Psychometric properties of a patient-reported outcome set in acute stroke patients

Quality of life measures for people following stroke: a structured content review

INTRODUCTION

Patient Reported Outcome Measures (PROMs) are used widely to collect patient perspectives on their Health-Related Quality of Life (HRQoL) after stroke. Existing reviews on PROMs typically report the psychometric properties but rarely focus on the content validity. We performed a structured review of the content of items of stroke-specific HRQoL outcomes.

METHODS

We searched four databases using a combination of terms (Stroke, HRQoL, PROMs) to choose the three most frequently used stroke-specific HRQoL-related PROMs. Two raters independently linked the items of the Stroke Impact Scale, Stroke Specific Quality of Life and the Stroke and Aphasia Quality of Life to the International Classification of Functioning, Disability and Health (ICF) and Item Perspective Classification (IPC). We compared the ICF codes to the ICF Core Sets for Stroke and calculated ICF linkage indicators.

RESULTS

More than 75% of the content for all three PROMs is represented in the Comprehensive Stroke Core Set, indicating the universality and validity of the content of these PROMs. All three PROMs represent the content of the ICF Core Sets for Stroke to a similar extent. Most items use an Intensity response option and have a Descriptive perspective. On the IPC framework, most items have a Rational appraisal type and represent the Biological domain.

CONCLUSION

Clinicians and researchers should use patient goals as a reference to choose the appropriate PROM. A deeper understanding of the content of PROMs can help clinicians and researchers make informed decisions on which HRQoL outcomes to use among people following stroke.

Physical and Psychological Symptoms After Stroke: Longitudinal Symptom Prevalence and Network Analysis

Stroke survivors experience physical and psychological symptoms. However, long-term symptom prevalence and symptom associations have not been extensively studied. The current study aimed to assess the prevalence of physical and psychological symptoms across four years after stroke and to evaluate the relationship between these symptoms. We conducted a secondary analysis of a prospective, clinical, observational study. Physical (pain, fatigue, and physical impairment) and psychological (loss of interest, depressed mood, anxiety, and worry) symptoms were assessed using the International Consortium for Health Outcomes Measurement Standard Set for Stroke and the Patient Health Questionnaire for Depression and Anxiety three months, one year, two years, three years, and four years after hospital admission. We evaluated the prevalence of these symptoms across time and conducted a network analysis using panel vector autoregressive modeling. Physical impairment and fatigue had the highest prevalence in the sample. Psychological symptoms were also consistently observed, however, at a lower prevalence. There was no reduction in any symptom's prevalence across the course of four years after stroke. Furthermore, psychological and physical symptoms were associated with each other. Physical impairment was most strongly associated with the other symptoms, and anxiety symptoms preceded depressive symptoms. Thus, despite established follow-up care in Germany, symptoms persisted for years after stroke. Further, the observed symptom associations suggest the need to investigate the impact of physical symptoms on psychological distress. Our findings emphasize the need to prevent and treat persisting physical and psychological symptoms after stroke.

Behavioral Monitoring in Transient Ischemic Attack and Stroke Patients: Exploratory Micro- and Macrostructural Imaging Insights for Identifying Post-Stroke Depression with Accelerometers in UK Biobank

To examine the association between post-stroke depression (PSD) and macrostructural and microstructural brain measures, and to explore whether changes in accelerometer-measured physical activity (PA) are associated with PSD, we conducted an exploratory study in UK Biobank with dementia-free participants diagnosed with at least one prior stroke. Eligible participants (n = 1186) completed an MRI scan. Depression was classified based on positive depression screening scores (PHQ-2 ≥ 3). Multivariate linear regression models assessed the relationships between depression and structural and diffusion measures generated from brain MRI scans. Logistic regression models were used to examine the relationship between accelerometer-measured daily PA and future depression (n = 367). Depression was positively associated with total white matter hyperintensities (WMHs) volume (standardized β [95% CI]-0.1339 [0.012, 0.256]; FDR-adjusted p-value-0.039), periventricular WMHs volume (standardized β [95% CI]-0.1351 [0.020, 0.250]; FDR-adjusted p-value-0.027), and reduced MD for commissural fibers (standardized β [95% CI]--0.139 [-0.255, -0.024]; adjusted p-value-0.045). The odds of depression decreased by 0.3% for each daily minute spent in objectively measured light PA, while each minute spent in sleep from midnight to 6:00 AM was associated with a 0.9% decrease in the odds of depression. This early-stage analysis using a population cohort offers a scientific rationale for researchers using multimodal data sources to investigate the heterogenous nature of PSD and, potentially, identify stroke patients at risk of poor outcomes.

