Scoring Depression on a Common Metric: A Comparison of EAP Estimation, Plausible Value Imputation, and Full Bayesian IRT Modeling

How Are Age, Gender, and Country Differences Associated With PROMIS Physical Function, Upper Extremity, and Pain Interference Scores?

BACKGROUND

The interpretation of patient-reported outcomes requires appropriate comparison data. Currently, no patient-specific reference data exist for the Patient-Reported Outcome Measurement Information System (PROMIS) Physical Function (PF), Upper Extremity (UE), and Pain Interference (PI) scales for individuals 50 years and older.

QUESTIONS/PURPOSES

(1) Can all PROMIS PF, UE, and PI items be used for valid cross-country comparisons in these domains among the United States, the United Kingdom, and Germany? (2) How are age, gender, and country related to PROMIS PF, PROMIS UE, and PROMIS PI scores? (3) What is the relationship of age, gender, and country across individuals with PROMIS PF, PROMIS UE, and PROMIS PI scores ranging from very low to very high?

METHODS

We conducted telephone interviews to collect custom PROMIS PF (22 items), UE (eight items), and PI (eight items) short forms, as well as sociodemographic data (age, gender, work status, and education level), with participants randomly selected from the general population older than 50 years in the United States (n = 900), United Kingdom (n = 905), and Germany (n = 921). We focused on these individuals because of their higher prevalence of surgeries and lower physical functioning. Although response rates varied across countries (14% for the United Kingdom, 22% for Germany, and 12% for the United States), we used existing normative data to ensure demographic alignment with the overall populations of these countries. This helped mitigate potential nonresponder bias and enhance the representativeness and validity of our findings. We investigated differential item functioning to determine whether all items can be used for valid crosscultural comparisons. To answer our second research question, we compared age groups, gender, and countries using median regressions. Using imputation of plausible values and quantile regression, we modeled age-, gender-, and country-specific distributions of PROMIS scores to obtain patient-specific reference values and answer our third research question.

RESULTS

All items from the PROMIS PF, UE, and PI measures were valid for across-country comparisons. We found clinically meaningful associations of age, gender, and country with PROMIS PF, UE, and PI scores. With age, PROMIS PF scores decreased (age ß Median = -0.35 [95% CI -0.40 to -0.31]), and PROMIS UE scores followed a similar trend (age ß Median = -0.38 [95% CI -0.45 to -0.32]). This means that a 10-year increase in age corresponded to a decline in approximately 3.5 points for the PROMIS PF score-a value that is approximately the minimum clinically important difference (MCID). Concurrently, we observed a modest increase in PROMIS PI scores with age, reaching half the MCID after 20 years. Women in all countries scored higher than men on the PROMIS PI and 1 MCID lower on the PROMIS PF and UE. Additionally, there were higher T-scores for the United States than for the United Kingdom across all domains. The difference in scores ranged from 1.21 points for the PROMIS PF to a more pronounced 3.83 points for the PROMIS UE. Participants from the United States exhibited up to half an MCID lower T-scores than their German counterparts for the PROMIS PF and PROMIS PI. In individuals with high levels of physical function, with each 10-year increase in age, there could be a decrease of up to 4 points in PROMIS PF scores. Across all levels of upper extremity function, women reported lower PROMIS UE scores than men by an average of 5 points.

CONCLUSION

Our study provides age-, gender-, and country-specific reference values for PROMIS PF, UE, and PI scores, which can be used by clinicians, researchers, and healthcare policymakers to better interpret patient-reported outcomes and provide more personalized care. These findings are particularly relevant for those collecting patient-reported outcomes in their clinical routine and researchers conducting multinational studies. We provide an internet application ( www.common-metrics.org/PROMIS_PF_and_PI_Reference_scores.php ) for user-friendly accessibility in order to perform age, gender, and country conversions of PROMIS scores. Population reference values can also serve as comparators to data collected with other PROMIS short forms or computerized adaptive tests.

LEVEL OF EVIDENCE

Level II, diagnostic study.

Using Auxiliary Item Information in the Item Parameter Estimation of a Graded Response Model for a Small to Medium Sample Size: Empirical Versus Hierarchical Bayes Estimation

Marginal maximum likelihood estimation (MMLE) is commonly used for item response theory item parameter estimation. However, sufficiently large sample sizes are not always possible when studying rare populations. In this paper, empirical Bayes and hierarchical Bayes are presented as alternatives to MMLE in small sample sizes, using auxiliary item information to estimate the item parameters of a graded response model with higher accuracy. Empirical Bayes and hierarchical Bayes methods are compared with MMLE to determine under what conditions these Bayes methods can outperform MMLE, and to determine if hierarchical Bayes can act as an acceptable alternative to MMLE in conditions where MMLE is unable to converge. In addition, empirical Bayes and hierarchical Bayes methods are compared to show how hierarchical Bayes can result in estimates of posterior variance with greater accuracy than empirical Bayes by acknowledging the uncertainty of item parameter estimates. The proposed methods were evaluated via a simulation study. Simulation results showed that hierarchical Bayes methods can be acceptable alternatives to MMLE under various testing conditions, and we provide a guideline to indicate which methods would be recommended in different research situations. R functions are provided to implement these proposed methods.

