Can the Oxford Scores be used to monitor symptomatic progression of patients awaiting knee or hip arthroplasty?

Patient expectations and satisfaction 6 and 12 months following total hip and knee replacement

PURPOSE

To assess (1) patient expectations before total hip (THR) and knee (TKR) replacement; (2) which expectations are met and unmet 6 and 12 months post-surgery; (3) the role of unmet expectations in satisfaction.

METHODS

Questionnaires were mailed to consecutive patients following surgeon referral for primary THR or TKR. Patients listed their own expectations and also completed the Hospital for Special Surgery (HSS) Expectation Survey. We used content analysis to group expectations into themes. At 6 and 12 months post-surgery, patients were given a copy of their own list of individual expectations and reassessed each one as met or unmet. We also assessed fulfilled HSS expectations and satisfaction with surgery.

RESULTS

The sample of 556 patients (49% THR, 57% female) had a mean age of 64 years (SD10). The five most frequent expectation themes were pain relief, mobility, walking, physical activities, and daily activities. Of these, physical activities had the lowest percentage met 12 months post-surgery. 95% (THR) and 87% (TKR) were satisfied/very satisfied with their surgery 12 months post-surgery. Very satisfied patients had a significantly greater percentage of met expectations (96% THR; 92% TKR) than dissatisfied patients (42% THR; 12% TKR). Although most expectations listed by patients were included in the HSS surveys, some were not, particularly for TKR. From 6 to 12 months, there was a significant increase in patient satisfaction for self-care, daily activities, and met expectations for THR and pain relief, self-care, daily activities, and recreational activities for TKR.

CONCLUSIONS

Expectations should be explicitly addressed before surgery, including a discussion of realistic expectations, particularly for physical activities.

Interpreter proxy versus healthcare interpreter for administration of patient surveys following arthroplasty: a pilot study

Background

Clinical quality registries and other systems that conduct routine post-discharge surveillance of patient outcomes following surgery may have difficulty surveying patients who have limited proficiency in the language of the healthcare provider. Interpreter proxies (family and carers) are often used due to limited access to certified healthcare interpreters (due to cost or availability). The aim of this study was to assess the reliability of engaging interpreter proxies compared with certified healthcare interpreters for the administration of patient-reported health-related surveys for people with limited English proficiency (LEP).

Methods

People with LEP and due for a routine 6-month telephone follow-up post knee or hip arthroplasty were invited to participate. Participants were randomly allocated to having their first interview with an interpreter proxy or a certified healthcare interpreter followed by the second (crossover) interview within 2 weeks (range: 4 to 12 days) after the first interview using the alternative method. Agreement between the two methods was assessed using quadratic weighted Cohen’s kappa, intraclass correlation and concordance correlation co-efficient where appropriate for EQ-5D health domains, total Oxford hip and knee scores, patient satisfaction, operation success, readmission, reoperation, and post-surgical complication responses. The mean of the differences between the same data items collected by each of the two methods was also calculated.

Results

Eighty five participants (96%) completed the study. There was substantial to excellent inter-rater agreement (kappa = 0.69–0.87 and ICCs above 0.74) for all but one measure. The mean differences between family proxy and healthcare interpreter scores for each participant were small, ranging from 0.01 (score range of 1–5) to 0.72 (score range of 0–100).

Conclusion

These results suggest that using interpreter proxies is a reliable alternative to certified healthcare interpreters in conducting patient-reported health surveys, potentially making this process easier and cost effective for researchers and registries.

Comparing the validity and responsiveness of the EQ-5D-5L to the Oxford hip and knee scores and SF-12 in osteoarthritis patients 1 year following total joint replacement

PURPOSE

(1) To assess responsiveness of the EQ-5D-5L compared to Oxford hip and knee scores and the SF-12 in osteoarthritis patients undergoing total hip (THR) or knee (TKR) replacement surgery; (2) to compare distribution and anchor-based methods of assessing responsiveness.

METHODS

Questionnaires were mailed to consecutive patients following surgeon referral for primary THR or TKR and 1 year post-surgery. We assessed effect size (ES), standardized response mean (SRM), and standard error of measurement (SEM). Minimum important difference (MID) was the mean change in patients reporting somewhat better in hip or knee, health in general, and those who were satisfied with surgery (5-point scales). Responders were compared using MID versus 1 and 2SEM.

