Minimal Clinically Important Difference for PROMIS Physical Function in Patients With Distal Radius Fractures

Operative treatment of Mason Type III radial head fractures - A comparative analysis using PROMIS

Objectives

The purpose of this study is to evaluate the outcomes of operatively treated Mason Type III radial head fractures. Additionally, this project seeks to assess efficacy of PROMIS in evaluating post-operative outcomes for this patient population.

Methods

A total of 143 patients who underwent operative treated Mason Type III radial head fractures were analyzed retrospectively. PROMIS physical function (PF), PROMIS upper extremity (UE), PROMIS pain interference (PI), demographic variables, and range of motion were collected and analyzed over 12-month follow-up.

Results

Radial head arthroplasty (RHA) was performed on 89 patients, open reduction and internal fixation (ORIF) was performed on 47 patients, and radial head excision was performed on 7 patients. Among the RHA patients, PROMIS PF, PI and UE demonstrated a change of -1.33 (p < 0.05), -1.48 (p < 0.05), and 2.23 (p < 0.05) respectively from injury to 12-months. Among the ORIF patients, PROMIS PF, PI and UE demonstrated a change of 3.22 (p < 0.05), -1.56 (p < 0.05), and 2.09 (p < 0.05) respectively from injury to 12-months. At the pre-operative and 12-month visits, the RHA group demonstrated lower PROMIS PF scores 34.75 vs 38.02 (p < 0.05) and 33.42 vs 41.24 (p < 0.05) respectively. Ther was no difference in PROMIS PI, UE, or elbow range of motion between the two groups at 6- or 12-month follow-up (p > 0.05).

Conclusion

Comparing the RHA and ORIF groups, there was no difference in PROMIS PI or UE scores nor was there a clinically significant improvement at the 6- or 12-month mark. The ORIF group demonstrated improved PROMIS PF at all follow-up periods and did show a clinically significant improvement. Patient Acceptable Symptom State (PASS) correlated only with PROMIS UE at 6- and 12- months for both groups.

Using PROMIS Scores to Provide Cost-Conscious Follow-up After Foot and Ankle Surgery

BACKGROUND

National campaigns in the United States, such as Choosing Wisely, emphasize that decreasing low-value office visits maximizes health care value. Although patient-reported outcomes (PROs) are frequently used to quantify postoperative outcomes, they have not been assessed as a tool to help guide clinicians consider alternatives or discontinue in-person follow-up visits. The purpose of this study is to assess the frequency and cost of in-person follow-up visits after patients report substantial improvement defined as 2 consecutive improvements above preoperative Patient Reported Outcomes Measurement Information System (PROMIS) pain interference (PI) scores.

METHODS

Retrospective PROMIS PI data were obtained between 2015 and 2020 for common elective foot (n = 759) and ankle (n = 578) surgical procedures. Patients were divided into quartiles according to their preoperative PI score. Multivariable Cox proportional hazards models were used to investigate time to substantial improvement. Substantial improvement was defined as having 2 consecutive postoperative minimal clinically important differences (MCIDs) above preoperative PROMIS PI scores. MCID was measured using the distribution-based method. Multivariable negative binomial models were used to determine the number of visits and direct associated costs after substantial improvement. The cost to payors was estimated using reimbursement rates.

RESULTS

Within 3 months, 12% to 46% of foot and 16% to 61% of ankle patients achieved substantial improvement. Results vary by preoperative pain quartile, with patients who report higher preoperative pain scores achieving earlier improvement. After achieving substantial improvement, foot and ankle patients averaged 3.60 and 4.01 follow-up visits during the remaining 9 months of the year. Visit costs averaged $266 and $322 per foot and ankle patient respectively.

CONCLUSION

Postoperative follow-up visits are time-consuming and costly. Physicians might consider objective measures, such as PROMIS PI, to determine the need, timing, and alternatives for in-person follow-up visits for elective foot and ankle surgeries after patients demonstrate reliable clinical improvement.

LEVEL OF EVIDENCE

Level III, retrospective cohort study at a single institution.

Is There a Role for Isolated Closed Reduction in the Emergency Department Without Fixation for Displaced Proximal Humerus Fractures in Adolescents?

OBJECTIVE

Pediatric proximal humerus fractures (PHFx) are uncommon and makeup ~2% of all pediatric fractures. Traditionally, most cases are treated nonoperatively with closed reduction (CR) or immobilization with no reduction (INR) with excellent outcomes. Indications for CR without fixation remain unclear as immobilization in the position of reduction (shoulder abduction and external rotation) is not practical. We aim to determine the need for CR among adolescents with displaced PHFx treated nonoperatively.

METHODS

We conducted an IRB-approved prospective multicenter study involving 42 adolescents aged 10 to 16 years, treated for displaced PHFx across 6 institutions between 2018 and 2022. CR was performed under conscious sedation in the emergency department, with data collected during follow-up visits at 6 weeks and 3 months. Radiographic measurements, range of motion, and patient-reported outcomes, including the Patient-Reported Outcomes Measurement Information System Upper Extremity and Physical Function, Shoulder Pain and Disability Index, and QuickDash scores, were compared between the INR and CR groups.

RESULTS

Among 42 fractures, 23 (55%) were treated with INR and 19 (45%) with CR, followed by placement in a hanging arm cast or sling. Of the cases, 62% were high-energy injuries. Radiographic alignment and range of motion were similar between groups at preoperative, 6 weeks, and 3 months with no significant differences noted.Patient-Reported Outcomes Measurement Information System Upper Extremity, Physical Function, QuickDash, and Shoulder Pain and Disability Index scores at 6 weeks and 3 months showed no significant differences between cohorts. Significant improvement was observed between 6 weeks and 3 months for every patient-reported outcome in both cohorts.

CONCLUSIONS

For displaced PHFx treated nonoperatively, our data suggests INR has a similar radiographic and clinical outcome when compared with CR. Our results question the necessity of performing CR in this group of patients.

LEVEL OF EVIDENCE

Level II-therapeutic studies: prospective cohort study.

The MCID of the PROMIS physical function instrument for operatively treated tibial plateau fractures

INTRODUCTION

Understanding minimal clinically important differences (MCID) in patient reported outcome measurement are important in improving patient care. The purpose of this study was to determine the MCID of Patient-Reported Outcome Measurement System (PROMIS) Physical Function (PF) domain for patients who underwent operative fixation of a tibial plateau fracture.

METHODS

All patients with tibial plateau fractures that underwent operative fixation at a single level 1 trauma center were identified by Current Procedural Terminology codes. Patients without PROMIS PF scores or an anchor question at two-time points postoperatively were excluded. Anchor-based and distribution-based MCIDs were calculated.

RESULTS

The MCID for PROMIS PF scores was 4.85 in the distribution-based method and 3.93 (SD 14.01) in the anchor-based method. There was significantly more improvement in the score from the first postoperative score (<7 weeks) to the second postoperative time (<78 weeks) in the improvement group 10.95 (SD 9.95) compared to the no improvement group 7.02 (SD 9.87) in the anchor-based method (P < 0.001). The percentage of patients achieving MCID at 7 weeks, 3 months, 6 months, and 1 year were 37-42 %, 57-62 %, 80-84 %, and 95-87 %, respectively.

DISCUSSION

This study identified MCID values for PROMIS PF scores in the tibial plateau fracture population. Both MCID scores were similar, resulting in a reliable value for future studies and clinical decision-making. An MCID of 3.93 to 4.85 can be used as a clinical and investigative standard for patients with operative tibial plateau fractures.

Breaking the Disability Spiral: A Case Series Report Illustrating the Delivery of a Brief Skills Based Coaching Intervention to Prevent Chronic Dysfunction and Pain After Orthopedic Injury

Orthopedic traumas are common, costly, and burdensome - particularly for patients who transition from acute to chronic pain. Psychosocial factors, such as pain catastrophizing and pain anxiety, increase risk for poor outcomes after injury. The Toolkit for Optimal Recovery (TOR) is a novel multi-component mind-body intervention informed by the fear-avoidance model to promote re-engagement in daily activities and prevent transition toward chronic pain and physical dysfunction. The current case series aims to 1) describe the intervention and 2) showcase the treatment course of three TOR completers from diverse geographic locations in the U.S. with distinct injury types and varying personal identities to illustrate how the intervention can be delivered flexibly. Results indicate pre-to-post program improvement in physical function, pain severity, pain catastrophizing, pain anxiety, and other relevant outcomes targeted by the intervention (i.e., depression, mindfulness, coping). Experiences of our three TOR completers suggest that integrating TOR with standard orthopedic care may promote physical recovery after injury.

Understanding recovery of people recovering from COVID-19 receiving treatment from primary care allied health professionals: a mixed-methods study

PURPOSE

To quantitatively assess changes in recovery of people recovering from COVID-19 treated by a primary care allied health professional, and to qualitatively describe how they dealt with persistent complaints.

MATERIALS AND METHODS

This mixed-methods study is part of a Dutch prospective cohort study, from which thirty participants were selected through purposive sampling. Quantitative data on recovery were collected at start of treatment and 6 months. Additionally, by use of semi-structured interviews participants were asked on how persistent complaints influenced their lives, and how they experienced received primary care allied health treatment.

RESULTS

Despite reported improvements, most participants still experienced limitations at 6 months. Hospital participants reported a higher severity of complaints, but home participants reported more diverse complaints and a longer recovery. Most participants were satisfied with the primary care allied healthcare. Tender loving care and a listening ear, learning to manage limits, and support and acceptance of building up in small steps were perceived as contributing most to participants' recovery.

CONCLUSION

Although improvements were reported on almost all outcomes, most participants suffered from persistent complaints. Despite these persistent complaints, many participants reported being better able to cope with persistent complaints because they had decreased substantially in their intensity.

TRIAL REGISTRATION

Clinicaltrials.gov registry (NCT04735744).

How Are Age, Gender, and Country Differences Associated With PROMIS Physical Function, Upper Extremity, and Pain Interference Scores?

BACKGROUND

The interpretation of patient-reported outcomes requires appropriate comparison data. Currently, no patient-specific reference data exist for the Patient-Reported Outcome Measurement Information System (PROMIS) Physical Function (PF), Upper Extremity (UE), and Pain Interference (PI) scales for individuals 50 years and older.

