Creating meaningful cut-scores for Neuro-QOL measures of fatigue, physical functioning, and sleep disturbance using standard setting with patients and providers

Clarifying thresholds for defining levels of physical function and pain interference using bookmarking in orthopaedics

PURPOSE

Bookmarking is a qualitative method used to assign descriptive labels to ranges of patient-reported outcome (PROM) scores. We aimed to evaluate variability between bookmarking samples and test score ranges where there was variability in expert opinion in previous studies.

METHODS

We conducted two bookmarking sessions with patients who experienced orthopaedic fractures (n = 11) and one session with orthopaedic clinicians (n = 10). Participants reviewed vignettes comprised of PROM items and responses that represented hypothetical patients with a range of severity. Vignettes were constructed for PROMIS Upper Extremity Function, Physical Function, and Pain Interference measures. Participants placed bookmarks between vignettes that reflected different levels of severity (e.g., mild, moderate). The score reflecting the midpoint between vignettes was used as the recommended threshold between categories. We evaluated the variability in thresholds across participants, bookmarking panels, and previous studies.

RESULTS

Although patients and clinicians were not unanimous, the majority agreed on thresholds separating levels of severity for PROMIS Upper Extremity (≥ 40 = within normal limits, 30-39 = mild, 23-29 = moderate, < 23 = severe), PROMIS Physical Function (≥ 46 = within normal limits, 38-45 = mild, 26-37 = moderate, < 26 = severe), and PROMIS Pain Interference (≤ 50 = within normal limits, 51-60 = mild, 61-68 = moderate, > 68 = severe).

CONCLUSION

Testing new vignette scores within the same patient population enables more nuanced testing of score ranges without clear consensus and provides additional evidence for recommending thresholds for severity categories. These thresholds can be utilized to help interpret PROMIS scores from patients receiving orthopaedic care.

The Impact of Functionality and Psychological Outcome on Social Engagement 3-months after Intracerebral Hemorrhage

BACKGROUND

Although it is well-known that intracerebral hemorrhage (ICH) is associated with physical and psychological morbidity, there is scant data on factors influencing social engagement after ICH. Understanding the relationship between functionality, psychological outcome and social engagement post-bleed may facilitate identification of patients at high risk for social isolation after ICH.

METHODS

Patients ≥18-years-old with non-traumatic ICH from January 2015-March 2023 were identified from the Neurological Emergencies Outcomes at NYU (NEON) registry. Data on discharge functionality were collected from the medical record. 3-months post-bleed, patients/their legally-authorized representatives (LARs) were contacted to complete Neuro-QoL social engagement, anxiety, depression, and sleep inventories. Patients were stratified by ability to participate in social roles and activities (good=T-score>50, poor=T-score≤50) and satisfaction with social roles and activities (high=T-score>50 and low=T-score≤50). Univariate comparisons were performed to evaluate the relationship between post-bleed social engagement and both functionality and psychological outcome using Pearson's chi-square, Fisher's Exact test, and Mann-Whitney U tests. Multivariate logistic regression was subsequently performed using variables that were significant on univariate analysis (p<0.05).

RESULTS

The social engagement inventories were completed for 55 patients with ICH; 29 (53 %) by the patient alone, 14 (25 %) by a LAR alone, and 12 (22 %) by both patient and LAR. 15 patients (27 %) had good ability to participate in social roles and activities and 10 patients (18 %) had high satisfaction with social roles and activities. Social engagement was associated with both functionality and psychological outcome on univariate analysis, but on multivariate analysis, it was only related to functionality; post-bleed ability to participate in social roles and activities was associated with discharge home, discharge GCS score, discharge mRS score, and discharge NIHSS score (p<0.05) and post-bleed satisfaction with social roles and activities was related to discharge mRS score and discharge NIHSS score (p<0.05).

CONCLUSION

In patients with nontraumatic ICH, social engagement post-bleed was related to discharge functionality, even when controlling for depression, anxiety, and sleep disturbance.

Low resilience is associated with worse health-related quality of life in caregivers of service members and veterans with traumatic brain injury: a longitudinal study

PURPOSE

To examine [a] the association of caregiver health-related quality of life (HRQOL) and service member/veteran (SMV) neurobehavioral outcomes with caregiver resilience; [b] longitudinal change in resilience at the group and individual level; and [c] the magnitude of change at the individual level.

METHODS

Caregivers (N = 232) of SMVs with traumatic brain injury completed a resilience measure, and 18 caregiver HRQOL and SMV neurobehavioral outcome measures at a baseline evaluation and follow-up evaluation three years later. Caregivers were divided into two resilience groups at baseline and follow-up: [1] Low Resilience (≤ 45 T, baseline n = 99, follow-up n = 93) and [2] High Resilience (> 45 T, baseline n = 133, follow-up n = 139).

RESULTS

At baseline and follow-up, significant effects were found between Low and High Resilience groups for the majority of outcome measures. There were no significant differences in resilience from baseline to follow-up at the group-mean level. At the individual level, caregivers were classified into four longitudinal resilience groups: [1] Persistently Low Resilience (Baseline + Follow-up = Low Resilience, n = 60), [2] Reduced Resilience (Baseline = High Resilience + Follow-up = Low Resilience, n = 33), [3] Improved Resilience (Baseline = Low Resilience + Follow-up = High Resilience, n = 39), and [4] Persistently High Resilience (Baseline + Follow-up = High Resilience, n = 100). From baseline to follow-up, approximately a third of the Reduced and Improved Resilience groups reported a meaningful change in resilience (≥ 10 T). Nearly all of the Persistently High and Persistently Low Resilience groups did not report meaningful change in resilience (< 10 T).

CONCLUSION

Resilience was not a fixed state for all caregivers. Early intervention may stall the negative caregiving stress-health trajectory and improve caregiver resilience.

An Exploratory Analysis of Preclinical and Clinical Factors Associated With Sleep Disturbance Assessed via the Neuro-QoL After Hemorrhagic Stroke

Background and Purpose

Sleep disturbance after hemorrhagic stroke (intracerebral or subarachnoid hemorrhage) can impact rehabilitation, recovery, and quality of life. We sought to explore preclinical and clinical factors associated with sleep disturbance after hemorrhagic stroke assessed via the Quality of Life in Neurological Disorders (Neuro-QoL) short form sleep disturbance inventory.

Methods

We telephonically completed the Neuro-QoL short form sleep disturbance inventory 3-months and 12-months after hemorrhagic stroke for patients >18-years-old hospitalized between January 2015 and February 2021. We examined the relationship between sleep disturbance (T-score >50) and social and neuropsychiatric history, systemic and neurological illness severity, medical complications, and temporality.

Results

The inventory was completed for 70 patients at 3-months and 39 patients at 12-months; 18 (26%) had sleep disturbance at 3-months and 11 (28%) had sleep disturbance at 12-months. There was moderate agreement (κ = .414) between sleep disturbance at 3-months and 12-months. Sleep disturbance at 3-months was related to unemployment/retirement prior to admission (P = .043), lower Glasgow Coma Scale score on admission (P = .021), higher NIHSS score on admission (P = .041) and infection while hospitalized (P = .036). On multivariate analysis, sleep disturbance at 3-months was related to unemployment/retirement prior to admission (OR 3.58 (95% CI 1.03-12.37), P = .044). Sleep disturbance at 12-months was related to premorbid mRS score (P = .046).

Conclusion

This exploratory analysis did not demonstrate a sustained relationship between any preclinical or clinical factors and sleep disturbance after hemorrhagic stroke. Larger studies that include comparison to patients with ischemic stroke and healthy individuals and utilize additional techniques to evaluate sleep disturbance are needed.

Improvement of fatigue in generalised myasthenia gravis with zilucoplan

BACKGROUND

Fatigue is a debilitating symptom of myasthenia gravis (MG). The impact of fatigue on MG can be assessed by Quality of Life in Neurological Disorders (Neuro-QoL) Short Form Fatigue scale. Transformation of raw Neuro-QoL fatigue scores to T-scores is a known approach for facilitating clinical interpretation of clinically meaningful and fatigue severity thresholds.

METHODS

In the Phase 3, double-blind, placebo-controlled RAISE study (NCT04115293), adults with acetylcholine receptor autoantibody-positive generalised MG (MG Foundation of America Disease Class II-IV) were randomised 1:1 to daily subcutaneous zilucoplan 0.3 mg/kg or placebo for 12 weeks. Patients completing RAISE could opt to receive zilucoplan 0.3 mg/kg in an ongoing, open-label extension study, RAISE-XT (NCT04225871). In this post-hoc analysis, we evaluated the long-term effect of zilucoplan on fatigue in RAISE patients who entered RAISE-XT. We report change in Neuro-QoL Short Form Fatigue T-scores and fatigue severity levels from RAISE baseline to Week 60.

RESULTS

Mean Neuro-QoL Short Form Fatigue T-scores improved from baseline to Week 12 in the zilucoplan group (n = 86) with a clinically meaningful difference versus placebo (n = 88; least squares mean difference: - 3.61 (nominal p-value = 0.0060]), and these improvements continued further to Week 60. At Week 12, more patients on zilucoplan (n = 34, 47.2%) experienced improvements in ≥ 1 fatigue severity level from baseline versus placebo (n = 23, 28.4%; p = 0.017). At Week 60, most (n = 55, 65.5%) patients had mild fatigue or none.

CONCLUSION

Treatment with zilucoplan demonstrated statistical and clinically meaningful improvements in fatigue scores and severity versus placebo during RAISE, which were sustained to Week 60 in RAISE-XT.

Health outcomes before and during the COVID-19 pandemic in caregivers of service members and veterans with traumatic brain injury

PURPOSE

To examine change in health-related quality of life (HRQOL) during the COVID-19 pandemic in caregivers of service members/veterans (SMVs) with traumatic brain injury (TBI), by comparing HRQOL during the first year of the pandemic to HRQOL 12 months pre-pandemic.

