A Pilot Study of Implementing Patient Reported Outcome Measures in the Australasian Pelvic Floor Procedure Registry

A Pilot Study of Implementing Patient Reported Outcome Measures in the Australasian Pelvic Floor Procedure Registry | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article A Pilot Study of Implementing Patient Reported Outcome Measures in the Australasian Pelvic Floor Procedure Registry Rasa Ruseckaite, Randi Jayasinghe, Michelle Merenda, Chethana Mudunna, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4220194/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract The Australasian Pelvic Floor Procedure Registry (APFPR) records information about procedures for stress urinary incontinence and pelvic organ prolapse. This study aimed to test the feasibility of capturing Patient Reported Outcome Measures (PROMs) in women with pelvic floor disorders (PFDs) identified via the APFPR. We administered the Australian Pelvic Floor Questionnaire (APFQ) in women with PFDs prior to surgery (baseline) and six months post-surgery through a combination of email, postal mail, SMS and telephone. Results were reported descriptively, as number and proportion for PROMs response rates and data completeness, and as a mean and standard deviation (SD) for the APFQ scores. The APFQ was administered to 140 patients at baseline and to 112 post-surgery. The baseline PROMs response rates were high (75%), but decreased to 56% at follow up. The overall APFQ completeness was ~98%. The APFQ dysfunction scores revealed a significant improvement at six months (mean (SD) score at baseline=14.5 (5.7), six months=11.4 (6.5), p≤0.001). Significant improvement in the bladder and prolapse domains (p≤0.001) were particularly observed. The results showed an overall improvement in quality of life scores at follow up, suggesting that the APFQ was a suitable instrument for the APFPR. Registry Quality of life PROMs Pelvic floor disorders Response rates Figures Figure 1 Introduction Up to 50% of women are affected by stress urinary incontinence (SUI) or pelvic organ prolapse (POP) at some point in their lives 1 . Under the umbrella of pelvic floor disorders (PFD), SUI and POP pose a significant burden to women prompting them to seek medical treatment to improve their health, self-perception, quality of life and sexual satisfaction 2 . Conservative therapies comprise first line management, but if PFDs remain troublesome, surgical procedures are considered 2,3 . Approximately one quarter of these procedures previously involved the use of a surgical mesh product, with an estimated 150,000 mesh devices being implanted in Australia since 1998 1 . Previously, some women undergoing mesh procedures reported suffering significant and painful complications that have been life-altering. Clinical data remains the primary way to assess outcomes following pelvic floor surgery but recently clinical quality registries have been utilising patient reported outcome measures (PROMs) to supplement the evaluation of the impact of treatment and outcomes 4 . PROMs are well established in female pelvic medicine, and play an important role as outcome measures, with many being developed specifically for this purpose 5 . Recently, in the report of the Independent Medicines and Medical Devices Safety review to investigate the safety of mesh implants for SUI and POP, the importance of capturing PROMs was identified as being an issue needing to be addressed 6 . The Australasian Pelvic Floor Procedure Registry (APFPR) is a government funded registry set up to monitor and report the safety of devices implanted for PFDs and patient outcomes including complications and adverse events 7 . At its inception in 2020, the registry held clinical outcomes of women with PFDs but it did not capture PROMs. Two acceptability studies were conducted with women and their treating surgeons in Australia to determine whether PROMS should be captured by the APFPR, and which instruments should be included 8,9 . The findings of these studies revealed that most of the existing measures for PFDs did not cover all the aspects of women’s’ daily life and health, or they were not suitable for the Australian population. The Australian Pelvic Floor Questionnaire (APFQ), evaluating most of the pelvic floor symptoms and their impact on women’s quality of life and discomfort, was deemed as the most appropriate instrument and has been chosen for inclusion in the APFPR 10 . We conducted a pilot study to evaluate the feasibility of capturing PROMs in women with PFDs identified via the APFPR using various modes and methods of administration. Therefore, the aims of this study were to evaluate processes for PROMs implementation, to determine response rates, data completion of the APFQ and to identify preferred modes and methods for PROMs administration in the APFPR. Materials and Methods Study design, setting and participants This was a pilot cohort study involving women undertaking surgery for SUI and POP recruited from the APFPR. The study was carried out at nine registry sites from July 2022 to May 2023 in New South Wales, South Australia, Queensland and Victoria, Australia. The sites were selected based on a sample of convenience and recruited upon them joining the registry. For this pilot, adult women, consented to the APFPR, were invited to complete PROMs at baseline (before surgery) and at six months post-surgery. To be eligible to participate in this study, participants needed to be 18 years of age, able to read and understand English language and have their procedure entered in the APFPR. Any participants with their procedure scheduled prior to their data entered into the registry at baseline were excluded. For the follow up, participants were required to complete PROMs within two months around six months post their procedure date. Instrument With permission from the authors, the APFQ was used for PROMs data collection 10 . The APFQ has been chosen after conducting two acceptability studies with women with PFDs and their clinicians, and was endorsed by the APFPR clinical advisory committee 9 . The APFQ is composed of 42 questions, divided into four independent domains: bladder function, bowel function, prolapse symptoms and sexual function 10 . Each question in the APFQ is scored from 0 to 3, with the total bladder function score of 45, bowel function score of 34, prolapse symptoms of 15, and sexual function of 21. Resulting scores are divided by the number of questions within each domain and multiplied by 10, giving a value between 0 and 10 for each of the four domains, and a max total pelvic floor dysfunction score of 40. The higher the score, the worse the symptoms/function i.e. a low score is 'good'. If women are not sexually active because of pelvic floor dysfunction, they will get a score of 8.5 (18/21) in sexual domain 10 . Changes in score of approximately by 1 in the appropriate pelvic floor domain can be considered clinically important differences 11 . PROMs administration The APFQ was administered through a combination of registry administration (postal mail, email, automated short message service (SMS), telephone) and health service administration, by participants completing PROMs on their own devices or on paper. At baseline, letters were sent out at the time of registration into the APFPR. For those with a postal address available, a cover letter with the APFQ and a reply-paid envelope was sent. An invitation letter was also enclosed. An opt-out for the PROMs study was provided for those who were not interested in this study. For participants with email, a unique weblink for the APFQ was generated. Once clicked it would lead to the APFPR portal where the questionnaire was launched. Participants were only allowed to submit their response once. A mobile number was required to send the APFQ via SMS. A text message was sent automatically at the required time