Response shift: a brief overview and proposed research priorities

Decision-making preferences and regret in rectal cancer patients undergoing restorative proctectomy: A prospective cohort study

BACKGROUND

How patients make treatment choices in rectal cancer is poorly understood and may affect long-term regret and satisfaction. The objective of this study is to characterize decision-making preferences and their effect on decisional regret in patients undergoing restorative proctectomy for rectal cancer.

METHODS

A prospective cohort study was conducted in a single academic specialist rectal cancer center from October 2018 to June 2022. Adult patients who underwent restorative proctectomy at least one year prior were recruited. Health literacy was assessed using the BRIEF instrument. Decision-making preferences regarding cancer treatment were assessed using the Control Preferences Scale. Decisional regret regarding their choice of restorative proctectomy was assessed using the Decision Regret Score. Bowel dysfunction was measured using the low anterior resection syndrome score.

RESULTS

Overall, 123 patients were included. Health literacy was categorized as adequate in 63%, marginal in 25%, and limited in 12%. Patients with adequate health literacy were more likely to prefer a collaborative decision-making role compared with those with low health literacy (86% vs 65%, P = .016). Patients with incongruence between preferred and actual decision-making roles were more likely to report high regret (56% vs 25%, P = .003). Patients with major low anterior resection syndrome were also more likely to experience high regret compared with patients with no/minor low anterior resection syndrome (44% vs 25%, P = .036).

CONCLUSION

A significant proportion of patients with rectal cancer undergoing restorative proctectomy do not have a decision-making role that is congruent with their preferences, and these patients experience a high degree of regret.

How is recovery defined and measured in patients with low back pain? A mixed study systematic review

BACKGROUND

Despite the burden of low back pain (LBP) there is no currently accepted definition for its recovery, nor is there a gold standard for measurement. In addition, it is currently unclear how the perspective of patients are used in making recovery determinations. The purpose of this mixed study systematic review across both quantitative and qualitative literature was to (1) explore how recovery has been defined and measured for patients experiencing LBP, and (2) examine how the perspectives of patients and providers for recovery of LBP align or differ.

METHODS

This was a mixed study systematic review. Key databases were searched from inception until February 20, 2023: Medline, EMBASE, CINAHL, Cochrane, PEDro looking for sources examining definitions and measures of recovery in patients with LBP. Grey literature was identified through the ProQuest Thesis & Dissertation database. Two reviewers used the Mixed Methods Appraisal Tool for quality assessment of both qualitative and quantitative studies to explore definitions, measurements and perspective of recovery.

RESULTS

466 original studies were included: 12 qualitative studies, 88 quantitative randomized control trials, 348 quantitative non-randomized studies, 16 quantitative descriptive studies, and two mixed methods studies. Most of the time recovery was not defined, with six other themes identified: comparison of scores, in relation to a singular cut-off score, improvement of absence of clinical symptoms, a return to a pre-injury state, change/improvement score from baseline and as a process/trajectory. For recovery measurements, six themes described the data: multiple measures, single measure excluding recovery, a recovery measure, recovery and an additional measure, pain and an additional measure, or indirect/ not specified. Lastly recovery perspectives were made from either the patient, provider, or a combination of patient and provider.

CONCLUSION

For patients living with LBP, the concept of recovery continues to lack consensus for its definition and measurement in patients with LBP. The perspectives of patients were mostly not preserved in making recovery determinations. Urgent action is needed to generate consensus across clinicians, researchers, and patients regarding how recovery should be defined and measured. A multitude of study-specific definitions limit knowledge syntheses and definition of best practice.

Evaluation of Cocurricular Learning and the Influence of Student Choice

OBJECTIVE

The primary objective of this study was to evaluate the students' choice of activities and perception of a cocurricular program (CCP). Attitude and skill development and areas for program improvement were also assessed.

METHODS

Data were evaluated from 2 sources: a student survey administered to all Doctor of Pharmacy students to determine student perceptions of the CCP and barriers to success and student activity reporting data from postexperience submissions to evaluate the CCP. Data were stratified by student demographics to identify trends. A comparison of data was conducted from both sources on the students' perception of learning value.

RESULTS

Data for 405 students were available for analysis. The highest preference overall from students for hosts of activities were professional student organizations; the highest preference of location was online, asynchronous. The most meaningful benefits were learning information about a new subject (n = 258, 63.7%), ability to extend learning from the classroom to real life (n = 247, 61%), and networking opportunities (n = 218, 53.8%). The top barriers for completion of the program included scheduling challenges (n = 296, 73.1%), lack of time (n = 249, 61.5%), and lack of interest (n = 187, 46.2%). Subpopulations identified different benefits and barriers to completion.

CONCLUSION

Students have overall positive perceptions of the CCP and its value for skill development. Findings were applied to adjust the CCP at the institution, including a reduction in total hours required. The continuous evaluation of CCPs is important to optimize student learning and address curricular overload.

Well-Being, Mental Health, and Study Characteristics of Medical Students before and during the Pandemic

Medical students report high demands, stressors, pressure to perform, and a lack of resources, and are therefore at a higher risk for mental strain and burnout. Due to the COVID-19 pandemic, study conditions have changed, and new challenges have emerged. Thus, this study aimed to examine medical students' well-being, mental health, and study characteristics before and during the pandemic. Data from 988 Austrian medical students were included into the cross-sectional comparisons, and 63 students were included into the longitudinal analyses (variance analyses/t-tests or appropriate non-parametric tests). Well-being before and during the pandemic did not differ significantly but the peri-pandemic cohort reported higher study satisfaction, more social support from lecturers, and less emotional exhaustion, cognitive demands, and stressors (information problems, organizational stressors, work overload). Longitudinally, work overload was also perceived to be higher before the pandemic; however, study satisfaction was lower. During the pandemic, approximately every seventh student exceeded the cut-off value for generalized anxiety disorder, and approximately every tenth student exceeded the cut-off value for major depression. These unexpected peri-pandemic results concerning constant high well-being, study satisfaction, and the perception of conditions may be based on response shift effects that require further exploration. The scores exceeding the reasonable cut-point for identifying probable cases of generalized anxiety disorder and depression may reflect medical students' needs, calling for an in-depth analysis if further health promotion is necessary.

Significant pain decrease in children with non-systemic Juvenile Idiopathic Arthritis treated to target: results over 24 months of follow up

BACKGROUND

The aim of this study was to compare pain-scores in three targeted treatment-strategies in JIA-patients and to identify characteristics predicting persistent pain.

METHODS

In the BeSt-for-Kids-study 92 DMARD-naïve JIA-patients were randomized in 3 treatment-strategies: 1) initial sequential DMARD-monotherapy 2) initial methotrexate (MTX)/prednisolone-bridging or 3) initial MTX/etanercept. Potential differences in VAS pain scores (0-100 mm) over time between treatment-strategies were compared using linear mixed models with visits clustered within patients. A multivariable model was used to assess the ability of baseline characteristics to predict the chance of high pain-scores during follow-up.

RESULTS

Pain-scores over time reduced from mean 55.3 (SD 21.7) to 19.5 (SD 25.3) mm after 24 months. On average, pain-scores decreased significantly with β -1.37 mm (95% CI -1.726; -1.022) per month. No significant difference was found between treatment-strategies (interaction term treatment arm*time (months) β (95% CI) arm 1: 0.13 (-0.36; 0.62) and arm 2: 0.37 (-0.12; 0.86) compared to arm 3). Correction for sex and symptom duration yielded similar results. Several baseline characteristics were predictive for pain over time. Higher VAS pain [β 0.44 (95% CI 0.25; 0.65)] and higher active joint count [0.77 (0.19; 1.34)] were predictive of higher pain over time, whereas, low VAS physician [ -0.34 (-0.55; -0.06)], CHQ Physical [ -0.42 (-0.72; -0.11)] and Psychosocial summary Score [ -0.42 (-0.77; -0.06)] were predictive of lower pain.

CONCLUSIONS

Treatment-to-target seems effective in pain-reduction in non-systemic JIA-patients irrespective of initial treatment-strategy. Several baseline-predictors for pain over time were found, which could help to identify patients with a high risk for development of chronic pain.

TRIAL REGISTRATION

Dutch Trial Registry number 1574.

