Patient-Reported Outcome Measures in Clinical Research

Patient-reported outcome measures in adult HIV care: A rapid scoping review of targeted outcomes and instruments used

OBJECTIVE

There is international interest in the integration of patient-reported outcome measures (PROMs) into routine HIV care, but little work has synthesized the content of published initiatives. We conducted a rapid scoping review primarily to identify their selected patient-reported outcomes and respective instruments.

METHODS

Four databases were searched on 4 May 2022 (Medline, Embase, CINAHL and PsychINFO) for relevant English language documents published from 2005 onwards. Dual review of at least 20% of records, full texts and data extraction was performed. Outcomes and instruments were classified with an adapted 14-domain taxonomy. Instruments with evidence of validation were described.

RESULTS

Of 13 062 records generated for review, we retained a final sample of 94 documents, referring to 60 distinct initiatives led mostly in the USA (n = 29; 48% of initiatives), Europe (n = 16; 27%) and Africa (n = 9; 15%). The measured patient-reported outcome domains were: mental health (n = 42; 70%), substance use (n = 23; 38%), self-management (n = 16; 27%), symptoms (n = 12; 20%), sexual/reproductive health (n = 12; 20%), physical health (n = 9; 15%), treatment (n= 8; 13%), cognition (n = 7; 12%), quality of life (n = 7; 12%), violence/abuse (n = 6; 10%), stigma (n = 6; 10%), socioeconomic issues (n = 5; 8%), social support (n = 3; 5%) and body/facial appearance (n = 1; 2%). Initiatives measured 2.6 outcome domains, on average (range = 1-11). In total, 62 distinct validated PROMs were identified, with 53 initiatives (88%) employing at least one (M = 2.2). Overwhelmingly, the most used instrument was any version of the Patient Health Questionnaire to measure symptoms of depression, employed by over a third (26; 43%) of initiatives.

CONCLUSION

Published PROM initiatives in HIV care have spanned 19 countries and disproportionately target mental health and substance use.

Patient-Reported Outcome Measures in Food and Drug Allergy

A patient-reported outcome is directly reported by the patient without interpretation of the patient's response by anyone else. It refers to the patient's health (symptoms and feelings), quality of life, or functional status associated with health care or treatment. Patient-reported outcome measures (PROMs) are defined as the tools or instruments that are used to measure patient-reported outcomes. Health-related quality of life has been the most studied psychosocial PROM in food allergy, using validated questionnaires. In drug allergy, PROMs are useful in capturing patients' experiences of potential allergic reactions, including subjective symptoms such as headache, dizziness, or fatigue. Patient-reported outcome measures can also help differentiate true allergies from side effects or other nonallergic reactions and inform decisions about drug challenges and de-labeling strategies. Ensuring the chosen tool is validated for the specific allergy context is crucial for accurate data collection. Integrating patient-reported experiences alongside traditional methods can lead to more accurate assessments and personalized care.

Patient perspectives on recall period and response options in patient-reported outcome measures for chronic rhinosinusitis symptomatology: An international multi-centered study

BACKGROUND

Existing patient-reported outcome measures (PROMs) for chronic rhinosinusitis (CRS) use a variety of recall periods and response scales to assess CRS symptom burden. Global perspectives of CRS patients regarding optimal recall periods and response scales for CRS PROMs are unknown.

METHODS

This was a multi-center, cross-sectional study recruiting 461 CRS patients from sites across the United States, Saudi Arabia, New Zealand, and Austria. Participants chose which CRS symptom recall period (1 day, 2 weeks, 1 month, >1 month) was most reflective of their current disease state and upon which to best base treatment recommendations (including surgery). Participants also chose which of six response scales (one visual analogue scale and five Likert scales ranging from four to eight items) was easiest to use, understand, and preferred.

RESULTS

A plurality of participants (40.0%) felt their CRS symptoms' current state was best reflected by a 1-month recall period. However, most patients (56.9%) preferred treatment recommendations to be determined by symptoms experienced over a >1 month period. The four- and five-item Likert scales were the easiest to understand (26.0% and 25.4%, respectively) and use (23.4% and 26.7%, respectively). The five-item (26.4% rating it most preferred and 70.9% rating it preferred) and four-item Likert (22.3% rating it most preferred and 56.4% rating it preferred) response scales were most preferred.

CONCLUSION

Future PROMs for CRS should consider assessment of symptoms over a 1-month period and use a four- or five-item Likert response scale to reflect global patient preferences. These findings also inform interpretation of current CRS PROMs.

Development of a new miniaturized system for ultrafiltration

Acute decompensated heart failure and fluid overload are the most common causes of hospitalization in heart failure patients, and often, they contribute to disease progression. Initial treatment encompasses intravenous diuretics although there might be a percentual of patients refractory to this pharmacological approach. New technologies have been developed to perform extracorporeal ultrafiltration in fluid overloaded patients. Current equipment allows to perform ultrafiltration in most hospital and acute care settings. Extracorporeal ultrafiltration is then prescribed and conducted by specialized teams, and fluid removal is planned to restore a status of hydration close to normal. Recent clinical trials and European and North American practice guidelines suggest that ultrafiltration is indicated for patients with refractory congestion not responding to medical therapy. Close interaction between nephrologists and cardiologists may be the key to a collaborative therapeutic effort in heart failure patients. Further studies are today suggesting that wearable technologies might become available soon to treat patients in ambulatory and de-hospitalized settings. These new technologies may help to cope with the increasing demand for the care of chronic heart failure patients. Herein, we provide a state-of-the-art review on extracorporeal ultrafiltration and describe the steps in the development of a new miniaturized system for ultrafiltration, called AD1 (Artificial Diuresis).

Is Replantation Associated With Better Hand Function After Traumatic Hand Amputation Than After Revision Amputation?

BACKGROUND

Replantation is an established treatment for traumatic upper extremity amputation. Only a few studies, however, have assessed the patient-reported outcomes of replantation, and the findings of these studies have been conflicting.

QUESTIONS/PURPOSES

(1) Is replantation associated with better hand function than revision amputation? (2) Is replantation associated with better health-related quality of life, less painful cold intolerance, and more pleasing hand esthetics than revision amputation after a traumatic hand amputation?

