Total shoulder arthroplasty (TSA) is a common orthopedic procedure, and demand continues to increase among both younger and older patients.1 Joint arthroplasty is an important driver of resource use in the United States, and specifically, TSA is likely to contribute to an increasingly higher proportion of health costs. To address the trend toward increased surgical use, the focus has shifted from volume-based health care models to value-based models.2 Value-based health care is frequently described as the ratio between the health outcomes achieved from a service and the associated costs.2–4 Some health care economists contend that value-based health care frameworks should include patient preferences and satisfaction.5–7
Incorporating patient preferences and professional standards into care is an important way to keep health care models patient centric.8 The TSA procedure offers an elective treatment option that can improve pain, function,9 and quality of life10 while maintaining good long-term survival.11 Assessment of whether these standard goals are met is typically accomplished with validated patient-reported outcome measures (PROMs) at various time points during recovery.12 Although PROMs use objective measures of impairment to focus on patient-centered subjective responses, these outcome measures may not reflect patient satisfaction with the outcome or the care provided.13 Patient satisfaction is multidimensional and subjective, whereas PROMs assess functional or general health-related quality of life that may not be specific to a procedure.5,14 For this reason, it is important to measure both functional outcomes and patient satisfaction after surgical procedures.
The goal of this systematic review was to assess patient satisfaction after TSA. The authors hypothesized that there would be inconsistent and heterogeneous methods of evaluating and reporting patient satisfaction after TSA.
Materials and Methods
In January 2018, a systematic review of the MEDLINE database was performed with the PubMed interface. The search query was conducted for shoulder arthroplasty satisfaction OR shoulder replacement satisfaction. This search returned 467 results. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and a PRISMA flow diagram was used (Figure 1). The title and the abstract of each article were reviewed for inclusion in this analysis. The following inclusion criteria were used: English language, clinical outcome study, TSA as the primary procedure, and use of a patient-reported satisfaction outcome measure. Studies that reported the outcomes of several different procedures (ie, anatomic TSA, reverse TSA, hemiarthroplasty [HA]) were included if the satisfaction results were listed individually for each procedure. Studies were excluded if they combined the satisfaction outcome reporting for TSA with the other procedures. Studies also were excluded if they were published in a language other than English or if they did not report both clinical outcomes and patient satisfaction.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart for study inclusion. Abbreviation: TSA, total shoulder arthroplasty.
Data Collection and Analysis
The following data were extracted from each article that met the inclusion criteria: patient demographics, level of evidence, types of surgery included, implant system used, indications for surgery, method of measuring satisfaction, clear statement of the method for determining satisfaction, level of satisfaction reported, other outcome measures reported, and postoperative intervals for measurement of satisfaction. If they were reported in the study, predictors of satisfaction and correlations with PROMs also were extracted. The quality of the included studies was assessed with the methodologic index for nonrandomized studies (MINORS) non-comparative or MINORS comparative score when applicable. Because the Jadad score is used only to assess the quality of randomized controlled trials and no randomized controlled trials were included, this score was not used. If satisfaction was measured and reported separately for other procedures in addition to TSA, these data also were extracted.
Detailed meta-analysis of the extracted data could not be performed because of the heterogeneity of methods used for outcome collection and outcome reporting. Therefore, qualitative analysis of each study was performed and descriptive statistics were used with means and proportions as appropriate.
Of the 467 studies identified on the initial search, 47 met the inclusion criteria. A total of 4450 shoulders and 4383 patients were evaluated, including 3716 TSAs, 559 HAs, and 175 reverse TSAs. Mean age among all patients at the time of surgery was 63.5 years. All studies that were included reported patient satisfaction after TSA (N=47, 100%); 5 (10.6%) studies reported patient satisfaction after reverse TSA (10.6%), and 16 (34.0%) reported patient satisfaction after HA (34%). Mean time to follow-up for evaluation of satisfaction was 89.1 months (range, 12–108 months). Among the included studies, the specific diagnoses included primary osteoarthritis in 35 studies (74.5%), posttraumatic osteoarthritis in 7 studies (14.9%), avascular necrosis in 8 studies (17.0%), and fracture in 2 studies (4.2%). Most of the included studies were level IV evidence (34; 72.3%), and the rest were level III (13; 27.7%). Mean score on the MINORS criteria for included studies was 4.1. Demographic variables are provided in Table 1.
