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.
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.
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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