The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 87, Issue 1

Scientific Articles | January 01, 2005

Determinants of Patient Satisfaction with Outcome After Rotator Cuff Surgery

James D. O'Holleran, MD¹; Mininder S. Kocher, MD, MPH²; Marilee P. Horan, BS³; Karen K. Briggs, MPH³; Richard J. Hawkins, MD³

¹ Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115
² Department of Orthopaedic Surgery, Children's Hospital, 300 Longwood Avenue, Boston, MA 02115
³ Clinical Research Department, Steadman Hawkins Clinic, Steadman Hawkins Sports Medicine Foundation, 181 West Meadow Drive, Suite 1000, Vail, CO 81657. E-mail address for M.P. Horan: marilee.horan@shsmf.org

View Disclosures and Other Information

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at Steadman Hawkins Research Foundation, Vail, Colorado, and Harvard School of Public Health, Boston, Massachusetts

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2005 Jan 01;87(1):121-126. doi: 10.2106/JBJS.C.01316

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Abstract

Background: The outcome after rotator cuff surgery has been reported frequently with use of condition-specific measures, but patient satisfaction has not been well studied. The purpose of this study was to identify the determinants of patient satisfaction with the outcome after rotator cuff surgery.

Methods: A cohort of 311 patients undergoing rotator cuff surgery was studied prospectively. Two hundred and fifty-four patients had subjective follow-up for a minimum of one year, and fifty-seven patients had subjective and objective follow-up for a minimum of one year. Diagnoses included tendinitis or impingement (eighty patients), a partial-thickness rotator cuff tear (fifty-five patients), and a full-thickness rotator cuff tear (176 patients). The dependent variable was patient satisfaction with the outcome, graded ordinally on a scale of 1 to 10. Independent variables included demographic, surgical, objective follow-up, and subjective follow-up parameters. Univariate and multivariate analyses were performed to identify the determinants of satisfaction.

Results: Univariate analysis of demographic variables demonstrated no significant differences (p > 0.05) with respect to patient satisfaction. Analysis of the surgical variables showed significantly decreased satisfaction (p < 0.05) for patients who had débridement for a massive, irreparable cuff tear; those who had subscapularis tears; and those with larger supraspinatus and infraspinatus tears. Analysis of the objective variables at follow-up demonstrated significantly decreased satisfaction (p < 0.05) for patients with diminished and weakened forward elevation, impingement signs, and acromioclavicular joint pain and tenderness. Univariate analysis of subjective variables at follow-up showed significantly decreased satisfaction (p < 0.001) for patients with pain, functional difficulty, and work disability.

Multivariate analysis demonstrated significantly decreased satisfaction associated with pain (p < 0.001) and dysfunction (p < 0.05). A significant relationship (p < 0.05) was detected between satisfaction and a willingness to recommend the surgery to another. A significant relationship (p < 0.05) was also found between satisfaction and the American Shoulder and Elbow Surgeons score.

Conclusions: Subjective variables of symptoms and function have the most robust associations with patient satisfaction following rotator cuff surgery. Thus, in assessing the outcome of rotator cuff surgery from the perspective of patient satisfaction with outcome, we emphasize the importance of patient-derived subjective assessment of symptoms and function.

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

Figures in this Article

Outcomes assessment measures include generic measures, condition-specific measures, and measures of patient satisfaction¹. Satisfaction measurement may be used for a variety of purposes, such as validating quality of care, developing patient-care models, evaluating health-care delivery systems, and facilitating quality improvement^2-13. As health care has shifted toward a market model, consumer satisfaction has assumed great importance, especially as those consumers play an increasingly prominent role in determining how health care is delivered⁷.

The assessment of outcome after rotator cuff surgery historically has involved condition-specific measures such as the University of California at Los Angeles (UCLA) end-result score, the criteria for a satisfactory result described by Neer, the Constant and Murley score, the Hospital for Special Surgery score, the Simple Shoulder Test, and the American Shoulder and Elbow Surgeons (ASES) score^1,14-20. Additionally, generic measures of health-related quality of life, such as the Short Form-36 (SF-36) and the Disabilities of the Arm, Shoulder and Hand (DASH) scores, have also been applied^18,21,22. However, patient satisfaction after rotator cuff surgery has not been well studied. The purpose of this study was to identify the determinants of patient satisfaction with the outcome after rotator cuff surgery.

