Minimal Clinically Important Differences for PROMIS Physical Function, Upper Extremity, and Pain Interference in Carpal Tunnel Release Using Region- and Condition-Specific PROM Tools

The PROPr can be measured using different PROMIS domain item sets

BACKGROUND

The Patient-Reported Outcomes Measurement Information System (PROMIS) Preference Score (PROPr) is estimated from descriptive health assessments within the PROMIS framework. The underlying item response theory (IRT) allows researchers to measure PROMIS health domains with any subset of items that are calibrated to this domain. Consequently, this should also be true for the PROPr. We aimed to test this assumption using both an empirical and a simulation approach.

METHODS

Empirically, we estimated 3 PROMIS Pain inference (PI) scores from 3 different item subsets in a sample of n=199 cancer patients: 4 PROMIS-29 items (estimate: θ4), the 2 original PROPr items (θ2), and 10 different items (θ10). We calculated mean differences and agreement between θ4, and θ2 and θ10, respectively, and between their resulting PROPr4, PROPr2, PROPr10, using intraclass correlation coefficients (ICC) and Bland-Altman (B-A) plots with 95 %-Limits of Agreement (LoA). For the simulation, we used the IRT-model to calculate all item responses of the entire 7 PROPr domain item banks from the empirically observed PROMIS-29+cognition θ. From these simulated item banks, we chose the 2 original PROPr items per domain to calculate PROPrsim and compared it to PROPr4 again using ICC and B-A plots.

RESULTS

θ4 vs θ10 showed smaller bias (-0.012, 95 %-LoA -0.88;0.85) than θ4 vs θ2 (0.025, 95 %-LoA -0.95;1.00. ICC>0.85 (p<0.001) in both θ-comparisons. PROPr4 vs PROPr10 showed lower bias (0.0012, 95 %-LoA -0.039;0.042) than PROPr4 vs PROPr2 (-0.0029, 95 %-LoA -0.049;0.044). ICC>0.98 (p<0.0001) on both PROPr-comparisons. Mean PROPrsim was larger than mean PROPr4 (0.0228, 95 %-LoA -0.1103; 0.1558) and ICC was 0.95 (95 %CI 0.93; 0.97).

CONCLUSION

Different item subsets can be used to estimate the PROMIS PI for calculation of the PROPr. Reduction to 2 items per domain rather than 4 does not significantly change the PROPr estimate on average. Agreements differ across the spectrum and in individual comparisons.

Two AIS Cases, 2 Surgeons, 1 Operating Room, 1 Day: Faster and Safer Than 1 Case in a Day

BACKGROUND

To lessen surgical times for patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal instrumentation and fusion (PSIF), our department developed a quality improvement initiative where 2 AIS cases were completed in 1 day by the same 2 surgeons operating together in 1 operating room (OR). We describe the results of this initiative, comparing operative times and outcomes to cases of these surgeons operating individually.

METHODS

From 2017 to 2023, patients aged 10 to 18 years with AIS undergoing PSIF were prospectively enrolled for "Two Spine Tuesday." Patients were matched by age, sex, curve severity, and number of levels fused to historical AIS controls. Outcomes included surgery time, total OR time, estimated blood loss (EBL), volume of cell saver transfused, allogenic blood transfusion, length of stay, 90-day readmissions, Clavien-Dindo-Sink Complication Classification System complication rates, and percentage who achieved the minimal clinically important difference (MCID) for SRS-22.

RESULTS

Fifty-five patients composing the 2-spine group (group 2) were compared with 55 historical sex-matched and age-matched controls (group 1). Major coronal curve and average number of levels fused were similar between groups. Overall surgery time (203 vs. 296 min, P <0.001), total OR time ( P <0.001), and EBL (400 vs. 550 mL, P <0.001) were lower for group 2. Group 2 had fewer complications [n=17 (31%) vs. n=28 (51%), P =0.03].

CONCLUSIONS

Performing 2 AIS cases in 1 OR by 2 surgeons the same day resulted in shorter surgery times, less total time in the operating room, lower complication rates, and less blood loss compared with single-surgeon matched controls.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Does the addition of Patient-Reported Outcome Measure Information System (PROMIS) pain instruments improve the sensitivity of PROMIS upper extremity scores after arthroscopic rotator cuff repair?

BACKGROUND

Although Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (P-UE) has been validated in upper extremity orthopedics, its ability to capture a patient's functional recovery after arthroscopic rotator cuff repair (aRCR), as measured by its responsiveness, is minimal in the early postoperative period. The primary purpose of this study is to determine if the addition of PROMIS Pain Intensity (P-Intensity) or Pain Interference (P-Interference) scores to PROMIS UE improves the responsiveness throughout the 1-year postoperative period after aRCR.

METHODS

This prospective, longitudinal study included 100 patients who underwent aRCR. Patients completed P-UE, P-Interference, P-Intensity, American Shoulder and Elbow Surgeons, and Western Ontario Rotator Cuff Index scores preoperatively and at 2 weeks, 6 weeks, 3 months, 6 months, and 12 months after surgery. Responsiveness at each time point relative to preoperative baseline and 1-way analysis of variance with post hoc analysis was conducted for each PROM. The responsiveness of the outcome score was determined using the effect size, graded as small (0.2), medium (0.5), or large (0.8). The Pearson correlation coefficient (r) was determined between these instruments at each time point.

RESULTS

In isolation, P-UE, P-Interference, and P-Intensity showed a medium-large ability to detect change (positive and negative) throughout the 1-year postoperative period. The addition of PROMIS pain scores to P-UE improved the responsiveness of the instrument (from medium to a large effect size) starting at 3 months and continued throughout the 12-month follow-up period. Although the addition of pain scores increases the response burden for PROMIS, this was still lower than the response burden for the legacy outcome scores (P < .05).

CONCLUSION

The addition of PROMIS pain instruments improves the responsiveness of the P-UE function score in patients undergoing aRCR.

Preliminary effectiveness and production time and costs of three-dimensional printed orthoses in chronic hand conditions: an interventional feasibility study

OBJECTIVE

To assess the preliminary effectiveness of three-dimensional printed orthoses compared with conventionally custom-fabricated orthoses in persons with chronic hand conditions on performance of daily activities, hand function, quality of life, satisfaction, and production time and costs.

DESIGN

Interventional feasibility study.

SUBJECTS

Chronic hand orthotic users (n = 21).

METHODS

Participants received a new three-dimensional printed orthosis according to the same type as their current orthosis, which served as the control condition. Primary outcome was performance of daily activities (Patient-Reported Outcomes Measurement Information System-Upper Extremity; Michigan Hand Questionnaire). Secondary outcomes were hand function, quality of life, and satisfaction. Furthermore, production time and costs were recorded.

RESULTS

At 4 months' follow-up, no significant differences were found between three-dimensional printed orthoses and participants' existing conventional orthoses on activity performance, hand function, and quality of life. Satisfaction with the three-dimensional printed orthosis was significantly higher and the production time and costs for three-dimensional printed orthoses were significantly lower compared with conventional orthoses. The three-dimensional printed orthosis was preferred by 79% of the participants.

CONCLUSIONS

This feasibility study in chronic hand conditions suggests that three-dimensional printed orthoses are similar to conventional orthoses in terms of activity performance, hand function, and quality of life. Satisfaction, and production time and costs favoured the three-dimensional printed hand orthoses.

Patient-Reported Outcomes and Computed Tomography Review After Minimally Invasive Fusion of the Sacroiliac Joint With Aggressive Joint Decortication and Joint Compression

The sacroiliac joint (SIJ) is a common, underrecognized source of low back pain. We evaluated outcomes in patients undergoing sacroiliac joint fusion (SIJF) using a novel, minimally invasive SIJF system emphasizing compressive forces across an aggressively debrided SIJ. We retrospectively reviewed data from a continuous set of patients presenting to a large, tertiary care hospital from September 2017 to August 2019. All patients received the novel SIJF device. Outcomes were assessed at 8 weeks, 6 months, and 12 months using the Oswestry Disability Index (ODI) score, Numerical Rating Scale (NRS) score, Single Assessment Numerical Evaluation (SANE) score, and Patient-Reported Outcomes Measurement Information System (PROMIS) measures, plus radiographic evaluation of fusion status. Data from 75 patients were analyzed. At 8 weeks, 6 months, and 12 months, the ODI score improved by 10.5 points (P=.002), 17.4 points (P<.0001), and 23.6 points (P<.0001), respectively, while the NRS score improved by 4.6 points (P<.0001), 4.4 points (P<.0001), and 4.6 points (P<.0001), respectively. SANE scores indicated high levels of patient satisfaction (81.0%, 92.18%, and 89.2%, respectively). PROMIS physical function scores improved by 2.65 points, 3.30 points, and 3.63 points, respectively, while PROMIS mental health scores showed changes of -1.93 points, 1.57 points, and -0.47 points, respectively. A review of computed tomography scans demonstrated grade 3 fusion (complete) in 81% of cases at a mean of 371 days postoperatively. There was one revision case for a malpositioned implant. The use of a novel SIJF device emphasizing compressive forces provided early, durable improvements in patient-reported outcomes and extremely high patient satisfaction. [Orthopedics. 2024;47(2):101-107.].

Responsiveness of the Brief Michigan Hand Outcomes Questionnaire and Patient-Reported Outcomes Measurement Information System Pain Interference in the Context of Patient Mental Health

PURPOSE

A patient-reported outcomes measure (PROM) is responsive if it is sensitive to clinical status changes. The minimal clinically important difference (MCID) is used to indicate meaningful change, helpful in designing studies and adding context to some study results, and is related to instrument responsiveness. Our purpose was to provide MCID estimates for the brief Michigan Hand Outcomes Questionnaire (bMHQ) and Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference (PI) in a hand and upper extremity surgery cohort within the context of varying patient-reported mental health.

METHODS

Data were analyzed from 1,262 adult patients who received surgical care at a single center between January 1, 2018, and December 31, 2019. Patients completed PROMIS PI, PROMIS Global Health (including global mental health [GMH] component), bMHQ, and a pain-focused anchor question before each clinic visit. Data were collected 8 ± 2 weeks before and after surgery. A distribution-based MCID then was calculated for the general patient population, lowest 10th percentile of GMH scores, and top 10th percentile of GMH scores.

RESULTS

Minimal clinically important difference estimates were 10.4 for the bMHQ and 4.3 for PROMIS PI. Analysis of MCID across different GMH score groups showed a mean score of 11.5 for bMHQ for the lowest 10th percentile of GMH, 9.6 for bMHQ for the top 10th percentile, 4.5 for PI for the lowest 10th percentile, and 4.9 for PI for the top 10th percentile.

CONCLUSIONS

Analysis of subgroups stratified by preoperative patient-reported mental health condition found that preoperative mental health status, as indicated by GMH score, does not have a meaningful impact on responsiveness of bMHQ or PROMIS PI.

CLINICAL RELEVANCE

A patient's reported mental health condition does not meaningfully change how these common PRO instruments reflect the patient condition after hand and upper extremity surgery.

