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Assessing our patients: Commentary on “A brief fatigue inventory of shoulder health developed by quality function deployment technique” and “Normal shoulder outcome score values in the young, active adult”
J Shoulder Elbow Surg (2009) 18, 429-430
www.elsevier.com/locate/ymse
COMMENTARY
Assessing our patients: Commentary on ‘‘A brief fatigue inventory of shoulder health developed by quality function deployment technique’’ and ‘‘Normal shoulder outcome score values in the young, active adult’’ E. Amory Codman, the father of shoulder surgery, gave up a promising career and personal fortune pursuing a novel and highly unpopular concept: that we should follow our patient’s outcomes and that surgeons should be rewarded based on their results, not on hierarchy or by political consequence.6 His ideas were largely ignored until recent times. We now appreciate Codman and his work and are trying to find the best ways to determine how our patients are doing. Although there are many ways to assess patients, it is important to approach the assessment of outcomes from the patient’s perspective. The bias of surgeons is to assess the outcome of the surgical technique, an approach that may lead to confusion; for example, the KT-1000 is a great tool to assess how tight a surgically reconstructed anterior cruciate ligament graft is, but is a surrogate marker for the patient’s perception of his or her outcome.9 With regard to the shoulder, we have a variety of assessment tools that can be used. Each assessment has strengths and weaknesses.3 The development of outcome assessment tools isdand should beda complicated process. Historically, surgeons created outcome assessments based on their own perception of what was important. For example, the University of California, Los Angeles (UCLA) score weights pain as 29% of the total score (10 of 35 points), whereas the American Shoulder and Elbow Surgeons (ASES) score weights pain as 50% of the total score (50 of 100 points).3 These scoring systems were based on an individual’s, or a group’s, expert opinionebased impression of what is important to patientselevel V evidence. Newer assessments are developed systematically, a process that is difficult, time consuming, and labor intensivedyet these assessments have far greater validity! For *Reprint requests: John E. Kuhn, MD, Vanderbilt Sports Medicine, 2601 Jess Neely Dr, Nashville, TN. E-mail address: [email protected]. (J.E. Kuhn)
example, Kirkley et al4 went to great lengths to develop condition-specific assessment tools by 1. identifying a specific population of patients; 2. reviewing the literature, health care providers, and patients with varying disease severity and demographic features to develop a number of items to include in the assessment; 3. reducing the number of items by using patient-based information on the importance of the questions and reducing duplication; and 4. pretesting the assessment tool on groups of patients. This method creates an assessment tool with greater content validity as it uses patient-derived information. Liu et al5 in this issue report the use a technique called quality function deployment to develop an instrument to assess the severity of symptoms of neck and shoulder pain and to determine the origin of these symptoms. Quality function deployment is a systematic approach that prioritizes and assigns weights to the items in the assessment scale and then makes multiple comparisons to reduce error. It is a technique to systematically approach and solve complex problems, and its use by Liu et al to determine risk in neck and shoulder pain is unique. Although this assessment tool is not able to measure outcomes, it may be able to help health care providers determine the source of patient complaints and identify when treatment may be helpful. Interestingly, the patient’s perception of his or her shoulder as measured by many of our outcome instruments is not perfect. Many outcome assessment tools have scores that are influenced by age, gender, or comorbidities. Clarke et al1 present their data on how these assessments work in an asymptomatic population of active young Navy personnel. They found that many of their participants did
1058-2746/2009/$36.00 - see front matter Ó 2009 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2009.03.010
430 not score perfectly in many of these tests.1 It is unclear why some young people who are healthy and active do not score well. We can speculate that comorbidities or other features may be responsible. The answer to this question should prompt further study. So, what should a clinician or researcher do? It really depends on what information you need. As a researcher, you must first define your research question and then find the best assessment tool to answer that question. Ideally, you would use a scoring tool that has been developed with content validity that has been shown to be reliable. If your patient population is elderly or a specific gender, you may wish to normalize the scores for accuracy. If you are a clinician and you are collecting data to assess individual outcomes, a general shoulder assessment that is popular, such as the ASES7 or Constant Score,2 will allow you to compare your results with those reported in the literature. In addition, a simple general score like the Single Assessment Numeric Evaluation (SANE) score is an easy way to quantify how the patient perceives his or her shoulder before and after treatment.8 Finally, asking patients about their satisfaction would be helpful as well. The assessment of the shoulder is an evolving field. In the future we can expect to see systems that develop outcome assessments with greater validity and that will be very clear in defining exactly what they are intended to measure and their inherent limitations.
