Factors associated with recording the exercise vital sign (EVS) in the electronic health records of patients in chiropractic teaching clinics

ObjectiveWe set out to identify factors associated with recording of exercise minutes per week in electronic patient files at chiropractic teaching clinics to better understand whether this important health determinant – exercise vital sign (EVS) – is captured or not.MethodsPatient files (4018) from 23 clinicians eligible for inclusion underwent multilevel logistic regression modeling to explore the association between a recorded EVS and the following: patients’ age, sex, comorbidities and interns nested within clinicians.ResultsEVS discussion was documented in 81.2% of patient files, whereas 44.9% had exercise minutes recorded numerically. Clinicians and interns explained 1.7% and 25.5% of the variance in the EVS outcome.ConclusionTo enhance EVS recording, clinic directors and clinicians should better educate the interns on the importance of exercise is medicine and appropriate record keeping, as they explained the largest portion of variability in recording exercise in minutes per week.     

Surgical interns in 2018: Objective assessment suggests they are better but still lack critical knowledge and skill

BackgroundThe transition from fourth-year medical student to surgical intern is difficult. A lack of repetitions, experience, and knowledge is problematic. We report our experience using simulation-based technical and nontechnical skills to assess the competency of surgical interns in July and January of their intern year.DesignAs part of a larger assessment effort, our general surgery interns (2010–2016) have been tested on performing an emergent cricothyrotomy, interpreting 2 arterial blood gases, and reading 3 chest x-rays in fewer than 7 minutes. We retrospectively analyzed general surgery interns’ performance on these 3 tests (total score = 20).ResultsA total of 210 interns completed both July and January (identical) assessments. Overall mean scores improved from July (12.62 ± 3.44) to January (16.5 ± 2.46; P < .05). During the study period general surgery interns’ mean baseline scores improved in both July (P < .05) and in January (P < .05). Although most individual general surgery interns did improve their total scores (92% improved, 3% same, 5% worse) between July and January (P < .05), in January 40% could not perform an emergent cricothyrotomy swiftly, and 6% missed a tension pneumothorax on chest x-ray.ConclusionOur data suggest that surgical interns start residency training with low levels of skill and comprehension with emergent cricothyrotomy, arterial blood gas, and chest x-ray. They improve with 6 months of clinical and simulation training. Encouragingly, overall scores for both July and January assessments have improved during the study period. Given that some interns still struggle in January to perform these three tasks, we believe that 2018 interns are better, but still potentially lack critical knowledge and skill.     

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.     

Construct validity and reliability of the Concussion Knowledge Assessment Tool (CKAT)

ObjectiveTo evaluate the test-retest reliability and construct validity of the concussion knowledge assessment tool (CKAT) as a measure of knowledge of concussion and its management among chiropractic subgroups and to compare these properties for two scoring strategies for the CKAT.MethodsThree chiropractic subgroups (first year students, interns and sports chiropractors) completed the CKAT via SurveyMonkey with as second administration two to six weeks later for a subset of respondents. Scatter plots and Intraclass Correlation Coefficients (ICC) were used for test-retest reliability. A priori hypotheses regarding the relationship of CKAT scores across known subgroups, and with concussion knowledge self-rankings were established prior to data collection. Distributions of CKAT scores were compared across the subgroups using boxplots and ANOVA for known groups validity, and correlation of CKAT scores with concussion knowledge self-ranking was examined.ResultsTest-retest ICC for the revised scoring was 0.68 (95%CI 0.51–0.80). First year students had a mean revised CKAT (out of 49) of 36.9 (SD= 4.7), interns 39.9 (SD=3.0) and sports chiropractors 41.8 (SD=3.2) which are significantly different (F_2,125=17.54; p<0.0001).ConclusionsThe CKAT distinguished between chiropractic subgroups expected to have different levels of knowledge, supporting construct validity, however, it did not achieve adequate test-retest reliability.     