Carpal Tunnel Syndrome Electrodiagnostic Severity is Not Associated with PROMIS Upper Extremity, PROMIS Pain Interference and PROMIS Pain Intensity

Background: The primary objective of this study was to determine the association between preoperative electrodiagnostic study (EDS) parameters and Patient-Reported Outcomes Measurement Information System (PROMIS) instruments in patients with EDS-confirmed carpal tunnel syndrome (CTS). Methods: A retrospective study of 45 patients with EDS-confirmed CTS was conducted. Patients completed the PROMIS Upper Extremity, PROMIS Pain Interference and PROMIS Pain Intensity. Explanatory variables included EDS disease severity (mild, moderate and severe), sensory peak latency, sensory amplitude, motor latency, motor amplitude, the presence of nonrecordable sensory latency and the presence of nonrecordable sensory amplitude. Explanatory variables also included patient-related factors, such as age, sex and diabetes mellitus. Associations between variables were assessed using simple linear regression, analysis of variance (ANOVA) and Student's t-test. Results: In our cohort, the EDS severity was mild in 38%, moderate in 42% and severe in 20% of patients. The mean PROMIS Upper Extremity score was 44.4, the mean PROMIS Pain Interference score was 53.5 and the mean PROMIS Pain Intensity score was 49.9. Bivariate analysis demonstrated no association between EDS severity overall or any EDS parameter individually and PROMIS Upper Extremity, PROMIS Pain Interference and PROMIS Pain Intensity. Diabetes mellitus was associated with poorer PROMIS Upper Extremity scores. Conclusions: EDS severity is not associated with PROMIS Upper Extremity, PROMIS Pain Interference and PROMIS Pain Intensity. Carpal tunnel release is commonly indicated for pain and dysfunction, but validated measures of pain and dysfunction do not correlate with EDS severity. Level of Evidence: Level III (Diagnostic).

An Evaluation of Patient-reported Outcome Measures and Minimal Clinically Important Difference Usage in Hand Surgery

Background

This study was designed to examine the current use of patient-reported outcome measures (PROMs) and minimal clinically important difference (MCID) calculations in the hand surgery literature in an effort to standardize their use for research purposes.

Methods

A systematic review of the hand surgery literature was conducted. All nonshoulder upper extremity articles utilizing PROMs were compared between different journals, different surgical indications, and differing usage. MCID values were reported, and calculation methods assessed.

Results

In total, 4677 articles were reviewed, and 410 met the inclusion criteria of containing at least one PROM. Of the 410 articles reporting PROMs, 148 also mentioned an associated MCID. Of the articles that mentioned MCIDs, 14 calculated MCID values based on their specific clinical populations, whereas the remainder referenced prior studies. An estimated 35 different PROMs were reported in the study period; 95 different MCID values were referenced from 65 unique articles.

Conclusions

There are many different PROMs currently being used in hand surgery clinical reports. The reported MCIDs from their related PROMs are from multiple different sources and calculated by different methods. The lack of standardization in the hand surgery literature makes interpretation of studies utilizing PROMs difficult. There is a need for a standardized method of calculating MCID values and applying these values to established PROMs for nonshoulder upper extremity conditions.

Operationalizing PROMs at the Musculoskeletal Practice and Policy Levels

There continues to be growing interest in patient-reported outcome measures (PROMs), especially as value-based healthcare initiatives gain more traction. Although it is well-established that PROMs can be useful in clinical research, how to operationalize PROMs in clinical care and policy initiatives remains a "work in progress." Following the design of a comprehensive PROM administration and routine collection system, orthopaedic surgeons and their patients can reap the benefits of PROMs in practice through improved shared clinical decision-making discussions at the individual patient level and closer symptom monitoring on a large scale, with improved resource allocation at the population health level. Although certain government and payer incentives exist to collect PROMs at present, it is reasonable to assume that future policy initiatives will begin to use the actual PROM scores to assess clinical outcomes. Orthopaedic surgeons with interest in this area should prioritize their involvement in policy discussion to ensure PROMs are being used appropriately in novel payment models and policy endeavors so that they are both evaluated and compensated fairly. Specifically, orthopaedic surgeons can help ensure appropriate risk adjustment of patients when this is being done. Undoubtedly, PROMs will only become a larger part of musculoskeletal care moving forward.

Responsiveness of PROMIS Instruments for Trigger Digit After Corticosteroid Injection or A1 Pulley Release

PURPOSE

The purpose of the study was to determine if the patient-reported outcomes measurement information system (PROMIS) is sufficiently sensitive to detect improvement after 2 common treatments of trigger finger: corticosteroid injection or A1 pulley release.

METHODS

This retrospective cohort study included 72 patients in the injection group and 51 in the A1 pulley release group. PROMIS physical function (PF), pain interference (PI), and upper extremity (UE) scores were collected at baseline and 6 weeks after injection for the injection group and at baseline, and 1 week, 6 weeks, and 3 months after surgery for A1 pulley release patients. Descriptive statistics and paired t tests were used to compare PROMIS scores within each cohort. Standardized response means (SRMs) were calculated for each PROMIS domain to gauge instrument responsiveness.

RESULTS

Average age was 62 years, 65% were female patients, and 86% were White for the steroid injection cohort, compared to 60 years, 71%, and 88%, respectively, for the A1 pulley release cohort. For the steroid injection group, mean PROMIS PI scores (-4.0 points; SRM = -0.6) and PROMIS UE scores (+3.3 points; SRM = 0.5) improved significantly at 6 weeks after injection compared to baseline. Meanwhile, A1 pulley release patients improved significantly in mean PI scores (-3.7 points; SRM = -0.5) and in UE scores (+4.9 points; SRM = 0.7) at 3 months after surgery compared to baseline.

CONCLUSIONS

Clinical improvements after trigger digit treatments are reflected in improved PROMIS PI and UE scores that reach previously accepted minimum clinically important difference values for hand patients. PROMIS PI and UE also are more responsive than PROMIS PF in capturing improvement for trigger digit treatments.

CLINICAL RELEVANCE

As health care payers continue to emphasize patient-reported outcomes to determine treatment value and set reimbursement rates, this study helps establish that clinical improvement after trigger digit treatments are reflected in PROMIS PI and UE domains by reaching previously established minimum clinically important difference values for hand patients.

Natural History of Pediatric Hand and Wrist Ganglion Cysts: Longitudinal Follow-Up of a Prospective, Dual-Center Cohort

PURPOSE

This investigation describes the outcomes of pediatric ganglion cysts in a prospective cohort that elected not to undergo cyst aspiration or surgical treatment. Our primary aim was to investigate the rate of spontaneous resolution over time among the subset of patients who did not undergo specific treatments.

METHODS

Children (aged ≤18 years) who presented to the clinic with ganglion cysts of the hand or wrist were enrolled in a prospective two-center registry between 2017 and 2021. Enrolled subjects who never elected to undergo cyst aspiration or surgical treatment were analyzed. The data collected included age, sex, cyst location and laterality, hand dominance, Wong-Baker pain scale scores, and Patient-Reported Outcome Measurement Information System upper-extremity scores. Follow-up surveys were completed for up to 5 years.

RESULTS

A total of 157 cysts in 154 children, with an average age of 9.4 years and a female-to-male ratio of 1.4:1, were eligible. The most common ganglion location was dorsal wrist (67/157, 42.7%), followed by volar wrist (49/157, 31.2%), the flexor tendon sheath (29/157, 18.5%), and the extensor tendon synovial lining (8/157, 5.1%). The average follow-up duration was 2.5 years after initial presentation to the clinic, and 63.1% (99/157) of the patients responded to follow-up surveys. Among them, 62.6% (62/99) of cysts spontaneously resolved; the resolution rates ranged from 51.9% of volar wrist ganglions to 81% of flexor tendon sheath cysts, with an average time to resolution of 14.1 months after cyst presentation. Cysts were more likely to resolve in the hand than in the wrist (84.0% vs 55.4%, respectively). Cysts present for >12 months at initial evaluation were less likely to resolve spontaneously (41.2% vs 67.1%).

CONCLUSIONS

Of children who elected not to undergo aspiration or surgical treatment, approximately two-thirds of families reported that their child's ganglion cyst resolved spontaneously. Cysts that resolve spontaneously usually do so within 2 years of presentation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Older Patients Demonstrate PROMIS Outcomes Comparable to Younger Cohorts After Carpal Tunnel Release

BACKGROUND

The utility of Patient-Reported Outcomes Measurement Information System (PROMIS) in monitoring clinical progress after carpal tunnel release (CTR) in patients of different ages remains unknown. We sought to evaluate early PROMIS scores in elderly patients (ie, those aged ≥65 years) after CTR and compare those with all younger patients after CTR.

METHODS

Patients presenting to a single academic medical center for CTR between September 2018 and January 2020 completed PROMIS physical function (PF), pain interference (PI), and upper extremity (UE) computer adaptive tests and answered a single 5-point Likert-scale question evaluating subjective changes in their condition following CTR. Patients were divided into 3 age groups, and preoperative and postoperative PROMIS scores were compared.

RESULTS

In all, 214 patients fit inclusion criteria: 86 aged 18-54 years, 71 aged 55-64 years, and 57 aged ≥65 years. Subjective improvement was reported in 70.9% (n = 61), 84.5% (n = 60), and 71.9% (n = 41) of patients aged ≤54, 55-64, and ≥65 years, respectively. Patients aged ≤54 years showed significantly worse UE scores (P = .02), whereas those aged 55-64 years demonstrated significant worsening in all 3 PROMIS domains (P < .01). Patients aged ≥65 years who reported subjective improvement after CTR demonstrated significant improvement in PI scores (P = .03), whereas significant worsening of all PROMIS scores was observed in the subset of patients aged 55-64 years who reported subjective improvement (P < .01, .04, and .04 for PF, PI, and UE, respectively).

CONCLUSIONS

Younger patients showed worsening in PROMIS scores after CTR, whereas elderly patients did not show similar magnitude reductions in PROMIS scores. Moreover, the subset of elderly patients endorsing subjective improvement after CTR had reduced PI scores, consistent with less postoperative pain limitations.

Patient-Reported Outcome Measurement and Minimal Clinically Important Difference for Hand Surgeons

Patient-reported outcome measurement (PROM) tools are used to evaluate health status and response to treatment and have been integral in the effort to improve the quality of care provided. Patient reported outcomes (PROs) have garnered additional attention since becoming a priority of the National Institutes of Health in the early part of this century, and their use in both clinical practice and research has subsequently increased. In the upper extremity, a variety of PRO instruments exist that can assist physicians in their ability to track and/or prognosticate outcomes, make comparisons between treatments as well as strengthen research methodologies, and help determine the value of care. A more complete interpretation of the clinical significance of patient-reported outcome measurements is informed by parameters such as minimal clinically important difference, substantial clinical benefit and patient acceptable symptom state.

Identification of Clinical and Demographic Predictors for Treatment Modality in Patients With Carpal Tunnel Syndrome

BACKGROUND

Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. There are multiple treatment modalities for CTS. This study examines both clinical and demographic predictors for initial treatment modality of CTS.

