Construct Validity of Pediatric PROMIS Computerized Adaptive Testing Measures in Children With Adolescent Idiopathic Scoliosis

Psychometric analysis and the implications for the use of the scoliosis research society questionnaire (SRS-22r English) for individuals with adolescent idiopathic scoliosis

Background

Despite widespread usage of the SRS-22r questionnaire (Scoliosis Research Society Questionnaire-22r), the English version has only sparingly been subjected to analysis using modern psychometric techniques for patients with adolescent idiopathic scoliosis (AIS). The study purpose was to improve interpretation and clinical utility of the SRS-22r for adolescents with AIS by generating additional robust evidence, using modern statistical techniques. Questions about (1) Structure and (2) Item and Scale Functioning are addressed and interpreted for clinicians and researchers.

Methods

This retrospective case review analyzed SRS-22r data collected from 1823 patients (mean age 14.9±2.2years) with a primary diagnosis of AIS who clinically completed an SRS-22r questionnaire.Individual SRS-22r questions and domain scores were retrieved through data queries. Patient information collected through chart review included diagnosis, age at assessment, sex, race and radiographic parameters. From 6044 SRS-22r assessments, 1 assessment per patient was randomly selected. Exploratory structural equation modeling (ESEM) and item response theory (IRT) techniques were used for data modeling, item calibration, and reliability assessment.

Results

ESEM demonstrated acceptable fit to the data: χ2 (130)=343.73, p<.001; RMSEA=0.035; CFI=0.98; TLI=0.96; SRMR=0.02. Several items failed to adequately load onto their assigned factor. Item fit was adequate for all items except SRSq10 (Self-Image), SRSq16 (Mental Health), and SRSq20 (Mental Health). IRT models found item discriminations are within normal levels for items in psychological measures, except items SRSq1 (pain), SRSq2 (pain), and SRSq16 (mental health). Estimated reliability of the Function domain (ρ=0.69) was low, however, Pain, Self-Image and Mental Health domains exhibited high (ρ>0.80) reliability.

Conclusions

Modern psychometric assessment of the SRS-22r, in adolescent patients with AIS, are presented and interpreted to assist clinicians and researchers in understanding its strengths and limitations. Overall, the SRS-22r demonstrated good psychometric properties in all domains except function. Cautious interpretation of the total score is suggested, as it does not reflect a single HRQoL construct.

Concurrent Validity of PROMIS and LD-SRS Scores in Pediatric Patients With Lower Limb Differences

BACKGROUND

We sought to assess the concurrent validity of select Patient Reported Outcomes Measurement Information System (PROMIS) domains and Limb Deformity-Scoliosis Research Society (LD-SRS) scores.

METHODS

We prospectively administered PROMIS - 25 (including anxiety, depression, fatigue, pain interference, peer relationships, and physical function) and LD-SRS questionnaires to 46 consecutive pediatric patients with lower limb differences, presenting to a single surgeon for reconstruction. Concurrent validity between various subdomains of the 2 outcome measures was assessed through Pearson's correlation, with significance defined as P <0.05. The strength of correlation was interpreted by Evans criteria: absolute r value <0.20 indicating very weak correlation; 0.20 to 0.39, weak; 0.40 to 0.59, moderate; 0.60 to 0.79, strong; and 0.8 or greater indicating very strong correlation.

RESULTS

The LD-SRS Pain, Function, and Mental Health domains most strongly correlated with the PROMIS pain interference ( r =-0.79, P <0.001), physical function ( r =0.74, P <0.001), and anxiety ( r =-0.68, P <0.001) domains, respectively. In addition, LD-SRS pain strongly correlated with PROMIS physical function ( r =0.61, P <0.001) and LD-SRS function with PROMIS pain interference ( r =-0.72, P <0.001). All PROMIS domains significantly correlated with total LD-SRS scores. PROMIS pain interference ( r =-0.79, P <0.001), physical function ( r =0.67, P <0.001), and fatigue ( r =-0.60, P <0.001) domains demonstrated the strongest correlations with the total LD-SRS score.

