Perceptions of Response Burden Associated with Completion of Patient-Reported Outcome Assessments in Oncology

[Patient-reported outcomes-the role of the patient's subjective perspective for research and clinical care]

Because only patients can adequately assess symptoms, disability, and quality of life, concordance between a patient's and physician's assessment is often low. Accordingly, patient-reported outcomes (PROs) are increasingly used in research and routine clinical care. In daily practice, PROs are not only applied to measure the patient's perceived outcome of medical treatments, but also to assess their health status before intervention starts. Typically, several patient-reported outcome measures (PROMs), which are reliable and valid, are available for the assessment of the most important PROMs. In daily clinical practice, the integration of PROs can be useful for clinical assessment and treatment planning or for quality management. Currently, the most promising application is routine patient monitoring using digital PROMs (ePROMs). Systematic reviews have revealed that the routine use of PROMs in daily clinical care is associated with, among others, improved physician-patient communication, higher patient satisfaction, reduced symptom burden, higher quality of life, and improved survival. This effect is especially strong if health care professionals continuously receive the results of the PRO monitoring. Patients are usually inclined to disclose their health status, and the positive effects of routine patient monitoring are widely recognized. However, several barriers to using PROs and PROMs still exist.

Patient adherence and response time in electronic patient-reported outcomes: insights from three longitudinal clinical trials

PURPOSE

Patient-reported outcome measures (PROMs) are used to collect data on disease symptoms in support of clinical trial endpoints. Clinical studies can last a year or more, and the patients' adherence and response time to daily at-home questionnaires may vary significantly over time. The aim of this study was to understand patterns and changes in patients' completion of daily PROMs during longitudinal clinical studies.

METHODS

Data were collected from 1342 patients randomized into three respiratory clinical trials (NCT03401229, NCT03347279, and NCT03406078). PROMs were completed by patients using electronic handheld devices that collected the starting and completion times. A Bayesian generalized linear mixed-effects model was used to identify unbiased coefficients associated with PROM adherence and response time using patient, site, and calendar features as covariates.

RESULTS

Adherence decreased over time after randomization, and the rate of decrease was higher in younger patients. The 14-day pre-randomization adherence was correlated with adherence throughout the study. Patients were also more adherent during working days compared to non-working days. Oldest patients took twice as long to complete PROMs throughout the study; however, the response time for all patients decreased during the first month of the study regardless of age. Response time increased 7 days before and after the date of a scheduled clinic visit and when a patient-reported higher symptom burden.

CONCLUSION

Detailed analyses of adherence and response time for daily PROMs in clinical trials can provide significant insights about trends of patient behavior in longitudinal clinical studies with high baseline adherence.

Enhanced clinical decisions for management of benign prostatic hyperplasia using patient-reported outcomes: protocol for a prospective observational study

BACKGROUND

Lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) significantly impact quality of life among older men. Despite the prevalent use of the American Urological Association Symptom Index (AUA-SI) for BPH, this measure overlooks key symptoms such as pain and incontinence, underscoring the need for more comprehensive patient-reported outcome (PRO) tools. This study aims to integrate enhanced PROs into routine clinical practice to better capture the spectrum of LUTS, thereby improving clinical outcomes and patient care.

METHODS

This prospective observational study will recruit men with LUTS secondary to BPH aged ≥ 50 years from urology clinics. Participants will be stratified into medical and surgical management groups, with PRO assessments scheduled at regular intervals to monitor LUTS and other health outcomes. The study will employ the LURN Symptom Index (SI)-29 alongside the traditional AUA-SI and other non-urologic PROs to evaluate a broad range of symptoms. Data on comorbidities, symptom severity, and treatment efficacy will be collected through a combination of electronic health records and PROs. Analyses will focus on the predictive power of these tools in relation to symptom trajectories and treatment responses. Aims are to: (1) integrate routine clinical tests with PRO assessment to enhance screening, diagnosis, and management of patients with BPH; (2) examine psychometric properties of the LURN SIs, including test-retest reliability and establishment of clinically meaningful differences; and (3) create care-coordination recommendations to facilitate management of persistent symptoms and common comorbidities measured by PROs.

DISCUSSION

By employing comprehensive PRO measures, this study expects to refine symptom assessment and enhance treatment monitoring, potentially leading to improved personalized care strategies. The integration of these tools into clinical settings could revolutionize the management of LUTS/BPH by providing more nuanced insights into patient experiences and outcomes. The findings could have significant implications for clinical practices, potentially leading to updates in clinical guidelines and better health management strategies for men with LUTS/BPH.

TRIAL REGISTRATION

This study is registered in ClinicalTrials.gov (NCT05898932).

Enhanced Clinical Decisions for Management of Benign Prostatic Hyperplasia using Patient-Reported Outcomes: Protocol for a Prospective Observational Study

Background

Lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) significantly impact quality of life among older men. Despite the prevalent use of the American Urological Association Symptom Index (AUA-SI) for BPH, this measure overlooks key symptoms such as pain and incontinence, underscoring the need for more comprehensive patient-reported outcome (PRO) tools. This study aims to integrate enhanced PROs into routine clinical practice to better capture the spectrum of LUTS, thereby improving clinical outcomes and patient care.

Methods

This prospective observational study will recruit men with LUTS secondary to BPH aged ≥ 50 years from urology clinics. Participants will be stratified into medical and surgical management groups, with PRO assessments scheduled at regular intervals to monitor LUTS and other health outcomes. The study will employ the LURN Symptom Index (SI)-29 alongside the traditional AUA-SI and other non-urologic PROs to evaluate a broad range of symptoms. Data on comorbidities, symptom severity, and treatment efficacy will be collected through a combination of electronic health records and PROs. Analyses will focus on the predictive power of these tools in relation to symptom trajectories and treatment responses. Aims are to: (1) integrate routine clinical tests with PRO assessment to enhance screening, diagnosis, and management of patients with BPH; (2) examine psychometric properties of the LURN SIs, including test-retest reliability and establishment of clinically meaningful differences; and (3) create care-coordination recommendations to facilitate management of persistent symptoms and common comorbidities measured by PROs.

Discussion

By employing comprehensive PRO measures, this study expects to refine symptom assessment and enhance treatment monitoring, potentially leading to improved personalized care strategies. The integration of these tools into clinical settings could revolutionize the management of LUTS/BPH by providing more nuanced insights into patient experiences and outcomes. The findings could have significant implications for clinical practices, potentially leading to updates in clinical guidelines and better health management strategies for men with LUTS/BPH.

Trial registration

This study is registered in ClinicalTrials.gov (NCT05898932).

