Interpreting patient-reported outcome results: US FDA guidance and emerging methods

Determination of the minimally important difference in a nasal symptom score in house dust mite allergy

BACKGROUND

House dust mite (HDM) allergens are responsible for the most prevalent persistent respiratory allergies. Clinical trials in this field often use a four-component nasal symptom score (T4NSS) as a measure of efficacy.

METHODS

The present observational, prospective, multinational, multicenter study determined the minimal important difference (MID) for a T4NSS in children, adolescents, and adults with physician-diagnosed HDM-induced allergic rhinoconjunctivitis (AR). Patients rated the T4NSS daily, a 15-point global rating of change scale (GRCS) and the Rhinoconjunctivitis Quality of Life Questionnaire weekly. The MID was determined primarily by using a regression method with a GRCS threshold of 2.

RESULTS

A total of 546 patients (210 adults, 133 adolescents, and 203 children) were included; 92.6% of the patients had moderate-to-severe AR, and 30.1% had concomitant mild asthma. During the first week, the mean ± standard deviation T4NSS was 5.68 ± 2.76 in adults, 5.34 ± 2.66 in adolescents, and 5.07 ± 2.48 in children. In a GRCS regression analysis, the MID [95% confidence interval] for the T4NSS was -0.90 [-1.06;-0.75] overall (n = 509), -0.94 [-1.19;-0.69] in children (n = 187), -0.74 [-1.07;-0.41] in adolescents (n = 125), and -1.04 [-1.29;-0.79] in adults (n = 197). The MID did not differ greatly from one disease severity tertile to another. Confirmatory distribution-based analyses yielded overall MID values of -0.87 for the first week of the study and -0.93 for the week 2-week 1 difference.

CONCLUSION

The MID for improvement in the T4NSS is at least -0.90 units in children, adolescents, and adults suffering from HDM-induced AR This value could be rounded up to -1 unit for convenience.

The minimal clinically important difference of the dyspnea index in laryngotracheal stenosis

OBJECTIVE

The Dyspnea Index (DI) is a validated patient-reported outcome (PRO) instrument that has been used in the management of laryngotracheal stenosis (LTS). The minimal clinically important difference (MCID) is an established concept to help determine the change in a PRO instrument that reflects meaningful change for the patient. It is not known what change in the DI is of clinical significance in airway surgery. This study aims to determine the MCID for the DI in patients undergoing surgical treatment for LTS.

METHODS

This is a prospective cohort study in which 26 patients with LTS completed the DI (score range 0 to 40) before and 6 to 8 weeks postoperatively, in addition to a Global Ratings Change Questionnaire (GRCQ), scored from -7 to +7, at the postoperative interval. A hypothesis test was carried out to test the association between GRCQ and change in DI. The MCID for change in DI was determined using anchor-based analysis.

RESULTS

Overall mean change in DI was -11, and mean change in GRCQ was +5. Change in DI scores were significantly different among the improvement and no improvement groups (P value <0.002). Area under the receiver operating curve was 0.92, demonstrating high discriminatory ability of the change in DI score. A change of -4 was determined to be the threshold that discriminated between significant improvement and no improvement.

CONCLUSION

A decrease of 4 in the DI can be considered as the MCID for patients with LTS after surgical treatment.

LEVEL OF EVIDENCE

2b Laryngoscope, 130:1775-1779, 2020.

Patients With Nonalcoholic Steatohepatitis Experience Severe Impairment of Health-Related Quality of Life

INTRODUCTION

Although there is substantial evidence suggesting poor health-related quality of life (HRQL) in patients with chronic hepatitis C (CHC), similar data in nonalcoholic steatohepatitis (NASH) have not been fully assessed. The aim is to compare HRQL scores in patients with CHC to those with NASH.

METHODS

Matched patients with advanced fibrosis (bridging fibrosis and compensated cirrhosis) due to CHC and NASH completed Short Form-36 (SF-36) questionnaire, Chronic Liver Disease Questionnaire (CLDQ), and Work Productivity and Activity Instrument questionnaire.

RESULTS

We included 1,338 patients with NASH with advanced fibrosis (mean age 57.2 years, 47% men, 55% cirrhosis) and 1,338 matched patients with CHC. Patients with CHC and NASH had similar rates of employment and psychiatric disorders (P > 0.05). As expected, patients with NASH had higher body mass index (mean 33.7 vs 27.6) and more type 2 diabetes (74% vs 16%) (all P < 0.01). Patients with NASH had significantly lower HRQL scores related to physical health: Physical Functioning, Bodily Pain, General Health, Vitality, Physical Summary of SF-36, and Fatigue of CLDQ (P < 0.02). By contrast, patients with CHC had a lower Mental Health score of SF-36 and Emotional score of CLDQ and reported greater impairment in daily activities as measured by the Work Productivity and Activity Instrument questionnaire (P < 0.002). In multivariate analysis, after adjustment for demographic parameters, cirrhosis, and history of psychiatric disorders, having NASH was associated with lower physical HRQL scores and higher mental health-related scores (P < 0.05).

DISCUSSION

Patients with NASH and advanced fibrosis have more impairment of their physical health-related scores than patients with CHC with advanced fibrosis. These data should dispel the misconception that NASH is an asymptomatic disease with little negative impact on patients' well-being.

A systematic review of estimates of the minimal clinically important difference and patient acceptable symptom state of the Western Ontario and McMaster Universities Osteoarthritis Index in patients who underwent total hip and total knee replacement

OBJECTIVE

To systematically review the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) estimates in pain and function measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) in patients who underwent primary total knee replacement (TKR) and primary total hip replacement (THR).

DESIGN

The study was carried out following PRISMA recommendations. We searched five electronic databases. Two reviewers independently screened titles, abstracts and full-text papers using a priori inclusion/exclusion criteria. Data were extracted by two independent reviewers. Data were synthesized, with WOMAC values converted to 0-100 scores (0 = best, 100 = worst).

RESULTS

Thirteen studies were included. Research methods used to calculate MCIDs and PASS varied across studies (e.g., using anchor-based or distribution methods, wording of anchor questions within anchor-based methods). Baseline WOMAC scores also varied across studies. Across studies and methods, MCIDs for the WOMAC in patients undergoing TKR ranged from 13.3 to 36.0 for pain and 1.8-33.0 for function; values for WOMAC in THR ranged from 8.3 to 41.0 for pain and from 9.7 to 34.0 for function. PASS cut-offs for TKR ranged from 25.0 to 28.6 for pain and 32.3-36.7 for function, and cut-offs for THR from 15.0 to 30.6 for pain and 28.0-42.0 for function.

CONCLUSION

Although the WOMAC is a commonly used measure for a single condition, the variability in methods used to calculate MCID and PASS estimates results in a range of values across studies making it unclear whether values reported in the literature can be applied with confidence. Future research is needed to refine methods used to calculate MCIDs and PASS.

Development and validation of the Axillary Sweating Daily Diary: a patient-reported outcome measure to assess axillary sweating severity

Background

Hyperhidrosis is estimated to affect ~ 4.8% of the US population, and most patients experience a negative psychological impact. Here, we describe development and psychometric evaluation of a patient-reported outcome (PRO) measure to assess severity of axillary hyperhidrosis in clinical trials that meets current U.S. regulatory standards to support product approvals.

Methods

Three rounds of hybrid concept-elicitation/cognitive-debriefing qualitative interviews were conducted in adults with clinician-diagnosed primary axillary hyperhidrosis, followed by similar interviews in children/adolescents. The draft measure included diary items for presence, severity, impact and bothersomeness (basis of the Axillary Sweating Daily Diary [ASDD]), exploratory weekly impact items, and a single-item Patient Global Impression of Change (PGIC). Phase 2 (adults only) and phase 3 (adults and children ≥9 years) clinical trial data were utilized to evaluate measurement properties of the resulting draft measure: floor/ceiling effects, nonresponse bias, test-retest reliability, construct validity, and responsiveness were assessed. The primary concept of interest was axillary sweating severity (ASDD Item 2); however, additional supportive concepts were explored to allow for development of a comprehensive hyperhidrosis measure.

