Minimal Important Clinical Difference Values Are Not Uniformly Valid in the Active Duty Military Population Recovering from Shoulder Surgery

Andrew J Sheean; Matthew S Tenan; Mikalyn T DeFoor; Daniel J Cognetti; Asheesh Bedi; Albert Lin; Travis J Dekker; MOTION Collaborative; Jonathan F Dickens

doi:10.1016/j.jse.2024.02.044

Minimal Important Clinical Difference Values Are Not Uniformly Valid in the Active Duty Military Population Recovering from Shoulder Surgery

J Shoulder Elbow Surg. 2024 Apr 11:S1058-2746(24)00246-5. doi: 10.1016/j.jse.2024.02.044. Online ahead of print.

Authors

Andrew J Sheean¹, Matthew S Tenan², Mikalyn T DeFoor³, Daniel J Cognetti¹, Asheesh Bedi⁴, Albert Lin⁴, Travis J Dekker⁵; MOTION Collaborative⁶; Jonathan F Dickens⁷

Collaborators

MOTION Collaborative:
Ivan J Antosh, James Bailey, Brian T Barlow, Craig R Bottoni, Matthew W Bradley, Kenneth L Cameron, William E Daner 3rd, Travis Dekker, Jonathan F Dickens, Michael A Donohue, Joseph W Galvin, Estephan J Garcia, Shawn Gee, Chad A Haley, Andrew P Hurvitz, Kelly Kilcoyne, Joseph T Lanzi Jr, Lance LeClere, Ian E Lee, Lucas S McDonald, Kyong S Min, Brett D Owens, Mark Pallis, Jeanne C Patzkowski, Matthew Posner, Benjamin K Potter, Matthew T Provencher, Daniel Rhon, Christopher J Roach, Richard Judd Robins, Marina J Rodriguez, Matthew R Schmitz, Mark Slabaugh, Andrew J Sheean, Jennifer L Smith, Daniel J Song, David T Streets, David Tennent, John M Tokish, Christopher J Tucker, Scott C Wagner, Robert Waltz, Matthew S Tenan, William R Volk

Affiliations

¹ San Antonio Military Medical Center, San Antonio, TX, USA.
² Defense Health Agency, College Park, MD, USA; Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA.
³ San Antonio Military Medical Center, San Antonio, TX, USA. Electronic address: mtdefoor@gmail.com.
⁴ University of Pittsburg Medical Center, Pittsburg, PA, USA.
⁵ 10(th) Medical Group, United States Air Force Academy, Colorado Springs, CO, USA.
⁶ Defense Health Agency, College Park, MD, USA.
⁷ Walter Reed National Military Medical Center, Bethesda, MD, USA; Uniformed Services University of Health Sciences, Bethesda, MD, USA; Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg Sweden.

PMID: 38614369
DOI: 10.1016/j.jse.2024.02.044

Abstract

Background: There are multiple methods for calculating the minimal clinically important difference (MCID) threshold, and previous reports highlight heterogeneity and limitations of anchor-based and distribution-based analyses. The Warfighter Readiness Survey assesses the perception of a military population's fitness to deploy and may be used as a functional index in anchor-based MCID calculations. The purpose of the current study in a physically demanding population undergoing shoulder surgery was to compare the yields of two different anchor-based methods of calculating MCID for a battery of PROMs, a standard receiver operator curve (ROC) -based MCIDs and baseline-adjusted ROC MCIDs.

Methods: All service members enrolled prospectively in a multicenter database with prior shoulder surgery that completed pre- and postoperative PROMs at a minimum of 12 months were included. The PROMs battery included Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons score (ASES), Patient Reported Outcome Management Information System (PROMIS) Physical Function (PF), PROMIS Pain Interference (PI), and the Warfighter Readiness survey. Standard anchor-based and baseline-adjusted ROC MCIDs were employed to determine if the calculated MCIDs were both statistically and theoretically valid (95% confidence interval either completely negative or positive).

Results: There were 117 patients (136 operations) identified, comprised of 83% males with a mean age of 35.7 ± 10.4 years and 47% arthroscopic labral repair/capsulorrhaphy. Using the standard, anchor-based ROC MCID calculation, the area under the curve (AUC) for SANE, ASES, PROMIS PF, and PROMIS PI were greater than 0.5 (statistically valid). For ASES, PROMIS PF, and PROMIS PI, the calculated MCID 95% CI all crossed 0 (theoretically invalid). Using the baseline-adjusted ROC MCID calculation, the MCID estimates for SANE, ASES, and PROMIS PI were both statistically and theoretically valid if the baseline score was less than 70.5, 69, and 65.7.

Conclusion: When MCIDs were calculated and anchored to the results of standard, anchor-based MCID, a standard ROC analysis did not yield statistically or theoretically valid results across a battery of PROMs commonly used to assess outcomes after shoulder surgery in the active duty military population. Conversely, a baseline-adjusted ROC method was more effective at discerning changes across a battery of PROMs among the same cohort.

Keywords: Minimal clinically important difference(MCID); anchor-based method; military readiness; patient reported outcome measures(PROM); receiver operator curve (ROC); shoulder.