The utility of PROMIS domain measures in dermatologic care

Improved patient- and caregiver-reported outcomes distinguish tacrolimus 0.03% from crisaborole in children with atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) is a chronic skin disease that affects 20% of children worldwide and is associated with low patient-reported quality of life (QoL). Crisaborole (CRIS) and tacrolimus 0.03% (TAC) are Food and Drug Administration (FDA)-approved topical treatments for mild to moderate AD with similar clinical efficacy. Utilization of patient-reported outcomes (PROs) may provide meaningful data on the impact of AD treatments on patients and caregivers. This study used PROs to monitor the impact of crisaborole (CRIS) and tacrolimus 0.03% (TAC) on children with mild/moderate atopic dermatitis (AD) and caregiver burden.

METHODS

This open-label study randomized 47 child-caregiver dyads to CRIS or TAC for 12 weeks. Disease severity, child quality of life (QoL), itch, pain interference, anxiety, depression, sleep, caregiver burden and caregiver QoL were assessed at baseline, 6 and 12 weeks.

RESULTS

A total of 36 dyads completed the study. Children (mean age = 8.0 ± 3.9 years) had mild baseline AD and were diverse by race (39% white; 36% Black) and gender (53% males). Caregivers were mostly female (78%; mean age = 37 ± 7.6 years). Both arms improved disease severity (Eczema Area and Severity Index) from baseline to 12 weeks (CRIS = -2.4 vs. TAC = -1.9). Within-arm analyses comparing baseline to 12 weeks revealed TAC, but not CRIS, improved all child and caregiver PROs except sleep (all p < 0.05).

CONCLUSIONS

Our results demonstrated that topical treatment for 12 weeks was more beneficial than 6 weeks, with TAC improving more PROs than CRIS. Future trials should implement PROs to fully understand the impact of AD treatments.

Which Clinical Measurement Tools for Atopic Dermatitis Severity Make the Most Sense in Clinical Practice?

Assessment of atopic dermatitis (AD) severity is essential for therapeutic decision making and monitoring treatment progress. However, there are a myriad of clinical measurement tools available, some of which are impractical for routine clinical use despite being recommended for clinical trials in AD. For measurement tools to be used in clinical practice, they should be valid, reliable, rapidly completed, and scored, and easily incorporated into existing clinic workflows. This narrative review addresses content, validity, and feasibility, and provides a simplified repertoire of assessments for clinical assessment of AD based on prior evidence and expert opinion. Tools that may be feasible for clinical practice include patient-reported outcomes (eg, dermatology life quality index, patient-oriented eczema measure, numerical rating scales for itch, pain, and sleep disturbance, AD Control Tool, and patient-reported global assessment), and clinician-reported outcomes (eg, body surface area and investigator's global assessment). AD is associated with variable clinical signs, symptoms, extent of lesions, longitudinal course, comorbidities, and impacts. Any single domain is insufficient to holistically characterize AD severity, select therapy, or monitor treatment response. A combination of these tools is recommended to balance completeness and feasibility.

Comparison of Psychometric Properties of Patient-Reported Outcomes Measurement Information System With Traditional Outcome Metrics in Spine Surgery

OBJECTIVE

Patient-Reported Outcomes Measurement Information System (PROMIS) was developed to address certain shortcomings of traditional, or legacy patient-reported outcome measures (PROMs). Because the use of PROMIS across orthopedic populations continues to increase, the purpose of this study was to provide a comprehensive overview of the use and validation of PROMIS in spine surgery.

METHODS

PubMed and Google Scholar were searched for relevant articles reporting on the use and validation of PROMIS in spine surgery. The PROMIS formats and individual domains used by investigators were noted. Additionally, psychometric properties reported in validation studies were evaluated.