Results

Twenty-nine patient interviews were conducted (N = 21 adult and N = 8 children/adolescents), resulting in the ASDD (4 items, patients ≥16y) and child-specific ASDD-C (2 items ≥9y to <16y), as well as 6 Weekly Impact items and the PGIC (patients ≥16y). No floor/ceiling effects or response biases were identified. Consistency between hypothesized and observed correlation patterns between ASDD/ASDD-C items and other efficacy measures supported construct validity. Intraclass correlation coefficients supported test-retest reliability (0.91–0.93; Item 2). Large effect sizes (− 2.2 to − 2.4) demonstrated that the ASDD/ASDD-C Item 2 could detect changes in hyperhidrosis severity, supporting the measure’s responsiveness. Patients perceiving a moderate improvement in symptoms on the PGIC experienced an average 3.8-point improvement on ASDD axillary sweating severity (Item 2); thus, a 4-point responder threshold was defined as a clinically meaningful change.

Conclusions

Qualitative and quantitative evidence support the reliability and validity of the ASDD/ASDD-C and its use in the clinical evaluation of axillary hyperhidrosis treatments. Further evaluation of this measure in future research studies is warranted to demonstrate consistent performance across different axillary hyperhidrosis populations and in different study contexts.

Guidelines for Composing and Assessing a Paper on the Treatment of Pain: A Practical Application of Evidence-Based Medicine Principles to the Mint Randomized Clinical Trials

Objective

To perform a thorough assessment of the recently published Mint Trials in order to illustrate how to read and analyze a study critically, according to principles of evidence-based medicine.

Design

Narrative review.

Method

We have applied the recently published guidelines for composing and assessing studies on the treatment of pain to a recently published article describing a large study that claimed its "findings do not support the use of radiofrequency denervation to treat chronic low back pain." These guidelines describe the critical components of a high-quality manuscript that allows communication of all relevant information from authors to readers.

Results

Application of evidence-based medicine principles to the publication describing the Mint Trials reveals significant issues with the methodology and conclusions drawn by the authors. A thorough assessment demonstrates issues with inclusion/exclusion criteria, diagnostic block protocols, radiofrequency neurotomy technique, co-interventions, outcome measurement, power analysis, study sample characteristics, data analysis, and loss to follow-up. A failure to definitively establish a diagnosis, combined with use of an inadequate technique for radiofrequency neurotomy and numerous other methodological flaws, leaves the reader unable to draw meaningful conclusions from the study data.

Conclusions

Critical analysis, rooted in principles of evidence-based medicine, must be employed by writers and readers alike in order to encourage transparency and ensure that appropriate conclusions are drawn from study data.

Clinically Meaningful Change

Abstract. In a recent paper, Ferrer and Pardo (2014) tested several distribution-based methods designed to assess when test scores obtained before and after an intervention reflect a statistically reliable change. However, we still do not know how these methods perform from the point of view of false negatives. For this purpose, we have simulated change scenarios (different effect sizes in a pre-post-test design) with distributions of different shapes and with different sample sizes. For each simulated scenario, we generated 1,000 samples. In each sample, we recorded the false-negative rate of the five distribution-based methods with the best performance from the point of view of the false positives. Our results have revealed unacceptable rates of false negatives even with effects of very large size, starting from 31.8% in an optimistic scenario (effect size of 2.0 and a normal distribution) to 99.9% in the worst scenario (effect size of 0.2 and a highly skewed distribution). Therefore, our results suggest that the widely used distribution-based methods must be applied with caution in a clinical context, because they need huge effect sizes to detect a true change. However, we made some considerations regarding the effect size and the cut-off points commonly used which allow us to be more precise in our estimates.

Understanding the Minimal Clinically Important Difference (MCID) of Patient-Reported Outcome Measures

OBJECTIVE

The minimal clinically important difference (MCID) of a patient-reported outcome measure (PROM) represents a threshold value of change in PROM score deemed to have an implication in clinical management. The MCID is frequently used to interpret the significance of results from clinical studies that use PROMs. However, an understanding of the many caveats of the MCID, as well as its strengths and limitations, is necessary. The objective of this article is to provide a review of the calculation, interpretation, and caveats of MCID.

DATA SOURCES

MEDLINE and PubMed Central.

REVIEW METHODS

Literature search-including primary studies, review articles, and consensus statements-pertinent to the objectives of this review using PubMed.

CONCLUSIONS

The MCID of a PROM may vary depending on the patients and clinical context in which the PROM is given. The primary approaches for calculating MCID are distribution-based and anchor-based methods. Each methodology has strengths and limitations, and the ideal determination of a PROM MCID includes synthesis of results from both approaches. The MCID of a PROM is also not perfect in detecting patients experiencing a clinically important improvement, and this is reflected in its accuracy (eg, sensitivity and specificity).

IMPLICATIONS FOR PRACTICE

Interpretation or application of MCID requires consideration of all caveats underlying the MCID, including the patients in whom it was derived, the limitations of the methodologies used to calculate it, and its accuracy for identifying patients who have experienced clinically significant improvement.

The Need for a Developmentally Based Measure of Social Communication Skills

The ability to demonstrate and quantify changes in social communication skills has been hindered by a lack of existing measures with appropriate standardization and psychometric properties. Such a measure would be helpful for research in many populations but would be particularly crucial for detecting incremental changes in youth with neurodevelopmental disorders who might gain skills but still lag substantially behind same-age peers. Although study designs and statistical methods are under development to try to account for slow and/or nonlinear, but potentially meaningful, improvements,¹ there is a dearth of measures designed to capture growth and loss of social communication skills. This opinion piece outlines the argument for such a measure and the primary issues to consider in its development.

Clostridium difficile Infection-Daily Symptoms (CDI-DaySyms™) questionnaire: psychometric characteristics and responder thresholds

Background

The purpose of the current study was to determine the final content validation, psychometric characteristics, clinically meaningful improvement, and responder thresholds of the Clostridium difficile infection (CDI)–Daily Symptoms (CDI-DaySyms™) patient-reported outcome (PRO) questionnaire.

Methods

This validation study was part of two phase III studies (NCT01987895 and NCT01983683) conducted in patients with mild-to-moderate or severe CDI who completed the CDI-DaySyms™ daily throughout the treatment period. The questionnaire was evaluated in three stages: final PRO item content validation (Stage I); psychometric evaluation of reliability and construct validity (Stage II); and determination of clinically meaningful improvement and responder thresholds using distribution-based methods (Stage III).

Results

The analysis included 168 patients. Most patients were female and Caucasian with mild-to-moderate CDI. The mean age was 57.1 years. Initial item analysis supported by confirmatory factor analysis demonstrated the relevance of 10 items grouped into three distinct domains (Diarrhea Symptoms, Abdominal Symptoms, and Systemic/Other Symptoms). Domain scores demonstrated acceptable internal consistency and test-retest reliability, were sensitive to change, and correlated in expected directions with other relevant symptom and disease-severity measures. Responder thresholds were defined as score changes of − 1.00, − 0.80, and − 0.70 in the Diarrhea Symptoms, Abdominal Symptoms, and Systemic/Other Symptoms domains, respectively.

Conclusions

The CDI-DaySyms™ is a valid measure of patient-reported CDI symptoms, with good measurement properties, which supports its utility as an endpoint in clinical studies. Further studies confirming responder thresholds based on anchor-based methods are required.

Trial registration

NCT01987895, registered November 20, 2013; NCT01983683, registered November 14, 2013.

Electronic supplementary material

The online version of this article (10.1186/s12955-019-1142-9) contains supplementary material, which is available to authorized users.

Peak Pruritus Numerical Rating Scale: psychometric validation and responder definition for assessing itch in moderate-to-severe atopic dermatitis

BACKGROUND

Moderate-to-severe atopic dermatitis (AD) is a chronic disease characterized by intense, persistent and debilitating itch, resulting in sleep deprivation, signs of anxiety and depression, impaired quality of life and reduced productivity. The Peak Pruritus Numerical Rating Scale (NRS) was developed and validated as a single-item, patient-reported outcome (PRO) of itch severity.

OBJECTIVES

To describe the content validity and psychometric assessment (test-retest reliability, construct validity, known-groups validity, sensitivity to change) of the Peak Pruritus NRS, and to derive empirically a responder definition to identify adults with a meaningful change in itch.

METHODS

Content validity was assessed through in-depth patient interviews. Psychometric assessments used data from phase IIb and phase III dupilumab clinical trials and included test-retest reliability, construct validity, known-groups validity and sensitivity to change in patients with moderate-to-severe AD.