Of the included studies, 40 stated clear methods for assessment of patient satisfaction after TSA (85.1%). The most common method was an ordinal scale (eg, very satisfied, satisfied, neither satisfied nor dissatisfied, dissatisfied), which was used in 27 studies (57.4%). An additional 7 studies (14.9%) assessed satisfaction with a visual analog scale of 0 to 10, and 2 studies (4.3%) assessed satisfaction by asking patients if they would have the surgery again. The remaining 11 (23.4%) studies used assessment of satisfaction as part of another outcome tool, such as the University of California–Los Angeles (UCLA) score (4.2%), Penn Shoulder (PENN) score (2.1%), and modified Neer questionnaire (17.0%).
All of the included studies assessed patient satisfaction at the time of final follow-up, and 3 studies evaluated satisfaction at multiple time points. Only 1 study evaluated patient expectations preoperatively, and 4 studies evaluated patient satisfaction preoperatively.15 Of the studies, 27 (57.4%) differentiated between patient satisfaction with the outcome and with the process of care; 26 specified satisfaction with the outcome, and 1 assessed satisfaction with the process of care.
Reported satisfaction rates after anatomic TSA ranged from 75% to 100%. For HA, satisfaction rates ranged from 65% to 78%, and for reverse TSA, rates ranged from 79% to 90%.
Analysis of the included studies showed that several factors were associated with or predictive of patient satisfaction after TSA (Table 2). A single study found that patients who were diagnosed with depression reported significantly lower satisfaction at 2 years.16 In addition, 5 studies reported significant positive association between PROMs (American Shoulder and Elbow Surgeons score, Subjective Shoulder Value score, Simple Shoulder Test score, and Short Form-36 physical component score) and patient satisfaction17–20; overall, patients who scored higher on PROMs were more likely to report satisfaction. In addition, Jacobs et al18 found that patients who showed improvement of less than 12 points on the American Shoulder and Elbow Surgeons score pre- to postoperatively were 19 times more likely to be dissatisfied. Sciascia et al17 determined threshold values for the American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, Constant score, and Western Ontario Osteoarthritis of the Shoulder Index and found that positive likelihood ratios for these threshold values predicted patient satisfaction. In 2 studies, patients who used opioids preoperatively were less likely to be satisfied with the surgery.18,21 In addition, 1 study found significant positive correlation between objective measurements of function (forward flexion, abduction, external rotation, isometric strength, and activities of daily living) and patient satisfaction, and the prevalence of preoperative opioid use was higher among dissatisfied patients.18,19 Further, one study19 found significant negative associations among workers' compensation status, age, and patient satisfaction (Table 2).16,18–22
Variables Affecting Patient Satisfaction
Patient satisfaction is increasingly being recognized as an essential component of measuring the relative success of orthopedic procedures.5–7 However, satisfaction is a complex concept that involves patient preference and may be influenced by several psychosocial factors. For this reason, it is not valid to extrapolate PROM scores to assess patient satisfaction. This systematic review found that studies that reported satisfaction after TSA were of low quality. In the available TSA literature, overall patient satisfaction is high; however, there is no standardized method of measuring satisfaction. For 85.7% of the included studies, the method used to assess patient satisfaction was clearly stated, and the most common method of assessment was the use of an ordinal scale that included qualitative values to indicate increasing levels of satisfaction. These results confirmed the authors' hypothesis that methods of reporting patient satisfaction after TSA are inconsistent and heterogeneous.
