the continued work of authors like Dr. Baumhauer and her colleagues, who are working to keep us at the forefront of that discussion.

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These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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