RESULTS

Interview participants indicated that the Peak Pruritus NRS was a relevant, clear and comprehensive assessment of itch severity. Peak Pruritus NRS scores showed large, positive correlations with existing PRO measures of itch, and weak or moderate correlations with clinician-reported measures assessing objective signs of AD. Peak Pruritus NRS score improvements were highly correlated with improvements in other itch PROs, and moderately correlated with improvements in clinician-reported measures assessing objective signs of AD. The most appropriate threshold for defining a clinically relevant, within-person response was ≥ 2-4-point change in the Peak Pruritus NRS.

CONCLUSIONS

The Peak Pruritus NRS is a well-defined, reliable, sensitive and valid scale for evaluating worst itch intensity in adults with moderate-to-severe AD.

Group and Individual-level Change on Health-related Quality of Life in Chiropractic Patients With Chronic Low Back or Neck Pain

STUDY DESIGN

A prospective observational study.

OBJECTIVE

The aim of this study was to evaluate group-level and individual-level change in health-related quality of life among persons with chronic low back pain or neck pain receiving chiropractic care in the United States.

SUMMARY OF BACKGROUND DATA

Chiropractors treat chronic low back and neck pain, but there is limited evidence of the effectiveness of their treatment METHODS.: A 3-month longitudinal study of 2024 patients with chronic low back pain or neck pain receiving care from 125 chiropractic clinics at six locations throughout the United States was conducted. Ninety-one percent of the sample completed the baseline and 3-month follow-up survey (n = 1835). Average age was 49, 74% females, and most of the sample had a college degree, were non-Hispanic White, worked full-time, and had an annual income of $60,000 or more. Group-level (within-group t tests) and individual-level (coefficient of repeatability) changes on the Patient-Reported Outcomes Measurement Information System (PROMIS-29) v2.0 profile measure was evaluated: six multi-item scales (physical functioning, pain, fatigue, sleep disturbance, social health, emotional distress) and physical and mental health summary scores.

RESULTS

Within-group t tests indicated significant group-level change (P < 0.05) for all scores except for emotional distress, and these changes represented small improvements in health (absolute value of effect sizes ranged from 0.08 for physical functioning to 0.20 for pain). From 13% (physical functioning) to 30% (PROMIS-29 v2.0 Mental Health Summary Score) got better from baseline to 3 months later according to the coefficient of repeatability.

CONCLUSION

Chiropractic care was associated with significant group-level improvement in health-related quality of life over time, especially in pain. But only a minority of the individuals in the sample got significantly better ("responders"). This study suggests some benefits of chiropractic on functioning and well-being of patients with low back pain or neck pain.

LEVEL OF EVIDENCE

3.

Impact of Teduglutide on Quality of Life Among Patients With Short Bowel Syndrome and Intestinal Failure

Background

Teduglutide reduces or eliminates parenteral support (PS) dependency in patients with short bowel syndrome (SBS). Recent post hoc analyses demonstrated that effects are correlated with baseline PS volume. We assessed the SBS‐related quality‐of‐life (QoL) impact of teduglutide, particularly whether improvements are greater among subgroups achieving more PS volume reduction.

Methods

Using phase 3 trial data of teduglutide in patients with SBS (NCT00798967), change in Short Bowel Syndrome–Quality of Life (SBS‐QoL) scores from baseline were compared between teduglutide vs placebo in the overall population and subgroups classified by baseline PS volume requirement, disease etiology, and bowel anatomy. Generalized estimating equation models were fitted to assess impact of teduglutide on SBS‐related QoL using data from all visits, adjusted for baseline characteristics.

Results

Of 86 patients, 43 each were randomized to teduglutide or placebo (mean age: 51 vs 50 years, respectively). In adjusted analyses, teduglutide had a nonsignificant reduction (improvement) of −8.6 points (95% CI: 2.6 to −19.8) in SBS‐QoL sum score from baseline to Week‐24 vs placebo. The impact of teduglutide varied by subgroup. Patients treated with teduglutide experienced significantly greater reductions in SBS‐QoL sum score at Week‐24 vs placebo in 2 subgroups, ie, the third (highest) tertile baseline PS volume (−27.3, 95% CI: −50.8 to −3.7) and inflammatory bowel disease (IBD; −29.6, 95% CI: −46.3 to −12.9). Results were similar for SBS‐QoL subscale and item scores.

Conclusions

The impact of teduglutide treatment on SBS‐related QoL vs placebo varied among subgroups and was significant and most pronounced among patients with highest baseline PS volume requirement or IBD.

Estimating minimally important differences for the PROMIS pain interference scales: results from 3 randomized clinical trials

Minimally important difference (MID) refers to the smallest meaningful difference that carries implications for patient care. Minimally important differences are necessary to help interpret patient-reported pain outcomes in research and clinical practice. The PROMIS pain interference scales were validated across diverse samples; however, more information about their MIDs could improve their interpretability. The purpose of this study was to estimate MIDs for 4 fixed-length PROMIS pain interference scales, including the 6-item Pain Short Form and the 4-, 6-, and 8-item pain interference scales used in the PROMIS profile instruments. Data were analyzed from 3 randomized controlled trials (N = 759). The 3 samples, respectively, consisted of patients with chronic low back pain (n = 261), chronic back pain or hip/knee osteoarthritis pain (n = 240), and a history of stroke (n = 258). For each sample, anchor- and distribution-based approaches were used to estimate MIDs. Standard error of measurement and effect sizes were used as distribution-based MID estimates. Anchor-based MID estimates were established by mapping PROMIS pain interference scores onto established anchor measures, including the Brief Pain Inventory, and retrospective and prospective global ratings of change. The distribution- and anchor-based MID estimates showed convergence. For the pain samples, MID estimates ranged from 2 to 3 T-score points. For the nonpain sample, MID estimates ranged from 3.5 to 4.5 T-score points. The MID estimates were comparable across the 4 fixed-length scales. These MIDs can be used to evaluate treatment effects in research and clinical care and to calculate estimates for powering clinical trials.

Considerations for Evaluating and Recommending Worker Productivity Outcome Measures: An Update from the OMERACT Worker Productivity Group

OBJECTIVE

The Outcome Measures in Rheumatology (OMERACT) Worker Productivity Group continues efforts to assess psychometric properties of measures of presenteeism.

METHODS

Psychometric properties of single-item and dual answer multiitem scales were assessed, as well as methods to evaluate thresholds of meaning.

RESULTS

Test-retest reliability and construct validity of single item global measures was moderate to good. The value of measuring both degree of difficulty and amount of time with difficulty in multiitems questionnaires was confirmed. Thresholds of meaning vary depending on methods and external anchors applied.

CONCLUSION

We have advanced our understanding of the performance of presenteeism measures and have developed approaches to describing thresholds of meaning.

Prospective Evaluation of the Patient Acceptable Symptom State to Identify Clinically Successful Anterior Cruciate Ligament Reconstruction

BACKGROUND

The length of most patient-reported outcome measures creates significant response burden, which hampers follow-up rates. The Patient Acceptable Symptom State (PASS) is a single-item, patient-reported outcome measure that asks patients to consider all aspects of life to determine whether the state of their joint is satisfactory; this measure may be viable for tracking outcomes on a large scale.

HYPOTHESIS

The PASS question would identify clinically successful anterior cruciate ligament reconstruction (ACLR) at 1-year follow-up with high sensitivity and moderate specificity. We defined "clinically successful" ACLR as changes in preoperative to postoperative scores on the Knee injury and Osteoarthritis Outcome Score (KOOS) pain subscale and the KOOS knee-related quality of life subscale in excess of minimal clinically important difference or final KOOS pain or knee-related quality of life subscale scores in excess of previously defined PASS thresholds.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

Patients enrolled in a prospective longitudinal cohort completed patient-reported outcome measures immediately before primary ACLR. At 1-year follow-up, patients completed the same patient-reported outcome measures and answered the PASS question: "Taking into account all the activity you have during your daily life, your level of pain, and also your activity limitations and participation restrictions, do you consider the current state of your knee satisfactory?"