Materials and Methods

Materials and Methods | Results | Discussion | Appendix | References

Acohort of 311 patients who had rotator cuff surgery performed, between 1991 and 1998, by four surgeons at a referral sports medicine center was studied prospectively. Two hundred and fifty-four patients had a subjective follow-up evaluation performed at a minimum of one year (mean, 33.7 months; range, twelve to eighty-nine months) postoperatively, and fifty-seven patients had subjective and objective follow-up evaluations done at a minimum of one year (mean, 30.7 months; range, twelve to seventy-one months) postoperatively. Data were collected with use of a scannable questionnaire that had been approved by the institutional review board. The part of the questionnaire completed by the patient provided demographic and subjective data, and the part completed by the surgeon or postresidency sports medicine fellow provided objective data. The data were maintained prospectively in a computerized clinical database. The mean age (and standard deviation) of the cohort was 51.4 ± 14.2 years (range, 16.5 to 80.3 years), and 216 (69.5%) of the 311 patients were male. Exclusion criteria included prior rotator cuff surgery, surgery on the contralateral side, lack of a minimum follow-up period of one year, and a tendon transfer or tendon-grafting performed at the time of the rotator cuff surgery. Diagnoses included tendinitis or impingement (eighty patients), a partial-thickness rotator cuff tear (fifty-five patients), and a full-thickness rotator cuff tear (176 patients). All patients with impingement underwent arthroscopic subacromial decompression. Patients with a partial-thickness tear underwent either arthroscopic subacromial decompression (forty-five patients) or arthroscopic subacromial decompression with open repair through a deltoid-splitting mini-open approach for high-grade partial tears (ten patients). Patients with a full-thickness tear underwent arthroscopic subacromial decompression with either open repair through a deltoid-splitting mini-open approach (159 patients) or débridement for a massive, irreparable tear (seventeen patients). Distal clavicle excision was performed in twenty-nine patients (twenty procedures were arthroscopic, and nine were open).

The dependent variable was patient satisfaction with the outcome at the time of follow-up. This variable was assessed with use of a scannable paper questionnaire, administered in the office waiting room, that asked the patient, "How satisfied are you with your outcome?" The question was scored on a discrete ordinal scale from 1 to 10, with 1 indicating "very unsatisfied;" 5 and 6, "neutral," and 10, "very satisfied." We attempted to distinguish satisfaction with the outcome from satisfaction with the process by the subsequent question, "How satisfied are you with the process of your treatment?"

Independent variables included various demographic, surgical, objective follow-up, and subjective follow-up parameters. Demographic variables included age, gender, side of involvement, and status with regard to Workers' Compensation. Surgical variables included the diagnosis (tendinitis or impingement, a partial-thickness rotator cuff tear, or a full-thickness rotator cuff tear), treatment (subacromial decompression, rotator cuff repair, or rotator cuff débridement), subscapularis status, size of each rotator cuff tendon tear, an associated labral tear, an associated distal clavicle excision for acromioclavicular joint involvement, and associated glenohumeral degenerative joint disease. Objective variables at the time of follow-up included active forward elevation, active external rotation, active internal rotation, forward elevation strength, abduction strength, external rotation strength, internal rotation strength, Neer impingement sign²³, Hawkins impingement sign²³, painful abduction arc, acromioclavicular pain with cross-arm adduction, acromioclavicular joint tenderness, and biceps tenderness. Subjective variables with regard to the shoulder at the time of follow-up included "pain today" (i.e., at the follow-up examination); pain at its worst; the use of pain medication; pain affecting the activities of daily living; pain affecting work; pain affecting recreation; pain affecting sleep; pain with the arm at the side; pain affecting competitiveness in sports; functional difficulty with work; functional difficulty with sports; functional difficulty with recreation; functional difficulty with putting on or taking off a coat; functional difficulty with sleeping; functional difficulty with washing; functional difficulty with toileting; functional difficulty with putting on or taking off a shirt; functional difficulty with the ability to lift 1, 10, or 20 lb (0.45, 4.5, or 9 kg); return to work; return to original fitness program; the willingness to undergo surgery again; the willingness to recommend surgery to another; and, finally, the American Shoulder and Elbow Surgeons score.