Determination of minimum clinically important difference (MCID) in pain,disability, and quality of life after revision fusion for symptomatic pseudoarthrosis

Background contextSpinal surgical outcome studies rely on patient reported outcome (PRO) measurements to assess the effect of treatment. A shortcoming of these questionnaires is that the extent of improvement in their numerical scores lacks a direct clinical meaning. As a result, the concept of minimum clinically important difference (MCID) has been used to measure the critical threshold needed to achieve clinically relevant treatment effectiveness. Post hoc anchor-based MCID methods have not been applied to the surgical treatment for pseudoarthrosis.PurposeTo determine the most appropriate MCID values for visual analog scale (VAS), Oswestry Disability Index (ODI), Short Form (SF)-12 physical component score (PCS), and European Quality of Life 5-Dimensions (EQ-5D) in patients undergoing revision lumbar arthrodesis for symptomatic pseudoarthrosis.Study design/ settingRetrospective cohort study.MethodsIn 47 patients undergoing revision fusion for pseudoarthrosis-associated back pain, PRO measures of back pain (BP-VAS), ODI, physical quality of life (SF-12 PCS), and general health utility (EQ-5D) were assessed preoperatively and 2 years postoperatively. Four subjective post hoc anchor-based MCID calculation methods were used to calculate MCID (average change; minimum detectable change; change difference; and receiver operating characteristic curve analysis) for two separate anchors (health transition index (HTI) of SF-36 and satisfaction index).ResultsAll patients were available for a 2-year PRO assessment. Two years after surgery, a significant improvement was observed for all PROs; Mean change score: BP-VAS (2.3±2.6; p<.001), ODI (8.6%±13.2%; p<.001), SF-12 PCS (4.0±6.1; p=.01), and EQ-5D (0.18±0.19; p<.001). The four MCID calculation methods generated a wide range of MCID values for each of the PROs (BP-VAS: 2.0–3.2; ODI: 4.0%–16.6%; SF-12 PCS: 3.2–6.1; and EQ-5D: 0.14–0.24). There was no difference in response between anchors for any patient, suggesting that HTI and satisfaction anchors are equivalent in this patient population. The wide variations in calculated MCID values between methods precluded any ability to reliably determine what the true value is for meaningful change in this disease state.ConclusionsUsing subjective post hoc anchor-based methods of MCID calculation, MCID after revision fusion for pseudoarthrosis varies by as much as 400% per PRO based on the calculation technique. MCID was suggested to be as low as 2 points for ODI and 3 points for SF-12. These wide variations and low values of MCID question the face validity of such calculation techniques, especially when applied to heterogeneous disease and patient groups with a multitude of psychosocial confounders such as failed back syndromes. The variability of MCID thresholds observed in our study of patients undergoing revision lumbar fusion for pseudoarthrosis raises further questions to whether ante hoc or Delphi methods may be a more valid and consistent technique to define clinically meaningful, patient-centered changes in PRO measurements.     

Impact of gender on outcomes following single-level anterior lumbar interbody fusion

BackgroundThere have been a multitude of studies attempting to identify the relationship between gender and postoperative outcomes; however, few studies have examined how this relationship may affect outcomes after anterior lumbar interbody fusion (ALIF) surgery. We aim to better characterize the impact that self-reported gender may have on patient reported outcome measures (PROMs) and achievement rates of minimum clinically important difference (MCID) after ALIF.MethodsA retrospective database of a single spine surgeon was searched for patients who had undergone single-level ALIF. Indications for surgery including acute trauma, infection, or malignancy were excluded. The population was separated into cohorts by self-reported gender, female or male. PROMs were recorded and compared within groups to their preoperative baselines and between groups. MCID achievement rate was compared between groups.Results140 patients were identified for this study, with 68 patients self-identifying as female gender. The male gender cohort was found to have a significantly greater prevalence of hypertension (p = 0.018). Both cohorts showed significant improvement during at least one or more postoperative time points for each evaluated outcome measure (p ≤ 0.048, all). No significant difference in mean PROM scores was noted between cohorts at any time point for any measured outcome. The female gender cohort had significantly greater MCID achievement rates for visual acuity scale (VAS) back pain overall and at the 6-month time point (p ≤ 0.043, both). The female gender cohort also had significantly greater achievement of MCID at the 1-year time point for VAS leg pain (p = 0.017).ConclusionBoth female and male gender cohorts demonstrated significant improvement in all outcomes measured at one or more postoperative time points. Postoperative outcomes did not differ by gender. MCID achievement was more common in female patients. Female patients may experience more tangible clinical improvement after ALIF compared to male patients.     

