Orthopedics

Feature Article 

Patient-Reported Outcomes of Shoulder Surgery in a Community Orthopedic Practice: A 5-Year Quality Improvement Project Using the QuickDASH Questionnaire

Daniel J. Shubert, MD; Sarah B. Shubert, MD

Abstract

There has been a shift in US health care to a system that emphasizes value. Patient-reported outcomes have become a critical component of that valuation. A 5-year quality improvement project at the community private practice level was undertaken to assess the authors' delivery of care and practice processes for shoulder surgery as compared with established standards. QuickDASH questionnaires were collected from 1304 consecutive shoulder surgery patients, and data were collected at 4 time points. Mean QuickDASH scores for each procedure and scores assessing biceps tenodesis, distal clavicle excision, workers' compensation status, and sex were analyzed for statistical significance. Rotator cuff repair patients who also underwent biceps tenodesis had statistically significant worse function preoperatively and at 3 and 6 months postoperatively but not at 1 year postoperatively (P<.05). Rotator cuff repair patients undergoing concomitant distal clavicle excision had statistically significantly higher pre-operative scores (P<.01). Male shoulder arthroplasty patients had statistically significant higher preoperative scores (P<.02). Non–workers' compensation patients had statistically significant higher scores at 1 year (P<.05), whereas workers' compensation patients were statistically significantly younger (P<.01). Maximum changes in scores that met minimal clinically important differences occurred between surgery and 6 months postoperatively in all procedures. Quality outcome studies can be performed in private practice by a single surgeon and yield helpful results that lead to quality improvement through practice and delivery of care processes. [Orthopedics. 2020;43(5):e383–e388.]

Abstract

There has been a shift in US health care to a system that emphasizes value. Patient-reported outcomes have become a critical component of that valuation. A 5-year quality improvement project at the community private practice level was undertaken to assess the authors' delivery of care and practice processes for shoulder surgery as compared with established standards. QuickDASH questionnaires were collected from 1304 consecutive shoulder surgery patients, and data were collected at 4 time points. Mean QuickDASH scores for each procedure and scores assessing biceps tenodesis, distal clavicle excision, workers' compensation status, and sex were analyzed for statistical significance. Rotator cuff repair patients who also underwent biceps tenodesis had statistically significant worse function preoperatively and at 3 and 6 months postoperatively but not at 1 year postoperatively (P<.05). Rotator cuff repair patients undergoing concomitant distal clavicle excision had statistically significantly higher pre-operative scores (P<.01). Male shoulder arthroplasty patients had statistically significant higher preoperative scores (P<.02). Non–workers' compensation patients had statistically significant higher scores at 1 year (P<.05), whereas workers' compensation patients were statistically significantly younger (P<.01). Maximum changes in scores that met minimal clinically important differences occurred between surgery and 6 months postoperatively in all procedures. Quality outcome studies can be performed in private practice by a single surgeon and yield helpful results that lead to quality improvement through practice and delivery of care processes. [Orthopedics. 2020;43(5):e383–e388.]

There is little doubt that a paradigm shift in the valuation of health care in the United States is well under way. Models of years past that rewarded volume are being replaced by systems that emphasize value to the patient.1 Value in health care can be defined as a ratio of the benefit of the treatment received by a patient to the dollars spent in providing treatment. Patient-reported outcomes have emerged as a critical component in the valuation of health care, and all signs point to their increasing use.2 For example, physicians sitting for part 2 of the 2019 American Board of Orthopaedic Surgeons board examination will have patient-reported outcome data from their cases as part of their evaluation. The American Academy of Orthopaedic Surgeons released this statement in 2012: “The current generation of quality measures, which primarily rely on process measures and administrative data, have not yet been proven to accurately correlate with improved functional outcomes, which are the primary outcomes of interest to patients who undergo orthopedic procedures.”3 Currently, the most effective tool for capturing quality-of-life changes as a result of orthopedic intervention are patient-reported outcome measures.

