BACKGROUND:Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of inappropriately used clinical practices in Canada. METHODS:We searched multiple bibliometric databases and grey literature to identify inappropriately used clinical practices in Canada between 2007 and 2021. Two team members independently screened citations, extracted data and assessed methodological quality. Findings were synthesized in 2 categories: diagnostics and therapeutics. We reported ranges of proportions of inappropriate use for all practices. Medians and interquartile ranges (IQRs), based on the percentage of patients not receiving recommended practices (underuse) or receiving practices not recommended (overuse), were calculated. All statistics are at the study summary level. RESULTS:We included 174 studies, representing 228 clinical practices and 28 900 762 patients. The median proportion of inappropriate care, as assessed in the studies, was 30.0% (IQR 12.0%-56.6%). Underuse (median 43.9%, IQR 23.8%-66.3%) was more frequent than overuse (median 13.6%, IQR 3.2%-30.7%). The most frequently investigated diagnostics were glycated hemoglobin (underused, range 18.0%-85.7%, n = 9) and thyroid-stimulating hormone (overused, range 3.0%-35.1%, n = 5). The most frequently investigated therapeutics were statin medications (underused, range 18.5%-71.0%, n = 6) and potentially inappropriate medications (overused, range 13.5%-97.3%, n = 9). INTERPRETATION:We have provided a summary of inappropriately used clinical practices in Canadian health care systems. Our findings can be used to support health care professionals and quality agencies to improve patient care and safety in Canada.

There is increasing recognition in Canada and globally that a substantial proportion of health care delivered is inappropriate as evidenced by (1) harmful and/or ineffective practices being overused, (2) effective clinical practices being underused, and (3) other clinical practices being misused. Inappropriate health care leads to negative patient experiences, poor health outcomes, and inefficient use of scarce health care resources. The purpose of this study is to conduct a systematic review of inappropriate health care in Canada. Our specific objectives are to (1) systematically search and critically review published and grey literature for studies on inappropriate health care in Canada; (2) estimate the nature and magnitude of inappropriate health care in Canada and its provincial and territorial jurisdictions.

Background We sought to determine whether patients seen in hospitals who had reduced overall emergency department (ED) length of stay (LOS) in the 2 years following the introduction of the Ontario Emergency Room Wait Time Strategy were more likely to experience improvements in other measures of ED quality of care for three important conditions. Methods Retrospective medical record review using difference-in-differences analysis to compare changes in performance on quality indicators over the 3-year period between 11 Ontario hospitals where the median ED LOS had improved from fiscal year 2008 to 2010 and 13 matched sites where ED LOS was unchanged or worsened. Patients with acute myocardial infarction (AMI), asthma and paediatric and adult upper limb fractures in these hospitals in 2008 and 2010 were evaluated with respect to 18 quality indicators reflecting timeliness and safety/effectiveness of care in the ED. In a secondary analysis, we examined shift-level ED crowding at the time of the patient visit and performance on the quality indicators. Results Median ED LOS improved by up to 26% (63 min) from 2008 to 2010 in the improved hospitals, and worsened by up to 47% (91 min) in the unimproved sites. We abstracted 4319 and 4498 charts from improved and unimproved hospitals, respectively. Improvement in a hospital's overall median ED LOS from 2008 to 2010 was not associated with a change in any of the other ED quality indicators over the same time period. In our secondary analysis, shift-level crowding was associated only with indicators that reflected timeliness of care. During less crowded shifts, patients with AMI were more likely to be reperfused within target intervals (rate ratio 1.59, 95% CI 1.03 to 2.45), patients with asthma more often received timely administration of steroids (rate ratio 1.88, 95% CI 1.59 to 2.24) and beta-agonists (rate ratio 1.47, 95% CI 1.25 to 1.74), and adult (but not paediatric) patients with fracture were more likely to receive analgesia or splinting within an hour (rate ratio 1.66, 95% CI 1.22 to 2.26). Conclusions These results suggest that a policy approach that targets only reductions in ED LOS is not associated with broader improvements in selected quality measures. At the same time, there is no evidence that efforts to address crowding have a detrimental effect on quality of care.