METHODS

In this retrospective, comparative study, we collected the details of all patients who sustained a traumatic upper extremity amputation and were treated at the study hospital. Between 2009 and 2019, we treated 2250 patients, and we considered all patients who sustained a traumatic amputation of two or more digital rays or a thumb as potentially eligible. Based on that, 15% (334 of 2250) were eligible; a further 2% (8 of 334) were excluded because of a subsequent new traumatic amputation or bilateral amputation, and another 22% (72 of 334) refused participation, leaving 76% (254 of 334) for analysis here. The primary outcome was the DASH score. Secondary outcomes included health-related quality of life (EuroQOL-5D [EQ-5D-5L] Index), painful cold intolerance (the Cold Intolerance Symptom Severity score), and hand esthetics (the Michigan Hand Questionnaire aesthetic domain score). The minimum follow-up time for inclusion was 18 months. Patients were classified into two treatment groups: replantation (67% [171 of 254], including successful replantation in 84% [144 of 171] and partially successful replantation in 16% [27 of 171], in which some but not all of the replanted tissue survived), and revision (complete) amputation (33% [83 of 254], including primary revision amputation in 70% [58 of 83] and unsuccessful replantation followed by secondary amputation in 30% [25 of 83]). In this cohort, replantation was performed if possible, and the reason for choosing primary revision amputation over replantation was usually an amputated part that was too severely damaged (15% [39 of 254]) or was unattainable (2% [4 of 254]). Some patients (3% [8 of 254]) refused to undergo replantation, or their health status did not allow replantation surgery and postoperative rehabilitation (3% [7 of 254]). Gender, age (mean 48 ± 17 years in the replantation group versus 50 ± 23 years in the revision amputation group; p = 0.41), follow-up time (8 ± 4 years in the replantation group versus 7 ± 4 years in the revision amputation group; p = 0.18), amputation of the dominant hand, smoking, extent of tissue loss, or presence of arterial hypertension did not differ between the groups. Patients in the replantation group less frequently had diabetes mellitus (5% [8 of 171] versus 12% [10 of 83]; p = 0.03) and dyslipidemia (4% [7 of 171] versus 11% [9 of 83]; p = 0.04) than those in the revision group and more often had cut-type injuries (75% [129 of 171] versus 60% [50 of 83]; p = 0.02).

RESULTS

After controlling for potential confounding variables such as age, injury type, extent of tissue loss before treatment, and accident of the dominant hand, replantation was not associated with better DASH scores than revision amputation (OR 0.82 [95% confidence interval (CI) 0.50 to 1.33]; p = 0.42). After controlling for potential cofounding variables, replantation was not associated with better EQ-5D-5L Index scores (OR 0.93 [95% CI 0.56 to 1.55]; p = 0.55), differences in Cold Intolerance Symptom Severity scores (OR 0.85 [95% CI 0.51 to 1.44]; p = 0.79), or superior Michigan Hand Questionnaire esthetic domain scores (OR 0.73 [95% CI 0.43 to 1.26]; p = 0.26) compared with revision amputation.

CONCLUSION

Replantation surgery was conducted, if feasible, in a homogenous cohort of patients who underwent amputation. If the amputated tissue was too severely damaged or replantation surgery was unsuccessful, the treatment resulted in revision (complete) amputation, which was not associated with worse patient-reported outcomes than successful replantation. These results contradict the assumed benefits of replantation surgery and indicate the need for credible evidence to better guide the care of these patients.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Development and Initial Validation of a Meniere's Disease Quality of Life Instrument: The MenQOL

OBJECTIVE

To design and validate a disease-specific quality of life instrument for Meniere's disease.

METHODS

We used a sequential process of expert input, patient focus groups, and analyses of responses to draft questionnaires to create a 24-item Meniere's disease quality of life (MenQOL) instrument. The MenQOL and the SF-36v2 were administered to a cohort of 50 patients with Meniere's disease and 60 comparison patients with tinnitus, vertigo, or hearing loss from other causes identified at a tertiary academic center. We performed exploratory factor analysis, Cronbach's α, between group comparisons of total MenQOL scores, and regression analyses between the MenQOL and SF-36v2 to evaluate the instrument's factor structure, internal consistency, face validity, and external validity. Segregation of the instrument into domains was assessed by exploratory factor analysis.

RESULTS

Exploratory factor analysis revealed that the MenQOL has a single domain. Cronbach's α = 0.914 indicated high internal consistency for the instrument as a whole. Mean MenQOL scores showing significantly worse quality of life among patients with Meniere's disease than comparison participants (52.5 ± 15.8 vs. 43.2 ± 12.6; p = 0.0051), indicating good construct validity. Significant inverse relationships in bivariate linear regressions between total MenQOL scores and SF-36v2 physical (slope = -0.94, p < 0.0001) and mental (slope = -1.16, p < 0.0001) composite scores showed acceptable concurrent validity.

CONCLUSIONS

We have described the initial development of the MenQOL, a simple, valid patient-reported outcome measure that, subject to further study, may be used to assess the effects of treatment on disease-specific quality of life in patients with Meniere's disease.

LEVEL OF EVIDENCE

3 Laryngoscope, 2024.

Reducing the global burden of cerebral venous thrombosis: An international research agenda

BACKGROUND

Due to the rarity of cerebral venous thrombosis (CVT), performing high-quality scientific research in this field is challenging. Providing answers to unresolved research questions will improve prevention, diagnosis, and treatment, and ultimately translate to a better outcome of patients with CVT. We present an international research agenda, in which the most important research questions in the field of CVT are prioritized.

AIMS

This research agenda has three distinct goals: (1) to provide inspiration and focus to research on CVT for the coming years, (2) to reinforce international collaboration, and (3) to facilitate the acquisition of research funding.

SUMMARY OF REVIEW

This international research agenda is the result of a research summit organized by the International Cerebral Venous Thrombosis Consortium in Amsterdam, the Netherlands, in June 2023. The summit brought together 45 participants from 15 countries including clinical researchers from various disciplines, patients who previously suffered from CVT, and delegates from industry and non-profit funding organizations. The research agenda is categorized into six pre-specified themes: (1) epidemiology and clinical features, (2) life after CVT, (3) neuroimaging and diagnosis, (4) pathophysiology, (5) medical treatment, and (6) endovascular treatment. For each theme, we present two to four research questions, followed by a brief substantiation per question. The research questions were prioritized by the participants of the summit through consensus discussion.

CONCLUSIONS

This international research agenda provides an overview of the most burning research questions on CVT. Answering these questions will advance our understanding and management of CVT, which will ultimately lead to improved outcomes for CVT patients worldwide.

