PROMIS Upper Extremity underperforms psychometrically relative to American Shoulder and Elbow Surgeons score in patients undergoing primary rotator cuff repair

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Analysis of factors associated with patient-reported outcome (PRO) score completion rate one year after shoulder surgeries

Background

Patient-reported outcome measurements (PROMs) are important metrics for monitoring improvements following shoulder surgery. Despite the easy accessibility of electronic PROM surveys, completion rates vary, and factors predictive of survey completion for patients enrolled in medical survey follow-up after shoulder surgery remain largely unknown. The purpose of this study is to investigate survey completion rates for common shoulder procedures and identify factors predictive of PROM completion at one-year postoperatively. We hypothesize that the response rate to shoulder PROMs may vary by the shoulder procedure type after surgery.

Methods

Patients undergoing total shoulder arthroplasty (TSA), rotator cuff repair (RCR), and instability surgery (Latarjet procedure [LP], and arthroscopic Bankart repair [ABR]) from 2019 to 2021 were prospectively enrolled. Each patient was administered PROM surveys via email preoperatively and at 2-weeks, 6-weeks, 3-months, 6-months, and 12-months following surgery. Demographics and socioeconomic characteristics were collected from our institutional database. The primary outcome studied was survey completion rate by procedure. Multivariable logistic regression was performed to identify factors predictive of completing 12-month follow-up.

Results

A total of 514 (251 TSA, 194 RCR, and 69 instability surgery (35 LP, 34 ABR)) patients with an average age of 58 ± 15 years were included in this study. Overall, the 12-month survey completion rate for all procedures was 57.2%. TSA had the highest completion rate (64.9%), followed by RCR (52.1%), ABR (44.2%), and LP (42.9%). ABR and LP demonstrated more than a 50% drop in survey response at 2 weeks, and the RCR cohort demonstrated an increased attrition in survey response at the 6-month mark. Patients who completed the 12-month follow-up survey were older [61 ± 14 vs. 54 ± 17; P < .001], less frequently self-identified as Hispanic [13% vs. 23%; P = .009], less frequently single [32% vs. 44%; P = .008], and most frequently classified as the American Society of Anesthesiology [ASA] score II [65%, P = .001].

Conclusion

Postoperative PROM survey completion rates vary significantly among commonly performed shoulder procedures during the first year after surgery. Hispanic ethnicity and younger age were all predictive of a lower propensity, and the TSA procedure is predictive of higher odds for PROM survey completion at the 12-month follow-up.

Longitudinal Analysis of the ASES and Constant-Murley Scores, and the Internal Rotation/Shift and Jobe Tests Following Arthroscopic Repair of Supraspinatus Lesions

It is essential to investigate patients post-surgery using functional surveys like the American Shoulder and Elbow Surgeons Shoulder (ASES) and the Constant-Murley shoulder (CMS) scores, as well as clinical tests, such as the Internal Rotation and Shift (IRO/Shift) and Jobe tests. In this study, 51 out of an initial 87 patients underwent an arthroscopic supraspinatus repair (22 single-row, 16 double-row, 13 debridement). Testing occurred pre-surgery, and 3 and 6 months post-surgery. Both surveys showed significant improvements over time among all 87 patients, but there were no differences between groups (lesion/no lesion) (p > 0.815) or time × group (p > 0.895). The IRO/Shift test showed a stronger ability to distinguish between both groups (positive vs. negative) with respect to the ASES and CMS scores over time, but the Jobe test did not (p > 0.100). Improvements in the CMS scores and the Jobe test were lower following repair compared to the ASES and IRO/Shift test. Most patients returned to adequate levels of functional abilities at 6 months post-surgery. The time required to return to activities of daily living and negative clinical tests was longer for the double-row repair patients compared to the single-row and debridement groups. In conclusion, both the functional surveys and the clinical tests demonstrated improvements following surgery.

Anxiety and Depressive Symptoms Correlated to Patient-Reported Outcome Measures after Rotator Cuff Repair: A Prospective Study in the Perioperative Period

Anxiety and depressive symptoms adversely affect surgical outcomes in patients with rotator cuff tear (RCT) undergoing surgical repair. Patients without a diagnosis of mood disorders, such as anxiety and depression, before rotator cuff repair (RCR) can be considered an optimal candidate for surgery. The objective of this prospective observational study was to evaluate the relationship between anxiety and depressive symptoms, using the Hospital Anxiety and Depression Scale (HADS) as an assessment tool, and patient-reported outcome measures in RCT after repair surgery. This study included patients with RCT undergoing arthroscopic rotator cuff repair (RCR). Forty-three patients were included who had completed the HADS, Constant Murley Score (CMS), and Short Form Health Survey 36 (SF-36) questionnaires before surgery and in the postoperative follow-up, at 1 month, 3 months, and 6 months. The Friedman test showed that there were statistically significant changes in the different times point for HADS (p < 0.001), anxiety subscale of HADS, i.e., HADS-A (p < 0.001), depression subscale of HADS, i.e., HADS-D (p < 0.001), CMS (p < 0.001), and SF-36 (p < 0.001). The average scores of HADS, HADS-A, and HADS-D improved at each follow-up, showing improvement in discomfort. From the third month after surgery, there was an improvement in anxiety and depression disorders related to improved quality of life, functionality, and pain perception. The trend remained stable until the sixth month of follow up. This study shows that anxiety and depressive symptoms in RCT patients are significantly reduced after RCR with subsequent important improvements in terms of functionality, ability to carry out activities of daily living, perceived pain, and quality of life.

