Evaluation of the Patient-Reported Outcomes Measurement Information System Upper Extremity Computer Adaptive Test

Patient Characteristics, Treatment, and Presenting PROMIS Scores Associated with Number of Office Visits for Traumatic Hand and Wrist Conditions

BACKGROUND

Overuse of healthcare resources is burdensome on society. Prior research has demonstrated that many patients with traumatic musculoskeletal injuries continue to seek care long after appropriate healing is well established, suggesting an overuse of services. However, few studies have examined the factors-including patient-reported outcomes-associated with an increased number of clinic visits for traumatic hand and wrist conditions.

QUESTIONS/PURPOSES

(1) After accounting for surgical treatment, surgeon, and demographic factors, is a patient's PROMIS Pain Interference score associated with the total number of office visits? (2) Is PROMIS Depression, combination of PROMIS Depression and Pain Interference, or Physical Function scores associated with the number of office visits?

METHODS

Between June 2015 and May 2018, 1098 patients presenting for a new patient visit at a single, urban academic medical center for distal radius fracture, wrist or hand sprain, tendon rupture, traumatic finger amputation, or scaphoid fracture were identified. Of those, 823 (75%) patients completed all PROMIS domains and presented before the trailing period and thus were included in this retrospective study. We recorded a number of variables including: Total number of office visits, age, sex, race, marital status, diagnosis, provider, and operative or nonoperative treatment. Multivariable Poisson regression analysis was conducted to determine whether Patient-Reported Outcomes Measurement Information System Pain Interference (PROMIS PI), Physical Function (PROMIS PF), and Depression scores measured at the first visit were associated with the total number of office visits, after accounting for the other factors we measured.

RESULTS

Higher PROMIS PI scores were associated with greater number of clinic visits (0.0077; 95% CI, 0.0018-0.014; p = 0.010). Although PROMIS Depression scores were not associated with the number of office visits (0.0042; 95% CI, -0.0099 to 0.0094; p = 0.112), higher PROMIS PF scores were associated with fewer office visits when accounting for confounding variables (-0.0077; 95% CI, -0.0012 to -0.0029; p = 0.001). Additionally, across all individual PROMIS models, there was an association between the variables "operative treatment" (PI: 0.85; 95% CI, 0.72-0.98; p < 0.001; Depression: 0.87; 95% CI, 0.74-1.0; p < 0.001; PF: 0.85; 95% CI, 0.72-0.99; p < 0.001) and "traumatic finger amputation" (PI: 0.22; 95% CI, 0.016-0.42; p = 0.034; Depression: 0.2; 95% CI, 0.086-0.47; p = 0.005; PF: 0.21; 95% CI, 0.014-0.41; p = 0.036) with an increased total number of office visits. Provider team 5 (PI: -0.62; 95% CI, -0.98 to -0.27; p = 0.001; Depression: -0.61; 95% CI, -0.96 to -0.26; p = 0.001; PF: -0.60; 95% CI, -0.96 to -0.25; p = 0.001) was associated with fewer office visits. In both the PROMIS Depression and PROMIS PF regression models, increasing age (Depression: -0.0048; 95% CI, -0.0088 to -0.00081; p = 0.018; PF: -0.0045; 95% CI, -0.0085 to -0.0006; p = 0.024) was also associated with fewer total number of office visits.

CONCLUSIONS

This study helps surgeons understand that patients who present at their initial office visit for traumatic hand and wrist conditions displaying worse pain coping strategies and decreased physical function will have more office visits. We recommend that surgeons engage in a comprehensive care approach that is empathetic, fosters effective pain coping strategies (and so might decrease PROMIS PI scores), and educates patients about expectations by providing educational materials and/or including other health professionals (such as, social work, physical therapy, mental health professional) as needed. This may decrease healthcare use in patients with traumatic hand and wrist conditions.

LEVEL OF EVIDENCE

Level IV, prognostic study.

PROMIS correlation with NDI and VAS measurements of physical function and pain in surgical patients with cervical disc herniations and radiculopathy

OBJECTIVE

The aim of this study was to compare the patient-reported outcome measures Neck Disability Index (NDI) and visual analog scale (VAS) with the Patient Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) measures, respectively, and to determine their correlations in a surgical population longitudinally.Legacy outcome measures such as NDI and VAS are essential for analyzing treatments in spine surgery for cervical disc herniations with radiculopathy. Despite their usefulness, administrative burdens impose limits on completion of these measures. PROMIS was developed as a patient outcome measure in order to improve reporting of patient symptoms and function and to reduce administrative burden. Despite early positive results of PROMIS in orthopedics, NDI and VAS scores have not been compared with PROMIS scores in patients with cervical disc herniations with radiculopathy.

METHODS

Eighty patients undergoing surgery for cervical disc herniations with radiculopathy were included. All patients were treated at the same tertiary spine center. Patients were seen and PROMIS PF and PI, NDI, and VAS arm and neck pain scores were collected preoperatively and at 1 year postoperatively. Correlations between NDI, VAS, and PROMIS PF and PI were quantified using Pearson correlation coefficients. Two-tailed Student t-tests were used to demonstrate correlation significance, with alpha = 0.05.

RESULTS

All 80 (100%) patients completed all preoperative questionnaires. Fifty-seven (72%) and 75 (94%) patients completed all questionnaires at baseline and at the 6-month and 1-year follow-ups, respectively. PROMIS PF and NDI scores demonstrated a strong negative correlation, with Pearson r values of -0.81, -0.77, and -0.75 at baseline, 6 months, and 1 year. PROMIS PI and VAS neck pain scores demonstrated a moderately positive correlation, with Pearson r values of 0.51, 0.61, and 0.6. PROMIS PI and VAS arm pain scores demonstrated a moderately positive correlation, with Pearson r values of 0.46, 0.47, and 0.45.

CONCLUSIONS

PROMIS PF scores have a strong negative correlation with NDI scores at baseline and in the postoperative course in patients undergoing surgery for cervical disc herniations with radiculopathy. PROMIS PI scores have a moderately positive correlation with VAS neck and arm pain scores at baseline and in the postoperative course. Surgeons may factor these correlation results into the interpretation of patient-reported outcome measures in patients with cervical radiculopathy. Use of PROMIS PF and PI for this patient population may reduce administrative burden while providing reliable outcomes data.

A Comparison of PROMIS UE Versus PF: Correlation to PROMIS PI and Depression, Ceiling and Floor Effects, and Time to Completion

PURPOSE

This study aimed to (1) determine the correlation of Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) with PROMIS Upper Extremity (UE) and compare the correlations of PF and UE with PROMIS Pain Interference (PI) and PROMIS Depression; (2) compare the ability of PF and UE to capture health outcomes across the spectrum in patients seeking hand care; and (3) compare the time to completion for PROMIS PF to that for PROMIS UE.

METHODS

Patients presenting to a hand clinic between October, 2015 and October, 2017 were asked to complete PROMIS PF, UE, PI, and Depression computerized adaptive tests. Spearman correlation coefficients (ρ) were calculated between the domains. Ceiling and floor effects and time to completion of each domain were compared.

