Establishing the Patient Acceptable Symptom State in a Nonshoulder Hand and Upper Extremity Population for the Disabilities of the Arm, Shoulder, and Hand and Patient-Reported Outcomes Measurement Information System Upper Extremity Computer Adaptive Tests

Published:September 18, 2022DOI:


      It is unclear what score thresholds on patient-reported outcomes instruments reflect an acceptable level of upper extremity (UE) function from the perspective of patients undergoing hand surgery. The purpose of this study was to calculate the patient acceptable symptom state (PASS) for the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Patient-Reported Outcomes Measurement Information System (PROMIS) UE Computer Adaptive Test (CAT), version 2.0, in a population who underwent hand surgery.


      Adult patients who underwent hand surgery between February 2019 and December 2019 at a single academic tertiary institution were identified. QuickDASH and PROMIS UE CAT version 2.0 scores were collected 1 year after surgery, as were separate symptom- and function-specific anchor questions that queried the acceptability of patients’ current state. Threshold values predictive of a patient reporting an acceptable symptom state (PASS[+]) were calculated for both instruments using the 75th percentile score for patients in the PASS(+) group and the Youden Index as determined by receiver operating curve (ROC) analysis.


      A total of 222 patients were included. QuickDASH and PROMIS UE CAT scores differed significantly between the PASS(+) and PASS(−) groups. The 75th percentile method yielded PASS values of <16 for the QuickDASH and >43 for the PROMIS UE CAT for both anchor questions. The ROC analysis yielded PASS estimates of <15.9 to <20.5 for the QuickDASH and >38.1 to >46.2 for the PROMIS UE CAT, with ranges calculated from differing threshold values for each of the 2 anchor questions. The ROC-based estimates demonstrated high levels of model discrimination (area under the curve ≥ 0.80).


      We propose PASS estimates obtained using the 75th percentile and ROC methods.

      Clinical relevance

      Specifically, PASS values in the range of 15.9–20.5 for the QuickDASH and 38.1–46.2 for the PROMIS UE CAT version 2.0 should be used when interpreting outcomes at a population level.