Commentary John E. Kuhn, MD) Department of Orthopaedics, Vanderbilt University Nashville, TN
References 1. Clarke MG, Solomon DJ, Schroeder DT, Provencher MT. Normal shoulder outcome score values in the young, active adult. J Shoulder Elbow Surg 2009;18:424-8. 2. Constant CR, Gerber C, Emery RJ, Sojberg JO, Gohlke F, Boileau P. J Shoulder Elbow Surg 2008;17:355-61. 3. Kirkley A, Grifin S, Dainty K. Scoring systems for the functional assessment of the shoulder. Arthroscopy 2003;19:1109-20. 4. Kirkley A, Griffin S, McLintock H, Ng L. The development and evaluation of a disease-specific quality of life measurement tool for shoulder instability. The Western Ontario shoulder instability Index (WOSI). Am J Sports Med 1998;26:764-72. 5. Liu SF, Lee Y, Huang Y. A brief fatigue inventory of shoulder health developed by quality function deployment technique. J Shoulder Elbow Surg 2009;18:418-23. 6. Mallon WJ. Ernest Amory Codman: the end result of a life in medicine. Philadelphia: WB Saunders; 2000. 7. Richards RR, An KN, Bigliani LU, Friedman RJ, Gartsman GM, Gristina AG, et al. A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg 1994;3:347-52. 8. Williams GN, Gangel TJ, Arciero RA, Uhorchak JM, Taylor DC. Comparison of the single assessment numeric evaluation method and two shoulder Rating Scales. Am J Sports Med 1999;27:214-21. 9. Zarins B. Are validated questionnaires valid? J Bone Joint Surg Am 2005;87:1671-2.
www.elsevier.com/locate/ymse
COMMENTARY
Assessing our patients: Commentary on ‘‘A brief fatigue inventory of shoulder health developed by quality function deployment technique’’ and ‘‘Normal shoulder outcome score values in the young, active adult’’ E. Amory Codman, the father of shoulder surgery, gave up a promising career and personal fortune pursuing a novel and highly unpopular concept: that we should follow our patient’s outcomes and that surgeons should be rewarded based on their results, not on hierarchy or by political consequence.6 His ideas were largely ignored until recent times. We now appreciate Codman and his work and are trying to find the best ways to determine how our patients are doing. Although there are many ways to assess patients, it is important to approach the assessment of outcomes from the patient’s perspective. The bias of surgeons is to assess the outcome of the surgical technique, an approach that may lead to confusion; for example, the KT-1000 is a great tool to assess how tight a surgically reconstructed anterior cruciate ligament graft is, but is a surrogate marker for the patient’s perception of his or her outcome.9 With regard to the shoulder, we have a variety of assessment tools that can be used. Each assessment has strengths and weaknesses.3 The development of outcome assessment tools isdand should beda complicated process. Historically, surgeons created outcome assessments based on their own perception of what was important. For example, the University of California, Los Angeles (UCLA) score weights pain as 29% of the total score (10 of 35 points), whereas the American Shoulder and Elbow Surgeons (ASES) score weights pain as 50% of the total score (50 of 100 points).3 These scoring systems were based on an individual’s, or a group’s, expert opinionebased impression of what is important to patientselevel V evidence. Newer assessments are developed systematically, a process that is difficult, time consuming, and labor intensivedyet these assessments have far greater validity! For *Reprint requests: John E. Kuhn, MD, Vanderbilt Sports Medicine, 2601 Jess Neely Dr, Nashville, TN. E-mail address: [email protected]. (J.E. Kuhn)
