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Original Investigation
March 25, 2020

Comparing Methods to Determine the Minimal Clinically Important Differences in Patient-Reported Outcome Measures for Veterans Undergoing Elective Total Hip or Knee Arthroplasty in Veterans Health Administration Hospitals

Author Affiliations
  • 1Orthopedic Surgery Section, San Francisco Veterans Affairs Health Care System, San Francisco, California
  • 2Department of Orthopaedic Surgery, University of California, San Francisco
  • 3Orthopedic Surgery Section, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
  • 4Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
  • 5Orthopedic Surgery Section, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
JAMA Surg. Published online March 25, 2020. doi:10.1001/jamasurg.2020.0024
Key Points

Question  What are the minimal clinically important differences in the Hip Disability and Osteoarthritis Outcome Score and in the Knee Injury and Osteoarthritis Outcome Score for veterans undergoing total hip or knee arthroplasty?

Findings  In this cohort study, a wide range of minimal clinically important differences were obtained depending on method. Methods anchored on the Self-Administered Patient Satisfaction Scale are recommended because they showed good to excellent discrimination based on receiver operating characteristic curve analysis.

Meaning  Because patient-reported outcome measures and their minimal clinically important differences may be used to guide policy and reimbursement, accurate minimal clinically important differences derived with clearly defined methods are required.


Importance  The minimal clinically important difference (MCID) in a patient-reported outcome measure (PROM) is the smallest change that patients perceive as beneficial. Accurate MCIDs are required when PROMs are used to evaluate the value of surgical interventions.

Objective  To use well-defined distribution-based and anchor-based methods to calculate MCIDs in the Hip Disability and Osteoarthritis Outcome Score (HOOS) and in the Knee Injury and Osteoarthritis Outcome Score (KOOS) for veterans undergoing primary total hip arthroplasty or total knee arthroplasty.

Design, Setting, and Participants  A prospective cohort study was conducted of 858 patients undergoing total joint replacement between March 16, 2015, and March 9, 2017, at 3 high-complexity Veterans Affairs Medical Centers.

Interventions  Patients undergoing total hip arthroplasty or total knee arthroplasty were administered HOOS or KOOS PROMs prior to and 1 year after surgery. The Self-Administered Patient Satisfaction Scale (SAPS) for primary hip or knee arthroplasty was administered at 1-year follow-up as an anchor PROM.

Main Outcomes and Measures  The HOOS and KOOS before and 1 year after surgery, change scores (difference between postoperative and preoperative PROM scores), and MCIDs for each measure. For anchor-based methods, receiver operating characteristic curve analysis was performed, including calculation of the area under the curve.

Results  The mean (SD) age of the 271 patients who underwent hip arthroplasty was 65.6 (8.3) years, and the mean (SD) age of the 587 patients who underwent knee arthroplasty was 66.1 (8.2) years. There were 547 men in the knee arthroplasty cohort and 256 men in the hip arthroplasty cohort (total, 803 men). There were significant improvements in the mean values of every PROM, with mean (SD) differences greater than 39 for HOOS Joint Replacement (JR) and every hip subscale (HOOS JR, 39.7 [20.2]; pain, 47.6 [20.5]; symptoms, 45.1 [21.5]; activities of daily living, 43.7 [22.1]; recreation, 49.2 [33.5]; quality of life, 50.3 [27.8]) and mean (SD) differences greater than 29 for KOOS JR and every knee subscale (KOOS JR, 30.4 [17.5]; pain, 38.0 [20.4]; symptoms, 29.5 [22.1]; activities of daily living, 34.8 [20.5]; recreation, 34.6 [31.1]; quality of life, 35.2 [26.8]). Different calculation methods yielded a wide range of MCIDs. Distribution-based approaches tended to give lower values than the anchor-based approaches, which gave similar values for most PROMs. Area under the curve values demonstrated good to excellent discrimination for SAPS for nearly all PROMs.

Conclusions and Relevance  Minimal clinically important difference estimates can be highly variable depending on the method used. Patient satisfaction measured by SAPS is a suitable anchor for the HOOS and KOOS. This study suggests that the SAPS-anchored MCID values presented here be used in future studies of total hip arthroplasty and total knee arthroplasty for veterans.

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