ArticleBMJ open2020
Analysis of change in patient-reported outcome measures with floor and ceiling effects using the multilevel Tobit model: a simulation study and an example from a National Joint Register using body mass index and the Oxford Hip Score.
Article in BMJ open, 2020. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 6 papers.
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Who cites it
6 citing papers in PubMed, 15 citations in OpenAlex.
- Patient-reported outcomes as markers and predictors of functional recovery in musculoskeletal rehabilitation.Rheumatology international · 2026Review
- Outcomes after reoperated medial unicompartmental knee arthroplasties compared with primary total and primary unicompartmental knee arthroplasties: a cohort study based on local Danish databases.Acta orthopaedica · 2026Observational
- Association between surgeon training grade and the risk of revision following total knee replacement: An analysis of National Joint Registry data.PLoS medicine · 2025Observational
- How and Who? Examining Real-World Evidence of Engagement and Use of an Electronic Patient-Reported Outcome Smartphone Application in Routine Clinical Care for Patients With Inflammatory Arthritides.ACR open rheumatology · 2025Article
- Association between surgeon training grade and the risk of revision following unicompartmental knee replacement: An analysis of National Joint Registry data.PLoS medicine · 2024Observational
- Collection and Reporting of Patient-reported Outcome Measures in Arthroplasty Registries: Multinational Survey and Recommendations.Clinical orthopaedics and related research · 2021Article
Corrections and comments
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Authors and funding
6 authors at 4 institutions in 1 country.
Funding
Abstract
objectivesThis study has three objectives. (1) Investigate the association between body mass index (BMI) and the efficacy of primary hip replacement using a patient-reported outcome measure (PROMs) with a measurement floor and ceiling, (2) Explore the performance of different estimation methods to estimate change in PROMs score following surgery using a simulation study and real word data where data has measurement floors and ceilings and (3) Lastly, develop guidance for practising researchers on the analysis of PROMs in the presence of floor and ceiling effects.
designSimulation study and prospective national medical device register.
settingNational Register of Joint Replacement and Medical Devices.
methodsUsing a Monte Carlo simulation study and data from a national joint replacement register (162 513 patients with pre- and post-surgery PROMs), we investigate simple approaches for the analysis of outcomes with floor and ceiling effects that are measured at two occasions: linear and Tobit regression (baseline adjusted analysis of covariance, change-score analysis, post-score analysis) in addition to linear and multilevel Tobit models. PRIMARY OUTCOME: The primary outcome of interest is change in PROMs from pre-surgery to 6 months post-surgery.
resultsAnalysis of data with floor and ceiling effects with models that fail to account for these features induce substantial bias. Single-level Tobit models only correct for floor or ceiling effects when the exposure of interest is not associated with the baseline score. In observational data scenarios, only multilevel Tobit models are capable of providing unbiased inferences.
conclusionsInferences from pre- post-studies that fail to account for floor and ceiling effects may induce spurious associations with substantial risk of bias. Multilevel Tobit models indicate the efficacy of total hip replacement is independent of BMI. Restricting access to total hip replacement based on a patients BMI can not be supported by the data.
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