Methodologic Considerations for Collecting Patient-reported Outcomes from Unselected Surgical Patients

OVER 200 million people¹  around the world undergo elective surgical procedures. International investigations reveal that adverse postoperative outcomes remain common. After in-patient surgeries, estimated 30-day mortality is between 1 and 5%^2–9  and, at 1 yr, between 5 and 10% of these patients have died.^6,7,10  About 10 to 20% of surgical patients experience major complications, such as heart attacks, unremitting pain, infections, and blood clots, in the weeks to months after their procedures.^3,8–12  Most of these studies, however, have extrapolated data from clinical trial populations or have relied on administrative databases. It is not currently standard practice to systematically track outcomes of unselected surgical patients.

A number of initiatives, such as the National Surgical Quality Improvement Project of the American College of Surgeons and the Society of Thoracic Surgeons’ database, have been implemented to systematically measure surgical outcomes.^13–15  These efforts are mostly focused on postoperative medical complications and do not encompass patients’ perspectives on their health status and recovery. Patients view surgical outcomes differently from their doctors; the traditional focus on medical complications may not be the foremost concern for patients. For example, there was only a moderate agreement between patients’ and clinicians’ views of disability after knee replacement surgery.¹⁶  Certain elements of recovery, such as health-related quality of life (HRQoL), functional independence, and pain resolution, can only be ascertained through patient reports. While healthcare practitioners are unable to advise reliably on the likelihood of adverse events, they are even more limited in their ability to predict outcomes that are relevant to patients (fig. 1). Only by engaging patients and obtaining their perspectives can we fully assess the multiple dimensions of short- and intermediate-term postsurgical recovery. Patient-reported outcomes (PROs) encompass any report of patient health or disease that comes directly from the patient without any interpretation from a clinician.¹⁷  PROs are increasingly used in comparative effectiveness research, in patient safety interventions, in quality improvement initiatives, and for performance assessment.^17,18  While obtaining PROs for specific surgeries is established in certain countries including the United Kingdom and Sweden, there has been minimal incorporation of perioperative PROs in U.S. healthcare systems.^19,20  Although PRO instruments are being developed and validated, there is relatively little practical guidance for increasing patient engagement and selecting the best approach for the collecting PROs.

This article describes the methods of the Systematic Assessment and Targeted Improvement of Services Following Yearlong Surgical Outcomes Surveys (SATISFY-SOS) registry, which combines perioperative PROs with granular electronic data to track patients’ postoperative trajectories in the short and intermediate term. We highlight practical considerations and potential barriers to patient engagement and collection of PROs in an academic medical center based on the registry’s first 2-yr experience. Specifically, we address the feasibility of this approach in a large, unselected surgical population; assess the practicality of consenting surgical patients; evaluate the utility of three different survey modalities in generating high response rates; and discuss how PROs can be used for quality improvement and research purposes.

SATISFY-SOS (clinicaltrials.gov: NCT02032030) was conceptualized with the intended purpose of integrating PROs with rigorous preoperative assessment and granular perioperative data of electronic medical records (fig. 2). The strategic goals of SATISFY-SOS are to refine risk stratification, enhance shared decision-making, and deliver tailored care to individual surgical patients. The immediate tasks of the project were to establish a process that would allow (1) engagement, education, and consent of patients for participation in the registry; (2) determination of patients’ expectations regarding the outcomes of their surgery; (3) baseline measurement of health and quality of life; (4) use of perioperative data from the electronic medical records; and (5) use of PROs for systematic tracking of surgical patients’ early and intermediate-term postoperative outcomes.

In 2011, a group of representative stakeholders at Washington University School of Medicine, Saint Louis, Missouri, and Barnes-Jewish Hospital, Saint Louis, Missouri, was convened. The group included anesthesiologists, surgeons, information technology professionals, research methodologists, psychometricians, public health experts, and hospital leadership. The SATISFY-SOS concept was presented, refined, and was broadly endorsed. The database was designed to combine four main elements of patient health information. The first element focused on collecting detailed patient phenotypes (characteristics and comorbidities) and used routinely collected, discrete electronic data from preprocedural clinical assessments performed during the preanesthesia visits at the Center for Preoperative Assessment and Planning (Barnes Hospital, St. Louis, Missouri). The second element, patients’ baseline expectations, HRQoL, and functional status, was collected using a survey conducted at the time of the preoperative assessment visit. The third element was perioperative care data obtained from electronic medical records. The fourth element was multidomain patient-reported postoperative outcomes obtained using two surveys, one conducted at approximately 30 days and a second at 1 yr after surgical procedures.

