What is the effect of socioeconomic status on patients with glenohumeral osteoarthritis?

 Lower Socioeconomic Status Is Associated With Worse Preoperative Function, Pain, and Increased Opioid Use in Patients With Primary Glenohumeral Osteoarthritis

These authors sought to characterize the role of socioeconomic status (SES) in 982 patients undergoing primary anatomic total shoulder arthroplasty (TSA) for primary glenohumeral osteoarthritis (OA).

They assessed patient demographics, comorbidities, patient-reported outcome scores, range of motion, and preoperative opioid use. Each patient was assigned to a quartile according to the Area Deprivation Index (ADI) using their home address (see this link).

The map for Texas shows a huge variation in the ADI, ranging from most disadvantaged 
(dark red) to least disadvantaged (blue).

They found that the most disadvantaged patients (lower SES) had 

a higher body mass index

higher rates of preoperative opioid use 

higher rates of diabetes.

more preoperative pain (Constant—Pain and American Shoulder and Elbow Surgeons [ASES]—Pain) and

lower function (Constant—ADL, Constant—Total, and ASES). 

Multivariate regression identified that male patients and advanced age at surgery had better reported ASES pain scores, while preoperative opioid use, chronic back pain, and the most disadvantaged quartile were associated with worse ASES pain scores.

Comment: This study provides a means for stratifying an important characteristic of patients having shoulder arthroplasty: their socioeconomic status. The authors suggest that the area deprivation index is a better measure of socioeconomic status than insurance status alone because its methodology accounts for factors such as income/poverty, education, employment, housing, and occupation.

A notable finding of this study is that SES was directly correlated with the preoperative patient assessed comfort and function as shown below

This is important because preoperative ASES score is recognized as a strong predictor of the postoperative ASES score.

This study suggests that patients who are identified as socioeconomically disadvantaged are likely to benefit from preoperative attention to their overall health, nutrition, pain management and home support systems.

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Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

Shoulder arthritis - x-ray appearance (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Does PROMIS have promise?

Correlation of Patient Reported Outcome Measurement Information System (PROMIS) with American Shoulder and Elbow Surgeon (ASES), and Constant (CS) scores in Idiopathic Adhesive Capsulitis


These authors sought to correlate the Patient Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE) score with preexisting validated outcomes scores, American Shoulder and Elbow Surgeons score (ASES), and Constant score (CS) in patients with idiopathic adhesive capsulitis (AC).

The final cohort included 100 patients with AC of which there were 72% female and 87% right hand dominant, with a mean age of 55 years.

The PROMIS UE required fewer question responses (5.02 ±1.84) compared to the fixed questions burden with ASES (12) and CS (9).

The PROMIS UE displayed excellent correlation with both the ASES (r = 0.80, 95% [CI:20 0.72, 0.86], p < 0.001) and CS (r = 0.76, 95% CI [0.67, 0.83], p < 0.001).

Neither ceiling nor floor effects were present.

The authors concluded that "the PROMIS UE displayed comparable efficacy to commonly used legacy outcome scores (ASES and CS) in adhesive capsulitis. A lower question burden with the PROMIS UE carries a potential for wider acceptibility with the researchers and patients with shoulder pathology"

Comment: Reports on the use of PROMIS need to examined in the light of "what question should we be asking?" The wonderful benefit of simple patient reported outcome measures (ASES, Simple Shoulder Test), is that they are inexpensive and easily accessible to patients in clinic and at their homes (mail, email, on line) so that long term followup of the maximal number of patients is facilitated.

The Constant score fails in these regards because clinical  measurements are required using a goniometer and dynamometer which mandate that the patient return to the office for examination.

The PROMIS system also fails in these regards because access to a computer and training in the use of the system is required, both of which factors may interfere with patient participation.

The observation that the PROMIS approach reduces the "question burden" from 12 to 5 does not offset its "access burden".

