Patient satisfaction after shoulder arthroplasty - anticipation and informing

Surgeons want their patients to be satisfied with the outcome of their shoulder arthroplasty. Two recent studies have correlated patient satisfaction with patient reported outcomes.

In the first, Reaching MCID, SCB, and PASS for ASES, SANE, SST, and VAS following Shoulder Arthroplasty Does Not Correlate with Patient Satisfaction, the authors attempted to correlate patient satisfaction with previously defined values for minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) for ASES, SANE, SST, and VAS at 2 years following shoulder arthroplasty for 352 patients.

They point out that historically the thresholds for MCID, SCB and PASS were established based on anchoring questions that did not account for patient satisfaction

In their study, satisfaction was assessed by a questionnaire asking: 1) on a scale of 1 to 10, what is your overall satisfaction with your surgical outcome? 2) if you could go back in time, would you undergo this operation again? (yes/no) 3) for the same condition, would you recommend this operation to a friend or family member? (yes/no).

ASES scores improved from 42 to 88, SANE improved from 36 to 87, SST improved from 5 to 10, and VAS improved from 5 to 1.

Mean patient satisfaction was 9.0. 94% of the patients would undergo surgery again
94% of the patients would recommend surgery.

12% of the patients reported satisfaction scores below 8 out of 10. This subset of patients had a mean ASES of 75, SANE of 71, SST of 8, and VAS of 2.

8 patients did not reach MCID for any of the outcome metrics, but 5 of these reported satisfaction scores of 8 or higher.

42 patients did not reach SCB in any of the four outcome metrics, but 28 of these reported satisfaction scores of 8 or higher.

24 patients did not reach PASS in any of the four outcome metrics, but 14 of these reported satisfaction scores of 8 or greater.

Spearman correlation coefficients were weak or very weak for reaching MCID, SCB, and PASS in ASES, SANE, SST, and VAS and all three study outcome metrics.


A second study, Anatomic Total Shoulder: Predictors of Excellent Outcomes at Five Years after Arthroplasty, reported minimum 5-year outcomes in patients undergoing TSA and sought to determine characteristics predictive of patients achieving an excellent functional outcome.

Preoperative demographic variables and Simple Shoulder Test (SST) scores were obtained pre-operatively and at a minimum of five years after surgery for 188 patients. A final SST ≥ 10 and percentage of maximal possible improvement (% MPI) of ≥ 66.7% were determined to be the thresholds for excellent outcomes. 

Mean SST scores improved from 3 to 10. 62% and 71% of these patients achieved an excellent outcome as defined by five-year SST ≥ 10 and %MPI ≥ 66.7%, respectively.

Male sex and commercial insurance coverage were predictors of both SST ≥ 10 and %MPI ≥ 66.7. Workers' Compensation insurance was predictive of not obtaining SST ≥ 10 or %MPI ≥ 66.7).









The threshold for MCID was passed by the vast majority (95%) of patients undergoing TSA but did not necessarily indicate an excellent, satisfactory outcome.

The authors remind us that while the type of insurance is associated with patient outcome,  the type of insurance coverage is a surrogate indicator for the patients’ social determinants of health. For example, patients having commercial insurance may be more likely to have higher levels of primary care, education, income, social support, as well as overall physical and mental health than patients covered by an alternative type of insurance. Each of those patient characteristics may be important factors affecting the outcome.

Comment: These studies point out that satisfaction is not strongly related to the absolute value of the amount of improvement. This makes sense: a patient improving from a preoperative SST sore from 2 to 6 will have exceeded the MCID, but still only can perform 6 of the 12 SST questions. Alternatively, an SST improvement from 9 to 11 would not exceed the MCID, but would indicate a shoulder that could perform 11 of the 12 SST functions.

A strong component of postoperative patient satisfaction is that the procedure met the patient's expectations of it. The observation that satisfaction is strongly correlated with an SST ≥ 10 and %MPI ≥ 66.7% indicate that the patient's expectation is that they will have a highly functional shoulder after arthroplasty (SST ≥ 10) and that most of their preoperative functional deficit will be mitigated by the procedure ( %MPI ≥ 66.7%).