points. The text message contained a unique weblink which directed participants to the APFQ. For those where PROMs were administered via email or SMS, consent was implied upon clicking on the link provided. If the APFQ was not completed electronically within two weeks, non-responders were contacted by phone. Up to three reminder phone calls would be made. For sites capturing PROMs on paper, Secure File Transfer Protocol (SFTP) was used to transfer scanned paper forms securely which were then entered to the registry. Assessment of feasibility As a part of feasibility testing, we examined response rates and data completeness of the APFQ across various modes and methods of administration at baseline and follow up. The APFQ scores for all domains were also calculated and compared. Staff notes and observations regarding PROMs administration were documented and then analysed thematically. Lessons learnt during this process were identified. Statistical analysis Results from the pilot were reported descriptively, as a number and percentage for the response rates, and as a mean and standard deviation (SD) for the APFQ scores and data completeness at baseline and post-surgery. To compare PROMs response rates for patients of different ages, the patients were divided into different age groups: <36, 36–45, 46–55, 56–65, 66–75, 76–85 and 85 + years. To explore the APFQ responses before and after the procedure, baseline scores were compared with the follow up scores using t-tests. Chi-squared test was used to compare response rates at baseline and 6 months follow up. Statistical significance was assumed at p < 0.05. STATA package (STATA Corporation, College Station, TX) was used for the analysis. Ethics approval This pilot study was approved by Monash Health Human Research Ethics Committee (RES-20-000-444A) and Monash University Human Research Ethics Committee (Project ID38179), Victoria, Australia. All participants gave their informed consent to be part of the study. All methods were performed in accordance with the relevant guidelines and regulations or in accordance with the Declaration of Helsinki by including a statement in the Declarations section. Results Participant characteristics The APFQ was administered to 141 participants at baseline and to 112 participants at 6 months follow up. Forty-two participants submitted their responses at both time points. All participants were able to communicate in English. Characteristics of those who participated in the pilot are summarised in Table 1 . Most of the study participants were between 46–55 and 66–75 years of age, with SUI related procedure performed for nearly three quarters of all participants. Table 1 Participant characteristics at baseline and 6 months follow up Baseline (n, %) N = 141 6 months follow up (n, %) N = 112 Age group (years) 86 2 (1.4) 2 (1.8) Procedure type Related to SUI 106 (75.2) 89 (79.5) Related to POP 12 (8.5) 11 (9.8) Related to both SUI and POP 23 (16.3) 12 (10.7) [Table 1 here please] APFQ response rates Response rates by mode of administration Of 141 participants who were eligible for a baseline PROM, 106 (75%) provided their responses. At 6 months follow up, the APFQ was administered to 112 participants with 62 responses received. At baseline, 61 (43%) questionnaires were administered via email, 34 (24%) via postal mail, 22 (16%) were completed on paper onsite and returned via SFTP, and 24 (17%) were sent via SMS. The response rates for completing APFQ via email was 70%, and 79% for postal/SFTP and SMS modes respectively. The overall response rate of the APFQ at baseline was 75% (Table 2 ). Table 2 PROMs response rates at baseline and follow up by mode of administration and age category Category Baseline 6 months p Eligible Responded Response Rate Eligible Responded Response Rate Mode of administration SMS 24 19 79.2 94 50 53.2 0.0216 Email 61 43 70.5 15 9 60.0 0.4362 Postal/SFTP 56 44 78.6 3 3 100 0.3735 Age group (years) < 35 3 2 66.7 3 1 33.3 0.4552 36–45 18 11 61.1 16 6 37.5 0.1759 46–55 38 29 76.3 30 17 56.7 0.0886 56–65 24 15 62.5 20 13 65.0 0.8653 66–75 38 35 92.1 31 19 61.3 0.0022 76–85 18 12 66.7 10 5 50.0 0.3945 > 86 2 2 100.0 2 1 50.0 0.3173 Total 141 106 75.2% 112 62 55.4 0.0009 [Table 2 here please] Of 112 PROMs administered at 6 months follow up, 94 (84%) were administered via SMS, 9 (8%) were sent by email and 3 (3%) via postal mail. The response rate for completing PROMs via email was 60%, and 100% for postal mode. The response rate was lower for those who completed PROMs via SMS (53%). The overall response rate at 6 months follow up was 55% (Table 2 ). The differences in response rates were not significant, except for SMS (p = 0.0216) where the response rate decreased from 79.2% at baseline to 53.2% at follow up. Response rates by participants age At baseline, 38 APFQ questionnaires were administered to participants of 46–55 and 66–75 years of age respectively, to 24 participants between 56–65 years, and to 18 participants between 76–85 years of age (Table 2 ). The highest response rates were observed in those between 66–75 years of age, followed by participants in the category of 46–55 years of age. At 6 months follow up, 31 questionnaires were sent to women between 66–75 years of age, 30 between 46–55 years, 20 between 46–65 years, and 16 to those between 36 and 45 years of age. The remaining ten APFQs were administered to those between 36 and 45 years of age. Three questionnaires were distributed to participants under 35 and to those above 86 years of age respectively. The highest response rates (65%) were observed in those between 56 and 65 years of age. The differences in response rates were not significant, except for those between 66 and 75 (p = 0.0022) years of age showing the reduction from 92.1% at baseline to 61.3% at follow up. Telephone follow up calls Table 3 summarises number of phone calls required to follow patients at baseline and 6 months post-surgery. Up to three phone calls were made per participant. Table 3 Number of follow up phone calls required Mode of administration Participants followed (N) Follow up calls made (N) Mean (SD) calls made Baseline 6 months Baseline 6 months Baseline 6 months p SMS 7 71 12 165 1.7 (1.3) 2.3 (1.9) 0.4180 Email 28 13 62 31 2.2 (1.4) 2.4 (1.7) 0.6931 Postal 32 3 63 8 1.9 (0.8) 2.6 (1.4) 0.1811 Total 67 87 137 204 2.1 (1.8) 2.3 (1.4) 0.2452 [Table 3 here please] The overall mean (SD) number of phone calls made at baseline was 2.1 (1.8), which increased to 2.34 (1.44) at 6 months. The average number of follow up phone calls varied between 1.7 (1.3) for SMS PROMs administration at baseline to 2.6 (1.4) calls made for those who were distributed the APFQ using postal mail. There was no statistical difference between number of phone calls made at baseline and follow up. The APFQ data completeness PROMs data completeness was determined as a percentage of the APFQ questions answered per patient for each domain and mode of administration (Table 4 ). [Table 4 here please] PROMs data completeness varied between 97.2% for postal mode of administration and 99.9% for SMS. The lowest completeness was observed in sexual health domain for those who completed their questionnaires on site with the forms returned via SFTP. APFQ scores Table 5 summarises mean (SD) APFQ scores at baseline and 6 months follow up. [Table 5 here please] The overall pelvic floor dysfunction scores revealed a significant improvement at 6 months with mean (SD) score at baseline 14.5 (5.7), and 11.4 (6.5) at the follow up, p ≤ 0.001). Significant improvements were observed in bladder and prolapse APFQ domains (p ≤ 0.001). With respect to bowel and sexual dysfunction, no significant change at 6 months was observed. The distribution of total pelvic floor dysfunction, prolapse, bladder, bowel, and sexual health dysfunction scores for all patients who completed the APFQ at baseline and at 6- months