The key to clinical outcome research is facilitating the long term followup for the maximum number of patients. Evidence is lacking that the PROMIS approach is helpful in this regard.

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How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Reverse total shoulder - a problem with the Constant score: 'significant' improvement may not be recognized by the patient

The minimal clinically important difference for function and strength in patients undergoing reverse shoulder arthroplasty.

These authors conducted a prospective longitudinal study of 60 patients with a cuff-deficient shoulder treated with a reverse total should (RSA). The Constant score was recorded before surgery and at a 1-year follow-up assessment. At the 1-year follow-up, all patients also filled out a 15-item anchor questionnaire to assess their perception of change in their overall function, forward elevation, lateral rotation, internal rotation, and strength to determine the (minimal clinically important difference) MCID:

1. Compared to your presurgery state, how do you rate the overall function of your shoulder?
2. Compared to your presurgery state, how do you rate the strength of your shoulder?
3. Compared to your presurgery state, how do you rate the forward elevation of your arm?
4. Compared to your presurgery state, how do you rate the lateral rotation of your arm?
5. Compared to your presurgery state, how do you rate the internal rotation of your arm?

The purpose of this study was to determine the cutoff points for the items of the Constant score involved with function and strength. The meaning of the cutoff point is that patients who exceed it almost always perceive a benefit from the treatment performed. The cutoff points for overall function, forward elevation, lateral rotation, internal rotation, and strength in the Constant score were 8, 6, 2, 2, and 11.5 points, respectively.

While the overall Constant score domains of forward elevation, lateral rotation, and strength  (except for internal rotation) were each significantly improved at one year after surgery; only 46.7%, 20%, 50%, 45.8%, and 33.3% of the patients, respectively, exceeded the MCID on each domain after surgery.

The authors concluded that a statistically significant improvement in the Constant score can be expected after a RSA for a cuff-deficient shoulder, but a considerable number of patients do not reach the MCID in the function and strength domains. Small improvements in rotation are perceived to be beneficial by patients, whereas large improvements in forward elevation are required for the improvement to be perceived to be beneficial.

Comment: This is an important paper in that it contrasts the physician-assessed metrics of range of motion and strength with the patient-assessed metrics of perceived improvement. From their study we see that it is easier to show 'statistically significant' improvement in the former than in the latter. In that delivering improvement perceived by the patient is our goal, we may need to focus more on patient-reported outcomes.

The Constant-Murley score is divided into four subscales: pain (15 points), activities of daily living (20 points), strength (25 points) and range of motion: forward elevation, external rotation, abduction and internal rotation of the shoulder (40 points). Thus only 35% of the Constant score reflects the assessment of the patient. There are numerous other disadvantages of the Constant score: it requires the patient to return to the office for follow-up (making follow-up more difficult for patients who live at a distance), it has a risk of observer bias, and the measurements of range of motion and strength may not be standardized among different observers.

For these reasons, many surgeon investigators prefer patient reported outcomes - such as the Simple Shoulder Test - that enable follow-up whether or not the patient is able to return to the office, are free from observer bias, and that do not require standardization of those making measurements.

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Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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Reverse total shoulder - what outcome score to use?

Assessment of the optimal shoulder outcome score for reverse shoulder arthroplasty

These authors used a database of 148 patients having reverse total shoulders to compare preoperative and postoperative Constant-Murley Scores, American Shoulder and Elbow Surgeons Scores, and Subjective Shoulder Values.

They found no significant differences in the mean improvement between the scores.  Multivariate regression analysis the 3 outcome measures was able to predict 38.9% of the variation in improvement in forward elevation.

The authors concluded that the 3 shoulder outcome scores, regardless of whether they were patient reported or physician based, appear to appropriately reflect improvements after RSA with equal validity.

Comment:  This study demonstrates that various outcome instruments can show the benefit of reverse total shoulder arthroplasty. So what is there to choose among them?

