Schultz Emily A, Gomez Giselle I, Gardner Michael J, Hu Serena S, Safran Marc, Amanatullah Derek F, Shapiro Lauren M, Kamal Robin N
VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA.
Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA.
Clin Orthop Relat Res. 2025 Apr 1;483(4):624-631. doi: 10.1097/CORR.0000000000003325. Epub 2024 Nov 22.
Pain self-efficacy, or the ability to carry out desired activities in the presence of pain, can affect a patient's ability to function before and after orthopaedic surgery. Previous studies suggest that shared decision-making practices such as discussing patient-reported outcome measures (PROMs) can activate patients and improve their pain self-efficacy. However, the ability of PROMs to influence pain self-efficacy in patients who have undergone orthopaedic surgery has yet to be investigated.
QUESTIONS/PURPOSES: (1) Is immediately discussing the results of a PROM associated with an increase pain self-efficacy in new patients presenting to the orthopaedic surgery clinic? (2) Is there a correlation between patient resilience or patient involvement in decision-making in changes in pain self-efficacy?
This was a prospective, sequential, comparative series completed between February to October 2023 at a single large tertiary referral center at a multispecialty orthopaedic clinic. Orthopaedic subspecialties included total joint arthroplasty, spine, hand, sports, and trauma. The first 64 patients underwent standard care, and the following 64 had a conversation with their orthopaedic surgeon about their PROMs during the initial intake visit. We collected scores from the Pain Self-Efficacy Questionnaire (PSEQ), Brief Resilience Scale (BRS), and Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function form (PF-SF10a) and data on demographic characteristics before the visit. The PSEQ is a validated PROM used to measure pain self-efficacy, while the BRS measures the ability of patients to recover from stress, and the PROMIS PF-SF10a is used to assess overall physical function. PROMs have been utilized frequently for their ability to report the real-time physical and psychological well-being of patients. In the standard care group, the PROMIS PF-SF10a score was not discussed with the patient. In the PROMs group, the physician discussed the PROMIS PF-SF10a score using a script that gave context to the patient's score. Additional conversation about the patient's score was permitted but not required for all patients. Scores from the Observing Patient Involvement in Decision Making (OPTION-5) instrument were recorded during the visit as a measure of patient involvement in clinical decision-making. After the visit, both groups completed the PSEQ. The primary outcome was change in the PSEQ. Change in pain self-efficacy was recorded as greater or less than the minimum clinically important difference, previously defined at 8.5 points for the PSEQ [ 10 ]. The secondary outcomes were correlation between PSEQ change and the BRS or OPTION-5.
Between the PROMs and standard care groups, there was no difference in the change in PSEQ scores from before the visit to after (mean ± SD change in control 4 ± 10 versus change in PROMs group 3 ± 7, mean difference 1 [95% confidence interval (CI) -2.0 to 4.0]; p = 0.29). Fifty-six percent (36 of 64) of patients in the standard care group demonstrated an increase in pain self-efficacy (of whom 22% [14 of 64] had clinically important improvements), and 59% (38 of 64) of patients in the PROMs group demonstrated an increase in pain self-efficacy (of whom 19% [12 of 64] had clinically important improvements). In the control group, there was no correlation between the change in PSEQ score and resiliency (BRS score r = -0.13 [95% CI -0.36 to 0.12]; p = 0.30) or patient involvement in decision-making (OPTION-5 r = 0.003 [95% CI -0.24 to 0.25]; p = 0.98). Similarly, in the PROMs group, there was no correlation between the change in PSEQ score and resiliency (BRS score r = -0.10 [95% CI -0.33 to 0.16]; p = 0.45) or patient involvement in decision-making (OPTION-5 r = -0.02 [95% CI -0.26 to 0.23]; p = 0.88).
