Extended literature review: Evaluation of Patient Satisfaction with Podiatric Surgery. Sarah O Connor. BSc (Honours) Podiatry

Transcription

1 Extended literature review: Evaluation of Patient Satisfaction with Podiatric Surgery Sarah O Connor BSc (Honours) Podiatry Division of Podiatry Centre for Healthcare Education Faculty of Applied Sciences University College Northampton Submitted May 2004

2 Abstract This paper reviews literature in the area relating to podiatric surgery and patient satisfaction. Reasoning behind this research is to gauge patient satisfaction with podiatric surgery and to assess both positive and negatives aspects of the surgical process, which included pre, intra and post operative phases. Research papers were searched for manually through journals and electronically via research engines. They were then examined and critiqued using a standardized critiquing method. There is a lack of research in this area nevertheless the research that has taken place has shown patient satisfaction to be high. Acknowledgements Many thanks to Mr Paul Beeson my Dissertation Supervisor for all the help and suggestions that you have given. Appreciation also to Mr Mike Curran and Miss Sharon Rees for all the additional help that you have supplied. I would like to thank my family, in particular my parents for all their encouragement care and support throughout. Finally I would like to thank Ms Nuala Winston for all the help that you have given.

3 Contents Page number Abstract ii Acknowledgements iii Contents iv Chapter 1 Introduction 1 Chapter 2 Research Strategy 5 Chapter 3 Literature Review 6 Chapter 4 Discussion 38 Chapter 5 Conclusion 43 References 44 Bibliography 47

4 Appendices 48 Introduction Chapter 1 Podiatric surgery is elective surgery on the foot and ankle. This involves surgery on bones distal to the Malleoli and soft tissue of the foot. Surgery is performed under local anaesthetic with the use of either an ankle or digital tourniquet on a day case basis by a specialist podiatrist. Podiatric surgery is of great use and value, as it is performed on a selected area by specialist surgeons and the day case basis makes it cost effective, as the use of beds is not required. Bligh & Rice (1997) state that Doctors in the UK have started to refer more patients to podiatrists for day case foot surgery and the benefits of podiatric surgery may be the reasons behind this. There are three phases involved in the management of the surgical patient; pre-operative, intraoperative and post-operative. Each of these processes are assessed (see appendices 1-3) A pre-operative evaluation of the patient is needed before surgery is considered and will include history taking and a physical examination. This is to ensure that the patient is eligible for surgery and does not have any risk factors that will affect the post-operative outcome. As a result of this evaluation, further investigations such as x-rays and blood tests may be indicated.

5 The pre-operative evaluation should start with the chief complaint and the patient s reasons for wanting surgery. Next, the patients past medical history should be reviewed along with each of the patient s medical conditions if applicable. After this, a neurological assessment should be carried out and the patient s mental history should be considered. Next, a review of any allergies that the patient may have and the medication that the patient may be taking should take place. A social history of the patient is then undertaken and once all of these have been assessed, a physical examination should be performed. On completion of the history and physical examination an evaluation of risk factors should be performed. Skully et al (2003) suggests that these should include the patient s age, social, mental, and physical status, and the general patient evaluation. Janis (2003) states, After each patient s physical, psychological, social and employment needs have been evaluated, a treatment program can then be designed which will set course for a successful outcome. This program should be discussed at length with the patient until the patient feels completely certain about the impending surgery. Part of the discussion should include details of the proposed procedure to be carried out, a description of how the procedure will be carried out, what having the procedure will entail, what is hoped to be achieved by the surgery and what the patient is expected to do in order to achieve a positive outcome. Additionally a letter is sent to the patients General Practitioner before surgery has taken place explaining what is proposed to be done surgically to the patient.

6 The intra-operative considerations include the type of anaesthetic to be used, the amount of anaesthetic to be used, and how the anaesthetic is given to the patient. The site preparation should also be considered and planned. This will entail the positioning of the patient and the foot including isolation of the foot. The foot should then be cleaned with a sufficient antiseptic such as iodine. After the previous has been carried out, the surgeon should then consider if the materials to be used such as sutures and metals used in internal fixation are appropriate for the patient. As well as making sure that these aspects are appropriate for the patient, the actual procedure should be deemed suitable for that specific patient. Once the procedure has been performed, thought should be given to haemostasis and the return of blood supply to the operative area. Medic alert stickers are placed on notes for the patients that have any allergies or other medical problems of relevance. Additionally there is a form for all operative details ie local anaesthetic, tourniquet time, blood pressure etc so that all of these details can be documented. Once surgery has been performed, a post-operative management plan should be carried out and a series of appointments will be required to maintain effective patient care. The patient should also be made to understand all that is required of them to enhance a successful outcome for their surgery. This involves advice about the surgical site including the cleaning and protection of the site and signs and symptoms of abnormalities in the area. In addition, the patient will need to be advised on post-operative pain and analgesia. An operative summery is taken which is then filed with the patient s notes post-operatively for documentation. Additional letters are then sent to the patients General Practitioner after surgery has taken place. This occurs two weeks post-operatively when sutures have been removed. Four

