What Are the Floor and Ceiling Effects of Patient-Reported Outcomes Measurement Information System Computer Adaptive Test Domains in Orthopaedic Patients? A Systematic Review

Patients' joint perception after anterior cruciate ligament reconstruction as a reliable patient-reported outcome measure

PURPOSE

This study aims to evaluate and compare patients' joint perception (PJP) with other commonly employed patient-reported outcome measures (PROMs) in a cohort of patients following anterior cruciate ligament reconstruction (ACLR).

METHODS

A retrospective study was conducted on 108 patients who underwent ACLR between 2017 and 2021, with complete data available for visual analogue scale (VAS) pain, PJP, Forgotten Joint Score (FJS), Tegner Activity Scale, Lysholm Knee Scoring Scale, Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI), Single Assessment Numeric Evaluation (SANE), Cincinnati Knee Rating System (CKRS) and The Hospital for Special Surgery Anterior Cruciate Ligament Satisfaction Survey (HSS ACL-SS) at a mean follow-up of 3 years. Spearman's rank-order correlation was used to determine the correlations between clinical scores. A receiver operating characteristic (ROC) curve analysis was used to assess the discriminatory power of the chosen PROMs in detecting natural joint perception. Natural joint perception was defined as patients responding 'like a native or natural joint' or PJP = 1. This study hypothesized that PJP would demonstrate significant correlations with established PROMs, indicating its reliability and validity as a tool for assessing outcomes following ACLR.

RESULTS

PJP showed significant correlations with all the reported PROMs, suggesting its potential as a valid and reliable assessment tool for evaluating ACLR outcomes. The ROC curve analysis indicated a good area under the curve for identifying natural joint perception using various PROMs. According to the PJP, nearly 20% of patients reported natural joint perception.

CONCLUSION

This study evaluates PJP as a reliable tool for assessing patient outcomes following ACLR. Its significant correlation with other established PROMs underscores its potential as a valuable addition to the existing array of PROMs in ACLR.

LEVEL OF EVIDENCE

Level III.

Relationships Between PROMIS and Legacy Patient-Reported Outcome Measure (PROM) Scores in the MARS Cohort at 10-Year Follow-up

BACKGROUND

Patient-reported outcome measures (PROMs) are used to evaluate the impact of musculoskeletal conditions and their treatment on patients' quality of life, but they have limitations, such as high responder burden and floor and ceiling effects. The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed to address these issues but needs to be further evaluated in comparison with legacy PROMs. The goals of this study were to evaluate the floor and ceiling effects of, the correlations between, and the predictive ability of PROMIS scores compared with traditional legacy measures at 10-year follow-up in a cohort who underwent revision anterior cruciate ligament (ACL) reconstruction.

METHODS

A total of 203 patients (88.7% White; 51.7% female) who underwent revision ACL reconstruction completed the PROMIS via computer adaptive tests as well as legacy PROMs at the cross-sectional, 10-year follow-up of the longitudinal MARS cohort study (MARS cohort n = 1,234). Floor and ceiling effects and Spearman rho correlations between PROMIS and legacy measures are reported. Linear regression with quadratic terms were used to develop and evaluate conversion equations to predict legacy scores from the PROMIS.

RESULTS

No floor or ceiling effects were reported for the PROMIS Physical Function (PF) domain, whereas a floor effect was found for 37.9% of the participants for the PROMIS Pain Interference (PI) domain, and a ceiling effect was found for 34.0% of the participants for the PROMIS Physical Mobility (PM) domain. PROMIS domains correlated moderately with the International Knee Documentation Committee total subjective score (absolute value of rho [|ρ|] = 0.68 to 0.74), fairly to moderately with the Knee injury and Osteoarthritis Outcome Score and Western Ontario and McMaster Universities Osteoarthritis Index scores (|ρ| = 0.52 to 0.67), and fairly with the Marx Activity Rating Scale (|ρ| = 0.35 to 0.44). None of the legacy-measure scores were accurately predicted by the PROMIS scores.

CONCLUSIONS

The PROMIS PF domain has value in assessing patients 10 years after revision ACL reconstruction. Because of floor and ceiling effects, using the PI and PM domains may not allow for precision when measuring long-term changes in pain and mobility. Although the PROMIS measures correlated with the legacy measures, with effect sizes ranging from fair to moderate, the legacy scores were not accurately predicted by the PROMIS. The results suggest that knee-specific legacy measures should not be eliminated from long-term follow-up when the goal is to capture the specific knee-related information that they provide.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Preoperative Hip Injection Response Does Not Reliably Predict 2-Year Postoperative Outcomes After Hip Arthroscopy for Femoroacetabular Impingement

PURPOSE

To determine whether response to preoperative local anesthetic or corticosteroid intra-articular injections can predict 2-year postoperative outcomes in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

METHODS

We performed a retrospective analysis of patients undergoing hip arthroscopy for FAIS at a single institution from 2014 to 2020. Patients who underwent preoperative intra-articular hip injections were classified based on injection type (local anesthetic or corticosteroid) and whether they experienced pain relief after injection (responders or nonresponders). Responders were matched 2:1 to nonresponders by age, body mass index, and sex. Patient-reported outcomes (PROs) including the Hip Disability and Osteoarthritis Outcome Score (HOOS), 12-Item Short-Form Health Survey (SF-12) Mental Component Summary score, SF-12 Physical Component Summary score, and visual analog scale pain score were collected preoperatively and 2 years postoperatively. Mean score change and minimal clinically important difference (MCID) achievement were calculated and compared between groups.

RESULTS

The matched cohort included 126 total patients (42 nonresponders and 84 responders; 74.6% female sex; age [mean ± standard deviation], 30.9 ± 9.9 years; body mass index, 24.7 ± 3.7) with no differences in demographic or radiographic hip variables. Both groups showed significant 2-year postoperative score improvements across all PROs, except the SF-12 Mental Component Summary score, which remained unchanged. There was no difference in mean score change or MCID achievement across all PROs between the corticosteroid injection responder and nonresponder groups. In the local anesthetic group, MCID achievement was similar across all PROs, except the visual analog scale pain score, which showed a greater percentage of MCID achievement among local anesthetic nonresponders (89.5%) than in responders (55.0%, P = .03). Significant ceiling effects were most readily apparent within the injection responder group, with greater percentages of patients achieving maximal 2-year postoperative survey scores (HOOS-Activities of Daily Living, 36.9%; HOOS-Pain, 19.0%; HOOS-Quality of Life, 15.5%; and HOOS-Sport, 32.1%).

CONCLUSIONS

Response to preoperative injection with either corticosteroid or local anesthetic did not predict 2-year outcomes after hip arthroscopy in patients with FAIS.

LEVEL OF EVIDENCE

Level III, retrospective matched-cohort study.

Enhancing the Evaluation of Physical Function Following Orthopaedic Trauma Care: Comparison of PROMIS Computerized Adaptive Testing and Short Musculoskeletal Function Assessment

OBJECTIVES

To compare measurement properties of Patient-Reported Outcomes Measurement Information System (PROMIS) (physical function [PF] and pain interference [PI]) computerized adaptive testing to traditional Short Musculoskeletal Function Assessment (SMFA) (dysfunction index [DI] and bother index [BI]). To explore factors associated with PROMIS scores.

METHODS

DESIGN

Cross-sectional study.

SETTING

Level I Trauma Center.

PATIENT SELECTION CRITERIA

Isolated upper/lower extremity fracture patients were recruited from the orthopaedic trauma outpatient clinic (October 1, 2021 to January 1, 2023).

