Patient-reported outcomes measurement and management with innovative methodologies and technologies

Country-specific reference values for PROMIS® pain, physical function and participation measures compared to US reference values

INTRODUCTION

Patient-Reported Outcomes Measurement Information System (PROMIS^®) is commonly used across medical conditions. To facilitate interpretation of scores across countries, we calculated Dutch reference values for PROMIS Physical Function (PROMIS-PF), Pain Interference (PROMIS-PI), Pain Behavior (PROMIS-PB), Ability to Participate in Social Roles and Activities (PROMIS-APSRA), and Satisfaction with Social Roles and Activities (PROMIS-SSRA), as compared to US reference values.

PATIENTS AND METHODS

A panel completed full PROMIS-PF (n=1310), PROMIS-PI and PROMIS-PB (n=1052), and PROMIS-APSRA and PROMIS-SSRA (n=1002) item banks and reported their level of health per domain (no, mild, moderate, severe limitations). T-scores were calculated by sample and subgroups (age, gender, self-reported level of domain). Distribution-based and anchor-based thresholds for mild, moderate, and severe scores were determined.

RESULTS

Mean T-scores were close to the US mean of 50 for PROMIS-PF (49.8) and PROMIS-APSRA (50.6), lower for PROMIS-SSRA (47.5) and higher for PROMIS-PI (54.9) and PROMIS-PB (52.0). Distribution-based thresholds for mild, moderate, and severe scores were comparable to US recommended cut-off values (except for PROMIS-PI) but participants reported limitations 'earlier' than suggested thresholds.

CONCLUSION

Dutch reference values were close to US reference values for some PROMIS domains but not all. We recommend country-specific reference values to facilitate worldwide PROMIS use.KEY MESSAGESPROMIS offers universally applicable IRT-based efficient and patient-friendly measures to assess commonly relevant patient-reported outcomes across medical conditions.To support the use of PROMIS in daily clinical practice and research across the world, country-specific general population reference values should be obtained.More research is necessary to obtain reliable and valid cut-off values for what constitutes mild, moderate and severe scores from the patients' perspective.

Feasibility of PROMIS using computerized adaptive testing during inpatient rehabilitation

BACKGROUND

There has been an increased significance on patient-reported outcomes in clinical settings. We aimed to evaluate the feasibility of administering patient-reported outcome measures by computerized adaptive testing (CAT) using a tablet computer with rehabilitation inpatients, assess workload demands on staff, and estimate the extent to which rehabilitation inpatients have elevated T-scores on six Patient Reported Outcomes Measurement Information System® (PROMIS®) measures.

METHODS

Patients (N = 108) with stroke, spinal cord injury, traumatic brain injury, and other neurological disorders participated in this study. PROMIS computerized adaptive tests (CAT) were administered via a web-based platform. Summary scores were calculated for six measures: Pain Interference, Sleep Disruption, Anxiety, Depression, Illness Impact Positive, and Illness Impact Negative. We calculated the percent of patients with T-scores equivalent to 2 standard deviations or greater above the mean.

RESULTS

During the first phase, we collected data from 19 of 49 patients; of the remainder, 61% were not available or had cognitive or expressive language impairments. In the second phase of the study, 40 of 59 patients participated to complete the assessment. The mean PROMIS T-scores were in the low 50 s, indicating an average symptom level, but 19-31% of patients had elevated T-scores where the patients needed clinical action.

CONCLUSIONS

The study demonstrated that PROMIS assessment using a CAT administration during an inpatient rehabilitation setting is feasible with the presence of a research staff member to complete PROMIS assessment.

Psychometric properties and reference values of the Patient-Reported Outcomes Measurement Information System (PROMIS) sleep item banks in the Dutch general population