Several factors showed a significant relationship with satisfaction. Interestingly, Chen et al19 found that increasing age was negatively correlated with postoperative patient satisfaction. It was reported previously that patients younger than 55 years who undergo TSA are more active and have a higher degree of participation in sports.23 It is likely that younger patients are more resilient and thus more able to remain active after TSA, resulting in higher levels of satisfaction. Multiple studies also showed that preoperative opioid use and depression were negatively correlated with patient satisfaction. These findings are particularly relevant because of the high level of pain and morbidity associated with pathologies that are treated with TSA and which may be associated with depression and opioid use. This finding highlights the need for a careful history before TSA so that patients may be properly counseled to set appropriate expectations or properly mitigate potentially adjustable factors associated with lower patient satisfaction. The collective findings of patient factors associated with higher postoperative satisfaction may be used to select ideal candidates and to address the expectations of those with negatively associated factors after TSA.
This review identified several shortcomings in the reporting of patient satisfaction after TSA. Previous studies in the joint and spine literature found that preoperative expectation levels were among the strongest predictors of postoperative satisfaction.24,25 However, only 1 study included in this review assessed preoperative expectations, and it found that higher expectations were associated with better PROMs but found no association with satisfaction.15 Hageman et al26 found that patient satisfaction after hand surgery was positively correlated with met expectations, but not with presurgical expectations. Although this finding may be ascribed to the lack of variance in preoperative expectations,26 it is also possible that patients who have unrealistically high expectations may be at risk for poor surgical outcomes.27 To avoid dissatisfaction, discrepancies between the expectations of patients and those of surgeons should be resolved before the procedure.27,28
It has been suggested that there is a need to distinguish between patient satisfaction with surgical outcomes and satisfaction with the process of care.13 Only 57.5% of the studies included in this review differentiated between satisfaction with outcomes and satisfaction with care. Although these considerations are related, they are not the same. A patient may achieve the desired outcome but feel dissatisfied with the care provided. Factors that may contribute to satisfaction with care include cost, time to reach the final outcome, inconvenience, lack of empathetic care, and difficulty with receiving care.
Recent reviews of patient satisfaction after various orthopedic procedures have had findings similar to those of the current study. Earlier studies of patient satisfaction after anterior cruciate ligament reconstruction, treatment for femoroacetabular impingement, and total hip arthroplasty found inconsistent methods and poor levels of evidence on satisfaction.5–7 In addition, these reviews found that preoperative expectations and delineation between satisfaction with the process of care and satisfaction with outcomes were rarely included. Unlike the current study, which found that an ordinal scale was most frequently used to assess patient satisfaction, all of the previous studies found that a 10-point visual analog scale was the most common assessment method. The current study emphasizes the need for a standardized method to evaluate patient satisfaction after orthopedic procedures.
The authors acknowledge several limitations of this study. The wide range of methods, technologies, and implants used for TSA may contribute to heterogeneity of the data. In addition, satisfaction was assessed at a vast range of follow-up intervals (12–108 months), which could contribute to inconsistent measurements. However, a recent study showed that patients who receive TSA reach maximal medical improvement at 1 year, which suggests that no further changes in patient satisfaction may be seen after this time point.29 Finally, the current study was limited by the level of evidence of the studies included for review, which were only level III and level IV.
In the available TSA literature, levels of evidence are low for studies of patient satisfaction. Overall, patient satisfaction is high; however, there is no standardized method of measurement. The method used to assess patient satisfaction was stated clearly in 85.7% of studies. The most common method of assessment was an ordinal scale consisting of qualitative values that represent increasing levels of satisfaction. Depression, opioid use, increasing age, and workers' compensation status are preoperative factors associated with lower postoperative satisfaction. As orthopedic surgeons are increasingly asked to demonstrate the value of procedures, a uniform and validated method of assessing patient satisfaction is needed.
