The Association Between Patient-Reported Outcome Measurement Scores and Preference for Specific Interventions.

To determine whether greater patient-reported symptom intensity and functional limitation influence expressed preferences for discretionary diagnostic and treatment interventions, we studied the association of patient factors and several Patient Reported Outcome Measure (PROM) scores with patient preferences for diagnostic and treatment interventions before and after the visit, a cross-sectional cohort study. One hundred and forty-three adult patients who completed several PROMs were asked their preferences for diagnostic and treatment interventions before and after a visit with an orthopedic surgeon. Patients with better physical function had fewer preferences for specific diagnostic interventions after the visit (P = .02), but PROM scores had no association with preferences for treatment interventions before or after the visit. A greater percentage of patients expressed the preference for no diagnostic or treatment intervention after the visit with a physician than before (diagnostic intervention; 2.1% before vs 30% after the visit; P ≤ .001 and treatment intervention; 2.1% before vs 17% after the visit; P ≤ .001). This study suggests that physician expertise may be more reassuring to people with more adaptive mind sets.

Do Patients Unconsciously Associate Suggestions for More-invasive Treatment with Better Care?

BACKGROUND: It seems common for patients to conceive of care in physical terms, such as medications, injections, and procedures rather than advice and support. Clinicians often encounter patients who seem to prefer more testing or invasive treatments than expertise supports. We wanted to determine whether patients unconsciously associate suggestions for invasive treatments with better care. QUESTIONS/PURPOSES: (1) Do patients have (A) an implicit preference and (B) an expressed preference for a physical intervention (such as a pill, an injection, or surgery) over supportive care (such as reassurance and education)? (2) What factors are independently associated with both an implicit and an expressed preference for a physical intervention over supportive care? (3) Is there a relationship between a patient's implicit preference toward or away from a physical intervention and his/her expressed preference on that subject? METHODS: In this study, we approached 129 new patients in a large urban area visiting one of 13 participating surgeons divided among six upper and lower extremity specialist offices. After excluding four patients based on our exclusion criteria, 125 patients (97%) completed a survey of demographics and their expressed preference about receiving either physical treatment or support. Treatment was defined as any surgery, procedure, injection, or medication; support was defined as reassurance, conversation, and education, but no physical treatment. Patients then completed the Implicit Association Test (IAT) to evaluate implicit preferences toward treatment or support. Although other IATs have been validated in numerous studies, the IAT used in this study was specifically made for this study. Scores (D scores) range from -2 to 2, where 0 indicates no implicit preference, positive scores indicate a preference toward receiving a physical treatment is good care, and negative scores indicate a preference toward receiving supportive care is good care. According to the original IAT, break points for a slight (± 0.15 to 0.35), moderate (± 0.35 to 0.65), and strong preference (± 0.65 to 2) were selected conservatively according to psychological conventions for effect size. Patients' mean age was 50 ± 15 years (range, 18-79 years) and 56 (45%) were men. The patients had a broad spectrum of upper and lower extremity musculoskeletal conditions, ranging from trigger finger to patellofemoral syndrome. RESULTS: We found a slight implicit association of good care with support (D = -0.17 ± 0.62; range, -2 to 1.2) and an expressed preference for physical treatment (mean score = 0.63 ± 2.0; range, -3 to 3). Patients who received both physical and supportive treatment had greater implicit preference for good care, meaning supportive care, than patients receiving physical care alone (ß = -0.42; 95% CI, -0.73 to -0.11; p = 0.008; semipartial R = 0.04; adjusted R full model = 0.13). Gender was independently associated with a greater expressed preference for physical treatment, with men expressing this preference more than women (ß = 1.0; 95% CI, 0.31-1.7; p = 0.005; semipartial R = 0.06; adjusted R full model = 0.08); receiving supportive treatment was independently associated with more expressed preference for support (ß = -0.98; 95% CI, -1.7 to -0.23; p = 0.011; semipartial R = 0.05). An expressed preference for treatment was not associated with implicit preference (ß = 0.01; 95% CI, -0.04 to 0.06; p = 0.721). CONCLUSIONS: Although surgeons may sometimes feel pressured toward physical treatments, based on our results and cutoff values, the average patient with upper or lower extremity symptoms has a slight implicit preference for supportive treatment and would likely be receptive. LEVEL OF EVIDENCE: Level II, prognostic study.

Does resiliency mediate the association of psychological adaptability with disability and pain in patients with an upper extremity injury or illness?

OBJECTIVE: Symptom intensity and magnitude of limitations are highly variable for a given nociception and pathophysiology. As psychological determinants are of great influence to physical wellbeing, we assessed the influence of the protective factor measured and labelled as resilience in upper extremity illness. METHODS: One hundred and six patients completed a survey of demographics, the Brief Resilience Scale (BRS), the Psychological Adaptation Scale (PAS), an 11-point ordinal measure of pain intensity, and the PROMIS Physical Function (PROMIS PF) Computer Adaptive Test (CAT). Measures of pain intensity and PROMIS PF were repeated 3 months later. We created mediation models using structural equation modeling (SEM) to assess the mediation effect of BRS on the association of PAS and other confounding variables with disability and pain at initial assessment and 3 months later. RESULTS: Resiliency does not mediate the association of psychological adaptability with physical limitations and pain intensity at baseline (P = .89 and .82 respectively) or 3 months after enrollment (P = .65 and .72 respectively). CONCLUSIONS: Positive and protective factors promote beneficial resilience mechanisms that strengthen coping responses to pain and disability. In future studies we should either include more patients to improve power and provide more information about the health benefits of resilience or focus more on mood and self-efficacy on symptoms and limitations in patients with musculoskeletal illness. LEVEL OF EVIDENCE: Prospective, longitudinal cohort study; Level II.