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Green T, Bosworth HB, Coronado GD, DeBar L, Green BB, Huang SS, Jarvik JG, Mor V, Zatzick D, Weinfurt KP, Check DK. Factors Affecting Post-trial Sustainment or De-implementation of Study Interventions: A Narrative Review. J Gen Intern Med 2024; 39:1029-1036. [PMID: 38216853 DOI: 10.1007/s11606-023-08593-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 12/28/2023] [Indexed: 01/14/2024]
Abstract
In contrast to traditional randomized controlled trials, embedded pragmatic clinical trials (ePCTs) are conducted within healthcare settings with real-world patient populations. ePCTs are intentionally designed to align with health system priorities leveraging existing healthcare system infrastructure and resources to ease intervention implementation and increase the likelihood that effective interventions translate into routine practice following the trial. The NIH Pragmatic Trials Collaboratory, funded by the National Institutes of Health (NIH), supports the conduct of large-scale ePCT Demonstration Projects that address major public health issues within healthcare systems. The Collaboratory has a unique opportunity to draw on the Demonstration Project experiences to generate lessons learned related to ePCTs and the dissemination and implementation of interventions tested in ePCTs. In this article, we use case studies from six completed Demonstration Projects to summarize the Collaboratory's experience with post-trial interpretation of results, and implications for sustainment (or de-implementation) of tested interventions. We highlight three key lessons learned. First, ineffective interventions (i.e., ePCT is null for the primary outcome) may be sustained if they have other measured benefits (e.g., secondary outcome or subgroup) or even perceived benefits (e.g., staff like the intervention). Second, effective interventions-even those solicited by the health system and/or designed with significant health system partner buy-in-may not be sustained if they require significant resources. Third, alignment with policy incentives is essential for achieving sustainment and scale-up of effective interventions. Our experiences point to several recommendations to aid in considering post-trial sustainment or de-implementation of interventions tested in ePCTs: (1) include secondary outcome measures that are salient to health system partners; (2) collect all appropriate data to allow for post hoc analysis of subgroups; (3) collect experience data from clinicians and staff; (4) engage policy-makers before starting the trial.
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Affiliation(s)
- Terren Green
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Hayden B Bosworth
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Duke University, 215 Morris St., Suite 210, Durham, NC, 27708, USA
- Department of Medicine, Duke University School of Medicine, Duke University, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | | | - Lynn DeBar
- Kaiser Permanente Center for Health Research, Portland, OR, USA
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Susan S Huang
- Irvine School of Medicine, University of California, Irvine, CA, USA
| | - Jeffrey G Jarvik
- Department of Radiology, University of Washington School of Medicine, University of Washington, Seattle, WA, USA
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University and Providence Veterans Administration Medical Center, Providence, RI, USA
| | - Douglas Zatzick
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, University of Washington, Seattle, WA, USA
| | - Kevin P Weinfurt
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Duke University, 215 Morris St., Suite 210, Durham, NC, 27708, USA
| | - Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine, Duke University, 215 Morris St., Suite 210, Durham, NC, 27708, USA.
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Coles T, Plyler K, Hernandez A, Fillipo R, Henke DM, Arizmendi C, Lagoo-Deenadayalan S, Goodwin CR, LeBlanc TW, Horodniceanu EG, Bhatnagar V, Reeve BB, Weinfurt KP. What facets of physical function are most important to adults diagnosed with cancer? Qual Life Res 2024:10.1007/s11136-024-03654-8. [PMID: 38642219 DOI: 10.1007/s11136-024-03654-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2024] [Indexed: 04/22/2024]
Abstract
PURPOSE Successful patient-focused drug development involves selecting and measuring outcomes in clinical trials that are important to patients. The U.S. Food & Drug Administration's definition of clinical benefit includes how patients feel, function, or survive. Patients are considered the experts in describing how they feel and function. In cancer trials, patient-reported measures of physical function provide insight into how patients function at baseline, benefit from the interventions being studied, and the impact of treatment side effects. We conducted a qualitative study with adults diagnosed with cancer to describe facets of physical function from their perspective and to identify which facets are most important to this patient population. METHODS Using concept elicitation and cognitive interviewing techniques, we conducted semi-structured interviews with 72 adults ≥ 22 years of age with cancer who received treatment with an anticancer drug or biologic within six months of the interview. We selected participants using purposive sampling with the aim to elicit diverse experiences regarding how they may interpret and respond to questions related to physical function. Participants were presented with patient-reported outcome (PRO) items representative of PRO measures used in cancer and general populations. RESULTS Five facets of how physical function relates to activities were defined from the patient perspective: ability, difficulty, limitation, satisfaction, and completion. More than half of the participants indicated that ability was the most important facet of physical function. The next most important were satisfaction (18.3%), limitation (14.1%), difficulty (5.6%), and completion (2.8%). CONCLUSION This study demonstrates that we must be more specific about the facets of physical function that we set out to assess when we use PRO measures to describe the patient experience. These results have implications for the specificity of physical function facets when measured in cancer clinical trials.
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Affiliation(s)
- Theresa Coles
- Center for Health Measurement, Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St., Durham, NC, 27701, USA.
| | - Kate Plyler
- Center for Health Measurement, Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St., Durham, NC, 27701, USA
| | - Alexy Hernandez
- Center for Health Measurement, Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St., Durham, NC, 27701, USA
| | - Rebecca Fillipo
- Center for Health Measurement, Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St., Durham, NC, 27701, USA
| | - Debra M Henke
- Center for Health Measurement, Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St., Durham, NC, 27701, USA
| | - Cara Arizmendi
- Center for Health Measurement, Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St., Durham, NC, 27701, USA
- AstraZeneca, Oncology Digital Health R&D, Durham, NC, USA
| | | | - C Rory Goodwin
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA
| | - Thomas W LeBlanc
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Erica G Horodniceanu
- Oncology Center of Excellence, U.S. Food & Drug Administration, Silver Spring, MD, USA
| | - Vishal Bhatnagar
- Oncology Center of Excellence, U.S. Food & Drug Administration, Silver Spring, MD, USA
| | - Bryce B Reeve
- Center for Health Measurement, Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St., Durham, NC, 27701, USA
| | - Kevin P Weinfurt
- Center for Health Measurement, Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St., Durham, NC, 27701, USA
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Sugarman J, Weir BW, Dun C, Gulick RM, Wilkin TJ, Mayer KH, McCauley M, Weinfurt KP. Expectations of preventative benefits and risk behaviors in a randomized trial evaluating oral HIV preexposure prophylaxis candidates. AIDS Care 2024:1-7. [PMID: 38606559 DOI: 10.1080/09540121.2024.2332446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 03/10/2024] [Indexed: 04/13/2024]
Abstract
When participants enrolled in an HIV prevention trial hold a preventive misconception (PM) - expectations that experimental interventions will confer protection from HIV infection - they may engage in behaviors that increase their risk of acquiring HIV. This can raise ethical concerns about whether those enrolled in the trial understand the nature of participation and their safety. Consequently, we systematically evaluated the prevalence of PM and its association with risk behaviors in a trial examining three candidate regimens for oral HIV pre-exposure prophylaxis in which all participants received at least one antiretroviral agent. Overall, trial participants exhibited relatively high preventive expectations that may be associated with an increase in risk behaviors among men who have sex with men. In addition, we identified substantial site variability in PM that necessitates future research to uncover its source. This will allow appropriate measures to be taken to mitigate PM and help ensure that participants have an accurate understanding of the potential risks and benefits of trial participation throughout the course of a trial.
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Affiliation(s)
- Jeremy Sugarman
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Brian W Weir
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Chen Dun
- Department of Biomedical Informatics and Data Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Roy M Gulick
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Timothy J Wilkin
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Kenneth H Mayer
- The Fenway Institute of Fenway Health and Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | | | - Kevin P Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
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4
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Weinfurt KP, Flynn K. Some Clarifications Regarding the PROMIS© SexFS: Commentary on Clements et al. (2023). Arch Sex Behav 2024; 53:869-870. [PMID: 38177606 DOI: 10.1007/s10508-023-02789-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 12/10/2023] [Accepted: 12/11/2023] [Indexed: 01/06/2024]
Affiliation(s)
- Kevin P Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Suite 210, Durham, NC, 27701, USA.
| | - Kathryn Flynn
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Nayak A, Alkaitis MS, Nayak K, Nikolov M, Weinfurt KP, Schulman K. Comparison of History of Present Illness Summaries Generated by a Chatbot and Senior Internal Medicine Residents. JAMA Intern Med 2023; 183:1026-1027. [PMID: 37459091 PMCID: PMC10352925 DOI: 10.1001/jamainternmed.2023.2561] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 03/23/2023] [Indexed: 07/20/2023]
Abstract
This prognostic study assesses the ability of a chatbot to write a history of present illness compared with senior internal medicine residents.
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Affiliation(s)
- Ashwin Nayak
- Department of Medicine, Stanford University, Stanford, California
| | | | - Kristen Nayak
- Department of Medicine, Stanford University, Stanford, California
| | - Margaret Nikolov
- Clinical Excellence Research Center, School of Medicine, Stanford University, Stanford, California
| | - Kevin P. Weinfurt
- Department of Population Health Sciences and Duke Clinical Research Institute, Durham, North Carolina
| | - Kevin Schulman
- Department of Medicine, Stanford University, Stanford, California
- Clinical Excellence Research Center, School of Medicine, Stanford University, Stanford, California
- Graduate School of Business, Stanford University, Stanford, California
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6
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Weinfurt KP. Developing, Selecting, and Modifying Performance Outcome Assessments. Value Health 2023; 26:957-958. [PMID: 37182821 DOI: 10.1016/j.jval.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 04/22/2023] [Indexed: 05/16/2023]
Affiliation(s)
- Kevin P Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.
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7
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Staman KL, Check DK, Zatzick D, Mor V, Fritz JM, Sluka K, DeBar LL, Jarvik JG, Volandes A, Coronado GD, Chambers DA, Weinfurt KP, George SZ. Intervention delivery for embedded pragmatic clinical trials: Development of a tool to measure complexity. Contemp Clin Trials 2023; 126:107105. [PMID: 36708968 PMCID: PMC10126825 DOI: 10.1016/j.cct.2023.107105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 01/03/2023] [Accepted: 01/23/2023] [Indexed: 01/27/2023]
Abstract
BACKGROUND Conducting an embedded pragmatic clinical trial in the workflow of a healthcare system is a complex endeavor. The complexity of the intervention delivery can have implications for study planning, ability to maintain fidelity to the intervention during the trial, and/or ability to detect meaningful differences in outcomes. METHODS We conducted a literature review, developed a tool, and conducted two rounds of phone calls with NIH Pragmatic Trials Collaboratory Demonstration Project principal investigators to develop the Intervention Delivery Complexity Tool. After refining the tool, we piloted it with Collaboratory demonstration projects and developed an online version of the tool using the R Shiny application (https://duke-som.shinyapps.io/ICT-ePCT/). RESULTS The 6-item tool consists of internal and external factors. Internal factors pertain to the intervention itself and include workflow, training, and the number of intervention components. External factors are related to intervention delivery at the system level including differences in healthcare systems, the dependency on setting for implementation, and the number of steps between the intervention and the outcome. CONCLUSION The Intervention Delivery Complexity Tool was developed as a standard way to overcome communication challenges of intervention delivery within an embedded pragmatic trial. This version of the tool is most likely to be useful to the trial team and its health system partners during trial planning and conduct. We expect further evolution of the tool as more pragmatic trials are conducted and feedback is received on its performance outside of the NIH Pragmatic Trials Collaboratory.
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Affiliation(s)
- Karen L Staman
- Duke Clinical Research Institute, CHB Wordsmith, Inc, Raleigh, NC, USA
| | - Devon K Check
- Population Health Sciences and Duke Clinical Research Institute, Durham, NC, USA
| | | | | | | | | | - Lynn L DeBar
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | | | | | | | - Kevin P Weinfurt
- Population Health Sciences and Duke Clinical Research Institute, Durham, NC, USA
| | - Steven Z George
- Department of Orthopaedic Surgery and Duke Clinical Research Institute, Durham, NC, USA.
