Episode Transcript
[00:00:03] Speaker A: Welcome to the Ortho Joe Podcast, a joint production of the Journal of Bone and Joint Surgery and Ortho Evidence.
Join hosts Mohit Bhandari and Mark Swankowski as they discuss current topics and publications in the world of orthopedics and beyond.
Well, good morning, Mo. Or I suppose it's afternoon.
[00:00:22] Speaker B: No, good afternoon. Yeah, it's 1:30pm today, but you're a
[00:00:26] Speaker A: bit under the weather, so I think you're probably in need of a caffeine lift.
[00:00:31] Speaker B: Absolutely.
Trusty Tim's. Trusty Tim's medium regular.
[00:00:36] Speaker A: What could be better than a, than a guy who, who would go in the corner after the puck with reckless abandon in the same way that he makes coffee to wake up.
[00:00:45] Speaker B: See, you have, see you've got the historical contents of Tim Hortons. Well done.
[00:00:49] Speaker A: Very nice maple leaf stand. Of course. Absolutely. Yeah. But I'm here actually in the office with the original priceless portable mug that we give all the guests. And since we don't have a guest today, we can't titillate them with the fact they're going to receive it.
[00:01:09] Speaker B: It's a nice coffee.
[00:01:10] Speaker A: It works good after five years.
So congratulations again on, on all the work you put in to change the, the COVID and the whole formatting of the journal. I think it's, it's a real positive thing.
And all the feedback that I've received from colleagues around the country and in my own department has been very positive.
So I, I was just perusing the October 7 issue.
[00:01:38] Speaker B: It's a good issue.
[00:01:40] Speaker A: Yeah, it's, it's good. And a nice cover with the, the bacteriophage AI image. I'm assuming it's AI Most likely, unless there's a more powerful electron microscope that I'm aware of. But anyway, and came across this article of predictors of loss to long term follow up after shoulder surgery, which comes from the University of Utah. And Bob Tashin was a deputy editor for shoulder and elbow for a long time, did a great job in that role. But it's his group and what they reported on is a focus on who are we most likely to get two year follow up. And so let me just very briefly summarize. So they did a retrospective chart review on over 1,000 consecutive patients who underwent shoulder surgery by a single surgeon between 2017 and 2022.
And all patients were contacted by the surgeon via telephone, text message and email at two years postoperatively. And then they analyzed the variables, including demographics, insurance status, surgical procedure type, social deprivation index, et cetera, and distance from the surgical site to home, and did logistic regression to figure out what were the factors that determined the ability to get, get follow up from these patients.
So of the 10, 28 patients, 507 or nearly 50%, completed the follow up.
And what they found was that older patients were most likely to be able to be contacted and follow up and give them information as to how they were doing.
And then they did a rather detailed analysis of what the factors were that were associated with that ability to follow up.
And they found out that older age emerges the most significant predictor of follow up adherence. And then went on to offer some thoughts about why that might be. And what are your thoughts about this whole issue of retrospective follow up and who's most likely to be able to, to be contacted?
[00:03:59] Speaker B: Well, I mean, so you probably. Well, you remember very well the sprint trial, right? 1998 and early 90s.
You know, one of the biggest things in that trial, because, you know, we were going to be in the same ballpark around about a thousand patients, we were going to be recruiting and we had set a target of, you know, minimum 80%, but we wanted over 90% follow up in trauma patients in that one year period. And, you know, we were told, mark, and you remember this, it's impossible. All patients are transient. You're not going to find them. They're going to move on. It's going to be very difficult.
But it became a number one concern, one of our key concerns. And so we developed all kinds of strategies, even published a paper on it. But to the point, because we were prospectively evaluating these patients, we were able to build in at the outset when we first saw the patient and were able to follow them over time, Maintaining ways to continue to follow those patients.
I think it's really challenging. So, and I think we got over 90%. It was like 94% follow up, if I recall, something very high, which is great, but I think it was the testament to the fact that it was prospective and we had built in those systems and we can talk about what that looked like, but we had built in real systems to try to follow patients over time.