RESULTS

A total of 20,489 unique visits representing 10,344 patients met inclusion criteria. On average, PROMIS UE demonstrated more functional disability than did PROMIS PF (PF: 43.9 [95% confidence interval (CI), 43.7-44.0] vs UE: 38.5 [95% CI, 38.4-38.7]). PROMIS PF and UE were positively correlated (ρ = 0.79) and both were inversely correlated with PROMIS PI (PF: ρ = -0.72; UE: ρ = -0.72). PROMIS PF and UE were both inversely correlated with PROMIS Depression (PF: ρ = -0.44; UE: ρ = -0.44). PROMIS PF demonstrated better ceiling (0.6% vs 7.5%) and floor effects (0.07% vs 0.4%). The PROMIS UE CAT was completed in about the same time as the PROMIS PF CAT (UE: 59.8 seconds [95% CI, 59.3-60.3 seconds] vs PF: 54.1 seconds [95% CI, 53.8-54.5 seconds]).

CONCLUSIONS

PROMIS PF captures functional outcomes similar to those of the UE domain with better performance (ie, ceiling and floor effects) in patients with hand pathologies.

CLINICAL RELEVANCE

Hand surgeons should consider the trade-off of using PROMIS PF instead of PROMIS UE or vice versa when selecting a domain for patient care. Although PROMIS PF may capture slight variations in function at the extremes better than the current PROMIS UE, this may not be as clinically important as capturing large changes in upper-extremity function more specifically, which PROMIS UE accomplishes.

The Impact of Workers' Compensation on Patient-Reported Outcomes Measurement Information System Upper Extremity and Legacy Outcome Measures in Patients Undergoing Arthroscopic Rotator Cuff Repair

PURPOSE

To examine the preoperative performance of the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) Computer Adaptive Test (CAT) with respect to legacy scores in patients receiving rotator cuff repair (RCR). In addition, to define the impact of Workers' Compensation (WC) status on both performance and floor and ceiling effects.

METHODS

The PROMIS UE CAT was administered preoperatively alongside legacy patient-reported outcome measures (PROMs) to patients undergoing isolated arthroscopic RCR from November 2017 to September 2018. Performance was assessed using Spearman correlation coefficients, and floor and ceiling effects were examined.

RESULTS

One hundred twenty-two patients (WC, n = 32; non-WC, n = 90; 62.3% male, 53.6 ± 11.5 years) were included. PROMs assessing physical function (r = 0.41-0.77) correlated more strongly to the PROMIS UE CAT than did multidomain or mental health PROMs (r = 0.25-0.61). In WC patients, the PROMIS UE CAT demonstrated diminished correlative strength relative to shoulder function PROMs. WC patients also demonstrated relative floor effects for Single Assessment Numerical Evaluation (SANE; 18.8%) and Constant-Murley (15.6%) and relative ceiling effects for the Brief Resilience Scale (53.1%), Short Form 12 Mental Component Score (50%), and Veterans Rand 12 Mental Component Score (53.1%) and were more likely to report the minimum SANE score (P < .01) and the maximum Brief Resilience Scale score (P < .01). No absolute or relative floor/ceiling effects for the PROMIS UE CAT were found.

CONCLUSIONS

Compared with a non-WC cohort, WC patients have significantly lower preoperative PROMIS UE CAT scores, are more likely to report the absolute minimum and maximum scores for various PROMs, and demonstrated relative floor and ceiling effects for PROMs assessing mental health. The absence of significant floor/ceiling effects for the PROMIS UE CAT may suggest improved outcome discrimination and may support the adoption of PROMIS UE for the assessment of functional status in WC patients with rotator cuff pathology.

LEVEL OF EVIDENCE

Level III, retrospective comparative trial.

Patient-Reported Outcomes Measurement Information System physical function correlates with Toronto Extremity Salvage Score in an orthopaedic oncology population

BACKGROUND

The National Institute of Health's Patient-Reported Outcomes Measurement Information System (PROMIS) uses computerised-adaptive testing to reduce survey burden and improve sensitivity. PROMIS is being used across medical and surgical disciplines but has not been studied in orthopaedic oncology.

QUESTIONS/PURPOSES

The aim of the study was to compare PROMIS measures with upper extremity (UE) and lower extremity (LE) Toronto Extremity Salvage Score (TESS) by assessing the following: (1) responder burden, (2) correlation between scores and (3) floor/ceiling effects.

PATIENTS AND METHODS

This cross-sectional trial analysed all 97 adult patients treated surgically for a bone or soft tissue tumour at a tertiary institution between November 2015 and March 2016. TESS (UE or LE) and PROMIS (Physical Function, Pain Interference and Depression) surveys were administered preoperatively. Pearson correlations between each PROMIS domain and TESS were calculated, as were floor/ceiling effects of each outcome measure.

RESULTS

(1) Completion of three PROMIS questionnaires required a mean total of 16.8 (+/- 5.8 standard deviation) questions, compared with 31 and 32 questions for the LE and UE TESS questionnaires, respectively. (2) The PROMIS Physical Function scores demonstrated a strong positive correlation with the LE TESS (r = 0.84; 95% confidence interval [CI], 0.72-0.91; p < 0.001) and moderate positive correlation with the UE TESS (r = 0.64; 95% CI, 0.34-0.83; p = 0.055). The PROMIS Depression scores demonstrated a weak negative correlation with both the LE TESS (r = -0.38; 95% CI, -0.61 to -0.10; p = 0.010) and with UE TESS (r = -0.38; 95% CI, -0.67 to -0.01; p = 0.055). The PROMIS Pain Interference scores demonstrated a strong negative correlation with the LE TESS (r = -0.71; 95% CI, -0.83 to -0.52; p < 0.001) and a moderate negative correlation with the UE TESS (r = -0.62; 95% CI, -0.81 to -0.30; p = 0.001). (3) The UE TESS had a range of scores from 16 to 100 with a 27% ceiling effect and no floor effect, and the LE TESS had a range from 10 to 98 with no floor or ceiling effect. There was no floor or ceiling effect for any PROMIS measures.

CONCLUSIONS

In an orthopaedic oncology population, the PROMIS Physical Function and Pain Interference scores correlate with the TESS and have the benefit of reduced survey burden and ceiling effect. The PROMIS Depression scores may provide additional information regarding patient outcomes not captured by the TESS.

LEVEL OF EVIDENCE

Level III.

THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE

Patient reported outcome measures asses patients' symptoms, function and health-related quality of life and are designed to capture more clinical information than can be gathered by objective medial testing alone. As reimbursements and the understanding of patient outcomes are becoming tied to performance on PROMIS measures, it is an important step to establish how PROMIS measures correlate and compare to traditional legacy measures.

Structural validity and construct validity of the Dutch-Flemish PROMIS® physical function-upper extremity version 2.0 item bank in Dutch patients with upper extremity injuries

INTRODUCTION

Aim of this study was to validate the Dutch-Flemish Patient-Reported Outcomes Measurement Information System Physical Function - Upper Extremity version 2.0 item bank in patients with upper extremity injuries.

MATERIALS AND METHODS

Cross-sectional study. Structural validity was assessed using Confirmatory Factor Analysis examining unidimensionality. In addition, a bi-factor model was fitted. Internal consistency was assessed by Cronbach's alpha. Construct validity was examined by assessing correlations with legacy instruments Disability of Arm Shoulder and Hand, Patient Reported Wrist Evaluation and Michigan Hand Questionnaire subscale Activities in Daily Life.

RESULTS

A total of 303 patients (144 female) with mean age of 50 years (standard deviation 18) were included. Confirmatory Factor Analysis showed Comparative Fit Index of 0.94, a Tucker Lewis Index of 0.93, a Root Mean Square Error of Approximation of 0.12 and a Standardized Root Mean Residual of 0.09. Factor loadings were all above 0.70. Bifactor analysis showed an omega-H of 0.79 and Explained Common Variance of 0.67. The correlations with the legacy instruments were as expected or higher than expected.