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8
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Marsolo KA, Weinfurt KP, Staman KL, Hammill BG. Moving From Idealism to Realism With Data Sharing. Ann Intern Med 2023; 176:402-403. [PMID: 36716450 DOI: 10.7326/m22-2973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Affiliation(s)
- Keith A Marsolo
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina (K.A.M., K.P.W., K.L.S., B.G.H.)
| | - Kevin P Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina (K.A.M., K.P.W., K.L.S., B.G.H.)
| | - Karen L Staman
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina (K.A.M., K.P.W., K.L.S., B.G.H.)
| | - Bradley G Hammill
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina (K.A.M., K.P.W., K.L.S., B.G.H.)
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Hovén E, Flynn KE, Weinfurt KP, Eriksson LE, Wettergren L. Psychometric evaluation of the Swedish version of the PROMIS Sexual Function and Satisfaction Measures in clinical and nonclinical young adult populations. Sex Med 2023; 11:qfac006. [PMID: 37007849 PMCID: PMC10065179 DOI: 10.1093/sexmed/qfac006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/03/2022] [Accepted: 10/11/2022] [Indexed: 01/13/2023] Open
Abstract
Abstract
Background
The Patient-Reported Outcomes Measurement Information System (PROMIS®) Sexual Function and Satisfaction (SexFS) version 2.0 measurement tool was developed to assess sexual functioning and satisfaction in the general population regardless of health condition and sexual orientation.
Aim
The study aimed to evaluate the psychometric properties of the Swedish version of the PROMIS SexFS measure in clinical and nonclinical populations of young adults (aged <40 years).
Methods
The SexFS was answered by a clinical population of young adult women (n = 180) and men (n = 110) with breast cancer and testicular cancer, respectively, and a nonclinical population of young adult women (n = 511) and men (n = 324) from the general population. Psychometric properties were evaluated by examining data quality (score distribution, floor and ceiling effects, proportion of missing data), construct validity (corrected item, total correlation, scaling success), and reliability (Cronbach α).
Outcomes
The following domains of the SexFS 2.0 were investigated: Vaginal Lubrication, Vaginal Discomfort, Vulvar Discomfort- Clitoral, Vulvar Discomfort- Labial, Erectile Function, Interest in Sexual Activity, Satisfaction With Sex Life, Orgasm– Ability, and Orgasm- Pleasure.
Results
The Swedish version of the SexFS 2.0 generated data of acceptable quality. Some noteworthy floor or ceiling effects were identified across domains and respondent groups. Corrected item totals were used to express the coherence between an item and the other items in the domain. The correlation coefficients were above 0.40 for all items, except for 1 of the items within the Vaginal Discomfort domain and for the items in the Erectile Function domain in the nonclinical group of men. High proportions of scaling success were noted across domains (96%-100%). Reliability was satisfactory (α = 0.74-0.92) for all domains, expect for Erectile Function of the nonclinical group (α = 0.53), due to low variability in item responses, which was improved somewhat (α = 0.65) when combined with the clinical group.
Clinical Implications
A flexible tool to measure self-reported sexual function and satisfaction in young men and women is available for researchers and clinicians in Sweden.
Strengths and Limitations
The nationwide population-based sample of patients with cancer, identified from national quality registers, minimized selection bias. However, men in the general population had a lower response rate (34%) compared to the other groups, which introduced a risk of bias in estimates. The psychometric evaluation was limited to young adults (aged 19-40 years).
Conclusion
The results provide evidence for the validity and reliability of the Swedish version of the SexFS measure for the assessment of sexual functioning and satisfaction in young adults from both clinical and nonclinical populations.
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Affiliation(s)
- Emma Hovén
- Uppsala University Department of Women’s and Children’s Health, , Uppsala, Sweden
- Karolinska Institutet Department of Women’s and Children’s Health, , Stockholm, Sweden
| | - Kathryn E Flynn
- Medical College of Wisconsin Department of Medicine, , Milwaukee, WI, United States
| | - Kevin P Weinfurt
- Duke University School of Medicine Department of Population Health Sciences, , Durham, NC, United States
| | - Lars E Eriksson
- Karolinska Institutet Department of Neurobiology, Care Sciences and Society, , Huddinge, Sweden
- University of London School of Health and Psychological Sciences, , London, United Kingdom
- Karolinska University Hospital Medical Unit Infectious Diseases, , Huddinge, Sweden
| | - Lena Wettergren
- Karolinska Institutet Department of Women’s and Children’s Health, , Stockholm, Sweden
- Uppsala University Department of Public Health and Caring Sciences, , Uppsala, Sweden
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Flynn KE, Wiseman JB, Helmuth ME, Smith AR, Bradley CS, Cameron AP, Lai HH, Kirkali Z, Kreder KJ, Geynisman-Tan J, Merion RM, Weinfurt KP. Comparing clinical bladder diaries and recalled patient reports for measuring lower urinary tract symptoms in the symptoms of Lower Urinary Tract Dysfunction Research Network (LURN). Neurourol Urodyn 2022; 41:1711-1721. [PMID: 36066068 PMCID: PMC9633398 DOI: 10.1002/nau.25030] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/06/2022] [Accepted: 08/05/2022] [Indexed: 11/11/2022]
Abstract
PURPOSE Bladder diaries are a key source of information about lower urinary tract symptoms (LUTS); however, many patients do not complete them as instructed. Questionnaire-based patient-reported outcome measures (PROMs) are another option for reporting LUTS but may have recall bias. We assessed the strength of the associations between PROMs and a 3-day bladder diary. MATERIALS AND METHODS Symptomatic adults from 6 tertiary care sites completed a 3-day paper bladder diary and 3-, 7-, and 30-day electronic PROMs. We assessed the linear associations between mapped pairs of diary variables and responses to PROM items using biserial and polyserial correlation coefficients with 95% confidence intervals. RESULTS Of 290 enrolled participants, 175 (60%) completed the bladder diary as instructed and at least one corresponding PROM. Linear associations were strongest between the diary and 3-day recall of daytime frequency (r = 0.75) and nighttime frequency (r = 0.69), followed by voids with urgency sensations (r = 0.62), and an item reporting any incontinence (r = 0.56). Linear associations between bladder diary and specific incontinence variables (e.g., stress, urgency) were low to negligible (ranging from r = 0.16-0.39). Linear associations were consistent across the 3-, 7-, and 30-day recall periods. CONCLUSIONS Missing and unusable bladder diary data were common, highlighting the patient burden associated with this method of data collection. A questionnaire-based PROM is a reasonable alternative to a diary for reporting voiding frequency and may offer an easier option for reporting some symptoms.
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Affiliation(s)
- Kathryn E. Flynn
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee WI
| | | | | | | | - Catherine S. Bradley
- Department of Obstetrics and Gynecology, University of Iowa, Carver College of Medicine, Iowa City IA
| | | | - H. Henry Lai
- Department of Surgery, Washington University in St Louis, St Louis MO
| | - Ziya Kirkali
- Division of Kidney, Urologic, and Hematologic Diseases; National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda MD
| | - Karl J. Kreder
- Department of Obstetrics and Gynecology, University of Iowa, Carver College of Medicine, Iowa City IA
| | | | | | - Kevin P. Weinfurt
- Department of Population Health Sciences, Duke University Medical Center, Durham NC
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Barlet MH, Barks MC, Ubel PA, Davis JK, Pollak KI, Kaye EC, Weinfurt KP, Lemmon ME. Characterizing the Language Used to Discuss Death in Family Meetings for Critically Ill Infants. JAMA Netw Open 2022; 5:e2233722. [PMID: 36197666 PMCID: PMC9535532 DOI: 10.1001/jamanetworkopen.2022.33722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/09/2022] [Indexed: 12/03/2022] Open
Abstract
Importance Communication during conversations about death is critical; however, little is known about the language clinicians and families use to discuss death. Objective To characterize (1) the way death is discussed in family meetings between parents of critically ill infants and the clinical team and (2) how discussion of death differs between clinicians and family members. Design, Setting, and Participants This longitudinal qualitative study took place at a single academic hospital in the southeast US. Patients were enrolled from September 2018 to September 2020, and infants were followed up longitudinally throughout their hospitalization. Participants included families of infants with neurologic conditions who were hospitalized in the intensive care unit and had a planned family meeting to discuss neurologic prognosis or starting, not starting, or discontinuing life-sustaining treatment. Family meetings were recorded, transcribed, and deidentified before being screened for discussion of death. Main Outcomes and Measures The main outcome was the language used to reference death during family meetings between parents and clinicians. Conventional content analysis was used to analyze data. Results A total of 68 family meetings involving 36 parents of 24 infants were screened; 33 family meetings (49%) involving 20 parents (56%) and 13 infants (54%) included discussion of death. Most parents involved in discussion of death identified as the infant's mother (13 [65%]) and as Black (12 [60%]). Death was referenced 406 times throughout the family meetings (275 times by clinicians and 131 times by family members); the words die, death, dying, or stillborn were used 5% of the time by clinicians (13 of 275 references) and 15% of the time by family members (19 of 131 references). Four types of euphemisms used in place of die, death, dying, or stillborn were identified: (1) survival framing (eg, not live), (2) colloquialisms (eg, pass away), (3) medical jargon, including obscure technical terms (eg, code event) or talking around death with physiologic terms (eg, irrecoverable heart rate drop), and (4) pronouns without an antecedent (eg, it). The most common type of euphemism used by clinicians was medical jargon (118 of 275 references [43%]). The most common type of euphemism used by family members was colloquialism (44 of 131 references [34%]). Conclusions and Relevance In this qualitative study, the words die, death, dying, or stillborn were rarely used to refer to death in family meetings with clinicians. Families most often used colloquialisms to reference death, and clinicians most often used medical jargon. Future work should evaluate the effects of euphemisms on mutual understanding, shared decision-making, and clinician-family relationships.
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Affiliation(s)
| | - Mary C. Barks
- Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Peter A. Ubel
- Duke University School of Medicine, Durham, North Carolina
- Fuqua School of Business, Duke University, Durham, North Carolina
- Sanford School of Public Policy, Duke University, Durham, North Carolina
| | - J. Kelly Davis
- Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Kathryn I. Pollak
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Erica C. Kaye
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Kevin P. Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Monica E. Lemmon
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
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12
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Affiliation(s)
- Kevin P Weinfurt
- Center for Health Measurement, Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Bryce B Reeve
- Center for Health Measurement, Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
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13
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Barlet MH, Ubel PA, Weinfurt KP, Glass HC, Pollak KI, Brandon DH, Lemmon ME. Decisional Satisfaction, Regret, and Conflict Among Parents of Infants with Neurologic Conditions. J Pediatr 2022; 245:81-88.e3. [PMID: 35227757 PMCID: PMC9232962 DOI: 10.1016/j.jpeds.2022.02.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 02/14/2022] [Accepted: 02/22/2022] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To characterize decisional satisfaction, regret, and conflict among parents of critically ill infants with neurologic conditions. STUDY DESIGN In this prospective cohort study, we enrolled parents of infants with neurologic conditions in the intensive care unit (ICU). Hospital discharge surveys included the validated Family Satisfaction with the ICU (FS-ICU) decision making subscale, Decision Regret Scale (DRS), and Decisional Conflict Scale (DCS). We defined high satisfaction with decision making as an FS-ICU score ≥75, high decisional regret/conflict as DRS/DCS score >25, and within-couple disagreement as a difference of at least 25 points between scores. RESULTS We enrolled 61 parents of 40 infants (n = 40 mothers, n = 21 fathers); 35 mothers and 15 fathers completed surveys. Most mothers reported high satisfaction with decision making (27 of 35; 77%) and low decision regret (28 of 35; 80%); 40% (14 of 35) reported high decisional conflict. Mothers and fathers reported higher decisional conflict in the domains of uncertainty and values clarity compared with the domain of effective decision making (Bonferroni-corrected P < .05). There were no differences in decision outcomes between paired mothers and fathers; however, within any given couple, there were numerous instances of disagreement (7 of 15 for decision regret and 5 of 15 for decisional conflict). CONCLUSIONS Many parents experience decisional conflict even if they ultimately have high satisfaction and low regret, underscoring the need for decision aids targeting uncertainty and values clarity. Couples frequently experience different levels of decisional regret and conflict.