Administering selected subscales of patient-reported outcome questionnaires to reduce patient burden and increase relevance: a position statement on a modular approach

Patient-reported outcome (PRO) questionnaires considered in this paper contain multiple subscales, although not all subscales are equally relevant for administration in all target patient populations. A group of measurement experts, developers, license holders, and other scientific-, regulatory-, payer-, and patient-focused stakeholders participated in a panel to discuss the benefits and challenges of a modular approach, defined here as administering a subset of subscales out of a multi-scaled PRO measure. This paper supports the position that it is acceptable, and sometimes preferable, to take a modular approach when administering PRO questionnaires, provided that certain conditions have been met and a rigorous selection process performed. Based on the experiences and perspectives of all stakeholders, using a modular approach can reduce patient burden and increase the relevancy of the items administered, and thereby improve measurement precision and eliminate wasted data without sacrificing the scientific validity and utility of the instrument. The panelists agreed that implementing a modular approach is not expected to have a meaningful impact on item responses, subscale scores, variability, reliability, validity, and effect size estimates; however, collecting additional evidence for the impact of context may be desirable. It is also important to recognize that adequate rationale and evidence (e.g., of fit-for-purpose status and relevance to patients) and a robust consensus process that includes patient perspectives are required to inform selection of subscales, as in any other measurement circumstance, is expected. We believe that the considerations discussed within (content validity, administration context, and psychometric factors) are relevant across multiple therapeutic areas.

Patient-Reported Outcome Measures for Patients With CKD: The Case for Patient-Reported Outcomes Measurement Information System (PROMIS) Tools

Chronic kidney disease (CKD), kidney failure, and kidney replacement therapies are associated with high symptom burden and impaired health-related quality of life (HRQOL). Symptoms change with disease progression or transition between treatment modalities and frequently go unreported and unmanaged. Tools that reliably monitor symptoms may improve the management of patients with CKD. Patient-reported outcome measures (PROMs) assess symptom severity; physical, psychological, social, and cognitive functioning; treatment-related side effects; and HRQOL. Systematic use of PROMs can improve patient-provider communication, patient satisfaction, clinical outcomes, and HRQOL. Potential barriers to their use include a lack of engagement, response burden, and limited guidance about PROM collection, score interpretation, and workflow integration. Well-defined, acceptable, and effective clinical response pathways are essential for implementing PROMs. PROMs developed by the Patient-Reported Outcomes Measurement Information System (PROMIS) address some challenges and may be suitable for clinical use among patients with CKD. PROMIS tools assess multiple patient-valued, clinically actionable symptoms and functions. They can be administered as fixed-length, customized short forms or computer adaptive tests, offering precise measurement across a range of symptom severities or function levels, tailored questions to individuals, and reduced question burden. Here we provide an overview of the potential use of PROMs in CKD care, with a focus on PROMIS.

Questionnaires About the End of Life for Cancer Patients - Is the Response Burden Acceptable?

CONTEXT

Research about the end of life with the help of patient-reported outcomes in vulnerable populations such as cancer patients is needed but is potentially burdensome and can therefore raise concerns.

OBJECTIVES

To assess the response burden due to questionnaires about the end of life in cancer patients and to explore associations with individual variables.

METHODS

In a cross-sectional design response burden was assessed using a six-item instrument after completion of a survey that concerned the end of life. Associations with age, gender, type of care (curative/palliative), years since diagnosis, distress, depression, anxiety, death anxiety, readiness for end-of-life conversations, and readiness for advance care planning were explored via correlational analyses and multiple regressions. Burden due to the topic of end-of-life and completing questionnaires in general was compared.

RESULTS

A total of 269 cancer patients (mean age 61.4 (SD =12.3); 59.5% male; 58.4% in palliative care) completed the survey in a German hospital. The majority did not report response burden; 29.7% reported at least some burden due to study participation. The multiple regression (F [10,26] = 9.97, p < 0.001) indicated that stable predictors of response burden were higher death anxiety (ß = 0.4), lower readiness to talk about one's end of life (ß = -0.34) and higher age (ß = 0.23). No additional subjective burden due to the topic of end-of-life was reported.

CONCLUSION

The reported response burden seems acceptable since it was generally low. However, a subgroup did report some burden. Minimising burden and enhancing participants' benefits without compromising the research quality should further influence study designs in this field.

Recommendations to address respondent burden associated with patient-reported outcome assessment

Patient-reported outcomes (PROs) are increasingly used in healthcare research to provide evidence of the benefits and risks of interventions from the patient perspective and to inform regulatory decisions and health policy. The use of PROs in clinical practice can facilitate symptom monitoring, tailor care to individual needs, aid clinical decision-making and inform value-based healthcare initiatives. Despite their benefits, there are concerns that the potential burden on respondents may reduce their willingness to complete PROs, with potential impact on the completeness and quality of the data for decision-making. We therefore conducted an initial literature review to generate a list of candidate recommendations aimed at reducing respondent burden. This was followed by a two-stage Delphi survey by an international multi-stakeholder group. A consensus meeting was held to finalize the recommendations. The final consensus statement includes 19 recommendations to address PRO respondent burden in healthcare research and clinical practice. If implemented, these recommendations may reduce PRO respondent burden.

Quality-of-life assessment instruments used across ALS clinics

INTRODUCTION/AIMS

Instruments have been developed to assess quality of life (QoL) among people with amyotrophic lateral sclerosis (ALS). It is unclear whether these are utilized regularly in the clinical setting to guide individual patient care. In this study we aimed to understand the current use of instruments and existing barriers to assessing QoL in clinical ALS care.

METHODS

An anonymous survey developed by Northeast ALS (NEALS) Consortium Palliative Committee members was distributed to all multidisciplinary NEALS members. Data were summarized via calculation of descriptive statistics. ALS Center characteristics were compared using chi-square and Fisher exact tests for categorical variables.

RESULTS

Seventy-three (6.4%) of the 1132 NEALS members responded to the survey, representing 148 clinics, 49.3% of whom reported assessing QoL during clinic visits. The most used ALS-specific instruments were the ALS Assessment Questionnaire (19.4%) and Amyotrophic Lateral Sclerosis Specific Quality of Life scale (16.6%). Barriers reported were uncertainty regarding which instrument to use and length of visits. QoL assessment was not significantly correlated with length of clinic visit but with access to specialty palliative care.

DISCUSSION

QoL assessments are performed by some, but not all, ALS centers during clinical visits. Although this study did have a low number of responding centers, the percentage, the proportion is similar to that seen in earlier studies, which limits the findings' generalizability. The value of QoL assessments' impact on outcomes should be further investigated and, if warranted, creative ways sought to increase the frequency of their use, including patient self-assessments before clinic and/or the use of teleheath to reduce the length of clinic visits.

Patient-reported outcomes measurement information system physical function and knee injury and osteoarthritis outcome score relationship on performance measures in people undergoing total knee arthroplasty

PURPOSE

Primary purpose was to identify relationships between performance-based measures onto both computerized adaptive testing [Physical Function-Computer Adaptive Testing (PF-CAT)] and joint-specific legacy [Knee injury and Osteoarthritis Outcome Score-Activities of Daily Living (KOOS-ADL)] instruments pre- and 12-month post-TKA.