QUESTIONS/PURPOSES

(1) Can all PROMIS PF, UE, and PI items be used for valid cross-country comparisons in these domains among the United States, the United Kingdom, and Germany? (2) How are age, gender, and country related to PROMIS PF, PROMIS UE, and PROMIS PI scores? (3) What is the relationship of age, gender, and country across individuals with PROMIS PF, PROMIS UE, and PROMIS PI scores ranging from very low to very high?

METHODS

We conducted telephone interviews to collect custom PROMIS PF (22 items), UE (eight items), and PI (eight items) short forms, as well as sociodemographic data (age, gender, work status, and education level), with participants randomly selected from the general population older than 50 years in the United States (n = 900), United Kingdom (n = 905), and Germany (n = 921). We focused on these individuals because of their higher prevalence of surgeries and lower physical functioning. Although response rates varied across countries (14% for the United Kingdom, 22% for Germany, and 12% for the United States), we used existing normative data to ensure demographic alignment with the overall populations of these countries. This helped mitigate potential nonresponder bias and enhance the representativeness and validity of our findings. We investigated differential item functioning to determine whether all items can be used for valid crosscultural comparisons. To answer our second research question, we compared age groups, gender, and countries using median regressions. Using imputation of plausible values and quantile regression, we modeled age-, gender-, and country-specific distributions of PROMIS scores to obtain patient-specific reference values and answer our third research question.

RESULTS

All items from the PROMIS PF, UE, and PI measures were valid for across-country comparisons. We found clinically meaningful associations of age, gender, and country with PROMIS PF, UE, and PI scores. With age, PROMIS PF scores decreased (age ß Median = -0.35 [95% CI -0.40 to -0.31]), and PROMIS UE scores followed a similar trend (age ß Median = -0.38 [95% CI -0.45 to -0.32]). This means that a 10-year increase in age corresponded to a decline in approximately 3.5 points for the PROMIS PF score-a value that is approximately the minimum clinically important difference (MCID). Concurrently, we observed a modest increase in PROMIS PI scores with age, reaching half the MCID after 20 years. Women in all countries scored higher than men on the PROMIS PI and 1 MCID lower on the PROMIS PF and UE. Additionally, there were higher T-scores for the United States than for the United Kingdom across all domains. The difference in scores ranged from 1.21 points for the PROMIS PF to a more pronounced 3.83 points for the PROMIS UE. Participants from the United States exhibited up to half an MCID lower T-scores than their German counterparts for the PROMIS PF and PROMIS PI. In individuals with high levels of physical function, with each 10-year increase in age, there could be a decrease of up to 4 points in PROMIS PF scores. Across all levels of upper extremity function, women reported lower PROMIS UE scores than men by an average of 5 points.

CONCLUSION

Our study provides age-, gender-, and country-specific reference values for PROMIS PF, UE, and PI scores, which can be used by clinicians, researchers, and healthcare policymakers to better interpret patient-reported outcomes and provide more personalized care. These findings are particularly relevant for those collecting patient-reported outcomes in their clinical routine and researchers conducting multinational studies. We provide an internet application ( www.common-metrics.org/PROMIS_PF_and_PI_Reference_scores.php ) for user-friendly accessibility in order to perform age, gender, and country conversions of PROMIS scores. Population reference values can also serve as comparators to data collected with other PROMIS short forms or computerized adaptive tests.

LEVEL OF EVIDENCE

Level II, diagnostic study.

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.

Pearls and pitfalls of PROMIS clinically significant outcomes in orthopaedic surgery

INTRODUCTION

Patient-Reported Outcome Measurement Information System (PROMIS) was developed as a uniform and generalizable PROM system using item response theory and computer adaptive testing. We aimed to assess the utilization of PROMIS for clinically significant outcomes (CSOs) measurements and provide insights into its use in orthopaedic research.

MATERIALS AND METHODS

We reviewed PROMIS CSO reports for orthopaedic procedures via PubMed, Cochrane Library, Embase, CINAHL, and Web of Science from inception to 2022, excluding abstracts and missing measurements. Bias was assessed using the Newcastle-Ottawa Scale (NOS) and questionnaire compliance. PROMIS domains, CSO measures, and study populations were described. A meta-analysis compared distribution and anchor-based MCIDs in low-bias (NOS ≥ 7) studies.

RESULTS

Overall, 54 publications from 2016 to 2022 were reviewed. PROMIS CSO studies were observational with increasing publication rates. Evidence-level was II in 10/54, bias low in 51/54, and compliance ≥ 86% in 46/54. Most (28/54) analysed lower extremity procedures. PROMIS domains examined Pain Function (PF) in 44/54, Pain Interference (PI) in 36/54, and Depression (D) in 18/54. Minimal clinically important difference (MCID) was reported in 51/54 and calculated based on distribution in 39/51 and anchor in 29/51. Patient acceptable symptom state (PASS), substantial clinical benefit (SCB), and minimal detectable change (MDC) were reported in ≤ 10/54. MCIDs were not significantly greater than MDCs. Anchor-based MCIDs were greater than distribution based MCIDs (standardized mean difference = 0.44, p < 0.001).

CONCLUSIONS

PROMIS CSOs are increasingly utilized, especially for lower extremity procedures assessing the PF, PI, and D domains using distribution-based MCID. Using more conservative anchor-based MCIDs and reporting MDCs may strengthen results. Researchers should consider unique pearls and pitfalls when assessing PROMIS CSOs.

Sex-related differences in PROMs prior to the outcome: comparison of preoperative PROMIS physical function scores in female vs. male patients undergoing shoulder arthroplasty

Background

Patient-reported outcome measures (PROMs) are increasingly used to evaluate outcomes in patients undergoing shoulder arthroplasty. The Patient-Reported Outcome Measures Information System (PROMIS) is popular due to low cost and question burden. Females have been reported to have lower postoperative PROMIS scores after shoulder surgery, but studies have not focused on a dedicated cohort of shoulder arthroplasty patients or examined upstream differences in preoperative scores. This study aimed to characterize sex differences in baseline PROMIS scores among anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (rTSA) patients.

Methods

Data were collected over a 9-month period. Demographics, Charlson Comorbidity Index (CCI), smoking status, BMI, American Shoulder and Elbow Surgeons (ASES) scores, PROMIS Pain, Physical Function (PF), Upper Extremity, Depression, and Anxiety scores, as well as Single Assessment Numeric Evaluation (SANE) scores were collected. Student t-tests were performed to determine correlation with baseline PROMs. A minimal clinically important difference (MCID) of 4 was used to determine if a PROMIS score difference between groups was clinically important. Significance was set as P < .05.

Results

A total of 88 females (34 TSAs 54 rTSA) and 99 males (35 TSA, 64 rTSA) were enrolled. Only sex showed a correlation with preoperative PROMIS score. In rTSA patients, females had significantly lower preoperative PROMIS PF scores (P < .05). Among females undergoing TSA vs. rTSA, lower preoperative PROMIS PF scores were found in rTSA (P < .05). These differences exceeded the MCID of 4. The same difference was not found in men undergoing TSA vs. rTSA.

Conclusion

Preoperative sex-based differences in PROMIS scores are underappreciated in the shoulder arthroplasty literature. This is the largest study to date focusing on sex-based differences among a dedicated cohort of TSA and rTSA patients, showing a difference in baseline PROMIS scores between males and females above the MCID. These findings suggest that PROMIS scores are affected by sex-based baseline differences in rTSA patients. Further study should investigate sex-based differences in baseline scores to determine their effects on ultimate outcome.

Evaluation of Primary Allied Health Care in Patients Recovering From COVID-19 at 6-Month Follow-up: Dutch Nationwide Prospective Cohort Study

BACKGROUND

Patients recovering from COVID-19 often experience persistent problems in their daily activities related to limitations in physical, nutritional, cognitive, and mental functioning. To date, it is unknown what treatment is needed to support patients in their recovery from COVID-19.

OBJECTIVE

This study aimed to evaluate the primary allied health care of patients recovering from COVID-19 at 6-month follow-up and to explore which baseline characteristics are associated with changes in the scores of outcomes between baseline and 6-month follow-up.

METHODS

This Dutch nationwide prospective cohort study evaluated the recovery of patients receiving primary allied health care (ie, dietitians, exercise therapists, occupational therapists, physical therapists, and speech and language therapists) after COVID-19. All treatments offered by primary allied health professionals in daily practice were part of usual care. Patient-reported outcome measures on participation, health-related quality of life, fatigue, physical functioning, and psychological well-being were assessed at baseline and at 3- and 6-month follow-up. Linear mixed model analyses were used to evaluate recovery over time, and uni- and multivariable linear regression analyses were used to examine the association between baseline characteristics and recovery.

RESULTS

A total of 1451 adult patients recovering from COVID-19 and receiving treatment from 1 or more primary allied health professionals were included. For participation (Utrecht Scale for Evaluation of Rehabilitation-Participation range 0-100), estimated mean differences of at least 2.3 points were observed at all time points. For the health-related quality of life (EuroQol Visual Analog Scale, range 0-100), the mean increase was 12.3 (95% CI 11.1-13.6) points at 6 months. Significant improvements were found for fatigue (Fatigue Severity Scale, range 1-7): the mean decrease was -0.7 (95% CI -0.8 to -0.6) points at 6 months. However, severe fatigue was reported by 742/929 (79.9%) patients after 6 months. For physical functioning (Patient-Reported Outcomes Measurement Information System-Physical Function Short Form 10b, range 13.8-61.3), the mean increase was 5.9 (95% CI 5.9-6.4) points at 6 months. Mean differences of -0.8 (95% CI -1.0 to -0.5) points for anxiety (Hospital Anxiety and Depression Scale range 0-21) and -1.6 (95% CI -1.8 to -1.3) points for depression were found after 6 months. A worse baseline score, hospital admission, and male sex were associated with greater improvement between baseline and 6-month follow-up, whereas age, the BMI, comorbidities, and smoking status were not associated with mean changes in any outcome measures.

