8111 appendix Gu by Tj0iyk

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									 1                                                              Appendix A

 2                                           Patient/Surgeon Survey Questionnaire

 3   Please help us determine how important quality of life versus length of life is to you by answering the following

 4   questions. You will be presented with 10 theoretical health states and asked to advise a friend/patient.

 5
 6   1.   Imagine your friend/patient is expected to live for 15 years with the quality of life that described below:

 7
 8              Successful Revision Hip Arthroplasty

 9             - 0 –2.5 Hip Pain on a scale of 0-10

10              - Ability to perform low impact activities (e.g. swimming, walking >1 mile, stationary bicycle, light

11                   weights, and golfing)

12               - Able to easily perform the Activities of Daily Living (e.g. driving, dressing,

13                bathing, cooking and self care)

14
15   Suppose a treatment could restore this person to full health, but would shorten their life. At most, how much time

16   would you advise giving up out of 15 years?

17
18   I would advise giving up at most ____ years to avoid the above health state and return to full health.

19   YEARS: 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

20
21   2.   Imagine your friend/patient is expected to live for 15 years with the quality of life that described below:

22
23               Re-Infection- Long Term Antibiotic Therapy

24               - Daily Oral Antibiotics 1 to 2 times a day, indefinitely

25               - 2.5 –7.5 Hip Pain on a 0 -10 scale

26               - Moderate limitation on ability to perform low impact activities (walk 1 mile, swim 2 laps in a pool,

27                   golf, or biking; all with moderate pain)




                                                                                                                          1
 1               - Mild to Moderate limitations on Activities of Daily Living (able to dress, cook, clean with

 2                   mild/moderate pain and will require some assistance)

 3
 4   Suppose a treatment could restore this person to full health, but would shorten their life. At most, how much time

 5   would you advise giving up out of 15 years?

 6
 7   I would advise giving up at most ____ years to avoid the above health state and return to full health.

 8   YEARS: 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

 9
10   3.   Imagine your friend/patient is expected to live for 15 years with the quality of life that described below:

11
12               Infected Hip Arthroplasty treated with Resection Arthroplasty

13               - 5 -10 Hip Pain on a 0 -10 scale

14               - Able to walk only very short distances using a walker or assistant with most

15                mobilization requiring a wheelchair indefinitely

16               - Severe limitations on all Activities of Daily Living (e.g. dressing, cooking, driving, bathing)

17                   indefinitely

18
19   Suppose a treatment could restore this person to full health, but would shorten their life. At most, how much time

20   would you advise giving up out of 15 years?

21
22   I would advise giving up at most ____ years to avoid the above health state and return to full health.

23   YEARS: 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

24
25   4.   Imagine your friend/patient is expected to live for 15 years with the quality of life that described below:

26
27               THA Infection treated with a 2 stage revision operation

28               Convalescence of 3 - 6 months:




                                                                                                                          2
 1                - 2.5 -7.5 Hip Pain on a 0 -10 scale

 2                -Moderate to Severe limitations on low impact activities and Activities of Daily Living

 3              Following Convalescent Period:

 4                - Hip Pain 0 -5 on a 0 -10 scale

 5                - Moderate restriction on ability to perform low impact activities (e.g. swimming, walking, light

 6                   weights, golfing with moderate pain)

 7                - Mild restrictions on ability to perform the Activities of Daily Living as previously defined

 8
 9   Suppose a treatment could restore this person to full health, but would shorten their life. At most, how much time

10   would you advise giving up out of 15 years?

11
12   I would advise giving up at most ____ years to avoid the above health state and return to full health.

13   YEARS: 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

14
15   5. Imagine your friend/patient is expected to live for 15 years with the quality of life that

16      described below:

17
18          Long-term medical complication (e.g. stroke, myocardial infarction, pulmonary embolism)

19              - 0 – 2.5 Hip Pain on a 0 -10 scale

20              - Need to take multiple medications throughout each day, indefinitely

21              - Moderate limitation on ability to perform low impact activities (e.g. swimming, walking, light-

22                   weights, golfing with moderate pain)

23              - Mild restrictions on ability to perform the Activities of Daily Living (able to dress, cook, clean with

24                   some assistance)

25
26   Suppose a treatment could restore this person to full health, but would shorten their life. At most, how much time

27   would you advise giving up out of 15 years?

28



                                                                                                                            3
 1   I would advise giving up at most ____ years to avoid the above health state and return to full health.

 2   YEARS: 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

 3
 4   6.   Imagine your friend/patient is expected to live for 15 years with the quality of life that described below:

 5
 6            Constant Severe Pain

 7               - No ability to avoid severe pain regardless of position/activity

 8               - 7.5 - 10 Hip Pain on a 0 -10 scale, indefinitely

 9
10   Suppose a treatment could restore this person to full health, but would shorten their life. At most, how much time

11   would you advise giving up out of 15 years?

12
13   I would advise giving up at most ____ years to avoid the above health state and return to full health.

14   YEARS: 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

15
16   7. Imagine your friend/patient is going to live the next 4 months with a quality of life

17        described below:

18
19
20               Interval Between Staged Procedures - An Average of 4 months

21               - 5 -10 Hip Pain on a 0 -10 scale for initial 2 weeks followed by 2.5 -7.5 Hip Pain on a 0 -10 scale for

22                   the subsequent 3.5 months

23             - Able to walk very short distances with a walker or an assistant (eg: to

24               bathroom) with most mobilization requiring a wheelchair

25               - Severe limitations with Activities of Daily Living (all activities: cooking, cleaning, bathing, dressing

26                   cause severe pain and will require assistance)

27               - 2 to 6 weeks of IV antibiotics +/- 2 to 6 weeks of Oral antibiotics

28               - Increased chance of medical complications (Decubitus ulcers, DVT, PE)




                                                                                                                              4
 1
 2   Now suppose your friend/patient could choose between the temporary state described above for 4 months or a state

 3   of constant severe pain described in Question 6 for a period of time up to 4 months. At the end of either state your

 4   friend/patient will have 0 -2.5 Hip Pain on a 0 -10 scale and can easily perform low impact activities as well as all

 5   activities of daily living. How many weeks and/or months of constant severe pain would you advise your

 6   friend/patient to choose in order to avoid the interval between staged procedures for 4 months?