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Affiliation(s)
| | - Peter A. Ubel
- Duke University School of Medicine, Durham, NC, USA,Fuqua School of Business, Duke University, Durham, NC, USA,Sanford School of Public Policy, Duke University, Durham, NC, USA
| | - Kevin P. Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Hannah C. Glass
- Department of Neurology and Pediatrics, University of California San Francisco, San Francisco, CA, USA,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Kathryn I. Pollak
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Debra H. Brandon
- Duke University School of Nursing, Durham, NC, USA,Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Monica E. Lemmon
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA,Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
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14
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O'Brien EC, Sugarman J, Weinfurt KP, Larson EB, Heagerty PJ, Hernandez AF, Curtis LH. The impact of COVID-19 on pragmatic clinical trials: lessons learned from the NIH Health Care Systems Research Collaboratory. Trials 2022; 23:424. [PMID: 35597988 PMCID: PMC9123729 DOI: 10.1186/s13063-022-06385-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 05/07/2022] [Indexed: 11/13/2022] Open
Abstract
Background The COVID-19 pandemic has considerably disrupted nearly all aspects of daily life, including healthcare delivery and clinical research. Because pragmatic clinical trials are often embedded within healthcare delivery systems, they may be at high risk of disruption due to the dual impacts on the conduct of both care and research. Methods We collected qualitative data using multiple methods to characterize the impact of COVID-19 on the research activities of 14 active pragmatic clinical trials in the National Institutes of Health (NIH) Health Care Systems Research Collaboratory. A COVID-19 impact questionnaire was administered electronically to principal investigators in June 2020. Text responses were analyzed thematically, and qualitative summaries were subsequently reviewed by five independent reviewers, who made iterative revisions. Additional COVID-19-related impacts were identified during virtual meetings with trial teams during April–July 2020 and combined with questionnaire responses for analysis. Results Impacts of the pandemic were broadly classified into two main types: healthcare operations and social distancing. In some instances, trial delays created statistical challenges, particularly with trials using stepped-wedge designs, and necessitated changing data collection strategies or modifying interventions. The majority of projects used existing stakeholder-driven approaches to adapt interventions. Several benefits of these adaptions were identified, including expanded outreach capabilities and ability to study virtual intervention delivery. All trial teams were able to adapt to pandemic-related modifications. Conclusion In a group of 14 ongoing pragmatic clinical trials, there was significant impact of COVID-19 on trial activities. Engaging appropriate stakeholders was critical to designing and implementing trial modifications and making continued safe progress toward meeting research objectives. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06385-8.
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Affiliation(s)
- Emily C O'Brien
- Department of Population Health Sciences, School of Medicine, Duke University, 215 Morris Street, Suite 210, Durham, NC, 27701, USA. .,Duke Clinical Research Institute, School of Medicine, Duke University, Durham, NC, USA.
| | - Jeremy Sugarman
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Kevin P Weinfurt
- Department of Population Health Sciences, School of Medicine, Duke University, 215 Morris Street, Suite 210, Durham, NC, 27701, USA.,Duke Clinical Research Institute, School of Medicine, Duke University, Durham, NC, USA
| | - Eric B Larson
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | - Adrian F Hernandez
- Duke Clinical Research Institute, School of Medicine, Duke University, Durham, NC, USA.,Department of Medicine, School of Medicine, Duke University, Durham, NC, USA
| | - Lesley H Curtis
- Department of Population Health Sciences, School of Medicine, Duke University, 215 Morris Street, Suite 210, Durham, NC, 27701, USA.,Duke Clinical Research Institute, School of Medicine, Duke University, Durham, NC, USA
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15
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Flynn KE, Atallah E, Lin L, Shah NP, Silver RT, Larson RA, Pinilla-Ibarz J, Thompson JE, Oehler VG, Radich JP, Kota V, Mauro MJ, Schiffer CA, Cortes J, Weinfurt KP. Patient- and physician-reported pain after tyrosine kinase inhibitor discontinuation among patients with chronic myeloid leukemia. Haematologica 2022; 107:2641-2649. [PMID: 35511672 PMCID: PMC9614525 DOI: 10.3324/haematol.2021.280377] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Indexed: 01/12/2023] Open
Abstract
For patients with optimally treated chronic myeloid leukemia (CML), discontinuation of tyrosine kinase inhibitor (TKI) therapy can lead to treatment-free remission. In previous trials, TKI discontinuation has been associated with increased musculoskeletal pain in some patients ("withdrawal syndrome"), based on physician-reported adverse events (AE). Patient-reported pain has not been described. The Life After Stopping TKI study was a 14-site prospective, non-randomized clinical trial of TKI discontinuation. We defined increased pain after discontinuation as: (i) a physician-reported pain AE, (ii) a 2-level increase in self-reported musculoskeletal pain (4-level single item), or (iii) initiation of a medication for pain. We plotted the trajectory of patient-reported pain over time using a piecewise mixed-effects ordinal logistic model. Within 3 months of discontinuation, 35 of 172 patients (20.3%) had a physician-reported pain AE, 22 of 172 (12.8%) had an increase in self-reported pain, and 18 of 154 (11.7%) initiated a pain medication. Agreement among these measures was limited; overall, 60 of 172 patients (34.9%) had increased pain. Three patients (1.7%) restarted a TKI because of pain. The modelpredicted trajectory showed an increase in pain in the first 3 months followed by a decrease, returning to baseline levels by 6 months and further decreasing after that. This trajectory was similar among patients who did and did not restart TKI, suggesting that resuming a TKI for withdrawal syndrome may be necessary for some, but other approaches to manage pain should be tried so that patients can remain in treatment-free remission when possible.
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Affiliation(s)
| | | | - Li Lin
- Duke University School of Medicine, Durham, NC
| | - Neil P. Shah
- University of California at San Francisco, San Francisco, CA
| | | | | | | | | | | | | | - Vamsi Kota
- Georgia Cancer Center at Augusta University, Augusta, GA
| | | | - Charles A. Schiffer
- Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
| | - Jorge Cortes
- Georgia Cancer Center at Augusta University, Augusta, GA
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16
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Weinfurt KP, Bollinger JM, May E, Geller G, Mathews DJH, Morain SR, Schmid L, Bloom DL, Sugarman J. Patients' Reactions to Letters Communicating Collateral Findings of Pragmatic Clinical Trials: a National Web-Based Survey. J Gen Intern Med 2022; 37:1658-1664. [PMID: 34383228 PMCID: PMC8359628 DOI: 10.1007/s11606-021-07087-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 07/28/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Collateral findings in pragmatic clinical trials are findings that may have implications for patients' health but were not generated to address a trial's primary research questions. It is uncertain how best to communicate these collateral findings to patients. OBJECTIVES To determine how reactions to a letter communicating collateral findings relate to who signed the letter, the type of finding, or whether the letter specified that the finding arose from a pragmatic clinical trial. RESEARCH DESIGN Web-based survey experiment using a between-subjects design in which respondents were randomly assigned within education strata to view and respond to 1 of 16 hypothetical scenarios. SUBJECTS Adults recruited from an online panel constructed from a probability sample of US-based postal addresses. MEASURES The primary outcomes were the action the respondent would take next (i.e., contact a doctor immediately or something else) and the respondent's emotional reactions (i.e., all positive, all negative, mixed, or none). RESULTS A total of 4080 respondents had analyzable data. Although some effects were statistically significant (P < .05), none exceeded a prespecified threshold for policy relevance (15 or more percentage points). Ratings of letter clarity and level of understanding were lower for letters that included a description of the clinical trial. CONCLUSIONS Signatory and level of detail about collateral findings did not substantially affect people's intentions to take the recommended action of contacting their doctor. Deciding whether to include a description of the pragmatic clinical trial requires a trade-off between transparency and more difficulty understanding the contents of the letter.
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Affiliation(s)
- Kevin P Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC, 27701, USA.
| | - Juli M Bollinger
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Elizabeth May
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Gail Geller
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Debra J H Mathews
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stephanie R Morain
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Lorrie Schmid
- Social Science Research Institute, Duke University, Durham, NC, USA
| | - Diane L Bloom
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jeremy Sugarman
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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17
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Amtmann D, Bamer AM, Salem R, McMullen K, Beier M, Flynn KE, Foley FW, Weinfurt KP, Wilkie D, Alschuler KN. Extension and Evaluation of the PROMIS Sexual Function and Satisfaction Measures for Use in Adults Living With Multiple Sclerosis. J Sex Med 2022; 19:719-728. [PMID: 35367163 DOI: 10.1016/j.jsxm.2022.01.523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 01/20/2022] [Accepted: 01/24/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Sexual dysfunction is a common symptom of multiple sclerosis (MS). Clinically meaningful and psychometrically sound measures of sexual function validated in people with MS are necessary to identify people with MS who experience problems with sexual function. AIM To evaluate the Patient-Reported Outcomes Measurement Information System (PROMIS) Sexual Function and Satisfaction (SexFS) v2.0 measure in people with MS and to extend the PROMIS SexFS Brief and Full Profiles to include additional aspects of sexual function relevant to people living with MS. METHODS A convenience sample of MS clinicians and sexually active individuals with MS ranked relevance of 26 items that listed specific factors that interfere with sexual function. Rankings were used to select items to include in the modified SexFS for Multiple Sclerosis (SexFS-MS) profiles. Sex-FS Brief and Full profiles along with the top 22 ranked interfering factor items underwent cognitive interviews (CI) to assess whether the items were understandable and meaningful. OUTCOMES The SexFS as originally published functioned well in people with MS after minor modifications. RESULTS Twelve MS clinicians and 26 people with MS ranked items. The 10 highest ranked questions about factors that interfere with sexual function most relevant to people with MS were added to the SexFS-MS Brief profiles and 18 to the Full profiles. Ten men and 12 women with MS participated in CIs and found most items to be clear and meaningful. However, important changes were made to the profile instructions, some response sets, and to some items to improve clarity and function. New items to assess numbness and reasons why sexually active people choose at times not to engage in sexual activity were added. CLINICAL IMPLICATIONS Brief and Full profiles are freely available and are recommended for research and clinical practice that include people with MS. STRENGTHS & LIMITATIONS This study is the first to provide validity evidence for the PROMIS SexFS in people living with MS. Though the PROMIS SexFS was tested in people who identify as lesbian, gay, or bisexual, only individuals who identified as heterosexual participated in this study. Results may not represent views of people with MS who identify as other sexual orientations who may have different concerns and priorities related to sexual function. CONCLUSION This study extended the PROMIS SexFS Brief and Full profiles to create the SexFS-MS by adding items that measure most relevant issues related to sexual function in individuals living with MS. Amtmann D, Bamer AM, Salem R, et al. Extension and Evaluation of the PROMIS Sexual Function and Satisfaction Measures for Use in Adults Living With Multiple Sclerosis. J Sex Med 2022;19:719-728.