This is valuable information for the arthroplasty surgeon. In patients who are unlikely to achieve SST ≥ 10 and %MPI ≥ 66.7%, it would seem prudent to inform them of this preoperatively - to set realistic expectations. Charles Neer understood this clearly; patients who were unlikely to achieve high levels of function were placed in a "limited goals" category and he carefully explained this reality to them before surgery.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

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Contact: shoulderarthritis@uw.edu

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link). 

What is the outcome of shoulder joint replacement arthroplasty? - need to consider all three dimensions.

Clinical research on the effectiveness of shoulder arthroplasty commonly focuses on a single dimension (e.g. the amount of improvement in a shoulder score) and seeks to establish a threshold value for this score in determining  "success" (see Quantifying Success After Reverse Total Shoulder Arthroplasty: the Minimal Clinically Important Percentage of Maximal Possible Improvement ).

Actually, there are three important dimensions in documenting the outcome of shoulder joint replacement:

(1) Satisfaction - the degree to which the outcome realized by the patient met their expectations.

(2) The outcome score (e.g. Simple Shoulder Test (SST), ASES, Constant, SANE, SCV)  achieved - for example using the SST, the outcome score is the number of positive responses to twelve questions regarding shoulder comfort and function. 12 "yes" responses would be a perfect score.

(3) The percent of maximum possible improvement (%MPI) in the outcome scare achieved - this is calculated as the amount of improvement divided by the maximum possible improvement (followup SST score - preoperative SST score)/(12 - preoperative score).

Interestingly, these three dimensions are not closely related.

A patient may be well satisfied by a modest final score and a modest improvement if their surgeon set modest expectations before surgery. Dr Neer referred to this as "limited goals" and he was adept at setting reasonable expectations for his patients. 

Let's consider two different patients achieving an SST score of 10 out of 12 at followup. 

Patient "A" had a preoperative SST score of 9  - thus the %MPI would be ((10-9)/(12-9) or 33%. 

Patient "B: had a preoperative SST score of 2 - thus the %MPI would be ((10-2)/(12-2) or 80%.

Both of these patients may be satisfied if the surgeon suggested preoperatively that the expected outcome would be about 10 out of 12 SST functions.

Both of these patients may be unsatisfied if the surgeon suggested preoperatively that the expected outcome would be 12 out of 12 SST functions.

Many publications have advocated defining "thresholds", i.e. certain values for each of these parameters above which the outcome would be defined as being successful and report the percent of patients exceeding the threshold. However, proposed "thresholds" vary for different patient populations, diagnoses and treatments.

It is more useful to present the raw data for each of the three dimensions, for example in 100 patients having total shoulder arthroplasty for osteoarthritis the average final SST score was 10, the average %MPI was 60% and the average patient was very satisfied

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link)

The challenge of measuring shoulder arthroplasty outcomes: bias, ceiling effects, and practicality.

Each surgeon has the opportunity - indeed the responsibility - to keep track of her or his surgical outcomes for the purpose of knowing what is and what is not working in the practice. This point is discussed in detail in this link. In that many failures of arthroplasty occur more than five years after surgery, long-term followup is critical.




Three of the key elements of an effective/informative/practical outcome system are (1) capturing the highest possible percentage of patients treated, (2) being able to present the results to patients in terms that patients and surgeons understand, and (3) having a system that is validated and universally applicable so that data can be compared among centers.

#1 requires minimizing exclusion bias. Many scales, such as the Constant Score, the UCLA score, and the Shoulder Arthroplasty Smart score require the patient to return to the office for the measurement of ranges of motion (and, in some cases, strength). In addition to risking observer bias and inter-observer variability, the requirement of returning to the office risks selectively excluding those patients living at a distance from their provider, those unwilling or unable to return, and those of limited economic means. Computer-based scoring systems, such as the PROMIS and Computer Adaptive Testing, risk selectively excluding patients without access to computers, those who are not computer literate and those not proficient in English. The ideal system makes it easy for all patients to be included in long-term followup: inexpensive, quick to complete, accessible independent of the location of the patient and independent of the patient's computer literacy and access.