Quality-of-life improvement is the principle outcome of interest in orthopedic procedures. The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire is one of several health-related quality-of-life measurement tools used by orthopedists. It has been extensively reviewed and proven to have longitudinal construct, content, and criterion validity in more than 15 languages.4 The QuickDASH is a shortened version of the DASH consisting of 11 questions (3 related to symptoms and 8 related to function). All questions reference only the prior week. Normative values have been established for different age groups, as has a range of minimal clinically important difference (MCID).5–8 In addition, the QuickDASH has excellent test/retest reliability, internal consistency, construct and content validity, and responsiveness.6–15 Several studies show the QuickDASH to correlate well with the DASH questionnaire.14,16–18 The questionnaire takes approximately 2 minutes to complete and 2 to 8 minutes to score; it is then converted to a 0 to 100 score, with a higher score indicating a greater disability.19

This article arose from a quality improvement project that set out to confirm the established standards in the authors' community practice and to evaluate and improve the delivery of care. Patient-reported outcome data via the QuickDASH score were collected by a single fellowship-trained shoulder surgeon (S.B.S.) during a 5-year period for all patients who underwent rotator cuff repair (RCR) and total shoulder arthroplasty (TSA). The authors' hypothesis was that use of patient-reported outcome data would reveal statistically significant data, leading to changes in practice processes regarding established standards and changes in certain areas of delivery of care. Selected areas of focus were the following:

  1. What are the mean QuickDASH scores for RCR and TSA patients when calculated preoperatively and at 3 and 6 months and 1 year postoperatively?

  2. Does biceps tenodesis performed during arthroscopic RCR have a statistically significant impact on QuickDASH scores and established processes in patient selection?

  3. Does distal clavicle excision during RCR have a statistically significant impact on QuickDASH scores and established processes in patient selection?

  4. Does workers' compensation status exhibit a statistically significant impact on QuickDASH scores in arthroscopic RCR patients? Should this affect how information is collected for this patient subset and their respective postoperative protocols?

  5. Does sex significantly affect QuickDASH scores of arthroscopic RCR and TSA patients, and if so does this change postoperative processes and care?

Materials and Methods

Between August 2012 and November 2017, a total of 1304 consecutive shoulder surgery patients of a single, fellowship-trained, board-certified, orthopedic sports medicine private practice surgeon (S.B.S.) were assessed with the QuickDASH questionnaire. All patients undergoing RCR or TSA were included for this quality improvement project. The only exclusion criteria was prior surgery on the ipsilateral shoulder. No patient refused participation in the project. All patients provided written and verbal consent, institutional review board approval was not required due to quality improvement status, and the project was approved and deemed ethical by the Spectrum Healthcare Partners Organization. All patients were de-identified, and all study results were made publicly available on the practice's website.

After obtaining verbal and written consent, patients completed Quick-DASH questionnaires at the beginning of each appointment, using pen and paper. If a patient missed a scheduled appointment or if a patient was doing well enough to be discharged to return on an “as needed” basis prior to 1 year postoperatively, then the questionnaire was mailed to the patient with a self-addressed stamped envelope at the correct time interval, along with a personalized note from the surgeon.

The questionnaires were scored by 2 technologists trained by the surgeon in the scoring process. Scores were then entered into a single Excel (Microsoft, Redmond, Washington) database. The following were also recorded: date of surgery; patient age; Current Procedural Terminology and International Classification of Diseases, Ninth Revision, codes; laterality; patient sex; hand dominance; workers' compensation status; and smoking status. Two additional data points were collected for arthroscopic RCR patients: biceps tenodesis or distal clavicle excision at the time of surgery. At no time throughout the 5 years was any surgical or other treatment technique modified.

Indications for arthroscopic RCR included failure of conservative treatment for 3 months or longer and/or symptomatic full-thickness rotator cuff tear. Indications for TSA or reverse total shoulder arthroplasty (RTSA) were failure of conservative treatment and the presence of advanced osteoarthritis or rotator cuff tear arthropathy on radiographs and/or advanced imaging. Surgical technique for RCR involved arthroscopic single-row repair using titanium suture anchors.