CONCLUSIONS

The significant concurrent validity between LD-SRS and multiple PROMIS domains suggests considerable overlap, and perhaps redundancy, between these 2 outcome measures. Given the high degree of concordance and the advantage of computer adaptive testing (CAT) in mitigating administrative burden and survey fatigue, along with the ability to compare outcomes across a wider group of children with a variety of underlying diagnoses, select PROMIS domains may be a viable alternative to LD-SRS score for assessing patient-reported outcomes when treating pediatric patients with lower limb deformities. A larger, multi-center study including pediatric patients with lower limb differences from a diverse background, including age, etiology, native language, and ethnicity, would be helpful to externally validate our findings.

LEVEL OF EVIDENCE

Level-I.

Back pain and disability according to early onset scoliosis etiology in children younger than 10 years

PURPOSE

To determine caregiver-reported back pain prevalence, disability, pain interference, and associations with curve magnitude in early onset scoliosis (EOS) using the Oswestry Disability Index (ODI) and Patient Reported Outcome Measurement Information Systems (PROMIS) measures.

METHODS

A single-center, retrospective review was performed in children below 10 years of age according to EOS etiology. Caregiver-reported back pain prevalence, ODI, PROMIS Pain Interference, Mobility, and Anxiety measures, and curve magnitude were recorded as part of routine clinic appointments.

RESULTS

A total of 1212 patients with EOS (588 idiopathic, 295 congenital, 217 neuromuscular, 112 syndromic) ages 6.6 ± 2.7 were included; 23% had caregiver-reported back pain. Neuromuscular EOS patients had the highest prevalence of back pain (29%). ODI scores were higher in neuromuscular (48%) and syndromic (35%) patients than congenital (20%, p < 0.05) and idiopathic (16%, p < 0.01) patients. Neuromuscular patients also had higher PROMIS Pain Interference scores (53.3) compared to idiopathic (41.6, p < 0.001) and syndromic (45.0, p = 0.016) patients. A higher curve was associated with the presence of back pain (39° vs. 30°, p < 0.001) and had positive correlations with ODI scores (r = 0.38, p < 0.001) and PROMIS Pain Interference scores (r = 0.34, p < 0.001).

CONCLUSION

Approximately one in five children with EOS under the age of 10 have caregiver-reported back pain, with the neuromuscular EOS type exhibiting higher pain prevalence, interference, and disability scores. Larger curve magnitude is associated with an increased prevalence of caregiver-reported back pain, increased disability, and increased pain interference.

LEVEL OF EVIDENCE

3 - case-control study.

Clinical outcomes measurement in pediatric lower limb prosthetics: A scoping review

OBJECTIVE

This study aimed to identify clinical measures that have been used to evaluate function, health related quality of life (HRQoL), and/or satisfaction in children who use lower limb prostheses (LLP). The data reported on psychometric properties for children who use LLP were collected for each measure.

METHODS

First, PubMed, CINAHL, and Web of Science databases were searched using broad search terms to identify standardized outcome measures of function, HRQoL, and/or satisfaction with treatment used in pediatric LLP research published in 2001 or after. For each of the eligible measures found, a second search was performed to identify psychometric properties (e.g., validity, reliability) assessed with children who use LLP.

RESULTS

Forty-four standardized outcome measures were identified from 41 pediatric LLP research articles. Five measures (i.e., Gait Outcomes Assessment for Lower Limb Differences, Functional Mobility Assessment, Child Amputee Prosthetics Project- Prosthesis Satisfaction Inventory, Child Amputee Prosthetics Project- Functional Scale Index, and Lower Limb Function Questionnaire) had data on psychometric properties for children who use LLP.

CONCLUSIONS

Few studies report psychometric data for assessing the overall HRQoL, function, and/or satisfaction for children who use LLP. Further research is needed to validate or create new outcome measures that assess the HRQoL, satisfaction, and/or function of children who use LLP.

Exploring Correlations Between Pain and Deformity in Idiopathic Scoliosis With Validated Self-reported Pain Scores, Radiographic Measurements, and Trunk Surface Topographic Measurements

BACKGROUND

Up to 75% of patients with idiopathic scoliosis (IS) report back pain, but the exact contributors are unclear. This study seeks to assess how pain correlates with demographics, radiographic and surface topographic (ST) measurements, and patient-reported outcome measures (PROMs) in patients with IS.

