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Lee Y, Issa TZ, Vaccaro AR. State-of-the-art Applications of Patient-Reported Outcome Measures in Spinal Care. J Am Acad Orthop Surg 2023; 31:e890-e897. [PMID: 36727887 DOI: 10.5435/jaaos-d-22-01009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 12/13/2022] [Indexed: 02/03/2023] Open
Abstract
Patient-reported outcome measures (PROMs) assign objective measures to patient's subjective experiences of health, pain, disability, function, and quality of life. PROMs can be useful for providers in shared decision making, outcome assessment, and indicating patients for surgery. In this article, we provide an overview of the legacy PROMs used in spinal care, recent advancements in patient-reported outcomes, and future directions in PROMs. Recent advances in patient-reported outcome assessments have included standardization of measurement tools, integration of data collection into workflow, and applications of outcome measures in predictive models and decision-making tools. Continual appraisal of instruments and incorporation into artificial intelligence and machine learning analytics will continue to augment the delivery of high-value spinal care.
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Affiliation(s)
- Yunsoo Lee
- From the Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA
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2
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Issa TZ, Lee Y, Toci GR, Lambrechts MJ, Kalra A, Pipa D, Canseco JA, Hilibrand AS, Vaccaro AR, Schroeder GD, Kepler CK. The role of socioeconomic factors as barriers to patient reported outcome measure completion following lumbar spine fusion. Spine J 2023; 23:1531-1539. [PMID: 37209966 DOI: 10.1016/j.spinee.2023.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/19/2023] [Accepted: 05/02/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND CONTEXT Although incorporating patient reported outcomes (PROMs) into practice allows healthcare systems to evaluate the value of care provided, research and policy reflecting PROMs can only be valid if they represent all patients. Few studies have evaluated socioeconomic barriers to PROM completion, and none have done so in a spine patient population. PURPOSE To identify patient barriers to PROM completion one year following lumbar spine fusion. STUDY DESIGN/SETTING Retrospective single-institution cohort study. PATIENT SAMPLE A total of 2,984 patients undergoing lumbar fusion between 2014 and 2020 OUTCOME MEASURES: Completion of Mental Component Score (MCS-12) and Physical Component Score (PCS-12) of Short Form-12 questionnaire 1 year postoperatively. METHODS A retrospective review was conducted of all patients undergoing 1-3-level lumbar fusion at a single urban tertiary center. PROMs were queried from our prospectively managed electronic outcomes database. Patients were considered to have complete PROMs if 1-year outcomes were available. Community-level characteristics were collected from patients' zip codes using the Economic Innovation Group Distressed Communities Index. Bivariate analyses were performed to assess factors associated with PROM incompletion along with multivariate logistic regression to control for confounders. RESULTS A total of 1,968 (66.0%) had incomplete 1-year PROMs. Patients with incomplete PROMs were more likely to be Black (14.5% vs 9.3%, p<.001), Hispanic (2.9% vs 1.6%, p=.027), reside in a distressed community (14.7% vs 8.5%, p<.001), and be active smokers (22.4% vs 15.5%, p<.001). On multivariate regression, Black race (OR: 1.46, p=.014, Hispanic ethnicity (OR: 2.19, p=.027), distressed community status (OR: 1.47, p=.024), workers' compensation status (OR: 2.82, p=.001), and active smoking (OR:1.31, p=.034) all were independently associated with PROM incompletion. Surgical characteristics, including primary surgeon, revision status, approach, and levels fused were not associated with PROM incompletion. CONCLUSIONS Social determinants of health impact completion of PROMs. Patients completing PROMs are overwhelmingly White, non-Hispanic, and reside in wealthier communities. Efforts should be taken to provide better education regarding PROMs and ensure closer follow-up of certain subgroups of patients to avoid furthering disparities in PROM research.
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Affiliation(s)
- Tariq Z Issa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA; Feinberg School of Medicine, Northwestern University, 420 E Superior St, Chicago, IL 60611, USA.
| | - Yunsoo Lee
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Gregory R Toci
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Mark J Lambrechts
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Andrew Kalra
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - David Pipa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
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Schwartz CE, Borowiec K, Rapkin BD. Depression trajectories during the COVID-19 pandemic: a secondary analysis of the impact of cognitive-appraisal processes. J Patient Rep Outcomes 2023; 7:67. [PMID: 37439964 DOI: 10.1186/s41687-023-00600-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 06/04/2023] [Indexed: 07/14/2023] Open
Abstract
PURPOSE This study characterized depression trajectories during the COVID pandemic and investigated how appraisal and changes in appraisal over time related to these depression trajectories. METHODS This longitudinal study of the psychosocial impact of the COVID-19 pandemic included 771 people with data at three timepoints over 15.5 months. The depression index was validated using item-response-theory methods and receiver-operating-characteristic curve analysis. The Quality of Life (QOL) Appraisal Profilev2 Short-Form assessed cognitive-appraisal processes. Sequence analysis characterized depression-trajectory groups, and random effects models examined appraisal main effects, appraisal-by-group, and appraisal-by-group-by-time interactions. RESULTS Sequence analysis generated six trajectory groups: Stably Well (n = 241), Stably Depressed (n = 299), Worsening (n = 79), Improving (n = 83), Fluctuating Pattern 1 (No-Yes-No; n = 41), and Fluctuating Pattern 2 (Yes-No-Yes; n = 28). While all groups engaged in negative appraisal processes when they were depressed, the Stably Depressed group consistently focused on negative aspects of their life. Response-shift effects were revealed such that there were differences in the appraisal-depression relationship over time for standards of comparison and recent changes for the Stably Depressed, and in health goals for those Getting Better. CONCLUSION The present work is, to our knowledge, the first study of response-shift effects in depression. During these first 15.5 pandemic months, group differences highlighted the connection between negative appraisals and depression, and response-shift effects in these relationships over time. Egregious life circumstances may play a lesser role for the Stably Depressed but a greater role for people who have transient periods of depression as well as for those with improving trajectories (i.e., endogenous vs. reactive depression). How one thinks about QOL is intrinsically linked to mental health, with clear clinical implications.
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Affiliation(s)
- Carolyn E Schwartz
- DeltaQuest Foundation, Inc., 31 Mitchell Road, Concord, MA, 01742, USA.