METHODS

Caregivers (N = 246) were classified into three COVID-19 Pandemic Impact groups based on impact ratings of the pandemic on HRQOL: No Impact (n = 50), Mild Impact (n = 117), and Moderate-Severe Impact (n = 79). Caregivers completed 19 measures across physical, social, caregiving, and economic HRQOL domains, and a measure of SMV Adjustment. T-scores were used to determine individual symptom trajectories for each measure as follows: Asymptomatic (pre + during < 60 T); Developed (pre < 60 + during ≥ 60 T); Improved (pre ≥ 60 T + during < 60 T); and Persistent (pre + during ≥ 60 T).

RESULTS

Using ANOVA, during the pandemic, the Moderate-Severe Impact group reported worse scores on 19 measures (d = 0.41-0.89) compared to the No Impact group and 18 measures (d = 0.31-0.62) compared to the Mild Impact group (d  = 0.31-0.38). The Mild Impact group reported worse scores on two measures compared to the No Impact group (d = 0.42-0.43). Using the entire sample, the majority of HRQOL measures were classified as Asymptomatic (47.2-94.7%), followed by Persistent (2.4-27.2%). Few were classified as Developed (0.4-12.6%) or Improved (2.4-13.8%). Using repeated measures ANOVA, no meaningful effects sizes were found for mean scores on all measures completed pre-pandemic compared to during the pandemic (d ≤ 0.17).

CONCLUSION

The vast majority of caregivers reported stability in HRQOL pre-pandemic compared to during the pandemic. The COVID-19 pandemic was not associated with a high prevalence of decline in caregiver HRQOL.

No Increase in Symptoms Toward the End of the Ocrelizumab Infusion Cycle in Patients With Multiple Sclerosis: Symptom Burden on Ocrelizumab: A Longitudinal Study (SymBOLS)

Background and Objectives

Some patients with multiple sclerosis (MS) receiving ocrelizumab (OCR) report worsening symptoms toward the end of the 6-month infusion cycle ('wearing off'). The objective of our study was to comprehensively assess changes in symptom burden across 2 consecutive OCR infusion cycles.

Methods

SYMptom Burden on Ocrelizumab, a Longitudinal Study (SymBOLS; NCT04855617) was an investigator-initiated, 2-center study of patients with MS starting or receiving OCR. Patients' symptoms were assessed with NeuroQoL short forms, SymptoMScreen, and Work Productivity and Activity Impairment Questionnaire at the start-cycle, mid-cycle, and end-cycle time points in each of the 2 infusion cycles. Symptom scores at the 3 time points within each cycle were compared with repeated-measures ANOVA or the Friedman rank-sum test for non-normal variables. The proportions of patients with a meaningful symptomatic change from the start to the end of each infusion cycle were calculated, and patients whose symptoms improved, worsened, and stayed the same from the start to the end of the cycle were compared with respect to demographic and clinical characteristics.

Results

One hundred three patients with MS provided longitudinal data for analyses (mean age [SD]: 46.7 [12.2] years, 68% female, 33% non-White, disease duration: 15.5 [5] years, 41% with the Extended Disability Status Scale score >3). On a group level, NeuroQoL and SymptoMScreen scores mostly remained stable or even improved slightly toward the end of each cycle. On an individual level, symptoms remained unchanged across either cycle for most patients, and meaningful symptom worsening from the start to the end of the cycle was no more common than improvement. Meaningful change in symptoms in both cycles was very rare and generally in the direction of improvement toward the end cycle. Despite the lack of evidence for symptom worsening with a longer time from infusion, 54% of patients endorsed feeling of "wearing off" at least sometimes, most commonly as an increase in fatigue.

Discussion

Our prospective study failed to uncover evidence for the worsening of symptoms with a longer time from OCR infusion. These findings cast doubt on the existence of wearing off as a physiologic phenomenon in OCR-treated patients with MS. The perception of wearing off is likely the result of natural fluctuations in MS symptoms and attribution bias.

Using bookmarking methods with orthopedic clinicians and patients with fractures produces score interpretation labels for patient-reported outcome measures

OBJECTIVE

The objective of this study was to determine the patient-reported outcome measure (PROM) score ranges associated with descriptive labels (i.e., within normal limits, mild, moderate, severe) by using bookmarking methods with orthopedic clinicians and patients who have experienced a bone fracture.

STUDY DESIGN AND SETTING

We created vignettes comprised of six items and responses from the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Function, Physical Function, and Pain Interference item banks reflecting different levels of severity. Two groups of patients with fractures (n = 11) and two groups of orthopedic clinicians (n = 16) reviewed the vignettes and assigned descriptive labels independently and then discussed as a group until reaching consensus via a videoconference platform.

RESULTS

PROMIS Physical Function and Pain Interference thresholds (T = 50, 40, 25/30 and T = 50/55, 60, 65/70, respectively) for patients with bone fractures were consistent with the results from other patient populations. Upper Extremity thresholds were about 10 points (1 SD) more severe (T = 40, 30, 25/20) compared to the other measures. Patient and clinician perspectives were similar.

CONCLUSION

Bookmarking methods generated meaningful score thresholds for PROMIS measures. These thresholds between severity categories varied by domain. Threshold values for severity represent important supplemental information to interpret PROMIS scores clinically.

Factors Associated With Anxiety After Hemorrhagic Stroke

OBJECTIVE

A significant number of patients develop anxiety after stroke. The objective of this study was to identify risk factors for anxiety after hemorrhagic stroke that may facilitate diagnosis and treatment.

METHODS

Patients admitted between January 2015 and February 2021 with nontraumatic hemorrhagic stroke (intracerebral [ICH] or subarachnoid [SAH] hemorrhage) were assessed telephonically 3 and 12 months after stroke with the Quality of Life in Neurological Disorders Anxiety Short Form to evaluate the relationships between poststroke anxiety (T score >50) and preclinical social and neuropsychiatric history, systemic and neurological illness severity, and in-hospital complications.

RESULTS

Of 71 patients who completed the 3-month assessment, 28 (39%) had anxiety. There was a difference in Glasgow Coma Scale (GCS) scores on admission between patients with anxiety (median=14, interquartile range [IQR]=12-15) and those without anxiety (median=15, IQR=14-15) (p=0.034), and the incidence of anxiety was higher among patients with ICH (50%) than among those with SAH (20%) (p=0.021). Among patients with ICH, anxiety was associated with larger median ICH volume (25 cc [IQR=8-46] versus 8 cc [IQR=3-13], p=0.021) and higher median ICH score (2 [IQR=1-3] versus 1 [IQR=0-1], p=0.037). On multivariable analysis with GCS score, hemorrhage type, and neuropsychiatric history, only hemorrhage type remained significant (odds ratio=3.77, 95% CI=1.19-12.05, p=0.024). Of the 39 patients who completed the 12-month assessment, 12 (31%) had anxiety, and there was a difference in mean National Institutes of Health Stroke Scale scores between patients with (5 [IQR=3-12]) and without (2 [IQR=0-4]) anxiety (p=0.045). There was fair agreement (κ=0.38) between the presence of anxiety at 3 and 12 months.

CONCLUSIONS

Hemorrhage characteristics and factors assessed with neurological examination on admission are associated with the development of poststroke anxiety.

Online Symptom Monitoring During Pelvic Radiation Therapy: Randomized Pilot Trial of the eRAPID Intervention

PURPOSE

Radiation therapy (RT) and chemoRT for pelvic cancers increase survival but are associated with serious treatment-related symptoms. Electronic-patient self-Reporting of Adverse-events: Patient Information and aDvice (eRAPID) is a secure online system for patients to self-report symptoms, generating immediate advice for hospital contact or self-management. This pilot study aimed to establish feasibility and acceptability of the system.

METHODS AND MATERIALS

In a prospective 2-center randomized parallel-group pilot study, patients undergoing radical pelvic RT for prostate cancer (prostateRT) or chemoRT for lower gastrointestinal and gynecological cancers were randomized to usual care (UC) or eRAPID (weekly online symptom reporting for 12, 18, and 24 weeks). Primary outcomes were recruitment/attrition, study completion, and patient adherence. Secondary outcomes were effect on hospital services and performance of patient outcome measures. Missing data, floor/ceiling effects, and mean change scores were examined for Functional Assessment of Cancer Therapy (FACT-G), European Organisation for Research and Treatment of Cancer, Quality of Life (EORTC QLQ C-30), self-efficacy, and EuroQol (EQ5D).

RESULTS

From 228 patients approached, 167 (73.2%) were consented and randomized (83, eRAPID; 84, UC; 87, prostateRT; 80, chemoRT); 150 of 167 completed 24 study weeks. Only 16 patients (9.6%) withdrew (10, eRAPID; 6, UC). In the eRAPID arm, completion rates were higher in patients treated with prostateRT compared with chemoRT (week 1, 93% vs 69%; week 2, 93% vs 68%; week 12, 69% vs 55%). Overall, over 50% of online reports triggered self-management advice for milder adverse events. Unscheduled hospital contact was low, with no difference between eRAPID and UC. Return rates for outcome measures were excellent in prostateRT (97%-91%; 6-24 weeks) but lower in chemoRT (95%-55%; 6-24 weeks). Missing data were low (1%-4.1%), ceiling effects were evident in EQ5D-5L, self-efficacy-scale, and FACT-Physical Wellbeing. At 6 weeks, the chemoRT-eRAPID group showed less deterioration in FACT-G, EORTC QLQ-C30, and EQ5D-Visual Analogue Scale than UC, after baseline adjustment.

CONCLUSIONS

eRAPID was successfully added to UC at 2 cancer centers in different patient populations. Acceptability and feasibility were confirmed with excellent adherence by prostate patients, but lower by those undergoing chemoRT for gynecological cancers.