CONCLUSIONS

Patients recovering from COVID-19 who receive primary allied health care make progress in recovery but still experience many limitations in their daily activities after 6 months. Our findings provide reference values to health care providers and health care policy makers regarding what to expect from the recovery of patients who receive health care from 1 or more primary allied health professionals.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04735744; https://tinyurl.com/3vf337pn.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2340/jrm.v54.2506.

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.

From numbers to meaningful change: Minimal important change by using PROMIS in a cohort of fracture patients

INTRODUCTION

use of the Patient-Reported Outcomes measurement Information System (PROMIS®) is slowly increasing in patients with a fracture. Yet, minimal important change of PROMIS in patients with fractures has been addressed in a very limited number of studies. As the minimal important change (MIC) is important to interpret PROMIS-scores, the goal is to estimate the MIC for PROMIS physical function (PF), PROMIS pain interference (PI) and PROMIS ability to participate in social roles and activities (APSRA) in patients with a fracture. Secondly, the smallest detectable change was determined.

MATERIALS AND METHODS

A longitudinal cohort study on patients ≥ 18 years receiving surgical or non-surgical care for fractures was conducted. Patients completed PROMIS PF V1.1, PROMIS PI V1.1 and PROMIS APSRA V2.0. For follow-up, patients completed three additional anchor questions evaluating patient-reported improvement on a seven point rating scale. The predictive modeling method was used to estimate the MIC value of all three PROMIS questionnaires.

RESULTS

Hundred patients with a mean age of 55.4 ± 12.6 years were included of which sixty (60%) were female. Seventy-two (72%) patients were recovering from a surgical procedure. PROMIS-CAT T-scores of all PROMIS measures showed significant correlations with their anchor questions. The predictive modeling method showed a MIC value of +2.4 (n = 98) for PROMIS PF, -2.9 (n = 96) for PROMIS PI and +3.2 (n = 91) for PROMIS APSRA.

CONCLUSION

By using the anchor based predictive modeling method, PROMIS MIC-values for improvement of respectively +2.4 points on a T-score metric for PROMIS-PF, -2.9 for PROMIS-PI and +3.2 for PROMIS APSRA give the impression of being meaningful to patients. These values can be used in clinical practice for managing patient expectations; to inform on treatment results; and to assess if patients experience significant change. This in order to encourage patient centered care.

The Minimum Clinically Important Difference for the Patient-Rated Wrist Evaluation in Surgical Fixation of Distal Radius Fractures: Does Hand Dominance Make a Difference?

BACKGROUND

Distal radius fractures (DRFs) are common orthopaedic injuries. They can be treated in many ways, but the volar locking plate (VLP) is more frequent. Currently, there is limited information regarding the minimum clinically important difference (MCID) in surgically treated DRFs. The purpose of this study was to calculate MCID values for the Patient-Reported Wrist Evaluation (PRWE) in the setting of VLP-treated DRFs.

METHODS

A retrospective review was conducted for patients with isolated, surgically-treated DRFs with a VLP. Exclusions included any concomitant procedure other than a carpal tunnel release, skeletal immaturity, polytrauma, open fracture, or missing PRWE data. MCID was calculated using PRWE, an overall health question, and the anchor-based method.

RESULTS

A total of 131 patients were identified. Approximately 54.2% injured their dominant hand. AO/OTA classification 23C was the most common (n=89, 67.9%). Average baseline, 6-week, and 12-week PRWE were 71.8 ± 19.6, 34.3 ± 20.1, and 21.2 ± 18.0 respectively. This corresponds to an average change from baseline PRWE at 6 weeks and 12 weeks of -37.5 ± 23.4 and -50.6 ± 22.3, respectively. Average MCID values for 6 weeks and 12 weeks were 43.1 ± 18 and 56.0 ± 20.0, respectively (p<0.001). Hand dominance did not correlate with MCID value (rs = 0.084 at six weeks, rs = 0.099 at 12 weeks). MCID value additionally did not correlate with sex, AO/OTA classification, smoking status, ASA score, or BMI. Treatment at a level 1 trauma center and diagnosis of anxiety and/or depression correlated with a higher 6-week MCID value (rs = 0.308 and rs = 0.410, respectively). Increasing age weakly correlated with higher 12-week MCID value (rs = 0.352).

CONCLUSIONS

This study demonstrated an MCID calculation using an overall health anchor. MCID value varied with follow-up time and correlated weakly with age, diagnosis of anxiety and/or depression, and treatment facility, but it did not correlate with injury of the dominant hand. Future research should analyze how to apply MCID and identify successful treatment in the setting of DRF care.

Minimal Clinically Important Differences of Patient-Reported Outcomes Measurement Information System Physical Function in Patients With Tibial Shaft Fracture

OBJECTIVE

To calculate the minimal clinically important differences (MCIDs) of patient-reported outcomes measurement information system physical function (PROMIS PF) scores for patients with operatively treated tibial shaft fractures.

DESIGN

Retrospective Cohort Study.

SETTING

A Level 1 trauma center.

PATIENTS

All operatively treated tibial shaft fractures identified by Current Procedural Terminology codes.

INTERVENTION

Enrolled patients treated acutely with operative fixation of their tibia.

MAIN OUTCOME MEASUREMENTS

MCIDs were calculated by distribution-based and anchor-based methods, calculated from PROMIS PF scores completed at least at two-time points postoperatively. MCIDs were calculated at different time points including overall, 7-12 weeks, 3-6 months, and 6-24 months. MCIDs were calculated for different subgroups including open fractures, closed fractures, any complications, and no complications.

RESULTS

MCID for PROMIS PF scores was 5.7 in the distribution-based method and 7.84 (SD 18.65) in the anchor-based method. At 6-24 postoperatively, the months the distribution-based MCID was 5.95 from a postoperative baseline 27.83 (8.74) to 42.85 (9.61), P < 0.001. At 6-24 months, the anchor-based MCID was 10.62 with a score difference between the improvement group of 16.03 (10.73) and the no improvement group of 5.41 (15.75), P < 0.001. Patients with open fractures (distribution-based 6.22 and anchor-based 8.05) and any complications (distribution-based 5.71 and anchor-based 9.29) had similar or higher MCIDs depending on the methodology used than the overall cohort MCIDs.

CONCLUSION

This study identified distribution-based MCID of 5.7 and anchor-based MCID of 7.84 calculated from PROMIS PF scores in operative tibial shaft fractures. Distribution-based methods yielded smaller MCIDs than anchor-based methods. These MCID scores provide a standard to compare clinical and investigational outcomes.

An Analysis of Patient-Reported Outcomes Measurement Information System (PROMIS) in Non-operative Posterolateral Elbow Dislocations

INTRODUCTION

The purpose of our study is to analyze the outcomes of traumatic posterolateral elbow dislocations using patient-reported outcomes measurement information system (PROMIS). We hypothesized that physical function (PF) and upper extremity (UE) scores in PROMIS will significantly improve over six months of follow-up and correlate with a positive change in the patient-acceptable symptom state (PASS).

METHODS

This is a seven-year retrospective study of 165 consecutive adult patients with traumatic posterolateral elbow dislocations. Demographic information, PROMIS PF, PROMIS UE, PROMIS pain interference (PI), PROMIS depression, and PASS were recorded over six months of follow-up.

RESULTS

At the time of injury, mean PROMIS scores were PF 41.24 (SD 11.16), UE 34.27 (SD 11.87), PI 60.44 (SD 8.07), and depression 49.82 (SD 10.42). At six months, the mean PROMIS scores were PF 39.71 (SD 9.71), UE 33.95 (SD 9.09), PI 57.35 (SD 8.59), and depression 51.43 (SD 10.62). The overall six-month changes in PROMIS scores were PF -1.53, UE -0.32, PI -3.09, and depression +1.61. At the 6-month follow-up, 41.7% responded positively on the PASS, which correlated only with PROMIS PI.

CONCLUSIONS

Among patients who improved from negative to positive response on PASS, the PROMIS PF, UE, and depression scores did not significantly improve. Only PROMIS PI correlated with PASS at the six-month follow-up; PROMIS PI significantly improved among simple posterolateral elbow dislocation patients at both short-term and long-term follow-up points. PROMIS PF, UE, and depression did not significantly differ between time of injury and short-term and long-term follow-up points.

Determining the clinical significance of the PROMIS physical function score in the setting of femur fractures

BACKGROUND

To adequately utilize patient reported outcome scores in the clinical setting, accurate determination of a cohort-specific minimal clinically important differences (MCID) is necessary. The purpose of this study was to assess MCID for Patient Reported Outcome Information System Physical Function Scores (PROMIS®) Physical Function (PF) in a sample of patients who have undergone operative fixation for femur fractures.

METHODS

All patients at a single Level 1 trauma center who were treated for operative femur fractures were identified by Current Procedural Terminology (CPT) codes (27,244, 27,245, 27,506, 27,507). PROMIS PF was collected as part of routine clinical care via computer adaptive testing (CAT). MCID calculations were performed using both anchor-based and distribution-based methods.

RESULTS

A total of 182 patients with 723 score observations were included in the overall distribution-based analysis and 131 patients with 309 score observations were included in the anchor-based analysis. In the overall cohort, the average age was 53.1 (SD 22.3), and 45% of participants were female. MCID for PROMIS PF scores was 5.43 in the distribution-based method and 5.18 in the anchor-based method. Overall scores in the distribution group improved from mean of 27.4 (SD 7.0) at the first postoperative visit to a mean of 36.7 (SD 10.0) at a subsequent follow up visit. Overall scores in the anchor group improved from mean of 26.7 (SD 7.3) at the first postoperative visit to a mean of 37.5 (SD 9.3) at a subsequent follow up visit.

CONCLUSIONS

This study identifies two MCID values (5.18, 5.43) based on two calculation methods for PROMIS physical function scores in the operative femur fracture population. This data could be helpful in targeting postoperative patients who fall below expected norms or in allowing clinical correlation with changes in surgical practice.

The trajectory of patient-reported outcomes and minimal clinically important differences in isolated and polytraumatic pelvis and acetabular fractures

PURPOSE

Patient-reported minimal clinically important differences (MCID) provide a standard to compare clinical outcomes. The purpose of this study was to calculate the MCID of PROMIS Physical Function (PF), Pain Interference (PI), Anxiety (AX), and Depression (DEP) scores in patients with pelvis and/or acetabular fractures.