Does the Low Anterior Resection Syndrome Score Accurately Represent the Impact of Bowel Dysfunction on Health-Related Quality of Life?

BACKGROUND

Bowel dysfunction after rectal cancer surgery is common, but its effect on health-related quality of life (HRQOL) is complex. Objective measures of bowel function may not be a good representation on the actual impact on HRQOL. Therefore, the objective of this study is to determine whether there are differences between patient-reported bowel-related impairment versus a standardized measure of bowel dysfunction on HRQOL.

METHODS

A prospective database starting in September 2018 of adult patients who had undergone sphincter preserving rectal cancer surgery up to October 2021 was queried. Patients were excluded if they had local recurrence, metastasis, persistent stoma, or had less than 1-year follow-up. Patients were administered the study instruments at their standard surveillance visit: patient-reported bowel-related quality of life(BQOL) impairment, HRQOL using the Short Form-36 (SF-36), and bowel dysfunction using the low anterior resection syndrome(LARS) score.

RESULTS

Overall, 136 patients were included. There were 43% with no LARS, 22% with minor LARS, and 35% with major LARS. For the BQOL, 26% of subjects reported no impairment, 57% minor impairment, and 17% major impairment. There was a high proportion of discordance between BQOL and LARS, with 23% minor or major LARS in patients with no BQOL impairment, and 32% with no or minor LARS with major BQOL impairment. The BQOL was associated with more changes in SF-36 scores compared to the LARS score.

CONCLUSIONS

The patient-reported BQOL is likely to be a more relevant outcome of interest to patients than the objective LARS score. This has important implications for shared decision-making for rectal cancer treatments.

A change of perspective? An explorative study on why patients may not subjectively report cognitive impairments after a cardiac arrest

AIM

Cardiac arrest survivors are at risk of long-term cognitive impairment. Patients with cognitive impairments do not always have cognitive complaints and vice versa. Not reporting cognitive complaints could be caused by a lack of awareness. We hypothesized that caregivers report more cognitive failures than patients, indicating patients' lack of insight into cognitive functioning.

METHODS

This is a secondary analysis of the Activity and Life After Survival of Cardiac Arrest study on survivors of cardiac arrest and their caregivers. They were assessed at two weeks, three months, and one year after cardiac arrest. At each time point, the patient and the caregiver filled out the cognitive failure questionnaire (CFQ) regarding the patient. We analysed the correlation, intraclass correlation, and self-proxy discrepancy between patients and caregivers on the CFQ over time.

RESULTS

One-hundred-and-nineteen cardiac arrest survivors (mean age = 60, 85 % male) and their caregivers were included. The CFQ scores of the patients and caregivers were equally low. The correlation (T1 r = 0.31; T2 r = 0.40; T3 r = 0.55) and intraclass correlation (T1 r = 0.48; T2 r = 0.56; T3 r = 0.71) between patient and caregiver increased over time.

CONCLUSION

This study does not support a lack of awareness of cognitive impairments by long-term cardiac arrest survivors. Future research may focus on alternative explanations for why patients have less cognitive complaints than expected based on the frequency of cognitive impairments. Possible explanations include a response shift.

Listening to the elephant in the room: response-shift effects in clinical trials research

Background

While a substantial body of work postulates that adaptation (response-shift effects) may serve to hide intervention benefits, much of the research was conducted in observational studies, not randomized-controlled trials. This scoping review identified all clinical trials that addressed response shift phenomena, and characterized how response-shift effects impacted trial findings.

Methods

A scoping review was done of the medical literature from 1968 to 2021 using as keywords “response shift” and “clinical trial.” Articles were included if they were a clinical trial that explicitly examined response-shift effects; and excluded if they were not a clinical trial, a full report, or if response shift was mentioned only in the discussion. Clinical-trials papers were then reviewed and retained in the scoping review if they focused on randomized participants, showed clear examples of response shift, and used reliable and valid response-shift detection methods. A synthesis of review results further characterized the articles’ design characteristics, samples, interventions, statistical power, and impact of response-shift adjustment on treatment effect.

Results

The search yielded 2148 unique references, 25 of which were randomized-controlled clinical trials that addressed response-shift effects; 17 of which were retained after applying exclusion criteria; 10 of which were adequately powered; and 7 of which revealed clinically-important response-shift effects that made the intervention look significantly better.

Conclusions

These findings supported the presumption that response shift phenomena obfuscate treatment benefits, and revealed a greater intervention effect after integrating response-shift related changes. The formal consideration of response-shift effects in clinical trials research will thus not only improve estimation of treatment effects, but will also integrate the inherent healing process of treatments.

Key points

This scoping review supported the presumption that response shift phenomena obfuscate treatment benefits and revealed a greater intervention effect after integrating response-shift related changes.

The formal consideration of response-shift effects in clinical trials research will not only improve estimation of treatment effects but will also integrate the inherent healing process of treatments.

Patient-reported outcomes in a pilot clinical trial of twice-weekly hemodialysis start with adjuvant pharmacotherapy and transition to thrice-weekly hemodialysis vs conventional hemodialysis

Background

Physical and emotional symptoms are prevalent in patients with kidney-dysfunction requiring dialysis (KDRD) and the rigors of thrice-weekly hemodialysis (HD) may contribute to deteriorated health-related quality of life. Less intensive HD schedules might be associated with lower symptom and/or emotional burden.

Methods

The TWOPLUS Pilot study was an individually-randomized trial conducted at 14 dialysis units, with the primary goal to assess feasibility and safety. Patients with incident KDRD and residual kidney function were assigned to incremental HD start (twice-weekly HD for 6 weeks followed by thrice-weekly HD) vs conventional HD (thrice-weekly HD). In exploratory analyses, we compared the two treatment groups with respect to three patient-reported outcomes measures. We analyzed the change from baseline in the score on Dialysis Symptom Index (DSI, range 0–150), Generalized Anxiety Disorder-7 (GAD-7, range 0–21), and Patient Health Questionnaire-9 (PHQ-9, range 0–27) at 6 (n = 20 in each treatment group) and 12 weeks (n = 21); with lower scores denoting lower symptom burden. Analyses were adjusted for age, race, gender, baseline urine volume, diabetes mellitus, and malignancy. Participants’ views on the intervention were sought using a Patient Feedback Questionnaire (n = 14 in incremental and n = 15 in conventional group).

Results

The change from baseline to week 6 in estimated mean score (standard error; P value) in the incremental and conventional group was − 9.7 (4.8; P = 0.05) and − 13.8 (5.0; P = 0.009) for DSI; − 1.9 (1.0; P = 0.07) and − 1.5 (1.4; P = 0.31) for GAD-7; and − 2.5 (1.1; P = 0.03) and − 3.5 (1.5; P = 0.02) for PHQ-9, respectively. Corresponding changes from week 6 to week 12 were − 3.1 (3.2; P = 0.34) and − 2.4 (5.5; P = 0.67) in DSI score; 0.5 (0.6; P = 0.46) and 0.1 (0.6; P = 0.87) in GAD-7 score; and − 0.3 (0.6; P = 0.70) and − 0.5 (0.6; P = 0.47) in PHQ-9 score, respectively. Majority of respondents felt their healthcare was not jeopardized and expressed their motivation for study participation was to help advance the care of patients with KDRD.

Conclusions

This study suggests a possible mitigating effect of twice-weekly HD start on symptoms of anxiety and depression at transition from pre-dialysis to KDRD. Larger clinical trials are required to rigorously test clinically-matched incrementally-prescribed HD across diverse organizations and patient populations.

Trial registration

Registered at ClinicalTrials.gov with study identifier NCT03740048, registration date 14/11/2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02946-w.

Reproducibility and responsiveness of the Frailty Index and Frailty Phenotype in older hospitalized patients

Background

There is growing interest for interventions aiming at preventing frailty progression or even to reverse frailty in older people, yet it is still unclear which frailty instrument is most appropriate for measuring change scores over time to determine the effectiveness of interventions. The aim of this prospective cohort study was to determine reproducibility and responsiveness properties of the Frailty Index (FI) and Frailty Phenotype (FP) in acutely hospitalized medical patients aged 70 years and older.

Methods

Reproducibility was assessed by Intra-Class Correlation Coefficients (ICC), standard error of measurement (SEM) and smallest detectable change (SDC); Responsiveness was assessed by the standardized response mean (SRM), and area under the receiver operating characteristic curve (AUC).