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Affiliation(s)
- Dagmar Amtmann
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA.
| | - Alyssa M Bamer
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Rana Salem
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Kara McMullen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Meghan Beier
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD, USA
| | - Kathryn E Flynn
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Frederick W Foley
- Holy Name Medical Center, Multiple Sclerosis Center, Teaneck, NJ, USA
| | - Kevin P Weinfurt
- Department of Population Health Sciences and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Dana Wilkie
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Kevin N Alschuler
- Department of Rehabilitation Medicine and Department of Neurology, University of Washington, Seattle, WA, USA
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18
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Weinfurt KP. Constructing and evaluating a validity argument for a performance outcome measure for clinical trials: An example using the Multi-luminance Mobility Test. Clin Trials 2022; 19:184-193. [PMID: 35102750 DOI: 10.1177/17407745211073609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Clinical trials that evaluate new medical products often use clinical outcome assessments to measure how patients feel or function. Determining the evidentiary support needed for clinical outcome assessments is challenging but necessary to ensure scores from a clinical outcome assessment reflect the relevant aspects of patients' health. Modern validity theory-from educational and psychological testing-addresses the challenge by requiring that investigators state key assumptions underlying the proposed use of a clinical outcome assessment and collect evidence for or against those assumptions. METHODS This article describes the argument-based approach to validity using an example of a performance outcome measure-the Multi-luminance Mobility Test-designed to assess patients with inherited retinal dystrophy that causes progressive loss of night vision. For the proposed interpretation and use of a performance outcome measure to be reasonable, several key assumptions need to be plausible. I describe the assumptions along with examples of supporting evidence from the published literature to evaluate each assumption within the rationale. RESULTS This article provides an example of a validity rationale to evaluate a clinical outcome assessment using the Multi-luminance Mobility Test as an example. CONCLUSION The demonstration illustrates the use of the argument-based approach to validity evaluation and the challenges in supporting parts of a validity rationale for clinical outcome assessments that measure how patients feel and function in a more indirect way. By making clinical outcome assessment validation practices consistent with modern validity theory, investigators, sponsors, and regulators should be able to communicate more clearly and direct resources more efficiently to support the creation of patient-centered endpoints in clinical trials.
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Affiliation(s)
- Kevin P Weinfurt
- Center for Health Measurement, Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
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19
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Schoenbeck KL, Atallah E, Lin L, Weinfurt KP, Cortes J, Deininger MWN, Kota V, Larson RA, Mauro MJ, Oehler VG, Pinilla-Ibarz J, Radich JP, Schiffer CA, Shah NP, Silver RT, Thompson JE, Flynn KE. Patient-Reported Functional Outcomes in Patients with Chronic Myeloid Leukemia after Stopping Tyrosine Kinase Inhibitors. J Natl Cancer Inst 2021; 114:160-164. [PMID: 34491344 DOI: 10.1093/jnci/djab184] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/14/2021] [Accepted: 09/02/2021] [Indexed: 12/20/2022] Open
Abstract
Treatment-free remission (TFR) is a goal for patients with chronic myeloid leukemia (CML). Functional outcomes after discontinuing Tyrosine Kinase Inhibitor (TKI) treatment have not been described. PROMIS patient-reported outcome measures (PROMs) of social, physical, cognitive, and sexual function were assessed over 36 months in 172 adult patients with chronic phase CML from 14 sites at baseline (on TKI) and after discontinuation. Linear mixed-effects models described the average trajectories for each PROM after discontinuation and in those who restarted TKI. Of 112 patients in TFR at 12 months, 103 (92.0%) had a ≥ 3-point improvement in social function, 80 (71.4%) in social isolation, 11 (9.8%) in satisfaction with sex life, 4 (3.6%) in physical function, and no patients had a ≥ 3-point improvement in cognitive function or interest in sexual activity. Patients' scores worsened after restarting TKI. This novel information on functional outcomes in TFR can help guide patient and clinician decision-making.
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Affiliation(s)
| | - Ehab Atallah
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Li Lin
- Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Jorge Cortes
- Georgia Cancer Center, Augusta University Medical Center, Augusta, Georgia, USA
| | | | - Vamsi Kota
- Georgia Cancer Center, Augusta University Medical Center, Augusta, Georgia, USA
| | - Richard A Larson
- Comprehensive Cancer Center, University of Chicago, Chicago, Illinois, USA
| | - Michael J Mauro
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Vivian G Oehler
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | | | - Jerald P Radich
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Charles A Schiffer
- Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Neil P Shah
- University of California San Francisco, San Francisco, California, USA
| | - Richard T Silver
- Weill Medical College of Cornell University, New York, New York, USA
| | - James E Thompson
- Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
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20
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Weinfurt KP. Analyzing and interpreting patient-reported outcome measures in clinical trials: comment on Collister et al. J Clin Epidemiol 2021; 140:202. [PMID: 34418545 DOI: 10.1016/j.jclinepi.2021.08.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 08/12/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Kevin P Weinfurt
- Center for Health Measurement, Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Suite 210, Durham NC 27701, USA..
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21
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Weinfurt KP. Generalizing from qualitative data as a moral activity: An example from regulatory decision making for medical products. Qualitative Psychology 2021. [DOI: 10.1037/qup0000180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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22
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Atallah E, Schiffer CA, Radich JP, Weinfurt KP, Zhang MJ, Pinilla-Ibarz J, Kota V, Larson RA, Moore JO, Mauro MJ, Deininger MWN, Thompson JE, Oehler VG, Wadleigh M, Shah NP, Ritchie EK, Silver RT, Cortes J, Lin L, Visotcky A, Baim A, Harrell J, Helton B, Horowitz M, Flynn KE. Assessment of Outcomes After Stopping Tyrosine Kinase Inhibitors Among Patients With Chronic Myeloid Leukemia: A Nonrandomized Clinical Trial. JAMA Oncol 2021; 7:42-50. [PMID: 33180106 DOI: 10.1001/jamaoncol.2020.5774] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Importance Tyrosine kinase inhibitors (TKIs) have been associated with improved survival of patients with chronic myeloid leukemia (CML) but are also associated with adverse effects, especially fatigue and diarrhea. Discontinuation of TKIs is safe and is associated with the successful achievement of treatment-free remission (TFR) for some patients. Objective To evaluate molecular recurrence (MRec) and patient-reported outcomes (PROs) after TKI discontinuation for US patients with CML. Design, Setting, and Participants The Life After Stopping TKIs (LAST) study was a prospective single-group nonrandomized clinical trial that enrolled 172 patients from 14 US academic medical centers from December 18, 2014, to December 12, 2016, with a minimum follow-up of 3 years. Participants were adults with chronic-phase CML whose disease was well controlled with imatinib, dasatinib, nilotinib, or bosutinib. Statistical analysis was performed from August 13, 2019, to March 23, 2020. Intervention Discontinuation of TKIs. Main Outcomes and Measures Molecular recurrence, defined as loss of major molecular response (BCR-ABL1 International Scale ratio >0.1%) by central laboratory testing, and PROs (Patient-Reported Outcomes Measurement Information System computerized adaptive tests) were monitored. Droplet digital polymerase chain reaction (ddPCR) was performed on samples with undetectable BCR-ABL1 by standard real-time quantitative polymerase chain reaction (RQ-PCR). Results Of 172 patients, 89 were women (51.7%), and the median age was 60 years (range, 21-86 years). Of 171 patients evaluable for molecular analysis, 112 (65.5%) stayed in major molecular response, and 104 (60.8%) achieved TFR. Undetectable BCR-ABL1 by either ddPCR or RQ-PCR at the time of TKI discontinuation (hazard ratio, 3.60; 95% CI, 1.99-6.50; P < .001) and at 3 months (hazard ratio, 5.86; 95% CI, 3.07-11.1; P < .001) was independently associated with MRec. Molecular recurrence for patients with detectable BCR-ABL1 by RQ-PCR was 50.0% (14 of 28), undetectable BCR-ABL1 by RQ-PCR but detectable by ddPCR was 64.3% (36 of 56), and undetectable BCR-ABL1 by both ddPCR and RQ-PCR was 10.3% (9 of 87) (P ≤ .001). Of the 112 patients in TFR at 12 months, 90 (80.4%) had a clinically meaningful improvement in fatigue, 39 (34.8%) had a clinically meaningful improvement in depression, 98 (87.5%) had a clinically meaningful improvement in diarrhea, 24 (21.4%) had a clinically meaningful improvement in sleep disturbance, and 5 (4.5%) had a clinically meaningful improvement in pain interference. Restarting a TKI resulted in worsening of PROs. Conclusions and Relevance In this study, TKI discontinuation was safe, and 60.8% of patients remained in TFR. Discontinuation of TKIs was associated with improvements in PROs. These findings should assist patients and physicians in their decision-making regarding discontinuation of TKIs. Detectable BCR-ABL1 by RQ-PCR or ddPCR at the time of TKI discontinuation was associated with higher risk of MRec; clinical application of this finding should be confirmed in other studies. Trial Registration ClinicalTrials.gov Identifier: NCT02269267.
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Affiliation(s)
- Ehab Atallah
- Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Charles A Schiffer
- Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, Michigan
| | - Jerald P Radich
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Kevin P Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Mei-Jie Zhang
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee
| | - Javier Pinilla-Ibarz
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Vamsi Kota
- Georgia Cancer Center, Augusta University Medical Center, Augusta
| | - Richard A Larson
- Department of Medicine and Comprehensive Cancer Center, University of Chicago, Chicago, Illinois
| | | | - Michael J Mauro
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael W N Deininger
- Division of Hematology and Hematologic Malignancies, Huntsman Cancer Institute, The University of Utah, Salt Lake City
| | - James E Thompson
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York
| | - Vivian G Oehler
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Martha Wadleigh
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Neil P Shah
- Department of Medicine, University of California at San Francisco, San Francisco
| | - Ellen K Ritchie
- Division of Medicine, Department of Medical Oncology and Hematology, Weill Medical College of Cornell University, New York, New York
| | - Richard T Silver
- Division of Medicine, Department of Medical Oncology and Hematology, Weill Medical College of Cornell University, New York, New York
| | - Jorge Cortes
- Georgia Cancer Center, Augusta University Medical Center, Augusta
| | - Li Lin
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Alexis Visotcky
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee
| | - Arielle Baim
- Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Jill Harrell
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Bret Helton
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mary Horowitz
- Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Kathryn E Flynn
- Department of Medicine, Medical College of Wisconsin, Milwaukee
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23
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Burgio KL, James AS, LaCoursiere DY, Mueller ER, Newman DK, Low LK, Weinfurt KP, Wyman JF, Cunningham SD, Vargo K, Connett J, Williams BR. Views of Normal Bladder Function Among Women Experiencing Lower Urinary Tract Symptoms. Urology 2020; 150:103-109. [PMID: 32841655 DOI: 10.1016/j.urology.2020.08.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/28/2020] [Accepted: 08/10/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To explore the perspectives of normal bladder function among women with lower urinary tract symptoms. METHODS This was a secondary analysis of qualitative data from structured interviews with 50 adult women with lower urinary tract symptoms. A directed content analysis of the transcripts explored women's perspectives on normal bladder function. RESULTS Participants' descriptions of "normal" took many forms and were based on several aspects of bladder function. A prominent feature of normal was that voiding occurred as a seamless process, beginning with an urge sensation, followed by voiding with ease and to completion, and then "being done." Descriptions of normal were based largely on concepts of voiding regularity, including voiding frequency, intervals, and patterns during the day and night. Another aspect of normal bladder function was the notion of having control in terms of not leaking urine, as well as the ability to hold urine and defer urination. Views of normal bladder function extended to the absence of symptoms and the impact of being symptom-free on day-to-day life, including not having to think about or worry about the bladder or limit daily activities. CONCLUSION Women's perspectives on normal bladder function are multifaceted, reflecting attributes most salient to each individual and likely informed by their personal experience with symptoms and their influence on daily life. This work has implications for how clinicians might engage women in discussing bladder symptoms and can inform future research and public health messaging about normal bladder function.