Symptomatic partial-thickness tears measuring greater than 50% of tendon thickness were taken down and repaired. Biceps tenodesis was performed in cases where the patient described pain extending down the biceps and had intraoperative findings of biceps tendon tearing greater than 50% of the tendon thickness. Asymptomatic tears were not treated operatively. Tenodesis was performed arthroscopically using a suture anchor technique in the bicipital groove. Distal clavicle excision was performed when the patient reported pain directly over the acromioclavicular joint, had tenderness in that location on physical examination, and had radiologic findings confirming arthrosis.

The TSA and RTSA technique involved a deltopectoral approach with repair of the subscapularis except when not possible in reverse TSAs. The Ascend Flex implant (Tornier/Wright, Memphis, Tennessee) was used in all cases. Postoperative protocol for RCR involved 6 weeks of passive range of motion only with weaning of a sling. Active range of motion was initiated at 6 weeks and strengthening at 10 to 12 weeks. Shoulder arthroplasty protocol included use of a sling for 4 to 6 weeks, immediate passive and active range of motion with limitations, and strengthening at 10 to 12 weeks.

Mean overall TSA and RCR Quick-DASH scores were calculated preoperatively and at 3 and 6 months and 1 year postoperatively. Mean scores at those time points were also compared for statistical significance based on sex using two-sample t testing with unequal variance where appropriate. For RCR patients, workers' compensation status and the presence of distal clavicle excision or biceps tenodesis were analyzed separately for statistical significance using two-sample t testing with unequal variance.

Results

A total of 662 RCR and 83 TSA patients were identified. A total of 642 (97.1%) RCR patients and 82 (98.8%) TSA patients completed preoperative QuickDASH questionnaires. An a priori power test found each RCR cohort comparison powered to 0.90 at all time points, when Cohen's d value was set at 0.5, indicative of a large sample size, and with P<.05. For the 82 TSA patients, sample size was large enough such that all cohorts studied were powered to 0.85 with two-tailed t testing, assuming a large sample size and with P<.05.

Questionnaire completion rates predictably decreased over time. For RCR patients, rates were 535 (80.8%), 415 (62.7%), and 202 (30.5%) at 3 and 6 months and 1 year postoperatively, respectively. Completion rates for arthroplasty patients were 57 (68.7%), 44 (53.0%), and 32 (38.6%) at 3 and 6 months and 1 year postoperatively, respectively.

Mean RCR and shoulder arthroplasty QuickDASH scores at each time period are presented in Figure 1 and Figure 2. The RCR patients who underwent concomitant biceps tenodesis had statistically significant higher (worse) QuickDASH scores at the 3- and 6-month time points (P=.47 and P=.33), respectively, than patients without biceps tenodesis. However, by 1 year postoperative, there was no MCID or statistically significant difference in QuickDASH scores.

Mean QuickDASH scores of all arthroscopic rotator cuff repair patients preoperatively and at 3 and 6 months and 1 year postoperatively.

Figure 1:

Mean QuickDASH scores of all arthroscopic rotator cuff repair patients preoperatively and at 3 and 6 months and 1 year postoperatively.

Mean QuickDASH scores of all total shoulder arthroplasty patients preoperatively and at 3 and 6 months and 1 year postoperatively.

Figure 2:

Mean QuickDASH scores of all total shoulder arthroplasty patients preoperatively and at 3 and 6 months and 1 year postoperatively.

The RCR patients with distal clavicle excisions had statistically significant higher preoperative QuickDASH scores (P=.01) than patients who did not undergo distal clavicle excision but insignificance was reached by 3 months postoperatively (Figure 3). No statistically significant postoperative QuickDASH score differences were found between male and female RCR (Figure 4) or TSA patients, and at 1 year postoperatively patients had reached age group norms. Non–workers' compensation RCR patients had a statistically significant higher (worse) QuickDASH score at 1 year postoperatively (P<.048). The workers' compensation patient cohort was of a statistically significant younger age (P<.01).

Mean QuickDASH scores of all arthroscopic rotator cuff repair patients with distal clavicle excision preoperatively and at 3 and 6 months and 1 year postoperatively (A). Mean QuickDASH scores of all arthroscopic rotator cuff repair patients without distal clavicle excision preoperatively and at 3 and 6 months and 1 year postoperatively (B).