It seems to us that the goals of outcome scores are (1) to enable each surgeon to track his/her results so that those patients failing to improve can be identified and the reasons for those failures investigations and (2) to enable different surgeons to compare and contrast results with different surgical approaches for different pathologies.

Keeping in mind that there is a cost with administering and analyzing each score in each patient, we have sought to optimize the benefit / cost ratio for outcome assessment. This consistently leads to the Simple Shoulder Test, a test that is patient-derived, sensitive, validated, short (12 questions), easy to administer and covers the range of complaints of individuals with shoulder disorders. For fun, compare the effort needed to administer the Constant Score or the ASES score and decide if there is enough incremental value (if any) of these instruments to justify the increased cost of administration and analysis.

The use of the Simple Shoulder Test in evaluating reverse total shoulders is illustrated in the articles below:

What is a Successful Outcome Following Reverse Total Shoulder Arthroplasty?

Clinical outcomes of reverse total shoulder arthroplasty in patients aged younger than 60 years.

The use of the reverse shoulder prosthesis for the treatment of failed hemiarthroplasty for proximal humeral fracture

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Use the "Search" box to the right to find other topics of interest to you.


You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'



See from which cities our patients come.



See the countries from which our readers come on this post.

minimal clinically important difference (MCID) vs I/MPI

Investigating minimal clinically important difference for Constant score in patients undergoing rotator cuff surgery

There has been a recent fascination with the minimal clinically important difference as a unit of treatment effectiveness. These authors prospectively analyzed collected cohort of 802 consecutive shoulders with arthroscopically treated partial- or full-thickness rotator cuff tears.. The Constant score was measured preoperatively and at 3 months and 1 year postoperatively. At follow-up visits, the patients were asked a simple 2-stage question: Is the shoulder better or worse after the operation compared with the preoperative state? This single 2-level question was used as an indicator of patient satisfaction and as an anchor to calculate the MCID for the Constant score.

The preoperative Constant score averaged 53.1 (SD 17.2) in all patients, 56.2 (SD 17.4) in male patients, and 48.2 (SD 15.6) in female patients. Postoperatively at 3 months, the scores were 61.7 (SD 16.4) in all patients, 65.1 (SD 16.1) in male patients, and 56.8 (SD 15.5) in female patients.  At 3 months postoperatively, 92.2% of male patients and 87.2% of female patients were satisfied with the outcome (P= .027). The 3-month mean change estimate of MCID was 10.4 points.

Comment: As surgeons, our goal is to restore as much of the patient's lost function and comfort as possible. The problem with the MCID is that an improvement of 10 points from a Constant score of 10 to 20 is not the same as an improvement of 10 points from a Constant score of 60 to 70, in that it does not reflect the amount of improvement in relation to the improvement possible.  As an alternative, we have used the I/MPI or percent of possible improvement as metric for measuring the result of treatment. The I/MPI is easily calculated as:

(score at the time of follow-up - score before surgery) 

divided by 

(perfect score - score before surgery) 

The beauty of the I/MPI  is that it can be used for any scoring system (Constant, SST, WOMAC, UCLA,  ASES, etc). Thus, taking the example above, if a perfect score is 100 and the patient records 60 before and 70 after surgery (improving by the MCID), the I/MPI  is

(70 - 60)/(100 - 60) 

or 

25% (the patient improved 25% of the possible improvement).

On the other hand, if the patient records 10 before and 20 after surgery (again improving by the MCID), the I/MPI  is

(20-10)/(100 - 10) 

or 

11% (the patient improved 11% of the possible improvement).

The I/MPI  (percentage of possible improvement) has the following advantages:

(1) It measures what is most important to the patient (how much better is the shoulder after treatment).

(2) It enables comparison of studies done using different outcome metrics (i.e. 'normal' is converted to 100%)

(3) It avoids the problem of having different MCIDs for each condition (arthritis, instability, cuff disease), for different genders, and for different instruments (ASES, SST, Constant). 

Try it, you will like it! 

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