Development of prediction models for clinically meaningful improvement in PROMIS scores after lumbar decompression

BACKGROUNDThe ability to preoperatively predict which patients will achieve a minimal clinically important difference (MCID) after lumbar spine decompression surgery can help determine the appropriateness and timing of surgery. Patient-Reported Outcome Measurement Information System (PROMIS) scores are an increasingly popular outcome instrument.PURPOSEThe purpose of this study was to develop algorithms predictive of achieving MCID after primary lumbar decompression surgery.PATIENT SAMPLEThis was a retrospective study at two academic medical centers and three community medical centers including adult patients 18 years or older undergoing one or two level posterior decompression for lumbar disc herniation or lumbar spinal stenosis between January 1, 2016 and April 1, 2019.OUTCOME MEASURESThe primary outcome, MCID, was defined using distribution-based methods as one half the standard deviation of postoperative patient-reported outcomes (PROMIS physical function, pain interference, pain intensity).METHODSFive machine learning algorithms were developed to predict MCID on these surveys and assessed by discrimination, calibration, Brier score, and decision curve analysis. The final model was incorporated into an open access digital application.RESULTSOverall, 906 patients completed at least one PROMs survey in the 90 days before surgery and at least one PROMs survey in the year after surgery. Attainment of MCID during the study period by PROMIS instrument was 74.3% for physical function, 75.8% for pain interference, and 79.2% for pain intensity. Factors identified for preoperative prediction of MCID attainment on these outcomes included preoperative PROs, percent unemployment in neighborhood of residence, comorbidities, body mass index, private insurance, preoperative opioid use, surgery for disc herniation, and federal poverty level in neighborhood of residence. The discrimination (c-statistic) of the final algorithms for these outcomes was 0.79 for physical function, 0.74 for pain interference, and 0.69 for pain intensity with good calibration. The open access digital application for these algorithms can be found here: https://sorg-apps.shinyapps.io/promis_pld_mcid/CONCLUSIONLower preoperative PROMIS scores, fewer comorbidities, and certain sociodemographic factors increase the likelihood of achieving MCID for PROMIS after lumbar spine decompression.     

Evaluation of transforaminal epidural steroid injections for discogenic axial lumbosacral back pain utilizing PROMIS as an outcome measure

Background contextDiscogenic lumbosacral back pain continues to present a challenging clinical entity with limited, controversial therapeutic options. No study to date has evaluated the efficacy of fluoroscopically guided transforaminal epidural steroid injections (TFESI) in a homogenous patient population with axial lumbosacral back pain from discogenic pathology utilizing strict, explicitly clinical and radiographic criteria. Additionally, there is a paucity of published data utilizing Patient Reported Outcome Measurement Information System (PROMIS) scores as an outcome measure for interventional spine procedures.PurposeEvaluate the therapeutic effect of TFESIs in a specific subset of patients with discogenic axial lumbosacral back pain. Investigate PROMIS as an outcome measure for interventional spine procedures targeting focal degenerative spinal pathology.Study design/settingRetrospective review of patients presenting to a multidisciplinary, tertiary academic spine center.Patient sampleThree thousand eight hundred eighty-one patients were screened for inclusion. A total of 26 patients with discogenic axial low back, based on strict clinical and radiographic criteria, underwent TFESIs. All patients had axial low back pain without radicular pain, ≥3 clinical features of discogenic pain, corroborative radiographic features of active discogenic pathology on lumbar spine magnetic resonance imaging without confounding spinal pathology.Outcome measuresPROMIS Pain Interference (PI) v1.1, PROMIS Physical Function (PF) v1.2/v2.0, and PROMIS Depression (D) v1.0 outcome scores were collected at baseline and postprocedure follow-up.MethodsQuery of an institutional, patient reported outcome database and subsequent retrospective review of electronic medical records was performed. Statistical analysis comparing baseline and postprocedural PROMIS outcome scores and correlation between these instruments was performed. Additionally, an exploratory investigation of minimal clinically important difference achievement rates was performed.ResultsAnalysis determined a statistically significant improvement in PROMIS PI (p=.017, 95% CI=?8.02 to ?1.82) and PROMIS PF (p=.003, 95% CI=0.91–8.72) scores after treatment with TFESIs. At post treatment time points, TFESI had medium effect size on pain (d=0.55) and function (d=0.59). Change in PROMIS D scores (p=.488, 95% CI ?1.74–3.54; d=.08) did not demonstrate statistical significance. Pearson correlation demonstrated a moderate negative correlation (r=?0.544, p=.004) between PROMIS PF with PROMIS PI. Correlation between PROMIS PF (r=?0.239, p=.24) and PROMIS PI (r=0.198, p=.33) with PROMIS D was not significant. Fourteen (53.8%) and 9 (34.6%) subjects achieved minimum clinically important difference (MCID) for PROMIS PI and PROMIS PF, respectively. Nine subjects (34.6%) achieved MCID for PROMIS D despite not otherwise reaching statistical significance otherwise.ConclusionsUtilizing PROMIS as an outcome measure, discogenic axial lumbosacral back pain patients appear to benefit from TFESI in terms of pain and physical function. This study contributes to the growing body of literature utilizing PROMIS scores in patients with clinical sequelae of degenerative spinal pathology; however, prospective studies are needed.     