post-op is shown in Fig. 1 . The higher proportion of women with lower scores at 6 months (i.e. a ‘shift of the graph to the left’) indicates better perception of their health compared to baseline. [Figure 1 here please] PROMs implementation in the APFPR: staff notes and observations Staff notes and observations regarding PROMs implementation were noted during the pilot. On-going communication between the registry and sites, site training, and enthusiasm to administer PROMs were commonly mentioned. Administrative e.g. time constraints for administration set up, continuously evolving mode and method for administration, limited health service staff resourcing, postal delays, incorrect or missing database information, incorrect email address, participant tracking, site staff resourcing, burden to patients and site staff were most-commonly identified as barriers. Registry team consultation regarding the processes on PROMs implementation occurred weekly. Minor adaptations were made to the instructions for administration and to the processes as necessary. These included adding dates of completion to the paper form of the APFQ questionnaire, and database changes such as 'comments field, date completed fields, opt-outs directed to main registry, branching logic for sexual domains amendments to accommodate those who responded as having no recent sexual activity. Discussion In this paper, we describe the process of capturing PROMs in a clinical quality registry. The aim of this study was to determine the feasibility and usefulness of the APFQ in women with PFDs using various modes and methods for PROMs administration, to assess its suitability for inclusion in the APFPR. Compared to other clinical areas, treating PFDs relies heavily on patient reported symptoms, and not all patient outcomes can be measured or quantified by objective tests. PROMs are increasingly being introduced in clinical registries, providing a personal perspective on the expectations and impact of treatment 12 . To function effectively as a quality-of-care instrument, the PROMs data must be accurately captured, complete and compared 13,14 . This is especially critical for surgical registries. Hundreds of PROMs have been developed for use in the evaluation of PFDs 15 . Careful consideration is required to choose the appropriate instrument for inclusion in a clinical registry. Mode of administration, frequency of data collection and length of the instrument should be considered 13 . For PROMs to be useful, they must provide an adequate amount of information without an unreasonable burden to the patient. Therefore, PROMs must be succinct while maintaining their psychometric properties (reliability, validity, and responsiveness to change) 16 . The responsiveness and comprehensiveness of the APFQ mean that it can be used for routine clinical assessment and outcome research into and audit of PFDs 17 . The primary metric we were interested in was response rates and data completeness of the APFQ. Baseline response rates obtained across various modes of administration during our pilot were high (> 70%). This result is similar to the previously recorded findings from other registry studies. Ho et al 18 reported high response rates (80%) in orthopaedic patients. Even higher response rates were reported in arthroplasty patients with an approximate 98% response rate for preoperative and 12-month PROM scores 19 . Although some studies demonstrate high response rate for PROM collection, especially for baseline/preoperative surveys, response rate may often be below 50% 20 , in particular for longer-term follow up data collection, which may lead to bias, despite the importance of PROMs for patients and clinicians 21 . Our observations are similar demonstrating lower response rate at 6 months post-surgery. This is not surprising, since a large variation over time in PROMs response rate being reported previously. A recently conducted scoping review 20 showed a downward trend in PROMs response rate in most of the registries as follow up time increased. Some registries had response rate ranging from 74–95% for baseline and around 50% and 42% for 1- and 2-year follow ups, respectively. For example, joint replacement registries reported baseline response rates greater than 72% (primaries) and 96% (complex revisions) and 1-year follow up rates around 63% (primaries) and 80% (complex revisions) 22 . In terms of the mode of administration, the highest response rate in our study occurred when we deployed multiple methods for PROMs data collection. Response rate between electronic and postal responders were similar, although the questionnaires returned via post had a few missing responses. In general, data completeness was very high, demonstrating that the APFQ was a sensible instrument for the APFPR. Some patients required follow up phone calls to ensure they completed their PROMs. While calling patients is effective for obtaining responses, it is resource intensive. Some registries employ a large number of research assistants to call, email, and send letters to patients to achieve high response rate. Previously conducted literature studies 23 revealed that electronic-only format patient reports returned the lowest response rates, at around 42%, compared to mixed paper and electronic (with response rates around 70%) or registry-based (> 90%) questionnaires. A recent large meta-analysis of PROMs implementation study revealed that, paper forms were still useful and where utilised when combined with electronic PROMs forms 24 . Being younger, having a native-speaking language background and even having a longer waiting time when patient reported feedback was collected appear to be related to the higher PROMs response rates 18 . Age-related digital illiteracy and, in some cases, access to the Internet, had been also highlighted barriers to higher response rates by other studies. Barriers, although they were resolved, directly impacted implementation of PROMs in the APFPR. A number of key learnings were made: ( 1 ) a well-considered protocol and detailed standard operating procedures should be in place; ( 2 ) allowing time for testing and troubleshooting of email and SMS prior to the roll-out; ( 3 ) automating patient tracking at follow up to avoid human error; and ( 4 ) maintaining consistent communication with sites. Finally, several limitations have to be addressed regarding the design and conduct of our study. We were unable to collect information about the reasons for non-response of automated APFQ questionnaires, which leads to potential selection bias. We also did not collect the information for patient preferences regarding mode of administration in this pilot, limiting the understanding of barriers for PROMs implementation in the APFPR. In conclusion, we have described a process for PROMs implementation in the clinical registry by the example of patients with PFDs. Preliminary findings indicate that the APFQ was a feasible instrument and could be administered ongoing for the APFPR at multiple time points using various mode of administration. Further studies will be conducted to evaluate the impact of PROMs data on clinical care and quality improvement in larger sample of patients. Declarations Acknowledgements We would like to thank John Liman and Marisa Caruso for their technical support to the study. We also thank to the Steering Committee of the APFPR, clinicians, consumers and registry participants for their time and participation in the study. Author contribution RR, RJ, MM, CM and SA conceptualised the study and supported the study methodology. RR conducted the data analysis and drafted the original manuscript. HEC, EG, JK, JKe, JY and SA reviewed and edited the manuscript. All authors have read and approved the manuscript. Data availability The datasets generated during and/or analysed during the current study are available from the corresponding author on request and pending approval to the APFPR Steering Committee. Funding This work is supported by the Australian Department of Health. Competing Interests The authors declare no competing interests. References Mollah, T. & Brennan, J. Australian trends in the treatment of pelvic organ prolapse in the non-mesh era. ANZ J Surg 93 , 469-475, doi:10.1111/ans.18268 (2023). Dułak, N. A. & Trzciński, R. The burden of pelvic floor dysfunction. J Sci Med Sport 25 , 293, doi:10.1016/j.jsams.2021.11.042 (2022). Good, M. Evidence-Based Treatment of Women with Pelvic Floor Disorders. 