Shoulder motion, function and satisfaction after arthroplasty

A recent article, Thresholds For Diminishing Returns In Postoperative Range Of Motion After Total Shoulder Arthroplasty, pointed out that satisfaction after shoulder arthroplasty - can be associated with scores on patient-reported outcome measures (PROMs). (See Patient satisfaction after shoulder arthroplasty - anticipation and informing). In turn, PROMs are dependent upon restoring lost shoulder range of motion (ROM). The authors questioned whether there was a threshold in postoperative active ROM beyond which additional improvement in motion was not associated with additional improvement in the PROMs that primarily measured function (Simple Shoulder Test [SST], American Shoulder and Elbow Surgeons [ASES] score, and the Shoulder Pain and Disability Index [SPADI]). (Of note, other outcome measures, such as the Shoulder Arthroplasty Smart Score, primarily measure motion (70% of the total score) attributing only 10% of the points to function).

They included 4,459 TSAs (1,802 aTSAs, 2,657 rTSAs) with minimum 2-year follow-up. Indeed they found thresholds in postoperative ROM that were associated with no further improvement in the standard PROMs.

The "S" shapes of these curves are interesting. See for example the figures below plotting the patient's Simple Shoulder Test (SST) responses against active flexion and active external rotation. 

At the left side of these curves, improvement in motion has little effect on the number of SST functions the shoulder could perform. In the middle, there is a steep improvement in function with increasing range. At the right hand of the "S", the curve flattens out so that further improvements in range are not strongly associated with increased function. For the SST the inflection points (thresholds) were 153 degrees for active flexion, 50 degrees of active external rotation, and active internal rotation to L2. Similar thresholds were found for other function-based outcome measures, including the ASES score and the SPADI.

Subjective satisfaction was assessed by asking patients to rate their shoulder as being  “worse”, “unchanged”, “better”, or “much better” compared to before surgery. Among shoulders that achieved all ROM thresholds, 93% of patients rated their shoulder as “much better” compared to before surgery.

It is interesting to view these results in the light of data presented in Practical Evaluation and Management of the Shoulder. The authors of that book characterized elevation in terms of the angle of elevation

and the plane of elevation.

They learned that - rather than being confined to "abduction" and "flexion" - different functions were performed in different planes and with different angles of elevation.

It can be seen that the average maximum angle of elevation for eight normal subjects was 148 degrees, and that this range was not necessary for most of the activities of daily living.

Of course the ability to perform functions does not only depend on elevation angle and plane, but also on the rotation of the arm as shown below.

Thresholds For Diminishing Returns In Postoperative Range Of Motion After Total Shoulder Arthroplasty is an important article in that it can help guide motion goals for arthroplasty surgery and postoperative rehabilitation. It suggests that a shoulder that has active elevation to 180, external rotation to 90 and internal rotation to T7 may not be more functional or satisfactory than one has 153 degrees of active flexion, 50 degrees of active external rotation, and active internal rotation to L2. 

Comment to shoulderarthritis@uw.edu

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/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
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). 

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

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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)

Reverse total shoulder: does physical therapy improve patient satisfaction and reduce instability?

The authors of Active Physical Therapy Does Not Improve Outcomes After Reverse Total Shoulder Arthroplasty: A Multi-Center, Randomized Clinical Trial sought to compare range of motion (ROM), patient-reported outcomes (PROs), postoperative stability, complications and patient satisfaction after reverse total shoulder arthroplasty between patients receiving a structured home exercise program (HEP) (n=46) and those placed on active, supervised physiotherapy (PT) (n=43) in a multi-center randomized clinical trial.

Complications occurred in 13% of HEP and 17% of PT patients. 

There were no significant differences between groups in PROs or ROM at final follow-up.

12% (72/82) of patients described some symptoms of instability within one year postoperatively. 

While 90% (74/82) were satisfied with the outcomes,

 only 76% (62/82) stated that they would have the surgery again, given the opportunity.

Comment: Interestingly a larger clinical trial comparing PT to home exercises has been posted (see Physical Therapy After Reverse Total Shoulder Arthroplasty), but the results are not yet available.

Home exercises have some tangible advantages: less cost, less travel, and greater ability to tailor the program to the specific needs and tolerance of each patient. Offering ready access to the surgical team via email or phone can enable patients to ask questions and to be assured they're on the right track.
 

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).

Total shoulder arthroplasty: how should we measure the value of care: improvement in comfort and function or HCAHPS score?