The Human Research Protection Office (HRPO) at Washington University in St. Louis, Missouri, approved the SATISFY-SOS initiative and provided a waiver of informed consent permitting the use of patient health information from all surgical patients for research and quality improvement under the banner of SATISFY-SOS. Patient consent was deemed necessary only for collecting baseline and postoperative PROs. Consent was obtained when patients completed the baseline survey. At the same time, the importance of the project was conveyed to patients, and the usefulness of their contribution was emphasized. We postulated that a priori consent would encourage patient participation and result in higher response rates to the postoperative surveys. The a priori decision was made to exclude patients who were unable to consent for reasons such as cognitive, visual, or hearing impairment. Proxy consents and responses were not permitted, as the project focuses on PROs.

All patients older than 18 yr visiting the Center for Preoperative Assessment and Planning, who were capable of giving consent, were considered eligible for participation in the SATISFY-SOS. This assessment center was previously established in 2002 at Barnes Jewish Hospital, with a strategic vision of developing a mechanism for performing standardized, in-depth preoperative assessment and applying evidence-based clinical protocols. With endorsement from hospital leadership, the majority of nurses in the center willingly completed the HRPO training process required for research studies. As part of their routine workflow, the trained nurses provided information on the SATISFY-SOS initiative to patients, obtained written informed consent, and administered the baseline SATISFY-SOS survey. Rolling updates on consent rates, patient characteristics, and PRO data from SATISFY-SOS surveys were provided to the nursing staff in the clinic at monthly quality assessment meetings.

With the increasing use of electronic medical records in recent years, discrete data fields and drop-down menus have facilitated collection and documentation of extensive medical information during preoperative assessment visits. In order to further improve the comprehensiveness of patient assessment, new fields, not traditionally included in preoperative assessments, such as obstructive sleep apnea risk assessment (STOP-BANG screen),²¹  activities of daily living (Barthel Index),²²  and dementia screening (Short Blessed Test and Aging and Dementia [AD8] screener)^23,24  indicators for frailty, were incorporated into the preoperative assessment form. Currently, approximately 280 discrete data fields from the preoperative assessment form can be imported directly into the SATISFY-SOS database. The aforementioned information is collected for all patients evaluated at the Center for Preoperative Assessment and Planning and is stored in the electronic medical record. After enrolling patients to participate in the SATISFY-SOS initiative, patients were asked to complete a baseline PRO survey (copy available as Supplemental Digital Content 1, https://links.lww.com/ALN/B295). This survey included questions on patients’ expectations regarding the surgery and their recovery, current and expected pain levels at 30 days, current employment status, expectation about returning to work, history of falls,^25,26  and the abbreviated Veterans’ Rand quality of life (QoL) questionnaire (VR-12).²⁷ 

To assess the impact of surgical procedures on patients’ global health, we developed a multidomain survey instrument administered at 30 days and 1 yr after surgery. The questionnaire was conceptualized to track patient recovery after surgery and to answer how the presence or absence of reported postoperative complications might impact quality of life and functional recovery after surgery. Based on the early feedback from patients and stakeholders, the survey instrument was modified. The composite postoperative survey instrument developed for this project focused on a generic multidimensional concept of recovery from surgical procedures. Domains in the survey include the abbreviated VR-12,²⁷  pain assessment on the Numerical Rating Scale,²⁸  abbreviated Patient Reported Outcomes Measurement Information System (PROMIS) cognition questions,^18,29  Prevention of Falls Network Earth questions for postoperative falls,^25,26  modified Brice questionnaire for intraoperative awareness,³⁰  and the Barthel Index for activities of daily living.²²  These previously validated questionnaires were included in the survey instrument without modifications. Additionally, questions for tracking patients’ perceptions of postoperative medical complications were included in the SATISFY-SOS survey instrument. The list of complications is similar to those followed by the American College of Surgeons’ National Surgical Quality Improvement Program.^13,14  Subjective perceptions of patients on their health status, return to work, and readmissions to hospital were also covered in the surveys. The latest version of the SATISFY-SOS 30-day survey consists of 61 questions with 140 items. The use of skip logic typically facilitates completion of the questionnaire in 15 to 20 min. Specific questions focused on in-hospital events and complications were dropped from the 1-yr survey, and the current version of the 1-yr survey contains 51 questions covering 100 items (copies of surveys available as Supplemental Digital Content 2, https://links.lww.com/ALN/B296).

