Toward Value Based Health Care in pituitary surgery: application of a comprehensive outcome set in perioperative care

Abstract

Objective Although widely advocated, applying Value Based Health Care (VBHC) in clinical practice is challenging. This study describes VBHC-based perioperative outcomes for patients with pituitary tumors up to 6 months postoperatively. Methods A total of 103 adult patients undergoing surgery were prospectively followed. Outcomes categorized according to the framework of VHBC included survival, degree of resection, endocrine remission, visual outcome (including self-perceived functioning), recovery of pituitary function, disease burden and health-related quality of life (HRQoL) at 6 months (Tier 1); time to recovery of disease burden, HRQoL, visual function (Tier 2); permanent hypopituitarism and accompanying hormone replacement (Tier 3). Generalized estimating equations (GEEs) analysis was performed to describe outcomes over time. Results Regarding Tier 1, there was no mortality, 72 patients (70%) had a complete resection, 31 of 45 patients (69%) with functioning tumors were in remission, 7 (12%, with preoperative deficits) had recovery of pituitary function and 45 of 47 (96%) had visual improvement. Disease burden and HRQoL improved in 36–45% at 6 months; however, there were significant differences between tumor types. Regarding Tier 2: disease burden, HRQoL and visual functioning improved within 6 weeks after surgery; however, recovery varied widely among tumor types (fastest in prolactinoma and non-functioning adenoma patients). Regarding Tier 3, 52 patients (50%) had persisting (tumor and treatment-induced) hypopituitarism. Conclusions Though challenging, outcomes of a surgical intervention for patients with pituitary tumors can be reflected through a VBHC-based comprehensive outcome set that can distinguish outcomes among different patient groups with respect to tumor type.

SF-12 or SF-36 in pituitary disease? Toward concise and comprehensive patient-reported outcomes measurements

“…However, this widely used questionnaire only consists of five items, limiting its ability to provide a comprehensive view on the self-perceived health of patients with complex conditions such as pituitary diseases. This is partially depicted by a strong ceiling effect, as most patients report (very) high scores and therefore, most patients only have room for deterioration [21]. Moreover, the EuroQoL-5D is primarily a questionnaire assessing utility, which is used for economic evaluations and should be distinguished from HRQoL.…”

“…Our research team has obtained experience with a combination of several PROMs in a comprehensive outcome set for pituitary care [21], which harmonizes outcomes, and enables systematic assessment of HRQoL of all patients. However, this comprehensive outcome set can be timeconsuming and therefore burdensome for patients, due to the relatively large number of questions [21].…”

“…For the analyses, data of two previously published cohorts [21,22] were used. The first study was a longitudinal cohort of consecutive patients treated surgically for a pituitary/ sellar tumor between August 2016 and December 2018 [21], who completed multiple PROMs before, and 6 weeks and 6 months after surgery. The second cohort was a large cross-sectional study performed in a chronic care setting [22], which was used to further validate our results.…”

“…For the longitudinal study, the baseline characteristics collected from patient charts included age, sex, marital status, education level, tumor type, size, and invasion, date of diagnosis, prior treatment of the tumor, preoperative pituitary function, visual functioning, and cerebral nerve deficits, if present. Detailed information on the collection and categorization of these data is presented elsewhere [21]. In addition, the Dutch comorbidity questionnaire, Statistics Netherlands, was used to assess the most common chronic diseases [23], categorized into diabetes mellitus, neurovascular disease, cardiovascular disease, and malignancies.…”

“…Due to the wide range of local and systemic symptoms, but also characteristic 'endocrine' symptoms caused by pituitary/sellar tumors, multiple disease-specific or symptom-specific PROMs should be used to comprehensively measure outcomes relevant for pituitary patients, together with a generic PROM allowing for comparison with other diseases [21]. To increase efficiency and to reduce the patient burden of completing these questionnaires, it would be valuable to investigate whether the number of questions can be reduced, whilst maintaining the capacity to reliably monitor HRQoL in patients with pituitary/sellar disease.…”