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Health Qual Life Outcomes 21 , 71, doi:10.1186/s12955-023-02155-5 (2023). Wang, K., Eftang, C. N., Jakobsen, R. B. & Årøen, A. Review of response rates over time in registry-based studies using patient-reported outcome measures. BMJ Open 10 , e030808, doi:10.1136/bmjopen-2019-030808 (2020). Vaitkevičienė, G. E. et al. Development and Integration of Patient-Reported Measures into E-Health System: Pilot Feasibility Study. Healthcare (Basel) 11 , doi:10.3390/healthcare11162290 (2023). MacLean, C., Vinicius C. Antao, Mark A. Fontana, Harvinder S. Sandhu & McLawhorn, A. S. PROMs: Opportunities, Challenges, and Unfinished Business. NEJM Catalyst 2 , DOI: 10.1056/CAT.1021.0280 (2021). Wintner, L. M. et al. Evaluation of electronic patient-reported outcome assessment with cancer patients in the hospital and at home. BMC Med Inform Decis Mak 15 , 110, doi:10.1186/s12911-015-0230-y (2015). Additional Declarations No competing interests reported. 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O’Connell","email":"","orcid":"","institution":"Monash University","correspondingAuthor":false,"prefix":"","firstName":"Helen","middleName":"E.","lastName":"O’Connell","suffix":""},{"id":290781976,"identity":"932d75e4-c781-4ccc-9c95-bf75185e3f27","order_by":5,"name":"Elizabeth Gallagher","email":"","orcid":"","institution":"Calvary John James, Canberra Private and Canberra Hospital","correspondingAuthor":false,"prefix":"","firstName":"Elizabeth","middleName":"","lastName":"Gallagher","suffix":""},{"id":290781977,"identity":"0ef1f3c5-bd64-4467-8866-47d2f3017cdc","order_by":6,"name":"Jennifer King","email":"","orcid":"","institution":"Westmead Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jennifer","middleName":"","lastName":"King","suffix":""},{"id":290781979,"identity":"93db0ee1-699e-4f1a-acf6-2b7bb751eaa4","order_by":7,"name":"James Keck","email":"","orcid":"","institution":"St Vincent’s Private Hospital","correspondingAuthor":false,"prefix":"","firstName":"James","middleName":"","lastName":"Keck","suffix":""},{"id":290781980,"identity":"c97bc5fd-e513-4b0c-ae35-bdd9a0aa75c7","order_by":8,"name":"Jessica Yin","email":"","orcid":"","institution":"Hollywood Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Jessica","middleName":"","lastName":"Yin","suffix":""},{"id":290781982,"identity":"2e0c9ca2-23ff-404a-8bd1-8de8ed6a3528","order_by":9,"name":"Susannah Ahern","email":"","orcid":"","institution":"Monash University","correspondingAuthor":false,"prefix":"","firstName":"Susannah","middleName":"","lastName":"Ahern","suffix":""}],"badges":[],"createdAt":"2024-04-05 01:29:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4220194/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4220194/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54993929,"identity":"5cf10b55-8f98-4774-ba92-37ca1359e0bc","added_by":"auto","created_at":"2024-04-19 17:44:12","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":592523,"visible":true,"origin":"","legend":"\u003cp\u003eScore distribution (proportion of patients with lower score vs higher scores, where higher score means more bothersome)\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4220194/v1/e7c45131ddc918d527142f09.png"},{"id":57265291,"identity":"c57d6403-1e3b-43ce-8ed4-2c58289e7e44","added_by":"auto","created_at":"2024-05-28 10:59:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1378388,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4220194/v1/29652dce-99b6-47bf-a2de-9b9444e4ac58.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Pilot Study of Implementing Patient Reported Outcome Measures in the Australasian Pelvic Floor Procedure Registry","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUp to 50% of women are affected by stress urinary incontinence (SUI) or pelvic organ prolapse (POP) at some point in their lives\u003csup\u003e1\u003c/sup\u003e. Under the umbrella of pelvic floor disorders (PFD), SUI and POP pose a significant burden to women prompting them to seek medical treatment to improve their health, self-perception, quality of life and sexual satisfaction\u003csup\u003e2\u003c/sup\u003e. Conservative therapies comprise first line management, but if PFDs remain troublesome, surgical procedures are considered\u003csup\u003e2,3\u003c/sup\u003e. Approximately one quarter of these procedures previously involved the use of a surgical mesh product, with an estimated 150,000 mesh devices being implanted in Australia since 1998\u003csup\u003e1\u003c/sup\u003e. Previously, some women undergoing mesh procedures reported suffering significant and painful complications that have been life-altering. Clinical data remains the primary way to assess outcomes following pelvic floor surgery but recently clinical quality registries have been utilising patient reported outcome measures (PROMs) to supplement the evaluation of the impact of treatment and outcomes\u003csup\u003e4\u003c/sup\u003e. PROMs are well established in female pelvic medicine, and play an important role as outcome measures, with many being developed specifically for this purpose\u003csup\u003e5\u003c/sup\u003e. Recently, in the report of the Independent Medicines and Medical Devices Safety review to investigate the safety of mesh implants for SUI and POP, the importance of capturing PROMs was identified as being an issue needing to be addressed\u003csup\u003e6\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe Australasian Pelvic Floor Procedure Registry (APFPR) is a government funded registry set up to monitor and report the safety of devices implanted for PFDs and patient outcomes including complications and adverse events\u003csup\u003e7\u003c/sup\u003e. At its inception in 2020, the registry held clinical outcomes of women with PFDs but it did not capture PROMs. Two acceptability studies were conducted with women and their treating surgeons in Australia to determine whether PROMS should be captured by the APFPR, and which instruments should be included\u003csup\u003e8,9\u003c/sup\u003e. The findings of these studies revealed that most of the existing measures for PFDs did not cover all the aspects of women\u0026rsquo;s\u0026rsquo; daily life and health, or they were not suitable for the Australian population. The Australian Pelvic Floor Questionnaire (APFQ), evaluating most of the pelvic floor symptoms and their impact on women\u0026rsquo;s quality of life and discomfort, was deemed as the most appropriate instrument and has been chosen for inclusion in the APFPR\u003csup\u003e10\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWe conducted a pilot study to evaluate the feasibility of capturing PROMs in women with PFDs identified via the APFPR using various modes and methods of administration. Therefore, the aims of this study were to evaluate processes for PROMs implementation, to determine response rates, data completion of the APFQ and to identify preferred modes and methods for PROMs administration in the APFPR.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design, setting and participants\u003c/h2\u003e \u003cp\u003eThis was a pilot cohort study involving women undertaking surgery for SUI and POP recruited from the APFPR. The study was carried out at nine registry sites from July 2022 to May 2023 in New South Wales, South Australia, Queensland and Victoria, Australia. The sites were selected based on a sample of convenience and recruited upon them joining the registry.