Development of an Item Bank to Assess Patient-Reported Outcomes: Signs, Symptoms, and Impacts of COVID-19

BACKGROUND AND OBJECTIVE

Patients experience a wide range of signs, symptoms, and impacts related to coronavirus disease 2019 (COVID-19). A patient-reported outcome (PRO) item bank that measures the most relevant patient experiences is needed to fully evaluate treatment benefit in COVID-19 clinical trials.

METHODS

A review of the literature and social media informed a novel PRO item bank of COVID-19 signs, symptoms, and impacts and general pandemic impacts. Twenty 1:1 concept elicitation and cognitive debriefing interviews were conducted with adults in the US who had symptomatic COVID-19. A conceptual model was developed and the PRO item bank refined following interviews.

RESULTS

A heterogenous set of signs, symptoms, and impacts of COVID-19, as well as impacts associated with the pandemic overall, was identified. Fifty-five short-term and long-term signs and symptom items, 26 items assessing disease-related impacts, and seven items evaluating pandemic-related impacts are included in the item bank.

CONCLUSIONS

The novel and preliminarily content-valid IQVIA COVID-19 Daily Diary Item Bank^© and the IQVIA COVID-19 Weekly Diary Item Bank^© were developed to measure signs and symptoms, their associated severity, and disease-related and pandemic-related impacts. The items are arranged in seven groups and can be individually selected based on research needs.

Qualitative interviews to improve patient-reported outcome measures in late-onset Pompe disease: the patient perspective

Background

Late-onset Pompe Disease (LOPD) is a rare, heterogeneous disease manifested by a range of symptoms varying in severity. Research establishing the frequency of these symptoms and their impact on patients’ daily lives is limited. The objective of this study was to develop a conceptual model that captures the most relevant symptoms and functional limitations experienced by patients with LOPD, to inform the development of new patient-reported outcome (PRO) tools.

Methods

A preliminary conceptual model was constructed following a literature review and revised through interviews with expert clinicians to identify important and relevant concepts regarding symptoms and impacts of LOPD. This preliminary model informed the development of a qualitative patient interview guide, which was used to gather the patient perspective on symptoms and impacts relating to LOPD or its treatment (including symptom/impact frequency and levels of disturbance). Patient interviews aided further refinement of the conceptual model. The findings from the patient interviews were triangulated with the literature review and clinician interviews to identify the most relevant and significant effects of LOPD from the patient perspective.

Results

Muscle weakness, fatigue, pain, and breathing difficulties (especially while lying down) were the most common and highly disturbing symptoms experienced by patients. Limitations associated with mobility (e.g., difficulty rising from a sitting position, getting up after bending) and activities of daily living, (e.g., reduced ability to participate in social/family activities or work/study) were the most frequently reported impacts with the highest levels of disturbance on the patient’s daily life. These identified symptoms and impacts were included in the new conceptual model of disease.

Conclusions

This qualitative patient interview study, also informed by a literature review and clinician interviews, identified the most frequent and relevant symptoms and the functional impact of LOPD on patients. The study interviews also captured the patient-preferred language to describe symptoms and impacts of LOPD. The results from this study can be used to develop future PRO instruments that are tailored to the specific symptoms and impacts experienced by patients with LOPD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-021-02067-x.

Patient Global Impression of Benefit-Risk (PGI-BR): Incorporating Patients' Views of Clinical Benefit-Risk into Assessment of New Medicines

INTRODUCTION

There is a need to understand how patients assess perceived benefits and risks of treatments.

OBJECTIVES

The study aimed to (i) elucidate how patients evaluate treatment experiences and (ii) develop a brief patient-reported outcome (PRO) instrument for use across disease areas for perceived benefit-risk evaluation of a new medicine in a clinical trial setting.

METHODS

Concepts relating to patient-perceived benefit-risk were identified from literature reviews and qualitative concept elicitation interviews with patients across a variety of primary medical conditions. Draft instrument items were developed from identified concepts and evaluated for clarity, relevance and appropriateness of response options in cognitive interviews. Items were iteratively revised to address patient feedback.

RESULTS

Qualitative interviews were conducted with 47 patients (primary condition: 20 oncological, 12 respiratory, 10 metabolic, 5 cardiovascular), of whom 32 contributed to concept elicitation and 42 to cognitive debriefing. Elicited concepts could be grouped into four medication-related categories: effectiveness of treatment, burden of side effects, convenience of use and overall acceptance/satisfaction. Cost, trial experience and altruism were additional concept categories unrelated to medication. The final instrument contained one item each on the medication's effectiveness, side effects and convenience, and an overall item capturing patient benefit-risk assessment. An upfront question was included to separate out non-medication aspects of patients' experiences.

CONCLUSION

We developed a brief PRO instrument, the Patient Global Impression of Benefit-Risk (PGI-BR), which can be applied across disease areas to assess patient views of benefit-risk of a new medicine in the clinical trial setting.

The patient's perspective on treatment with dacomitinib: patient-reported outcomes from the Phase III trial ARCHER 1050

Aim: Patient-reported symptoms, functioning and overall quality of life (QoL) were compared between dacomitinib and gefitinib in ARCHER 1050. Patients & methods: Patients (n = 448) with advanced EGFR mutation-positive non-small-cell lung cancer completed the EORTC-QLQ-C30 questionnaire and its lung-specific module, LC-13. Mean scores over time were analyzed using a mixed model for repeated measures. Results: Both treatments showed early improvement in disease-related symptoms that was maintained during treatment. Treatment-related diarrhea and sore mouth decreased following dose reduction with dacomitinib. There were no clinically meaningful changes in functioning and overall QoL in either treatment group. Conclusion: Longer treatment duration, enabled by dose reduction, allowed patients on dacomitinib to improve treatment-related symptoms and maintain functioning and overall QoL for longer than gefitinib.