7 weeks post-operatively when x-rays have been taken and three months post-operatively when the patient has been discharged. Both the patient and surgeon will have ideas of what makes a positive outcome regarding surgery. Althof & Beasley (2003) argue that, Positive results from surgery involve the long term improvement in the patient s pain and overall function. The justification for carrying out this literature review is that by identifying both positive and negative aspects of the surgical process, components of the surgical process can be enhanced. Once these have been highlighted, the quality of service provided by the surgeons in the podiatric profession can be improved. There is a lack of evidence in the podiatric field regarding patient satisfaction and their experiences of surgery as few studies have been carried out with the sole aim of assessing and measuring these. The aim of this study is hoped to gauge patient satisfaction with podiatric surgery. This will include patient expectations of podiatric surgery, patient perceptions of podiatric surgery, patient experiences of podiatric surgery and patient quality of life following podiatric surgery. All papers will be critiqued using a standard critical evaluation of research, format. Gould (1994) suggests that this should include assessing whether each paper contains an abstract or summary, an introduction, a literature review either separately or contained in the introduction, a methodology, a results section, a discussion, a conclusion and a reference section. After this each section will be assessed further to, determine whether the content of each section is deemed adequate based upon a methodological assessment.

8 Chapter 2 Research Strategy The research strategy involved searching for papers both manually and electronically. The manual search of papers was undertaken by looking through journals that had a connection with podiatric surgery. These journals included the British Journal of Podiatry, British Medical Journal, British Journal of Podiatric Medicine and Surgery, Clinics in Podiatric Medicine, Foot and Ankle International, Journal of Foot and Ankle Surgery, Journal of British Podiatry, Journal of British Podiatric Medicine, Podiatry Now and The Foot. The electronic search took place on databases, which included Amed, Cinahl, Embase, Medline, Science Direct, Swetwise, Web of Knowledge and Zetoc all of which store medical papers. Searching this way meant that papers were found that were full text papers or abstracts taken from full text papers. When abstracts were found both the reference and the source of that paper were provided. This meant that the articles were searched for either manually or electronically on databases that stored full text papers such as Lancet. When papers were not found by these means the Nursing Union List of Journals (NULJ) and Inter Library Loan Systems were used. If the papers were available on the NULJ system then the papers were ordered from here first. If they were not available from this system then they were ordered from the Inter Library Loan System.

9 Chapter 3 Literature review Bellocosa & Pollack (1993) entitled patient s expectations of elective foot and ankle surgery. The abstract of the paper was deficient as it was not labelled and failed to state the purpose of the study. However description of how the study was undertaken and a brief mention of the results were given. The next chapter of the paper was mediocre. The authors failed to give a heading to this section and any justifications for carrying out this piece of research. This chapter was presumed to be the introduction, as the papers aims and objectives were presented here which were, to determine patient s expectations of elective foot surgery and to assess the level of fulfilment and satisfaction of those expectations. This section of the paper also contained literature. However the Authors state that there is a lack of literature in this area so offered literature from other fields in the medical profession regarding elective surgery and expectations and satisfaction. The authors reporting of the methodology was inadequate. There was a failure to mention both the study s sample and research design. Consequently it was not known how many participants were involved in the study or whether the format for the study had been borrowed or selfdesigned. Nevertheless the authors did describe the tools used in the study even though their description of how the study was undertaken was vague. The study was a two-part questionnaire with the first questionnaire given pre-operatively and the second questionnaire post-operatively to subjects. The authors, however, did not mention if the questionnaires had been either piloted or