The Impact of Total Hip Arthroplasty Surgical Approach on Patient-Reported Outcomes Measurement Information System Computer Adaptive Tests of Physical Function and Pain Interference

BackgroundThe present study examines Patient Reported Outcomes Measurement Information System (PROMIS) Computer Adaptive Test (CAT) scores for domains of physical function (PF) and pain interference (PI) in patients undergoing elective THA from either a direct anterior or posterior surgical approach.MethodsA total of 1358 patients who underwent THA at our institution from 1/1/2015 to 12/1/2018 were identified. Visual analog scale (VAS) pain scores, PROMIS CAT PF and PI data were collected at the last preoperative visit as well as 6 weeks, 6 months, and 1-2 years postoperatively. Literature-derived minimum clinically important difference (MCID) for PROMIS CAT PF metric with regard to THA was used for data comparison.ResultsFour hundred nine patients were included in the final analysis. Fifty-one percent underwent a posterior approach, and 49% underwent a direct anterior approach. Both approaches led to a significant improvement in PROMIS CAT PF and PI scores. Patients undergoing a direct anterior approach had significantly higher preoperative and postoperative PROMIS CAT PF scores as well as significantly lower preoperative PROMIS CAT PI scores. Each approach yielded similar interval improvements of PROMIS CAT PF and PI. One hundred three direct anterior approach THA patients (51%) and 119 posterior approach THA patients (57.5%) achieved PROMIS PF MCID at 1- to 2-year follow-up.ConclusionNeither the direct anterior nor posterior THA surgical approach conferred an advantage to postoperative improvements of PROMIS CAT PF and PI scores. Adult reconstructive surgeons should continue to execute the direct anterior or posterior THA surgical approaches based upon personal preference. Despite surgeon confidence in THA, the potential for further innovation exists given the number of THA patients who failed to achieve PROMIS PF MCID.     

Weightbearing and Activity Restriction Treatments and Quality of Life in Patients with Perthes Disease

BackgroundWeightbearing and activity restrictions are commonly prescribed during the active stages of Perthes disease. These restrictions, ranging from cast or brace treatment with nonweightbearing to full weightbearing with activity restrictions, may have a substantial influence on the physical, mental, and social health of a child. However, their impact on the patient’s quality of life is not well-described.Questions/purposesAfter controlling for confounding variables, we asked (1) are restrictions on weightbearing and activity associated with physical health measures (as expressed by the Patient-Reported Outcome Measurement Information System [PROMIS] mobility, PROMIS pain interference, and PROMIS fatigue) of children in the active stages of Perthes disease? (2) Are these restrictions associated with poorer scores for mental health measures (PROMIS depressive symptoms and PROMIS anxiety)? (3) Are these restrictions associated with poorer scores for social health measures (PROMIS peer relationships)?MethodsBetween 2013 and 2020, 211 patients with Perthes disease at a single institution were assigned six PROMIS measures to assess physical, mental, and social health. Patients who met the following eligibility criteria were analyzed: age 8 to 14 years old, completion of six PROMIS measures, English-speaking, and active stage of Perthes disease (Waldenstrom Stage I, II, or III). Weightbearing and activity restrictions were clinically recommended to patients in the initial through early reossification stages of Perthes disease when patients had increasing pain, loss of hip motion, loss of hip containment, progression of femoral head deformity, increased hip synovitis, and femoral head involvement on MRI or as a postoperative regimen. Patients were categorized into four intervention groups based on weightbearing and activity regimen. We excluded 111 patients who did not meet the inclusion criteria. The following six pediatric self-report PROMIS measures were assessed: mobility, pain interference, fatigue, depressive symptoms, anxiety, and peer relationships. Of the 100 patients, 36 were categorized into the no-restriction regimen, 27 into the mild-restriction regimen, 25 into the moderate-restriction regimen, and 12 into the severe-restriction regimen at the time of PROMIS administration. The median (range) age at diagnosis was 8 years old (range 2 to 13 years). There were 85 boys and 15 girls. Eleven patients had hips in Waldenstrom Stage I, 10 were in Stage II, and 79 were in Stage III. Forty-four patients had hips classified as lateral pillar B and 47 patients as lateral pillar C. Nine patients had not reached the mid-fragmentation stage for appropriate lateral pillar classification by the time they took the PROMIS survey. ANOVA was used to compare differences between the mean PROMIS T-scores of these weightbearing/activity regimens. Results were assessed with a significance of p < 0.05 and adjusted for Waldenstrom stage, gender, age at diagnosis, and history of major surgery using multivariate regression analysis.ResultsAfter controlling for confounding variables, the mild- (β regression coefficient -15 [95% CI -19 to -10]; p < 0.001), moderate- (β -19 [95% CI -24 to -14]; p < 0.001), and severe- (β -25 [95% CI -30 to -19]; p < 0.001) restriction groups were associated with worse mobility T-scores compared with the no-restriction group, but no association was detected for the pain interference or fatigue measures. Weightbearing and activity restrictions were not associated with mental health measures (depressive symptoms and anxiety). Weightbearing and activity restrictions were not associated with social health measures (peer relationships). Earlier Waldenstrom stage was associated with worse pain interference (β 10 [95% CI 2 to 17]; p = 0.01) and peer relationships scores (β -8 [95% CI -15 to -1]; p = 0.03); female gender was linked with worse depressive symptoms (β 7 [95% CI 2 to 12]; p = 0.005) and peer relationships scores (β -6 [95% CI -12 to 0]; p = 0.04); and earlier age at diagnosis was associated with worse peer relationships scores (β 1 [95% CI 0 to 2]; p = 0.03). History of major surgery had no connection to any of the six PROMIS measures.ConclusionWe found that weightbearing and activity restriction treatments are associated with poorer patient-reported mobility in the active stages of Perthes disease after controlling for Waldenstrom stage, gender, age at diagnosis, and history of surgery. Weightbearing/activity restrictions, however, are not associated with pain interference, fatigue, depressive symptoms, anxiety, and peer relationships. Understanding how these treatments are associated with quality of life in patients with Perthes disease can aid in decision-making for providers, help set expectations for patients and their parents, and provide opportunities for better education and preparation. Because of the chronic nature of Perthes disease, future studies may focus on longitudinal trends in patient-reported outcomes to better understand the overall impact of this disease and its treatment.Level of EvidenceLevel III, therapeutic study.     