 7
 8   I would advise a state of constant severe pain for ____ weeks and/or ____ months in order to avoid the interval

 9   between staged procedures for 4 months.

10   (Please circle only one option in the “WEEKS” row and only one option in the “MONTHS” row):

11   WEEKS: 0 1 2 3 4

12   MONTHS: 0 1 2 3

13
14   8. Imagine a friend/patient who is going to live the next 6 weeks with a quality of life described below:

15
16              THA Mechanical Complication with Non-Operative Treatment (Example: greater trochanteric

17              nonunion, dislocation treated closed, stable periprosthetic fracture)

18              - Unexpected but short (1-2 day) readmission to the hospital

19              - 5 -10 Hip Pain on a 0 -10 scale for initial 2 weeks followed by 2.5 -7.5 Hip

20                Pain on a 0 -10 scale for the subsequent 4 weeks

21              - Restricted activity for 6 weeks (toe touch weight bearing or able to walk only short distances with use

22                of a walker or crutches)

23              - After recovery at 6 weeks, 0 -2.5 Hip Pain on a 0 -10 scale

24              - After recovery one is able to perform low impact activities (e.g. swim, walk

25                >1 mile, light-weights, stationary bicycle, and golfing) and easily perform

26              all Activities of Daily Living (e.g. driving, dressing, bathing, cooking)

27




                                                                                                                             5
 1   Now suppose your friend/patient could choose between the temporary state described above for 6 weeks or a state of

 2   constant severe pain described in Question 6 for a period of time up to 6 weeks. At the end of either state the

 3   patient will have 0 -2.5 Hip Pain on 0 -10 scale and can easily perform low impact activities as well as all activities

 4   of daily living. How many weeks and/or months of constant severe pain would you advise your friend/patient to

 5   choose in order to avoid 6 weeks with the THA mechanical complication described above?

 6
 7   I would advise a state of constant severe pain for ____ days and/or ____ weeks in order to avoid 6 weeks with a

 8   THA mechanical complication described above.

 9   (Please circle only one option in the “DAYS” row and only one option in the “WEEKS” row)

10   DAYS: 0 1 2 3 4            5       6   7

11   WEEKS: 0 1 2         3 4       5

12
13   9. Imagine your friend/patient is going to live the next 3 months with a quality of life described below:

14
15              Mechanical Complication requiring Operative Treatment (e.g. recurrent

16              dislocation, aseptic loosening, unstable/displaced periprosthetic fracture)

17              - Additional 1 week hospitalization with major surgery and 5% chance of major

18              medical complications

19              - 4 -8 week convalescence, with 5 -10 Hip Pain on a 0 -10 scale

20            - Severe limitations of Activities of Daily Living (Eg., Not able to walk, dress,

21              shower, or cook with out help, and all activities cause Severe pain)

22              - Following recovery (after 3 months):

23                   - 0 – 2.5 Hip Pain on a 0 –10 scale

24                   - Able to easily perform low impact activities and Actities of Daily Living

25
26   Now suppose your friend/patient could choose between the temporary state described above for 3 months or a state

27   of constant severe pain described in Question 6 for a period of time up to 3 months. At the end of either state your

28   friend/patient will have 0 -2.5 Hip Pain on 0 -10 scale and can easily perform low impact activities as well as all




                                                                                                                               6
 1   activities of daily living. How many weeks and/or months of constant severe pain would you advise your

 2   friend/patient to choose in order to avoid 3 months of recovery from a mechanical THA complication that required

 3   surgical intervention?

 4
 5   I would advise a state of constant severe pain for ____ weeks and/or ____ months in order to avoid 3 months of

 6   recovery from a mechanical THA complication that required surgical intervention.

 7   (Please circle only one option in the “WEEKS” row and only one option in the “MONTHS” row)

 8
 9   WEEKS: 0      1 2 3 4

10   MONTHS: 0 1 2

11
12   10. Imagine your friend/patient is going to live the next 3 months with a quality of life described below:

13
14              Short-term Major Medical Complication- (e.g. stroke, myocardial infarction,

15             pulmonary embolism)

16              - Hip Pain between 0 -2.5 on 0-10 scale

17              - Prolonged hospitalization requiring medical interventions (2 – 6 weeks)

18              - Substantially limited in terms of recreational/low-impact activities as for 3 months but able to perform

19                most ADLs with minimal assistance

20
21   Now suppose your friend/patient could choose between the temporary state described above for 3 months or a state

22   of constant severe pain described in Question 6 for a period of time up to 3 months At the end of either state the

23   patient will have 0 -2.5 Hip Pain on 0 -10 scale and can easily perform low impact activities as well as all activities

24   of daily living. How many weeks and/or months of constant severe pain would you advise your friend/patient to

25   choose in order to avoid 3 months of recovery from a Short-term Medical Complication?

26
27   I would advise a state of constant severe pain for ____ weeks and/or ____ months in order to avoid 3 months of

28   recovery from the above short-term major medical complication.




                                                                                                                               7
1   (Please circle only one option in the “WEEKS” row and only one option in the “MONTHS” row)

2   WEEKS: 0 1 2 3 4

3   MONTHS: 0 1 2

4




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