Psychometric properties of the v1.0 Patient-Reported Outcomes Measurement Information System (PROMIS®) sleep disturbance (27 items) and sleep-related impairment (SRI; 16 items) item banks, short forms derived from the item bank, and simulated computerised adaptive test (CAT), were assessed in a representative sample of 1,006 adults from the Dutch general population. For sleep disturbance all items fitted the item response theory model. Four items showed differential item functioning (i.e., lack of measurement invariance) for age and two for language but the impact on scores (expressed as T-scores) was small. Reliable scores (r > 0.90) were found for 92.2%-96.3% of respondents with the full bank, short forms with six and eight items, and CAT, but for only 25.6% with the four-item short form. For SRI two items did not fit the item response theory model. Four items showed differential item functioning for language but the impact on T-scores was small. Reliable scores were found for 82.1% with the full bank, for 47.8%-69.5% with short forms and CAT. T-scores of 49.7 and 49.3 represent the average score of the Dutch general population for sleep disturbance and SRI, respectively. In conclusion, sufficient structural validity, reliability, and cross-cultural validity was found for the full banks but short forms of four items are not reliable enough for clinical practice. For SRI we recommend the full item bank if this is the primary outcome.

Patient-Reported Outcomes (PROs) in HIV Infection: Points to Consider and Challenges

INTRODUCTION

The aim of this study was to reach consensus on the use of PROs (patient-reported outcome measures) in people living with HIV (PLHIV).

METHODS

A scientific committee of professionals with experience in PROMs methodology issued recommendations and defined the points to support by evidence. A systematic review of the literature identified the coverage, utility, and psychometric properties of PROMs used in PLHIV. A Delphi survey was launched to measure the degree of agreement with the recommendations of a group of practicing clinicians and a group of patient representatives.

RESULTS

Four principles and ten recommendations were issued; however, the results of the Delphi showed significant differences in the opinion between health professionals and PLHIV, and polarization within collectives, hampering consensus.

CONCLUSIONS

Despite a wealth of evidence on the benefit of PROMs, there are clear barriers to their use by healthcare professionals in HIV care. Intervention on these barriers is paramount to allow truly patient-centered care.

Utilising Electronic PROMs to Measure a Change in Health Following Elective Laparoscopic Cholecystectomy: A Feasibility Study

BACKGROUND

The collection of patient-reported outcome measures (PROMs) has many benefits for clinical practice. However, there are many barriers that prevent them from becoming a part of routine clinical care. The aim of this feasibility study was to pilot the use of a digital platform to facilitate the routine collection of pre- and post-operative electronic PROMs (ePROMs) in participants undergoing elective laparoscopic cholecystectomy and to validate the use of existing patient-reported outcomes for our population.

METHODS

Participants scheduled for elective laparoscopic cholecystectomy were asked to complete digital versions of the Otago gallstones Condition-Specific Questionnaire (CSQ), and the RAND 36-item health survey (SF36). An assessment of methodological quality of ePROM questionnaires was also performed.

RESULTS

Preoperative ePROMs were completed by 200 participants undergoing laparoscopic cholecystectomy. Post-operatively attrition was high (completion at 30 days, 3 months, and 6months: n = 61, 54, and 38, respectively) due to difficulties accessing our ePROMs portal. Of those able to complete, a significant improvement in quality of life was seen across all health domains post-operatively when compared with baseline preoperative values for both disease-specific and generic PROMs. Methodological quality was assessed as good to excellent in both digital questionnaires.

CONCLUSION

The collection of ePROMs is possible with current technological advances. Although it may be an acceptable, and convenient process for patients, and a useful measure of quality-of-life trends for clinicians, further developmental work is necessary to improve accessibility for patients, improve compliance, and reduce reporting bias from high attrition rates.

Common patient-reported outcomes across ICHOM Standard Sets: the potential contribution of PROMIS®

BACKGROUND

The International Consortium for Health Outcomes Measurement (ICHOM) develops condition-specific Standard Sets of outcomes to be measured in clinical practice for value-based healthcare evaluation. Standard Sets are developed by different working groups, which is inefficient and may lead to inconsistencies in selected PROs and PROMs. We aimed to identify common PROs across ICHOM Standard Sets and examined to what extend these PROs can be measured with a generic set of PROMs: the Patient-Reported Outcomes Measurement Information System (PROMIS®).

METHODS

We extracted all PROs and recommended PROMs from 39 ICHOM Standard Sets. Similar PROs were categorized into unique PRO concepts. We examined which of these PRO concepts can be measured with PROMIS.

RESULTS

A total of 307 PROs were identified in 39 ICHOM Standard Sets and 114 unique PROMs are recommended for measuring these PROs. The 307 PROs could be categorized into 22 unique PRO concepts. More than half (17/22) of these PRO concepts (covering about 75% of the PROs and 75% of the PROMs) can be measured with a PROMIS measure.