Exploring Perspectives on Stroke Standard Set Data Collection: A Qualitative Descriptive Study

ABSTRACT

BACKGROUND: The International Consortium on Health Outcome Measurement developed a standard set for stroke (SSS) that includes patient-reported outcome measures to help capture patients' perspectives on their poststroke recovery. The objective of this study was to explore the experiences and perspectives of individuals who collected SSS data from patients who were admitted to hospital for a stroke. METHODS: A qualitative descriptive approach was taken. Semistructured, audio-recorded interviews were conducted with individuals employed at 2 acute neurological inpatient units in Southwestern Ontario, Canada. Interviews were transcribed verbatim and written text responses were analyzed directly. Transcripts were coded line by line and then organized into 5 overarching themes: adoption, acceptance, appropriateness, feasibility, and sustainability. RESULTS: Six interviews were conducted with participants from varying roles (eg, nurses, manager, web developer, social worker, medical clerk). Participants reported that patients were receptive to completing the SSS. Follow-up phone calls provided a significant opportunity to monitor patients' recovery postdischarge. Many patients requested medical guidance and help navigating health and social resources for unmet stroke-related needs. Barriers to consistent SSS assessment included high employee turnover and lack of time, space, or capacity for follow-up. To sustain data collection, a dedicated, financially supported neurological nursing role was suggested. CONCLUSION: Participants were supportive of SSS data collection that could provide monitoring, oversight, and follow-up of stroke patients after discharge from acute care. However, the utility of the dataset is heavily dependent on having the data collection process properly resourced.

Psychometric properties and general population reference values for PROMIS Global Health in Hungary

OBJECTIVES

Patient-Reported Outcomes Measurement Information System-Global Health (PROMIS-GH) is a widely used generic measure of health status. This study aimed to (1) assess the psychometric properties of the Hungarian PROMIS-GH and to (2) develop general population reference values in Hungary.

METHODS

An online cross-sectional survey was conducted among the Hungarian adult general population (n = 1700). Respondents completed the PROMIS-GH v1.2. Unidimensionality (confirmatory factor analysis and bifactor model), local independence, monotonicity (Mokken scaling), graded response model fit, item characteristic curves and measurement invariance were examined. Spearman's correlations were used to analyse convergent validity of PROMIS-GH subscales with SF-36v1 composites and subscales. Age- and gender-weighted T-scores were computed for the Global Physical Health (GPH) and Global Mental Health (GMH) subscales using the US item calibrations.

RESULTS

The item response theory assumptions of unidimensionality, local independence and monotonicity were met for both subscales. The graded response model showed acceptable fit indices for both subscales. No differential item functioning was detected for any sociodemographic characteristics. GMH T-scores showed a strong correlation with SF-36 mental health composite score (rs = 0.71) and GPH T-scores with SF-36 physical health composite score (rs = 0.83). Mean GPH and GMH T-scores of females were lower (47.8 and 46.4) compared to males (50.5 and 49.3) (p < 0.001), and both mean GPH and GMH T-scores decreased with age, suggesting worse health status (p < 0.05).

CONCLUSION

This study established the validity and developed general population reference values for the PROMIS-GH in Hungary. Population reference values facilitate the interpretation of patients' scores and allow inter-country comparisons.

Higher comorbidity burden is associated with lower self-reported quality of life after stroke

Introduction

This study assesses the association of comorbidity burden and polypharmacy with self-reported quality of life after stroke.

Patients and methods

We performed a post-hoc analysis of a prospective, single-center, observational study of outcome evaluation by patient-reported outcome measures in stroke clinical practice. Consecutive patients with acute ischemic stroke (AIS) were enrolled and self-reported health-related quality of life (HrQoL) was assessed 90 days after acute stroke using the Patient-reported Outcomes Measurement Information System 10-Question Short-Form (PROMIS-10). Comorbidities at baseline were assessed by the Charlson Comorbidity Index (CCI). Polypharmacy was defined as medication intake of ≥5 at baseline. We used linear regression analysis to study the association of CCI, polypharmacy and other clinical covariates with HrQoL after stroke.

Results

Of 781 patients (median age 76 years, 48.4% female) enrolled, 30.2% had a CCI Score ≥2, and 31.5% presented with polypharmacy. At follow up, 71 (9.1%) had died. In 409 (52.4%) reached for outcome evaluation, Global Physical Health T-Score was 43.8 ± 10 and Global Mental Health T-Score was 43.5 ± 8.76, indicating lower HrQoL than the average population. A CCI Score ≥2, higher NIHSS Score, female sex, dependency on others for dressing, toileting and mobility before index stroke, atrial fibrillation and hypertension were independent predictors of worse physical and mental health outcomes, while polypharmacy was not.

Conclusion

In patients with AIS, high comorbidity burden and polypharmacy are frequent. Comorbidity burden at admission is independently associated with worse self-reported physical and mental health three months after stroke.

