Do Surgeon Expectations Predict Clinically Important Improvements in WOMAC Scores After THA and TKA?
Do Surgeon Expectations Predict Clinically Important Improvements in WOMAC Scores After THA and TKA?
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DOI：
10.1007/s11999-017-5331-8
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发表时间：
2017-09-01
影响因子：
4.2
通讯作者：
Mushlin, Alvin I.
中科院分区：
文献类型：
--
作者：
Ghomrawi, Hassan M. K.;Mancuso, Carol A.;Mushlin, Alvin I.
背景全髋关节置换术或全膝关节置换术未能达到患者的期望可能会导致患者失望和诉讼。然而，几乎没有证据表明外科医生可以始终如一地预测哪些患者将从这些干预措施中受益。问题/目的是确定外科医生在手术前识别将从THA或TKA中受益的患者和不会从THA或TKA中受益的患者的能力，其中“好处”被定义为在经过验证的患者报告的结果评分中的临床重要改善。方法在这项前瞻性研究中，8名大容量骨科医生完成了有效的THA和TKA期望问卷(得分0-100,100分为最高期望)，作为对所有计划接受THA或TKA并登记在医院特殊外科机构登记的患者的术前评估的一部分。入选的患者在术前和术后2年完成WOMAC。成功的结果被定义为在WOMAC疼痛和功能分量表中达到最小的临床重要差异(MCID)。敏感度、特异度和受试者操作特征(ROC)曲线被用来评估外科医生的期望分数识别可能达到WOMAC量表上的MCID的患者的能力。对于THA和TKA的患者，分析是分开进行的。我们招募了259名THA患者和247名TKA患者，其中77%(n=200)和77%(n=191)分别在术后2年完成了随访调查。结果外科医生的期望分数有效地预测了THA后患者的病情改善，但在识别TKA后2年WOMAC评分中达到MCID的患者方面，他们并不比机率高。对于THA患者，WOMAC功能和疼痛结果的ROC曲线下面积分别为0.67(95%CI，0.53~0.82；p=0.02)和0.74(95%CI，0.63~0.85；p<；0.01)，显示出良好的准确性。WOMAC疼痛和功能评分(对疼痛和功能的敏感度=0.69，特异度=0.72)的敏感度和特异度在预期分数为83或更高时达到最大。外科医生的预期对于男性患者、体重指数低于30公斤/米(2)的患者、有一种以上合并症的患者以及65岁以上的患者更准确。对于人工全膝关节置换术的患者，医生的期望分数并不比随机数高，以确定哪些患者的WOMAC评分将会有重要的改善(ROC曲线下面积：功能=0.51，[95%CI，0.42~0.61]，p=0.78；疼痛=0.51，[95%CI，0.40~0.61]，p=0.92)。然而，外科医生的期望得分不能准确地区分THA患者中受益的患者和没有受益的患者，这些患者是年轻的、没有合并症的、BMI升高的，以及所有接受TKA的患者中，外科医生需要花更多的时间与这些患者一起充分了解和满足他们的需求和期望。使用标准化的评估工具来比较外科医生和他们的患者的期望，可能有助于进一步集中外科医生和患者的讨论，并更有效地满足患者的期望。
Background Failure of THA or TKA to meet a patient's expectations may result in patient disappointment and litigation. However, there is little evidence to suggest that surgeons can consistently anticipate which patients will benefit from those interventions.Questions/purposes To determine the ability of surgeons to identify, in advance of surgery, patients who will benefit from THA or TKA and those who will not, where 'benefit' is defined as a clinically important improvement in a validated patient-reported outcomes score.Methods In this prospective study, eight high-volume orthopaedic surgeons completed validated THA and TKA expectations questionnaires (score 0-100, 100 being the highest expectation) as part of preoperative assessment of all their patients scheduled for a THA or TKA and enrolled in the Hospital for Special Surgery institutional registry. Enrolled patients completed the WOMAC preoperatively and at 2 years. Successful outcomes were defined as achieving the minimum clinically important difference (MCID) in WOMAC pain and function subscales. Sensitivity, specificity, and receiver operating characteristic (ROC) curves were used to evaluate the ability of surgeons' expectation scores to identify patients likely to achieve the MCID on the WOMAC scale. Analyses were run separately for patients having THA and TKA. We enrolled 259 patients undergoing THA and 247 undergoing TKA, of whom 77% (n = 200) and 77% (n = 191) completed followup surveys 2 years after their procedures, respectively.Results Surgeons' expectation scores effectively anticipated patients who would improve after THA, but they were no better than chance in identifying patients who would achieve the MCID on the WOMAC score 2 years after TKA. For patients having THA, the areas under the ROC curve were 0.67 (95% CI, 0.53-0.82; p = 0.02) and 0.74 (95% CI, 0.63-0.85; p < 0.01) for WOMAC function and pain outcomes, respectively, indicating good accuracy. Sensitivity and specificity were maximized on WOMAC pain and function scores (sensitivity = 0.69, specificity = 0.72, both for pain and function) at an expectations score of 83 or greater of 100. Surgeons' expectations were more accurate for patients who were men, who had a BMI less than 30 kg/m(2), who had more than one comorbidity, and who were older than 65 years. For patients having TKA, surgeons' expectation scores were not better than chance for identifying those who would experience a clinically important improvement on the WOMAC scale (area under ROC curve: Function = 0.51, [95% CI, 0.42-0.61], p = 0.78; Pain = 0.51, [95% CI, 0.40-0.61], p = 0.92).Conclusions Most patients having THA and TKA achieved the MCID improvement after surgery. However, the inability of surgeons' expectation scores to discriminate accurately between patients who benefit and those who do not among patients scheduled for THA who are young, with no comorbidities, and with elevated BMIs, and among all patients scheduled for TKA, calls for surgeons to spend more time with these patients to fully understand and address their needs and expectations. Using standardized assessment tools to compare surgeons' expectations and those of their patients may help focus the surgeon-patient discussion further, and address patients' expectations more effectively.