Results

At baseline, 243 patients were included with a median age of 76 years (range 70–98). The analytic samples included 192 and 187 patients in the three and twelve months follow-up analyses, respectively. ICC of the FI were 0.85 (95 % confidence interval [CI]: 0.76; 0.91) and 0.84 (95% CI: 0.77; 0.90), and 0.65 (95% CI: 0.49; 0.77) and 0.77 (95% CI: 0.65; 0.84) for the FP. SEM ranged from 5 to 13 %; SDC from 13 to 37 %. SRMs were good in patients with unchanged frailty status (< 0.50), and doubtful to good for deteriorated and improved patients (0.43–1.00). AUC’s over three months were 0.77 (95% CI: 0.69; 0.86) and 0.71 (95% CI: 0.62; 0.79) for the FI, and 0.68 (95% CI: 0.58; 0.77) and 0.65 (95% CI: 0.55; 0.74) for the FP. Over twelve months, AUCs were 0.78 (95% CI: 0.69; 0.87) and 0.82 (95% CI: 0.73; 0.90) for the FI, and 0.78 (95% CI: 0.69; 0.87) and 0.75 (95% CI: 0.67; 0.84) for the FP.

Conclusions

The Frailty Index showed better reproducibility and responsiveness properties compared to the Frailty Phenotype among acutely hospitalized older patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02444-y.

Mapping Health-Related Quality Of Life After Kidney Transplantation By Group Comparisons: A Systematic Review

Background

Health-related quality of life (HRQOL) is becoming an increasingly important outcome in kidney transplantation (KT). To describe HRQOL in kidney transplant recipients (KTRs), this systematic review summarizes literature that compared HRQOL among KTRs and other relevant populations [i.e. patients receiving dialysis, patients on the waiting list (WL) for KT, patients with chronic kidney disease (CKD) not receiving renal replacement therapy (RRT), the general population (GP) and healthy controls (HCs)] and themselves before KT.

Methods

The literature search was conducted in PubMed, Embase, Web of Science and the Cochrane Library. Eligible studies published between January 2000 and October 2020 were included.

Results

Forty-four studies comprising 6929 KTRs were included in this systematic review. Despite the study heterogeneity, KTRs reported a higher HRQOL after KT compared with pre-transplantation and compared with patients receiving dialysis with or without being on the WL, especially in disease-specific domains (i.e. burden and effects of kidney disease). Additionally, KTRs had similar to marginally higher HRQOL compared with patients with CKD Stages 3–5 not receiving RRT. When compared with HCs or the GP, KTRs reported similar HRQOL in the first 1 or 2 years after KT and lower physical HRQOL and lower to comparable mental HRQOL in studies with longer post-transplant time.

Conclusions

The available evidence suggests that HRQOL improves after KT and can be restored to but not always maintained at pre-CKD HRQOL levels. Future studies investigating intervention targets to improve or maintain post-transplant HRQOL are needed.

Patient-relevant health outcomes for hemophilia care: Development of an international standard outcomes set

BACKGROUND

Patient-relevant health outcomes for persons with hemophilia should be identified and prioritized to optimize and individualize care for persons with hemophilia. Therefore, an international group of persons with hemophilia and multidisciplinary health care providers set out to identify a globally applicable standard set of health outcomes relevant to all individuals with hemophilia.

METHODS

A systematic literature search was performed to identify possible health outcomes and risk adjustment variables. Persons with hemophilia and multidisciplinary health care providers were involved in an iterative nominal consensus process to select the most important health outcomes and risk adjustment variables for persons with hemophilia. Recommendations were made for outcome measurement instruments.

RESULTS

Persons with hemophilia were defined as all men and women with an X-linked inherited bleeding disorder caused by a deficiency of coagulation factor VIII or IX with plasma activity levels <40 IU/dL. We recommend collecting the following 10 health outcomes at least annually, if applicable: (i) cure, (ii) impact of disease on life expectancy, (iii) ability to engage in normal daily activities, (iv) severe bleeding episodes, (v) number of days lost from school or work, (vi) chronic pain, (vii) disease and treatment complications, (viii) sustainability of physical functioning, (ix) social functioning, and (x) mental health. Validated clinical as well as patient-reported outcome measurement instruments were endorsed. Demographic factors, baseline clinical factors, and treatment factors were identified as risk-adjustment variables.

CONCLUSION

A consensus-based international set of health outcomes relevant to all persons with hemophilia, and corresponding measurement instruments, was identified for use in clinical care to facilitate harmonized longitudinal monitoring and comparison of outcomes.

Patient-reported outcome measures ( PROMs): making sense of individual PROM scores and changes in PROM scores over time

Patient-reported outcome measures (PROMs) are increasingly being used in nephrology care. However, in contrast to well-known clinical measures such as blood pressure, health-care professionals are less familiar with PROMs and the interpretation of PROM scores is therefore perceived as challenging. In this paper, we provide insight into the interpretation of PROM scores by introducing the different types and characteristics of PROMs, and the most relevant concepts for the interpretation of PROM scores. Concepts such as minimal detectable change, minimal important change and response shift are explained and illustrated with examples from nephrology care.

Critical examination of current response shift methods and proposal for advancing new methods

Purpose

This work is part of an international, interdisciplinary initiative to synthesize research on response shift in results of patient-reported outcome measures. The objective is to critically examine current response shift methods. We additionally propose advancing new methods that address the limitations of extant methods.

Methods

Based on literature reviews, this critical examination comprises design-based, qualitative, individualized, and preference-based methods, latent variable models, and other statistical methods. We critically appraised their definition, operationalization, the type of response shift they can detect, whether they can adjust for and explain response shift, their assumptions, and alternative explanations. Overall limitations requiring new methods were identified.

Results

We examined 11 methods that aim to operationalize response shift, by assessing change in the meaning of one’s self-evaluation. Six of these methods distinguish between change in observed measurements (observed change) and change in the construct that was intended to be measured (target change). The methods use either (sub)group-based or individual-level analysis, or a combination. All methods have underlying assumptions to be met and alternative explanations for the inferred response shift effects. We highlighted the need to address the interpretation of the results as response shift and proposed advancing new methods handling individual variation in change over time and multiple time points.

Conclusion

No single response shift method is optimal; each method has strengths and limitations. Additionally, extra steps need to be taken to correctly interpret the results. Advancing new methods and conducting computer simulation studies that compare methods are recommended to move response shift research forward.

Supplementary Information

The online version of this article (10.1007/s11136-020-02755-4) contains supplementary material, which is available to authorized users.

Response-shift effects in neuromyelitis optica spectrum disorder: estimating response-shift-adjusted scores using equating

Background

In our companion paper, random intercept models (RIMs) investigated response-shift effects in a clinical trial comparing Eculizumab to Placebo for people with neuromyelitis optica spectrum disorder (NMOSD). RIMs predicted Global Health using the EQ-5D Visual Analogue Scale item (VAS) to encompass broad criteria that people might consider. The SF36™v2 mental and physical component scores (MCS and PCS) helped us detect response shift in VAS. Here, we sought to “back-translate” the VAS into the MCS/PCS scores that would have been observed if response shift had not been present.

Methods

This secondary analysis utilized NMOSD clinical trial data evaluating the impact of Eculizumab in preventing relapses (n = 143). Analyses began by equating raw scores from the VAS, MCS, and PCS, and computing scores that removed response-shift effects. Correlation analysis and descriptive displays provided a more comprehensive examination of response-shift effects.

Results

MCS and PCS crosswalks with VAS equated the scores that include and exclude response-shift effects. These two sets of scores had low shared variance for MCS for both groups, suggesting that corresponding mental health constructs were substantially different. The shared variance contrast for physical health was distinct only for the Placebo group. The larger MCS response-shift effects were found at end of study for Placebo only and were more prominent at extremes of the MCS score distribution.

Conclusions

Our results reveal notable treatment group differences in MCS but not PCS response shifts, which can explain null results detected in previous work. The method introduced herein provides a way to provide further information about response-shift effects in clinical trial data.