The challenge, I think, is that if you get to a point of two years and you say, okay, let's go back and see, are we surprised that we can only find 49% of the patients? Probably not. Does that create real challenges? I mean, so the data might be valid for the data that they have, but what about the 51%? You can almost guarantee that the 51% of the patients despite their really give them credit for finding 500 of those patients still. But the additional 500 that they didn't find, you can almost model that that could lead to dramatic shifts. You can argue and say, okay, well this patient, if the 500 that we didn't follow are similar to the ones we had, we can probably argue that we'd have the same results.
But the truth of the matter is you don't know. Right. That's why these loss to follow up experiments are so important. Because the more loss to follow up, the more information you lose and the more you're hoping that your data is generalizable to that loss population. So, yes, there's some real challenges there.
[00:06:09] Speaker A: Right. Well, one of the things I would like to point out is the heavy involvement of the senior author in trying to contact these patients, and that's certainly been my experience as well, is that most patients, if you can contact them either by having access to their demographic data, and of course, for the most part we need institutional review board approval to be able to contact patients afterwards because this is not something that they consented to. But if the attending surgeon is involved, you will get the highest proportion of patients and follow up that is possible.
Way more effective than a research coordinator or a medical student or a resident trying to contact a patient. It's the personal touch that I think produce these results.
[00:07:00] Speaker B: I think you're right. And I think if it isn't the surgeon who calling the operating surgeon. There's, I think there's sometimes, not always a time, there's sometimes a concern around why are they calling me? Is this a payment issue?
I'm not going to pick this up. I don't want to risk something. You know, it could be a host of reasons why they don't pick up yet. They're actually there, they're just not picking up. We found that lots of times with a number of our trials, especially where healthcare systems, you know, weren't universal pay. So in other words, you know, if the government pays, fine, you could follow those patients. They were more likely to contact us. But when there was private systems involved, oftentimes it was harder to find those patients. And probably because of concerns around someone's, it's a collecting agency calling, like why is the doc's office calling things like that. I'm not saying it was universal, but we definitely had those issues pop up in our trials.
[00:07:48] Speaker A: Yeah, no question about it.
The exact way that we've done it that's proven to be very effective is once we've had IRB approval to contact patients.
I texted the patient saying this is really me and I would like for you to consider completing this follow up. Would it be okay if I sent you the link and 90% of the patients in one of our tibial plateau studies responded to complete the survey.
So, just for anybody that's listening that's faced with this challenge, but let me just ask you, as the person making the major decisions for the direction of the journal, what is your current stance on the issue of retrospective versus prospective literature? Is there still, obviously there's still interest because this article was published. What's your position on that?
[00:08:45] Speaker B: Yeah, for a couple of reasons. One is I think you already know my stance.
Ideally I would love for us to publish the highest quality evidence that is possibly available.
The reality is sometimes the highest quality evidence doesn't come to your journal and you have to be aware to understand that. But that would be very standard to for a therapeutic intervention. A high quality clinical trial would be the ideal. Prospectively collected or prospectively collected hypothesis, like with a hypothesis are ideally what we like because you just have more control of the question. You have more control of follow up control in the sense of you can plan for it, you can think about it in a prospective way and it makes things a little easier. However, there are going to be situations where there will be a paper that comes across and has a number of messages that might be important that haven't been raised and then you, as you know, you can make exceptions for a whole bunch of these things. That doesn't mean, and I think you've said the same thing multiple times, doesn't mean the case series is no longer valuable. It's absolutely valuable. Doesn't mean a large administrative database isn't valuable. It means that for certain things like I think for safety monitoring for there's all kinds of reasons why having a massive data set where you have a very objective outcome measure that can be evaluated, looking for safety signals, I think are really important. Sometimes you'll see them there before you might see in studies because they're just not big enough.
So there are lots of ways in which we think about it. But I do think in the end if you look again, Mark, if you look at, and you know this again, if you look at what's happening, forget about the orthopedic surgical domain, forget about even surgical domain. If we just look at, you know, I use this, you know, Lancet, New England Journal of Medicine, you know, Annals of Internal Medicine, jama, if you look at their table of contents, you know, they are almost uniformly, almost uniformly presenting prospective data and almost uniformly presenting either a clinical trial or a very large observational cohort.