RESULTS

A total of 555 patients enrolled in our cohort; 464 were eligible for this study. Of these, 300 patients (64.7%) completed 1-year follow-up, of whom 83.3% reported satisfaction with their knee after surgery. The PASS question demonstrated high sensitivity to identify clinically successful ACLR (92.6%; 95% CI, 88.4%-95.6%). The specificity of the question was 47.1% (95% CI, 35.1%-59.5%). The overall agreement between the PASS and our KOOS-based criteria for clinically successful intervention was 81.9%, and the kappa value indicated moderate agreement between the two methods (κ = 0.44).

CONCLUSION

The PASS question identifies individuals who have experienced clinically successful ACLR with high sensitivity. The limitation of the PASS is its low specificity, which we calculated to be 47.1%. Answering "no" to the PASS question meant that a patient neither improved after surgery nor achieved an acceptable final state of knee health. The brevity, interpretability, and correlation of the PASS question with significant improvements on various KOOS subscales make it a viable option in tracking ACLR outcomes on a national or global scale.

An overview of using qualitative techniques to explore and define estimates of clinically important change on clinical outcome assessments

Establishing meaningful change thresholds for Clinical Outcome Assessments (COA) is critical for score interpretation. While anchor- and distribution-based statistical methods are well-established, qualitative approaches are less frequently used. This commentary summarizes and expands on a symposium presented at the International Society for Quality of Life Research (ISOQOL) 2017 annual conference, which provided an overview of qualitative methods that can be used to support understanding of meaningful change thresholds on COAs. Further published literature and additional examples from multiple disease areas which have also qualitatively explored the concept of meaningful change are presented.Semi-structured interviews conducted independently from a clinical trial, exit interviews conducted in the context of a clinical trial, focus groups, vignettes and the Delphi panel method can be used to obtain data regarding meaningful change thresholds, with advantages and disadvantages to each method. Semi-structured interviews using concept elicitation (CE) or cognitive debriefing (CD) methods conducted independently from a clinical trial can be an efficient way to gain in-depth patient/caregiver insights. However, there can be challenges with reconciling heterogeneous data across diverse samples and in interpreting the qualitative insights in the context of quantitative score changes. Semi-structured qualitative interviews using CE/CD methods embedded as exit interviews in a clinical trial context with patients/caregivers can provide insights which can augment quantitative findings based on analysis of clinical trial data. However, there are logistical challenges relating to embedding the interviews in a clinical trial.Focus groups and the Delphi panel method can be valuable for reaching consensus regarding meaningful change thresholds; however, for face-to-face interactions, social desirability bias can affect responses. Finally, using vignettes and taking a mixed methods approach can aid in achieving consensus on the minimum score change endorsed by respondents as a meaningful improvement/decrement. However, the approach can be cognitively challenging for participants and reaching a consensus is not guaranteed.Anchor- and distribution- based methods remain critical in establishing responder definitions. Nonetheless, qualitative data has the potential to provide complementary support that a certain level of change on the target COA, which has been statistically supported, is truly important and meaningful for the target population.

EuroInf 2: Subthalamic stimulation, apomorphine, and levodopa infusion in Parkinson's disease

OBJECTIVE

Real-life observational report of clinical efficacy of bilateral subthalamic stimulation (STN-DBS), apomorphine (APO), and intrajejunal levodopa infusion (IJLI) on quality of life, motor, and nonmotor symptoms (NMS) in Parkinson's disease (PD).

METHODS

In this prospective, multicenter, international, real-life cohort observation study of 173 PD patients undergoing STN-DBS (n = 101), IJLI (n = 33), or APO (n = 39) were followed-up using PDQuestionnaire-8, NMSScale (NMSS), Unified PD Rating Scale (UPDRS)-III, UPDRS-IV, and levodopa equivalent daily dose (LEDD) before and 6 months after intervention. Outcome changes were analyzed with Wilcoxon signed-rank or paired t test when parametric tests were applicable. Multiple comparisons were corrected (multiple treatments/scales). Effect strengths were quantified with relative changes, effect size, and number needed to treat. Analyses were computed before and after propensity score matching, balancing demographic and clinical characteristics.

RESULTS

In all groups, PDQuestionnaire-8, UPDRS-IV, and NMSS total scores improved significantly at follow-up. Levodopa equivalent daily dose was significantly reduced after STN-DBS. Explorative NMSS domain analyses resulted in distinct profiles: STN-DBS improved urinary/sexual functions, mood/cognition, sleep/fatigue, and the miscellaneous domain. IJLI improved the 3 latter domains and gastrointestinal symptoms. APO improved mood/cognition, perceptual problems/hallucinations, attention/memory, and the miscellaneous domain. Overall, STN-DBS and IJLI seemed favorable for NMSS total score, and APO favorable for neuropsychological/neuropsychiatric NMS and PDQuestionnaire-8 outcome.

CONCLUSIONS

This is the first comparison of quality of life, nonmotor. and motor outcomes in PD patients undergoing STN-DBS, IJLI, and APO in a real-life cohort. Distinct effect profiles were identified for each treatment option. Our results highlight the importance of holistic nonmotor and motor symptoms assessments to personalize treatment choices. © 2019 International Parkinson and Movement Disorder Society.

Follow-up score, change score or percentage change score for determining clinical important outcome following surgery? An observational study from the Norwegian registry for Spine surgery evaluating patient reported outcome measures in lumbar spinal stenosis and lumbar degenerative spondylolisthesis

Background

Assessment of outcomes for spinal surgeries is challenging, and an ideal measurement that reflects all aspects of importance for the patients does not exist. Oswestry Disability Index (ODI), EuroQol (EQ-5D) and Numeric Rating Scales (NRS) for leg pain and for back pain are commonly used patients reported outcome measurements (PROMs). Reporting the proportion of individuals with an outcome of clinical importance is recommended. Knowledge of the ability of PROMs to identify clearly improved patients is essential. The purpose of this study was to search cut-off criteria for PROMs that best reflect an improvement considered by the patients to be of clinical importance.

Methods

The Global Perceived Effect scale was utilized to evaluate a clinically important outcome 12 months after surgery. The cut-offs for the PROMs that most accurately distinguish those who reported ‘completely recovered’ or ‘much improved’ from those who reported ‘slightly improved’, unchanged’, ‘slightly worse’, ‘much worse’, or ‘worse than ever’ were estimated. For each PROM, we evaluated three candidate response parameters: the (raw) follow-up score, the (numerical) change score, and the percentage change score.

Results

We analysed 3859 patients with Lumbar Spinal Stenosis [(LSS); mean age 66; female gender 50%] and 617 patients with Lumbar Degenerative Spondylolisthesis [(LDS); mean age 67; 72% female gender]. The accuracy of identifying ‘completely recovered’ and ‘much better’ patients was generally high, but lower for EQ-5D than for the other PROMs. For all PROMs the accuracy was lower for the change score than for the follow-up score and the percentage change score, especially among patients with low and high PROM scores at baseline.

The optimal threshold for a clinically important outcome was ≤24 for ODI, ≥0.69 for EQ-5D, ≤3 for NRS leg pain, and ≤ 4 for NRS back pain, and, for the percentage change score, ≥30% for ODI, ≥40% for NRS leg pain, and ≥ 33% for NRS back pain. The estimated cut-offs were similar for LSS and for LDS.

Conclusion

For estimating a ‘success’ rate assessed by a PROM, we recommend using the follow-up score or the percentage change score. These scores reflected a clinically important outcome better than the change score.

Minimally important difference and predictors of change in quality of life in type 2 diabetes: A community-based survey in China

BACKGROUND

To identify the minimally important difference (MID) of the EQ-5D-3L and determinants of change in quality of life (QoL) as measured by the EQ-5D-3L over 1 year for Chinese type 2 diabetic patients (T2DPs).

METHODS

Clinically diagnosed T2DPs were recruited from 66 community health centres in five Chinese cities using a multistage quota sampling method between December 2010 and October 2011. Demographics, diabetes-related information, and health-related behaviours were collected at baseline. The EQ-5D-3L was administered at baseline and at 12 months. Anchor-based and distribution-based approaches were employed to estimate MIDs. Using the MIDs as cut-points, we identified the change in EQ-5D-3L-measured QoL into "worsening," "no change," and "bettering." Logistic and ordered logistic regressions were conducted for those who reported best possible EQ-5D health state ("best possible HS") and impaired EQ-5D health states ("impaired HS") at baseline, respectively. Explanatory variables included demographics, diabetes-related information, and health-related behaviours.