OUTCOME MEASURES

Correlations (Pearson), reliability (standard error [SE] [T score]), efficiency (amount of information per item [1 - SE2/Nitems]), and floor/ceiling effects were assessed. An r > 0.7 represented high correlation, and SE ≤ 2.2 represented sufficient reliability. Factors associated with worse PROMIS scores were also identified.

RESULTS

In total, 202 patients completed PROMs at median 98 days follow-up. Correlations between PROMIS-PF and SMFA-DI, and PROMIS-PI and SMFA-BI were -0.84 and 0.65. Reliability was very high for both instruments (mean SE 2.0 [PROMIS-PF], SE 2.1 [PROMIS-PI], and SE 1.2 [SMFA-DI], SE 1.8 [SMFA-BI]). Relative efficiency for PROMIS-PF versus SMFA-DI, and PROMIS-PI versus SMFA-BI was 7.8 (SD 2.5) and 4.1 (SD 1.7), respectively. Neither PROMIS nor SMFA exhibited floor/ceiling effects. In the multivariable regression analyses, elevated levels of depression, among other factors, showed an (independent) association with worse PROMIS-PF and PROMIS-PI scores.

CONCLUSIONS

PROMIS-PF and PROMIS-PI CATs showed a (high and moderate) correlation with SMFA and hence measure a comparable construct of physical function and discomfort. As computerized adaptive tests are much more efficient to administer, they present a compelling alternative to SMFA for evaluating impact of fracture treatment. The relation between symptoms of depression and PROMIS scores emphasizes the importance of psychosocial aspects of health in orthopaedic trauma patients.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Evaluating the psychometric properties of the simplified Chinese version of PROMIS-29 version 2.1 in patients with hematologic malignancies

The Patient-Reported Outcomes Measurement Information System 29-item Profile version 2.1 (PROMIS-29 V2.1) is a widely utilized self-reported instrument for assessing health outcomes from the patients' perspectives. This study aimed to evaluate the psychometric properties of the PROMIS-29 V2.1 Chinese version among patients with hematological malignancy. Conducted as a cross-sectional, this research was approved by the Medical Ethical Committee of the Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (registration number QTJC2022002-EC-1). We employed convenience sampling to enroll eligible patients with hematological malignancy from four tertiary hospitals in Tianjin, Shandong, Jiangsu, and Anhui province in China between June and August 2023. Participants were asked to complete a socio-demographic information questionnaire, the PROMIS-29 V2.1, and the Functional Assessment of Cancer Therapy-General (FACT-G). We assessed the reliability, ceiling and floor effects, structural, convergent discriminant and criterion validity of the PROMIS-29 V2.1. A total of 354 patients with a mean age of 46.93 years was included in the final analysis. The reliability of the PROMIS-29 V2.1 was affirmed, with Cronbach's α for the domains ranging from 0.787 to 0.968. Except sleep disturbance, the other six domains had ceiling effects, which were seen on physical function (26.0%), anxiety (37.0%), depression (40.4%), fatigue (18.4%), social roles (18.9%) and pain interference (43.2%), respectively. Criterion validity was supported by significant correlations between the PROMIS-29 V2.1 and FACT-G scores, as determined by the Spearman correlation test (P < 0.001). Confirmatory factor analysis (CFA) indicated a good model fit, with indices of χ2/df (2.602), IFI (0.960), and RMSEA (0.067). The Average Variance Extracted (AVE) values for the seven dimensions of PROMIS-29 V2.1, ranging from 0.500 to 0.910, demonstrated satisfactory convergent validity. Discriminant validity was confirmed by ideal √AVE values. The Chinese version of the PROMIS-29 V2.1 profile has been validated as an effective instrument for assessing symptoms and functions in patients with hematological malignancy, underscoring its reliability and applicability in this specific patient group.

What does routine depression screening in the ambulatory orthopedic clinic teach us? Results from nearly 60,000 patient encounters

Background

It remains unclear what role depression screening plays in routine ambulatory orthopedic care. The purpose of this study was to determine (1) the floor and ceiling effects of the Patient-Reported Outcomes Measurement Information System Depression (PROMIS-D) form, (2) the prevalence of positive PROMIS-D screening forms across an orthopedic service line, and (3) the prevalence of previously diagnosed depression and interventions among a representative sample of patients.

Methods

This retrospective study analyzed 58,227 patients who presented to ambulatory orthopedic clinics across an orthopedic service line between January 1, 2019 to December 31, 2021. All patients completed a self-administered PROMIS-D form as part of the ambulatory encounter. Scores were analyzed with respect to patient characteristics including age, gender, and presenting orthopedic complaint. A sample of 1000 patients was evaluated for prevalence of depressive symptoms and formal psychiatric diagnosis and interventions in the 5 years preceding the clinic visit.

Results

PROMIS-D displayed a negligible ceiling effect (<0.001 %) but a large floor effect (19.0 %). PROMIS-D scores indicating depressive symptoms were highest among patients presenting with spine complaints (42.8 %) and lowest among patients presenting to orthopedic pediatric clinics (28.6 %). Women and those in the lowest quartile median household income (MHI) were more likely to report depressive symptoms. Among the 1000 patient sample, 31.3 % exhibited depressive symptoms. Of these, 39 % had previously received some form of mental health treatment, including 33.2 % who were prescribed antidepressants.

Conclusions

PROMIS-D is a useful screening questionnaire for patients in the orthopedic clinic, although there is a consistent floor effect. There are a number of patients who present to the orthopedic clinic who have depressive symptoms but have had no interaction with behavioral health. Given the impact depression can have on outcomes, screening for depressive symptoms should be considered as part of routine orthopedic practice.

Validation of the Persian Version of the Palin Parent Rating Scales

INTRODUCTION

The Palin Parent Rating Scale (Palin PRS) is a structured questionnaire filled out by parents of children who stutter. It is designed to assess the effects of stuttering on both the children and their parents. The goal of this study was to translate the Palin PRS into Persian and to evaluate its validity and reliability for application in preschool children who stutter.

METHODS

This research was conducted from August 2021 to December 2022, involving 139 parents of children who stutter. The parents completed the Palin PRS and provided their demographic data. Descriptive statistics were used to examine the floor and ceiling effects on all subscales of the Palin PRS. The internal consistency of the scale was assessed using Cronbach's alpha method, while the intraclass correlation coefficient (ICC) was calculated to determine its test-retest reliability. An exploratory factor analysis was also performed to clarify the factor structure of the scale.

RESULTS

The exploratory factor analysis results were highly consistent with the factor structure found in the original version. No floor or ceiling effects were observed for the factors of the Palin PRS. The three factors of the Persian version of the Palin PRS (P-Palin PRS) showed good internal consistency (Cronbach's alpha >0.8) and excellent test-retest reliability (ICC >0.9). Additionally, normative scores were derived by converting raw scores into Stanine scores.

CONCLUSION

The P-Palin PRS showed strong reliability, thereby establishing it as a suitable instrument for evaluating how parents perceive the effects of stuttering on their children and themselves. Further research may explore its application in diverse clinical settings and populations.