#2 requires that the outcome data are presented in a way that is meaningful to the patient and surgeon. Most patients will have difficulty understanding the significance of a "score of 72" on PROMIS, Constant, UCLA or SAS, but many would understand the significance of the improvement in specific shoulder functions achieved by their surgeon for a specific condition presented as shown below (showing results obtained using the Simple Shoulder Test results for extended head hemiarthroplasty in the treatment of patients having cuff tear arthropathy with retained active elevation).





#3 Most of the commonly used outcome measures have been carefully validated, for example see Is the Simple Shoulder Test a valid outcome instrument for shoulder arthroplasty? which shows, in spite of the fact that 15% percent of the patients achieved the maximal SST score, there was a near-perfect correlation between satisfaction and the final SST score, suggesting that the "ceiling effect" is likely to have little clinical significance.





What this means is that a shoulder that can perform each of the 12 SST functions (below) is an excellent and highly satisfactory shoulder.





If the ceiling effect was a concern, one could add a thirteenth question: "Can you throw a football 100 yards with the affected arm?". Very few shoulders, normal or post-arthroplasty, would hit the ceiling of 13/13 "yes" responses.


In the same vein, the authors of Validation of a machine learning–derived clinicalmetric to quantify outcomes after total shoulderarthroplasty and Exactech Equinoxe anatomic versus reverse total shoulder arthroplasty for primary osteoarthritis: case controlled comparisons using the machine learning–derived Shoulder Arthroplasty Smart score correctly point out that the Shoulder Arthroplasty Smart score (you can experiment with it on this link) does not have a ceiling effect. In order to achieve the ceiling of the SAS score, the shoulder needs to be measured as having 180 degrees of active forward elevation, internal rotation to T7, and 90 degrees of active external rotation with the arm at the side.


These values will be difficult to attain because they are substantially greater than those found in the general population (see Shoulder range of movement in the general population: age and gender stratified normative data using a community-based cohort): average active shoulder flexion was 160° and average active external rotation was 59°.

Another approach for those concerned about the "ceiling effect" is put forth by the authors of Quantifying success after anatomic total shoulder arthroplasty: the minimal clinically important percentage of maximal possible improvement. They expressed the amount of improvement as the percentage of maximum possible improvement (%MPI) (based on a prior study: The prognosis for improvement in comfort and function after the ream-and-run arthroplasty for glenohumeral arthritis: an analysis of 176 consecutive cases). The %MPI is calculated as (postoperative score - preoperative score)/(perfect score - preoperative score). The "ceiling" in the %MPI would only be reached if the score improved from the worst possible score to the best possible score - a rare event.
Then they determined the minimal clinically important difference (MCID) for the %MPI using the anchor method. Interestingly their calculated MCID-%MPI values are similar for many of the commonly used scores: 33% for the SST, 32% for the ASES score, 38% for the UCLA score, 30% for the Shoulder Pain and Disability Index score, and 33% for the Shoulder Arthroplasty Smart score.


Comment: A surgeon's choice of the optimal patient followup system needs to be made in consideration of the above factors as well as the required staff time and cost of implementation. The goal is to capture long-term data on the highest percentage of patients treated using a method that is affordable and practical for the office.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Shoulder arthroplasty outcomes - it's not academic, it's personal

Many articles written about measuring surgical outcomes fail to emphasize the greatest value of collecting followup data - the opportunity for self-improvement. As the inscription on the Temple of Apollo states: "physician, know thyself".

The phrase "the surgeon is the method" means that each surgeon's indications, technique and outcomes are particular to her or him. While it is of interest to know how patients fare at some famous center, it is more important for each of us to know the characteristics of the patients we treat and how they do with the treatments we provide for them. In order for us to "own our outcomes" we need to collect our results in a systematic way that minimizes selection bias. We need to follow each of our patients long enough to know if our treatment was successful and to ask "if not, why not" (Codman: A Study of Hospital Efficiency).

