Original Research

Predicting 1-Year Postoperative Visual Analog Scale Pain Scores and American Shoulder and Elbow Surgeons Function Scores in Total and Reverse Total Shoulder Arthroplasty

Author and Disclosure Information

Shared decision-making provides patients a measure of autonomy in making choices for their health and their future. Patient-reported outcome measures (PROMs) use clinically sensitive and specific metrics to evaluate a patient’s self-reported pain, functional ability, and mental state.

We conducted a study to create an evidence-based clinical decision-making tool. We used PROMs to create a predictive model of a patient’s outcome to help set patient expectations and facilitate a collaborative decision-making environment for patient and physician. The study used a comprehensive prospective database that stores preoperative and 1-year postoperative patient demographics and total shoulder arthroplasty PROM data. Linear regression models were used to evaluate the predictive ability of each factor and the overall predictive ability of each model. One model predicts 1-year postoperative visual analog scale (VAS) pain scores; the other predicts 1-year postoperative American Shoulder and Elbow Surgeons (ASES) Function scores.

The total number of observations was 1004 for modeling 1-year postoperative VAS pain scores and 986 for modeling 1-year postoperative ASES Function scores. Regression coefficients and P and ω2 values are reported. Preoperative VAS pain scores predicted 1-year postoperative VAS pain scores (P < .001) but not 1-year postoperative ASES Function scores (P = .485). Preoperative Veterans RAND 12-Item Health Survey (VR-12) mental health component summary (MCS) scores predicted self-reported pain and function (Ps < .001) 1 year after surgery. In these models, preoperative VR-12 MCS score was the most predictive PROM for 1-year postoperative VAS pain score (ω2 = .023) and 1-year postoperative ASES Function score (ω2 = .029).

Together, a patient’s preoperative VAS pain score, ASES Function score, VR-12 MCS score, age, sex, and type of arthroplasty can provide significant predictive value that may aid in setting appropriate expectations for pain and function 1 year after surgery.


 

References

Take-Home Points

  • Shared decision-making tools, such as predictive models, can help empower the patient to make decisions for or against surgery equipped with more information about the expected outcome.
  • There is a role for preoperative collection of PROMs in the clinical decision-making process.
  • Mental health state, as reported by the VR-12 MCS, is a significant predictor of postoperative pain and function as reported by the VAS pain and ASES function scores.
  • A significant portion of the predictive ability of this model comes from the fact that at 1-year postoperatively, patients receiving a rTSA will on average have a 3.8 point lower on ASES function score than those receiving a TSA ( P < .001, ω 2=.083).
  • Future studies to discern the role of different modalities to improve a patient’s emotional health preoperatively will be beneficial as the healthcare industry trends toward value based medicine collecting PROMs as part of reimbursement schemes.

Over the past few decades, decisions regarding patients’ care have gradually transitioned from a paternalistic model to a more cooperative exchange between patient and physician. Shared decision-making provides patients a measure of autonomy in making choices for their health and their future. Patient participation may mitigate uncertainty and discomfort during selection of a course of treatment, which may lead to increased satisfaction levels after surgery. 1 Moreover, shared decision-making may help patients better manage postoperative expectations through evidenced-based discussions of preoperative health levels and their corresponding outcomes. Patient-reported outcome measures (PROMs) use clinically sensitive and specific metrics to evaluate a patient’s self-reported pain, functional ability, and mental state. 2 These metrics are useful in setting patient expectations for potential outcomes of treatment options. Use of evidence-based clinical decision-making tools, such as PROM-based predictive models, can facilitate a collaborative decision-making environment for patient and physician. Given the present cost-containment era, and the need for preoperative metrics that can assist in predictive analysis of postoperative improvement, models are clearly valuable.

In attempts to help patients set well-informed and reasonable expectations, physicians have turned to PROMs to facilitate preoperative evidence-based discussions. Although PROMs have been in use for almost 30 years, only recently have they been used to create tools that can aid quantitatively in the surgical decision-making process. 2-6 Combining physical examination findings, imaging studies, comorbidities, and quantitative tools, such as this model, may enhance patients’ understanding of their preoperative condition and expected prognosis and thereby guide their surgical decisions.

We conducted a study to determine whether certain preoperative PROMs can predict 1-year postoperative visual analog scale (VAS) pain scores and American Shoulder and Elbow Surgeons (ASES) Function scores in total shoulder arthroplasty (TSA) and reverse TSA (rTSA). We hypothesized that preoperative mental health status as captured by Veterans RAND 12-Item Health Survey (VR-12) mental health component summary (MCS) score and preoperative VAS pain score would predict both VAS pain score and ASES Function score 1 year after surgery. Specifically, we hypothesized that a higher preoperative VR-12 MCS score would predict less pain and better function 1 year after surgery and that a higher preoperative VAS pain score would predict more pain and worse function 1 year after surgery.

Methods

This study was approved by the Institutional Review Board of Partners Healthcare. The study used the Surgical Outcome System (Arthrex), a comprehensive prospective database that stores preoperative and 1-year postoperative patient demographics and TSA-PROM data. Surveys are emailed to all enrolled patients before surgery and 1 year after surgery. As indicated by the Institutional Review Boards of all participating institutions, patients in the Surgical Outcome System have to sign a consent form to permit use of their responses in research.

The database includes patient data from 42 orthopedic surgeons across the United States. All primary TSAs and primary rTSAs in the database were included in this study, regardless of arthroplasty indication. Revisions were excluded. Also excluded were cases in which the 1-year postoperative questionnaire was not completed. Of the 1681 patients eligible for 1-year follow-up, 1225 (73%) completed the 1-year postoperative questionnaire. PROMs used in the study were VAS pain score, ASES Function score, VR-12 MCS score, and Single Assessment Numerical Evaluation (SANE). Unfortunately, not all surgeons use every measure in the 1-year postoperative questionnaire set. Thus, in our complete models, total number of observations was 1004 for modeling 1-year postoperative VAS pain scores and 986 for modeling 1-year postoperative ASES Function scores. 

Metrics

On VAS, pain is rated from 0 (no pain) to 10 (pain as bad as it can be). Tashjian and colleagues 7 estimated that the minimal clinically important difference (MCID)

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