Overcoming floor and ceiling effects in knee arthroplasty outcome measurement

Aims

To map the Oxford Knee Score (OKS) and High Activity Arthroplasty Score (HAAS) items to a common scale, and to investigate the psychometric properties of this new scale for the measurement of knee health.

Methods

Patient-reported outcome measure (PROM) data measuring knee health were obtained from the NHS PROMs dataset and Total or Partial Knee Arthroplasty Trial (TOPKAT). Assumptions for common scale modelling were tested. A graded response model (fitted to OKS item responses in the NHS PROMs dataset) was used as an anchor to calibrate paired HAAS items from the TOPKAT dataset. Information curves for the combined OKS-HAAS model were plotted. Bland-Altman analysis was used to compare common scale scores derived from OKS and HAAS items. A conversion table was developed to map between HAAS, OKS, and the common scale.

Results

We included 3,329 response sets from 528 patients undergoing knee arthroplasty. These generally met the assumptions of unidimensionality, monotonicity, local independence, and measurement invariance. The HAAS items provided more information than OKS items at high levels of knee health. Combining both instruments resulted in higher test-level information than either instrument alone. The mean error between common scale scores derived from the OKS and HAAS was 0.29 logits.

Conclusion

The common scale allowed more precise measurement of knee health than use of either the OKS or HAAS individually. These techniques for mapping PROM instruments may be useful for the standardization of outcome reporting, and pooling results across studies that use either PROM in individual-patient meta-analysis.

Remote Symptom Monitoring With Ecological Momentary Computerized Adaptive Testing: Pilot Cohort Study of a Platform for Frequent, Low-Burden, and Personalized Patient-Reported Outcome Measures

BACKGROUND

Remote patient-reported outcome measure (PROM) data capture can provide useful insights into research and clinical practice and deeper insights can be gained by administering assessments more frequently, for example, in ecological momentary assessment. However, frequent data collection can be limited by the burden of multiple, lengthy questionnaires. This burden can be reduced with computerized adaptive testing (CAT) algorithms that select only the most relevant items from a PROM for an individual respondent. In this paper, we propose "ecological momentary computerized adaptive testing" (EMCAT): the use of CAT algorithms to reduce PROM response burden and facilitate high-frequency data capture via a smartphone app. We develop and pilot a smartphone app for performing EMCAT using a popular hand surgery PROM.

OBJECTIVE

The aim of this study is to determine the feasibility of EMCAT as a system for remote PROM administration.

METHODS

We built the EMCAT web app using Concerto, an open-source CAT platform maintained by the Psychometrics Centre, University of Cambridge, and hosted it on an Amazon Web Service cloud server. The platform is compatible with any questionnaire that has been parameterized with item response theory or Rasch measurement theory. For this study, the PROM we chose was the patient evaluation measure, which is commonly used in hand surgery. CAT algorithms were built using item response theory models derived from UK Hand Registry data. In the pilot study, we enrolled 40 patients with hand trauma or thumb-base arthritis, across 2 sites, between July 13, 2022, and September 14, 2022. We monitored their symptoms with the patient evaluation measure, via EMCAT, over a 12-week period. Patients were assessed thrice weekly, once daily, or thrice daily. We additionally administered full-length PROM assessments at 0, 6, and 12 weeks, and the User Engagement Scale at 12 weeks.

RESULTS

The use of EMCAT significantly reduced the length of the PROM (median 2 vs 11 items) and the time taken to complete it (median 8.8 seconds vs 1 minute 14 seconds). Very similar scores were obtained when EMCAT was administered concurrently with the full-length PROM, with a mean error of <0.01 on a logit (z score) scale. The median response rate in the daily assessment group was 93%. The median perceived usability score of the User Engagement Scale was 4.0 (maximum possible score 5.0).

CONCLUSIONS

EMCAT reduces the burden of PROM assessments, enabling acceptable high-frequency, remote PROM data capture. This has potential applications in both research and clinical practice. In research, EMCAT could be used to study temporal variations in symptom severity, for example, recovery trajectories after surgery. In clinical practice, EMCAT could be used to monitor patients remotely, prompting early intervention if a patient's symptom trajectory causes clinical concern.

TRIAL REGISTRATION

ISRCTN 19841416; https://www.isrctn.com/ISRCTN19841416.