METHODS

The PF-CAT and KOOS-ADL were identified as outcomes and performance on the 40-m fast-paced walking test, stair climb test and chair stand test were identified as predictors. Linear regression was used for all comparisons after adjusting for confounders.

RESULTS

Sixty-eight people with TKA (56.7% male) were tested. Better scores on the 40-m fast-paced walking (KOOS-ADL, p = 0.02), stair climb (KOOS-ADL, p = 0.05) and chair stand (KOOS-ADL, p < 0.01) associated with better self-reported scores pre-TKA. Better scores on the 40-m fast-paced walking (PF-CAT, p = 0.05; KOOS-ADL, p = 0.01), stair climb (KOOS-ADL, p < 0.01), chair stand (PF-CAT, p < 0.01) and range of motion (KOOS-ADL, p = 0.02) were associated with better self-reported scores 12-month post-TKA. Decrease knee range of motion related to poorer 40-m fast-paced walking (p = 0.01) and stair climb (p = 0.03) scores pre-TKA. Quadriceps weakness related to poorer 40-m fast-paced walking (p = 0.04) score pre-TKA.

CONCLUSION

Self-reported instruments are a moderate, but inconsistent surrogate to performance-based measures pre- and post-TKA. Our findings indicate that both self-reported and performance-based measures are necessary to fully characterize physical function and should be used jointly to aid in the recovery analysis of people undergoing TKA.Implications for RehabilitationMonitoring the trajectory of pre- to post-total knee arthroplasty (TKA) physical function is important as it directly relates to mortality, morbidity and poorer quality of life in older adults.Both self-reported and performance-based measures of physical function are used to determine progress in recovery for patients pre- and post- TKA.This study provides evidence that perceived physical function measures are a moderate, but an inconsistent, surrogate to objective physical function measures pre- and post-TKA.Joint specific deficits in knee range of motion and quadriceps strength were weakly associated with deficits in function measures pre-TKA, but no association was observed 12-month post-TKA.Our findings indicate that both self-reported and performance-based measures are necessary to fully characterize physical function and should be used jointly to aid in the complete recovery analysis of people undergoing TKA.

Not all questions are created equal: the weight of the Oxford Knee Scores questions in a multicentric validation study

BACKGROUND

The Oxford Knee Score (OKS) has been designed for patients with knee osteoarthritis and has a widespread use. It has 12 questions, with each question having the same weight for the overall score. Some authors have observed a significant ceiling effect, especially when distinguishing slight postoperative differences. We hypothesized that each questions' weight will depend significantly on the patient's sociodemographic data and lifestyle.

METHODS

In this international multicentric prospective study, we included patients attending a specialist outpatient knee clinic. Each patient filled out 3 questionnaires: (a) demographic data and data pertaining to the OKS, (b) the standard OKS, and (c) the patient gave a mark on the weight of the importance of each question, using a 5-point Likert scale (G OKS). Linear regression models were used for the analysis.

RESULTS

In total 203 patients (106 female and 97 male) with a mean age of 64.5 (±12.7) years and a mean body mass index (BMI) of 29.34 (±5.45) kg/m2 were included. The most important questions for the patients were the questions for pain, washing, night pain, stability, and walking stairs with a median of 5. In the regression models, age, gender, and driving ability were the most important factors for the weight of each of the question.

CONCLUSION

The questions in the OKS differ significantly in weight for each patient, based on sociodemographic data, such as age, self-use of a car, and employment. With these differences, the Oxford Knee Score might be limited as an outcome measure. Adjustment of the OKS that incorporates the demographic differences into the final score might be useful if the ceiling effect is to be mitigated.

LEVEL OF EVIDENCE

Level II prospective prognostic study.

Construct and discriminant validity testing of the FACE-Q Head and Neck Cancer Module for assessing speech and swallowing outcomes for patients undergoing maxillectomy or mandibulectomy

BACKGROUND

The FACE-Q H&N is a patient reported outcome measure covering multiple constructs for patients with head and neck tumors. Additional testing is needed to determine suitability in assessing speech- and swallowing-related quality of life and function.

METHODS

FACE-Q H&N, The M. D. Anderson Dysphagia Inventory (MDADI), and Speech Handicap Index (SHI) scores were collected from two patient cohorts who had undergone jaw reconstruction. Construct validity was assessed using convergent validity testing and known groups testing to assess discriminant validity.

RESULTS

A priori hypotheses testing demonstrated strong correlations (ρ > 0.6, p < 0.05) between FACE-Q H&N eating and drinking, swallowing and eating distress scales with MDADI subscales, and between FACE-Q H&N speech function and distress scales and the SHI. Known groups testing demonstrated all instruments could delineate outcomes among patients who had radiation, advanced tumors, and tracheostomy.

CONCLUSION

The FACE-Q H&N may be an alternative for the SHI and MDADI in this patient cohort.

Associations of Age and Sex with the Efficacy of Inpatient Cancer Rehabilitation: Results from a Longitudinal Observational Study Using Electronic Patient-Reported Outcomes

Cancer rehabilitation is thought to increase the quality of life (QOL) and functioning of cancer survivors. It remains, however, uncertain whether subgroups benefit equally from rehabilitation. We wished to investigate the outcomes of multimodal rehabilitation according to age, sex and functioning. Patients of an Austrian rehabilitation center routinely completed the EORTC QLQ-C30 and the hospital anxiety and depression scale (HADS) questionnaires prior to (T1), and after rehabilitation (T2). To compare the outcomes between age groups (i.e., <40, 41–69, and ≥70 years), sex, and the Norton scale risk status, repeated measures of analyses of variance were calculated. A total of 5567 patients with an average age of 60.7 years were included, of which 62.7% were female. With T1 indicating the cancer survivors’ needs, older and high-risk patients reported lower functioning (all p < 0.001) and a higher symptom burden for most scales (all p < 0.05) before rehabilitation. Regardless of age, sex or risk status, the patients showed at a least small to medium improvement during rehabilitation for anxiety, depression, and most functioning and symptom scales. Some between-group differences were observed, none of which being of a relevant effect size as determined with the Cohen’s d. In conclusion, QOL is improved by rehabilitation in all patients groups, independently from age, sex, or the risk status.

Recommendations on the use of item libraries for patient-reported outcome measurement in oncology trials: findings from an international, multidisciplinary working group

The use of item libraries for patient-reported outcome (PRO) measurement in oncology allows for the customisation of PRO assessment to measure key health-related quality of life concepts of relevance to the target population and intervention. However, no high-level recommendations exist to guide users on the design and implementation of these customised PRO measures (item lists) across different PRO measurement systems. To address this issue, a working group was set up, including international stakeholders (academic, independent, industry, health technology assessment, regulatory, and patient advocacy), with the goal of creating recommendations for the use of item libraries in oncology trials. A scoping review was carried out to identify relevant publications and highlight any gaps. Stakeholders commented on the available guidance for each research question, proposed recommendations on how to address gaps in the literature, and came to an agreement using discussion-based methods. Nine primary research questions were identified that formed the scope and structure of the recommendations on how to select items and implement item lists created from item libraries. These recommendations address methods to drive item selection, plan the structure and analysis of item lists, and facilitate their use in conjunction with other measures. The findings resulted in high-level, instrument-agnostic recommendations on the use of item-library-derived item lists in oncology trials.