- Departments of Medicine and Orthopaedic Surgery, Tufts University Medical School, Boston, MA, USA.
| | - Katrina Borowiec
- DeltaQuest Foundation, Inc., 31 Mitchell Road, Concord, MA, 01742, USA
- Department of Measurement, Evaluation, Statistics, and Assessment, Boston College Lynch School of Education and Human Development, Chestnut Hill, MA, USA
| | - Bruce D Rapkin
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
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Huang IC, Sim JA, Srivastava D, Krull KR, Ness KK, Robison LL, Baker JN, Hudson MM, Schwartz CE. Response-shift effects in childhood cancer survivors: A prospective study. Psychooncology 2023; 32:1085-1095. [PMID: 37189277 PMCID: PMC10330734 DOI: 10.1002/pon.6150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 04/24/2023] [Accepted: 04/28/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Treatment-related late effects can worsen over time among cancer survivors. Such worsening health states may trigger changes in internal standards, values, or conceptualization of quality-of-life (QOL). This "response-shift" phenomenon can jeopardize the validity of QOL assessment, and misrepresent QOL comparisons over time. This study tested response-shift effects in reporting future-health concerns among childhood cancer survivors who experienced progression in chronic health conditions (CHCs). METHODS 2310 adult survivors of childhood cancer from St. Jude Lifetime Cohort Study completed a survey and clinical assessment at two or more timepoints. Based on 190 individual CHCs graded for adverse-event severity, global CHC burden was classified as "progression" or "non-progression". QOL was assessed using the SF-36TM eight domains and physical- and mental-component summary scores (PCS, MCS). A single global item measured concerns about future health. Random-effects models comparing survivors with and without progressive global CHC burden (progressors vs. non-progressors) evaluated response-shift effects (recalibration, reprioritization, reconceptualization) in reporting future-health concerns. RESULTS Compared with non-progressors, progressors were more likely to de-emphasize (or downplay) overall physical and mental health in evaluating future-health concerns (p-values<0.05), indicating recalibration response-shift, and more likely to de-emphasize physical health earlier rather than later in follow-up (p-value<0.05), indicating reprioritization response-shift. There was evidence for a reconceptualization response-shift with progressor classification associated with worse-than-expected future-health concerns and physical health, and better-than-expected pain and role-emotional functioning (p-values<0.05). CONCLUSION We identified three types of response-shift phenomena in reporting concerns about future health among childhood cancer survivors. Survivorship care or research should consider response-shift effects when interpreting changes in QOL over time.
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Affiliation(s)
- I-Chan Huang
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Jin-ah Sim
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
- School of AI Convergence, Hallym University, Chuncheon, Gangwon-do, Republic of Korea
| | - DeoKumar Srivastava
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Kevin R. Krull
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Kirsten K. Ness
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Justin N. Baker
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Melissa M. Hudson
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Carolyn E. Schwartz
- DeltaQuest Foundation, Concord, Massachusetts, United States of America
- School of Medicine, Tufts University, Boston, Massachusetts, United States of America
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Schwartz CE, Rapkin BD. Impact of comorbidities on people with and without cancer early in the COVID-19 pandemic: An observational study. Cancer Med 2023; 12:15601-15611. [PMID: 37269193 PMCID: PMC10417288 DOI: 10.1002/cam4.6212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 05/24/2023] [Accepted: 05/24/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND The present study sought to investigate how comorbidity burden influences cancer survivors' quality of life (QoL) and the challenges/adaptations during the coronavirus disease 2019 (COVID) pandemic, and to examine how appraisal processes are related to this impact. METHODS This cross-sectional study, administered in spring/summer 2020, compared cancer survivors to a general-population comparison sample. QoL was assessed with standardized tools. COVID-specific questions included selected items compiled by the US National Institutes of Health, and cognitive appraisal processes were assessed using the QoL Appraisal Profilev2 Short-Form. Principal components analysis reduced the number of comparisons. Multivariate analysis of covariance investigated group differences in QoL, COVID-specific variables, and cognitive-appraisal processes. Linear regression investigated group differences in COVID-specific variables as a function of cognitive-appraisal processes, QoL, demographic covariates, and their interactions. RESULTS Cancer survivors fared substantially better than non-cancer participants in QoL and cognitive functioning when they had no other comorbidities, but substantially worse on QoL when they had three or more comorbidities. Cancer survivors with no comorbidities were less likely to feel worried about COVID, less likely to engage in self-protection, and prioritized engaging in problem-focused and prosocial actions compared to non-cancer participants. Conversely, cancer survivors confronted with multiple comorbidities exhibited more proactive self-protection and experienced more anxiety about the pandemic. CONCLUSION The impact of having multiple comorbidities in the context of cancer is associated with notable differences in social determinants of health, QoL outcomes, COVID-specific challenges/adaptations, and appraisal of QoL. These findings provide an empirical basis for implementing appraisal-based coping interventions.
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Affiliation(s)
- Carolyn E. Schwartz
- DeltaQuest Foundation, Inc.ConcordMassachusettsUSA
- Department of MedicineTufts University Medical SchoolBostonMassachusettsUSA
- Department of Orthopaedic SurgeryTufts University Medical SchoolBostonMassachusettsUSA
| | - Bruce D. Rapkin
- Department of Epidemiology and Population HealthAlbert Einstein College of MedicineBronxNew YorkUSA
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Harris LK, Troelsen A, Terluin B, Gromov K, Overgaard S, Price A, Ingelsrud LH. Interpretation Threshold Values for the Oxford Hip Score in Patients Undergoing Total Hip Arthroplasty: Advancing Their Clinical Use. J Bone Joint Surg Am 2023; 105:797-804. [PMID: 36947604 DOI: 10.2106/jbjs.22.01293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
BACKGROUND Patient-reported outcome measures such as the Oxford Hip Score (OHS) can capture patient-centered perspectives on outcomes after total hip arthroplasty (THA). The OHS assesses hip pain and functional limitations, but defining interpretation threshold values for the OHS is warranted so that numerical OHS values can be translated into whether patients have experienced clinically meaningful changes. Therefore, we determined the minimal important change (MIC), patient acceptable symptom state (PASS), and treatment failure (TF) threshold values for the OHS at 12 and 24-month follow-up in patients undergoing THA. METHODS This cohort study used data from patients undergoing THA at 1 public hospital between July 2016 and April 2021. At 12 and 24 months postoperatively, patients provided responses for the OHS and for 3 anchor questions about whether they had experienced changes in hip pain and function, whether they considered their symptom state to be satisfactory, and if it was not satisfactory, whether they considered the treatment to have failed. The anchor-based adjusted predictive modeling method was used to determine interpretation threshold values. Baseline dependency was evaluated using a new item-split method. Nonparametric bootstrapping was used to determine 95% confidence intervals (CIs). RESULTS Complete data were obtained for 706 (69%) of 1,027 and 728 (66%) of 1,101 patients at 12 and 24 months postoperatively, respectively. These patients had a median age of 70 years, and 55% to 56% were female. Adjusted OHS MIC values were 6.3 (CI, 4.6 to 8.1) and 5.2 (CI, 3.6 to 6.7), adjusted OHS PASS values were 30.6 (CI, 29.0 to 32.2) and 30.5 (CI, 29.3 to 31.8), and adjusted OHS TF values were 25.5 (CI, 22.9 to 27.7) and 27.0 (CI, 25.2 to 28.8) at 12 and 24 months postoperatively, respectively. MIC values were 5.4 (CI, 2.1 to 9.1) and 5.0 (CI, 1.9 to 8.7) higher at 12 and 24 months, respectively, in patients with a more severe preoperative state. CONCLUSIONS The established interpretation threshold values advance the interpretation and clinical use of the OHS, and may prove especially beneficial for registry-based evaluations of treatment quality. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Lasse K Harris
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Anders Troelsen
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Berend Terluin
- Department of General Practice, Amsterdam UMC Location, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Kirill Gromov
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Søren Overgaard
- Department of Orthopaedic Surgery and Traumatology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andrew Price
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, England
| | - Lina H Ingelsrud
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
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Schwartz CE, Rapkin BD, Borowiec K, Finkelstein JA. Cognitive Processes during Recovery: Moving toward Personalized Spine Surgery Outcomes. J Pers Med 2022; 12:jpm12101545. [PMID: 36294682 PMCID: PMC9605664 DOI: 10.3390/jpm12101545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 09/13/2022] [Accepted: 09/16/2022] [Indexed: 11/24/2022] Open
Abstract
This paper focuses on a novel application of personalized medicine: the ways one thinks about health (i.e., appraisal processes) as relevant predictors of spine-surgery response. This prospective longitudinal cohort study (n = 235) investigated how appraisal processes relate to outcomes of spinal decompression and/or fusion surgery, from pre-surgery through one-year post-surgery. Patient-reported outcomes assessed spine-specific disability (Oswestry Disability Index (ODI)), mental health functioning (Rand-36 Mental Component Score (MCS)), and cognitive appraisal processes (how people recall past experiences and to whom they compare themselves). Analysis of Variance examined the appraisal-outcomes association in separate models at pre-surgery, 3 months, and 12 months. We found that appraisal processes explained less variance at pre-surgery than later and were differentially relevant to health outcomes at different times in the spine-surgery recovery trajectory. For the ODI, recall of the seriousness of their condition was most prominent early in recovery, and comparing themselves to positive standards was most prominent later. For the MCS, not focusing on the negative aspects of their condition and/or on how others see them was associated with steady improvement and higher scores at 12 months. Appraisal processes are relevant to both spine-specific disability and mental-health functioning. Such processes are modifiable objects of attention for personalizing spine-surgery outcomes.