- Padegimas EM, Maltenfort M, Lazarus MD, Ramsey ML, Williams GR, Namdari S. Future patient demand for shoulder arthroplasty by younger patients: national projections. Clin Orthop Relat Res. 2015;473(6):1860–1867. doi:10.1007/s11999-015-4231-z [CrossRef] PMID:25758376
- Bozic KJ, Wright JG. Value-based health-care and orthopaedic surgery. Clin Orthop Relat Res. 2012;470(4):1004–1005. doi:10.1007/s11999-012-2267-x [CrossRef] PMID:22302657
- Callahan CD, Adair D, Bozic KJ, Manning BT, Saleh JK, Saleh KJ. Orthopaedic surgery under national health reform: an analysis of power, process, adaptation, and leadership. AOA critical issues. J Bone Joint Surg Am. 2014;96(13):e111. doi:10.2106/JBJS.M.01067 [CrossRef] PMID:24990985
- Chad Mather RC III, Bozic KJ. Value-based care. J Shoulder Elbow Surg. 2013;22(12):1599–1600. doi:10.1016/j.jse.2013.10.007 [CrossRef] PMID:24246528
- Kahlenberg CA, Nwachukwu BU, Ferraro RA, Schairer WW, Steinhaus ME, Allen AA. How are we measuring patient satisfaction after anterior cruciate ligament reconstruction?Orthop J Sports Med. 2016;4(12):2325967116673971. doi:10.1177/2325967116673971 [CrossRef] PMID:28203583
- Kahlenberg CA, Nwachukwu BU, Schairer WW, McCormick F, Ranawat AS. Patient satisfaction reporting for the treatment of femoroacetabular impingement. Arthroscopy. 2016;32(8):1693–1699. doi:10.1016/j.arthro.2016.02.021 [CrossRef] PMID:27157663
- Kahlenberg CA, Nwachukwu BU, Schairer WW, Steinhaus ME, Cross MB. Patient satisfaction reporting after total hip arthroplasty: a systematic review. Orthopedics. 2017;40(3):e400–e404. doi:10.3928/01477447-20170120-04 [CrossRef] PMID:28135370
- Lynn J, McKethan A, Jha AK. Value-based payments require valuing what matters to patients. JAMA. 2015;314(14):1445–1446. doi:10.1001/jama.2015.8909 [CrossRef] PMID:26378889
- Levy JC, Everding NG, Gil CC Jr, Stephens S, Giveans MR. Speed of recovery after shoulder arthroplasty: a comparison of reverse and anatomic total shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(12):1872–1881. doi:10.1016/j.jse.2014.04.014 [CrossRef] PMID:24981553
- Simovitch R, Flurin P-H, Wright T, Zuckerman JD, Roche CP. Quantifying success after total shoulder arthroplasty: the minimal clinically important difference. J Shoulder Elbow Surg. 2018;27(2):298–305. doi:10.1016/j.jse.2017.09.013 [CrossRef] PMID:29162305
- Raiss P, Bruckner T, Rickert M, Walch G. Longitudinal observational study of total shoulder replacements with cement: fifteen to twenty-year follow-up. J Bone Joint Surg Am. 2014;96(3):198–205. doi:10.2106/JBJS.M.00079 [CrossRef] PMID:24500581
- Ring D, Bozic KJ. Value-based healthcare: the value of considering patient preferences and circumstances in orthopaedic surgery. Clin Orthop Relat Res. 2016;474(3):633–635. doi:10.1007/s11999-015-4648-4 [CrossRef] PMID:26626925
- Graham B, Green A, James M, Katz J, Swiontkowski M. Measuring patient satisfaction in orthopaedic surgery. J Bone Joint Surg Am. 2015;97(1):80–84. doi:10.2106/JBJS.N.00811 [CrossRef] PMID:25568398
- Angst F, Goldhahn J, Drerup S, Aeschlimann A, Schwyzer H-K, Simmen BR. Responsiveness of six outcome assessment instruments in total shoulder arthroplasty. Arthritis Rheum. 2008;59(3):391–398. doi:10.1002/art.23318 [CrossRef] PMID:18311752