Consent forms were collected daily, and patient identifiers were uploaded to the master SATISFY-SOS database. Using unique patient identifier numbers, consents were cross-referenced against the anesthesia information management system daily to detect if a consented patient had undergone any surgical procedure. When a consented patient underwent a surgery or procedure requiring anesthetic services, the date of procedure was counted as day 0 and the survey process was initiated after 30 days. For this study period, only those patients who answered the 30-day questionnaire were contacted for the 1-yr survey. We have recently amended our process, and all consented patients are now contacted for the 1-yr survey regardless of their 30-day response status.

Three survey modalities, electronic mail (web based), paper and pencil based through conventional mail, and telephone (verbal interview based), were attempted sequentially, and always in the same order, to allow patients different options to respond. If there was no response after the fifth telephone call, the patient was considered a nonresponder. A third-party commercial vendor with significant experience in collecting surveys (Press Ganey®, USA) was selected for the postal and telephone surveys. In keeping with the Health Insurance Portability and Accountability Act, an HRPO-approved contractual agreement with third-party vendor, was obtained to ensure protection of participants’ healthcare information.

For patients who provided e-mail addresses, the initial contact was made by e-mail, requesting them to follow a secure web link to complete the SATISFY-SOS 30-day survey. The secure web address enables the creation of a link between the survey server and the master database without using patient identifiers. SelectSurvey.NET software (ClassApps, USA) was used to develop the web-based survey. This method ensured that the survey was completed only once by each participant. If a patient did not respond to the initial e-mail, reminders were sent on day 2 and 4 after the first contact.

If no web-based survey was completed 11 days after the initial e-mail, the patient’s details were moved to the postal list. Combined with patients who did not provide an e-mail address, the patients’ postal list is sent to the third-party vendor (Press Ganey) for a pencil and paper (P&P) survey by conventional mail. A preaddressed and stamped envelope was provided to return the survey. The P&P survey was designed to be readable by optical mark recognition software. Each document contained a barcode encoding a unique SATISFY-SOS identifier without protected health information, enabling the software to populate a database automatically. Completed paper surveys were scanned as tagged image file format and the database was populated via optical mark recognition. If no mail response was obtained within 10 days, a second survey was mailed. Finally, attempts were made to contact patients with in-person telephone calls. All patient conversations were stored as audio files. After five failed telephone attempts to contact a patient, the patient was labeled as a nonresponder.

To develop and implement SATISFY-SOS, specific resources and personnel were allocated to the project. A full-time project manager, a methodologist with experience in survey research, and an informaticist were recruited. Initial fixed costs included physical space allocation for SATISFY-SOS team members, purchase of data servers, development of a web-based platform for electronic surveys, and contract fees for third-party vendors. Regarding the postoperative surveys, the e-mail modality is the most economical, while telephone interviews are the most expensive.

The aggregate data from SATISFY-SOS were stored on a dedicated research database server. The server was attached to a private network with no public access. Completed surveys collected by the third-party vendor were transmitted to the SATISFY-SOS server using an encrypted Secure File Transfer Protocol connection (fig. 3). The SATISFY-SOS database server hosts this information along with patient medical information from multiple clinical data sets, including the anesthesia information system, the surgical scheduling system, professional billing system, the hospital electronic health records, the longitudinal data repository, and the Barnes Jewish Hospital mortality review database. These data were linked to the consent and survey databases using a nonprotected health information primary key. This key was used as the only patient identifier whenever possible, to minimize the risk of data compromise. Researchers at Washington University conducted random quality control, comparing the survey answers entered in the database against the scanned tagged image file format mail surveys, and audio recordings.