\u003c/p\u003e \u003cp\u003eFor this pilot, adult women, consented to the APFPR, were invited to complete PROMs at baseline (before surgery) and at six months post-surgery. To be eligible to participate in this study, participants needed to be 18 years of age, able to read and understand English language and have their procedure entered in the APFPR. Any participants with their procedure scheduled prior to their data entered into the registry at baseline were excluded. For the follow up, participants were required to complete PROMs within two months around six months post their procedure date.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eInstrument\u003c/h2\u003e \u003cp\u003eWith permission from the authors, the APFQ was used for PROMs data collection\u003csup\u003e10\u003c/sup\u003e. The APFQ has been chosen after conducting two acceptability studies with women with PFDs and their clinicians, and was endorsed by the APFPR clinical advisory committee\u003csup\u003e9\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe APFQ is composed of 42 questions, divided into four independent domains: bladder function, bowel function, prolapse symptoms and sexual function\u003csup\u003e10\u003c/sup\u003e. Each question in the APFQ is scored from 0 to 3, with the total bladder function score of 45, bowel function score of 34, prolapse symptoms of 15, and sexual function of 21. Resulting scores are divided by the number of questions within each domain and multiplied by 10, giving a value between 0 and 10 for each of the four domains, and a max total pelvic floor dysfunction score of 40. The higher the score, the worse the symptoms/function i.e. a low score is 'good'. If women are not sexually active because of pelvic floor dysfunction, they will get a score of 8.5 (18/21) in sexual domain\u003csup\u003e10\u003c/sup\u003e. Changes in score of approximately by 1 in the appropriate pelvic floor domain can be considered clinically important differences\u003csup\u003e11\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePROMs administration\u003c/h2\u003e \u003cp\u003eThe APFQ was administered through a combination of registry administration (postal mail, email, automated short message service (SMS), telephone) and health service administration, by participants completing PROMs on their own devices or on paper.\u003c/p\u003e \u003cp\u003eAt baseline, letters were sent out at the time of registration into the APFPR. For those with a postal address available, a cover letter with the APFQ and a reply-paid envelope was sent. An invitation letter was also enclosed. An opt-out for the PROMs study was provided for those who were not interested in this study.\u003c/p\u003e \u003cp\u003eFor participants with email, a unique weblink for the APFQ was generated. Once clicked it would lead to the APFPR portal where the questionnaire was launched. Participants were only allowed to submit their response once.\u003c/p\u003e \u003cp\u003eA mobile number was required to send the APFQ via SMS. A text message was sent automatically at the required time points. The text message contained a unique weblink which directed participants to the APFQ. For those where PROMs were administered via email or SMS, consent was implied upon clicking on the link provided.\u003c/p\u003e \u003cp\u003eIf the APFQ was not completed electronically within two weeks, non-responders were contacted by phone. Up to three reminder phone calls would be made.\u003c/p\u003e \u003cp\u003eFor sites capturing PROMs on paper, Secure File Transfer Protocol (SFTP) was used to transfer scanned paper forms securely which were then entered to the registry.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eAssessment of feasibility\u003c/h2\u003e \u003cp\u003eAs a part of feasibility testing, we examined response rates and data completeness of the APFQ across various modes and methods of administration at baseline and follow up. The APFQ scores for all domains were also calculated and compared.\u003c/p\u003e \u003cp\u003eStaff notes and observations regarding PROMs administration were documented and then analysed thematically. Lessons learnt during this process were identified.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eResults from the pilot were reported descriptively, as a number and percentage for the response rates, and as a mean and standard deviation (SD) for the APFQ scores and data completeness at baseline and post-surgery. To compare PROMs response rates for patients of different ages, the patients were divided into different age groups: \u0026lt;36, 36\u0026ndash;45, 46\u0026ndash;55, 56\u0026ndash;65, 66\u0026ndash;75, 76\u0026ndash;85 and 85\u0026thinsp;+\u0026thinsp;years.\u003c/p\u003e \u003cp\u003eTo explore the APFQ responses before and after the procedure, baseline scores were compared with the follow up scores using t-tests. Chi-squared test was used to compare response rates at baseline and 6 months follow up. Statistical significance was assumed at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eSTATA package (STATA Corporation, College Station, TX) was used for the analysis.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eEthics approval\u003c/h2\u003e \u003cp\u003e This pilot study was approved by Monash Health Human Research Ethics Committee (RES-20-000-444A) and Monash University Human Research Ethics Committee (Project ID38179), Victoria, Australia.\u003c/p\u003e \u003cp\u003e All participants gave their informed consent to be part of the study. All methods were performed in accordance with the relevant guidelines and regulations or in accordance with the Declaration of Helsinki by including a statement in the Declarations section.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\"\u003e\n \u003ch2\u003eParticipant characteristics\u003c/h2\u003e\n \u003cp\u003eThe APFQ was administered to 141 participants at baseline and to 112 participants at 6 months follow up. Forty-two participants submitted their responses at both time points. All participants were able to communicate in English. Characteristics of those who participated in the pilot are summarised in Table \u003cspan\u003e1\u003c/span\u003e. Most of the study participants were between 46\u0026ndash;55 and 66\u0026ndash;75 years of age, with SUI related procedure performed for nearly three quarters of all participants.\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eParticipant characteristics at baseline and 6 months follow up\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBaseline (n, %)\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;141\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e6 months follow up (n, %)\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;112\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAge group (years)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36\u0026ndash;45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18 (12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46\u0026ndash;55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e38 (27.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30 (26.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56\u0026ndash;65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e24 (17.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20 (17.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66\u0026ndash;75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e38 (27.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e31 (27.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e76\u0026ndash;85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18 (12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10 (8.