Physical performance tasks were linked to the PROMIS physical function metric in patients undergoing hemodialysis

OBJECTIVES

To investigate whether a multi-item performance outcome measure, the physical performance test (PPT), can be calibrated to a common scale with patient-reported outcome measures, using the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) metric.

STUDY DESIGN AND SETTING

We analyzed baseline data (N = 1,113) from the CONVINCE study, an international trial in end-stage kidney disease patients comparing high-dose hemodiafiltration with high-flux hemodialysis. Assumptions of item response theory (IRT) modelling were investigated for the combined set of the nine-item PPT and a four-item PROMIS PF short form (PROMIS-PF4a). We applied unidimensional IRT linking for calibrating the PPT to the PROMIS PF metric.

RESULTS

Although some evidence for multidimensionality was found, classical test statistics (Cronbach's Alpha = 0.93), Mokken (Loevinger's H = 0.50), and bifactor analysis (explained common variance = 0.65) indicated that PPT and PROMIS-PF4a items can be used to assess a common PF construct. On the group level, the agreement between PROMIS-PF4a and linked PPT scores was stable across several subsamples. On the individual level, scores differed considerably.

CONCLUSION

We found preliminary evidence that the PPT can be linked to the PROMIS PF metric in hemodialysis patients, enabling group comparisons across patient-reported outcome and performance outcome measures. Alternative linking methods should be applied in future studies using a more comprehensive PROMIS PF item set.

Item response theory assumptions were adequately met by the Oxford hip and knee scores

OBJECTIVES

To develop item response theory (IRT) models for the Oxford hip and knee scores which convert patient responses into continuous scores with quantifiable precision and provide these as web applications for efficient score conversion.

STUDY DESIGN AND SETTING

Data from the National Health Service patient-reported outcome measures program were used to test the assumptions of IRT (unidimensionality, monotonicity, local independence, and measurement invariance) before fitting models to preoperative response patterns obtained from patients undergoing primary elective hip or knee arthroplasty. The hip and knee datasets contained 321,147 and 355,249 patients, respectively.

RESULTS

Scree plots, Kaiser criterion analyses, and confirmatory factor analyses confirmed unidimensionality and Mokken analysis confirmed monotonicity of both scales. In each scale, all item pairs shared a residual correlation of ≤ 0.20. At the test level, both scales showed measurement invariance by age and gender. Both scales provide precise measurement in preoperative settings but demonstrate poorer precision and ceiling effects in postoperative settings.

CONCLUSION

We provide IRT parameters and web applications that can convert Oxford Hip Score or Oxford Knee Score response sets into continuous measurements and quantify individual measurement error. These can be used in sensitivity analyses or to administer truncated and individualized computerized adaptive tests.

Item response theory may account for unequal item weighting and individual-level measurement error in trials that use PROMs: a psychometric sensitivity analysis of the TOPKAT trial

OBJECTIVES

To apply item response theory as a framework for studying measurement error in superiority trials which use patient-reported outcome measures (PROMs).

METHODS

We reanalyzed data from the The Total or Partial Knee Arthroplasty Trial, which compared the Oxford Knee Score (OKS) responses of patients undergoing partial or total knee replacement, using traditional sum-scoring, after accounting for OKS item characteristics with expected a posteriori (EAP) scoring, and after accounting for individual-level measurement error with plausible value imputation (PVI). We compared the marginalized mean scores of each group at baseline, 2 months, and yearly for 5 years. We used registry data to estimate the minimal important difference (MID) of OKS scores with sum-scoring and EAP scoring.

RESULTS

With sum-scoring, we found statistically significant differences in mean OKS score at 2 months (P = 0.030) and 1 year (P = 0.030). EAP scores produced slightly different results, with statistically significant differences at 1 year (P = 0.041) and 3 years (P = 0.043). With PVI, there were no statistically significant differences.

CONCLUSION

Psychometric sensitivity analyses can be readily performed for superiority trials using PROMs and may aid the interpretation of results.

Measuring individual true change with PROMIS using IRT-based plausible values

AIMS

A primary advantage of IRT-based patient-reported outcome measures such as PROMIS short forms and computer-adaptive tests is that each estimate of the latent trait comes with a standard error. Such measurement error needs to be acknowledged, in particular when monitoring individual patients over time. In this study, we use plausible values to account for measurement error and analyze the probability of true within-individual change.

METHODS

We use a longitudinal, observational study of stable and exacerbated COPD patients (N = 185), providing PROMIS Physical Function and Fatigue T-scores over 3 months. At each measurement, we imputed 1000 plausible values from the scores' posterior distribution. These were then used to calculate probability of true change using a pre-specified threshold such as minimally important difference supported by the literature, or [Formula: see text] > 0. We demonstrate assessment of change in individuals and in groups, across different measures (Short Forms and CATs), and at various levels of confidence.

