Patient-centered endpoints for perioperative outcomes research.

T trite but enduring cliché can be traced back to the late 19th century. The fact that it survived to this day indicates that perceptions of “success” can still differ widely between doctors and patients. For example, although the “1-yr graft patency” after coronary artery bypass surgery may be a highly meaningful outcome for a cardiac surgeon, it could have been achieved without any meaningful change in the patient’s health status.1 Mortality obviously is a patient-centered outcome. A high postoperative troponin level predicts future cardiac events including mortality,2 but it is in itself not a patient-centered outcome. However, a postoperative myocardial infarction that results in new disability, such as extreme fatigue and decreased exercise tolerance with delayed return to work, clearly is. In a trial on the effectiveness of epidural analgesia, a difference of one point on the numeric pain rating scale may be statistically significant, but Number Rating Scale scores 2 versus 3 may have no meaning from the perspective of the patient.3 Similarly, “cognitive decline” on a battery of postoperative neuropsychological tests may be important from a scientific viewpoint, but if not matched with new disability—as perceived by the patient or a close relative—it cannot be considered a patient-centered outcome. In this issue of ANeStHeSIology, Shulman et al.4 propose “disability-free survival” as a new and truly patient-centered outcome that can be used as a valid endpoint in perioperative outcomes research. outcomes that “matter to the patient” need to be distinguished from those that do not, and only patients can make that distinction. We are now entering a new era in medicine where differences in patient-centered outcomes will determine what constitutes medical success or failure, not only doctors’ perceptions of success. Increasingly, healthcare purchasing decisions by third-party payers—and even individuals— will be based on such outcomes. Add to that mounting economic pressures to contain total healthcare expenditures. The value-based healthcare concept5 simply boils down to seeking the highest value for the patient per healthcare dollar spent. More and more the patient will decide if his or her consent to a surgical procedure has resulted in the intended health improvement (cure or symptom relief ). While “disability-free survival” can be used as a valid patientcentered endpoint in perioperative outcomes research, it can be equally useful for shared decision making, quality metrics, and benchmarking quality of care. Disability-free survival is a combination of survival (1 – mortality) and a patient-reported assessment of disability measured with a validated questionnaire. The authors took an instrument, which was originally developed by the World Health organization to measure disability from various chronic diseases in a wide range of national and cultural settings (World Health organization Disability Assessment Schedule 2.0 [WHoDAS]),6 and validated it in 510 surgical patients. The short version of WHoDAS 2.0 consists Patient-centered Endpoints for Perioperative Outcomes Research