10 validated to determine its accuracy. The authors also failed to mention any ethical considerations given to the study to ensure confidentiality and safety of the subjects. The result s section of the paper was adequate. It stated how many questionnaires were completed but failed to mention the response rate of the study. Nevertheless the sample size used in the study was adequate with 73 subjects being used. The authors also gave information about the participants giving both the mean and range of the subject s sex and age. Findings were presented in the form of text and tables with all tables being labelled appropriately. However analysis of the results was not explained. Results presented by the authors were dependent on the question asked. Open-ended questions were presented in tables while close-ended questions were described in the text and presented in the form of percentages with it stating that 99% of participants were satisfied with the results of their surgery. The next chapter was poor and was the discussion section of the paper. There was a discussion of their findings but the study failed to compare these findings to others. However the authors did compare the results of the two questionnaires discussing expectations pre-operatively with satisfaction post-operatively. This aspect of the discussion and study was excellent. However this process was not mentioned either in the aims and objectives of the study or the methodology. Also any difficulties encountered in the study were not accounted for here either. The conclusion in this study was adequate. It discussed and made comment upon the findings obtained. The conclusions made by the authors were that 99% of patients were satisfied with their post-operative outcomes and that pre-operative concerns revolved around pain, swelling and recovery. However the authors failed to give suggestions of further research that could be carried out in this area.

11 The references in this paper were styled in the Vancouver system of referencing. The number of references was sparse and did not come from podiatric journals and as a result of this the references may not be relevant to podiatry. The references however were from variable sources and appeared appropriately when displayed in the text. The overall view of this paper was that it was adequate. The authors answered the research questions that were posed in the beginning of the paper and achieved a high level of patient satisfaction in the results. The adequate sample size of the study gave validity to the findings but flaws in the methodology or reporting of the methodology means that the results obtained have to be queried. Tollafield (1993) carried out a Podiatric Surgical audit. The abstract was excellent; it was clear and concise and contained all information required for this section of the paper. These included the purpose of the study, description of how the study was carried out and results obtained from the study. The introduction was adequate. Background information was given along with acknowledgement of others work in the podiatric profession but not specific to surgery. The introduction also had justifications for the research but failed to give any aims for the research. Tying in with the unorthodox layout of the study the aim was presented in a separate section, which was to determine whether the practice of podiatric surgical procedures was successful. In this chapter the author also gave explanations of problems faced regarding this area of podiatry.

12 The methodology chapter was poor. The general research design and sample design was not commented upon. The authors did explain the method and tools used in the study. Postal questionnaires were sent to patients who had received podiatric surgery in a specific time span and a second questionnaire was sent to local General Practitioners to determine the performance of podiatric surgical procedures. However there was a lack of information regarding the questionnaires used in terms of the questions and details included in these. In addition there was a lack of information about validation and reliability of the questionnaires. The authors also failed to comment upon the response rate for the study and reasons for non-participation. The result section was adequate with results being broken down into two parts formed from the two questionnaires. In this section the response rate for both questionnaires was given with 112 General Practitioners and 175 patients participating in the study but reasons for non-participation in the study were not stated. The results from the questionnaires were discussed but statistical analysis of these findings was not described. Results were displayed in either a pi chart or standard graphs both being adequately labelled and results being presented in percentages. Results presented were that 90% of subjects believed that an improvement in their condition had occurred. The conclusion was sufficient with the author drawing conclusions from the findings obtained in the study. These were that the performance by specialists in podiatric surgical procedures appears to be very satisfactory on the basis of the study presented. The author also made comparisons to others work which both agreed with and refuted these findings. However this has been included in the wrong chapter and should have been discussed in the discussion section. The author did, nevertheless, suggest that further research needed to be carried out in this area

13 to improve the standard of care available but failed to suggest ways in which this could be achieved. The reference style displayed in this paper was the Vancouver style of referencing. The author used a vast amount of references from a considerable number of sources. The references were relevant, up to date and were used appropriately in the text. This study was convincing and produced good results in terms of patient satisfaction. The author answered the research questions posed in terms of determining whether the practice of surgical procedures was successful. However the author stated that measurement of the success of the procedure would be based upon patient satisfaction but the author failed to state how satisfaction was defined and what level of satisfaction was required to be achieved in order to deem the result as satisfactory. A patient audit following Podiatric Surgery by Tagoe (1994). This paper had an unorthodox layout with an abstract or summary at the beginning of the report not being present. The introduction was mediocre with no justification for research or literature being presented. The author however stated the aim of the research with this being to substantiate the claim that podiatric surgery has produced consistently high patient satisfaction. The methodology was inadequate, as this was not carried out in great detail giving only an explanation of what occurred, with a questionnaire being sent to participants post-operatively. There was no mention of the research design, validation of the questionnaire or response rate of

