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Determining the Generalizability of the PROMIS Depression Domain’s Floor Effect and Completion Time in Patients Undergoing Orthopaedic Surgery

Hamilton, David F. PhD

Clinical Orthopaedics and Related Research®: October 2019 - Volume 477 - Issue 10 - p 2226–2227
doi: 10.1097/CORR.0000000000000829

D. F. Hamilton, Research Fellow, University of Edinburgh, Department of Trauma and Orthopaedics, Edinburgh, United Kingdom

D. F. Hamilton PhD, University of Edinburgh, Department of Trauma and Orthopaedics, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH164SB, United Kingdom, Email:

This CORR Insights® is a commentary on the article “Determining the Generalizability of the PROMIS Depression Domain’s Floor Effect and Completion Time in Patients Undergoing Orthopaedic Surgery” by Bernstein and colleagues available at: DOI: 10.1097/CORR.0000000000000782.

The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

The opinions expressed are those of the writer, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

Received April 26, 2019

Accepted May 03, 2019

Online date: May 30, 2019

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Where Are We Now?

Last year, Guattery and colleagues [5] reported in this Journal that a large proportion of patients attending orthopaedic outpatient appointments seemed to misreport scores on the computer adaptive Patient-Reported Outcome Measurement Information System (PROMIS) depression questionnaire. In the current study, Bernstein and colleagues [2] confirm this important and surprising finding in a much-larger group of more than 300,000 orthopaedic consultations.

The PROMIS methodology is based on a comparison to wider population scores. In a large cohort like this, we should see the normal bell curve of data—where most people cluster around the middle value and only a tiny proportion (0.15%) report extreme scores. Our patients could be expected to report abnormally higher pain scores than wider US population averages but are not expected to report abnormally low levels of depression. This data is not a critique of the PROMIS tool, which has been thoroughly validated [3, 7, 10], but a comment on inaccurate patient reporting masking the true proportion of depression symptoms in those surveyed.

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Where Do We Need To Go?

Mental health disorders are a major global health problem [11] and are well known to influence the results of orthopaedic procedures [1, 4, 9]. Clearly, surgeons need to be aware of all such relevant factors that could influence the success of an intervention to make the best clinical decisions, appropriately council patients, and to set expectations.

The prescient question is why is this happening? Why do 20% of all orthopaedic patients [2, 5] either wilfully or accidentally hide important comorbid information from orthopaedic providers?

It may be that patients don’t link the completion of forms in the waiting room with their current episode of care—and they may be correct. How often are data collected from waiting-room questionnaires put to use in our clinical consultations? How and why we collect and use questionnaire data (and how we explain this to our patients) is extremely important. If the forms are seen to be bureaucratic hospital administrative tools of no clinical relevance, some patients may not understand the importance of providing accurate information.

The patients in the current study were asked to complete three PROMIS questionnaires in a defined sequence with the depression questions last [2]. It is possible then that the floor effect described in the depression tool is due to questionnaire fatigue; irritable patients defaulting to the baseline answer in a desperate effort to finish filling in the various forms associated with a trip to hospital. It seems unlikely that the PROMIS tools themselves are too onerous as the computer adaptive designs limit the number of questions asked, but these are applied in the context of all the paperwork we ask to be completed. If the depression tool is always last, it could be the one to suffer most from questionnaire fatigue.

The worrying alternative reason for misreporting is a purposeful obscuring of depressive symptoms through the stigma of depressive illness [6] or because they think (correctly) that disclosure will influence the care they receive [8]. This is potentially very problematic, and if found to be the case, highlights that we need to find ways to address this issue within orthopaedics.

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How Do We Get There?

Addressing the floor effect is a comparatively simple task. We could randomize the order in which the questions appear and then reevaluate whether floor effects remain in the depression score or perhaps newly appear in whatever questionnaire was completed last in line. If depression misreporting is still evident, we then need to determine if there is wider misreporting of relevant information to clinicians or perhaps our patients do not wish to complete “perceived irrelevant” hospital questionnaires. Data linkage should enable cross-examination of the clinical notes to see whether patients disclosed mental health details to clinicians that contradicted their scores on the questionnaires. Qualitative studies would then be conducted, interviewing patient directly, to evaluate why these responses occur.

If this proposed new research finds a clear and causal link between mental health stigma and a purposeful hiding of depressive symptoms from the surgical team, we need to address that expediently by careful patient education and decision aids that explain how depression can adversely affect surgical outcomes and explain why (in some cases) this should influence treatment choices, in the best interests of the patient. We need to see mental health as a comorbidity that can, and should, be treated prior to, or alongside orthopaedic intervention in the spirit of comprehensive care [8]. We should also further evaluate predictors of misreporting, as the only data we currently have comes from large institutions in Northern states [2, 5]. Ideally national level data would be reviewed, but cohort studies such as reported by Bernstein and colleagues from demographically diverse institutions across America could be linked to run enhanced predictive models as a more feasible research target.

It may be that wider demographic factors are relevant and will help target educational interventions to enhance accurate disclosure of important comorbid symptoms.

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