AAOS Now

Published 8/2/2022
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Patrick Daly

Study Identifies Recall Bias in Patient Perception of Preoperative Function after RTSA for Cuff Tear Arthropathy

Reverse total shoulder arthroplasty (RTSA) has been shown to be extremely effective in the treatment of cuff tear arthropathy (CTA); however, studies aiming to define the efficacy profile of RTSA have relied on patients’ postoperative recollections of previous symptom burden.

To determine whether recall bias impacted patients’ memories of impairments and pain, a study compared American Shoulder and Elbow Surgeons (ASES) scores collected prospectively before RTSA and ASES scores collected retrospectively after RTSA in patients with CTA.

The study’s first author, Jorge Figueras, BE, of the department of orthopaedics and sports medicine at the University of Cincinnati, who presented the study during the AAOS 2022 Annual Meeting, reported that patients who underwent RTSA for CTA were found to have inaccurate recollections of preoperative function and also recalled significantly worse pain at 24 months after surgery. “In other words, two years after surgery, patients are not good at remembering what their functional impairments and pain levels were like before surgery,” Mr. Figueras told AAOS Now.

The study included a total of 72 patients who had completed the ASES Standardized Assessment Form preoperatively, underwent RTSA surgery, and then provided retrospective ASES scores at a mean of 28.3 months (± 7.3 months) postoperatively.

The investigators used a previously identified minimal clinically important difference (MCID; 13.6) to qualify whether differences between prospective and retrospective ASES scores were clinically significant. ASES mismatches were defined as the absolute difference between prospectively and retrospectively collected scores.

According to the report, retrospective ASES scores were significantly lower than prospective ASES scores (28.9 ± 20.0 versus 36.5 ± 19.8; P = 0.01). Patients had “significantly overestimated” their pain during evaluation (11.0 ± 10.1 versus 18.4 ± 13.6; P <0.001). additionally, patients who had an effective rtsa had a higher ases mismatch than patients who did not (17.9 ± 32.4 versus 49.7 ± 24.4;> P = 0.0003). Patients’ age, sex, BMI, Charlson Comorbidity Index score, presence of pseudo-paralysis, and previous rotator cuff scores were not correlated with greater differences between their scores (P >0.05).

Overall, 59.8 percent of patients “reported a clinically significant worse ASES score than indicated at time of enrollment,” the researchers reported. According to Mr. Figueras, this finding was not entirely surprising, as the study’s collaborators were initially motivated by their “frequent” encounters with patients who appeared to have forgotten their prior pain and functioning levels after RTSA, he commented.

The authors noted, however, that patients with better preoperative ASES scores (i.e., less pain and/or impairments) were worse at remembering their symptom burden when compared to patients with poorer preoperative ASES scores. Specifically, “Less severe preoperative shoulder dysfunction was predictive of a greater difference between prospectively collected preoperative ASES and retrospectively collected preoperative ASES (P <0.001),” the authors wrote.>

Mr. Figueras and colleagues inferred that patient perception of RTSA efficacy may be “dictated by differences in how patients perceive their shoulder function before and after surgery, rather than by the actual improvement in function that they obtained,” which they asserted could help explain why some patients with seemingly favorable outcomes are occasionally unsatisfied with their postoperative function.

The authors suggested that patients with higher preoperative shoulder function, who may be more susceptible to recall bias and treatment dissatisfaction, “could be identified and counseled preoperatively to help them better understand their disease burden and establish expectations in order to allow for the highest level of satisfaction.”

Ultimately, the authors judged that this population was susceptible to a “clinically significant” recall bias. These findings have since motivated the researchers to conduct another study on how patients’ expectations can impact satisfaction after shoulder surgery. “We are expecting to see that patients’ preoperative expectations do not necessarily align with their postoperative outcomes,” Mr. Figueras added.

Mr. Figueras’ coauthors of “Recall Bias in Retrospective Assessment of Preoperative American Shoulder and Elbow Surgeons Scores after Reverse Total Shoulder Arthroplasty,” are Nihar Samir Shah, MD; Ramsey Samir Sabbagh, MS; Cameron G. Thomson, MD; Austin Michael Foote, BS; Chase Anthony Steele, BS; Olivia Ashley Woods, BS; Violet Tessa Schramm, BS; and Brian M. Grawe, MD, FAAOS.

Patrick Daly is a medical writer for AAOS Now.