      Key words

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        • Alderman A.K.
        • Chung K.C.
        Measuring outcomes in hand surgery.
        Clin Plast Surg. 2008; 35: 239-250
        • Chung K.C.
        • Burns P.B.
        • Sears E.D.
        Outcomes research in hand surgery: where have we been and where should we go?.
        J Hand Surg Am. 2006; 31: 1373-1379
        • Hand Surgery Quality Consortium
        Candidate quality measures for hand surgery.
        J Hand Surg Am. 2017; 42: 859-866.e3
        • Hoang-Kim A.
        • Pegreffi F.
        • Moroni A.
        • Ladd A.
        Measuring wrist and hand function: common scales and checklists.
        Injury. 2011; 42: 253-258
        • Smith M.V.
        • Calfee R.P.
        • Baumgarten K.M.
        • Brophy R.H.
        • Wright R.W.
        Upper extremity-specific measures of disability and outcomes in orthopaedic surgery.
        J Bone Joint Surg Am. 2012; 94: 277-285
        • Makhni E.C.
        Meaningful clinical applications of patient-reported outcome measures in orthopaedics.
        J Bone Joint Surg Am. 2021; 103: 84-91
        • Saleh K.J.
        • Shaffer W.O.
        Understanding value-based reimbursement models and trends in orthopaedic health policy: an introduction to the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.
        J Am Acad Orthop Surg. 2016; 24: e136-e147
        • Porter M.E.
        What is value in health care?.
        N Engl J Med. 2010; 363: 2477-2481
        • Cepeda N.A.
        • Polascik B.A.
        • Ling D.I.
        A primer on clinically important outcome values: going beyond relying on P values alone.
        J Bone Joint Surg Am. 2020; 102: 262-268
        • Tubach F.
        • Ravaud P.
        • Baron G.
        • et al.
        Evaluation of clinically relevant states in patient reported outcomes in knee and hip osteoarthritis: the patient acceptable symptom state.
        Ann Rheum Dis. 2005; 64: 34-37
        • Hubbard J.C.
        • Zhang Y.
        • Qiu Y.
        • et al.
        Establishing the substantial clinical benefit in a non-shoulder hand and upper extremity population for the QuickDASH and PROMIS upper extremity and physical function computer adaptive tests.
        J Hand Surg Am. 2022; 47: 358-369.e3
        • Orr M.N.
        • Klika A.K.
        • Gagnier J.J.
        • Bhandari M.
        • Piuzzi N.S.
        A call for a standardized approach to reporting patient-reported outcome measures: clinical relevance ratio.
        J Bone Joint Surg Am. 2021; 103: e91
        • Marks M.
        • Grobet C.
        • Audigé L.
        • Herren D.B.
        Clinical thresholds of symptoms for deciding on surgery for trapeziometacarpal osteoarthritis.
        J Hand Surg Eur Vol. 2019; 44: 937-945
        • Marks M.
        • Hensler S.
        • Wehrli M.
        • Schindele S.
        • Herren D.B.
        Minimal important change and patient acceptable symptom state for patients after proximal interphalangeal joint arthroplasty.
        J Hand Surg Eur Vol. 2019; 44: 175-180
        • Döring A.C.
        • Nota S.P.F.T.
        • Hageman M.G.J.S.
        • Ring D.C.
        Measurement of upper extremity disability using the patient-reported outcomes measurement information system.
        J Hand Surg Am. 2014; 39: 1160-1165
        • Beaton D.E.
        • Wright J.G.
        • Katz J.N.
        Upper Extremity Collaborative Group. Development of the QuickDASH: comparison of three item-reduction approaches.
        J Bone Joint Surg Am. 2005; 87: 1038-1046
        • Angst F.
        • Schwyzer H.-K.
        • Aeschlimann A.
        • Simmen B.R.
        • Goldhahn J.
        Measures of adult shoulder function: Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) and its Short Version (QuickDASH), Shoulder Pain and Disability Index (SPADI), American Shoulder and Elbow Surgeons (ASES) Society Standardized Shoulder Assessment Form, Constant (Murley) Score (CS), Simple Shoulder Test (SST), Oxford Shoulder Score (OSS), Shoulder Disability Questionnaire (SDQ), and Western Ontario Shoulder Instability Index (WOSI).
        Arthr Care Res (Hoboken). 2011; 63: S174-S188
        • Polson K.
        • Reid D.
        • McNair P.J.
        • Larmer P.
        Responsiveness, minimal importance difference and minimal detectable change scores of the shortened disability arm shoulder hand (QuickDASH) questionnaire.
        Man Ther. 2010; 15: 404-407
        • Sorensen A.A.
        • Howard D.
        • Tan W.H.
        • Ketchersid J.
        • Calfee R.P.
        Minimal clinically important differences of 3 patient-rated outcomes instruments.
        J Hand Surg Am. 2013; 38: 641-649
        • Mintken P.E.
        • Glynn P.
        • Cleland J.A.
        Psychometric properties of the shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) and Numeric Pain Rating Scale in patients with shoulder pain.
        J Shoulder Elbow Surg. 2009; 18: 920-926
        • Beckmann J.T.
        • Hung M.
        • Voss M.W.
        • Crum A.B.
        • Bounsanga J.
        • Tyser A.R.
        Evaluation of the patient-reported outcomes measurement information system upper extremity computer adaptive test.
        J Hand Surg Am. 2016; 41: 739-744.e4
        • Beleckas C.M.
        • Padovano A.
        • Guattery J.
        • Chamberlain A.M.
        • Keener J.D.
        • Calfee R.P.