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2 (1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eProcedure type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRelated to SUI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e106 (75.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e89 (79.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRelated to POP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12 (8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11 (9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRelated to both SUI and POP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23 (16.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12 (10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e[Table \u003cspan\u003e1\u003c/span\u003e here please]\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\"\u003e\n \u003ch2\u003eAPFQ response rates\u003c/h2\u003e\n \u003cdiv id=\"Sec12\"\u003e\n \u003ch2\u003eResponse rates by mode of administration\u003c/h2\u003e\n \u003cp\u003eOf 141 participants who were eligible for a baseline PROM, 106 (75%) provided their responses. At 6 months follow up, the APFQ was administered to 112 participants with 62 responses received. At baseline, 61 (43%) questionnaires were administered via email, 34 (24%) via postal mail, 22 (16%) were completed on paper onsite and returned via SFTP, and 24 (17%) were sent via SMS. The response rates for completing APFQ via email was 70%, and 79% for postal/SFTP and SMS modes respectively. The overall response rate of the APFQ at baseline was 75% (Table \u003cspan\u003e2\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003ePROMs response rates at baseline and follow up by mode of administration and age category\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEligible\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponded\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse Rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEligible\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponded\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponse Rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMode of administration\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSMS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e79.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0216\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmail\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e70.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.4362\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostal/SFTP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e78.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.3735\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge group (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.4552\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36\u0026ndash;45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.1759\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46\u0026ndash;55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e76.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0886\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56\u0026ndash;65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.8653\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66\u0026ndash;75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e92.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e76\u0026ndash;85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.3945\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.3173\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e141\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e106\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e75.2%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e112\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e62\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e55.4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0009\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e[Table \u003cspan\u003e2\u003c/span\u003e here please]\u003c/p\u003e\n \u003cp\u003eOf 112 PROMs administered at 6 months follow up, 94 (84%) were administered via SMS, 9 (8%) were sent by email and 3 (3%) via postal mail. The response rate for completing PROMs via email was 60%, and 100% for postal mode. The response rate was lower for those who completed PROMs via SMS (53%). The overall response rate at 6 months follow up was 55% (Table \u003cspan\u003e2\u003c/span\u003e). The differences in response rates were not significant, except for SMS (p\u0026thinsp;=\u0026thinsp;0.0216) where the response rate decreased from 79.2% at baseline to 53.2% at follow up.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\"\u003e\n \u003ch2\u003eResponse rates by participants age\u003c/h2\u003e\n \u003cp\u003eAt baseline, 38 APFQ questionnaires were administered to participants of 46\u0026ndash;55 and 66\u0026ndash;75 years of age respectively, to 24 participants between 56\u0026ndash;65 years, and to 18 participants between 76\u0026ndash;85 years of age (Table \u003cspan\u003e2\u003c/span\u003e). The highest response rates were observed in those between 66\u0026ndash;75 years of age, followed by participants in the category of 46\u0026ndash;55 years of age.\u003c/p\u003e\n \u003cp\u003eAt 6 months follow up, 31 questionnaires were sent to women between 66\u0026ndash;75 years of age, 30 between 46\u0026ndash;55 years, 20 between 46\u0026ndash;65 years, and 16 to those between 36 and 45 years of age. The remaining ten APFQs were administered to those between 36 and 45 years of age. Three questionnaires were distributed to participants under 35 and to those above 86 years of age respectively. The highest response rates (65%) were observed in those between 56 and 65 years of age. The differences in response rates were not significant, except for those between 66 and 75 (p\u0026thinsp;=\u0026thinsp;0.0022) years of age showing the reduction from 92.1% at baseline to 61.3% at follow up.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\"\u003e\n \u003ch2\u003eTelephone follow up calls\u003c/h2\u003e\n \u003cp\u003eTable \u003cspan\u003e3\u003c/span\u003e summarises number of phone calls required to follow patients at baseline and 6 months post-surgery. Up to three phone calls were made per participant.\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 3\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eNumber of follow up phone calls required\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMode of administration\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eParticipants followed (N)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eFollow up calls made (N)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMean (SD) calls made\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSMS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e165\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.7 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.3 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.4180\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmail\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.2 (1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.4 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.6931\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.9 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.6 (1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.1811\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e137\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e204\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.1 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.3 (1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.2452\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cdiv\u003e\n \u003cdiv align=\"left\"\u003e\u003cbr\u003e\u003cimg 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\"\u003e\u003c/div\u003e\n \u003c/div\u003e\n \u003cp\u003e[Table \u003cspan\u003e3\u003c/span\u003e here please]\u003c/p\u003e\n \u003cp\u003eThe overall mean (SD) number of phone calls made at baseline was 2.1 (1.8), which increased to 2.34 (1.44) at 6 months. The average number of follow up phone calls varied between 1.7 (1.3) for SMS PROMs administration at baseline to 2.6 (1.4) calls made for those who were distributed the APFQ using postal mail. There was no statistical difference between number of phone calls made at baseline and follow up.