Figure 3:

Mean QuickDASH scores of all arthroscopic rotator cuff repair patients with distal clavicle excision preoperatively and at 3 and 6 months and 1 year postoperatively (A). Mean QuickDASH scores of all arthroscopic rotator cuff repair patients without distal clavicle excision preoperatively and at 3 and 6 months and 1 year postoperatively (B).

Mean QuickDASH scores of all male arthroscopic rotator cuff repair patients preoperatively and at 3 and 6 months and 1 year postoperatively (A). Mean QuickDASH scores of all female arthroscopic rotator cuff repair patients preoperatively and at 3 and 6 months and 1 year postoperatively (B).

Figure 4:

Mean QuickDASH scores of all male arthroscopic rotator cuff repair patients preoperatively and at 3 and 6 months and 1 year postoperatively (A). Mean QuickDASH scores of all female arthroscopic rotator cuff repair patients preoperatively and at 3 and 6 months and 1 year postoperatively (B).

Discussion

The current findings show RCR and TSA to be quality-of-life improving procedures from the patient perspective. Mean Quick-DASH scores across all RCR and TSA patients showed MCIDs at 3 and 6 months postoperatively, but no MCID between 6 months and 1 year postoperatively. The results for RCR patients who underwent distal clavicle excision or biceps tenodesis had nearly identical scores at 1 year postoperatively compared with patients who underwent RCR alone.

These results were also close to age group normative values. The authors interpret this as distal clavicle excision and biceps tenodesis having a significant positive impact when patient selection is systematic and stringent, which reinforces the notion that the process they use to select patients as candidates for these procedures is appropriate and reflects established standards.20–25

This has led the authors to reconsider the follow-up schedule they have used for RCR patients. In their geographic region, many patients travel for hours to reach their appointment, so lessening the number of follow-up visits by a single appointment (eg, an appointment at 9 months instead of both 6 months and 1 year) would have a significant impact on both the patient and administrative ends. At a minimum, patient costs would decrease and the surgeon could see more new patients.

Quality improvement initiatives are used to analyze a program, process, or system and compare with established standards, with the goal of improving these processes. The ultimate purpose of orthopedic shoulder surgery is to improve quality of life. There is abundant literature about RCR and TSA regarding implants, survivorship, and so forth, but a paucity of literature is dedicated to pure patient-reported outcome measures. With the creation of entities such as the Patient-Reported Outcomes Measurement Information System (PROMIS), the American Joint Replacement Registry, and the Kaiser Permanente Shoulder Arthroplasty Registry, it seems that a national shoulder joint or sports medicine registry is inevitable.26–28

As delivery of care becomes more patient centered, and along with it ties to compensation, patient-reported outcome measures will continue to grow in popularity, importance, and accessibility. These realizations were the impetus for this quality improvement project—to determine whether the authors could increase their patients' quality of life and improve function and pain relief via patient-reported outcome data. The authors chose RCR and TSA patients because these are the shoulder procedures most validated in relation to the QuickDASH.17 The QuickDASH was selected due to its relative brevity but comparable validity to the DASH in these procedures.

In the current cohort of workers' compensation patients undergoing RCR, it was the non–workers' compensation patients who showed a statistically significant higher (worse) score at 1 year postoperatively, and values were otherwise similar at 3 and 6 months postoperatively. This finding is generally at odds with the literature, which tends to state that workers' compensation patients who undergo RCR experience worse outcomes and start with worse preoperative scores, regardless of the scoring instrument used.29–35

However, there are studies where workers' compensation patients performed equally well when characteristics are controlled for, and others where differences in outcomes were just at the threshold of statistical significance.35,36 The majority of these studies use the 36-item Short Form survey, the UCLA shoulder scores, or the American Shoulder and Elbow Surgeons shoulder score, the latter of which is often presented as a patient-reported outcome but in reality has a physician component to it.37

Only one study could be found that used a purely patient-reported outcome measurement tool, validated for RCR, to conclude worse outcomes in workers' compensation RCR patients.30 The difference between the authors' workers' compensation cohort and non–workers' compensation cohort barely met statistical significance at 1 year postoperatively (P=.048). The workers' compensation group was also of a statistically significant younger age, which may contribute to their better recoveries. Neither group differed significantly in smoking status or handedness.

