Defining Clinically Meaningful Thresholds for Patient-Reported Outcomes in Knee Arthroplasty

Most, Jasper; Hoelen, Thomáy-Claire Ayala; Spekenbrink-Spooren, Anneke; Schotanus, Martijn G.M.; Boonen, Bert

doi:10.1016/j.arth.2022.01.092

Cited by 19 publications

(12 citation statements)

References 17 publications

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“…Likewise, previous studies determined baseline dependency of OKS PASS and TF values, using a similar methodological approach, in patients undergoing TKA ( 13 , 23 ). For the MIC, previous results are sparse and conflicting with different methods used to evaluate baseline dependency ( 16 , 24 ). We demonstrated baseline dependency also of MIC values, using a newly developed method that avoids redistributing measurement error ( 20 ).…”

Section: Discussionmentioning

confidence: 99%

Interpretation threshold values for the Oxford Knee Score in patients undergoing unicompartmental knee arthroplasty

Harris

Troelsen

Terluin³

et al. 2022

ActaO

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Background and purpose: Developing meaningful thresholds for the Oxford Knee Score (OKS) advances its clinical use. We determined the minimal important change (MIC), patient acceptable symptom state (PASS), and treatment failure (TF) values as meaningful thresholds for the OKS at 3-, 12-, and 24-month follow-up in patients undergoing unicompartmental knee arthroplasty (UKA).Patients and methods: This is a cohort study with data from patients undergoing UKA collected at a hospital in Denmark between February 2016 and September 2021. The OKS was completed preoperatively and at 3, 12, and 24 months postoperatively. Interpretation threshold values were calculated with the anchor-based adjusted predictive modeling method. Non-parametric bootstrapping was used to derive 95% confidence intervals (CI).Results: Complete 3-, 12-, and 24-month postoperative data was obtained for 331 of 423 (78%), 340 of 479 (71%), and 235 of 338 (70%) patients, median age of 68–69 years (58–59% females). Adjusted OKS MIC values were 4.7 (CI 3.3–6.0), 7.1 (CI 5.2–8.6), and 5.4 (CI 3.4– 7.3), adjusted OKS PASS values were 28.9 (CI 27.6–30.3), 32.7 (CI 31.5–33.9), and 31.3 (CI 29.1–33.3), and adjusted OKS TF values were 24.4 (CI 20.7–27.4), 29.3 (CI 27.3–31.1), and 28.5 (CI 26.0–30.5) at 3, 12, and 24 months postoperatively, respectively. All values statistically significantly increased from 3 to 12 months but not from 12 to 24 months.Interpretation: The UKA-specific measurement properties and clinical thresholds for the OKS can improve the interpretation of UKA outcome and assist quality assessment in institutional and national registries.

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Section: Discussionmentioning

confidence: 99%

Interpretation threshold values for the Oxford Knee Score in patients undergoing unicompartmental knee arthroplasty

Harris

Troelsen

Terluin³

et al. 2022

ActaO

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“…TKA rates are rising due to obesity and ageing, both risk factors for knee OA 1 4 5. While, on average, TKA is highly effective, 15%–30% of recipients report little or no symptom improvement and/or dissatisfaction with results 6 7. Among primary TKA recipients in an Ontario OA cohort, we found that changes in pain, function and health resource use after TKA varied substantially; while mean changes were positive, 23.6% experienced no meaningful change in symptoms and 17.1% were worse after surgery 8.…”

Section: Introductionmentioning

confidence: 84%

Patient appropriateness for total knee arthroplasty and predicted probability of a good outcome

et al. 2023

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ObjectivesOne-fifth of total knee arthroplasty (TKA) recipients experience a suboptimal outcome. Incorporation of patients’ preferences in TKA assessment may improve outcomes. We determined the discriminant ability of preoperative measures of TKA need, readiness/willingness and expectations for a good TKA outcome.MethodsIn patients with knee osteoarthritis (OA) undergoing primary TKA, we preoperatively assessed TKA need (Western Ontario-McMaster Universities OA Index (WOMAC) Pain Score and Knee injury and Osteoarthritis Outcome Score (KOOS) function, arthritis coping), health status, readiness (Patient Acceptable Symptom State, depressive symptoms), willingness (definitely yes—yes/no) and expectations (outcomes deemed ‘very important’). A good outcome was defined as symptom improvement (met Outcome Measures in Rheumatology and Osteoarthritis Research Society International (OMERACT–OARSI) responder criteria) and satisfaction with results 1 year post TKA. Using logistic regression, we assessed independent outcome predictors, model discrimination (area under the receiver operating characteristic curve, AUC) and the predicted probability of a good outcome for different need, readiness/willingness and expectations scenarios.ResultsOf 1,053 TKA recipients (mean age 66.9 years (SD 8.8); 58.6% women), 78.1% achieved a good outcome. With TKA need alone (WOMAC pain subscale, KOOS physical function short-form), model discrimination was good (AUC 0.67, 95% CI 0.63 to 0.71). Inclusion of readiness/willingness, depressive symptoms and expectations regarding kneeling, stair climbing, well-being and performing recreational activities improved discrimination (p=0.01; optimism corrected AUC 0.70, 0.66–0.74). The predicted probability of a good outcome ranged from 44.4% (33.9–55.5) to 92.4% (88.4–95.1) depending on level of TKA need, readiness/willingness, depressive symptoms and surgical expectations.ConclusionsAlthough external validation is required, our findings suggest that incorporation of patients’ TKA readiness, willingness and expectations in TKA decision-making may improve the proportion of recipients that experience a good outcome.