Measuring children's sustained selective attention and working memory: validity of new minimally linguistic tasks

This study introduces visual tasks using nonlinguistic stimuli that measure sustained selective attention (SSA) and working memory (WM), two constructs foundational to learning and associated with developmental disorders in children. Using an argument-based approach to validation, we examine whether each task (a) measures distinct constructs, (b) shows internal consistency, (c) captures a range of performance, and (d) relates to development as indexed by age. Participants included 71 children, ages 4-10, of whom 12 had parental concern for language/learning. The SSA task presented spatial locations within a long and uninteresting task, following the continuous performance task paradigm. The WM task presented paired location sequences of increasing length, incorporating key elements of the n-back and complex span paradigms. Controlling for age, tasks were found to be minimally associated with each other (r = .26), suggesting related but distinct constructs. Internal consistency was high, with split-half reliability of .94 (SSA) and .92 (WM); the stability of these estimates was supported by bootstrapping simulations. Task performance was evenly distributed, with minimal floor or ceiling effects within this age range. Performance was positively related to age (SSA r = .49; WM r = .53). Exploratory correlations with a measure of parental concern were significant for SSA but not WM. The results show that these new tasks can be used to measure children's SSA and WM in a visual domain with minimal linguistic influence. These tasks capture developmental changes in the early school years. Further investigation can examine their utility for classifying children with developmental disorders.

Brazilian dentist's knowledge of minimum intervention dentistry for caries management: application of a developed knowledge scale (MIDDeC-KS) and evaluation of its psychometric properties

AIM

To assess the knowledge of Brazilian dentists about Minimum Intervention (MI) using a Minimum Intervention Dentistry to Dental Caries-Knowledge Scale (MIDDeC-KS) and evaluate its psychometric properties.

MATERIALS AND METHODS

An online scale was developed to evaluate dentists' knowledge about MI. The higher the score, the greater the knowledge and vice versa. A preliminary study was carried out with 143 dentists to validate the MIDDeC-KS. For psychometric properties analysis, convergent and discriminant validity, test-retest reliability, and internal consistency of the instrument were assessed. After validation, MIDDeC-KS was applied to a representative sample of Brazilian dentists. T test for independent samples, Chi-square, and/or ANOVA one-way tests were applied.

RESULTS

The MIDDeC-KS convergent (Spearman's = 0.48) and discriminant (P = 0.001) validity and reliability (ICC = 0.85, α = 0.72 and ω = 0.74) were proved. The participants (n = 637) obtained an overall mean score of 7.4 ± 2.5. The sample was mainly composed of females (P < 0.01), who graduated over 10 years prior (P = 0.02), from public colleges (P < 0.01), and most were pediatric dentists (38.2%). The highest and lowest scores were reached by pediatric dentists (9.2 ± 1.6) and bucomaxillofacial professionals (3.1 ± 2.1), respectively. Brazilian dentists demonstrated more knowledge about diet, biofilm, and topical fluoride control (84.3%), while the Hall technique (31.9%), resin infiltrant (47.6%), and chemical mechanical caries removal (48.4%) were the least known MI techniques.

CONCLUSION

Brazilian dentists demonstrated more knowledge about preventive measures and less about more recent protocols, such as the Hall technique, resin infiltrant, and chemical mechanical caries tissue removal. Sufficient psychometric evidence of the MIDDeC-KS was found.

CLINICAL RELEVANCE

Identify dentist's knowledge about MI.

Validity and Reliability of Hindi version of Foot and Ankle Disability Index in patients with chronic recurrent lateral ankle sprain

BACKGROUND

Lateral Ankle Sprain (LAS) is a recurrent musculoskeletal injury commonly noticed in primary care, podiatry, orthopaedics, and physical therapy centers. The Foot and Ankle Disability Index (FADI) is a self-reported and region-specific tool with no previous literature available on the translation of the FADI scale into Hindi language.

AIM

The study aims to translate and evaluate each translated domain of FADI to see its cross-cultural adaptation, content validity and reliability for patients with chronic recurrent LAS.

STUDY DESIGN

A Cross-Sectional Study.

METHODS

The scale was translated from the reference language to the target language, Hindi, using the instructions provided in the literature. Delphi survey was conducted for content validation followed by recruitment of 51 participants with a history of long lasting repetitive lateral sprain of ankle to evaluate test-retest reliability of Hindi version of FADI.

RESULT

The S-CVI/Ave and S-CVI/UA came out to be 0.988 and 0.884, respectively and I-CVI for all items of Hindi version of FADI were more than 0.90. The ICC (Intra-class Correlation Coefficient) and internal consistency was evaluated, which came out to 0.961 and 0.980, respectively for Hindi version of FADI.

CONCLUSION

Hindi version of FADI is a valid and reliable scale that has been translated and adapted to be implemented among Indian population suffering from long lasting repetitive LAS.

Differential item functioning for the Tendency of Avoiding Physical Activity and Sport Scale across two subculture samples: Taiwanese and mainland Chinese university students

Aims

The aims of the study were to examine the differential item functioning (DIF) of the Tendency of Avoiding Physical Activity and Sport Scale (TAPAS) among three subgroups (gender, weight status, and region) and to test the construct and concurrent validities of the scale.

Methods

Using an online survey, university students (608 Taiwanese and 2319 mainland Chinese) completed the TAPAS. Rasch analysis examined if all the 10 TAPAS items fitted the same construct and displayed no substantial DIF across three subgroups: gender (male vs. female), weight status (overweight vs. non-overweight), and region (Taiwan vs. China). Concurrent validity was examined using the scores on the Weight Self-Stigma Questionnaire (WSSQ) and Weight Bias Internalization Scale (WBIS).

Results

All TAPAS items, except for Item 10 ("Prefer to participate in physical activity in a more private setting"), fitted the same construct. None of the TAPAS items displayed DIF in any of the subgroups except for Item 10 across participants from Taiwan and China (DIF contrast = -1.41).

Conclusion

The TAPAS can appropriately assess the tendency to avoid physical activity and sport among both Taiwanese and mainland Chinese university students. However, Item 10 may need to be further examined.

Pearls and pitfalls of PROMIS clinically significant outcomes in orthopaedic surgery

INTRODUCTION

Patient-Reported Outcome Measurement Information System (PROMIS) was developed as a uniform and generalizable PROM system using item response theory and computer adaptive testing. We aimed to assess the utilization of PROMIS for clinically significant outcomes (CSOs) measurements and provide insights into its use in orthopaedic research.

MATERIALS AND METHODS

We reviewed PROMIS CSO reports for orthopaedic procedures via PubMed, Cochrane Library, Embase, CINAHL, and Web of Science from inception to 2022, excluding abstracts and missing measurements. Bias was assessed using the Newcastle-Ottawa Scale (NOS) and questionnaire compliance. PROMIS domains, CSO measures, and study populations were described. A meta-analysis compared distribution and anchor-based MCIDs in low-bias (NOS ≥ 7) studies.

RESULTS

Overall, 54 publications from 2016 to 2022 were reviewed. PROMIS CSO studies were observational with increasing publication rates. Evidence-level was II in 10/54, bias low in 51/54, and compliance ≥ 86% in 46/54. Most (28/54) analysed lower extremity procedures. PROMIS domains examined Pain Function (PF) in 44/54, Pain Interference (PI) in 36/54, and Depression (D) in 18/54. Minimal clinically important difference (MCID) was reported in 51/54 and calculated based on distribution in 39/51 and anchor in 29/51. Patient acceptable symptom state (PASS), substantial clinical benefit (SCB), and minimal detectable change (MDC) were reported in ≤ 10/54. MCIDs were not significantly greater than MDCs. Anchor-based MCIDs were greater than distribution based MCIDs (standardized mean difference = 0.44, p < 0.001).

CONCLUSIONS

PROMIS CSOs are increasingly utilized, especially for lower extremity procedures assessing the PF, PI, and D domains using distribution-based MCID. Using more conservative anchor-based MCIDs and reporting MDCs may strengthen results. Researchers should consider unique pearls and pitfalls when assessing PROMIS CSOs.