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Affiliation(s)
- Kathryn L Burgio
- University of Alabama at Birmingham School of Medicine, Birmingham, AL; Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham, AL.
| | - Aimee S James
- Washington University School of Medicine, St. Louis, MO
| | | | | | - Diane K Newman
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Lisa Kane Low
- University of Michigan School of Nursing, Ann Arbor, MI
| | | | - Jean F Wyman
- University of Minnesota, School of Nursing, Minneapolis, MN
| | | | - Keith Vargo
- University of Minnesota School of Public Health, Minneapolis, MN
| | - John Connett
- University of Minnesota School of Public Health, Minneapolis, MN
| | - Beverly Rosa Williams
- University of Alabama at Birmingham School of Medicine, Birmingham, AL; Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham, AL
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- National Institutes of Health (NIH), National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, MD
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Agochukwu-Mmonu N, Wiseman JB, Smith AR, Helmuth ME, Sarma AV, Cameron AP, Amundsen CL, Flynn KE, Cella D, Weinfurt KP, Kirkali Z, Clemens JQ. Relationship of symptom severity and bother in individuals seeking care for lower urinary tract symptoms. Neurourol Urodyn 2020; 39:2161-2170. [PMID: 32761962 DOI: 10.1002/nau.24466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 06/03/2020] [Accepted: 07/03/2020] [Indexed: 11/05/2022]
Abstract
AIMS Bother attributed to lower urinary tract symptoms (LUTS) drives care-seeking and treatment aggressiveness. The longitudinal relationship of LUTS severity and bother in a care-seeking cohort, however, is not well understood. We aim to conduct a longitudinal evaluation of LUTS severity and bother and identify characteristics of patients with discordant LUTS bother relative to severity. METHODS Men and women with LUTS seeking care at six US tertiary care centers enrolled in the symptoms of lower urinary tract dysfunction research network study. Patients reporting at least one urinary symptom based on the LUTS Tool were prospectively enrolled from June 2015 to January 2017. Correlations were used to assess the relationship between LUTS severity and bother. Discordance scores (ie, the difference between bother and severity) were used to classify patients with high and low bother. Patients were classified as having high or low bother phenotypes if scores were one standard deviation above or below zero, respectively. Repeated measures multinomial logistic regression evaluated characteristics associated with high and low bother phenotypes. RESULTS LUTS severity and bother were at least moderately correlated for all symptom items and highly correlated for 13 out of 21 items. Correlations were highest for urgency, and lowest for daytime frequency and urinary incontinence. Odds of being in high bother phenotype were lowest at 3 and 12 months (3 months vs baseline odds ratio [OR] = 0.71, 95% confidence ninterval [CI] = 0.54-0.94; 12 months vs baseline OR = 0.66, 95% CI = 0.48-0.91), and highest for those who endorsed all urgency questions (OR = 3.65, 95% CI = 2.17-6.13). Odds of being in the low bother phenotype were lowest for patients who endorsed all urgency items (OR = 0.33, 95% CI = 0.26-0.42), and all frequency items (OR = 0.68, 95% CI = 0.53-0.88). CONCLUSIONS LUTS severity and bother correlate highly and measurement of both in clinical practice is likely redundant. There are patient factors associated with discordance which may justify additional evaluation.
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Affiliation(s)
- Nnenaya Agochukwu-Mmonu
- Department of Urology, University of Michigan Health System, Ann Arbor, Michigan.,Michigan Medicine Department of Urology, Dow Division of Health Services Research, Ann Arbor, Michigan.,Department of Urology, New York University Langone Medical Center, New York, New York
| | | | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | - Aruna V Sarma
- Department of Urology, University of Michigan Health System, Ann Arbor, Michigan.,Michigan Medicine Department of Urology, Dow Division of Health Services Research, Ann Arbor, Michigan
| | - Anne P Cameron
- Department of Urology, University of Michigan Health System, Ann Arbor, Michigan
| | - Cindy L Amundsen
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Kathryn E Flynn
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David Cella
- Department of Medical Social Sciences, Northwestern University, Chicago, Illinois
| | - Kevin P Weinfurt
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - J Quentin Clemens
- Department of Urology, University of Michigan Health System, Ann Arbor, Michigan.,Michigan Medicine Department of Urology, Dow Division of Health Services Research, Ann Arbor, Michigan
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Flynn KE, Mansfield SA, Smith AR, Gillespie BW, Bradley CS, Cella D, Helmuth ME, Lai HH, Kirkali Z, Talaty P, Griffith JW, Weinfurt KP. Patient demographic and psychosocial characteristics associated with 30-day recall of self-reported lower urinary tract symptoms. Neurourol Urodyn 2020; 39:1939-1948. [PMID: 32856723 DOI: 10.1002/nau.24461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/09/2020] [Indexed: 11/09/2022]
Abstract
AIMS Measurement of self-reported lower urinary tract symptoms (LUTS) typically uses a recall period, for example, "In the past 30 days…." Compared to averaged daily reports, 30-day recall is generally unbiased, but recall bias varies by item. We examined the associations between personal characteristics (eg, age, symptom bother) and 30-day recall of LUTS using items from the Symptoms of Lower Urinary Tract Dysfunction Research Network Comprehensive Assessment of Self-reported Urinary Symptoms questionnaire. METHODS Participants (127 women and 127 men) were recruited from 6 US tertiary care sites. They completed daily assessments for 30 days and a 30-day recall assessment at the end of the study month. For each of the 18 tested items, representing 10 LUTS, the average of the participant's daily responses was modeled as a function of their 30-day recall, the personal characteristic, and the interaction between the 30-day recall and the characteristic in separate general linear regression models, adjusted for sex. RESULTS Nine items representing 7 LUTS exhibited under- or overreporting (recall bias) for at least 25% of participants. Bias was associated with personal characteristics for six LUTS. Underreporting of incontinence was associated with older age, lower anxiety, and negative affect; overreporting of other LUTS was associated with, symptom bother, symptom variability, anxiety, and depression. CONCLUSIONS We identified under- or overreporting that was associated with personal characteristics for six common LUTS. Some cues (eg, less bother and lower anxiety) were related to recall bias in an unexpected direction. Thus, providers should exercise caution when making judgments about the accuracy of a patient's symptom recall based on patient demographic and psychosocial characteristics.
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Affiliation(s)
- Kathryn E Flynn
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Brenda W Gillespie
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Catherine S Bradley
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - David Cella
- Department of Medical Social Sciences, Northwestern University, Chicago, Illinois
| | | | - H Henry Lai
- Division of Urologic Surgery, Washington University in St Louis, St Louis, Missouri
| | - Ziya Kirkali
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - Pooja Talaty
- NorthShore University Health System, Glenview, Illinois
| | - James W Griffith
- Department of Medical Social Sciences, Northwestern University, Chicago, Illinois
| | - Kevin P Weinfurt
- Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina
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Bennett AV, Jonsson M, Chen RC, Al-Khatib SM, Weinfurt KP, Curtis LH. Applying patient-reported outcome methodology to capture patient-reported health data: Report from an NIH Collaboratory roundtable. Healthc (Amst) 2020; 8:100442. [PMID: 32919581 DOI: 10.1016/j.hjdsi.2020.100442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/31/2020] [Indexed: 11/28/2022]
Abstract
Patient-reported health data provide information for pragmatic clinical trials that may not be readily available from electronic health records or administrative claims data. In this report, we present key considerations for collecting patient-reported health information in pragmatic clinical trials, which are informed by best practices from patient-reported outcome research. We focus on question design and administration via electronic data collection platforms with respect to 3 types of patient-reported health data: medication use, utilization of health care services, and comorbid conditions. We summarize key scientific literature on the accuracy of these patient-reported data compared with electronic health record data. We discuss question design in detail, specifically defining the concept to be measured, patient understanding of the concept, recall periods of the question, and patient willingness to report. In addition, we discuss approaches for question administration and data collection platforms, which are key aspects of successful patient-reported data collection.
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Affiliation(s)
- Antonia V Bennett
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, USA; Patient-Reported Outcomes Core, Cancer Outcomes Research Program, Lineberger Comprehensive Cancer Center, USA
| | - Mattias Jonsson
- Patient-Reported Outcomes Core, Cancer Outcomes Research Program, Lineberger Comprehensive Cancer Center, USA
| | - Ronald C Chen
- Department of Radiation Oncology, UNC School of Medicine, USA
| | - Sana M Al-Khatib
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Duke Clinical Research Institute, USA; Departments of Medicine, USA
| | - Kevin P Weinfurt
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Duke Clinical Research Institute, USA; Population Health Sciences, USA
| | - Lesley H Curtis
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Duke Clinical Research Institute, USA; Population Health Sciences, USA; Duke University School of Medicine, Durham, NC, USA.
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27
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Weinfurt KP. A Model to Be Emulated. Am J Bioeth 2020; 20:18-20. [PMID: 32364489 DOI: 10.1080/15265161.2020.1745949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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Flynn KE, Mansfield SA, Smith AR, Gillespie BW, Bradley CS, Cella D, Helmuth ME, Henry Lai H, Kirkali Z, Talaty P, Weinfurt KP. MP27-02 PERSONAL CHARACTERISTICS ASSOCIATED WITH 30-DAY RECALL OF SELF-REPORTED LOWER URINARY TRACT SYMPTOMS. J Urol 2020. [DOI: 10.1097/ju.0000000000000866.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Affiliation(s)
- Kevin P. Weinfurt
- The reviewer is at the Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
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30
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Affiliation(s)
- Kevin P Weinfurt
- Kevin P. Weinfurt, PhD, Duke University School of Medicine, Durham, NC; and Kathryn E. Flynn, PhD, Medical College of Wisconsin, Milwaukee, WI
| | - Kathryn E Flynn
- Kevin P. Weinfurt, PhD, Duke University School of Medicine, Durham, NC; and Kathryn E. Flynn, PhD, Medical College of Wisconsin, Milwaukee, WI
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Affiliation(s)
- Kevin P Weinfurt
- Center for Health Measurement, Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
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Affiliation(s)
- Rick Ostrander
- Department of Psychiatry Georgetown University Medical Center
| | - Kevin P. Weinfurt
- Department of Psychology and Department of Psychiatry Georgetown University
| | - W. Robert Nay
- Department of Psychiatry Georgetown University Medical Center
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Weinfurt KP. Viewing assessments of patient-reported heath status as conversations: Implications for developing and evaluating patient-reported outcome measures. Qual Life Res 2019; 28:3395-3401. [PMID: 31485914 DOI: 10.1007/s11136-019-02285-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2019] [Indexed: 10/26/2022]
Abstract
Patient-reported outcome measures (PROMs) are frequently used in research to reflect the patient's perspective. In this commentary, I argue that further improvements can be made in how we develop and evaluate PROMs by viewing assessment as a type of conversation. Philosophically speaking, a PROM assessment can be conceptualized as a formal conversation that serves as a model of an informal, longer, and more nuanced conversation with a research participant about their health experience. Psychologically speaking, evidence from research in survey methodology and discursive psychology shows that respondents to self-report measures behave in ways consistent with the idea that they are doing their best to participate in a conversation, albeit an unusual one. Several suggestions are offered for creating a better conversational context through study materials and PROM instructions, and by improving the yield of cognitive interviews. It is hoped that this commentary can stimulate further discussions in our field regarding how to integrate insights about the conversational nature of assessment from survey research and discursive psychology to better reflect the patient's voice in research.
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Affiliation(s)
- Kevin P Weinfurt
- Department of Population Health Sciences, Center for Health Measurement, Duke University Medical Center, 215 Morris Street, Suite 210, Durham, NC, 27701, USA.
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Weinfurt KP, Lin L, Sugarman J. Public views regarding the responsibility of patients, clinicians, and institutions to participate in research in the United States. Clin Trials 2019; 16:574-579. [PMID: 31256635 DOI: 10.1177/1740774519858917] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The need for more and better evidence to inform clinical decision making among all stakeholders has fueled calls for creating learning healthcare systems. The successful realization of a learning healthcare system seems to assume that various parties have a responsibility to participate in learning activities, including research. The objective of this study was to determine whether members of the general public perceive an ethical responsibility to participate in pragmatic clinical research that would be inherent to a learning health system. METHODS A total of 2994 English-speaking adults completed a nationally representative online survey. RESULTS About two-thirds of respondents were relatively neutral regarding a responsibility for themselves and others to participate in research; the remainder felt that they and others did not have a responsibility to participate in research. CONCLUSIONS Efforts to justify and develop a robust learning health system in an ethically acceptable fashion need to take these findings into account.