Hospital satisfaction does not predict functional outcome one year after total shoulder arthroplasty

These authors point out that currently 2% of Medicare reimbursements is linked to value measures including the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) hospital satisfaction survey. In this study they sought to determine whether HCAHPS survey results correlated with patient self-assessed measures of comfort and function in 84 patients undergoing elective total shoulder arthroplasty. 

Patients were contacted by a third-party survey company between 48 hours and 6 weeks after hospital discharge to complete the HCAHPS survey by telephone. All patients enrolled in this study were attempted to be contacted one time by the survey company to complete the HCAHPS survey.  

Patients completed the ASES and WOOS questionnaires by mail or online at the 3-month and 1-year post-operative time points. They were also asked to complete a self-reported satisfaction questionnaire about how effective surgery was in improving pain and function (0–10 ordinal scale). Patients who failed to complete the enrollment packet, HCAHPS survey, or the 1-year ASES follow-up survey were excluded from the analysis. 

Approximately 200 patients were approached for study enrollment of which 163 consented to participation. Of these 84 patients  completed the necessary forms for inclusion in the study. 

As can be seen below, the HCAHPS score is based on questions related to the process of care rather than the functional outcome.

The average ASES scores improved by 45 points from 36 before surgery to 82 at one year. The HCAHPS scores ranged from 57 to 100 

As can be seen from the above chart, the HCAHPS scores were not correlated with ASES (r=0.09, P=0.44) at one year after surgery. HCAHPS was also not correlated with the absolute improvement in ASES (r=−0.02, P=0.85)  from pre- to one year post-operatively.

The single question “How effective was the surgery in restoring a normal level of function?” at three months after surgery showed high correlation with improvements in ASES score (r=0.38, P=0.001) at the one-year post-operative time point. Similarly, the question “How helpful was the surgery in relieving pain?” at three month post-operatively was associated with improvements in ASES (r=0.43, P<0.001) scores at one year after surgery. Neither the function question (r=0.21, P=0.07) nor the pain question (r=−0.06, P=0.62) at three months was correlated with HCAHPS scores.

Comment: This is an interesting study indicating that the 2 day to 6 week post op HCAHPS score did not correlate with improvement in comfort and function at 1 year. The HCAHPS is based on patient-nursing interactions, patient-doctor interactions, hospital environment, and pain management, As might be suspected, recollection of these characteristics would be fresh in the patient's mind soon after discharge ("the bathroom was clean/dirty", "the nurses brought my pain meds promptly/late"). On the other hand, at a year after surgery the patient's mind is more likely to be focused on improvement in and current function of the shoulder. Thus it is not a surprise that the two metrics which measure different things at different times would be discordant. It would be of interest to obtain an HCAHPS score at one year to compare with (1) the ASES score at one year and (2) the HCAHPS immediately after surgery. It seems likely that the recollection of a dirty bathroom would subside in the presence of a comfortable functional shoulder.

The authors point out that under CMS procedures, reimbursement to hospitals is directly affected by survey results which in turn may directly or at least indirectly affect providers in some health care models. 

As far as we know, there are no direct Medicare incentives for improving shoulder comfort and function, yet that is presumably the reason patients have shoulder arthroplasty to begin with (not to have a pleasant hospital stay). 

The author of What Switching to Value-Based Care from Fee-for-Service Reimbursement Means for Healthcare Providers states, "The transition to value-based care revolves around a recalibration of how healthcare is measured and how payments are reimbursed. The traditional model, known as fee-for-service, simply assigns reimbursements based on what services a healthcare organization provides. But in value-based care, reimbursement is contingent upon the quality of the care provided and it comes tethered to patient outcomes." The authors of Hospital satisfaction does not predict functional outcome one year after total shoulder arthroplasty point out that current measures of the quality of patient care (vis HCAHPS) are NOT, in fact, "tethered to patient outcomes". 

At present, the incentives for surgeons to safely improve the comfort and function of patients with shoulder arthritis via shoulder arthroplasty are patient gratitude ("you gave me back a shoulder that works and is comfortable") and surgeon satisfaction ("I did good"). For now, that's plenty. Meanwhile, we will continue to urge our medical centers to support our efforts to provide a good patient experience. 

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)

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).

Prediction of satisfaction after total shoulder arthroplasty

Development of Supervised Machine Learning Algorithms for Prediction of Satisfaction at Two Years Following Total Shoulder Arthroplasty

These authors point out that TSA confers improvement in pain and function for most patients, however some will remain unsatisfied postoperatively. The purpose of their study was to (1) train supervised machine learning (SML) algorithms to predict satisfaction after TSA and (2) develop a clinical tool for individualized assessment of patient-specific risk factors.