Table 1 summarizes characteristics for patient enrollment in SATISFY-SOS for the first 2 yr (July 2012 to June 2014). During this period, using structure query language, 49,687 patients were identified in the electronic database. After removing duplicate and incomplete records, as well as eliminating patients who did not undergo preoperative assessment at the Assessment Center during the selected time period, a total of 44,081 patients were considered eligible for consent (fig. 4). Eligible patients for the SATISFY-SOS registry were defined as patients who visited the Center for Preoperative Assessment and Planning for the first time or those patients who were already enrolled but had their previous surgery more than 60 days before the current visit. Patients younger than 18 yr and those unable to provide informed consent were also not approached for participation. Of 44,081 eligible patients, 20,719 patients were consented for the SATISFY-SOS registry, resulting in an overall consent rate of 47%. The consent rate improved over time from 41% during the first year to 53% in the second year. The characteristics of patients who consented for participation and those who did not enroll are shown in table 1. The overall patient population was predominantly female (56 vs. 44% male) and white (81%). One third of enrolled patients (32%) were older than 65 yr (mean age, 56 ± 15.5 yr), whereas only 22% of the patients were younger than 45 yr. As expected, a substantial number of patients had several comorbidities, as evidenced by the fact that 43% of patients were evaluated to be of American Society of Anesthesiologists physical status III or above. Although the consent rate was only 47% for the period reported in this article, consented patients were very similar to those who were not enrolled in terms of demographic characteristics and health status including comorbidities (table 1); those enrolled were generally representative of the broader population of the Center for Preoperative Assessment and Planning. Importantly, the overwhelming majority of the patients who were approached to participate in this observational registry study consented and completed the baseline survey. The common reasons for not enrolling patients were that nurses who had not participated in the HRPO training saw them, or they were evaluated when the assessment center was especially busy.

During the study period, 12,482 (61.9%) of 20,719 patients completed the 30-day survey (table 2). A relatively small number, 3,520 (17%), of eligible patients provided their e-mail contact information during their consent. Of those who had provided their e-mail addresses, only a third of patients completed the questionnaire using the Web-based survey. Overall, 8% of surveys were collected by the electronic method, whereas a majority (73%) of patients responded using a paper and pencil mail survey. Nineteen percent of patients responded to the telephone survey.

More than 90% of the respondents completed the entire survey, answering all 61 questions in the 30-day survey. However, as the questionnaire progressed, there was an increasing tendency for participants to skip or stop answering questions, reaching a highest rate of 9.5% missing data (patients’ fatigue rate) for the last section in the questionnaire (fig. 4).

One year after the launch of the 30-day survey, the 1-yr survey was initiated in October 2013. In the second year of the stated study period, 2,526 were considered eligible for 1-yr survey. As per the original study design, the 1-yr survey was triggered 1 yr after the date of surgery, but only for those patients who already responded to the 30-day survey. Seventy-one percent of 2,526 eligible patients responded to the 1-yr survey. Once again, the majority (78%) of patients responded to the P&P survey, with 13% responding to the e-mail survey and only 8% answering the in-person telephone interview.

SATISFY-SOS has been successfully implemented as a prospective patient registry that systematically combines rigorous patient phenotype and granular perioperative data with comprehensive PROs from surgical patients at baseline, 30 days, and 1-yr after surgery. While many centers have implemented routine collection of PROs for specific surgeries or research studies,^31,32  this is the first report in the United States describing the feasibility of using PROs to follow changes in the health of unselected surgical patients at 30 days and 1-yr after hospital discharge.

Our approach embeds the process of obtaining consents and baseline PROs within the routine organizational clinical workflow. Our experience reinforces the view that a preoperative assessment encounter offers an opportunity for clinicians to establish patients’ preferences and expectations, while collecting baseline data on patient health, functional status, and HRQoL. This approach is similar to that pursued by England’s National Health Services where patients consent to participation in PRO data collection and complete health surveys during preoperative clinic visits.³³  Since anesthesiologists interact with all surgical patients, they are well positioned to encourage patient engagement, develop patient education tools, and track postoperative outcomes. Compared with other PROs initiatives,^13,14,33,34  the SATISFY-SOS registry combines extensive perioperative data captured in a searchable format with PROs. This rich information can be used to develop risk-adjusted outcome models. A preoperative anesthesiology encounter provides an ideal opportunity for clinicians to discuss the importance of reporting health outcomes beyond the scope and time frame generally captured with routine postoperative visits.

