Patient-Reported Outcomes Measurement Information System (PROMIS) Instruments Correlate Better With Legacy Measures in Knee Cartilage Patients at Postoperative Than at Preoperative Assessment

Social vulnerability adversely affects emergency-department utilization but not patient-reported outcomes after total joint arthroplasty

INTRODUCTION

Multiple studies demonstrate social deprivation is associated with inferior outcomes after total hip (THA) and total knee (TKA) arthroplasty; its effect on patient-reported outcomes is debated. The primary objective of this study evaluated the relationship between social vulnerability and the PROMIS-PF measure in patients undergoing THA and TKA. A secondary aim compared social vulnerability between patients who required increased resource utilization or experienced complications and those who didn't.

MATERIALS AND METHODS

A retrospective review of 537 patients from March 2020 to February 2022 was performed. The Centers for Disease Control Social Vulnerability Index (SVI) were used to quantify socioeconomic disadvantage. The cohort was split into THA and TKA populations; univariate and multivariate analyses were performed to evaluate primary and secondary outcomes. Statistical significance was assessed at p < 0.05.

RESULTS

48.6% of patients achieved PROMIS-PF MCID at 1-year postoperatively. Higher levels of overall social vulnerability (0.40 vs. 0.28, p = 0.03) were observed in TKA patients returning to the ED within 90-days of discharge. Increased overall SVI (OR = 9.18, p = 0.027) and household characteristics SVI (OR = 9.57, p = 0.015) were independent risk factors for 90-day ED returns after TKA. In THA patients, increased vulnerability in the household type and transportation dimension was observed in patients requiring 90-day ED returns (0.51 vs. 0.37, p = 0.04).

CONCLUSION

Despite an increased risk for 90-day ED returns, patients with increased social vulnerability still obtain good 1-year functional outcomes. Initiatives seeking to mitigate the effect of social deprivation on TJA outcomes should aim to provide safe alternatives to ED care during early recovery.

The Current Utilization of Patient-reported Outcome Measurement Information System in Shoulder, Elbow, and Sports Medicine

Clinical research using patient-reported outcome measures has been critical within the field of shoulder, elbow, and sports medicine in helping clinicians deliver evidence-based and value-based medicine. Recently, however, clinicians have advocated for improving the process of obtaining clinically meaningful information from patients while decreasing survey fatigue and increasing compliance. To that end, the National Institutes of Health created the Patient-Reported Outcome Measures Information System (PROMIS) in which a number of institutions and research investigations have adopted for reporting outcomes. A special focus has also been placed on PROMIS Computer Adaptive Testing forms, which tailor questioning through item response theory. The purpose of this study was to provide insight into the utilization, advantages, and disadvantages of PROMIS within the field of shoulder, elbow, and sports medicine and provide a comparison with legacy patient-reported outcome measure measurements.

Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Instruments Compare Favorably With Legacy Patient-Reported Outcome Measures in Upper- and Lower-Extremity Orthopaedic Patients: A Systematic Review of the Literature

PURPOSE

To compare Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) with traditional ("legacy") patient-reported outcome measures (PROMs) in regard to correlations, ease of use, and quality criteria for upper (UE) and lower extremity (LE) orthopaedic conditions.

METHODS

A systematic search of the PubMed/MEDLINE database was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify published articles that referenced the various PROMIS PF measures. Two authors independently reviewed selected studies. The search returned 857 studies, 85 of which were selected for independent review by 2 authors. Of these, 54 were selected for inclusion. Mixed linear models were performed to assess for differences between legacy PROMs and PROMIS measures.

RESULTS

The combined sample size of all included studies yielded 6,074 UE and 9,366 LE patients. Overall, PROMIS PF measures demonstrated strong correlations with legacy PROMs among UE (weighted Pearson correlation, 0.624, standard error [SE] = 0.042; weighted Spearman correlation, 0.566, SE = 0.042) and LE patients (weighted Pearson correlation, 0.645, SE = 0.062; weighted Spearman correlation, 0.631, SE = 0.041). PROMIS PF questionnaires completed by UE patients had fewer questions than legacy PROMs (5.9 vs 17.7, P = .0093) and were completed in less time (90.5 vs 223.8 seconds, P = .084). PROMIS PF questionnaires completed by LE patients had fewer questions than legacy PROMs (4.81 vs 15.33, P < .001) and were completed in less time (63.6 vs 203.2 seconds, P = .0063). The differences for the reliability measures were not significant.