CONCLUSION

The Dutch-Flemish Patient-Reported Outcomes Measurement Information System Physical Function - Upper Extremity version 2.0 item bank measures a unidimensional trait and sufficient construct validity was found.IMPLICATIONS FOR REHABILITATIONCompleting Patient Reported Outcomes is time-consuming for patients and interpretability of outcomes is sometimes unclear due to some variation in psychometric properties.Computerized Adaptive Testing reduces the burden for patients by using an algorithm which decreases the amount of questions that need to be answered to 4 to 7 items.The Dutch-Flemish Patient-Reported Outcomes Measurement Information System Physical Function - Upper Extremity version 2.0 item bank measures a unidimensional trait and has sufficient structural validity, internal consistency and construct validity.After calibration of the Patient-Reported Outcomes Measurement Information System Physical Function - Upper Extremity version 2.0, the item bank is operable to use with Computerized Adaptive Testing.

What Role Does Positive Psychology Play in Understanding Pain Intensity and Disability Among Patients with Hand and Upper Extremity Conditions?

BACKGROUND

A large body of research shows that psychologic distress and ineffective coping strategies substantially contribute to more severe pain and increased physical limitations among patients with orthopaedic disorders. However, little is known about the relationship between positive psychology (constructs that enable individuals to thrive and adapt to challenges) and pain and physical limitations in this population.

QUESTIONS/PURPOSES

(1) Which positive-psychology factors (satisfaction with life, gratitude, coping through humor, resilience, mindfulness, and optimism) are independently associated with fewer upper-extremity physical limitations after controlling for the other clinical and demographic variables? (2) Which positive-psychology factors are independently associated with pain intensity after controlling for relevant clinical and demographic variables?

METHODS

In a cross-sectional study, we recruited patients presenting for a scheduled appointment with an orthopaedic surgeon at a hand and upper-extremity clinic of a major urban academic medical center. Of 125 approached patients, 119 (44% men; mean age, 50 ± 17 years) met screening criteria and agreed to participate. Patients completed a clinical and demographic questionnaire, the Numerical Rating Scale to assess pain intensity, the Patient-reported Outcomes Measurement Information System (PROMIS) Upper Extremity Physical Function computerized adaptive test to assess physical limitations, and six measures assessing positive-psychology constructs: The Satisfaction with Life Scale, the Gratitude Questionnaire, the Coping Humor Scale, the Brief Resilience Scale, the Cognitive and Affective Mindfulness Scale-Revised, and the Life Orientation Test-Revised. We first examined bivariate associations among physical limitations, pain intensity, and all positive-psychology factors as well as demographic and clinical variables. All variables that demonstrated associations with physical limitations or pain intensity at p < 0.05 were included in two-stage multivariable hierarchical regression models.

RESULTS

After controlling for the potentially confounding effects of prior surgical treatment and duration since pain onset (step1; R total = 0.306; F[7,103] = 6.50), the positive-psychology variables together explained an additional 15% (R change = 0.145, F change [5, 103] = 4.297, p = 0.001) of the variance in physical limitations. Among the positive-psychology variables tested, mindfulness was the only one associated with fewer physical limitations (β = 0.228, t = 2.293, p = 0.024, 4% variance explained). No confounding demographic or clinical variables were found for pain intensity in bivariate analyses. All positive-psychology variables together explained 23% of the variance in pain intensity (R = 0.23; F[5,106] = 6.38, p < 0.001). Among the positive-psychology variables, satisfaction with life was the sole factor independently associated with higher intensity (β = -0.237, t = -2.16, p = 0.033, 3% variance explained).

CONCLUSIONS

Positive-psychology variables explained 15% of the variance in physical limitations and for 23% of the variance in pain intensity among patients with heterogenous upper extremity disorders within a hand and upper extremity practice. Of all positive-psychology factors, mindfulness and satisfaction with life were most important for physical limitations and pain intensity, respectively. As positive-psychology factors are more easily modifiable through skills-based interventions than pain and physical limitations, results suggest implementation of such interventions to potentially improve outcomes in this population. Skills-based interventions targeting mindfulness and satisfaction with life may be of particular benefit.

LEVEL OF EVIDENCE

Level II, prognostic study.

Evaluation of the PROMIS Upper Extremity Computer Adaptive Test Against Validated Patient-Reported Outcomes in Patients With Basilar Thumb Arthritis

PURPOSE

The Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) computer adaptive test was developed to reduce test burden and improve precision. We hypothesized that, in patients with thumb basilar joint arthritis (BJA), (1) PROMIS UE would correlate with established patient-outcomes (PROs), (2) PROMIS UE would require less time and fewer questions than current metrics, (3) there would be no floor or ceiling effects, and (4) PROMIS UE would not correlate with radiographic disease severity.

METHODS

Patients presenting with a primary diagnosis of thumb BJA completed the Quick Disabilities of the Arm Shoulder and Hand (QuickDASH), Thumb Disability Examination (TDX), Patient-Rated Wrist Hand Evaluation (PRWHE), and PROMIS UE. Radiographic disease severity as described by the Eaton scoring system was recorded. The relationships among PROs were described with Spearman correlation coefficients. The presence of a floor or ceiling effect was confirmed if greater than 15% of patients achieved the lowest or the highest possible score, respectively.

RESULTS

One hundred patients with thumb BJA formed the sample for this study. A good to excellent correlation was identified between PROMIS UE and QuickDASH. There were good correlations between PROMIS UE and TDX as well as PRWHE. The PROMIS UE was significantly less time consuming (average: 58.5 seconds vs QuickDASH, 92.2; TDX, 62.6; and PRWHE, 144.7), and required fewer questions than current metrics (average: 4.9 questions vs QuickDASH, 11; TDX, 20; and, 15). In addition, there were no appreciable floor or ceiling effects. Radiographic disease severity did not correlate with PROMIS UE.

CONCLUSIONS

The PROMIS UE has a good to excellent correlation with QuickDASH and good correlations with PRWHE and TDX. In addition, PROMIS UE required less time and fewer questions than established PROs. There were no floor or ceiling effects. Used as a single PRO, PROMIS UE may be a practical alternative to legacy scales in patients with thumb BJA.

CLINICAL RELEVANCE

The PROMIS UE PRO instrument may be a valuable addition in the assessment of patients with basilar thumb arthritis.

Comparison of the Michigan Hand Outcomes Questionnaire, Boston Carpal Tunnel Questionnaire, and PROMIS Instruments in Carpal Tunnel Syndrome

PURPOSE

Patient-reported outcomes are important to assess improvement after surgery. Common instruments for carpal tunnel syndrome include the Michigan Hand Outcomes Questionnaire (MHQ) and Boston Carpal Tunnel Questionnaire (CTQ). The Patient-Reported Outcomes Measurement Information System (PROMIS) are newer measures. We evaluated how the PROMIS Pain Interference (PI) and Upper Extremity (UE) scores change after carpal tunnel release.

METHODS

All adult patients with carpal tunnel syndrome treated surgically were asked to participate in this prospective study. PROMIS instruments, MHQ, and CTQ were completed by 101 patients. Estimated means and standard errors were calculated, and piecewise linear fixed effects regression models were applied to the data. Standardized response means were calculated for each outcome measure.