Examining the Psychometric Properties of the Taiwanese Version of the Hospice Quality of Life Index

Quality of life is an important outcome for people with cancer throughout their cancer trajectory. Having a valid and reliable instrument to measure the quality of life is critical. This cross-sectional study examined the psychometric properties of the Taiwanese version of the Hospice Quality of Life Index among patients with advanced cancer in Taiwan. There were 3 phases: (1) translation of the Hospice Quality of Life Index from English to Mandarin, (2) pilot testing among 30 targeted participants, and (3) field testing to examine validity and reliability. The results of confirmatory factor analysis indicated that the original factor structure of the Hospice Quality of Life Index did not fit the data. After 5 items were deleted from the original questionnaire, principal factor extraction with oblique rotation for exploratory factor analysis yielded 3 subscales: Social/Spiritual Well-Being, Psychological Well-Being, and Functional/Physiological Well-Being. For convergent validity, the small to moderate strength of associations showed shared variance with the Memorial Symptom Assessment Scale. The internal consistency was supported by Cronbach α ranging from 0.77 to 0.86. This study shows early evidence that the quality of life of people with advanced cancer can be appropriately assessed by the Taiwanese Hospice Quality of Life Index.

Development and Validation of a Dual-Language (English and Malay) Needs Assessment Tool for Breast Cancer (NeAT-BC)

Background: Needs assessment tools may be used to guide the optimisation of cancer survivorship services. We sought to develop and validate a dual-language needs assessment tool for women with breast cancer. Methods: The study comprised two phases; (I) co-design, and (II) psychometric testing. In Phase I, items were generated based on focus group discussions with patients and a literature review. These items were then translated into the Malay language. Content and face validation were undertaken with an expert panel. In phase II, 315 Malaysian women living with breast cancer were recruited. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were conducted to determine construct validity and reliability. Criterion validity was assessed using the EORTC QLQ-C30 questionnaire. Results: We co-designed and validated a 48-item dual-language needs assessment tool for breast cancer (NeAT-BC). Five underlying constructs were revealed in the EFA: (1) emotional support, (2) social and intimate relationships, (3) hospital appointments, (4) personal care and health, and (5) information and services. The NeAT-BC demonstrated good reliability across all constructs (Cronbach’s alpha: 0.90 to 0.96). CFA also demonstrated acceptable convergent and divergent validity, composite reliability ≥ 0.87, and Heterotrait−Monotrait index < 0.85 for all constructs. Criterion validity was established given the significant negative correlation between overall needs and quality of life (r = −0.14; p = 0.02). The NeAT-BC took approximately 25 min to be completed and could be interviewer-administered or self-administered. Conclusion: The utilization of the NeAT-BC is expected to guide establishment of evidence-based cancer survivorship services in Malaysia, with wider potentials for adoption in other multi-ethnic and/or low-and-middle income settings.

Key considerations to reduce or address respondent burden in patient-reported outcome (PRO) data collection

Patient-reported outcomes (PROs) are used in clinical trials to provide evidence of the benefits and risks of interventions from a patient perspective and to inform regulatory decisions and health policy. The collection of PROs in routine practice can facilitate monitoring of patient symptoms; identification of unmet needs; prioritisation and/or tailoring of treatment to the needs of individual patients and inform value-based healthcare initiatives. However, respondent burden needs to be carefully considered and addressed to avoid high rates of missing data and poor reporting of PRO results, which may lead to poor quality data for regulatory decision making and/or clinical care.

Exploring the Patient Experience with Patient-Reported Outcomes: A Qualitative, Multistakeholder Study

OBJECTIVES

Although the literature provides guidance regarding patient-reported outcome (PRO) implementation barriers, patients' perspectives are underreported. This study aimed to improve the understanding of patient experiences with PRO tools through examining perceptions of and attitudes toward PROs and expectations of data use after collection.

METHODS

Ethnographic human-centered design approaches were used to conduct free-form interviews. Two case studies of existing PRO use in clinics also were examined. Unstructured thematic analyses were performed using notes taken during these interviews.

RESULTS

Patients generally reported a good understanding of the need for PRO collection, both for research and clinical use. Many expected that results would be acted upon by the clinicians promptly. Thematic analyses identified the following patient perception topics: transparency, individualization to patient needs, timely response, different "identities" while accessing care locally compared with at a destination center, and preference for brief PROs.

CONCLUSIONS

Design and implementation of PRO assessments into patient care should include the patients as key end users. Transparency of the purpose for data collection is critical for broader patient adoption. Ensuring that only necessary and sufficient data are collected for clinical action, and associated research may help minimize burden and maximize patient participation.

Assessing Pain Research: A Narrative Review of Emerging Pain Methods, Their Technosocial Implications, and Opportunities for Multidisciplinary Approaches

Pain research traverses many disciplines and methodologies. Yet, despite our understanding and field-wide acceptance of the multifactorial essence of pain as a sensory perception, emotional experience, and biopsychosocial condition, pain scientists and practitioners often remain siloed within their domain expertise and associated techniques. The context in which the field finds itself today-with increasing reliance on digital technologies, an on-going pandemic, and continued disparities in pain care-requires new collaborations and different approaches to measuring pain. Here, we review the state-of-the-art in human pain research, summarizing emerging practices and cutting-edge techniques across multiple methods and technologies. For each, we outline foreseeable technosocial considerations, reflecting on implications for standards of care, pain management, research, and societal impact. Through overviewing alternative data sources and varied ways of measuring pain and by reflecting on the concerns, limitations, and challenges facing the field, we hope to create critical dialogues, inspire more collaborations, and foster new ideas for future pain research methods.

The EORTC QLU-C10D discrete choice experiment for cancer patients: a first step towards patient utility weights

Background

The European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Utility-Core 10 Dimensions (QLU-C10D) is a novel cancer-specific preference-based measure (PBM) for which value sets are being developed for an increasing number of countries. This is done by obtaining health preferences from the respective general population. There is an ongoing discussion if instead patients suffering from the disease in question should be asked for their preferences. We used the QLU-C10D valuation survey, originally designed for use in the general population, in a sample of cancer patients in Austria to assess the methodology’s acceptability and applicability in this target group before obtaining QLU-C10D patient preferences.

Methods

The core of the QLU-C10D valuation survey is a discrete choice experiment in which respondents are asked to give preferences for certain health states (described by a relatively large number of 10 quality of life domains) and an associated survival time. They therewith are asked to trade off quality of life against life time. As this might be a very burdensome task for cancer patients undergoing treatment, a cognitive interview was conducted in a pilot sample to assess burden and potential additional needs for explanation in order to be able to use the DCE for the development of QLU-C10D patient preferences. In addition, responses to general feedback questions on the survey were compared against responses from a matched control group from the already completed Austrian general population valuation survey.