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Affiliation(s)
- Kevin P Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Li Lin
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Jeremy Sugarman
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
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Cella D, Smith AR, Griffith JW, Flynn KE, Bradley CS, Gillespie BW, Kirkali Z, Talaty P, Jelovsek JE, Helfand BT, Weinfurt KP. A new outcome measure for LUTS: Symptoms of Lower Urinary Tract Dysfunction Research Network Symptom Index-29 (LURN SI-29) questionnaire. Neurourol Urodyn 2019; 38:1751-1759. [PMID: 31225927 DOI: 10.1002/nau.24067] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 04/25/2019] [Accepted: 05/21/2019] [Indexed: 11/09/2022]
Abstract
AIMS To develop a representative, self-report assessment of lower urinary tract symptoms (LUTS) for men and women, the symptoms of Lower Urinary Tract Dysfunction Research Network Symptom Index-29 (LURN SI-29). METHODS Women and men seeking treatment for LUTS at one of six academic medical centers in the US were assessed at baseline, 3-month and 12-month intervals. Twelve-month data on 78 LURN SI-29 items were analyzed among 353 women and 420 men using exploratory factor analysis (EFA), with factor structure confirmed using confirmatory factor analysis (CFA). Internal consistency, reliability, and validity of the five developed scales were evaluated by assessing correlations with the American Urological Association Symptom Index (AUA-SI), the genitourinary pain index (GUPI), and the Pelvic Floor Distress Inventory-20 (PFDI-20), and by examining expected sex differences in scores. RESULTS EFA results (n = 150 women; 150 men) produced an interpretable eight-factor solution, with three of the factors comprised of dichotomous items addressing LUTS-associated sensations. The remaining five factors, confirmed with CFA in an independent sample of 473 participants, produced five scales: incontinence, urgency, voiding difficulty, bladder pain, and nocturia. Subscales and total LURN SI-29 scores were correlated as expected with AUA-SI, GUPI, and PFDI-20. LURN SI-29 scores also performed as expected in differentiating men from women based upon clinically expected differences, with men reporting more voiding difficulties and nocturia, and women reporting more urgency and incontinence. CONCLUSIONS The LURN SI-29 questionnaire has the potential to improve research and clinical outcome measurement for both men and women with LUTS.
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Affiliation(s)
- David Cella
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - James W Griffith
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Catherine S Bradley
- Department of Obstetrics and Gynecology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Brenda W Gillespie
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - Pooja Talaty
- NorthShore University Health System, Glenview, Illinois
| | - J Eric Jelovsek
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
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Abstract
Data documenting poor understanding among research participants and real-time efforts to assess comprehension in large-scale studies are focusing new attention on informed consent comprehension. Within the context of biobanking consent, we previously convened a multidisciplinary panel to reach consensus about what information must be understood for a prospective participant's consent to be considered valid. Subsequently, we presented them with data from another study showing that many U.S. adults would fail to comprehend the information the panel had deemed essential. When asked to evaluate the importance of the information again, panelists' opinions shifted dramatically in the direction of requiring that less information be understood. Follow-up interviews indicated significant uncertainty about defining a threshold of understanding and what should happen when prospective participants are unable to grasp key information. These findings have important implications for urgently needed discussion of whether consent comprehension is an ethical requirement or an ethical aspiration.
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Affiliation(s)
- Laura M. Beskow
- Center for Biomedical Ethics and Society and Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN USA
| | - Kevin P. Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC USA
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Sugarman J, Lin L, Baeten JM, Palanee-Phillips T, Brown ER, Matovu Kiweewa F, Mgodi NM, Nair G, Siva S, Seils DM, Weinfurt KP. Preventive Misconception and Risk Behaviors in a Multinational HIV Prevention Trial. AJOB Empir Bioeth 2019; 10:79-87. [PMID: 31002583 DOI: 10.1080/23294515.2019.1593257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Some HIV prevention research participants may hold a "preventive misconception" (PM), an overestimate of the probability or level of personal protection afforded by trial participation. However, these reports typically rely upon small, retrospective qualitative assessments that did not use a standardized approach. METHODS We administered a measure of PM called PREMIS, during Microbicide Trials Network 020-A Study to Prevent Infection with a Ring for Extended Use, a large, multicenter, placebo-controlled, phase III trial evaluating the safety and efficacy of a dapivirine vaginal ring among women at risk for HIV infection in Malawi, South Africa, Uganda, and Zimbabwe. The maximum follow-up period was 2.6 years. RESULTS One thousand two hundred sixty-one respondents completed PREMIS at their month 3 visit (M3); 2085 at their month 12 visit (M12); and 1010 at both visits. Most participants expressed high expectations of personal benefit (EPB) and that at least one of the rings used in the trial would reduce the risk of getting HIV (expectation of maximum aggregate benefit or EMAB). There was a moderate positive correlation between EPB and EMAB at M3 (r = .43, 95% CI: .37, .47) and M12 (r = .44, 95% CI: .40, .48). However, there was variability among sites in the strength of the relationship. There was no relationship between either expectation variable and condom use, adherence, or HIV infection. CONCLUSIONS A majority of trial participants expressed some belief that their risk of HIV infection would be reduced by using a vaginal ring, which may signal PM. However, such beliefs were not associated with adherence, condom use, or subsequent HIV infection, and there was variability across sites. Further work is needed to understand these findings.
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Affiliation(s)
- Jeremy Sugarman
- a Berman Institute of Bioethics and Department of Medicine , Johns Hopkins University , Baltimore , Maryland , USA
| | - Li Lin
- b Department of Population Health Sciences , Duke University School of Medicine , Durham , North Carolina , USA
| | - Jared M Baeten
- c Global Health, Epidemiology, and Medicine , University of Washington , Seattle , Washington , USA
| | - Thesla Palanee-Phillips
- d Wits Reproductive Health and HIV Institute, University of the Witwatersrand , Johannesburg , South Africa
| | - Elizabeth R Brown
- e Vaccine and Infectious Disease and Public Health Sciences Divisions, Fred Hutchinson Cancer Research Center and Department of Biostatistics , University of Washington , Seattle , Washington , USA
| | | | - Nyaradzo M Mgodi
- g University of Zimbabwe College of Health Sciences Clinical Trials Research Centre , Harare , Zimbabwe
| | - Gonasagrie Nair
- h Desmond Tutu HIV Centre , University of Cape Town , Cape Town , South Africa
| | - Samantha Siva
- i HIV Prevention Research Unit , South African Medical Research Council , Durban , South Africa
| | - Damon M Seils
- j Duke Clinical Research Institute , Durham , North Carolina , USA
| | - Kevin P Weinfurt
- b Department of Population Health Sciences , Duke University School of Medicine , Durham , North Carolina , USA
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Dickert NW, Scicluna VM, Adeoye O, Angiolillo DJ, Blankenship JC, Devireddy CM, Frankel MR, Goldkind SF, Kumar G, Ko YA, Mitchell AR, Nogueria RG, Parker RM, Patel MR, Riedford M, Silbergleit R, Speight CD, Spokoyny I, Weinfurt KP, Pentz RD. Emergency Consent: Patients' and Surrogates' Perspectives on Consent for Clinical Trials in Acute Stroke and Myocardial Infarction. J Am Heart Assoc 2019; 8:e010905. [PMID: 30663498 PMCID: PMC6497349 DOI: 10.1161/jaha.118.010905] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Emergent informed consent for clinical trials in acute myocardial infarction (AMI) and stroke is challenging. The role and value of consent are controversial, and insufficient data exist regarding patients’ and surrogates’ experiences. Methods and Results We conducted structured interviews with patients (or surrogates) enrolled in AMI or acute stroke trials at 6 sites between 2011 and 2016. Primary domains included trial recall, consent experiences, and preferences regarding involvement. Descriptive and test statistics were used to characterize responses and explore relationships between key domains and characteristics. Multivariable logistic regression was used to examine associations between key covariates and consent preferences. There were 176 (84 stroke, 92 AMI) completed interviews. Most stroke respondents (82%) were surrogates; all AMI respondents were patients. Average time from trial enrollment to interview was 1.9 years (stroke) and 2.8 years (AMI); 89% of stroke and 62% of AMI respondents remembered being in the trial, and among these respondents, 80% (stroke) and 44% (AMI) remembered reading some of the consent form. Over 90% reported not feeling pressure to enroll, being treated in a caring way, and being treated with dignity. A minority (16% stroke and 26% AMI) reported they would have preferred not to be asked for consent. Just over half (61% stroke and 53% AMI) recalled a postenrollment conversation about the study. Conclusions Most respondents felt they were treated respectfully and were glad they had been asked for consent. Trial recall was relatively low, and many respondents recalled little postenrollment discussion. Further development of context‐sensitive approaches to consent is important.
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Affiliation(s)
- Neal W Dickert
- 1 Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | | | - Opeolu Adeoye
- 5 Department of Emergency Medicine University of Cincinnati College of Medicine Cincinnati OH
| | - Dominick J Angiolillo
- 6 Division of Cardiology Department of Medicine University of Florida College of Medicine-Jacksonville Jacksonville FL
| | | | - Chandan M Devireddy
- 1 Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Michael R Frankel
- 2 Department of Neurology Emory University School of Medicine Atlanta GA
| | - Sara F Goldkind
- 8 Research and Clinical Bioethics Consultant Goldkind Consulting LLC Potomac MD
| | - Gautam Kumar
- 1 Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA.,9 Atlanta VA Medical Center Decatur GA
| | - Yi-An Ko
- 10 Department of Biostatistics and Bioinformatics Emory University Rollins School of Public Health Atlanta GA
| | - Andrea R Mitchell
- 1 Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Raul G Nogueria
- 2 Department of Neurology Emory University School of Medicine Atlanta GA
| | - Ruth M Parker
- 11 Department of Medicine Emory University School of Medicine Atlanta GA
| | - Manesh R Patel
- 12 Division of Cardiology Department of Medicine Duke University School of Medicine Durham NC
| | - Michele Riedford
- 14 Emory Healthcare Patient and Family Advisory Council Atlanta GA
| | - Robert Silbergleit
- 15 Department of Emergency Medicine University of Michigan Medical School Ann Arbor MI
| | - Candace D Speight
- 1 Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Ilana Spokoyny
- 16 Department of Neurology California Pacific Medical Center San Francisco CA
| | - Kevin P Weinfurt
- 13 Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - Rebecca D Pentz
- 3 Winship Cancer Institute Emory University School of Medicine Atlanta GA
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Andreev VP, Liu G, Yang CC, Smith AR, Helmuth ME, Wiseman JB, Merion RM, Weinfurt KP, Cameron AP, Lai HH, Cella D, Gillespie BW, Helfand BT, Griffith JW, DeLancey JOL, Fraser MO, Clemens JQ, Kirkali Z. Symptom Based Clustering of Women in the LURN Observational Cohort Study. J Urol 2018; 200:1323-1331. [PMID: 29990467 PMCID: PMC6298822 DOI: 10.1016/j.juro.2018.06.068] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2018] [Indexed: 11/17/2022]
Abstract
PURPOSE Women with lower urinary tract symptoms are often diagnosed based on a predefined symptom complex or a predominant symptom. There are many limitations to this paradigm as often patients present with multiple urinary symptoms which do not perfectly fit the preestablished diagnoses. We used cluster analysis to identify novel, symptom based subtypes of women with lower urinary tract symptoms. MATERIALS AND METHODS We analyzed baseline urinary symptom questionnaire data obtained from 545 care seeking female participants enrolled in the LURN (Symptoms of Lower Urinary Tract Dysfunction Research Network) Observational Cohort Study. Symptoms were measured with the LUTS (lower urinary tract symptoms) Tool and the AUA SI (American Urological Association Symptom Index), and analyzed using a probability based consensus clustering algorithm. RESULTS Four clusters were identified. The 138 women in cluster F1 did not report incontinence but experienced post-void dribbling, frequency and voiding symptoms. The 80 women in cluster F2 reported urgency incontinence as well as urgency and frequency but minimal voiding symptoms or stress incontinence. Cluster F3 included 244 women who reported all types of incontinence, urgency, frequency and mild voiding symptoms. The 83 women in cluster F4 reported all lower urinary tract symptoms at uniformly high levels. All but 2 of 44 LUTS Tool and 8 AUA SI questions significantly differed between at least 2 clusters (p <0.05). All clusters contained at least 1 member from each conventional group, including continence, and stress, urgency, mixed and other incontinence. CONCLUSIONS Women seeking care for lower urinary tract symptoms cluster into 4 distinct symptom groups which differ from conventional clinical diagnostic groups. Further validation is needed to determine whether management improves using this new classification.