RESULTS

A total of 1958 patients (54.9% female, mean age 61.2 years, mean diabetes duration 7.9 years) were included in our analysis. MIDs of the EQ-5D-3L for deterioration and improvement were estimated as -0.066 to -0.003, and 0.049 to 0.077, respectively. For the impaired HS group, older age, lower education, and less exercise were significant predictors for worsening in QoL; whereas, those predictors were older age, female gender, and lower income for the best possible HS group.

CONCLUSIONS

Minimally important differences for deterioration and improvement were estimated for the EQ-5D-3L. Age, gender, education, income, and exercise were significant determinants of QoL change for Chinese T2DPs.

Working toward precision medicine approaches to treat severe obesity in adolescents: report of an NIH workshop

Adolescent severe obesity is a prevalent, chronic, and serious disease with few effective and safe treatment options. To address this issue, a National Institutes of Health-sponsored workshop entitled "Developing Precision Medicine Approaches to the Treatment of Severe Obesity in Adolescents," was convened, bringing together a multidisciplinary group of experts to review the current state of the science and identify (1) what is known regarding the epidemiology and biopsychosocial determinants of severe obesity in adolescents, (2) what is known regarding effectiveness of treatments for severe obesity in adolescents and predictors of response, and (3) gaps and opportunities for future research to develop more effective and targeted treatments for adolescents with severe obesity. Major topical areas discussed at the workshop included: appropriate BMI metrics, valid measures of phenotypes and predictors, mechanisms associated with the development of severe obesity, novel treatments informed by biologically and psychosocially plausible mechanisms, biopsychosocial phenotypes predicting treatment response, standardization of outcome measures and results reporting in research, and improving clinical care. Substantial gaps in knowledge were identified regarding the basic behavioral, psychosocial, and biological mechanisms driving the development of severe obesity and the influence of these factors on treatment response. Additional exploratory and observational studies are needed to better understand the heterogeneous etiology of severe obesity and explain the high degree of variability observed with interventions. Tailored treatment strategies that may be developed by achieving a better understanding of individual differences in genetic endowment, clinical, metabolic, psychological, and behavioral phenotypes, and response to environmental exposures need to be tested. It is anticipated that these recommendations for future research, including strategies to enhance methodological rigor, will advance precision medicine approaches to treat severe obesity in adolescents more effectively.

Important differences and meaningful changes for the Functional Assessment of Cancer Therapy-Cognitive Function (FACT-Cog)

Background

We estimated clinically important, group-level differences in self-reported cognitive function for the Functional Assessment of Cancer Therapy-Cognitive Function (FACT-Cog) instrument. We also investigated individual level change that could be considered meaningful for cancer survivors affected by cognitive impairment following chemotherapy, and that could be used for responder analyses. We used data from a multi-site randomized controlled trial in 242 participants that evaluated a web-based intervention for improving self-reported cognitive functioning in adult cancer survivors who reported cognitive impairment and who had adjuvant chemotherapy in the previous 6–60 months. We used anchor and distribution methods to estimate a range of clinically important differences (CIDs) and investigated meaningful change thresholds (MCTs) for the FACT-Cog and the Perceived Cognitive Impairments (PCI) subscale, post-intervention and at six-month follow-up with empirical cumulative distribution functions. Our primary anchor was the patient reported cognitive function subscale of the European Organization for Research and Treatment of Cancer Quality of Life-Cognitive Functioning Scale (EORTC-CF).

Results

Most participants were female (95%) breast cancer survivors (89%). Correlation of changes in the FACT-Cog and the EORTC-CF were 0.55 post-intervention and 0.61 at follow-up. Anchor-based CID estimates for the FACT-Cog using our primary anchor were 11.3 points (post) and 8.8 (follow-up), which corresponds to a standardized effect size of 0.49 and 0.38; 8.6% and 6.6% of the total scale’s range. Anchor-based CID estimates for the FACT-Cog PCI subscale were 7.4 (post) and 4.6 points (follow-up), which corresponds to a standardized effect size of 0.50 and 0.31; 10.3% and 6.4% of the PCI range). Empirical cumulative distribution functions of change in FACT-Cog demonstrating possible MCTs showed that anchor change of none, minimally better and much better were well separated.

Conclusions

The CID and MCT estimates from this manuscript can help in the design, analysis and interpretation of self-reported cognitive function in cancer patients and survivors.

Minimal important change values for the Oxford Knee Score and the Forgotten Joint Score at 1 year after total knee replacement

Background and purpose - Interpreting changes in Oxford Knee Score (OKS) and Forgotten Joint Score (FJS) following total knee replacement (TKR) is challenged by the lack of methodologically rigorous methods to estimate minimal important change (MIC) values. We determined MIC values by predictive modeling for the OKS and FJS in patients undergoing primary TKR. Patients and methods - We conducted a prospective cohort study in patients undergoing TKR between January 2015 and July 2016. OKS and FJS were completed preoperatively and at 1 year postoperatively, accompanied by a 7-point anchor question ranging from "better, an important improvement" to "worse, an important worsening." MIC improvement values were defined with the predictive modeling approach based on logistic regression, with patients' decisions on important improvement as dependent variable and change in OKS/FJS as independent variable. Furthermore, the MICs were adjusted for high proportions of improved patients. Results - 333/496 (67.1%) patients with a median age of 69 years (61% female) had complete data for OKS, FJS, and anchor questions at 1 year postoperatively. 85% were importantly improved. Spearman's correlations between the anchor and the change score were 0.56 for OKS, and 0.61 for FJS. Adjusted predictive MIC values (95% CI) for improvement were 8 (6-9) for OKS and 14 (10-18) for FJS. Interpretation - The MIC value of 8 for OKS and 14 for FJS corresponds to minimal improvements that the average patient finds important and aids in our understanding of whether improvements after TKR are clinically relevant.

Patient perspectives on Peyronie's disease: results of poststudy interviews from a phase 2 trial of collagenase clostridium histolyticum

Intralesional injection of collagenase clostridium histolyticum (CCH) improves Peyronie’s disease (PD) symptoms; however, patient perspectives regarding PD and CCH treatment have not been fully elucidated. This cross-sectional qualitative study included heterosexual men with PD who received ≥1 injection of study medication and had ≥1 posttreatment Peyronie’s Disease Questionnaire (PDQ) assessment during a prior phase 2b clinical trial. These patients were “responders” if they reported (as part of the Global Assessment of the PDQ) that overall symptoms and effects of PD had at least “improved in a small but important way” after CCH therapy. Among 45 patients interviewed, penile bending or curvature was the most common and bothersome PD symptom reported (by 97.8% and 48.9% of patients, respectively). Patients indicated that multiple alterations were necessary in their sex lives because of penile symptoms and specified that these changes impacted their emotional health and partner relationship. Treatment with CCH improved PD symptoms (44.4%), frequency of or ability to have vaginal intercourse (22.2%) and partner relationship (22.2%), particularly among responders. Given that physical, psychologic and sexual function are impacted by PD, clinical trials that evaluate treatments for PD should include patient-reported outcome measures (e.g., the PDQ) to assess overall well-being after treatment.

Creating a personalized evaluation framework for patient-reported outcomes: an illustration using the EQ-5D visual analogue scale

BACKGROUND

This paper outlines the creation of an intuitive, personalized evaluation framework for Patient-Reported Outcomes, using the EQ-5D visual analog scale (VAS) as an illustration.

METHODS

A draft framework asked patients to divide and label the EQ-5D-VAS into different levels or categories of health. Comprehension of the framework and patient-defined health level labels, and how they map onto the EQ-5D-VAS, were tested through in-person, semi-structured interviews with individuals self-reporting cardiovascular disease. Interviews were conducted in three waves, with the framework revised between waves.

RESULTS

Analyses included 14 participants. Eight participants (57.1%) felt that four levels of health were appropriate and there was general agreement on the labels; Poor, Fair, Good, and Excellent. There was substantial variability in where patients drew lines to indicate the level boundaries; Poor ranged between 0 and 50; Fair 10-75; Good 40-91; Excellent 60-100. In wave 3, all participants demonstrated appropriate comprehension of the framework.