Impact of insurance type on patient-reported outcome measures in patients with lumbar disc herniation

BACKGROUNDLumbar disc herniations (LDH) are among the most common spinal conditions. Despite increased appreciation for the importance of social determinants of health, the role that these factors play in patients with lumbar disc herniations is poorly defined.PURPOSETo elucidate the association between insurance status and baseline patient reported outcome measures (PROMs) in the setting of lumbar disc herniations.STUDY DESIGN/SETTINGRetrospective cohort studyPATIENT SAMPLEBaseline patient-reported outcome measures (PROMS) were reviewed from 924 adult patients presenting for treatment of lumbar disc herniation within our institutional healthcare system (2015–2020).OUTCOME MEASURESThe Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Short Form 10a (PF10a), PROMIS Global-Mental, PROMIS Global-Physical, and visual analogue scale (VAS) for back and leg pain were assessed.METHODSPROMIS scores at presentation were defined at the primary outcome and insurance status as the primary predictor. Differences in clinical and sociodemographic characteristics between our cohorts, stratified by insurance status, were evaluated using Wilcoxon rank-sum or chi-squared testing. We used multivariable negative binomial regression modeling to adjust for potential confounders including age, gender, race, language, ethnicity, comorbidity index, and median geospatial household income.RESULTSWe included 924 patients, with mean age of 58.4 +/- 15.2 years and 52.6% male prevalence. Patients insured through Medicaid were more likely to be Black, Hispanic, and non-English speaking patients compared with the commercially insured. The Charlson Comorbidity index was significantly higher in the Medicare group. Following adjusted analysis, patients with Medicaid insurance had significantly worse PF10a (IRR, 0.90, 95% CI 0.85–0.96), as well as PROMIS Global-Physical score (IRR 0.88, 95% CI 0.82–0.94), and VAS low back pain (IRR 1.20, 95% CI 1.04–1.40) when compared to the commercially insured.CONCLUSIONSWe encountered worse physical function, mental, and pain-related patient-reported outcomes for those with Medicaid insurance in a population of patients presenting for evaluation of lumbar disc herniation. These findings, including worse depression, anxiety, and higher axial back pain scores, merit further investigation into potential health system asymmetries, and should be accounted for by treating providers.     

Characterizing MCID and assessing the role of preoperative PROMIS scores in predicting outcomes for reverse total shoulder arthroplasty at 2-year follow-up

BackgroundThe Patient-Reported Outcomes Measurement Information System (PROMIS) has gained more ground as a reliable and efficient means of collecting patient outcomes in different shoulder surgeries. The purpose of this study is to determine if preoperative PROMIS scores are able to predict improvement in postoperative PROMIS scores and anchor this data to determine if a patient will achieve MCID after reverse total shoulder arthroplasty (RTSA). We hypothesize that preoperative PROMIS will significantly correlate, with anchor questions allowing clinicians to predict which patients are most likely to achieve MCID after RTSA.MethodsThree PROMIS CAT forms (PROMIS Upper Extremity Physical Function CAT v2.0 (“PROMIS-UE”), PROMIS Pain Interference v1.1 (“PROMIS-PI”), and PROMIS Depression v1.0 (“PROMIS-D”)) were provided to all patients scheduled to undergo RTSA by board-certified shoulder and elbow surgeons at 1 institution. Demographic data was collected, including age, median household income, zip code, body mass index, sex, smoking status, and race. All patients enrolled in the study were contacted and asked the same 3 anchor questions pertaining to the 3 PROMIS CAT forms above.ResultsA total of 71 patients (52.1% male) were included in our cohort with an average age of 67.8 years (standard deviation, 8.4). Mean follow-up time point was 21.4 months (standard deviation, 9.9) after surgery. Neither preoperative PROMIS-UE, nor preoperative PROMIS-PI showed any significant predictive ability to achieve their respective domain MCIDs (AUC: 0.564 and 0.631, respectively). PROMIS-UE and PROMIS-PI improved to a significant degree at an average 21.4 months postoperatively from 29.2 ± 5.8 and 63.8 ± 4.8 to 39.8.9 ± 8.9 and 50.0 ± 9.7, respectively. Improvements in PRMOIS-D scores were insignificant at average 21.4 months (Baseline: 49.8 ± 8.0 vs. 44.5 ± 9.4 at final follow-up). Using anchor-based analysis to determine MCID, we found the following MCID values for PROMIS-UE, PROMIS-PI, and PROMIS-D: 7.0, -6.6, and -3.9, respectively. ROC analysis revealed MCID values for PROMIS-UE, PI, and D as 7.0, -6.6, and -3.9 respectively (AUC: 0.743, 0.805, 0.601). SCB values for PROMIS-UE, PI, and D were identified as 8.4, -12.1, and -4.0, respectively (AUC: 0.883, 0.932, 0.652).ConclusionsPROMIS-UE and PROMIS-PI questionnaires can adequately assess the symptoms and outcomes of RTSA patients out to two years postoperatively. Preoperative baseline PROMIS-UE, PROMIS-PI, and PROMIS-D scores cannot adequately predict achievement of MCID in patients indicated for primary RTSA when using anchor-based methods at final follow-up, and should not be used to counsel patients on surgery or guide postoperative treatment.Level of EvidenceLevel II; Retrospective Cohort Study     