METHODS

All patients with operatively treated pelvic and/or acetabular fractures were identified. Patients were categorized as either only pelvis and/or acetabular fractures (PA) or polytrauma (PT). PROMIS PF, PI, AX, and DEP scores were evaluated at 3-month, 6-month, and 12-month intervals. Distribution-based MCID and anchor-based MCID were calculated for the overall cohort, PA, and PT groups.

RESULTS

The overall distribution-based MCIDs were PF (5.19), PI (3.97), AX (4.33), and DEP (4.41). The overall anchor-based MCIDs were PF (7.18), PI (8.03), AX (5.85), DEP (5.00). The percentage of patients achieving MCID for AX was 39.8-54% at 3 months and 32.7-56% at 12 months. The percentage of patients achieving MCID for DEP was 35.7-39.3% at 3 months and 32.1-35.7% at 12 months. The PT group had worse PROMIS PF scores than the PA group at all time points [post-operative, 3-month, 6-month, and 12-month scores, (28.3 (6.3) vs. 26.8 (6.8) P = 0.016), (38.1 (9.2) vs. 35.0 (8.7) P = 0.037), (42.8 (8.2) vs. 39 (9.6) P = 0.015), (46.2 (9.7) vs. 41.2 (9.7) P = 0.011)].

CONCLUSION

An overall MCID for PROMIS PF was 5.19-7.18, PROMIS PI 3.97-8.03, PROMIS AX of 4.33-5.85, and PROMIS DEP of 4.41-5.00. The PT group had worse PROMIS PF at all time points. The percentage of patients achieving MCID for AX and DEP plateaued at 3 months post-operatively.

LEVEL OF EVIDENCE

Level IV.

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.

Longitudinal Predictors of PROMIS Satisfaction With Social Roles and Activities After Shoulder and Knee Sports Orthopaedic Surgery in United States Military Servicemembers: An Observational Study

Background

Satisfaction with social roles and activities is an important outcome for postsurgical rehabilitation and quality of life but not commonly assessed.

Purpose

To evaluate longitudinal patterns of the Patient-Reported Outcomes Measurement Information System (PROMIS) Satisfaction with Social Roles and Activities measure, including how it relates to other biopsychosocial factors, before and up to 6 months after sports-related orthopaedic surgery.

Study Design

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

Methods

Participants (N = 223) who underwent knee and shoulder sports orthopaedic surgeries between August 2016 and October 2020 completed PROMIS computer-adaptive testing item banks and pain-related measures before surgery and at 6-week, 3-month, and 6-month follow-ups. In a generalized additive mixed model, covariates included time point; peripheral nerve block; the PROMIS Anxiety, Sleep Disturbance, and Pain Behavior measures; and previous 24-hour pain intensity. Patient-reported outcomes were modeled as nonlinear (smoothed) effects.

Results

The linear (estimate, 2.06; 95% CI, 0.77-3.35; P = .002) and quadratic (estimate, 2.93; 95% CI, 1.78-4.08; P < .001) effects of time, as well the nonlinear effects of PROMIS Anxiety (P < .001), PROMIS Sleep Disturbance (P < .001), PROMIS Pain Behavior (P < .001), and pain intensity (P = .02), were significantly associated with PROMIS Satisfaction with Social Roles and Activities. The cubic effect of time (P = .06) and peripheral nerve block (P = .28) were not. The proportion of patients with a 0.5-SD improvement in the primary outcome increased from 23% at 6 weeks to 52% by 6 months postsurgery, whereas those reporting worsening PROMIS Satisfaction with Social Roles and Activities decreased from 30% at 6 weeks to 13% at 6 months.

Conclusion

The PROMIS Satisfaction with Social Roles and Activities measure was found to be related to additional domains of function (eg, mental health, behavioral, pain) associated with postsurgical rehabilitation.

Non-operative Treatment of Mason Type I Radial Head Fractures: A Comparative Analysis Using Patient-Reported Outcomes Measurement Information System (PROMIS)

OBJECTIVES

The purpose of this study is to compare the outcomes of Mason type I radial head fractures. This information will help to provide physicians with a critical decision-making tool when considering non-operative intervention and evaluate Patient-Reported Outcomes Measurement Information System (PROMIS) as a potentially valuable measure to track outcomes.

METHODS

We retrospectively identified 527 patients undergoing non-operative intervention. Demographic information, physical exam measurements, patient acceptable symptom state (PASS), and PROMIS Upper Extremity (UE), Physical Function (PF), and Pain Interference (PI) scores were analyzed over 12 months.

RESULTS

At the initial outpatient post-injury visit (within one week of injury), the average PROMIS PF, UE, PI, and Depression were 42.04 (SD: 6.3), 35.31 (SD: 7.3), 59.18 (SD: 9.2), and 48.68 (SD: 6.8), respectively. The average change in PROMIS PF, UE, PI, and Depression scores from the time of injury to six weeks were -0.23 (p=0.7), 1.43 (p=0.03), -2.1 (p=0.01), and -0.99 (p=0.1). The average change in PROMIS PF, UE, PI, and Depression scores from the time of injury to six months was -0.56 (p=0.56), 1.84 (p<0.001), -1.84 (p<0.001), and -0.13 (p=0.68). Among patients initially reporting "not acceptable" on PASS and reporting "acceptable" at the six-month visit, the average PROMIS PF, UE, PI, and Depression scores were 42.14, 38.91, 56.91, and 47.51 respectively. This represents an average difference of 1.11 (p=0.07), 2.82 (p<0.01), -1.19 (p=0.04), and -1.7 (p=0.01) respectively.

CONCLUSION

PROMIS UE and PI significantly improved among Mason I radial head fractures treated non-operatively at both six-week and six-month follow-up points but did not meet the mean clinically important difference (MCID) PROMIS PF did not significantly differ between the time of injury, six-week or six-month follow-up points. Only PROMIS UE correlated with PASS at six-week and six-month follow-up. Among patients who improved from negative to positive responses on PASS, PROMIS UE, and PI significantly improved.

Improvements in Physical Function and Pain Interference and Changes in Mental Health Among Patients Seeking Musculoskeletal Care

Importance

Among patients seeking care for musculoskeletal conditions, there is mixed evidence regarding whether traditional, structure-based care is associated with improvement in patients' mental health.

Objective

To determine whether improvements in physical function and pain interference are associated with meaningful improvements in anxiety and depression symptoms among patients seeking musculoskeletal care.

Design, Setting, and Participants

This cohort study included adult patients treated by an orthopedic department of a tertiary care US academic medical center from June 22, 2015, to February 9, 2022. Eligible participants presented between 4 and 6 times during the study period for 1 or more musculoskeletal conditions and completed Patient-Reported Outcomes Measurement Information System (PROMIS) measures as standard care at each visit.

Exposure

PROMIS Physical Function and Pain Interference scores.

Main Outcomes and Measures

Linear mixed effects models were used to determine whether improvements in PROMIS Anxiety and PROMIS Depression scores were associated with improved PROMIS Physical Function or Pain Interference scores after controlling for age, gender, race, and PROMIS Depression (for the anxiety model) or PROMIS Anxiety (for the depression model). Clinically meaningful improvement was defined as 3.0 points or more for PROMIS Anxiety and 3.2 points or more for PROMIS Depression.

Results

Among 11 236 patients (mean [SD] age, 57 [16] years), 7218 (64.2%) were women; 120 (1.1%) were Asian, 1288 (11.5%) were Black, and 9706 (86.4%) were White. Improvements in physical function (β = -0.14; 95% CI, -0.15 to -0.13; P < .001) and pain interference (β = 0.26; 95% CI, 0.25 to 0.26; P < .001) were each associated with improved anxiety symptoms. To reach a clinically meaningful improvement in anxiety symptoms, an improvement of 21 PROMIS points or more (95% CI, 20-23 points) on Physical Function or 12 points or more (95% CI, 12-12 points) on Pain Interference would be required. Improvements in physical function (β = -0.05; 95% CI, -0.06 to -0.04; P < .001) and pain interference (β = 0.04; 95% CI, 0.04 to 0.05; P < .001) were not associated with meaningfully improved depression symptoms.

Conclusions and Relevance

In this cohort study, substantial improvements in physical function and pain interference were required for association with any clinically meaningful improvement in anxiety symptoms, and were not associated with any meaningful improvement in depression symptoms. Patients seeking musculoskeletal care clinicians providing treatment cannot assume that addressing physical health will result in improved symptoms of depression or potentially even sufficiently improved symptoms of anxiety.

Relationships between improvement in physical function, pain interference, and mental health in musculoskeletal patients

Importance

Among patients seeking care for musculoskeletal conditions, there is mixed evidence regarding whether traditional, structure-based care is associated with improvement in patients' mental health.

Objective

To determine whether improvements in physical function and pain interference are associated with meaningful improvements in anxiety and depression symptoms among patients seeking musculoskeletal care.

Design

Retrospective cohort study from June 22, 2015 to February 9, 2022.

Setting

Orthopedic department of a tertiary care US academic medical center.

Participants

Consecutive sample of adult patients who presented to the musculoskeletal clinic 4 to 6 times during the study period and completed Patient-Reported Outcomes Measurement Information System (PROMIS) measures as standard care at each visit.

Exposure

PROMIS Physical Function and Pain Interference scores.

Main Outcomes and Measures

Linear mixed effects models were used to determine whether: 1) PROMIS Anxiety and 2) PROMIS Depression scores improved as a function of improved PROMIS Physical Function or Pain Interference scores, after controlling for age, gender, race, and PROMIS Depression (for the Anxiety model) and PROMIS Anxiety (for the Depression model). Clinically meaningful improvement was defined as ≥3.0 points for PROMIS Anxiety and ≥3.2 points for PROMIS Depression.

Results

Among 11,236 patients (mean [SD] age 57 [16] years), 9,706 (86%) were White, and 7,218 (64%) were women. Improvements in physical function (β=-0.14 [95% CI -0.15- -0.13], p<0.001) and pain interference (β=0.26 [0.25-0.26], p<0.001) were each associated with improved anxiety symptoms. To reach a clinically meaningful improvement in anxiety symptoms, an improvement of ≥21 [20-23] PROMIS points on Physical Function or ≥12 [12-12] points on Pain Interference would be required. Improvements in physical function (β=-0.05 [- 0.06- -0.04], p<0.001) and pain interference (β=0.04 [0.04-0.05], p<0.001) were not associated with meaningfully improved depression symptoms.

