Depression and Patient-Reported Outcomes Following Total Shoulder Arthroplasty

Werner, Brian C. MD1,a; Wong, Alexandra C. BA2; Chang, Brenda MS, MPH2; Craig, Edward V. MD, MPH3; Dines, David M. MD2; Warren, Russell F. MD2; Gulotta, Lawrence V. MD2

Journal of Bone & Joint Surgery - American Volume: 19 April 2017 - Volume 99 - Issue 8 - p 688–695
doi: 10.2106/JBJS.16.00541
Scientific Articles
Disclosures
Commentary

Background: Recent studies have found that depression is associated with increased pain and impairment following lower-extremity arthroplasty; however, this association has not been investigated for total shoulder arthroplasty. The objective of this study was to investigate the association between depression and patient-reported outcomes following total shoulder arthroplasty.

Methods: A prospectively collected institutional registry was queried for consecutive patients who underwent total shoulder arthroplasty for osteoarthritis from 2007 to 2013 with baseline and minimum 2-year postoperative American Shoulder and Elbow Surgeons (ASES) scores. Revision procedures and total shoulder arthroplasty for diagnoses other than osteoarthritis were excluded. Patients with a preoperative diagnosis of depression (n = 88) formed the study cohort; control patients without a diagnosis of depression were matched to the study patients by age and sex in a 2:1 ratio (n = 176). Baseline characteristics and patient-reported outcome measures were compared between groups, as were minimum 2-year patient-reported outcomes and change in patient-reported outcomes. A multivariable regression was performed to investigate the independent effect of depression on improvement in ASES scores.

Results: Except for the Short Form-12 Mental Component Summary (SF-12 MCS) scores, there were no significant differences (p > 0.05) in baseline characteristics between study patients and controls. There was a significant improvement in the ASES score for patients with depression (p < 0.0001) and controls (p < 0.0001). Patients with depression had significantly lower final ASES scores (p = 0.001) and less improvement in ASES scores (p = 0.001) and SF-12 Physical Component Summary scores (p = 0.006) as well as lower satisfaction levels at 2 years; however, the latter difference did not reach clinical importance. Depression (p = 0.018) was an independent predictor of less improvement in ASES scores.

Conclusions: Patients with a diagnosis of depression should be counseled that they will experience a significant clinical improvement from baseline after total shoulder arthroplasty. A preoperative diagnosis of depression is an independent predictor of significantly less improvement in ASES scores following total shoulder arthroplasty; however, this difference does not reach clinical importance and should not discourage patients with a clinical diagnosis of depression from undergoing total shoulder arthroplasty.

Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

1Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia

2Sports Medicine and Shoulder Surgery, Hospital for Special Surgery, New York, NY

3Department of Orthopaedic Surgery, TRIA Orthopaedic Center, Bloomington, Minnesota

E-mail address for B.C. Werner: bcw4x@virginia.edu

Article Outline

Approximately 1 in 10 adults in the United States report symptoms of depression, and the lifetime prevalence of depressive disorders is about 17%, making depression one of the most common psychiatric comorbidities1-3. The prevalence of depression appears to be even higher in orthopaedic patients or those patients with chronic musculoskeletal pain4-10. In a recent study of patients with orthopaedic trauma, the prevalence of depression was 45%, nearly quadruple the prevalence in the general U.S. population5. Depression has also been associated with inferior outcomes and poor improvement following numerous orthopaedic procedures, including lower-extremity total joint arthroplasty as evidenced by higher levels of postoperative pain, poor clinical and functional improvement, increased revision rates, and increased infection rates1,11-24.

Chronic shoulder pain and dysfunction, including those due to glenohumeral arthritis, have also been associated with higher rates of depression4,25-27. Although extensive study has been devoted to the effect of depression on outcomes following lower-extremity arthroplasty, to our knowledge, there are few studies that examine any association between depression and outcomes following shoulder arthroplasty. In the only available study on the topic, to our knowledge, Bot et al. found that psychiatric illness, including depression, was associated with increased risk of perioperative morbidity and need for post-hospitalization care following shoulder arthroplasty11. That study did not assess the effect of depression on patient-reported outcomes and satisfaction, which are the outcomes most affected by a diagnosis of depression for other orthopaedic procedures1,9,15,18,22,28,29.

Although the quality of medical care has traditionally been evaluated on the basis of discrete measures such as mortality or complication rates, patient-reported outcome measures have become increasingly important in determining economic impact of surgical procedures28. Patient-reported outcomes are now being used by health-care facilities for assessment and by insurers such as Medicare in compensation formulas as criteria for reimbursement28. This highlights the importance of identifying factors that affect improvement in patient-reported outcomes following total shoulder arthroplasty. The goal of the present study was to investigate the association between depression and improvement in patient-reported outcomes following anatomic total shoulder arthroplasty.