Yet it is surprising how few surgeons (whether in community or academic practice) have implemented a meaningful followup system that will help improve their practice. The best time to implement such a self-improvement system is now - for surgeons new to practice, start on day one before things get "too busy". It's a gift that will keep on giving.

To attain this goal, a practical method of following patient comfort and function is needed - one that is accessible for all patients treated (including those who cannot use computers or tablets, those who cannot return to the office for periodic followup, and those who have a limited command of the language). An inexpensive, validated method approach is provided by the Simple Shoulder Test, the SST: 12 simple "yes" or "no" questions that can answered with nothing more than a pencil and then mailed in to the surgeon's office. The SST is now being used in multiple languages, including Arabic, Argentinian, Chinese, Dutch, Italian, Japanese, Lithuanian, Persian, Polish, Portuguese, Spanish, and Turkish.

Patients can be encouraged to participate in long term followup with periodic completion of the SST by explaining, "I care about how my patients do over time after their treatment. When patients fill out this simple followup form, it lets me learn how well things are working out and what adjustments I may need to make in my approach to get the best possible results in the future. What I know today is based on past patients helping me in this effort".

The value of systematic followup is shown in the figure below that presents the results of 176 patients having the ream and run procedure for glenohumeral arthritis. The SST score is on the vertical axis and the years after surgery are shown on the horizontal axis. The solid line shows excellent average long-term outcomes (the dotted lines represent the standard deviations). End of story? No! The opportunities for practice improvement lie in the red box. The surgeon can learn by studying each of these cases: wrong indication? wrong patient? wrong implant? wrong technique? wrong rehabilitation? or subtle complication (e.g. delayed Cutibacterium infection)?

An important additional value of the SST is provided by its granularity, which presents data on the ability to perform specific functions before and after surgery in a form that is meaningful to surgeons and patients alike. This is in contrast to presenting the data as single number ASES, Codman, SAS, SANE, or PROMIS score or as the percent of patients that exceeded the minimal clinically important difference (MCID) - neither of which are likely to be as helpful to surgeons and to their patients as information on the improvement in the ability to perform specific shoulder functions.

The figure below shows the preoperative and minimum two year post-operative functions performable by patients with cuff tear arthropathy with retained active elevation having a CTA hemiathroplasty. These are the personal results from an individual surgeon presented in a form easily understood by the surgeon and patients alike.

An additional way of presenting a surgeon's outcome data is discussed by the authors of Quantifying Success After Anatomic Total Shoulder Arthroplasty: the Minimal Clinically Important Percentage of Maximal Possible Improvement. They point to the value of the percent maximal possible improvement (%MPI) as a way of communicating the improvement after shoulder arthroplasty. This concept was introduced in The Prognosis for Improvement in Comfort andFunction After the Ream-and-Run Arthroplastyfor Glenohumeral Arthritis and is defined as the amount of improvement divided by the maximum possible improvement:

%MPI = 100% X (post operative score - preoperative score/(maximum possible score - preoperative score).

For the SST the maximum possible score is 12.

Thus a patient with a preoperative SST score of 2 and a postoperative score of 10 would have achieved 100% X (10-2)/(12-2) or 80% maximum possible improvement.

They conducted a retrospective review of 1,593 primary anatomic total shoulders having a minimum of 2 year followup.

They found that the SST, ASES, UCLA had higher rates of patients achieving a %MPI > 30%, but lower rates of achieving the minimum clinically important difference (MCID). Conversely, the Constant and SAS scores had higher rates of patients achieving the MCID, but a lower rate of achieving %MPI > 30%.

They concluded that the %MPI offers a simple method to quickly assess improvements across patient outcome scores.