The influence of mental health on outcomes following total shoulder arthroplasty

BackgroundAnxiety and depression symptoms have been associated with higher pain and lower functional scores in patients with glenohumeral osteoarthritis (GHOA). The influence of mental health on outcomes following total shoulder arthroplasty (TSA) for GHOA has not been fully investigated .MethodsThis observational cohort study included 143 shoulders in 135 subjects undergoing TSA for GHOA. Preoperative imaging was assessed for glenoid wear pattern. Patients completed preoperative and postoperative American Shoulder and Elbow Surgeons (ASES) score, Visual Analog Pain Scale (VAS), and PROMIS Upper Extremity (UE), Physical Function (PF), and Pain Interference (PI) scores. The Western Ontario Osteoarthritis Score (WOOS) was collected postoperatively. Mean postoperative pain and functional scores, improvement from preoperative scores, and surgical regret were compared between varying severity of anxiety or depression and pattern of glenoid wear.ResultsCompared to subjects without anxiety, those with moderate-to-severe anxiety reported worse postoperative ASES (p=0.019), WOOS (p<0.01) and PROMIS UE (p=0.02) and higher PROMIS PI scores (p<0.01). Compared to those without depression, those with moderate-to-severe depression reported worse postoperative ASES and WOOS and higher VAS and PROMIS Pain scores (p<0.01). Linear regression showed that anxiety and concentric glenoid wear were associated with worse postoperative PROMIS scores. There were no significant differences in pre-to-postoperative improvement in any outcome measures among those with and without anxiety or depression. Patients with moderate-to-severe depression were less likely to want to undergo the same procedure again (p=0.035).DiscussionPatients with anxiety and depression report similar improvements in pain and function following TSA similar to those without depression or anxiety. Despite the similar improvement, those with moderate-to-severe depression and anxiety symptoms reported persistently lower functional and higher pain scores. Though most patients are satisfied following TSA, those with moderate-to-severe depression may be more likely to regret undergoing surgery. Future studies should identify mental health symptoms preoperatively and evaluate the effect of preoperative intervention on postoperative outcomes following TSA.     

Preoperative MRI predictors of health-related quality of life improvement after microscopic lumbar discectomy

BACKGROUNDLumbar herniated nucleus pulposus (HNP) is a common spinal pathology often treated by microscopic lumbar discectomy (MLD), though prior reports have not demonstrated which preoperative MRI factors may contribute to significant clinical improvement after MLD.PURPOSETo analyze the MRI characteristics in patients with HNP that predict meaningful clinical improvement in health-related quality of life scores (HRQoL) after MLD.STUDY DESIGN/SETTINGRetrospective clinical and radiological study of patients undergoing MLD for HNP at a single institution over a 2-year period.PATIENT SAMPLEEighty-eight patients receiving MLD treatment for HNP.OUTCOME MEASURESCephalocaudal Canal Migration; Canal & HNP Anterior-Posterior (AP) Lengths and Ratio; Canal & HNP Axial Areas and Ratio; Hemi-Canal & Hemi-HNP Axial Areas and Ratio; Disc appearance (black, gray, or mixed); Baseline (BL); and 3-month (3M) postoperative HRQoL scores.METHODSPatients >18 years old who received MLD for HNP with BL and 3M HRQoL scores of PROMIS (Physical Function, Pain Interference, and Pain Intensity), ODI, VAS Back, and VAS Leg scores were included. HNP and spinal canal measurements of cephalocaudal migration, AP length, area, hemi-area, and disc appearance were performed using T2 axial and sagittal MRI. HNP measurements were divided by corresponding canal measurements to calculate AP, Area, and Hemi-Area ratios. Using known minimal clinically important differences (MCID) for each ΔHRQoL score, patients were separated into two groups based on whether they reached MCID (MCID+) or did not reach MCID (MCID–). The MCID for PROMIS pain intensity was calculated using a decision tree. A linear regression illustrated correlations between PROMIS vs ODI and VAS Back/Leg scores. Independent t-tests and chi-squared tests were utilized to investigate significant differences in HNP measurements between the MCID+ and MCID– groups.RESULTSThere were 88 MLD patients included in the study (Age=44.6±14.9, 38.6% female). PROMIS pain interference and pain intensity were strongly correlated with ODI and VAS Back/Leg (R≥0.505), and physical function correlated with ODI and VAS Back/Leg (R=−0.349) (all p<.01). The strongest MRI predictors of meeting HRQoL MCID were gray disc appearance, HNP area (>116.6 mm²), and Hemi-Area Ratio (>51.8%). MCID+ patients were 2.7 times more likely to have a gray HNP MRI signal than a mixed or black HNP MRI signal in five out of six HRQoL score comparisons (p<.025). MCID+ patients had larger HNP areas than MCID– patients had in five out of six HRQoL score comparisons (116.6 mm²±46.4 vs 90.0 mm²±43.2, p<.04). MCID+ patients had a greater Hemi-Area Ratio than MCID– patients had in four out of six HRQoL score comparisons (51.8%±14.7 vs 43.9%±14.9, p<.05).CONCLUSIONSPatients who met MCID after MLD had larger HNP areas and larger Hemi-HNP Areas than those who did not meet MCID. These patients were also 2.7× more likely to have a gray MRI signal than a mixed or black MRI signal. When accounting for HNP area relative to canal area, patients who met MCID had greater Hemi-HNP canal occupation than patients who did not meet MCID. The results of this study suggest that preoperative MRI parameters can be useful in predicting patient-reported improvement after MLD.     