Establishing severity levels for patient-reported measures of functional communication, participation, and perceived cognitive function for adults with acquired cognitive and language disorders

PURPOSE

To empirically assign severity levels (e.g., mild, moderate) to four relatively new patient-reported outcome measures (PROMs) for adults with acquired cognitive/language disorders. They include the Communicative Participation Item Bank, the Aphasia Communication Outcome Measure, and Neuro-QoL's item banks of Cognitive Function (v2.0) and Ability to Participate in Social Roles and Activities (v1.0).

METHOD

We conducted 17 focus groups that comprised 22 adults with an acquired cognitive/language disorder from stroke, Parkinson's disease, or traumatic brain injury; 30 care partners of an adult with an acquired cognitive/language disorder; and 42 speech-language pathologists who had experience assessing/treating individuals with those and other cognitive/language disorders. In a small, moderated focus-group format, participants completed "PROM-bookmarking" procedures: They discussed hypothetical vignettes based on PROM item responses about people with cognitive/language disorders and had to reach consensus regarding whether their symptoms/function should be categorized as within normal limits or mild, moderate, or severe challenges.

RESULTS

There was generally good agreement among the stakeholder groups about how to classify vignettes, particularly when they reflected very high or low functioning. People with aphasia described a larger range of functional communication challenges as "mild" compared to other stakeholder types. Based on a consensus across groups, we present severity levels for specific score ranges for each PROM.

CONCLUSION

Standardized, stakeholder-informed severity levels that aid interpretation of PROM scores can help clinicians and researchers derive better clinical meaning from those scores, for example, by identifying important clinical windows of opportunity and assessing when symptoms have returned to a "normal" range.

Exploring the impact of the COVID-19 pandemic on social isolation and mental health in people with MS

BACKGROUND

People with multiple sclerosis (MS) may be disproportionally impacted by the coronavirus disease of 2019 (COVID-19) as various factors important to their functioning and quality of life are at-risk and/or compromised during the pandemic. In particular, the social distancing and quarantine practice during the pandemic maybe detrimental to MS patients' social and emotional health. Compared with the general population, MS patients may be under increased social strain and suffer worse health consequences from social isolation. To date, there has been no research examining the social consequences of the pandemic on MS patients' emotional and social health.

METHODS

This is a retrospective longitudinal study of 266 adults with MS who were followed at a large academic medical center in the Midwest. Each participant completed monthly surveys including depression, anxiety, and social health variables.

RESULTS

T-Tests shows worse anxiety (95% CI [-5.03, -3.05]; p-value < 0.001), worse depression (95% CI [-2.67, -1.03]; p-value < 0.001), and worse satisfaction with social roles (95% CI [2.37, 3.95]; p-value < 0.001) since the COVID-19 outbreak (March 2020). Social isolation is associated with worse anxiety (95% CI [-8.98, -4.58]; p-value < 0.001) and depression (95% CI [-6.88, -3.24]; p-value < 0.001). However, individuals who had in-person visits before and after the outbreak did not experience any changes in anxiety, depression, or social health.

CONCLUSION

MS patients' anxiety, depression, and social participation worsened during the COVID-19 pandemic. Social isolation is found to be associated with worse anxiety and depression. However, those who attended in-person visits for their MS treatment did not experience negative changes in their emotional or social health. This study highlights the importance of healthcare provider's alertness to MS patients' social health and the interplay between social and emotional health during the COVID-19 pandemic.

Caregiver sleep impairment and service member and veteran adjustment following traumatic brain injury is related to caregiver health-related quality of life

STUDY OBJECTIVES

To examine the relationship between caregiver sleep impairment and/or service member/veteran (SMV) adjustment post-traumatic brain injury, with caregiver health-related quality of life (HRQOL).

METHODS

Caregivers (n = 283) completed 18 measures of HRQOL, sleep impairment, and SMV adjustment. Caregivers were classified into 4 sleep impairment/SMV adjustment groups: 1) Good Sleep/Good Adjustment (n = 43), 2) Good Sleep/Poor Adjustment (n = 39), 3) Poor Sleep/Good Adjustment (n = 55), and 4) Poor Sleep/Poor Adjustment (n = 146).

RESULTS

The Poor Sleep/Poor Adjustment group reported significantly worse scores on most HRQOL measures and a higher prevalence of clinically elevated T-scores (≥ 60T) on the majority of comparisons compared to the other 3 groups. The Good Sleep/Poor Adjustment and Poor Sleep/Good Adjustment groups reported worse scores on the majority of the HRQOL measures and a higher prevalence of clinically elevated scores on 7 comparisons compared to the Good Sleep/Good Adjustment group. Fewer differences were found between the Good Sleep/Poor Adjustment and Poor Sleep/Good Adjustment groups. The Poor Sleep/Poor Adjustment group reported a higher prevalence of severe ratings for SMV Irritability, Anger, and Aggression compared to the Good Sleep/Poor Adjustment group.

CONCLUSIONS

While the presence of either caregiver sleep impairment or poor SMV adjustment singularly was associated with worse caregiver HRQOL, the presence of both sleep impairment and poor SMV adjustment was associated with further impairment in HRQOL. Caregivers could benefit from sleep intervention. Treatment of SMVs neurobehavioral problems may improve the SMV's recovery and lessen sleep problems, distress, and burden among their caregivers.

CITATION

Brickell TA, Wright MM, Sullivan JK, et al. Caregiver sleep impairment and service member and veteran adjustment following traumatic brain injury is related to caregiver health-related quality of life. J Clin Sleep Med. 2022;18(11):2577-2588.

Development and Implementation of the Cochlear Implant Quality of Life (CIQOL) Functional Staging System

OBJECTIVES

The purpose of this study is to develop and implement a functional staging system using the Cochlear Implant Quality of Life (CIQOL) framework. The CIQOL-35 Profile was developed and validated following a rigorous research design and found to be more comprehensive and psychometrically sound than previous patient-reported outcome measures (PROMs) applied to adult CI users. However, interpreting the CIQOL-35 Profile (and all PROMs) relative to real-world functioning remains difficult for patients and clinicians, which limits the capacity of PROMs to direct clinical care. To address this limitation, a functional staging system based on PROM scores was developed to provide detailed descriptions of patients' self-reported abilities (clinical vignettes) without sacrificing the inherent value of the psychometrically derived scores. The current study (1) creates an evidence-based CIQOL functional staging system using advanced psychometric techniques, (2) confirms the clarity and meaningfulness of the staging system with patients, and (3) implements the staging system to measure CIQOL stage progression using data from a longitudinal study design.

METHODS

Item response theory (IRT) analyses of CIQOL-35 Profile data from 705 experienced adult CI users and expert opinion were used to determine the cut-scores that separated adjacent stages for the six CIQOL-35 domains (communication, emotional, entertainment, environment, listening effort, and social). The research team then created clinical vignettes based on item response patterns for each stage. Semi-structured key informant interviews were conducted with 10 adult CI users to determine the clarity and meaningfulness of the CIQOL stages and associated clinical vignettes. Finally, we prospectively collected CIQOL-35 Profile scores from 42 CI users prior to cochlear implantation and then at 3- and 6-months post-CI activation to measure CIQOL stage progression.

RESULTS

Psychometric analyses identified five statistically distinct stages for the communication domain and three stages for all other domains. Using IRT analysis results for guidance, research team members independently identified the cut-scores that represented transitions between the functional stages for each domain with excellent agreement (κ = 0.98 [95% confidence interval 0.96-0.99]). Next, the key informant interviews revealed that CI users found the clinical vignettes to be clear and only minor changes were required. Participants also agreed that stage progression represented meaningful improvements in functional abilities. Finally, 88.1% of 42 patients in the prospective cohort (n = 37) improved from pre-CI functional stage by at least one functional stage in one or more domains. The communication domain had the greatest number of patients improve by one or more stages (59.5%) and the social domain the fewest (25.6%). There was also a trend for less improvement at 3- and 6-months post-CI activation for patients at higher pre-CI functional stages, even though higher stages were achievable.

CONCLUSION

The new CIQOL functional staging system provides an evidence-based understanding of the real-world functional abilities of adult CI users from pre-CI to 3- to 6-months post-CI activation across multiple domains. In addition, study results provide the proportion of CI users in each stage at each timepoint. Results can be used during discussions of expectations with potential CI users to provide enhanced insight regarding realistic outcomes and the anticipated timing for improvements. The use of the CIQOL functional staging system also presents an opportunity to develop individualized goal-based rehabilitation strategies that target barriers to stage advancement faced by CI users.

LEVEL OF EVIDENCE

2 Laryngoscope, 132:S1-S13, 2022.

Common measures or common metrics? A plea to harmonize measurement results

OBJECTIVE

There is a great variety of measurement instruments to assess similar constructs in clinical research and practice. This complicates the interpretation of test results and hampers the implementation of measurement-based care.

METHOD

For reporting and discussing test results with patients, we suggest converting test results into universally applicable common metrics. Two well-established metrics are reviewed: T scores and percentile ranks. Their calculation is explained, their merits and drawbacks are discussed, and recommendations for the most convenient reference group are provided.

RESULTS

We propose to express test results as T scores with the general population as reference group. To elucidate test results to patients, T scores may be supplemented with percentile ranks, based on data from a clinical sample. The practical benefits are demonstrated using the published data of four frequently used instruments for measuring depression: the CES-D, PHQ-9, BDI-II and the PROMIS depression measure.

DISCUSSION

Recent initiatives have proposed to mandate a limited set of outcome measures to harmonize clinical measurement. However, the selected instruments are not without flaws and, potentially, this directive may hamper future instrument development. We recommend using common metrics as an alternative approach to harmonize test results in clinical practice, as this will facilitate the integration of measures in day-to-day practice.

Is Traumatic Brain Injury Severity in Service Members and Veterans Related to Health-Related Quality of Life in Their Caregivers?