RESULTS

The MHQ Total Score did not show a considerable change from the preoperative to 1-week postoperative visit but improved from the 1-week to 3-month postoperative visit (55 to 80). The CTQ Functional Status Score (FSS) worsened from 2.3 preoperatively to 2.6 at the 1-week postoperative visit before improving through the 3-month postoperative visit (1.6). PROMIS UE showed responsiveness similar to the CTQ FSS with a decline at the 1-week visit, 38 to 33, followed by improvement (45 at 3 mo). However, the standardized response mean values were greater for the CTQ FSS compared with PROMIS UE. The average administration time was shortest for PROMIS UE. The CTQ Symptom Severity Scale and MHQ Pain Scores showed improvements as early as the 1-week visit. The CTQ Symptom Severity Scale improved from 3.1 to 2.3, and MHQ Pain Scores improved from 55 to 46. PROMIS PI did not change at the 1-week visit but improved at 6 weeks and 3 months, from 56 to 52 and 49. The standardized response means for PROMIS PI achieved a large effect size only at 3 months.

CONCLUSIONS

The CTQ FSS is more responsive than PROMIS UE and the MHQ, with the CTQ FSS showing the largest effect sizes. PROMIS PI does not show the responsiveness seen in the CTQ Symptom Severity Scale and MHQ Pain Score. PROMIS instruments require less time to complete.

CLINICAL RELEVANCE

This study demonstrates the change in PROMIS scores after carpal tunnel release and how they compare with legacy outcome instruments.

Evaluation of Version 2.0 of the PROMIS Upper Extremity Computer Adaptive Test in Nonshoulder Upper Extremity Patients

PURPOSE

The Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Computer Adaptive Test (UE CAT) was recently updated to version 2.0 (v2.0). We hypothesized that the PROMIS UE CAT v2.0 would exhibit improved performance characteristics compared with the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) when administered to a nonshoulder upper extremity patient population.

METHODS

The UE CAT v2.0, Physical Function (PF) CAT v2.0, and the QuickDASH were each prospectively administered via tablet computer to all patients presenting to a tertiary hand and upper extremity clinic between April 2017 and October 2017. Patient responses were analyzed, and the mean, range, floor and ceiling effect, and correlations between instruments were calculated.

RESULTS

Among 825 patients, the mean UE CAT v2.0 score was 38.3 (SD 10.7) with a range of 15 to 61 and interquartile range of 15.4. The UE CAT v2.0 had a strong correlation with the QuickDASH (r = -0.749) and the PF CAT v2.0 (r = 0.719). No patient scored between 56 and 60, indicating a gap in scoring in that range. The UE CAT v2.0 demonstrated a floor effect of 1%, a ceiling effect of 6.9%, and a high internal consistency with a Cronbach alpha of 0.99.

CONCLUSIONS

The PROMIS UE CAT v2.0 demonstrated improved ceiling effects, range, and a decreased gap in scoring compared with prior versions. Limitations of the PROMIS UE CAT v2.0 are still present, but updates have led to an incremental improvement over prior versions, demonstrating the ability to influence PROMIS instrument performance through upgrades.

CLINICAL RELEVANCE

The updated PROMIS UE CAT v2.0 still demonstrates a ceiling effect and gap in scores at the upper end of the instrument, both of which may limit discrimination between different levels of upper extremity function for high-functioning patients.

Patient-Reported Outcomes Measurement Information System instruments: outperforming traditional quality of life measures in patients with back and neck pain

OBJECTIVE

The Patient-Reported Outcomes Measurement Information System (PROMIS) has become increasingly popular due to computer adaptive testing methodology. This study aims to validate the association between PROMIS and legacy outcome metrics and compare PROMIS to legacy metrics in terms of ceiling and floor effects and questionnaire burden.

METHODS

A retrospective review of an outcomes database was performed at a single institution from December 2016 to April 2017. Inclusion criteria were age > 18 years and a chief complaint of back pain or neck pain. The PROMIS computer adaptive testing Pain Interference, Physical Function (PF), and Pain Intensity domains; Oswestry Disability Index (ODI); Neck Disability Index (NDI); and visual analog scale (VAS) back, VAS leg, VAS neck, and VAS arm were completed in random order. PROMIS was compared to legacy metrics in terms of the average number of questions needed to complete each questionnaire and the score distributions in the lower and higher bounds of scores.

RESULTS

A total of 494 patients with back pain and 130 patients with neck pain were included. For back pain, ODI showed a strong correlation with PROMIS-PF (R = -0.749, p < 0.001), Pain Intensity (R = 0.709, p < 0.001), and Pain Interference (R = 0.790, p < 0.001) domains. Additionally, the PROMIS Pain Intensity domain correlated to both VAS back and neck pain (R = 0.642, p < 0.001 for both). PROMIS-PF took significantly fewer questions to complete compared to the ODI (4.123 vs 9.906, p < 0.001). When assessing for instrument sensitivity, neither survey presented a significant ceiling and floor effect in the back pain population (ODI: 0.40% and 2.63%; PROMIS-PF: 0.60% and 1.41%). In the neck pain cohort, NDI showed a strong correlation with PROMIS-PF (R = 0.771, p < 0.001). Additionally, PROMIS Pain Intensity correlated to VAS neck (R = 0.642, p < 0.001). The mean number of questions required to complete the questionnaire was much lower for PROMIS-PF compared to NDI (4.417 vs 10, p < 0.001). There were no significant differences found in terms of ceiling and floor effects for neck complaints (NDI: 2.3% and 6.92%; PROMIS-PF: 0.00% and 5.38%) or back complaints (ODI: 0.40% and 2.63%; PROMIS-PF: 1.41% and 0.60%).

CONCLUSIONS

PROMIS correlates strongly with traditional disability measures in patients with back pain and neck pain. For both back and neck pain, the PROMIS-PF required patients to answer significantly fewer questions to achieve similar granularity. There were no significant differences in ceiling and floor effects for NDI or ODI when compared with the PROMIS-PF instrument.

Relationship Between PROMIS Computer Adaptive Tests and Legacy Hip Measures Among Patients Presenting to a Tertiary Care Hip Preservation Center

BACKGROUND

Legacy hip outcome measures may be burdensome to patients and sometimes yield floor or ceiling effects. Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive tests (CATs) allow for low-burden data capture and limited ceiling and floor effects.

PURPOSE/HYPOTHESIS

The purpose of this study was to determine whether the PROMIS CAT domains demonstrate correlation against commonly used legacy patient-reported outcome measures in a population of patients presenting to a tertiary care hip preservation center. The authors hypothesized the following: (1) PROMIS CAT scores based on physical function (PF), pain interference (PIF), pain behavior, and pain intensity would show strong correlation with the following legacy scores: modified Harris Hip Score (mHHS), International Hip Outcome Tool-12 (iHOT-12), Hip Outcome Score (HOS) Sports and Activities of Daily Living subscales, and Veterans RAND-6D (VR-6D) utility measure. (2) The mental and physical health portions of the VR-6D legacy measure would show weak correlation with mental- and psychosocial-specific PROMIS elements-depression, anxiety, fatigue, sleep, and ability to participate in social roles and activities. (3) All PROMIS measures would exhibit fewer floor and ceiling effects than legacy scores.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

Prospective data were collected on 125 patients in the hip preservation clinics. Enrollees completed legacy scores (visual analog scale for pain, mHHS, iHOT-12, HOS, and VR-6D) and PROMIS CAT questionnaires (PF, PIF, pain behavior, anxiety, depression, sleep, social roles and activities, pain intensity, fatigue). Spearman rank correlations were calculated, with r_s values of 0 to 0.3 indicating negligible correlation; 0.3 to 0.5, weak correlation; 0.5 to 0.7, moderately strong correlation; and >0.7, strong correlation. Floor and ceiling effects were evaluated.