Machine Learning-Based Predictive Models for 90-Day Readmission of Total Joint Arthroplasty Using Comprehensive Electronic Health Records and Patient-Reported Outcome Measures

Background

The Centers for Medicare & Medicaid Services currently incentivizes hospitals to reduce postdischarge adverse events such as unplanned hospital readmissions for patients who underwent total joint arthroplasty (TJA). This study aimed to predict 90-day TJA readmissions from our comprehensive electronic health record data and routinely collected patient-reported outcome measures.

Methods

We retrospectively queried all TJA-related readmissions in our tertiary care center between 2016 and 2019. A total of 104-episode care characteristics and preoperative patient-reported outcome measures were used to develop several machine learning models for prediction performance evaluation and comparison. For interpretability, a logistic regression model was built to investigate the statistical significance, magnitudes, and directions of associations between risk factors and readmission.

Results

Given the significant imbalanced outcome (5.8% of patients were readmitted), our models robustly predicted the outcome, yielding areas under the receiver operating characteristic curves over 0.8, recalls over 0.5, and precisions over 0.5. In addition, the logistic regression model identified risk factors predicting readmission: diabetes, preadmission medication prescriptions (ie, nonsteroidal anti-inflammatory drug, corticosteroid, and narcotic), discharge to a skilled nursing facility, and postdischarge care behaviors within 90 days. Notably, low self-reported confidence to carry out social activities accurately predicted readmission.

Conclusions

A machine learning model can help identify patients who are at substantially increased risk of a readmission after TJA. This finding may allow for health-care providers to increase resources targeting these patients. In addition, a poor response to the "social activities" question may be a useful indicator that predicts a significant increased risk of readmission after TJA.

Patient-reported outcomes in adults after status epilepticus: A systematic review

Impairments after status epilepticus have generally been assessed by physicians, using generic scales. Patient-reported outcomes (PROs) directly reflect each patient's experience and are therefore recommended to improve patient-centered care. The objective of this systematic review was to compile the available information on patient-reported outcomes of adults after status epilepticus. We used Medical Subject Headings terms to search PubMed, Embase, and the Cochrane Library from database inception to February 2023. We excluded reviews, case reports, abstract-only reports, editorials, and publications in languages other than English or French. Studies reporting PROs in adults after SE were eligible. Bias in included studies was assessed using the Newcastle-Ottawa Scale (NOS). Given the heterogeneity in assessment tools and outcomes, most of the results are presented separately for each included study. Only three studies met our criteria. All used an observational cohort design. Two were retrospective and one prospective. Of the 141 patients (76 males and 65 females, mean age 43-63 years), 105 (74.4 %) had a history of epilepsy before status epilepticus. The studies used four epilepsy-specific and five generic tools to assess five patient-reported outcomes: quality of life (n = 141), mental health (depression, n = 81, or anxiety, n = 49), physical health including fatigue (n = 130), return to work (n = 49), and side effects of antiepileptic drugs (n = 81). A single study (n = 81) was of good methodological quality. Health-related quality of life (HRQOL) and mental health were the most extensively studied outcomes, and both were impaired. HRQOL scores ranged from 41.7 ± 11.5 to 48.3 ± 24.5. The prevalence of depression and anxiety varied from 30 % to 36 %, and from 22 % to 62 %, respectively. However, data were not collected before the status epilepticus episode, and the possible impact of this last on the outcomes cannot therefore be assessed. Information on PROs of adults after status epilepticus is extremely scant. Patient-reported outcomes should be collected more widely in adults after status epilepticus.

Concurrent validity study of QuickDASH with respect to DASH in patients with traumatic upper extremity amputation

BACKGROUND

The Disability of the Arm, Shoulder and Hand Outcome Measure (DASH) is a validated patient-reported outcome measure (PROM) for many upper extremity musculoskeletal disorders. In patients with severe traumatic conditions, limited evidence exists regarding the equivalence between DASH and its shortened version, QuickDASH, which is more feasible in clinical practice. The rationale of this study was to analyze the concurrent validity of QuickDASH with respect to DASH in patients with traumatic upper extremity amputation.

METHODS

This study is based on a consecutive cohort of traumatic upper extremity amputation patients treated with replantation or revision (completion) amputation at Tampere University Hospital between 2009 and 2019. We estimated the concurrent validity of QuickDASH with respect to DASH by correlation coefficients, mean score differences, Bland-Altman plots, and distribution density. Additionally, we assessed internal reliability with Cronbach's alpha coefficients and item-total correlations.

RESULTS

We found a very strong linear correlation between DASH and QuickDASH scores (r = 0.97 [CI 95% 0.97-0.98], p < 0.001). The mean difference between DASH and QuickDASH was minor (MD = -1, SD 4 [CI95% from -1 to 0] p = 0.02). The mean sub-score for the activity domain was higher for QuickDASH than DASH (MD = -3 [CI95% from -4 to -3] p < 0.000) and lower for the symptom domain (MD = 7 [CI95% from 6 to 9] p < 0.000). The Bland and Altman plot showed good agreement between DASH and QuickDASH scores, but there was measurement error in QuickDASH with high scores (r = -0.20, [CI95% from -0.31 to -0.09], p = 0.001).

CONCLUSION

QuickDASH demonstrates higher total scores than the full DASH and emphasizes rating of activity over symptoms. Still, on average the differences in total scores are likely less than the MCID of DASH, and consequently, this study shows that QuickDASH can be recommended instead of the full DASH when assessing a traumatic condition.

TRIAL REGISTRATION

Retrospectively registered.

Effects of a Remote Multimodal Intervention Involving Diet, Walking Program, and Breathing Exercise on Quality of Life Among Newly Diagnosed People with Multiple Sclerosis: A Quasi-Experimental Non-Inferiority Pilot Study

Background

Interventions involving diet, physical activity, and breathing exercises are shown to be beneficial in managing both fatigue and quality of life (QoL) related to MS; however, the impact of such interventions among people newly diagnosed with clinically isolated syndrome (CIS) or relapsing-remitting multiple sclerosis (RRMS) who decline disease-modifying therapies (DMTs) is unknown.