Adjuvant sunitinib in patients with high-risk renal cell carcinoma: safety, therapy management, and patient-reported outcomes in the S-TRAC trial

Background

Adjuvant sunitinib has significantly improved disease-free survival versus placebo in patients with renal cell carcinoma at high risk of recurrence post-nephrectomy (hazard ratio 0.76; 95% confidence interval, 0.59–0.98; two-sided P = 0.03). We report safety, therapy management, and patient-reported outcomes for patients receiving sunitinib and placebo in the S-TRAC trial.

Patients and methods

Patients were stratified by the University of California, Los Angeles Integrated Staging System and Eastern Cooperative Oncology Group performance status score, and randomized (1 : 1) to receive sunitinib (50 mg/day) or placebo. Single dose reductions to 37.5 mg, dose delays, and dose interruptions were used to manage adverse events (AEs). Patients’ health-related quality of life, including key symptoms typically associated with sunitinib, were evaluated with the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30).

Results

Patients maintained treatment for 9.5 (mean, SD 4.4) and 10.3 (mean, SD 3.7) months in the sunitinib and placebo arms, respectively. In the sunitinib arm, key AEs occurred ∼1 month (median) after start of treatment and resolved within ∼3.5 weeks (median). Many (40.6%) AEs leading to permanent discontinuation were grade 1/2, and most (87.2%) resolved or were resolving by 28 days after last treatment. Patients taking sunitinib showed a significantly lower EORTC QLQ-C30 overall health status score versus placebo, although this reduction was not clinically meaningful. Patients reported symptoms typically related to sunitinib treatment with diarrhea and loss of appetite showing clinically meaningful increases.

Conclusions

In S-TRAC, AEs were predictable, manageable, and reversible via dose interruptions, dose reductions, and/or standard supportive medical therapy. Patients on sunitinib did report increased symptoms and reduced HRQoL, but these changes were generally not clinically meaningful, apart from appetite loss and diarrhea, and were expected in the context of known sunitinib effects.

Clinical trial registration

ClinicalTrials.gov, NCT00375674.

Prospective development of a patient-reported outcomes instrument for desmoid tumors or aggressive fibromatosis

BACKGROUND

Desmoid tumors (or aggressive fibromatosis) are locally infiltrative connective-tissue tumors that can arise in any anatomic location; they can be asymptomatic, or they can result in pain, deformity, swelling, and loss of mobility and/or threaten visceral organs with bowel perforation, hydronephrosis, neurovascular damage, and other complications. Existing clinical trial endpoints such as the Response Evaluation Criteria in Solid Tumors (version 1.1) and progression-free survival are inadequate in capturing treatment efficacy. This study was designed to develop a novel clinical trial endpoint by capturing patient-reported outcomes (PROs).

METHODS

Following best practices in qualitative methodology, this study used concept elicitation (CE) interviews to explore desmoid patients' perspectives on key disease-related symptoms and impacts. Qualitative analysis was performed to determine the relative frequency and disturbance of symptoms and impacts as well as other characteristics of these concepts. A draft PRO scale was then developed and tested with cognitive interviewing. Information from the interviews was subsequently incorporated into the refined PRO scale.

RESULTS

CE interviews with desmoid patients (n = 31) helped to identify salient concepts and led to a draft scale that included symptom and impact scales. Cognitive interviews were completed with additional patients (n = 15) across 3 phases. Patient input was used to refine instructions, revise and/or remove items, and modify the response scale. This resulted in an 11-item symptom scale and a 17-item impact scale.

CONCLUSIONS

This is the first disease-specific PRO instrument developed for desmoid tumors. The instrument is available as an exploratory endpoint in clinical trials. This study highlights the feasibility and challenges of developing PRO instruments for rare diseases.

Symptoms and Impacts in Metastatic Castration-Resistant Prostate Cancer: Qualitative Findings from Patient and Physician Interviews

BACKGROUND

There is little information available on health-related quality of life in patients with chemotherapy-naïve metastatic castration-resistant prostate cancer. This study aimed to develop a conceptual model that describes patients' experiences of living with this condition.

METHODS

This was a cross-sectional, non-interventional qualitative research study. Sixty-minute semi-structured interviews were conducted with physicians experienced in treating metastatic castration-resistant prostate cancer and with chemotherapy-naïve patients with metastatic castration-resistant prostate cancer. Interviews were audio-recorded and transcripts were analysed to identify the key symptoms and impacts on quality of life. Results were used to expand a previously published conceptual model for non-metastatic castration-resistant prostate cancer.

RESULTS

Three physicians and 19 patients with metastatic castration-resistant prostate cancer were interviewed. Physicians identified several symptoms frequently mentioned by their patients: fatigue, bone pain, anxiety, stress, depression and interference with daily activities. The most salient symptoms emerging from the patient interviews were urinary frequency and urgency, fatigue, pain/stiffness and sexual dysfunction. The most salient impacts were interference with daily activities, frustration, anxiety and sleep problems. Compared with non-metastatic castration-resistant prostate cancer, some symptoms and impacts in metastatic castration-resistant prostate cancer were more common and rated as more disturbing (e.g. fatigue, pain, urinary frequency, interference with daily activities and frustration). New concepts that were added to the non-metastatic castration-resistant prostate cancer model, to more accurately reflect the experiences of patients with metastatic disease, were enlarged breasts, muscle loss/deconditioning, inability to focus/mental slowing, body image perception, interference with work and lack of ambition/motivation.

CONCLUSIONS

Chemotherapy-naïve patients with metastatic castration-resistant prostate cancer experience a substantial burden from their condition. Furthermore, as castration-resistant prostate cancer progresses from the non-metastatic stage to the early metastatic (pre-chemotherapy) stage, certain symptoms become more common and disturb patients' lives to a greater extent. The resulting conceptual model for metastatic castration-resistant prostate cancer highlights areas that are not adequately assessed with current patient-reported outcome instruments.