RESULTS

As anticipated, the PF-CAT yielded strong correlations with the iHOT-12, mHHS, HOS-Sports, HOS-Activities of Daily Living, and VR-6D, with r_s values of 0.76, 0.71, 0.81, 0.87, and 0.71, respectively. The PIF-CAT was the only pain score to show moderately strong to strong correlation with all 14 patient-reported outcome measures. A strong correlation was observed between the VR-6D and the social roles and activities CAT ( r_s = 0.73). The depression CAT had a significant floor effect at 19%. No additional floor or ceiling effect was present for any other legacy or PROMIS measure.

CONCLUSION

The PF-CAT shows strong correlation with legacy patient-reported outcome scores among patients presenting to a tertiary care hip preservation center. The PIF-CAT also correlates strongly with legacy and PROMIS measures evaluating physical and mental well-being. PROMIS measures are less burdensome and demonstrate no floor or ceiling effects, making them a potential alternative to legacy patient-reported outcome measures for the hip.

Variability of PROMIS Scores Across Hand Conditions

PURPOSE

This study aimed to determine whether Patient-Reported Outcome Measurement Information System (PROMIS) Physical Function and Pain Interference scores varied at presentation for specialty care by nontrauma hand condition. The secondary aim was to compare PROMIS scores with a reference standard, the Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH), regarding the magnitude and direction of score differentials among diagnoses.

METHODS

PROMIS Physical Function and Pain Interference scores were analyzed from 1,471 consecutive new adult patient clinic visits at a tertiary orthopedic hand clinic presenting with 1 of 5 nontrauma hand conditions. A 5-point difference on PROMIS assessments was presumed to be clinically relevant. A random sample of 30 QuickDASH scores from each diagnostic group was evaluated for score differentials among groups. We also measured the correlation between PROMIS and QuickDASH scores.

RESULTS

Patients with carpal tunnel syndrome and thumb basal joint arthritis reported worse physical function and more pain interference, whereas those with Dupuytren contractures and ganglion cysts reported less pain and better function. For both domains, patients with trigger fingers averaged PROMIS scores among the other groups. Similar differences were observed in QuickDASH scores because patients with carpal tunnel syndrome and thumb arthritis reported clinically worse upper-extremity function than did patients with ganglion cysts and Dupuytren contracture. A strong correlation was seen between QuickDASH scores with both PROMIS Physical Function scores and Pain Interference scores.

CONCLUSIONS

The PROMIS system is sufficiently able to capture differences in self-reported function and pain interference among patients with different hand conditions. Moreover, PROMIS Physical Function demonstrates construct validity when evaluated against a reference of the QuickDASH across nontrauma hand conditions.

CLINICAL RELEVANCE

The use of PROMIS is expanding, but because PROMIS is not disease-specific, assessment of its construct validity is necessary for hand conditions.

Item reduction of the patient-rated wrist evaluation using decision tree modelling

Background: The aim of this study is to assess the viability of a decision tree version of an often used questionnaire to measure wrist pain and disability, the Patient Rated Wrist Evaluation.Methods: Patient Rated Wrist Evaluation scores were collected from a cohort of 10394 patients who are part of a routine outcome measurement system. A decision tree version of the Patient Rated Wrist Evaluation (PRWE) was created. The intraclass correlation was used to evaluate the inter-version reliability between the original PRWE and the decision tree version.Results: The decision tree reduced the number of questions from 5 to 3 for the pain subscale, and from 10 to 3 for the disability subscale. The intraclass correlation between the original PRWE and the decision tree version was 0.97. The mean difference between the Patient Rated Wrist Evaluation and the decision tree Patient Rated Wrist Evaluation total sumscore was 0.35 (95% CI -9.92-10.62).Conclusions: We found that the decision tree was successful at reducing the items of the Patient Rated Wrist Evaluation from fifteen to only six questions with very high similarity to the scores of the full questionnaire.Implications for rehabilitationThe Patient Rated Wrist Evaluation can reliably be used with 6 instead of 15 questions.Decision trees are useful statistical tools to shorten lengthy questionnaires, especially when large amounts of data are available.Having a shortened Patient Rated Wrist Evaluation saves patients and clinicians time in answering this specific questionnaire.

Factors Associated With a Discretionary Upper-Extremity Surgery

PURPOSE

Surgery for nontraumatic upper-extremity problems is largely discretionary and preference-sensitive. Psychological and social determinants of health correlate with greater symptoms and limitations and might be associated with discretionary operative treatment.

METHODS

We used routinely collected patient-reported outcome measures from patients with de Quervain tendinopathy, ganglion cyst, trapeziometacarpal arthritis, trigger digit, and carpal tunnel syndrome to study factors associated with discretionary surgery using multiple logistic regression. Patients completed a measure of the magnitude of physical limitations (Patient-Reported Outcomes Measurement Information System [PROMIS] Physical Function Computerized Adaptive Test [CAT]), a measure of the degree to which a person limits activities owing to pain (PROMIS Pain Interference CAT), and a measure of symptoms of depression (PROMIS Depression CAT) at every office visit.

RESULTS

Higher PROMIS Pain Interference score, diagnoses of carpal tunnel syndrome, and treatment by teams 3, 4, or 5 were independently associated with discretionary operative treatment.

CONCLUSIONS

People with a greater tendency to limit activity owing to pain are more likely to choose discretionary surgery.

CLINICAL RELEVANCE

Interventions that help people remain active despite pain by addressing the psychological and social determinants of health might affect the rate of discretionary surgery.

The influence of mental health on Patient-Reported Outcomes Measurement Information System (PROMIS) and traditional outcome instruments in patients with symptomatic glenohumeral arthritis

BACKGROUND

The Patient-Reported Outcomes Measurement Information System (PROMIS) assessment includes computerized adaptive tests (CATs) that assess function, pain, depression, and anxiety. The influence of mental health on patients' self-reported pain and function has not been explored using PROMIS in patients with symptomatic glenohumeral osteoarthritis.

METHODS

This cross-sectional study included 284 shoulders in 276 patients presenting with isolated glenohumeral osteoarthritis. All patients completed the American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST), Visual Analog Pain Scale (VAS), and PROMIS CATs at the time of presentation. PROMIS anxiety and depression scores were converted into Generalized Anxiety Disorder-7 and Patient Health Questionnaire-9 scores, respectively, using the PROsetta Stone "crosswalk" tool. Mean pain and functional scores were compared between patients with and without PROMIS-converted scores corresponding to a diagnosis of anxiety or depression, as well as between scores corresponding to varying degrees of anxiety or depression.

RESULTS

Patients with scores corresponding to a diagnosis of anxiety or depression reported lower functional and higher pain scores compared to those with scores in the normal range (P < .001). Analysis of variance showed progressively lower functional and higher pain scores as anxiety severity increased (P < .001). Similar results were seen with ASES, upper extremity CAT, and pain scores as depression severity increased (P < .001). Functional ASES (P = .004), SST (P < .001), and physical function CAT (P = .002) scores were statistically significantly lower in patients with moderate to severe depression than those without depression or with mild depression.

DISCUSSION

In patients with glenohumeral osteoarthritis, PROMIS-reported anxiety and depression scores, particularly in those with moderate-to-severe scores, correlate with lower functional and higher pain scores. Further investigation is necessary to examine the influence that mental health has on outcomes after operative intervention in this population.