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Affiliation(s)
| | - Gang Liu
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | | | - Robert M Merion
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | | | - H Henry Lai
- Washington University School of Medicine, St. Louis, Missouri
| | - David Cella
- Northwestern University Feinberg School of Medicine, Chicago
| | | | | | | | | | | | | | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
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Eluri S, Cross RK, Martin C, Weinfurt KP, Flynn KE, Long MD, Chen W, Anton K, Sandler RS, Kappelman MD. Correction to: Inflammatory Bowel Diseases Can Adversely Impact Domains of Sexual Function Such as Satisfaction with Sex Life. Dig Dis Sci 2018; 63:2816. [PMID: 30136046 DOI: 10.1007/s10620-018-5250-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The original version of the article unfortunately contained an error in Results section of Abstract.
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Affiliation(s)
- Swathi Eluri
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA.
| | - Raymond K Cross
- University of Maryland Medical Center, University of Maryland School of Medicine, 22 S Green St, Baltimore, MD, 21201, USA
| | - Christopher Martin
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Kevin P Weinfurt
- Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt St, Durham, NC, 27705, USA
| | - Kathryn E Flynn
- Medical College of Wisconsin, 9200 West Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Millie D Long
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Wenli Chen
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Kristen Anton
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Robert S Sandler
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
| | - Michael D Kappelman
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, 4119B Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7080, USA
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Atallah E, Schiffer CA, Weinfurt KP, Zhang MJ, Radich JP, Oehler VG, Pinilla-Ibarz J, Deininger MWN, Lin L, Larson RA, Mauro MJ, Moore JO, Ritchie EK, Shah NP, Silver RT, Wadleigh M, Cortes J, Thompson J, Guhl J, Horowitz MM, Flynn KE. Design and rationale for the life after stopping tyrosine kinase inhibitors (LAST) study, a prospective, single-group longitudinal study in patients with chronic myeloid leukemia. BMC Cancer 2018; 18:359. [PMID: 29609532 PMCID: PMC5879565 DOI: 10.1186/s12885-018-4273-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 03/20/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Treatment of chronic myeloid leukemia with a tyrosine kinase inhibitor (TKI) offers significant improvements over previous treatments in terms of survival and toxicity yet nevertheless is associated with reduced health-related quality of life and very high cost. Several small studies from Europe and Australia suggested that discontinuing TKIs with regular monitoring was safe. METHODS The Life After Stopping TKIs (LAST) study is a large, U.S.-based study that aims to improve the evidence for clinical decision making regarding TKI discontinuation with monitoring in patients with chronic myeloid leukemia who have a deep molecular response to TKI therapy. The LAST study is a non-randomized, prospective, single-group longitudinal study of 173 patients. The co-primary objectives are to determine the proportion of patients who develop molecular recurrence (> 0.1% BCR-ABLIS) after discontinuing one of four TKIs (imatinib, dasatinib, nilotinib, or bosutinib) and to compare the patient-reported health status of patients before and after stopping TKIs. Outcomes are assessed at baseline and throughout the 36-month study follow-up period with a central laboratory used for blood samples. All samples with undetectable BCR-ABL are also examined using digital polymerase chain reaction, which is a more sensitive nanofluidic polymerase chain reaction system. DISCUSSION Because of their high cost and side effects, discontinuation of TKIs for patients with chronic myeloid leukemia who have a deep molecular response to TKI therapy is a promising approach to treatment. The LAST study is the largest U.S.-based TKI discontinuation study. It is the first to allow participation from patients on any of 4 first- and second-generation TKIs, includes a robust approach to measurement of clinical and patient-reported outcomes, and is using digital polymerase chain reaction to explore better prediction of safe discontinuation. TRIAL REGISTRATION This study was registered prospectively on October 21, 2014 and assigned trial number NCT02269267 .
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MESH Headings
- Antineoplastic Agents/therapeutic use
- Clinical Protocols
- Fusion Proteins, bcr-abl/genetics
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnosis
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/psychology
- Longitudinal Studies
- Molecular Targeted Therapy
- Patient Reported Outcome Measures
- Protein Kinase Inhibitors/therapeutic use
- Quality of Life
- Recurrence
- Research Design
- Watchful Waiting
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Affiliation(s)
- Ehab Atallah
- Department of Medicine, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226 USA
| | - Charles A. Schiffer
- Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI USA
| | - Kevin P. Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC USA
| | - Mei-Jie Zhang
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI USA
| | - Jerald P. Radich
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA USA
| | - Vivian G. Oehler
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA USA
| | - Javier Pinilla-Ibarz
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL USA
| | - Michael W. N. Deininger
- Division of Hematology and Hematologic Malignancies, Huntsman Cancer Institute, The University of Utah, Salt Lake City, UT USA
| | - Li Lin
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC USA
| | - Richard A. Larson
- Department of Medicine and Comprehensive Cancer Center, University of Chicago, Chicago, IL USA
| | | | | | | | - Neil P. Shah
- Department of Medicine, University of California at San Francisco, San Francisco, CA USA
| | | | - Martha Wadleigh
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA USA
| | - Jorge Cortes
- University of Texas MD Anderson Cancer Center, Houston, TX USA
| | | | - Jessica Guhl
- Cancer Center, Medical College of Wisconsin, Milwaukee, WI USA
| | - Mary M. Horowitz
- Department of Medicine, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226 USA
| | - Kathryn E. Flynn
- Department of Medicine, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226 USA
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Dickert NW, Frankel M, Goldkind SF, Mitchell AR, Nogueira RG, Pentz RD, Silbergleit R, Speight CD, Weinfurt KP. Abstract WP307: Patients’ and Surrogates’ Experiences and Views of Consent in Acute Stroke Trials. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.wp307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Informed consent for clinical trials in acute stroke is challenging. Enrollment decisions must be made quickly, in stressful situations, and typically by a surrogate. Moreover, trials are complex and unfamiliar. Understanding patients’ and surrogates’ experiences may help maximize respect for them while facilitating important studies.
Methods:
Telephone interviews were conducted with consented patients or surrogates for patients enrolled in acute stroke trials at 3 US sites between 2011 and 2016. Interviews assessed trial recall, experiences with consent, and preferences regarding consent. Questions were primarily closed-ended. Descriptive statistics were calculated, and bivariate analyses (Fisher’s exact) were conducted to examine predictors of consent preference.
Results:
Eighty-four respondents (69 surrogates, 15 patients) across 3 sites and 10 trials were interviewed and included in final analysis. Nine did not recall enrollment, and only about half (53%) recalled that the trial involved an intervention. Of 75 respondents who remembered enrolling, 65 (87%) remembered signing a consent form, 52 (80%) of whom said they read at least some of it. Most respondents reported being treated respectfully during consent. Only 12 respondents (16%) wished they had been enrolled in the trial without prospective consent. Individuals with low health literacy were less likely to prefer enrollment without consent (p<0.0007) but more likely to wish they had not had to sign a consent form (p<0.0001). Forty-six (61%) recalled someone talking with them about the study after enrollment.
Conclusions:
Patients and surrogates in stroke trials reported mostly positive consent experiences and generally appreciated having been asked for consent prior to enrollment. Recall of trial details, however, was low, and post-enrollment contact was recalled to be somewhat infrequent. Further work may help to identify the most context-appropriate strategies.
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Dickert NW, Eyal N, Goldkind SF, Grady C, Joffe S, Lo B, Miller FG, Pentz RD, Silbergleit R, Weinfurt KP, Wendler D, Kim SYH. Reframing Consent for Clinical Research: A Function-Based Approach. Am J Bioeth 2017; 17:3-11. [PMID: 29148951 DOI: 10.1080/15265161.2017.1388448] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Although informed consent is important in clinical research, questions persist regarding when it is necessary, what it requires, and how it should be obtained. The standard view in research ethics is that the function of informed consent is to respect individual autonomy. However, consent processes are multidimensional and serve other ethical functions as well. These functions deserve particular attention when barriers to consent exist. We argue that consent serves seven ethically important and conceptually distinct functions. The first four functions pertain principally to individual participants: (1) providing transparency; (2) allowing control and authorization; (3) promoting concordance with participants' values; and (4) protecting and promoting welfare interests. Three other functions are systemic or policy focused: (5) promoting trust; (6) satisfying regulatory requirements; and (7) promoting integrity in research. Reframing consent around these functions can guide approaches to consent that are context sensitive and that maximize achievable goals.
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Affiliation(s)
| | - Nir Eyal
- b Harvard University T H Chan School of Public Health
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DeLamater JD, Weinfurt KP, Flynn KE. Patients' Conceptions of Terms Related to Sexual Interest, Desire, and Arousal. J Sex Med 2017; 14:1327-1335. [PMID: 29017897 PMCID: PMC5675768 DOI: 10.1016/j.jsxm.2017.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 08/04/2017] [Accepted: 09/09/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Measurement of sexual function typically uses self-report, which, to work as intended, must use language that is understood consistently by diverse respondents. Commonly used measures employ multiple terms, primarily (sexual) interest, desire, and arousal, that might not be understood in the same way by laypeople and professionals. AIM To inform self-reported measurement efforts for research and clinical settings by examining how US men and women recruited from a health care setting understand and interpret different terms. METHODS We conducted 10 focus groups in Durham, NC (N = 57). Discussions were audio-recorded and transcribed, and the content of the discussions was systematically analyzed in 2 phases of coding by the research team, facilitated by Nvivo qualitative analysis software (QSR International, Doncaster, VIC, Australia). OUTCOMES Patient focus group discussions about the meanings and connotations of multiple terms related to sexual function, especially interest, desire, and arousal. RESULTS 5 groups included male participants and 5 included female participants. Participants characterized (sexual) interest as a cognitive phenomenon and a situational response to a specific person. Similarly, they characterized (sexual) desire as a situational person-specific experience with some support for it as a cognitive phenomenon but more support for it as a physical phenomenon. In contrast, participants characterized sexual arousal as a physical phenomenon occurring in response to physical or visual stimulation and not related to a specific person. CLINICAL IMPLICATIONS These results can help us understand how laypeople are using and responding to these terms when they are used in clinical and research settings. STRENGTHS AND LIMITATIONS Patient participants in these groups were diverse in age, gender, sexual orientation, and health, with the potential to voice diverse perspectives on sexual functioning; however, the sample was limited to a single city in the southeastern United States. CONCLUSION The meanings of interest, desire, and arousal were defined, compared, and contrasted in the context of patient focus groups. Qualitative coding showed that interest was considered the most "cognitive," arousal the most "physical," and desire somewhere in between. DeLamater JD, Weinfurt KP, Flynn KE. Patients' Conceptions of Terms Related to Sexual Interest, Desire, and Arousal. J Sex Med 2017;14:1327-1335.
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Affiliation(s)
- John D DeLamater
- Department of Sociology, University of Wisconsin, Madison, WI, USA
| | - Kevin P Weinfurt
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Kathryn E Flynn
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
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Weinfurt KP, Hernandez AF, Coronado GD, DeBar LL, Dember LM, Green BB, Heagerty PJ, Huang SS, James KT, Jarvik JG, Larson EB, Mor V, Platt R, Rosenthal GE, Septimus EJ, Simon GE, Staman KL, Sugarman J, Vazquez M, Zatzick D, Curtis LH. Pragmatic clinical trials embedded in healthcare systems: generalizable lessons from the NIH Collaboratory. BMC Med Res Methodol 2017; 17:144. [PMID: 28923013 PMCID: PMC5604499 DOI: 10.1186/s12874-017-0420-7] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 08/31/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The clinical research enterprise is not producing the evidence decision makers arguably need in a timely and cost effective manner; research currently involves the use of labor-intensive parallel systems that are separate from clinical care. The emergence of pragmatic clinical trials (PCTs) poses a possible solution: these large-scale trials are embedded within routine clinical care and often involve cluster randomization of hospitals, clinics, primary care providers, etc. Interventions can be implemented by health system personnel through usual communication channels and quality improvement infrastructure, and data collected as part of routine clinical care. However, experience with these trials is nascent and best practices regarding design operational, analytic, and reporting methodologies are undeveloped. METHODS To strengthen the national capacity to implement cost-effective, large-scale PCTs, the Common Fund of the National Institutes of Health created the Health Care Systems Research Collaboratory (Collaboratory) to support the design, execution, and dissemination of a series of demonstration projects using a pragmatic research design. RESULTS In this article, we will describe the Collaboratory, highlight some of the challenges encountered and solutions developed thus far, and discuss remaining barriers and opportunities for large-scale evidence generation using PCTs. CONCLUSION A planning phase is critical, and even with careful planning, new challenges arise during execution; comparisons between arms can be complicated by unanticipated changes. Early and ongoing engagement with both health care system leaders and front-line clinicians is critical for success. There is also marked uncertainty when applying existing ethical and regulatory frameworks to PCTS, and using existing electronic health records for data capture adds complexity.