The Potential Role of Individual-Level Benefit-Risk Assessment in Treatment Decision Making: A DIA Study Endpoints Community Workstream

Benefit-risk assessment is the cornerstone of decision making in medical care, playing a critical role in bringing treatments to market by informing decisions regarding drug development, licensing and reimbursement, and informing treatment decisions made by health care professionals and patients in clinical practice. In regulatory approval decision making, benefit and risk attributes are identified and defined based on available, aggregated clinical data from registration trials. In the context of major developments in recent years for involvement of patients as partners in all phases of drug development and in health care improvement, decision makers increasingly recognize the importance of informing treatment decisions by patient needs, values, experiences, and preferences. Using this as a basis, a DIA workstream was convened to explore the potential of individual-level benefit-risk assessment as a supplement to traditional group-level benefit-risk assessment for evaluating treatment. Various approaches as to how this information could be collected, including via patient-reported outcome measures, open-ended questioning, and stated-preference methods are presented. The utility of this information for various stakeholders is discussed.

Talking About Breast Cancer: Which Symptoms and Treatment Side Effects are Important to Patients with Advanced Disease?

BACKGROUND

Patients' experience of symptoms and associated treatment is an increasingly important consideration in both regulatory and health technology assessments, and can inform treatment decisions.

OBJECTIVE

This study aimed to gain insight directly from patients with advanced breast cancer about which symptoms and treatment side effects are important to them.

METHODS

Women with locally advanced or metastatic breast cancer were interviewed individually by trained interviewers, using a semi-structured interview guide. Verbatim transcripts were analyzed qualitatively, including whether symptoms were mentioned spontaneously (indicating their importance to patients) or only when questioned directly.

RESULTS

Sixteen women (aged 38-74 years) participated. The most commonly reported symptom aspects were: pain (16/16 [all reported spontaneously]); feeling tired/fatigued (15/16 [12 spontaneously]); changes in weight (15/16 [2 spontaneously]); hair loss (15/16 [5 spontaneously]); changes in appetite (11/16 [8 spontaneously]); nausea (9/16 [all spontaneously]). Pain was attributed mostly to the disease or to its treatment. Tiredness, changes in weight/appetite, and hair loss were attributed mostly to the treatment. All women (14 spontaneously) reported that the cancer affected their emotional well-being and their ability to perform daily activities.

CONCLUSIONS

Further qualitative research is needed to understand how patients distinguish cancer-related symptoms from treatment-related side effects, to gain insight into which patient experiences should be measured and how best to measure them.

Development and content validation of a patient-reported endometriosis pain daily diary

Background

Endometriosis is a common gynecological disorder that causes inflammation and pelvic pain. Endometriosis-related pain is best captured with patient-reported outcome (PRO) measures, however, assessment of endometriosis-related pain in clinical trials has been difficult in the absence of a reliable and valid PRO instrument. We describe the development of the Endometriosis Pain Daily Diary (EPDD), an electronic PRO developed as a survey instrument to assess endometriosis-related pain and its impact on patients’ lives.

Methods

The EPDD was initially developed on the basis of an existing Endometriosis Pain and Bleeding Diary, a targeted review of relevant literature, clinical expert interviews, and open-ended (concept elicitation) patient interviews in the United States (US) and Japan which captured patients’ experience with endometriosis. Cognitive interviews of patients with endometriosis were conducted to evaluate patient comprehension of the EPDD items. A conceptual model of endometriosis was developed, and meetings with US and European regulatory authorities provided feedback for validating the EPDD in the context of clinical trials. Translatability assessments of the EPDD were conducted to confirm its appropriate interpretation and ease of completion across 17 languages.

Results

The iterative development progressed through three versions of the instrument. The EPDDv1 included 18 items relating to dysmenorrhea/pelvic pain, dyspareunia and sexual activity, bleeding, hot flashes, daily activities, and use of rescue medication. The EPDDv2 was a larger 43-item survey tested in cognitive interviews and subsequently revised to yield the current 11-item EPDDv3, consisting of five core items relating to dysmenorrhea, non-menstrual pelvic pain, and dyspareunia, and six extension items relating to sexual activity, daily activities, and use of rescue medication.

Conclusions

The EPDD is a PRO for the evaluation of endometriosis-related pain and its associated impacts on patients’ lives. The EPDD represents an important step in providing a PRO that is relevant to patients with endometriosis-related pain in the context of a clinical study setting (ie, fit-for-purpose), designed to evaluate pain associated with endometriosis, including regulatory agency support for its further exploration in clinical trials.

Understanding polycystic ovary syndrome from the patient perspective: a concept elicitation patient interview study

BACKGROUND

The aim of this study was to explore the need for a new disease-specific patient reported outcome (PRO) measure for use in clinical trials of drugs designed to target the underlying causes of polycystic ovary syndrome (PCOS), and in the process contribute to our understanding of the symptoms and impacts that define the patient experience with PCOS.

METHODS

Semi-structured interviews were conducted in 20 women diagnosed with PCOS according to the Rotterdam criteria who had not menstruated in the previous month. The relative importance of PCOS symptoms and impact concepts to patients was determined by analyzing the frequency of their expression in the interview transcripts. These insights were compared to clinicians' perceptions of PCOS.

RESULTS

Pain- and discomfort-related symptoms accounted for the highest proportion (27.6%) of the 735 patient expressions, although clinicians did not consider pain to be important to patients with PCOS. The most frequently expressed individual symptoms were cramping (70% of patients; 14.7% of concepts), irregular menstruation (95% of patients; 12.2% of concepts), facial hair growth (75% of patients; 10.6% of concepts), heavy bleeding (70% of patients; 8.8% of concepts), infertility (70% of patients; 5.4% of concepts), and bloating (60% of patients; 5.2% of concepts). Cramping, heavy bleeding, and bloating were not identified by clinicians as being important to patients with PCOS. The impacts most frequently reported by patients with PCOS related to emotional well-being (e.g. anxiety/stress) and coping behaviors (e.g. acne medication, hair removal).