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Materials and Methods

Institutional review board approval was obtained before proceeding with the study. A prospectively collected institutional shoulder arthroplasty registry was queried for consecutive patients who underwent total shoulder arthroplasty for glenohumeral arthritis between 2007 and 2013. Patients who underwent revision procedures and patients who underwent primary total shoulder arthroplasty for rotator cuff tear arthropathy, trauma, rheumatoid arthritis, osteonecrosis, or infection were excluded. We identified 776 patients who met inclusion and exclusion criteria and 616 of these patients had baseline and 2-year postoperative American Shoulder and Elbow Surgeons (ASES) scores, yielding an overall database follow-up of 79%. No included patients had full-thickness rotator cuff tears identified at the time of the surgical procedure, nor did any included patients require intraoperative rotator cuff repair. All included patients had a Biomet Comprehensive TSA (Biomet) implanted.

Patients with a preoperative diagnosis of depression from their primary care provider or psychiatrist (n = 88) were identified and were designated to the study cohort. All patients who are enrolled in the registry are screened for a current diagnosis of depression at the time of entry. Those patients reporting a current diagnosis of depression and those patients with an active diagnosis of depression from their preoperative history and physical examination were included in the depression group. An age and sex-matched group of patients who underwent total shoulder arthroplasty without a diagnosis of depression formed the matched control cohort, as both age and sex are risk factors for a diagnosis of depression30. Controls were matched 2:1 to study patients.

Baseline patient demographic characteristics were queried from the database, including age, sex, body mass index (BMI), and American Society of Anesthesiologists (ASA) class31. Baseline ASES scores, Short Form-12 Physical Component Summary (SF-12 PCS) and Mental Component Summary (MCS) scores, and Marx shoulder activity scores32 were averaged and were compared between the study cohort and matched controls.

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Outcome Measures

Outcome measures assessed included the ASES score, the SF-12 PCS and MCS scores, the Marx shoulder activity score, and a nonvalidated satisfaction survey that assessed overall satisfaction as well as satisfaction in various domains including pain, work, activities, and quality of life (Table I). For the ASES, SF-12, and Marx shoulder activity scores, both the absolute final score at a minimum of 2 years postoperatively and the change from baseline were compared between the study cohort and matched controls. The final satisfaction scores at a minimum 2-year follow-up were also compared. Each satisfaction question was scored on a 5-point Likert scale (1: very satisfied; 2: somewhat satisfied; 3: neither satisfied nor dissatisfied; 4: somewhat dissatisfied; and 5: very dissatisfied). Box plots were constructed for the survey outcome measures. For each box plot, the box represents the interquartile range (IQR), which contains the middle 50% of patients; the line across the box represents the median score; and the whiskers indicate the highest and lowest values that are no greater than 1.5 times the IQR. Values between 1.5 and 3 times the IQR were considered outliers and are indicated by circles outside the whiskers. Means and standard deviations for each final outcome score and 2-year change in outcome score from baseline were also calculated and were compared using a Student t test, with p < 0.05 considered significant. Results of the satisfaction surveys were compared using a Kruskal-Wallis test, with p < 0.05 considered significant.

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Power Analysis

An a priori power analysis was performed to determine the number of patients needed in each group to determine a significantly and clinically important difference in the ASES improvement between patients with and without depression. The ASES was used for the power analysis because the minimum clinically important difference has been reported for this outcome measure for patients undergoing shoulder arthroplasty33,34. A minimum clinically important difference of 16.1 for anatomic total shoulder arthroplasty based on an overall satisfaction anchor was used for the power analysis calculation34. To detect this minimum clinically important difference, 45 total patients were required (15 patients with depression and 30 controls) for α = 0.05 at 80% power.

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Linear Regression Analysis

A multivariable linear regression was performed to examine the independent effect of the diagnosis of depression on the improvement in ASES score following total shoulder arthroplasty. The following variables were entered into the regression analysis: age, sex, ASA class, previous surgical procedure that was not arthroplasty, subscapularis management (tenotomy compared with osteotomy, and repair compared with no repair), status of the rotator cuff, total number of medical comorbidities, BMI, and baseline ASES score. The outcome variable of interest was the improvement in ASES as a continuous variable. A stepwise linear regression with backward elimination of independent variables was performed. For the regression analysis, p < 0.05 was considered significant.

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Results

There were no significant differences (p > 0.05) in the baseline demographic characteristics and patient-reported outcomes between the patients with depression and the matched controls, with the exception of the SF-12 MCS, which was significantly lower (p < 0.0001) in patients with depression (Table II).

