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 Table of Contents  
Year : 2021  |  Volume : 36  |  Issue : 3  |  Page : 57-63

Impact of demographic and hospital environmental variables on postoperative PROMIS depression anxiety and anger short form in patients undergone fracture elective surgery

Department of Paediatric Orthopaedics, King George’s Medical University, Lucknow, Uttar Pradesh, India

Date of Submission18-Nov-2021
Date of Acceptance29-Nov-2021
Date of Web Publication22-Dec-2021

Correspondence Address:
Ajai Singh
Department of Paediatric Orthopaedics, King George’s Medical University, Shah Mina Rd, Chowk, Lucknow 226003, Uttar Pradesh.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jbjd.jbjd_18_21

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Aim: So far, several studies have been evaluated in foreign countries via Patient-Reported Outcomes Measurement Information System (PROMIS) initiatives. PROMIS is a research tool for the evaluation of orthopedic disorders and is preferred for short-term and long-term performance. Fractured patients face many problems during a hospital stay, such as unhygienic wards, staff’s behavior, no hospital support, and a lot of expenditure, which adversely affects their social and mental status. Therefore, the Patient-Reported Outcome Measures (PROMs) capture the health status of patients that making it a more important tool in the health-care evaluation. Thus, the study aimed to assess the level of depression anxiety and anger by measuring the T-score of the same in hospitalized fractured patients with other factors during a hospital stay. Purpose/Hypothesis: The purpose of this study was to examine the association between PROMIS depression anxiety and anger with the atmosphere of the hospital, fracture conditions, and demographics. We believe that these variables play an important role in the quality of life of patients after having fractures and that they had to remain in the hospital unexpectedly. Study Design: This was a cross-sectional pilot study among fractured patients based on hospital environment. Materials and Methods: PROM assessment tool was used to measure depression anxiety and anger domains having seven and five items categorized as mild, moderate, and severe based on T-score. Results: A total of 113 patient’s response was obtained. The mean age was 34.84 years. Seventy-two patients were male (63.71%) and 41 patients (32.28%) were female. The mean and standard deviation (SD) of PROM T-score depression, anxiety, and anger was 57.67 (13.60), 50.56(11.47), and 57.08 (15.49), respectively. PROMIS anger and PROMIS anxiety were significantly correlated in many factors. Depression and anxiety were correlated in male patients. Anger and anxiety were significant in patients facing hospital hygiene and no support from the hospital (P = 0.008 and 0.05). Conclusion: PROM is an emerging tool to diagnose the level of depression anxiety and anger the patient faces during the hospital stay. Demographical factors like nuclear family and reason for fracture also play a significant role in anger and anxiety. Hospital hygiene significantly plays an important role in depression anxiety and anger in fracture patients.

Keywords: Anxiety, anger, depression, fracture, hospital environment, PROMs

How to cite this article:
Raikwar A, Yadav M, Singh A, Yadav S. Impact of demographic and hospital environmental variables on postoperative PROMIS depression anxiety and anger short form in patients undergone fracture elective surgery. J Bone Joint Dis 2021;36:57-63

How to cite this URL:
Raikwar A, Yadav M, Singh A, Yadav S. Impact of demographic and hospital environmental variables on postoperative PROMIS depression anxiety and anger short form in patients undergone fracture elective surgery. J Bone Joint Dis [serial online] 2021 [cited 2023 Jun 7];36:57-63. Available from: http://www.jbjd.in/text.asp?2021/36/3/57/333203

  Introduction Top

Patient-Reported Outcome Measures (PROMs) are tools that ask health-related questions that assess the quality of life of the patient’s well-being or functioning state that is expressly reported by the patient rather than perceived and recorded by the researchers and clinicians. PROMs are generally assessed in absolute terms and can be used after treatment or during treatment to monitor the significant improvements in the physical or mental health of the patient. PROMs have been established for a number of different domains. The domains are defined as one attempt to quantify the emotion, feature, or perception. PROMs can be profiled in the fields of physical, mental, and social health. The physical health domain includes pain intervention, physical function, and the mental health domain includes depression anxiety, and anger, as well as the social health domain, which includes ability to engage in social roles and activities, and social isolation.[1] The PROM profiles are small sets of short forms that calculate several separate domains simultaneously. There are three responses of the PROM item: the first is response theory, the second is computerized adaptive testing, and the third is T-scores. PROMs measure global health, physical function, and pain interference, which is seemingly well-suited for orthopedic trauma research. These tools help to assess the symptoms and different domains mentioned above.[1],[2] However, to date the use of PROMs in orthopedic trauma research has been limited. A T-score is a standardized score generated using a representative population sample in its entirety, much like a z-score in an IQ test. Just as a z-score centers around an average IQ score of 100, the Patient-Reported Outcomes Measurement Information System (PROMIS) T-score centers around 50, and 10 equals to 1 standard deviation (SD) of that population.[3 PROMs were validated in patient populations with orthopedic conditions in the foot],[ ankle],[ spine],[ and significantly improved measurement characteristics and also reduced patient’s as well as an administrative burden.[4]