14 the study. However the author did state that the use of the questionnaire had been approved but the author failed to state any ethical considerations that may have occurred to ensure patient consent and confidentiality. There was also a lack of information about the sample design with the number of participants, the age and gender of the participants not being stated. However there was a separate section that gave the response rate of the study and stated that 223 subjects participated in the study but there was no explanation of non-participation. The author also failed to describe any statistical analysis used on the findings. Results were satisfactory with what seems like results being given from all questions. The results were displayed in a table, a graph or pi chart with 72.2% being very satisfied and 21.2% being satisfied with podiatric surgery. Each result was discussed in length and occurred, as there was no separate discussion chapter. Due to they re not being a discussion section, comparisons of others findings were not made. The conclusion was mediocre and lacked justification. Statements were made, which were that the service provides a consistently high degree of satisfaction with surgical outcomes, waiting times and patient care. But the author failed to mention any additional research that could be carried out to further substantiate these claims. There were no references used in this paper throughout to justify any of the statements made and as a result there was no reference section. The study as a whole was competent. The reporting of the methodology was poor which could hinder the significance of the results obtained from the study. However aspects of the study were positive as it showed which aspects of the surgical process patients were satisfied or dissatisfied with. This is of great benefit to podiatric surgery as it has shown some of the aspects of the surgical process that could be improved.

15 Tollafield & Parmar (1994) setting standards for day care Foot Surgery. The summary of the paper was poor. The authors failed to mention the results obtained from the study and the purpose for carrying out the study. The authors did however give an explanation of how the study was undertaken. The introduction was insufficient as a justification for performing the study was not given and a hypothesis or the aims and objectives were not stated either. The author did however present and make reference to others work. The methodology was adequate but it failed to state the research and subject design of the study. The authors did explain that a postal questionnaire was sent to both patients and General Practitioners with the aim of measuring General Practitioners attitudes towards podiatric surgery and patient s attitudes towards the level of care that they received. The authors also stated that the aim of the study was to measure the hypothesis that Podiatric Surgeons could perform surgery safely. The result section and the discussion of the results were presented as one. This is not how papers are traditionally presented but nevertheless this section of the paper was satisfactory. The response rate and reasons for non-participation were given, as were the characteristics of the subjects with the average and range of the subject s gender and age being stated. The results given were presented separately with the findings being split into General Practitioner results and patient results. Results from each question posed to both sets of subjects were stated and discussed. Results showed that 62% of General Practitioners referred patients for podiatric

16 surgery and that 75% of patients were satisfied with their surgery. These results were also expressed in the form of graphs and pi charts that were accurately labelled. In addition to the authors presenting the results and discussion sections together there was also a failure to present a separate conclusion section. As a result conclusions were drawn in this chapter of the paper with the authors suggesting that the measurement of patient satisfaction was difficult and refers to the suggestion that both the patient and the clinician should measure satisfaction. The referencing in this paper was completed in the Vancouver system of referencing. The references were used appropriately and were correctly placed in the text. The number of references used was substantial and were from a variety of sources. The references were also up to date and relevant to the subject area. The overall view of the study was that it was sufficient. The authors stated a hypothesis but failed to state a null hypothesis for the study. Also even though a hypothesis was given statistical analysis to determine whether this hypothesis should be accepted or rejected was not performed therefore giving uncertainty to the results obtained. The authors do however break down each of the questions asked and as a result show which aspects in terms of pre, intra or post-operative aspects of the surgical process that the patients are not satisfied with. A clinical audit by Vohra (1995). There was no labelling of the first chapter of the study. This section contained a brief statement about podiatric surgery and stated the aims of this study, which were to monitor and measure patient satisfaction and the level of surgical care delivered by the surgical podiatry department. If this section was to be the abstract or summary then a purpose for carrying out the study should

17 have been given along with how the study was undertaken and results obtained from the study. However these were not stated. There was then a separate chapter that was labelled the purpose of the study and this section did give in depth reasons for carrying out the research. The next chapter should have been the introduction. This section however was not present indicating that there was no justification for carrying out the research or the presentation of literature in this area. The methodology section was inadequate. There was no explanation of the research or sample design, with the author only stating how the study was undertaken. This was that a postal questionnaire was sent to subjects post-operatively. There was no mention of the survey used or the questions asked in this survey. In terms of the subjects, their age and gender was not commented upon, neither were any ethical considerations that the author faced. The number of questionnaires sent to patients was given but the response rate was not stated. The response rate however was given in the next section of the study with 160 subjects participating in the study. This chapter was the results and discussion section of the paper and was inadequate. The results were given for each question asked and a labelled graph was presented for each question. Each question and its results were presented and discussed but statistical analysis of each result was not discussed. The result of patient satisfaction given was that over 90% felt satisfied with the results of their surgery. Although each response was discussed this failed to meet the standards of a discussion section as there were no comparisons made between the authors findings and previous findings.