CONCLUSIONS

PROMIS PF scores correlate strongly with commonly used legacy PROMs in orthopaedics, particularly in UE and LE patients. PROMIS PF forms can be administered efficiently and to a broad patient population while remaining highly reliable. Therefore, they can be justified for standardized use among orthopaedic patients with UE and LE conditions, improving the ability to aggregate and compare outcomes in orthopaedic research.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV evidence.

PROMIS Versus Legacy Patient-Reported Outcome Measures for Sports Medicine Patients Undergoing Arthroscopic Knee, Shoulder, and Hip Interventions: A Systematic Review

BACKGROUND

The Patient-Reported Outcomes Measurement Information System (PROMIS®) was designed to monitor the global wellbeing of patients, with the Physical Function Computer-Adaptive Test (PF-CAT) component focused specifically on functional outcome. PROMIS aims for increased item-bank accuracy, lower administrative burden, and decreased floor and ceiling effects compared to legacy patient-reported outcome measures (PROMs). Our primary research outcomes focused on sports medicine surgical populations, which may skew younger or have wide-ranging functional statuses. Specifically, for this population, we questioned if PROMIS PF-CAT was equal to legacy PROMs in (1) construct validity and (2) convergent/divergent validities; and superior to legacy PROMs with respect to (3) survey burden and (4) floor and ceiling effects.

METHODS

Searches were performed in April 2019 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, utilizing PubMed, Cochrane Central, and Embase databases for Level I-III evidence. This resulted in 541 records, yielding 12 studies for inclusion. PROM data was available for patients undergoing arthroscopic orthopaedic procedures of the knee, shoulder, and hip. Measures of construct validity, convergent/divergent validity, survey burden, and floor/ceiling effects were evaluated for PROMIS PF-CAT versus legacy PROMs.

RESULTS

PROMIS PF-CAT demonstrated excellent or excellent-good correlation with legacy PROMS for physical function and quality of life for patients undergoing arthroscopic interventions of the knee, shoulder, and hip. Compared to legacy PROM instruments, PROMIS PF-CAT demonstrated the lowest overall survey burden and had the lowest overall number of floor or ceiling effects across participants.

CONCLUSION

PROMIS PF-CAT is an accurate, efficient evaluation tool for sports medicine surgical patients. PROMIS PF-CAT strongly correlates with legacy physical function PROMs while having a lower test burden and less incidence of floor and ceiling effects. PROMIS PF-CAT may be an optimal alternative for traditional physical function PROMs in sports medicine patients undergoing arthroscopic procedures. Further studies are required to extend the generalizability of these findings to patients during postoperative timepoints after shoulder and hip interventionsLevel of Evidence: III.

A High-Sensitivity International Knee Documentation Committee Survey Index From the PROMIS System: The Next-Generation Patient-Reported Outcome for a Knee Injury Population

BACKGROUND

Patient-reported outcomes (PROs) measure progression and quality of care. While legacy PROs such as the International Knee Documentation Committee (IKDC) survey are well-validated, a lengthy PRO creates a time burden on patients, decreasing adherence. In recent years, PROs such as the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function and Pain Interference surveys were developed as computer adaptive tests, reducing time to completion. Previous studies have examined correlation between legacy PROs and PROMIS; however, no studies have developed effective prediction models utilizing PROMIS to create an IKDC index. While the IKDC is the standard knee PRO, computer adaptive PROs offer numerous practical advantages.

PURPOSE

To develop a nonlinear predictive model utilizing PROMIS Physical Function and Pain Interference to estimate IKDC survey scores and examine algorithm sensitivity and validity.

STUDY DESIGN

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

METHODS

The MOTION (Military Orthopaedics Tracking Injuries and Outcomes Network) database is a prospectively collected repository of PROs and intraoperative variables. Patients undergoing knee surgery completed the IKDC and PROMIS surveys at varying time points. Nonlinear multivariable predictive models using Gaussian and beta distributions were created to establish an IKDC index score, which was then validated using leave-one-out techniques and minimal clinically important difference analysis.

RESULTS

A total of 1011 patients completed the IKDC and PROMIS Physical Function and Pain Interference, providing 1618 complete observations. The algorithms for the Gaussian and beta distribution were validated to predict the IKDC (Pearson = 0.84-0.86; R² = 0.71-0.74; root mean square error = 9.3-10.0).