CONCLUSIONS

The only validated PCOS-specific PRO, the PCOSQ, does not capture some key PCOS symptoms and impacts expressed by patients with PCOS, most notably those related to pain and discomfort, bleeding intensity and coping behaviours. Furthermore, some key PCOS symptoms may be under-recognized in the clinic.

Prospective development of a patient reported outcomes (PRO) tool in desmoid tumors: A novel clinical trial endpoint

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Background: Desmoid tumors (DT) are locally aggressive and cause significant morbidity. Clinical trials in DT typically utilize response rates and progression free survival as primary endpoints. However, these endpoints do not capture improvements in clinical symptoms. To date, there are no validated PRO tools in DT to capture the patient experience and efficacy of a drug. Methods: A review of the published literature and interviews with sarcoma clinicians were used to formulate a list of signs and symptoms and impact on patients (pts). These were collected to build a conceptual model. DT pts (n = 31) with a range of anatomical locations and presentations were interviewed, initially in an open-ended fashion, followed by interrogating the conceptual model. For the concepts that pts reported, they were asked to rate how disturbing each was on a 0-10 scale (0 being not at all, and 10 being as bad as they can imagine). The pts interview data was then used to refine the conceptual model and generate two new PRO instruments Results: Pt interviews demonstrated that across tumor locations, the most frequent and disturbing symptoms were: ‘muscle’ pain (65% pts, median disturbance (MD) of 6.8), ‘nerve’ pain (73%, MD 6.0), and fatigue (65%, MD 5.0). Some symptoms were specific to tumor locations, especially abdominal tumors. Restricted range of motion (68%, MD 4.0), fear (84%, MD 6.5), sleep disturbance (77%, MD 7.5) , disfigurement (81%, MD 6.8), and impact on daily activities (65%, MD 6.8) were the most frequent and disturbing impact on pts lives. These concepts were then used to develop two new PRO instruments: the sign and symptom PRO includes 11 items; the impact on pts lives instrument includes 17 items. The instruments vary in asking pts about the last 24 hours, or the last week. Conclusions: This is the first validated PRO tool in DT. This tool adequately captures symptoms central to the DT pts experience and its impacts on their lives. The instruments are ready for implementation in a DT clinical trial for further evaluation of their measurement properties.

Development of a harmonized patient-reported outcome questionnaire to assess myelofibrosis symptoms in clinical trials

Along with reducing spleen size, relieving symptom severity is a key objective of the treatment of myelofibrosis (MF). Several questionnaires have been developed for patient self-report of MF symptoms in clinical trials and each includes unique instructions, items, and/or response scales. This variability in questionnaire content increases uncertainty; it is unclear which questionnaire is the most appropriate for assessing MF symptoms and it makes comparisons across trials difficult. The Patient-Reported Outcome (PRO) Consortium's MF Working Group (WG) was established to review existing MF symptom questionnaires and to develop a harmonized, consensus-based PRO questionnaire for use in future MF trials. The WG focused on the seven core symptoms of MF: fatigue, night sweats, pruritus, abdominal discomfort, pain under the ribs on the left side, early satiety, and bone pain. The resulting Myelofibrosis Symptom Assessment Form version 4.0 (MFSAF v4.0) asks respondents to report symptom severity at its worst for each of the seven items on a 0 (Absent) to 10 (Worst Imaginable) numeric rating scale. The MFSAF v4.0, for which there are 24-h and 7-day recall formats, will be maintained and licensed by the Critical Path Institute and made publicly available for use in future clinical trials.

Interactive Voice Response and Text-based Self-report Versions of the Electronic Columbia-Suicide Severity Rating Scale Are Equivalent

Objectives: Our study objective was to compare the equivalence of a new version of the electronic Columbia-Suicide Severity Rating Scale that was administered on a tablet device with the existing interactive voice response version in order to support the prospective monitoring of suicidal ideation and behavior in clinical trials and clinical practice. Design: This was a randomized, crossover-equivalence study with no treatment intervention. Setting: The study setting was a psychiatric hospital. Participants: Fifty-eight recently admitted psychiatric inpatients and 28 employees of the hospital site were included in the study. Mean age was 41.0 years (standard deviation=12.5), and 59 percent were female. Measurements: Participants completed both tablet and interactive voice response versions in randomized order, with a 25-minute break between administrations. Finally, participants completed a second administration of the first administered version. Intraclass correlation coefficients (ICCs) and Kappa coefficients were used to evaluate agreement across modalities. Results: High levels of agreement were observed for most severe lifetime (ICC=0.88) and recent (ICC=0.79) ideation, occurrence of actual lifetime (Kappa=0.81) and recent (Kappa=0.73) suicide attempts, and occurrence of lifetime interrupted attempts (Kappa=0.78), aborted attempts (Kappa=0.54), and preparatory behaviors (Kappa=0.77), as well as non-suicidal self-injurious behavior (Kappa=0.73). Scores from both modes significantly differentiated psychiatric patients and hospital employee controls, and the test-retest reliability of both modes was excellent. Conclusions: These results support the validity and reliability of the new tablet-based electronic Columbia-Suicide Severity Rating Scale. This will allow the inclusion of the electronic Columbia-Suicide Severity Rating Scale in a wider range of clinical studies, particularly where a tablet is also being used to collect other study data.

Content Validity for the VVSymQ® Instrument: A New Patient-Reported Outcome Measure for the Assessment of Varicose Veins Symptoms

BACKGROUND

Varicose veins are common and can impact patients' quality of life, but consensus regarding the evaluation of varicose vein symptoms is lacking and existing measures have limitations.

OBJECTIVE

This research aimed to develop and establish the content validity of a new electronic patient-reported outcome (PRO) measure, the VVSymQ® instrument, to assess symptoms of superficial venous insufficiency (varicose veins) in clinical trials.