Results

We included 48 patients (mean age 59.9 years; 46% female). In the cognitive interview, the majority indicated that their experience with the survey was positive (85%) and overall clarity as good (90%). In response to the general feedback questions, patients rated the presentation of the health states less clear than matched controls (p = 0.008). There was no difference between patients and the general population concerning the difficulty in choosing between the health states (p = 0.344).

Conclusion

Despite the relatively large number of DCE domains the survey was manageable for patients and allows going on with the QLU-C10D patient valuation study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00430-5.

Health-related Quality of Life for Patients Undergoing Radical Cystectomy: Results of a Large Prospective Cohort

BACKGROUND

Radical cystectomy (RC) has the potential for profound changes to health-related quality of life (HRQOL).

OBJECTIVE

To evaluate a broad range of HRQOL outcomes in a large RC cohort.

DESIGN, SETTING, AND PARTICIPANTS

A single-center prospective study enrolled RC patients from 2008 to 2014. We collected 14 separate patient-reported outcome measures at the presurgical visit and at 3, 6, 12, 18, and 24 mo after RC.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

To visualize the patterns of recovery over time across domains, we used generalized estimating equations (GEEs) with nonlinear terms. Given substantial differences in patient selection for the type of urinary diversion, we separately modeled longitudinal HRQOL within conduit and continent diversion groups. The mean pre-RC scores were compared to illustrate the baseline HRQOL differences between diversion groups.

RESULTS AND LIMITATIONS

The analyzed cohort included 411 patients (n = 205 ileal conduit, n = 206 continent diversion). At baseline, patients receiving continent diversion reported better mean physical (p < 0.001), urinary (p = 0.006), and sexual function (p < 0.001), but lower social function (p = 0.015). After RC, GEE modeling showed physical function scores decreasing 5/100 points by 6 mo, and subsequently stabilizing or returning to baseline. By 12 mo, social function improved by 10/100 points among continent diversions, while remaining stable among ileal conduits. Global quality of life exceeded baseline scores by 6 mo. Sexual function scores were low before RC, with limited recovery. Psychosocial domains were stable or improved, except for 10/100-point worsening of body image among ileal conduits.

CONCLUSIONS

RC patients reported favorable HRQOL recovery within 24 mo in most areas other than body image (ileal conduits) and sexual function (both). Importantly, large measurable decreases in scores were not reported by 3 mo after RC. These contemporary outcomes and the excellent locoregional control provided by RC further support it as the gold standard therapy for high-risk bladder cancer.

PATIENT SUMMARY

We review quality of life in the 24 mo following radical cystectomy. Large decreases in health-related quality of life were not reported, with most areas returning to, or exceeding, baseline, except for sexual function and body image.

Intensive Daily Symptom and Function Monitoring Is Feasible and Acceptable to Women Undergoing First-Line Chemotherapy for Gynecologic Cancer

BACKGROUND

Women receiving chemotherapy for gynecologic cancer (GC) experience severe symptoms with associated functional changes. Understanding day-to-day symptom and function variation within and across chemotherapy treatment cycles could inform improved symptom management, but such studies are rare and may be infeasible in clinical care.

OBJECTIVE

The aim of this study was to evaluate feasibility and acceptability of daily symptom monitoring combined with objective and self-reported functional assessments every 21 days during active chemotherapy for GC.

METHODS

Thirty women enrolled in a prospective observational study during first-line chemotherapy completed a daily symptom and falls diary during their entire chemotherapy treatment period. Patient-reported outcomes and objective symptom and function testing were assessed before each chemotherapy appointment. Study outcomes included accrual and attrition rates, completion of study assessments, and qualitative perceptions of study participation.

RESULTS

Participants were 92% White, 60% had high school or higher education, 68% were married/partnered, and 62% had stage III or IV cancer at diagnosis. The study had an 83% accrual rate, 6.6% early withdrawal rate, and 17% total attrition rate. Missing assessments for prechemotherapy patient-reported outcomes and objective assessments ranged from 27% to 35% and 35% to 47% respectively, with a general decrease across cycles. Daily diary completion rate was 83% overall. Participants rated study participation positively.

CONCLUSIONS

Intensive daily symptom and function monitoring was feasible and acceptable to GC patients and may provide a sense of symptom controllability.

IMPLICATIONS FOR PRACTICE

Daily symptom and function monitoring in research studies may provide patients with information to support symptom discussions with the clinical team. Future work should develop proactive symptom management interventions using personalized symptom trajectories.

Patient perspectives on patient-reported outcomes in multiple sclerosis treatment trajectories: A qualitative study of why, what, and how?

BACKGROUND

Interest in patient-reported outcomes has been growing in multiple sclerosis research and clinical care in recent years. This situation reflects the need for developing, testing, and integrating measures that adequately capture patients' perspectives on symptoms, functional capacity, health status, and health-related quality of life. However, the patient perspective on the relevance, content, and use of patient-reported outcomes is yet to be investigated. Hence, this study aims to investigate the perspectives of people with multiple sclerosis on the value of patient-reported outcomes in clinical encounters, the most important aspects of living with multiple sclerosis that should be reflected in these reports, and possible opportunities and barriers for integrating this data into clinical care.

METHODS

A qualitative study was conducted to capture patient perspectives in a Danish population of people with multiple sclerosis. Initially, two focus group interviews were conducted with a total of 11 participants to explore their perspectives on patient-reported outcomes and related prospects and barriers. Subsequently, nine individual interviews were conducted to further investigate the identified aspects, opportunities, and barriers to use patient-reported outcomes in clinical care and treatment.

RESULTS

In general, the informants were motivated to report patient-reported outcomes, and they believed these reports to be relevant in clinical encounters as well as to have potential to promote patient involvement by focusing on current challenges for others with this disease. However, differences in the perceived need for reporting patient-reported outcomes were detected regarding the stage in the multiple sclerosis care trajectory and in relation to the disease phenotypes. In terms of domains to be incorporated into patient-reported outcomes, a total of 28 were identified by the informants, including neurological symptoms, cognitive impairments, mental health and well-being, self-care activities, and social challenges. Several factors for integrating patient-reported outcomes into clinical care emerged as important, in particular related to timing and frequency of reporting patient reported outcomes, considerations of cognitive impairments, the need for individualized approaches to patient-reported outcomes, and the need for active use of these reports for adjustment of treatment approaches in clinical encounters.

CONCLUSION

From the perspective of people with multiple sclerosis, patient-reported outcomes hold important potential for enhanced patient involvement leading to a more multifaceted agenda in clinical consultations. However, patient-reported outcomes need to be comprehensive and encompass a broad range of measures regarding neurological symptoms, cognitive impairments, mental health and well-being, self-care activities, and social challenges to adequately capture and support the needs of people with multiple sclerosis in clinical encounters. It is important to address barriers for integration of patient-reported outcomes into clinical care, with the aim of preventing misuse. Future studies should focus on the synergy between perspectives from both patients and clinicians to understand how integration of patient-reported outcomes in clinical care can succeed.