RESULTS

Using plausible value imputation and with 95% certainty, 47.5% of participants in the exacerbated group reported less fatigue, compared with 26.5% of participants in the stable group. Comparison of Short Forms and CATs suggests that CATs have better ability to detect change compared to short forms. We also illustrate this method using an individual's probability of change at different time points.

CONCLUSION

Plausible values offer a flexible way to include measurement error in analysis of individuals and on sample level. Assessment of probability of true change can complement existing distribution-based approaches and facilitates interpretation of improvement or decline.

Norms and T-scores for screeners of alcohol use, depression and anxiety in the population of Suriname

Background

There is a considerable gap between care provision and the demand for care for common mental disorders in low-and-middle-income countries. Screening for these disorders, e.g., in primary care, will help to close this gap. However, appropriate norms and threshold values for screeners of common mental disorders are lacking.

Methods

In a survey study, we gathered data on frequently used screeners for alcohol use disorders, (AUDIT), depression, (CES-D), and anxiety disorders (GAD-7, ACQ, and BSQ) in a representative sample from Suriname, a non-Latin American Caribbean country. A stratified sampling method was used by random selection of 2,863 respondents from 5 rural and 12 urban resorts. We established descriptive statistics of all scale scores and investigated unidimensionality. Furthermore, we compared scores by gender, age-group, and education level with t-test and Mann-Whitney U tests, using a significance level of p < 0.05.

Results

Norms and crosswalk tables were established for the conversion of raw scores into a common metric: T-scores. Furthermore, recommended cut-off values on the T-score metric for severity levels were compared with international cut-off values for raw scores on these screeners.

Discussion

The appropriateness of these cut-offs and the value of converting raw scores into T-scores are discussed. Cut-off values help with screening and early detection of those who are likely to have a common mental health disorder and may require treatment. Conversion of raw scores to a common metric in this study facilitates the interpretation of questionnaire results for clinicians and can improve health care provision through measurement-based care.

Systems Medicine Approach for Tinnitus with Comorbid Disorders

Despite the fact that chronic diseases usually occur together with a spectrum of possible comorbidities that may differ strongly between patients, they are classically still viewed as distinct disease entities and, consequently, are often treated with uniform therapies. Unfortunately, such an approach does not take into account that different combinations of symptoms and comorbidities may result from different pathological (e.g., environmental, genetic, dietary, etc.) factors, which require specific and individualised therapeutic strategies. In this opinion paper, we aim to put forward a more differentiated, systems medicine approach to disease and patient treatment. To elaborate on this concept, we focus on the interplay of tinnitus, depression, and chronic pain. In our view, these conditions can be characterised by a variety of phenotypes composed of variable sets of symptoms and biomarkers, rather than distinct disease entities. The knowledge of the interplay of such symptoms and biomarkers will provide the key to a deeper, mechanistic understanding of disease pathologies. This paves the way for prediction and prevention of disease pathways, including more personalised and effective treatment strategies.

Common measures or common metrics? A plea to harmonize measurement results

OBJECTIVE

There is a great variety of measurement instruments to assess similar constructs in clinical research and practice. This complicates the interpretation of test results and hampers the implementation of measurement-based care.

METHOD

For reporting and discussing test results with patients, we suggest converting test results into universally applicable common metrics. Two well-established metrics are reviewed: T scores and percentile ranks. Their calculation is explained, their merits and drawbacks are discussed, and recommendations for the most convenient reference group are provided.

RESULTS

We propose to express test results as T scores with the general population as reference group. To elucidate test results to patients, T scores may be supplemented with percentile ranks, based on data from a clinical sample. The practical benefits are demonstrated using the published data of four frequently used instruments for measuring depression: the CES-D, PHQ-9, BDI-II and the PROMIS depression measure.

DISCUSSION

Recent initiatives have proposed to mandate a limited set of outcome measures to harmonize clinical measurement. However, the selected instruments are not without flaws and, potentially, this directive may hamper future instrument development. We recommend using common metrics as an alternative approach to harmonize test results in clinical practice, as this will facilitate the integration of measures in day-to-day practice.

Durability of the Treatment Effects of an 8-Week Self-administered Home-Based Virtual Reality Program for Chronic Low Back Pain: Follow-up Study of a Randomized Clinical Trial

Background

We previously reported the efficacy of an 8-week home-based therapeutic immersive virtual reality (VR) program in a double-blind randomized placebo-controlled study. Community-based adults with self-reported chronic low back pain were randomized 1:1 to receive either (1) a 56-day immersive therapeutic pain relief skills VR program (EaseVRx) or (2) a 56-day sham VR program. Immediate posttreatment results revealed the superiority of therapeutic VR over sham VR for reducing pain intensity; pain-related interference with activity, mood, and stress (but not sleep); physical function; and sleep disturbance. At 3 months posttreatment, therapeutic VR maintained superiority for reducing pain intensity and pain-related interference with activity, stress, and sleep (new finding).