OBJECTIVE

To examine the relationship between service member/veteran (SM/V) traumatic brain injury (TBI) severity with caregiver health-related quality of life (HRQOL).

SETTING

Military treatment facility.

PARTICIPANTS

Caregivers (N = 316) of SM/Vs following a TBI divided into 2 groups based on SM/V TBI severity: (1) caregivers of SM/Vs following an uncomplicated mild TBI (UnMTBI Caregiver group, n = 246), and (2) caregivers of SM//Vs following a complicated mild, moderate, severe, or penetrating TBI (STBI Caregiver group, n = 70). The STBI Caregiver group was further divided into 2 subgroups: Parent (n = 21) versus Intimate Partner (n = 49). The UnMTBI Caregiver group consisted of intimate partners.

DESIGN

Prospective cohort.

MAIN MEASURES

Caregivers completed 15 HRQOL measures.

RESULTS

Using analysis of variance and chi-square analysis, the UnMTBI Caregiver group reported worse scores on 12 HRQOL measures and more clinically elevated scores for 6 of 15 comparisons than the STBI Caregiver group. The UnMTBI Caregiver group also reported worse scores on 10 HRQOL measures than intimate partners in the STBI Caregiver group and 5 measures than parents in the STBI Caregiver group. Parents reported worse scores on 3 measures than intimate partners in the STBI Caregiver group. The UnMTBI Caregiver group reported more clinically elevated scores for 7 of 15 comparisons than intimate partners in the STBI Caregiver group.

CONCLUSION

Intimate partner caregivers of an SM/V following a remote uncomplicated MTBI reported worse HRQOL than intimate partners and parent caregivers of an SM/V following a more severe TBI, mostly likely due to SM/V physical and mental health comorbidities. Interventions that focus on the SM/V's TBI and other comorbidities, the caregiver's behavioral health problems, and the relationship and family factors that interact with each other will likely have the most success in improving individual and family outcomes for military families.

Aggression in Military Members With Mild Traumatic Brain Injury and Post-Traumatic Stress Disorder Is Associated With Intimate Partner Health-Related Quality of Life

OBJECTIVE

We aimed to examine the relationship between service member/veteran (SMV) aggression and health-related quality of life (HRQOL) in their intimate partners.

METHODS

This prospective cohort study included 201 female intimate partner caregivers of post-9/11 male SMVs with a diagnosis of uncomplicated mild traumatic brain injury and post-traumatic stress disorder from a military treatment facility. Caregivers completed 17 HRQOL measures and rated the level the SMV experiences problems with verbal or physical expressions of irritability, anger, or aggression on the Mayo-Portland Adaptability Inventory, 4th edition. Caregivers were classified into three SMV Aggression groups: i) none or very mild (n = 53); ii) mild (n = 47); and iii) moderate or severe (n = 101). HRQOL scores were classified as clinically elevated using a cutoff of 60T or higher.

RESULTS

Using χ² analysis, the moderate or severe group had a significantly higher proportion of clinically elevated scores on 15 HRQOL measures compared with the none or very mild group, and six measures compared with the mild group. The mild group had higher scores on two measures compared with the none or very mild group. Using analysis of covariance (and controlling for caregiver strain), the moderate or severe group had significantly higher scores on 11 HRQOL measures compared with the none or very mild group, and two measures compared with the mild group. The mild group had higher scores on five measures compared with the none or very mild group.

CONCLUSIONS

Many caregivers who report moderate to severe SMV aggression after a traumatic brain injury, report poor HRQOL beyond the strain of care provision. Traumatic brain injury and post-traumatic stress disorder programs should screen for and treat SMV aggression, and attend to the health needs of their caregivers.

Psychological Outcome after Hemorrhagic Stroke is Related to Functional Status

BACKGROUND

To identify opportunities to improve morbidity after hemorrhagic stroke, it is imperative to understand factors that are related to psychological outcome.

DESIGN/METHODS

We prospectively identified patients with non-traumatic hemorrhagic stroke (intracerebral or subarachnoid hemorrhage) between January 2015 and February 2021 who were alive 3-months after discharge and telephonically assessed 1) psychological outcome using the Quality of Life in Neurological Disorders anxiety, depression, emotional and behavioral dyscontrol, fatigue and sleep disturbance inventories and 2) functional outcome using the modified Rankin Scale (mRS) and Barthel Index. We also identified discharge destination for all patients. We then evaluated the relationship between abnormal psychological outcomes (T-score >50) and discharge destination other than home, poor 3-month mRS score defined as 3-5 and poor 3-month Barthel Index defined as <100.

RESULTS

73 patients were included; 41 (56%) had an abnormal psychological outcome on at least one inventory. There were 41 (56%) patients discharged to a destination other than home, 44 (63%) with poor mRS score and 28 (39%) with poor Barthel Index. Anxiety, depression, emotional and behavioral dyscontrol and sleep disturbance were all associated with a destination other than home, poor mRS score, and poor Barthel Index (all p<0.05). Fatigue was related to poor mRS score and poor Barthel Index (p=0.005 and p=0.006, respectively).

CONCLUSION

Multiple psychological outcomes 3-months after hemorrhagic stroke are related to functional status. Interventions to improve psychological outcome and reduce morbidity in patients with poor functional status should be explored by the interdisciplinary team.

Adapting a Patient-Reported Outcome Bookmarking Task to be Accessible to Adults With Cognitive and Language Disorders

Background Patient-reported outcome (PRO) measures produce scores that do not always have obvious clinical meaning. The PRO-bookmarking procedure is a new and promising way to make PRO measures more meaningful and interpretable. However, the materials and procedures of the task may benefit from adaptations to be more accessible to individuals with cognitive and language disorders. Aims This study aims to provide an overview of the iterative refinement process used to modify the materials and procedures of the PRO-bookmarking task so that they are more accessible to adults with acquired cognitive and language impairments. Method and Procedures Our team of health psychologists, neuropsychologists, and speech-language pathologists (SLPs) conducted two focus groups with SLPs and care partners of people with aphasia using the same PRO-bookmarking materials and procedures as previous reports. These PRO-bookmarking materials and procedures were then refined iteratively based on discussion with those who participated in focus groups and among the research team, and three more times in the course of 16 additional focus groups of different stakeholders: people with Parkinson's disease, aphasia, or traumatic brain injury; care partners of people with those conditions; and SLPs who have experience with those, and other adult-acquired conditions. Outcomes and Results The PRO-bookmarking materials and procedures underwent four iterations to make them clearer, simpler, and more accessible. For example, the materials included more structured text and graphic supports where appropriate and the procedures were clustered into smaller discrete tasks and displayed graphically when possible and appropriate. Conclusions PRO-bookmarking materials and procedures were made simpler and more structured to increase their accessibility to adults with cognitive and language impairments. In fact, these adaptations made the tasks simpler and clearer for all types of stakeholders.

Patients and clinicians define symptom levels and meaningful change for PROMIS pain interference and fatigue in RA using bookmarking

OBJECTIVES

Using patient-reported outcomes to inform clinical decision-making depends on knowing how to interpret scores. Patient-Reported Outcome Measurement Information System® (PROMIS®) instruments are increasingly used in rheumatology research and care, but there is little information available to guide interpretation of scores. We sought to identify thresholds and meaningful change for PROMIS Pain Interference and Fatigue scores from the perspective of RA patients and clinicians.

METHODS

We developed patient vignettes using the PROMIS item banks representing a continuum of Pain Interference and Fatigue levels. During a series of face-to-face 'bookmarking' sessions, patients and clinicians identified thresholds for mild, moderate and severe levels of symptoms and identified change deemed meaningful for making treatment decisions.

RESULTS

In general, patients selected higher cut points to demarcate thresholds than clinicians. Patients and clinicians generally identified changes of 5-10 points as representing meaningful change. The thresholds and meaningful change scores of patients were grounded in their lived experiences having RA, approach to self-management, and the impacts on function, roles and social participation.

CONCLUSION

Results offer new information about how both patients and clinicians view RA symptoms and functional impacts. Results suggest that patients and providers may use different strategies to define and interpret RA symptoms, and select different thresholds when describing symptoms as mild, moderate or severe. The magnitude of symptom change selected by patients and clinicians as being clinically meaningful in interpreting treatment efficacy and loss of response may be greater than levels determined by external anchor and statistical methods.

Postintensive Care Syndrome in Survivors of Critical Illness Related to Coronavirus Disease 2019: Cohort Study From a New York City Critical Care Recovery Clinic

OBJECTIVE

Determine the characteristics of postintensive care syndrome in the cognitive, physical, and psychiatric domains in coronavirus disease 2019 ICU survivors.

DESIGN

Single-center descriptive cohort study from April 21, to July 7, 2020.

SETTING

Critical care recovery clinic at The Mount Sinai Hospital in New York City.

PATIENTS

Adults who had critical illness due to coronavirus disease 2019 requiring an ICU stay of 7 days or more and who agreed to a telehealth follow-up in the critical care recovery clinic 1-month post hospital discharge.

INTERVENTIONS

None.

MEASURES AND MAIN RESULTS

Patient-reported outcome measures assessing physical and psychiatric domains were collected electronically, a cognitive test was performed by a clinician, and clinical data were obtained through electronic medical records. Outcome measures assessed postintensive care syndrome symptoms in the physical (Modified Rankin Scale, Dalhousie Clinical Frailty Scale, Neuro-Quality of Life Upper Extremity and Lower Extremity Function, Neuro-Quality of Life Fatigue), psychiatric (Insomnia Severity Scale; Patient Health Questionnaire-9; and Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), and cognitive (Telephone Montreal Cognitive Assessment) domains. The 3-Level Version of Euro-QoL-5D was used to assess the physical and psychiatric domains. A diagnosis of postintensive care syndrome was made in cases with evidence of impairment in at least one postintensive care syndrome domain. We included 45 patients with a mean (sd) age of 54 (13) years, and 73% were male. Ninety-one percent of coronavirus disease 2019 ICU survivors fit diagnostic criteria for postintensive care syndrome. 86.7 % had impairments in the physical domain, 22 (48%) reported impairments in the psychiatric domain, and four (8%) had impairments on cognitive screening. We found that 58% had some degree of mobility impairment. In the psychiatric domain, 38% exhibited at least mild depression, and 18 % moderate to severe depression. Eighteen percent presented Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, scores suggestive of posttraumatic stress syndrome diagnosis. In the Telephone Montreal Cognitive Assessment, 9% had impaired cognition.