RESULTS

Both individual studies and systematic reviews have demonstrated the convergent validity of PROMIS domains, reporting moderate-to-strong correlations with legacy measures in a variety of spine patient populations. Across spine surgery patient populations, PROMIS instruments are consistently efficient, demonstrating decreased question burden compared with legacy PROMs. PROMIS domains overall exhibit responsiveness comparable with legacy measures, and the normalization of PROMIS scores to a general population allows for broad coverage, resulting in acceptable floor and ceiling effects. Despite the many strengths of PROMIS, there remain some populations where PROMIS is not suited to be used in isolation.

CONCLUSIONS

PROMIS is widely used as an outcome measure in spine surgery and has been validated in a range of patient populations. Although PROMIS domains cannot fully replace legacy measures in spine patients, they can be used in certain settings to provide an efficient and psychometrically sound PROM.

Meaningful Improvement in General Health Outcomes with Guselkumab Treatment for Psoriatic Arthritis: Patient-Reported Outcomes Measurement Information System-29 Results from a Phase 3 Study

OBJECTIVE

The Phase 3 DISCOVER-1 study of guselkumab is the first randomized controlled trial to use Patient-Reported Outcomes Measurement Information System (PROMIS) measures to assess the effects of treatment on general health outcomes in patients with psoriatic arthritis (PsA).

METHODS

Patients (N = 381) with active PsA were randomized 1:1:1 to guselkumab 100 mg every 4 weeks (Q4W); guselkumab 100 mg at Week 0, Week 4, then every 8 weeks (Q8W); or placebo with Week 24 crossover to guselkumab Q4W. The PROMIS-29 Profile contains four items for each of seven domains (anxiety, depression, fatigue, pain interference, physical function, sleep disturbance, and social participation) and one pain-intensity item. Raw domain scores are converted to standardized T-scores, with norms based on a US general population mean of 50 (1 standard deviation (SD) = 10). T-score changes of ≥ 5 are considered clinically meaningful. Least-squares mean PROMIS-29 T-score changes from baseline to Week 24 and Week 52 were summarized for the guselkumab and placebo groups; nominal p-values comparing results between guselkumab and placebo were calculated at Week 24 using a mixed model for repeated measures. The proportions of patients who achieved clinically meaningful improvement in PROMIS-29 T-scores were also summarized at Week 24 and Week 52; nominal p-values comparing results between guselkumab and placebo were calculated at Week 24 using the Cochran-Mantel-Haenszel test.

RESULTS

In the DISCOVER-1 patient population, mean PROMIS-29 T-scores at baseline were ~ 1 SD worse for physical function and pain interference and were numerically worse for social participation, fatigue, and sleep disturbance compared with the US general population. At Week 24, mean PROMIS-29 T-scores improved in guselkumab-treated patients, approaching US population norms; T-scores continued to improve through Week 52. Significantly higher proportions of patients in both guselkumab treatment arms (31-52% across domains) had clinically meaningful improvements in pain interference, fatigue, physical function, sleep, and social participation at Week 24 versus placebo (all nominal p ≤ 0.05).

CONCLUSION

In patients with active PsA, guselkumab treatment provided clinically meaningful reductions in fatigue and pain and improvement in physical function and social participation, as measured by the PROMIS-29 Profile. These improvements were maintained through 1 year.

CLINICALTRIALS

GOV: Registration number, NCT03162796; Submission date 19 May 2017.

Patient-Reported Outcome Measures for Health-Related Quality of Life in Patients With Acne Vulgaris: A Systematic Review of Measure Development and Measurement Properties

Importance

Multiple patient-reported outcome measures (PROMs) for health-related quality of life (HRQoL) exist for patients with acne. However, little is known about the content validity and other measurement properties of these PROMs.

Objective

To systematically review PROMs for HRQoL in adults or adolescents with acne.

Data Sources

Eligible studies were extracted from PubMed and Embase (OVID).

