Can Patient-Reported Outcomes Measurement Information System® (PROMIS) measures accurately enhance understanding of acceptable symptoms and functioning in primary care?

Patient-reported outcome and experience domains for diagnostic excellence: a scoping review to inform future measure development

PURPOSE

"Diagnostic excellence," as a relatively new construct centered on the diagnostic process and its health-related outcomes, can be refined by patient reporting and its measurement. We aimed to explore the scope of patient-reported outcome (PRO) and patient-reported experience (PRE) domains that are diagnostically relevant, regardless of the future diagnosed condition, and to review the state of measurement of these patient-reported domains.

METHODS

We conducted an exploratory analysis to identify these domains by employing a scoping review supplemented with internal expert consultations, 24-member international expert convening, additional environmental scans, and the validation of the domains' diagnostic relevance via mapping these onto patient diagnostic journeys. We created a narrative bibliography of the domains illustrating them with existing measurement examples.

RESULTS

We identified 41 diagnostically relevant PRO and PRE domains. We classified 10 domains as PRO, 28 as PRE, and three as mixed PRO/PRE. Among these domains, 19 were captured in existing instruments, and 20 were captured only in qualitative studies. Two domains were conceptualized during this exploratory analysis with no examples identified of capturing these domains. For 27 domains, patients and care partners report on a specific encounter; for 14 domains, reporting relates to an entire diagnostic journey over time, which presents particular measurement opportunities and challenges.

CONCLUSION

The multitude of PRO and PRE domains, if measured rigorously, would allow the diagnostic excellence construct to evolve further and in a manner that is patient-centered, prospectively focused, and concentrates on effectiveness and efficiency of diagnostic care on patients' well-being.

ICON 2020-International Scientific Tendinopathy Symposium Consensus: the development of a core outcome set for gluteal tendinopathy

Gluteal tendinopathy (GT) is common and can be debilitating and challenging to manage. A lack of condition specific and appropriate outcome measures compromise evidence synthesis for treatment and limits clinical guideline development. Our objective was to develop a core outcome measurement set for GT (COS-GT). Participants were patients with GT and expert health professionals (HPs). A scoping review identified measures used in GT research, which were mapped to the nine International Scientific Tendinopathy Symposium Consensus core domains, and included in two surveys of HPs. The first survey identified the feasible and true measures for each domain. The second survey refined the list which a patient focus group then considered. Meeting online, HPs reached consensus (agreement ≥70%) on the most appropriate COS-GT measures. 34 HPs and seven patients were recruited. 57 measures were mapped to the nine core domains. Six measures did not proceed past survey one. Of those that progressed, none had adequate clinimetric properties for a COS-GT. Thus, participants decided on interim measures: the global rating of change, pain at night, time to pain onset with single limb stance, pain with stair walking, pain self-efficacy and hip abduction strength. HP participants additionally recommended that pain over the last week, the European Quality of Life-5 dimensions-5 levels and the Victorian Institute of Sport Assessment-Gluteal be considered in clinical trials, as they currently provide best easures of the relevant tendinopathy domains. In conclusion this interim COS-GT should guide outcome measure selection in clinical practice and future research trials in patients with GT.

PROMIS-25 Reliability and Validity Among Children Living with Burn Injury: A Burn Model System National Database Study

This study examined the reliability and validity of the Patient Reported Outcomes Measurement System (PROMIS)-25, a profile instrument consisting of four-item fixed short forms for six health domains, in children living with burn injury. Data were provided by children participating in a multi-center longitudinal study of outcomes after burn injury. Floor and ceiling effects, unidimensionality, internal consistency, reliability, and differential item functioning (DIF) of the PROMIS-25 Profile v.2.0 were examined. Correlations with other established measures were calculated to assess concurrent validity. Children (n = 256) between the ages of 8-18 years with moderate to severe injury provided responses on PROMIS-25 domains. All PROMIS-25 domains showed high internal consistency. Substantial portions of the sample reported no symptoms (anxiety [58.2%], depressive symptoms [54.6%], fatigue [50.8%], pain [60.1%]). There was a large ceiling effect on peer relationships (46.8%) and physical function mobility (57.5%). One-factor confirmatory factor analyses supported unidimensionality for all domains. Reliability was sufficient for group mean comparisons (>0.8) across at least some trait levels for most domains except fatigue and anxiety. No DIF with respect to burn status was detected when comparing the burn sample to the PROMIS pediatric general U.S. population testing sample. These results provide evidence of reliability and validity of PROMIS-25 scores among children living with burn injury. Reliability of domains was low to moderate and would likely be improved, and ceiling effects reduced for some domains, by administering the PROMIS-37, which includes six items per domain.