Conclusions and Relevance

In this cohort study, substantial improvements in physical function and pain interference were required for association with any clinically meaningful improvement in anxiety symptoms and were not associated with any meaningful improvement in depression symptoms. Among patients seeking musculoskeletal care, musculoskeletal clinicians and patients cannot assume that addressing physical health will result in improved symptoms of depression or potentially even sufficiently improved symptoms of anxiety.

Key Points

Question: Among patients seeking musculoskeletal care, are improvements in physical function and pain interference associated with meaningful changes in symptoms of anxiety and depression?Findings: In this large cohort study, improvement by ≥2.3 population-level standard deviations (SD) on PROMIS Physical Function or ≥1.2 SD on PROMIS Pain Interference were required for any association with meaningful improvement in anxiety symptoms. Improvements in physical function and pain interference were not associated with meaningfully improved depression symptoms.Meaning: Musculoskeletal clinicians and patients cannot assume that exclusively addressing the physical aspect of a musculoskeletal condition will improve symptoms of depression or potentially even anxiety.

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.

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.

The Effect of Social Deprivation on Fracture-Healing and Patient-Reported Outcomes Following Intramedullary Nailing of Tibial Shaft Fractures

BACKGROUND

Social deprivation is a state marked by limited access to resources due to poverty, discrimination, or other marginalizing factors. We investigated the links between social deprivation and orthopaedic trauma, including patient-reported outcomes, radiographic healing, and complication rates following intramedullary nailing of tibial shaft fractures.

METHODS

We retrospectively reviewed 229 patients who underwent intramedullary nailing of tibial shaft fractures at our Level-I trauma center. The Area Deprivation Index (ADI), a validated proxy for social deprivation, was used to group patients into the most deprived tercile (MDT), the intermediate deprived tercile (IDT), and the least deprived tercile (LDT) for outcome comparison. The Patient-Reported Outcomes Measurement Information System (PROMIS) was used to measure the domains of Physical Function (PF), Pain Interference (PI), Anxiety, and Depression, and radiographic healing was assessed with the Radiographic Union Scale in Tibial fractures (RUST) system.

RESULTS

On univariate analyses, patients from the MDT reported worse PF, PI, Anxiety, and Depression scores than those from the LDT within the first year of postoperative follow-up. On multivariable regression analysis, PROMIS score outcomes were influenced by age, race, and smoking status, but not by social deprivation tercile. Furthermore, residing in the MDT was associated with a 31% increase in time to radiographic union compared with the LDT (β = 0.27; p = 0.01).

CONCLUSIONS

Following intramedullary nailing of tibial shaft fractures, social deprivation is associated with slower fracture-healing and potentially influences short-term PROMIS scores. These results warrant further investigation in additional patient populations with orthopaedic trauma and highlight the importance of developing interventions to reduce inequities faced by patients from low-resource settings.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Impact of insurance type on patient-reported outcome measures in patients with lumbar disc herniation

BACKGROUND

Lumbar disc herniations (LDH) are among the most common spinal conditions. Despite increased appreciation for the importance of social determinants of health, the role that these factors play in patients with lumbar disc herniations is poorly defined.

PURPOSE

To elucidate the association between insurance status and baseline patient reported outcome measures (PROMs) in the setting of lumbar disc herniations.

STUDY DESIGN/SETTING

Retrospective cohort study PATIENT SAMPLE: Baseline patient-reported outcome measures (PROMS) were reviewed from 924 adult patients presenting for treatment of lumbar disc herniation within our institutional healthcare system (2015-2020).

OUTCOME MEASURES

The Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Short Form 10a (PF10a), PROMIS Global-Mental, PROMIS Global-Physical, and visual analogue scale (VAS) for back and leg pain were assessed.

METHODS

PROMIS scores at presentation were defined at the primary outcome and insurance status as the primary predictor. Differences in clinical and sociodemographic characteristics between our cohorts, stratified by insurance status, were evaluated using Wilcoxon rank-sum or chi-squared testing. We used multivariable negative binomial regression modeling to adjust for potential confounders including age, gender, race, language, ethnicity, comorbidity index, and median geospatial household income.

RESULTS

We included 924 patients, with mean age of 58.4 +/- 15.2 years and 52.6% male prevalence. Patients insured through Medicaid were more likely to be Black, Hispanic, and non-English speaking patients compared with the commercially insured. The Charlson Comorbidity index was significantly higher in the Medicare group. Following adjusted analysis, patients with Medicaid insurance had significantly worse PF10a (IRR, 0.90, 95% CI 0.85-0.96), as well as PROMIS Global-Physical score (IRR 0.88, 95% CI 0.82-0.94), and VAS low back pain (IRR 1.20, 95% CI 1.04-1.40) when compared to the commercially insured.

CONCLUSIONS

We encountered worse physical function, mental, and pain-related patient-reported outcomes for those with Medicaid insurance in a population of patients presenting for evaluation of lumbar disc herniation. These findings, including worse depression, anxiety, and higher axial back pain scores, merit further investigation into potential health system asymmetries, and should be accounted for by treating providers.

Risk factors for failure to achieve minimal clinically important difference and significant clinical benefit in PROMIS computer adaptive test domains in patients undergoing rotator cuff repair

BACKGROUND

The Patient-Reported Outcomes Measurement Information System (PROMIS) has emerged as a valid and efficient means of collecting outcomes in patients with rotator cuff tears. The purpose of this study was to establish threshold score changes to determine minimal clinically important difference (MCID) and substantial clinical benefit (SCB) in PROMIS computer adaptive test (CAT) scores following rotator cuff repair (RCR). Additionally, we sought to identify potential risk factors for failing to achieve MCID and SCB.

METHODS

Patients undergoing arthroscopic RCR were identified over a 24-month period. Only patients who completed both preoperative and postoperative PROMIS CAT assessments were included in this cohort. PROMIS CAT forms for upper extremity physical function (PROMIS-UE), pain interference (PROMIS-PI), and depression (PROMIS-D) were used with a minimum of 1.5-year follow-up. Statistical analysis was performed to determine threshold score changes to determine anchor-based MCID and SCB, as well as risk factors for failure to achieve significant clinical improvement following surgery.

RESULTS

Of 198 eligible patients, 168 (84.8%) were included in analysis. ΔPROMIS-UE values of 5.8 and 9.7 (area under the curve [AUC] = 0.906 and 0.949, respectively) and ΔPROMIS-PI values of -11.4 and -12.9 (AUC = 0.875 and 0.938, respectively) were identified as threshold predictors of MCID and SCB achievement. On average, 81%, 65%, and 55% of patients achieved MCID for PROMIS-UE, PROMIS-PI, and PROMIS-D whereas 71%, 61%, and 38% of patients in the cohort, respectively, achieved SCB. MCID achievement in PROMIS-UE significantly differed according to risk factors, including smoking status (likelihood ratio [LR]: 9.8, P = .037), tear size (LR: 10.4, P < .001), distal clavicle excision (LR: 6.1, P = .005), and prior shoulder surgery (LR: 19.2, P < .001). Factors influencing SCB achievement for PROMIS-UE were smoking status (LR: 9.3, P = .022), tear size (LR: 8.0, P = .039), and prior shoulder surgery (11.9, P < .001). Significantly different rates of MCID and SCB achievement in PROMIS-PI for smoking status (LR: 7.0, P = .030, and LR: 5.2, P = .045) and prior shoulder surgery (LR: 9.1, P = .002, and LR: 7.4, P = .006) were also identified.

DISCUSSION AND CONCLUSION

The majority of patients showed clinically significant improvements that exceeded the established MCID for PROMIS-UE and PROMIS-PI following RCR. Patients with larger tear sizes, a history of prior shoulder surgery, tobacco users, and those who received concomitant distal clavicle excision were at risk for failing to achieve MCID in PROMIS-UE. Additionally, smokers and patients who underwent prior shoulder surgery demonstrated significantly lower improvements in pain scores following surgery.

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.

Depression and Anxiety Screening Identifies Patients That may Benefit From Treatment Regardless of Existing Diagnoses

Background

This study investigated the utility of depression and anxiety symptom screening in patients scheduled for total knee arthroplasty to examine differences in active symptoms according to patients' mental health diagnoses and associated prescription medications.

Material and methods

This cross-sectional study analyzed 594 patients scheduled for total knee arthroplasty at a tertiary practice between June 2018 and December 2018. Patients completed Patient-Reported Outcomes Measurements Information System (PROMIS) Depression and Anxiety Computerized Adaptive Tests in clinic quantifying active symptoms. Mental health diagnoses and associated medications were extracted from health records. Statistical analysis assessed between-group differences in mean PROMIS scores and the prevalence of heightened depressive and anxiety symptoms.

Results

Multivariable linear regression modeling demonstrated that being diagnosed with depression without medication (β 7.1; P < .001) and with medication (β 8.6; P < .001) were each associated with higher PROMIS Depression scores. Similar modeling demonstrated that patients diagnosed with anxiety and prescribed an anxiolytic (β 8.4; P < .001) were associated with higher PROMIS Anxiety scores than undiagnosed patients. Eighty-six (15%) patients experienced heightened anxiety and/or depressive symptoms. Heightened depressive symptoms were more prevalent among those diagnosed with depression (19% without medication, 24% with antidepressant vs 5% undiagnosed: P < .001). Heightened anxiety symptoms were most prevalent among those diagnosed with anxiety and on anxiolytic medication (25% vs 7% diagnosed with anxiety without medication, 8% undiagnosed: P < .001).

Conclusion

One in seven arthroplasty patients screened reported heightened depressive and/or anxiety symptoms. Despite the majority of arthroplasty patients on antidepressants and anxiolytics having symptoms controlled, these patients remain at increased risk of heightened active symptoms.