METHODS

Patients diagnosed with CTS between February 2015 and October 2020 with a hand clinic visit within 6 weeks before treatment were included in our study. Patients completed Patient-Reported Outcomes Measurement Information System Pain Interference, Physical Function, and Depression and had complete data on relevant predictor variables. Primary outcomes were treatment group: (1) injection only; (2) release only; and (3) injection followed by release. Bivariate analyses and multinomial logistic regression was used to identify statistically significant variables and independent predictors associated with the treatment groups, respectively.

RESULTS

A total of 1409 patients fit our inclusion criteria. Sex, age, body mass index (BMI), race, ethnicity, Pain Interference, and Depression were statistically significant predictors for treatment group in bivariate analysis (P < .05). In multivariable analysis, adults older than 65 years were less likely to receive either injection only or injection followed by release (odds ratio [OR]: 0.56 and OR: 0.52, respectively; P < .01). Overweight (BMI: ≥25) individuals were less likely to receive injection only (OR: 0.45; P < .01). Women were more likely to have either injection only or injection followed by released (OR: 1.50 and 1.55; P < .01). Similarly, black, Indigenous, or Persons of Color had an increased odds of injection only and injection followed by release (OR: 1.61 and OR: 1.69, respectively; P < .05).

CONCLUSIONS

Sex, age, BMI, race, and ethnicity were found to be independent predictors of treatment modality for CTS.

What are the Minimum Clinically Important Difference Values for the PROMIS and QuickDASH After Carpal Tunnel Release? A Prospective Cohort Study

BACKGROUND

To better define the clinical significance of patient-reported outcomes, the concept of a minimum clinically important difference (MCID) exists. The MCID is the minimum change that a patient will perceive as meaningful. Prior attempts to determine the MCID after carpal tunnel release are limited by methodologic concerns, including the lack of a true anchor-based MCID calculation.

QUESTIONS/PURPOSES

To address previous methodologic concerns in existing studies, as well as establish a clinically useful value for clinicians, we asked: What are the MCID values for the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE), PROMIS Pain Interference (PI), and the QuickDASH after carpal tunnel release?

METHODS

We conducted a prospective cohort study at an urban, Midwest, multihospital, academic health system. One hundred forty-seven adult patients undergoing unilateral carpal tunnel release between September 2020 and February 2022 were identified. PROMIS UE, PI, and QuickDASH scores were collected preoperatively and 3 months postoperatively. We also collected responses to an anchor-based question: "Since your treatment, how would you rate your overall function?" (much worse, worse, slightly worse, no change, slightly improved, improved, or much improved). Patients who did not respond to the 3-month postoperative surveys were excluded. A total of 122 patients were included in the final analysis (83% response proportion [122 of 147]). The mean age was 57 years (range 23 to 87 years), and 68% were women. The MCID was calculated using both anchor-based and distribution-based methods. Although anchor-based calculations are generally considered more clinically relevant because they consider patients' perceptions of improvement, an estimation of the minimum detectable change (which represents measurement error) relies on a distribution-based calculation. We determined a range of MCID values to propose a final MCID value for all three instruments. A negative MCID value for the PROMIS PI instrument represents a decrease in pain, whereas a positive value for the PROMIS UE instrument represents an improvement in function. A negative value for the QuickDASH instrument represents an increase in function.

RESULTS

The final proposed MCID values were 6.2 (interquartile range [IQR] 5.4 to 9.0) for the PROMIS UE, -7.8 (IQR -6.1 to -8.5) for the PROMIS PI, and -18.2 (IQR -13.3 to -34.1) for the QuickDASH.

CONCLUSION

We recommend that clinicians use the following values as the MCID after carpal tunnel release: 6 for the UE, -8 for the PI, and -18 for the QuickDASH. Surgeons may find these values useful when counseling patients postoperatively regarding improvement. Future studies could examine whether a single MCID (or small range) for PROMIS instruments is applicable to a variety of conditions and interventions.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Responsiveness and Minimal Important Change of the PROMIS Pain Interference Item Bank in Patients Presented in Musculoskeletal Practice

We evaluated the responsiveness of the Patient Reported Outcome Information System Pain Interference item bank in patients with musculoskeletal pain by testing predefined hypotheses about the relationship between the change scores on the item bank, change scores on legacy instruments and Global Ratings of Change (GRoC), and we estimated Minimal Important Change (MIC). Patients answered the full Dutch-Flemish V1.1 item bank. From the responses we derived scores for the standard 8-item short form (SF8a) and a CAT-score was simulated. Correlations between the change scores on the item bank, GRoC and legacy instruments were calculated, together with Effect Sizes, Standardized Response Means, and Area Under the Curve. GRoC were used as an anchor for estimating the MIC with (adjusted) predictive modeling. Of 1,677 patients answering baseline questionnaires 960 completed follow-up questionnaires at 3 months. The item bank correlated moderately high with the GRoC (Spearman's rho 0.63) and with the legacy instruments (Pearson's R ranging from .45 to .68). It showed a high ES (.97) and Standardized Response Means (.71), and could distinguish well between improved and not improved patients based on the GRoC (Area Under the Curve .77). Comparable results were found for the derived SF8a and CAT-scores. The MIC was estimated to be 3.2 (CI 2.6-3.7) T-score points. PERSPECTIVE: Our study supports the responsiveness of the PROMIS-PI item bank in patients with musculoskeletal complaints. Almost all predefined hypotheses were met (94%). The PROMIS-PI item bank correlated well with several legacy instruments which supports generic use of the item bank. MIC for PROMIS-PI was estimated to be 3.2 T-score points.

The Responsiveness of the Patient-Reported Outcomes Measurement Information System Upper Extremity and Physical Function in Patients With Cubital Tunnel Syndrome

PURPOSE

The Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) and PROMIS Physical Function (PF) are increasingly referenced patient-reported outcomes. To interpret treatment effects with these patient-reported outcomes, investigators must understand magnitudes of change that represent clinically relevant improvement. This study assessed the responsiveness of PROMIS UE and PF in patients with cubital tunnel syndrome.

METHODS

A retrospective analysis of PROMIS UE and PROMIS PF computer adaptive test scores was performed for patients treated nonoperatively for cubital tunnel syndrome over 3 years at a tertiary institution. The Patient-Reported Outcomes Measurement Information System UE and PROMIS PF outcome scores were collected at initial and return clinic visits. At follow-up appointments, patients completed clinical anchor questions evaluating their degree of interval clinical improvement. Anchor questions allowed categorization of patients into groups that had experienced "no change," "minimal change," and "much change." Minimal clinically important difference (MCID) values were calculated for the PROMIS assessments with anchor-based and distribution-based methods.

RESULTS

A total of 304 patients with PROMIS PF scores and 111 with PROMIS UE scores were analyzed. The MCID for the PROMIS UE was 3.1 (95% confidence interval, 1.4-4.8) using the anchor-based method and 3.7 (95% confidence interval, 2.9-4.4) using the distribution-based method. These point estimates exceeded the minimal detectable change of 2.3. The MCID for the PROMIS PF was unable to be determined in this patient sample because patients reporting mild change did not have score changes exceeding measurement error.

CONCLUSIONS

The PROMIS UE v2.0 computer adaptive test detected minimal change in patients managed nonoperatively for cubital tunnel syndrome with an estimated MCID range of 3.1-3.7. While PROMIS PF has demonstrated acceptable performance in patients with a variety of upper extremity conditions, for cubital tunnel syndrome, it was less able to detect subtle change. PROMIS UE appears more responsive to subtle changes in cubital tunnel syndrome symptoms.

CLINICAL RELEVANCE

Patient-reported outcomes may have varied responsiveness depending on the condition studied.

Minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) of upper extremity PROMIS scores in idiopathic adhesive capsulitis

INTRODUCTION

The purpose of this study is to calculate the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) of Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Computer Adaptive Testing v2.0 (UE), Pain Interference (P-Interference), and Pain Intensity (P-Intensity) in patients treated nonoperatively for idiopathic adhesive capsulitis (IAC).

METHODS

The anchor-based MCID, SCB, and PASS were calculated as the change in PROMIS scores representing the optimal cutoff for a ROC curve with an area under the curve (AUC) analysis. The distribution-based MCID was calculated as a range between the average standard error of measurement multiplied by two different constants: 1 and 2.77. Effect sizes and standardized response means (SRM) were calculated to assess the responsiveness of each PROMIS instrument while regression analyses were performed to identify factors associated with achieving these thresholds.

RESULTS

This study enrolled 115 patients. The anchor-based MCID for PROMIS UE, P-Interference, and P-Intensity was 5.11, 4.16, and 8.16, respectively. The respective SCB was 8.44, 6.65, and 10.05. The respective PASS was 8.47, 7.01, and 10.41. The odds of achieving MCID values in adhesive capsulitis were negatively affected by gender (male), higher forward elevation at the time of presentation, higher pain scores (P-Interference), need for ≥ 2 corticosteroid injections, and a concomitant diagnosis of diabetes.

CONCLUSION

The MCID, SCB, and PASS parameters for PROMIS scores can be utilized to determine the clinical meaningfulness of patient-reported improvements in these instruments during the nonoperative treatment and as a research tool to compare the efficacy of new treatments for adhesive capsulitis.

LEVEL OF EVIDENCE

Level III, basic science study, validation of outcome instruments. Key points • This is the first study to calculate the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) for the Patient-Reported Outcome Measurement Information System (PROMIS) Upper Extremity and Pain instruments in patients with idiopathic adhesive capsulitis (IAC) of the shoulder.• This study determined the impact of symptom severity, demographics, and comorbidities on achieving the MCID, SCB, and PASS for PROMIS instruments in IAC patients treated nonoperatively.

Minimal clinically important difference (MCID) and substantial clinical benefit (SCB) of upper extremity PROMIS scores following arthroscopic rotator cuff repairs

PURPOSE

To calculate and determine what factors are associated with achieving the Minimal Clinically Important Difference (MCID) and the Substantial Clinical Benefit (SCB) of Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Computer Adaptive Testing v2.0 (UE), Pain Interference (P-Interference), and Pain Intensity (P-Intensity) in patients undergoing arthroscopic rotator cuff repair (aRCR).

METHODS

The change in PROMIS scores representing the optimal cutoff for a ROC curve with an area under the curve analysis was used to calculate the anchor-based MCID and SCB. To assess the responsiveness of each PROM, effect sizes and standardized response means (SRM) were calculated. To identify factors associated with attaining the MCID and SCB, univariate and multivariate logistic regression analyses were performed.

RESULTS

A total of 323 patients with an average age of 59.9 ± 9.5 were enrolled in this study, of which, 187/323 [57.9%] were male and 136/323 [42.1%] were female. The anchor-based MCID for PROMIS UE, P-Interference, and P-Intensity was: 9.0, 7.5, and 11.2, respectively. The respective SCB was 10.9, 9.3, and 12.7. Effect size and SRM were: PROMIS UE (1.4, 1.3), P-Interference (1.8, 1.5), and P-Intensity (2.3, 2.0). Lower preoperative P-Intensity scores (p = 0.02), dominant arm involvement (p = 0.03), and concomitant biceps tenodesis (p = 0.03) were associated with patients achieving the SCB for PROMIS UE.