Response-shift effects in neuromyelitis optica spectrum disorder: a secondary analysis of clinical trial data

Background

Researchers have long posited that response-shift effects may obfuscate treatment effects. The present work investigated possible response-shift effects in a recent clinical trial testing a new treatment for Neuromyelitis Optica Spectrum Disorder (NMOSD). This pivotal trial provided impressive support for the drug Eculizumab in preventing relapse, but less strong or null results as the indicators became more subjective or evaluative. This pattern of results suggests that response-shift effects are present.

Methods

This secondary analysis utilized data from a randomized, double-blind trial evaluating the impact of Eculizumab in preventing relapses in 143 people with NMOSD. Treatment arm and then relapse status were hypothesized ‘catalysts’ of response shift in two series of analyses. We devised a “de-constructed” version of Oort structural-equation modeling using random-effects modeling for use in small samples. This method begins by testing an omnibus response-shift hypothesis and then, pending a positive result, implements a series of random-effects models to elucidate specific response-shift effects.

Results

In the omnibus test, the ‘standard quality-of-life (QOL) model’ captured substantially less well the experience of placebo as compared to Eculizumab group. Recalibration and reconceptualization response-shift effects were detected. Detected relapse-related response shifts included recalibration, reprioritization, and reconceptualization.

Conclusions

Trial patients experienced response shifts related to treatment- and relapse-related experiences. Published trial results likely under-estimated Eculizumab vs. Placebo differences due to recalibration and reconceptualization, and relapse effects due to recalibration, reprioritization, and reconceptualization. This novel random-effects- model application builds on response-shift theory and provides a small-sample method for better estimating treatment effects in clinical trials.

Electronic supplementary material

The online version of this article (10.1007/s11136-020-02707-y) contains supplementary material, which is available to authorized users.

Capturing patient experience: does quality-of-life appraisal entail a new class of measurement?

Background

Two decades of research on quality-of-life (QOL) appraisal have demonstrated links between patient experience and health outcomes and have accounted for both intra-individual change and inter-individual differences in a wide range of research contexts. The present work investigates patterns across diagnostic and demographic groupings to demonstrate how population-specific circumstances drive the structure of QOL appraisal.

Methods

This secondary analysis (N = 6448) utilized data from six patient groups: spine surgery, multiple sclerosis, heterogeneous chronically ill, heterogeneous cancer, bladder cancer, and human immunodeficiency virus (HIV). We explored patterns of inter-item correlation across patient samples, using items from the Standards of Comparison and Sampling of Experience subsections of the QOL Appraisal Profile v1 and v2. Similar matrices were compared by demographic characteristics.

Results

Patterns of inter-item correlations for Standards of Comparison items varied sharply across disease groups and racial groups while being similar across age, gender, and education levels. Inter-item correlation matrices for Sampling of Experience items revealed marked differences among disease groups and educational and racial categories but were similar across age and gender groups.

Conclusions

Appraisal parameters showed evidence of shared and unique aspects across samples and circumstances, findings which make sense in light of sample differences in health status and demographic influences. Tools to assess patient experience and meaning may be best understood as idiometric instruments. We discuss their distinctions from psychometric and clinimetric tools at theoretical, statistical, and applied levels.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s41687-020-00254-1.

What Influences Patient Satisfaction after TKA? A Qualitative Investigation

BACKGROUND

Patient satisfaction is a common measure of the success of an orthopaedic intervention. However, there is poor understanding of what satisfaction means to patients or what influences it.

QUESTIONS/PURPOSES

Using qualitative study methodology in patients undergoing TKA, we asked: (1) What does it mean to be satisfied after TKA? (2) What factors influence satisfaction levels after TKA?

METHODS

People in a hospital registry who had completed 12-month follow-up questionnaires and were not more than 18 months post-TKA at the time of sampling were eligible (n = 121). To recruit a sample that provided insight into a range of TKA experiences, we divided eligible candidates on the registry into quadrants based on their responder status and satisfaction level. A responder was an individual who experienced a clinically meaningful change in pain and/or function on the WOMAC according to the Outcome Measures in Rheumatology-Osteoarthritis Research Society International (OMERACT-OARSI) responder criteria. Individuals were considered satisfied unless they indicated somewhat dissatisfied or very dissatisfied for one or more of the four items on the Self-Administered Patient Satisfaction Scale. From the resulting quadrants: responder satisfied, nonresponder satisfied, nonresponder dissatisfied, responder dissatisfied, we identified men and women with a range of ages and invited them to participate (n = 85). The final sample (n = 40), consisted of 10 responder satisfied, nine nonresponder satisfied, eight nonresponder dissatisfied, and 13 responder dissatisfied; 71% were women, with a mean age of 71 ± 7 years and a mean time since TKA surgery of 17 ± 2 months (range 13 to 25 months). Interview transcripts were analyzed by looking for factors in the participants' narrative that appeared to underscore their level of satisfaction and attaching inductive (data-derived, rather than a priori derived) codes to relevant sections of text. Coded data from participants who reported high and low levels of satisfaction were compared/contrasted and emerging patterns were mapped into a conceptual model. Recruitment continued until no new information was uncovered in data analysis of subsequent interviews, signalling to the researchers that further interviews would not change the key themes identified and data collection could cease.

RESULTS

In those with high satisfaction levels, satisfaction was conceptualized as an improvement in pain and function. In those with low satisfaction levels, rather than an improvement, satisfaction was conceptualized as completely resolving all symptoms and functional limitations. In addition, we identified three pathways through which participants reached different levels of low and high satisfaction: (1) The full-glass pathway, characterized by no or minimal ongoing symptoms and functional deficits, which consistently led to high levels of satisfaction; (2) the glass-half-full pathway, characterized by ongoing symptoms and functional limitations, which led to high satisfaction; and (3) the glass-half-empty pathway, also characterized by ongoing symptoms and functional limitations, which led to low satisfaction levels. The latter two pathways were mediated by three core mechanisms (recalibration, reframing valued activities, and reconceptualization) influenced either positively or negatively by (1) a persons' thoughts and feelings such as optimism, self-efficacy, pain catastrophizing, external locus of control; and (2) social and contextual factors such as fulfilment of social roles, therapeutic alliance, lack of family/social support.

CONCLUSIONS

This qualitative study suggests that for preoperative patients in whom unrealistically high hopes for complete symptom resolution and restoration of functional capacity persists, it may be appropriate to direct them away from TKA due to the risk of low satisfaction. For postoperative patients troubled by ongoing symptoms or functional limitations, clinicians may improve levels of satisfaction by targeting the three core mechanisms (recalibration, reframing valued activities, and reconceptualization) through addressing modifiable negative thoughts and feelings in interventions such as psychology or psychotherapy; and negative social and contextual factors by promoting a strong therapeutic alliance and engagement in community activities. Given that these factors may be identifiable preoperatively, future research is needed to explore if and how addressing them preoperatively may improve satisfaction post-TKA.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Longitudinal changes of self-perceived manual ability the first year after stroke: a cohort study

BACKGROUND

Recovery patterns of motor function and activity capacity of the upper extremity after stroke have been described, but less is known about longitudinal changes of perceived manual activity performance. The aim of this study was to investigate longitudinal changes of self-perceived manual ability at several timepoints from onset until 12 months post-stroke in a cohort of consecutively recruited individuals with mild, moderate and severe stroke.

METHODS

The study included 106 participants from a non-selected cohort with first-ever mild, moderate or severe stroke and impaired upper extremity function (Stroke Arm Longitudinal Study at the University of Gothenburg, SALGOT). Self-perceived manual ability was assessed with the ABILHAND Questionnaire at 3 and 10 days, 4 weeks, 3, 6 and 12 months after stroke. Longitudinal change was assessed by linear mixed models (fixed and random effects) and adjusted models were built by adding effects of cofactors age, gender, stroke severity, living condition and affected hand.

RESULTS

Self-perceived manual ability increased over time the first year after stroke for the total group and the subgroups. The final adjusted model for the total group included fix-effects of time (expected mean change 0.24 logits per month) adjusted by age (- 0.06 per year) and stroke severity (- 0.19 per NIHSS-score). In addition to significant effect of time, the adjusted models for moderate stroke subgroup included fixed effect of age, and for mild and severe subgroups there was an interaction effect between time and age. Further analyses between time-points showed that no significant change of self-perceived manual ability was detected beyond 3 months post-stroke.

CONCLUSIONS

Self-perceived manual ability increased over time the first year after stroke, and this change was to some degree modulated by age and stroke severity at onset. Most of the improvements occurred early, predominantly within the first three months after stroke.