If a surgeon knows her or his average %MPI after anatomic shoulder arthroplasty (say 45%) is easy for the patient to understand this information: "in my experience patients with your findings before surgery regain about 45% of their normal comfort and function".

That is easier to understand than the more abstract concept of the MCID:"You have an X% chance of an improvement exceeding a calculated minimal clinically important difference (which may vary according to which procedure is performed as pointed out by the authors of The minimal clinically important differences of the Simple Shoulder Test are different for different arthroplasty types).

An issue with applying the MCID as a threshold for success is that it does not differentiate between different situations in which the improvement exceeded the MCID. For example an improvement after aTSA from 2 to 4 (a modest result) and an improvement from 9 to 11 (an excellent outcome) are not at all the same, even though both had an improvement in excess of the MCID of 1.6 for aTSA. It seems of greater value to use %MPI which is (4-2)/(12-2) or 20% for the first case and (11-9)/(12-9) or 67%.

Comment: Following patients to determine their outcome is the responsibility of each surgeon. As illustrated above, systematic followup can be both simple and powerful. The keys are (1) starting now, (2) using a outcome measure that is both practical and that does not systematically exclude patients because of inability to return to the office or inability to use computers or tablets, (3) analyzing and learning from the causes of failure to achieve the desired result, and (4) sharing the data with patients in a manner they can easily understand.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: click on this link

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

What is the best way to measure shoulder outcomes?

Characteristics of Anatomic and Reverse Total Shoulder Arthroplasty Patients Who Achieve Ceiling Scores with 3 Common Patient Reported Outcome Measures

The goal of shoulder surgery outcome measurement is to capture the patient reported assessment of the condition of the shoulder before and after treatment for the highest percentage of patients having the procedure; in the words of E.A.Codman, "Every hospital should follow every patient it treats, long enough to determine whether or not the treatment has been successful, and then to inquire, 'if not, why not' with a view to preventing similar failure in future." 

To achieve this goal, surgeons need a validated assessment tool that maximizes the ability of every patient to participate in long-term followup, minimizing the risk of non-reasponse bias (see this link). Potential barriers to achieving this goal include (1) restricting capture of followup data to those patients who are able to return to the providers office sequentially for long term followup and (2) restricting capture of followup data to those patients who are able effectively use a computer interface (see this link).

Shoulder arthroplasty outcomes are commonly assessed using validated measures such as the Simple Shoulder Test (SST) (see this link), the American Shoulder and Elbow Surgeons Score (ASES) (see this link), the Constant score (see this link) and the UCLA score (see this link). The first two of which (SST and ASES) are patient reported outcome measures (PROMs), emphasizing the ability to perform important activities of daily living; the SST and ASES assessments can be completed remotely without the patient needing to return to the provider's office, minimizing the risk of election bias, especially the risk of excluding those who are more remote and less able to afford repeated trips to visit the provider over the period of followup (a recent article, What is a Successful Outcome Following Reverse Total Shoulder Arthroplasty?, demonstrated that the easily accessible Simple Shoulder Test enabled 87% of the patients in the original sample to provide two year followup).  The latter two (Constant and UCLA) require a provider to measure range of motion and/or strength thus a requirement for in person evaluation and incurring the potential for selection and observer bias.

The authors of Characteristics of Anatomic and Reverse Total Shoulder Arthroplasty Patients Who Achieve Ceiling Scores with 3 Common Patient Reported Outcome Measures have introduced another score, the Shoulder Arthroplasty Smart Score that requires a computer interface for scoring (see this link and this link). This score requires provider measurement of active forward elevation, internal rotation and external rotation in addition to three questions about pain and overall function. As shown in the slide below, there is low reliance on assessment of the patient's ability to perform activities of daily living (ADLs).

They used data from a database of a single shoulder prosthesis utilizing data from 30 different clinical sites to quantify and compare outcomes for 1817 anatomic (aTSA) and 2635 reverse (rTSA) patients using SST, ASES, UCLA, Constant, and SAS scores. 