Statistical Methods

Nonparametric univariate analysis was performed with the Mann-Whitney U test for two-group comparisons and with the Kruskal-Wallis analysis of variance for multiple group comparisons. The Spearman rho (r) was used to assess associations between continuous variables. Multivariate analysis was performed, with use of a stepwise, multiple linear regression model with backward selection, to identify independent determinants of patient satisfaction with the outcome. Collinearity and residual diagnostics were performed. The coefficient of multiple determination (adjusted R²) was used to indicate how much of the variability in patient satisfaction was accounted for by the determinants in the final multiple linear regression model. Statistical analysis was performed with use of SPSS (version 10.0; SPSS, Chicago, Illinois) and SAS (version 6.12; SAS Institute, Cary, North Carolina) software packages. All reported p values are two-tailed, with an alpha level of 0.05 indicating significance.

Results

Materials and Methods | Results | Discussion | Appendix | References

Descriptive Statistics

The median score for patient satisfaction with the outcome was 9 (interquartile range: 6 to 10). Seventy-four patients (23.8%) had a score of 5 or lower (Fig. 1). The patient satisfaction scores demonstrated a significant departure from normal distribution with substantial left skew (coefficient of skewness = -1.00; Kolmogorov-Smirnov test for normality, p < 0.001). The normal distribution is symmetric, and it has a skewness value of zero. A distribution with a significant negative skewness is asymmetric with a long left tail. Ceiling effects, i.e., use of the highest possible score, were seen in 127 (40.8%) of the 311 patients.

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Fig. 1: Distribution of scores for patient satisfaction with the outcome.

Univariate Analysis(see Appendix)

Analysis of the demographic variables for all 311 patients demonstrated no significant differences with respect to patient satisfaction (p > 0.05).

Analysis of the surgical variables for all 311 patients showed significantly decreased satisfaction (p < 0.05) for patients who had débridement for a massive, irreparable cuff tear; those with subscapularis tears; and those with larger-grade supraspinatus and infraspinatus tears.

Analysis of the objective variables at the time of follow-up for the fifty-seven patients with objective follow-up data demonstrated significantly decreased satisfaction (p < 0.05) among those with less active forward elevation, weakness of forward elevation, positive impingement signs, acromioclavicular joint pain with crossed-arm adduction, and acromioclavicular joint tenderness.

Analysis of the subjective variables at the time of follow-up for all 311 patients showed a significantly decreased satisfaction (p < 0.001) for those with pain (specifically, "pain today," i.e., at the time of the follow-up visit; pain at its worst; pain requiring medication; pain affecting the activities of daily living, work, recreation, or sleep; pain with arm at the side; and pain affecting sports); functional difficulty (difficulty affecting work, sports, or recreation; difficulty in putting on or taking off a coat and shirt; or difficulty in sleeping, washing, toileting, or lifting objects), and work disability.

A significant association was found between satisfaction and a willingness to have the surgery again (p < 0.001) or to recommend the surgery to a family member or friend with the same problem (p < 0.001). A significant relationship (p < 0.001) was also found between patient satisfaction and the American Shoulder and Elbow Surgeons score.

Multivariate Analysis

Significant (p < 0.05) independent multivariate determinants of patient satisfaction with the outcome included "pain today" (i.e., at the time of the follow-up visit), the ability to return to work, dysfunction with toileting, dysfunction with lifting 20 lb (9 kg), a willingness to recommend the surgery to another, active forward elevation, and the American Shoulder and Elbow Surgeons score (Table I). These seven variables together accounted for 66% of the variability in the scores for patient satisfaction with the outcome (adjusted R² = 0.663). Collinearity diagnostics revealed minimal collinearity; the regression residuals were normally distributed and had equal variances, and there were no abnormal outliers.