The Impact of Social Deprivation on Pediatric PROMIS Health Scores After Upper Extremity Fracture

PURPOSE

Although social deprivation is acknowledged to influence physical and mental health in adults, it is unclear if and how social deprivation influences perceived health in children. This study was conducted to evaluate the impact of social deprivation on Patient-Reported Outcomes Measurement Information System (PROMIS) scores in children presenting for treatment of upper extremity fractures.

METHODS

This cross-sectional evaluation analyzed data from 975 new pediatric patients (8-17 years old) with upper extremity fractures presenting to a tertiary orthopedic center between June 1, 2016, and June 1, 2017. They completed self-administered PROMIS Computer Adaptive Tests (CATs). The Area Deprivation Index was used to quantify social deprivation. Bivariate statistical analysis determined the effect of disparate area deprivation (based on most and least deprived national quartiles) for the entire population.

RESULTS

A total of 327 children (34%) lived in areas categorized as the most socially deprived quartile of the United States, whereas 202 (21%) arrived from homes in the least socially deprived quartile. Children in the most deprived quartile had significantly worse mean PROMIS Upper Extremity Function, Mobility, Pain Interference, and Peer Relations scores than those in the least deprived quartile. Significantly more children from the most socially deprived areas were black. Patient age, sex, and fracture type were not significantly different between patients from the least and the most socially deprived quartiles.

CONCLUSIONS

Children living in areas of greatest social deprivation report worse Upper Extremity Function, Mobility, Pain Interference, and Peer Relations scores on self-administered PROMIS CATs than children from areas of least social deprivation at presentation for care of upper extremity fractures. The impact of social deprivation on perceived health and function is evident before adulthood and, therefore, interventions to mitigate this effect should be offered to children as well as adults.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Validating the Patient Reported Outcomes Measurement Information System (PROMIS) computerized adaptive tests for upper extremity fracture care

BACKGROUND

Computerized adaptive testing (CAT) for patient-reported outcomes (PROs) is a developing area within orthopedic surgery. Our objective was to validate the Patient Reported Outcomes Measurement Information System (PROMIS) CATs for upper extremity fracture care. We sought to correlate PROMIS with legacy PROs and to investigate floor and ceiling effects.

METHODS

Patients who underwent open reduction and internal fixation of upper extremity trauma were prospectively enrolled. Legacy PROs included the visual analog scale for pain, the Disabilities of the Arm, Shoulder and Hand questionnaire, the University of California-Los Angeles Shoulder Rating Scale, the Mayo Elbow Performance Score, and the 36-Item Short Form Health Survey. PROMIS CATs included Physical Function (PROMIS PF), PROMIS Pain Interference (PROMIS Pain), and PROMIS Upper Extremity (PROMIS UE). Correlations between the PROs were calculated as were the absolute and relative floor and ceiling effect.

RESULTS

The study prospectively enrolled 174 patients with upper extremity trauma. There was moderate to high correlation between PROMIS UE CAT and legacy upper extremity-specific PROs (ρ = 0.42-0.79), and high correlation between the PROMIS PF CAT and the 36-Item Short Form Health Survey Physical Component Summary (ρ = 0.71, P < .001). The visual analog scale for pain, University of California-Los Angeles Shoulder Rating Scale, Constant Score, and Mayo Elbow Score demonstrated a significant absolute ceiling effect (20.5%-23.7%), whereas the PROMIS PF, PROMIS UE, and PROMIS Pain CATs demonstrated no absolute ceiling effect.

CONCLUSION

PROMIS PF, Pain, and UE correlate well with legacy PROs in a upper extremity trauma population, with less absolute floor or ceiling effects. This study provides preliminary evidence for the utility of PROMIS CATs in upper extremity trauma patients.

PROMIS Physical Function Correlation With NDI and mJOA in the Surgical Cervical Myelopathy Patient Population

STUDY DESIGN

Retrospective review.

OBJECTIVE

To determine the correlation of Patient-Reported Outcomes Measurement Information System (PROMIS) physical function with Neck Disability Index (NDI) and Modified Japanese Orthopedic Association (mJOA) scores in the surgical cervical myelopathy patient population.

SUMMARY OF BACKGROUND DATA

Outcome measures such as NDI and mJOA are essential for analyzing treatments for cervical myelopathy. Administrative burdens impose limits on completion of these measures. The PROMIS group developed an outcome measure to improve reporting of patient symptoms and function and to reduce administrative burden. Despite early success, NDI and mJOA have not been compared with PROMIS in patients with cervical myelopathy. This study determines the correlation of NDI and mJOA with PROMIS in surgical patients with cervical myelopathy.

METHODS

A total of 60 patients with cervical myelopathy undergoing surgery were included. PROMIS, NDI, and mJOA were collected preoperatively, and in the first 6 months postoperatively. Correlations between NDI, mJOA, and PROMIS were quantified using Pearson correlation coefficients. Students t tests were used to test significance.

RESULTS

All 60 (100%) of patients completed preoperative questionnaires. Fifty-five (92%) of patients completed initial follow-up questionnaires within the first 6 months. PROMIS physical function and NDI demonstrated a strong negative correlation at baseline and in initial follow-up (R = -0.69, -0.76). PROMIS and mJOA demonstrated a strong positive correlation at baseline and in initial follow-up (R = 0.61, 0.72).

CONCLUSION

PROMIS physical function has a strong negative correlation with NDI and a strong positive correlation with mJOA at baseline and in the early postoperative course in patients undergoing surgery for cervical myelopathy. Surgeons may factor these outcomes into the delivery and interpretation of patient-reported outcome measures in this population. Use of PROMIS may improve completion of outcome measures in the office and reduce administrative burden while still providing reliable outcomes data.

LEVEL OF EVIDENCE

3.

Correlation of PROMIS Physical Function Upper Extremity Computer Adaptive Test with American Shoulder and Elbow Surgeons shoulder assessment form and Simple Shoulder Test in patients with shoulder arthritis

BACKGROUND

The purpose of this study was to evaluate the Patient-Reported Outcomes Measurement Informative System Physical Function Upper Extremity Computer Adaptive Test (PROMIS PFUE CAT) measurement tool against the already validated American Shoulder and Elbow Surgeons (ASES) shoulder assessment form and the Simple Shoulder Test (SST) in patients with shoulder arthritis.

METHODS

Fifty-two patients with the primary diagnosis of shoulder arthritis were asked to fill out the ASES, SST, and PROMIS PFUE CAT. The time for completion of each survey was measured to determine responder burden, and correlation between the 3 instruments was defined as excellent (>0.7), strong-moderate (0.61-0.7), moderate (0.31-0.6), and poor (0.2-0.3).

RESULTS

The PROMIS PFUE CAT showed a strong-moderate correlation with the SST (r = 0.64; P < .001) and a moderate correlation with the ASES (r = 0.57; P < .001). The average times to complete the SST, ASES, and PROMIS PFUE CAT were determined to be 96.9 ± 25.1 seconds, 160.6 ± 51.5 seconds, and 62.6 ± 22.8 seconds, respectively. The time to complete the PROMIS PFUE CAT was significantly less than the time to complete the SST (P < .001) and the ASES (P < .001).