Two-step screening for depressive symptoms in patients treated with kidney replacement therapies: a cross-sectional analysis

BACKGROUND

Systematic screening for depressive symptoms may identify patients who may benefit from clinical assessment and psychosocial support. Here we assess a two-step screening using ultrabrief pre-screeners [Edmonton Symptom Assessment Survey-revised Depression item (ESASr-D) or Patient Health Questionnaire-2 (PHQ-2)] followed by the Patient-Reported Outcomes Measurement Information System Depression questionnaire (PROMIS-D) to identify depressive symptoms in patients on kidney replacement therapies.

METHODS

We conducted a cross-sectional study of adults (kidney transplant recipients or treated with dialysis) in Toronto, ON, Canada. We simulated various two-step screening scenarios where only patients above a pre-screening cut-off score on the ESASr-D or PHQ-2 would move to step 2 (PROMIS-D). Screening performance was evaluated by sensitivity, specificity and positive and negative predictive values using the Patient Health Questionnaire-9 (PHQ-9) as the referent. The average number of items completed by patients in different scenarios was reported.

RESULTS

Of 480 participants, 60% were male with a mean age of 55 years. Based on PHQ-9, 19% of patients had moderate or severe depressive symptoms. Pre-screening with a PHQ-2 score ≥1 combined with a PROMIS-D score of ≥53 provided the best two-step results (sensitivity 0.81, specificity 0.84, NPV 0.95). Two-step screening also reduces question burden.

CONCLUSIONS

A two-step screening using a PHQ-2 score ≥1 followed by a PROMIS-D score ≥53 has good sensitivity and specificity for identifying potentially significant depressive symptoms among patients on kidney replacement therapies. This approach has lower question burden. Screened-in patients will need further clinical assessment to establish a diagnosis.

Self-Efficacy for Managing Injury After Distal Radius Fracture: A Mixed Methods Exploration

Self-efficacy for managing injury may contribute to variation in clients' support needs after distal radius fracture (DRF). This study aimed to (a) explore associations between self-efficacy for managing injury and self-reported health and (b) compare qualitative descriptions of the self-management process and outcome between high and low self-efficacy groups. In this cross-sectional convergent mixed methods study, 31 adults aged 45 to 72 with a unilateral DRF completed patient-reported outcome measures and a semi-structured interview 2 to 4 weeks after discontinuing full-time wrist immobilization. Higher self-efficacy was moderately associated with better physical, mental, and social health. The High-Self-Efficacy group described self-directed behaviors to manage injury sequelae and more confidence in their ability to use their injured hand. They also described less disruptive physical and emotional symptoms and fewer participation restrictions compared with the Low-Self-Efficacy group. Findings suggest that occupational therapy practitioners should assess and address self-efficacy for managing DRF sequelae to support recovery.

Disparities of Health Program Information Systems in Indonesia: A Cross-Sectional Indonesian Health Facility Research 2019

Although a recording and reporting format for health centers already exists for Indonesia's standard information system, numerous health applications still need to meet the needs of each program. Therefore, this study aimed to demonstrate the potential disparities in information systems in the application and data collection of health programs among Indonesian community health centers (CHCs) based on provinces and regions. This cross-sectional research used data from 9831 CHCs from the Health Facilities Research 2019 (RIFASKES). Significance was assessed using a chi-square test and analysis of variance (ANOVA). The number of applications was depicted on a map using the spmap command with STATA version 14. It showed that region 2, which represented Java and Bali, was the best, followed by regions 1, which comprised Sumatra Island and its surroundings, and 3, Nusa Tenggara. The highest mean, equaling that of Java, was discovered in three provinces of region 1, namely, Jambi, Lampung, and Bangka Belitung. Furthermore, Papua and West Papua had less than 60% for all types of data-storage programs. Hence, there is a disparity in the health information system in Indonesia by province and region. The results of this analysis recommend future improvement of the CHCs' information systems.