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Affiliation(s)
- Kevin P. Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, 220 W Main St., Suite 720A, Durham, NC 27705 USA
- Duke Clinical Research Institute, 2400 Pratt St., Durham, NC 27710 USA
- Department of Psychology and Neuroscience, Duke Clinical Research Institute, Durham, NC 27710 USA
| | - Adrian F. Hernandez
- Duke Clinical Research Institute, 2400 Pratt St., Durham, NC 27710 USA
- Duke University School of Medicine, 3115 N. Duke Street, Durham, NC 27704 USA
| | - Gloria D. Coronado
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR 97227-1098 USA
| | - Lynn L. DeBar
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR 97227-1098 USA
| | - Laura M. Dember
- Perelman School of MedicineBlockley Hall, Office 920, 423 Guardian Drive, Philadelphia, PA 19104 USA
| | - Beverly B. Green
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101-1466 USA
| | - Patrick J. Heagerty
- University of Washington, 325 Ninth Ave, Box 359728, Seattle, WA 98104-2499 USA
| | - Susan S. Huang
- University of California Irvine School of Medicine, 101 The City Drive South, City Tower, Suite 400, Mail Code: 4081, Orange, CA 92868 USA
| | - Kathryn T. James
- University of Washington, 325 Ninth Ave, Box 359728, Seattle, WA 98104-2499 USA
| | - Jeffrey G. Jarvik
- University of Washington, 325 Ninth Ave, Box 359728, Seattle, WA 98104-2499 USA
| | - Eric B. Larson
- Group Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101-1466 USA
| | - Vincent Mor
- Department of Community Health, Brown University, Box G-S121-2, Providence, RI 02912 USA
| | - Richard Platt
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, 401 Park Drive, Suite 401 East, Boston, MA 02215 USA
| | - Gary E. Rosenthal
- Department of Internal Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157 USA
| | - Edward J. Septimus
- Hospital Corporation of America Nashville TN, AND Texas A&M College of Medicine, One Park Plaza, Nashville, TN 37203 USA
| | - Gregory E. Simon
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101-1466 USA
| | | | - Jeremy Sugarman
- Johns Hopkins Berman Institute of Bioethics, 1809 Ashland Ave., Room 203, Baltimore, MD 21205 USA
| | - Miguel Vazquez
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8856 USA
| | - Douglas Zatzick
- University of Washington School of Medicine, 325 9th Ave, Seattle, WA 98104 USA
| | - Lesley H. Curtis
- Duke Clinical Research Institute, 2400 Pratt St., Durham, NC 27710 USA
- Duke University School of Medicine, 3115 N. Duke Street, Durham, NC 27704 USA
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Griffith JW, Messersmith EE, Gillespie BW, Wiseman JB, Flynn KE, Kirkali Z, Kusek JW, Bavendam T, Cella D, Kreder KJ, Nero JJ, Corona ME, Bradley CS, Kenton KS, Helfand BT, Merion RM, Weinfurt KP. Reasons for Seeking Clinical Care for Lower Urinary Tract Symptoms: A Mixed Methods Study. J Urol 2017; 199:528-535. [PMID: 28734864 DOI: 10.1016/j.juro.2017.07.067] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE The primary objective of this study was to evaluate reasons for seeking care among men and women with lower urinary tract symptoms. MATERIALS AND METHODS Participants were recruited from urology and urogynecology clinics, and the community. The sample was enriched with persons expected to have abnormal or diminished bladder sensations (eg participants with lower back surgery and participants 65 years old or older). Interviews were performed in person beginning with an open-ended assessment of urinary symptoms and associated bother followed by more directed questions, including reasons for seeking or not seeking treatment. We also examined the relationship between symptom frequency and bother using the LUTS (Lower Urinary Tract Symptoms) Tool. RESULTS A total of 88 participants, including 38 men and 50 women, with a mean ± SD age of 52.2 ± 14.3 years provided information about urinary symptoms, including a range of quality of life consequences and coping behaviors. They sought treatment mostly because of new, continuing or bothersome symptoms. Factors associated with not seeking treatment included low symptom severity and concerns about the costs vs the benefits of treatment (eg side effects of medication). Symptom frequency and bother were associated with each other across symptoms assessed by the LUTS Tool. CONCLUSIONS In this large qualitative study we obtained useful insights into the impact of lower urinary tract symptoms from the perspective of the person with the symptoms. Removing barriers and misconceptions about the treatment of lower urinary tract symptoms may increase the number of people who seek clinical care and improve the clinical course of men and women who experience lower urinary tract symptoms.
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Affiliation(s)
- James W Griffith
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | | | - Brenda W Gillespie
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | | | | | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - John W Kusek
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - Tamara Bavendam
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - David Cella
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Karl J Kreder
- University of Iowa Department of Urology, Iowa City, Iowa
| | | | - Maria E Corona
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Catherine S Bradley
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Kimberly S Kenton
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Robert M Merion
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
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Flynn KE, Lin L, Weinfurt KP. Sexual function and satisfaction among heterosexual and sexual minority U.S. adults: A cross-sectional survey. PLoS One 2017; 12:e0174981. [PMID: 28403193 PMCID: PMC5389646 DOI: 10.1371/journal.pone.0174981] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 03/19/2017] [Indexed: 12/03/2022] Open
Abstract
Background Despite known health disparities for sexual minorities, few studies have described sexual function by sexual orientation using a robust approach to measurement of sexual function. We compared recent sexual function and satisfaction by sexual orientation among English-speaking US adults. Methods and findings Cross-sectional surveys were administered by KnowledgePanel® (GfK), an online panel that uses address-based probability sampling and is representative of the civilian, noninstitutionalized US population. Data were collected in 2013 from the general population (n = 3314, 35% response rate) and in 2014 from self-identified lesbian, gay, and bisexual adults (n = 1011, 50% response rate). Sexual function and satisfaction were measured using the Patient-Reported Outcomes Measurement Information System® Sexual Function and Satisfaction measure version 2.0 (PROMIS SexFS v2). The PROMIS SexFS v2 is a comprehensive, customizable measurement system with evidence for validity in diverse populations. A score of 50 (SD 10) on each domain corresponds to the average for US adults sexually active in the past 30 days. We adjusted all statistics for the complex sample designs and report differences within each sex where the 95% CIs do not overlap, corresponding to p<0.01. Among US men who reported any sexual activity in the past 30 days, there were no differences in erectile function or orgasm-ability. Compared to heterosexual men, sexual minority men reported higher oral dryness and lower orgasm-pleasure and satisfaction. Compared to heterosexual men, gay men reported lower interest, higher anal discomfort and higher oral discomfort. Among sexually active women, there were no differences in the domains of vulvar discomfort-clitoral, orgasm-pleasure, or satisfaction. Compared to heterosexual women, sexual minority women reported higher oral dryness. Lesbian women reported lower vaginal discomfort than other women; lesbian women reported higher lubrication and orgasm-ability than heterosexual women. Bisexual women reported higher interest, higher vulvar discomfort-labial and higher anal discomfort than other women, as well as higher oral discomfort compared to heterosexual women. Conclusions Recent sexual function and satisfaction differed by sexual orientation among US adults. Sexual minority men and women had decrements in domains of sexual function that have not traditionally been included in multi-dimensional self-report measures. Clinicians should make themselves aware of their patients’ sexual concerns and recognize that sexual minority patients may be more vulnerable to certain sexual difficulties than heterosexual patients.
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Affiliation(s)
- Kathryn E. Flynn
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
- * E-mail:
| | - Li Lin
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Kevin P. Weinfurt
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States of America
- Department of Psychiatry and Behavioral Sciences Duke University School of Medicine, Durham, North Carolina, United States of America
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Flynn KE, Carter J, Lin L, Lindau ST, Jeffery DD, Reese JB, Schlosser BJ, Weinfurt KP. Assessment of vulvar discomfort with sexual activity among women in the United States. Am J Obstet Gynecol 2017; 216:391.e1-391.e8. [PMID: 27988269 DOI: 10.1016/j.ajog.2016.12.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 12/01/2016] [Accepted: 12/07/2016] [Indexed: 01/23/2023]
Abstract
BACKGROUND Multidimensional self-report measures of sexual function for women do not include the assessment of vulvar discomfort, limiting our understanding of its prevalence. In an effort to improve the measurement of patient-reported health, the National Institutes of Health funded the creation of the Patient Reported Outcomes Measurement Information System (PROMIS). This included the development of the PROMIS Sexual Function and Satisfaction measure, and version 2.0 of the Sexual Function and Satisfaction measure included 2 scales to measure vulvar discomfort with sexual activity. OBJECTIVES The objectives of the study were to describe the development of 2 self-reported measures of vulvar discomfort with sexual activity, describe the relationships between these scales and scales for lubrication and vaginal discomfort, and report the prevalence of vulvar discomfort with sexual activity in a large, nationally representative sample of US women. STUDY DESIGN We followed PROMIS measure development standards, including qualitative development work with patients and clinicians and psychometric evaluation of candidate items based on item response theory, in a probability sample of 1686 English-speaking US adult women. We tested 16 candidate items on vulvar discomfort. We present descriptive statistics for these items, correlation coefficients among the vulvar and vaginal scales, and mean PROMIS scores with 95% confidence intervals separately by menopausal status for the 1046 women who reported sexual activity in the past 30 days. RESULTS Based on the psychometric evaluation of the candidate items, we created 2 separate 4 item scales, one to measure labial discomfort and pain and one to measure clitoral discomfort and pain. Additional items not included in the scales assess pain quality, numbness, and bleeding. The correlations between the lubrication, vaginal discomfort, and the 2 vulvar discomfort measures ranged from 0.46 to 0.77, suggesting that these measures represent related yet distinct concepts. In our nationally representative sample, 1 in 5 US women endorsed some degree of vulvar discomfort with sexual activity in the past 30 days. Menopausal status was associated with lower lubrication and higher vaginal discomfort but not with vulvar discomfort. CONCLUSION The PROMIS Vulvar Discomfort with Sexual Activity-Labial and Vulvar Discomfort with Sexual Activity-Clitoral scales are publicly available for use in research and clinical settings. There is limited overlap between vulvar discomfort and lubrication or vaginal discomfort. The importance of measuring vulvar discomfort as part of a comprehensive assessment of sexual function is underscored by its prevalence.
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Affiliation(s)
- Kathryn E Flynn
- Center for Patient Care and Outcomes Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI.
| | - Jeanne Carter
- Departments of Surgery and Psychiatry, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Li Lin
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Stacy T Lindau
- Departments of Obstetrics-Gynecology and Medicine-Geriatrics, University of Chicago, Chicago, IL
| | - Diana D Jeffery
- Defense Health Agency, Department of Defense-Health Affairs, Falls Church, VA
| | - Jennifer Barsky Reese
- Cancer Prevention and Control Program, Fox Chase Cancer Center, Philadelphia, PA; Department of Social and Behavioral Sciences, College of Public Health, Temple University, Philadelphia, PA
| | - Bethanee J Schlosser
- Departments of Dermatology and Obstetrics-Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Kevin P Weinfurt
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC
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Affiliation(s)
- Kevin P Weinfurt
- Duke Clinical Research Institute, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
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