CONCLUSION

A large responsiveness for each of the PROMIS instruments due to the majority of patients reporting great improvement after aRCR and a small standard deviation across all outcome measures was shown in our study. Lower preoperative P-Intensity scores and concomitant biceps tenodesis were associated with higher odds of achieving the SCB for PROMIS UE. The knowledge of MCID and SCB values for PROMIS instruments will allow the surgeon to determine whether the improvements in the PROMIS scores after aRCR are clinically meaningful.

LEVEL OF EVIDENCE

Level III.

Evaluation of Clinical Recovery After Surgical Treatment for Hand Ischemia From Vasospastic and Occlusive Disease Using PROMIS

BACKGROUND

There is a paucity of literature describing the recovery trajectory after surgery for upper extremity ischemia. Using Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), Upper Extremity (UE), Pain Interference (PI), and Depression domains, we aimed to describe the postoperative recovery of such patients.

METHODS

We queried our PROMIS database for patients undergoing surgery for vasospastic or occlusive disease over a 4.5-year period. Inclusion criteria were preoperative, early (average 3 weeks) and late (average 6 months) postoperative PROMIS PF and/or UE, PI, and Depression scores. The change in PROMIS scores was calculated for each time point. Changes in PROMIS scores were compared with minimal clinically important difference estimates.

RESULTS

We identified 13 patients undergoing 13 surgical interventions that met inclusion criteria. More than one-half of our patients were men (n = 7 [54%]), and more than one-half of the surgeries (n = 7 [54%]) were for isolated occlusive diagnoses, with the remainder for vasospastic disease. At short-term postoperative follow-up, the change in PROMIS PF, UE, PI, and Depression scores was -6.34 (SD: 9.13), -6.81 (SD: 9.61), 3.16 (SD: 5.78), and -3.05 (SD: 8.37), respectively. At mid-term postoperative follow-up, the change in PROMIS PF, UE, PI, and Depression scores was 4.45 (SD: 10.33), 8.04 (SD: 13.84), -7.03 (SD: 7.06), and -12.27 (SD: 10.85), respectively.

CONCLUSIONS

Our findings suggest patients undergoing surgical treatment for upper extremity ischemia experience a worsening of functional symptoms initially, as expected, followed by notable improvement.

Value-based health care in Western countries: a scoping review on the implementation of patient-reported-outcomes sets for hospital-based interventions

INTRODUCTION

For implementation of the value-based health-care (VBHC) concept, use of patient-reported outcome measures (PROMs), patient-reported experience measures (PREMs), and clinical outcomes is crucial. The aim of this study was to summarize published studies on implemented PROMs, PREMs, and clinical-outcomes sets in health-care practice.

AREAS COVERED

A scoping review was conducted by using PubMed and Embase. Our study focused on implementation examples of patient-reported outcome sets in Western countries' hospitals. Included papers were analyzed on content, in particular concerning PROMs, PREMs, and clinical outcomes. We also assessed differences between diseases, categorized as patient-reported outcomes in curative, chronic, and palliative treatments in the hospital.

EXPERT OPINION

A total of 20 studies were found that presented VBHC implementation examples. Results illustrate the disconnection between the development of PROMs and PREMs and the implementation phase, with implementation still in infancy. Hospital organizations should enhance organization for the implementation of VBHC. It is crucial that leading examples of successful VBHC serve as blueprints for implementation, with the participation of all relevant stakeholders. Affordability and sustainability of health care can be enhanced by scaling up successful VBHC-interventions on population levels.

Factors Influencing Why Children and Their Families Choose Surgery for Ganglion Cysts

PURPOSE

Ganglion cysts of the hand/wrist are frequently managed without surgery but can be treated with surgical excision if there is pain or dysfunction. No studies have examined the specific factors predictive of surgical treatment for pediatric patients.

METHODS

This was a study of pediatric patients (≤18 years) with ganglion cysts of the hand/wrist seen between 2017 and 2019 at 2 institutions. Baseline demographic data were collected in addition to cyst characteristics, Wong-Baker pain scores, and Patient-Reported Outcomes Measurement Information System scores (pain, depression, upper extremity function, anxiety). Multivariable regression was used to determine the factors predictive of surgical intervention at ≥6 months of eligible follow-up.

RESULTS

A total of 167 patients with a mean age of 10.1 ± 5.3 years were included for analysis. Forty-three (25.7%) underwent surgical excision of their ganglion cyst at means of 2.3 months after the initial visit and 12.6 months after cyst appearance. Sex and cyst location were similar between cohorts. Surgical patients were older (12.1 vs 9.4 years, respectively) and presented to the clinic later after an appearance (10.9 vs 6.5 months, respectively) compared to nonsurgical patients. Surgical patients also had higher pain scores at presentation (median, 3 vs 0, respectively). Cysts receiving surgery were larger than those without surgery (81.4% vs 55.3% >1 cm, respectively). Pain interference Patient-Reported Outcomes Measurement Information System scores were higher in the surgical than the nonsurgical group (45.2 vs 39.6, respectively). In a multivariable analysis, pain scores ≥4 (odds ratio, 3.4) were predictive of surgery for patients ≥3 years, whereas older age (odds ratio, 1.1) and a cyst size >1 cm (odds ratio, 3.3) predicted surgery across all patients.

CONCLUSIONS

Pediatric patients with ganglion cysts who initially present at older ages with moderate/severe pain scores and larger cysts are more likely to ultimately choose surgical excision. Surgeons may observe a preference for earlier surgery in this subset of patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Preoperative Opioid Use Is Associated With Inferior Patient-Reported Outcomes Measurement Information System Scores Following Rotator Cuff Repair

PURPOSE

To determine the influence of preoperative opioid use on Patient-Reported Outcomes Measurement Information System (PROMIS) scores pre- and postoperatively in patients undergoing arthroscopic rotator cuff repair (RCR).

METHODS

A retrospective review of all RCR patients aged >18 years old was performed. PROMIS pain interference ("PROMIS PI"), upper extremity function ("PROMIS UE"), and depression ("PROMIS D") scores, were reviewed. These measures were collected at preoperative, 6-month, and 1-year postoperative time points. A prescription drug-monitoring program was queried to track opioid prescriptions. Patients were categorized as chronic users, acute users, and nonusers based on prescriptions filled. Comparison of means were carried out using analysis of variance and least squares means. Effect sizes and 95% confidence intervals were calculated.

RESULTS

In total, 184 patients who underwent RCR were included. Preoperatively, nonusers (n = 92) had superior PROMIS UE (30.6 vs 28.9 vs 26.1; P < .05) and PI scores (61.5 vs 64.9 vs 65.3; P < .001) compared with acute users (n = 65) and chronic users (n = 27), respectively. At 6 months postoperatively; nonusers demonstrated significantly greater PROMIS UE (41.7 vs 35.6 vs. 33.5; P < .001), lower PROMIS D (41.6 vs 45.8 vs 51.1; P < .001), and lower PROMIS PI scores (50.7 vs 56.3 vs 58.1; P < .01) when compared with acute and chronic users, respectively. Nonusers had lower PROMIS PI (47.9 vs 54.3 vs 57.4; P < .0001) and PROMIS D (41.6 vs 48.3 vs 49.2; P = .0002) scores compared with acute and chronic users at 1-year postoperatively. Nonusers experienced a significantly greater magnitude of improvement in PROMIS D 6 months postoperatively compared with chronic opioid users (-5.9 vs 0.0; P < .01).

CONCLUSIONS

Patients undergoing RCR demonstrated superior PROMIS scores pre- and postoperatively if they did not use opioids within 3 months before surgery.

LEVEL OF EVIDENCE

III, retrospective comparative trial.

Bringing Patient-Reported Outcome Measures (PROMs) Into Practice: A Review of the Latest Developments in PROM Use in the Evaluation and Treatment of Carpal Tunnel Syndrome

As health care systems globally shift toward optimizing value, defined as health outcomes achieved per dollar spent across a full cycle of care, there has been increasing focus on using patient-reported outcome measures (PROMs) to gauge success. Patient-reported outcome measures are validated questionnaires that allow patients to share their health status across several domains (eg, pain or physical function). This trend has been particularly notable in hand surgery, with PROM use investigated for many common hand conditions, including carpal tunnel syndrome, Dupuytren contracture, trigger finger, osteoarthritis, and wrist ganglion. The purpose of this article is to review recent developments in the use of PROM instruments, including the Boston Carpal Tunnel Questionnaire; Michigan Hand Outcomes Questionnaire; Disabilities of the Arm, Shoulder, and Hand; and Patient-Reported Outcomes Measurement Information System, for the evaluation and treatment of patients with carpal tunnel syndrome. The considerable progress in establishing PROMs for use in carpal tunnel syndrome is reviewed, and future improvements are proposed to standardize PROM use and bring PROMs into day-to-day clinical practice for individualized patient treatment decision-making and counseling.

Establishing the Minimal Clinically Important Difference and Substantial Clinical Benefit for the Pain Visual Analog Scale in a Postoperative Hand Surgery Population

PURPOSE

Although the pain visual analog scale (VAS-pain) is a ubiquitous patient-reported outcome instrument, it remains unclear how to interpret changes or differences in scores. Therefore, our purpose was to calculate the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) for the VAS-pain instrument in a nonshoulder hand and upper extremity postoperative population.

METHODS

Adult postoperative patients treated by 1 of 5 fellowship-trained orthopedic hand surgeons at a single tertiary academic medical center were identified. Inclusion required VAS-pain scores at baseline (up to 3 months before surgery) and follow-up (up to 4 months after surgery), in addition to a response to a pain-specific anchor question at follow-up. The MCID estimates were calculated with (1) the 1/2 standard deviation method; and (2) an anchor-based approach. The SCB estimates were calculated with (1) an anchor-based approach; and (2) a receiver operator curve method that maximized the sensitivity and specificity for detecting a "much improved" pain status.

RESULTS

There were 667 and 148 total patients included in the MCID and SCB analyses, respectively. The 1/2 standard deviation MCID estimate was 1.6, and the anchor-based estimate was 1.9. The anchor-based SCB estimate was 2.2. The receiver operator curve analysis yielded an SCB estimate of 2.6, with an area under the curve of 0.72, consistent with acceptable discrimination.

CONCLUSIONS

We propose MCID values in the range of 1.6 to 1.9 and SCB values in the range of 2.2 to 2.6 for the VAS-pain instrument in a nonshoulder hand and upper extremity postoperative population.

CLINICAL RELEVANCE

These MCID and SCB estimates may be useful for powering clinical studies and when interpreting VAS-pain score changes or differences reported in the hand surgery literature. These values are to be applied at a population level, and should not be applied to assess the improvement, or lack thereof, for individual patients.