CONCLUSION

The publicly available predictive models can approximate the IKDC score. The results can be used to compare PROMIS Physical Function and Pain Interference against historical IKDC scores by creating an IKDC index score. Serial use of the IKDC index allows for a lower minimal clinically important difference than the conventional IKDC. PROMIS can be substituted to reduce patient burden, increase completion rates, and produce orthopaedic-specific survey analogs.

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.

A Longitudinal Comparison of Patient-Reported Outcomes Measurement Information System to Legacy Scales in Knee and Shoulder Arthroscopy Patients

PURPOSE

The purpose of this prospective correlational study was to compare the psychometric properties of the Defense and Veterans Pain Rating Scale (DVPRS) and Patient-Reported Outcomes Measurement Information System (PROMIS) scales with those of traditional legacy scales over a longitudinal postoperative period in patients undergoing arthroscopic procedures.

METHODS

Active-duty military personnel undergoing shoulder and knee arthroscopic procedures completed the DVPRS, PROMIS, and legacy scales preoperatively and again at 3 months postoperatively. Rolling correlation coefficients (r_rm) were used to assess the concurrent validity between the DVPRS average pain scores and computer adaptive testing PROMIS scales (Anxiety, Depression, Pain Behavior, Pain Interference, Mobility, Sleep Disturbance, Satisfaction With Social Roles, and Upper Extremity Physical Function) and the legacy scales (American Shoulder and Elbow Surgeons [ASES] scale, Shoulder Activity Scale, International Knee Documentation Committee [IKDC] questionnaire, Single Assessment Numeric Evaluation [SANE], Marx Activity Rating Scale, and Veterans RAND 12-Item Health Survey).

RESULTS

A total of 121 participants completed the scales preoperatively, 80 completed them at 3 months postoperatively, and 59 (49% of participants) completed them at both times. Rolling correlation coefficients between PROMIS Pain Interference (r_rm = -0.41, P = .006), Satisfaction With Social Roles (r_rm = 0.56, P < .001), and Upper Extremity (r_rm = 0.71, P < .001) scores showed acceptable concurrent validity with ASES scores over a longitudinal postoperative period. DVPRS scores (r_rm = -0.69, P = .002) and PROMIS Pain Behavior (r_rm = -0.57, P = .018), Pain Interference (r_rm = -0.71, P = .001), Sleep Disturbance (r_rm = -0.64, P = .005), and Mobility (r_rm = 0.65, P = .005) scores showed acceptable concurrent validity with IKDC scores. There was poor correlation between the PROMIS and DVPRS scores and the Single Assessment Numeric Evaluation, Marx Activity Rating Scale, Shoulder Activity Scale, and Veterans RAND 12-Item Health Survey scores.

CONCLUSIONS

PROMIS scales measuring physical function, pain presentation, and other health domains showed acceptable concurrent validity with ASES and IKDC scores. By integrating the prospective collection of biopsychosocial PROMIS scales into practice, it is possible for clinicians in orthopaedic settings to assess changes in validated patient-reported outcomes to inform patient-centered care planning throughout the postoperative recovery period.

LEVEL OF EVIDENCE

Level II, prospective comparative study (with not all participants completing follow-up).

The Patient-Reported Outcomes Measurement Information System (PROMIS): Can We Finally Compare Apples to Oranges?

Legacy patient-reported outcome mea`sures lack standardization, resulting in difficulty comparing the results of diverse clinical outcome studies: "You can't compare apples to oranges." To address this concern, the National Institutes of Health initiated the Patient-Reported Outcomes Measurement Information System (PROMIS) to assess common dimensions of a wide range of diseases. PROMIS uses computer adaptive testing: A fluid questionnaire chooses subsequent questions based on the responses to previous questions to efficiently characterize outcomes using only 4 to 6 questions. This greatly reduces survey fatigue. Research correlating PROMIS to legacy measures is of value. For now, some questions may require more information than PROMIS can provide, in which case legacy measures could be preferred. In the future, developing and adding a utility score to PROMIS could assess "value" and allow decision analyses and cost-effectiveness analyses for diverse health interventions. In the end, PROMIS may allow us to compare apples to oranges.

Editorial Commentary: Patient-Reported Outcomes Measurement Information System (PROMIS) Is Important Part of Future Clinical Research

The Patient-Reported Outcomes Measurement Information System (PROMIS) is more efficient than legacy measures and is generalizable across all patients and diseases. Patient-reported outcome scores may eventually become related to physician reimbursement and give patients a voice in their care.