Study Selection

Full-text articles published in English or Spanish on development, pilot, or validation studies for acne-specific, dermatology-specific, or generic HRQoL PROMs were included. Development studies included original development studies, even if not studied in acne patients per Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) recommendations. If a study included several diagnoses, the majority (ie, over 50%) of patients must have acne or acne-specific subgroup analyses must be available. Abstract and full-text screening was performed by 2 independent reviewers.

Data Extraction and Synthesis

Two independent reviewers assessed study quality applying the COSMIN checklist and extracted and analyzed the data. For each distinctive PROM, quality of evidence was graded by measurement property.

Main Outcomes and Measures

PROM properties (target population, domains, recall period, development language), PROM development and pilot studies, content validity (relevance, comprehensiveness, comprehensibility), and remaining measurement properties (structural validity, internal consistency, cross-cultural validity, reliability, measurement error, criterion validity, construct validity, and responsiveness). Quality of evidence was assigned for each measurement property of included PROMs. An overall recommendation level was assigned based on content validity and quality of the evidence of measurement properties.

Results

We identified 54 acne PROM development or validation studies for 10 acne-specific PROMs, 6 dermatology-specific PROMs, and 5 generic PROMs. Few PROMs had studies for responsiveness. The only acne-specific PROMs with sufficient evidence for content validity were the CompAQ and Acne-Q. Based on available evidence, the Acne-Q and CompAQ can be recommended for use in acne clinical studies.

Conclusions and Relevance

Two PROMs can currently be recommended for use in acne clinical studies: the Acne-Q and CompAQ. Evidence on content validity and other measurement properties were lacking for all PROMs; further research investigating the quality of remaining acne-specific, dermatology-specific, and generic HRQoL PROMs is required to recommend their use.

Psychometric evaluation of an Italian custom 4-item short form of the PROMIS anxiety item bank in immune-mediated inflammatory diseases: an item response theory analysis

Background

There has recently been growing interest in the roles of inflammation in contributing to the development of anxiety in people with immune-mediated inflammatory diseases (IMID). Patient-reported outcome measures can facilitate the assessment of physical and psychological functioning. The National Institutes of Health (NIH)'s Patient-Reported Outcomes Measurement Information System (PROMIS®) is a set of Patient-Reported Outcomes (PROs) that cover physical appearance, mental health, and social health. The PROMIS has been built through an Item Response Theory approach (IRT), a model-based measurement in which trait level estimates depend on both persons' responses and on the properties of the items that were administered. The aim of this study is to test the psychometric properties of an Italian custom four-item Short Form of the PROMIS Anxiety item bank in a cohort of outpatients with IMIDs.

Methods

We selected four items from the Italian standard Short Form Anxiety 8a and administered them to consecutive outpatients affected by Inflammatory Bowel disease (n = 246), rheumatological (n = 100) and dermatological (n = 43) diseases, and healthy volunteers (n = 280). Data was analyzed through an Item Response Theory (IRT) analysis in order to evaluate the psychometric properties of the Italian adaptation of the PROMIS anxiety short form.

Results

Taken together, Confirmatory Factor Analysis and Exploratory Factor analysis suggest that the unidimensionality assumption of the instrument holds. The instrument has excellent reliability from a Classical Theory of Test (CTT) standpoint (Cronbach's α = 0.93, McDonald's ω = 0.92). The 2PL Graded Response Model (GRM) model provided showed a better goodness of fit as compared to the 1PL GRM model, and local independence assumption appears to be met overall. We did not find signs of differential item functioning (DIF) for age and gender, but evidence for uniform (but not non-uniform) DIF was found in three out of four items for the patient vs. control group. Analysis of the test reliability curve suggested that the instrument is most reliable for higher levels of the latent trait of anxiety. The groups of patients exhibited higher levels of anxiety as compared to the control group (ps < 0.001, Bonferroni-corrected). The groups of patients were not different between themselves (p = 1, Bonferroni-corrected). T-scores based on estimated latent trait and raw scores were highly correlated (Pearson's r = 0.98) and led to similar results.