example, Kirkley et al4 went to great lengths to develop condition-specific assessment tools by 1. identifying a specific population of patients; 2. reviewing the literature, health care providers, and patients with varying disease severity and demographic features to develop a number of items to include in the assessment; 3. reducing the number of items by using patient-based information on the importance of the questions and reducing duplication; and 4. pretesting the assessment tool on groups of patients. This method creates an assessment tool with greater content validity as it uses patient-derived information. Liu et al5 in this issue report the use a technique called quality function deployment to develop an instrument to assess the severity of symptoms of neck and shoulder pain and to determine the origin of these symptoms. Quality function deployment is a systematic approach that prioritizes and assigns weights to the items in the assessment scale and then makes multiple comparisons to reduce error. It is a technique to systematically approach and solve complex problems, and its use by Liu et al to determine risk in neck and shoulder pain is unique. Although this assessment tool is not able to measure outcomes, it may be able to help health care providers determine the source of patient complaints and identify when treatment may be helpful. Interestingly, the patient’s perception of his or her shoulder as measured by many of our outcome instruments is not perfect. Many outcome assessment tools have scores that are influenced by age, gender, or comorbidities. Clarke et al1 present their data on how these assessments work in an asymptomatic population of active young Navy personnel. They found that many of their participants did
1058-2746/2009/$36.00 - see front matter Ó 2009 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2009.03.010
430 not score perfectly in many of these tests.1 It is unclear why some young people who are healthy and active do not score well. We can speculate that comorbidities or other features may be responsible. The answer to this question should prompt further study. So, what should a clinician or researcher do? It really depends on what information you need. As a researcher, you must first define your research question and then find the best assessment tool to answer that question. Ideally, you would use a scoring tool that has been developed with content validity that has been shown to be reliable. If your patient population is elderly or a specific gender, you may wish to normalize the scores for accuracy. If you are a clinician and you are collecting data to assess individual outcomes, a general shoulder assessment that is popular, such as the ASES7 or Constant Score,2 will allow you to compare your results with those reported in the literature. In addition, a simple general score like the Single Assessment Numeric Evaluation (SANE) score is an easy way to quantify how the patient perceives his or her shoulder before and after treatment.8 Finally, asking patients about their satisfaction would be helpful as well. The assessment of the shoulder is an evolving field. In the future we can expect to see systems that develop outcome assessments with greater validity and that will be very clear in defining exactly what they are intended to measure and their inherent limitations.
Commentary John E. Kuhn, MD) Department of Orthopaedics, Vanderbilt University Nashville, TN
References 1. Clarke MG, Solomon DJ, Schroeder DT, Provencher MT. Normal shoulder outcome score values in the young, active adult. J Shoulder Elbow Surg 2009;18:424-8. 2. Constant CR, Gerber C, Emery RJ, Sojberg JO, Gohlke F, Boileau P. J Shoulder Elbow Surg 2008;17:355-61. 3. Kirkley A, Grifin S, Dainty K. Scoring systems for the functional assessment of the shoulder. Arthroscopy 2003;19:1109-20. 4. Kirkley A, Griffin S, McLintock H, Ng L. The development and evaluation of a disease-specific quality of life measurement tool for shoulder instability. The Western Ontario shoulder instability Index (WOSI). Am J Sports Med 1998;26:764-72. 5. Liu SF, Lee Y, Huang Y. A brief fatigue inventory of shoulder health developed by quality function deployment technique. J Shoulder Elbow Surg 2009;18:418-23. 6. Mallon WJ. Ernest Amory Codman: the end result of a life in medicine. Philadelphia: WB Saunders; 2000. 7. Richards RR, An KN, Bigliani LU, Friedman RJ, Gartsman GM, Gristina AG, et al. A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg 1994;3:347-52. 8. Williams GN, Gangel TJ, Arciero RA, Uhorchak JM, Taylor DC. Comparison of the single assessment numeric evaluation method and two shoulder Rating Scales. Am J Sports Med 1999;27:214-21. 9. Zarins B. Are validated questionnaires valid? J Bone Joint Surg Am 2005;87:1671-2.