Underreporting of Symptomatic Adverse Events in Phase I Clinical Trials

BACKGROUND

Clinician reporting of symptomatic adverse events (AEs) in phase I trials uses the Common Terminology Criteria for Adverse Events (CTCAE). The utility of the patient-reported outcomes (PROs) version of the CTCAE (PRO-CTCAE) in this setting is unknown. This prospective, observational study compared patient- and clinician-reported symptomatic AEs in phase I patients.

METHODS

Phase I study-eligible patients at Princess Margaret were surveyed with the PRO-CTCAE full-item library (78 symptomatic AEs) at baseline (BL), mid-cycle 1, and mid-cycle 2 (C2). Patient and trial characteristics, best response, and survival data were collected. Presence or absence of patient- (PRO-CTCAE) or clinician-reported symptomatic AEs were compared (kappa) at defined timepoints and overall (BL+ mid-cycle 1 + C2).

RESULTS

Of 292 patients approached from May 2017 to January 2019, a total of 265 (90.8%) were consented, with 243 (91.7%) evaluable and 552 PRO-CTCAE surveys (completion rate = 98.7%) included in analyses. Evaluation of overall patient-reported symptomatic AEs identified 50 PRO-CTCAE and 11 CTCAE items with 10% or greater reporting frequency. Nineteen CTCAE items were reported as 1% or less despite matched PRO-CTCAE items reporting as 10% or greater. Underreported categories included sexual health, bodily emissions, and cognition. Clinician- relative to patient-reporting frequency (ratio) demonstrated 9 symptomatic AEs with a 50-fold or more lower clinician reporting rate. Overall patient-clinician agreement for individual symptomatic AEs ranged from poor (κ = 0.00-0.19) to moderate (κ = 0.40-0.59), with discordance driven by lack of clinician reporting. Dyspnea (κ = 0.54) and peripheral neuropathy (κ = 0.63) at BL and limb edema (κ = 0.55) at C2 demonstrated the highest patient-clinician agreement.

CONCLUSIONS

Poor to moderate patient-clinician agreement for symptomatic AEs suggests clinician underreporting in phase I trials. Analyses of severity and interference PRO categories are ongoing.

Correlation and responsiveness of global health, upper extremity-specific, and shoulder-specific functional outcome measures following reverse total shoulder arthroplasty for proximal humerus fracture

PURPOSE

Reverse total shoulder arthroplasty (rTSA) is effective and increasingly utilized for the management of proximal humerus fracture (PHF). However, the optimal patient-reported outcome metrics (PROMs) for the evaluation of patient outcomes after this surgery are unclear. We investigated the correlation among global, upper extremity-specific, and shoulder-specific PROMs in patients undergoing rTSA for PHF as well as the responsiveness of these PROMs as assessed by floor and ceiling effects. We hypothesized that patients' post-operative outcome would be best reflected by a combination of these metrics.

METHODS

Thirty patients with a history of rTSA for ipsilateral PHF filled out the following outcomes questionnaires at a minimum of 3 years post-op: EQ-5D, EQ-5D VAS, PROMIS physical function, DASH, SSV, SPADI, and ASES. Correlation between metrics was assessed using the Spearman correlation coefficient. Responsiveness was assessed by comparing the proportion of patients reaching floor or ceiling values using McNemar's test.

RESULTS

Global health metrics (EQ-5D and PROMIS physical function) were strongly correlated with the upper extremity-specific metric (DASH). Shoulder-specific outcomes (SPADI, ASES, and ASES) were moderately correlated with both the global metrics and DASH. There was no significant difference between PROMs with regards to floor and ceiling effects.

CONCLUSIONS

The DASH score has been shown to be valid and responsive for shoulder interventions, and our data demonstrate that it correlates strongly with overall quality of life. Shoulder-specific metrics are valid and responsive for shoulder interventions but correlate less with global quality of life. An optimal PROM strategy in rTSA for PHF might involve both DASH and a shoulder-specific score. Based on our assessment of floor and ceiling effects, none of these metrics should be excluded for poor responsiveness.

Patient-reported outcomes and patient-reported outcome measures in interstitial lung disease: where to go from here?

Patient-reported outcome measures (PROMs), tools to assess patient self-report of health status, are now increasingly used in research, care and policymaking. While there are two well-developed disease-specific PROMs for interstitial lung diseases (ILD) and idiopathic pulmonary fibrosis (IPF), many unmet and urgent needs remain. In December 2019, 64 international ILD experts convened in Erice, Italy to deliberate on many topics, including PROMs in ILD. This review summarises the history of PROMs in ILD, shortcomings of the existing tools, challenges of development, validation and implementation of their use in clinical trials, and the discussion held during the meeting. Development of disease-specific PROMs for ILD including IPF with robust methodology and validation in concordance with guidance from regulatory authorities have increased user confidence in PROMs. Minimal clinically important difference for bidirectional changes may need to be developed. Cross-cultural validation and linguistic adaptations are necessary in addition to robust psychometric properties for effective PROM use in multinational clinical trials. PROM burden of use should be reduced through appropriate use of digital technologies and computerised adaptive testing. Active patient engagement in all stages from development, testing, choosing and implementation of PROMs can help improve probability of success and further growth.

PROMs are essential tools for research and care in ILD and IPF. They report patient perceptions of the impact of disease and its treatments on whole-person wellbeing and can guide research to make care more patient-centred.https://bit.ly/3s7Y0a8

A narrative review of current evidence supporting the implementation of electronic patient-reported outcome measures in the management of chronic diseases

An application of telemedicine of growing interest and relevance is the use of personal computers and mobile devices to collect patient-reported outcomes (PROs). PROs are self-reports of patients' health status without interpretation by anyone else. The tools developed to assess PROs are known as patient-reported outcomes measures (PROMs). The technological innovations that have led to an increased ownership of electronic devices have also facilitated the development of electronic PROMs (ePROMs). ePROMs are a conduit for telemedicine in the care of patients with chronic diseases. Various studies have demonstrated that the use of ePROMs in routine clinical practice is both acceptable and feasible with patients increasingly expressing a preference for an electronic mode of administration. There is increasing evidence that the use of electronic patient-reported outcome (ePROMs) could have significant impacts on outcomes valued by patients, healthcare providers and researchers. Whilst the development and implementation of these systems may be initially costly and resource-intensive, patient preferences and existing evidence to support their implementation suggests the need for continued research prioritisation in this area. This narrative review summarises and discusses evidence of the impact of ePROMs on clinical parameters and outcomes relevant to chronic diseases. We also explore recently published literature regarding issues that may influence the robust implementation of ePROMs for routine clinical practice.