Outcomes following surgical treatment of distal radial fracture: a comparison of older and younger patients using PROMIS

The purpose of this study was to assess the recovery patterns following surgery for distal radial fracture (DRF) in patients over (n = 99) and under (n = 273) the age of 65 using the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) questionnaires. Both the older and younger cohorts showed postoperative improvement in PF and PI. The younger cohort had higher PF scores from 1 to 6 months postoperatively, however, PI scores were not significantly different between the cohorts during any period. A greater proportion of younger patients achieved the minimal clinically important difference improvement on the PROMIS PF (80% versus 66%) and PI (88% versus 75%) scales. To appropriately manage postoperative expectations, older patients should be counselled that they would likely experience most of their functional recovery by 3 months and limitations due to pain would likely be stable by 1 month.Level of evidence: II.

How Do PROMIS Scores Correspond to Common Physical Abilities?

BACKGROUND

The Patient-Report Outcomes Measurement Information System (PROMIS) is increasingly used as a general-purpose tool for measuring orthopaedic surgery outcomes. This set of questionnaires is efficient, precise, and correlates well with specialty-specific measures, but impactful implementation of patient-specific data, especially at the point of care, remains a challenge. Although clinicians may have substantial experience with established patient-reported outcome measures in their fields, PROMIS is relatively new, and the real-life meaning of PROMIS numerical summary scores may be unknown to many orthopaedic surgeons.

QUESTIONS/PURPOSES

We aimed to (1) identify a small subset of important items in the PROMIS Physical Function (PF) item bank that are answered by many patients with orthopaedic conditions and (2) graphically display characteristic responses to these items across the physical function spectrum in order to translate PROMIS numerical scores into physical ability levels using clinically relevant, familiar terms.

METHODS

In a cross-sectional study, 97,852 PROMIS PF assessments completed by 37,517 patients with orthopaedic conditions presenting to a tertiary-care academic institution were pooled and descriptively analyzed. Between 2017 and 2020, we evaluated 75,354 patients for outpatient orthopaedic care. Of these, 67% (50,578) were eligible for inclusion because they completed a PROMIS version 2.0 physical function assessment; 17% (12,720) were excluded because they lacked information in the database on individual item responses, and another < 1% (341) were excluded because the assessment standard error was greater than 0.32, leaving 50% of the patients (37,517) for analysis. The PROMIS PF is scored on a 0-point to 100-point scale, with a population mean of 50 and SD of 10. Anchor-based minimum clinically important differences have been found to be 8 to 10 points in a foot and ankle population, 7 to 8 points in a spine population, and approximately 4 points in a hand surgery population. The most efficient and precise means of administering the PROMIS PF is as a computerized adaptive test (CAT), whereby an algorithm intelligently tailors each follow-up question based on responses to previous questions, requiring only a few targeted questions to generate an accurate result. In this study, the mean PROMIS PF score was 41 ± 9. The questions most frequently used by the PROMIS CAT software were identified (defined in this study as any question administered to > 0.1% of the cohort). To understand the ability levels of patients based on their individual scores, patients were grouped into score categories: < 18, 20 ± 2, 25 ± 2, 30 ± 2, 35 ± 2, 40 ± 2, 45 ± 2, 50 ± 2, 55 ± 2, 60 ± 2, and > 62. For each score category, the relative frequency of each possible response (ranging from "cannot do" to "without any difficulty") was determined for each question. The distribution of responses given by each score group for each question was graphically displayed to generate an intuitive map linking PROMIS scores to patient ability levels (with ability levels represented by how patients responded to the PROMIS items).

RESULTS

Twenty-eight items from the 165-question item bank were used frequently (that is, administered to more than 0.1% of the cohort) by the PROMIS CAT software. The top four items constituted 63% of all items. These top four items asked about the patient's ability to perform 2 hours of physical labor, yard work, household chores, and walking more than 1 mile. Graphical displays of responses to the top 28 and top four items revealed how PROMIS scores correspond to patient ability levels. Patients with a score of 40 most frequently responded that they experienced "some difficulty" with physical labor, yard work, household chores, and walking more than 1 mile, compared with "little" or "no" difficulty for patients with a score of 50 and "cannot do" for patients with a score of 30.

CONCLUSION

We provided a visual key linking PROMIS numerical scores to physical ability levels using clinically relevant, familiar terms. Future studies might investigate whether using similar graphical displays as a patient education tool enhances patient-provider communication and improves the patient experience.

CLINICAL RELEVANCE

The visual explanation of PROMIS scores provided by this study may help new users of the PROMIS understand the instrument, feel empowered to incorporate it into their practices, and use it as a tool for counseling patients about their scores.

There are more things in physical function and pain: a systematic review on physical, mental and social health within the orthopedic fracture population using PROMIS

Background

The Patient-Reported Outcomes Information System (PROMIS®) is more and more extensively being used in medical literature in patients with an orthopedic fracture. Yet, many articles studied heterogeneous groups with chronic orthopedic disorders in which fracture patients were included as well. At this moment, there is no systematic overview of the exact use of PROMIS measures in the orthopedic fracture population. Therefore this review aimed to provide an overview of the PROMIS health domains physical health, mental health and social health in patients suffering an orthopedic fracture.

Methods

This systematic review was documented according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. We searched Embase, Medline, Web of Science Core Collection, and Cochrane Central Register of controlled Trials, CINAHL and Google Scholar in December 2020 using a combination of MeSH terms and specific index terms related to orthopedic fractures and PROMIS questionnaires. Inclusion criteria were available full text articles that were describing the use of any PROMIS questionnaires in both the adult and pediatric extremity fracture population.

Results

We included 51 relevant articles of which most were observational studies (n = 47, 92.2%). A single fracture population was included in 47 studies of which 9 involved ankle fractures (9/51; 17.6%), followed by humeral fractures (8/51; 15.7%), tibia fractures (6/51; 11.8%) and radial -or ulnar fractures (5/51; 9.8%). PROMIS Physical Function (n = 32, 32/51 = 62.7%) and PROMIS Pain Interference (n = 21, 21/51 = 41.2%) were most frequently used questionnaires. PROMIS measures concerning social (n = 5/51 = 9.8%) and mental health (10/51 = 19.6%) were much less often used as outcome measures in the fracture population. A gradually increasing use of PROMIS questionnaires in the orthopedic fracture population was seen since 2017.

Conclusion

Many different PROMIS measures on multiple domains are available and used in previous articles with orthopedic fracture patients. With physical function and pain interference as most popular PROMIS measures, it is important to emphasize that other health-domains such as mental and social health can also be essential to fracture patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00440-3.

Establishing the Substantial Clinical Benefit in a Non-Shoulder Hand and Upper Extremity Population for the QuickDASH and PROMIS Upper Extremity and Physical Function Computer Adaptive Tests

PURPOSE

It is unclear what score changes on the abbreviated Disabilities of the Arm, Hand, and Shoulder (QuickDASH), Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) computer adaptive test (CAT), and PROMIS physical function (PF) CAT represent a substantial improvement. We calculated the substantial clinical benefit (SCB) for these 3 instruments in a non-shoulder hand and upper extremity population.

METHODS

Adult patients treated between March 2015 and September 2019 at a single academic tertiary institution were identified. The QuickDASH, PROMIS UE CAT v2.0, and PROMIS PF CAT v2.0 scores were collected using a tablet computer. Responses to the QuickDASH both at baseline and follow-up 6 ± 4 weeks later, and a response to the anchor question "Compared to your first evaluation at the University Orthopaedic Center, how would you describe your physical function level now?" were required for inclusion. A second anchor question querying treatment-related improvement was also used. The SCB was calculated using an anchor-based approach comparing the mean change difference between groups reporting no change and a maximal change for both anchor questions.

RESULTS

Of 1,119 included participants, the mean age was 48 ± 17 years, 53% were women, and half were recovering from surgery. Score changes between baseline and follow-up were significantly different between groups reporting no improvement and maximal improvement on both anchor questions. The SCB values ranged between 16.9 and 22.8 on the QuickDASH, 5.9 and 7.1 on the UE CAT, and 3.5 and 6.7 on the PF CAT.

CONCLUSIONS

These score improvements for the QuickDASH, UE CAT, and PF CAT represent a substantial clinical improvement in a non-shoulder hand and upper extremity population.

CLINICAL RELEVANCE

These SCB estimates may assist with the interpretation of outcome scores at a population level.

Adding Centralized Electronic Patient-Reported Outcome Data Collection to an Established International Clinical Outcomes Registry

The importance of patient-reported outcomes (PROs) in cellular therapies, including hematopoietic cell transplantation (HCT) is highlighted in this study. Longitudinal collection of PROs in a registry is recommended for several reasons, yet to date, PROs are not routinely collected from HCT patients to augment clinical registry data. The aim of this study was to determine the feasibility of electronic PRO data collection by a national clinical outcomes registry, by assessing differences between who does and does not report PROs. We conducted a cross-sectional pilot collection of PROs from HCT recipients after treatment using computer-adapted tests from the Patient-Reported Outcome Measurement Information System (PROMIS). We implemented centralized data collection through the Center for International Blood and Marrow Transplant Research (CIBMTR) among patients who underwent HCT for myelodysplastic syndromes (MDS), were at least 6 months post-HCT, and spoke English or Spanish. The main objective was identifying patient, disease, and transplant-related differences associated with completion of electronic PROs. Patients were excluded from analysis if they were determined to be ineligible (deceased, did not speak English or Spanish, refused to be contacted by the CIBMTR). A total of 163 patients were contacted and potentially eligible to participate; of these, 92 (56%) enrolled and 89 (55%) completed the PRO assessment. The most frequent reason for incomplete surveys was inability to contact patients (n = 88), followed by declining to participate in the study (n = 37). There were no sociodemographic or age differences between those who completed the PRO survey (n = 89) and eligible nonresponders (n = 155). Patient scores were within 3 points of the US average of 50 for all symptoms and functioning except physical functioning. Responders and nonresponders did not exhibit meaningfully different sociodemographic characteristics. Difficulty contacting patients posed the greatest barrier and also provided the greatest opportunity for improvement. Once enrolled, survey completion was high. These results support standardizing centralized PRO data collection through the CIBMTR registry.

How Should We Measure Social Deprivation in Orthopaedic Patients?