Literature also supports the notion that this is a complex problem involving a variety of components, from prior comorbidities to psychiatric elements.32,33 In addition, at 1 year postoperatively the authors may be capturing a larger percentage of the workers' compensation patients who have done well and are motivated to return to work. This may be true since the workers' compensation system requires follow-up until maximal medical improvement is reached, often at 1 year postoperatively. Non–workers' compensation patients doing well at that time simply may not present for follow-up. Conversely, this may truly reflects what patient-reported outcome measures are all about—that there can be substantially different findings when patient-reported measures are used rather than physician-directed data collection.

The above offers a glimpse into the amount of information from the patient's perspective that a simple, 2-minute questionnaire provides orthopedic surgeons. The authors chose pen and paper and in-person collection because, for these procedures, their patient age group was thought to be overall more comfortable using this medium than tablets, email, or online completion. The decrease in completion rate as time extended out from the date of surgery is likely due to a combination of factors, including the following: an increasing likelihood of missing their appointment; forgetfulness; less inclination to complete questionnaires as patients feel better; either too incomplete to be scored or not at all; fatigue from answering multiple questionnaires; and not enough stress on the importance of each completed questionnaire from the surgeon's end. Higher completion rates for this study would likely be more possible with the support and personnel of an academic system, as well.

Tying patient outcomes to national registries is a concept that is gaining popularity and has numerous benefits.3,38,39 One advantage includes access to sizeable patient cohorts for data comparison, offering a larger and clearer picture of the value of treatment. This can result in gains ranging from aid in the development of standardized practices to negotiation leverage with entities such as insurance companies, hospitals, accountable care organizations, and other payers.3

The limitations of this project included the loss to follow-up of patients, particularly at 1 year postoperatively, despite the authors' efforts. Although this decrease was expected, it can be improved on. The brevity and simplistic nature of the QuickDASH survey can also allow the authors to increase these patients' participation rates. Another limitation was the necessity of combining TSA and RTSA outcomes because both currently share the same Current Procedural Terminology code.

Conclusion

It is clear that quality outcome studies can be performed successfully in private practice and yield helpful results. This single-surgeon, shoulder-focused, community practice project reflected in real statistical analysis many of the findings in previous literature as assessed from the physician's standpoint, several of which will lead to significant changes in practice processes. Some of the changes to be implemented are aimed at involving patients more directly with their own health care. For example, patients' QuickDASH scores will be tied into the authors' electronic medical record such that it is on the screen when patients enters the examination room, in an easily interpretive graph, allowing patients to see the score trending.

Other changes include putting patient-reported outcome data on the authors' practice website along with what it means and why it is important; changing follow-up protocols for both arthroplasty and RCR repair; and helping the patient to understand the QuickDASH with a thank you card at the final office visit explaining why patient-reported outcome measures are so critical to improving quality of care. These patient-reported outcome data also provide the authors' practice a means of assessing delivery of care in future years, and recognizing any positive or negative trends.

Finally, the authors found that patient-reported outcome measures can be used to empower patients to be more involved with their care. This has helped to forge stronger physician–patient relationships in the setting of this surgical practice.

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Authors

The authors are from the Department of Orthopaedics (DJS), West Virginia University, Morgantown, West Virginia; and Falmouth Orthopaedic Center (SBS), Falmouth, Maine

The authors have no relevant financial relationships to disclose.

The authors thank Miriam Dowling-Schmitt, MS, RN, AGNP-C, CCRN, for her contributions to data collection and management.

Correspondence should be addressed to: Daniel J. Shubert, MD, Department of Orthopaedics, West Virginia University, PO Box 9196, Morgantown, WV 26506-9196 ( djshubert@hsc.wvu.edu).

Received: March 28, 2019
Accepted: July 01, 2019
Posted Online: July 08, 2020

10.3928/01477447-20200619-06

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