STUDY OBJECTIVE:In recent years, lean principles have been applied to improve wait times in the emergency department (ED). In 2009, an ED process improvement program based on lean methods was introduced in Ontario as part of a broad strategy to reduce ED length of stay and improve patient flow. This study seeks to determine the effect of this program on ED wait times and quality of care.METHODS:We conducted a retrospective cohort study of all ED visits at program and control sites during 3 program waves from April 1, 2007, to June 30, 2011, in Ontario, Canada. Time series analyses of outcomes before and after the program and difference-in-differences analyses comparing changes in program sites with control sites were conducted.RESULTS:In before-after models among program sites alone, 90th percentile ED length of stay did not change in wave 1 (-14 minutes [95% confidence interval {CI} -47 to 20]) but decreased after wave 2 (-87 [95% CI -108 to -66]) and wave 3 (-33 [95% CI -50 to -17]); median ED length of stay decreased after wave 1 (-18 [95% CI -24 to -12]), wave 2 (-23 [95% CI -27 to -19]), and wave 3 (-15 [95% CI -18 to -12]). In all waves, decreases were observed in time to physician assessment, left-without-being-seen rates, and 72-hour ED revisit rates. In the difference-in-difference models, in which changes in program sites were compared with controls, the program was associated with no change in 90th percentile ED length of stay in wave 2 (17 [95% CI -0.2 to 33]) and increases in wave 1 (23 [95% CI 0.9 to 45]) and wave 3 (31 [95% CI 10 to 51]), modest reductions in median ED length of stay in waves 2 and 3 alone, and a decrease in time to physician assessment in wave 3 alone.CONCLUSION:Although the program reduced ED waiting times, it appeared that its benefits were diminished or disappeared when compared with that of control sites, which were exposed to system-wide initiatives such as public reporting and pay for performance. This study suggests that further evaluation of the effectiveness of lean methods in the ED is warranted before widespread implementation.

Purpose: Few functional outcomes of total femoral endoprosthetic replacement (TFEPR) using contemporary modular systems are available. We compared functional results between TFEPR patients receiving fixed- and rotating-hinge knee componentry following oncologic resections. Method: Eighteen TFEPR patients were identified from a prospectively gathered sarcoma database. Six were secondary procedures and 12 primary. Four patients had metastatic carcinoma, 8 osteosarcoma, 4 non-osteogenic spindle cell sarcomas of bone, 1 Ewing’s sarcoma, and 1 femur-invading soft-tissue sarcoma. All reconstructions used modular implants from a single company. Proximally, all were bipolar hip hemiarthoplasties, 12 including abductor reattachment. Distally, 8 had fixed- and 10 had rotating-hinge knee componentry. Toronto Extremity Salvage Score (TESS), and both Musculoskeletal Tumor Society Scores (MSTS) were compared between fixed- and rotating-hinge groups using the Mann-Whitney test. Results: Complications included 1 hip dislocation, 1 femoral malrotation, and wound problems requiring 3 debridements and 1 amputation. One metastatic carcinoma patient developed local relapse. Follow-up averaged 4 years (range 1 month to 14 years). At latest follow-up, 10 patients had died of disease. Eight remained alive, 6 disease-free, 2 with distant disease. Among patients surviving 6 months, 6 used no assistive devices, 5 used a single cane, and 4 were wheelchair bound, each at least partly due to distant disease progression. TESS averaged 74.5±17.4, MSTS1987 25.2±4.4; and MSTS1993 58.6±22.9 among the 12 patients for whom functional results were available from latest follow-up. No statistically significant differences or even trends were detected between fixed-hinge and rotating-hinge patients (lowest p = 0.755), but both instability problems were in the rotating-hinge group. Conclusion: While both rotating- and fixed-hinge TFEPR reconstructions may function well, consideration should be given to fixed-hinge knee reconstruction when massive myectomies or poorer conditioning make hip and knee stability a primary concern in the short-term.