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TABLE I Multivariate Analysis: Determinants of Patient Satisfaction with Outcome^*

Variable	Scale	Regression Coefficient (B)	Standard Error	P Value
Pain today	0-10	-0.44	0.17	<0.001
Return to work	No or yes	0.31	0.49	0.022
Dysfunction with toileting	1-4	-0.29	0.63	0.046
Dysfunction with lifting 20 lb (9 kg)	1-4	-0.19	0.40	0.047
Recommend surgery?	No or yes	0.18	0.16	0.034
Active forward elevation	Degrees	0.82	0.57	0.048
ASES score	0-100	1.20	0.09	0.046

Multiple linear regression model summary: adjusted R² = 0.663, p < 0.001. ASES = American Shoulder and Elbow Surgeons.

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TABLE I Multivariate Analysis: Determinants of Patient Satisfaction with Outcome^*

Variable	Scale	Regression Coefficient (B)	Standard Error	P Value
Pain today	0-10	-0.44	0.17	<0.001
Return to work	No or yes	0.31	0.49	0.022
Dysfunction with toileting	1-4	-0.29	0.63	0.046
Dysfunction with lifting 20 lb (9 kg)	1-4	-0.19	0.40	0.047
Recommend surgery?	No or yes	0.18	0.16	0.034
Active forward elevation	Degrees	0.82	0.57	0.048
ASES score	0-100	1.20	0.09	0.046

Multiple linear regression model summary: adjusted R² = 0.663, p < 0.001. ASES = American Shoulder and Elbow Surgeons.

Discussion

Materials and Methods | Results | Discussion | Appendix | References

The role of outcomes research is becoming widely recognized as a fundamental means to achieving assessment and accountability, the so-called third revolution in health care²⁴. Societal, economic, and technological forces, such as increased oversight, escalating costs, lack of an evidence-based foundation for certain practices, and wide variability in the delivery of care, all contribute to this perceived need for increased accountability¹. Outcomes assessment after rotator cuff surgery has historically involved condition-specific measures, with subjective domains (concerning specific symptoms, functioning, and activities of daily living) and objective domains (concerning range of motion, strength, stability, and impingement signs) found in varying proportions^14-21,25-37. While satisfaction is technically addressed in some of these condition-specific scoring systems, it is not a major feature and it has relatively little impact in overall scoring. Patient satisfaction has assumed importance over the last decade as a critical outcomes measure to aid in evaluating quality of care and delivery of care, to develop patient-care models, and to allow for improvement in the economics and quality of healthcare delivery and overall societal health status^2-13.

In this study, we identified the univariate and multivariate determinants of patient satisfaction with the outcome after rotator cuff surgery. Demographic variables, including age, gender, status of the patient with respect to Workers' Compensation, and side of involvement, revealed no significant differences with respect to patient satisfaction (p > 0.05). While reports have varied as to the effect of age on rotator cuff surgery (and the effect of age varies depending on the rating scale used¹⁸), our findings correlate with those in a recent prospective longitudinal follow-up study by Galatz et al., which postulated that, as patients advance in age, their functional requirements decrease and thus satisfaction does not decline²⁸.

Surgical variables associated with decreased satisfaction included débridement for massive, irreparable cuff tears; subscapularis tears; and larger-grade supraspinatus and infraspinatus tears. This finding supports prior work emphasizing the importance of the size of the tear in determining outcome and satisfaction^18,25-27,37. Additionally, while reports in the literature have varied with regard to the appropriate treatment for massive rotator cuff tears^15,30,35,36, these data suggest that patients are less satisfied with simple débridement for a massive tear than with repair. Interestingly, glenohumeral degenerative joint disease, which was noted intraoperatively in fifteen of our patients, was not found, with these numbers, to have a significant (p > 0.05) relationship with satisfaction, suggesting that patients may be satisfied with rotator cuff surgery despite the presence of osteoarthritis. Also, these results emphasize the importance of subscapularis muscle function after shoulder surgery.

Objective variables at the time of follow-up that were associated with decreased satisfaction included less active forward elevation, weakness of forward elevation, positive impingement signs, pain with crossed-arm adduction, and acromioclavicular joint tenderness. These data are in accord with those in a recent prospective long-term study by Cofield et al., demonstrating the negative influence on outcome of postoperative weakness and acromioclavicular disease, both of which are associated with larger tear size²⁶.