18 The conclusion was reasonable with conclusions being drawn that patient satisfaction was high. Additionally the author made suggestions of further research to be carried out in this area. There was no use of references throughout this paper and therefore there was no reference section in the paper. This meant that the author was not up to date with information in this area. The author answered the research questions in terms of patient satisfaction. However the methodology and analysis of the results hinders the validity of the findings. The author also failed to use literature in the paper, which meant that the author was unaware of findings and theories in this area. Laxton (1996) a clinical audit of Forefoot Surgery performed by registered Medical Practitioners and Podiatrists. The abstract was excellent containing a purpose for carrying out the study, the method used to carry out this study and findings obtained from the study. The introduction was insufficient. The author only gave a justification for carrying out the research and failed to present adequate literature on this subject or give a hypothesis or state the aims and objectives for this study. The methodology was adequate with the method and the questionnaires used along with the number of subjects asked to participate in the study all being described. The author does not however expand on the subject or research designs. The author also explains in great detail that

19 results will be achieved by Podiatrists, General Practitioners, General Surgeons and Orthopaedic Surgeons all giving their own acceptable standard of patient satisfaction, with the author then averaging these standards to assess findings. The analysis of results was discussed further with the author stating that comparisons of Podiatrists results would be made against the results of General Practitioners, Orthopaedic Surgeons and General Surgeons in terms of nail surgery and that Podiatric results would be compared to Orthopaedic results with regard to forefoot surgery. The result s chapter was satisfactory and was split into two sections. The first was nail surgery and the second being forefoot surgery. For both sections the response rate and reasons for nonparticipation were given. The number of subjects participating in the study was 239 General Practitioners, 9 General Surgeons, 12 Orthopaedic Surgeons and 5 Podiatrists. Results showed that for nail surgery patient s satisfaction was 85% with satisfaction levels for forefoot surgery being 73%. The discussion was constructive but had aspects of the conclusion in it, as there was no separate conclusion section. The author draws conclusions about the results obtained which were that Podiatric Surgeon s reached an acceptable standard. The author also critiques the methodology that was used to obtain these findings and suggests that interpretation and clinical validity of results was hampered by insufficient sample sizes. The author did not compare findings to others but stated that there was a lack of literature to be able to do so. There were also suggestions for further research to support these findings. The reference style of this paper was the Vancouver style of referencing. The amount and significance of the references, which were up to date, was sufficient. Additionally they were displayed accurately in the text.

20 The standard of the study overall was sufficient. The author states that results obtained by Podiatric Surgeons regarding patient satisfaction was high and exceeded results of other professions. However these findings can be questioned as even though findings obtained from podiatric surgery were above the mean acceptable standard set by all professions, the acceptable standard set for podiatry was not noted. Findings could therefore have been below the set standard for podiatric surgery and as a result patient satisfaction in this study may not have met the required standard. Rees & Tagoe (1997) carried out a complication audit and patient satisfaction survey following Podiatric Surgery. There was no summary at the beginning of the paper so a brief overview of the purpose of the study, how the study was carried out and findings from the study was not given. The first chapter was the introduction, which was sufficient. This section contained both justifications for carrying out the research and the aims of the study. The aims stated were to identify risk factors for complications and to evaluate patient satisfaction. The author however did not review literature in this area. The methodology was inadequate with the author only stating how many subjects were recruited for the study, which were 177. The author failed to mention the research design and the subject design with no explanation of how the study was undertaken. The results section was adequate with each section of the survey being broken down and results stated and labelled graphs being displayed. The author failed to comment on any statistical

21 analysis used on the findings with results being displayed as percentages. The results stated show that 82.2% of the patients showed satisfaction with results of their surgery. The results were discussed in full in the discussion section. The author also compared the findings to those of others, which were in support of the author s results. This section also benefited from the author s explanation of negative and inaccurate results. The conclusion section was also sufficient as statements and conclusions were made along with suggestions of work that could be carried out to improve and support the author s findings. The referencing of the paper was completed in the Vancouver style of referencing. The number of references used was sparse but the quality was sufficient, as they were relevant, up to date and from a variety of sources. The references used were displayed in the paper adequately. The overall view of this paper was satisfactory. The reporting of the methodology used to undertake the study was vague and as a result the findings could have been affected. However the results obtained from the study were of benefit and the reporting and discussion of these was done in great detail with the use of literature to support these. A study by Ashford et al (2000) entitled a retrospective analysis of Swanson Silastic Double Stemmed Great Toe Implants with Titanium Grommets following Podiatric Surgery for Arthritic Joint Disease. The summary of the study was acceptable. It contained all that was required with the authors stating a purpose for carrying out the research, how the study was undertaken and results