CONCLUSION

Considerable overlap was found in PROs across ICHOM Standard Sets, and large differences in terminology used and PROMs recommended, even for the same PROs. We recommend a more universal and standardized approach to the selection of PROs and PROMs. Such an approach, focusing on a set of core PROs for all patients, measured with a system like PROMIS, may provide more opportunities for patient-centered care and facilitate the uptake of Standard Sets in clinical practice.

Electronic Health Interventions in the Case of Multiple Sclerosis: From Theory to Practice

(1) Background: eHealth interventions play a growing role in shaping the future healthcare system. The integration of eHealth interventions can enhance the efficiency and quality of patient management and optimize the course of treatment for chronically ill patients. In this integrative review, we discuss different types of interventions, standards and advantages of quality eHealth approaches especially for people with multiple sclerosis (pwMS). (2) Methods: The electronic databases PubMed, Cochrane and Web of Science were searched to identify potential articles for eHealth interventions in pwMS; based on 62 articles, we consider different ways of implementing health information technology with various designs. (3) Results: There already exist some eHealth interventions for single users with a single-use case, interventions with a social setting, as well as eHealth interventions that integrate various single and social interventions and even those that may be used additionally for complex use cases. A key determinant of consumer acceptance is a high-quality user-centric design for healthcare practitioners and pwMS. In pwMS, the different neurological disabilities should be considered, and particular attention must be paid to the course of the treatment and the safety processes of each treatment option. (4) Conclusion: Depending on the field of application and the respective users, interventions are designed for single, social, integrated or complex use. In order to be accepted by their target group, interventions must be beneficial and easy to use.

International application of PROMIS computerized adaptive tests: US versus country-specific item parameters can be consequential for individual patient scores

OBJECTIVE

PROMIS offers computerized adaptive tests (CAT) of patient-reported outcomes, using a single set of US-based IRT item parameters across populations and language-versions. The use of country-specific item parameters has local appeal, but also disadvantages. We illustrate the effects of choosing US or country-specific item parameters on PROMIS CAT T-scores.

STUDY DESIGN AND SETTING

Simulations were performed on response data from Dutch chronic pain patients (n = 1110) who completed the PROMIS Pain Behavior item bank. We compared CAT T-scores obtained with (1) US parameters; (2) Dutch item parameters; (3) US item parameters for DIF-free items and Dutch item parameters (rescaled to the US metric) for DIF items; (4) Dutch item parameters for all items (rescaled to the US metric).

RESULTS

Without anchoring to a common metric, CAT T-scores cannot be compared. When scores were rescaled to the US metric, mean differences in CAT T-scores based on US vs. Dutch item parameters were negligible. However, 0.9%-4.3% of the T-score differences were larger than 5 points (0.5 SD).

CONCLUSION

The choice of item parameters can be consequential for individual patient scores. We recommend more studies of translated CATs to examine if strategies that allow for country-specific item parameters should be further investigated.

Digital Phenotyping and Patient-Generated Health Data for Outcome Measurement in Surgical Care: A Scoping Review

Digital phenotyping-the moment-by-moment quantification of human phenotypes in situ using data related to activity, behavior, and communications, from personal digital devices, such as smart phones and wearables-has been gaining interest. Personalized health information captured within free-living settings using such technologies may better enable the application of patient-generated health data (PGHD) to provide patient-centered care. The primary objective of this scoping review is to characterize the application of digital phenotyping and digitally captured active and passive PGHD for outcome measurement in surgical care. Secondarily, we synthesize the body of evidence to define specific areas for further work. We performed a systematic search of four bibliographic databases using terms related to "digital phenotyping and PGHD," "outcome measurement," and "surgical care" with no date limits. We registered the study (Open Science Framework), followed strict inclusion/exclusion criteria, performed screening, extraction, and synthesis of results in line with the PRISMA Extension for Scoping Reviews. A total of 224 studies were included. Published studies have accelerated in the last 5 years, originating in 29 countries (mostly from the USA, n = 74, 33%), featuring original prospective work (n = 149, 66%). Studies spanned 14 specialties, most commonly orthopedic surgery (n = 129, 58%), and had a postoperative focus (n = 210, 94%). Most of the work involved research-grade wearables (n = 130, 58%), prioritizing the capture of activity (n = 165, 74%) and biometric data (n = 100, 45%), with a view to providing a tracking/monitoring function (n = 115, 51%) for the management of surgical patients. Opportunities exist for further work across surgical specialties involving smartphones, communications data, comparison with patient-reported outcome measures (PROMs), applications focusing on prediction of outcomes, monitoring, risk profiling, shared decision making, and surgical optimization. The rapidly evolving state of the art in digital phenotyping and capture of PGHD offers exciting prospects for outcome measurement in surgical care pending further work and consideration related to clinical care, technology, and implementation.