Purpose: To review the oncologic outcomes following treatment of soft tissue sarcomas in the foot and ankle, and to determine the results of limb salvage surgery in this anatomically constrained area with often expected close pathologic margins. Method: One hundred twenty-nine patients with soft tissue sarcomas of the foot were treated at our institution since 1986. Average age at presentations was 55 years old. Females and males were equally represented. Most common diagnosis was MFH in 31 patients, followed by leiomyosarcoma in 16 patients, synovial sarcoma in 13, and clear cell sarcoma in 6, the remainder being other soft tissue sarcomas. Most of sarcomas were intermediate or high grade. Our follow-up averaged 58 months. Results: Limb salvage surgery was possible in 97 patients. Of those, negative margin excision was achieved in 75 patients, 18 patients had micro-positive margins, and 4 had grossly positive margins. Fifty-three patients in the limb salvage group required free tissue transfer for coverage. Of 97 limb salvage patients, 82 received radiation therapy, 5 patients received chemotherapy. Local recurrence occurred in 24 patients. Two of these were amenable to re-excision, the remaining required amputation. Thirty-two patents developed systemic disease. Average disease-free survival for patients with recurrent disease was 23 months. At last follow-up, 78 patients were alive with no evidence of disease and 24 were alive with disease. Seventeen patients died of disease, and the remainder of other causes. Conclusion: In the setting of soft tissue sarcoma in foot and ankle, amputation rate is higher than in other anatomic areas. However, limb salvage surgery can be achieved with good oncological outcomes despite often unavoidable close margins. Soft tissue reconstructive procedures aid in achieving good surgical results while radiation therapy aids local control. Given these results, limb salvage in soft tissue tumors of foot and ankle should be the goal.

BACKGROUND:Rigorous evaluation of an intervention requires that its allocation be unbiased with respect to confounders; this is especially difficult in complex, system-wide healthcare interventions. We developed a short survey instrument to identify factors for a minimization algorithm for the allocation of a hospital-level intervention to reduce emergency department (ED) waiting times in Ontario, Canada.METHODS:Potential confounders influencing the intervention's success were identified by literature review, and grouped by healthcare setting specific change stages. An international multi-disciplinary (clinical, administrative, decision maker, management) panel evaluated these factors in a two-stage modified-delphi and nominal group process based on four domains: change readiness, evidence base, face validity, and clarity of definition.RESULTS:An original set of 33 factors were identified from the literature. The panel reduced the list to 12 in the first round survey. In the second survey, experts scored each factor according to the four domains; summary scores and consensus discussion resulted in the final selection and measurement of four hospital-level factors to be used in the minimization algorithm: improved patient flow as a hospital's leadership priority; physicians' receptiveness to organizational change; efficiency of bed management; and physician incentives supporting the change goal.CONCLUSION:We developed a simple tool designed to gather data from senior hospital administrators on factors likely to affect the success of a hospital patient flow improvement intervention. A minimization algorithm will ensure balanced allocation of the intervention with respect to these factors in study hospitals.

Lymph node metastasis in soft tissue sarcoma is considered to be a rare event (1.6–8.2%), From 1986 to 2001 1066 patients with extremity soft tissue sarcoma were treated surgically (+/− adjuvant therapy) at our institution. Thirty-nine patients (3.6%) were identified with lymph node metastasis, most common histological subtypes were: Epitheliod sarcoma (3/15), rhabdomyosarcoma (4/21), clear cell sarcoma (2/18), and angiosarcoma (2/18). Comparing expected five- year survivorship, we found that surprisingly in this study, extremity soft tissue sarcoma patients initially presenting with lymph node metastases had survival comparable to patients with high grade soft tissue sarcoma and no metastases. To determine the outcome in patients with soft tissue sarcoma (STS) of the limbs that presented with lymph node metastasis (LNM) at diagnosis or developed them after it, comparing to all STS of limbs population that was treated at our center. LNM in soft tissue sarcoma is considered to be a rare event (1.6–8.2%) with a devastating effect on the outcome,our study represent one of the largest reported cohorts, and suggest that agressive approach to LNM might contribute to survivorship. Thirty-nine patients (3.6%) were identified with LNM along their course of disease Thirteen patients presented with both lymphatic and systemic disease while twenty-six had isolated LNM at time of diagnosis. The mean follow-up from diagnosis of the primary tumor was 46.3 months (range zero to one hundred and forty-eight), and from diagnosis of lymph node involvement was 29.9 months (range zero to one hundred and twenty). Expected five year survival in patients initially presenting with LNM was comparable to patients with high grade soft tissue sarcoma and no metastases. From Jan’ 1986 to Dec’ 2001 1066 patients with extremity STS were treated at our institution. Fifteen patients presented with LNM at time of first diagnosis, and twenty-four subsequently developed LNM after it. Linear regression analysis and Kaplan-meier curves were used to compare expected survivorship in all patients with STS of limbs. Comparing expected five- year survivorship, we found that Surprisingly in this study, extremity STS patients initially presenting with LNM had survival comparable to patients with high grade soft tissue sarcoma and no metastases.

