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Editorial Commentary: Outcomes After Hip Arthroscopy—Am I Better, Improved, or Who Knows?
Editorial Commentary: Outcomes After Hip ArthroscopydAm I Better, Improved, or Who Knows? Karen K. Briggs, M.P.H., M.B.A.
Abstract: Patient-reported outcomes are critical in the evaluation of the success of hip arthroscopy. Many different outcome scores are currently being used; however, that is a totally different subject. Most scores range from 0 to 100 or use some type of scale. The question becomes, Is a good outcome a score of 70 or 90? In many cases, it depends on the patient and his or her personal experiences. One way we gauge whether the patient is better is to use summary scores, which provide us with general goals for improvement. These include the minimal clinically important difference and substantial clinical benefit. While these are being defined, they can be used to help gauge patients’ progress and provide improved treatment of patients.
See related article on page 411
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lthough outcomes were pioneered by Codman over 100 years ago, we continue to refine the use of outcome scores.1 For many years, patient-reported outcome scores were considered “second-class citizens” of outcomes. Because these scores did not include objective measures, many clinicians thought they did not give the overall picture. But, really, isn’t the patient the most important thing? Dr. Richard Steadman* (personal communication, June 1993) told me when I first started working in outcomes that if a patient does not think he or she has a great result, then he or she does not. He was always committed to listening to the patient first. In the article “Minimal Clinically Important Difference and Substantial Clinical Benefit Values for the 12-Item International Hip Outcome Tool” by Martin, Kivlan, Christoforetti, Wolff, Nho, Salvo, Ellis, Van
Vail, Colorado The author reports that she has no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2019 by the Arthroscopy Association of North America 0749-8063/181355/$36.00 https://doi.org/10.1016/j.arthro.2018.11.026 *J. Richard Steadman, M.D., retired orthopaedic surgeon; Founder, The Steadman Clinic; and Founder and Co-chairman, Steadman Philippon Research Institute, Vail, Colorado.
Theil, Matsuda, and Carreira,2 important information is provided to help gauge whether the patient’s outcome is acceptable. They focus on the minimal clinically important difference (MCID) and substantial clinical benefit (SCB). Several editorials have described these 2 measures.3,4 The 12-item International Hip Outcome Tool (iHOT-12) is the shorter version of the International Hip Outcome Tool 33 (iHOT-33).5 It is easier for patients to complete in a timely manner in the clinic and has similar psychometric properties. The iHOT-12 score is one of the newer scores to be developed. It is now being used more frequently; however, the modified Harris Hip Score and the Hip Outcome Score are still the most commonly reported scores.6 The MCID is the lowest improvement from the preoperative status that a patient would consider clinically important. One would have to question the definition of what is clinically important to a patient. In their study, Martin et al.2 defined the MCID as half the standard deviation of the change in score. The MCID can be calculated using many different methods.7 In this study, the standard deviation was divided in half. This method has been used by other authors and has been reported for the iHOT-33.8 In addition, the authors investigated SCB, which has also been reported for the iHOT-33.9 They defined SCB as improvement that the patients consider substantial improvement. To determine substantial improvement, the study grouped
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 35, No 2 (February), 2019: pp 417-418
417
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EDITORIAL COMMENTARY
patients into those having normal or abnormal function ratings. The authors should be commended for getting all the surgeons together to perform a multicenter study with over 1,000 patients. The study is well done and will be a reference article for future studies. This study reports the MCID and SCB at 1-year follow-up. I wonder if the same numbers will apply at 2, 5, and 10 years. That is research we must look forward to in the coming years. Also, we can hope to wrap up the definition and calculation of the MCID. Currently, there are multiple ways to calculate it, and it can vary depending on the method used. It may also be important to look at other factors that may help define it. Do patients with lower scores to start with have different MCID values than patients with higher scores? Martin et al.2 found a score of 86 was associated with a normal rating. What happens if a patient has a score of 86 but does not improve according to the MCID? Now that we have all these outcome metrics, we need to figure out the best way to use them. We often find that scores are much lower initially in young female patients. While many parents also find it difficult to understand young female patients, I wonder if these types of factors can also influence these summaries. One final point that Martin et al.2 brought up was the follow-up percentage. In this study, the follow-up percentage was 71%, which I consider excellent considering it is from a multicenter study. This statistic is so important and often ignored. To know whether the patients are doing well or not, they must be contacted. You cannot assume the patients are doing well or did not need a revision if you have not contacted them. Part of all outcomes and quality-control programs must be capturing outcomes of patients at specific time points, with a plan to round up those who do not reply. This is challenging and may be costly, but it is a critical component of this type of research. The demand for more of this type of research is increasing. Where do we go from here? What is the best way to determine whether the patient believes he or she has a good outcome? We need to make sure patients are satisfied with the outcome of their care. We need to define which summary score works best and whether it is a sliding scale depending on age, sex, or how poor the patient’s condition is to start with. Then, we need to make sure the patient is satisfied with his or
her outcome. Much more work lies ahead, but we just have to remember that it is about the patient, and according to Dr. Steadman, if the patient is not satisfied, then the outcome is not successful. In conclusion, the authors should be commended for being dedicated not only to the outcomes of their patients but also to the science behind the outcomes.