METHODS

The development of the VVSymQ® instrument began with qualitative interviews with patients based on the symptom domain of the VEINES-QOL/Sym, an existing PRO instrument for chronic venous disorders of the leg. Three phases of qualitative research were conducted to examine the relevance and importance of the symptoms to patients with varicose veins, and the patients' ability to understand and use the VVSymQ® instrument. The development included evaluating questions that had 1-week and 24-h recall periods, and paper and electronic versions of the new instrument.

RESULTS

Five symptoms (heaviness, achiness, swelling, throbbing, and itching [HASTI™]) were consistently reported by patients across all sources of qualitative data. The final version of the VVSymQ® instrument queries patients on the HASTI™ symptoms using a 24-h recall period and a 6-point duration-based response scale ranging from "None of the time" to "All of the time," and is administered daily via an electronic diary. Cognitive interviews demonstrated varicose vein patients' understanding of and their ability to use the final version of the VVSymQ® instrument.

CONCLUSION

Content validity was established for the VVSymQ® instrument, which assesses the five HASTI™ symptoms of varicose veins daily via an electronic diary and has promise for use in research and practice.

Practical Considerations for the Use of Clinical Outcome Assessments (COAs) in Pediatric Clinical Research: Examples From Pediatric Gastroenterology

Clinical outcome assessments (COAs), including patient-reported outcome (PRO) measures, are routinely used in drug development and other clinical research initiatives to assess the impact of treatment on patient health and well-being. The FDA Guidance for Industry Patient-Reported Outcome Measures: Use in Medical Product Development to Support Labeling Claims (2009), the European Medicines Agency's Reflection Paper on the Regulatory Guidance for the Use of Health-Related Quality of Life Measures in the Evaluation of Medicinal Products (2005), and the International Society for Pharmacoeconomics and Outcomes Research PRO Good Research Practices for the Assessment of Children and Adolescence Task Force (2013) outline key considerations and good measurement principles that are relevant to the selection and use of COAs in a pediatric population. However, challenges remain in the appropriate selection and use of COAs to assess treatment benefit in pediatric clinical research. The purpose of this paper is to summarize proceedings from a panel presentation at the Critical Path Institute's 2015 Annual PRO Consortium Workshop. This paper underscores the importance of considering children's specific needs and the numerous challenges faced when developing and implementing well-defined and reliable COAs in pediatric clinical trials evaluating medical products, and describes some approaches to addressing these unique needs and challenges.

The Patient Perspective on Living with Acute Myeloid Leukemia

INTRODUCTION

Acute myeloid leukemia (AML) imposes significant burden on patients, their families, and the healthcare system. Published literature has reported many AML signs and symptoms, as well as their impact on patients. However, there are no publications on the experience of living with AML from the patient's perspective. In this study, we performed qualitative interviews with patients with AML to understand their experience.

METHODS

Participants were recruited from the US and Japan. All patients were screened to assess eligibility, and were divided into four subgroups (i.e., newly-diagnosed, high-intensity chemotherapy; newly-diagnosed, low-intensity chemotherapy; relapse/refractory; and post-transplant). Patients were interviewed over the phone by a trained researcher and asked about their day-to-day experience with AML. Signs/symptoms and impacts were coded, analyzed using Atlas.ti software, and reported as frequencies, with the medians of patient-reported disturbance levels (0-10) computed for each symptom and impact.

RESULTS

The most commonly reported sign/symptom in the US was fatigue (95.7%), followed by bruising and weakness (both 78.3%), and in Japan, nausea (94.4%), followed by fatigue and headache (both 88.9%). The most commonly reported impact in the US was a decreased ability to maintain social/familial roles (91.3%), followed by anxiety and a decreased ability to function (both 87.0%), and most commonly reported in Japan was anxiety, a decreased ability to function, and remission uncertainty (94.4%).

CONCLUSION

Although the frequency of signs/symptoms and their level of disturbance varied between the US and Japan, there was remarkable consistency in the types of signs/symptoms and impacts reported across all patients. The consistency in the experience of the disease across patients suggests that measurement of AML experience can be achieved by using the same tool for most, if not all, of these patients.

FUNDING

Astellas Pharma Inc., Northbrook, IL, USA.

The VVSymQ® instrument: Use of a new patient-reported outcome measure for assessment of varicose vein symptoms

Introduction

No existing patient-reported outcome instrument focuses solely on assessment of varicose veins symptoms that are bothersome to patients.

Methods

The VVSymQ® instrument is a five-item patient-reported outcome that assesses symptoms most important to patients with varicose veins (heaviness, achiness, swelling, throbbing and itching). This paper describes how the VVSymQ® instrument was incorporated into an electronic daily diary to monitor key outcomes over time and capture treatment benefit in two randomized, controlled, phase 3 clinical trials.

Results

Patients were highly compliant in completing the electronic daily diary, and the VVSymQ® instrument demonstrated ability to detect overall change and ability to detect change that is meaningful to patients.

Conclusion

The VVSymQ® instrument is a reliable, valid instrument responsive to measuring change in the patient experience of varicose vein symptoms pre- and post-intervention, and is uniquely focused on patient-reported symptoms compared with other widely used questionnaires completed by clinicians.

Electronic bladder diaries of differing duration versus a paper diary for data collection in overactive bladder

AIMS

This observational study compared data values, reliability, consistency and compliance collected by electronic and paper diaries of differing durations.

METHODS

Subjects ≥18 years with overactive bladder (OAB) on stable antimuscarinic treatment for ≥12 weeks were assigned to one of five, 15-week diary schedules in this randomized, parallel-group observational study. Sample size was sufficient to assess reliability and consistency of diary data with adequate precision. Reliability was assessed via intraclass correlation coefficients, variability with ANCOVAs, and consistency using Cronbach's alpha.