Association Between Isokinetic Knee Strength and Perceived Function and Patient Satisfaction With Sports and Recreational Ability After Matrix-Induced Autologous Chondrocyte Implantation

Background:

Returning to a sound level of activity after matrix-induced autologous chondrocyte implantation (MACI) is important to patients. Evaluating the patient’s level of satisfaction with his or her sports and recreational ability is critical.

Purpose:

To investigate (1) satisfaction with sports and recreational ability after MACI and (2) the role that knee strength plays in self-reported knee function and satisfaction.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

Isokinetic knee strength was assessed in 97 patients at 1, 2, and 5 years after MACI to calculate hamstrings-quadriceps ratios and peak knee extensor and flexor torque limb symmetry indices (LSIs). The Sports and Recreation subscale of the Knee injury and Osteoarthritis Outcome Score (KOOS Sports/Rec) was completed. A satisfaction scale was used to evaluate how satisfied the patients were with their ability to return to recreational activities and their ability to participate in sport. Associations between knee strength LSI, KOOS Sports/Rec, and satisfaction with recreational and sporting activities were assessed through use of multivariable linear and logistic regression, with adjustment for confounders. Mediation analysis was conducted to assess the extent to which self-reported knee function mediated associations between strength LSI and satisfaction.

Results:

Satisfaction with the ability to return to recreational activities was achieved in 82.4%, 85.6%, and 85.9% of patients at 1, 2, and 5 years, respectively, and satisfaction with sports participation was achieved in 55.7%, 73.2%, and 68.5% of patients at 1, 2, and 5 years, respectively. Knee extension torque LSIs were associated with KOOS Sports/Rec after adjustment for confounders over 1, 2, and 5 years (5-year regression coefficient, 6.0 points; 95% CI, 1.4-10.7; P = .012). KOOS Sports/Rec was associated with the likelihood of being satisfied at all time points (recreation: 5-year adjusted odds ratio [OR], 2.26; 95% CI, 1.48-3.46; P < .001; and sports: 5-year adjusted OR, 1.98; 95% CI, 1.47-2.68; P < .001). In a multivariable mediation model, the knee extension torque LSI was associated with satisfaction directly (standardized coefficient, 0.16; 95% CI, 0.03-0.28; P = .017) and indirectly via KOOS Sports/Rec (standardized coefficient, 0.19; 95% CI, 0.01-0.38; P = .027), the latter representing 55% of the total association of knee extension torque LSI with satisfaction.

Conclusion:

Knee extensor symmetry was associated with satisfaction in recreational and sporting ability, both directly and indirectly, via self-reported sports and recreation–related knee function. Restoring strength deficits after MACI is important for achieving optimal outcomes.

Comparison of structural equation modelling, item response theory and Rasch measurement theory-based methods for response shift detection at item level: A simulation study

When assessing change in patient-reported outcomes, the meaning in patients’ self-evaluations of the target construct is likely to change over time. Therefore, methods evaluating longitudinal measurement non-invariance or response shift at item-level were proposed, based on structural equation modelling or on item response theory. Methods coming from Rasch measurement theory could also be valuable. The lack of evaluation of these approaches prevents determining the best strategy to adopt. A simulation study was performed to compare and evaluate the performance of structural equation modelling, item response theory and Rasch measurement theory approaches for item-level response shift detection. Performances of these three methods in different situations were evaluated with the rate of false detection of response shift (when response shift was not simulated) and the rate of correct response shift detection (when response shift was simulated). The Rasch measurement theory-based method performs better than the structural equation modelling and item response theory-based methods when recalibration was simulated. Consequently, the Rasch measurement theory-based approach should be preferred for studies investigating only recalibration response shift at item-level. For structural equation modelling and item response theory, the low rates of reprioritization detection raise issues on the potential different meaning and interpretation of reprioritization at item-level.

Testing for response shift in treatment evaluation of change in self-reported psychopathology amongst secondary psychiatric care outpatients

OBJECTIVES

If patients change their perspective due to treatment, this may alter the way they conceptualize, prioritize, or calibrate questionnaire items. These psychological changes, also called "response shifts," may pose a threat to the measurement of therapeutic change in patients. Therefore, it is important to test the occurrence of response shift in patients across their treatment.

METHODS

This study focused on self-reported psychological distress/psychopathology in a naturalistic sample of 206 psychiatric outpatients. Longitudinal measurement invariance tests were computed across treatment in order to detect response shifts.

RESULTS

Compared with before treatment, post-treatment psychopathology scores showed an increase in model fit and factor loading, suggesting that symptoms became more coherently interrelated within their psychopathology domains. Reconceptualization (depression/mood) and reprioritization (somatic and cognitive problems) response shift types were found in several items. We found no recalibration response shift.

CONCLUSION

This study provides further evidence that response shift can occur in adult psychiatric patients across their mental health treatment. Future research is needed to determine whether response shift implies an unwanted potential bias in treatment evaluation or a desired cognitive change intended by treatment.

Response shift effects in patients' assessments of their quality of life after cardiac rehabilitation

PURPOSE

The effect of intervention programs on health-related quality of life (HRQoL) can be underestimated due to response shift effects. This study aims to compare HRQoL between cardiac patients taking part in a rehabilitation program and the general population and to investigate changes in HRQoL in terms of response shift with two approaches.

METHODS

A sample of 282 cardiac rehabilitation inpatients (response rate: 58.9%) responded to the self-report quality of life questionnaire EORTC QLQ-C30 at baseline (during rehabilitation) and three months later (actual and retrospective judgment). Their HRQoL was compared to that of the general population. Response shift evaluation complemented the thentest with the structural equation modeling approach.

RESULTS

Compared to the general population, patients showed impaired quality of life on all scales (Hedges' g between 0.31 and 1.57). The complementation of the thentest with the structural equation modeling approach revealed response shift effects in physical, emotional, cognitive, and social functioning. No effects were found in role functioning.

CONCLUSIONS

The combination of both the thentest and the structural equation modeling approaches proved to be essential for obtaining comprehensive statistical evidence that response shift can distort measurements of change. Our results suggest that studies that use the thentest to evaluate the effectiveness of interventions should complement their analyses with the structural equation modeling approach to avoid biased effects.

LSVT BIG in late stroke rehabilitation: A single-case experimental design study

BACKGROUND.

Late stroke rehabilitation interventions often target impairment with limited carryover to daily occupation.

PURPOSE.

This study explored whether the LSVT BIG program could lead to improved performance in client-identified occupations and decreased impairment late poststroke.

METHOD.

A single-case experimental design with one repetition was completed. Participants were two adults who had experienced a stroke 3 and 12 years previously. Each participant selected up to six occupational goals, and the intervention was applied to half. Repeated measures were taken using the Canadian Occupational Performance Measure and the Rating of Everyday Arm-Use in the Community and Home. Additional measures of performance and impairment were applied pre- and postintervention.

FINDINGS.

Performance improved on either self-assessment or blinded-rater assessment for all but one activity (trained or untrained).

IMPLICATIONS.

LSVT BIG is a promising intervention to improve occupational performance. Further research is required to clarify elements of the program essential to improving occupational performance.

Using structural equation modeling to detect response shift in quality of life in patients with Alzheimer's disease

ABSTRACTBackground:Our study aims to detect different types of response shifts (RS) and true changes of quality of life (QOL) measurement in patients with Alzheimer's disease (AD) using structural equation modeling (SEM) in domain level.

METHODS

Patients with AD aged over 60 years old were collected from the Department of Neurology and Geriatrics in Taiyuan Central Hospital, China. The 12-item Short Form (SF-12) Health Survey was measured in 238 patients with AD prior to hospitalization and one month following discharge. RS was detected by SEM approach. The statistical process consisted of four steps and fitted four models. We interpreted changes of parameters in models to detect RS and to assess true change.

RESULTS

The results showed reprioritization of social functioning (SF) (χ2 = 4.13, p &lt; 0.05), reconceptualization of role limitations due to emotional problems (RE) (χ2 = 17.03, p &lt; 0.001), uniform recalibration of bodily pain (BP) (χ2 = 12.24, p &lt; 0.001), and non-uniform recalibration of mental health (MH) (χ2 = 4.41, p &lt; 0.05), respectively. The true changes of common factors were deteriorated in general physical health (PHYS) (-0.10, χ2 = 8.30, p &lt; 0.005) and improved in general mental health (MENT) (+0.29, χ2 = 20.95, p &lt; 0.001). The effect-sizes of RS were only small.