The overall response rate of 62% is modest compared with initiatives where PROs have been obtained at the point of contact in clinics, such as at the Cleveland Clinic’ Knowledge Program (more than 80%).³¹  With point of contact collection of PROs, patients can be encouraged and assisted by clinicians. This is exemplified by the SATISFY-SOS project; more than 90% of consented patients completed the baseline survey during their preoperative visit. PROs in England’s National Health Service (NHS) are collected long after the patients are discharged; yet report higher response rates (more than 75%).³³  It is possible that patients undergoing complex surgeries are more likely to respond to follow-up surveys. This has been the experience from the NHS initiative, where patients undergoing hernia repairs or varicose veins surgeries generated lower response rates than patients undergoing knee and hip replacement surgeries.³³  With the California Joint Replacement registry, PROs were administered at physician offices or at home, and completion rates were less than 30% at baseline.³²  Survey fatigue can impact response rates; the SATISFY-SOS 30-day survey is offered after other surveys, such as the Health Consumer Assessment of Healthcare Providers and Systems and the American College of Surgeons National Surgical Quality Improvement Program, are completed.^,13,14  Nonresponse has implications for generalizability of PROs, and further studies exploring the differences between respondents and nonrespondents are warranted.

In contrast to some other PROs collection efforts,^20,31–33  our method was developed to capture PROs after hospital discharge. We used three modalities: e-mail, paper surveys, and telephone interviews, hoping to increase response rates and to engage otherwise hard-to-reach patients. Even though our patients consented for participation, only 18% provided an e-mail address, of whom 32% responded via Internet. This suggests that if PROs were to be used to monitor patients beyond their hospital stay, e-mail or electronic patient portal may not be appropriate for all patients. Similarly, clinical trials relying on Web-based PROs have reported low response rates.³⁴  Since an increasing number of hospitals are implementing unified systems, and with increasing availability of smart phones and tablet computers, patient portals might provide a viable option for future patient engagement. Currently, paper surveys and telephone interviews remain essential to capture large surgical populations. Telephone modalities might be important for some patients such as those with low health literacy and vision problems. The comparative psychometric properties of different survey modalities need further investigation.^,35,36 

The key determinants of successful PROs collection include time and cognitive burden. From field tests and recorded telephone interviews, we estimated that with the help of skip logic, most patients take 15 to 20 min to complete our surveys. We observed very low survey fatigue, and more than 90% of our patients completed the questionnaires. Even as we observed low fatigue rate, it is possible that some patients chose not to respond to the questionnaire based on the length of the instrument. Recently, the National Institutes of Health (Bethesda, Maryland) led the development of PROMIS, which includes an array of psychometrically validated assessment tools for PROs collection.³⁷  Using computer adaptive methods in electronic portals, these variable length instruments can reduce time and cognitive burden for the patient, while maintaining the precision and consistency of the questionnaire.^37,38  We anticipate assimilating a similar approach to reduce the length and the cognitive burden of SATISFY-SOS surveys. In the next iteration, we plan to use recently validated PROMIS quality of life questionnaire (short version) to replace equivalent questions of VR-12. The modified Brice Questionnaire will also be eliminated after successful implementation of a quality improvement initiative, targeting intraoperative awareness.

The SATISFY-SOS survey instruments include generic components to evaluate patients’ understanding of the impact of surgery and postsurgical complications on their health and functional status. Our generic, multidomain survey instruments can be used for all surgical patients. However, the surveys lack the precision to measure outcomes specific to particular surgeries. Ideally, a combination of generic and procedure-specific questions is needed for measuring postsurgical outcomes. Future adoption of patient portals and other electronic PRO collection methods might facilitate modular survey instruments, where disease- and procedure-specific questionnaires are combined with generic questionnaires.

Other large-scale efforts to measure postoperative complications after discharge such as National Surgical Quality Improvement Program limit their measurement to 30 days.^13,14  As recovery from surgery often takes longer than 30 days, evaluation of the impact of invasive surgical procedures requires patient feedback beyond the acute recovery phase. Therefore, our first postoperative survey is initiated 30 days after surgery. This approach captures PROs between approximately 30 to 90 days after surgery, similar to England’s NHS, and Force initiative, which conduct surveys 3 to 12 months postoperatively.^20,33  By collecting baseline health information and conducting additional 1-yr postsurgical surveys, we aim to use PROs to track longitudinal health outcomes after surgery.