RESULTS

Demographic characteristics of randomized subjects were representative of OAB trial populations. For mean volume voided, reliability was comparable across diary groups. For incontinence, reliability improved with increasing diary duration. For micturition frequency, electronic 7-day diary results had highest reliability and lowest variability. Lowest overall reliability was observed in the 3-day paper diary. Consistency was highest in the electronic continuous groups; Cont A (daily measurements throughout the study period [fully Continuous]) and Cont B (daily measurements for some but not all endpoints of interest [Partially Continuous]). Compliance was generally high; across groups ≥90% of diaries had at least one entry per day. There was no significant change in average micturition frequency with diary duration, suggesting no diary fatigue. One-third of subjects in the electronic Cont B group also reported micturitions as incontinence when they only needed to report incontinence; they also reported lowest satisfaction with the study. The electronic 7-day and electronic Cont A schedules (who reported incontinence and micturitions throughout the study) had lowest residual errors.

CONCLUSIONS

For future OAB trials, 7-day or continuous electronic diaries may improve accuracy and reliability of micturition and incontinence frequency data compared with shorter collection periods and paper diaries. Neurourol. Urodynam. 35:743-749, 2016. © 2015 Wiley Periodicals, Inc.

PRO data collection in clinical trials using mixed modes: report of the ISPOR PRO mixed modes good research practices task force

The objective of this report was to address the use and mixing of data collection modes within and between trials in which patient-reported outcome (PRO) end points are intended to be used to support medical product labeling. The report first addresses the factors that should be considered when selecting a mode or modes of PRO data collection in a clinical trial, which is often when mixing is first considered. Next, a summary of how to "faithfully" migrate instruments is presented followed by a section on qualitative and quantitative study designs used to evaluate measurement equivalence of the new and original modes of data collection. Finally, the report discusses a number of issues that must be taken into account when mixing modes is deemed necessary or unavoidable within or between trials, including considerations of the risk of mixing at different levels within a clinical trial program and mixing between different types of platforms. In the absence of documented evidence of measurement equivalence, it is strongly recommended that a quantitative equivalence study be conducted before mixing modes in a trial to ensure that sufficient equivalence can be demonstrated to have confidence in pooling PRO data collected by the different modes. However, we also strongly discourage the mixing of paper and electronic field-based instruments and suggest that mixing of electronic modes be considered for clinical trials and only after equivalence has been established. If proceeding with mixing modes, it is important to implement data collection carefully in the trial itself in a planned manner at the country level or higher and minimize ad hoc mixing by sites or individual subjects. Finally, when mixing occurs, it must be addressed in the statistical analysis plan for the trial and the ability to pool the data must be evaluated to then evaluate treatment effects with mixed modes data. A successful mixed modes trial requires a "faithful migration," measurement equivalence established between modes, and carefully planned implementation to minimize the risk of increased measurement error impacting the power of the trial to detect a treatment effect.

Natural history of nicotine withdrawal

AIMS

To examine the natural history of nicotine withdrawal and individual differences associated with withdrawal duration and severity.

DESIGN AND SETTING

Prospective study of withdrawal symptoms among smokers who quit for at least 24 hours. Participants used Ecological Momentary Assessment to monitor symptoms in their natural environment using an Electronic Diary (ED).

PARTICIPANTS

A total of 214 cigarette smokers (59% female, 92% Caucasian).

INTERVENTION

All participants received a clinic-based, behavioral, group cessation intervention. Severity and duration of withdrawal was not addressed explicitly in treatment.

MEASUREMENTS

Participants were 'beeped' by the ED approximately five times/day to complete affect assessments (negative affect, arousal, attention disturbance, restlessness), and daily assessments of sleep disturbance (at waking) and of cognitive performance (each evening) for a week prior to quitting and for up to 21 days after quitting. Withdrawal was considered resolved when withdrawal scores returned to baseline levels for at least 2 consecutive days.

FINDINGS

All symptoms returned to baseline levels within 10 days of quitting. All variables except arousal and sleep disturbance showed change over time. No robust predictors of individual differences in withdrawal responses emerged.

CONCLUSIONS

The time-course of withdrawal may be shorter than previously reported. The natural history of nicotine withdrawal may have implications for theories of withdrawal and smoking relapse and for smoking cessation treatment.

Smoking patterns and dependence: contrasting chippers and heavy smokers

The authors used ecological momentary assessment to contrast smoking patterns among chippers (CHs; n = 26)--smokers who smoke despite an apparent absence of tobacco dependence--with those seen in heavy smokers (HSs; n = 28). Smoking and nonsmoking settings (activity, mood, etc.) were assessed by means of electronic diary. CHs were not social smokers; like HSs, they smoked half their cigarettes while alone. When smoking, CHs' urge levels equaled those of HSs; between cigarettes, CHs had few urges, whereas HSs reported moderate urges. CHs' smoking was particularly associated with indulgent activities: relaxation, socializing, eating, and drinking alcohol. Outside of these indulgent settings, CHs' (but not HSs') smoking was associated with negative affect. In idiographic analyses, CHs' smoking was under much stronger stimulus control than was that of HSs. The authors propose that the disappearance of stimulus control over use is a characteristic of dependence.

Prévalence de la plainte relative aux troubles du sommeil : Suivi de 205 347 sujets de 1988 à 1998

Primary healthcare checkups are regularly performed by French healthcare centers. We report analysis of sleep disorders complaint registered from 1988 to 1998 in Bordeaux-Cauderan and Cenon CPAM welfare centers. The prevalence of sleep disorders is estimated from a total of 205 347 checkups. The population is segmented by age (18-24: 19 332, 25-34:46 694, 35-44:51 072, 45-54:46 886, 55-64:32 658, 65 +:7 705), gender (male: 101 801; female: 103 546) and population category (general: 147 188, underprivileged: 22 785, prioritized: 35 374). Datas shows a relationship between sex and age. Surprisingly we found a relation between Buying Power for Net Wages and Prevalence of Sleep Complaint. There is a significant correlation (R(2)=0,718, p<0,0079). These data are in relationship with M. Ohayon findings relatively to low income and sleep complaint.