CONCLUSION

This study showed that patients with AD occurred three types of RS and true changes one month following discharge. RS had effects on the QOL of patients. Better understanding of potential changes in QOL in patients with AD is crucial.

The paradox of self-rated health following joint replacement surgery

PURPOSE

Self-rated health is a commonly used patient-reported outcome, but its responsiveness to is not well documented. We examined the ability of self-rated health to capture health changes attributable to a highly effective surgical intervention.

METHODS

Prospective study of patients with severe osteoarthritis of the hip (N = 990) or knee (N = 907) who underwent total hip replacement (THA) or total knee replacement (TKA). Self-rated health was assessed pre-operatively and 1 year after surgery on a scale between "excellent" and "poor," along with other health items (other 11 items of the SF12 questionnaire) and multi-item Pain and Function scales.

RESULTS

On average, self-rated health was unchanged by surgery. In both THA and TKA cohorts, of 10 patients, 6 rated their health the same after surgery as before, 2 gave a higher rating, and 2 gave a lower rating. In contrast, major improvements were observed for all other SF12 items, and for the Pain and Function scales, in both cohorts of patients. Nevertheless, both before and after surgery, self-rated health was associated with the other SF12 items and with Pain and Function scores. These associations were stronger after surgery than before.

CONCLUSIONS

Self-rated health was not responsive to major improvements in health, documented by other instruments, attributable to joint replacement surgery. However, self-rated health was even more strongly associated with concurrent assessments of more specific health problems after surgery than before. Caution is advised in interpreting changes in self-rated health following health-altering interventions.

Potential benefits of the cognitive orientation to daily occupational performance approach in young adults with spina bifida or cerebral palsy: a feasibility study

Purpose: People with cerebral palsy (CP) or spina bifida (SB) often struggle to perform everyday-life activities. Both groups frequently also have difficulties in creating and using strategies effectively when performing tasks. The cognitive orientation to daily occupational performance (CO-OP) Approach combines the learning of cognitive strategies with task-specific approaches through a client-centred procedure. The aim of this study was to investigate whether the CO-OP Approach is feasible for and potentially beneficial to adolescents and young adults with CP or SB in Sweden by analysing four areas of feasibility (acceptability, efficacy, adaptation, and expansion).Methods: Exploratory multiple-case study using mixed methods. Ten persons aged 16-28, five with each condition, participated in an intervention period. Assessments were performed on three occasions: baseline, post-intervention, and six-month follow-up.Results: The result demonstrates that the CO-OP Approach has the potential to enable adolescents and young adults with either condition to achieve personal goals and to enhance their planning skills and their ability to use strategies when performing activities. This approach is also compatible with the core values of habilitation in Sweden and was found by the participants to be highly meaningful and useful.Conclusions: The CO-OP Approach is feasible for adolescents and young adults with SB or CP in Sweden.Implications for rehabilitationThe Cognitive Orientation to daily Occupational Performance• is a feasible approach for adolescents and young adults with spina bifida and with cerebral palsy.• is a promising approach when it comes to enabling the achievement of personal goals.• might have potential to enhance executive functioning through strategy use.• is in line with the fundamental core values of disability rights of inclusion, empowerment, and participation.

Impact of reconceptualization response shift on rating of quality of life over time among people with advanced cancer

BACKGROUND

People with cancer may experience change in what constitutes quality of life (QOL) over time as a result of the cancer progression (true change) or adaptation to the experience, considered as a response shift phenomenon. As individualized measures are ideally suited to explore response shift, this study aimed to estimate the extent to which reconceptualization response shift occurred over time in a cancer population and the impact of this response shift on estimates of change on QOL measures.

METHODS

Ninety-seven people with advanced cancer completed the study measures including the Patient-Generated Index (PGI) at diagnosis (T0) and 1 year later (T1). The response shift indicator was the change in the number of areas nominated (range - 4 to + 3). Multivariate linear regression was used to estimate the effect of changing areas on change in the PGI score, single indicators of global QOL, and the EQ-5D_index adjusted for age and sex.

RESULTS

Approximately 72% of people in this sample either added or dropped areas over time. People who dropped more than two areas had higher PGI scores at T1 than T0 while people who added areas showed low PGI score.

CONCLUSION

The results are consistent with the PGI framework as areas nominated tend to focus on negative aspects of QOL.

Preoperative surgical rehearsal using cadaveric fresh tissue surgical simulation increases resident operative confidence

BACKGROUND

Rehearsal is an essential part of mastering any technical skill. The efficacy of surgical rehearsal is currently limited by low fidelity simulation models. Fresh cadaver models, however, offer maximal surgical simulation. We hypothesize that preoperative surgical rehearsal using fresh tissue surgical simulation will improve resident confidence and serve as an important adjunct to current training methods.

METHODS

Preoperative rehearsal of surgical procedures was performed by plastic surgery residents using fresh cadavers in a simulated operative environment. Rehearsal was designed to mimic the clinical operation, complete with a surgical technician to assist. A retrospective, web-based survey was used to assess resident perception of pre- and post-procedure confidence, preparation, technique, speed, safety, and anatomical knowledge on a 5-point scale (1= not confident, 5= very confident).

RESULTS

Twenty-six rehearsals were performed by 9 residents (PGY 1-7) an average of 4.7±2.1 days prior to performance of the scheduled operation. Surveys demonstrated a median pre-simulation confidence score of 2 and a post-rehearsal score of 4 (P<0.01). The perceived improvement in confidence and performance was greatest when simulation was performed within 3 days of the scheduled case. All residents felt that cadaveric simulation was better than standard preparation methods of self-directed reading or discussion with other surgeons. All residents believed that their technique, speed, safety, and anatomical knowledge improved as a result of simulation.

CONCLUSIONS

Fresh tissue-based preoperative surgical rehearsal was effectively implemented in the residency program. Resident confidence and perception of technique improved. Survey results suggest that cadaveric simulation is beneficial for all levels of residents. We believe that implementation of preoperative surgical rehearsal is an effective adjunct to surgical training at all skill levels in the current environment of decreased work hours.

Associations between maternal characteristics and women's responses to acupuncture during labour: a secondary analysis from a randomised controlled trial

Background

Patient characteristics are modulators of pain experience after acupuncture treatment for chronic pain. Whether this also applies to labour pain is unknown.

Aim

To examine for associations between maternal characteristics and response to acupuncture in terms of labour pain intensity in close proximity to the treatment (within 60 min) and over a longer time period (up to 240 min), and whether or not epidural analgesia is used, before and after adjustment for obstetric status upon admission to the labour ward.

Methods

Cohort study (n=253) using data collected for a randomised controlled trial. Associations were examined using linear mixed models and logistic regression analyses. Tests of interactions were also applied to investigate whether maternal characteristics were influenced by treatment group allocation.

Results

In close proximity to the treatment, advanced age and cervical dilation were associated with lower pain scores (mean difference (MD) −13.2, 95% CI −23.4 to −2.9; and MD −5.0, 95% CI −9.6 to −0.5, respectively). For the longer time period, labour pain was negatively associated with age (MD −11.8, 95% CI −19.6 to −3.9) and positively associated with dysmenorrhoea (MD 5.5, 95% CI 1.6 to 9.5). Previous acupuncture experience and advanced cervical dilatation were associated with higher and lower use of epidural analgesia (OR 2.7, 95% CI 1.3 to 5.9; and OR 0.3, 95% CI 0.1 to 0.5, respectively). No interactions with treatment allocation were found.

Conclusions

This study did not identify any maternal characteristics associated with women's responses to acupuncture during labour.

Trial registration number

NCT01197950; Post-results.