Prospective application of implementation science theories and frameworks to inform use of PROMs in routine clinical care within an integrated pain network

PURPOSE

The objective of this study is to present the implementation science approaches that were used before implementing electronic patient-reported outcome measures (ePROMs) across an integrated chronic pain network that includes primary, rehabilitation, and hospital-based care.

METHODS

The Theoretical Domains Framework (TDF) was used to identify potential barriers and enablers to the use of ePROMS by primary care clinicians. In rehabilitation and tertiary care, the Consolidated Framework for Implementation (CFIR) was used to guide the identification of determinants of implementations, through observation of workflow, patient and clinician surveys, and clinician interviews. A mixed-method concurrent design comprising a quantitative and qualitative analysis was used. The results were reviewed by a steering committee to iteratively inform the ePROM implementation plan. The Proctor framework of evaluation was used to guide the development of an evaluation plan for the implementation of ePROMs in the integrated chronic pain network.

RESULTS

Both frameworks provided similar results with respect to healthcare provider knowledge, behaviour, and experience interpreting PROM scores. The TDF and CFIR frameworks differed in identifying organizational-level determinants. The resultant implementation plan was structured around the adoption of PROMs to inform individual treatment planning and quality improvement. The evaluation plan focused on implementation and impact outcomes to evaluate the ePROM intervention.

CONCLUSIONS

The TDF and CFIR guided the development of a multi-component knowledge translation and training intervention that will address multiple gaps and barriers to implementation of PROMs across the integrated network. The ePROM intervention will aim to increase clinicians' knowledge and skills and foster best practices.

Developing theory-informed knowledge translation strategies to facilitate the use of patient-reported outcome measures in interdisciplinary low back pain clinical practices in Quebec: mixed methods study

Background

There is a growing interest among healthcare providers (HCPs) to use Patient Reported Outcome Measures (PROMs) in clinical care. PROMs can help improve patient-care provider communication and may be used to inform the need for interdisciplinary care for Low Back Pain (LBP). However, PROM implementation to support clinical decision-making is complex and requires knowledge translation (KT) interventions that will overcome barriers to using PROMs in interdisciplinary clinical settings.

Objectives

to 1) identify potential barriers and enablers to using PROMs in primary care LBP clinical practice from the perspective of healthcare team members, and 2) develop a theory-based tailored KT intervention to facilitate the use of PROMs in interdisciplinary clinical practice.

Methods

We invited 25 HCPs working in an interdisciplinary team to complete a self-administered survey designed based on the Theoretical Domain Framework (TDF) to identify the barriers and enablers to using PROM scores in LBP clinical practice. The questionnaire consisted of 30 questions rated on a 5-point Likert scale (quantitative) and included open-ended questions (qualitative). Quantitative and qualitative data were analysed to estimate the frequency of barriers and enablers. Findings were then reviewed by a panel of four KT experts who mapped behaviour change techniques to barriers identified that informed the design of a KT intervention.

Results

Eighteen HCPs responded to the survey. Factors identified as likely to restrict the use of PROM scores included knowledge, skills, social/professional role and identity, goals, decision processes, beliefs about consequences, environmental context and resources, behavioural regulation, and social influence. A multi-component evidence-based KT intervention was proposed by the panel of experts to address these barriers: a training workshop; educational materials; and use of PROM score reports to HCPs that were all delivered by an opinion leader.

Conclusion

The routine use of PROMs in clinical practice may optimize the quality of LBP care and improve patients’ outcomes. The proposed multi-component KT intervention is expected to be an effective strategy to increase HCPs’ ability to integrate PROMs into clinical decision-making and to engage patients in their care.