PROMIS physical function and pain perform poorly psychometrically in patients undergoing medial patellofemoral ligament reconstruction

PURPOSE

The purpose of this study was to assess the validity, floor and ceiling effects, and dimensionality of PROMIS Physical Function (PF) and Pain compared to legacy patient reported outcome (PRO) measures in patients undergoing medial patellofemoral ligament (MPFL) reconstruction.

METHODS

Patients who underwent MPFL reconstruction between 2018 to 2020 were retrospectively reviewed. Preoperatively, patients completed the IKDC, VR-12, Kujala, SF-12, KOOS JR, PROMIS PF and Pain surveys. Inter-survey convergence was assessed with Spearman correlations. Psychometric analysis included investigations of inter-survey convergent validity, intra-survey floor and ceiling effects, and Rasch analyses with person-item fit and iterative question elimination model fit testing.

RESULTS

A total of 76 patients (mean age: 22.6 ± 8.4 years) who completed preoperative surveys were included (compliance: 91.7-96.2%). Preoperatively, age was significantly associated with both PROMIS PF (coefficient:  - 0.291, P = 0.005) and Pain scores (coefficient: 0.294, P = 0.002). PROMIS PF had a Very Good correlation with IKDC and PROMIS Pain had a Very Good correlation with KOOS JR. Other correlations ranged from Poor to Good. No significant floor or ceiling effects were observed for any PRO. On iterative question elimination Rasch modelling, only two questions from PROMIS PF remained after 6 rounds of elimination while PROMIS Pain had no questions remaining after 3 rounds of elimination.

CONCLUSION

Preoperative PROMIS PF and Pain provided only Fair to Good correlations with most legacy PROs. Although no significant floor and ceiling effects were observed, PROMIS PF and Pain did not perform well psychometrically in this population of patients undergoing MPFL reconstruction. These results suggest PROMIS questionnaires should be used with caution in this population, especially if used in isolation, when discussing clinical expectations with patients. The authors recommend continued use of legacy PROs specific to assessment of patellar instability and function that have established validity in patellar instability populations.

LEVEL OF EVIDENCE

Level IV.

The Death Literacy Index: translation, cultural adaptation, and validation of the Chinese version

Objective

Applying public health approaches to address palliative care allows for a broader perspective. The Death Literacy Index (DLI) is a novel instrument designed to assess the knowledge and skills required to access, comprehend, and make informed decisions regarding end-of-life care. Translation of the DLI could strengthen the capacity to build desirable services and policies regarding dying and death. It could also help to identify the barriers to services and future advocacy efforts.

Methods

The DLI was forward translated into Chinese and backward translated through two panels. Two rounds of cognitive interviews and a pilot test were conducted before the survey. A sample of 3,221 participants was recruited via an online survey in five cities in southern China (Guangzhou, Zhuhai, Jiangmen, Hong Kong and Macao) to evaluate the factor structure, validity and reliability of the translated DLI. Additionally, multi-group confirmatory factor analyses (MGCFA) were performed to examine measurement invariance across genders and the experiences of parental death.

Results

Exploratory factor analysis showed a six-factor structure for the translated DLI, and confirmatory factor analysis confirmed the structure. The overall scale and subscales had high internal consistency and satisfactory validity. The results from MGCFA showed that death literacy was adequately invariant for different genders and experiences of parental death.

Conclusion

The Chinese DLI is a reliable and valid instrument for measuring death literacy among people in southern China, and therefore can be used for both research and community practice.

Editorial Commentary: Legacy Patient-Reported Outcome Measures Remain Important Today Despite Responder Burden, but With Further Refinement, Patient-Reported Outcomes Measurement Information System Could Replace Legacy Instruments in the Future

Measuring patient-reported outcomes (PROs) is a key tenet in the drive toward value-based care. A more detailed understanding of outcomes has traditionally been obtained with increasingly frequent and more in-depth patient questionnaires. Legacy PROs require patients to complete a predetermined set of questions. Administering lengthy surveys repeatedly can generate respondent fatigue that compromises quality of the survey responses and overall compliance. In addition, these legacy scales have notable ceiling and floor effects, which limit their capacity to describe the condition of patients who are functioning at relatively high or low levels. Modern computer adaptive instruments, such as PROMIS, strive to minimize responder burden and mitigate floor and ceiling effects associated with many legacy instruments. However, although these new newer instruments correlate (moderately) with legacy scores, PROMIS also shows floor and ceiling effects, and PROMIS responsiveness is currently understudied. Today, we collect both PROMIS and legacy scores for tracking patient outcomes and for research purposes. We predict that with further refinement, PROMIS will replace legacy patient-reported outcome measures.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Canadian version of the National Institutes of Health minimum dataset for chronic low back pain research: reference values from the Quebec Low Back Pain Study

ABSTRACT

The National Institutes of Health (NIH) minimum dataset for chronic low back pain (CLBP) was developed in response to the challenge of standardizing measurements across studies. Although reference values are critical in research on CLBP to identify individuals and communities at risk of poor outcomes such as disability, no reference values have been published for the Quebec (Canada) context. This study was aimed to (1) provide reference values for the Canadian version of the NIH minimum dataset among individuals with CLBP in Quebec, both overall and stratified by gender, age, and pain impact stratification (PIS) subgroups, and (2) assess the internal consistency of the minimum data set domains (pain interference, physical function, emotional distress or depression, sleep disturbance, and PIS score). We included 2847 individuals living with CLBP who completed the baseline web survey of the Quebec Low Back Pain Study (age: 44.0 ± 11.2 years, 48.1% women) and were recruited through social media and healthcare settings. The mean score was 6.1 ± 1.8 for pain intensity. Pain interference, physical function, emotional distress or depression, sleep disturbance, and PIS scores were 12.9 ± 4.1, 14.4 ± 3.9, 9.8 ± 4.4, 13.0 ± 3.6, and 26.4 ± 6.6, respectively. Emotional distress or depression showed floor effects. Good-to-excellent internal consistency was found overall and by language, gender, and age subgroups for all domains (alpha: 0.81-0.93) and poor-to-excellent internal consistency for PIS subgroups (alpha: 0.59-0.91). This study presents reference values and recommendations for using the Canadian version of the NIH minimum dataset for CLBP that can be useful for researchers and clinicians.

PROMIS Utilization in Pediatric Orthopaedics: A Scoping Review

BACKGROUND

The lack of a common patient-reported outcome metric used among the orthopaedic population is a problem that has been previously identified by the American Academy of Orthopaedic Surgeons. The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed by the National Institute of Health with the goal of creating a precise and efficient measurement tool for patient-reported symptoms, functioning, and health-related quality of life to be used in clinical research. A study summarizing its use in the pediatric orthopaedic population has not been previously performed.

METHODS

We performed a literature search of Ovid Medline, Embase, Scopus, and the Cochrane Central Register of Controlled Trials from 2010 to August 2021. There were 1961 unique citations included after the removal of 1756 duplicates. After initial screening, 183 studies were screened under full-text review leaving a final number of 51 studies included in this scoping review.

RESULTS

Pediatric PROMIS studies were grouped by body part or sub-speciality: "Hand and Upper Extremity" (25.5%, n=13), "Sports" (23.5%, n=12), "Spine" (13.7%, n=7), "Trauma" (13.7%, n=7), "General Pediatric Orthopaedics" (11.8%, n=6), "Lower Extremity" (9.8%, n=5), and "Orthopaedic Oncology" (2%, n=1). An increase in studies utilizing PROMIS was seen throughout the study period with only 3 studies published from 2013 to 2016 to 39 in 2020 and 2021 alone. The 3 most frequently used pediatric PROMIS domains were Pain Interference (76.5%, n=39/51), Mobility (60.8%, n=31/51), and Upper Extremity (54.9%, n=28/51). 64.3% (n=9/14) of the included studies which reported on the floor effects of Pain Interference exhibited a significant floor effect. In all, 77.8% (n=7/9) of the included studies which reported on ceiling effects of Upper Extremity exhibited a significant ceiling effect.

