Add Sleep Disturbance Data to PROMs?

Patient-Reported Outcome Measurement Information System (PROMIS) are likely the predominant method for assessing patient orthopedic surgery outcomes. Yet, they too often miss the mark. A team from Duke University decided to test whether additional domains like sleep disturbance, dyspnea or anxiety measures would improve the accuracy of PROMs. Their study, titled, “Sleep disturbance, dyspnea, and anxiety following total joint arthroplasty: an observational study,” was published in the August 19, 2022, edition of the Journal of Orthopaedic Surgery and Research.

Co-author Steven Z. George, P.T., Ph.D., Laszlo Ormandy Distinguished Professor in Orthopaedic Surgery and vice chair of research in that department at Duke University, explained to OTW why he and his team decided to tackle this subject systematically.

“We had completed a systematic review in 2020 that indicated outcomes for sleep disturbances, anxiety, and dyspnea are rarely reported following common orthopedic surgeries like total joint arthroplasty (TJA). So, we thought the time was right to report on these outcomes since they are of importance to the patient, and also impact overall quality of life.”

The team collected PROMIS scores for sleep disturbance, anxiety, and dyspnea data from 2,638 patients and compared that data to TJA location (hip, knee, and shoulder) and postoperative chronic pain status (chronic pain absent, mild chronic pain, bothersome chronic pain, high impact chronic pain).

“In my view,” said Dr. George to OTW, “the most important results are:

• that levels of sleep disturbance, anxiety, and dyspnea are clinically very similar across total hip, knee, and shoulder arthroplasty;
• while these levels do not correspond with location of surgery, they do correspond with the amount of pain experienced after surgery, with those having chronic postoperative pain having noticeably poorer outcomes for sleep, anxiety, and dyspnea; and
• dyspnea is not typically measured following orthopedic surgery but was associated with poorer physical function and higher pain interference for all three surgical locations.”

Getting a Clearer Picture of Patient Experience

“This study was not designed to directly alter practice but there are some caveats worth noting that could influence practice patterns,” said Dr. George to OTW.

“First, this study could be used to inform future selection of outcome measures collected from patients. Typically, outcome assessment focuses on pain interference and/or physical function but this study suggests that broadening outcome selection to consider other factors—like sleep disturbance and/or dyspnea—could provide a better understanding of the patient experience following total joint arthroplasty.”

“Second, this study could be used to design postoperative rehabilitation programs to focus on sleep hygiene and/or addressing reasons for shortness of breath, especially in patients that have chronic pain following surgery.”