Objective

This study assessed between-group and within-group treatment effects 6 months posttreatment to determine the extended efficacy, magnitude of efficacy, and clinical importance of home-based therapeutic VR.

Methods

E-surveys were deployed at pretreatment, end-of-treatment, and posttreatment months 1, 2, 3, and 6. Self-reported data for 188 participants were analyzed in a mixed-model framework using a marginal model to allow for correlated responses across the repeated measures. Primary outcomes were pain intensity and pain-related interference with activity, mood, stress, and sleep at 6 months posttreatment. Secondary outcomes were Patient-Reported Outcome Measurement Information System (PROMIS) sleep disturbance and physical function.

Results

Therapeutic VR maintained significant and clinically meaningful effects 6 months posttreatment and remained superior to sham VR for reducing pain intensity and pain-related interference with activity, stress, and sleep (d_s=0.44-0.54; P<.003). Between-group comparisons for physical function and sleep disturbance showed superiority of EaseVRx over sham VR (d_s=0.34; P=.02 and d_s=0.46; P<.001, respectively). Participants were encouraged to contact study staff with any problems experienced during treatment; however, no participants contacted study staff to report adverse events of any type, including nausea and motion sickness.

Conclusions

Our 8-week home-based VR pain management program caused important reductions in pain intensity and interference up to 6 months after treatment. Additional studies are needed in diverse samples.

Trial Registration

ClinicalTrials.gov NCT04415177; https://clinicaltrials.gov/ct2/show/NCT04415177

International Registered Report Identifier (IRRID)

RR2-10.2196/25291

Treating random effects as observed versus latent predictors: The bias-variance tradeoff in small samples

Random effects in longitudinal multilevel models represent individuals' deviations from population means and are indicators of individual differences. Researchers are often interested in examining how these random effects predict outcome variables that vary across individuals. This can be done via a two-step approach in which empirical Bayes (EB) estimates of the random effects are extracted and then treated as observed predictor variables in follow-up regression analyses. This approach ignores the unreliability of EB estimates, leading to underestimation of regression coefficients. As such, previous studies have recommended a multilevel structural equation modeling (ML-SEM) approach that treats random effects as latent variables. The current study uses simulation and empirical data to show that a bias-variance tradeoff exists when selecting between the two approaches. ML-SEM produces generally unbiased regression coefficient estimates but also larger standard errors, which can lead to lower power than the two-step approach. Implications of the results for model selection and alternative solutions are discussed.

Three-Month Follow-Up Results of a Double-Blind, Randomized Placebo-Controlled Trial of 8-Week Self-Administered At-Home Behavioral Skills-Based Virtual Reality (VR) for Chronic Low Back Pain

Prior work established post-treatment efficacy for an 8-week home-based therapeutic virtual reality (VR) program in a double-blind, parallel arm, randomized placebo-controlled study. Participants were randomized 1:1 to 1 of 2 56-day VR programs: 1) a therapeutic immersive pain relief skills VR program; or 2) a Sham VR program within an identical commercial VR headset. Immediate post-treatment results demonstrated clinically meaningful and superior reduction for therapeutic VR compared to Sham VR for average pain intensity, indices of pain-related interference (activity, mood, stress but not sleep), physical function, and sleep disturbance. The objective of the current report was to quantify treatment effects to post-treatment month 3 and describe durability of effects. Intention-to-treat analyses revealed sustained benefits for both groups and superiority for therapeutic VR for pain intensity and multiple indices of pain-related interference (activity, stress, and newly for sleep; effect sizes ranged from d_rm = .56-.88) and physical function from pre-treatment to post-treatment month 3. The between-group difference for sleep disturbance was non-significant and pain-interference with mood did not survive multiplicity correction at 3 months. For most primary and secondary outcomes, treatment effects for therapeutic VR showed durability, and maintained superiority to Sham VR in the 3-month post-treatment period. PERSPECTIVE: We present 3-month follow-up results for 8-week self-administered therapeutic virtual reality (VR) compared to Sham VR in adults with chronic low back pain. Across multiple pain indices, therapeutic VR had clinically meaningful benefits, and superiority over Sham VR. Home-based, behavioral skills VR yielded enduring analgesic benefits; longer follow-up is needed.

Efficacy of a Single-Session "Empowered Relief" Zoom-Delivered Group Intervention for Chronic Pain: Randomized Controlled Trial Conducted During the COVID-19 Pandemic

BACKGROUND

Cognitive behavioral therapy-pain is an evidence-based treatment for chronic pain that can have significant patient burden, including health care cost, travel, multiple sessions, and lack of access in remote areas.