CONCLUSIONS

The framework was well understood. The wide range of margins and the extent of overlap between the levels provide strong evidence for the relevance of the personalized evaluation framework approach, and specifically a personalized EQ-5D-VAS evaluation framework, to better understand and interpret each individual's response to the item.

Protocol for a Delphi consensus exercise to identify a core set of criteria for selecting health related outcome measures (HROM) to be used in primary health care

BACKGROUND

Promoting the collection and use of health related outcome measures (HROM) in daily practice has long been a goal for improving and assessing the effectiveness of care provided to patients. However, there has been a lack of consensus on what criteria to use to select outcomes or instruments, particularly in the context of primary health care settings where patients present with multiple concurrent health conditions and interventions are whole-health and person-focused. The purpose of this proposed study is to undertake a formal consensus exercise to establish criteria for selecting HROM (including patient-reported (PRO or PROM), observer-reported (ObsR)), clinician-reported (ClinRO) and performance related outcomes (PerfO) for use in shared decision-making, or in assessing, screening or monitoring health status in primary health care settings.

METHODS

A Delphi consensus online survey will be developed. Criteria for the Delphi panel participants to consider were selected from a targeted literature search. These initial criteria (n = 35) were grouped into four categories within which items will be presented in the Delphi survey, with the option to suggest additional items. Panel members invited to participate will include primary health care practitioners and administrators, policy-makers, researchers, and experts in HROM development; patients will be excluded. Standard Delphi methodology will be employed with an expectation of at least 3 rounds to achieve consensus (75% agreement). As the final list of criteria for selecting HROM emerges, panel members will be asked to provide opinions about potential weighting of items. The Delphi survey was approved by the Ethics Committee in the Faculty of Health Sciences at McMaster University.

DISCUSSION

Previous literature establishing criteria for selecting HROM were developed with a focus on patient reported outcomes, psychological/ behavioural outcomes or outcomes for minimum core outcome sets in clinical trials. Although helpful, these criteria may not be applicable and feasible for application in a primary health care context where patients with multi-morbidity and complex interventions are typical and the constraints of providing health services differ from those in research studies. The findings from this Delphi consensus study will address a gap for establishing consensus on criteria for selecting HROM for use across primary health care settings.

Development of a novel observer reported outcome tool as the primary efficacy outcome measure for a rare disease randomized controlled trial

We developed an Observer-Reported Outcome (ObsRO) survey instrument to be applied in a multicenter, placebo-controlled, crossover randomized controlled trial of dichloroacetate in children with pyruvate dehydrogenase complex deficiency. The instrument quantifies a subject's at-home level of functionality, as reported by a parent/caregiver, who were instrumental in providing the clinical descriptors and domains that formed the instrument's content. Feasibility testing of the ObsRO tool showed it to be easy to use and comprehensive in capturing the major clinical functional limitations of affected children and requires less than 5min for a parent/caregiver to complete daily.

Randomised controlled trial of a self-guided online fatigue intervention in multiple sclerosis

OBJECTIVE

Fatigue is a major disabling symptom in many chronic diseases including multiple sclerosis (MS), but treatment options are limited.Here, we tested the effectiveness of a self-guided , interactive, online fatigue management programme (ELEVIDA) based on principles of cognitive behavioural therapy (CBT) and related psychotherapeutic approaches (eg, mindfulness) for reducing fatigue in MS.

METHODS

Patients with MS and self-reported fatigue were recruited via the website of the German MS Society and assigned via an automated randomisation generator (1:1, no blocking or stratification) to a 12-week online intervention (ELEVIDA, n=139, 82% female, mean age 40.8, median patient determined disease steps (PDDS) 3.0) or a waitlist control group (n=136, 79% female, mean age 41.9, median PDDS 3.0). The primary outcome was the Chalder Fatigue Scale. Outcomes were assessed at baseline, at week 12 (postintervention) and at follow-up (week 24).

RESULTS

Compared with the control group, significantly greater reductions in Chalder Fatigue Scale scores were seen in the ELEVIDA group at week 12 (primary endpoint, intention-to-treat analysis: between-group mean difference 2.74 points; 95% CI 1.16 to 4.32; p=0.0007; effect size d=0.53), with effects sustained at week 24 (intention-to-treat analysis: between-group mean difference 2.19 points; 95% CI 0.57 to 3.82; p=0.0080).

CONCLUSIONS

Our trial provides evidence for the effectiveness of a self-guided , internet-based intervention to reduce fatigue in MS. Interventions such as ELEVIDA may be a suitable low barrier, cost-effective treatment option for MS fatigue.

TRIAL REGISTRATION NUMBER

ISRCTN registry (number ISRCTN25692173).

Minimum important difference of the Epworth Sleepiness Scale in obstructive sleep apnoea: estimation from three randomised controlled trials

BACKGROUND

The Epworth Sleepiness Scale (ESS) is a widely used tool for assessing sleepiness in patients with obstructive sleep apnoea (OSA). We aimed to estimate the minimal important difference (MID) in patients with OSA.

METHODS

We used individual data from three randomised controlled trials (RCTs) in patients with OSA where the preintervention to postintervention change in ESS was used as a primary outcome. We used anchor-based linear regression and responder analysis approaches to estimate the MID. For anchors, we used the change in domains of the Functional Outcomes of Sleep Questionnaire and 36-Item Short Form Health Survey. We also used the distribution-based approaches Cohen's effect size, SE of measurement and empirical rule effect size to support the anchor-based estimates. The final MID was determined by triangulating all estimates to a single MID.

FINDINGS

A total of 639 patients with OSA were included in our analyses across the three RCTs with a median (IQR) baseline ESS score of 10 (6-13). The median (IQR) ESS change score overall was -2 (-5 to 1). The anchor-based estimates of the MID were between -1.74 and -4.21 points and estimates from the responder analysis were between -1 and -3 points. Distribution-based estimates were smaller, ranging from -1.46 to -2.36.

INTERPRETATION

We propose an MID for the ESS of 2 points in patients with OSA with a disease severity from mild to severe. This estimate provides the means to plan trials and interpret the clinical relevance of changes in ESS.

TRIAL REGISTRATION NUMBER

Provent, NCT01332175; autoCPAP trial, NCT00280800; MOSAIC,ISRCTN (3416388).

Can the health related quality of life measure QOLIBRI- overall scale (OS) be of use after stroke? A validation study

BACKGROUND

Brief measures of health-related quality of life (HRQOL) that assess both patient-reported functioning and well-being after stroke are scarce. The objective of this study was to examine reliability and validity of one of these measures, the patient-reported Quality of Life after Brain Injury-Overall Scale (QOLIBRI-OS), in patients after stroke.

METHODS

Stroke survivors were examined prospectively using survey methods. Core survey data (n = 125) and retest data (n = 36) were obtained at 3 and 12 months, respectively. Item properties (distribution, floor and ceiling effects), psychometric properties (reliability and model fit), and validity (correlations with established measures of anxiety, depression and HRQOL) of the QOLIBRI-OS were examined.

RESULTS

Missing responses on the questionnaire were low (0.5%). All items were positively skewed. No floor effects were present, whereas five out of six items showed ceiling effects. The summary QOLIBRI-OS score exhibited no floor or ceiling effects, and had excellent internal consistency (Cronbach's α =0.93). All item-total correlations were high (0.73-0.88). The test-retest reliability of single items varied from 0.74 to 0.91 and was 0.93 for the overall score. The confirmatory factor analysis yielded an excellent fit for a five-item version and provided tentative support for the original six-item version. The convergent validity correlations were in the hypothesized directions, thus supporting the construct validity.

CONCLUSIONS

The brief QOLIBRI-OS is a valid and reliable brief health-related outcome measure that is appropriate for screening HRQOL in patients after stroke.

Selection of and Evidentiary Considerations for Wearable Devices and Their Measurements for Use in Regulatory Decision Making: Recommendations from the ePRO Consortium

BACKGROUND

Wearable devices offer huge potential to collect rich sources of data to provide insights into the effects of treatment interventions. Despite this, at the time of writing this report, limited regulatory guidance on the use of wearables in clinical trial programs has been published.

OBJECTIVES

To present recommendations from the Critical Path Institute's Electronic Patient-Reported Outcome Consortium regarding the selection and evaluation of wearable devices and their measurements for use in regulatory trials and to support labeling claims.

