Improving Interpretation of the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Scale for Specific Tasks in Community-Dwelling Older Adults

Using PROMIS Scores to Provide Cost-Conscious Follow-up After Foot and Ankle Surgery

BACKGROUND

National campaigns in the United States, such as Choosing Wisely, emphasize that decreasing low-value office visits maximizes health care value. Although patient-reported outcomes (PROs) are frequently used to quantify postoperative outcomes, they have not been assessed as a tool to help guide clinicians consider alternatives or discontinue in-person follow-up visits. The purpose of this study is to assess the frequency and cost of in-person follow-up visits after patients report substantial improvement defined as 2 consecutive improvements above preoperative Patient Reported Outcomes Measurement Information System (PROMIS) pain interference (PI) scores.

METHODS

Retrospective PROMIS PI data were obtained between 2015 and 2020 for common elective foot (n = 759) and ankle (n = 578) surgical procedures. Patients were divided into quartiles according to their preoperative PI score. Multivariable Cox proportional hazards models were used to investigate time to substantial improvement. Substantial improvement was defined as having 2 consecutive postoperative minimal clinically important differences (MCIDs) above preoperative PROMIS PI scores. MCID was measured using the distribution-based method. Multivariable negative binomial models were used to determine the number of visits and direct associated costs after substantial improvement. The cost to payors was estimated using reimbursement rates.

RESULTS

Within 3 months, 12% to 46% of foot and 16% to 61% of ankle patients achieved substantial improvement. Results vary by preoperative pain quartile, with patients who report higher preoperative pain scores achieving earlier improvement. After achieving substantial improvement, foot and ankle patients averaged 3.60 and 4.01 follow-up visits during the remaining 9 months of the year. Visit costs averaged $266 and $322 per foot and ankle patient respectively.

CONCLUSION

Postoperative follow-up visits are time-consuming and costly. Physicians might consider objective measures, such as PROMIS PI, to determine the need, timing, and alternatives for in-person follow-up visits for elective foot and ankle surgeries after patients demonstrate reliable clinical improvement.

LEVEL OF EVIDENCE

Level III, retrospective cohort study at a single institution.

Lipedema Reduction Surgery Improves Pain, Mobility, Physical Function, and Quality of Life: Case Series Report

Background

Lipedema is a chronic inflammatory subcutaneous adipose-rich connective tissue disease affecting millions of women worldwide. Disproportionate fat accumulation on the extremities characterized by heaviness, tenderness, and swelling can affect function, mobility, and quality of life. Treatments include conservative measures and lipedema reduction surgery (LRS). Here, we report lipedema comorbidities and surgical techniques, outcomes measures, and complications after LRS.

Methods

This is a single outpatient clinic retrospective chart review case series of comorbidities and complications in 189 women with lipedema. Bioelectrical impedance analyses, knee kinematics, gait, physical examinations, Patient-Reported Outcomes Measurement Information System, and RAND Short Form-36 questionnaires collected before and after LRS were analyzed for 66 of the 189 women. Hemoglobin levels were measured by transdermal hemoglobin monitor (Masimo noninvasive hemoglobin monitoring; Irvine, Calif.).

Results

Common comorbidities in 189 women were hypermobile joints (50.5%), spider/varicose veins (48.6/24.5%), arthritis (29.1%), and hypothyroidism (25.9%). The most common complication in 5.5% of these women after LRS was lightheadedness with a 2-g reduction or more in hemoglobin. After conservative measures and LRS in 66 women, significant improvements (P ≤ 0.0009) were found for: (1) knee flexion (10 degrees); (2) gait; (3) Patient-Reported Outcomes Measurement Information System T-score (16%); (4) mobility questions: gait velocity, rising from a chair, stair ascent; (5) RAND Short Form-36 scores: physical functioning, energy/fatigue, emotional well-being, social function, general health; (6) and Bioelectrical impedance analyses total and segmental body fat mass.

Conclusion

LRS provided significant improvements to women with lipedema using direct physical measurements and validated outcome measures, comparable to those seen after total knee replacement.

Measures of perceived mobility ability in community-dwelling older adults: a systematic review of psychometric properties

OBJECTIVES

The objective of this systematic review was to synthesise the psychometric properties of measures of perceived mobility ability and related frameworks used to define and operationalise mobility in community-dwelling older adults.

METHODS

We registered the review protocol with PROSPERO (CRD42022306689) and included studies that examined the psychometric properties of perceived mobility measures in community-dwelling older adults. Five databases were searched to identify potentially relevant primary studies. We qualitatively summarised psychometric property estimates and related operational frameworks. We conducted risk of bias and overall quality assessments, and meta-analyses when at least three studies were included for a particular outcome. The synthesised results were compared against the Consensus-based Standards for the Selection of Health Measurement Instruments criteria for good measurement properties.

RESULTS

A total of 36 studies and 17 measures were included in the review. The Late-Life Function and Disability Index: function component (LLFDI-FC), lower extremity functional scale (LEFS), Mobility Assessment Tool (MAT)-short form (MAT-SF) or MAT-Walking, and Perceived Driving Abilities (PDA) Scale were identified with three or more eligible studies. Most measures showed sufficient test-retest reliability (moderate or high), while the PDA scale showed insufficient reliability (low). Most measures had sufficient or inconsistent convergent validity (low or moderate) or known-groups validity (low or very low), but their predictive validity and responsiveness were insufficient or inconsistent (low or very low). Few studies used a conceptual model.