METHODS

Patient-Reported Outcome Measurement Information System (PROMIS) Pain Interference (PI) and Scoliosis Research Society revised (SRS-22r) pain domain from an IRB approved prospectively collected registry containing patients 11 to 21 years old with IS were correlated (Spearman coefficients) with measurements from whole-body EOS radiography and ST scanning, PROMIS 1.0 PROMs, Trunk Appearance Perception Scale (TAPS), and SRS-22r domains. SRS-22r and PROMIS-PI were also compared between different sex, scoliosis severities, and primary curve locations with Mann-Whitney U or Kruskal-Wallis tests, and if significant differences were found, included with the 5 highest univariate correlated variables into stepwise multivariate linear regression models ( P <0.05 to enter, P >0.1 to remove) predicting SRS-22r pain and PROMIS-PI.

RESULTS

One hundred and forty-nine patients (14.5 ± 2.0 y, body mass index 20.6 ± 4.1 kg/m 2 , 96 (64%) female, mean major coronal curve 40 ± 19 deg, range: 10 deg, 83 deg) reported mean PROMIS-PI of 42.2 ± 10.0 and SRS-22r pain of 4.4 ± 0.6. SRS-22r self-image was the most correlated variable with both SRS-22r pain (rho=0.519) and PROMIS-PI (rho=-0.594). Five variables, none of which were ST or radiographic measures, strongly predicted SRS pain domain (R=0.711, R2=0.505, N=138). Two variables (SRS-22r self-image and SRS-22r function) were utilized by a model correlated with PROMIS-PI (R=0.687, R2=0.463, N=124).

CONCLUSIONS

SRS-22r function and self-image domains were more strongly correlated with SRS-22r pain and PROMIS-PI than any radiographic or ST measurements.

LEVEL OF EVIDENCE

Level II-retrospective study.

Time to Completion of Pediatric PROMIS Computerized Adaptive Testing Measures and the SRS-22r in an Adolescent Idiopathic Scoliosis Population

BACKGROUND

Patient-reported outcome measures are useful tools to quantify patients' pre-treatment and post-treatment symptoms. Historically used "legacy measures", such as the Scoliosis Research Society-22 revised questionnaire (SRS-22r), are often disease-specific and can be time-intensive. Recently developed Patient-Reported Outcomes Measurement Information System (PROMIS) computerized adaptive testing (CAT) measures may reduce administrative burdens and permit more efficient outcome collection within clinic workflows. In an era of medicine where payments are becoming tied to outcomes, we sought to assess the time to completion (TTC) of 8 pediatric PROMIS CAT measures and the SRS-22r in adolescents with idiopathic scoliosis.

MATERIALS AND METHODS

Patients presenting to a large, urban tertiary referral hospital were prospectively enrolled into the study. Subjects were first-time survey respondents in various phases and types of treatment for adolescent idiopathic scoliosis. In total, 200 patients ranging from 10 to 17 years old completed 8 Pediatric PROMIS CATs and the SRS-22r. PROMIS CATs administered include Physical Activity, Mobility, Anxiety, Depressive symptoms, Peer Relationships, Physical Stress Experiences, Pain Behavior and Pain Interference. TTC was calculated using start and stop timestamps in the REDCap software.

RESULTS

The mean (±SD) TTC for each PROMIS CAT was 1.1 (±0.9) minutes with physical activity, mobility, anxiety, depressive symptoms, peer relationships, physical stress experiences, pain behavior, and pain interference taking 1.2, 1.4, 1.0, 0.9, 1.2, 1.0, 1.0, and 1.2 minutes on average to complete, respectively. Mean TTC for the SRS-22r was 5.2 (±3.0) minutes.

CONCLUSIONS

In this pediatric orthopaedic cohort, completion of 8 PROMIS CATs demonstrated minimal test-taker burden and time required for completion. These findings support rapid and easily integrable PROMIS CATs in clinical practice to aid in increased delivery of efficient, patient-centered care.

LEVEL OF EVIDENCE

III, cross-sectional study.