title: Can Preoperative Patient-reported Outcome Measures Be Used to Predict Meaningful Improvement in Function After TKA?
abstract: BACKGROUND
  Despite the overall effectiveness of total knee arthroplasty (TKA), a subset of patients do not experience expected improvements in pain, physical function, and quality of life as documented by patient-reported outcome measures (PROMs), which assess a patient's physical and emotional health and pain. It is therefore important to develop preoperative tools capable of identifying patients unlikely to improve by a clinically important margin after surgery.
  
  
  OBJECTIVE
  The purpose of this study was to determine if an association exists between preoperative PROM scores and patients' likelihood of experiencing a clinically meaningful change in function 1 year after TKA.
  
  
  METHODS
  A retrospective study design was used to evaluate preoperative and 1-year postoperative Knee injury and Osteoarthritis Outcome Score (KOOS) and SF-12 version 2 (SF12v2) scores from 562 patients who underwent primary unilateral TKA. This cohort represented 75% of the 750 patients who underwent surgery during that time period; a total of 188 others (25%) either did not complete PROM scores at the designated times or were lost to follow-up. Minimum clinically important differences (MCIDs) were calculated for each PROM using a distribution-based method and were used to define meaningful clinical improvement. MCID values for KOOS and SF12v2 physical component summary (PCS) scores were calculated to be 10 and 5, respectively. A receiver operating characteristic analysis was used to determine threshold values for preoperative KOOS and SF12v2 PCS scores and their respective predictive abilities. Threshold values defined the point after which the likelihood of clinically meaningful improvement began to diminish. Multivariate regression was used to control for the effect of preoperative mental and emotional health, patient attributes quantified by SF12v2 mental component summary (MCS) scores, on patients' likelihood of experiencing meaningful improvement in function after surgery.
  
  
  RESULTS
  Threshold values for preoperative KOOS and SF12v2 PCS scores were a maximum of 58 (area under the curve [AUC], 0.76; p < 0.001) and 34 (AUC, 0.65; p < 0.001), respectively. Patients scoring above these thresholds, indicating better preoperative function, were less likely to experience a clinically meaningful improvement in function after TKA. When accounting for mental and emotional health with a multivariate analysis, the predictive ability of both KOOS and SF12v2 PCS threshold values improved (AUCs increased to 0.80 and 0.71, respectively). Better preoperative mental and emotional health, as reflected by a higher MCS score, resulted in higher threshold values for KOOS and SF12v2 PCS.
  
  
  CONCLUSIONS
  We identified preoperative PROM threshold values that are associated with clinically meaningful improvements in functional outcome after TKA. Patients with preoperative KOOS or SF12v2 PCS scores above the defined threshold values have a diminishing probability of experiencing clinically meaningful improvement after TKA. Patients with worse baseline mental and emotional health (as defined by SF12v2 MCS score) have a lower probability of experiencing clinically important levels of functional improvement after surgery. The results of this study are directly applicable to patient-centered informed decision-making tools and may be used to facilitate discussions with patients regarding the expected benefit after TKA.
  
  
  METHODS
  Level III, prognostic study.
authors.affiliation: Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA.
authors.forename: Jonathan L
authors.initials: JL
authors.lastname: Berliner
authors.affiliation: Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA.
authors.forename: Dane J
authors.initials: DJ
authors.lastname: Brodke
authors.affiliation: Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA.|Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA, USA.
authors.forename: Vanessa
authors.initials: V
authors.lastname: Chan
authors.affiliation: Department of Orthopaedic Surgery, University of California Los Angeles, Santa Monica, CA, USA.
authors.forename: Nelson F
authors.initials: NF
authors.lastname: SooHoo
authors.affiliation: Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, 1400 Barbara Jordan Boulevard, Suite 1.114, Austin, TX, 78723, USA. kevin.bozic@austin.utexas.edu.
authors.forename: Kevin J
authors.initials: KJ
authors.lastname: Bozic
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019645:Arthroplasty, Replacement, Knee; D004185:Disability Evaluation; D006801:Humans; D007719:Knee Joint / Q000503:physiopathology / Q000601:surgery*; D008297:Male; D008603:Mental Health; D008875:Middle Aged; D020370:Osteoarthritis, Knee / Q000601:surgery*; D010147:Pain Measurement; D010149:Postoperative Pain; D000071066:Patient Reported Outcome Measures; D017060:Patient Satisfaction; D020127:Recovery of Function / Q000502:physiology*; D012042:Registries; D012189:Retrospective Studies; D016896:Treatment Outcome