Reactivity to ecological momentary assessment: an example using undergraduate problem drinkers

A. A. Stone and S. Shiffman (1994) defined ecological momentary assessment (EMA) as monitoring or sampling strategies that assess phenomena at the moment they occur in natural settings, thus maximizing ecological validity while avoiding retrospective recall. To address the extent to which EMA affects the behaviors and cognitions under observation, the authors examined behavioral and motivational reactivity to EMA among male and female undergraduate problem drinkers (n = 33). Participants completed a 2-week monitoring protocol using palmtop computers as well as pre- and postmonitoring measures of their drinking behavior and motivation for change. The findings suggest that the magnitude of reactivity to EMA is small. Suggestions for future research are presented.

Are prescribed medications effective in the treatment of insomnia complaints?

Although frequently investigated in the general population, the epidemiology of insomnia complaints and their treatment have received little attention in general practice. This study recruited patients > or =15 years of age, consecutively, from 127 general practitioners in France. The physicians collected data from 11,810 of their patients, of whom 55.5% were women. Insomnia complaints were reported by 26.2% (25.4% to 27%) of the sample and use of sleep-promoting medication by 10.1% (9.7% to 10.7%). About 47% of the prescribed drugs used were anxiolytics and 45% hypnotics. Most consumers took sleep-enhancing drugs on a daily and long-term basis and most reported that the medication improved their quality of sleep. However, few distinctions emerged between elderly drug-taking insomniacs and elderly nontreated insomniacs with respect to the various dimensions of sleep. Results underscore the persistent general tendency among French general practitioners to overprescribe anxiolytics for the treatment of insomnia complaints and that they do so on a long-term basis, despite the findings of numerous studies showing that benzodiazepines are ineffective in the treatment of sleep complaints over the long term.

Improvement predictors in obsessive-compulsive disorder. An event-related potential study

The treatment of patients with obsessive-compulsive disorder gives variable and unpredictable results. Numerous clinical features have been investigated as potential predictors of medication response but without consistent results. Preliminary findings have shown that some impairments of pre-treatment event-related potentials (ERPs) could be associated with future treatment outcome (Morault et al., 1997). The present study aimed to confirm the relationships between ERPs and treatment efficacy with larger sample sizes. ERP components were elicited during a verbal auditory 'oddball' paradigm and were recorded in 21 unmedicated patients compared to 21 control subjects. After a pharmacological treatment, the disorder improved in 12 patients. Pre-treatment ERP data were retrospectively compared between treatment responders, non-responders and control subjects. Patients who were to respond favorably to treatment had significantly reduced N2 amplitude and shorter N2 and P3 latencies compared to non-responders and control subjects. In contrast, no difference was shown between non-responders and control subjects. Our findings provide evidence for abnormalities of ERPs which could be considered as potential predictors of treatment response in patients with OCD. These results need to be tested in a prospective protocol.

A comparison of coping assessed by ecological momentary assessment and retrospective recall

Recent research suggests that retrospective coping assessments may not correspond well with day-to-day reports. The authors extended this work by examining the correspondence between short-term (within 48 hr) retrospective coping reports and momentary reports recorded via a palm-top computer close in time to when the stressor occurred. There was relatively poor correspondence between the 2 assessments. Some reports of momentary coping were not reported retrospectively, and some coping reported retrospectively was not reported at the time the stressor occurred. Cognitive coping was more likely to be underreported retrospectively; behavior coping was overreported. Participants were consistent in their discrepancies, but there was no correspondence between discrepancy rates and demographic or personality variables.

A comparison of coping assessed by ecological momentary assessment and retrospective recall

Recent research suggests that retrospective coping assessments may not correspond well with day-to-day reports. The authors extended this work by examining the correspondence between short-term (within 48 hr) retrospective coping reports and momentary reports recorded via a palm-top computer close in time to when the stressor occurred. There was relatively poor correspondence between the 2 assessments. Some reports of momentary coping were not reported retrospectively, and some coping reported retrospectively was not reported at the time the stressor occurred. Cognitive coping was more likely to be underreported retrospectively; behavior coping was overreported. Participants were consistent in their discrepancies, but there was no correspondence between discrepancy rates and demographic or personality variables.

[Propriospinal myoclonus induced by relaxation and drowsiness]

Propriospinal myoclonus is a subtype of spinal myoclonus characterized by axial flexion or extension jerks, arrhythmic and prolonged muscle bursts with a pattern of activation consistent with a slow conduction within the propriospinal pathways. We describe a new idiopathic case of flexion propriospinal myoclonus occurring upon relaxation and drowsiness. This syndrome is to be added to the spectrum of movement disorders occurring during drowsiness.

Psychophysiological and clinical value of event-related potentials in obsessive-compulsive disorder

To investigate brain correlates of cognitive function in obsessive-compulsive disorder (OCD), event-related potentials (ERPs) were recorded in a group of thirteen unmedicated OCD patients and thirteen normal controls for verbal auditory stimuli in an oddball paradigm. The patients showed longer latencies of the N1 and P2, shorter latency of the P3, and reduced amplitude of the N2. These results suggest that OCDs stress the speed of task-dependent processes (i.e., by showing shorter N2 and P3 latencies) and have impairment of task-independent ones (i.e., by showing longer N1 and P2 latencies and reduced N2 amplitude). The components were more positive in the left hemisphere in OCDs and in the right hemisphere in normal controls. Future responders to treatment had significantly reduced N2 and enhanced P3 amplitudes relative to future nonresponders. So ERPs might provide psychophysiological profiles in OCDs with clinical and pharmacological implications.