They conducted a retrospective review of 413 primary anatomic and reverse TSA patients of which of which 331 (82.6%) were satisfied at two years postoperatively. 

The most 22 important factors for predicting satisfaction were baseline single assessment numeric evaluation (SANE) score, exercise and activity, workers compensation status, diagnosis, symptom duration prior to surgery, body mass index, age, smoking status, anatomic vs. reverse TSA, and diabetes. 

Their algorithm was incorporated into an open-access digital application for patient-level explanations of risk and predictions available at this link: 

They concluded that the best performing model demonstrated excellent discrimination and adequate calibration for predicting satisfaction following TSA.  They caution, however, that rigorous external validation in different geographic locations and patient populations is essential prior to assessment of clinical utility.

Comment: This is a commendable effort and readers are encouraged to try out the tool. We ran a series of five hypothetical patients having anatomic TSA for primary glenohumeral osteoarthritis with symptoms  for > 2 yrs, a preoperative SANE of 30 and a BMI of 25. The predictions are shown in the chart and figures below. Importantly it suggested that - even in the ideal candidate - the probability of satisfaction was only 84%. These results did not demonstrate a difference between the satisfaction of older and younger patients, and did not demonstrate a detrimental effect of adding Worker's Compensation insurance or diabetes to the 65 year old patient who smoked.

Click on each print out to enlarge it.

Our approach to total shoulder arthroplasty can be viewed by clicking here.

To support our research to improve outcomes for patients with shoulder problems, click here.

To subscribe to this blog, enter your email in the box to your right that looks like the below

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

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

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  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 shoulders - which patients are satisfied?

Predictors of patient satisfaction after reverse shoulder arthroplasty

These authors sought to determine patient satisfaction and to identify predictors of satisfaction at two years after reverse shoulder arthroplasty (RSA) in 161 patients.

Improvements in ASES, Shoulder Activity Scale, VAS pain, and SF-12 physical component summary scores were associated with higher satisfaction.

On multivariate analysis, patients with higher preoperative ASES scores were less satisfied after surgery. In addition, patients with worse VAS fatigue and SF-12 mental and physical component summary scores preoperatively had lower satisfaction. 

Comment: This paper is instructive. First of all, it shows that patient factors (such as those measured by the SF-12 mental health and VAS fatigue scores) play heavily into the patients' satisfaction with this procedure (and probably with most other procedures as well).  Along with the problem, the procedure and the provider, the patient is one of the 4 Ps that determine the result of treatment.  

Secondly, while the means and medians are interesting, the variation is even more interesting as shown in the chart below. Patients with a preoperative ASES score of 100 have little room for improvement and are unlikely to be satisfied with surgery (see this link). Some patients experienced a drop of 64 points in their ASES score; these folks are likely to be unsatisfied.

Thus we come to the "tipping point"for  reverse total shoulders (see this link), i.e. when is it time to do this surgery. As shown in the link above, a recent study found that the tipping point for reverses was an ASES score of 38, a value approximately the same as the average preoperative ASES score of 35 in this paper.

The take away point is that surgeons should be cautious about offering elective surgery to patients with high levels of preoperative self-assessed comfort and function as well as those who have poor mental and physical health.

==

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

=====

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

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

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: how much does it improve patients - the %MPI

Predicting outstanding results after reverse shoulder arthroplasty using percentage of maximal outcome improvement

These authors correlated the percentage of maximal possible improvement (%MPI) in the Simple Shoulder Test (SST) score and American Shoulder and Elbow Surgeons (ASES) with satisfaction after reverse shoulder arthroplasty (RSA) in 198 patients at a minimum 2-year follow-up.

The % of maximum possible improvement at a given time after surgery is easy to calculate:

They found that 61.3% (P < .001) and 68.2% (P < .001) of maximal possible improvement in the SST and ASES scores, respectively, predicted excellent satisfaction.

Patients achieving 61.3% of maximal possible SST score improvement or 68.3% of maximal possible ASES score improvement can be expected to reach excellent satisfaction about 80% of the time, whereas patients who do not reach these thresholds have excellent satisfaction only about 45% of the time.

Surgery on the dominant hand, greater baseline visual analog scale pain score, and cuff arthropathy were independent predictors for achieving the respective SST and ASES score thresholds.