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Affiliation(s)
- Carolyn E. Schwartz
- DeltaQuest Foundation, Inc., Concord, MA 02111, USA
- Departments of Medicine and Orthopaedic Surgery, Tufts University School of Medicine, Boston, MA 02111, USA
- Correspondence: ; Tel.: +1-978-318-7914
| | - Bruce D. Rapkin
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Katrina Borowiec
- DeltaQuest Foundation, Inc., Concord, MA 02111, USA
- Department of Measurement, Evaluation, Statistics & Assessment, Boston College Lynch School of Education and Human Development, Chestnut Hill, MA 02467, USA
| | - Joel A. Finkelstein
- Department of Surgery, University of Toronto, Toronto, ON M4N 3M5, Canada
- Division of Orthopedic Surgery, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Division of Spine Surgery, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
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Schwartz CE, Rapkin BD, Sniderman J, Finkelstein JA. Appraisal and patient-reported outcomes following total hip arthroplasty: a longitudinal cohort study. J Patient Rep Outcomes 2022; 6:93. [PMID: 36064834 PMCID: PMC9445109 DOI: 10.1186/s41687-022-00498-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 08/21/2022] [Indexed: 11/10/2022] Open
Abstract
Background Total hip arthroplasty (THA) is a successful procedure that provides pain relief, restores function, and improves quality of life (QOL) for patients with advanced arthritis in their hip joint. To date, little research has examined the role of cognitive appraisal processes in THA outcomes. This study examined the role of cognitive appraisal processes in THA outcomes in the first year post-surgery. Methods This longitudinal cohort study collected data at pre-surgery, 6 weeks post-surgery, 3 months post-surgery, and 12 months post-surgery. Adults (n = 189) with a primary diagnosis of osteoarthritis were consecutively recruited from an active THA practice at a Canadian academic teaching hospital. Measures included the Hip Disability and Osteoarthritis Outcome Score (HOOS), the Mental Component Score (MCS) of the Rand-36, and the Brief Appraisal Inventory (BAI). Analysis of Variance examined the association between BAI items and the HOOS or MCS scores. Random effects models investigated appraisal main effects and appraisal-by-time interactions for selected BAI items. Results HOOS showed great improvement over the first 12 months after THA, and was mitigated by three appraisal processes in particular: focusing on problems with healthcare or living situation, and preparing one’s family for health changes. MCS was stable and low over time, and the following appraisal processes were implicated by very large effect sizes: not comparing themselves to healthier people, focusing on money problems, preparing their family for their health changes, or trying to shed responsibilities. Conclusions Appraisal processes are relevant to health outcomes after THA, with different processes coming into play at different points in the recovery trajectory. Supplementary Information The online version contains supplementary material available at 10.1186/s41687-022-00498-z.
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Schwartz CE, Stark RB, Borowiec K, Rapkin BD. Drivers of caregiver impact in Duchenne muscular dystrophy: a cohort study. J Patient Rep Outcomes 2022; 6:22. [PMID: 35274180 PMCID: PMC8911104 DOI: 10.1186/s41687-022-00421-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/08/2022] [Indexed: 11/17/2022] Open
Abstract
Background In our companion paper, we addressed the interplay between caregiver impact, out-of-pocket expenditures, and Duchenne Muscular Dystrophy (DMD) disability. We found that DMD caregiver impact could be characterized by four Latent Profile Analysis impact profiles: lowest, lower middle, upper middle, and highest impact. The impact on caregivers was often but not always worse with greater out-of-pocket expenditures. Further, while the lowest-, lower-middle, and highest-impact profiles reflected low, moderate and high disability-related caregiver burden, respectively, the upper-middle profile group was quite variable in level of disability across domains. To better understand the four caregiver-impact profiles, we examine how a comprehensive set of psychosocial factors differentiate the four profile groups. Methods Psychosocial factors assessed included demographic characteristics, quality of life (QOL), stress, cognitive appraisal, reserve-building, and general and COVID-specific resilience. Linear modeling examined relationships between impact profiles and psychosocial factors. We used effect size rather than p-value as the criterion for determining relevance of the broad range of characteristics examined. Results Multivariate analyses implicated stress and environmental mastery, appraisal sampling of experience, COVID-specific variables, appraisal standards of comparison, appraisal goals, demographics, appraisal combinatory algorithm, reserve-building, and resilience, in order of prominence (average eta2 = 0.29, 0.29, 0.16, 0.15, 0.09, 0.07, 0.07, 0.06, 0.05, and 0.02, respectively). On the whole, comparisons of highest-versus-lowest impact profiles revealed more and larger differences than comparisons of upper-middle versus lower-middle impact profiles. Life stress, goals, and reserve-building activities had a smaller differentiating effect in the middle groups. Conclusion A more comprehensive ‘story’ about DMD caregiver impact involves life stress, environmental mastery, COVID-specific variables, and cognitive and behavioral factors. Implications are discussed for coaching interventions to support DMD caregivers.