An important benefit of the SATISFY-SOS registry is that it can serve as the infrastructure for clinical trials, observational studies, and quality improvement initiatives. Several salient examples are briefly provided. The Electroencephalography Guidance of General Anesthesia to Alleviate Geriatric Syndromes clinical trial (NCT02241655) received funding from the National Institute on Aging (Bethesda, Maryland) partly on the basis that it benefits from the robust SATISFY-SOS infrastructure. Another relevant example is the assessment of the recently implemented enhanced recovery after surgery protocol in patients undergoing total cystectomy. We aim to determine whether the enhanced recovery after surgery care bundle is associated with improved patient-reported physical health. A third example is an ongoing observational study, which aims to assess the misalignment between patients’ expectations of postoperative pain and their reported experience of postoperative pain. SATISFY-SOS enables this project by providing baseline data on patient expectations, which can be directly compared with patient postoperative reports. Preliminary findings suggest that many patients who expect to have minimal or no pain a month after surgery actually experience severe or debilitating pain.

Our approach to PROs collection has a number of limitations and logistical challenges. While SATISFY-SOS has been successful in enrolling a large number of patients, consent rate averaged over the 2-yr period was relatively modest at 47%. A number of additional factors might explain the relatively modest patient enrollment to SATISY-SOS registry. First, recruitment rate was especially low (41%) during the first year as nurses completed regulatory training (approximately 10 h/nurse). With increasing numbers of nurses completing institutional review board training, the consent rate improved to 52% in the second year and has subsequently continued to improve. Second, production pressure in a busy preoperative assessment center that evaluates up to 100 patients per day, including many unscheduled patients, remains a barrier to enrollment. Third, there might be systematic bias against enrolling certain patients, such as those with poor literacy, sicker patients, patients with disabilities (cognitive, visual, or hearing), and possibly patients from specific populations. These hypothetical biases need to be explored and addressed. Other likely important limitations include survey fatigue, reliability of the survey instrument, response bias, and inaccurate recall of information by the patients.³⁹  These and other limitations will be explored in future studies.

The cohort included only elective surgery patients attending the assessment center. As such, the information might be less applicable to patients undergoing urgent surgeries or to those who do not comply with usual perioperative care pathways. One of the proposed benefits of including PROs in medical records is improved shared decision, better patient compliance, and increased satisfaction with treatment outcomes. While our PROs collection method is well suited to conduct population-based interventions and quality improvement projects, we have not yet developed a mechanism to provide PROs information to patients and physicians.

In conclusion, we have demonstrated through SATISFY-SOS that a process for including rigorous preoperative health information, for tracking patients’ perioperative course, and for obtaining postoperative PROs can be successfully assimilated in the organizational workflow of a busy academic hospital. Importantly, patient engagement, consent, strong support from the leadership, and buy-in from the frontline clinicians are helpful in sustaining such programs.

Future studies should elaborate the limitations and describe findings of the SATISFY-SOS projects. Initiatives like SATISFY-SOS should proliferate in order to drive perioperative implementation science and quality improvement, to enable efficient conduct of perioperative research, and ultimately to improve outcomes that matter to surgical patients.

The authors thank Drs. Alex S. Evers, M.D. (Department of Anesthesiology, Washington University, St. Louis, Missouri), Bruce L. Hall, M.D., Ph.D., M.B.A. (Department of Surgery, Washington University), Graham A. Colditz, Dr.P.H., M.D., M.P.H. (Institute of Public Health, Washington University), and John P. Lynch, M.D. (Department of Internal Medicine, Washington University and Barnes Jewish Hospital, St. Louis, Missouri), for their support in the development of the SATISFY-SOS project. They also thank the staff (in particular Amy Campbell, R.N., Tammy Murphy, R.N., Dawn Anderson, R.N., Marsha Fizette, B.S.N., Mark Foesterling, B.S.N., Beth Grace, R.N., Michelle Hieger, B.S.N., Jill Lafata, R.N., Jessica McGown, B.S.N., Angelike Nagele, R.N., Linda Quint, B.S.N., Mary Scherer, R.N., Tina Thomlison, R.N., Bonnie Vemmer, R.N., Keryn Padgett, B.S.N., Pathena Williams, R.N., and Linda Wiemer, B.S.N.) of the Center for Preoperative Assessment and Planning, Barnes Hospital, St. Louis, Missouri, for their ongoing work in patient engagement.

Supported by departmental resources (to SATISFY-SOS) and a BJHF grant 7937–77 from the Barnes-Jewish Hospital Foundation, St. Louis, Missouri (to Dr. Avidan).

The authors declare no competing interests.