Preoperative patient activation predicts minimum clinically important difference for PROMIS pain and physical function in patients undergoing elective spine surgery

BACKGROUND CONTEXTPatient activation is a patient's willingness to take independent actions to manage their own health care.PURPOSEThe goal of this study is to determine whether preoperative patient activation measure (PAM) predicts minimum clinically important difference (MCID) for Patient-Reported Outcomes Measurement Information System (PROMIS) pain, physical function, depression, and anxiety for patients undergoing elective spine surgery.STUDY DESIGN/SETTINGRetrospective review.PATIENT SAMPLEA single-institution, academic database of patients undergoing elective spine surgery.OUTCOME MEASUREMCID at 1-year follow-up for PROMIS pain, physical function, depression and anxiety.METHODSWe retrospectively reviewed a single-institution, academic database of patients undergoing elective spine surgery. Preoperative patient activation was evaluated using the PAM-13 survey, which was used to stratify patients into four activation stages. Primary outcome variable was achieving MCID at 1-year follow-up for PROMIS pain and physical function. Multivariable logistic regression analysis was used to determine impact of patient activation on PROMIS pain and the physical function.RESULTSOf the 430 patients, 220 (51%) were female with a mean age of 58.2±16.8. Preoperatively, 34 (8%) were in activation stage 1, 45 (10%) in stage 2, 98 (23%) in stage 3, and 253 (59%) in stage 4. At 1-year follow up, 248 (58%) achieved MCID for PROMIS physical function, 256 (60%) achieved MCID for PROMIS pain, 151 (35.28%) achieved MCID for PROMIS depression, and 197 (46%) achieved MCID for PROMIS anxiety. For PROMIS physical function, when compared to patients at stage 1 activation, patients at stage 2 (aOR:3.49, 95% CI:1.27, 9.59), stage 3 (aOR:3.54, 95% CI:1.40, 8.98) and stage 4 (aOR:7.88, 95% CI:3.29, 18.9) were more likely to achieve MCID. For PROMIS pain, when compared against patients at stage 1, patients at stage 3 (aOR:2.82, 95% CI:1.18, 6.76) and stage 4 (aOR:5.44, 95% CI:2.41, 12.3) were more likely to achieve MCID. For PROMIS depression, when compared against patients at stage 1, patients at stage 4 were more likely to achieve MCID (Adjusted Odds Ratio (aOR):2.59, 95% CI:1.08–6.19). For PROMIS anxiety, when compared against patients at stage 1, stage 3 (Adjusted Odds Ratio (aOR):3.21, 95% CI:1.20–8.57), and stage 4 (aOR:5.56, 95% CI:2.20–14.01) were more likely to achieve MCID.CONCLUSIONPatients at higher stages of activation were more likely to achieve MCID for PROMIS pain, physical function, depression, and anxiety at 1-year follow-up. Routine preoperative assessment of patient activation may help identify patients at risk of poor outcomes.     

How Should We Define Clinically Significant Outcome Improvement on the iHOT-12?

Background

There is increased emphasis on efficiently administering patient-reported outcome measures (PROMs). The International Hip Outcome Tool-12 (iHOT-12) is a short-form version of the iHOT-33, and relatively little is known about clinically significant outcomes using the iHOT-12.

Questions/Purposes

The purpose of this study was to define minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) for the iHOT-12 and to identify predictors for achieving these psychometric end points in patients undergoing arthroscopic treatment of femoroacetabular impingement (FAI).

Methods

Data was prospectively collected and retrospectively analyzed as part of an institutional hip preservation repository. One hundred and twenty patients were included; mean age and body mass index (BMI) were 38.7 years and 25.9, respectively. A majority of patients were female (67.5%) and white (81.7%) and participated in recreational sports (79.2%). The iHOT-12 was administered pre-operatively and at 1-year follow-up to patients undergoing primary hip arthroscopy for FAI. The following anchor question was also asked at 1-year follow-up: “Taking into account all the activities you have during your daily life, your level of pain, and also your functional impairment, do you consider that your current state is satisfactory?” MCID was calculated using a distribution-based method. Receiver-operating characteristic analysis with area under the curve was used to confirm the significance of the PASS threshold.