Choosing and Using Patient-Reported Outcome Measures in Clinical Practice

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

Incorporating patient centered benefits as endpoints in randomized trials of maintenance therapies in advanced ovarian cancer: A position paper from the GCIG symptom benefit committee

BACKGROUND

Quality of life and patient reported outcome measures (PROMs) are important secondary endpoints and incorporated in most contemporary clinical trials. There have been deficiencies in their assessment and reporting in ovarian cancer clinical trials, particularly in trials of maintenance treatment where they are of particular importance. The Gynecologic Cancer InterGroup (GCIG) symptom benefit committee (SBC) recently convened a brainstorming meeting with representation from all collaborative groups to address questions of how to best incorporate PROMs into trials of maintenance therapies to support the primary endpoint which is usually progression free survival (PFS). These recommendations should harmonize the collection, analysis and reporting of PROM's across future GCIG trials.

METHODS

Through literature review, trials analysis and input from international experts, the SBC identified four relevant topics to address with respect to promoting the role of PROMs to support the PFS endpoint in clinical trials of maintenance treatment for OC.

RESULTS

The GCIG SBC unanimously accepted the importance of integrating PROM's in future maintenance trials and developed four guiding principles to be considered early in trial design. These include 1) adherence to SPIRIT-PRO guidelines, 2) harmonization of selection, collection and reporting of PROM's; 3) combining Health Related Quality of Life (HRQL) measures with clinical endpoints and 4) common approaches to dealing with incomplete HRQL data.

CONCLUSIONS

Close attention to incorporating HRQL and PROM's is critical to interpret the results of ovarian cancer clinical trials of maintenance therapies. There should be a consistent approach to assessing and reporting patient centered benefits across all GCIG trials to enable cross trial comparisons which can be used to inform practice.

Implementation of a standard outcome set in perinatal care: a qualitative analysis of barriers and facilitators from all stakeholder perspectives

BACKGROUND

To improve their quality, healthcare systems are increasingly focused on value delivered to patients. For perinatal care, the International Consortium for Health Outcomes Measurement (ICHOM) proposed a patient-centred outcome set with both clinical and patient-reported measures for pregnancy and childbirth (PCB set). This study aimed to identify factors that affect the implementation of the PCB set at the pre-implementation stage, using the consolidated framework for implementation research (CFIR).

METHODS

In this qualitative study, we conducted semi-structured interviews amongst a purposive sample of key stakeholders within an obstetric care network (OCN): 1) patients, 2) perinatal care professionals involved in the full cycle of perinatal care, and 3) policy makers, including hospital managers, administrative staff and health care insurers. While the CFIR guided data capture and structuring, thematic analysis revealed overarching themes that best reflected the barriers and facilitators from different stakeholder perspectives. Within these overarching themes, the CFIR constructs were maintained.

RESULTS

Interviews were conducted with 6 patients, 16 professionals and 5 policy makers. Thematic analysis supported by the CFIR framework identified four main themes: the instrument and its implementation process, use in individual patient care, use in quality improvement, and the context of the OCN. Important barriers included professional workload, data reliability, and interprofessional and interorganizational collaboration. Potential facilitators were the PCB set's direct value in individual care, interprofessional feedback and education, and aligning with existing systems. Prominent variations between stakeholder groups included the expected patient burden, the level of use, transparency of outcomes and the degree of integrated care.

CONCLUSIONS

This study clarified critical factors that affect successful implementation of the PCB set in perinatal care. Practice recommendations, suggested at multiple levels, can enable structural patient-centred care improvement and may unite stakeholders towards integrated birth care.

The Patient Acceptable Symptomatic State in Primary Anterior Cruciate Ligament Reconstruction: Predictors of Achievement

PURPOSE

To identify thresholds for patient acceptable symptomatic state (PASS) achievement in a cohort of primary anterior cruciate ligament reconstruction (ACLR) recipients, and to identify factors predictive of PASS achievement.

METHODS

A prospective clinical registry was queried for primary ACLR patients from January 2014 to April 2017 with serial patient-reported outcome measure (PROM) completion at 6, 12, and 24 months. Exclusion criteria included significant concomitant procedures. Knee-based PROMs included the International Knee Documentation Committee (IKDC) score and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores. PASS threshold values were calculated using receiver operating characteristic (ROC) curves with area under the curve (AUC) analysis. A stepwise multivariate regression identified preoperative and operative predictors of PASS achievement.

RESULTS

A total of 144 primary ACLR patients (30.86 ± 12.78 years, body mass index 25.51 ± 4.64, 41.0% male) were included in the analysis. PASS threshold values were established using ROC curve analysis, all of which exceeded 0.7 on AUC analysis (0.742 to 0.911). Factors impacting odds of PASS achievement in the ACLR cohort included preoperative exercises (odds ratio [OR] 2.95 to 4.74, P = .003 to .038), worker's compensation status (OR 0.25 to 0.28, P = .014 to .033), preoperative scores (OR 1.03 to 1.07, P = .005 to <.001), iliotibial band tenodesis (OR 11.08, P = .010), and anteromedial approach (OR 18.03 to 37.05, P < .001).

CONCLUSION

Factors predictive of PASS achievement in recipients of primary ACLR include functional status (e.g., preoperative exercise, preoperative KOOS Sport/Recreation score), worker's compensation status, technique (e.g., anteromedial) and preoperative PROMs. The results of our study are important in better informing shared decision-making models and improving evidence-based guidelines to optimize patient outcomes.

Development and content validation of the Satisfaction and Experience Questionnaire for Granulocyte Colony-Stimulating Factor (SEQ-G-CSF)

BACKGROUND

Several options for granulocyte colony-stimulating factor (G-CSF) prophylaxis of chemotherapy-induced febrile neutropenia are available to patients worldwide. We have developed a novel patient-reported outcome measure, the Satisfaction and Experience Questionnaire for G-CSF (SEQ-G-CSF), to help understand patients' perspectives of and satisfaction with different G-CSF options.

RESULTS

Three oncology nurses and 40 adult oncology patients in the United States were enrolled and participated in focus group discussions to develop and refine the SEQ-G-CSF. Nurses had ≥ 5 years of experience treating oncology patients and were currently involved in the management of oncology patients receiving G-CSF prophylaxis. The patients had breast cancer, lung cancer, non-Hodgkin lymphoma, or prostate cancer (10 patients in each group) and were receiving G-CSF prophylaxis via injection or the on-body injector (OBI) device. The preliminary SEQ-G-CSF contained an item relevance questionnaire and three SEQ modules (sociodemographic, medical history, and G-CSF-related healthcare characteristics questionnaires). Twenty-one patients (53% of total sample size) discussed their experience and satisfaction with G-CSF. Their most common experiences were G-CSF effectiveness, convenience and benefits of the OBI, and relationships with healthcare providers. Side effects and having to undergo additional treatment were also reported. Satisfaction with aspects of G-CSF included the OBI and effectiveness of G-CSF treatment; dissatisfaction included inconvenience (having to return to the clinic the next day and administration of the injection) and the insurance approval process. The SEQ-G-CSF was finalized after three rounds of cognitive interviews and includes five domains related to general satisfaction (one item), treatment burden (four items), travel burden (two items), time burden (four items), and treatment compliance (two items).