Relationship between postpartum mood disorder and birth experience: a prospective observational study

BackgroundThis study aims to investigate the relationship between the birth experience and the risk of developing postpartum depression or post-traumatic stress disorder.MethodsIn this prospective, longitudinal, observational study, women were assessed at different time points for depression and post-traumatic stress disorder. The risk of depression or post-traumatic stress disorder based on patient characteristics and specific birth events was assessed within three months postpartum.ResultsWe enrolled 600 women; 426 were eligible for postpartum assessment. At six weeks and three months postpartum, 15.9% and 12.7% screened positive for depression respectively. Positive post-traumatic stress disorder screenings at six weeks and three months postpartum were 6.2% and 5.1% respectively. Twenty-seven women (8.3%) with a negative screening at six weeks converted to a positive depression or post-traumatic stress disorder screening at three months. A pre-existing history of anxiety or depression was associated with an increased risk of developing depression (aOR 2.12, 95% CI 1.30 to 3.47) and post-traumatic stress (aOR 3.15, 95% CI 1.42 to 7.02) within three months postpartum. The risk of developing post-traumatic stress disorder within three months postpartum was also increased among patients experiencing their first delivery (aOR 2.55, 95% CI 1.10 to 5.88) or operative management of postpartum hemorrhage (aOR 4.44, 95% CI 1.16 to 17.02).ConclusionDepression and post-traumatic stress symptoms either persisted or had new onset at three months postpartum. Mental health screening and postpartum follow-up after six weeks should be considered in high-risk patients who have a history of psychopathology, nulliparity, or undergo operative management of postpartum hemorrhage.     

The relationship between depression,anxiety, and pain interference with therapy referral and utilization among patients with hand conditions

IntroductionPatients with upper extremity conditions may also experience symptoms of depression, anxiety, and pain that limit functional recovery.Purpose of the StudyThis study examined the impact of mental health and pain symptoms on referral rates to therapy and utilization of therapy services to achieve functional recovery among patients with common hand conditions.Study DesignThis is a retrospective cohort study of patients from one orthopedic center.MethodsData extraction provided demographics, the International Classification of Diseases, 10th revision diagnoses, therapy referral, therapy visit counts, treatment goal attainment, and Patient-Reported Outcomes Measurement Information System (PROMIS) Depression, Anxiety, and Pain Interference scores. The chi-square test, t-test, and logistic regression analyses assessed associations between baseline PROMIS depression, anxiety, and pain interference to therapy referral, the number of therapy visits, and goal attainment.ResultsForty-nine percent (172/351) of patients were referred to hand therapy. There was no relationship between three baseline PROMIS scores based on physician referral (t-test P values .32-.67) and no association between PROMIS scores and therapy utilization or goal attainment (Pearson correlation (r): 0.002 to 0.020, P > .05). Referral to therapy was most strongly associated with having a traumatic condition (P < .01). Patients with high depression, anxiety, and pain interference scores on average required one more therapy visit to achieve treatment goals (average visits: 3.7 vs 3.1; 4.1 vs 2.7; 3.4 vs 2.3, respectively). Fewer patients with high depression scores (50%) achieved their long-term goals than patients with low depression scores (69%, P = .20).ConclusionsPatients' baseline level of depressive symptoms and anxiety do not predict referrals to hand therapy by orthopedic hand surgeons. There is some indication that patients with increased depressive symptoms, anxiety, and pain interference require more therapy with fewer achieving all goals, suggesting that mental health status may affect response to therapy. Therapists may address mental health needs in treatment plans. Future studies should examine if nonreferred patients with depressive symptoms achieve maximal functional recovery.     

Early Experience and Results Using Patient-Reported Outcomes Measurement Information System Scores in Primary Total Hip and Knee Arthroplasty

BackgroundOur study determined if preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores could predict achieving minimum clinically important differences (MCIDs) in postoperative PROMIS scores after primary total hip and knee arthroplasty.MethodsNinety-three patients were administered the PROMIS Depression, Pain Interference, and Physical Function domains at their preoperative appointment and 6-week follow-up visit. MCIDs were drawn from existing literature for the PROMIS domains.ResultsThe MCID was achieved in 74% of patients for Pain Interference, 34% for Physical Function, and 24% for Depression. Our model could predict with 90% specificity which patients would meet MCID if their preop PROMIS Pain score was above 38, Physical Function score less than 19, or Depression score above 22.ConclusionPreoperative PROMIS Pain Interference, Physical Function, and Depression scores can predict achieving MCID in postoperative PROMIS scores.     