Methods

A 12-month prospective quasi-experimental non-inferiority trial recruited people newly diagnosed with CIS or RRMS who voluntarily declined DMTs (health behavior group; HB, n = 29) or followed standard of care (SOC, n = 15). Participants in the HB group were remotely coached on the study diet, moderate-intensity walking, and breathing exercises. All participants completed questionnaires validated to assess MS symptoms, including perceived mental and physical QoL (MSQOL54); fatigue (Fatigue Severity Scale, FSS; and Modified Fatigue Impact Scale, MFIS); mood (Hospital Anxiety and Depression Scale, HADS); and cognitive function (Perceived Deficits Questionnaire, PDQ).

Results

During the 12 months, the HB group experienced improvement in scores for mental QoL (MSQOL54 - Mental, 0.24, 95% CI 0.01, 0.47; p = 0.04), fatigue (Total MFIS, -7.26, 95% CI -13.3,-1.18; p = 0.02), and perceived cognitive function (Total PDQ, PDQ-Attention, PDQ-Promemory, and PDQ-Planning, p ≤ 0.03 for all). A between-group difference was observed only for PDQ-Planning (p = 0.048). Non-inferiority analysis revealed that the 12-month changes in means for the HB group were not worse than those for the SOC group with respect to fatigue (FSS, p = 0.02), mood (HDS-Anxiety, p = 0.02; HADS-Depression, p < 0.0001), physical QoL (MSQOL54 - Physical, p = 0.02), or cognitive dysfunction (Total PDQ, p = 0.01).

Conclusion

The multimodal lifestyle intervention for individuals newly diagnosed with CIS or RRMS, who voluntarily decline DMTs, did not yield patient-reported outcomes worse than those observed in the SOC group regarding perceived mental quality of life, mood, fatigue, and cognitive function.

Trial Registration

clinicaltrials.gov identifier: NCT04009005.

Landscape Analysis of Neurodevelopmental Comorbidities in Newborn Screening Conditions: Challenges and Opportunities

Newborn screening (NBS) is a large-scale public health program in the US that screens 3.8 million newborns for up to 81 genetic conditions each year. Many of these conditions have comorbidities, including neurodevelopmental disorders (NDDs). These comorbidities can have a significant impact on health outcomes across the lifespan. Most screened conditions are inborn errors of metabolism. PKU, the first condition identified by NBS, is an inherited metabolic disorder that can cause developmental delays and intellectual/developmental disabilities if not treated. The Newborn Screening Translational Research Network (NBSTRN) is a program that has been funded by the National Institute of Child Health and Human Development since 2008. NBSTRN is charged with developing, maintaining, and enhancing tools, resources, and expertise supporting NBS research. One of the tasks led by NBSTRN is to provide direction for developing question/answer sets used in the Longitudinal Pediatric Data Resource (LPDR) to create consensus-based and standardized common data elements (CDEs) for NBS conditions. There is growing interest in the NBS community in assessing neurodevelopmental trajectories through long-term follow-up studies. This could be streamlined by employing uniform CDEs. To address this unmet need, we conducted a landscape analysis to (1) explore the co-occurrence of NDD-related comorbidities and NBS conditions using text mining in MedGen, (2) compile a list of NDD-related CDEs from existing repositories as well as LPDR data dictionaries, and (3) identify challenges and knowledge gaps hindering the early identification of risks for NDDs in NBS conditions. Our findings can inform future efforts toward advancing the research infrastructure for this established public health program. The renewed awareness of the risk of NDDs after a positive NBS and diagnosis could lead to improved treatment guidelines for mental health conditions.

Anterior cervical X-shape-corpectomy and fusion vs. anterior cervical corpectomy and fusion for two-level cervical spondylosis

PURPOSE

Anterior cervical X-shape-corpectomy and fusion (ACXF) is a novel cervical surgery, designed as partial alternative to the classic technique, anterior cervical corpectomy and fusion (ACCF). The aim of this study was to evaluate the early-stage outcomes of ACXF in treating two-level cervical spondylosis (CS) through comparisons with ACCF.

METHODS

A retrospectively comparative study was conducted in two cohorts of patients who underwent single-vertebral ACXF or ACCF to treat two-level CS during September 2019 and October 2021. Clinical and radiological data of all the patients were collected from pre-operation to 1 year after the surgery, following by intra- and intergroup analyses and comparisons.

RESULTS

Fifty-seven patients were included, with 24 undergoing ACXF and 33 undergoing ACCF. ACXF group had significantly shorter drainage duration (2.13 ± 0.61 days vs. 3.48 ± 1.30 days, P < 0.001) and less drainage volume (30.21 ± 26.88 ml vs. 69.30 ± 37.65 ml, P < 0.001) than ACCF group. Both techniques significantly improved all the clinical parameters (P < 0.01) with comparable effects (P > 0.05). Each complication rate in ACXF group was lower than that in ACCF group without significant difference (P > 0.05). ACXF showed a significantly smaller transverse decompression range than ACCF (11.93 ± 1.27 mm vs. 16.29 ± 1.88 mm, P < 0.001). Postoperatively, ACXF yielded a comparable fusion rate (P > 0.05) and a significantly lower subsidence rate (P < 0.01) than ACCF technique at all time points.

CONCLUSIONS

ACXF is a potential surgical alternative for certain patients with two-level CS, as it provides both adequate decompression range and fewer adverse events than ACCF. The further modifications on ACXF worth exploration.

Patient-reported significant disability after major traumatic upper extremity amputation

The aims of this study were to record patient-reported outcomes of treatment of proximal upper extremity amputation injuries and subsequent return to work. A consecutive cohort of 38 patients with a traumatic amputation at or proximal to the carpus had been treated with a replantation or revision (completion) amputation in Tampere University Hospital between 2009 and 2019, and 31 of them participated in this study. The primary outcome was the Disabilities of the Arm, Shoulder and Hand Outcome Measure (DASH). Patients reported significant disability indicated by DASH score after replantation (median 30; interquartile range [IQR] 21-47) and revision (completion) amputation (median 33; IQR 16-52). Most patients had cold intolerance and reported low hand function and aesthetics scores. Out of 17 working patients, 10 did not return to their previous work. Our study demonstrates the influence of major upper extremity amputation on daily life activities, even after a successful replantation.Level of evidence: IV.

The Assessment of Patient-Reported Outcomes for the Authorisation of Medicines in Europe: A Review of European Public Assessment Reports from 2017 to 2022

OBJECTIVES

Health regulators have progressively increased their attention and focus on patient-reported outcomes (PROs), driven by the diffusion of a patient-centred approach to the drug development process. This study investigates the consideration of PROs and their measures (PROMs) in the authorisation of medicines in Europe.