Utility of Patient-Reported Risk Factors for Identifying Advanced Chronic Kidney Disease Prior to Outpatient CT: Comparison With Recent ACR/NKF Consensus Criteria

Background: Practices vary for screening patients for risk of renal dysfunction before iodinated contrast media administration. A recent American College of Radiology/National Kidney Foundation (ACR/NKF) consensus statement provided streamlined screening criteria. Objective: To assess the yield of patient-reported risk factors for identifying eGFR <30 ml/min/1.73m² before outpatient CT. Methods: This retrospective study was performed at a health system that implemented an electronic screening form used by patients before outpatient CT encounters to report presence of dialysis, cancer-treating medications, kidney disease, prior kidney surgery, diabetes mellitus treated with medication, hypertensiontreated with medication, and multiple myeloma. Patients with any risk factor were required to undergo eGFR testing before CT. Of 44,708 patients completing the form from June 1, 2020 through February 28, 2021, 10,256 patients (5315 men, 4941 women; mean age, 66.8±11.9 years) underwent eGFR testing on date of CT. Multivariable regression analysis for predicting reduced eGFR was performed. Findings were compared with theoretical approach using ACR/NKF criteria. Results: Same-day testing yielded eGFR <30 mL/min/1.73m² in 1.4% (144/10,256) of patients. Only significant independent predictors of low eGFR were dialysis [odds ratio (OR)= 203.30], kidney disease (OR=12.55), and diabetes mellitus treated with medication (OR=2.44). If following ACR/NKF criteria [only kidney disease (defined as dialysis, kidney disease, or prior kidney surgery) as trigger for eGFR testing], patients requiring testing would have decreased by 89.6% from 10,256 to 1059, yield woul have increased to 7.1% (76/1059), and 47.2% (68/144) of patiens with low eGFR would have been missed. If following ACR/NKF criteria but considering diabetes mellitus as a required rather than optional criterion, patients requiring testing would have decreased by 77.1% to 2353, yield would have increased to 4.0% (95/2353), and 34.0% (49/144) with low eGFR would have been missed. Conclusion: Using patient-reported risk factors resulted in frequent eGFR testing but low yield of low eGFR. Commonly applied risk factors were not independently associated with low eGFR. Clinical Impact: Application of ACR/NKF criteria would substantially reduce eGFR testing, though miss patients with renal dysfunction. The statement should consider omitting kidney surgery as trigger for eGFR testing and treating diabetes mellitus as a required trigger.

Detecting the patient’s need for help with machine learning based on expressions

Background

Developing machine learning models to support health analytics requires increased understanding about statistical properties of self-rated expression statements used in health-related communication and decision making. To address this, our current research analyzes self-rated expression statements concerning the coronavirus COVID-19 epidemic and with a new methodology identifies how statistically significant differences between groups of respondents can be linked to machine learning results.

Methods

A quantitative cross-sectional study gathering the “need for help” ratings for twenty health-related expression statements concerning the coronavirus epidemic on an 11-point Likert scale, and nine answers about the person’s health and wellbeing, sex and age. The study involved online respondents between 30 May and 3 August 2020 recruited from Finnish patient and disabled people’s organizations, other health-related organizations and professionals, and educational institutions (n = 673). We propose and experimentally motivate a new methodology of influence analysis concerning machine learning to be applied for evaluating how machine learning results depend on and are influenced by various properties of the data which are identified with traditional statistical methods.

Results

We found statistically significant Kendall rank-correlations and high cosine similarity values between various health-related expression statement pairs concerning the “need for help” ratings and a background question pair. With tests of Wilcoxon rank-sum, Kruskal-Wallis and one-way analysis of variance (ANOVA) between groups we identified statistically significant rating differences for several health-related expression statements in respect to groupings based on the answer values of background questions, such as the ratings of suspecting to have the coronavirus infection and having it depending on the estimated health condition, quality of life and sex. Our new methodology enabled us to identify how statistically significant rating differences were linked to machine learning results thus helping to develop better human-understandable machine learning models.

Conclusions

The self-rated “need for help” concerning health-related expression statements differs statistically significantly depending on the person’s background information, such as his/her estimated health condition, quality of life and sex. With our new methodology statistically significant rating differences can be linked to machine learning results thus enabling to develop better machine learning to identify, interpret and address the patient’s needs for well-personalized care.

Are Patient Reported Outcome Measurement Information System scales responsive in patients attending physical therapy with foot and ankle diagnoses?