Pathologic fracture through giant cell tumor is thought to be associated with higher rates of recurrence and poor functional outcome. We compared patients with and without pathologic fracture through giant cell tumor of weightbearing long bones. We retrospectively reviewed 139 patients with giant cell tumor of weightbearing long bones with (n = 43) and without (n = 96) pathologic fracture at presentation; the two groups had similar demographics. Joint salvage was successful in 84% of the fracture group and 96% of the nonfracture group. Five-year recurrence-free survival rates were comparable between the two groups (82.6% [95% confidence interval, 69.1-95.9%] in the fracture group and 77.9% [95% confidence interval, 67.7-88.1%] in the non-fracture group). There was a trend toward lower 5-year metastatic-free survival in the fracture group (94.7% [95% confidence interval, 87.3-100%]) than in the nonfracture group (97.3% [95% confidence interval, 93.5-100%]). Functional outcome was good and similar in the two groups. Arthrofibrosis was more common in the group with pathologic fracture. Joint salvage for patients with pathologic fractures through giant cell tumor of weightbearing bones is a reasonable option with functional outcomes and recurrence rates comparable to those of patients without fracture. Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

With a strong sense that MOE/MAR and its implementation have been a resounding success, the authors offer a final set of insights for healthcare leaders.

OBJECTIVE:To evaluate how functional disability impacts on health related quality of life (HRQOL) of patients with extremity soft tissue sarcoma (STS) at 1 year post-surgery.DESIGN AND SETTING:Survey of extremity STS patients pre-surgery and one-year post-treatment.PARTICIPANTS:100 participants who were treated for extremity STS between 2001 and 2003 at four Canadian hospitals. Patients were over 16 years, non-metastatic at diagnosis, and had limb salvage surgery.OUTCOME MEASURES:Musculoskeletal Tumor Society Rating Scale (MSTS), a measure of impairment; Toronto Extremity Salvage Score (TESS), a measure of activity limitations; Reintegration to Normal Living Index (RNL), a measure of participation restrictions; and EQ-VAS, a measure of HRQOL.RESULTS:After adjusting for demographic and clinical variables, impairment explained 54%, activity limitations explained 48%, and participation restrictions explained 61% of the variation in HRQOL. After adjustment, when all three functional measures were included in the model, only participation restrictions had a significant impact on HRQOL explaining 63% of the variation.CONCLUSION:Impairment and activity limitations affect the daily activities a patient can perform, but it is the restriction in participation of life roles and situations that has the greatest effect on patient's HRQOL.

Purpose: To evaluate whether satellite tumor cells can be identified histologically in the tissues surrounding a soft tissue sarcoma and whether their presence correlates with increased T2-weighted signal intensity on MRI. Methods and Materials: Fifteen patients with a high-grade extremity or truncal soft tissue sarcoma underwent preoperative MRI. The extent of high T2-weighted signal changes in the tissues surrounding tumor, thought to represent peritumoral edema/reactive changes, was determined. Twelve patients received i.v. gadolinium, and contrast enhancement was determined. All patients underwent surgical resection in the absence of preoperative chemotherapy or radiotherapy. The presence of tumor cells in the surrounding tissues was determined histologically in representative paraffin-embedded sections and correlated with the MRI findings. Results: The extent of peritumoral T2-weighted MRI signal changes ranged from 0 to 7.1 cm (mean, 2.5 cm); contrast enhancement ranged from 0 to 5.3 cm (mean, 1.1 cm). Sarcoma cells were identified histologically in the tissues beyond the tumor in 10 of 15 cases. In 6 cases, tumor cells were located within 1 cm of the tumor margin, and in 4 cases, malignant cells were found at a distance >1 cm and up to a maximum of 4 cm. The location of tumor cells beyond the margin did not correlate with tumor size nor did it correlate with the location or extent of peritumoral changes. Conclusion: The ability to identify tumor cells beyond the margin of a soft tissue sarcoma has important implications in planning appropriate targets for treatment. This could influence the use of new radiotherapy technologies such as intensity-modulated radiotherapy that aim to minimize treatment volumes through conformal planning.