METHODS

All medicines for human use authorised or refused by the European Medicines Agency (EMA) in the period 2017-2022 were identified, and corresponding European Public Assessment Reports (EPARs) were downloaded for review. Medicine and PROs/PROM characteristics were systematically recorded. A multivariate logistic regression was performed to identify variables associated with the use of patient-reported evidence in EPARs.

RESULTS

Overall, 497 EPARs of authorised medicines and 19 EPARs of refused medicines were analysed; of these, 240 (48.3%) and 10 (52.6%), respectively, reported any use of PROs/PROMs (p = 0.710). For authorised medicines, the likelihood of using PROs/PROMs was negatively affected by generic (OR = 0.01, p < 0.001) and biosimilar status (OR = 0.46, p = 0.013) and positively affected by orphan status (OR = 1.41, p = 0.177). The use of PROMs (50.6% in 2017 vs 47.9% in 2022) did not show a clear pattern over the 6-year period considered (p = 0.758) and was particularly uncommon in some therapeutic areas (e.g., 15.2% in infectious diseases). A total of 816 dyads of PROs/PROMs were identified. On average each EPAR considered 1.6 (range: 0-14) instruments. Patient-reported outcomes were typically secondary (53.3%) and exploratory endpoints (18.8%); in one-third of cases (32.5%), they assessed generic quality of life. Among the PROMs, 227 (27.8%) targeted general population; EQ-5D (11.0%), SF-36/SF-12 (5.9%) and EORTC QLQ-C30 (5.6%) were the instruments most frequently used.

CONCLUSIONS

This study suggests PROs/PROMs are considered in less than half of total medicine assessments and even more rarely in some disease areas. The adoption of PROs is key in EMA strategy to 2025 and would be facilitated by consensus development on their measures and optimisation of data collection.

Patient-reported outcomes and their predictors 2 years after burn injury: A cross-sectional study

This study aimed to describe patient-reported outcomes 2 years after burn injury and to comprehensively elucidate predictors that may influence these outcomes. This cross-sectional, prospective study included 352 patients who were admitted to the Department of Burn Surgery at a tertiary teaching hospital between January 2017 and December 2020. We collected demographic and disease-related data and instructed participants to complete the Readiness for Hospital Discharge Scale (RHDS) and the Burn Specific Health Scale-Brief (BSHS-B) questionnaire. The overall score of patient-reported outcomes 2 years after burn injury was 126.55 ± 33.32 points, and the dimensions with the lowest scores were "hand function" (13.96 ± 5.75), "heat sensitivity" (14.84 ± 4.90), "treatment regimens" (13.41 ± 6.77) and "work" (11.30 ± 4.97). Multiple linear regression analysis revealed that less postburn pruritus, better readiness for hospital discharge, less total body surface area (TBSA), better social participation, white-collar jobs, older age, better sleep quality and burns not caused by electricity were associated with better outcomes. Patients experienced poor patient-reported outcomes 2 years after burn injury. Integrated rehabilitative care is necessary to address patients' unique needs and improve long-term patient-reported outcomes.

The Use of Historical Controls in Clinical Trials

This JAMA Guide to Statistics and Methods explains the use of historical controls—persons who had received a specific control treatment in a previous study—when randomizing participants to that control treatment in a subsequent trial may not be practical or ethical.

Patient-reported outcome measures in physical therapy practice for neck pain: an overview of reviews

BACKGROUND

Understanding which patient-reported outcome measures are being collected and utilized in clinical practice and research for patients with neck pain will help to inform recommendations for a core set of measures that provide value to patients and clinicians during diagnosis, clinical decision-making, goal setting and evaluation of responsiveness to treatment. Therefore, the aim of this study was to conduct a review of systematic reviews using a qualitative synthesis on the use of patient-reported outcome measures (PROMs) for patients presenting with neck pain to physical therapy.

METHODS

An electronic search of systematic reviews and guideline publications was performed using MEDLINE (OVID), Embase (Elsevier), CINAHL Complete (EBSCOhost), and Web of Science (Clarivate) databases to identify reviews that evaluated physical therapy interventions or interventions commonly performed by a physical therapist for individuals with neck pain and included at least one patient-reported outcome measure. The frequency and variability in which the outcome measures were reported among the studies in the review and the constructs for which they measured were evaluated. The evaluation of a core set of outcome measures was assessed. Risk of bias and quality assessment was performed using A Measurement Tool to Assess systematic Reviews 2.

RESULTS

Of the initial 7,003 articles, a total of 37 studies were included in the final review. Thirty-one PROMs were represented within the 37 reviews with eleven patient-reported outcome measures in three or more reviews. The eleven PROMs assessed the constructs of disability, pain intensity, psychosocial factors and quality of life. The greatest variability was found amongst individual measures assessing psychosocial factors. Assessment of psychosocial factors was the least represented construct in the included studies. Overall, the most frequently utilized patient reported outcome measures were the Neck Disability Index, Visual Analog Scale, and Numeric Pain Rating Scale. The most frequently used measures evaluating the constructs of disability, pain intensity, quality of life and psychosocial functioning included the Neck Disability Index, Visual Analog Scale, Short-Form-36 health survey and Fear Avoidance Belief Questionnaire respectively. Overall risk of bias and quality assessment confidence levels ranged from critically low (2 studies), low (12 studies), moderate (8 studies), and high (15 studies).

CONCLUSION

This study identified a core set of patient-reported outcome measures that represented the constructs of disability, pain intensity and quality of life. This review recommends the collection and use of the Neck Disability Index and the Numeric Pain Rating Scale or Visual Analog Scale. Recommendation for a QoL measure needs to be considered in the context of available resources and administrative burden. Further research is needed to confidently recommend a QoL and psychosocial measure for patients presenting with neck pain. Other measures that were not included in this review but should be further evaluated for patients with neck pain are the Patient Reported Outcomes Measurement Information System (PROMIS) Physical function, PROMIS Pain Interference and the Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) tool.

New York Heart Association Class and Kansas City Cardiomyopathy Questionnaire in Acute Heart Failure

Importance

Sparse data exist regarding how clinician-assigned New York Heart Association (NYHA) class compares with heart failure (HF)-specific Kansas City Cardiomyopathy Questionnaire (KCCQ) in acute HF.