CONCLUSION

The use of PROMIS increased significantly since the first publication in 2013 suggesting orthopaedic providers have increasingly utilized PROMIS in their day-to-day practice as an outcome measure. Ceiling and floor effects were prominent in several of the included domains (Pain Interference and Upper Extremity). Overall, PROMIS measures are efficient, reliable, and effective to use.

LEVEL OF EVIDENCE

IV.

Machine Learning Improves Functional Upper Extremity Use Capture in Distal Radius Fracture Patients

Current outcome measures, including strength/range of motion testing, patient-reported outcomes (PROs), and motor skill testing, may provide inadequate granularity in reflecting functional upper extremity (UE) use after distal radius fracture (DRF) repair. Accelerometry analysis also has shortcomings, namely, an inability to differentiate functional versus nonfunctional movements. The objective of this study was to evaluate the accuracy of machine learning (ML) analyses in capturing UE functional movements based on accelerometry data for patients after DRF repair. In this prospective study, six patients were enrolled 2-6 weeks after DRF open reduction and internal fixation (ORIF). They all performed standardized activities while wearing a wrist accelerometer, and the data were analyzed by an ML algorithm. These activities were also videotaped and evaluated by visual inspection. Our novel ML algorithm was able to predict from accelerometry data whether the limb was performing a movement rated as functional, with accuracy of 90.4% ± 3.6% for within-subject modeling and 79.8% ± 8.9% accuracy for between-subject modeling. The application of ML algorithms to accelerometry data allowed for capture of functional UE activity in patients after DRF open reduction and internal fixation and accurately predicts functional UE use. Such analyses could improve our understanding of recovery and enhance routine postoperative rehabilitation in DRF patients.

Construct Validity of Pediatric PROMIS Computerized Adaptive Testing Measures in Children With Adolescent Idiopathic Scoliosis

BACKGROUND

The use of patient-reported outcome measures, especially Patient-Reported Outcomes Measurement Information System (PROMIS) measures, has increased in recent years. Given this growth, it is imperative to ensure that the measures being used are validated for the intended population(s)/disease(s). Our objective was to assess the construct validity of 8 PROMIS computer adaptive testing (CAT) measures among children with adolescent idiopathic scoliosis (AIS).

METHODS

We prospectively enrolled 200 children (aged 10 to 17 y) with AIS, who completed 8 PROMIS CATs (Anxiety, Depressive Symptoms, Mobility, Pain Behavior, Pain Interference, Peer Relationships, Physical Activity, Physical Stress Experiences) and the Scoliosis Research Society-22r questionnaire (SRS-22r) electronically. Treatment categories were observation, bracing, indicated for surgery, or postoperative from posterior spinal fusion. Construct validity was evaluated using known group analysis and convergent and discriminant validity analyses. Analysis of variance was used to identify differences in PROMIS T -scores by treatment category (known groups). The Spearman rank correlation coefficient ( rs ) was calculated between corresponding PROMIS and SRS-22r domains (convergent) and between unrelated PROMIS domains (discriminant). Floor/ceiling effects were calculated.

RESULTS

Among treatment categories, significant differences were found in PROMIS Mobility, Pain Behavior, Pain Interference, and Physical Stress Experiences and in all SRS-22r domains ( P <0.05) except Mental Health ( P =0.15). SRS-22r Pain was strongly correlated with PROMIS Pain Interference ( rs =-0.72) and Pain Behavior ( rs =-0.71) and moderately correlated with Physical Stress Experiences ( rs =-0.57). SRS-22r Mental Health was strongly correlated with PROMIS Depressive Symptoms ( rs =-0.72) and moderately correlated with Anxiety ( rs =-0.62). SRS-22r Function was moderately correlated with PROMIS Mobility ( rs =0.64) and weakly correlated with Physical Activity ( rs =0.34). SRS-22r Self-Image was weakly correlated with PROMIS Peer Relationships ( rs =0.33). All unrelated PROMIS CATs were weakly correlated (| rs |<0.40). PROMIS Anxiety, Mobility, Pain Behavior, and Pain Interference and SRS-22r Function, Pain, and Satisfaction displayed ceiling effects.

CONCLUSIONS

Evidence supports the construct validity of 6 PROMIS CATs in evaluating AIS patients. Ceiling effects should be considered when using specific PROMIS CATs.

LEVEL OF EVIDENCE

Level II, prognostic.

Responsiveness of the UW Concerns About Pain Scale and UW Pain-Related Self-Efficacy Scale in Individuals With Chronic Low Back Pain

OBJECTIVES

The aim was to examine the responsiveness, presence of floor or ceiling effects, and minimal clinically important differences (MCIDs) for 2 new measures of pain-related catastrophizing and self-efficacy in individuals with chronic low back pain.

METHODS

A total of 183 individuals with chronic low back pain recruited from physical therapy clinics in Thailand completed the Thai versions of the 6-item University of Washington Concerns About Pain scale (T-UW-CAP6) and 6-item University of Washington Pain-Related Self-Efficacy scale (T-UW-PRSE6) at baseline and at 4 weeks follow-up. Perceived change in low back symptom was assessed at 4 weeks using a 7-point measure of Global Perceived Effect (GPE). Responsiveness of the T-UW-CAP6 and the T-UW-PRSE6 scale scores were evaluated by computing the effect sizes and standardized response means for change over time, and examining these as a function of the GPE ratings. Floor and ceiling effects were examined by evaluating the score distributions. Scale core MCIDs were estimated by computing a half a SD and SE of measurement statistics for each scale.

RESULTS

Responsiveness of the scales to pain treatment was supported by differences found in the mean change scores as a function of the treatment response categories. No significant floor or ceiling effects were found for either measure. Changes of 4.38 and 3.68 appeared to be the smallest change score perceived as clinical meaningful for the T-UW-CAP6 and T-UW-PRSE 6 scale scores, respectively.

DISCUSSION

The T-UW-CAP6 and T-UW-PRSE6 demonstrated good ability to detect perceived changes over time in patients with chronic low back pain. The MCIDs values provide a benchmark for assessing individual improvement in this clinical context.

The metabolic equivalent of task score : a useful metric for comparing high-functioning hip arthroplasty patients

AIMS

This study investigates the use of the metabolic equivalent of task (MET) score in a young hip arthroplasty population, and its ability to capture additional benefit beyond the ceiling effect of conventional patient-reported outcome measures.

METHODS

From our electronic database of 751 hip arthroplasty procedures, 221 patients were included. Patients were excluded if they had revision surgery, an alternative hip procedure, or incomplete data either preoperatively or at one-year follow-up. Included patients had a mean age of 59.4 years (SD 11.3) and 54.3% were male, incorporating 117 primary total hip and 104 hip resurfacing arthroplasty operations. Oxford Hip Score (OHS), EuroQol five-dimension questionnaire (EQ-5D), and the MET were recorded preoperatively and at one-year follow-up. The distribution was examined reporting the presence of ceiling and floor effects. Validity was assessed correlating the MET with the other scores using Spearman's rank correlation coefficient and determining responsiveness. A subgroup of 93 patients scoring 48/48 on the OHS were analyzed by age, sex, BMI, and preoperative MET using the other metrics to determine if differences could be established despite scoring identically on the OHS.