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Affiliation(s)
- Carolyn E Schwartz
- DeltaQuest Foundation, Inc., 31 Mitchell Road, Concord, MA, 01742, USA. .,Departments of Medicine and Orthopaedic Surgery, Tufts University Medical School, Boston, MA, USA.
| | - Roland B Stark
- DeltaQuest Foundation, Inc., 31 Mitchell Road, Concord, MA, 01742, USA
| | - Katrina Borowiec
- DeltaQuest Foundation, Inc., 31 Mitchell Road, Concord, MA, 01742, USA.,Department of Measurement, Evaluation, Statistics, and Assessment, Boston College Lynch School of Education and Human Development, Chestnut Hill, MA, USA
| | - Bruce D Rapkin
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
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Schwartz CE, Rohde G, Biletch E, Stuart RBB, Huang IC, Lipscomb J, Stark RB, Skolasky RL. If it's information, it's not "bias": a scoping review and proposed nomenclature for future response-shift research. Qual Life Res 2021; 31:2247-2257. [PMID: 34705159 DOI: 10.1007/s11136-021-03023-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND The growth in response-shift methods has enabled a stronger empirical foundation to investigate response-shift phenomena in quality-of-life (QOL) research; but many of these methods utilize certain language in framing the research question(s) and interpreting results that treats response-shift effects as "bias," "noise," "nuisance," or otherwise warranting removal from the results rather than as information that matters. The present project will describe the various ways in which researchers have framed the questions for investigating response-shift issues and interpreted the findings, and will develop a nomenclature for such that highlights the important information about resilience reflected by response-shift findings. METHODS A scoping review was done of the QOL and response-shift literature (n = 1100 articles) from 1963 to 2020. After culling only empirical response-shift articles, raters characterized how investigators framed and interpreted study research questions (n = 164 articles). RESULTS Of 10 methods used, papers using four of them utilized terms like "bias" and aimed to remove response-shift effects to reveal "true change." Yet, the investigators' reflections on their own conclusions suggested that they do not truly believe that response shift is error to be removed. A structured nomenclature is proposed for discussing response-shift results in a range of research contexts and response-shift detection methods. CONCLUSIONS It is time for a concerted and focused effort to change the nomenclature of those methods that demonstrated this misinterpretation. Only by framing and interpreting response shift as information, not bias, can we improve our understanding and methods to help to distill outcomes with and without response-shift effects.
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Affiliation(s)
- Carolyn E Schwartz
- DeltaQuest Foundation, Inc., 31 Mitchell Road, Concord, MA, 01742, USA. .,Departments of Medicine and Orthopaedic Surgery, Tufts University Medical School, Boston, MA, USA.
| | - Gudrun Rohde
- Department of Clincal Research Sorlandet Hospital, Faculty of Health and Sport Sciences at University of Agder, Kristiansand, Norway
| | - Elijah Biletch
- DeltaQuest Foundation, Inc., 31 Mitchell Road, Concord, MA, 01742, USA
| | | | - I-Chan Huang
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Joseph Lipscomb
- Department of Health Policy and Management, Rollins School of Public Health, and the Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Roland B Stark
- DeltaQuest Foundation, Inc., 31 Mitchell Road, Concord, MA, 01742, USA
| | - Richard L Skolasky
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Boaro A, Leung J, Reeder HT, Siddi F, Mezzalira E, Liu G, Mekary RA, Lu Y, Groff MW, Onnela JP, Smith TR. Smartphone GPS signatures of patients undergoing spine surgery correlate with mobility and current gold standard outcome measures. J Neurosurg Spine 2021; 35:796-806. [PMID: 34450590 DOI: 10.3171/2021.2.spine202181] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/23/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Patient-reported outcome measures (PROMs) are currently the gold standard to evaluate patient physical performance and ability to recover after spine surgery. However, PROMs have significant limitations due to the qualitative and subjective nature of the information reported as well as the impossibility of using this method in a continuous manner. The smartphone global positioning system (GPS) can be used to provide continuous, quantitative, and objective information on patient mobility. The aim of this study was to use daily mobility features derived from the smartphone GPS to characterize the perioperative period of patients undergoing spine surgery and to compare these objective measurements to PROMs, the current gold standard. METHODS Eight daily mobility features were derived from smartphone GPS data in a population of 39 patients undergoing spine surgery for a period of 2 months starting 3weeks before surgery. In parallel, three different PROMs for pain (visual analog scale [VAS]), disability (Oswestry Disability Index [ODI]) and functional status (Patient-Reported Outcomes Measurement Information System [PROMIS]) were serially measured. Segmented linear regression analysis was used to assess trends before and after surgery. The Student paired t-test was used to compare pre- and postoperative PROM scores. Pearson's correlation was calculated between the daily average of each GPS-based mobility feature and the daily average of each PROM score during the recovery period. RESULTS Smartphone GPS features provided data documenting a reduction in mobility during the immediate postoperative period, followed by a progressive and steady increase with a return to baseline mobility values 1 month after surgery. PROMs measuring pain, physical performance, and disability were significantly different 1 month after surgery compared to the 2 immediate preoperative weeks. The GPS-based features presented moderate to strong linear correlation with pain VAS and PROMIS physical score during the recovery period (Pearson r > 0.7), whereas the ODI and PROMIS mental scores presented a weak correlation (Pearson r approximately 0.4). CONCLUSIONS Smartphone-derived GPS features were shown to accurately characterize perioperative mobility trends in patients undergoing surgery for spine-related diseases. Features related to time (rather than distance) were better at describing patient physical and performance status. Smartphone GPS has the potential to be used for the development of accurate, noninvasive and personalized tools for patient mobility monitoring after surgery.