OBJECTIVE

The study aims to pilot test the efficacy of a single-session videoconference-delivered empowered relief (ER) intervention compared to waitlist control (WLC) conditions among individuals with chronic pain. We hypothesized that ER would be superior to WLC in reducing pain catastrophizing, pain intensity, and other pain-related outcomes at 1-3 months posttreatment.

METHODS

We conducted a randomized controlled trial involving a web-based sample of adults (N=104) aged 18-80 years with self-reported chronic pain. Participants were randomized (1:1) to 1 of 2 unblinded study groups: ER (50/104, 48.1%) and WLC (54/104, 51.9%). Participants allocated to ER completed a Zoom-delivered class, and all participants completed follow-up surveys at 2 weeks and 1, 2, and 3 months posttreatment. All the study procedures were performed remotely and electronically. The primary outcome was pain catastrophizing 1-month posttreatment, with pain intensity, pain bothersomeness, and sleep disruption as secondary outcomes. We also report a more rigorous test of the durability of treatment effects at 3 months posttreatment. Data were collected from September 2020 to February 2021 and analyzed using intention-to-treat analysis. The analytic data set included participants (18/101, 17.8% clinic patients; 83/101, 82.1% community) who completed at least one study survey: ER (50/101, 49.5%) and WLC (51/104, 49%).

RESULTS

Participants (N=101) were 69.3% (70/101) female, with a mean age of 49.76 years (SD 13.90; range 24-78); 32.7% (33/101) had an undergraduate degree and self-reported chronic pain for 3 months. Participants reported high engagement (47/50, 94%), high satisfaction with ER (mean 8.26, SD 1.57; range 0-10), and high satisfaction with the Zoom platform (46/50, 92%). For the between-groups factor, ER was superior to WLC for all primary and secondary outcomes at 3 months posttreatment (highest P<.001), and between-groups Cohen d effect sizes ranged from 0.45 to 0.79, indicating that the superiority was of moderate to substantial clinical importance. At 3 months, clinically meaningful pain catastrophizing scale (PCS) reductions were found for ER but not for WLC (ER: PCS -8.72, 42.25% reduction; WLC: PCS -2.25, 11.13% reduction). ER resulted in significant improvements in pain intensity, sleep disturbance, and clinical improvements in pain bothersomeness.

CONCLUSIONS

Zoom-delivered ER had high participant satisfaction and very high engagement. Among adults with chronic pain, this single-session, Zoom-delivered, skills-based pain class resulted in clinically significant improvement across a range of pain-related outcomes that was sustained at 3 months. Web-based delivery of ER could allow greater accessibility of home-based pain treatment and could address the inconveniences and barriers faced by patients when attempting to receive in-person care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04546685; https://clinicaltrials.gov/ct2/show/NCT04546685.

Solving the Tower of Babel Problem for Patient-Reported Outcome Measures : Comments on: Linking Scores with Patient-Reported Health Outcome Instruments: A Validation Study and Comparison of Three Linking Methods

The PROsetta Stone Project, summarized in this issue by Schalet et al. (Psychometrika 86, 2021), is a major step forward in enabling comparability between different patient-reported outcomes measures. Schalet et al. clearly describe the psychometric methods used in the PROsetta Stone project and other projects from the Patient-Reported Outcomes Measurement Information System (PROMIS): linking based on unidimensional item response theory (IRT), equipercentile linking, and calibrated projection based on multidimensional IRT. Analyses in a validation data set and simulation studies provide strong support that the linking methods are robust when basic assumptions are fulfilled. The links already established will be of great value to the field, and the methodology described by Schalet et al. will hopefully inspire the next series of linking studies. Among potential improvements that should be considered by new studies are: (1) a thorough evaluation of the content of the measures to be linked to better guide the evaluation of measurement assumptions, (2) improvements in the design of linking studies such as selection of the optimal sample to provide data in the score ranges where linking precision is most critical and using counterbalanced designs to control for order effects. Finally, it may be useful to consider how the linking algorithms are used in subsequent data analyses. Analytic strategies based on plausible values or latent regression IRT models may be preferable to the simple transformation of scores from one patient at the time.