References 1. Codman EA. The classic: A study in hospital efficiency: as demonstrated by the case report of first five years of private hospital. Clin Orthop Relat Res 2013;471:1778-1783. 2. Martin RL, Kivlan BR, Christoforetti JJ, et al. Minimal clinically important difference and substantial clinical benefit values for the 12-item International Hip Outcome Tool. Arthroscopy 2019;35:411-416. 3. Larson CM. Editorial Commentary: Patient-related outcome measures, minimal clinically important differences, and substantial clinical benefits for adolescent hip arthroscopy: Making progress with outcome measures or unquestionably spinning out of control? Arthroscopy 2017;33: 1819-1820. 4. Lall AC, Maldonado DR, Domb BG. Editorial Commentary: Is it acceptable to have symptoms after hip arthroscopy?? Depends on whom you ask.. Arthroscopy 2018;34: 3030-3032. 5. Griffin DR, Parsons N, Mohtadi NG, Safran MR, Multicenter Arthroscopy of the Hip Outcomes Research Network. A short version of the International Hip Outcome Tool (iHOT-12) for use in routine clinical practice. Arthroscopy 2012;28:611-616. 6. Stone AV, Jacobs CA, Luo TD, et al. High degree of variability in reporting of clinical and patient-reported outcomes after hip arthroscopy. Am J Sports Med 2018;46: 3040-3046. 7. Cook CE. Clinimetrics corner: The minimal clinically important change score (MCID): A necessary pretense. J Man Manip Ther 2008;16:E82-E83. 8. Nwachukwu BU, Fields K, Chang B, Nawabi DH, Kelly BT, Ranawat AS. Preoperative outcome scores are predictive of achieving the minimal clinically important difference after arthroscopic treatment of femoroacetabular impingement. Am J Sports Med 2017;45:612-619. 9. Nwachukwu BU, Chang B, Fields K, et al. Defining the "substantial clinical benefit" after arthroscopic treatment of femoroacetabular impingement. Am J Sports Med 2017;45: 1297-1303.
Abstract: Patient-reported outcomes are critical in the evaluation of the success of hip arthroscopy. Many different outcome scores are currently being used; however, that is a totally different subject. Most scores range from 0 to 100 or use some type of scale. The question becomes, Is a good outcome a score of 70 or 90? In many cases, it depends on the patient and his or her personal experiences. One way we gauge whether the patient is better is to use summary scores, which provide us with general goals for improvement. These include the minimal clinically important difference and substantial clinical benefit. While these are being defined, they can be used to help gauge patients’ progress and provide improved treatment of patients.
See related article on page 411
A
lthough outcomes were pioneered by Codman over 100 years ago, we continue to refine the use of outcome scores.1 For many years, patient-reported outcome scores were considered “second-class citizens” of outcomes. Because these scores did not include objective measures, many clinicians thought they did not give the overall picture. But, really, isn’t the patient the most important thing? Dr. Richard Steadman* (personal communication, June 1993) told me when I first started working in outcomes that if a patient does not think he or she has a great result, then he or she does not. He was always committed to listening to the patient first. In the article “Minimal Clinically Important Difference and Substantial Clinical Benefit Values for the 12-Item International Hip Outcome Tool” by Martin, Kivlan, Christoforetti, Wolff, Nho, Salvo, Ellis, Van
Vail, Colorado The author reports that she has no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2019 by the Arthroscopy Association of North America 0749-8063/181355/$36.00 https://doi.org/10.1016/j.arthro.2018.11.026 *J. Richard Steadman, M.D., retired orthopaedic surgeon; Founder, The Steadman Clinic; and Founder and Co-chairman, Steadman Philippon Research Institute, Vail, Colorado.