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“…Research provides general support for our approach. Our definition of “less pain” is consistent with a reported patient-acceptable pain level of 2.5 with activities [26]. Pain and function have been included in a composite reference anchor, but with different questions than we used and not applied to the HOOS JR and KOOS JR [6, 27].…”

Section: Discussionmentioning

confidence: 99%

“…This limitation underscores an important take-home point: Patient characteristics must be considered, even informally, to understand how the change in HOOS JR and KOOS JR score reflects a patient's pain and dysfunction [4]. Other analytic approaches could yield different deltas, although the ROC method we used is commonly used [25,26,32]. Research provides general support for our approach.…”

Section: Limitationsmentioning

confidence: 99%

How Much Perioperative Pain and Dysfunction Underlie the HOOS JR and KOOS JR?

Cowen

Zheng²,

Hughes

et al. 2023

Clin Orthop Relat Res

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Background The Hip Disability and Osteoarthritis Outcome Score Joint Replacement (HOOS JR) and Knee Injury and Osteoarthritis Outcome Score Joint Replacement (KOOS JR) scores represent pain and dysfunction as a single number ranging from 0 (extreme pain and dysfunction) to 100 (no pain or functional limitations). However, scores between 0 and 100 lack a simple interpretation because they reflect varying combinations of pain levels and dysfunction. Given that most adverse events and improvement occur within the first 90 days after surgery, a deeper understanding of the level of pain and dysfunction may reveal missed opportunities for patient care. Questions/purposes (1) What does a given preoperative or postoperative HOOS JR and KOOS JR score indicate about pain and ability to perform daily activities? (2) How much of a change in score (that is, delta) is needed to indicate significant improvement in pain control and daily functioning? Methods The Michigan Arthroplasty Registry Collaborative Quality Initiative contains more than 95% of THAs and TKAs performed in Michigan. Between January 2017 and March 2019, 84,175 people in the registry underwent primary THA or TKA and were potentially eligible for this retrospective, comparative study of the first 90 postoperative days. Eighty-four percent (70,608 of 84,175) were excluded because their surgeons did not attain a target survey collection proportion of 70% and another 6% (5042) were missing covariate information or surveys, leaving 10% (8525) for analysis. The mean age and percentage of women were 65 ± 11 years and 55% (2060 of 3716), respectively, for patients undergoing THA and 67 ± 9 years and 61% (2936 of 4809), respectively, for those undergoing TKA. There were no clinically meaningful differences between patients who were analyzed and those who were excluded except for lower representation of non-White patients in the analyzed group. For interpretation, patient responses to Question 7 (pain) and Question 6 (function) from the Patient-Reported Outcomes Measurement Information System global items (PROMIS-10) were dichotomized into “much pain” (rating of pain 4 to 10 of 10) versus “less pain” (rating of ≤ 3) and “good function” (able to perform most activities) versus “poor function” (not able to perform most activities) and combined into four pain-function categories. We examined the mean preoperative and postoperative HOOS JR and KOOS JR scores for each pain‐function category, adjusted for patient characteristics. We calculated the size of the delta associated with an increase to a more favorable category postoperatively (versus staying in the same or worse category) via multivariable logistic regression that controlled for patient characteristics. Results Patients in the least favorable “much pain, poor function” category preoperatively had adjusted mean scores of 40 (95% confidence interval 39 to 41) for both the HOOS JR and KOOS JR. Those with mixed levels of pain and function had mean scores between 46 and 55. Those in the most favorable “less pain, good function” category had means of 60 (95% CI 58 to 62) and 59 (95% CI 58 to 61) for the HOOS JR and KOOS JR, respectively. The adjusted delta to achieve a pain level of ≤ 3 or the ability to perform most activities was 30 (95% CI 26 to 36) on the HOOS JR and 27 (95% CI 22 to 29) on the KOOS JR scales. Conclusion These adjusted means of the HOOS JR and KOOS JR provide context for understanding the levels of pain and dysfunction for individuals as well for patients reported in other studies. Potential quality improvement efforts could include tracking the proportion of patients with THA or TKA who achieved a sufficient delta to attain pain levels of ≤ 3 or the ability to perform most activities. Future studies are needed to understand pain and function represented by the HOOS JR and KOOS JR at 1 to 2 years, how these may differ by patient subgroups, and whether scores can be improved through quality improvement efforts. Level of Evidence Level III, therapeutic study.

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Defining Clinically Meaningful Thresholds for Patient-Reported Outcomes in Knee Arthroplasty

Cited by 19 publications

References 17 publications

Interpretation threshold values for the Oxford Knee Score in patients undergoing unicompartmental knee arthroplasty

Interpretation threshold values for the Oxford Knee Score in patients undergoing unicompartmental knee arthroplasty

Patient appropriateness for total knee arthroplasty and predicted probability of a good outcome

How Much Perioperative Pain and Dysfunction Underlie the HOOS JR and KOOS JR?

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