CONCLUSIONS

The SEQ-G-CSF is a novel instrument that quantifies a patient's experience and satisfaction with different G-CSF options using 13 easy-to-understand items. This study provides evidence for the content validity of SEQ-G-CSF. Although further psychometric testing is required, the SEQ-G-CSF may be a useful addition to clinical trials, observational studies, and clinical practice.

Respondent Understanding in Discrete Choice Experiments: A Scoping Review

Introduction

Despite the recognised importance of participant understanding for valid and reliable discrete choice experiment (DCE) results, there has been limited assessment of whether, and how, people understand DCEs, and how ‘understanding’ is conceptualised in DCEs applied to a health context.

Objectives

Our aim was to identify how participant understanding is conceptualised in the DCE literature in a health context. Our research questions addressed how participant understanding is defined, measured, and used.

Methods

Searches were conducted (June 2019) in the MEDLINE, EMBASE, PsychINFO and Econlit databases, as well as hand searching. Search terms were based on previous DCE systematic reviews, with additional understanding keywords used in a proximity-based search strategy. Eligible studies were peer-reviewed journal articles in the field of health, related to DCE or best-worst scaling type 3 (BWS3) studies, and reporting some consideration or assessment of participant understanding. A descriptive analytical approach was used to chart relevant data from each study, including publication year, country, clinical area, subject group, sample size, study design, numbers of attributes, levels and choice sets, definition of understanding, how understanding was tested, results of the understanding tests, and how the information about understanding was used. Each study was categorised based on how understanding was conceptualised and used within the study.

Results

Of 306 potentially eligible articles identified, 31 were excluded based on titles and abstracts, and 200 were excluded on full-text review, resulting in 75 included studies. Three categories of study were identified: applied DCEs (n = 52), pretesting studies (n = 7) and studies of understanding (n = 16). Typically, understanding was defined in relation to either the choice context, such as attribute terminology, or the concept of choosing. Very few studies considered respondents’ engagement as a component of understanding. Understanding was measured primarily through qualitative pretesting, rationality or validity tests included in the survey, and participant self-report, however reporting and use of the results of these methods was inconsistent.

Conclusions

Those conducting or using health DCEs should carefully select, justify, and report the measurement and potential impact of participant understanding in their specific choice context. There remains scope for research into the different components of participant understanding, particularly related to engagement, the impact of participant understanding on DCE validity and reliability, the best measures of understanding, and methods to maximise participant understanding.

Electronic supplementary material

The online version of this article (10.1007/s40271-020-00467-y) contains supplementary material, which is available to authorized users.

A feasibility study of implementing a patient-centered outcome set for pregnancy and childbirth

BACKGROUND AND AIMS

Patient-reported outcome and experience measures (PROM and PREM) can facilitate shared decision making and hold potential to improve healthcare quality. However, their adoption in perinatal care is still limited. The International Consortium for Health Outcomes Measurement (ICHOM) developed a Pregnancy and Childbirth (PCB) outcome set, including PROM and PREM questionnaires. We studied the feasibility to use these PROMs/PREMs in Dutch perinatal care, addressing both women's and professionals' perspective.

METHODS

Patients and professionals in primary and hospital care participated. Women under care at one of five timepoints for PROM/PREM collection of the PCB set (2 during pregnancy, 3 postpartum) were e-mailed a questionnaire and discussed their answers with their obstetric professional the next regular visit. Compliance was recorded. After discussing the PROMs/PREMs, usability and experience were assessed with separate surveys amongst women and professionals.

RESULTS

Of 26 women approached, 21 completed and discussed their PROM/PREM questionnaire. Mean questionnaire completion rate was 97%. Average reported time completing the questionnaires was 10 minutes; most women (90%) stated this was acceptable. Women preferred completing questionnaires digitally and discuss their answers with an obstetric professional rather than other care professionals, also 6 months postpartum. Over half of women agreed PROMs/PREMs supported shared decision making (58%), ability to raise issues (60%), and patient-clinician relationship (52%). Six professionals participated: two obstetricians, two clinical midwives, and two community midwives. Most professionals experienced sufficient time to discuss the responses, except at 6 months postpartum. They knew what items to discuss but did not always feel responsible to act upon them. Professionals agreed PROMs/PREMs supported symptom detection and personalized care.

CONCLUSIONS

Patients and obstetric professionals consider the PCB set a feasible instrument for PROM/PREM assessment, with good compliance, acceptability and usability. Important determinants of successful implementation are a well-equipped ICT-tool, agreements regarding professionals' responsibilities and how outcomes are discussed or acted upon.

Responsiveness of standard spine outcome tools: do they measure up?

OBJECTIVE

Over the past 2 decades, spine outcome research has become more standardized in response to recommendations from Deyo and others. By using the same generic and condition-specific patient-reported outcome (PRO) measures across studies, results are more easily compared. Given the challenges of maintaining high-quality data in clinical research studies, it would be important to evaluate the contribution of each PRO to confirm that it merits the respondent burden. This study aimed to examine the spine PROs' association with clinically important change and relative responsiveness in explaining variance in patients' global assessment of change (GAC).

METHODS

This prospective longitudinal cohort study included adults recruited from 4 active spine surgery practices at a Toronto-based hospital. Patients were diagnosed with a degenerative lumbar spinal condition and underwent spinal decompression and/or fusion surgery. Participants completed the RAND-36 (to generate the physical component score [PCS] and mental component score [MCS]), Oswestry Disability Index (ODI), the numeric rating scale (NRS) for pain, Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference, and a GAC item. Random-effects models were used to investigate the sensitivity of PROs to the GAC and their responsiveness over time (i.e., PRO main effects and PRO-by-time interactions, respectively).

RESULTS

The study sample included 168 patients (mean age 61 years, 50% female) with preoperative and up to 12 months of postoperative data. Random-effects models revealed significant main effects for all PROs. Significant time-by-PRO interactions were detected for the PCS, PROMIS, ODI, and NRS (p < 0.0005 in all cases), but not for the MCS. Further examination revealed different sensitivity of the PROs to the GAC at different times. The NRS, PROMIS, and PCS showed higher sensitivity early after surgery, and the PCS evinced a marked drop in sensitivity to the GAC at about 8 months postsurgery.

CONCLUSIONS

All PROs currently included in the spine outcome core measures are associated with patients' subjective assessment of a clinically important change, and all but the MCS scores are responsive to such change. Based on these findings, the core spine PROs could be reduced to include fewer estimates of pain. The authors suggest replacing the less responsive measures with tools that help to characterize factors that are driving the patients' subjective assessment of change and that meaningfully address some of the higher levels in the hierarchy of quality-of-life outcomes.