Responsiveness of Patient Reported Outcome Measures in Total Joint Arthroplasty Patients

doi:10.1016/j.arth.2014.09.026

The Journal of Arthroplasty

Volume 30, Issue 2, February 2015, Pages 176-191

https://doi.org/10.1016/j.arth.2014.09.026 Get rights and content

Abstract

This study reports the responsiveness to change and minimal clinically important difference (MCID) of three patient reported outcome measures following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patient-reported outcome measures were collected preoperatively and 3 months postoperatively for 391 patients enrolled in the California Joint Replacement Registry. Effect size, standardized response means, and MCID were calculated for each measure. The WOMAC and the SF12v2 physical component summary (PCS) score were the most responsive to perioperative changes. The MCID was 4.97 for the SF12v2 PCS and 10.21 for the WOMAC. THA patients were more likely to exhibit improvements above the MCID than TKA patients. The WOMAC and SF12v2 PCS are useful to measure health status changes in TJA patients.

Level of Evidence: Prognostic Level II.

Section snippets

Patient Sample

PROMs were collected preoperatively and three-months postoperatively for 391 patients enrolled in the California Joint Replacement Registry (CJRR). Patients undergoing either unilateral or bilateral primary total hip arthroplasty (THA) or primary total knee arthroplasty (TKA) were included. In order to ensure the analysis was performed on a relatively homogenous patient population, the data analysis excluded patients with pathological fracture or malignant neoplasms (primary or metastatic

Patient Sample

The patient sample consisted of 391 patients from 12 hospitals who completed all three PRO surveys both preoperatively and 3-months postoperatively. A total of 162 THA patients and 229 TKA patients were included in the analysis (Table 1). The mean age at the time of the index procedure was 65 with a standard deviation of 9.7 years. The study population consisted of 57.8% female patients and 72.9% patients of Caucasian race. The THA and TKA patients were statistically similar with the exception

Discussion

We evaluated responsiveness to change and the proportion of patients achieving minimal clinically important differences on patient reported outcome measures in 391 patients with hip or knee arthritis who underwent TJA and were enrolled in the California Joint Replacement Registry. The WOMAC and SF12v2 PCS were highly responsive to change following TJA. Specifically, both questionnaires demonstrated large effect sizes greater than 0.80, which is consistent with a high level of sensitivity to

Acknowledgment

The authors wish to acknowledge Vanessa Chan, MPH for her assistance in preparing this manuscript and the California HealthCare Foundation (CHCF) and Pacific Business Group on health (PBGH) for funding this study.

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There are more references available in the full text version of this article.