RESULTS

Postoperatively the OHS and EQ-5D demonstrate considerable negatively skewed distributions with ceiling effects of 41.6% and 53.8%, respectively. The MET was normally distributed postoperatively with no relevant ceiling effect. Weak-to-moderate significant correlations were found between the MET and the other two metrics. In the 48/48 subgroup, no differences were found comparing groups with the EQ-5D, however significantly higher mean MET scores were demonstrated for patients aged < 60 years (12.7 (SD 4.7) vs 10.6 (SD 2.4), p = 0.008), male patients (12.5 (SD 4.5) vs 10.8 (SD 2.8), p = 0.024), and those with preoperative MET scores > 6 (12.6 (SD 4.2) vs 11.0 (SD 3.3), p = 0.040).

CONCLUSION

The MET is normally distributed in patients following hip arthroplasty, recording levels of activity which are undetectable using the OHS. Cite this article: Bone Joint Res 2022;11(5):317-326.

Patients With Preoperative Clinical Depression Symptomology Experience Significant Improvements in Postoperative Pain, Function, and Depressive Symptoms Following Rotator Cuff Repair

PURPOSE

To determine the impact of clinical depression on outcomes after rotator cuff repair (RCR), as measured by Patient-Reported Outcomes Measurement Information System (PROMIS) Computer Adaptive Test (CAT) health domains.

METHODS

RCR patients were given PROMIS CAT assessments for physical function (PROMIS UE), pain interference (PROMIS PI), and depression (PROMIS D) during preoperative and postoperative clinic visits. PROMIS D scores ≥55 correlate with mild clinical depression; thus patients with PROMIS D scores ≥ 55 were placed in the clinical depression (CD) group, whereas patients with scores <55 were placed in the "no clinical depression" (NCD) group. Categorical variables were compared at preoperative and postoperative (6 months and ≥1 year) timepoints using χ² tests. Continuous variables were compared using Student's t-tests.

RESULTS

Of the 340 RCR patients included in this study, 65 (19.1%) were found to have mild clinical depression preoperatively, with that number being reduced to 23 (6.8%) at 6 months and 19 (5.6%) at ≥1 year after surgery. Compared with preoperative PROMIS scores, CD patients had significant postoperative improvements at 6 months and ≥1 year in mean PROMIS UE (26.7 vs 35.5 vs 38.9; P < .001) and PROMIS PI (67.6 vs 56.7 vs 56.4; P < .001). NCD patients had similar postoperative improvements at 6 months and ≥1 year in mean PROMIS UE (30.8 vs 38.6 vs 46.9; P < .001) and PROMIS PI (61.7 vs 53.0 vs 47.6; P < .001). The improvement in PROMIS scores was similar for the CD and NCD groups in both PROMIS UE (12.2 vs 16.1, respectively) and PROMIS PI (-11.2 vs -14.1, respectively).

CONCLUSION

Despite starting with worse PROMIS UE and PROMIS PI scores, patients undergoing RCR with symptoms of CD experienced significant improvement in function, pain, and depressive symptoms. Preoperative depression should not be a contraindication to arthroscopic RCR in patients who are otherwise appropriate operative candidates.

LEVEL OF EVIDENCE

Level III, retrospective comparative trial.

Cerebral Visual Impairment in CDKL5 Deficiency Disorder Correlates With Developmental Achievement

Cyclin-dependent kinase-like 5 (CDKL5) deficiency disorder is a rare neurodevelopmental disorder characterized by infantile-onset refractory epilepsy, profound developmental delays, and cerebral visual impairment. Although there is evidence that the presence of cerebral visual impairment in CDKL5 deficiency disorder is common, the potential impact of cerebral visual impairment severity on developmental attainment has not been explored directly. Focusing on a cohort of 46 children with CDKL5 deficiency disorder, examination features indicative of cerebral visual impairment were quantified and compared to developmental achievement. The derived cerebral visual impairment severity score was inversely correlated with developmental attainment, bolstering the supposition that cerebral visual impairment severity may provide a useful early biomarker of disease severity and prognosis. This study demonstrates the utility of a cerebral visual impairment score to better capture the range of cerebral visual impairment severity in the CDKL5 deficiency disorder population and further elucidates the interaction between cerebral visual impairment and developmental outcomes.

Examining the Association Between Self-Reported Estimates of Function and Objective Measures of Gait and Physical Capacity in Lumbar Stenosis

Objective:

To evaluate the association of self-reported physical function with subjective and objective measures as well as temporospatial gait features in lumbar spinal stenosis (LSS).

Design:

Cross-sectional pilot study.

Setting:

Outpatient multispecialty clinic.

Participants:

Participants with LSS and matched controls without LSS (n=10 per group; N=20).

Interventions:

Not applicable.

Main Outcome Measures:

Self-reported physical function (36-Item Short Form Health Survey [SF-36] physical functioning domain), Oswestry Disability Index, Swiss Spinal Stenosis Questionnaire, the Neurogenic Claudication Outcome Score, and inertia measurement unit (IMU)-derived temporospatial gait features

Results:

Higher self-reported physical function scores (SF-36 physical functioning) correlated with lower disability ratings, neurogenic claudication, and symptom severity ratings in patients with LSS (P<.05). Compared with controls without LSS, patients with LSS have lower scores on physical capacity measures (median total distance traveled on 6-minute walk test: controls 505 m vs LSS 316 m; median total distance traveled on self-paced walking test: controls 718 m vs LSS 174 m). Observed differences in IMU-derived gait features, physical capacity measures, disability ratings, and neurogenic claudication scores between populations with and without LSS were statistically significant.

Conclusions:

Further evaluation of the association of IMU-derived temporospatial gait with self-reported physical function, pain related-disability, neurogenic claudication, and spinal stenosis symptom severity score in LSS would help clarify their role in tracking LSS outcomes.

Preoperative psychometric properties of Patient-Reported Outcomes Measurement Information System Upper Extremity, Pain Interference, and Depression in Bankart repair and rotator cuff repair

BACKGROUND

We aimed to examine the preoperative performance of Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE, versions 1.2 and 2.0), Pain Interference (PI, version 1.1), and Depression (version 1.0) testing across multiple orthopedic procedures for the upper extremity and define its susceptibility to preoperative floor and ceiling effects.

METHODS

We conducted a retrospective analysis of prospectively collected patient-reported outcome measures using an electronic outcome registry for procedures performed between May 2017 and April 2019. Current Procedural Terminology (CPT) codes were used to examine cohorts for 2 upper-extremity orthopedic procedures: Bankart repair and arthroscopic rotator cuff repair (ARCR). Shapiro-Wilk normality testing was used to assess score distributions for normalcy; given non-normal score distributions, Spearman correlation coefficients were calculated for preoperative patient-reported outcome scores. Absolute floor and ceiling effects were calculated for preoperative time points based on CPT code.

RESULTS

A total of 488 patients were included across the Bankart repair cohort (n = 109; mean age, 29.3 ± 12.5 years) and ARCR cohort (n = 379; mean age, 57.5 ± 9.5 years). In the Bankart repair cohort, the PROMIS PI score demonstrated strong correlations with the American Shoulder and Elbow Surgeons score (r = -0.63), Constant score (r = -0.75), PROMIS UE score (r = -0.75), and Veterans RAND-6 Domain score (r = -0.61). The PROMIS Depression score (r = 0.23 and r = 0.17, respectively), Short Form 12 Mental Composite Scale score (r = 0.34 and r = 0.11, respectively), and Veterans RAND 12-item health survey Mental Composite Scale score (r = 0.44 and r = 0.15, respectively) exhibited poor correlations with the PROMIS PI and UE scores. In the ARCR cohort, the PROMIS PI score demonstrated a good correlation with the PROMIS UE score (r = 0.61). The Constant score (r = 0.58 and r = 0.67, respectively), Veterans RAND 12-item health survey Physical Composite Scale score (r = 0.58 and r = 0.47, respectively), and Veterans RAND-6 Domain score (r = 0.67 and r = 0.53, respectively) exhibited good correlations with the PROMIS PI and UE measures. No significant absolute floor or ceiling effects were observed for the PROMIS instruments except the PROMIS Depression measure: An absolute floor effect was noted for both the Bankart repair (n = 12, 30%) and ARCR (n = 38, 14.7%) groups.

