It Is Good To Feel Better, But Better To Feel Good: Whether A Patient Finds Treatment ‘Successful’ Or Not Depends On The Questions Researchers Ask
Roos EM, Boyle E, Frobell RB, Lohmander LS, Ingelsrud LH. Br J Sports Med. 2019 Apr. doi:10.1136/ bjsports-2018-100260. Epub Ahead of Print
Take Home Message: While patients may exceed minimal important change on patient-reported outcome scores after an ACL injury, many feel their treatment was unsuccessful
We commonly use patient-reported outcome (PRO) measures in clinical trials to determine the success or failure of a treatment regimen after a musculoskeletal injury. Several PROs are readily available to clinicians, yet these measurements often focus on a patient’s functional ability or symptoms and not their satisfaction with how they feel after treatment. When clinicians focus on a change score from baseline to follow-up it tells them if a patient is “feeling better,” but not if a patient “feels good.” It’s important to appreciate how these different ways to interpret PROs may alter the reported benefit of a treatment. Hence, the authors applied three different criteria to determine responders and non-responders in the KANON trial, which was a high-quality randomized trial that compared (1) exercise therapy and early anterior cruciate ligament reconstruction surgery and (2) exercise therapy and delayed reconstruction surgery (if needed). The trial included 121 young active adults. For the first treatment response criteria, the authors calculated the minimal important change over 2 years for four of five subscales (pain, symptoms, sports and recreation activities, and quality of life) of the Knee injury and Osteoarthritis Scale (KOOS 4) and a secondary outcome of all five subscales (including activities of daily living) of the KOOS. A minimal important change was defined as “a change that patients would consider important to reach in their situation, dependent on baseline values or severity of disease, on the type of intervention, and on the duration of the follow-up period”. The authors also included two post-intervention responder criteria using the patient acceptable symptom state (PASS) and treatment failure. These criteria asked patients a ‘Yes’ or ‘No’ question to determine their satisfaction with their current knee function and if they felt their treatment failed them. Both treatment groups had similar rates of responders and non-responders according to all three criteria. Nine out of 10 participants exceeded minimal important change scores on the KOOS subscales, which indicates successful improvements in function or symptoms following either treatment. However, only 5 out of 10 participants were satisfied with their current state after the treatments according to the PASS and 1 out of 10 participants actually felt their treatment had failed.
At first glance, the results of the KANON trial show either treatment option is highly successful at returning patients to a more functional state following an anterior cruciate ligament tear. However, when patients were able to give input on their satisfaction with their recovery, these favorable outcomes shifted. Reaching a minimal change score on the KOOS failed to equate to patients experiencing a suitable outcome. For example, a person at the time of surgery may report a 70% functional impairment and 2 years later report a 30% impairment. If a clinician only looked at change, they would see a huge improvement but miss that the patient is still reporting significant functional impairments. Patients are more concerned with their current health status than their progress. Taking a patient-centered approach during the rehabilitation process can enhance patient outcomes. Clinicians should talk with their patients recovering from an anterior cruciate ligament injury to gain insight into a patients’ perception and satisfaction with their current health status.
Questions for Discussion: How often do you ask your patients if they are satisfied with their recovery following an ACL injury? What clinical parameters do you rely on to determine a successful treatment/recovery following an ACL injury- does it include patient
Written by: Danielle M. Torp
Reviewed by: Jeffrey Driban