An update on joint-specific outcome measures in total hip replacement

This is the latest review of joint-specific tools used to evaluate patients undergoing total hip replacement (THR) surgery, which is an effective treatment for end-stage osteoarthritis. Due to the large number and multitude of scales and their variants used, a critical assessment of the available tools is necessary. In the article, we briefly describe six different clinical tools: the Western Ontario and McMaster Universities Osteoarthritis Index, the Hip Disability and Osteoarthritis Outcome Score, the Harris Hip Score, the Oxford Hip Score, the Mayo Hip Score, and the Rheumatoid and Arthritis Outcome Score. We present the advantages and constraints of the different outcome measures, providing a helpful resource of information for clinical trials and for everyday routine evaluation.

Measuring patient-reported outcomes in orthognathic surgery: Linguistic and psychometric validation of the Mandarin Chinese version of FACE-Q instrument

Background

Orthognathic surgery is useful for correction of dental malocclusion and improvement of facial appearance. The FACE-Q is a patient-reported outcome instrument for evaluation of surgical and psychosocial effect. The purposes of this study were to conduct a linguistic validation of all FACE-Q scales to Mandarin Chinese, to test the orthognathic surgery-related scales for reliability and validity, and to evaluate the effect of orthognathic surgery.

Methods

All FACE-Q scales and checklists were translated from English to Mandarin Chinese according to international recommendations: forward translations, backward translation, and cognitive interviews. Psychometric testing of orthognathic surgery-related scales of translated version was administered to patients with facial deformities and history of orthognathic surgery (n = 53; 17 scales) or no history of orthognathic surgery (n = 44; 11 scales), and control subjects (n = 57; 11 scales).

Results

All FACE-Q scales and checklists were linguistically validated into Mandarin Chinese. The contents were confirmed valid among Mandarin Chinese-speaking population. The FACE-Q scales had excellent internal consistency (Cronbach's alpha >0.70) and discriminated (p < 0.05) well between patients before and after orthognathic surgeries and normal subjects.

Conclusions

This study discovered significant benefit of orthognathic surgery on improving facial appearance and psychosocial function, as compared with the non-surgical patients and normal controls.

The Use of Measurement Systems to Support Patient Self-Management of Long-Term Conditions: An Overview of Opportunities and Challenges

Long-term conditions are a major public health concern that present many challenges for patients living with them. There is increasing policy focus on promoting patient self-management and supporting patients to take ownership of managing their conditions. Because long term conditions often fluctuate over time, ongoing monitoring of disease activity is necessary for self-management; this can be achieved through using Patient Reported Outcome Measures (PROMs). PROMs can provide additional information about patients’ symptoms, functioning, and emotional wellbeing, informing clinical care for patients. Measurement systems are an innovative method to gather and report PROMs throughout a patient’s course of care, to support clinical practice and improve overall quality of care. Measurement systems are often delivered via a digital platform, which can convey patient-reported information to healthcare professionals and provide tailored self-management advice to patients, all based on information collected via PROMs. There are a number of potential benefits of this approach to self-management. Measurement systems can improve clinical practice, creating efficient clinical encounters and positively influencing patient-clinician interactions. The use of monitoring throughout a patient’s care is also thought to empower patients, by improving their knowledge of their condition, increasing their engagement with their health, and influencing their overall management of their condition. Challenges associated with using measurement systems in this way include finding appropriate PROMs, provisioning of suitable technology, and limiting the burden for patients. To increase the implementation of measurement systems into practice it is important to consider how to engage and educate healthcare professionals and patients to empower their use. Overall, adopting measurement systems into clinical practice may improve clinicians’ ability to support patient self-management of long-term conditions.

Psychometric validation of PROMIS® Anxiety and Depression Item Banks for the Brazilian population

PURPOSE

Scientific evidence indicates that depression and anxiety symptoms may be understood as risk factors associated with the incidence and progression of chronic diseases. Considering the lack of mental health assessment tools that meet strict methodological standards, the authors have chosen to validate the psychometric properties of Anxiety and Depression Item Banks - Emotional Distress domain of the Patient-Reported Outcomes Measurement Information System (PROMIS®) for the Brazilian population.