Shared Decision-Making Tool for Opioid Prescribing After Ambulatory Orthopedic Surgery in Veterans: A Randomized Controlled Clinical Trial

Purpose

We examined whether an educational, shared-decision-making tool designed to empower patients, individualize pain management, and maximize use of nonopioid, over-the-counter analgesics reduces opioid use and waste while maintaining adequate pain relief.

Methods

We developed an educational, shared-decision-making tool regarding postoperative pain medication for outpatient hand surgery. Patients randomized to groups with and without the tool were surveyed for 4 weeks after surgery. Survey variables included Patient-Reported Outcomes Measurement Information System pain intensity and pain interference scores, as well as the number of oxycodone or over-the-counter pills taken. Results were compared using chi-squared, Wilcoxon rank-sum, and Welch’s t tests.

Results

Fifty-three patients participated: 25 in the shared-tool group and 28 in the no-tool group. The mean age was 60 years, with more women in the no-tool group than the shared-tool group (n =17 versus 11, respectively). The shared-tool group averaged 6.4 prescribed oxycodone pills, versus 10 for the no-tool group (P < .01). The median numbers of oxycodone pills taken the first week after surgery were 2 (interquartile range, 6) for the shared-tool group and 3 (interquartile range, 6) for the no-tool group (P = .97). Patient-reported outcome measures for pain intensity and pain interference were not significantly different for weeks 1, 3, and 4 after surgery. Pain interference was significantly lower in week 2 in the shared-tool group (difference, −4.4; 95% confidence interval, −8.57 to −0.30; P = .04).

Conclusions

The shared-tool group had equivalent or better pain control and were prescribed a lower number of opioid pain pills than the no-tool group. Both groups used nonopioid medications, with no difference in the types of over-the-counter medications used. Shared decision-making strategies could be applied to other outpatient orthopedic surgical settings, and may reduce the amount of opioids prescribed without compromising pain control.

Type of study/level of evidence

Therapeutic II.

Opioid versus opioid-free analgesia after surgical discharge: a systematic review and meta-analysis of randomised trials

BACKGROUND

Excessive opioid prescribing after surgery has contributed to the current opioid crisis; however, the value of prescribing opioids at surgical discharge remains uncertain. We aimed to estimate the extent to which opioid prescribing after discharge affects self-reported pain intensity and adverse events in comparison with an opioid-free analgesic regimen.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, Embase, the Cochrane Library, Scopus, AMED, Biosis, and CINAHL from Jan 1, 1990, until July 8, 2021. We included multidose randomised controlled trials comparing opioid versus opioid-free analgesia in patients aged 15 years or older, discharged after undergoing a surgical procedure according to the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity definition (minor, moderate, major, and major complex). We screened articles, extracted data, and assessed risk of bias (Cochrane's risk-of-bias tool for randomised trials) in duplicate. The primary outcomes of interest were self-reported pain intensity on day 1 after discharge (standardised to 0-10 cm visual analogue scale) and vomiting up to 30 days. Pain intensity at further timepoints, pain interference, other adverse events, risk of dissatisfaction, and health-care reutilisation were also assessed. We did random-effects meta-analyses and appraised evidence certainty using the Grading of Recommendations, Assessment, Development, and Evaluations scoring system. The review was registered with PROSPERO (ID CRD42020153050).

FINDINGS

47 trials (n=6607 patients) were included. 30 (64%) trials involved elective minor procedures (63% dental procedures) and 17 (36%) trials involved procedures of moderate extent (47% orthopaedic and 29% general surgery procedures). Compared with opioid-free analgesia, opioid prescribing did not reduce pain on the first day after discharge (weighted mean difference 0·01cm, 95% CI -0·26 to 0·27; moderate certainty) or at other postoperative timepoints (moderate-to-very-low certainty). Opioid prescribing was associated with increased risk of vomiting (relative risk 4·50, 95% CI 1·93 to 10·51; high certainty) and other adverse events, including nausea, constipation, dizziness, and drowsiness (high-to-moderate certainty). Opioids did not affect other outcomes.

INTERPRETATION

Findings from this meta-analysis support that opioid prescribing at surgical discharge does not reduce pain intensity but does increase adverse events. Evidence relied on trials focused on elective surgeries of minor and moderate extent, suggesting that clinicians can consider prescribing opioid-free analgesia in these surgical settings. Data were largely derived from low-quality trials, and none involved patients having major or major-complex procedures. Given these limitations, there is a great need to advance the quality and scope of research in this field.

FUNDING

The Canadian Institutes of Health Research.

Outcomes of Acute Repair Versus Nonrepair of Zone I Flexor Digitorum Profundus Tendon Injuries

PURPOSE

The aim of this study was to determine whether the clinical results of zone I flexor digitorum profundus (FDP) tendon injuries managed with acute surgical repair are comparable to the clinical results of those managed without repair (eg, primary FDP excision or observation).

METHODS

Patients aged ≥18 years presenting to a level 1 trauma center between 2015 and 2020 with zone I FDP tendon injury were identified with retrospective chart review. We assessed the following data: age, sex, physical therapy visits, surgical intervention, surgical complications (including infection, repeat surgery after the primary intervention, and rupture of repair), and patient-reported outcomes measurement information system scores.

RESULTS

Twenty-six patients met the inclusion criteria. Group 1 (N = 15 patients, 23 fingers) patients were treated with acute surgical repair. Group 2 (N = 11 patients, 11 fingers) patients were managed without surgical repair, including FDP excision (N = 7) or observation alone (N = 4). In group 1, the average distance from the distal palmar crease to fingertip at the final follow-up was 1.6 cm (range, 0-4 cm). Fourteen of the 15 patients participated in >3 therapy visits. The following complications occurred: 4 fingers with rerupture (2 patients), 4 fingers with surgical wound dehiscence (2 patients), 3 infections (2 patients), and 4 repeat surgeries for these complications. In group 2, the average distance from the distal palmar crease to fingertip at the final follow-up was 1.1 cm (range, 0.5-3 cm). There were no infections, episodes of wound dehiscence, or repeat surgeries. At the final follow-up, both groups showed clinically meaningful improvement on Patient Reported Outcomes Measurement Information System (PROMIS) upper extremity, pain interference, and physical function scores, with similar PROMIS domain scores between groups.

CONCLUSIONS

Patients treated without FDP tendon repair had similar outcomes to, and fewer complications than, patients treated with acute tendon repair. Our data suggest that the notable commitment of health care costs, time, and adherence to protocols/restrictions after surgical repair may not confer functional benefit.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Evaluating the Impact of Patient Social Deprivation on the Level of Symptom Severity at Carpal Tunnel Syndrome Presentation

Background: There is a paucity of research examining the impact of social deprivation on the level of symptom severity at presentation, including in common hand conditions like carpal tunnel syndrome. We aimed to determine whether patient deprivation is associated with worse Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE), Physical Function (PF), Pain Interference (PI), and Depression scores. Methods: Patients presenting to an academic hand clinic from December 2016 to December 2018 for a new patient visit for carpal tunnel syndrome completed PROMIS UE, PF, PI, and Depression Computer Adaptive Tests. Bivariate analyses were done to compare patient variables between the least and most deprived thirds, as measured by Area Deprivation Index (ADI), at the state (New York) and national levels. Multivariable linear regression was used to determine whether there was an association between social deprivation and PROMIS UE, PF, PI, and Depression scores. Results: All PROMIS domain scores were significantly worse in the most deprived cohort at the national level (P < .05) but not at the state level (P > .05). In multivariable regression at the national level, ADI values were associated with PROMIS UE (β = -0.06, P < .01) and PROMIS PI (β = .05, P < .01) but not PROMIS PF or PROMIS Depression. In multivariable regression at the state level, ADI values were associated with PROMIS UE (β = -0.79, P = .03) and PROMIS PI (β = 0.58, P < .05) but not PROMIS PF or PROMIS Depression. Conclusions: Higher levels of social deprivation are associated with worse PROMIS UE and PROMIS PI scores on both the state and national levels when initially seeking care for carpal tunnel syndrome.

Are Patient Reported Outcome Measurement Information System scales responsive in patients attending physical therapy with foot and ankle diagnoses?

BACKGROUND

Patient-reported outcomes (PROs) have been used to provide insight into the patient experience while uncovering an opportunity to improve patient care. Current studies document responsiveness of outcomes using the Patient Reported Outcome Measurement Information System (PROMIS) for a variety of orthopedic problems but are not specific to a physical therapy interval of care.

PURPOSE

The main purpose of this study was to examine responsiveness of the PROMIS Physical Function (PF) and Pain Interference (PI) scales across an interval of care for physical therapy in patients with foot and ankle conditions.

METHODS

Adult records (299 records, averaged 45.1 ± 15.4 years; 61% female) were assessed. Comparisons between pre- and post-physical therapy intervals of care were evaluated using a repeated-measures ANOVA, and the effect size was reported using Cohen's d.

RESULTS

PROMIS PF scores significantly improved from 38.5 ± 8.8 to 45.2 ± 9.1 (6.6; p < .001; Cohen's d = 1.0). PROMIS PI scores significantly improved from 56.8 ± 8.8 to 53.0 ± 9.8 (-3.8; p < .001; Cohen's d = 0.52).

CONCLUSIONS

The person-centered PROMIS PF and PI outcome measures were responsive to change following an interval of care in physical therapy for a large sample of orthopedic patients with foot and ankle diagnoses. The magnitude of change was dependent on starting score and diagnosis.

Minimal Clinically Important Difference for PROMIS Physical Function and Pain Interference in Patients Following Surgical Treatment of Distal Radius Fracture

PURPOSE

We estimated the minimal clinically important difference (MCID) for the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) computer adaptive tests (CATs) following surgical treatment of distal radius fracture (DRF).

METHODS

Adult patients surgically treated between November 2017 and November 2020 for isolated DRF were identified. Demographic and patient-reported outcome data were extracted from the electronic health record. Outcomes of interest were the PROMIS PF and PI CATs. Inclusion criteria were met if: (1) PROMIS PF and PI scores were available at preoperative and postoperative visits; and (2) a postoperative clinical anchor question asking about overall response to treatment was answered. An anchor-based MCID estimate was determined by calculating the average absolute score change in PROMIS PF and PI for patients who indicated a mild change to the anchor question. A distribution-based MCID estimate was also calculated using the standard error of measurement and effect sizes of change.

RESULTS

The changes in PROMIS PF and PI scores were significantly different between patients who gave responses of much change (n = 73), mild change (n = 51), and no change (n = 19) to the clinical anchor question. The average score changes in the mild change group for PROMIS PF and PI were 5.2 (SD, 3.7) and 6.8 (SD, 4.3) points, respectively, representing the anchor-based MCID estimates. The PROMIS PI anchor-based estimate was moderately correlated with the preoperative score (r = -0.41), time between visits (r = -0.39), and age (r = 0.30). The distribution-based MCID estimates were 3.8 (SD, 1.3) and 3.7 (SD, 1.3) points for the PROMIS PF and PI, respectively.

CONCLUSIONS

The MCIDs were estimated as 5.2 and 6.8 for the PROMIS PF and PI CATs, respectively, following surgery for DRF.