The number of aTSA and rTSA patients with ceiling scores were calculated and sorted into those that achieved ceiling scores and compared to patients without ceiling scores. A univariate and multivariate analysis then identified the patient demographics, comorbidities and implant and operative parameters associated with ceiling scores for each outcome measure.

They found that aTSA patients achieved ceiling scores at a significantly greater rate than rTSA patients for all outcome measures.

The authors observed that patients achieving the maximum (ceiling) score for each of the SST, ASES, UCLA, and Constant scores had a range of results from the SAS score. See the example below for the SST.

The reason for this is probably related to the fact that fully half of the SAS score depends on the measured ranges of elevation, internal rotation and external rotation. 

However to our knowledge it has not been demonstrated that a post arthroplasty shoulder with 180 degrees of active elevation and 90 degrees of external rotation would be more satisfactory or more functional than a shoulder with 140 degrees of active elevation and external rotation to 60 degrees (see Defining functional shoulder range of motion for activities of daily living, which concluded "Average shoulder motions required to perform the 10 functional tasks were flexion, 121° ± 6.7°; extension, 46° ± 5.3°; abduction, 128° ± 7.9°; cross-body adduction, 116° ± 9.1°; external rotation with the arm 90° abducted, 59° ± 10°; and internal rotation with the arm at the side, 102° ± 7.7°.") 

With regard to the "ceiling effect" another recent article, Performance and responsiveness to change of PROMIS UE in patients undergoing total shoulder arthroplasty found that the ceiling effect for the SST in patients having aTSA was 18%.  

In the graph below from The prognosis for improvement in comfort and function after the ream-and-run arthroplasty for glenohumeral arthritis: an analysis of 176 consecutive cases  ...

..it can be seen a large number of patients having the ream and run for osteoarthritis "hit the ceiling" of 12 out of 12 on the SST. This means that 

-the shoulder was comfortable at the side

-the shoulder allowed the patient to sleep comfortably

-the shoulder allowed reach to the small of the back to tuck in a shirt

-the shoulder allowed placement of the hand behind the head with the elbow straight out to the side

-the shoulder could lift a coin, a one pound weight, and an eight pound weight to the level of the top of the head without bending the elbow

-the shoulder allowed carrying 20 pounds at the side

-the shoulder allowed tossing a softball 20 yards underhand

-the shoulder allowed throwing a soft ball 20 yards overhand

-the shoulder allowed washing the back of the opposite shoulder

-the shoulder allowed work full time at the patient's usual job

In our view that's a pretty high ceiling; it is remarkable that so many patients can hit it after the ream and run. Obviously one could avoid the "ceiling effect" by adding a question such as, "would your shoulder allow you to throw 100 yards?", but it seems that "yes" responses to each of the 12 existing questions indicates a comfortable and highly functional shoulder.

In choosing an outcome measure for shoulder treatment, surgeons need to decide on their priorities.

In our practice we have found the SST to be broadly applicable to multiple procedures (arthroplasty, rotator cuff surgery, fracture surgery, etc), to be easily accessible to a broad range of patients without travel or socioeconomic barriers, valid (see this link), inexpensive, interpretable without a computer interface, and understandable to patients - rather than an abstract score, the SST reveals the outcome with respect to specific shoulder functions as shown below for aTSA for rheumatoid arthritis.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: click on this link

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest

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

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

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

Shoulder rehabilitation exercises (see this link).

How surgeons can improve their surgical outcomes.

This post was prompted by a recent article, Strategies for Effective Implementation of Patient-Reported Outcome Measures in Arthroplasty Practice, that highlighted some of the challenges of using information technology to capture meaningful data on the comfort and function of patients before and sequentially after treatment. 

Now may be an opportune time to re-examine the purpose and practicality of documenting the patient's condition over time.