CONCLUSIONS

Survivors of critical illness related to coronavirus disease 2019 are at high risk of developing postintensive care syndrome. These findings highlight the importance of planning for appropriate post-ICU care to diagnose and treat this population.

Emotional Suppression and Hypervigilance in Military Caregivers: Relationship to Negative and Positive Affect

OBJECTIVE

To investigate the relationship of 2 health-related quality-of-life (QOL) item banks (Emotional Suppression and Caregiver Vigilance), developed for caregivers of service members/veterans with traumatic brain injury (TBI), to caregivers' positive and negative affect.

SETTING

Community.

PARTICIPANTS

One hundred sixty-five caregivers of service members/veterans with TBI.

DESIGN

Retrospective database analysis.

MAIN MEASURES

TBI-CareQOL Emotional Suppression; TBI-CareQOL Caregiver Vigilance; measures of negative (Patient-Reported Outcomes Measurement Information System [PROMIS] Depression, PROMIS Anger, TBI-CareQOL Caregiver-Specific Anxiety, National Institutes of Health Toolbox [NIHTB] Perceived Stress, GAD-7) and positive affect (Neuro-QOL Positive Affect and Well-being, NIHTB Self-efficacy, NIHTB General Life Satisfaction, Family Resilience Scale for Veterans, TBI-QOL Resilience).

RESULTS

When considered separately, linear regression showed that higher levels of Emotional Suppression and greater Caregiver Vigilance were individually associated with more negative affect and less positive affect. When considered together, the pattern of findings was generally consistent for both Emotional Suppression and Caregiver Vigilance with regard to negative affect and for Emotional Suppression with regard to positive affect. However, when considered together, Caregiver Vigilance was no longer related to positive affect.

CONCLUSIONS

Caregivers with high emotional suppression and/or vigilance are more likely to show emotional distress and less likely to have positive affect than caregivers with lower levels of emotional suppression and vigilance. A combination of education and individual counseling targeting coping with negative emotions and TBI-related problems may be beneficial.

Clinical Use of PROMIS, Neuro-QoL, TBI-QoL, and Other Patient-Reported Outcome Measures for Individual Adult Clients with Cognitive and Language Disorders

Patient-reported outcome measures (PROMs) assess health outcomes from the patient's perspective. The National Institutes of Health has invested in the creation of numerous PROMs that comprise the PROMIS, Neuro-QoL, and TBI-QoL measurement systems. Some of these PROMs are potentially useful as primary or secondary outcome measures, or as contextual variables for the treatment of adults with cognitive/language disorders. These PROMs were primarily created for clinical research and interpretation of group means. They also have potential for use with individual clients; however, at present there is only sparse evidence and direction for this application of PROMs. Previous research by Cohen and Hula (2020) described how PROMs could support evidence-based practices in speech-language pathology. This companion article extends upon that work to present clinicians with implementation information about obtaining, administering, scoring, and interpreting PROMs for individual clients with cognitive/language disorders. This includes considerations of the type and extent of communication support that is appropriate, implications of the relatively large measurement error that accompanies individual scores and pairs of scores, and recommendations for applying minimal detectable change values depending on the clinician's desired level of measurement precision. However, more research is needed to guide the interpretation of PROM scores for an individual client.

Choosing and Using Patient-Reported Outcome Measures in Clinical Practice

The increasing use of patient-reported outcome (PRO) measures is forcing clinicians and health care systems to decide which to select and how to incorporate them into their records and clinical workflows. This overview addresses 3 topics related to these concerns. First, a literature review summarizes key psychometric and practical factors (such as reliability, responsiveness, computer adaptive testing, and interpretability) in choosing PROs for clinical practice. Second, 3 clinical decision support issues are highlighted: gathering PROs, electronic health record effect on providers, and incorporating PROs into clinical decision support design and implementation. Lastly, the salience of crosscutting domains as well as 9 key pragmatic decisions are reviewed. Crosscutting domains are those that are relevant across most medical and mental health conditions, such as the SPADE symptom pentad (sleep problems, pain, anxiety, depression, low energy/fatigue) and physical functioning. The 9 pragmatic decisions include (1) generic vs disease-specific scales; (2) single- vs multidomain scales; (3) universal scales vs user-choice selection; (4) number of domains to measure; (5) prioritization of domains when multiple domains are assessed; (6) action thresholds; (7) clinical purpose (screening vs monitoring); as well as the (8) frequency and (9) logistical aspects of PRO administration.

Interpreting Life Impact Burn Recovery Evaluation Profile Scores for Use by Clinicians, Burn Survivors, and Researchers

The Life Impact Burn Recovery Evaluation (LIBRE) Profile is a patient-reported outcome measure developed to assess social participation in adult burn survivors. This study identified numeric score cut-points that define different levels of social participation ability and described each level. An expert panel identified numeric score cut-points that distinguish different levels of social participation for the six LIBRE Profile domains. Methods employed an iterative, modified-Delphi approach, and bookmarking to review calibrated item banks. Analyses (using calibration sample data and repeated in a validation sample) examined means, SDs, and sample distributions for each level. Analyses of variance examined score differences between levels. The panel developed descriptions for each established level. Initial cut-points resulted in four levels for five domains (Social Activities, Social Interactions, Romantic Relationships, Sexual Relationships, and Work & Employment) and five levels for the sixth domain (Relationships with Family & Friends). Comparisons demonstrated significant differences between level mean scores for all domains (P < .05) except Relationships with Family & Friends. Based on follow-up surveys, Relationships with Family & Friends score cut-points were adjusted to identify four levels with significant score differences between all levels. Panelists reached consensus for level descriptions. Score cut-points and descriptions identify different levels of social participation, providing a relevant context for interpreting LIBRE Profile numeric scores. LIBRE Profile Social Participation levels will help clinicians and persons with burn injury interpret LIBRE Profile numeric scores and promote use of this important new assessment.

Psychometric properties of a new self-report measure of medical student stress using classic and modern test theory approaches

Background

Medical students face significant stressors related to the intense rigors of their training and education. Accurate measurement of their stress is important to quickly identify, characterize and ameliorate these challenges. Existing measures have limitations that modern measurement approaches, such as item response theory (IRT), are able to address. This study presents the calibration and validation of a new IRT-based measure called the Medical Student Stress Scale (MSSS).

Methods

Following rigorous measurement development procedures described elsewhere, the authors created and tested a pool of 35 items with 348 1st – 4th year medical students along with demographic and external validity measures. Psychometric analysis included exploratory and confirmatory factor analyses, IRT modeling, and correlations with legacy measures.

Results

Of the original 35 items, 22 were retained based on their ability to discriminate, provide meaningful information, and perform well against legacy measures. The MSSS differentiated stress scores between male and female students, as well as between year in school.

Conclusion

Developed with input from medical students, the MSSS represents a student-centered measurement tool that provides precise, relevant information about stress and holds potential for screening and outcomes-related applications.

Development and initial validation of ability levels to interpret pediatric spinal cord injury activity measure and pediatric measure of participation scores

PURPOSE

To develop ability levels and descriptions to interpret Pediatric Spinal Cord Injury Activity Measure (PEDI-SCI AM) and Pediatric Measure of Participation (PMoP) scores.

METHODS

Mixed-methods approach to 1.) create item maps using PEDI-SCI AM and PMoP calibration data; 2.) employ bookmarking methods and an iterative consensus process including semi-structured interviews, focus groups and surveys to establish PEDI-SCI AM and PMoP level score cut-points and descriptions; 3.) use calibration sample data to examine mean score differences across levels [analyses of variance (ANOVAs)] and assess the sample distribution (%) across levels; 4.) repeat in a separate validation sample; 5.) develop level descriptions. Throughout the mixed methods approach, the sample participants include children with spinal cord injury (SCI), parents of children with SCI, and professionals who work with children with SCI.

RESULTS

Four or five ability levels were identified for each PEDI-SCI AM and PMoP domain along with descriptions for each level. ANOVA results revealed significant overall differences for level mean scores and pairwise comparisons (p < 0.05). Consensus (>80%) was achieved for all PEDI-SCI AM and some PMoP level descriptions.

CONCLUSION

PEDI-SCI AM and PMoP score cut-points identify different levels of activity and participation among children with SCI. These levels and descriptions provide clinical relevance for PEDI-SCI and PMoP numeric scores.

Evaluating the Utility of Smartphone-Based Sensor Assessments in Persons With Multiple Sclerosis in the Real-World Using an App (elevateMS): Observational, Prospective Pilot Digital Health Study

Background

Multiple sclerosis (MS) is a chronic neurodegenerative disease. Current monitoring practices predominantly rely on brief and infrequent assessments, which may not be representative of the real-world patient experience. Smartphone technology provides an opportunity to assess people’s daily-lived experience of MS on a frequent, regular basis outside of episodic clinical evaluations.

Objective

The objectives of this study were to evaluate the feasibility and utility of capturing real-world MS-related health data remotely using a smartphone app, “elevateMS,” to investigate the associations between self-reported MS severity and sensor-based active functional tests measurements, and the impact of local weather conditions on disease burden.