BACKGROUND

Social deprivation negatively affects a myriad of physical and behavioral health outcomes. Several measures of social deprivation exist, but it is unclear which measure is best suited to describe patients with orthopaedic conditions.

QUESTIONS/PURPOSES

(1) Which measure of social deprivation, defined as "limited access to society's resources due to poverty, discrimination, or other disadvantage," is most strongly and consistently correlated with patient-reported physical and behavioral health in patients with orthopaedic conditions? (2) Compared with the use of a single measure alone, how much more variability in patient-reported health does the simultaneous use of multiple social deprivation measures capture?

METHODS

Between 2015 and 2017, a total of 79,818 new patient evaluations occurred within the orthopaedic department of a single, large, urban, tertiary-care academic center. Over that period, standardized collection of patient-reported health measures (as described by the Patient-reported Outcomes Measurement Information System [PROMIS]) was implemented in a staged fashion throughout the department. We excluded the 25% (19,926) of patient encounters that did not have associated PROMIS measures reported, which left 75% (59,892) of patient encounters available for analysis in this cross-sectional study of existing medical records. Five markers of social deprivation were collected for each patient: national and state Area Deprivation Index, Medically Underserved Area Status, Rural-Urban Commuting Area code, and insurance classification (private, Medicare, Medicaid, or other). Patient-reported physical and behavioral health was measured via PROMIS computer adaptive test domains, which patients completed as part of standard care before being evaluated by a provider. Adults completed the PROMIS Physical Function version 1.2 or version 2.0, Pain Interference version 1.1, Anxiety version 1.0, and Depression version 1.0. Children ages 5 to 17 years completed the PROMIS Pediatric Mobility version 1.0 or version 2.0, Pain Interference version 1.0 or version 2.0, Upper Extremity version 1.0, and Peer Relationships version 1.0. Age-adjusted partial Pearson correlation coefficients were determined for each social deprivation measure and PROMIS domain. Coefficients of at least 0.1 were considered clinically meaningful for this purpose. Additionally, to determine the percentage of PROMIS score variability that could be attributed to each social deprivation measure, an age-adjusted hierarchical regression analysis was performed for each PROMIS domain, in which social deprivation measures were sequentially added as independent variables. The model coefficients of determination (r2) were compared as social deprivation measures were incrementally added. Improvement of the r2 by at least 10% was considered clinically meaningful.

RESULTS

Insurance classification was the social deprivation measure with the largest (absolute value) age-adjusted correlation coefficient for all adult and pediatric PROMIS physical and behavioral health domains (adults: correlation coefficient 0.40 to 0.43 [95% CI 0.39 to 0.44]; pediatrics: correlation coefficient 0.10 to 0.19 [95% CI 0.08 to 0.21]), followed by national Area Deprivation Index (adults: correlation coefficient 0.18 to 0.22 [95% CI 0.17 to 0.23]; pediatrics: correlation coefficient 0.08 to 0.15 [95% CI 0.06 to 0.17]), followed closely by state Area Deprivation Index. The Medically Underserved Area Status and Rural-Urban Commuting Area code each had correlation coefficients of 0.1 or larger for some PROMIS domains but neither had consistently stronger correlation coefficients than the other. Except for the PROMIS Pediatric Upper Extremity domain, consideration of insurance classification and the national Area Deprivation Index together explained more of the variation in age-adjusted PROMIS scores than the use of insurance classification alone (adults: r2 improvement 32% to 189% [95% CI 0.02 to 0.04]; pediatrics: r2 improvement 56% to 110% [95% CI 0.01 to 0.02]). The addition of the Medically Underserved Area Status, Rural-Urban Commuting Area code, and/or state Area Deprivation Index did not further improve the r2 for any of the PROMIS domains.

CONCLUSION

To capture the most variability due to social deprivation in orthopaedic patients' self-reported physical and behavioral health, insurance classification (categorized as private, Medicare, Medicaid, or other) and national Area Deprivation Index should be included in statistical analyses. If only one measure of social deprivation is preferred, insurance classification or national Area Deprivation Index are reasonable options. Insurance classification may be more readily available, but the national Area Deprivation Index stratifies patients across a wider distribution of values. When conducting clinical outcomes research with social deprivation as a relevant covariate, we encourage researchers to consider accounting for insurance classification and/or national Area Deprivation Index, both of which are freely available and can be obtained from data that are typically collected during routine clinical care.

LEVEL OF EVIDENCE

Level III, therapeutic study.

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.

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 the Minimal Clinically Important Difference for the PROMIS Upper Extremity Computer Adaptive Test Version 2.0 in a Nonshoulder Hand and Upper Extremity Population

PURPOSE

Our primary purpose was to calculate the minimal clinically important difference (MCID) for the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) Computer Adaptive Test (CAT) version 2.0 (v2.0) for a nonshoulder hand and upper extremity population. Secondarily, we calculated the PROMIS Physical Function (PF) CAT v2.0 and the abbreviated version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) MCID.

METHODS

Adult patients treated by 1 of 5 fellowship-trained hand surgeons between March 2015 and September 2019 at an academic tertiary institution were identified. The PROMIS UE CAT v2.0, PROMIS PF CAT v2.0, and QuickDASH were collected via tablet computer. Inclusion required response to at least 1 of the instruments at both baseline and follow-up (6 ± 4 weeks), and a response to the anchor question: "Compared to your first evaluation at the University Orthopaedic Center, how would you describe your physical function level now?" An additional anchor question assessing treatment-related improvement was also asked. The MCID was calculated using an anchor-based approach using the mean change difference between groups reporting no change and slight change for both anchor questions, and with the 1/2 SD method.

RESULTS

Of 2,106 participants, mean age was 48 ± 17 years, 53% were female, and 53% were recovering from surgery. Of these patients, 381 completed the PROMISE UE CAT v2.0, 497 completed the PROMIS PF CAT v2.0, and 2,018 completed the QuickDASH. The score change between baseline and follow-up was significantly different between anchor groups for both anchor-based MCID calculations. Anchor-based MCID values were 3.0 to 4.0 for the UE CAT, 2.1 to 3.6 for the PF CAT, and 10.3 for the QuickDASH. The MCID values per the 1/2 SD method were 4.1, 4.1, and 10.2, respectively.

CONCLUSIONS

We propose MCID ranges of 3.0 to 4.1 for the PROMIS UE CAT v2.0, and 2.1 to 4.1 for the PROMIS PF CAT v2.0. The observed QuickDASH MCID values (10.2-10.3) are within the range of previously published values.

CLINICAL RELEVANCE

These MCID estimates will aid in interpreting clinical outcomes and in powering clinical studies.

Multidimensional Perioperative Recovery Trajectories in a Mixed Surgical Cohort: A Longitudinal Cluster Analysis Utilizing National Institutes of Health Patient-Reported Outcome Measurement Information System Measures

BACKGROUND

Pain trajectories have been described in numerous surgical settings where preoperative characteristics have been used to predict trajectory membership. Suboptimal pain intensity trajectories have been linked to poor longitudinal outcomes. However, numerous biopsychosocial modulators of postoperative pain may also have distinct longitudinal trajectories that may inform additional targets to improve postoperative recovery.

METHODS

Patients undergoing total joint arthroplasty, thoracic surgery, spine surgery, major abdominal surgery, or mastectomy completed Patient Reported Outcome Measurement Information System (PROMIS) measures and additional scales preoperatively and at 1 week, 2 weeks, 1 month, 3 months, and 6 months postoperatively. A k-means clustering for longitudinal data was utilized to explore and describe distinct pain impact (PROMIS Pain Interference and Physical Function) trajectories and associated changes in additional biopsychosocial measures. Follow-up analyses examined participant demographics and clinical characteristics associated with trajectory memberships.

RESULTS

Three postoperative biopsychosocial symptom clusters were identified across all patients (n = 402): low (35%), average (47%), and high (18%) performance cluster trajectories. Participants undergoing total knee arthroplasty (TKA), spinal surgery, reporting presurgical opioid use, and higher pain catastrophizing scale scores were found to be associated with the low performance trajectory. Patients within the low performance trajectory, while demonstrating small improvements by 6 months, remained mild to moderately impaired in both pain impact and physical health outcomes. Alternatively, participants in the average performance trajectory demonstrated improvement in pain impact to population norms compared to baseline and demonstrated continued improvement across physical and psychological outcomes. Patients within the high performance cluster started within population norms across all measures at baseline and returned to baseline or exceeded baseline values by 6 months postoperatively. Self-reported opioid utilization was significantly higher in the low performance cluster across all time points. While a larger proportion of average performance patients reported opioid utilization during the first postoperative month compared to the high performance cluster, no differences were detected at 6 months postoperatively between these 2 clusters.

CONCLUSIONS

These pain impact trajectories build upon previous unidimensional pain intensity trajectories and suggest that additional distinct biopsychosocial measures may have unique trajectories related to cluster assignment. Additionally, these findings highlight the importance of continued pain impact surveillance through the perioperative recovery period to detect patients at risk of experiencing a poor trajectory and subsequently poor longitudinal health outcomes.

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.

The Minimal Clinically Important Difference for PROMIS Physical Function in Patients With Thumb Carpometacarpal Arthritis

Background: This study was performed to determine the minimal clinically important difference (MCID) of Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) computer adaptive test (CAT) for patients with thumb carpometacarpal (CMC) arthritis. Methods: This study retrospectively analyzed data from 152 adults receiving surgical and nonsurgical care for unilateral thumb CMC arthritis at a single institution between January 2016 and January 2018. Patients completed PROMIS PF v1.2/2.0 CAT at each visit. At follow-up, patients also completed two 6-item anchor questions assessing the degree of perceived improvement. Statistical testing analyzed the ability of the clinical anchor to discriminate levels of improvement. An anchor-based MCID estimate was calculated as the mean PROMIS PF change score in the mild improvement group. The anchor-based MCID value was examined for the influence of patient age, initial and final PROMIS scores, and follow-up interval. A distribution-based MCID value was calculated incorporating the standard error of measurement and effect size. Results: The change in PROMIS PF scores was significantly different between encounters where patients reported no change, mild improvement, and much improvement. The anchor-based MCID estimate for PROMIS PF was 3.9 (95% confidence interval, 3.3-4.7). Individual MCID values were weakly correlated with the final absolute PROMIS PF score but did not correlate with patient age, time between visits, or the initial absolute PROMIS PF score. The distribution-based MCID value was 3.5 (95% confidence interval, 3.1-3.9). Conclusions: The estimated range of MCID values for PROMIS PF is 3.5 to 3.9 points in patients treated for thumb CMC arthritis.