For us, the most important reason for recording patient-reported data is to learn for different groups of patients what is and what is not working in our hands. Only our patients can teach us if we're going about treatment in the most effective way. But in order to gather actionable intelligence, we must strive to "follow each of our patients long enough to learn if the treatment was successful and if not to ask "why not"?" (see A Study in Hospital Efficiency: As Demonstrated by the Case Report of First Five Years of Private Hospital). Whatever method is applied, the principal priority is to capture data on the highest possible percentages of patients being treated. Patients at increased risk for treatment failure - for example, those who are socially disadvantaged, less well educated, who are not fluent in English, who live in remote rural settings, who have co-morbidities - are subject to systematic exclusion if followup depends on hooking up with a computer or tablet or traveling to the office for an examination of range of motion.

By contrast the most user-friendly and inclusive approach is a short questionnaire that can be filled either in the office or at home (see this link). This approach eliminates the travel and technology hurdles that can create a non-response bias in the data.

For shoulder surgery, we've found that the 12 "yes" or "no" questions of the Simple Shoulder Test (SST - see this link) enable the capture the information from a high percentage of the patients at a year after surgery: in a recent comparison the 2 year non-response rate for the SST was 13% while the 1 year non-response rate for the PROMIS system was 33% (see this link).

The SST does not require scoring but rather enables the surgeon and the patients to identify the specific functions that were improved after treatment - e.g. the ability to sleep on the affected side, or the ability to reach over head - in contrast to a "score", the significance of which is more difficult to communicate. 

While the minimal clinically important difference (MCID) for the SST has been well studied (see this link), again this concept is harder to discuss with patients. Instead, we've found that the percent of maximal possible improvement (%MPI) is more straightforward: "our experience with shoulders like yours is that we can improve comfort and function X% of the way to normal" (see MCID vs %MPI at this link).

The bottom line is that by engaging our patients by emphasizing the importance of their providing us with longitudinal updates on their comfort and function, we can learn which treatments work best for which patients with which diagnoses and which do not.

Only our patients can teach us why those in the red rectangle did not get the outcome that they and we desired. For our learning, the individuals in the red rectangle have more to teach than the curves showing the mean ± standard deviation.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

How you can support research in shoulder surgery Click on this link.

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).

Shoulder rehabilitation exercises (see this link).

This is a non-commercial site, the purpose of which is education, consistent with "Fair Use" as defined in Title 17 of the U.S. Code.          

Note that author has no financial relationships with any orthopaedic companies

 

Measuring the success of shoulder surgery - keeping it simple

 The American Shoulder and Elbow Surgeons score highly correlates with the Simple Shoulder Test

The most important reason for a shoulder surgeon to document his or or patients' shoulder comfort and function before and sequentially after therapeutic interventions is so that the surgeon can know his or her personal effectiveness in managing patients with a specific diagnosis using a specific treatment. The consistent application of standardized patient-assessed measures of shoulder comfort and function will help the surgeon identify what is not working well for which patients so that the treatment algorithm can be modified.

The value of a scoring system depends primarily on its ability to capture results from the highest percentage of patients. 

Systematically documenting shoulder comfort and function in the context of a busy surgical practice can be time consuming and expensive. The ideal tool is (a) one that is simple for the patient to access and use whether the patient is in the office or at home (by mail, email, phone, internet) and (b) simple for the surgeon's office to score and record. 

This article examines two extensively validated measures of shoulder comfort and function: 

the ASES score

and the Simple Shoulder Test

These authors conducted a retrospective review of the senior author’s database of 1810 simultaneous measurements on patients undergoing rotator cuff repair and total shoulder arthroplasty.

The correlation was excellent for the ASES and SST for all patients (n =1810; r = 0.81; P < .0001). The correlation of preoperative scores was strong-moderate (n = 1191; r = 0.60; P < .0001), and the correlation of postoperative scores was excellent (n = 619; r = 0.78; P < .0001). 

Both scores were determined to be highly responsive (see this link), for both the standardized response mean (2.8 for the ASES and 2.1 for the SST) and the effect size (2.2 for the ASES and 1.8 for the SST).

Comment: It is evident that the total SST and the ASES scores yield similar information. Here is a side by side comparison from the article, One and two-year clinical outcomes for a polyethylene glenoid with a fluted peg: one thousand two hundred seventy individual patients from eleven centers.