[Depressive pseudodementia. Diagnostic importance of quantified EEG]

The accuracy of computerized EEG to discriminate depressive pseudodementia from dementia was evaluated in 12 inpatients with recent cognitive impairments (all with DSM III R diagnosis of dementia). EEG were performed during wash-out period, then all subjects underwent an ECT and/or antidepressant trial. After this trial, clinical improvement was significant for six patients, while the six others remained unimproved. According to these two groups, electrophysiological data were retrospectively compared. Discriminant stepwise analysis exhibited that the combination of two parameters: symmetry of occipital alpha power and frontal alpha/theta ratio, was able to discriminate future responders from non responders patients with a greater accuracy than clinical and classical EEG parameters.

Psychosocial and personality differences in chippers and regular smokers

Tobacco chippers are an anomalous group of smokers who, while having smoked regularly for years, have avoided the clutches of nicotine dependence. In an attempt to better understand the factors associated with nondependent cigarette smoking, this paper describes a study in which matched groups of regular smokers, chippers, and nonsmokers were compared on a number of personality and psychosocial variables believed relevant to drug-seeking behavior. The strongest finding indicated that sensation seeking best discriminates among the three groups, with nonsmokers clearly viewing themselves as more socially inhibited and less interested in pursuing sensations relative to both regular smokers and chippers, both of whom evidenced comparable scores. Regular smokers evidenced less self-control, or restraint, and appeared more impulsive and unable to resist temptation, compared to chippers and nonsmokers. Surprisingly, none of the groups could be differentiated on the basis of perceived stress, coping, or social support. Even among the personality variables, however, the effect sizes were relatively small, indicating that these differences in personality cannot fully account for chipper's resistance to dependence.

[Fatigue, drowsiness and sleep]

Vigilance is a critical output of adaptative processes related to sleep/wake continuity and circadian rhythms. Since vigilance is highly stressed in the modern technic society, its sudden failures, expressed as fatigue, drowsiness and/or sleepiness, may be dramatically involved in accident's incidence, as observed in work accidents, manufacturing and transport sectors and private life. There is a detectable human factor involved in 70% of cases. Even if there are multifactorial circumstances, human factor such as fatigue, overwork or errors in decision are generally reported. Two main cases may be described: on one hand sleepiness and fatigue occur as sleep deprivation builds up, with an excessive duration of wakefulness (that suggests that it may be prevented by information and hygienic precautions), on the other hand sleepiness is the expression of a sleep illness or disease (and it must be detected early by a clinical biological survey). Three levels are reviewed and discussed for a comprehensive view of abnormal fatigue and sleepiness: what is the prevalence as evaluated by epidemiologic, biologic and psychologic methods? is there any specificity of cognitive disturbances associated with intrinsic or rhythmic dyssomnic illness and how can one evaluate or measures them? on the basis of some experimental reports in normal subjects by changing wake and sleep schedules it is assumed that the recovery which follows a sleep deprivation may be quite different when there is an early or a late night sleep deprivation. Possibilities for self-sleep training are discussed. The actual great interest in abnormal sleepiness is supported by its human and socio-economic consequences. If new pharmacological or physiological treatments have recently be suggested, information and cooperation are required in healthy subjects and in patients. Self-detection in the course of sleepiness is a critical factor: it may be learned and taught by medical preventive projects.

Smoking typology profiles of chippers and regular smokers

This study examined smoking patterns among chippers--light, nondependent cigarette smokers--by contrasting their smoking motives (Russell's Reasons for Smoking) and patterns (McKennell's Smoking Occasions) with those of a matched group of regular smokers. Differences between group profiles were initially confounded by differences in overall level of item endorsement, which obscured meaningful interpretation of group differences in smoking patterns. Group differences were clarified by correcting for profile elevation and scatter, as suggested by Cronbach and Gleser (1953). As expected, chippers' subscale profiles deemphasized pharmacological and addiction-related motives such as craving and habit, while emphasizing appetitive and sensory motives such as handling and pleasurable smoking. Social motives for smoking were also more prominent in chippers' smoking profiles.

Nicotine elimination and tolerance in non-dependent cigarette smokers

Although most smokers are nicotine-dependent, recent studies suggest that some very light smokers ("chippers", who smoke fewer than five cigarettes per day) may smoke for decades without developing dependence. It was considered that slowed nicotine elimination and/or reduced nicotine tolerance might underlie chippers' ability to maintain smoking at such low levels. To evaluate this hypothesis, we studied the elimination kinetics and pharmacodynamics of nicotine in chippers and matched regular smokers. Plasma nicotine levels and cardiovascular responses were observed for several hours after subjects were administered uniform doses of tobacco smoke. Chippers did show less chronic nicotine tolerance, but only on some response measures. Their rates of nicotine elimination equaled those of regular smokers. This finding, when coupled with other data about chippers' smoking patterns and nicotine absorption, establish that chippers cannot maintain substantial plasma nicotine levels between cigarettes, and thus suggest that attempts to maintain minimal trough levels of nicotine do not underlie chippers' smoking.

[Trigeminal somatosensory evoked potentials in workers handling trichloroethylene]

Trigeminal somatosensory evoked potentials (TSEP) were studied in 33 workers manipulating trichlorethylene for 3 to 22 years and in 33 control subjects. A significant excessive latency delay of N13, P17 and N45 waves in workers was found. Evoked potential abnormalities found in 15 exposed subjects (45%) were as following: excessive latency delay in 9 cases (27%), decrease of amplitude in 2 cases (6%) and asymmetrical responses in 4 cases (12%). Among 5 workers (15%) presenting clinical abnormalities of trigeminal nerve impairment, only one had normal evoked potential. TSEP were altered in 11 workers (33%) who had no clinical impairment. We suggest that TSEP should be confirm trigeminal impairment in chronic cases of workers exposed to carbon tetrachloride and to predict infraclinic lesions.