- Swarup I, Henn CM, Nguyen JT, et al. Effect of pre-operative expectations on the outcomes following total shoulder arthroplasty. Bone Joint J. 2017;99-b(9):1190–1196. doi:10.1302/0301-620X.99B9.BJJ-2016-1263.R1 [CrossRef]
- Werner BC, Wong AC, Chang B, et al. Depression and patient-reported outcomes following total shoulder arthroplasty. J Bone Joint Surg Am. 2017;99(8):688–695. doi:10.2106/JBJS.16.00541 [CrossRef] PMID:28419037
- Sciascia AD, Morris BJ, Jacobs CA, Edwards TB. Responsiveness and internal validity of common patient-reported outcome measures following total shoulder arthroplasty. Orthopedics. 2017;40(3):e513–e519. doi:10.3928/01477447-20170327-02 [CrossRef] PMID:28358978
- Jacobs CA, Morris BJ, Sciascia AD, Edwards TB. Comparison of satisfied and dissatisfied patients 2 to 5 years after anatomic total shoulder arthroplasty. J Shoulder Elbow Surg. 2016;25(7):1128–1132. doi:10.1016/j.jse.2015.12.001 [CrossRef] PMID:26897317
- Chen AL, Bain EB, Horan MP, Hawkins RJ. Determinants of patient satisfaction with outcome after shoulder arthroplasty. J Shoulder Elbow Surg. 2007;16(1):25–30. doi:10.1016/j.jse.2006.04.013 [CrossRef] PMID:17097315
- Harreld K, Clark R, Downes K, Virani N, Frankle M. Correlation of subjective and objective measures before and after shoulder arthroplasty. Orthopedics. 2013;36(6):808–814. doi:10.3928/01477447-20130523-29 [CrossRef] PMID:23746020
- Morris BJ, Sciascia AD, Jacobs CA, Edwards TB. Preoperative opioid use associated with worse outcomes after anatomic shoulder arthroplasty. J Shoulder Elbow Surg. 2016;25(4):619–623. doi:10.1016/j.jse.2015.09.017 [CrossRef] PMID:26652698
- Eichinger JK, Miller LR, Hartshorn T, Li X, Warner JJ, Higgins LD. Evaluation of satisfaction and durability after hemiarthroplasty and total shoulder arthroplasty in a cohort of patients aged 50 years or younger: an analysis of discordance of patient satisfaction and implant survival. J Shoulder Elbow Surg. 2016;25(5):772–780. doi:10.1016/j.jse.2015.09.028 [CrossRef] PMID:26700556
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|Reverse TSA, No.||175|
|Age, mean, y||63.5|
|Time to follow-up, mean, mo||89.1|
|Diagnoses included in studies, No.|
| Primary osteoarthritis||35 (74.5%)|
| Posttraumatic osteoarthritis||7 (14.9%)|
| AVN||8 (17.0%)|
| Fracture||2 (4.2%)|
|Procedures included in studies, No.|
| TSA||47 (100%)|
| Reverse TSA||5 (10.6%)|
| HA||16 (34.0%)|
|Level of evidence, No.|
| III||13 (27.7%)|
| IV||34 (72.3%)|
Variables Affecting Patient Satisfaction
|Variable||Relationship to Satisfaction||Statistical Calculation|
|ASES19,20||Positive correlation||R=0.68, P<.00119; R=0.58920|
|SSV22||Predictive of satisfaction||OR, 0.24; CI, 0.09–0.68|
|SF-36 MCS20||Positive correlation||R=0.385|
|Increasing age19||Negative correlation||R=0.31, P<.01|
|Workers' compensation19||Negative correlation||P=.018|
|Preoperative opioid use18,21||Negative association||P=.0318; P=.0318|
|Range of motion18||Positive correlation||Forward flexion: R=0.16, P=.02; abduction: R=0.15, P=.02|
|Pain18,19,22||Negative correlation||Preoperative: R=−0.13, P=.04; postoperative: R=−0.47, P<.00118; R=−0.60, P<.00119|
|Predictive of dissatisfaction||OR, 4.4; CI, 1.4–13.7; P=.01122; P<.00119|
|ADLs||Positive correlation||R=0.40, P<.001|