Methods

This was a 12-week, observational, digital health study involving 3 cohorts: self-referred participants who reported an MS diagnosis, clinic-referred participants with neurologist-confirmed MS, and participants without MS (controls). Participants downloaded the elevateMS app and completed baseline assessments, including self-reported physical ability (Patient-Determined Disease Steps [PDDS]), as well as longitudinal assessments of quality of life (Quality of Life in Neurological Disorders [Neuro-QoL] Cognitive, Upper Extremity, and Lower Extremity Function) and daily health (MS symptoms, triggers, health, mobility, pain). Participants also completed functional tests (finger-tapping, walk and balance, voice-based Digit Symbol Substitution Test [DSST], and finger-to-nose) as an independent assessment of MS-related cognition and motor activity. Local weather data were collected each time participants completed an active task. Associations between self-reported baseline/longitudinal assessments, functional tests, and weather were evaluated using linear (for cross-sectional data) and mixed-effects (for longitudinal data) regression models.

Results

A total of 660 individuals enrolled in the study; 31 withdrew, 495 had MS (n=359 self-referred, n=136 clinic-referred), and 134 were controls. Participation was highest in clinic-referred versus self-referred participants (median retention: 25.5 vs 7.0 days). The top 5 most common MS symptoms, reported at least once by participants with MS, were fatigue (310/495, 62.6%), weakness (222/495, 44.8%), memory/attention issues (209/495, 42.2%), and difficulty walking (205/495, 41.4%), and the most common triggers were high ambient temperature (259/495, 52.3%), stress (250/495, 50.5%), and late bedtime (221/495, 44.6%). Baseline PDDS was significantly associated with functional test performance in participants with MS (mixed model–based estimate of most significant feature across functional tests [β]: finger-tapping: β=–43.64, P<.001; DSST: β=–5.47, P=.005; walk and balance: β=–.39, P=.001; finger-to-nose: β=.01, P=.01). Longitudinal Neuro-QoL scores were also significantly associated with functional tests (finger-tapping with Upper Extremity Function: β=.40, P<.001; walk and balance with Lower Extremity Function: β=–99.18, P=.02; DSST with Cognitive Function: β=1.60, P=.03). Finally, local temperature was significantly associated with participants’ test performance (finger-tapping: β=–.14, P<.001; DSST: β=–.06, P=.009; finger-to-nose: β=–53.88, P<.001).

Conclusions

The elevateMS study app captured the real-world experience of MS, characterized some MS symptoms, and assessed the impact of environmental factors on symptom severity. Our study provides further evidence that supports smartphone app use to monitor MS with both active assessments and patient-reported measures of disease burden. App-based tracking may provide unique and timely real-world data for clinicians and patients, resulting in improved disease insights and management.

Identifying clinically meaningful severity categories for PROMIS pediatric measures of anxiety, mobility, fatigue, and depressive symptoms in juvenile idiopathic arthritis and childhood-onset systemic lupus erythematosus

PURPOSE

A key limitation to widespread adoption of patient-reported outcome (PRO) measures is the lack of interpretability of scores. We aim to identify clinical severity thresholds to distinguish categories of no problems, mild, moderate, and severe along the PROMIS® Pediatric T-score metric for measures of anxiety, mobility, fatigue, and depressive symptoms for use in populations with juvenile idiopathic arthritis (JIA) and childhood-onset systemic lupus erythematosus (cSLE).

METHODS

We used a modified standard setting methodology from educational testing to identify clinical severity thresholds (clinical cut scores). Using item response theory-based parameters from PROMIS item banks, we developed a series of clinical vignettes that represented different severity or ability levels along the PROMIS Pediatric T-score metric. In stakeholder workshops, participants worked individually and together to reach consensus on clinical cut scores. Median cut-score placements were taken when consensus was not reached. Focus groups were recorded and qualitative analysis was conducted to identify decision-making processes.

RESULTS

Nine adolescents (age 13-17 years) with JIA (33% female) and their caregivers, five adolescents (age 14-16 years) with cSLE (100% female) and their caregivers, and 12 pediatric rheumatologists (75% female) participated in bookmarking workshops. Placement of thresholds for bookmarks was highly similar across stakeholder groups (differences from 0 to 5 points on the PROMIS t-score metric) for all but one bookmark placement.

CONCLUSION

This study resulted in clinical thresholds for severity categories for PROMIS Pediatric measures of anxiety, mobility, fatigue, and depressive symptoms, providing greater interpretability of scores in JIA and cSLE populations.

Evaluating the Thresholds for Clinical Importance of the EORTC QLQ-C15-PAL in Patients Receiving Palliative Treatment

Background: The EORTC QLQ-C15-PAL is a shortened version of the widely used EORTC QLQ-C30. This questionnaire was developed to measure the symptoms and functional health of patients receiving palliative care. Objective: To enhance clinical interpretability of the EORTC QLQ-C15-PAL, our aim was to evaluate the sensitivity and specificity of thresholds for clinical importance developed previously for the QLQ-C30 when applied to the QLQ-C15-PAL scales. Design: Cross-sectional observational study. Setting/Subjects: Patients with cancer receiving any type of palliative treatment. Measurement: Patients completed the EORTC QLQ-C15-PAL and anchor items on limitations, worries, and need for help for each of the health domains covered by the questionnaire. The anchor items were summarized in a binary criterion for clinical importance to calculate the sensitivity and specificity of the thresholds for clinical importance. Results: In total, 225 patients participated in the study (mean age 64.5 years). Patients were recruited from Austria, Italy, the Netherlands, Poland, Spain, and the United Kingdom. The thresholds for clinical importance for the QLQ-C15-PAL scales showed a median sensitivity of 0.88 (range: 0.82 for sleep disturbances to 1.00 for dyspnea) and a median specificity of 0.74 (range: 0.54 for dyspnea to 0.89 for constipation). Conclusion: The thresholds for clinical importance showed high sensitivity and mostly high specificity in identifying clinically important symptoms and functional health impairments as assessed by the QLQ-C15-PAL. These thresholds will facilitate interpretation of EORTC QLQ-C15-PAL scores in daily clinical practice and clinical research.

Patient-acceptable symptom states in myasthenia gravis

Objectives

To estimate patient-acceptable symptom state (PASS) cut points for myasthenia gravis (MG) health scales.

Methods

We conducted an electronic survey that included the Myasthenia Gravis Impairment Index (MGII), EuroQol 5-Dimension (EQ5D), and a simple PASS question. PASS-anchored thresholds were estimated for the MGII questionnaire through receiver operating characteristic curves. We used the MGII PASS cut point in a validation cohort of 257 patients to estimate PASS thresholds for other clinically relevant health scales such as the Quantitative Myasthenia Gravis Scale (QMGS), Myasthenia Gravis Activities of Daily Living (MG-ADL), Myasthenia Gravis Composite (MGC), and Myasthenia Quality of Life (MG-QoL15).

Results

One hundred twenty-four of ≈250 invited patients answered the electronic survey (49% response rate), and 80 considered their current symptom state acceptable (PASS-positive). They had lower MGII scores than PASS-negative patients (7.76 ± 9.37 vs 25.0 ± 13.7, p < 0.0001) and better EQ5D scores (0.86 ± 0.17 vs 0.69 ± 0.18, p < 0.0001). The MGII questionnaire threshold for PASS was ≤10 points. With the use of this threshold in an independent dataset of 257 patients, all patients in remission or minimal manifestation status were PASS-positive. In addition, some patients in Classes I, II, and IIIA also achieved PASS status. PASS thresholds for the QMGS, MG-ADL, MGC, and MG-QoL15 were ≤7, 2, 3, and 8 points, respectively.

Conclusions

We have estimated thresholds for commonly used myasthenia health scales reflecting patient-acceptable states in patients with MG. These thresholds indicate a global state of well being, rather than a change in scores, or being better. Therefore, PASS thresholds can be used as secondary endpoints for myasthenia research.

Fatigue in patients with hereditary neuropathy with liability to pressure palsies

OBJECTIVE

Hereditary Neuropathy with Liability to Pressure Palsies (HNPP) is caused by a heterozygous deletion of peripheral myelin protein-22 (PMP22) gene resulting in focal sensorimotor deficits. Our lab has identified a disruption of myelin junctions in excessively permeable myelin that impairs action potential propagation. This mechanism is expected to cause fatigue in patients with HNPP. Therefore, the objective was to characterize fatigue in patients with HNPP and determine the relationship of fatigue to nerve pathology, disability, and quality of life.

METHODS

Nine females with HNPP participated in a single visit that included genotyping, nerve conduction studies, neurological exam, quantitative magnetic resonance imaging, and a physical therapy exam incorporating upper and lower extremity function and survey measures of fatigue. This visit was followed by 2 weeks of ecological momentary assessment (wrist-worn device) that captured fatigue ratings five times per day.

RESULTS

Participants demonstrated mild neurological impairment (CMTNS: 5.7 ± 2.8), yet reported high fatigue levels (average fatigue intensity over 2 weeks: 5.9 out of 10). Higher fatigue levels were associated with poorer quality of life and more pain. Higher fatigue was associated with significantly greater distal nerve proton density changes on peripheral nerve MRI, which is in line with hyper-permeable myelin in HNPP.

INTERPRETATION

Fatigue is common and severe among patients with HNPP whose disabilities are minimal by conventional outcome measures. Therapeutic interventions targeting fatigue have the potential to improve quality of life and may serve as a robust outcome measure to show longitudinal changes for patients with HNPP.

Development and Implementation of Clinical Outcome Measures for Automated Collection Within Specialty Pharmacy Practice

BACKGROUND

Johns Hopkins Specialty Pharmacy Services recognized the need to identify and develop standardized collection methods for clinical outcome measures (COMs) to demonstrate program quality and value to third-party payers, manufacturers, and internal stakeholders.

OBJECTIVE

To define specialty COMs and develop a framework for standardized data collection and reporting.