Depression is a serious psychological condition and 1 in 10 experiences it once or twice for a lifetime, and the probability for a lifetime is as high as 30%. In each country, the rates of extreme depression were higher for women than men when admitted to a longer hospital stay.[5],[6]

Depression among hospitalized patients is frequently unrecognized, undiagnosed, and often untreated. The efficacy of hospitalization screening for depression is unclear, or whether depression is associated with worse outcomes, longer hospital stays as well as higher readmission rates. The prevalence of depression among hospitalized patients ranged from 5% to 60%, with a median of 33%.[4] However, depression is common especially in people with poor physical health, hip fracture, stroke, and alcoholism. Hospitalization is an unacknowledged opportunity to optimize mental and physical health outcomes. Yet little bit of knowledge about how often depression is unrecognized, undiagnosed, and therefore untreated.[6]

Anger is a hostile emotional condition typically characterized by physical agitation and antagonism aimed at a person or individual perceived as the source of an adverse incident.[7] Anger manifestos vary from moderate frustration to out-of-control.[8] Anger can also be suppressed, such as when directed inward toward the self or in the form of confrontations or aggressive behavior it can be directed at others. Recognizing patient distress is key to keeping health-care workers in good health. Anger is one of the best predictors of violence among psychiatric patients.[9]

In our study, we hypothesize that a patient’s degree of anger and depression rises or impacts their mental condition during their hospital stay. Such factors included were the mode of fracture, hospital hygiene, food, as well as financial assistance. We intended to include hospitalization of patient, family support, and other factors for considerations in our approach. There was some correlation with the PROMIS tool that was correlated and contributed equally or considerably in revealing the patient’s social and mental stress during their stay in the hospital. Thus, the purpose of this research was to concentrate on certain patients who had an accident and faced fractures and where they had their usual activities but had remained in the hospital setting as a consequence of a sudden incident. How their mental changes and their views on the hospitals have been presented in this paper.

  Materials and Methods Top

This was a hospital-based cross-sectional study conducted at the Department of Orthopaedics, King George’s Medical University, Lucknow, Uttar Pradesh, India from December 2019 to February 2020. Patients having fractures were admitted to the orthopedics department of the hospital. After the surgery, they were shifted to the ward, and only those patients were recruited who spent 1 or more weeks of stay in the hospital. A simple and convenient type of sampling was used for the data collection. All the patients were verbally asked to participate in the study and after their consent, the patient was enrolled for the study. All patients above 18 years of age having fractures either simple or compound whether undergone surgery or not were included in the study. However, the patients taking antidepressants and related drugs with high blood pressure were excluded from the study.

Symptoms of depression, anxiety, and anger were evaluated with the PROMIS emotional distress depression, anxiety, and anger short-forms from the Diagnostic and Statistical Manual of Mental Disorders (DSM–5—The DSM-5 level 1 cross-cutting symptom measure is a self- or informant-rated measure that assesses mental health domains that are important across psychiatric diagnoses) cross-cutting measure.

The sociodemographic profile such as age, caste, religion, type of family education, and occupation of patients and their parents along with any comorbid diseases such as TB, diabetes, and any type of drug abuse were recorded.