The Minimal Clinically Important Difference for PROMIS Physical Function in Patients With Thumb Carpometacarpal Arthritis

Background: This study was performed to determine the minimal clinically important difference (MCID) of Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) computer adaptive test (CAT) for patients with thumb carpometacarpal (CMC) arthritis. Methods: This study retrospectively analyzed data from 152 adults receiving surgical and nonsurgical care for unilateral thumb CMC arthritis at a single institution between January 2016 and January 2018. Patients completed PROMIS PF v1.2/2.0 CAT at each visit. At follow-up, patients also completed two 6-item anchor questions assessing the degree of perceived improvement. Statistical testing analyzed the ability of the clinical anchor to discriminate levels of improvement. An anchor-based MCID estimate was calculated as the mean PROMIS PF change score in the mild improvement group. The anchor-based MCID value was examined for the influence of patient age, initial and final PROMIS scores, and follow-up interval. A distribution-based MCID value was calculated incorporating the standard error of measurement and effect size. Results: The change in PROMIS PF scores was significantly different between encounters where patients reported no change, mild improvement, and much improvement. The anchor-based MCID estimate for PROMIS PF was 3.9 (95% confidence interval, 3.3-4.7). Individual MCID values were weakly correlated with the final absolute PROMIS PF score but did not correlate with patient age, time between visits, or the initial absolute PROMIS PF score. The distribution-based MCID value was 3.5 (95% confidence interval, 3.1-3.9). Conclusions: The estimated range of MCID values for PROMIS PF is 3.5 to 3.9 points in patients treated for thumb CMC arthritis.     

The minimum clinically important difference for the Japanese version of the new Knee Society Score (2011KSS) after total knee arthroplasty

BackgroundThe new Knee Society Score (2011KSS) has been used to evaluate post-operative outcomes after total knee arthroplasty (TKA). However, there is no minimum clinically important difference (MCID) for 2011KSS. The purpose of this study is to define MCID of 2011KSS after TKA.MethodsPatients who underwent primary TKA for primary knee osteoarthritis between April 2012 and December 2016 were included in the study. The Japanese version of 2011KSS and original Knee Society Score (OKSS) were recorded preoperatively and at one-year postoperatively. With improvement in pain score of OKSS as an anchor, an anchor-based approach was used to identify the MCID of 2011KSS. The improvement in pain of OKSS was classified into 5 categories. The MCID was determined using a linear regression analysis of delta 2011KSS against improvement in the category of pain in OKSS. The MCID for 2011KSS expectation was not calculated because the items of pre- and post-operative questionnaires were different.ResultsFive hundred and twenty-two cases were enrolled (age: 74.8 ± 7.3 years, female: 80.0%). After 1-year follow-up, 344 TKAs were finally included (age: 74.6 ± 7.1 years, female: 77.9%). Linear regression analyses showed that MCID for 2011KSS was 1.9 (95% confidential interval (CI): 1.3–2.5) in symptom, 2.2 (95%CI: 1.4–2.9) in satisfaction, and 4.1 (95%CI: 2.5–5.7) in functional activities.ConclusionsMCID for 2011KSS was successfully calculated. These MCID values make the 2011KSS a more efficient tool for evaluating the physical activities of the populations of patients undergoing TKA. These MCID values can also be used to calculate sample size to evaluate the power of a study in designing clinical studies.     

Correlation of mJOA,PROMIS physical function,and patient satisfaction in patients with cervical myelopathy: an analysis of the Michigan Spine Surgery Improvement Collaborative (MSSIC) database

BACKGROUND CONTEXTPatient-reported outcomes (PROs) are increasingly utilized to evaluate the efficacy and value of spinal procedures. Among patients with cervical myelopathy, the modified Japanese Orthopaedic Association (mJOA) remains the standard instrument, with Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and patient satisfaction also frequently assessed. These outcomes have not all been directly compared using a large spine registry at 2 years follow-up for cervical myelopathic patients undergoing surgery.PURPOSETo determine the correlation and association of PROMIS PF, mJOA, and patient satisfaction outcomes in patients undergoing surgery for cervical myelopathy.STUDY DESIGN/SETTINGRetrospective review of a multicenter spine registry database.PATIENT SAMPLEAdult patients with cervical myelopathy who underwent cervical spine surgery between 2/26/2018 and 4/17/2021.OUTCOME MEASURESPROMIS PF, mJOA, and North American Spine Society (NASS) patient satisfaction index.METHODSThe MSSIC database was accessed to gather pre- and postoperative outcome data on patients with cervical myelopathy. Spearman's correlation coefficients relating mJOA and PROMIS PF were quantified up to 2 years postoperatively. The correlations between patient satisfaction with mJOA and PROMIS were determined. Kappa statistics were used to evaluate for agreement between those reaching the minimum clinically important difference (MCID) for mJOA and PROMIS PF. Odds ratios were calculated to determine the association between patient satisfaction and those reaching MCID for mJOA and PROMIS PF. Support for MSSIC is provided by BCBSM and Blue Care Network as part of the BCBSM Value Partnerships program.RESULTSData from 2,023 patients were included. Moderate to strong correlations were found between mJOA and PROMIS PF at all time points (p<.001). These outcomes had fair agreement at all postoperative time points when comparing those who reached MCID. Satisfaction was strongly related to changes from baseline for both mJOA and PROMIS PF at all time points (p<.001). Odds ratios associating satisfaction with PROMIS PF MCID were higher at all time points compared with mJOA, although the differences were not significant.CONCLUSIONSPROMIS PF has a strong positive correlation with mJOA up to 2 years postoperatively in patients undergoing surgery for cervical myelopathy, with similar odds of achieving MCID with both instruments. Patient satisfaction is predicted similarly by these outcome measures by 2 years postoperatively. These results affirm the validity of PROMIS PF in the cervical myelopathic population. Given its generalizability and ease of use, PROMIS PF may be a more practical outcome measure for clinical use compared with mJOA.     