CONCLUSION

In patients with shoulder arthritis, The PROMIS PFUE CAT demonstrated strong-moderate correlation with the SST and moderate correlation with the ASES. The time savings of the PROMIS PFUE CAT were small compared with the ASES and SST but demonstrate that moving forward, using the PROMIS PFUE CAT would not place any additional burden on the patient filling out the survey. These findings indicate that the PROMIS PFUE CAT is an appropriate measurement tool for patients with shoulder arthritis.

Patient-Reported Outcomes Measurement Information System and Legacy Patient-Reported Outcome Measures in the Field of Orthopaedics: A Systematic Review

PURPOSE

To compare Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) with legacy patient-reported outcome measures with regard to correlations, ease of use, and quality criteria for orthopaedic conditions.

METHODS

A systematic search of the PubMed/MEDLINE database was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify published articles that referenced the various PROMIS PF measures. Three authors independently reviewed selected studies. The search returned 130 studies, 44 of which underwent review. Of these, 18 were selected for inclusion. A general linear model and paired t-tests were used to assess for differences between legacy patient-reported outcome measures and PROMIS.

RESULTS

The combined sample size of all articles yielded 3,047 total patients. Overall, PROMIS PF measures and legacy scores showed strong correlations (range: 0.59-0.83) when evaluating upper extremity, lower extremity, and spine patients. PROMIS questionnaires (6.04, standard error [SE] = 0.7) have significantly fewer questions than legacy forms (24.27, SE = 4.36). In lower extremity studies, the PROMIS PF (100.14 seconds, SE = 28.41) forms were completed in significantly less time (P = .03) than legacy forms (243.70 seconds, SE = 45.8). No significant difference was found between the reliabilities of the 2 types of measures.

CONCLUSIONS

PROMIS PF scores correlate strongly, particularly in lower extremity patients, with some of the most commonly used legacy measures in orthopaedics. PROMIS can be administered quicker and applied to a broader patient population while remaining highly reliable.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV evidence.

Palliative Care in Surgery: Defining the Research Priorities

OBJECTIVE

To describe the existing science of palliative care in surgery within three priority areas and expose specific gaps within the field.

BACKGROUND

Given the acute and often life-limiting nature of surgical illness, as well as the potential for treatment to induce further suffering, surgical patients have considerable palliative care needs. Yet these patients are less likely to receive palliative care than their medical counterparts and palliative care consultations often occur when death is imminent, reflecting poor quality end-of-life care.

METHODS

The National Institutes of Health and the National Palliative Care Research Center convened researchers from several medical subspecialties to develop a national agenda for palliative care research. The surgeon work group reviewed the existing surgical literature to identify critical knowledge gaps.

RESULTS

To date, evidence to support the role of palliative care in surgical practice is sparse and palliative care research in surgery is encumbered by methodological challenges and entrenched cultural norms that impede appropriate provision of palliative care. Priorities for future research on palliative care in surgery include: 1) measuring outcomes that matter to patients, 2) communication and decision making, and 3) delivery of palliative care to surgical patients.

CONCLUSIONS

Surgical patients would likely benefit from early palliative care delivered alongside surgical treatment to promote goal-concordant decision making and to improve patients' physical, emotional, social and spiritual well-being and quality of life. We propose a research agenda to address major gaps in the literature and provide a road map for future investigation.

PROMIS Pain Interference and Physical Function Scores Correlate With the Foot and Ankle Ability Measure (FAAM) in Patients With Hallux Valgus

BACKGROUND

Traditional patient-reported outcome instruments like the Foot and Ankle Ability Measure (FAAM) quantify patient disability but often are limited by responder burden and incomplete questionnaires. The Patient-Reported Outcome Measurement Information System (PROMIS) overcomes such obstacles through computer-adaptive technology and can capture outcome data from various domains including physical and psychosocial function. Prior work has compared the FAAM with PROMIS physical function; however, there is little evidence comparing the association between foot and ankle-specific tools like the FAAM with more general outcomes measures of PROMIS pain interference and depression in foot and ankle conditions.

QUESTIONS/PURPOSES

(1) We asked whether there was a relationship between FAAM Activities of Daily Living (ADL) scores with PROMIS physical function, pain interference, and depression in patients with hallux valgus. (2) Additionally, we asked if we could identify specific factors that are associated with variance in FAAM and PROMIS physical function scores in patients with hallux valgus.

METHODS

Eighty-five new patients with either a primary or secondary diagnosis of hallux valgus based on clinic billing codes from July 2015 to February 2016 were retrospectively identified. Patients completed FAAM ADL paper-based surveys and electronic PROMIS questionnaires for physical function, pain interference, and depression from new patient visits at a single time. Spearman rho correlations were performed between FAAM ADL and PROMIS scores. Analyses then were used to identify differences in FAAM ADL and PROMIS physical function measures based on demographic variables. Stepwise linear regressions then determined which demographic and/or outcome variable(s) accounted for the variance in FAAM ADL and PROMIS physical function scores.

RESULTS

FAAM scores correlated strongly with PROMIS physical function (r = 0.70, p < 0.001), moderately with PROMIS pain interference (r = -0.65, p < 0.001), and weakly with PROMIS depression (r = -0.35, p < 0.001) scores. Regression analyses showed that PROMIS pain interference scores alone were associated with sizeable portions of the variance in FAAM ADL (R² = 0.44, p < 0.001) and PROMIS physical function (R² = 0.57, p < 0.001) measures.

CONCLUSIONS

PROMIS function and pain measures correlated with FAAM ADL scores, highlighting the interrelationship of pain and function when assessing outcomes in patients with hallux valgus. PROMIS tools allow for more-efficient data collection across multiple domains and, moving forward, may be better poised to monitor changes in pain and function with time compared with traditional outcome measures like the FAAM.

CLINICAL RELEVANCE

The relationships shown here between PROMIS and FAAM scores further support the use of PROMIS tools in outcomes-based research. In patients with hallux valgus, pain-related disability appears to be a central feature of the patient-experience. Future studies should assess the association of various outcome domains on other common foot and ankle diagnoses.

Performance of Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) Versus Physical Function (PF) Computer Adaptive Tests (CATs) in Upper Extremity Clinics

PURPOSE

To examine the performance of the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) Function Computer Adaptive Test (CAT) relative to the PROMIS Physical Function (PF) CAT in patients seeking specialty care for upper extremity conditions.

METHODS

This observational trial analyzed prospectively collected PROMIS UE and PF CAT scores from 5,202 adult patients with 10,344 outpatient clinic visits presenting to a tertiary orthopedic clinic. Pearson correlation coefficient was utilized to evaluate the association between initial PF and UE scores as well as the association between changes in PF and UE scores between visits. Differences in scores between populations presenting with hand conditions versus shoulder and elbow conditions were evaluated via Student t test, as were differences in scores between new and return patient visits.

RESULTS

The PROMIS UE CAT scores were strongly correlated with PROMIS PF CAT scores. However, patients averaged 8 points lower scoring on UE CAT testing than on PF CAT scores. The UE CAT demonstrated a ceiling effect at a score of 56 that affected 7% of patients with a secondary ceiling at 50. Changes in PF and UE scores between visits were moderately correlated with a mean difference of less than 1 point. Patients presenting for hand conditions achieved better PF and UE scores than patients presenting for shoulder and elbow conditions.