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Affiliation(s)
- Alessandro Boaro
- 1Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School.,4Institute of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Italy; and
| | - Jeffrey Leung
- 1Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School
| | - Harrison T Reeder
- 2Department of Biostatistics, Harvard T.H. Chan School of Public Health
| | - Francesca Siddi
- 1Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School
| | - Elisabetta Mezzalira
- 1Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School
| | - Gang Liu
- 2Department of Biostatistics, Harvard T.H. Chan School of Public Health
| | - Rania A Mekary
- 1Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School.,3School of Pharmacy, MCPHS University, Boston, Massachusetts
| | - Yi Lu
- 5Department of Neurosurgery, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
| | - Michael W Groff
- 5Department of Neurosurgery, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
| | | | - Timothy R Smith
- 1Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School.,5Department of Neurosurgery, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
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Schwartz CE, Stark RB, Rapkin BD. Creating idiometric short-form measures of cognitive appraisal: balancing theory and pragmatics. J Patient Rep Outcomes 2021; 5:57. [PMID: 34255208 PMCID: PMC8276902 DOI: 10.1186/s41687-021-00317-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 05/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Rapkin and Schwartz appraisal theory and measure provided a path toward documenting response-shift effects and describing individual differences in ways of thinking about quality of life (QOL) that distinguished people in different circumstances. Recent work developed and validated the QOL Appraisal Profileversion 2 (QOLAPv2), an 85-item measure that taps response-shift-detection domains of Frame of Reference, Standards of Comparison, Sampling of Experience, and Combinatory Algorithm. Recent theoretical work proposed that appraisal measurement constitutes a new class of measurement (idiometric), distinct from psychometric and clinimetric. To validate an idiometric measure, one would document that its items reflect different circumstances and population characteristics, and explain variance in QOL. The present work sought to develop idiometric short-forms of the QOLAPv2 item bank by examining which items were most informative, retaining the appraisal-domain structure. METHODS This secondary analysis (n = 1481) included chronically-ill patients and their caregivers from a longitudinal web-based survey (mean follow-up 16.6 months). Data included the QOLAPv2, the Center for Disease Control Healthy Days Core Module, the PROMIS-10 Global Health, and demographic/medical variables. Appraisal items were measured at baseline (relevant to understanding cognitive appraisal processes); and with change scores (sensitive to response-shift effects). Multivariate analysis of covariance examined what demographic and health-status change variables were reflected by each of 85 appraisal items (in five sets), as dependent variables, and other demographic/medical variables. Multiple linear regression examined how appraisal items explained variance in global physical- and mental-health change, after covariate adjustment. A tally summarized item performance across all five sets of cross-sectional and longitudinal analyses. RESULTS The vast majority (i.e., 80%) of the QOLAPv2 items performed well across the analyses presented. Using a relatively strict criterion of explaining meaningful variance across 60% of analyses, one would retain 68 items. A more lenient criterion (40%) would retain 71. CONCLUSIONS The present study provides heuristics to support investigators' creating 'discretionary' QOLAPv2 short-forms to fit their study aim and amplifying individual differences in the cognitive processes underlying QOL. This approach enables adapting the measure to the study population, as per the expectation that respondent populations differ in the predominant cognitive processes used.
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Affiliation(s)
- Carolyn E Schwartz
- DeltaQuest Foundation, Inc., 31 Mitchell Road, Concord, MA, 01742, USA. .,Departments of Medicine and Orthopaedic Surgery, Tufts University Medical School, Boston, MA, USA.
| | - Roland B Stark
- DeltaQuest Foundation, Inc., 31 Mitchell Road, Concord, MA, 01742, USA
| | - Bruce D Rapkin
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
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Schwartz CE, Stark RB, Michael W, Rapkin BD, Finkelstein JA. "Looking Under the Hood" of Anchor-Based Assessment of Clinically Important Change: A Machine Learning Approach. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:1009-1015. [PMID: 34243824 DOI: 10.1016/j.jval.2021.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 03/05/2021] [Accepted: 03/07/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES The Global Assessment of Change (GAC) item has facilitated the interpretation of change in patient-reported outcomes, providing an anchor for computing minimally important differences. Construct validity has been documented via disease-specific patient-reported outcomes change. We examined what domains, sociodemographic characteristics, attributions of change, and cognitive-appraisal processes are reflected in GAC ratings. METHODS This secondary analysis examined data from 1,481 chronically ill patients and caregivers surveyed at baseline and 17 months. Items queried change since baseline in overall disease symptoms (GAC) and in physical, emotional, and social functioning. Candidate predictors included sociodemographic factors, health-related quality-of-life domains, change attributions, and quality-of-life appraisal processes. Least absolute shrinkage and selection operator and bootstrapping tested 77 predictors' effectiveness and stability. RESULTS GAC worsening was notably associated with being disabled (β = -0.24) and having difficulty paying bills (β = -0.13). GAC was better explained by the physical domain than the emotional or social (β = 0.67, 0.10, and 0.03, respectively; R2adj = 0.63) after sociodemographic-covariate adjustment. In a separate model (R2adj = 0.18), GAC variance was explained by attributions about changing health and changing response of one's health team, goals related to solving healthcare problems and maintaining activities, and appraisal about things getting better (β = -0.14, 0.08, -0.07, 0.05, 0.21, respectively; prange ~0.0005-0.05) after adjustment. CONCLUSIONS The GAC primarily reflects the physical domain, and the GAC reflects attributions, goals, and patterns of emphasis related to change in health and healthcare. Commonly unmeasured factors have some bearing on GAC scores and can facilitate the interpretation of change.
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Affiliation(s)
- Carolyn E Schwartz
- DeltaQuest Foundation, Inc, Concord, MA, USA; Departments of Medicine and Orthopaedic Surgery, Tufts University School of Medicine, Boston, MA, USA.
| | | | | | - Bruce D Rapkin
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Joel A Finkelstein
- Divisions of Orthopedic Surgery and Spine Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Patient Factors That Matter in Predicting Hip Arthroplasty Outcomes: A Machine-Learning Approach. J Arthroplasty 2021; 36:2024-2032. [PMID: 33558044 DOI: 10.1016/j.arth.2020.12.038] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/09/2020] [Accepted: 12/22/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Despite the success of total hip arthroplasty (THA), approximately 10%-15% of patients will be dissatisfied with their outcome. Identifying patients at risk of not achieving meaningful gains postoperatively is critical to pre-surgical counseling and clinical decision support. Machine learning has shown promise in creating predictive models. This study used a machine-learning model to identify patient-specific variables that predict the postoperative functional outcome in THA. METHODS A prospective longitudinal cohort of 160 consecutive patients undergoing total hip replacement for the treatment of degenerative arthritis completed self-reported measures preoperatively and at 3 months postoperatively. Using four types of independent variables (patient demographics, patient-reported health, cognitive appraisal processes and surgical approach), a machine-learning model utilizing Least Absolute Shrinkage Selection Operator (LASSO) was constructed to predict postoperative Hip Disability and Osteoarthritis Outcome Score (HOOS) at 3 months. RESULTS The most predictive independent variables of postoperative HOOS were cognitive appraisal processes. Variables that predicted a worse HOOS consisted of frequent thoughts of work (β = -0.34), frequent comparison to healthier peers (β = -0.26), increased body mass index (β = -0.17), increased medical comorbidities (β = -0.19), and the anterior surgical approach (β = -0.15). Variables that predicted a better HOOS consisted of employment at the time of surgery (β = 0.17), and thoughts related to family interaction (β = 0.12), trying not to complain (β = 0.13), and helping others (β = 0.22). CONCLUSIONS This clinical prediction model in THA revealed that the factors most predictive of outcome were cognitive appraisal processes, demonstrating their importance to outcome-based research. LEVEL OF EVIDENCE Prognostic Level 1.