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\"\u003e\n \u003ch2\u003eThe APFQ data completeness\u003c/h2\u003e\n \u003cp\u003ePROMs data completeness was determined as a percentage of the APFQ questions answered per patient for each domain and mode of administration (Table \u003cspan\u003e4\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv\u003e\u003cbr\u003e\u003c/div\u003e\n \u003cp\u003e[Table \u003cspan\u003e4\u003c/span\u003e here please]\u003c/p\u003e\n \u003cp\u003ePROMs data completeness varied between 97.2% for postal mode of administration and 99.9% for SMS. The lowest completeness was observed in sexual health domain for those who completed their questionnaires on site with the forms returned via SFTP.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\"\u003e\n \u003ch2\u003eAPFQ scores\u003c/h2\u003e\n \u003cp\u003eTable \u003cspan\u003e5\u003c/span\u003e summarises mean (SD) APFQ scores at baseline and 6 months follow up.\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab5\" border=\"1\"\u003e\u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cimg 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\"\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e[Table \u003cspan\u003e5\u003c/span\u003e here please]\u003c/p\u003e\n \u003cp\u003eThe overall pelvic floor dysfunction scores revealed a significant improvement at 6 months with mean (SD) score at baseline 14.5 (5.7), and 11.4 (6.5) at the follow up, p\u0026thinsp;\u0026le;\u0026thinsp;0.001). Significant improvements were observed in bladder and prolapse APFQ domains (p\u0026thinsp;\u0026le;\u0026thinsp;0.001). With respect to bowel and sexual dysfunction, no significant change at 6 months was observed. The distribution of total pelvic floor dysfunction, prolapse, bladder, bowel, and sexual health dysfunction scores for all patients who completed the APFQ at baseline and at 6- months post-op is shown in Fig. \u003cspan\u003e1\u003c/span\u003e. The higher proportion of women with lower scores at 6 months (i.e. a \u0026lsquo;shift of the graph to the left\u0026rsquo;) indicates better perception of their health compared to baseline.\u003c/p\u003e\n \u003cp\u003e[Figure \u003cspan\u003e1\u003c/span\u003e here please]\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\"\u003e\n \u003ch2\u003ePROMs implementation in the APFPR: staff notes and observations\u003c/h2\u003e\n \u003cp\u003eStaff notes and observations regarding PROMs implementation were noted during the pilot. On-going communication between the registry and sites, site training, and enthusiasm to administer PROMs were commonly mentioned. Administrative e.g. time constraints for administration set up, continuously evolving mode and method for administration, limited health service staff resourcing, postal delays, incorrect or missing database information, incorrect email address, participant tracking, site staff resourcing, burden to patients and site staff were most-commonly identified as barriers.\u003c/p\u003e\n \u003cp\u003eRegistry team consultation regarding the processes on PROMs implementation occurred weekly. Minor adaptations were made to the instructions for administration and to the processes as necessary. These included adding dates of completion to the paper form of the APFQ questionnaire, and database changes such as \u0026apos;comments field, date completed fields, opt-outs directed to main registry, branching logic for sexual domains amendments to accommodate those who responded as having no recent sexual activity.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this paper, we describe the process of capturing PROMs in a clinical quality registry. The aim of this study was to determine the feasibility and usefulness of the APFQ in women with PFDs using various modes and methods for PROMs administration, to assess its suitability for inclusion in the APFPR.\u003c/p\u003e \u003cp\u003eCompared to other clinical areas, treating PFDs relies heavily on patient reported symptoms, and not all patient outcomes can be measured or quantified by objective tests. PROMs are increasingly being introduced in clinical registries, providing a personal perspective on the expectations and impact of treatment\u003csup\u003e12\u003c/sup\u003e. To function effectively as a quality-of-care instrument, the PROMs data must be accurately captured, complete and compared\u003csup\u003e13,14\u003c/sup\u003e. This is especially critical for surgical registries.\u003c/p\u003e \u003cp\u003eHundreds of PROMs have been developed for use in the evaluation of PFDs\u003csup\u003e15\u003c/sup\u003e. Careful consideration is required to choose the appropriate instrument for inclusion in a clinical registry. Mode of administration, frequency of data collection and length of the instrument should be considered\u003csup\u003e13\u003c/sup\u003e. For PROMs to be useful, they must provide an adequate amount of information without an unreasonable burden to the patient. Therefore, PROMs must be succinct while maintaining their psychometric properties (reliability, validity, and responsiveness to change)\u003csup\u003e16\u003c/sup\u003e. The responsiveness and comprehensiveness of the APFQ mean that it can be used for routine clinical assessment and outcome research into and audit of PFDs\u003csup\u003e17\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe primary metric we were interested in was response rates and data completeness of the APFQ. Baseline response rates obtained across various modes of administration during our pilot were high (\u0026gt;\u0026thinsp;70%). This result is similar to the previously recorded findings from other registry studies. Ho et al\u003csup\u003e18\u003c/sup\u003e reported high response rates (80%) in orthopaedic patients. Even higher response rates were reported in arthroplasty patients with an approximate 98% response rate for preoperative and 12-month PROM scores\u003csup\u003e19\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAlthough some studies demonstrate high response rate for PROM collection, especially for baseline/preoperative surveys, response rate may often be below 50%\u003csup\u003e20\u003c/sup\u003e, in particular for longer-term follow up data collection, which may lead to bias, despite the importance of PROMs for patients and clinicians\u003csup\u003e21\u003c/sup\u003e. Our observations are similar demonstrating lower response rate at 6 months post-surgery. This is not surprising, since a large variation over time in PROMs response rate being reported previously. A recently conducted scoping review\u003csup\u003e20\u003c/sup\u003e showed a downward trend in PROMs response rate in most of the registries as follow up time increased. Some registries had response rate ranging from 74\u0026ndash;95% for baseline and around 50% and 42% for 1- and 2-year follow ups, respectively. For example, joint replacement registries reported baseline response rates greater than 72% (primaries) and 96% (complex revisions) and 1-year follow up rates around 63% (primaries) and 80% (complex revisions)\u003csup\u003e22\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn terms of the mode of administration, the highest response rate in our study occurred when we deployed multiple methods for PROMs data collection. Response rate between electronic and postal responders were similar, although the questionnaires returned via post had a few missing responses. In general, data completeness was very high, demonstrating that the APFQ was a sensible instrument for the APFPR.