With the help of PROM tool, we measured different domains such as anger, depression anxiety, pain, and pain interference as per the scores obtained. Each domain has different items, as for this study we only used anger anxiety and depression scale. We used the paper adaptive short form to record the feedback from the patients. The short form was taken from the PROM health-care assessment center. These were converted into local languages so that it will be easily be understood by the patients. The PROM short form is instruments that are scored using item-level calibrations. The severity of depression anxiety and anger was assessed by calculating the raw score which was obtained by answering the questionnaire items in the domains. Anxiety anger and depression domains have seven, five, and eight items, respectively, questions such as “I felt angry,” “I was grouchy,” “I felt annoyed,” “I felt like I was ready to explode,” and “I was irritated more than people knew”. For anger scale, the questions differed for the depression scale which measured on 1–5 scale rating as 1––never; 2––rarely; 3––sometimes; 4––often; and 5––always with a range score from 7 to 25 for anxiety, 5 to 25 for anger, and 8 to 40 for depression. The raw score was summed up to obtain total raw score and T-score obtained using the reference table provided by the PROM health-care assessment center. Then T-score associated with the raw score was recorded. The patients with higher T-score (>70) were categorized as severe anxiety, anger, and depression, and patients with T-score (<70) were categorized as mild to moderate or no anger. This test can be helpful when determining an average person’s social and physical and mental state adjustments following the abrupt occurrence that occurs in life. We provided the questionnaire performa and asked them to self-administer the same and asked them to answer the questions that were given. Basic details were recorded by the interviewer. The reason for providing the performa to the patients was that the patient hesitates to be himself in front of an unknown so we asked to write whatever he feels while staying in the hospital.

Statistical analysis

We performed a descriptive analysis of the PROMIS domains using the SPSS software program, version 22.0. t Test was used for comparison of PROMIS domains with patient’s demographical factors. Pearson’s correlation was calculated between PROMIS domains and PROMIS outcomes. A value of P< 0.05 was considered statistically significant.

  Results Top

Frequency and percentage were calculated for depression anxiety and anger with a score of more than 70, indicating a high level. The incidence of depression, anxiety, and anger was 29.2%, 3.5%, and 32.7%, respectively. The majority of patients were in the age group less than 60 (71.2%) and the rest were of the geriatric group (28.3%). Of 113 patients, majority were men (63.7%) and 36.3% were women. The mean age was 48.12 (SD 18.47). Majority of them were educated up to primary level (37.2%) with majority of occupation being businessmen (20.4%). Among women, most of them were housewives (33.6%). Most of the patient's family was from nuclear family (67.3%). As per fracture, many patients were having simple fractures (51.3%) with less number of compound fractures (45.1%). Many were due to road accidents (51.3%) followed by other reasons (48.7%) of fractures like personal fights with legs and hands being the popular site of fracture. As per the hospital environment, the condition of the washroom was indicated dirty by 78 (69.0%) patients and there was no financial support from the hospital 101 (89.4%) [Table 1]. The mean and SD of PROM T-score depression, anxiety, and anger was 57.67 (13.60), 50.56 (11.47), and 57.08 (15.49), respectively [Table 2]. On correlating among three domains, PROMIS Depression, PROMIS Anxiety and PROMIS Anger, and PROMIS Anger And PROMIS Anxiety showed a significant difference between PROMIS anger and PROMIS anxiety (P = 0.03). When patients were stratified according to sex, PROMIS depression was found to be significantly correlated with PROMIS anxiety (r = 0.25;P = 0.03) in male patients; however there was no correlation with female patients. With regard to the type of family of patients, anger was significantly correlated with anxiety (r = 0.22;P = 0.05) in patients belonging to nuclear family. Patients who faced injury due to sports had a significant correlation with anger and anxiety (r = 0.69; P = 0.009). However, there was no correlation in other patients and their T-scores were high. Patients having no comorbidities were significantly correlated with anger and anxiety (r = 0.21; P = 0.02), whereas the patients having comorbidities were significantly correlated with hypertension and diabetes. The hospital environment and the condition of the washroom were significantly correlated with anger and anxiety (r = 0.29; P = 0.008). Dirty washrooms and the patients with family income of less than 1 lakh per year were significantly correlated with anger and anxiety (r = 0.25; P = 0.01).
Table 1: Patient demographic characteristics

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Table 2: Impact of patients demographic on PROMIS

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  Discussion Top

The level of depressive symptoms in our enrolled subjects was found to be 29.20% after 1 week of hospital stay whereas higher being the symptoms of anger (32.74%). In a recent publication on depression, the prevalence in orthopedic trauma patients with HADS score was found to be 42.63% which is quite higher than that observed in our study.[10]