MORe PREcISE: a multicentre prospective study of patient reported outcome measures in stroke morbidity: a cross sectional study

Background and Purpose

The use of patient reported outcomes measures (PROMs) may offer utility that are important for stroke survivors. This study assessed the PROMIS-10, which contains Mental health (MH) and Physical Health (PH) domains, with an additional five stroke specific questions. The aim of this study was to evaluate the association between the MH and PH measures following a stroke and pre-existing health conditions.

Methods

A multicentre prospective cohort study at 19 hospital sites across England and Wales during 2019 was conducted. The association between each PROMIS-10 domain and demographic and health conditions were calculated using a multilevel multivariable linear and present the adjusted mean difference (aMD).

Results

The study enrolled 549 stroke survivors within 14 days of the index event, 232 were women (42.3%) and with a mean age of 72.7 years (SD = 12.9, range 25 to 97). The MH domain was scored as poor in 3.9% of participants, and very good or excellent in almost a half (48.4%). In contrast the PH domain was scored as poor in 39.9%, compared to very good or excellent in 8.5%. The MH domain was associated with pre-existing diabetes (aMD = − 2.01; 95%CI -3.91, − 0.12; p = 0.04), previous stroke (aMD = − 3.62; 95%CI -5.86, − 1.39; p = 0.001), age (aMD = 0.07; 95%CI: 0.01, 0.14; p = 0.037), and female sex (aMD = 1.91; 95%CI 0.28, 3.54; p = 0.022). The PH domain was found to be associated with sex (female) (aMD = 2.09; 95%CI 0.54, 3.65; p = 0.008) and previous stroke (aMD = − 3.05; 95%CI -5.17, − 0.93; p = 0.005).

Conclusions

Almost half of stroke survivors reported poor PH using a PROM with less reporting poor MH. age, and sex were associated with both MH and PH domains, and additionally pre-exising diabetes and stroke were associated with poorer MH. Clinical management offers an opportunity to investigate and intervene to prevent long term poorer health in stroke survivors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02634-0.

Implementability of collecting patient-reported outcome data in stroke unit care - a qualitative study

Background

Patient-reported outcome measures (PROMs) assess patient-relevant effects of medical treatments. We aimed to evaluate the implementation of the International Consortium for Health Outcomes Measurement Standard Set for Stroke (ICHOM-SSS) into routine inpatient care of a stroke unit.

Methods

The ICHOM-SSS was administered in a certified stroke unit during and after inpatient care. Semi-structured interviews with medical staff (n = 5) and patients or their proxies (n = 19) about their experience were audio-recorded and analysed using thematic analyses. Implementation outcomes were chosen in advance and adhered to current standards of implementation science.

Results

Patients perceived the ICHOM-SSS to be relevant and feasible. They reported limited understanding of why the assessment was introduced. The overall acceptance of using PROMs was high. While medical staff, too, perceived the assessment to be appropriate and relevant, their appraisal of feasibility, sustainability, and their acceptance of the implementation were low.

Conclusions

For a sustainable implementation of PROMs in clinical practice, IT resources need to be adapted, medical care needs to be reorganized, and additional clinical resources are required. Future research should investigate benefits of the ICHOM-SSS and a simpler, automated implementation in stroke care.

Trial registration

ClinicalTrials.gov Identifier: NCT03795948, retrospectively registered on 8 January 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07722-y.

Psychometric properties of a patient-reported outcome set in acute stroke patients

OBJECTIVES

Impairments after stroke may affect multiple domains of health-related quality of life (HRQoL). Patient-reported outcome measures (PROMs) have proven valuable in measuring patients' well-being. We examine the psychometric properties of a standard set of PROMs assessing global health, anxiety, and depression, and functioning in a German health care setting.

METHOD

We included inpatients at the Department of Neurology at the University Medical Center Hamburg-Eppendorf, diagnosed with stroke. Following the stroke-specific standard set of the International Consortium for Health Outcome Measurement, we collected demographic and clinical information at baseline, and PROMs for global health (PROMIS-10), three items for self-reported functioning, anxiety, and depression (PHQ-4) at 90 days follow-up. We calculated confirmatory factor analyses to test factorial validity and correlation analyses to test construct validity. We further conducted item and reliability analyses.

RESULTS

In a sample of 487 patients (mean age, SD: 71.1, 12.6; 47% female) with mild and moderate symptoms, model fit for the PROMIS-10 was acceptable for the two-factor and single-factor models. Factor loadings ranged from 0.52 to 0.94. The postulated single-factor model for functioning was saturated with zero degrees of freedom. Factor loadings ranged from 0.90 to 0.96. For the PHQ-4, the two-factor model showed excellent model fit. Factor loadings ranged from 0.78 to 0.87. Internal consistency was acceptable to good. Construct validity was generally confirmed.

CONCLUSIONS

The PROMIS-10 is a valid and reliable instrument to measure HRQoL among German stroke patients. While the PHQ-4 was confirmed as a screening measure for mental disorders, further research is needed on items assessing self-reported functioning. Results are limited to patients showing minimal functional deficits.