The relationship between perceived own health state and health assessments of anchoring vignettes

Background/Objective: Self-reported health depends on the internal frame of reference and on response styles. One way of studying this dependency is using anchoring vignettes. Response shift effects are assumed to induce a negative correlation between self-reported health and the health assessments attributed to the vignettes. Method: A representative sample of the German adult population (N = 2,409) was selected. Participants were asked to rate their health state and the health states of two rather complex vignettes representing patients with several health complaints on a 0-100 scale. Results: The mean score of self-assessed health was M = 76.20 (SD = 20.6). There was a very small positive correlation between the assessment of the vignettes and the self-assessed health state (r = .12). After controlling for a proxy of objective health, measured in terms of chronic conditions, the relationship remained slightly positive. Chronic conditions were only marginally associated with the assessments of the vignettes (0 conditions: M = 44.8; ≥ 2 conditions: M = 42.2). Conclusions: The lack of the postulated association between self-reported health and vignettes' ratings means that we cannot derive tools to correct the subjective ratings for differential use of frames of reference.

Prospective, multicenter, controlled study of quality of life, psychological adjustment process and medical outcomes of patients receiving a preemptive kidney transplant compared to a similar population of recipients after a dialysis period of less than three years--The PreKit-QoL study protocol

BACKGROUND

Treatment of end stage renal disease has an impact on patients' physical and psychological health, including quality of life (QoL). Nowadays, it is known that reducing the dialysis period has many advantages regarding QoL and medical outcomes. Although preemptive transplantation is the preferred strategy to prevent patients undergoing dialysis, its psychological impact is unknown. Moreover, transplantation can be experienced in a completely different manner among patients who were on dialysis and those who still had a functioning kidney at the time of surgery. Longitudinal data are often collected to allow analyzing the evolution of patients' QoL over time using questionnaires. Such data are often difficult to interpret due to the patients' changing standards, values, or conceptualization of what the questionnaire is intended to measure (e.g. QoL). This phenomenon is referred to as response shift and is often linked to the way the patients might adapt or cope with their disease experience. Whether response shift is experienced in a different way among patients who were on dialysis and those who still had a functioning kidney at time of surgery is unknown and will be studied in the PreKit-QoL study (trial registration number: NCT02154815). Understanding the psychological impact of pre-emptive transplantation is an important issue since it can be associated with long-term patient and graft survival.

METHODS/DESIGN

Adult patients with a pre-emptive transplantation (n = 130) will be prospectively included along with a control group of patients with a pre-transplant dialysis period < 36 months (n = 260). Only first and single kidney transplantation will be considered. Endpoints include: comparison of change between groups in QoL, anxiety and depressive disorders, perceived stress, taking into account response shift. These criteria will be evaluated every 6 months prior to surgery, at hospital discharge, at three and six months, one and two years after transplantation.

DISCUSSION

The PreKit-QoL study assesses and compares the evolution of QoL and other psychological criteria in preemptive and dialyzed patients taking patients' adaptation into account through response shift analyses. Our study might help to conceive specific, adapted educational programs and psychological support to prevent a possible premature loss of the kidney as a consequence of non-compliance in patients that may be insufficiently prepared for transplantation.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT02154815 , registered on May 28, 2014.

Testing for Response Shift Bias in Evaluations of School Antibullying Programs

BACKGROUND

Involvement in bullying at school is detrimental to students' mental and physical health; however, school antibullying programs have not been found to be uniformly successful. Self-reported frequency of involvement in bullying victimization and perpetration, often used as outcome measures in intervention impact evaluation studies, may be subject to response shift, particularly in intervention conditions. Such differential shifts could lead to biased estimates of intervention effects.

OBJECTIVES

This study investigated the presence of reconceptualization, reprioritization, and recalibration response shift, resulting from intervention implementation.

METHOD

The study subjects were Grade 8 students (n = 3,382, 53% female) in the 35 schools participating in the Cyber Friendly Schools Project, a longitudinal group-randomized intervention trial. Response shift was assessed by comparing traditional and retrospective pretest measures of bullying involvement, as well as testing for measurement invariance over time in the Forms of Bullying Scale (FBS) using confirmatory factor analyses.

RESULTS

No evidence of response shift was found, indicating students' understandings of bullying behavior remained stable over time. These findings also demonstrate the applicability of the FBS in longitudinal studies involving adolescents.

CONCLUSION

While response shift was not present in our study, researchers conducting program evaluations in other contexts are advised to consider testing for this potential source of bias in their studies.

Response shift and disease activity in inflammatory bowel disease

PURPOSE

Response shift (RS) may mask true change in health-related quality of life in longitudinal studies. People with chronic conditions may experience RS as they adapt to their disease, but it is unknown whether fluctuations in disease activity will influence the presence of RS. The study purpose was to test for RS in individuals with inflammatory bowel disease (IBD), a condition characterized by periods of symptom flares and remission.

METHODS

Data were from the Manitoba IBD Cohort Study (N = 388). Multi-group confirmatory factor analysis (MG-CFA) and a RS detection method based on structural equation modeling were used to test for reconceptualization, reprioritization, and recalibration RS in participants with consistent active, consistent inactive, and inconsistent disease activity over a 6-month period on the SF-36.

RESULTS

The MG-CFA revealed that a weak invariance model with equal factor loadings across groups was the best fit to the baseline SF-36 data. Reconceptualization, uniform recalibration, and non-uniform recalibration RS was detected in the consistent active group, but effect sizes were small. For the consistent inactive group, recalibration RS was observed and effect sizes were small to moderate. For the inconsistent disease activity group, small-to-moderate recalibration RS effects were observed. There was no evidence of reprioritization.

CONCLUSIONS

Individuals with a chronic disease may exhibit RS even if they are not actively experiencing symptoms on a consistent basis. Heterogeneity in the type and magnitude of RS effects may be observed in chronic disease patients who experience changes in disease symptoms.

Experience sampling and ecological momentary assessment studies in psychopharmacology: A systematic review

Experience sampling methods (ESM) and ecological momentary assessment (EMA) offer insight into daily life experiences, including symptoms of mental disorders. The application of ESM/EMA in psychopharmacology can be a valuable addition to more traditional measures such as retrospective self-report questionnaires because they may help reveal the impact of psychotropic medication on patients' actual experiences. In this paper we systematically review the existing literature on the use of ESM/EMA in psychopharmacology research. To this end, we searched the PsycInfo and Medline databases for all available ESM/EMA studies on the use of psychotropic medication in patients with DSM-III-R and DSM-IV disorders. Dissertations were excluded. We included 18 studies that applied ESM/EMA to study the effects of medication on patients with major depressive disorder, substance use disorder, attention-deficit hyperactivity disorder, psychotic disorder, and anxiety disorder. We found that ESM/EMA may allow researchers and clinicians to track patients during different phases of treatment: before treatment to predict outcome, during treatment to examine the effects of treatment on symptoms and different aspects of daily life experience, and after treatment to detect vulnerability for relapse. Moreover, ESM/EMA can potentially help determine how long and in what contexts medications are effective. Thus, ESM/EMA may benefit both researchers and clinicians and might prove to be an effective tool for improving the treatment of psychiatric patients.

Patient preferences for side effects associated with cervical cancer treatment

OBJECTIVES

The aim of this study was to assess patient preferences regarding side effects associated with cervical cancer treatment.

METHODS/MATERIALS

The visual analog scale (VAS) and modified standard gamble (SG) were used to elicit preferences of women with no evidence of disease after primary treatment of cervical cancer. Higher scores on VAS and SG indicated more favorable ratings for a given health state. Health states (HS) included vaginal shortening, diarrhea, dietary changes, menopause, moderate nausea/vomiting, rectal bleeding, sexual dysfunction, and urinary self-catheterization. Descriptive statistics, Kruskal-Wallis, Mann-Whitney U, and Wilcoxon signed-ranks tests and correlation coefficients were used for statistical analysis.

RESULTS

Seventy-eight patients participated in the study. Median age was 44.1 years (range, 24.9-67.8 years). Median time since treatment completion was 31.2 months (range, 1.0-113.3 months). The HSs rated as most favorable by VAS were also rated as most favorable by SG. Increasing age was associated with higher VAS scores for menopause and vaginal shortening (P = 0.04 and 0.036). African Americans had higher VAS scores for dietary changes (P = 0.05), sexual dysfunction (P = 0.028), and diarrhea (P = 0.05) when compared with Hispanic and non-Hispanic white patients. Women receiving radiation had more favorable VAS scores for menopause compared with women undergoing radical hysterectomy (P = 0.05). Women receiving chemotherapy rated urinary self-catheterization less favorably by VAS score compared with those not receiving chemotherapy (P = 0.045).