OBJECTIVE:To identify patterns of extracapsular extension of synovial osteochondromatosis of the hip.DESIGN AND PATIENTS:Seven cases of synovial osteochondromatosis of the hip were retrospectively reviewed. Imaging performed included conventional radiography ( n=7), arthrography ( n=1), CT ( n=3) and MR imaging ( n=3). Disease extent on imaging was assessed for each patient and the presence of intra-articular effusion, capsular abnormality and osteochondral bodies recorded. The presence and distribution of extra-articular spread was also assessed and correlated with the surgical findings. In all cases diagnosis was confirmed by biopsy, with all patients undergoing tumor resection with or without synovectomy.RESULTS:In five cases (5/7) disease extended beyond the hip capsule, while the remaining two cases (2/7) were confined to the hip joint. These findings were confirmed at surgery. Two distinct patterns of extracapsular spread were identified. The first pattern, noted in three cases, involved tumor extension along iliopsoas. The second pattern, noted in five cases, involved tumor extension along the obturator externus fat plane. In three cases both patterns were present.CONCLUSIONS:Extra-articular spread of synovial osteochondromatosis is common. Patterns of extra-articular spread may be predictable based on involvement of recognized periarticular bursae of the hip joint. Bursal patterns of extra-articular spread include extension into the iliopsoas bursa as well as communication along the obturator externus bursa of the hip.

The treatment of acetabular bone metastases presents numerous clinical challenges including the necessity for careful patient selection for surgery, determination of the extent of bone destruction, and providing the patient with stable surgical reconstruction of the pelvis. There are relatively few patient series reported in the literature to inform treatment planning, surgical reconstruction techniques, and patient outcomes. We describe a rationale for assessment of patients with acetabular metastases and options for reconstruction. The three general principles for surgical treatment of metastatic bone disease (tumor removal, filling of the resultant bone defect, and bypass of the defect) are defined for acetabular metastases. The results of surgical treatment are described with reference to recent articles in the literature. The reconstruction of acetabular metastatic disease is a major surgical procedure with a significant risk of complications. The surgeon must be certain that the patient's longevity and potential improvement in quality of life justify the risk of the operation.

Patients with soft-tissue sarcoma (STS) of the extremities who die from sarcoma do so because of metastatic disease. Consequently, local disease control is a secondary, albeit important, objective; in a relative sense, this applies also to disability resulting from treatment. These factors are particularly important in the high-risk patient with a large (>5 cm), high-grade, deep lesion. The report from Massachusetts General Hospital by Delaney et al. in this volume of IJROBP is relevant to these issues (1).

Cyclins play an important role in regulating the passage of dividing cells through critical checkpoints in the cell cycle. Because alterations of several cyclins, especially cyclin D1, have been implicated in the development of many human neoplasms, we examined 32 cases of giant cell tumor of long bones for cyclin D1 gene amplification and protein overexpression using differential polymerase chain reaction and immunohistochemistry, respectively. In addition, the expression of cyclin D3, cyclin B1, and the proliferation-associated antigen Ki-67 (MIB-1) was assessed immunohistochemically. Low-level cyclin D1 gene amplification was detected in 61% of giant cell tumor cases. All tumors showed cyclin D1, cyclin D3, cyclin B1, and Ki-67 (MIB-1) staining; however, the distribution was very characteristic. Cyclin D1 protein expression was seen predominantly in the nuclei of the giant cells, with occasional mononuclear cells staining. There was no correlation between cyclin D1 gene amplification and protein overexpression. Cyclin D3 staining showed a similar distribution, with 88% of cases showing protein overexpression. Cyclin D1 and/or D3 staining in the giant cells was never associated with staining for either cyclin B1 or Ki-67 (MIB-1), as the expression of the latter two proteins was restricted to the mononuclear cells. Cyclin B1 overexpression was seen in 44% of cases. Ki-67 (MIB-1) staining was present in all cases, and between 10 to 50% of the mononuclear cells were positive. These results suggest that alterations in cyclin D1 and/or D3 might play a role in the pathogenesis of giant cell tumor of bone.