CLINICAL RELEVANCE

As reports continue to publish a consistent range of MCID values, researchers can be confident in these values and begin using them across a broader spectrum of conditions treated by hand surgeons.

Trends in Patient-Reported Outcomes Measurement Information System Scores Exist Between Day of Surgical Scheduling and Day of Surgery

PURPOSE

To examine trends in Patient-Reported Outcome Measurement Information System (PROMIS) scores among orthopedic sports medicine patients undergoing surgery who completed PROMIS forms both in the ambulatory (preoperative) setting at the time of surgical scheduling, as well as on the day of surgery (perioperative) prior to their procedure.

METHODS

Consecutive patients undergoing various sports medicine-related surgeries were recruited. Patients were included if they were scheduled for surgery and completed preoperative PROMIS on the day of surgical scheduling and on the day of surgery. Patients were excluded if they refused the questionnaire or had been administered perioperative anesthesia, which would interfere with questionnaire completion. Paired samples t-tests were run between preoperative and perioperative PROMIS scores to determine statistical significance.

RESULTS

153 patients were included with an average age of 46.5 years. The average (SD) time between completion of PROMIS questionnaires was 46.5 (44.4) days. The absolute value change in scores between preoperative and perioperative visits was 4.09 for PROMIS UE, 3.59 for PROMIS PF, 3.67 for PROMIS PI, and 4.13 for PROMIS D. The overall net change of scores between preoperative and perioperative visits were -.57 for PROMIS UE CAT, .16 points for PROMIS PF CAT, -.85 points for PROMIS PI CAT, and -2.14 points for PROMIS D CAT. Statistically significant differences in preoperative and perioperative PROMIS PI (P =.042) and PROMIS D (P =.004) scores were found.

CONCLUSIONS

Health states-as measured by PROMIS CAT forms completed among patients undergoing orthopedic surgery-can either improve or worsen preoperatively between the time of administration in both the ambulatory and perioperative setting. Despite the existence of these preoperative trends, it is important to consider patient and surgery-specific causes, such as the anatomic region, type of surgical intervention, and timing of preoperative PROMIS administration.

LEVEL OF EVIDENCE

III, prognostic.

Editorial Commentary: Preoperative Patient-Reported Outcomes Measurement Information System Scores Vary Over Time

Patient-Reported Outcomes Measurement Information System (PROMIS) scores have considerable potential to both streamline the collection of outcome data and provide a common set of metrics to compare and benchmark patient-reported outcomes after orthopaedic procedures. An analysis of PROMIS scores collected at the preoperative clinical visit and the day of surgery found considerable changes in upper- and lower-extremity physical function, pain interference, and depression. These findings suggest that health status may vary between the day of operative consent and the day of surgery. Given the importance of patient-reported outcomes in clinical research, quality assurance, and value-based health care, the potential for large changes in scores leading up to the procedure warrants attention toward the timing of PROMIS administration to ensure that the health status of the patient-and its variation-is accurately captured.

Clinical Presentation and Characteristics of Hand and Wrist Ganglion Cysts in Children

PURPOSE

Ganglion cysts are the most common mass of the hand or wrist. In adults, ganglions have a female predilection and are commonly located in the dorsal wrist. However, their presentation in children has not been well reported. This investigation sought to describe the presentation of pediatric ganglion cysts in a prospective cohort.

METHODS

A multicenter prospective investigation of children (aged ≤18 years) who presented with ganglion cysts of the hand or wrist was conducted between 2017 and 2019. The data collected included age, sex, cyst location, hand dominance, pain, and patient-reported outcomes measurement information system (PROMIS) scores for upper-extremity (UE) function. The patients were divided into cohorts based on age, cyst location, and cyst size. Multivariable analyses were performed to identify factors predictive of worse UE function and higher pain scores.

RESULTS

A total of 173 patients with a mean age of 10.1 ± 5.3 years and female-to-male ratio of 1.4:1 were enrolled. The dorsal wrist was the most commonly affected (49.7%), followed by the volar wrist (26.6%) and flexor tendon sheath (18.5%). In older patients, dorsal wrist ganglions were more common than tendon sheath cysts (11.9 ± 4.1 years vs 6.2 ± 5.8 years) and were larger (86.7% were >1 cm) than cysts in other locations (34.5% were >1 cm). Patients aged >10 years reported higher pain scores, with 21.5% of older patients reporting moderate/severe pain scores versus 5.0% of younger children. This cohort of patients had an average PROMIS UE function score of 47.4 ± 9.5, and lower PROMIS scores were associated with higher pain scores.

CONCLUSIONS

Ganglions in pediatric populations, which most commonly affect the dorsal wrist, demonstrate a female predilection. In younger children, cysts are smaller and more often involve the volar wrist or flexor tendon sheath. Older children report higher pain scores. Pediatric ganglion cysts do not appear to result in a clinically meaningful decrease in UE function.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

The minimal clinically important difference of the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function and upper extremity computer adaptive tests and QuickDASH in the setting of elbow trauma

Background

Minimal clinically important difference (MCID) estimates are useful for gauging clinical relevance when interpreting changes or differences in patient-reported outcomes scores. These values are lacking in the setting of elbow trauma. Our primary purpose was to estimate the MCID of the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) computer adaptive test (CAT), the PROMIS upper extremity (UE) CAT, and the QuickDASH using an anchor-based approach for patients recovering from elbow trauma and related surgeries. Secondarily, we aimed to estimate the MCID using the 1/2 standard deviation method.

Materials & methods

Adult patients undergoing treatment for isolated elbow injuries between July 2014 and April 2020 were identified at a single tertiary academic medical center. Outcomes, including the PROMIS PF CAT v1.2/2.0, PROMIS UE CAT v1.2, and QuickDASH, were collected via a tablet computer. For inclusion, baseline (6 months before injury up to 11 days postoperatively or after injury) and follow-up (11 to 150 days postoperative or after injury) PF or UE CAT scores were required, as well as a response to an anchor question querying improvement in physical function. The MCID was calculated using (1) an anchor-based approach using the difference in mean score change between anchor groups reporting “No change” and “Slightly Improved/Improved” and (2) the 1/2 standard deviation method.

Results

Of the 146 included patients, the mean age was 46 ± 18 years and 67 (46%) were women. Most patients (129 of 146 or 88%) were recovering from surgery, and the remaining 12% were recovering from nonoperatively managed fractures and/or dislocations. The mean follow-up was 157 ± 192 days. Scores for each instrument improved significantly between baseline and follow-up. Anchor-based MCID values were calculated as follows: 5.7, 4.6, and 5.3 for the PROMIS PF CAT, PROMIS UE CAT, and QuickDASH, respectively. MCID values estimated using the 1/2 standard deviation method were 4.3, 4.8, and 11.7 for the PROMIS PF CAT, PROMIS UE CAT, and QuickDASH, respectively.

Conclusions

In the setting of elbow trauma, we propose MCID ranges of 4.3 to 5.7 for the PROMIS PF CAT, 4.6 to 4.8 for the PROMIS UE CAT, and 5.3 to 11.7 for the QuickDASH. These values will provide a framework for clinical relevance when interpreting clinical outcomes studies, or powering clinical trials, for populations recovering from trauma.

Establishing clinically significant outcomes of the Patient-Reported Outcomes Measurement Information System Upper Extremity questionnaire after primary reverse total shoulder arthroplasty

BACKGROUND AND HYPOTHESIS

Since its introduction, the Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE) assessment has been increasingly used in shoulder arthroplasty outcome measurement. However, determination of clinically significant outcomes using the PROMIS UE has yet to be investigated following reverse total shoulder arthroplasty (RTSA). We hypothesized that we could establish clinically significant outcomes of the PROMIS UE outcome assessment in patients undergoing primary RTSA and identify significant baseline patient factors associated with achievement of these measures.

METHODS

Consecutive patients undergoing primary RTSA between 2018 and 2019 who received preoperative baseline and follow-up PROMIS UE assessments at 12 months after surgery were retrospectively reviewed. Domain-specific anchor questions pertaining to pain and function assessed at 12 months after surgery were used to determine minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) values for the PROMIS UE using receiver operating characteristic curve and area-under-the-curve (AUC) analysis. Univariate logistic regression analysis was then performed to identify significant patient factors associated with achieving the MCID, SCB, or PASS.

RESULTS

A total of 95 patients met all inclusion criteria and were included in the analysis. By use of an anchor-based method, the PASS value was 36.68 (sensitivity, 0.795; specificity, 0.765; AUC, 0.793) and the SCB value was 11.62 (sensitivity, 0.597; specificity, 1.00; AUC, 0.806). By use of a distribution-based method, the MCID value was calculated to be 4.27. Higher preoperative PROMIS UE scores were a positive predictor in achievement of the PASS (odds ratio [OR], 1.107; P = .05), whereas lower preoperative PROMIS UE scores were associated with obtaining SCB (OR, 0.787; P < .001). Greater baseline forward flexion was negatively associated with achievement of the PASS (OR, 0.986; P = .033) and MCID (OR, 0.976, P = .013). Of the patients, 83.2%, 69.5%, and 47.4% achieved the MCID, PASS, and SCB, respectively.

CONCLUSION

This study defines the MCID, SCB, and PASS for the PROMIS UE outcome assessment in patients undergoing primary RTSA, of whom the majority achieved meaningful outcome improvement at 12 months after surgery. These values may be used in assessing the outcomes and extent of functional improvement following RTSA.

Early Outcomes of Endoscopic Versus Open Carpal Tunnel Release

PURPOSE

To compare the short-term outcomes of endoscopic carpal tunnel release (ECTR) and open carpal tunnel release (OCTR), including patient-reported outcomes, pain and satisfaction scores, return to work, and postoperative prescription pain medication use.

METHODS

We included all patients over 18 years of age undergoing carpal tunnel release at a single hand center between January 2018 and December 2019. The carpal tunnel release method was driven by variations in surgeon practice. Data from patient-reported outcomes measurement information system (PROMIS) questionnaires and brief Michigan hand outcomes questionnaires and data on patient-reported pain levels, satisfaction with care, return to work, and postoperative prescription pain medication use were collected at preoperative visits and the first follow-up visit between postoperative days 7 and 14.

RESULTS

We included 678 (586 ECTR and 92 OCTR) patients. The median age was 58 years, and 75% of the patients were women. At early follow up, patients who underwent OCTR reported significantly lower postoperative PROMIS upper-extremity scores than those who underwent ECTR (median, 32 vs 36 points, respectively) but similar postoperative PROMIS pain interference, global physical health, global mental health, and brief Michigan hand outcomes questionnaire scores. The postoperative pain and satisfaction scores were similar between the 2 groups. In multivariable models, patients who underwent OCTR had 62% lower odds of returning to work and 30% greater odds of remaining on a postoperative pain prescription at the first follow-up visit.