Results

Mean iHOT-12 scores improved from 35.6 at pre-operative assessment to 70.7 at 1-year follow-up. Patients indicating satisfaction with their outcome improved from 37.5 pre-operatively to 79.0 at 1-year follow-up. MCID value for the iHOT-12 was 13.0. The PASS threshold was 63.0, indicating an excellent predictive value that patients scoring above this threshold were likely to have met an acceptable symptom state. Worker’s compensation patients and those with increased BMI were less likely to achieve PASS; lower pre-operative iHOT-12 score was predictive for achieving MCID, and achieving MCID was predictive for achieving PASS.

Conclusion

This is the first study to define PASS and MCID for the iHOT-12, which measures clinically significant outcome improvement comparably to that of other commonly used hip PROMs. As its use becomes more widespread, the iHOT-12 data-points presented in this study can be used to determine clinically significant improvement of patient-reported outcomes.

     

Are Functional Outcomes of a Total Hip Arthroplasty Predictive of a Contralateral Total Hip Arthroplasty: A Retrospective Cohort Study

BackgroundCurrent literature suggests that 8%-35% of patients undergoing total hip arthroplasty (THA) undergo a subsequent contralateral THA. This study aims to determine if functional outcomes after primary THA predict outcomes in the subsequent primary THA of the contralateral side.MethodsA retrospective cohort of patients undergoing staged bilateral primary THA was reviewed. The Oxford Hip Score (OHS) was utilized as the functional outcome measurement tool and was assessed preoperatively and at one year postoperatively. The minimal clinically important difference (MCID) was assessed. Based on the first-side THA one-year outcomes, the odds of maintaining an MCID, or not, for the second-side THA were determined.ResultsThe study cohort consisted of 551 patients and 1102 primary THAs. The average postoperative OHSs were similar after the first and second THA. Patients achieving the MCID with the first-side surgery were 2.6 times (95% confidence interval 1.0 to 6.64, P = .04) more likely to achieve the MCID for the second-side surgery than patients failing to reach the MCID for their first-side surgery. After the first THA, 29 (5.3%) patients failed to reach the predefined MCID for the OHS compared with 54 (9.8%) patients undergoing their second THA (odds ratio: 1.96 [95% confidence interval: 1.23 to 3.1], χ² = 8.14, P = .005).ConclusionsFunctional outcomes after the first THA are predictive of functional outcomes of the second THA. Patients are more likely to achieve a clinically significant improvement after their first THA related to higher preoperative OHSs before the second THA.     

Are Oxford Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index Useful Predictors of Clinical Meaningful Improvement and Satisfaction After Total Hip Arthroplasty?

BackgroundUp to 15% of patients express dissatisfaction after total hip arthroplasty (THA). Preoperative patient-report outcome measures (PROMs) scores can potentially mitigate this by predicting postoperative satisfaction, identifying patients that will benefit most from surgery. The aim of this study was to (1) calculate the minimal clinically important difference (MCID) thresholds for Oxford Hip Score (OHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Short Form-36 (SF-36) mental component summary (MCS) and physical component summary (PCS) scores and (2) identify the threshold values of these PROMs that could be used to predict patient satisfaction and expectation fulfilment.MethodsProspectively collected registry data of 1334 primary THA patients who returned for 2-year follow-up from 1998 to 2016 were reviewed. All patients were assessed preoperatively and postoperatively at 2 years using the OHS, WOMAC, and SF-36 PCS/MCS scores. The MCID for each PROMs was calculated, and the proportion of patients that attained MCID was recorded. The relationship between satisfaction, expectation fulfilment, and MCID attainment was analyzed using Spearman rank correlation. Optimal threshold scores for each PROM that predicted MCID attainment and satisfaction/expectation fulfilment at 2 years were calculated using receiver operating curve analysis.ResultsThe calculated MCID for OHS, WOMAC, SF-36 PCS, and SF-36 MCS were 5.2, 10.8, 6.7, and 6.2, respectively. A threshold value of 24.5 for the preoperative OHS was predictive of achieving WOMAC MCID at 2 years after THA (area under the curve 0.80, P < .001). 93.1% of patients were satisfied, and 95.5% had expectations fulfilled at 2 years. None of the PROMs were able to predict satisfaction.ConclusionOHS and WOMAC scores can be used to determine clinical meaningful improvement but are limited in their ability to predict patient satisfaction after THA.     

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.     