Linking Scores with Patient-Reported Health Outcome Instruments:A VALIDATION STUDY AND COMPARISON OF THREE LINKING METHODS

The psychometric process used to establish a relationship between the scores of two (or more) instruments is generically referred to as linking. When two instruments with the same content and statistical test specifications are linked, these instruments are said to be equated. Linking and equating procedures have long been used for practical benefit in educational testing. In recent years, health outcome researchers have increasingly applied linking techniques to patient-reported outcome (PRO) data. However, these applications have some noteworthy purposes and associated methodological questions. Purposes for linking health outcomes include the harmonization of data across studies or settings (enabling increased power in hypothesis testing), the aggregation of summed score data by means of score crosswalk tables, and score conversion in clinical settings where new instruments are introduced, but an interpretable connection to historical data is needed. When two PRO instruments are linked, assumptions for equating are typically not met and the extent to which those assumptions are violated becomes a decision point around how (and whether) to proceed with linking. We demonstrate multiple linking procedures-equipercentile, unidimensional IRT calibration, and calibrated projection-with the Patient-Reported Outcomes Measurement Information System Depression bank and the Patient Health Questionnaire-9. We validate this link across two samples and simulate different instrument correlation levels to provide guidance around which linking method is preferred. Finally, we discuss some remaining issues and directions for psychometric research in linking PRO instruments.

An 8-Week Self-Administered At-Home Behavioral Skills-Based Virtual Reality Program for Chronic Low Back Pain: Double-Blind, Randomized, Placebo-Controlled Trial Conducted During COVID-19

BACKGROUND

Chronic low back pain is the most prevalent chronic pain condition worldwide and access to behavioral pain treatment is limited. Virtual reality (VR) is an immersive technology that may provide effective behavioral therapeutics for chronic pain.

OBJECTIVE

We aimed to conduct a double-blind, parallel-arm, single-cohort, remote, randomized placebo-controlled trial for a self-administered behavioral skills-based VR program in community-based individuals with self-reported chronic low back pain during the COVID-19 pandemic.

METHODS

A national online convenience sample of individuals with self-reported nonmalignant low back pain with duration of 6 months or more and with average pain intensity of 4 or more/10 was enrolled and randomized 1:1 to 1 of 2 daily (56-day) VR programs: (1) EaseVRx (immersive pain relief skills VR program); or (2) Sham VR (2D nature content delivered in a VR headset). Objective device use data and self-reported data were collected. The primary outcomes were the between-group effect of EaseVRx versus Sham VR across time points, and the between-within interaction effect representing the change in average pain intensity and pain-related interference with activity, stress, mood, and sleep over time (baseline to end-of-treatment at day 56). Secondary outcomes were global impression of change and change in physical function, sleep disturbance, pain self-efficacy, pain catastrophizing, pain acceptance, pain medication use, and user satisfaction. Analytic methods included intention-to-treat and a mixed-model framework.

RESULTS

The study sample was 179 adults (female: 76.5%, 137/179; Caucasian: 90.5%, 162/179; at least some college education: 91.1%, 163/179; mean age: 51.5 years [SD 13.1]; average pain intensity: 5/10 [SD 1.2]; back pain duration ≥5 years: 67%, 120/179). No group differences were found for any baseline variable or treatment engagement. User satisfaction ratings were higher for EaseVRx versus Sham VR (P<.001). For the between-groups factor, EaseVRx was superior to Sham VR for all primary outcomes (highest P value=.009), and between-groups Cohen d effect sizes ranged from 0.40 to 0.49, indicating superiority was moderately clinically meaningful. For EaseVRx, large pre-post effect sizes ranged from 1.17 to 1.3 and met moderate to substantial clinical importance for reduced pain intensity and pain-related interference with activity, mood, and stress. Between-group comparisons for Physical Function and Sleep Disturbance showed superiority for the EaseVRx group versus the Sham VR group (P=.022 and .013, respectively). Pain catastrophizing, pain self-efficacy, pain acceptance, prescription opioid use (morphine milligram equivalent) did not reach statistical significance for either group. Use of over-the-counter analgesic use was reduced for EaseVRx (P<.01) but not for Sham VR.

CONCLUSIONS

EaseVRx had high user satisfaction and superior and clinically meaningful symptom reduction for average pain intensity and pain-related interference with activity, mood, and stress compared to sham VR. Additional research is needed to determine durability of treatment effects and to characterize mechanisms of treatment effects. Home-based VR may expand access to effective and on-demand nonpharmacologic treatment for chronic low back pain.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04415177; https://clinicaltrials.gov/ct2/show/NCT04415177.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/25291.

Self-Administered Behavioral Skills-Based At-Home Virtual Reality Therapy for Chronic Low Back Pain: Protocol for a Randomized Controlled Trial

BACKGROUND

Chronic pain is one of the most common and debilitating health conditions. Treatments for chronic low back pain typically focus on biomedical treatment approaches. While psychosocial treatments exist, multiple barriers prevent broad access. There is a significant unmet need for integrative, easily accessible, non-opioid solutions for chronic pain. Virtual reality (VR) is an immersive technology allowing innovation in the delivery of behavioral pain treatments. Behavioral skills-based VR is effective at facilitating pain management and reducing pain-related concerns. Continued research on these emerging approaches is needed.