Objective

To compare concordance between NYHA class and KCCQ overall summary score (KCCQ-OS) in acute HF and investigate associations of changes in NYHA class and KCCQ-OS with long-term outcomes.

Design, Setting, and Participants

In this cohort study, patients with HF were enrolled from 52 hospitals in China between August 2016 and May 2018. Among patients with NYHA class and KCCQ-OS at admission and 1 month, levels of each scale were categorized into 4 groups from worst to best. Mild and moderate to severe discordance were defined as NYHA class and KCCQ-OS differing by 1 level or 2 or more levels, respectively. Multivariable models evaluated associations between improvements in the 2 measures and outcomes. Analysis was conducted from January to March 2023.

Exposure

Changes in NYHA class and KCCQ-OS from admission to 1 month.

Main Outcomes and Measures

All-cause mortality, cardiovascular death, or first HF rehospitalization.

Results

A total of 2683 patients (1709 [63.7%] male; median [IQR] age, 66 [56-75] years) were included. NYHA class II, III, and IV were presented in 374 patients (13.9%), 1179 patients (44.0%), and 1130 patients (42.1%), respectively, and the median (IQR) KCCQ-OS was 44.4 (28.3-61.9). Concordance, mild discordance, and moderate to severe discordance between admission NYHA class and KCCQ-OS occurred in 954 patients (35.6%), 1203 patients (44.8%), and 526 patients (19.6%), respectively. For KCCQ-OS, kernel density overlaps were 73.6% between NYHA II and III, 63.8% between NYHA II and IV, and 88.3% between NYHA III and IV. Most patients experienced improvements in NYHA and KCCQ-OS from admission to 1 month. After adjustment, there was no significant association between improvements in NYHA class and 4-year all-cause mortality, whereas 5 or more point improvements in KCCQ-OS were independently associated with a lower risk of 4-year mortality (hazard ratio, 0.84; 95% CI, 0.74-0.96; P = .01). NYHA class and KCCQ-OS improvements were both associated with decreased risk of 1-year composite cardiovascular death or HF rehospitalization.

Conclusions and Relevance

In this cohort study of acute HF, discordance between NYHA class and KCCQ was common, and KCCQ was more relevant to subsequent mortality than NYHA class.

Measuring Overall Severity of Myasthenia Gravis (MG): Evidence for the Added Value of the MG Symptoms PRO

INTRODUCTION

Accurate measurement of myasthenia gravis (MG) severity is required for appropriate clinical monitoring of patients with MG and assessment of the benefit of new treatments in clinical trials. Our objective was to explore how MG severity can be measured and to determine how the newly developed MG Symptoms Patient-Reported Outcome (PRO) instrument complements the available measures of MG severity.

METHODS

The conceptual coverage of the Quantitative MG (QMG), MG Composite (MGC), MG-Activities of Daily Living (MG-ADL), and MG Symptoms PRO was scrutinized against core symptoms of MG: muscle weakness in three muscle groups (ocular, bulbar, and respiratory), muscle weakness fatigability, and physical fatigue. Post hoc analyses of the MG0002 study, a Phase 2a clinical trial of rozanolixizumab in adults with moderate to severe generalized MG, included correlation and Rasch model analyses.

RESULTS

The qualitative appraisal highlighted that only the MG Symptoms PRO captured physical fatigue. Data from 541 assessments (43 unique patients) were used for the analyses. Correlations ranged between 0.56 and 0.74 for the MG-ADL, QMG, MGC, and MG Symptoms PRO Muscle Weakness Fatigability score, and between 0.20 and 0.71 for the MG Symptoms PRO scores focusing on independent muscle groups. Analyses with the Rasch model estimated a meaningful continuum of severity of MG, including all items, except ocular muscles, from the four instruments. The QMG and MG Symptoms PRO had the broadest coverage of the MG severity continuum. Muscle fatigability and physical fatigue were more characteristic of low severity while bulbar weakness indicated more severe MG.

CONCLUSION

The severity of MG can be reflected in a meaningful continuum underpinned by the MG-specific outcome measures. Only ocular muscle manifestations were shown to reflect a possibly different facet of MG severity. With its modular nature and comprehensive content, the MG Symptoms PRO provides complementary information to the outcome measures widely used in MG.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03052751.

Cross-sectional Associations of Multiracial Identity with Self-Reported Asthma and Poor Health Among American Indian and Alaska Native Adults

INTRODUCTION

American Indian and Alaska Native (AI/AN) multiracial subgroups are underrecognized in health outcomes research.

METHODS

We performed a cross-sectional analysis of Behavioral Risk Factor Surveillance System surveys (2013-2019), including adults who self-identified as AI/AN only (single race AI/AN, n = 60,413) or as AI/AN and at least one other race (multiracial AI/AN, (n = 6056)). We used log binomial regression to estimate the survey-weighted prevalence ratios (PR) and 95% confidence intervals (CI) of lifetime asthma, current asthma, and poor self-reported health among multiracial AI/AN adults compared to single race AI/AN adults, adjusting for age, obesity, and smoking status. We then examined whether associations differed by sex and by Latinx identity.

RESULTS

Lifetime asthma, current asthma, and poor health were reported by 25%, 18%, and 30% of multiracial AI/AN adults and 18%, 12%, and 28% single race AI/AN adults. Multiracial AI/AN was associated with a higher prevalence of lifetime (PR 1.30, 95% CI 1.18-1.43) and current asthma (PR 1.36, 95% CI 1.21-1.54), but not poor health. Associations did not differ by sex. The association of multiracial identity with current asthma was stronger among AI/AN adults who identified as Latinx (PR 1.77, 95% CI 1.08-2.94) than non-Latinx AI/AN (PR 1.18, 95% CI 1.04-1.33), p-value for interaction 0.03.

CONCLUSIONS

Multiracial AI/AN adults experience a higher prevalence of lifetime and current asthma compared to single race AI/AN adults. The association between multiracial identity and current asthma is stronger among AI/AN Latinx individuals. The mechanisms for these findings remain under-explored and merit further study.

Patient-Reported Outcomes of Omission of Breast Surgery Following Neoadjuvant Systemic Therapy: A Nonrandomized Clinical Trial

Importance

Patients should have an active role in decisions about pursuing or forgoing specific therapies in treatment de-escalation trials.