Comment: There are five compelling features of using the %MPI. First, it is easy for surgeons to calculate. Second it is easy for patients to understand. Third, it avoids the "floor and ceiling" issues. Fourth, in contrast to the MCID (minimal clinically important difference) it differentiates an improvement in SST from 0 to 3 from an improvement in SST from 7 to 10. Fifth,  as shown in this study and in others it yields very similar results for different patient self-assessment tools (note the similarity in values for the SST and ASES score). As a result it enables comparisons of studies in which different outcome measures are used. See for example this study:

One and two-year clinical outcomes for a polyethylene glenoid with a fluted peg: one thousand two hundred seventy individual patients from eleven centers, which showed essentially the same %MPI for the SST, ASES, Constant, and Penn scores.

The utility of the %MPI is that it enables surgeons to contrast the characteristics of patients, shoulders  and techniques that yield outcomes above and below the desired %MPI threshold.
=====

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

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

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'

Total shoulder: patient satisfaction vs functional outcomes

Negative Patient-Experience Comments After Total Shoulder Arthroplasty

These authors point out that patient narratives are a potentially valuable but largely unscrutinized source of information. Patients often write free text comments on these surveys, but in the past these comments have been difficult and time-consuming to analyze. These authors used  natural language processing via machine learning algorithms to explore the content of negative comments after total shoulder arthroplasty (TSA), their associated factors, and their relationship with traditional measures of patient satisfaction and with perioperative outcomes in 186 patients who had undergone elective primary TSA.

Satisfaction data included patient comments and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. 

Using a machine-learning-based natural language processing approach, all patient comments were mined for sentiment and classified as positive, negative, mixed, or neutral. Negative comments were further classified into themes. 

Most patients (71%) provided at least 1 comment; 32% of the comments were negative, 62% were positive, 5% were mixed, and 1% were neutral. The themes of the negative comments were room condition (27%), time management (17%), inefficient communication (13%), lack of compassion (12%), difficult intravenous (IV) insertion (10%), food (10%), medication side effects (6%), discharge instructions (4%), and pain management (2%). Patients who made negative comments were more likely to be dissatisfied with overall hospital care and with pain management.

Women and sicker patients were more likely to provide negative comments. 

There were no differences in any of the studied outcomes (peak pain intensity, opioid intake, operative time, hospital length of stay, discharge disposition, or 1-year American Shoulder and Elbow Surgeons [ASES] score) between those who provided negative comments and those who did not.

Comment: As physicians, we seek to provide not only the safest and most effective patient care, but also a process of care that meets patient expectations. It is surely the case that some patients with superb functional outcomes after shoulder arthroplasty cannot get over their recollection that their hospital room was not kept clean. In a sense we're like a restaurant that wants to provide not only good food, but also a positive dining experience. 

Some of the "dissatisfiers" may cost hospitals money to address: single larger rooms are more expensive than shared rooms, spending money on increased staffing can improve responsiveness and allow more time for staff to listen to patient concerns and for effective communication, investing in upgraded food series can assure prompt delivery of warm food to the bedside. Hospitals need to evaluate the cost-benefit of these investments. It also seems the case that these data support efforts to shorten the hospital stay, i.e. getting the patient back to their own home and their own kitchen.

We were particularly interest in the use of machine learning in this study. Efforts to measure patient satisfaction with the process of care traditionally rely on structured tools, such as the Hospital Consumer Assessment of Healthcare Providers and Systems survey, that ask specific, closed-ended questions that may not fully capture the spectrum of patient experiences. Machine learning can enable the efficient mining of free text to extract important themes from the text.

===

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

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

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'

Younger patients are harder to satisfy after total shoulder replacement.

Results of total shoulder arthroplasty in patients aged 55 years or younger versus those older than 55 years: an analysis of 1135 patients with over 2 years of follow-up

These authors sought to compare early outcomes after total shoulder arthroplasty (TSA) in patients aged 55 years or younger versus patients older than 55 years.

They found that female patients, patients with a history of surgery, and patients with a diagnosis of osteonecrosis were more likely to undergo TSA when aged 55 years or younger. 

Even though the pain and functional scores were similar prior to surgery, the postoperative pain and some outcomes scores were worse in the younger patients and as a group they were less satisfied.

Comment: The key to the differences in pain and satisfaction may be due to the effects of gender differences in the assessment of the results of surgery and to the other significant differences in the two patient populations: prior surgery (i.e. a prior surgical failure), osteonecrosis (patients with this diagnosis tend to have more pain), smoking (associated with a lower pain threshold) and comorbidities (making life less happy overall) may all negatively influence the younger patients' perceived benefit from the surgery. It is also possible that the expectations of younger patients are different. As a wise person once pointed out, "when you're young, pain is the absence of pleasure, when you're old, pleasure is the absence of pain". 

===
We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

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

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'