OBJECTIVE

In this randomized controlled trial, we seek to test the efficacy of a self-administered behavioral skills-based VR program as a nonpharmacological home-based pain management treatment for people with chronic low back pain (cLBP).

METHODS

We will randomize 180 individuals with cLBP to 1 of 2 VR programs: (1) EaseVRx (8-week skills-based VR program); or (2) Sham VR (control condition). All participants will receive a VR headset to minimize any biases related to the technology's novelty. The Sham VR group had 2D neutral content in a 3D theater-like environment. Our primary outcome is average pain intensity and pain-related interference with activity, stress, mood, and sleep. Our secondary outcomes include patient-reported physical function, sleep disturbance, pain self-efficacy, pain catastrophizing, pain acceptance, health utilization, medication use, and user satisfaction. We hypothesize superiority for the skills-based VR program in all of these measures compared to the control condition. Team statisticians blinded to treatment assignment will assess outcomes up to 6 months posttreatment using an approach suitable for the longitudinal nature of the data.

RESULTS

The study was approved by the Western Institutional Review Board on July 2, 2020. The protocol (NCT04415177) was registered on May 27, 2020. Recruitment for this study was completed in July 2020, and data collection will remain active until March 2021. In total, 186 participants were recruited. Multiple manuscripts will be generated from this study. The primary manuscript will be submitted for publication in the winter of 2020.

CONCLUSIONS

Effectively delivering behavioral treatments in VR could overcome barriers to care and provide scalable solutions to chronic pain's societal burden. Our study could help shape future research and development of these innovative approaches.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04415177; https://clinicaltrials.gov/ct2/show/NCT04415177.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/25291.

Imaging suicidal thoughts and behaviors: a comprehensive review of 2 decades of neuroimaging studies

Identifying brain alterations that contribute to suicidal thoughts and behaviors (STBs) are important to develop more targeted and effective strategies to prevent suicide. In the last decade, and especially in the last 5 years, there has been exponential growth in the number of neuroimaging studies reporting structural and functional brain circuitry correlates of STBs. Within this narrative review, we conducted a comprehensive review of neuroimaging studies of STBs published to date and summarize the progress achieved on elucidating neurobiological substrates of STBs, with a focus on converging findings across studies. We review neuroimaging evidence across differing mental disorders for structural, functional, and molecular alterations in association with STBs, which converges particularly in regions of brain systems that subserve emotion and impulse regulation including the ventral prefrontal cortex (VPFC) and dorsal PFC (DPFC), insula and their mesial temporal, striatal and posterior connection sites, as well as in the connections between these brain areas. The reviewed literature suggests that impairments in medial and lateral VPFC regions and their connections may be important in the excessive negative and blunted positive internal states that can stimulate suicidal ideation, and that impairments in a DPFC and inferior frontal gyrus (IFG) system may be important in suicide attempt behaviors. A combination of VPFC and DPFC system disturbances may lead to very high risk circumstances in which suicidal ideation is converted to lethal actions via decreased top-down inhibition of behavior and/or maladaptive, inflexible decision-making and planning. The dorsal anterior cingulate cortex and insula may play important roles in switching between these VPFC and DPFC systems, which may contribute to the transition from suicide thoughts to behaviors. Future neuroimaging research of larger sample sizes, including global efforts, longitudinal designs, and careful consideration of developmental stages, and sex and gender, will facilitate more effectively targeted preventions and interventions to reduce loss of life to suicide.

Measuring fatigue in cancer patients: a common metric for six fatigue instruments

PURPOSE

Fatigue is one of the most disabling symptoms in cancer patients. Many instruments exist to measure fatigue. This variety impedes the comparison of data across studies or to the general population. We aimed to estimate a common metric based on six different fatigue instruments (EORTC QLQ-C30 subscale fatigue, EORTC QLQ-FA12, MFI subscale General Fatigue, BFI, Fatigue Scale, and Fatigue Diagnostic Interview Guide) to convert the patients' scores from one of the instruments to another. Additionally, we linked the common metric to the general population.

METHODS

For n = 1225 cancer patients, the common metric was estimated using the Item Response Theory framework. The linking between the common metric of the patients and the general population was estimated using linear regression.

RESULTS

The common metric was based on a model with acceptable fit (CFI = 0.94, SRMR = 0.06). Based on the standard error of measurement the reliability coefficients of the questionnaires ranged from 0.80 to 0.95. The common metric of the six questionnaires, also linked to the general population, is reported graphically and in supplementary crosswalk tables.

CONCLUSIONS

Our study enables researchers and clinicians to directly compare results across studies using different fatigue questionnaires and to assess the degree of fatigue with respect to the general population.