METHODS

The evaluation group was composed of Critical Path Institute's clinical outcome assessment (COA) scientists and COA specialists from pharmaceutical trial eCOA solution providers, including COA development and validation specialists. The resulting recommendations were drawn from a broad range of backgrounds, perspectives, and expertise that enriched the development of this report. Recommendations were developed through analysis of existing regulatory guidance relating to COA development and use in clinical trials, medical device certification/clearance regulations, literature-reported best practice, and practical experience of wearable technology application in clinical trials.

RESULTS

We identify the essential properties of fit-for-purpose wearables and propose evidence needed to support their use. In addition, we overview the activities required to establish clinical endpoints derived from wearables data.

CONCLUSIONS

Using this framework, we believe there is enough current understanding to promote the appropriate use of wearables in study protocols. We hope this will provide a basis for discussion among clinical trial stakeholders and catalyze the development of more robust regulatory guidance.

Determination of the Minimal Clinically Important Difference of the University of North Carolina Dry Eye Management Scale

PURPOSE

To establish an initial estimation of the MCID of the University of North Carolina Dry Eye Management Scale (UNC DEMS) and assess its association with patient perceptions of symptom change.

METHODS

Thirty-three patients (33.3% men, 67.7% women, mean age 60.5 yrs) with previous DEMS scores were recruited from a UNC ophthalmology clinic in spring 2014. We used anchor-based methods, categorizing important symptom change, to compare the change in the DEMS scores across visits to patient assessments of change; linear regression coefficients estimated the MCID. We correlated clinical assessments, patient perceptions, and DEMS scores.

RESULTS

DEMS score changes correlated with global anchors [-0.4229 (P = 0.014)]. Unadjusted linear regression yielded a beta coefficient of -0.54 (confidence interval, -0.97 to -0.12, R = 0.18, P = 0.014), which estimated the DEMS MCID. Adjusting the regression model for days since the last visit and DEMS score improved the association (beta = -0.56; confidence interval, -0.99 to -0.13; R = 0.43; P = 0.013). Descriptive statistics produced an MCID of 1 point. Patients said that 2 points would represent a significant change. The DEMS modestly correlated with the Schirmer test (-0.4045, P = 0.0266), Oxford Grading Scheme (+0.3713, P = 0.0364), and tear breakup time (-0.3559, P = 0.0456).

CONCLUSIONS

The UNC DEMS is a valid, responsive patient-reported outcome measure instrument, which is easy to use in the clinic and capable of showing an MCID of 1 point.

Meaningful Change Scores in the Knee Injury and Osteoarthritis Outcome Score in Patients Undergoing Anterior Cruciate Ligament Reconstruction

BACKGROUND

Meaningful change scores in the Knee injury and Osteoarthritis Outcome Score (KOOS) in patients undergoing anterior cruciate ligament (ACL) reconstruction have not yet been established.

PURPOSE

To define the minimal important change (MIC) for the KOOS after ACL reconstruction.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

KOOS and anchor questions with 7-point scales ranging from "better, an important improvement" to "worse, an important worsening" were completed postoperatively by randomly chosen participants from the Norwegian Knee Ligament Registry. Presurgery KOOS scores were retrieved from the registry. The MIC for improvement was calculated with anchor-based approaches using the predictive modeling method adjusted for the proportion of improved patients, the mean change method, and the receiver operating characteristic (ROC) method.

RESULTS

Complete data for at least one of the KOOS subscales were obtained from 542 (45.3%) participants. Predictive modeling MIC values were 12.1 for the KOOS subscales of Sport and Recreational Function and 18.3 for Knee-Related Quality of Life. These values aid in interpreting within-group improvement over time and can be used as responder criteria when comparing groups. The corresponding and much lower values for the subscales of Pain (2.5), Symptoms (-1.2), and Activities of Daily Living (2.4) are the results from patients reporting, on average, only mild problems with these domains preoperatively. Although 4% to 10% of patients reported subscale-specific worsening, MIC deterioration calculations were not possible. The ROC MIC values were associated with high degrees of misclassification. Values obtained by the mean change method were considered less reliable because these estimates are derived from subgroups of patients. Average KOOS change scores were approximately similar for patients reporting acceptable symptoms postoperatively and patients reporting important improvements on the anchor items after surgery.

CONCLUSION

KOOS users should apply subscale-specific cutoffs for meaningful improvement. Our results confirm using the subscales of Sport and Recreational Function and Knee-Related Quality of Life as primary patient-reported outcomes after ACL reconstruction. The predictive modeling approach gave the most robust estimates of MIC values. Our data suggest that reporting acceptable symptoms postoperatively corresponds to reporting an important improvement after ACL reconstruction.

Establishing anchor-based minimally important differences (MID) with the EORTC quality-of-life measures: a meta-analysis protocol

INTRODUCTION

As patient assessment of health-related quality of life (HRQOL) in cancer clinical trials has increased over the years, so has the need to attach meaningful interpretations to differences in HRQOL scores between groups and changes within groups. Determining what represents a minimally important difference (MID) in HRQOL scores is useful to clinicians, patients and researchers, and can be used as a benchmark for assessing the success of a healthcare intervention. Our objective is to provide an evidence-based protocol to determine MIDs for the European Organisation for Research and Treatment for Cancer Quality of life Questionnaire core 30 (EORTC QLQ-C30). We will mainly focus on MID estimation for group-level comparisons. Responder thresholds for individual-level change will also be estimated.

METHODS AND ANALYSIS

Data will be derived from published phase II and III EORTC trials that used the QLQ-C30 instrument, covering several cancer sites. We will use individual patient data to estimate MIDs for different cancer sites separately. Focus is on anchor-based methods. Anchors will be selected per disease site from available data. A disease-oriented and methodological panel will provide independent guidance on anchor selection. We aim to construct multiple clinical anchors per QLQ-C30 scale and also to compare with several anchor-based methods. The effects of covariates, for example, gender, age, disease stage and so on, will also be investigated. We will examine how our estimated MIDs compare with previously published guidelines, hence further contributing to robust MID guidelines for the EORTC QLQ-C30.

ETHICS AND DISSEMINATION

All patient data originate from completed clinical trials with mandatory written informed consent, approved by local ethical committees. Our findings will be presented at scientific conferences, disseminated via peer-reviewed publications and also compiled in a MID 'blue book' which will be made available online on the EORTC Quality of Life Group website as a free guideline document.

Criteria for gauging response to sodium oxybate for narcolepsy

Our objective was to define responder criteria using an anchor-based approach for frequency of cataplexy attacks and excessive daytime sleepiness in patients with narcolepsy undergoing sodium oxybate treatment. We used pooled data from two randomized, placebo-controlled, double-blind, multicentre 4- and 8-week trials of sodium oxybate for narcolepsy with cataplexy and analysed using receiver operator characteristics analysis. The percentage change in frequency of weekly cataplexy attacks and the Epworth Sleepiness Scale outcomes were compared with Clinical Global Impression of Change ratings, used as the anchor to define true response. Participants (n = 336) were 39% male, 89% white, with a mean age of 41.5 (15.3) years, reporting a median of 20.5 cataplexy attacks per week and a mean Epworth Sleepiness score of 17.5 at baseline. A majority (51%) were Much Improved or Very Much Improved based on Clinical Global Impression of Change ratings, considered a true response to treatment. Area under the curve values for % reduction in cataplexy attacks (77%) and % change in sleepiness score (78%) supported response definition thresholds of 46% and 12%, respectively. Classification using either response definition agreed with the anchor for approximately 71% of participants. Cataplexy response definition was more sensitive (cataplexy = 0.77, Epworth Sleepiness Scale = 0.69), while sleepiness was more specific (cataplexy = 0.66, Epworth Sleepiness Scale = 0.75). Both responder definitions showed a dose-response relationship with sodium oxybate, demonstrating their validity using an external criterion. Weekly cataplexy attacks and Epworth Sleepiness Scale can be used to help document clinical response to narcolepsy treatment using criteria of 46% and 12% reductions, respectively.