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15
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Finkelstein JA, Stark RB, Lee J, Schwartz CE. Patient factors that matter in predicting spine surgery outcomes: a machine learning approach. J Neurosurg Spine 2021; 35:127-136. [PMID: 34020414 DOI: 10.3171/2020.10.spine201354] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/08/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There is an increasing recognition of the importance of predictive analytics in spine surgery. This, along with the addition of personalized treatment, can optimize treatment outcomes. The goal of this study was to examine the value of clinical, demographic, expectation, and cognitive appraisal variables in predicting outcomes after surgery. METHODS This prospective longitudinal cohort study followed adult patients undergoing spinal decompression and/or fusion surgery for degenerative spinal conditions. The authors focused on predicting the numeric rating scale (NRS) for pain, based on past research finding it to be the most responsive of the spine patient-reported outcomes. Clinical data included type of surgery, adverse events, comorbidities, and use of pain medications. Demographics included age, sex, employment status, education, and smoking status. Data on expectations related to pain relief, ability to do household and exercise/recreational activities without pain, preventing future disability, and sleeping comfort. Appraisal items addressed 22 cognitive processes related to quality of life (QOL). LASSO (least absolute shrinkage and selection operator) and bootstrapping tested predictors hierarchically to determine effective predictive subsets at approximately 10 months postsurgery, based on data either at baseline (model 1) or at approximately 3 months (model 2). RESULTS The sample included 122 patients (mean age 61 years, with 53% being female). For model 1, analysis revealed better outcomes with patients expecting to be able to exercise or do recreational activities, focusing on recent events, and not focusing on how others see them (mean bootstrapped R2 [R2boot] = 0.12). For model 2, better outcomes were predicted by expecting symptom relief, focusing on the positive and on one's spinal condition (mean R2boot = 0.38). Bootstrapped analyses documented the stability of parameter estimates despite the small sample. CONCLUSIONS Nearly 40% of the variance in spine outcomes was accounted for by cognitive factors, after adjusting for clinical and demographic factors. Different expectations and appraisal processes played a role in long- versus short-range predictions, suggesting that cognitive adaptation is important and relevant to pain relief outcomes after spine surgery. These results underscore the importance of addressing how people think about QOL and surgery outcomes to maximize the benefits of surgery.
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Affiliation(s)
- Joel A Finkelstein
- Divisions of1Orthopedic Surgery and
- 2Spine Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Roland B Stark
- 3DeltaQuest Foundation, Inc., Concord, Massachusetts; and
| | - James Lee
- 2Spine Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Carolyn E Schwartz
- 3DeltaQuest Foundation, Inc., Concord, Massachusetts; and
- 5Orthopaedic Surgery, Tufts University School of Medicine, Boston, Massachusetts
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Minimal important change (MIC): a conceptual clarification and systematic review of MIC estimates of PROMIS measures. Qual Life Res 2021; 30:2729-2754. [PMID: 34247326 PMCID: PMC8481206 DOI: 10.1007/s11136-021-02925-y] [Citation(s) in RCA: 178] [Impact Index Per Article: 59.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 02/07/2023]
Abstract
We define the minimal important change (MIC) as a threshold for a minimal within-person change over time above which patients perceive themselves importantly changed. There is a lot of confusion about the concept of MIC, particularly about the concepts of minimal important change and minimal detectable change, which questions the validity of published MIC values. The aims of this study were: (1) to clarify the concept of MIC and how to use it; (2) to provide practical guidance for estimating methodologically sound MIC values; and (3) to improve the applicability of PROMIS by summarizing the available evidence on plausible PROMIS MIC values. We discuss the concept of MIC and how to use it and provide practical guidance for estimating MIC values. In addition, we performed a systematic review in PubMed on MIC values of any PROMIS measure from studies using recommended approaches. A total of 50 studies estimated the MIC of a PROMIS measure, of which 19 studies used less appropriate methods. MIC values of the remaining 31 studies ranged from 0.1 to 12.7 T-score points. We recommend to use the predictive modeling method, possibly supplemented with the vignette-based method, in future MIC studies. We consider a MIC value of 2-6 T-score points for PROMIS measures reasonable to assume at this point. For surgical interventions a higher MIC value might be appropriate. We recommend more high-quality studies estimating MIC values for PROMIS.
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17
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Response-shift effects in neuromyelitis optica spectrum disorder: a secondary analysis of clinical trial data. Qual Life Res 2020; 30:1267-1282. [PMID: 33269417 PMCID: PMC8068626 DOI: 10.1007/s11136-020-02707-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2020] [Indexed: 11/24/2022]
Abstract
Background Researchers have long posited that response-shift effects may obfuscate treatment effects. The present work investigated possible response-shift effects in a recent clinical trial testing a new treatment for Neuromyelitis Optica Spectrum Disorder (NMOSD). This pivotal trial provided impressive support for the drug Eculizumab in preventing relapse, but less strong or null results as the indicators became more subjective or evaluative. This pattern of results suggests that response-shift effects are present. Methods This secondary analysis utilized data from a randomized, double-blind trial evaluating the impact of Eculizumab in preventing relapses in 143 people with NMOSD. Treatment arm and then relapse status were hypothesized ‘catalysts’ of response shift in two series of analyses. We devised a “de-constructed” version of Oort structural-equation modeling using random-effects modeling for use in small samples. This method begins by testing an omnibus response-shift hypothesis and then, pending a positive result, implements a series of random-effects models to elucidate specific response-shift effects. Results In the omnibus test, the ‘standard quality-of-life (QOL) model’ captured substantially less well the experience of placebo as compared to Eculizumab group. Recalibration and reconceptualization response-shift effects were detected. Detected relapse-related response shifts included recalibration, reprioritization, and reconceptualization. Conclusions Trial patients experienced response shifts related to treatment- and relapse-related experiences. Published trial results likely under-estimated Eculizumab vs. Placebo differences due to recalibration and reconceptualization, and relapse effects due to recalibration, reprioritization, and reconceptualization. This novel random-effects- model application builds on response-shift theory and provides a small-sample method for better estimating treatment effects in clinical trials. Electronic supplementary material The online version of this article (10.1007/s11136-020-02707-y) contains supplementary material, which is available to authorized users.
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Horn ME, Reinke EK, Couce LJ, Reeve BB, Ledbetter L, George SZ. Reporting and utilization of Patient-Reported Outcomes Measurement Information System® (PROMIS®) measures in orthopedic research and practice: a systematic review. J Orthop Surg Res 2020; 15:553. [PMID: 33228699 PMCID: PMC7684926 DOI: 10.1186/s13018-020-02068-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 11/04/2020] [Indexed: 12/15/2022] Open
Abstract
Background The Patient-Reported Outcomes Measurement Information SystemⓇ (PROMISⓇ) is a dynamic system of psychometrically sound patient-reported outcome (PRO) measures. There has been a recent increase in the use of PROMIS measures, yet little has been written about the reporting of these measures in the field of orthopedics. The purpose of this study was to conduct a systematic review to determine the uptake of PROMIS measures across orthopedics and to identify the type of PROMIS measures and domains that are most commonly used in orthopedic research and practice. Methods We searched PubMed, Embase, and Scopus using keywords and database-specific subject headings to capture orthopedic studies reporting PROMIS measures through November 2018. Our inclusion criteria were use of PROMIS measures as an outcome or used to describe a population of patients in an orthopedic setting in patients ≥ 18 years of age. We excluded non-quantitative studies, reviews, and case reports. Results Our final search yielded 88 studies published from 2013 through 2018, with 57% (50 studies) published in 2018 alone. By body region, 28% (25 studies) reported PROMIS measures in the upper extremity (shoulder, elbow, hand), 36% (32 studies) reported PROMIS measures in the lower extremity (hip, knee, ankle, foot), 19% (17 studies) reported PROMIS measures in the spine, 10% (9 studies) reported PROMIS measures in trauma patients, and 6% (5 studies) reported PROMIS measures in general orthopedic patients. The majority of studies reported between one and three PROMIS domains (82%, 73 studies). The PROMIS Computerized Adaptive Test (CAT) approach was most commonly used (81%, 72 studies). The most frequently reported PROMIS domains were physical function (81%, 71 studies) and pain interference (61%, 54 studies). Conclusion Our review found an increase in the reporting of PROMIS measures over the recent years. Utilization of PROMIS measures in orthopedic populations is clinically appropriate and can facilitate communication of outcomes across different provider types and with reduced respondent burden. Registration The protocol for this systematic review was designed in accordance with the PRISMA guidelines and is registered with the PROSPERO database (CRD42018088260). Supplementary Information The online version contains supplementary material available at 10.1186/s13018-020-02068-9.