Background External-beam radiotherapy (delivered either preoperatively or postoperatively) is frequently used in local management of sarcomas in the soft tissue of limbs, but the two approaches differ substantially in their potential toxic effects. We aimed to determine whether the timing of external-beam radiotherapy affected the number of wound healing complications in soft-tissue sarcoma in the limbs of adults.Methods After stratification by tumour size (less than or equal to10 cm or >10 cm), we randomly allocated 94 patients to preoperative radiotherapy (50 Gy in 25 fractions) and 96 to postoperative radiotherapy (66 Gy in 33 fractions). The primary endpoint was rate of wound complications within 120 days of surgery. Analyses were per protocol for primary outcomes and by intention to treat for secondary outcomes.Findings Median follow-up was 3.3 years (range 0.27-5.6). Four patients, all in the preoperative group, did not undergo protocol surgery and were not evaluable for the primary outcome. Of those patients who were eligible and evaluable, wound complications were recorded in 31 (35%) of 88 in the preoperative group and 16 (17%) of 94 in the postoperative group (difference 18% [95% Cl 5-30], p=0.01). Tumour size and anatomical site were also significant risk factors in multivariate analysis. Overall survival was slightly better in patients who had preoperative radiotherapy than in those who had postoperative treatment (0=0.0481).Interpretation Because preoperative radiotherapy is associated with a greater risk of wound complications than postoperative radiotherapy, the choice of regimen for patients with soft-tissue sarcoma should take into account the timing of surgery and radiotherapy, and the size and anatomical site of the tumour.

The Short Form 36, The Toronto Extremity Salvage Score, and the 1987 and 1993 Musculoskeletal Tumor Society Rating Scales were compared as measures of functional status for patients with lower extremity sarcoma. The study included 97 patients with lower extremity sarcoma and evaluated each measure on the following measurement properties: conceptual framework; statement of the purpose; feasibility; breadth of content; depth of measurement; cross sectional and longitudinal reliability; and validity and responsiveness. The Short Form 36 represents patients' perceptions of their physical and mental health and is practical to use. However, the validity of the measure is questionable for the patients with sarcoma because the subscale structure could not be reproduced in the current data. The Toronto Extremity Salvage Score meets all standards of measurement with the exception of breadth of content as it measures only physical function. The 1987 and 1993 Musculoskeletal Tumor Society scales do not meet the standards of measurement. In choosing an outcome measure for the extremity sarcoma population, the Toronto Extremity Salvage Score has superior measurement properties when compared with the Short Form 36 or the 1987 and 1993 Musculoskeletal Tumor Society scales. The Toronto Extremity Salvage Score is a reliable and efficient measure for monitoring patients and for use in clinical trials.

Patients undergoing limb salvage surgery for bone and soft tissue sarcoma of the extremities experience significant physical disability as a result of life-preserving treatment. The existing health status measures do not adequately evaluate physical function from the patient's perspective. This paper presents the developmental studies (item selection, reduction, reliability, validity and responsiveness) of a new measure, The Toronto Extremity Salvage Score (TESS). Patients with bone and soft tissue sarcoma (76 upper and 83 lower extremity) were randomly selected and mailed the TESS. Patients rated the severity and importance of physical disabilities; the response options included a 'not applicable' category and open-ended questions that allowed patients to suggest additional items for inclusion in the questionnaire. Therefore, patient perceptions were used to determine item content. Difficulty and importance frequencies were calculated and items rated 'totally unimportant' or 'not applicable' by 30% of the sample were eliminated. Extra items identified 30% of the time were added to the questionnaire. Internal consistency was evaluated by Cronbach's alpha. Test-retest reliability and validity were evaluated on subsequent patient samples. The intraclass correlation coefficient (ICC) was calculated for test-retest reliability and correlations with The Musculoskeletal Tumour Society Rating Scale (MSTS) were calculated for construct validity. Standardized effect sizes were calculated as a measure of responsiveness. Fifty upper extremity and sixty-six lower extremity patients responded to the mailed questionnaire. No items were eliminated based on importance or not applicable ratings. Sporting activities were identified as additional items in both the upper and lower extremity questionnaire. High internal consistency was demonstrated: 0.94 for the lower and 0.92 for the upper extremity questionnaires respectively. Test-retest reliability was evaluated at multiple time-points and the intraclass correlation coefficient was greater than 0.87 in all instances. Construct validity was shown by a moderate correlation with the MSTS. The effect sizes were large demonstrating responsiveness. The use of patients' perceptions in determining the content of the TESS has resulted in a reliable and valid measure that is able to detect change over time.