Validation of a consensus-based minimal clinically important difference (MCID) threshold using an objective functional external anchor

Background contextThe minimal clinically important difference (MCID) is defined as the smallest change in an outcome that a patient would perceive as meaningful. The Initiative on Methods, Measurement and Assessment in Clinical Trials (IMMPACT) group proposed defining the MCID as a 30% improvement in self-reported pain or function. However, this MCID threshold has not been validated against an objective physical measure.PurposeTo test the validity of the IMMPACT-based MCID threshold, using an objective physical measure as an external anchor.Study design/settingProspective study of chronic disabling occupational lumbar disorder (CDOLD) patients completing a functional restoration program.Patient sampleA consecutive cohort of 743 CDOLD patients.Outcome measuresSelf-report measures of pain-related function were compared with an objective lifting measure, the progressive isoinertial lifting evaluation (PILE), obtained after treatment.MethodsThe association between reporting 30% or greater improvement (the IMMPACT's MCID key criterion) and the PILE score after treatment was assessed.ResultsA 30% or greater improvement on the self-report measures was significantly associated with improvement in physical function on the PILE task.ConclusionsDespite extensive use of the MCID to evaluate effects of treatment in spinal disorders, this is the first empirical documentation of the validity of the IMMPACT's 30% change criterion compared with an objective physical anchor.     

Identifying Aseptic Revision Total Knee Arthroplasty Diagnoses That Achieve Minimal Clinically Important Difference and Patient Acceptable Symptom State

BackgroundMinimal clinically important difference (MCID) defines a meaningful clinical change in patient-reported outcome measures. Patient acceptable symptom state (PASS) provides a patient-reported outcome measures threshold value to indicate a satisfactory clinical state. MCID and PASS for revision total knee arthroplasty (rTKA) are ill-defined. Moreover, it is unknown whether diagnosis influences the likelihood of achieving MCID or PASS. The purpose of this study was to calculate MCID for aseptic rTKA and compare the percentage of patients achieving MCID and PASS per diagnosis.MethodsAn institutional registry of rTKA was used. First-time aseptic rTKA were included. Demographics, revision diagnosis, preoperative Knee Injury and Osteoarthritis Outcome Score, Jr (KOOS Jr), and 1-year postoperative KOOS Jr were recorded. The 1-year postoperative KOOS Jr PASS score was available. MCID was calculated using distribution-based methods. Three hundred fifty eight first-time aseptic rTKAs were analyzed. The 3 most common diagnoses were aseptic loosening (n = 156), instability (n = 109), and stiffness (n = 37).ResultsThe mean KOOS Jr 1-year postoperative MCID for rTKA was 10.3. Overall, 75.4% achieved MCID and 56.9% achieved PASS. The percentage of patients per diagnosis achieving MCID and PASS, respectively, were periprosthetic fracture (100, 44), aseptic loosening (94, 60), implant fracture (88, 63), stiffness (60, 38), instability (59, 61), polyethylene wear/osteolysis (57, 57), and metal allergy (44, 33).ConclusionAseptic rTKA MCID is 10.3 for KOOS Jr at 1 year postoperatively. rTKA outcomes vary depending on preoperative diagnosis. Even in diagnoses with a high proportion of MCID achieved, less than 2/3 of patients achieved PASS, suggesting rTKA provides noticeable improvement but may not return patients to a satisfactory state.     

Minimal clinically important difference in patients who underwent decompression alone for lumbar degenerative disease