Box plots of the 2-year change in ASES scores, Marx shoulder activity scores, and SF-12 scores are provided in Figures 1-A and 1-B. There were significant improvements (p < 0.0001 for both) in the mean change in ASES score (and standard deviation) from baseline for both patients with depression (50.5 ± 24.4 points) and controls (59.7 ± 17.5 points). There was significantly, although not clinically important, less improvement in the ASES score (p = 0.001) in patients with depression compared with controls. There was also significantly but not clinically important less improvement (p = 0.006) in the mean change in SF-12 PCS in patients with depression (7.0 ± 10.6 points) compared with controls (10.7 ± 9.9 points). There was a greater improvement (p = 0.007) in SF-12 MCS in patients with depression (5.1 ± 8.8 points) compared with controls (2.1 ± 8.2 points). There was no significant difference between groups in mean improvement in Marx shoulder activity scores (p = 0.877).

Box plots of the final 2-year ASES scores, Marx shoulder activity scores, and SF-12 scores are provided in Figures 2-A and 2-B. There were significantly lower mean final ASES scores (p = 0.001) in patients with depression (84.9 ± 17.3 points) compared with controls (90.8 ± 11.3 points), although this difference did not reach clinical importance. There were significantly lower final mean SF-12 MCS scores (p < 0.0001) in patients with depression (49.6 ± 10.2 points) compared with controls (55.6 ± 8.0 points). There were no significant differences between groups in the mean final SF-12 PCS scores (p = 0.165) and Marx shoulder activity scores (p = 0.875).

Patients with depression also had significantly lower satisfaction levels at 2 years for all assessed domains with the exception of pain, which approached, but did not reach, significance (p = 0.066) (Table III). Multivariable linear regression analysis determined that depression (p = 0.018) was an independent predictor of less improvement in ASES scores following total shoulder arthroplasty.

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Discussion

Depression is a highly prevalent comorbidity among patients seeking care for musculoskeletal pain, including those with upper-extremity and shoulder symptoms4,25-27. The impact of depression on clinical outcomes after total shoulder arthroplasty in the present study was significant, but did not reach clinical importance. Although patients with and without depression both experienced significantly and clinically important improvement in ASES scores after total shoulder arthroplasty, patients with depression had significantly less improvement in patient-reported outcomes and significantly lower levels of satisfaction following total shoulder arthroplasty compared with age and sex-matched controls, although these differences did not achieve clinical importance. However, patients with depression had significantly greater improvement in their mental health scores compared with controls. These findings highlight the importance of screening for depression in patients planned for total shoulder arthroplasty, and appropriately counseling patients with depression regarding likely functional improvements and expectations of the surgical procedure. Patients with depression can be counseled that they may have slightly less improvement after total shoulder arthroplasty than patient without depression, but the difference is not of clinical importance. Appropriate counseling preoperatively may help to improve the patient’s perception of his or her outcome.

It is important to note that the age and sex-matched study and control cohorts had similar baseline characteristics, including demographic characteristics and baseline ASES, SF-12 PCS, and Marx shoulder activity scores. Although depression appears to have a significant effect on postoperative improvement following total shoulder arthroplasty, the only major preoperative difference between age and sex-matched patients with and without depression was the SF-12 mental component, which is not a surprising finding. There were no significant differences in baseline shoulder function and activity as reported by the ASES and Marx shoulder activity scores between patients with and without depression.

One previous study has investigated the association of depression with perioperative complications following shoulder arthroplasty11. The authors utilized the National Hospital Discharge Survey database to examine the association between psychiatric comorbidities, including depression, and inpatient complications, length of hospital stay and discharge destination. Depression was found to have a significant association with higher rates of adverse inpatient events, blood transfusion, and non-routine discharge11. The authors were not able to comment on adverse outcomes outside of the initial hospitalization, such as long-term infection risk or revision risk, which is a notable limitation of discharge survey databases. Furthermore, and most notably, Bot et al. could not evaluate any association between depression and postoperative clinical or patient-reported outcomes in their study, which are often the outcome measures that are most negatively impacted by depression in studies of other orthopaedic procedures1,9,15,18,22,28,29.

Our findings were similar to that reported for lower-extremity arthroplasty. In a recent study of 202 patients who underwent total knee arthroplasty, Utrillas-Compaired et al. found that preoperative psychological distress, which included depressive symptoms, was significantly associated with poorer outcomes in patient-reported function and quality of life at 1 year postoperatively29. Ellis et al. compared outcomes after total knee arthroplasty for patients with psychopathology (n = 54), of whom 74% had a diagnosis of depression, with those for patients without any Axis-I diagnoses (n = 100)18. The authors found that patients with preoperative psychopathology had similar improvement in patient-perceived outcome scores, but lower final outcome scores, compared with patients without psychopathology at a minimum of 1 year postoperatively18. In contrast, we found lower final outcome scores and less improvement in outcome scores in patients with a preoperative diagnosis of depression compared with the matched controls.