Workers compensation patients experiencing depression report meaningful improvement in mental health scores after anterior cervical discectomy and fusion

BackgroundMental health has been demonstrated to affect postoperative outcomes. No prior literature has reported the relationship between preoperative mental health on outcomes following anterior cervical discectomy and fusion (ACDF) in the Workers Compensation (WC) population.MethodsWC claimants who underwent primary ACDF were identified from a single-surgeon retrospective database. Patients were separated by SF-12 MCS score into Depressed (<45.6) or Not Depressed (ND) (≥45.6) cohorts. Patient-reported Outcome Measurement Information System Physical Function (PROMIS PF), SF-12 Physical Component Score (SF-12 PCS), SF-12 MCS, visual analog scale (VAS) neck/arm pain, and Neck Disability Index (NDI) were collected and compared within and between groups. Minimum clinically important difference (MCID) achievement rates were compared between groups.ResultsDepressed patients had greater length of stay (p = 0.007) and postoperative narcotic consumption (p = 0.026). Depressed patients improved at 12-week to 2-year PROMIS PF, 6-month SF-12 PCS, 6-week to 6-month SF-12 MCS, 6-week to 6-month and 2-year VAS neck, all VAS arm, and 6-month NDI (p ≤ 0.045, all). ND patients improved at 12-week to 1-year PROMIS PF, 6-month to 2-year SF-12 PCS, 12-week to 1-year VAS neck, 6-week to 1-year VAS arm, and 12-week to 1-year NDI (p ≤ 0.044, all). Between groups, ND patients reported superior PROMIS PF, SF-12 MCS, VAS neck, VAS arm, and NDI scores at two or more periods (p ≤ 0.045, all). MCID achievement rate regarding SF-12 MCS was greater in the Depressed cohort at all postoperative points up to 1 year (p ≤ 0.020, all).ConclusionDepressed patients tended to have a greater length of stay and postoperative narcotic consumption immediately after surgery. Not depressed patients reported more favorable physical and mental function, pain, and disability scores preoperatively and postoperatively. Depressed patients reported greater MCID achievement in mental function following surgery. Depressed patients with WC have a greater likelihood of reporting tangible improvement in mental health scores following ACDF.     

Does perceived injustice correlate with pain intensity and disability in orthopaedic trauma patients?

IntroductionIndividuals who experience musculoskeletal trauma may construe the experience as unjust and themselves as victims. Perceived injustice is a cognitive construct comprised by negative appraisals of the severity of loss as a consequence of injury, blame, injury-related loss, and unfairness. It has been associated with worse physical and psychological outcomes in the context of chronic health conditions. The purpose of this study is to explore the association of perceived injustice to pain intensity and physical function in patients with orthopaedic trauma.MethodsA total of 124 orthopaedic trauma patients completed the Injustice Experience Questionnaire (IEQ), the PROMIS Physical Function Computer Adaptive Testing (CAT), the PROMIS Pain Intensity instruments, the short form Patient Health Questionnaire for depression (PHQ-2), the short form Pain Self-Efficacy Questionnaire (PSEQ-2), and the short form Pain Catastrophizing Scale (PCS-4) on a tablet computer. A stepwise linear regression model was used to identify the best combination of predictors explaining variance in PROMIS Physical Function and PROMIS Pain Intensity.ResultsThe IEQ was associated with PROMIS Physical Function (r = −0.36; P < 0.001) and PROMIS Pain Intensity (r = 0.43; P < 0.001). In multivariable analysis, however, Caucasian race (β = 5.1, SE: 2.0, P = 0.013, 95% CI: 1.1–9.2), employed work status (β = 5.1, SE: 1.5, P = 0.001, 95% CI: 2.1–8.2), any cause of injury other than sports, mvc, or fall (β = 7.7, SE: 2.1, P < 0.001, 95% CI: 3.5–12), and higher self-efficacy (PSEQ-2; β = 0.93, SE: 0.23, P < 0.001, 95% CI: 0.48–1.4) were selected as part of the best model predicting variance in PROMIS Physical Function. Only a higher degree of catastrophic thinking (PCS-4; β = 1.2, SE: 0.12, P < 0.001, 95% CI: 0.99 to 1.5) was selected as important in predicting higher PROMIS Pain Intensity.ConclusionPerceived injustice was associated with both physical function and pain intensity in bivariate correlations, but was not deemed as an important predictor when assessed along with other demographic and psychosocial variables in multivariable analysis. This study confirms prior research on the pivotal role of catastrophic thinking and self-efficacy in reports of pain intensity and physical function in patients with acute traumatic musculoskeletal pain.     

Is Social Deprivation Associated with PROMIS Outcomes After Upper Extremity Fractures in Children?