METHODS

COMs for specialty pharmacy disease states (cystic fibrosis; hepatitis C; inflammatory conditions in dermatology, gastroenterology and rheumatology; and multiple sclerosis) were identified through a literature search, collaboration with specialty pharmacists, and committee review. Once identified, these measures were distributed to internal and external stakeholders that included specialty clinic team members, drug manufacturers, and third-party payers for input and validation. A standardized process for discrete documentation and data collection of these measures was implemented using case management software, electronic medical record integration, and informatics support.

RESULTS

28 COMs were identified. The various data sources used to collect the COMs were incorporated into an automated virtual dashboard to allow for regular review and sharing with clinicians, leadership, and other key stakeholders. The virtual dashboard included COMs with data derived from electronic medical records (n = 9), patient-reported outcomes based on responses to pharmacist-delivered questions (n = 11), and pharmacist assessment of outcomes (n = 8). The completed virtual dashboard was further refined to allow for reporting of both population and patient-level outcome results on a quarterly basis.

CONCLUSIONS

This project describes methods to standardize documentation, data collection, and reporting of clinical outcomes data for multiple specialty conditions in a health system-integrated specialty pharmacy program. Through literature review and stakeholder consultation, a variety of potential COMs were identified for further evaluation of feasibility and value considering documentation and data collection requirements. Incorporation of COMs into a virtual dashboard will help facilitate the evaluation of program effectiveness, quality improvement planning, and sharing with stakeholders. Additional opportunities exist to further standardize COMs across the pharmacy industry to allow for future benchmarking and standardized evaluation of patient care programs.

DISCLOSURES

No funding supported the writing of this article. The authors have no relevant conflicts of interest to disclose. This study was presented as a poster presentation at the APhA Annual Meeting, March 2018, Nashville, TN, and as a platform presentation at the Eastern States Conference, May 2018, Hershey, PA.

Describing the emotional exhaustion, depersonalization, and low personal accomplishment symptoms associated with Maslach Burnout Inventory subscale scores in US physicians: an item response theory analysis

PURPOSE

Current US health policy discussions regarding physician burnout have largely been informed by studies employing the Maslach Burnout Inventory (MBI); yet, there is little in the literature focused on interpreting MBI scores. We described the burnout symptoms and precision associated with MBI scores in US physicians.

METHODS

Using item response theory (IRT) analyses of secondary, cross-sectional survey data, we created response profiles describing the probability of burnout symptoms associated with US physicians' MBI emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA) subscale scores. Response profiles were mapped to raw subscale scores and used to predict symptom endorsements at mean scores and commonly used cut-points.

RESULTS

The average US physician was likely to endorse feeling he/she is emotionally drained, used up, frustrated, and working too hard and all PA indicators once weekly or more but was unlikely to endorse feeling any DP symptoms once weekly or more. At the commonly used EE and DP cut-points of 27 and 10, respectively, a physician was unlikely to endorse feeling burned out or any DP symptoms once weekly or more. Each subscale assessed the majority of sample score ranges with ≥ 0.70 reliability.

CONCLUSIONS

We produced a crosswalk mapping raw MBI subscale scores to scaled scores and response profiles calibrated in a US physician sample. Our results can be used to better understand the meaning and precision of MBI scores in US physicians; compare individual/group MBI scores against a reference population of US physicians; and inform the selection of subscale cut-points for defining categorical physician burnout outcomes.

Do emotional distress and functional problems in persons with traumatic brain injury contribute to perceived sleep-related impairment in caregivers?

OBJECTIVE

The goal of this study was to examine the association between characteristics of persons with traumatic brain injury (PwTBI) and perceived sleep-related impairment of the caregivers.

METHOD

Fifty-two dyads (n = 23 civilians, n = 29 service members/veterans [SMVs]) were enrolled. Caregivers completed the Patient-Reported Outcomes Measurement Information System Sleep-Related Impairment computer adaptive test, and PwTBI completed Quality of Life in Neurological Disorders measures of depression, anxiety, anger, cognitive functioning, and upper and lower extremity functioning. Hierarchical linear regression models, stratified by civilian/SMV group, were employed to assess prediction of caregiver-perceived sleep-related impairment from emotional distress of the PwTBI (anxiety, depressed mood, and anger) and perceived functional status of the PwTBI (cognitive, upper extremity, lower extremity functioning).

RESULTS

Compared with caregivers of civilians, caregivers of SMVs reported higher perceived sleep-related impairment. Regression results showed that characteristics of the PwTBI accounted for moderate amounts of variance in the sleep-related impairment of caregivers of both civilians and SMVs. Within-group analyses showed that the strongest predictor of sleep-related impairment of caregivers of civilians was self-reported cognitive function of the PwTBI (β = -0.82, p = .08); the strongest predictor of sleep-related impairment of caregivers of SMVs was self-reported anger of the PwTBI (β = 0.54, p = .07).

CONCLUSIONS

In both caregivers of civilians and SMVs with TBI, characteristics of the PwTBI were related to perceived caregiver sleep-related impairment. These preliminary data can inform future research with larger samples that examine the impact of multiple characteristics of the caregiver and care recipient on caregiver sleep. Findings highlight the potential importance of considering the dynamics of the dyad in rehabilitation programming not only for the PwTBI but for caregivers as well. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Development and validation of an interpretive guide for PROMIS scores

BACKGROUND

Accurate score interpretation is required for the appropriate use of patient-reported outcome measures in clinical practice.

OBJECTIVE

To create and evaluate figures (T-score Maps) to facilitate the interpretation of scores on Patient-Reported Outcome Measurement Information System (PROMIS) measures.

METHODS

For 21 PROMIS® short forms, item-level information was used to predict the most probable responses to items for the range of possible scores on each short form. Predicted responses were then "mapped" graphically along the range of possible scores. In a previously conducted longitudinal study, 1594 adult participants with chronic conditions (e.g., multiple sclerosis) responded to four items each of a subset of these PROMIS short forms. Participants' responses to these items were compared to those predicted by the T-score Maps. Difference scores were calculated between observed and predicted scores, and Spearman correlations were calculated.

RESULTS

We constructed T-score Maps for 21 PROMIS short forms for adults and pediatric self- and parent-proxy report. For the clinical population, participants' actual responses were strongly correlated with their predicted responses (r = 0.762 to 0.950). The majority of predicted responses exactly matched observed responses (range 69.5% to 85.3%).

CONCLUSION

Results support the validity of the predicted responses used to construct T-score Maps. T-score Maps are ready to be tested as interpretation aids in a variety of applications.

Patient-Reported Outcomes and Evidence-Based Practice in Speech-Language Pathology

Purpose The patient's perspective of their health is a core component of evidence-based practice (EBP) and person-centered care. Patient-reported outcomes (PROs), captured with PRO measures (PROMs), are the main way of formally soliciting and measuring the patient's perspective. Currently, however, PROs play a relatively small role in mainstream speech-language pathology practice. The purpose of this article is to raise important questions about how PROs could be applied to EBP in speech-language pathology for individuals with communication disorders and to propose preliminary approaches to address some of these questions. Method Based on a narrative review of the literature, this article introduces relevant terminology and broadly describes PRO applications in other health care fields. The article also raises questions related to PRO-informed clinical practice in speech-language pathology. To address some of these questions, the article explores previous research to provide suggestions for clinical administration, interpretation, and future research. Conclusion More routine measurement of subjective health constructs via PROMs-for example, constructs such as effort, participation, self-efficacy, and psychosocial functioning-may improve EBP. More routine use of PROMs could significantly expand the information that is available to clinicians about individual clients and add to the evidence base for the profession of speech-language pathology. However, careful consideration and more research are needed on how to capture and interpret PROs from individuals with cognitive and language disorders.

Measuring Clinical Treatment Response in Myasthenia Gravis

In this article we provide an overview of health-related outcome measurement-to better understand what different outcomes used in myasthenia actually measure-and to provide some guidance when choosing measures based on the clinical context and question. In myasthenia, the most commonly used outcome measures are aimed at assessing the signs and symptoms. In this review, we provide a summary of the most commonly used outcome measures. We discuss instruments that gauge disease overall health impact, such as on disability and quality of life. Finally, we discuss other relevant outcomes such as steroid-sparing effects and the role of surrogate markers.

Establishing clinically-relevant terms and severity thresholds for Patient-Reported Outcomes Measurement Information System® (PROMIS®) measures of physical function, cognitive function, and sleep disturbance in people with cancer using standard setting

PURPOSE

Patient-Reported Outcomes Measurement Information System^® (PROMIS^®) physical function, cognitive function, and sleep disturbance measures are increasingly used in cancer care. However, there is limited guidance for interpreting the clinical meaning of scores. This study aimed to apply bookmarking, a standard setting methodology, to identify PROMIS score thresholds in the context of cancer care.

METHODS

Using item parameters, we constructed vignettes of five items covering the range of possible scores. Focus groups were held with cancer care providers and people with cancer. Terminology for categorizing levels of severity was explored. Participants rank ordered vignettes by severity and then placed bookmarks between vignettes representing different levels of severity. Group discussion was held until consensus on bookmark placement was reached.

RESULTS

Clinicians selected "within normal limits," "mild," "moderate," and "severe" to describe levels of severity. Both patients and clinicians were able to apply these labels, but there was not unanimous support for any set of descriptors. Clinicians and patients agreed on all severity thresholds for sleep disturbance. For cognitive and physical function, clinicians and patients agreed on the threshold between "within normal limits" and "mild." However, patients required greater dysfunction than clinicians before applying "moderate" and "severe" labels.

CONCLUSIONS

Bookmarking can be applied to develop provisional score interpretation for PROMIS measures. Patients and clinicians were frequently consistent in their bookmark placement. When there was variance, patients required more dysfunction before assigning more severity. Additional research with other cancer samples is needed to evaluate the replicability and generalizability of our findings.

