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

Is the VISA-A Still Seaworthy, or Is It in Need of Maintenance?

Background

The Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire is validated and widely used in Achilles tendinopathy. How well it can evaluate treatment outcomes is not well understood.

Purpose

To evaluate the responsiveness of the VISA-A in midportion Achilles tendinopathy and compare it with other patient-reported outcome measures.

Study Design

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

Methods

Enrolled were 97 participants with clinically diagnosed Achilles tendinopathy (median age, 50 years [interquartile range, 18 years]; symptom duration, 10 months [interquartile range, 28.7 months). The participants underwent a baseline evaluation and completed between 1 and 6 follow-up evaluations at 8, 16, 24, 32, 40, and/or 48 weeks. Participants completed the VISA-A, the Patient Reported Outcomes Measurement Information System short form Version 2.0 (PROMIS) Physical Function and Pain Interference subscales, and the Tampa Scale for Kinesiophobia (TSK). Three thresholds were evaluated with a receiver operating characteristic analysis (minimal clinically important difference [MCID], substantial benefit [SB], and complete recovery [CR]) using an 11-point global rating of change scale as an anchor. Thresholds were evaluated on raw scores as well as changes from baseline.

Results

The VISA-A was able to detect all 3 thresholds for changes over time, with raw scores >70.5, >77.5, and >89.5 representing the MCID, SB, and CR, respectively; thresholds for changes from baseline on the VISA-A were increases of 23.5, 19.5, and 37.5 points from baseline, respectively. The PROMIS subscale raw scores had identical thresholds for SB and CR (52.45 for Physical Function and 45.6 for Pain Interference). A score <34.5 on the TSK was the threshold for SB.

Conclusion

The VISA-A was the most responsive outcome measure evaluated. Raw scores had increasingly higher thresholds for the MCID, SB, and CR, which were therefore logically consistent.

Editorial Commentary: Preoperative Patient-Reported Outcomes Measurement Information System Scores Vary Over Time

Patient-Reported Outcomes Measurement Information System (PROMIS) scores have considerable potential to both streamline the collection of outcome data and provide a common set of metrics to compare and benchmark patient-reported outcomes after orthopaedic procedures. An analysis of PROMIS scores collected at the preoperative clinical visit and the day of surgery found considerable changes in upper- and lower-extremity physical function, pain interference, and depression. These findings suggest that health status may vary between the day of operative consent and the day of surgery. Given the importance of patient-reported outcomes in clinical research, quality assurance, and value-based health care, the potential for large changes in scores leading up to the procedure warrants attention toward the timing of PROMIS administration to ensure that the health status of the patient-and its variation-is accurately captured.

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.

Pain Is the Primary Factor Associated With Satisfaction With Symptoms for New Patients Presenting to the Orthopedic Clinic

PURPOSE

The purpose of the current study was to (1) determine the percentage of new orthopedic patients reporting their symptoms to be acceptable at presentation, as measured by the Patient Acceptable Symptom State (PASS) question, and (2) evaluate whether patient-reported outcome measures (PROMs), including Patient-Reported Outcome Measurement Information System (PROMIS) Physical Function (PF) or Upper Extremity, Pain Interference (PI), and Depression (D), or sociodemographic factors are associated with acceptable symptoms at presentation.

METHODS

Between February 7, 2020, and March 16, 2020, new orthopedic patients who completed PROMs were identified. Patient records were reviewed for those who also completed the PASS question, a yes/no question about whether a patient's current symptom state is satisfactory. Bivariate analysis was conducted to compare patient characteristics, such as area deprivation index (ADI), between those reporting acceptable symptoms and those who did not. Multivariable logistic regression models were used to determine factors associated with acceptable symptoms at presentation.

RESULTS

A total of 570 patients were included, with one-fourth (n = 143 [25%]) reporting acceptable symptoms at presentation. In multivariable regression analysis, only pain, as measured by the PROMIS PI, was associated with acceptable symptoms at presentation (non-upper extremity patient regression: PROMIS PI: odds ratio [OR], 0.84; 95% confidence interval [CI], 0.79-0.90, P < .01; upper extremity patient regression: PROMIS PI: OR, 0.91; 95% CI, 0.85-0.98, P < .01). In both multivariable regression analyses, insurance type (private, Medicare, Medicaid, other), visit subspecialty (sports, hand, joints, foot and ankle, spine, other), PROMIS PF, PROMIS D, and national ADI were not associated with acceptable symptoms at presentation (all P > .05).

CONCLUSIONS

One-fourth of new orthopedic patients reported their symptoms to be acceptable at presentation. Of those who considered their symptom state unsatisfactory, pain-not functional status, mental health, or sociodemographic factors-was the primary determinant.

LEVEL OF EVIDENCE

Level III, diagnostic.

Advances in FAI Imaging: a Focused Review

PURPOSE OF REVIEW

Femoroacetabular impingement (FAI) is one of the main causes of hip pain in young adults and poses clinical challenges which have placed it at the forefront of imaging and orthopedics. Diagnostic hip imaging has dramatically changed in the past years, with the arrival of new imaging techniques and the development of magnetic resonance imaging (MRI). This article reviews the current state-of-the-art clinical routine of individuals with suspected FAI, limitations, and future directions that show promise in the field of musculoskeletal research and are likely to reshape hip imaging in the coming years.

RECENT FINDINGS

The largely unknown natural disease course, especially in hips with FAI syndrome and those with asymptomatic abnormal morphologies, continues to be a problem as far as diagnosis, treatment, and prognosis are concerned. There has been a paradigm shift in recent years from bone and soft tissue morphological analysis towards the tentative development of quantitative approaches, biochemical cartilage evaluation, dynamic assessment techniques and, finally, integration of artificial intelligence (AI)/deep learning systems. Imaging, AI, and hip preserving care will continue to evolve with new problems and greater challenges. The increasing number of analytic parameters describing the hip joint, as well as new sophisticated MRI and imaging analysis, have carried practitioners beyond simplistic classifications. Reliable evidence-based guidelines, beyond differentiation into pure instability or impingement, are paramount to refine the diagnostic algorithm and define treatment indications and prognosis. Nevertheless, the boundaries of morphological, functional, and AI-aided hip assessment are gradually being pushed to new frontiers as the role of musculoskeletal imaging is rapidly evolving.