BACKGROUND

Patient-reported outcomes (PROs) have been used to provide insight into the patient experience while uncovering an opportunity to improve patient care. Current studies document responsiveness of outcomes using the Patient Reported Outcome Measurement Information System (PROMIS) for a variety of orthopedic problems but are not specific to a physical therapy interval of care.

PURPOSE

The main purpose of this study was to examine responsiveness of the PROMIS Physical Function (PF) and Pain Interference (PI) scales across an interval of care for physical therapy in patients with foot and ankle conditions.

METHODS

Adult records (299 records, averaged 45.1 ± 15.4 years; 61% female) were assessed. Comparisons between pre- and post-physical therapy intervals of care were evaluated using a repeated-measures ANOVA, and the effect size was reported using Cohen's d.

RESULTS

PROMIS PF scores significantly improved from 38.5 ± 8.8 to 45.2 ± 9.1 (6.6; p < .001; Cohen's d = 1.0). PROMIS PI scores significantly improved from 56.8 ± 8.8 to 53.0 ± 9.8 (-3.8; p < .001; Cohen's d = 0.52).

CONCLUSIONS

The person-centered PROMIS PF and PI outcome measures were responsive to change following an interval of care in physical therapy for a large sample of orthopedic patients with foot and ankle diagnoses. The magnitude of change was dependent on starting score and diagnosis.

Clinimetric Criteria for Patient-Reported Outcome Measures

Patient-reported outcome measures (PROMs) are self-rated scales and indices developed to improve the detection of the patients' subjective experience. Given that a considerable number of PROMs are available, it is important to evaluate their validity and usefulness in a specific research or clinical setting. Published guidelines, based on psychometric criteria, do not fit in with the complexity of clinical challenges, because of their quest for homogeneity of components and inadequate attention to sensitivity. Psychometric theory has stifled the field and led to the routine use of scales widely accepted yet with a history of poor performance. Clinimetrics, the science of clinical measurements, may provide a more suitable conceptual and methodological framework. The aims of this paper are to outline the major limitations of the psychometric model and to provide criteria for clinimetric patient-reported outcome measures (CLIPROMs). The characteristics related to reliability, sensitivity, validity, and clinical utility of instruments are critically reviewed, with particular reference to the differences between clinimetric and psychometric approaches. Of note is the fact that PROMs, rating scales, and indices developed according to psychometric criteria may display relevant clinimetric properties. The present paper underpins the importance of the clini-metric methodology in choosing the appropriate PROMs. CLIPROM criteria may also guide the development of new indices and the validation of existing PROMs to be employed in clinical settings.

Implementation of PROMIS® in an Optometry Clinic

PURPOSE

The full utility of general health Patient-Reported Outcomes Measurement Information System® (PROMIS) surveys in the eye care setting has not been previously demonstrated. This report demonstrates the feasibility of implementing PROMIS in an eye care clinic.

PATIENTS AND METHODS

Over 2 months, general health and functioning PROMIS surveys were offered to all patients in an optometric clinic in Rochester, NY. Demographic and clinical variables were recorded along with percent completion and time to completion of the survey.

RESULTS

Across 651 patients, 258 chose to attempt PROMIS. Patients with low visual acuity were less likely to attempt the survey (p=0.049), and younger patients were more likely to complete the survey (p=0.025); no other patient characteristics were found to differ between those who did and did not participate in, nor complete, PROMIS. A total of 193 patients completed the survey (74.8%) in a mean time of 6.36 minutes (range = [1.43, 51.92] minutes; standard deviation = 5.62 minutes). Time to completion did not vary significantly across any groups.

CONCLUSION

Our relatively high completion rate among those who attempted PROMIS indicates that PROMIS surveys are feasible to implement in an optometry clinic. While most patients completed the survey in little time, the large range of time to completion may indicate that some patients had difficulty completing the survey. Furthermore, the significant difference in visual acuity between those who participated in the survey and those who did not highlights the need to address the way PROMIS is delivered in order to foster greater inclusion.

Physical Function and Pain Interference Levels of Hallux Rigidus Patients Before and After Synthetic Cartilage Implant vs Arthrodesis Surgery

BACKGROUND

Hallux rigidus is a common and painful degenerative condition of the great toe limiting a patient's physical function and quality of life. The purpose of this study was to investigate pre- and postoperative physical function (PF) and pain interference (PI) levels of patients undergoing synthetic cartilage implant hemiarthroplasty (SCI) vs arthrodesis (AD) for treatment of hallux rigidus using the Patient-Reported Outcomes Measurement Information System (PROMIS).