CONCLUSION

The PROMIS PI and UE instruments perform favorably compared with legacy outcome instruments in patients receiving Bankart repair, as well as those undergoing ARCR. Furthermore, in both populations, the PROMIS Depression instrument exhibits absolute floor effects whereas the PROMIS PI and UE instruments fail to demonstrate any absolute floor or ceiling effects.

Use of Patient-Reported Outcomes Measurement Information System (PROMIS) measures to characterise health status for patients seeking care from an orthopaedic provider: a retrospective cohort study

OBJECTIVES

Characterise the health status of patients newly consulting an orthopaedic specialist across eight clinical subspecialties.

DESIGN

Retrospective cohort.

SETTING

18 orthopaedic clinics, including 8 subspecialties (14 ambulatory and 4 hospital based) within an academic health system.

PARTICIPANTS

14 910 patients consulting an orthopaedic specialist for a new patient consultation who completed baseline Patient-Reported Outcomes Measurement Information System (PROMIS) measures associated with their appointment from 17 November 2017 to 13 May 2019. Patients were aged 55.72±5.8 years old, and 61.3% were female and 79.3% were Caucasian and 13.4% were black or African American. Patients who did not complete PROMIS measures or cancelled their appointment were excluded from the study.

PRIMARY OUTCOME

PROMIS domains of physical function, pain interference, pain intensity, depression, anxiety, fatigue, sleep disturbance and the ability to participate in social roles.

RESULTS

Mean PROMIS scores for physical function were (38.1±9.2), pain interference (58.9±8.1), pain intensity (4.6±2.5), depression (47.9±8.9), anxiety (49.9±9.5), fatigue (50.5±10.3), sleep disturbance (51.1±9.8) and ability to participate in social roles (49.1±10.3) for the entire cohort. Across the clinical subspecialties, neurosurgery, spine and trauma patients were most profoundly affected across almost all domains and patients consulting with a hand specialist reported the least limitations or symptoms across domains. There was a moderate, negative correlation between pain interference and physical functioning (r=-0.59) and low correlations between pain interference with anxiety (r=0.36), depression (r=0.39) as well as physical function and anxiety (r=-0.32) and depression(r=-0.30) and sleep (r=-0.31).

CONCLUSIONS

We directly compared clinically meaningful PROMIS domains across eight orthopaedic subspecialties, which would not have been possible with legacy measures alone. These results support PROMIS's utility as a common metric to assess and compare patient health status across multiple orthopaedic subspecialties.

Normative PROMIS Scores in Healthy Collegiate Athletes: Establishing a Target for Return to Function in the Young Adult Athlete

Background

The Patient-Reported Outcomes Measurement Information System (PROMIS) computer-adaptive testing (CAT) has been shown to be a valid and reliable means of assessing patient-reported outcomes. However, normal scores and distributions for a subset of a healthy young athletic population have not been established.

Purpose

To establish normative PROMIS scores for the domains of Physical Function (PF-CAT), Mobility (M-CAT), Upper Extremity Function (UE-CAT), and Pain Interference (PI-CAT) and determine the frequency of floor and ceiling effects in a population of healthy collegiate athletes.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

Healthy collegiate athletes (18-23 years of age) were prospectively enrolled to complete the 4 PROMIS CAT domains. Additionally, the athletes provided information regarding their age, sex, and sport(s). Mean scores (±SD) and identification of ceiling or floor effects were calculated. Ceiling and floor effects were considered significant if >15% of the participants obtained the highest or lowest possible score on a domain.

Results

A total of 194 healthy athletes (mean age, 19.1 years) were included in the study: 118 (60.8%) men and 76 (39.2%) women. Mean scores were 62.9 ± 6.7 for PF-CAT, 58.2 ± 4.1 for M-CAT, 57.4 ± 5.8 for UE-CAT, and 43.2 ± 6.2 for PI-CAT. Distributions of scores for M-CAT and UE-CAT indicated strong ceiling effects by 77.3% and 66.0% of the participants, respectively. In healthy athletes, the PF-CAT differed most from the expected population-based mean score (50), with the mean being >1 SD above (62.9), without a ceiling effect observed. There were no significant sex- or age-based differences on any of the PROMIS domain scores.

Conclusion

Healthy collegiate athletes scored nearly 1 SD from population-based means for all of the domains tested. M-CAT and UE-CAT demonstrated ceiling effects in more than two-thirds of healthy athletes, which may limit their utility in this population. The PF-CAT did not demonstrate floor or ceiling effects and demonstrated differences in a young adult athletic population from the population mean. The mean PF-CAT score of 62.9 can represent a target for return of function in injured athletes.

Correlation of Patient-Reported Outcomes Measurement Information System Questionnaires With the Brief Michigan Hand Questionnaire in Patients With 5 Common Hand Conditions

PURPOSE

We evaluated the concurrent validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) Global Mental Health (GMH), Global Physical Health (GPH), Upper Extremity (UE), Pain Interference (PI), and Self-Efficacy for Managing Medications and Treatment (SE-MMT) by analyzing correlation to the brief Michigan Hand Questionnaire (bMHQ) in patients with 5 common hand conditions: carpal tunnel syndrome, Dupuytren contracture, trigger finger, thumb carpometacarpal osteoarthritis, and wrist ganglion cysts.

METHODS

Our cohort included 11,782 unique visits representing 4,401 patients. Patient demographics, PROMIS Computer Adaptive Test questionnaires, and bMHQ were collected prospectively at all visits for all patients. Spearman rank correlation was used to evaluate the relationship between the PROMIS and bMHQ scores. Multivariable linear regression models were used to evaluate the relationship between questionnaires and patient demographics.

RESULTS

The PROMIS UE and PI showed strong correlations to the bMHQ. The PROMIS GPH showed moderate correlation to the bMHQ. The PROMIS GMH and SE-MMT were weakly correlated with the bMHQ. These results for the overall group were consistent across subgroup analysis for each condition, and regression models confirmed these correlation findings when controlling for demographic variables. The bMHQ had the smallest ceiling and floor effects compared with the PROMIS questionnaires. The PROMIS UE, PI, and SE-MMT took significantly less time to complete than the bMHQ.

CONCLUSION

Correlations between the PROMIS questionnaires and the bMHQ were similar regardless of condition.

CLINICAL RELEVANCE

Given their moderate-to-strong correlations with the bMHQ and consistency across conditions, the PROMIS UE and PI may be adequate replacements for the bMHQ for evaluating these domains in both clinical and research applications in patients with these common upper extremity pathologies. The PROMIS GPH, GMH, and SE-MMT, in conjunction with the bMHQ, may provide more information regarding patient's physical and mental health and ability to manage medications and treatment without substantially increasing patient burden. Clinicians and researchers can use these findings to guide questionnaire selection based on the clinical or research question(s) of interest.