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The Nationwide Inpatient Sample database was queried for primary and revision anatomic total shoulder arthroplasty, reverse total shoulder arthroplasty, and hemiarthroplasty from 2011-2018. Multivariate regression was used to predict cases and charges through the year 2030 adjusted to 2021 purchasing power parity.
From 2011 to 2018, PJI was found to be 1.1% shoulder arthroplasties, from 0.8% (2011) to 1.4% (2018). Anatomic total shoulder arthroplasty experienced the greatest proportion of infections at 2.0%, followed by hemiarthroplasty at 1.0% and reverse total shoulder arthroplasty at 0.3%. Total hospital charges grew 324%, from $44.8 million (2011) to $190.3 million (2018). Our regression model projects 176% growth in cases and 141% growth in annual charges by 2030.
This study demonstrates the large economic burden that shoulder PJIs pose on the American healthcare system, which is predicted to reach nearly $500 million in charges annually by 2030. Understanding trends in procedure volume and hospital charges will be critical in evaluating strategies to reduce shoulder PJIs.
Patient-Reported Outcome Measures in Conventional Total Hip Arthroplasty Versus Robotic-Arm Assisted Arthroplasty: A Prospective Cohort Study With Minimum 3 Years’ Follow-Up
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Robotic-arm assisted total hip arthroplasty (RO THA) has been shown to improve the accuracy of component positioning compared with conventional total hip arthroplasty (CO THA). This study reports Patient-Reported Outcome Measures (PROMs) of a previous trial that showed that RO THA was associated with improved accuracy and reduced outliers in acetabular component positioning compared with CO THA.
This prospective cohort study included 50 patients undergoing CO THA versus 50 patients receiving RO THA. The Oxford hip score, Forgotten Joint Score (FJS), University of California at Los Angeles hip score were recorded at a minimum of 3 years following surgery.
At minimum 3 years follow-up, there was no statistically significant difference in CO THA versus RO THA with respect to the Oxford hip score [median 42(6.25) versus 41(5.5), P = .914]; FJS [89 (9.25) versus 86 (9), P = .065], and University of California at Los Angeles score [median 7.5 (3) versus 7 (2), P = .381]. None of the study patients had dislocations or underwent revision surgery within 3 years follow-up.
The previously reported improvement in accuracy of acetabular component in this study population did not translate to statistically significant improvements in PROMs. Patients in both groups achieved excellent PROMs and there was a trend towards higher FJS scores postoperatively in the RO THA group that did not reach statistical significance. Further studies are needed to assess the significance of these findings on longer-term clinical outcomes and implant survivorships, and also to explore the impact of the enhanced RO THA workflow and functional implant positioning on these outcomes.
Selective Patella Resurfacing in Contemporary Cruciate Retaining and Substituting Total Knee Arthroplasty: A Matched Cohort Analysis
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A total of 166 TKAs performed without patellar resurfacing were case-control matched to 166 TKAs with patella resurfacing. Case-control matching was based on demographics, American Society of Anesthesiology Physical Status, comorbidities, and osteoarthritis severity. No significant differences were observed between cohorts for demographics (P ≥ .347), comorbidities (P ≥ .443), or radiographic osteoarthritis severity (P ≥ .078). Radiographic alignment and prospectively collected PROMs were evaluated preoperatively and at latest clinical follow-up.
Preoperatively, patellar tilt was less for the unresurfaced patella group (3 versus 4°, P = .003); however, postoperative patellar tilt was not different (3 versus 3°, P = .225). At a mean of 2.1 years follow-up (range, 1 to 7), University of California Los Angeles Activity Level was significantly higher for the unresurfaced patella group (6.3 versus 5.5, P = .002), but the mean group difference did not reach a minimal clinically important difference. There were no other significant differences in PROMs or reoperation rates between cohorts (P ≥ .135).
In contemporary cruciate retaining and substituting TKA designs, not resurfacing the patella in select patients may achieve comparable PROMs and re-operation rates; and potentially greater activity level compared to patella resurfacing at early follow-up.
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Many patient-reported outcome measures (PROMs) have been utilized to assess outcomes after unicompartmental knee arthroplasty (UKA). However, most are not specifically designed for UKA and the measurement properties of these PROMs have never been elucidated in the setting of UKA. This study aimed to evaluate the reliability and validity of commonly used PROMs after UKA, which includes the Oxford knee score (OKS), Knee Society Score (KSS)-function score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Knee Injury and Osteoarthritis Outcome Score (KOOS).
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Prospectively collected postoperative follow-up PROMs scores of patients after medial UKA cases for osteoarthritis between May 2015 and June 2018 were retrospectively analyzed. All of the PROMs were finished on the same electronic questionnaires. Reliability (internal consistency, test-retest reliability, measurement error), construct validity and floor/ceiling effects were assessed.
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Citation Excerpt :
To identify changes in PROMs which amount to meaningful differences for patients, the concept of the minimal clinically important difference (MCID) was introduced. Two common methods for determining an MCID are “anchoring,” or comparing, PROM score changes to patients’ subjective reports of symptom changes, or by comparison to a second PROM for which a MCID had previously been identified [22–25]. MCID values are specific to the surgical intervention and postoperative timing for which comparisons are made.
In total knee arthroplasty (TKA), computer-assisted navigation (N-TKA) and robotic-assisted methods (RA-TKA) are intended to increase precision of mechanical and component alignment. However, the clinical significance of published patient-reported outcome measure (PROM) differences in comparison to conventional TKA (C-TKA) is unknown.
A systematic review was performed to identify all studies reporting perioperative PROMs for either primary N-TKA or RA-TKA with a C-TKA comparison cohort with a minimum 1-year follow-up. Relative improvements in PROMs for the two cohorts were compared to published minimal clinically important difference (MCID) values.
After systematic review, 21 studies (N = 3,214) reporting on N-TKA and eight studies (N = 1,529) reporting on RA-TKA met inclusion criteria. Eighteen of 20 studies (90%) reported improved radiographic outcomes with N-TKA relative to C-TKA; five of five studies reported improved radiographic outcomes with RA-TKA relative to C-TKA. Five of 21 studies (24%) reported statistically significant greater improvements in clinical PROMs for N-TKA relative to C-TKA, whereas only two (10%) achieved clinical significance relative to MCID on a secondary analysis. One of 8 studies (13%) reported statistically significant greater improvements in PROMs for RA-TKA relative to C-TKA, whereas none achieved clinical significance relative to MCID on a secondary analysis. No studies reported a significant difference in revision rates.
While most studies comparing RA-TKA and N-TKA with C-TKA demonstrate improved radiographic alignment outcomes, a minority of studies reported PROM differences that achieve clinical significance. Future studies should report data and be interpreted in the context of clinical significance to establish patient and surgeon expectations for emerging technologies.

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: Source of funding: This study was funded by the California HealthCare Foundation (CHCF) and Pacific Business Group on Health (PBGH). The funding source did not play a role in the investigation or the interpretation of the results.

: The Conflict of Interest statement associated with this article can be found at http://dx.doi.org/10.1016/j.arth.2014.09.026.

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Responsiveness of Patient Reported Outcome Measures in Total Joint Arthroplasty Patients

Abstract

Section snippets

Patient Sample

Patient Sample

Discussion

Acknowledgment

J Arthroplasty

Inpatient surgery

California Joint Replacement Registry

Effect sizes for interpreting changes in health status

Med Care

How to validate clinically important change in health-related functional status. Is the magnitude of the effect size consistently related to magnitude of change as indicated by a global question rating?

J Eval Clin Pract

Minimal clinically important differences: review of methods

J Rheumatol