CONCLUSION

The LLFDI-FC, LEFS, PDA and MAT-SF/Walking can be used in community-dwelling older adults by considering the summarised psychometric properties. No available comprehensive mobility measure was identified that covered all mobility domains.

The Quick Physical Activity Rating (QPAR) scale: A brief assessment of physical activity in older adults with and without cognitive impairment

INTRODUCTION

Alzheimer's disease and related dementias (ADRD) currently affect over 5.7 million Americans and over 35 million people worldwide. At the same time, over 31 million older adults are physically inactive with impaired physical performance interfering with activities of daily living. Low physical activity is a risk factor for ADRD. We examined the utility of a new measure, the Quick Physical Activities Rating (QPAR) as an informant-rated instrument to quantify the dosage of physical activities in healthy controls, MCI and ADRD compared with Gold Standard assessments of objective measures of physical performance, fitness, and functionality.

METHODS

This study analyzed 390 consecutive patient-caregiver dyads who underwent a comprehensive evaluation including the Clinical Dementia Rating (CDR), mood, neuropsychological testing, caregiver ratings of patient behavior and function, and a comprehensive physical performance and gait assessment. The QPAR was completed prior to the office visit and was not considered in the clinical evaluation, physical performance assessment, staging or diagnosis of the patient. Psychometric properties including item variability and distribution, floor and ceiling effects, strength of association, known-groups performance, and internal consistency were determined.

RESULTS

The patients had a mean age of 75.3±9.2 years, 15.7±2.8 years of education and were 46.9% female. The patients had a mean CDR-SB of 4.8±4.7 and a mean MoCA score of 18.6±7.1 and covered a range of healthy controls (CDR 0 = 54), MCI or very mild dementia (CDR 0.5 = 161), mild dementia (CDR 1 = 92), moderate dementia (CDR 2 = 64), and severe dementia (CDR 3 = 29). The mean QPAR score was 20.2±18.9 (range 0-132) covering a wide range of physical activity. The QPAR internal consistency (Cronbach alpha) was very good at 0.747. The QPAR was correlated with measures of physical performance (dexterity, grip strength, gait, mobility), physical functionality rating scales, measures of activities of daily living and comorbidities, the UPDRS, and frailty ratings (all p < .001). The QPAR report of physical activities was able to discriminate between individuals with impaired physical functionality (32.2±23.9 vs 15.2±13.8, p < .001), falls risk (28.4±21.6 vs. 14.5±13.2, p < .001), and the presence of frailty (28.1±22.7 vs. 11.8±9.4, p < .001). The QPAR showed strong psychometric properties and excellent data quality, and worked equally well across different patient ages, sexes, informant relationships, and in individuals with and without cognitive impairment.

DISCUSSION

The QPAR is a brief detection tool that captures informant reports of physical activities and differentiates individuals with normal physical functionality from those individuals with impaired physical functionality. The QPAR correlated with Gold Standard assessments of strength and sarcopenia, activities of daily living, gait and mobility, fitness, health related quality of life, frailty, global physical performance, and provided good discrimination between states of physical functionality, falls risk, and frailty. The QPAR performed well in comparison to standardized scales of objective physical performance, but in a brief fashion that could facilitate its use in clinical care and research.

Pattern of recovery and outcomes of patient reported physical function and pain interference after ankle fusion: a retrospective cohort study

Background

Research on outcomes after ankle fusion focuses on basic activities of daily living, fusion rates, and gait parameters. Little has been reported on the patient’s perspective after surgery. The purpose of this study was to determine the change in patient reported physical function and pain interference after ankle fusion surgery to guide patient expectations and improve provider communication.

Methods

This was a retrospective review of prospectively collected patient reported outcome measurement information system (PROMIS) data in 88 ankle arthrodesis procedures performed from May 2015 to March 2018. The PROMIS Physical function (PF) and pain interference (PI) measures were collected as routine care. Linear mixed models were used to assess differences at each follow-up point for PF and PI. Preoperative to last follow-up in the 120–365 day interval was assessed using analysis of variance. Outcomes included T-scores, z-scores, and PROMIS-Preference (PROPr) utility scores for PF and PI and the percentage of patients improving by at least 4 T-score points.

Results

The linear mixed model analysis for PF after the 120–149 days, and for PI, after 90–119 days, indicated recovery plateaued at 39–40 for PF and 57–59 for PI T-scores. The change in the PI T-score was the greatest with a mean T-score improvement of − 5.4 (95% CI − 7.7 to − 3.1). The proportion of patients improving more than 4 points was 66.2% for either PF or PI or both. The change in utility T-scores for both PF (0.06, 95% CI 0.02 to 0.11) and PI (0.15, 95% CI 0.09 to 0.20) was significantly improved, however, only PI approached clinical significance.

Conclusion

Average patients undergoing ankle fusion experience clinically meaningful improvement in pain more so than physical function. Average patient recovery showed progressive improvement in pain and function until the four-month postoperative time point. Traditional dogma states that recovery after an ankle fusion maximizes at a year, however based on the findings in this study, 4 months is a more accurate marker of recovery. A decline in function or an increase in pain after 4 months from surgery may help to predict nonunion and other complications after ankle arthrodesis.

Level of evidence

Level II, prospective single cohort study.