Development and Evaluation of the Psychosocial Adaptation Questionnaire among Patients with Chronic Skin Disease

BACKGROUND/OBJECTIVE

Chronic skin disease (CSD) often has physiological, psychological, and social impacts, which requires the patient to adjust to achieve psychosocial adaptation (PSA). As a standardized assessment instrument was lacking, we developed a PSA questionnaire for patients with CSD (PSAQ-CSD).

METHODS

According to the steps of questionnaire development, a systematic process of scoping review, qualitative research, content validity expert review, testing in a sample of 321 adults, item analysis, and classical test theory methods were applied.

RESULTS

Following item analysis and exploratory factor analyses, 18 items were eventually entered into the model of confirmatory factor analyses, with a cumulative contribution of 65.435%. Three subscales were developed: emotional, self-cognitive, and social dimensions. Item analysis, exploratory factor analyses, and content validity expert review narrowed the subscales to 8, 6, and 4 items, respectively.

CONCLUSIONS

The 18-item PSAQ-CSD has been confirmed to have good internal consistency reliability and convergent and discriminant validity. It may be a useful tool to evaluate the PSA among patients with CSD and provide a basis for further research.

The PROMIS CAT Demonstrates Responsiveness in Patients After ACL Reconstruction Across Numerous Health Domains

Background:

The Patient-Reported Outcomes Measurement Information System (PROMIS) has emerged as a dynamic, efficient, and validated patient-reported outcome measure in the field of orthopaedics. However, the responsiveness, which is defined as the ability to detect changes in scores over time, of PROMIS computer adaptive tests (CATs) after anterior cruciate ligament reconstruction (ACLR) has not been well documented.

Purpose:

To investigate the responsiveness up to 1 year postoperatively of multiple PROMIS CAT domains in patients undergoing ACLR.

Study Design:

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

Methods:

All patients who underwent ACLR by 1 of 2 fellowship-trained sports medicine orthopaedic surgeons, with preoperative and at least 6 months postoperative visits, were included in this study. PROMIS CAT physical function (PF), pain interference (PI), and depression (D) scores from each visit were collected and analyzed. Preoperative patient-centric factors, including demographic factors and meniscal pathology, were analyzed for associations with improvements in PROMIS scores.

Results:

A total of 100 patients (62 male patients and 38 female patients; mean age, 27.6 ± 11.8 years) with an average follow-up of 338.5 ± 137.5 days were included in this study. Preoperative PF, PI, and D scores improved significantly from 38.5 ± 7.3, 60.3 ± 7.0, and 47.9 ± 9.1, respectively, to 53.6 ± 10.3, 48.1 ± 8.5, and 41.0 ± 9.9, respectively (P < .001 for each domain). Lower preoperative PF scores, PI scores, and a lower body mass index (BMI) were predictive for greater improvements in PF. Higher preoperative PI scores and a lower BMI were predictors for greater improvements in PI. Meniscal pathology was not predictive of improvement in PROMIS scores.

Conclusion:

PROMIS CAT assessments of PF, PI, and D demonstrated responsiveness in patients undergoing ACLR up to 1 year. Worse preoperative PROMIS scores and a lower BMI were predictive of greater improvements in PROMIS scores.

Pediatric PROMIS Computer Adaptive Tests Are Highly Correlated With Adult PROMIS Computer Adaptive Tests in Pediatric Sports Medicine Patients

BACKGROUND

The Patient-Reported Outcomes Measurement Information System (PROMIS) is a powerful set of patient-reported outcome measures (PROMs) that are gaining popularity throughout orthopaedic surgery. The use of both adult and pediatric PROMIS questionnaires in orthopaedic sports medicine limits the value of the PROMIS in routine sports medicine clinical care, research, and quality improvement. Because orthopaedic sports medicine surgeons see patients across a wide age range, simplifying the collection of PROMIS computer adaptive tests (CATs) to a single set of questionnaires, regardless of age, is of notable value.

PURPOSE/HYPOTHESIS

The purpose was to determine the strength of the correlation between the pediatric and adult PROMIS questionnaires. We hypothesized that there would be a high correlation between the adult and pediatric versions for each PROMIS domain, thereby justifying the use of only the adult version for most sports medicine providers, regardless of patient age.

STUDY DESIGN

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

METHODS

Between December 2018 and December 2019, all pediatric sports medicine patients presenting to a single, academic, orthopaedic sports medicine clinic were asked to participate in the present study with their parents' consent. Patients were asked to complete a set of adult PROMIS domains (Physical Function and/or Upper Extremity, Pain Interference, and Depression) as well as a set of pediatric PROMIS domains (Mobility and/or Upper Extremity, Pain Interference, and Depressive Symptoms). Concurrent validity was assessed using Pearson correlation coefficients (r). Ceiling and floor effects were determined.

RESULTS

A total of 188 patients met our inclusion criteria. The correlation between the adult and pediatric PROMIS Upper Extremity, Physical Function and Mobility, Pain Interference, and Depression and Depressive Symptoms forms were high-moderate (r = 0.68; P < .01), high-moderate (r = 0.69; P < .01), high (r = 0.78; P < .01), and high (r = 0.85; P < .01), respectively. Both adult and pediatric depression-related PROMIS domains demonstrated notable floor effects (adult: 38%; pediatric: 24%). The pediatric PROMIS Upper Extremity domain demonstrated a ceiling effect (20%).

CONCLUSION

Adult PROMIS CATs may be used in an orthopaedic sports medicine clinic for both adult and pediatric patients. Our findings will help decrease the amount of resources needed for the implementation and use of PROMs for patient care, research, and quality improvement in orthopaedic sports medicine clinics.

Reporting and utilization of Patient-Reported Outcomes Measurement Information System® (PROMIS®) measures in orthopedic research and practice: a systematic review

BACKGROUND

The Patient-Reported Outcomes Measurement Information SystemⓇ (PROMISⓇ) is a dynamic system of psychometrically sound patient-reported outcome (PRO) measures. There has been a recent increase in the use of PROMIS measures, yet little has been written about the reporting of these measures in the field of orthopedics. The purpose of this study was to conduct a systematic review to determine the uptake of PROMIS measures across orthopedics and to identify the type of PROMIS measures and domains that are most commonly used in orthopedic research and practice.

METHODS

We searched PubMed, Embase, and Scopus using keywords and database-specific subject headings to capture orthopedic studies reporting PROMIS measures through November 2018. Our inclusion criteria were use of PROMIS measures as an outcome or used to describe a population of patients in an orthopedic setting in patients ≥ 18 years of age. We excluded non-quantitative studies, reviews, and case reports.

RESULTS

Our final search yielded 88 studies published from 2013 through 2018, with 57% (50 studies) published in 2018 alone. By body region, 28% (25 studies) reported PROMIS measures in the upper extremity (shoulder, elbow, hand), 36% (32 studies) reported PROMIS measures in the lower extremity (hip, knee, ankle, foot), 19% (17 studies) reported PROMIS measures in the spine, 10% (9 studies) reported PROMIS measures in trauma patients, and 6% (5 studies) reported PROMIS measures in general orthopedic patients. The majority of studies reported between one and three PROMIS domains (82%, 73 studies). The PROMIS Computerized Adaptive Test (CAT) approach was most commonly used (81%, 72 studies). The most frequently reported PROMIS domains were physical function (81%, 71 studies) and pain interference (61%, 54 studies).

CONCLUSION

Our review found an increase in the reporting of PROMIS measures over the recent years. Utilization of PROMIS measures in orthopedic populations is clinically appropriate and can facilitate communication of outcomes across different provider types and with reduced respondent burden.

REGISTRATION

The protocol for this systematic review was designed in accordance with the PRISMA guidelines and is registered with the PROSPERO database (CRD42018088260).