John Charnley Award: Preoperative Patient-reported Outcome Measures Predict Clinically Meaningful Improvement in Function After THA

Abstract

BackgroundDespite the overall effectiveness of total hip arthroplasty (THA), a subset of patients remain dissatisfied with their results because of persistent pain or functional limitations. It is therefore important to develop predictive tools capable of identifying patients at risk for poor outcomes before surgery.Questions/purposesThe purpose of this study was to use preoperative patient-reported outcome measure (PROM) scores to predict which patients undergoing THA are most likely to experience a clinically meaningful change in functional outcome 1 year after surgery.MethodsA retrospective cohort study design was used to evaluate preoperative and 1-year postoperative SF-12 version 2 (SF12v2) and Hip Disability and Osteoarthritis Outcome Score (HOOS) scores from 537 selected patients who underwent primary unilateral THA. Minimum clinically important differences (MCIDs) were calculated using a distribution-based method. A receiver operating characteristic analysis was used to calculate threshold values, defined as the levels at which substantial changes occurred, and their predictive ability. MCID values for HOOS and SF12v2 physical component summary (PCS) scores were calculated to be 9.1 and 4.6, respectively. We analyzed the effect of SF12v2 mental component summary (MCS) scores, which measure mental and emotional health, on SF12v2 PCS and HOOS threshold values.ResultsThreshold values for preoperative HOOS and PCS scores were a maximum of 51.0 (area under the curve [AUC], 0.74; p < 0.001) and 32.5 (AUC, 0.62; p < 0.001), respectively. As preoperative mental and emotional health improved, which was reflected by a higher MCS score, HOOS and PCS threshold values also increased. When preoperative mental and emotional health were taken into account, both HOOS and PCS threshold values’ predictive ability improved (AUCs increased to 0.77 and 0.69, respectively).ConclusionsWe identified PROM threshold values that predict clinically meaningful improvements in functional outcome after THA. Patients with a higher level of preoperative function, as suggested by HOOS or PCS scores above the defined threshold values, are less likely to obtain meaningful improvement after THA. Lower preoperative mental and emotional health decreases the likelihood of achieving a clinically meaningful improvement in function after THA. The results of this study may be used to facilitate discussion between physicians and patients regarding the expected benefit after THA and to support the development of patient-based informed decision-making tools. For example, despite significant disease, patients with high preoperative function, as measured by PROM scores, may choose to delay surgery given the low likelihood of experiencing a meaningful improvement postoperatively. Similarly, patients with notably low MCS scores might best be counseled to address mental health issues before embarking on surgery.Level of EvidenceLevel III, prognostic study.

Better early functional outcome after short stem total hip arthroplasty? A prospective blinded randomised controlled multicentre trial comparing the Collum Femoris Preserving stem with a Zweymuller straight cementless stem total hip replacement for the treatment of primary osteoarthritis of the hip

“…These scores are in the lower spectrum of the preoperative HOOS value range defined by Berliner et al, which could result in lower overall postoperative scores in our study. 47 This may explain the difference between the high PASS cut-off scores defined by Paulsen et al and the functional scores found in our study. 49 Our mean preoperative total HOOS scores and accompanying 95% CIs were, however, comparable and within that range in both groups, thereby suggesting a similar responsiveness to the surgical procedure.…”

“…34 47 48 50 Berliner et al calculated the preoperative threshold values of HOOS. 47 Patients with preoperative HOOS values below 32.5 or above 51 were less likely to experience a minimal clinical important difference of 9.1 points. Our preoperative HOOS total score was 36.5 (95% CI 32.9 to 40.2) in the short stem group and 37.1 (95% CI 33.9 to 40.3) in the conventional straight stem group.…”

“…A large retrospective series of 537 primary THAs found a HOOS score of 83.1 at 1 year follow-up. 47 Likewise, Nilsdotter et al reported a HOOS pain subscale score of 82.3 at 6 months follow-up. 48 Paulsen et al calculated the minimal postoperative HOOS score acceptable to patients after primary THA, also known as the patient-acceptable symptom state (PASS) in a large series of 1239 patients.…”

Value-based Healthcare: Part 2—Addressing the Obstacles to Implementing Integrated Practice Units for the Management of Musculoskeletal Disease

“…Technology enables ongoing outcomes data collection, which is critical for enabling the real-time use of these data to continuously improve value. For example, Berliner and colleagues [2] have shown that preoperative joint function, pain, and mental health PROs can be used to predict which patients are most likely to achieve a clinically meaningful improvement in pain and function from surgery. This algorithm (and others like it) are built into risk calculators for use during the office visit so patients can receive a personalized risk/benefit assessment during the shared-decision making process.…”

Value-based Healthcare: Patient-reported Outcomes in Clinical Decision Making

“…A recent publication [2] utilizing PROMs found higher functioning patients who underwent hip replacement surgery had a lower chance of meaningful clinical improvement. Patients come to surgeons for advice.…”