JOA - 2026-06-19 - Journal Article
The EQ-5D-3L Questionnaire Demonstrates Moderate Ceiling Effects at One and Two Years After Total Hip Arthroplasty: Preoperative Predictors and Clinical Implications.
Lee YJ, Clement ND, Asopa V, Sochart DH
Topics
Key Takeaway
Nearly half of primary THA patients (47.5% at 1 year, 48.6% at 2 years) hit the EQ-5D-3L ceiling score, with a preoperative EQ-5D ≥0.534 predicting ceiling attainment (AUC 65.6%).
Summary Depth
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Summary
This study evaluated ceiling effects of the EQ-5D-3L in a prospective institutional THA database of 7,871 cases, collecting preoperative and 1- and 2-year postoperative EQ-5D-3L and Oxford Hip Score data. Ceiling effects were observed in 47.5% at 1 year and 48.6% at 2 years; independent predictors of ceiling attainment included female sex, younger age, lower socioeconomic deprivation, and higher preoperative EQ-5D and OHS. Paradoxically, ceiling-attaining patients demonstrated greater absolute improvement from baseline and were more likely to achieve minimal clinically important difference and patient-acceptable symptom state.
Key Limitation
The EQ-5D-3L's three-level response structure is the structural source of ceiling effects, and this study cannot determine whether the EQ-5D-5L would eliminate the problem in this cohort.
Original Abstract
BACKGROUND
The objectives were to evaluate whether the EQ-5D-3L questionnaire demonstrated a ceiling effect after total hip arthroplasty (THA), identify which patients were more likely to reach the ceiling score, and determine whether this limited assessment of potential improvement, relative to baseline, in their outcomes.
METHODS
A cohort of 7,871 primary THAs was identified from an institutional arthroplasty database. Patient demographics, American Society of Anesthesiologists grade, socioeconomic status, Oxford Hip Score (OHS), and EQ-5D-3L were prospectively collected preoperatively and one and two years postoperatively. Regression analyses were performed to determine which preoperative factors were independently associated with achieving a ceiling score.
RESULTS
The median preoperative EQ-5D-3L was 0.516, improving significantly at one year to 0.850 (P < 0.001), with non-significant change at two years (median, 0.883; P = 0.075). A ceiling effect was observed in 47.5% (n = 2,961) at one year, increasing to 48.6% (n = 2,853) at two years. Women, younger age, lower socioeconomic deprivation, and higher preoperative OHS, EQ-5D, and EQ-VAS were independent predictors of achieving a ceiling EQ-5D. Receiver operating characteristic (ROC) curve analyses indicated that a preoperative EQ-5D score (≥ 0.534) predicted postoperative ceiling scores at one and two years (area under the ROC curve, 65.6 and 64.1%, respectively; P < 0.001). Patients who reached the postoperative EQ-5D ceiling had significant improvements in OHS, EQ-5D, and EQ-VAS and were more likely to achieve minimal important change and a patient-acceptable symptom state compared with those below the ceiling.
CONCLUSION
He EQ-5D showed moderate ceiling effects at one and two years following THA, with higher preoperative scores being associated with ceiling attainment. Patients who reached the ceiling experienced greater improvements from baseline and were more likely to achieve clinically meaningful outcomes.