CONCLUSIONS

This study found no evidence suggesting the definitive superiority of 1 surgical technique with regard to clinical outcomes in the early postoperative period. However, OCTR was associated with lower postoperative PROMIS upper-extremity scores of unclear clinical significance, higher odds of remaining on pain medication, and lower odds of returning to work by the first postoperative visit. Endoscopic carpal tunnel release may be preferred in patients who need to return to work within the first 2 weeks after the procedure.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state of PROMIS upper extremity after total shoulder arthroplasty

Background

The Patient-Reported Outcomes Measurement Information System minimal clinically important difference (PROMIS MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) of patient-reported outcome measures provide clinical significance to patient-reported outcome measures scores. The goal of this study is to measure the MCID, SCB, and PASS of PROMIS Upper Extremity v2.0 (PROMIS UE) in patients undergoing total shoulder arthroplasty (TSA).

Methods

All patients who underwent TSA since October 2017 were identified from our institutional database. Patients who had completed the PROMIS UE outcome measure before surgery were asked to complete a PROMIS UE and anchor survey that contained two transition questions to assess patient satisfaction and change in symptoms since treatment. The anchor-based MCID, SCB, and PASS were calculated as the change in PROMIS UE score that represented the optimal cutoff for a receiver operating characteristic curve. The distribution-based MCID was calculated as a range between the average standard error of measurement multiplied by 2 different constants: 1 and 2.77.

Results

This study enrolled 165 patients. The anchor-based MCID for PROMIS UE was calculated to be 8.05 with an AUC of 0.814. The anchor-based SCB was calculated to be 10.0 with an AUC of 0.727. The distribution-based MCID was calculated to be between 3.12 and 8.65. The PASS was calculated to be 37.2 with an AUC of 0.90.

Conclusions

The establishment of MCID, SCB, and PASS for PROMIS UE scores after shoulder arthroplasty provides meaningful and objective clinical interpretation of the improvements in outcome scores after TSA.

Press Ganey Surveys in Patients Undergoing Upper-Extremity Surgical Procedures: Response Rate and Evidence of Nonresponse Bias

BACKGROUND

Patient satisfaction surveys are important measures of the patient experience that provide data for quality improvement. The purpose of this study was to establish the response rate and the factors associated with the completion of the Press Ganey (PG) Ambulatory Surgery Survey (PGAS) in patients who underwent ambulatory upper-extremity surgical procedures.

METHODS

A prospective orthopaedic registry at a single academic ambulatory surgical center was retrospectively reviewed for patients who underwent an upper-extremity surgical procedure from 2015 to 2019. The institutional PG database was queried to determine the patients who completed the PGAS postoperatively. The response rate was calculated, and baseline characteristics and patient-reported outcome measures were compared between responders and nonresponders.

RESULTS

Of the 1,489 patients included, 201 (13.5%) were responders and 1,288 (86.5%) were nonresponders. Differences existed in baseline characteristics between groups, with responders being significantly older (p = 0.004) and having significantly higher proportions of White race (p < 0.001), college education (p = 0.011), employment (p = 0.005), marriage (p = 0.006), and higher income earners (p < 0.001). Responders had significantly better baseline Patient-Reported Outcomes Measurement Information System scores across multiple domains (p < 0.05), but these differences were not clinically meaningful.

CONCLUSIONS

PGAS response rates were low (13.5%), and differences between responders and nonresponders may be utilized by hospitals to target feedback from underrepresented patient populations. Surgeons, policymakers, and health-care administrators should use caution with the interpretation of PGAS results because responders may not be representative of all patients.

Establishing Age-calibrated Normative PROMIS Scores for Hand and Upper Extremity Clinic

The purpose of our study is to investigate differences in normative PROMIS upper extremity function (PROMIS-UE), physical function (PROMIS-PF), and pain interference (PROMIS-PI) scores across age cohorts in individuals without upper extremity disability.

Correlation of Patient-Reported Outcomes Measurement Information System Questionnaires With the Brief Michigan Hand Questionnaire in Patients With 5 Common Hand Conditions

PURPOSE

We evaluated the concurrent validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) Global Mental Health (GMH), Global Physical Health (GPH), Upper Extremity (UE), Pain Interference (PI), and Self-Efficacy for Managing Medications and Treatment (SE-MMT) by analyzing correlation to the brief Michigan Hand Questionnaire (bMHQ) in patients with 5 common hand conditions: carpal tunnel syndrome, Dupuytren contracture, trigger finger, thumb carpometacarpal osteoarthritis, and wrist ganglion cysts.

METHODS

Our cohort included 11,782 unique visits representing 4,401 patients. Patient demographics, PROMIS Computer Adaptive Test questionnaires, and bMHQ were collected prospectively at all visits for all patients. Spearman rank correlation was used to evaluate the relationship between the PROMIS and bMHQ scores. Multivariable linear regression models were used to evaluate the relationship between questionnaires and patient demographics.

RESULTS

The PROMIS UE and PI showed strong correlations to the bMHQ. The PROMIS GPH showed moderate correlation to the bMHQ. The PROMIS GMH and SE-MMT were weakly correlated with the bMHQ. These results for the overall group were consistent across subgroup analysis for each condition, and regression models confirmed these correlation findings when controlling for demographic variables. The bMHQ had the smallest ceiling and floor effects compared with the PROMIS questionnaires. The PROMIS UE, PI, and SE-MMT took significantly less time to complete than the bMHQ.

CONCLUSION

Correlations between the PROMIS questionnaires and the bMHQ were similar regardless of condition.

CLINICAL RELEVANCE

Given their moderate-to-strong correlations with the bMHQ and consistency across conditions, the PROMIS UE and PI may be adequate replacements for the bMHQ for evaluating these domains in both clinical and research applications in patients with these common upper extremity pathologies. The PROMIS GPH, GMH, and SE-MMT, in conjunction with the bMHQ, may provide more information regarding patient's physical and mental health and ability to manage medications and treatment without substantially increasing patient burden. Clinicians and researchers can use these findings to guide questionnaire selection based on the clinical or research question(s) of interest.

Minimal Clinically Important Difference of the PROMIS Upper-Extremity Computer Adaptive Test and QuickDASH for Ligament Reconstruction Tendon Interposition Patients

PURPOSE

To calculate the minimal clinically important difference (MCID) of the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Computer Adaptive Test (UE CAT) and Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) for ligament reconstruction tendon interposition (LRTI) patients.

METHODS

Adult patients treated with LRTI for trapeziometacarpal OA by fellowship-trained hand surgeons between December 2014 and February 2018 at an academic tertiary institution were included. Outcomes were prospectively collected at each visit by tablet computer, including the QuickDASH, PROMIS UE, Pain Interference, Depression, and Anxiety CATs. Inclusion required a response to the anchor question "How much relief and/or improvement do you feel you have experienced as a result of your treatment?" on a 6-option Likert scale, as well as preoperative (≤120 days before surgery) and follow-up (2-26 weeks) outcomes. We calculated MCID both by an anchor-based approach using the mean score of the minimal change group, and with the 0.5 SD method.

RESULTS

Of 145 included participants, mean age was 63 ± 8 years and 74% were female. Anchor-based MCID estimates for the total cohort were 4.2 for the PROMIS UE CAT and 8.8 for the QuickDASH. The MCID estimates using the 0.5 SD method were 4.8 and 11.7, respectively.

CONCLUSIONS

We propose MCID values of 4.2 to 4.8 for the PROMIS UE CAT and 8.8 to 11.7 for the QuickDASH when powering clinical studies or when assessing improvement among a cohort of patients who have undergone LRTI surgery.

CLINICAL RELEVANCE

Minimal clinically important difference estimates are helpful when interpreting clinical outcomes after LRTI and for powering prospective trials.

Evaluation of PROMIS' Ability to Detect Immediate Postoperative Symptom Improvement Following Carpal Tunnel Release

PURPOSE

We sought to determine whether subjective clinical improvement immediately after carpal tunnel release (CTR) was captured by Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE), Physical Function (PF), Pain Interference (PI), and Depression.

METHODS

Between September 2018 and January 2020, patients presenting to a single academic medical center hand clinic were asked to complete PROMIS UE, PF, PI, and Depression computer adaptive tests. In addition, patients who had CTR were asked to answer the following at their first postoperative clinic visit: "Since my last clinic visit, my condition is: (1) much better; (2) mildly better; (3) no change; (4) mildly worse; (5) much worse." For each patient, the last clinic visit was the final preoperative visit. The PROMIS domain scores were compared before and after surgery using paired t tests. The percentage of patients subjectively reporting better symptoms was calculated.

RESULTS

A total of 156 patients fit our inclusion criteria. The average number of days between the final preoperative visit and CTR was 7 (range, 0-30), and the average number of days between CTR and the first postoperative visit was 9 (range, 3-21). A total of 116 patients (74%) reported their carpal tunnel syndrome was better at their first postoperative visit. However, PROMIS UE, PF, and PI scores were significantly worse at the first postoperative visit, although not at clinically appreciable levels. There was no statistical or clinical difference in PROMIS Depression scores from pre- to postoperative time points.

CONCLUSIONS

Nearly 75% of patients subjectively report their carpal tunnel syndrome is better at their first follow-up visit within 3 weeks of CTR; however, PROMIS does not capture this improvement.

CLINICAL RELEVANCE

Hand surgeons evaluating patients shortly following CTR should be aware of the potential limitation of PROMIS to accurately capture immediate postoperative clinical outcomes. Disease-specific Patient-Reported Outcome Measures, such as the Boston Carpal Tunnel Questionnaire, may be preferred during this immediate postoperative timeframe.

Long-Term Outcomes of Operatively Treated Medial Epicondyle Fractures in Pediatric and Adolescent Patients

Purpose

Medial epicondyle fractures are among the most common pediatric elbow injuries. The management of these fractures continues to be debated. To better understand patient results with operative fixation, we reviewed the outcomes of operatively treated medial epicondyle fractures.

Methods

A retrospective review was performed to identify all patients less than 18 years of age at the time of injury who were treated surgically for medial epicondyle fractures. Outcomes were assessed based on the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity and Pain Interference domains, Visual Analog Scale for pain, subjective range of motion, ulnar nerve function, and requirement for secondary surgery.

Results

We identified a cohort of 95 patients treated for a medial epicondyle fracture with open reduction and screw fixation. Of these, 39 patients with a mean age of 12.2 years (SD, 2.2 years; range, 7.6–16.0 years) at surgery were assessed for an average follow-up of 6.3 years (SD, 3.2 years; range, 2.2–13.9 years). Outcome measures and pain scores were excellent. The mean PROMIS Upper Extremity score was 56.9, the mean Pain Interference score was 38.5, and the mean Visual Analog Scale score was 0.4.Sixteen patients (41%) required secondary surgery for symptomatic hardware removal. Seven patients (18%) developed sensory complaints and 2 (5%) developed motor complaints consistent with ulnar nerve irritability. Three patients (8%) reported dissatisfaction with elbow range of motion. Patients who required secondary surgeries had higher (worse) PROMIS Pain Interference scores.

Conclusions

At an average of 6.3 years after surgery, the clinical outcomes for medial epicondyle fracture were excellent. While operative treatment for medial epicondyle fractures in children leads to excellent clinical outcomes, patients and surgeons should be aware of high rates of hardware removal.