22 obtained from the research. The summary also stated that ethical approval was sought and granted for this piece of research. This was well reported but should have been reported in the methodology section of the paper. The introduction was good and contained a vast amount of background information about the subject. The authors stated the aim of the study, which was to analyse the Swanson total implant Arthroplasty with respect to pain levels, physiological function and quality of life. The introduction also contained literature from others in this field. The methodology section was sufficient. It stated what took place, were it took place and who participated in the study. The method of the study was a questionnaire using the podiatric audit in surgical and clinical outcome measurement system (PASCOM) followed by an interview and a clinical examination of the subject, with the latter two focusing on the pain levels and physiological functions of the subjects. As the PASCOM system was used the questionnaire was validated and reliable but the authors do not state this. The methodology also stated the inclusion and exclusion criteria of the subjects. The authors also gave the number of subjects participating in the study along with the average age of the subjects and their gender. Despite this it does not state the response rate for the study in this chapter. The response rate and number of participants, which was 20, was given in the result section and the authors also stated reasons for non-participation. Analysis of the results was not described but was presented in the form of percentages. It was not noted whether all results were given or if results were selected. Findings showed that 62.5% were very satisfied with their surgery while no subjects stated that they were dissatisfied. The result section of this paper was therefore sufficient.

23 The discussion section was also adequate with description of the analysis used on the author s findings. A one tailed Wilcoxin statistical test was carried out on pain and activity level results. The authors stated that there was a significant relief in pain. From the statistical test it was found that this had a level of significance of p< The activity levels were found to be significantly increased, and statistical analysis showed that the level of significance was p< In this section the authors also compared their findings to those of others, which agreed with their findings. The conclusion states that there was an improvement in the patient s quality of life. However results to support these were not presented here or previously. The authors also failed to suggest ways in which this research could be improved and to expand upon existing knowledge. The reference style of the paper was Vancouver and the number of references used was substantial and from a variety of sources. The sources were of good quality and were relevant and up to date. The overall view of this study was that it was a satisfactory piece of research. The author fulfilled the aim of the study by determining the patient s quality of life following podiatric surgery. A hypothesis was not given for this study and yet statistical analysis of findings was performed. The analysis of results found that the level of significance was p<0.005 and as a result the hypothesis if it had been presented could have been accepted. The analysis used and the results of this analysis was neither explained nor justified and as a result reliability of the results is compromised.

24 A study by Kilmartin (2000) on a review of: activity, surgical outcomes and patient satisfaction over a 27month period. The abstract was poor with the author failing to state the purpose of the study and how it was undertaken with only the results established being stated. The introduction was also inadequate with only background information and a justification being given. The author failed to state a hypothesis or give aims and objectives for the research along with an absence of evaluation of other research on this topic. The next chapter ought to have been the methodology but this was absent. However the author did state the method used to carry out the research, which included using two measuring tools. The first was a clinical rating system that was given pre and post-operatively to subjects. The American orthopaedic foot and ankle society developed the rating system (AOFAS) and therefore it is presumed that the research design had been borrowed and validated but the author failed to state that this was the case. The second tool was a questionnaire. The author failed however to state whether this had been self designed or borrowed or whether it had been validated and therefore reliable. Along with the failure to report on the research design the author also failed to mention the subject design. The result s section of the paper was adequate. The results of the clinical rating scale and the survey were presented in tables that were adequately labelled. These showed that 91% of patients were satisfied with the results of their surgery. Analysis of the results was not explained and was presented in the form of percentages or the mean score. The author also stated the response rate of the study but failed to gives reasons for non-participation.