Objective

To evaluate longitudinal patient-reported outcomes (PROs) encompassing decisional comfort and health-related quality of life (HRQOL) among patients who elected to enroll in a clinical trial evaluating radiotherapy alone, without breast surgery, for invasive breast cancers with exceptional response to neoadjuvant systemic therapy (NST).

Design, Setting, and Participants

Prospective, single-group, phase 2 clinical trial at 7 US medical centers. Women aged 40 years or older with invasive cT1-2 N0-1 M0 triple-negative or human epidermal growth factor receptor 2 (ERBB2)-positive breast cancer with no pathologic evidence of residual disease following standard NST enrolled from March 6, 2017, to November 9, 2021. Validated PRO measures were administered at baseline and 6, 12, and 36 months post-radiotherapy. Data were analyzed from January to February 2023.

Interventions

PRO measures included the Decision Regret Scale (DRS), Functional Assessment of Cancer Therapy-Lymphedema (FACT-B+4), and Breast Cancer Treatment Outcomes Scale (BCTOS).

Main Outcomes and Measures

Changes in PRO measure scores and subscores over time.

Results

Among 31 patients, the median (IQR) age was 61 (56-66) years, 26 (84%) were White, and 26 (84%) were non-Hispanic. A total of 15 (48%) had triple-negative disease and 16 (52%) had ERBB2-positive disease. Decisional comfort was high at baseline (median [IQR] DRS score 10 [0-25] on a 0-100 scale, with higher scores indicating higher decisional regret) and significantly increased over time (median [IQR] DRS score at 36 months, 0 [0-20]; P < .001). HRQOL was relatively high at baseline (median [IQR] FACT-B composite score 121 [111-134] on a 0-148 scale, with higher scores indicating higher HRQOL) and significantly increased over time (median [IQR] FACT-B score at 36 months, 128 [116-137]; P = .04). Perceived differences between the affected breast and contralateral breast were minimal at baseline (median [IQR] BCTOS score 1.05 [1.00-1.23] on a 1-4 scale, with higher scores indicating greater differences) and increased significantly over time (median [IQR] BCTOS score at 36 months, 1.36 [1.18-1.64]; P < .001). At 36 months postradiotherapy, the cosmetic subscore was 0.45 points higher than baseline (95% CI, 0.16-0.74; P = .001), whereas function, pain, and edema subscores were not significantly different than baseline.

Conclusions and Relevance

In this nonrandomized phase 2 clinical trial, analysis of PROs demonstrated an overall positive experience for trial participants, with longitudinal improvements in decisional comfort and overall HRQOL over time and minimal lasting adverse effects of therapy.

Trial Registration

ClinicalTrials.gov Identifier: NCT02945579.

A Clinical Qualification Protocol Highlights Overlapping Genomic Influences and Neuro-Autonomic Mechanisms in Ehlers-Danlos and Long COVID-19 Syndromes

A substantial fraction of the 15% with double-jointedness or hypermobility have the traditionally ascertained joint-skeletal, cutaneous, and cardiovascular symptoms of connective tissue dysplasia and its particular manifestation as Ehlers-Danlos syndrome (EDS). The holistic ascertainment of 120 findings in 1261 EDS patients added neuro-autonomic symptoms like headaches, muscle weakness, brain fog, chronic fatigue, dyspnea, and bowel irregularity to those of arthralgia and skin laxity, 15 of these symptoms shared with those of post-infectious SARS-CoV-2 (long COVID-19). Underlying articulo-autonomic mechanisms guided a clinical qualification protocol that qualified DNA variants in 317 genes as having diagnostic utility for EDS, six of them identical (F2-LIFR-NLRP3-STAT1-T1CAM1-TNFRSF13B) and eighteen similar to those modifying COVID-19 severity/EDS, including ADAMTS13/ADAMTS2-C3/C1R-IKBKG/IKBKAP-PIK3C3/PIK3R1-POLD4/POLG-TMPRSS2/TMPRSS6-WNT3/WNT10A. Also, contributing to EDS and COVID-19 severity were forty and three genes, respectively, impacting mitochondrial functions as well as parts of an overlapping gene network, or entome, that are hypothesized to mediate the cognitive-behavioral, neuro-autonomic, and immune-inflammatory alterations of connective tissue in these conditions. The further characterization of long COVID-19 natural history and genetic predisposition will be necessary before these parallels to EDS can be carefully delineated and translated into therapies.

Facial involvement is reflective of patients' global perception of vitiligo extent

BACKGROUND

The involvement of visible areas in vitiligo has been found to be correlated with increased psychiatric morbidity. Although multiple tools have been developed to assess vitiligo, no cutoff for improvement or worsening of vitiligo from a patient's perspective has been established.

OBJECTIVES

To determine the minimal clinically important difference (MCID) of the Self-Assessment Vitiligo Extent Score (SA-VES) in patients with vitiligo and to evaluate, from the patient's perspective, the importance of the change in the involvement of visible areas (face and hands) in patients' overall perception of disease worsening or improving.

METHODS

This was a cross-sectional study in the context of the ComPaRe e-cohort. Adult patients with vitiligo were invited to answer online questionnaires. They completed the SA-VES twice, 1 year apart. In addition, patients answered a 5-point Likert anchor question aimed at assessing their perception of the evolution of the extent of their vitiligo. The MCID was calculated using distribution- and anchor-based approaches. Using ordinal logistic regression, the change of vitiliginous lesions on the face or hands was compared to the overall extent of vitiligo (patches on all body areas).

RESULTS

In total, 244 patients with vitiligo were included in the analyses; 20 (8%) were found to have an improvement in their vitiligo. The MCID in worsened patients was equal to a 1.3% body surface area [95% confidence interval (CI) 1.01-1.43] increase in the SA-VES. For participants with improved vitiligo, the MCID was equal to a decrease in total SA-VES of 1.3% (95% CI 0.867-1.697). Patients' perceptions of change in their vitiligo was increased sevenfold when it affected the face vs. the rest of the body.

CONCLUSIONS

Changes in the facial SA-VES were highly correlated with patients' impressions of the extent of vitiligo.

Interventions to improve outcomes in community-acquired pneumonia

INTRODUCTION

Community-acquired pneumonia (CAP) is a common infection associated with high morbimortality and a highly deleterious impact on patients' quality of life and functionality. We comprehensively review the factors related to the host, the causative microorganism, the therapeutic approach and the organization of health systems (e.g. setting for care and systems for allocation) that might have an impact on CAP-associated outcomes. Our main aims are to discuss the most controversial points and to provide some recommendations that may guide further research and the management of patients with CAP, in order to improve their outcomes, beyond mortality.

