Copyright © 2008 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Elizabeth A. Lingard, BPhty, MPhil, MPH*,
Freeman Hospital, Newcastle Upon Tyne, United Kingdom
Posted February 2008
The importance of collecting preoperative patient-reported
health-status data as part of prospective studies of the outcomes of
orthopaedic procedures has been noted in the literature. The collection of detailed
preoperative data from the patients is easily done when there is a standard process
for patient admission. Preoperative data are often collected within a four to six-week
period prior to surgery. In this paper, Bryant et al. evaluate the validity and
reliability of collecting preoperative data on the day of surgery. This work is
of great relevance to clinical researchers who make use of patient-reported
outcomes.
A concern with collecting detailed patient-reported data on
the day of surgery is that these data may not be reliable because patients may
have increased levels of anxiety at this time. Anxiety levels can vary greatly
from patient to patient, depending on the patient's individual characteristics
and his or her previous experience of surgery, and it is unknown to what extent
these factors may affect patient-reported health status. Unfortunately,
measures of anxiety were not reported in this paper, and the reader is unable
to identify the group of patients who exhibited signs of anxiety on the day of
surgery. Measures such as the Hospital Anxiety and Depression Scale (HADS)1 and the State-Trait Anxiety Inventory (STAI)2 have commonly been
used to assess anxiety in patients. The STAI has the ability to determine
anxiety both in a specific situation and as a general trait. Components of the Short-Form
Health Survey (SF-36) Mental Health domain, although not a specific measure of
anxiety, would have given an indication of patients who had psychological
distress preoperatively3 and/or patients who demonstrated a substantial
change in their mental health status in the preoperative period. Subgroup
analyses would have evaluated if this group of patients gave less valid and
reliable reports of health status on the day of surgery.
Level of anxiety may also be related to the type of
procedure that is being performed as well as to the associated complications,
postoperative limitations, and rehabilitation regimens associated with that
procedure. For example, patients undergoing anterior cruciate ligament
reconstruction may exhibit greater anxiety preoperatively when compared with
patients undergoing diagnostic arthroscopy because patients undergoing anterior
cruciate ligament reconstruction may contemplate a more intensive postoperative
rehabilitation and a longer recovery time. It would be of interest to assess if
these patients were more anxious and if there was a difference in the validity
and reliability of patient-reported health status on the day of surgery between
these two surgical groups. Indeed, extending this work to study other groups
of patients, including older cohorts such as knee arthroplasty patients, would
be of great importance.
There are now many patient-reported measures available for
the assessment of knee injury, and the knee-specific measures used by Bryant et
al. have been reported to be the most important to patients4. All
knee-specific instruments have been validated and shown to be reliable and
responsive measures of outcome following arthroscopy and anterior cruciate
ligament reconstruction. All instruments, with the exception of the Knee Injury
and Osteoarthritis Outcome Score (KOOS), are commonly reported by means of a
single summary score. The KOOS, in contrast, is usually reported according to five
domains: pain, symptoms, activities of daily living, sport and recreation, and quality
of life, and the developer has never endorsed or described how these subscales
should be combined into one score5.
In contrast to the data reported in the paper by Bryant et
al., published KOOS data shows differences between mean scores for each domain
preoperatively, with consistently lower scores reported for the sport-and-recreation
and quality-of-life domains. This is consistent for cohorts of patients with various
knee problems, including isolated meniscal tears and meniscal tears with
associated anterior cruciate ligament injury or cartilage damage6. In
addition, each of the domains has different levels of responsiveness. In a
study of patients who had anterior cruciate ligament reconstruction, the twelve-month
postoperative effect sizes ranged from 0.84 for pain to 1.65 for the quality-of-life
domain5.
Reporting only the Physical Component Score (PCS)
and Mental Component Score (MCS) for the
SF-36 general health status may have reduced the ability of the authors to
detect if there were significant differences in the eight health domains of the
SF-36. Each of the eight health domains would assess a different level of
responsiveness following arthroscopy with or without anterior cruciate ligament
reconstruction. Additionally, the use of aggregate scores of the PCS
and the MCS from the SF-36 to report general
health status for patients with knee osteoarthritis has recently been questioned7.
In this current era in which same-day admission for elective
orthopaedic surgery is the norm, it is essential that we ascertain the
implications of collecting patient-reported data on the day of surgery and the
potential impact that these data may have on the validity of the outcome
results reported. Bryant et al. identified the issue of patient anxiety
potentially biasing results, but the results that they report in their paper do
not fully inform the reader. Further research is needed to extend this work to evaluate
patient-reported scores and their specific domains in more detail. It is
necessary to establish the extent to which preoperative anxiety is present and
the impact that such anxiety has on baseline scores. This work should be
expanded to include patients who are undergoing other elective orthopaedic
procedures, such as knee arthroplasty.
*The author did not receive any outside funding or grants in support of her research for or preparation of this work. Neither she nor a member of her immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of her immediate family, is affiliated or associated.
References
1. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand.1983;67:361-70.
2. Spielberger, CD, Ritterband, LE, Sydeman, SJ, Reheiser, EC, Unger KK. Assessment of emotional states and personality traits: measuring psychological vital signs. In: Butcher JN, editor. Clinical personality assessment: practical approaches. New York: Oxford University Press; 1995.
3. Lingard EA, Riddle DL. Impact of psychological distress on pain and function following knee arthroplasty. J Bone Joint Surg Am. 2007;89:1161-9.
4. Tanner SM, Dainty KN, Marx RG, Kirkley A. Knee-specific quality-of-life instruments: which ones measure symptoms and disabilities most important to patients? Am J Sports Med. 2007;35:1450-8.
5. Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD. Knee Injury and Osteoarthritis Outcome Score (KOOS)--development of a self-administered outcome measure. J Orthop Sports Phys Ther. 1998;28:88-96.
6. Roos EM, Roos HP, Ryd L, Lohmander LS. Substantial disability 3 months after arthroscopic partial meniscectomy: a prospective study of patient-relevant outcomes. Arthroscopy. 2000;16:619-26.
7. Rannou F, Boutron I, Jardinaud-Lopez M, Meric G, Revel M, Fermanian J, Poiraudeau S. Should aggregate scores of the Medical Outcomes Study 36-item Short Form Health Survey be used to assess quality of life in knee and hip osteoarthritis? A national survey in primary care. Osteoarthritis Cartilage. 2007;15:1013-8.
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