The most robust relationships with patient satisfaction with the outcome, however, were the subjective measures of symptoms and function. Decreased satisfaction was noted for patients who had pain, functional difficulty, or work disability. While relief of pain is often the primary goal of treatment and the measurement of success, these data strongly suggest the additional contribution of functional outcome to patient satisfaction. Moreover, the many iterations of function, from recreation to sports to the activities of daily living to work, were demonstrated to be important to our patients. These subjective data are supported by the objective surgical and physical examination data, which demonstrated lower satisfaction scores for débridement alone of massive tears, the presence of subscapularis tears, larger-sized tears, and deficiencies in active elevation. Thus, in determining treatment algorithms and in evaluating patients postoperatively, the restoration of function should be viewed as a primary goal in addition to the alleviation of pain.

Finally, most people report a willingness to have the surgery again and most would recommend surgery to another. This finding underscores the importance of patient-derived assessments of outcome and illustrates the often anecdotally recognized phenomenon of the satisfied patient in the face of objectively imperfect results.

The limitations of our study lie in the very nature of attempting to quantify the vagaries of patient satisfaction. Such analysis categorizes satisfaction with care into conceptual domains with regard to the interpersonal, technical, and financial aspects of care as well as the accessibility, convenience, continuity, efficacy, and the physical setting of care^2-13. Additionally, operational categories are defined; for instance, patient satisfaction is measured as a global or component score, graded in an ordinal, categorical, or continuous manner^2-13. In this study, we attempted to measure satisfaction with regard to the efficacy of care by questioning patients about their satisfaction with "the outcome of surgery," which we graded ordinally on a scale of 1 to 10. This was an attempt to separate satisfaction with the "outcome" from satisfaction with various aspects of the "process." We found a significant difference between the two means of these satisfaction questions, which may show that the questions are measuring different things. Nevertheless, these components of patient satisfaction may be difficult for patients to distinguish. Our results therefore may not be translatable to the other domains of satisfaction with care. In addition, satisfaction was not assessed over various points in time to assess the stability of patient satisfaction. In terms of follow-up, there was a relatively low rate of objective follow-up data compared with subjective follow-up data. Given the destination nature of the clinic, the majority of the patients traveled from a distance for the shoulder surgery and the postoperative follow-up examinations. Thus, objective long-term follow-up was limited, whereas subjective follow-up could be determined from the questionnaire and telephone interviews. Nevertheless, since the goal of the study was not to assess satisfaction after rotator cuff surgery in general for a group of patients but to assess the determinants of patient satisfaction, each patient served as his or her own study unit. Also, while we attempted to measure a broad range of demographic, surgical, objective, and subjective variables to correlate with satisfaction, certainly other variables may have been omitted. We did not measure the patients' preoperative expectations regarding surgery; recent literature on patient satisfaction has suggested that patients are more satisfied if their expectations are well defined, reasonable, and attained^1,7,11,13.

In conclusion, we found that while some specific surgical and objective variables were associated with patient satisfaction after rotator cuff surgery, the most robust associations were with subjective variables of symptoms and function. Thus, reflecting the philosophy of the outcomes assessment movement in health care¹, we would emphasize the importance of patient-derived subjective assessment in evaluating the outcome of rotator cuff surgery. We believe that the assessment of patient satisfaction with the outcome should be an essential part of shoulder assessment. Nevertheless, we think that objective assessment of shoulder motion, stability, and strength is still an important feature, and a comprehensive approach to outcomes assessment of the shoulder should include assessment of patient satisfaction with the outcome, a condition-specific validated shoulder outcome instrument, and a measure of health-related quality of life.

Appendix

Materials and Methods | Results | Discussion | Appendix | References

A table presenting all of the data from the univariate analysis is available with the electronic versions of this article, on our web site at (go to the article citation and click on "Supplementary Material") and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM). ?

References

Materials and Methods | Results | Discussion | Appendix | References

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Topics

client satisfaction ; elbow region ; pain ; rotator cuff ; shoulder region

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James D. O'Holleran, Mininder S. Kocher, Marilee P. Horan, Karen K. Briggs, Richard J. Hawkins; Determinants of Patient Satisfaction with Outcome After Rotator Cuff Surgery. The Journal of Bone & Joint Surgery. 2005 Jan;87(1):121-126.

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