CONCLUSIONS

The PROMIS UE module appears responsive to changes over time. However, the current UE CAT has a ceiling score of 56, which does not allow for improvement of scores 0.6 SD higher than the presumptive normative population mean of 50. Although a specific assessment of upper extremity function is desirable, continued refinement of the PROMIS UE CAT is required to better assess patients with higher levels of function.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

Association of Physical Function, Anxiety, and Pain Interference in Nonshoulder Upper Extremity Patients Using the PROMIS Platform

PURPOSE

The relationship between psychosocial factors and self-reported physical function among hand and upper extremity patients is complex. The Patient-Reported Outcomes Measurement Information System (PROMIS) platform has attempted to create a variety of specifically targeted metrics that can be administered using computer adaptive testing (CAT). Three metrics measuring self-reported physical function (herein referred to in combination as "functional" metrics) include the PROMIS Physical Function (PF) CAT, PROMIS Upper Extremity (UE) CAT, and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH). Two metrics assessing psychosocial factors include the PROMIS Anxiety and Pain Interference (PI) CATs ("nonfunctional" metrics). This study evaluates whether the functional metrics were correlated with nonfunctional metrics.

METHODS

The 5 questionnaires were administered prospectively on a tablet computer to all consecutive adult patients presenting to an outpatient hand and upper extremity (nonshoulder) clinic at a tertiary academic medical center from January 1 to November 1, 2014. For patients with multiple visits during the study period, only the first was included. Data were evaluated retrospectively to assess the relationship between functional and nonfunctional measures, with Pearson correlation coefficients to understand the relationship between continuous variables, and 1-way analysis of variance to examine for differences in outcome measures across demographic groups. Multivariable linear regression analyses were performed to determine factors predicting functional disability.

RESULTS

We included 1,299 patients: mean age was 46.8 years, 53% were female, and 23% were unemployed or on disability. The PROMIS PF CAT, PROMIS UE CAT, and QuickDASH scores were all significantly correlated with PROMIS Anxiety CAT (Pearson correlation coefficients, -0.46, -0.48, and 0.53, respectively) and PROMIS PI CAT (-0.60, -0.65, and 0.76, respectively) scores. Multivariable regression analyses demonstrated that increased PROMIS Anxiety and PI CAT scores each independently and adversely influenced PROMIS PF CAT, PROMIS UE CAT, and QuickDASH scores.

CONCLUSIONS

Increasing levels of patient anxiety and pain interference are independently associated with decreased patient-reported upper extremity function.

CLINICAL RELEVANCE

This study provides further support of the biopsychosocial model by highlighting that increased anxiety is associated with decreased self-reported function using the PROMIS platform.

Preoperative Performance of the Patient-Reported Outcomes Measurement Information System in Patients With Rotator Cuff Pathology

PURPOSE

To evaluate the Patient-Reported Outcomes Measurement Information System upper extremity item bank (PROMIS UE) and physical function computerized adaptive test (PROMIS PF CAT) in patients with rotator cuff (RC) pathology at their preoperative clinic visit.

METHODS

Patient data were collected from January 2015 to September 2015. Patients with a preoperative diagnosis of RC pathology were prospectively enrolled at the time of their surgical indication for RC repair. Each patient was asked to fill out the Western Ontario Rotator Cuff Index (WORC), American Shoulder and Elbow Surgeons Shoulder Assessment Form, Marx Shoulder Activity Scale, Short Form 36 Health Survey Physical Function and General Health (SF-36 PF and GH), EuroQol-5 Dimension (EQ-5D), PROMIS PF CAT, and PROMIS UE. Correlation was defined as excellent (>0.7), excellent-good (0.61-0.7), good (0.4-0.6), and poor (0.2-0.3).

RESULTS

Patient data were collected from January 2015 to September 2015. No patients were excluded from participation in the study. In 82 patients with preoperative RC pathology, the PROMIS UE showed excellent correlation with American Shoulder and Elbow Surgeons Shoulder Assessment Form (r = 0.77, P < .01), WORC (r = 0.73, P < .01), and the EQ-5D (r = 0.73, P < .01); there was excellent-good correlation with the SF-36 PF (r = .66, P < .01) and PROMIS PF CAT (r = .70, P < .01). The PROMIS PF CAT showed excellent correlation with the SF-36 PF (r = 0.77, P < .01); there was excellent-good correlation with EQ-5D (r = 0.65, P < .01) and WORC (r = 0.61, P < .01). There were no significant floor or ceiling effects using the PROMIS UE item bank or PROMIS PF CAT.

CONCLUSIONS

We report that in a patient population with preoperative RC pathology, the PROMIS UE and PROMIS CAT are valid patient-reported outcome alternatives that have high correlation with traditional shoulder and upper extremity patient-reported outcomes. We find a decreased question burden using the PROMIS PF CAT. We find no significant floor or ceiling effects present in the PROMIS UE or PROMIS PF CAT.

LEVEL OF EVIDENCE

Level II, prospective diagnostic study.

Efficacy of PROMIS Pain Interference and Likert Pain Scores to Assess Physical Function

PURPOSE

The Patient Reported Outcome Measurement Information System (PROMIS), developed by the National Institutes of Health, utilizes a health domain related to Pain Interference (PI). We evaluated this domain and its association with physical function (as determined by PROMIS Physical Function [PF]), administered as a computer adaptive test (CAT), and secondarily its association to a numerical 0 to 10 pain score. Our null hypothesis was that PI, as measured by CAT, has no correlation to PF and thus, there is no difference between comparisons of numerical pain scores and PROMIS PF.

METHODS

Adult patients presenting to an upper extremity clinic from February to December 2015 completed PROMIS PF, PI, and numerical 0 to 10 pain score questionnaires. The PROMIS modules were completed electronically in their computer adaptive form. Mean population scoring on each module is defined at 50. Patients were also asked to rate their pain on a 0 to 10 scale. These data were collected as routine clinical care and were extracted from the electronic health record for cross-sectional evaluation. Bivariate Pearson correlation analysis defined the association between the PROMIS modules and the numerical pain scores. Correlations between PF and PI were compared with correlations between PF and pain scores.

RESULTS

We recorded data from patients' 10,574 first, 5,210 second, 2,633 third, 1,382 fourth, and 722 fifth visits. The PROMIS PI was negatively correlated to the PROMIS PF. Numerical pain scores were also negatively correlated to PROMIS PF. Numerical pain scores were less correlated than PROMIS PI through time relative to PF.

CONCLUSIONS

Both PROMIS PI and numerical pain scores had significant correlations with PF for each office visit. The PI had a larger correlation to PF than did numerical pain scores. The PI and numerical pain scale scores are also correlated.

CLINICAL RELEVANCE

Patient-reported pain using a 0 to 10 pain score can be a predictor of patients' level of function, and although pain score does not replace other patient-reported outcomes, it can provide useful information, particularly when other patient-reported outcomes are not available.

Palliative Care in Surgery: Defining the Research Priorities

Given the acute and often life-limiting nature of surgical illness, as well as the potential for treatment to induce further suffering, surgical patients have considerable palliative care needs. Yet, these patients are less likely to receive palliative care than their medical counterparts and palliative care consultations often occur when death is imminent, reflecting poor quality end-of-life care. Surgical patients would likely benefit from early palliative care delivered alongside surgical treatment to promote goal-concordant decision making and to improve patients' physical, emotional, social, and spiritual well-being and quality of life. To date, evidence to support the role of palliative care in surgical practice is sparse and palliative care research in surgery is encumbered by methodological challenges and entrenched cultural norms that impede appropriate provision of palliative care. The objective of this article was to describe the existing science of palliative care in surgery within three priority areas and expose specific gaps within the field. We propose a research agenda to address these gaps and provide a road map for future investigation.