CONCLUSIONS

Multiple demographic and clinical factors influence the severity of treatment-related adverse effects perceived by women surviving cervical cancer. A better understanding of factors influencing patient preferences regarding treatment side effects will allow providers to formulate care better tailored to the individual desires of each patient.

Overall performance of Oort's procedure for response shift detection at item level: a pilot simulation study

OBJECTIVE

This simulation study was designed to provide data on the performance of Oort's procedure (OP) for response shift (RS) detection (regarding type I error, power, and overall performance), according to sample characteristics, at item level. A specific objective was to assess the impact of using different information criteria (IC), as alternatives to the LRT (likelihood-ratio test), for global assessment of RS occurrence.

METHODS

Responses to five binary items at two times of measurement were simulated. Thirty-six combinations of sample characteristics [sample size (n), "true change," correlations between the two latent variables and presence/absence of uniform recalibration RS (ur)] were considered. A thousand datasets were generated for each combination. RS detection was performed on each dataset following OP. Type I error and power of the global assessment of RS occurrence, as well as overall performance of the OP, were assessed.

RESULTS

The estimated type I error was close to 5 % for the LRT and lower than 5 % for the IC. The estimated power was higher for the LRT as compared to the AIC, which was the highest among the other IC. For the LRT, the estimated power for n = 100 and for the combination of n = 200 and ur = 1 item was below 80 %. Otherwise, for other combinations of sample characteristics, the estimated power was above 90 %.

CONCLUSION

For the LRT, higher values of power were estimated compared to IC with appropriate values of type I error. These results were consistent with Oort's proposal to use the LRT as the criterion to assess global RS occurrence.

Semantic primes theory may be helpful in designing questionnaires such as to prevent response shift

OBJECTIVES

The purpose of randomized control trials (RCTs) can be the assessment of the direct effect of treatment on health-related quality of life (HRQL). Response shift (RS) theory considers that a change in HRQL scores observed over time cannot be explained solely by a direct effect of a medical condition, it may also result from a change in the way people appraise their HRQL. The RS effect is a potential bias that is liable to compromise efficient assessment of the effect of treatment on HRQL.

STUDY DESIGN AND SETTING

We hypothesize a link between the RS effect on HRQL scores and the level of complexity of HRQL conceptualization.

RESULTS

We discuss how the impact of reconceptualization on scores depends on the complexity of the linguistic definition of a subjective construct and how for reprioritization the impact depends on the dimensionality. The linguistic theory of semantic primes is used to help identify how subjective constructs can be classified according to the complexity of their definitions.

CONCLUSION

Finally, we suggest that the impact of the RS effect on HRQL scores could be avoided (or lessened) if questionnaires were designed with a rule of "the least semantic and psychometric complexity" in mind.

Getting on with the rest of your life following stroke: a randomized trial of a complex intervention aimed at enhancing life participation post stroke

Objective:

To enhance participation post stroke through a structured, community-based program.

Design:

A controlled trial with random allocation to immediate or four-month delayed entry.

Setting:

Eleven community sites in seven Canadian cities.

Subjects:

Community dwelling persons within five years of stroke onset, cognitively intact, able to toilet independently.

Interventions:

Evidence-based program delivered in three 12-week sessions including exercise and project-based activities, done as individuals and in groups.

Main measures:

Hours spent per week in meaningful activities outside of the home and Reintegration to Normal Living Index; Stroke-Specific Geriatric Depression Scale, Apathy Scale, gait speed, EuroQuol EQ-5D, and Preference-Based Stroke Index. All measures were transformed to a scale from 0 to 100. Assessments prior to randomization, after the first session at three months, six months, 12 months, and 15 months.

Results:

A total of 186 persons were randomized. The between-group analysis showed no disadvantage to waiting and so groups were combined and a within-person analysis was carried out at three time points. There were statistically significant increases in all study outcomes on average over all persons. Over 45% of people met or exceeded the pre-specified target of a three hour per week increase in meaningful activity and this most often took a full year of intervention to achieve. Greatest gains were in satisfaction with community integration (mean 4.78; 95% CI: 2.01 to 7.55) and stroke-specific health-related quality of life (mean 4.14; 95% CI: 2.31 to 5.97).

Conclusions:

Community-based programs targeting participation are feasible and effective, but stroke survivors require time to achieve meaningful gains.

Measuring change in quality of life: bias in prospective and retrospective evaluation

OBJECTIVES

Treatment effects on health-related quality of life (QOL) often differ depending on whether they are measured prospectively (before and after treatment) or retrospectively (after treatment only). These two approaches can be subject to different sorts of bias: Prospective evaluations may be biased by scale recalibration (a changed understanding of the response scale), and retrospective evaluations may be biased by recall bias (a wrong assessment of former QOL).

METHODS

On the basis of an analysis of the literature, we present an overview on possible biases in prospective and retrospective measurement of QOL and how these biases are named and defined in the literature.

RESULTS

The definitions of different biases are inconsistent. Many authors do not clearly distinguish measurement bias from true change. Furthermore, some consider only scale recalibration or only recall bias.

CONCLUSIONS

Much of the current discussion on bias in prospective and retrospective QOL measurement suffers from unclear definitions, especially of "response shift" and "recall bias," or from neglecting one of the possible biases. We suggest more elaborate definitions for different types of bias and recommend taking both kinds of bias into consideration when measuring change in QOL. The relevance of the different biases depends on the type of study, and so either prospective or retrospective assessment may be more appropriate.

Evaluating response shift in training evaluation: comparing the retrospective pretest with an adapted measurement invariance approach in a classroom management training program

BACKGROUND

Response shift (RS) can threaten the internal validity of pre-post designs. As RS may indicate a redefinition of the target construct, its occurrence in training evaluation is rather likely. The most common approach to deal with RS is to implement a retrospective pretest (then-test) instead of the traditional pre-test. In health psychology, an adapted measurement invariance approach (MIad) was developed as an alternative technique to study RS. Results produced by identifying RS with the two approaches were rarely studied simultaneously or within an experimental framework.

OBJECTIVES

To study RS in two different treatment conditions and compare results produced by both techniques in identifying various types of RS. We further studied validity aspects of the then-test.

RESEARCH DESIGN

We evaluated RS by applying the then-test procedure (TP) and the measurement invariance apporach MIad within an experimental design: Participants either attended a short-term or a long-term classroom management training program.

SUBJECTS

Participants were 146 student teachers in their first year of master's study.

MEASURES

Pre (before training), post, and then self-ratings (after training) on classroom management knowledge were administered.

RESULTS

Results indicated that the two approaches do not yield the same results. The MIad identified more and also group-specific RS as opposed to the findings of the TP, which found less and only little evidence for group-specific RS.

CONCLUSIONS

Further research is needed to study the usability and validity of the respective approaches. In particular, the usability of the then-test seems to be challenged.

Emotional vitality in caregivers: application of Rasch Measurement Theory with secondary data to development and test a new measure

OBJECTIVE

To describe the practical steps in identifying items and evaluating scoring strategies for a new measure of emotional vitality in informal caregivers of individuals who have experienced a significant health event.

DESIGN

The psychometric properties of responses to selected items from validated health-related quality of life and other psychosocial questionnaires administered four times over a one-year period were evaluated using Rasch Measurement Theory.

SETTING

Community.

SUBJECTS

A total of 409 individuals providing informal care at home to older adults who had experienced a recent stroke.

MAIN MEASURES

Rasch Measurement Theory was used to test the ordering of response option thresholds, fit, spread of the item locations, residual correlations, person separation index, and stability across time.

RESULTS

Based on a theoretical framework developed in earlier work, we identified 22 candidate items from a pool of relevant psychosocial measures available. Of these, additional evaluation resulted in 19 items that could be used to assess the five core domains. The overall model fit was reasonable (χ(2) = 202.26, DF = 117, p = 0.06), stable across time, with borderline evidence of multidimensionality (10%). Items and people covered a continuum ranging from -3.7 to +2.7 logits, reflecting coverage of the measurement continuum, with a person separation index of 0.85. Mean fit of caregivers was lower than expected (-1.31 ±1.10 logits).

CONCLUSION

Established methods from the Rasch Measurement Theory were applied to develop a prototype measure of emotional vitality that is acceptable, reliable, and can be used to obtain an interval level score for use in future research and clinical settings.