Determining the Time Required to Achieve Clinically Significant Outcomes on the PROMIS Upper Extremity Questionnaire After Arthroscopic Rotator Cuff Repair

Background

Clinically significant outcome (CSO) thresholds for the Patient-Reported Outcome Measurement Information System-Upper Extremity (PROMIS-UE) score have been previously defined after arthroscopic rotator cuff repair (RCR). However, the time required to achieve CSOs for the PROMIS-UE score is unknown.

Purpose

To (1) determine the time required to achieve the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptom State (PASS) score thresholds after RCR for the PROMIS-UE questionnaire and (2) identify patient factors associated with earlier or delayed achievement of these clinical benchmarks.

Study Design

Case-control study; Level of evidence, 3.

Methods

A prospectively maintained institutional database was retrospectively reviewed for consecutive patients who underwent RCR between January 2018 and January 2019. Patients were included if they completed the PROMIS-UE questionnaire both preoperatively and at standardized postoperative time intervals: 5 to 7 months (6-month time point), 11 to 13 months (1-year time point), and ≥23 months (2-year time point). Kaplan-Meier survival curves with interval censoring were used to define the cumulative percentage of patients who achieved the MCID, SCB, and PASS. Patient variables associated with earlier or delayed achievement of the MCID, SCB, and PASS were determined using Weibull parametric survival regression analysis.

Results

Included were 105 patients undergoing RCR (age, 57.3 ± 10.3 years; body mass index, 31.5 ± 6.1 kg/m²). By 2-year follow-up, the cumulative percentage of patients achieving the MCID, SCB, and PASS was 86.7%, 76.2%, and 74.3%, respectively. The mean time required to reach the MCID, SCB, and PASS score thresholds was 9.5 ± 3.8, 10.3 ± 4.4, and 9.8 ± 4.6 months, respectively. Factors associated with delayed achievement of CSOs included greater baseline PROMIS-UE score (MCID and SCB) and workers' compensation insurance (PASS). Greater baseline PROMIS-UE scores were associated with earlier achievement of the PASS.

Conclusion

Most patients achieved CSOs for the PROMIS-UE within 12 months of RCR. Patient-specific factors found to be associated with earlier or delayed achievement of CSOs can be used to inform patient discussions on the expected timeline for recovery after RCR.

Excellent Correlation of the Patient-Reported Outcomes Measurement Information System Upper Extremity Score With Legacy Outcome Scores Preoperatively and at 1 Year After Arthroscopic Rotator Cuff Repair

Purpose

To assess the preoperative and postoperative performance of the Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS-UE, version 2.0) outcome score in comparison to the American Shoulder and Elbow Surgeons (ASES) and Western Ontario Rotator Cuff Index (WORC) instruments in patients undergoing rotator cuff repair.

Methods

This prospective longitudinal study included 91 patients undergoing rotator cuff repair. Patients completed the PROMIS-UE, ASES, and WORC instruments preoperatively and postoperatively at 2 weeks, 6 weeks, 3 months, and 12 months. The Pearson correlation coefficient (r) between these tools was calculated at each time point. Correlations were graded as excellent (>0.7), excellent-good (0.61-0.7), good (0.4-0.6), or poor (<0.4). Responsiveness to change was assessed using the effect size and the standardized response mean. Floor and ceiling effects for each instrument were also assessed.

Results

The PROMIS-UE instrument showed good to excellent correlation with the legacy instruments at all time points. There were variations in the measured effect sizes of the various instruments, with the PROMIS-UE instrument showing responsiveness to change at 3 and 12 months but the ASES and WORC instruments showing responsiveness at 6 weeks, 3 months, and 12 months. Both PROMIS-UE and ASES scores displayed ceiling effects at 12 months.

Conclusions

The PROMIS-UE instrument shows excellent correlation with the ASES instrument and a rotator cuff-specific outcome instrument-the WORC instrument-preoperatively and at 1 year after arthroscopic rotator cuff repair. Variations in the measured effect sizes at different postoperative time points and high ceiling effects of the PROMIS-UE instrument at the 1-year time point may limit its utility in the early postoperative phase and at long-term follow-up after rotator cuff repair.

Clinical Relevance

The performance of the PROMIS-UE outcome measure after arthroscopic rotator cuff repair was investigated.