Background ContextThe minimal clinically important difference (MCID) represents the smallest change in an outcome measure recognized as clinically meaningful to a patient after receiving a clinical intervention. Most studies that discussed the MCIDs for lumbar spinal stenosis (LSS) included mixed pathologies or procedures despite that the MCID value should be different depending on the intervention. Moreover, despite the efficacy of adopting percentage-change improvement for the MCID threshold, there are limited reports and discussions in the field of lumbar surgery.PurposeThe aim of the present study was to elucidate the MCIDs for the Oswestry Disability Index (ODI), EuroQOL 5-dimension 3-level (EQ-5D-3L), physical component summary (PCS) of the Short Form of the Medical Outcomes Study, and Numeric Rating Scale (NRS) in patients with degenerative LSS treated with decompression surgery without fusion.Study Design/SettingA multicenter retrospective cohort study was performed.Patient SampleA total of 422 patients who underwent decompression surgery for LSS and answered a complete set of questionnaires were included in the study. Patients who underwent endoscopic or revision surgery were excluded.Outcome MeasuresPreoperative and 1-year postoperative scores of each health-related quality of life questionnaires (HRQOLs) and patient satisfaction questionnaire responseMethodsThe patient satisfaction question was used as an anchor, and the cutoff values were estimated based on absolute point improvement from baseline using a receiver-operating characteristic (ROC) curve analysis and the “mean change” method for MCIDs. The MCID values for percentage-change in HRQOLs were also calculated using ROC curve analysis. The three cutoff values for each HRQOL were validated using the Youden index for determining the most robust MCIDs.ResultsOf the patients, 356 (84.4%) were at least “somewhat satisfied” with the treatment results. The two cutoff values of absolute point-change in each HRQOL, which were estimated by two different anchor-based methods, were similar. The area under the curve of the ROC curve for percentage-change tended to be higher than that for absolute point-change. Moreover, the Youden index of the percentage-change in each HRQOL was higher than that of the absolute point-change calculated by either the “mean change” method or the ROC curve analysis. Based on these results, it was proposed that MCID was 42.4% for percentage-change in ODI, 22.0% for EQ-5D-3L, 13.7% for PCS, 25.0% for NRS (low back pain), 55.6% for NRS (leg pain), 22.2% for NRS (leg numbness).ConclusionsThe MCIDs of HRQOLs were calculated in patients with LSS treated with decompression surgery without concomitant fusion procedure. The MCID cutoffs based on percentage-change from baseline were more effective than those of absolute point-change.     

Reporting Clinical Significance in Hip Arthroscopy: Where Are We Now?

Background

Although p values are standard for reporting statistical significance of patient-reported outcome measures (PROMs), the shift toward clinically important outcome values, including minimal clinically important difference (MCID) and substantial clinical benefit (SCB), necessitates re-evaluation of the current literature.

Questions/Purposes

We sought to answer two questions regarding studies on primary hip arthroscopy performed for the treatment of femoroacetabular impingement syndrome (FAIS). (1) Do such studies reporting statistical significance on common PROMs meet published MCID/SCB thresholds? (2) What proportion of such studies report both statistical and clinical significance?

Methods

We identified four papers published in two journals defining MCID/SCB values on the modified Harris Hip Score (mHHS), Hip Outcome Score–Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sport (HOS-Sport), international Hip Outcome Tool (iHOT-33), and its short version (iHOT-12) for different groups of FAIS patients undergoing hip arthroscopy. We reviewed these two journals from the dates of publication to the present to identify papers reporting changes in post-operative PROMs. The difference in pre- and post-operative scores on each PROM was calculated and compared to MCID/SCB thresholds.

Results

Twelve studies were included. Ten studies (83%) evaluated mHHS (90% met MCID, 50% met SCB), seven (58%) evaluated HOS-ADL (100% met MCID/SCB) and HOS-Sport (100% met MCID, 57% met SCB), and one (8%) evaluated iHOT-33 (met MCID/SCB) and iHOT-12 (met MCID). Most studies met MCID and SCB at both 1- and 2-year timepoints. Of the studies evaluated, 50% reported clinical relevance.

Conclusions

Nearly all studies evaluated met MCID, while fewer met SCB. Only half discussed these clinical measures. It is proposed that all future studies report both statistical and clinical significance as standard best practice.

     

Should We Aim to Help Patients “Feel Better” or “Feel Good” After Total Hip Arthroplasty? Determining Factors Affecting the Achievement of the Minimal Clinically Important Difference and Patient Acceptable Symptom State

BackgroundRecent attempts have been made to use preoperative patient-reported outcome measure (PROM) thresholds as prior authorization criteria based on the assumption that patients who have higher baseline scores are less likely to achieve the minimal clinically important difference (MCID). This study aimed to identify factors affecting the achievement of MCID and patient acceptable symptom state (PASS) after total hip arthroplasty (THA), and to determine the overlap between the two outcomes.MethodsWe identified 3,581 primary, unilateral THAs performed at a single practice in 2015-2019. PROMs including Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR) and 12-item Short Form Health Survey were collected preoperatively and 1-year postoperatively. The likelihood of attaining PASS according to attainment of MCID was assessed. Multivariable regression was used to identify independent predictors of MCID and PASS.ResultsIn total, 79.8% achieved MCID and 73.6% achieved PASS for HOOS-JR. Approximately 1 in 7 patients who achieved MCID did not eventually achieve PASS. Worse preoperative HOOS-JR (odd ratio 0.933) was associated with MCID attainment. Better preoperative HOOS-JR (odd ratio 1.015) was associated with PASS attainment. Men, lower body mass index, better American Society of Anesthesiologists score, and better preoperative 12-item Short Form Health Survey mental score were predictors of MCID and PASS. Age, race, ethnicity, Charlson Comorbidity Index, and smoking status were not significant predictors.ConclusionPreoperative PROMs were associated with achieving MCID and PASS after THA, albeit in opposite directions. Clinicians should strive to help patients “feel better” and “feel good” after surgery. Preoperative PROMs should not solely be used to prioritize access to care.     