How Normal Are "Normal" Errors of Language and Cognition?

Purpose The aim of this study was to estimate the frequency and severity of common errors and inefficiencies of language and cognition in the general population. Method Item-response theory parameters were analyzed from the Neuro-QOL Cognitive Function Item Bank v2.0, which references a large normative sample that mirrors the demographics of the U.S. Census. Item parameters were analyzed to reveal the most likely responses to items about errors and inefficiencies of language and cognition. These most likely responses were estimated for each of 25 levels of theta to reveal normal and gradations of abnormal experiences of errors and inefficiencies. Results A typical experience with language and cognitive errors and inefficiencies (e.g., producing a T score between 40 and 60) is to have "a little" difficulty with each task that was assessed or to experience nearly every error/inefficiency at least once a week. Word-finding effort was particularly ubiquitous, as was the experience of walking into a room and forgetting one's intention. Conclusions It is typical to experience errors and inefficiencies of language and cognition. This analysis describes a typical experience for an average person in a highly representative sample. However, more work is needed in order to learn what is typical for more specific subgroups, for example, based on age.

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

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

Important Group Differences on the Functional Assessment of Cancer Therapy-Kidney Symptom Index Disease-Related Symptoms in Patients with Metastatic Renal Cell Carcinoma

BACKGROUND

The Functional Assessment of Cancer Therapy-Kidney Symptom Index Disease-Related Symptoms (FKSI-DRS) is important to gauge clinical benefit in metastatic renal cell carcinoma (mRCC).

OBJECTIVES

To estimate important difference (ID) in FKSI-DRS scores that is considered to be meaningful when comparing treatment effect between groups, using mRCC trial data.

METHODS

Data were derived from two pivotal phase III mRCC trials comparing sunitinib versus interferon alfa (N = 750) in first-line mRCC, and axitinib versus sorafenib (N = 723) in second-line mRCC. The change from baseline in FKSI-DRS score was examined as a function of a set of anchors using the repeated-measures model. Several anchors were evaluated: FKSI item "I am bothered by side effects of treatment," EuroQol five-dimensional questionnaire utility score, and adverse events.

RESULTS

When the "I am bothered by side effects of treatment" score was used as an anchor, the ID ranged between 1.2 and 1.3 points. When change in the EuroQol five-dimensional questionnaire utility score was used as an anchor, the FKSI-DRS ID ranged between 0.62 and 0.63 points. Selecting the adverse events that corresponded to a maximum worsening in the FKSI-DRS score in either trial, the ID ranged between 0.62 and 0.74 points.

CONCLUSIONS

Among patients undergoing treatment for mRCC, between-group differences in FKSI-DRS scores as low as 1 point might be meaningful.

EQ-5D-5L and SF-6D health utility index scores in patients with myasthenia gravis

BACKGROUND AND PURPOSE

Health utilities are a preference-based method of valuing health states that are used in healthcare research, such as economic evaluations. There are limited health utility valuation data for patients with myasthenia gravis (MG). The aim of the study was to describe health utilities for patients with MG and different health states, using the EQ-5D-5L and SF-6D utility instruments, and to explore clinical and demographic determinants of utilities in this population.

METHODS

Patients completed the EQ-5D-5L and SF-6D. In addition, patients were assessed with the Myasthenia Gravis Foundation of America classification, Myasthenia Gravis Impairment Index and MG-QOL15 as disease-specific measures, and the Neuro-QoL Fatigue scale. We calculated mean utilities for each Myasthenia Gravis Foundation of America severity class. We built regression models for the EQ-5D-5L and SF-6D to determine the clinical and demographic factors that determine patients' valuation of their health state.

RESULTS

Among 254 patients, mean EQ-5D-5L health utilities were as follows: Remission, 0.94 ± 0.03; Minimal Manifestations, 0.92 ± 0.04; Class I, 0.89 ± 0.06; Class II, 0.78 ± 0.16; Class III, 0.58 ± 0.24 and Class IV, 0.61 ± 0.22. Mean SF-6D health utilities were as follows: Remission, 0.83 ± 0.07; Minimal Manifestations, 0.86 ± 0.14; Class I, 0.82 ± 0.14; Class II, 0.67 ± 0.12; Class III, 0.56 ± 0.11 and Class IV, 0.50 ± 0.10. The limb/axial scores were more highly correlated to health utilities than ocular or bulbar scores.

CONCLUSIONS

We present estimates of health utilities for patients with MG that can be used in cost-utility and decision analyses. Limb/axial symptoms had a higher impact on health utilities than ocular or bulbar symptoms, which might reflect the impact of mobility on health valuation.

eRAPID electronic patient self-Reporting of Adverse-events: Patient Information and aDvice: a pilot study protocol in pelvic radiotherapy

Background

An estimated 17,000 patients are treated annually in the UK with radical radiotherapy (RT) for pelvic cancer. New treatment approaches in RT have increased survivorship and changed the subjective toxicity profile for patients who experience acute and long-term pelvic-related adverse events (AE). Multi-disciplinary follow-up creates difficulty for monitoring and responding to these events during treatment and beyond. Originally developed for use in systemic oncology therapy eRAPID (electronic patient self-Reporting of Adverse-events: Patient Information and aDvice) is an online system for patients to report AEs from home. eRAPID enables patient data to be integrated into the electronic patient records for use in clinical practice, provides patient management advice for mild and moderate AE and advice to contact the hospital for severe AE. The system has now been developed for pelvic RT patients, and we aim to test the intervention in a pilot study with staff and patients to inform a future randomised controlled trial (RCT).

Methods

Eligible patients are those attending St James’s University hospital cancer centre and The Christie Hospital Manchester undergoing pelvic radiotherapy+/−chemotherapy/hormonotherapy for prostate, lower gastrointestinal and gynaecological cancers. A prospective 1:1 randomised (intervention or usual care) parallel group design with repeated measures and mixed methods will be employed. We aim to recruit 168 patients following recommendations for sample size estimates for pilot studies. Participants using eRAPID will report AE (at least weekly) from home weekly for 6 weeks and 6 weeks post-treatment (12-week total) then at 18 and 24 weeks. Hospital staff will review eRAPID reports and use information during consultations. Notifications will be sent to the relevant clinical team when severe symptoms are reported. We will measure patient-reported outcomes using validated questionnaires (Functional Assessment in Cancer Therapy Scale-General (FACT-G), European Organisation for Research and Treatment of Cancer Core Quality of Life questionnaire (EORTC-QLQ-C30), process of care impact (hospital records of patient contacts and admissions) and economic variables (EQ5D-5L, patient use of resources)). Staff and patient experiences will be explored via semi-structured interviews.

Discussion

The objectives are to establish feasibility, recruitment, integrity of the system and attrition rates, determine effect sizes and aid selection of the primary outcome measure for a future RCT. We will also refine the intervention by exploring staff and patient views. The overall goal of this complex intervention is to improve the safe delivery of cancer treatments, enhance patient care and standardise documentation of AE within the clinical datasets.

Trial registration

ClinicalTrials.gov NCT02747264.

Electronic supplementary material

The online version of this article (10.1186/s40814-018-0304-6) contains supplementary material, which is available to authorized users.

Evaluation of options for presenting health-states from PROMIS® item banks for valuation exercises

PURPOSE

Health status descriptive systems based on item response theory (IRT), such as the Patient-Reported Outcomes Measurement Information System (PROMIS®), have item banks to measure domains of health. We developed a method to present such banks for health-state valuation.

METHODS

We evaluated four different presentation approaches: a single item (1S), 2 items presented separately (2S), 2 items presented together (2T), or 5 items presented together (5T). We evaluated these four approaches in three PROMIS item banks (depression, physical function, and sleep disturbance). Adult community members valued health-state descriptions using the visual analog scale and standard gamble methods. We compared the approaches by the range of item bank theta scores captured, participants' assessments of difficulty (1 = very easy to 7 = very hard), and exit interviews.

RESULTS

Participants (n = 118) ranged in age from 18 to 71; 63% were female and 54% were white. The 1S approach captured the smallest range of theta scores. A monotonic relationship between theta score and mean standard gamble estimate was found with all approaches except 2S. Across all 3 item banks, mean difficulty assessments were 2.35 (1S), 2.69 (2T), 2.78 (5T), and 2.80 (2S). In exit interviews, participants generally found all four approaches similarly meaningful and realistic.

CONCLUSIONS

Creating health descriptions by presenting 2 items maximized the range of theta while minimizing difficulty and maintaining a monotonic relationship with utility estimates. We recommend this approach for valuation of IRT-based descriptive systems such as PROMIS.

Fatigue is a relevant outcome in patients with myasthenia gravis

INTRODUCTION

Patients with myasthenia gravis often experience fatigue, but its effect on quality of life (QoL) is underestimated, and fatigue is rarely measured in clinical trials.

METHODS

Two hundred fifty-seven myasthenic patients completed the Neuro-QoL-Fatigue and measures of disease severity and QoL. We studied the relationship between fatigue and clinical and demographic variables. Finally, we studied the responsiveness of the Neuro-QoL-Fatigue in 95 patients receiving treatments for myasthenia and estimated the minimal important difference (MID).

RESULTS

Fatigue correlated with greater disease severity (r = 0.52-0.69, P < 0.0001) and worse QoL (r = 0.65-0.75, P < 0.0001). Patients in remission, with minimal manifestations, and pure ocular symptoms reported minimal fatigue. Regression modeling showed that, in addition to its relationship with disease severity, fatigue was worse in females, patients with generalized disease, and those with anxiety/depression. Fatigue improved after immunomodulation (P < 0.0001), and the MID was 5.3 points.

DISCUSSION

Fatigue in myasthenia correlates with disease severity, affects QoL, and can improve after treatment. Muscle Nerve 58: 197-203, 2018.