Discussion

The Italian custom four-item short form from the PROMIS anxiety form 8a shows acceptable psychometric properties both from a CTT and an IRT standpoint. The Test Reliability Curve shows that this instrument is mostly informative for people with higher levels of anxiety, making it particularly suitable for clinical populations such as IMID patients.

Generation and Validation of the PROMIS Itch Questionnaire - Child to Measure the Impact of Itch on Life Quality

Itch compromises quality of life, but most itch assessments focus only on itch intensity. We aimed to develop and validate a comprehensive PROMIS (Patient Reported Outcomes Measurement Information System®) pediatric measure for itch symptoms and itch impact, defined as the effect specifically of itch on physical, mental, and social health, all of which can affect life quality. After literature review, concept elicitation and cognitive interviews with parents and children with itch, and repeated content-expert review, an item pool was generated and refined. The pool was calibrated with data from 499 pruritic children using exploratory and confirmatory factor analyses, item response theory, and item fit analysis. The resultant 45-item bank, PROMIS Itch Questionnaire - Child (PIQ-C), showed good convergent and discriminant validity in 181 children 8-17 years of age, discriminating children with different levels of severity, and was responsive to change. Strong correlations (rho>.60) were observed with pain and sleep measures, and moderate correlations with other pediatric PROMIS measures. PIQ-C comprehensively measures itch intensity and burden, providing an itch-specific alternative for assessing life quality. The independent calibration of each item/question allows for flexibility in generating short-forms or computerized adaptive testing for efficient use in research and office practice.

Implementation of PROMIS® in an Optometry Clinic

PURPOSE

The full utility of general health Patient-Reported Outcomes Measurement Information System® (PROMIS) surveys in the eye care setting has not been previously demonstrated. This report demonstrates the feasibility of implementing PROMIS in an eye care clinic.

PATIENTS AND METHODS

Over 2 months, general health and functioning PROMIS surveys were offered to all patients in an optometric clinic in Rochester, NY. Demographic and clinical variables were recorded along with percent completion and time to completion of the survey.

RESULTS

Across 651 patients, 258 chose to attempt PROMIS. Patients with low visual acuity were less likely to attempt the survey (p=0.049), and younger patients were more likely to complete the survey (p=0.025); no other patient characteristics were found to differ between those who did and did not participate in, nor complete, PROMIS. A total of 193 patients completed the survey (74.8%) in a mean time of 6.36 minutes (range = [1.43, 51.92] minutes; standard deviation = 5.62 minutes). Time to completion did not vary significantly across any groups.

CONCLUSION

Our relatively high completion rate among those who attempted PROMIS indicates that PROMIS surveys are feasible to implement in an optometry clinic. While most patients completed the survey in little time, the large range of time to completion may indicate that some patients had difficulty completing the survey. Furthermore, the significant difference in visual acuity between those who participated in the survey and those who did not highlights the need to address the way PROMIS is delivered in order to foster greater inclusion.

The most recent advances in understanding and managing hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic, inflammatory, recurrent, and debilitating skin disease of the hair follicle unit that typically develops after puberty. HS has a significant negative impact on both the quality of life (QOL) of patients affected by this disease as well as family members and caregivers. However, the pathogenesis of HS is multifactorial and still remains to be fully elucidated, which makes the development of treatments difficult. The last 10 years have seen a surge in HS research, and many new findings have come to light, yet much more remains to be elucidated. Physicians must employ a multidisciplinary approach to maximally address all facets of HS. Clinical characteristics of the disease that differ between females and males as well as across different races and ethnic groups must be considered. Targeted topical, oral, and injectable therapies continue to be developed for HS as a greater understanding of the pathogenesis is reached. However, randomized controlled trials regarding dietary factors that may contribute to HS are needed to meet our patients’ growing concerns and questions about the role of diet in HS pathogenesis. Finally, improved outcome measures are needed to standardize HS severity and grading between physicians and clinical trials, and a more diverse representation of HS populations is needed in clinical trials.