The Chorus of User Voices: Meeting the Challenge of Patient-Reported Outcomes From Medications

Prescription medication management by both healthcare providers and patients describe struggles not to inflict harm and encourage safe use in the context of culture and social relationships. Risk vs benefit assessments conducted in these contexts are essential for understanding how medication-taking decisions are made. Qualitatively-based Patient Reported Outcomes (PROs) are critical to understanding how medication pathways are navigated by both healthcare providers and patients seeking relief from maladies. Qualitative PROs have the potential to improve understanding of social and cultural factors that impact patient decision making whether to take a drug at all and would also serve to support developing models of patient-centered care.

Spanish Cultural Adaptation of the Questionnaire Early Arthritis for Psoriatic Patients

INTRODUCTION AND OBJECTIVES

The Early Arthritis for Psoriatic patients (EARP) questionnaire is a screening tool for psoriatic arthritis. The original Italian version has good measurement properties but the EARP required translation and adaptation for use in Spain. This article describes the cultural adaptation process as a step prior to validation.

MATERIAL AND METHODS

We used the principles of good practice for the cross-cultural adaptation of patient-reported outcomes measurement established by the International Society Pharmacoeconomics and Outcome Research. The steps in this process were preparation, forward translation, reconciliation, back-translation and review, harmonization, cognitive debriefing and review, and proofreading. During preparation the developers of the original questionnaire were asked for their permission to adapt the EARP for use in Spain and to act as consultants during the process.

RESULTS

The original questionnaire was translated into Spanish by native Spanish translators, who made slight changes that were approved by the questionnaire's developers. The Spanish version was then back-translated into Italian; that version was reviewed to confirm equivalence with the original Italian text. The reconciled Spanish EARP was then tested for comprehensibility and interpretation in a group of 35 patients. All the patients answered all items without making additional comments.

CONCLUSION

This cultural adaptation of the EARP questionnaire for Spanish populations is the first step towards its later use in routine clinical practice. The application of a cross-cultural adaptation method ensured equivalence between the original and Spanish versions of the EARP. The Spanish questionnaire will be validated in a second stage.

Patient-reported outcomes and survival in multiple sclerosis: A 10-year retrospective cohort study using the Multiple Sclerosis Impact Scale-29

BACKGROUND

There is increasing emphasis on using patient-reported outcomes (PROs) to complement traditional clinical outcomes in medical research, including in multiple sclerosis (MS). Research, particularly in oncology and heart failure, has shown that PROs can be prognostic of hard clinical endpoints such as survival time (time from study entry until death). However, unlike in oncology or cardiology, it is unknown whether PROs are associated with survival time in neurological diseases. The Multiple Sclerosis Impact Scale-29 (MSIS-29) is a PRO sensitive to short-term change in MS, with questions covering both physical and psychological quality of life. This study aimed to investigate whether MSIS-29 scores can be prognostic for survival time in MS, using a large observational cohort of people with MS.

METHODS AND FINDINGS

From 15 July 2004 onwards, MSIS-29 questionnaires were completed by people with MS registered with the MS Society Tissue Bank (n = 2,126, repeated 1 year later with n = 872 of the original respondents). By 2014, 264 participants (12.4%) had died. Higher baseline MSIS-29 physical (MSIS-29-PHYS) score was associated with reduced survival time (subgroup with highest scores versus subgroup with lowest scores: hazard ratio [HR] 5.7, 95% CI 3.1-10.5, p < 0.001). Higher baseline MSIS-29 psychological score was also associated with reduced survival time (subgroup with highest scores versus subgroup with lowest scores: HR 2.8, 95% CI 1.8-4.4, p < 0.001). In those with high baseline MSIS-29 scores, mortality risk was even greater if the MSIS-29 score worsened over 1 year (HR 2.3, 95% CI 1.2-4.4, p = 0.02). MSIS-29-PHYS scores were associated with survival time independent of age, sex, and patient-reported Expanded Disability Status Scale score in a Cox regression analysis (per 1-SD increase in MSIS-29-PHYS score: HR 1.8, 95% CI 1.1-2.9, p = 0.03). A limitation of the study is that this cohort had high baseline age and disability levels; the prognostic value of MSIS-29 for survival time at earlier disease stages requires further investigation.

CONCLUSIONS

This study reports that PROs can be prognostic for hard clinical outcomes in neurological disease, and supports PROs as a meaningful clinical outcome for use in research and clinical settings.

MANAGEMENT OF ENDOCRINE DISEASE: Quality of life tools for the management of pituitary disease

BACKGROUND

In the last few years, quality of life (QoL) has become an outcome measure in patients with pituitary diseases.

OBJECTIVE

To describe the available data on QoL impairment evaluated with questionnaires in patients with pituitary diseases.

DESIGN

Critical review of the pertinent literature and pragmatic discussion of available information.

METHODS

Selection of relevant literature from PubMed and WOK, especially from the last 5 years and comprehensive analysis.

RESULTS

QoL is impaired in all pituitary diseases, mostly in acromegaly and Cushing's disease (similar to other causes of Cushing's syndrome), but also in non-functioning pituitary adenomas and prolactinomas, especially in the active phase of the disease. Nevertheless, even after endocrine 'cure', scores tend to be below normative values, indicative of residual morbidity after hormonal control. The presence of hypopituitarism worsens subjective QoL perception, which can improve after optimal substitution therapy, including recombinant human growth hormone, when indicated.

CONCLUSIONS

To improve the long-term outcome of pituitary patients, helping them to attain the best possible health, it appears desirable to include subjective aspects captured when evaluating QoL, so that the affected dimensions are identified and if relevant treated. Additionally, being aware that treatment outcome may not always mean complete normalisation of physical and mental issues related to QoL can be a first step to adaptation and conforming to this new status.

New targets in psoriatic arthritis

PsA is an immune-mediated chronic inflammatory disease that affects both skin and joints; it is a heterogeneous disease characterized by synovitis, enthesitis, dactylitis and spondylitis. The impact on patients and the burden of disease are substantial. For assessment of the disease, patient-reported outcomes are increasingly important. Conventional therapy consists of NSAIDs, local and systemic CSs, and synthetic and biological DMARDs. While MTX, LEF, SSZ and CYC are the synthetic drugs mainly used, TNF-α blocking agents have represented the majority of biologics used in the last decade (infliximab, etanercept, adalimumab, certolizumab and golimumab). Treat-to-target strategies have been used successfully in PsA. This review concentrates on new developments, mainly covering biologic agents with an IL-17 inhibitor (secukinumab) and an anti-IL-23 agent (ustekinumab), but also synthetic drugs, including a novel phosphodiesterase-4 inhibitor (apremilast) and a Janus kinase inhibitor (tofacitinib) that blocks mainly Jak3 and Jak1 and, to a lesser extent, Jak2. The efficacy of some of these new agents may be even better for the skin than for the joints.

Validity of the rheumatoid arthritis impact of disease (RAID) score and definition of cut-off points for disease activity states in a population-based European cohort of patients with rheumatoid arthritis

OBJECTIVES

To assess the validity of the rheumatoid arthritis impact of disease (RAID) for measuring disease activity of rheumatoid arthritis (RA) and to determine cut-off values for defining the disease activity states.

METHODS

A total of 622 RA patients from an European database have been included. Cross-validation was based on assessment of convergent and discriminant validity. Optimal cut-offs were determined against external criteria by calculating the respective 25th and 75th percentiles mean values of RAID. External criteria included definitions for remission (REM), low disease activity (LDA), moderate disease activity (MDA) and high disease activity (HDA), cut-offs of the 28-joint disease activity score-C-reactive protein (DAS28-CRP) score.

RESULTS

The RAID showed a moderate degree of correlation with respect to DAS28-CRP (rho=0.417; P<0.0001). The receiver operating characteristic (ROC) curves to discriminate the ability of RAID to distinguish patients with active and non-active disease was very good with an area under the curve (AUC) of 0.847 (95% confidence interval [CI]: 0.816 to 0.878; P<0.0001). Based on the distributions of RAID in the different disease activity groups, we propose the following cut-off values for REM: RAID ≤3; for LDA: RAID >3 and ≤4; for MDA: RAID >4 and ≤6; for HDA: RAID >6. Mean RAID differed significantly between patients classified as REM, LDA, MDA or HDA (P=0.001).

CONCLUSIONS

The cut-offs revealed good measurement characteristics in cross-validation analysis, had great discriminatory performance in distinguishing patients with different levels of disease activity and are suited for widespread use in everyday practice application and research.