25 In the discussion the author poses questions about research in this area but fails to make comparisons with others work or inform of any difficulties encountered while carrying out the research. For these reasons the discussion was deemed inadequate The conclusion was however sufficient with statements and conclusions being made which was that podiatric surgery was safe, effective and popular. The author also gave suggestions of further research that could aid these. The style of referencing used in this paper was that of the Vancouver system. The quality of referencing in this paper was satisfactory and they were used appropriately throughout the text. The number of references was appropriate and they were relevant, up to date and from various sources. A hypothesis for the study was not given, neither were any aims or objectives. As the author did not have any research questions at the beginning of the research it is difficult to ascertain what was wished to be achieved from the research and what conclusions were hoped to be obtained on completion of the research. In a study by Bennett et al (2001) entitled health related quality of life following Podiatric Surgery. The abstract or summary of the paper was not labelled but its content was satisfactory. This section did not contain the purpose for carrying out the study but did give a brief overview of how the study was undertaken and the results obtained from the study. The authors also stated new

26 findings, which gave validity to their findings. These new findings were that there is an advantage in assessing health related quality of life as opposed to patient satisfaction. The next chapter was not labelled and was inadequate. This section contained a justification for carrying out the research and literature was presented in this section also but it was not specific or relevant to the research topic. The authors also failed to state the aims and objectives of the study or give a hypothesis to be tested by the research. The research and subject designs are not noted here in the methodology section. The method used was the recruitment of subjects who met the selection criteria. However the authors failed to mention whether this was done randomly or by selection. The inclusion criteria mentioned was not described and details of what this involved were not given. This also applied for the exclusion criteria of the study. The tools used to measure the outcomes of podiatric surgery were described. This included using two measuring tools. The first was the foot health status questionnaire (FHSQ) and the second was the short form 36 questionnaire (SF-36). In this section the authors also state the aims of the study, which were to establish the patients foot health status post-operatively and to see to what extent Podiatric Surgeons alter this. The result s section was adequate and gave explanations of non-participation. The number of participants was 140 and their characteristics regarding gender and age were also given. It was stated that the questionnaires used were used to evaluate whether health related quality of life changes over time. Results were compared with those of a validated study group and it was explained that these findings from the validated group were used to calculate the acceptable standard. Results from the survey were presented in the form of graphs and not referred to in the text. The graphs showed that subject s general foot health perception scores all increased post-

27 operatively and were above the acceptable score given from the validated group. The results of the SF36 gave differing results to that of the FHSQ with regard to patient quality of life. The results from the FHSQ were more positive than the SF36 results with the FHSQ giving higher levels of satisfaction. The discussion section was adequate with the authors comparing findings to others, which agreed with their research, and as a result gave validity to their findings. The findings from this study were compared to each other also with findings from the patient satisfaction surveys being compared to that of the quality of life outcomes. The authors also stated and showed that statistical analysis was used on the findings in the form of analysis of variance (ANOVA). However how and why this was used is not discussed either here or previously in the methodology section. The conclusion section was sufficient. The authors concluded that subjects experienced significant post-operative improvements across a range of health related quality of life parameters and that the use of patient satisfaction surveys leads to an underreporting of the benefits of foot surgery. The authors however fail to mention any suggestions of further research that could be carried out to verify these findings. The referencing of this study was that of the Vancouver style and the references used in this paper were up to date and relevant. Additionally the number of references used was satisfactory and from a number of sources. The references used in the paper were appropriate for the study and displayed appropriately throughout the text.

28 The overall view of this study was adequate, with the content of the paper in general being satisfactory. The authors do however state that the quality of life surveys are better than patient satisfaction surveys, as patient satisfaction surveys leads to underreporting of the benefits of podiatric surgery. This aspect of the paper was valuable, but as the reporting of the methodology and statistical analysis used in the study was inadequate, this could have lead to the interpretation of the results being inaccurate. As a result the findings from the health related quality of life surveys could have been overestimated leading to a distortion of the results. Kilmartin (2001) an audit of Podiatric Surgery in a community trust; a review of activity, Surgical outcomes, complications and patient satisfaction over a 4 year period. The abstract or summary was not labelled and a purpose for carrying out the study was not given. However there was a brief description of how the study was undertaken along with the results obtained from the study. As a result this section of the paper was satisfactory. The introduction was adequate as it gave a justification for carrying out the research. It also gave background information in this area and presented work of others. However a hypothesis or aims and objectives were not given. The methodology was mediocre, as it did not contain a subject or research design. The method used in the study was described. This included using the AOFAS clinical rating scale pre and post-operatively, along with two questionnaires, given to the subjects post-operatively to measure complications and patient satisfaction. The tools used to measure the outcomes had been borrowed and therefore validated in the case of the clinical rating system but it was not mentioned whether the questionnaires had been borrowed or self designed.