BackgroundWe previously found that social deprivation was associated with worse perceived function and pain among children presenting with upper extremity fractures. We performed the current study to determine whether this differential in outcome scores would resolve after children received orthopaedic treatment for their fractures. This was needed to understand whether acute pain and impaired function were magnified by worse social deprivation or whether social deprivation was associated with differences in health perception even after injury resolution.Questions/purposesComparing patients from the least socially deprived national quartile and those from the most deprived quartile, we asked: (1) Are there differences in age, gender, race, or fracture location among children with upper extremity fractures? (2) After controlling for relevant confounding variables, is worse social deprivation associated with worse self-reported Patient-Reported Outcomes Measurement Information System (PROMIS) scores before and after the treatment of pediatric upper extremity fractures? (3) Is social deprivation associated with PROMIS score improvements as a result of fracture treatment?MethodsIn this this retrospective, comparative study, we considered data from 1131 pediatric patients (aged 8 to 17 years) treated nonoperatively at a single tertiary academic medical center for isolated upper extremity fractures between June 2016 and June 2017. We used the Area Deprivation Index to define the patient’s social deprivation by national quartiles to analyze those in the most- and least-deprived quartiles. After excluding patients with missing zip codes (n = 181), 18% (172 of 950) lived in the most socially deprived national quartile, while 31% (295 of 950) lived in the least socially deprived quartile. Among these 467 patients in the most- and least-deprived quartiles, 28% (129 of 467) were excluded for lack of follow-up and 9% (41 of 467) were excluded for incomplete PROMIS scores. The remaining 297 patients were analyzed (107 most-deprived quartile, 190 least-deprived quartile) longitudinally in the current study; they included 237 from our initial cross-sectional investigation that only considered reported health at presentation (60 patients added and 292 removed from the 529 patients in the original study, based on updated Area Deprivation Index quartiles). The primary outcomes were the self-completed pediatric PROMIS Upper Extremity Function, Pain Interference, and secondarily PROMIS Peer Relationships computer-adaptive tests. In each PROMIS assessment, higher scores indicated more of that domain (such as, higher function scores indicate better function but a higher pain score indicates more pain), and clinically relevant differences were approximately 3 points. Bivariate analysis compared patient age, gender, race, fracture type, and PROMIS scores between the most- and least-deprived groups. A multivariable linear regression analysis was used to determine factors associated with the final PROMIS scores.ResultsBetween the two quartiles, the only demographic and injury characteristic difference was race, with Black children being overrepresented in the most-deprived group (most deprived: white 53% [57 of 107], Black 45% [48 of 107], other 2% [2 of 107]; least deprived: white 92% [174 of 190], Black 4% [7 of 190), other 5% [9 of 190]; p < 0.001). At presentation, accounting for patient gender, race, and fracture location, the most socially deprived quartile remained independently associated with the initial PROMIS Upper Extremity (β 5.8 [95% CI 3.2 to 8.4]; p < 0.001) scores. After accounting for patient gender, race, and number of days in care, we found that the social deprivation quartile remained independently associated with the final PROMIS Upper Extremity (β 4.9 [95% CI 2.3 to 7.6]; p < 0.001) and Pain Interference scores (β -4.4 [95% CI -2.3 to -6.6]; p < 0.001). Social deprivation quartile was not associated with any differential in treatment impact on change in PROMIS Upper Extremity function (8 ± 13 versus 8 ± 12; mean difference 0.4 [95% CI -3.4 to 2.6]; p = 0.79) or Pain Interference scores (8 ± 9 versus 6 ± 12; mean difference 1.1 [95% CI -1.4 to 3.5]; p = 0.39) from presentation to the conclusion of treatment.ConclusionDelivering upper extremity fracture care produces substantial improvement in pain and function that is consistent regardless of a child’s degree of social deprivation. However, as social deprivation is associated with worse perceived health at treatment initiation and conclusion, prospective interventional trials are needed to determine how orthopaedic surgeons can act to reduce the health disparities in children associated with social deprivation. As fractures prompt interaction with our health care system, the orthopaedic community may be well placed to identify children who could benefit from enrollment in proven community health initiatives or to advocate for multidisciplinary care coordinators such as social workers in fracture clinics.Level of EvidenceLevel III, therapeutic study.     

Class III Obesity Increases Risk of Failure to Achieve the 1-Year Hip Disability and Osteoarthritis Outcome Score-Physical Function Short Form Minimal Clinically Important Difference Following Total Hip Arthroplasty

BackgroundThe relationship between obesity and failure to achieve a minimal clinically important difference (MCID) following total hip arthroplasty (THA) has not been well defined. The aims of this study are to determine whether increasing body mass index (BMI) is associated with failure to achieve the 1-year Hip Disability and Osteoarthritis Outcome Score-Physical Function Short Form (HOOS-PS) MCID and to determine a threshold BMI beyond which this risk is significantly increased.MethodsA multi-institutional arthroplasty registry was queried for THA patients from 2016 to 2018 with completion of preoperative and 1-year postoperative HOOS-PS. A previously defined anchor-based MCID threshold of 23 was used. Variables collected included demographics and patient-reported outcome measures. BMI was analyzed continuously and categorically. The association was analyzed via logistic regression. A BMI threshold was determined using the Youden index and receiver operating characteristic curve.ResultsA total of 1256 THAs were included. The average HOOS-PS improvement was 27.6 ± 18 points. The area under the receiver operating characteristic curve for BMI and risk of failure to achieve HOOS-PS MCID was 0.54 (95% confidence interval [CI], 0.50-0.57). Increasing BMI assessed continuously was a significant risk factor (odds ratio [OR], 1.03; 95% CI, 1.01-1.05; P value = .010). When BMI was analyzed categorically, this association was only observed for obese class III patients (>40 kg/m²) (OR, 2.5; 95% CI, 1.21-5.3; P value = .010).ConclusionThis study found an association between increasing BMI and failure to achieve the 1-year HOOS-PS MCID. Obese class III patients (>40 kg/m²) face a near 3-fold increased risk of suffering this adverse outcome.