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 Between Patient-Reported Outcome Measures and Health Insurance Provider Types in Patients with Hip Osteoarthritis

BACKGROUND

Patient-reported outcome measures (PROMs) are frequently utilized to assess patient perceptions of health and function. Numerous factors influence self-reported physical and mental health outcome scores. The purpose of this study was to examine if an association exists between insurance payer type and baseline PROM scores in patients diagnosed with hip osteoarthritis.

METHODS

We retrospectively reviewed the baseline PROM scores of 5,974 patients diagnosed with hip osteoarthritis according to the International Classification of Diseases, Tenth Revision (ICD-10) code within our institutional database from 2015 to 2020. We examined Hip disability and Osteoarthritis Outcome Score-Physical Function Short-form (HOOS-PS), Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Short Form 10a (PF10a), PROMIS Global-Mental, and PROMIS Global-Physical scores. Descriptive analyses, analysis of variance (ANOVA), analysis of covariance (ANCOVA), and post hoc analyses were utilized to assess variations in PROM scores across insurance type.

RESULTS

The mean age (and standard deviation) of the study population was 63.5 ± 12.2 years, and 55.7% of patients were female. The Medicaid cohort had a comparatively higher percentage of Black, Hispanic, and non-English-speaking patients and a lower median household income. The Charlson Comorbidity Index was highest in the Medicare and Medicaid insurance cohorts. Patients utilizing commercial insurance consistently demonstrated the highest baseline PROMs, and patients utilizing Medicaid consistently demonstrated the lowest baseline PROMs. Subsequent analyses found significantly poorer mean scores for the Medicaid cohort for all 4 PROMs when compared with the commercial insurance and Medicare cohorts. These score differences exceeded the minimal clinically important differences (MCIDs). For the PROMIS Global-Mental subscore, a significantly lower mean score was observed for the Workers' Compensation and motor vehicle insurance cohort when compared with the commercial insurance and Medicare cohort. This difference also exceeded the MCID.

CONCLUSIONS

PROM scores in patients with hip osteoarthritis varied among those with different insurance types. Variations in certain demographic and health indices are potential drivers of these observed baseline PROM differences. For patients with hip osteoarthritis, the use of PROMs for research, clinical, or quality-linked payment metrics should acknowledge baseline variation between patients with different insurance types.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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.

Outcome Measurement for Distal Radius Fractures

Distal radius fractures (DRFs) are among the most common upper extremity injuries. Multiple medical conditions now are evaluated by standardized outcome sets that enable comparability. Recent international working groups have provided consensus statements for outcomes measurement after DRFs. These statements emphasized the growing importance of patient-reported outcome measures as well as traditional measures, including pain assessment, radiographic alignment, performance, and assessment of complications. A standardized instrument and timeline for measuring outcomes following DRFs offers clinicians, researchers, and health care economists a powerful tool. This article reviews the current evidence and provides recommendations for a DRF standardized outcome set.

A Critical Assessment of the Most Cited Papers on Distal Radius Fractures

This article reviews the impact of the most cited works on distal radius fractures. Judged by the most cited works in this field, distal radius fracture research has followed other paradigm shifts in the history of science. Landmark papers showed that restoring premorbid anatomy led to better outcomes, and a plurality of fixation strategies emerged. A breakthrough in technology came with volar plating, and the new paradigm emerged: precise anatomic reduction is achieved typically with volar plates, unless fragment-specific approaches are needed. This paradigm is being challenged as the association among malunion, arthritis, and function continues to be understood. The best treatment of distal radius fractures in the elderly has also evolved through time.

Is Social Deprivation Associated with PROMIS Outcomes After Upper Extremity Fractures in Children?

BACKGROUND

We previously found that social deprivation was associated with worse perceived function and pain among children presenting with upper extremity fractures. We performed the current study to determine whether this differential in outcome scores would resolve after children received orthopaedic treatment for their fractures. This was needed to understand whether acute pain and impaired function were magnified by worse social deprivation or whether social deprivation was associated with differences in health perception even after injury resolution.

QUESTIONS/PURPOSES

Comparing patients from the least socially deprived national quartile and those from the most deprived quartile, we asked: (1) Are there differences in age, gender, race, or fracture location among children with upper extremity fractures? (2) After controlling for relevant confounding variables, is worse social deprivation associated with worse self-reported Patient-Reported Outcomes Measurement Information System (PROMIS) scores before and after the treatment of pediatric upper extremity fractures? (3) Is social deprivation associated with PROMIS score improvements as a result of fracture treatment?

METHODS

In this this retrospective, comparative study, we considered data from 1131 pediatric patients (aged 8 to 17 years) treated nonoperatively at a single tertiary academic medical center for isolated upper extremity fractures between June 2016 and June 2017. We used the Area Deprivation Index to define the patient's social deprivation by national quartiles to analyze those in the most- and least-deprived quartiles. After excluding patients with missing zip codes (n = 181), 18% (172 of 950) lived in the most socially deprived national quartile, while 31% (295 of 950) lived in the least socially deprived quartile. Among these 467 patients in the most- and least-deprived quartiles, 28% (129 of 467) were excluded for lack of follow-up and 9% (41 of 467) were excluded for incomplete PROMIS scores. The remaining 297 patients were analyzed (107 most-deprived quartile, 190 least-deprived quartile) longitudinally in the current study; they included 237 from our initial cross-sectional investigation that only considered reported health at presentation (60 patients added and 292 removed from the 529 patients in the original study, based on updated Area Deprivation Index quartiles). The primary outcomes were the self-completed pediatric PROMIS Upper Extremity Function, Pain Interference, and secondarily PROMIS Peer Relationships computer-adaptive tests. In each PROMIS assessment, higher scores indicated more of that domain (such as, higher function scores indicate better function but a higher pain score indicates more pain), and clinically relevant differences were approximately 3 points. Bivariate analysis compared patient age, gender, race, fracture type, and PROMIS scores between the most- and least-deprived groups. A multivariable linear regression analysis was used to determine factors associated with the final PROMIS scores.

RESULTS

Between the two quartiles, the only demographic and injury characteristic difference was race, with Black children being overrepresented in the most-deprived group (most deprived: white 53% [57 of 107], Black 45% [48 of 107], other 2% [2 of 107]; least deprived: white 92% [174 of 190], Black 4% [7 of 190), other 5% [9 of 190]; p < 0.001). At presentation, accounting for patient gender, race, and fracture location, the most socially deprived quartile remained independently associated with the initial PROMIS Upper Extremity (β 5.8 [95% CI 3.2 to 8.4]; p < 0.001) scores. After accounting for patient gender, race, and number of days in care, we found that the social deprivation quartile remained independently associated with the final PROMIS Upper Extremity (β 4.9 [95% CI 2.3 to 7.6]; p < 0.001) and Pain Interference scores (β -4.4 [95% CI -2.3 to -6.6]; p < 0.001). Social deprivation quartile was not associated with any differential in treatment impact on change in PROMIS Upper Extremity function (8 ± 13 versus 8 ± 12; mean difference 0.4 [95% CI -3.4 to 2.6]; p = 0.79) or Pain Interference scores (8 ± 9 versus 6 ± 12; mean difference 1.1 [95% CI -1.4 to 3.5]; p = 0.39) from presentation to the conclusion of treatment.

CONCLUSION

Delivering upper extremity fracture care produces substantial improvement in pain and function that is consistent regardless of a child's degree of social deprivation. However, as social deprivation is associated with worse perceived health at treatment initiation and conclusion, prospective interventional trials are needed to determine how orthopaedic surgeons can act to reduce the health disparities in children associated with social deprivation. As fractures prompt interaction with our health care system, the orthopaedic community may be well placed to identify children who could benefit from enrollment in proven community health initiatives or to advocate for multidisciplinary care coordinators such as social workers in fracture clinics.

LEVEL OF EVIDENCE

Level III, therapeutic study.

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.

Relevance of Diagnosed Depression and Antidepressants to PROMIS Depression Scores Among Hand Surgical Patients

PURPOSE

We aimed to test the utility of screening for depressive symptoms in the hand surgical office focusing on chances of heightened depressive symptoms in patients with no history of diagnosed depression and by quantifying ongoing depressive symptoms among patients diagnosed with depression accounting for antidepressant use. The clinical importance of this study was predicated on the documented negative association between depressive symptoms and hand surgical outcomes.

METHODS

This cross-sectional study analyzed 351 patients presenting to a tertiary hand center between April 21, 2016, and November 22, 2017. Adult patients completed self-administered Patient-Reported Outcomes Measurement Information System (PROMIS) Depression computer adaptive tests at registration. Health records were examined for a past medical history of diagnosed depression and whether patients reported current use of prescription antidepressants. Mean PROMIS Depression scores were compared by analysis of variance (groups: no diagnosed depression, depression without medication, depression with medication). Four points represented a clinically relevant difference in PROMIS Depression scores between groups and Depression scores greater than 59.9 were categorized as having heightened depressive symptoms.

RESULTS

Sixty-two patients (18%) had been diagnosed with depression. Thirty-four of these patients (55%) reported taking antidepressant medications. The PROMIS Depression scores indicated greater current depressive symptoms among patients with a history of diagnosed depression when not taking antidepressants (11 points worse than unaffected) and also among patients taking antidepressants (7 points worse than unaffected). Heightened depressive symptoms were detected in all groups but were more prevalent among those diagnosed with depression (36% with no medication, 29% with antidepressant medication) compared with unaffected patients (7%).

CONCLUSIONS

Depression screening for heightened depressive symptoms identifies 1 in 14 patients without diagnosed depression and 1 in 3 patients diagnosed with depression as having currently heightened depressive symptoms. Hand surgeons can use PROMIS Depression screening in all patients and using this to guide referrals for depression treatment to ameliorate one confounder of hand surgical outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Symptom prevalence study II.