However, the Simple Shoulder Test has the advantage of yielding easy to understand data on the on ability of patients to perform individual functions before and after treatment. For example, as shown in this link, patient can easily understand the function-specific data shown below for two year outcomes of anatomic total shoulder. 

It is more difficult to extract such information from more complex scoring systems. 

What is important is for each shoulder surgeon to build a system for measuring patient comfort and function into their practice workflow so that they can learn the effectiveness of their treatment approaches.

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

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

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

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

Shoulder rehabilitation exercises (see this link).

Total Shoulder Arthroplasty - how valuable is it?

Patient-Reported Outcome Measures and Health-Related Quality-of-Life Scores of Patients Undergoing Anatomic Total Shoulder Arthroplasty

These authors analyzed 92 patients with glenohumeral osteoarthritis treated with anatomic total shoulder arthroplasty performed by an individual surgeon using a a press-fit, short-stem anatomic humeral component and a hybrid, all-polyethylene, pegged glenoid implant and that had 1-year follow-up with respect to their health-related quality-of-life (HRQoL) scores and patient-reported outcome measures (PROMs): Disabilities of the Arm, Shoulder and Hand (DASH) score, the American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST), and a visual analog scale (VAS) for shoulder pain and function.

There were significant improvements in all PROMs and HRQoL scores (p < 0.001) at 1 year after the surgical procedure.

The changes in VAS QoL (very weak to moderate), EQ-5D (weak), and SF-6D (weak) were significantly correlated (p < 0.05) with the changes in PROMs, demonstrating comparably acceptable validity. 

 There were large effect sizes in the VAS QoL (1.843), EQ-5D (1.186), and SF-6D (1.084) and large standardized response mean values in the VAS QoL (1.622), EQ-5D (1.230), and SF-6D (1.083), demonstrating responsiveness. The effect sizes of all PROMs were larger than those of the HRQoL scores.

Comment: In this well-done study, the authors point out that shoulder patient reported outcome metrics cannot be used in an analysis of comparative value of shoulder arthroplasty relative to other orthopaedic and nonorthopaedic conditions. 

Measurement of quality-adjusted life-years (QALYs a summary measure of health outcome that combines the impact of a treatment on a patient’s length of life) and health-related quality of life (HRQoL) can be used to compare alternative treatments of a specific condition, as well as treatments of disparate conditions. QALYs can be used with costs (direct and indirect) to determine cost utility (monetary cost/QALY), which can be used to perform cost utility analysis to compare, say a total shoulder to a rhinoplasty. 

It is not surprising to see a lack of tight correlation between patient reported outcome metrics and measures of health-related quality of life measures: they do not measure the same thing. The PROMS are used to measure the change in patient-assessed shoulder comfort and function. In this study the SST changed from 3 preoperatively to 10 postoperatively. This is exactly the same change documented in many different case series by different surgeons using different makes of implants. It is very reassuring to see consistently large effect sizes for the PROMs.

On the other hand, one could expect the HRQoL to have a strong correlation with the SST only if the shoulder operated on was the only factor affecting the patients health-related quality of life. Consider the patient who has a SST 3=>10 after a shoulder arthroplasty, but who at one year comes in  saying "now my other shoulder (or my hip or my knee or my back)  is killing me" or "I fell and broke my wrist" or "I now have cancer or ....". This is why the effect sizes are smaller for the HRQoL than for the PROM.

As shoulder surgeons we are responsible for an important, but only one part of a patient's health equation. The measure of our success is the value of our treatment, that is the benefit the patient realizes from our intervention divided by the cost of our evaluation and treatment (i.e. change in SST decided by the sum of preoperative imaging, implants, hospital costs, professional fees, rehabilitation and complications). In that the numerator seems pretty standard, optimization of this quotient is most effected by the denominator.

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To see a YouTube of our technique for total shoulder arthroplasty, click on this link.

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To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

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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'