RESULTS

The sample of 537 (50% TKR) was composed of 56% female with a mean age of 64 years (SD 10). EQ-5D-5L ES was 1.86 (THR) and 1.19 (TKR) compared to 3.00 and 2.05 for Oxford scores, respectively. MID for the EQ-5D-5L was 0.22 (THR) and 0.20 (TKR) for patients who rated their hip or knee as somewhat better. There was a wide variation in the MID and the percentage of responders, depending on the joint, method of assessment, and the outcome measure. The percent agreement of responder classification using 2SEM vs. MID ranged from 79.6 to 99.6% for the EQ-5D-5L and from 69.4 to 94.8% for the Oxford scores.

CONCLUSIONS

Responsiveness of the EQ-5D-5L was acceptable in TKR and THR. Caution should be taken in interpreting responder to TJR based on only one method of assessment.

A Systematic Review of Measurement Properties of Patient-Reported Outcome Measures Used in Patients Undergoing Total Knee Arthroplasty

BACKGROUND

While clinical research on total knee arthroplasty (TKA) outcomes is prevalent in the literature, studies often have poor methodological and reporting quality. A high-quality patient-reported outcome instrument is reliable, valid, and responsive. Many studies evaluate these properties, but none have done so with a systematic and accepted method. The objectives of this study were to identify patient-reported outcome measures (PROMs) for TKA, and to critically appraise, compare, and summarize their psychometric properties using accepted methods.

METHODS

MEDLINE, EMBASE, SCOPUS, Web of Science, PsycINFO, and SPORTDiscus were systematically searched for articles with the following inclusion criteria: publication before December 2014, English language, non-generic PRO, and evaluation in the TKA population. Methodological quality and evidence of psychometric properties were assessed with the COnsensus-based standards for the selection of health Status Measurement INstruments (COSMIN) checklist and criteria for psychometric evidence proposed by the COSMIN group and Terwee et al.

RESULTS

One-hundred fifteen studies on 32 PROMs were included in this review. Only the Work, Osteoarthritis or joint-Replacement Questionnaire, the Oxford Knee Score, and the Western Ontario and McMaster Universities Arthritis Index had 4 or more properties with positive evidence.

CONCLUSION

Most TKA PROMs have limited evidence for their psychometric properties. Although not all the properties were studied, the Work, Osteoarthritis or joint-Replacement Questionnaire, with the highest overall ratings, could be a useful PROM for evaluating patients undergoing TKA. The methods and reporting of this literature can improve by following accepted guidelines.

Minimal detectable change for mobility and patient-reported tools in people with osteoarthritis awaiting arthroplasty

BACKGROUND

Thoughtful use of assessment tools to monitor disease requires an understanding of clinimetric properties. These properties are often under-reported and, thus, potentially overlooked in the clinic. This study aimed to determine the minimal detectable change (MDC) and coefficient of variation per cent (CV%) for tools commonly used to assess the symptomatic and functional severity of knee and hip osteoarthritis.

METHODS

We performed a test-retest study on 136 people awaiting knee or hip arthroplasty at one of two hospitals. The MDC95 (the range over which the difference [change] for 95% of patients is expected to lie) and the coefficient of variation per cent (CV%) for the visual analogue scale (VAS) for joint pain, the six-minute walk test (6MWT), the timed up-and-go (TUG) test, the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Hip Disability and Osteoarthritis Outcome Score (HOOS) subscales were calculated.

RESULTS

Knee cohort (n = 75) - The MDC95 and CV% values were as follows: VAS 2.8 cm, 15%; 6MWT 79 m, 8%; TUG +/-36.7%, 13%; KOOS pain 20.2, 19%; KOOS symptoms 24.1, 22%; KOOS activities of daily living 20.8, 17%; KOOS quality of life 26.6, 44. Hip cohort (n = 61) - The MDC95 and CV% values were as follows: VAS 3.3 cm, 17%; 6MWT 81.5 m, 9%; TUG +/-44.6%, 16%; HOOS pain 21.6, 22%; HOOS symptoms 22.7, 19%; HOOS activities of daily living 17.7, 17%; HOOS quality of life 24.4, 43%.

CONCLUSIONS

Distinguishing real change from error is difficult in people with severe osteoarthritis. The 6MWT demonstrates the smallest measurement error amongst a range of tools commonly used to assess disease severity, thus, has the capacity to detect the smallest real change above measurement error in everyday clinical practice.