\u003c/p\u003e \u003cp\u003eSome patients required follow up phone calls to ensure they completed their PROMs. While calling patients is effective for obtaining responses, it is resource intensive. Some registries employ a large number of research assistants to call, email, and send letters to patients to achieve high response rate. Previously conducted literature studies\u003csup\u003e23\u003c/sup\u003e revealed that electronic-only format patient reports returned the lowest response rates, at around 42%, compared to mixed paper and electronic (with response rates around 70%) or registry-based (\u0026gt;\u0026thinsp;90%) questionnaires. A recent large meta-analysis of PROMs implementation study revealed that, paper forms were still useful and where utilised when combined with electronic PROMs forms\u003csup\u003e24\u003c/sup\u003e. Being younger, having a native-speaking language background and even having a longer waiting time when patient reported feedback was collected appear to be related to the higher PROMs response rates\u003csup\u003e18\u003c/sup\u003e. Age-related digital illiteracy and, in some cases, access to the Internet, had been also highlighted barriers to higher response rates by other studies.\u003c/p\u003e \u003cp\u003eBarriers, although they were resolved, directly impacted implementation of PROMs in the APFPR. A number of key learnings were made: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) a well-considered protocol and detailed standard operating procedures should be in place; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) allowing time for testing and troubleshooting of email and SMS prior to the roll-out; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) automating patient tracking at follow up to avoid human error; and (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) maintaining consistent communication with sites.\u003c/p\u003e \u003cp\u003eFinally, several limitations have to be addressed regarding the design and conduct of our study. We were unable to collect information about the reasons for non-response of automated APFQ questionnaires, which leads to potential selection bias. We also did not collect the information for patient preferences regarding mode of administration in this pilot, limiting the understanding of barriers for PROMs implementation in the APFPR.\u003c/p\u003e \u003cp\u003eIn conclusion, we have described a process for PROMs implementation in the clinical registry by the example of patients with PFDs. Preliminary findings indicate that the APFQ was a feasible instrument and could be administered ongoing for the APFPR at multiple time points using various mode of administration. Further studies will be conducted to evaluate the impact of PROMs data on clinical care and quality improvement in larger sample of patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank John Liman and Marisa Caruso for their technical support to the study. We also thank to the Steering Committee of the APFPR, clinicians, consumers and registry participants for their time and participation in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRR, RJ, MM, CM and SA\u003csup\u003e\u0026nbsp;\u003c/sup\u003econceptualised the study and supported the study methodology. RR conducted the data analysis and drafted the original manuscript. HEC, EG, JK, JKe, JY and SA reviewed and edited the manuscript. All authors have read and approved the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and/or analysed during the current study are available from the corresponding author on request and pending approval to the APFPR Steering Committee.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work is supported by the Australian Department of Health.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMollah, T. \u0026amp; Brennan, J. 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Response rates in clinical quality registries and databases that collect patient reported outcome measures: a scoping review. \u003cem\u003eHealth Qual Life Outcomes\u003c/em\u003e \u003cstrong\u003e21\u003c/strong\u003e, 71, doi:10.1186/s12955-023-02155-5 (2023).\u003c/li\u003e\n\u003cli\u003eWang, K., Eftang, C. N., Jakobsen, R. B. \u0026amp; \u0026Aring;r\u0026oslash;en, A. Review of response rates over time in registry-based studies using patient-reported outcome measures. \u003cem\u003eBMJ Open\u003c/em\u003e \u003cstrong\u003e10\u003c/strong\u003e, e030808, doi:10.1136/bmjopen-2019-030808 (2020).\u003c/li\u003e\n\u003cli\u003eVaitkevičienė, G. E.\u003cem\u003e et al.\u003c/em\u003e Development and Integration of Patient-Reported Measures into E-Health System: Pilot Feasibility Study. \u003cem\u003eHealthcare (Basel)\u003c/em\u003e \u003cstrong\u003e11\u003c/strong\u003e, doi:10.3390/healthcare11162290 (2023).\u003c/li\u003e\n\u003cli\u003eMacLean, C., Vinicius C. Antao, Mark A. Fontana, Harvinder S. Sandhu \u0026amp; McLawhorn, A. S. PROMs: Opportunities, Challenges, and Unfinished Business. \u003cem\u003eNEJM Catalyst\u003c/em\u003e \u003cstrong\u003e2\u003c/strong\u003e, DOI: 10.1056/CAT.1021.0280 (2021).\u003c/li\u003e\n\u003cli\u003eWintner, L. M.\u003cem\u003e et al.\u003c/em\u003e Evaluation of electronic patient-reported outcome assessment with cancer patients in the hospital and at home. \u003cem\u003eBMC Med Inform Decis Mak\u003c/em\u003e \u003cstrong\u003e15\u003c/strong\u003e, 110, doi:10.1186/s12911-015-0230-y (2015).\u003cstrong\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Registry, Quality of life, PROMs, Pelvic floor disorders, Response rates","lastPublishedDoi":"10.21203/rs.3.rs-4220194/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4220194/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"The Australasian Pelvic Floor Procedure Registry (APFPR) records information about procedures for stress urinary incontinence and pelvic organ prolapse. This study aimed to test the feasibility of capturing Patient Reported Outcome Measures (PROMs) in women with pelvic floor disorders (PFDs) identified via the APFPR. We administered the Australian Pelvic Floor Questionnaire (APFQ) in women with PFDs prior to surgery (baseline) and six months post-surgery through a combination of email, postal mail, SMS and telephone. Results were reported descriptively, as number and proportion for PROMs response rates and data completeness, and as a mean and standard deviation (SD) for the APFQ scores. The APFQ was administered to 140 patients at baseline and to 112 post-surgery. The baseline PROMs response rates were high (75%), but decreased to 56% at follow up. The overall APFQ completeness was ~98%. The APFQ dysfunction scores revealed a significant improvement at six months (mean (SD) score at baseline=14.5 (5.7), six months=11.4 (6.5), p≤0.001). Significant improvement in the bladder and prolapse domains (p≤0.001) were particularly observed. The results showed an overall improvement in quality of life scores at follow up, suggesting that the APFQ was a suitable instrument for the APFPR.","manuscriptTitle":"A Pilot Study of Implementing Patient Reported Outcome Measures in the Australasian Pelvic Floor Procedure Registry","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-19 17:44:07","doi":"10.21203/rs.3.rs-4220194/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b1bfee53-f6c2-4cc4-8faf-425395829358","owner":[],"postedDate":"April 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-28T10:51:17+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-19 17:44:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4220194","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4220194","identity":"rs-4220194","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}