Test-retest reliability,minimal detectable change and minimal clinically important differences in modified shuttle walk test in children and adolescents with cystic fibrosis

BackgroundIn youths with cystic fibrosis (CF) the modified shuttle walk test (MSWT) has been shown to be useful for assessing exercise tolerance; however, no studies to date have evaluated the reliability of MSWT, the minimal detectable change (MDC) and the minimal clinically important differences (MCID) for the MSWT distance for children and adolescents with CF.MethodsTest-retest reliability: 35 CF patients and 34 healthy controls performed two MSWTs (separated by 2–4 days). MCID: 33 patients were invited to participate in a 6-week home-based exercise program consisting of 30–60-min sessions, 5 days a week.ResultsThe test-retest reliability of the MSWT distance for children and adolescents with CF was excellent, obtaining a MDC₉₀ and MDC₉₅ of 97.08 m and 115.32 m, respectively. The test-retest reliability also was excellent in healthy controls, founding a MDC₉₀ and MDC₉₅ of 69.12 m and 82.11 m, respectively. The ROC curve analysis established (with a sensitivity of 82% and specificity of 76%) that a change of 60 m represented MCID.ConclusionsThe MSWT is a reliable tool to measure of exercise tolerance in children/adolescents with CF and those without CF. We propose a change in the score of at least 97.08 m (MDC₉₀) as the most appropriate value for assessing the exercise response of children and adolescents with CF, given that this value exceeds the MCID based on the children's perception.     

Minimum clinically important difference for the American Shoulder and Elbow Surgeons score after revision shoulder arthroplasty

BackgroundPatients undergoing revision total shoulder arthroplasty (TSA) typically achieve smaller improvements in outcome measurements than those undergoing primary TSA. The minimum clinically important difference (MCID) in the American Shoulder and Elbow Surgeons (ASES) questionnaire for primary shoulder arthroplasty ranges from 13.6 to 20.9, but the MCID for revision shoulder arthroplasty remains unclear. This study aims to define the MCID in ASES score for revision TSA and ascertain patient factors that affect achieving the MCID threshold.MethodsPatients were identified from an institutional shoulder arthroplasty database. Prospective data collected included demographic variables, prior shoulder surgeries, primary and revision implants, indication for revision, and pre- and postoperative ASES scores. All patients provided informed consent to participate. An anchor-based method was used with a binary answer choice. The MCID was calculated using the receiver-operator curve (ROC) method, and the sensitivity, specificity, and area under the curve were obtained from the ROC. MCID values were compared between groups using Student's t-test. Multivariate logistic regression modeling was used to determine significant predictors for reaching MCID. Significance was defined as P< .05.ResultsA total of 46 patients underwent revision TSA with minimum 2-year follow-up. The MCID using ROC method was 16.7 with 71% sensitivity and 62% specificity. There was a trend toward males being more likely to reach MCID after revision arthroplasty (P= .058). There were also trends toward increased forward flexion and abduction range of motion in patients who met MCID (P= .08, P= .07). Multivariate logistic regression modeling demonstrated male sex to be associated with achieving MCID (P= .03), while younger age and fewer prior shoulder surgeries demonstrated a trend to association with achieving MCID (P= .06, P= .10).ConclusionThe MCID for ASES score in patients undergoing revision shoulder arthroplasty is similar to previously reported MCID values for patients undergoing primary shoulder arthroplasty. Younger, male patients with fewer prior shoulder surgeries were more likely to achieve MCID after revision TSA.Level of EvidenceLevel III; Retrospective Comparative Treatment Study