Theil, Matsuda, and Carreira,2 important information is provided to help gauge whether the patient’s outcome is acceptable. They focus on the minimal clinically important difference (MCID) and substantial clinical benefit (SCB). Several editorials have described these 2 measures.3,4 The 12-item International Hip Outcome Tool (iHOT-12) is the shorter version of the International Hip Outcome Tool 33 (iHOT-33).5 It is easier for patients to complete in a timely manner in the clinic and has similar psychometric properties. The iHOT-12 score is one of the newer scores to be developed. It is now being used more frequently; however, the modified Harris Hip Score and the Hip Outcome Score are still the most commonly reported scores.6 The MCID is the lowest improvement from the preoperative status that a patient would consider clinically important. One would have to question the definition of what is clinically important to a patient. In their study, Martin et al.2 defined the MCID as half the standard deviation of the change in score. The MCID can be calculated using many different methods.7 In this study, the standard deviation was divided in half. This method has been used by other authors and has been reported for the iHOT-33.8 In addition, the authors investigated SCB, which has also been reported for the iHOT-33.9 They defined SCB as improvement that the patients consider substantial improvement. To determine substantial improvement, the study grouped
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 35, No 2 (February), 2019: pp 417-418
417
418
EDITORIAL COMMENTARY
patients into those having normal or abnormal function ratings. The authors should be commended for getting all the surgeons together to perform a multicenter study with over 1,000 patients. The study is well done and will be a reference article for future studies. This study reports the MCID and SCB at 1-year follow-up. I wonder if the same numbers will apply at 2, 5, and 10 years. That is research we must look forward to in the coming years. Also, we can hope to wrap up the definition and calculation of the MCID. Currently, there are multiple ways to calculate it, and it can vary depending on the method used. It may also be important to look at other factors that may help define it. Do patients with lower scores to start with have different MCID values than patients with higher scores? Martin et al.2 found a score of 86 was associated with a normal rating. What happens if a patient has a score of 86 but does not improve according to the MCID? Now that we have all these outcome metrics, we need to figure out the best way to use them. We often find that scores are much lower initially in young female patients. While many parents also find it difficult to understand young female patients, I wonder if these types of factors can also influence these summaries. One final point that Martin et al.2 brought up was the follow-up percentage. In this study, the follow-up percentage was 71%, which I consider excellent considering it is from a multicenter study. This statistic is so important and often ignored. To know whether the patients are doing well or not, they must be contacted. You cannot assume the patients are doing well or did not need a revision if you have not contacted them. Part of all outcomes and quality-control programs must be capturing outcomes of patients at specific time points, with a plan to round up those who do not reply. This is challenging and may be costly, but it is a critical component of this type of research. The demand for more of this type of research is increasing. Where do we go from here? What is the best way to determine whether the patient believes he or she has a good outcome? We need to make sure patients are satisfied with the outcome of their care. We need to define which summary score works best and whether it is a sliding scale depending on age, sex, or how poor the patient’s condition is to start with. Then, we need to make sure the patient is satisfied with his or
her outcome. Much more work lies ahead, but we just have to remember that it is about the patient, and according to Dr. Steadman, if the patient is not satisfied, then the outcome is not successful. In conclusion, the authors should be commended for being dedicated not only to the outcomes of their patients but also to the science behind the outcomes.
References 1. Codman EA. The classic: A study in hospital efficiency: as demonstrated by the case report of first five years of private hospital. Clin Orthop Relat Res 2013;471:1778-1783. 2. Martin RL, Kivlan BR, Christoforetti JJ, et al. Minimal clinically important difference and substantial clinical benefit values for the 12-item International Hip Outcome Tool. Arthroscopy 2019;35:411-416. 3. Larson CM. Editorial Commentary: Patient-related outcome measures, minimal clinically important differences, and substantial clinical benefits for adolescent hip arthroscopy: Making progress with outcome measures or unquestionably spinning out of control? Arthroscopy 2017;33: 1819-1820. 4. Lall AC, Maldonado DR, Domb BG. Editorial Commentary: Is it acceptable to have symptoms after hip arthroscopy?? Depends on whom you ask.. Arthroscopy 2018;34: 3030-3032. 5. Griffin DR, Parsons N, Mohtadi NG, Safran MR, Multicenter Arthroscopy of the Hip Outcomes Research Network. A short version of the International Hip Outcome Tool (iHOT-12) for use in routine clinical practice. Arthroscopy 2012;28:611-616. 6. Stone AV, Jacobs CA, Luo TD, et al. High degree of variability in reporting of clinical and patient-reported outcomes after hip arthroscopy. Am J Sports Med 2018;46: 3040-3046. 7. Cook CE. Clinimetrics corner: The minimal clinically important change score (MCID): A necessary pretense. J Man Manip Ther 2008;16:E82-E83. 8. Nwachukwu BU, Fields K, Chang B, Nawabi DH, Kelly BT, Ranawat AS. Preoperative outcome scores are predictive of achieving the minimal clinically important difference after arthroscopic treatment of femoroacetabular impingement. Am J Sports Med 2017;45:612-619. 9. Nwachukwu BU, Chang B, Fields K, et al. Defining the "substantial clinical benefit" after arthroscopic treatment of femoroacetabular impingement. Am J Sports Med 2017;45: 1297-1303.