AREA COVERED

In this review, we aim to provide a critical account of potential measures to improve outcomes of CAP and the supporting evidence from observational studies and clinical trials.

EXPERT OPINION

CAP is associated with high mortality and a highly deleterious impact on patients' quality of life. To improve CAP-associated outcomes, it is important to understand the factors related to the patient, etiology, therapeutics, and the organization of health systems.

Patient-reported outcomes in vasculitis

Systemic vasculitis encompasses a group of multisystem disorders; both the diseases and the treatment strategies can have a significant impact on a patient's health-related quality of life (HRQoL). Using patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) to evaluate the patient's view of their condition, treatments, and healthcare journey is essential to the patient-centered care approach. In this paper, we discuss the use of generic, disease-specific, and treatment-specific PROMs and PREMs in systemic vasculitis and future research goals.

Torn between two lovers - on being a psychologist in a university medical centre

Background

Psychology as applied to health and illness has a relatively short history. Nevertheless, that history shows a rapid development of the theoretical models that guide the field over the past 60 years. Core theoretical approaches are concisely reviewed, in the context of Kaplan's paper 'Behavior as the central outcome in health care' (1990), which is used as a model to examine the extent to which these approaches embrace Kaplan's notions.

Advances

Empirical studies from the health psychology domain are used, which demonstrate the gains in terms of quality of life and behavioural outcomes in patients with (chronic) somatic diseases. Over a period of some 60 years, theoretical models and core concepts in psychology as applied to health and illness have evolved from psychosomatic views to neuropsychology, quality of life, patient education, self-management, illness perceptions, patient-reported outcome measures (PROMs), shared decision-making (SDM) and health humanities (HH). The more recent models (SDM, HH) appear to align to a considerable degree with adopting 'behavior as the central outcome an outcome in health care'; shared decision-making and health humanities focus on encouraging patients to make sense of and give meaning to their illness in order to attain optimal psychosocial adjustment.

Conclusions

In addition to 'behavior as the central outcome in health care', a new definition of the concept of health (i.e. 'the ability to adapt and to self-manage' - Huber et al., 2011) seems to favour patients, healthcare providers, society, and health psychology. Incorporating this concept into medical care may be viewed as a challenge for health psychologists - and as a source of continual struggle with strong biomedical forces.

DENTAL PATIENT-REPORTED OUTCOMES UPDATE 2022

Much progress has been made this year in patient-reported outcomes related research. A number of important articles were published, shedding light on relevant methodological issues as well as future directions. In order to further promote the wide use of dental patient-reported outcomes (dPROs) and dental patient-reported outcome measures (dPROMs) in dental research and dental practice, and to provide novel insights into relevant measurement and analytical methods, the Journal of Evidence-Based Dental Practice has put together this special issue, the second of a series entitled Dental Patient-Reported Outcomes Update. To put Special Issue articles into a broader perspective, this review will provide a concise summary of key, relevant PRO and dPRO articles published during the year of 2022. A brief introduction of those manuscripts collected in this Special Issue follows. Six main domains are covered in this Special Issue: (i) the availability and applicability of dPROs and dPROMs, (ii) the current usage of dPROs and dPROMs in published research, (iii) methodological considerations in dPRO-related research, (iv) the landscape and trends of dPRO-related research, (v) the significance and relevance of dPRO usage, and (vi) dPROs and value-based oral health care.

One-Year Functional Decline in COVID-19 and Non-COVID-19 Critically Ill Survivors: A Prospective Study Incorporating a Pre-ICU Status Assessment

We aimed to describe the one-year (1-y) functional status of survivors of COVID-19 critical illness, compared to non-COVID-19 survivors, and compared to their pre-ICU status. Adults who survived a COVID-19 critical illness (COVID group) during the first two waves in 2 hospitals were contacted by phone 1-y after discharge. They were compared to non-COVID-19 ICU survivors. A standardized assessment focused on quality of life (EQ-5D-3L), autonomy for activities of daily living (Barthel Index), and physical activity quantification (IPAQ-SF). Patients rated their 1-y and pre-ICU status. We included 220 survivors (132 COVID and 88 NC). Their age and severity scores were similar. ICU stay was shorter in NC group (3 [3−6] d) than in COVID group (8 [4.2−16.7] d) (p = 0.001). Proportions of organ supports were similar in the two groups. At 1-y, a significant reduction in EQ-5D-3L total score, in Barthel Index and in physical activity was observed in both groups, compared to the respective baseline values. Dependency (Barthel < 100) was observed in at least 35% of survivors at 1-y. Independently of the critical illness, HRQoL, autonomy and physical activities at 1-y were still significantly inferior to the pre-ICU values.

A novel methodology to integrate outcomes regarding perioperative pain experience into a composite score: prediction model development and validation

BACKGROUND

An integrated score that globally assesses perioperative pain experience and rationally weights each component has not yet been developed.

METHODS

A development dataset specific to adult Chinese patients undergoing orthopedic surgery was obtained from PAIN OUT (1985 qualified patients of 2244). A more recent validation dataset obeying the same conditions was obtained from the Chinese Anesthesia Shared-database Platform (1004 qualified patients of 1032). Outcomes were assessed using the International Pain Outcomes Questionnaire (IPO-Q), which comprises key patient-level outcomes of perioperative pain management, including pain experience and perceptions of care. Using principal component analysis and regression models, a composite score was inferred to integrate pain experience. The discrimination of the composite score for dissatisfaction and desire for more pain treatment was compared with that of the worst pain score.

RESULTS

A composite score was developed from the 12 items of the IPO-Q regarding pain experience. The weight for calculating the composite score was worst pain 11, least pain 17, time spent in severe pain 11, interference with activity in bed 9, interference with breathing deeply or coughing 10, interference with sleep 9, anxiety 12, helplessness 12, nausea 0, drowsiness 2, itch 5, and dizziness 2. In external validation, the composite score indicated superior discrimination to the worst pain in predicting dissatisfaction (P<0.001) and desire for more pain treatment (P<0.001).

CONCLUSIONS

This study introduced a methodology to integrate outcomes regarding perioperative pain experience into a composite score, which was based on the weight of each item.