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Affiliation(s)
- Maggie E Horn
- Duke Clinical Research Institute, Duke University, Durham, NC, USA. .,Department of Orthopaedic Surgery, Duke University, Box 10042, Durham, NC, 27710, USA.
| | - Emily K Reinke
- Department of Orthopaedic Surgery, Duke University, Box 10042, Durham, NC, 27710, USA
| | - Logan J Couce
- University of Utah Orthopaedic Center, University of Utah Health, Salt Lake City, UT, USA
| | - Bryce B Reeve
- Duke Clinical Research Institute, Duke University, Durham, NC, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.,Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Leila Ledbetter
- Duke University Medical Center Library, Duke University, Durham, NC, USA
| | - Steven Z George
- Duke Clinical Research Institute, Duke University, Durham, NC, USA.,Department of Orthopaedic Surgery, Duke University, Box 10042, Durham, NC, 27710, USA
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Schwartz CE, Stark RB, Rapkin BD. Capturing patient experience: does quality-of-life appraisal entail a new class of measurement? J Patient Rep Outcomes 2020; 4:85. [PMID: 33108540 PMCID: PMC7591682 DOI: 10.1186/s41687-020-00254-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 10/11/2020] [Indexed: 11/11/2022] Open
Abstract
Background Two decades of research on quality-of-life (QOL) appraisal have demonstrated links between patient experience and health outcomes and have accounted for both intra-individual change and inter-individual differences in a wide range of research contexts. The present work investigates patterns across diagnostic and demographic groupings to demonstrate how population-specific circumstances drive the structure of QOL appraisal. Methods This secondary analysis (N = 6448) utilized data from six patient groups: spine surgery, multiple sclerosis, heterogeneous chronically ill, heterogeneous cancer, bladder cancer, and human immunodeficiency virus (HIV). We explored patterns of inter-item correlation across patient samples, using items from the Standards of Comparison and Sampling of Experience subsections of the QOL Appraisal Profile v1 and v2. Similar matrices were compared by demographic characteristics. Results Patterns of inter-item correlations for Standards of Comparison items varied sharply across disease groups and racial groups while being similar across age, gender, and education levels. Inter-item correlation matrices for Sampling of Experience items revealed marked differences among disease groups and educational and racial categories but were similar across age and gender groups. Conclusions Appraisal parameters showed evidence of shared and unique aspects across samples and circumstances, findings which make sense in light of sample differences in health status and demographic influences. Tools to assess patient experience and meaning may be best understood as idiometric instruments. We discuss their distinctions from psychometric and clinimetric tools at theoretical, statistical, and applied levels. Supplementary information Supplementary information accompanies this paper at 10.1186/s41687-020-00254-1.
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Affiliation(s)
- Carolyn E Schwartz
- DeltaQuest Foundation, Inc., 31 Mitchell Road, Concord, MA, 01742, USA. .,Departments of Medicine and Orthopaedic Surgery, Tufts University Medical School, Boston, MA, USA.
| | - Roland B Stark
- DeltaQuest Foundation, Inc., 31 Mitchell Road, Concord, MA, 01742, USA
| | - Bruce D Rapkin
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
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Schwartz CE, Stark RB, Michael W, Rapkin BD. Understanding haemophilia caregiver burden: does appraisal buffer the impact of haemophilia on caregivers over time? Psychol Health 2020; 35:1516-1530. [PMID: 32475167 DOI: 10.1080/08870446.2020.1766042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: The present work investigated haemophilia caregiver and patient characteristics associated with change in negative and positive aspects of caregiving. Design: Web-based survey data were collected from haemophilia A or B caregivers at baseline and two years later. Main Outcome Measures: Outcomes included Burden Summary and Positive Emotions change scores from the Haemophilia Caregiver Impact measure. Results: The sample included 323 caregivers (71% response rate; mean age 40, 90% female). Brief Appraisal Inventory Principal Components Analysis with varimax rotation yielded five scores: Awareness of Challenges, Fulfillment and Growth, Stay Positive, Social Comparison, and Interpersonal Problem-Solving. Regression analyses revealed that caregivers with more health conditions, who care for patients with increased bleeds and worse pain, and who focused more on Awareness of Challenges, Social Comparisons, and Interpersonal Problem-Solving reported worsened burden over follow-up (Adj. R2 = 0.37). Prioritisation of Stay[ing] Positive and reduced emphasis on Interpersonal Problem-Solving were associated with increased Positive Emotions (Adj. R2 = 0.32). Conclusion: Caregivers who focused less on a life unfettered by caregiving, comparing themselves to others, and interpersonal problem-solving and more on staying positive reported reductions in burden and improvements in positive emotions. These findings could translate to multicomponent psychoeducational interventions to help caregivers buffer haemophilia's impact.