        Performance of patient-reported outcomes measurement information system (PROMIS) upper extremity (UE) versus physical function (PF) computer adaptive tests (CATs) in upper extremity clinics.
        J Hand Surg Am. 2017; 42: 867-874
        • Kazmers N.H.
        • Hung M.
        • Rane A.A.
        • Bounsanga J.
        • Weng C.
        • Tyser A.R.
        Association of physical function, anxiety, and pain interference in nonshoulder upper extremity patients using the PROMIS platform.
        J Hand Surg Am. 2017; 42: 781-787
        • Tyser A.R.
        • Hung M.
        • Bounsanga J.
        • Voss M.W.
        • Kazmers N.H.
        Evaluation of version 2.0 of the PROMIS upper extremity computer adaptive test in nonshoulder upper extremity patients.
        J Hand Surg Am. 2019; 44: 267-273
        • Gordon D.
        • Pines Y.
        • Ben-Ari E.
        • et al.
        Minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state of PROMIS upper extremity after total shoulder arthroplasty.
        JSES Int. 2021; 5: 894-899
        • Paulsen A.
        • Roos E.M.
        • Pedersen A.B.
        • Overgaard S.
        Minimal clinically important improvement (MCII) and patient-acceptable symptom state (PASS) in total hip arthroplasty (THA) patients 1 year postoperatively.
        Acta Orthop. 2014; 85: 39-48
        • Perkins N.J.
        • Schisterman E.F.
        The inconsistency of “optimal” cutpoints obtained using two criteria based on the receiver operating characteristic curve.
        Am J Epidemiol. 2006; 163: 670-675
        • Hosmer D.W.
        • Lemeshow S.
        Applied Logistic Regression.
        2nd ed. Wiley, 2000: 156-164
        • Souza K.E.
        • Kellam P.J.
        • Stephens A.R.
        • Kazmers N.H.
        Evaluation of risk factors for loss of acceptable alignment for distal radius fractures that are nondisplaced or minimally displaced on initial presentation.
        J Hand Surg Am. 2022; 47: 54-61
        • Carter J.V.
        • Pan J.
        • Rai S.N.
        • Galandiuk S.
        ROC-ing along: evaluation and interpretation of receiver operating characteristic curves.
        Surgery. 2016; 159: 1638-1645
        • Haunschild E.D.
        • Gilat R.
        • Fu M.C.
        • et al.
        Establishing the minimal clinically important difference, patient acceptable symptomatic state, and substantial clinical benefit of the PROMIS Upper Extremity questionnaire after rotator cuff repair.
        Am J Sports Med. 2020; 48: 3439-3446
        • Wilkinson J.T.
        • Clawson J.W.
        • Allen C.M.
        • Presson A.P.
        • Tyser A.R.
        • Kazmers N.H.
        Reliability of telephone acquisition of the PROMIS upper extremity computer adaptive test.
        J Hand Surg Am. 2021; 46: 187-199
        • Forlenza E.M.
        • Lu Y.
        • Cohn M.R.
        • et al.
        Establishing clinically significant outcomes for Patient-Reported Outcomes Measurement Information System after biceps tenodesis.
        Arthroscopy. 2021; 37: 1731-1739
      1. HealthMeasures. Interpret Scores: PROMIS.
        • Tyser A.R.
        • Allen C.M.
        • Presson A.P.
        • et al.
        Evaluating the performance of PROMIS and QuickDASH instruments in an intercollegiate Division 1 athlete population.
        J Shoulder Elbow Surg. 2021; 30: 158-164
        • Christie A.
        • Dagfinrud H.
        • Garratt A.M.
        • Ringen Osnes H.
        • Hagen K.B.
        Identification of shoulder-specific patient acceptable symptom state in patients with rheumatic diseases undergoing shoulder surgery.
        J Hand Ther. 2011; 24 (quiz 61): 53-60
        • Ring D.
        • Lozano-Calderón S.
        • Shin R.
        • Bastian P.
        • Mudgal C.
        • Jupiter J.
        A prospective randomized controlled trial of injection of dexamethasone versus triamcinolone for idiopathic trigger finger.
        J Hand Surg Am. 2008; 33: 516-522
        • Kind A.J.H.
        • Buckingham W.R.
        Making neighborhood-disadvantage metrics accessible—the neighborhood atlas.
        N Engl J Med. 2018; 378: 2456-2458
        • Tyser A.R.
        • Gaffney C.J.
        • Zhang C.
        • Presson A.P.
        The association of patient satisfaction with pain, anxiety, and self-reported physical function.
        J Bone Joint Surg Am. 2018; 100: 1811-1818
        • Greenslade J.R.
        • Mehta R.L.
        • Belward P.
        • Warwick D.J.
        Dash and Boston questionnaire assessment of carpal tunnel syndrome outcome: what is the responsiveness of an outcome questionnaire?.
        J Hand Surg Br. 2004; 29: 159-164
        • Hutchinson D.T.
        • Sueoka S.
        • Wang A.A.
        • Tyser A.R.
        • Papi-Baker K.
        • Kazmers N.H.
        A prospective, randomized trial of mobilization protocols following ligament reconstruction and tendon interposition.
        J Bone Joint Surg Am. 2018; 100: 1275-1280
        • Dilaver N.M.
        • Gwilym B.L.
        • Preece R.
        • Twine C.P.
        • Bosanquet D.C.
        Systematic review and narrative synthesis of surgeons' perception of postoperative outcomes and risk.
        BJS Open. 2020; 4: 16-26
        • Kazmers N.H.
        • Qiu Y.
        • Yoo M.
        • Stephens A.R.
        • Tyser A.R.
        • Zhang Y.
        The minimal clinically important difference of the PROMIS and QuickDASH instruments in a nonshoulder hand and upper extremity patient population.
        J Hand Surg Am. 2020; 45: 399-407.e6