Brander et al. reported minimum 5-year outcomes of 109 total knee arthroplasties in 89 patients and found that depression impacts long-term outcomes15. In addition to preoperative pain, depression was found to be predictive of lower Knee Society scores at 5 years postoperatively, mostly related to lower function subscores. Our results demonstrate that this association is important not only for lower-extremity arthroplasty, but also for total shoulder arthroplasty. Furthermore, as the volume of total shoulder arthroplasties performed in the United States has increased substantially over the past decade, from 8,154 performed in 1998 to 26,773 performed in 2008, representing an increase of >200% in annual total shoulder arthroplasty incidence, it has become increasingly important to identify risk factors for poor functional improvement to allow adequate preoperative patient counseling and management of patient expectations35,36.

In addition to patient-reported outcome measures, we also evaluated the effect of depression on patient satisfaction following total shoulder arthroplasty. Recently, practitioners have recognized that patients’ perception of their care is as important as objective measures of functional improvement. In addition to patient-reported functional outcomes, employers and hospitals are now directly incorporating patient satisfaction into compensation formulas28. Furthermore, insurers such as Medicare are using patient satisfaction as criteria for reimbursement. Lastly, satisfaction is also being used by accreditation agencies and licensing bodies to evaluate physician performance37. We found that depression was associated with significantly lower levels of satisfaction following total shoulder arthroplasty, most notably for the quality-of-life and activities subscales.

The present study had several limitations. First, this study was a retrospective review of a prospectively collected database and thus was subject to the typical biases of retrospective studies. The study may have been biased by the specific peculiarities of our patient population and may not translate to other patient populations. Although controls were matched to study patients by age and sex, there are numerous other factors that affect outcomes that were not included in the matching process but may have affected the results, including preoperative functional scores, preoperative range of motion, and glenoid deformity, among others. Additional factors were controlled for in the multivariable analysis, but the impact of all potential confounding variables could not be controlled. The statistical associations described in this study should not be interpreted as causative, as there was a possibility for confounding variables in this type of analysis. Although we included ASES scores, Marx shoulder activity scores, SF-12 scores, and patient satisfaction to determine clinical outcome, we did not have physical examination or range-of-motion measurements to include in our assessment. Our study population was a large cohort of patients undergoing anatomic total shoulder arthroplasty with a minimum 2-year follow-up, but factors that were not found to be significant could have been nonsignificant as a result of a lack of study power. This was a sample of opportunity from a registry database; thus, we could not add any more patients to improve our statistical power. Another limitation of the study design was that we defined depression as a categorical diagnosis, but mood is fundamentally a continuous variable. All patients entered into the registry were screened for a diagnosis of depression on the day of the surgical procedure, which mitigates this effect somewhat. Furthermore, baseline MCS scores demonstrate that patients in our depression cohort truly were experiencing lower levels of mental health compared with the control patients, and the SF-12 MCS has been demonstrated to be a valid measure of depressive symptomatology38. Another limitation was that we could not include hand dominance in the regression analysis; however, the effect of this limitation was mitigated by the fact that a recent study had found no correlation between hand dominance and clinical outcomes after total shoulder arthroplasty39.

Future prospective studies on this topic are needed to confirm the findings of the present investigation. We also do not know when the patients were diagnosed with depression or how long they had had depressive symptoms, which leave us unable to determine the difference between those patients with situational depression due to several years of shoulder pain and those patients with biological depression. We also do not have information regarding what medications, if any, patients were taking for depression perioperatively, which could influence the frequency and magnitude of depressive symptoms experienced. It is also unclear whether adequate recognition and treatment of depression can improve outcomes following total shoulder arthroplasty. Finally, we did not know what the status of the patients’ depression was at the time of the final follow-up, although we did note significant improvement in the SF-12 MCS from baseline.

In conclusion, patients with a diagnosis of depression should be counseled that they will experience a significant functional improvement from baseline after total shoulder arthroplasty. A preoperative diagnosis of depression is an independent predictor of significantly less improvement in ASES scores following total shoulder arthroplasty; however, this difference does not reach clinical importance and should not discourage patients with depression from undergoing total shoulder arthroplasty.

Investigation performed at Sports Medicine and Shoulder Surgery, Hospital for Special Surgery, New York, NY

A commentary by David Ring, MD, PhD, is linked to the online version of this article at jbjs.org.

Disclosure: There was no external funding obtained for this study. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/C256).

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