METHODS

PROMIS PF and PI t scores were analyzed for patients who underwent either SCI or AD. Postoperative final PROMIS t scores were obtained via phone survey. Linear mixed model analysis was used to assess differences in PF and PI at each follow-up point. Final follow-up scores were analyzed using independent sample t tests.

RESULTS

Total 181 (59 SCI, 122 AD) operatively managed patients were included for analysis of PROMIS scores. Final phone survey was performed at a minimum of 14 (mean 33, range, 14-59) months postoperatively, with 101 patients (40 SCI, 61 AD) successfully contacted. The mean final follow-up was significantly different for SCI and AD: 27 vs 38 months, respectively (P < .01). The mean age of the SCI cohort was lower than the AD cohort (57.5 vs 61.5 years old, P = .01). Average PF t scores were higher in the SCI cohort at baseline (47.1 and 43.9, respectively, P = .01) and at final follow-up (51.4 vs 45.9, respectively, P < .01). A main effect of superior improvement in PF was noted in the SCI group (+4.3) vs the AD group (+2) across time intervals (P < .01). PI t scores were similar between the 2 procedures across time points.

CONCLUSION

The SCI cohort reported slightly superior PF t scores preoperatively and at most follow-up time points compared with the arthrodesis group. No differences were found for PI or complication rates between the 2 treatment groups during this study time frame.

LEVEL OF EVIDENCE

Level IV, case series.

Multimodal Interventions to Improve the Management of Chronic Non-Malignant Pain in Primary Care Using Participatory Research

BACKGROUND

The use of diverse therapies combined with a multidisciplinary approach and prevention initiatives for patients with chronic non-malignant pain (CNMP) can improve health and have a positive impact on psychotropic drug use and the self-management of pain.

PURPOSE

This purpose of this study has been two-fold: to conduct a literature review with a view to selecting best evidence recommendations for CNMP and to prioritize self-care recommendations using a participatory methodology for the analysis and selection of interventions.

METHODS

A qualitative, descriptive, and documentary method based on participatory action research was used.

FINDINGS

Based on the study results, a multimodal psychosocial intervention program has been designed for CNMP that includes psychoeducational therapy, pharmacological therapy, physical exercise, and health assets.

DISCUSSION

The findings are consistent with previous studies underlining the need to invest in resources for the management of CNMP, including strategies for good differential diagnoses and pharmacological treatments combined with non-pharmacological treatments to confer greater well-being for people living with pain who want to participate in their own recovery.

Preoperative Patient-Reported Outcomes Measurement Information System (PROMIS)-Physical Function and Perioperative Complication in Major Abdominal Colorectal Operations

BACKGROUND

Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) is a validated tool for capturing a patient's perception of their physical capacity. The goal of this study was to determine whether preoperative PF correlates with a risk of postoperative complications.

STUDY DESIGN

Patients from a single-institution American College of Surgeons NSQIP database undergoing elective colorectal abdominal operations from January 2018 to June 2019 with a preoperative PROMIS-PF T-score were eligible for this retrospective study. Patients were divided into moderate to severe (score <40) and minimal to mild (score ≥40) physical disability cohorts. Primary outcomes were any complication and any Clavien-Dindo grade III or higher complication. Multivariate logistic regression was performed.

RESULTS

In total, 249 patients were included: 78 (31%) with self-scored moderate to severe disability and 171 (69%) with minimal to mild disability. Patients who scored as moderate to severe disability had a higher frequency of comorbidities and an open operative approach compared with patients with minimal to mild disability. These patients then had higher rates of any complication (37.2% vs 19.9%; p = 0.0036) and Clavien-Dindo grade III or higher complications (14.1% vs 7.6%; p = 0.017). After adjusting for patient factors, surgical procedure, and approach, patients scoring as moderate to severe disability were 2.00 times more likely (95% CI, 1.05 to 3.84; p = 0.036) to have any complication and 2.76 times more likely (95% CI, 1.07 to 7.14; p = 0.036) to have a Clavien-Dindo grade III or higher complication.

CONCLUSIONS

Moderate to severe PF disability score is associated with increased risk of postoperative complications among patients undergoing colorectal operations. PROMIS-PF T-score can be a useful tool to identify patients who would benefit from targeted preoperative interventions, such as patient education, nutritional optimization, and prehabilitation.