Type of study/level of evidence

Therapeutic IV

Long-Term Outcomes after Surgical Treatment of Radial Sensory Nerve Neuromas: Patient-Reported Outcomes and Rate of Secondary Surgery

BACKGROUND

This study aimed to (1) describe long-term patient-reported outcomes of surgically treated symptomatic radial sensory nerve neuromas on function, pain interference, pain intensity, and satisfaction; (2) assess which factors were associated with worse function, higher pain intensity, and more pain interference; and (3) describe the secondary surgery rate and factors associated with secondary surgery.

METHODS

The authors conducted a retrospective review of patients surgically treated for radial sensory nerve neuroma from 2002 to 2016 (n = 54). Twenty-five of these 54 patients completed a follow-up survey including the Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity, pain interference, and depression scales; numerical rating scale pain and satisfaction instruments; and the global rating scale of change, at a mean period of 10.7 ± 4.3 years after neuroma surgery.

RESULTS

The mean PROMIS scores were 45.0 ± 12.1 for upper extremity, 55.5 ± 10.3 for pain interference, and 49.9 ± 10.2 for depression, and were within 1 SD of the general population. Eight patients (32 percent) reported symptoms as unchanged or worse following neuroma surgery. The median numerical rating scale pain was 3 (interquartile range, 1 to 6) and the global rating scale of change satisfaction was 10 (interquartile range, 7 to 10). Older patients (p = 0.002) and patients with higher PROMIS pain interference (p < 0.001), higher numerical rating scale for pain (p = 0.012), and lower global rating scale of change scores (p = 0.01) had worse PROMIS upper extremity scores. The secondary surgery rate was 20 percent and was associated with the presence of multiple neuromas (p = 0.001).

CONCLUSIONS

Radial sensory nerve neuromas remain difficult to treat. They have a high secondary surgery rate (20 percent), with only 68 percent of patients reporting improvement after surgical intervention. Patient-reported outcomes after surgery are similar to conditions of the general population; however, the range of outcomes is wide.

Reliability of Telephone Acquisition of the PROMIS Upper Extremity Computer Adaptive Test

PURPOSE

Our primary purpose was to evaluate the reliability of telephone administration of the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) Computer Adaptive Test (CAT) version 2.0 in a hand and upper extremity population, and secondarily to make comparisons with the abbreviated version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH).

METHODS

Patients more than 1 year out from hand surgeries performed at a single tertiary institution were enrolled. Half of the patients completed telephone PROMIS UE CAT and QuickDASH surveys first, followed by computer-based surveys 1 to 10 days later, and the other half completed them in the reverse order. Telephone surveys were readministered 2 to 6 weeks later to evaluate test-retest reliability. Concordance correlation coefficients (CCCs) were used to assess agreement between telephone and computer-based scores, and intraclass correlation coefficients (ICCs) were used to assess test-retest reliability. The proportion of patients with discrepancies in follow-up scores that exceeded estimates of the minimal clinically important difference (MCID) was evaluated.

RESULTS

For the 89 enrolled patients, the PROMIS UE CAT CCC was 0.82 (83% confidence interval [83% CI], 0.77-0.86; good), which was significantly lower than 0.92 (83% CI, 0.89-0.94; good to excellent) for the QuickDASH. The PROMIS UE CAT ICC did not differ significantly from the QuickDASH (0.85 and 0.91, respectively). Differences in telephone versus computer scores exceeded 5 points (MCID estimate) for the PROMIS UE CAT in 34% of patients versus 5% of patients exceeding 14 points (MCID estimate) for the QuickDASH.

CONCLUSIONS

Significantly better reliability was observed for the QuickDASH than the PROMIS UE CAT when comparing telephone with computer-based score acquisition. Over one-third of patients demonstrated a clinically relevant difference in scores between the telephone and the computer-administered tests. We conclude that the PROMIS UE CAT should only be administered through computer-based methods.

CLINICAL RELEVANCE

These findings suggest that differences in collection methods for the PROMIS UE CAT may systematically affect the scores obtained, which may erroneously influence the interpretation of postoperative scores for hand surgery patients.

Impact of Insurance Type on Self-Reported Symptom Severity at the Preoperative Visit for Carpal Tunnel Release

PURPOSE

Prior studies evaluated the impact of insurance type on access to hand care. However, there is limited literature quantifying whether patient symptoms are worse at the time of intervention. Our primary null hypothesis was that insurance type would not be associated with Patient-Reported Outcomes Measure Information System (PROMIS) Upper-Extremity (UE), Physical Function (PF), Pain Interference (PI), and Depression scores at the preoperative visit before carpal tunnel release (CTR).

METHODS

Between December 2016 and November 2018, patients with known carpal tunnel syndrome presenting to a tertiary academic hand clinic for the preoperative visit within 3 months of CTR, completed PROMIS UE, PF, PI, and Depression computer adaptive tests. Patient characteristics were recorded, including insurance type as commercial, Medicare, Medicaid, or workers' compensation. Multivariable linear regression was used to determine which variables were associated with PROMIS scores at the preoperative visit before CTR.

RESULTS

A total of 301 patients were included in the analysis. All PROMIS domains were significantly different by insurance type; Medicaid patients had the worst preoperative score for all domains in bivariate analysis. In multivariable linear regression modeling, commercial insurance was associated with better preoperative PROMIS UE, PF, PI, and Depression scores.

CONCLUSIONS

Commercial insurance is associated with significantly better preoperative PROMIS PF, PI, and Depression scores compared with other insurance types (ie, Medicaid, Medicare, and Workers' compensation). This may be the result of a number of factors, including differences in access to hand care or life circumstances that allow for only certain individuals to seek hand care early on in the disease process. However, further research is warranted to determine more definitively why this association exists.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Evaluating the performance of PROMIS and QuickDASH instruments in an intercollegiate Division 1 athlete population

BACKGROUND

Athletes demonstrate high levels of physical function, leading to difficulties in patient-reported outcome scoring and interpretation. In particular, the ability of patient-reported outcome (PRO) instruments to adequately discriminate between high levels of upper extremity function-that is, the ceiling effect-is limited. This study evaluated performance characteristics of the shortened version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) survey and Patient-Reported Outcomes Measurement Information System (PROMIS) metrics in a population of Division 1 intercollegiate athletes, with specific attention to ceiling effects.

METHODS

At a single institution, Division I intercollegiate athletes cleared for full participation in the 2018-2019 season were eligible. The following PROs were collected prospectively via tablet computer: PROMIS upper extremity (UE) computer adaptive test (CAT), PROMIS physical function (PF) CAT, QuickDASH, and QuickDASH Sports/Performing Arts Module. Descriptive statistics, and ceiling and floor effects, were calculated. The proportion of athletes with maximal scores on each PRO were compared to normative values using the 1-sample Wilcoxon signed rank test.

RESULTS

A total of 268 participants were included; the mean age was 19.9 ± 1.5 years, 49% were female, and 61% were overhead athletes. Large ceiling effects were observed for the UE CAT (46%), QuickDASH (58%), and QuickDASH Sports Module (82%). The PF CAT demonstrated a relatively low ceiling effect of 6.7%. Athlete scores were all significantly better than published age-matched values from a normative population for all instruments, with the exception of no difference on the QuickDASH for males.

DISCUSSION AND/OR CONCLUSION

The PROMIS UE CAT and QuickDash instruments are limited in their ability to assess and discriminate upper extremity function in highly functioning individuals such as Division I athletes. The PROMIS PF CAT, a measure of general physical function, did not suffer from a large ceiling effect.

Minimal important change (MIC): a conceptual clarification and systematic review of MIC estimates of PROMIS measures

We define the minimal important change (MIC) as a threshold for a minimal within-person change over time above which patients perceive themselves importantly changed. There is a lot of confusion about the concept of MIC, particularly about the concepts of minimal important change and minimal detectable change, which questions the validity of published MIC values. The aims of this study were: (1) to clarify the concept of MIC and how to use it; (2) to provide practical guidance for estimating methodologically sound MIC values; and (3) to improve the applicability of PROMIS by summarizing the available evidence on plausible PROMIS MIC values. We discuss the concept of MIC and how to use it and provide practical guidance for estimating MIC values. In addition, we performed a systematic review in PubMed on MIC values of any PROMIS measure from studies using recommended approaches. A total of 50 studies estimated the MIC of a PROMIS measure, of which 19 studies used less appropriate methods. MIC values of the remaining 31 studies ranged from 0.1 to 12.7 T-score points. We recommend to use the predictive modeling method, possibly supplemented with the vignette-based method, in future MIC studies. We consider a MIC value of 2-6 T-score points for PROMIS measures reasonable to assume at this point. For surgical interventions a higher MIC value might be appropriate. We recommend more high-quality studies estimating MIC values for PROMIS.

Establishing the Minimal Clinically Important Difference, Patient Acceptable Symptomatic State, and Substantial Clinical Benefit of the PROMIS Upper Extremity Questionnaire After Rotator Cuff Repair

BACKGROUND

The Patient-Reported Outcome Measurement Information System Upper Extremity (PROMIS UE) questionnaire has been validated as an effective and efficient outcome measure after rotator cuff repair (RCR). However, definitions of clinically significant outcomes used in interpreting this outcome measure have yet to be defined.

PURPOSE

To define clinically significant outcomes of the PROMIS UE questionnaire in patients undergoing arthroscopic RCR.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

We reviewed charts of consecutive patients undergoing RCR in our institution between 2017 and 2018 and included patients who were administered the PROMIS UE before surgery and 12 months after surgery. At 12 months postoperatively, patients were asked domain-specific anchor questions regarding their function and satisfaction after surgery, which were then used to determine the minimal clinically important difference (MCID), Patient Acceptable Symptomatic State (PASS), and substantial clinical benefit (SCB) using receiver operating characteristic and area under the curve (AUC) analysis. Univariate and multivariate logistic regression analysis was utilized to identify patient factors associated with clinically significant outcomes.

RESULTS

A total of 105 patients with RCR and minimum 12-month postoperative PROMIS UE were included in the analysis. The defined clinically significant outcomes were 4.87 for the MCID using a distribution-based method, 7.95 for the SCB (sensitivity, 0.708; specificity, 0.833; AUC, 0.760), and 39.00 for the PASS (sensitivity, 0.789; specificity, 0.720; AUC, 0.815). Among respondents, 79.0%, 62.9%, and 64.8% achieved the MCID, SCB, and PASS score thresholds, respectively. Workers' compensation was negatively associated with achievement of the PASS. Lower preoperative PROMIS UE scores were associated with obtaining the MCID (odds ratio [OR], 0.871; P = .001) and the SCB (OR, 0.900; P = .040), whereas higher preoperative scores were predictive of achieving the PASS (OR, 1.111; P = .020).

CONCLUSION

This study defines the clinically significant outcomes for the PROMIS UE after RCR, of which the majority of patients achieved the MCID, PASS, and SCB at 12 months after surgery. These thresholds should be considered in future study design and interpretation of PROMIS UE in patients with RCR.