Occasionally they'll have retrospective data, occasionally they'll have administrative databases. Occasionally they'll put in a meta analysis of randomized trials for the most part. So, you know, it's just a matter of saying that that information exists in our field, but you know, there's a lot of journals out there and you know, it's our job to try to, you know, do our best to, you know, encourage people to submit to ours.
Long winded answer for what I think you could have said is randomized trials.
[00:11:16] Speaker A: Well, it just basically sounds like the, the policy that we've, we've had for the last four editors and chiefs have, hasn't really changed, is that there's value in all, but the preference is prospective and ideally hypothesis driven prospective randomized trials wherever possible.
I would just, you know, maybe we could call this, this podcast tips and tricks for prospective and retrospective research.
But when one is conducting prospective research like we did with the Sprint trial and others when initially recruiting patients, it's really, really important to get all the contact information one can from the patient, their significant other, from relatives, from, from their work, multiple emails, et cetera, et cetera, and let them know that we may be, we, we will be trying to contact you at the one and two year mark. And please don't assume it's the hospital about your bill or anything like that. It's about this research which you're agreeing to sign up for. It's a really, really important step.
[00:12:21] Speaker B: It is, you know, like, you know, you know, often phones change, you know, often numbers change depending on, you know, the population and the individual you're dealing with, it could change all the time. And so asking them for two, ideally three separate numbers in which they can be contacted often creates a little bit of like, what do you mean I only have the one phone? I go, no, no. Well, of a significant other, of a parent, of a child.
It makes a big difference because then you can hunt them down. And I don't mean hunt as in this is a bad thing. You're trying to identify them in a way that allows the research to go forward and hopefully allows them to gain from that research. Right. Because the information you get is going to help them as well. So fully agree with you. And that's kind of the, and you can't do that retrospectively to be truthful. Right. You got to have that upfront. Right. And the thing is, the other thing I think is important, right. Is you know, you do something and then, you know, try, go back, try to find people from two years ago. Right. It's a lot harder. And of course you're going to think. But if you, if we get them at day one and we fight and we follow them up at six weeks, at six weeks, they see it's a positive experience. We say, hey, listen, everything's same, the numbers are same, everything's good. We can still get a hold of you, we're excited to see you back in three months.
You're basically cheerleading them on throughout the year. So, yeah, you don't want to have 100 touch points, but if you can get a few critical touch points in between two years, your chance of getting patients to follow up to two years is just that much higher.
The probability of follow up is based on the last follow up.
[00:13:43] Speaker A: Right. Yeah. Another great tip.
[00:13:46] Speaker B: But they found, in this paper, but you remember Mark, in this paper they found a predictor not following up is that they wouldn't even complete the baseline information.
So again, it gets back to if you can't even get baseline information completed, it's a really big red flag to the fact that they're going to be compliant with the rest of the study. But you'd figure that out in a trial like this or in a prospective study very quickly.
[00:14:07] Speaker A: Yeah.
And the overall age of the population which was the major finding of this predictor of loss to long term follow up is the age of the patient. And obviously younger adults in particular are way more mobile, more likely to move, more likely to Change cell phones, etc. Etc. Etc. And more likely to be suspicious of the reason for the contact than an older person like myself.
[00:14:34] Speaker B: And probably you need to get a TikTok account of theirs, you need to get their Instagram account, you need to get their Facebook. I don't know what it is. I don't know what it is. But you know, it's a whole different way of communicating. Right. So, yeah.
[00:14:45] Speaker A: Well, thanks for this little chat, Mo. And despite all the changes in the COVID and the way that information has been displayed, it's nice to know that the policy is carried forward that all research techniques have value in the journal, but the preference is prospective research and ideally whenever possible, randomized.
[00:15:07] Speaker B: The amino acids, the building blocks are always the same. You're absolutely right.
[00:15:13] Speaker A: Well, cheers. I'm gonna finish my coffee now.
[00:15:15] Speaker B: Me too. Me too. Me too.
[00:15:17] Speaker A: I hope you feel better. Thanks so much.