Discussing PROMs results (PROMIS PF-SF10a) at the point of care did not increase pain self-efficacy during one visit. Therefore, surgeons do not need to discuss pain self-efficacy PROM scores in order to influence patient pain self-efficacy. While PROMs remain valuable tools for assessing patient outcomes, further work may assess whether the collection of PROMs itself may increase pain self-efficacy or whether longitudinal discussion of PROMs with patients changes pain self-efficacy.
Level II, therapeutic study.
疼痛自我效能，即在疼痛情况下开展期望活动的能力，会影响患者在骨科手术前后的功能。既往研究表明，诸如讨论患者报告结局指标（PROMs）等共同决策实践可激发患者并提高其疼痛自我效能。然而，PROMs对接受骨科手术患者的疼痛自我效能的影响尚未得到研究。
问题/目的：（1）在骨科手术门诊向新患者立即讨论PROM的结果是否与疼痛自我效能增加相关？（2）患者恢复力或患者参与决策与疼痛自我效能变化之间是否存在关联？
这是一项前瞻性、序贯性、比较性系列研究，于2023年2月至10月在一家大型三级转诊中心的多专科骨科诊所完成。骨科亚专业包括全关节置换术、脊柱、手部、运动和创伤。前64例患者接受标准护理，随后的64例患者在初次就诊时与骨科医生就其PROM进行了交谈。我们收集了疼痛自我效能量表（PSEQ）、简易恢复力量表（BRS）以及患者报告结局测量信息系统（PROMIS）身体功能表（PF-SF10a）的评分，以及就诊前的人口统计学特征数据。PSEQ是一种经过验证的用于测量疼痛自我效能的PROM，而BRS测量患者从压力中恢复的能力，PROMIS PF-SF10a用于评估总体身体功能。PROMs因其能够报告患者的实时身体和心理健康状况而被频繁使用。在标准护理组中，未与患者讨论PROMIS PF-SF10a评分。在PROMs组中，医生使用为患者评分提供背景信息的脚本讨论了PROMIS PF-SF10a评分。允许但并非要求所有患者就其评分进行额外交谈。在就诊期间记录观察患者参与决策（OPTION-5）工具的评分，作为患者参与临床决策的衡量指标。就诊后，两组均完成PSEQ。主要结局是PSEQ的变化。疼痛自我效能的变化记录为大于或小于最小临床重要差异，先前已确定PSEQ的最小临床重要差异为8.5分[10]。次要结局是PSEQ变化与BRS或OPTION-5之间的相关性。
在PROMs组和标准护理组之间，从就诊前到就诊后PSEQ评分变化无差异（对照组平均±标准差变化为4±10，PROMs组变化为3±7，平均差异为1[95%置信区间（CI）-2.0至4.0]；p = 0.29）。标准护理组中56%（64例中的36例）的患者疼痛自我效能增加（其中22%[64例中的14例]有临床重要改善），PROMs组中59%（64例中的38例）的患者疼痛自我效能增加（其中19%[64例中的12例]有临床重要改善）。在对照组中，PSEQ评分变化与恢复力（BRS评分r = -0.13[95%CI -0.36至0.12]；p = 0.30）或患者参与决策（OPTION-5 r = 0.003[95%CI -0.24至0.25]；p = 0.98）之间无相关性。同样，在PROMs组中，PSEQ评分变化与恢复力（BRS评分r = -0.10[95%CI -0.33至0.16]；p = 0.45）或患者参与决策（OPTION-5 r = -0.02[95%CI -0.26至0.23]；p = 0.88）之间无相关性。
在护理点讨论PROMs结果（PROMIS PF-SF10a）在一次就诊期间并未增加疼痛自我效能。因此，外科医生无需为影响患者疼痛自我效能而讨论疼痛自我效能PROM评分。虽然PROMs仍然是评估患者结局的有价值工具，但进一步的研究可能会评估PROMs本身的收集是否会增加疼痛自我效能，或者与患者进行PROMs的纵向讨论是否会改变疼痛自我效能。
II级治疗性研究。