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Affiliation(s)
- Carolyn E Schwartz
- DeltaQuest Foundation, Inc, Concord, MA, USA.,Departments of Medicine and Orthopaedic Surgery, Tufts University Medical School, Boston, MA, USA
| | | | | | - Bruce D Rapkin
- Department of Epidemiology and Population Health, Division of Community Collaboration & Implementation Science, Albert Einstein College of Medicine, Bronx, NY, USA
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Zahrai A, Bhanot K, Mei XY, Crawford E, Tan Z, Yee A, Palda V. Surgeon clinical practice variation and patient preferences during the informed consent discussion: a mixed-methods analysis in lumbar spine surgery. Can J Surg 2020; 63:E284-E291. [PMID: 32437095 DOI: 10.1503/cjs.005619] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background Patients with lumbar disc herniation may greatly benefit from microdiscectomy. Although spine surgeons performing microdiscectomy routinely obtain informed consent, the potential adverse events they disclose often vary. Moreover, little is known about what disclosures are deemed most valuable by patients. The aim of this mixed-methods study was to determine practice variations among spine surgeons in regard to the disclosure of potential adverse events during informed consent discussions for lumbar microdiscectomy and to determine which topics patients perceived to be valuable in the consent discussion. Methods A survey evaluating the frequency with which spine surgeons disclose 15 potential adverse events related to lumbar microdiscectomy during informed consent discussions was distributed among Canadian Spine Society members. Additionally, semistructured interviews were conducted with preoperative patients, postoperative patients, attending spine surgeons, spine fellows and orthopedic residents. Interview transcripts were analyzed using thematic analysis with open coding. Results Fifty-one Canadian Spine Society members completed the survey. The number of potential adverse events not routinely discussed was greater among orthopedic surgeons than among neurosurgeons (relative risk 1.83; 95% confidence interval 1.22-2.73; p = 0.003). Three preoperative patients, 7 postoperative patients, 6 attending spine surgeons, 3 spine fellows and 5 orthopedic residents participated in the semistructured interviews. The interviews identified gaps in information provided to patients, particularly on topics relating to postoperative care such as expected recovery time, activity restrictions and need for a caregiver. Conclusion There is variation in the disclosure of potential adverse events during informed consent discussions for lumbar microdiscectomy among Canadian spine surgeons. Patients desire more information regarding their postoperative care. Further research should focus on developing guidelines to reduce practice variation and optimize the effectiveness of consent discussions.
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Affiliation(s)
- Ali Zahrai
- From the Division of Orthopaedic Surgery, University of Toronto, Toronto, Ont
| | - Kunal Bhanot
- From the Division of Orthopaedic Surgery, University of Toronto, Toronto, Ont
| | - Xin Y Mei
- From the Division of Orthopaedic Surgery, University of Toronto, Toronto, Ont
| | - Eric Crawford
- From the Division of Orthopaedic Surgery, University of Toronto, Toronto, Ont
| | - Zachary Tan
- From the Division of Orthopaedic Surgery, University of Toronto, Toronto, Ont
| | - Albert Yee
- From the Division of Orthopaedic Surgery, University of Toronto, Toronto, Ont
| | - Valerie Palda
- From the Division of Orthopaedic Surgery, University of Toronto, Toronto, Ont
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Schwartz CE, Stark RB, Balasuberamaniam P, Shrikumar M, Wasim A, Finkelstein JA. Responsiveness of standard spine outcome tools: do they measure up? J Neurosurg Spine 2020; 33:106-113. [PMID: 32084630 DOI: 10.3171/2019.12.spine191367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 12/31/2019] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Carolyn E Schwartz
- 1DeltaQuest Foundation, Inc., Concord
- Departments of2Medicine and
- 3Orthopaedic Surgery, Tufts University School of Medicine, Boston, Massachusetts; and
| | | | | | | | | | - Joel A Finkelstein
- Divisions of4Orthopedic Surgery and
- 5Spine Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Schwartz CE, Stark RB, Stucky BD, Michael W, Rapkin BD. Positive emotions despite substantial burden: The alchemy of haemophilia caregiving. Haemophilia 2019; 26:86-96. [PMID: 31797497 DOI: 10.1111/hae.13874] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 10/16/2019] [Accepted: 10/17/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Qualitative interviews when developing the haemophilia caregiver impact measure© (HCI) documented the importance of capturing the positive aspects of caregiving, not just the negative. AIM The present study thus investigates the construct underlying the positive emotions HCI subscale and tests models proposing a more comprehensive way of thinking about this construct. METHODS Secondary analysis was implemented on longitudinal web-based survey data (n = 323) from haemophilia A or haemophilia B caregivers. Person-reported outcomes (PROs) included the HCI, the PROMIS-10 and Ryff psychological well-being subscales. Predictors included caregiver demographics; patient haemophilia characteristics; exercise; adherence; and quality-of-life (QOL) appraisal processes as measured by the brief appraisal inventory (BAI) which yields composite scores assessing awareness of challenges, fulfillment and growth, stay positive, social comparison and interpersonal problem-solving. Second-order factor analysis, structural equation modelling and residual modelling were implemented. RESULTS A structural equation model fit the data well that contained bifactor representation of well-being with a general factor comprised of environmental mastery, positive relations with others, physical functioning and emotional functioning. Positive emotions was modelled as a component of well-being, with a unique component ('Alchemy') characterized by its associations with stay positive, and awareness of challenges appraisals, and difficulty paying bills. Alchemy had positive linear relationships with the first two, and a positive quadratic relationship with difficulty paying bills. CONCLUSIONS Adopting positive-focused ways of thinking about one's life limitations may transform the negatives of haemophilia caregiving into something positive. Such cognitive habits reflect an awareness and acceptance of the limitations imposed by haemophilia caregiving.
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Affiliation(s)
- Carolyn E Schwartz
- DeltaQuest Foundation, Inc., Concord, MA, USA.,Departments of Medicine and Orthopaedic Surgery, Tufts University Medical School, Boston, MA, USA
| | | | | | | | - Bruce D Rapkin
- Department of Epidemiology and Population Health, Division of Community Collaboration & Implementation Science, Albert Einstein College of Medicine, Bronx, NY, USA
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Measurement of appraisal is a valuable adjunct to the current spine outcome tools: a clinician's perspective on the Rapkin and Schwartz commentary. Qual Life Res 2019; 28:2631-2632. [PMID: 31531838 DOI: 10.1007/s11136-019-02275-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2019] [Indexed: 02/07/2023]
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Finkelstein JA, Schwartz CE. Patient-reported outcomes in spine surgery: past, current, and future directions. J Neurosurg Spine 2019; 31:155-164. [PMID: 31370009 DOI: 10.3171/2019.1.spine18770] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 01/29/2019] [Indexed: 11/06/2022]
Abstract
The purpose of this article is to review the current state of outcome measurement in spine surgery, with an emphasis on patient-reported outcome measures (PROMs). The commonly used generic and disease-specific outcome measures used in spinal surgery and research will be discussed. The authors will introduce the concepts of response shift and appraisal processes, which may affect the face validity of PROMs, as well as their interpretation over time. It is not uncommon for there to be a discrepancy between the observed and expected outcome, which is not wholly explainable by objective measures. Current work on understanding how appraisal affects outcome measurement will be discussed, and future directions will be suggested to facilitate the continued evolution of PROMs.There has been an evolution in the way clinicians measure outcomes following spinal surgery. In moving from purely physical, objective measures to a growing emphasis on the patient's perspective, spine surgery outcomes are better able to integrate the impact at multiple levels of relevant change. Appraisal concepts and methods are gaining traction as ways to understand the cognitive processes underlying PROMs over time. Measurement of appraisal is a valuable adjunct to the current spine outcome tools.
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Affiliation(s)
- Joel A Finkelstein
- 1Division of Orthopedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Carolyn E Schwartz
- 2DeltaQuest Foundation, Inc., Concord; and
- 3Departments of Medicine and Orthopaedic Surgery, Tufts University School of Medicine, Boston, Massachusetts
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