29 The results showed that 93% of the subjects were happy with the results of their surgery. Statistical analysis of the results was performed, calculating the mean and standard deviation of the results. There was also a paired t test carried out that showed the findings to be p< This however was not explained and was inadequately presented. The authors also stated the response rate of each of the questionnaires but failed to give reasons for non-participation. The discussion chapter was adequate with the authors making comparisons to others work which agreed with the author s findings. The author also made suggestions of additional research to be carried out to improve the research in this area. In the conclusion the author gave a review of findings, which were that podiatric surgery was safe, effective and popular and was deemed sufficient. The reference style of this paper was that of the Vancouver style of referencing. The number of references used was sufficient and from a number of sources. The references were of quality as they were relevant and up to date. As a hypothesis was not given it is not known what was proposed in terms of measurement and findings and consequently it is not known if the authors research questions and aims were answered on completion of the research. In addition though the level of significance was p<0.001 which meant that the hypothesis could be accepted, as there was no hypothesis in the paper the level of significance is insignificant. Reasoning for the use of the statistical test was not given and findings of these tests were not explained. As a result there is a lack of clarity of the findings.

30 Tollafeild (2001) an audit of lesser Metatarsal Osteotomy by Capital Proximal Displacement. The abstract was adequate stating the aim for carrying out the research, giving description of how the study was undertaken and the results acquired from this research. In the introduction the author presented background information about the surgery and findings and opinions from others. Along with this a justification for carrying out the research was given. The aims of the study, which was to evaluate the rate of success of the surgery based upon patient satisfaction, were included. A hypothesis was also given that Proximal Displacement Osteotomies (PDO) provides better or worse results than other Osteotomies. All aspects of the introduction were covered so this section was satisfactory. The methodology stated what was to occur in the study in terms of the operation to be performed and the tools used to measure the rate of patient satisfaction. The methodology also stated that 36 subjects participated in the study and gave the range of subject s age and the gender of the participants, which was broken down into percentages. The PASCOM system was used to measure patient satisfaction and the author described how this tool was to be used. The author also stated that the measurement of the PDO was to be carried out and that the patient s mobility of the joint and internal fixation of the joint would determine these results. Due to the information offered here the methodology was deemed sufficient but the author did fail to describe both the research and subject design in full. In the results section the author stated that PDO scores were analysed using the U Mann Whitney statistical test. The author reported that the findings from the statistical test showed that there was no significance. However the exact figures that were found were not reported.

31 The discussion section nevertheless was adequate with the author comparing findings to those of others but failing to comment upon the methodology used and any difficulties that may have been encountered while using this methodology. In the conclusion section the author states that PDO fares better or as well as other Osteotomies and makes recommendations for further research. The reference section was completed in the Vancouver style and was done in an appropriate way throughout the text. There was a useful quantity of references, which were from a various number of sources and were relevant and up to date. The author stated in the conclusion that PDO gave better or similar results in terms of patient satisfaction in comparison to other Osteotomies. However analysis of other Osteotomies was not performed or given by the author and as a result the author cannot substantiate the claims that PDO gives greater patient satisfaction. Also analysis used on PDO findings was found not to have any significance and as a result the hypothesis that PDO gives better or similar results should be rejected. The use of the analysis and the findings was not explained or justified and as a result the validity of the findings is questionable. The authors also stated that patient satisfaction was to be measured in this paper yet there was a failure to present this and as a result the author did not answer the research questions posed at the beginning of the research. A study by Kilmartin (2002) entitled revision of failed foot surgery.

32 The abstract was adequate but was not labelled. It contained a purpose for carrying out the research. Both results and new findings that emerged from the research were stated but the authors did not mention how the study was carried out. The introduction was not labelled either but was also adequate. It contained a justification for the research and the aims of the study, which was to find the causes of patient s dissatisfaction following foot surgery. The author also used literature to support the justification and aims given for the research. The reporting of the methodology was poor with the authors giving no mention of both the research and subject designs. The methodology did state what was to occur with subjects being given a questionnaire at their last post-operative appointment to assess their satisfaction rate with revision surgery. The results section stated the response rate of the study and that 176 subjects participated in the study along with the age and gender of participants. Statistical analysis of the findings was not discussed but described, with 69% of participants being completely satisfied with their revision surgery while 6% were dissatisfied. The discussion section was sufficient with authors giving an in depth analysis of their findings and reasons for these to occur. In addition the author uses others findings to support their own. The conclusion was insufficient with the authors making a statement that the patients who underwent revision surgery achieved high levels of satisfaction but did not expand on or give