In a study published in the US where data from large national samples included over 34,000 individuals, the prevalence of anger was 7.8%, which is common in men and younger adults. Anger and anxiety have been significantly associated with psychiatric disorder. As in our study, men were related to anger and anxiety, but in women there was no anger. The data were gathered using a face-to-face interview or personal interview assisted by computer. Logistic regression for individuals was calculated.[11]

Based on the meta-analysis data of 19,639 patients involved, males were less likely to develop depression compared to females, so as in our study was slightly larger in females but the results were not significant. This study concluded that it is essential to comprehend the gender differences in depression because women’s high rates of melancholy have such significant costs in terms of quality of life and productivity for themselves and their families, the health-care system should provide gender-specific care to ameliorate the problem that is why depression is more common among females than male patients.[12]

Occupation was not significantly associated with depression; however, the patients who belonged to labor group were more depressed than other groups. In a study conducted in Korea the prevalence of depression was more in unemployed (13.7%) than in employed (9.9%),[13] which in our study was 33.33% for labor which is the highest among the all group occupation recorded in our study [Table 1].

A review published by IsHak et al.[6] described the efficacy and effectiveness of depression screening tools in patient care settings, hospital setting, and clinical and utilization results for correlations between diagnosed depression. The median depression detection rate among patients ranged from 5% to 60%, which is also 33% in our study. Mood disorders predominate in patients in hospitals. Symptoms of depression and anxiety are a major concern in surgical patients, especially in female patients who have underlying diseases, postoperative complications, and lack of family support with a longer hospital stay.[14] As in our research, both men and women experienced depression almost equally during the hospital stay. Adult patients were more depressed than older age groups; on the contrary, patients from nuclear family were more depressed but the findings were not significant [Table 2].

We found a significant T-score of PROMs (>70) in patients who faced dirty washrooms in hospitals, and there could be no financial support from the hospital due to their lack of awareness of government running schemes as well as patients were not in the category to obtain such benefits. The major anger factors identified in the study were high medical costs, hospital fees, and repeated exams.[15]

Among the fracture-related information, patients with compound fracture had high level of depression (33.33%) as compared to simple fracture; however, the results were not significant but the reasons how the fracture happened was significant with anger and anxiety but not in depression. In a US study, the lifetime incidence of depression was found to be approximately 16% among adults, which was associated with the fracture.[16]

Depression in primary care is underdetected, underdiagnosed, and undertreated. Depression in health-care systems has significant depressive symptoms.[17] Anger and anxiety were common in patients who faced low hospital hygiene such as dirty washrooms and no hospital support to the patients, which were found highly significant in our study.

Several studies found that the extent of comorbidity between depression and alcohol use disorders is highly significant but there was no correlation in our study with depression.[18] In a new research on PROM assessment, a significant correlation was found between pain intervention and physical activity, which are associated with tobacco use in knee pain and injury.[19]

  Conclusion Top

Symptoms of depression anxiety and anger are of significant concern during the hospital stay and both men and women face stress equally, and these are correlated to each other. Patients with longer hospital stays are also at increased risk notably with underlying diseases, postoperative complications, lack of familial support, and need for reoperation as well as they are also get affected by the hospital environment and conditions. Hence, providing special attention and proper care with mental and social support could be useful to slow down the depression. We had planned to perform the study on a large scale with more domains in India in more orthopedic conditions and fracture-related infections (FRIs). Many studies on different DSM scores are available but studies related to PROMIS tools are lack in India and also in children to measure their level of depression, anger, and anxiety during orthopedics conditions. In our study, anger and anxiety were mostly associated with each other in many factors related to demographical and hospital environment whereas depression and anger domain had a correlation in certain subpopulations such as male patients and nuclear families than in other groups.

Limitations of the study

We planned to perform this on very high scale and long term but due to COVID-19 we were unable to continue our study; follow-up of patients could also not be done. Patient’s contacts were taken but due to unavoidable circumstances of the situation we had to stop our study. Our study limits to only patients who stayed in hospital for 1 week; we have not included any follow-up in the study. Study has not included children. PROMIS is a wide tool and is performed on large populations with applications like REDCAP, however in this study we tried to measure depression according to T scores where higher scores indicated severity and low scores indicated normal mental status.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2]


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