METHODS

In this study, 606 adults responded to the self-administered Anxiety and Depression Item Banks, which were calibrated using Factor Analyses (Exploratory and Confirmatory analysis) and adjustment of the Graded Response Model. Transcultural validity was assessed by Differential Item Functioning (DIF).

RESULTS

The two-factor analysis confirmed the unidimensionality of Emotional Distress Items (CFI = 0.96, TLI = 0.96, RMSEA = 0.05). The residual correlation matrix did not identify item pairs with local dependence. Indicators marked with DIF presented a low impact for gender, age, and language variables. The instrument demonstrated greater reliability in the moderate-severe range, indicating that the error reduction is reflected in the - 1.0 to + 3.0 amplitude.

CONCLUSION

The psychometric measurements of Anxiety and Depression Item Banks in the Brazilian version were equivalent to those in the original version. Additional research contemplating patients with different levels of emotional distress are necessary to better comprehend the results obtained in this study.

PROMs data: can it be used to make decisions for individual patients? A narrative review

Patient-reported outcome measures (PROMs) are increasingly used in clinical practice providing health care professionals with patients’ perceptions and views of their health. They have traditionally been utilized in health research and health service evaluation and are now starting to be used in routine clinical practice with individual patients. The repeated administration of PROMs over the course of care with individual patients has a role in patient assessment, assisting clinical decision-making, and tracking patient progress. This approach can influence the patient–clinician encounter impacting the therapeutic alliance and increasing patient engagement with care. It is also theorized to improve patient outcomes and satisfaction with care. Advances in technologies and innovations in methodology have led to the use of electronic systems to simplify the collection and reporting of PROMs. Challenges of using PROMs with individual patients include clinician knowledge and skills, and access to appropriate technology. This paper reviews the use of PROMs with individual patients, illustrating how they may affect the patient–clinician encounter impact satisfaction and health outcomes. The routine use of PROMs during a course of care rather than just at the start and end provides additional opportunity to inform clinician and patient with benefits to both. The adoption of PROMs in clinical practice can help health care professionals to make decisions for individual patients. Further work is needed to examine the implementation of PROMs and benefits of PROMs in different clinical contexts.

Chiropractors' views on the use of patient-reported outcome measures in clinical practice: a qualitative study

Background

Patient-reported outcome measures (PROMs) are widely available for use in musculoskeletal care. However, there is little research exploring the implementation of PROMs in clinical practice. This qualitative study explored chiropractors' views on PROMs to identify any barriers and facilitators to implementing PROMs in chiropractic care and the training needs of chiropractors regarding the use of PROMs.

Methods

A qualitative study of chiropractors' views on PROMs was undertaken as part of a larger project to address the feasibility of conducting a randomised controlled trial of PROM use in chiropractic clinics for patients with low back pain. Contact was made with chiropractors working in chiropractic companies with multiple clinic sites. Semi-structured interviews were conducted with eight chiropractors, either face-to-face at their place of work or over the telephone. The interviews were transcribed verbatim and analysed using thematic analysis. The data were coded inductively by two authors.

Results

Chiropractors discussed their knowledge and engagement with PROMs in clinical practice, identifying reasons for their use, such as understanding clinic performance, clinical practice, and research. They also discussed how they used PROMs within their clinical practice and the benefits of using them with individual patients, for example during the consultation, identifying yellow flags, and tracking patient progress. Chiropractors voiced concerns about patient engagement with PROMs, questioning if patients find them burdensome, and the appropriate PROMs to use with patients with pain. Finally, chiropractors acknowledged the organisational barriers and facilitators to using PROMs within their practice, such as busy practices, electronic systems, and use of reception staff.

Conclusions

Using participating chiropractors' views of PROMs, the study identified barriers and facilitators to implementing PROMs in chiropractic care, such as clinician knowledge, engagement, and organisational concerns and identified the potential training needs of chiropractors regarding PROMs. The results from the study suggested chiropractors use PROMs with their individual patients, but PROMs should be meaningful to patients and chiropractors to improve engagement.

Barriers to antiretroviral therapy adherence in developed countries: a qualitative synthesis to develop a conceptual framework for a new patient-reported outcome measure

Suboptimal adherence to antiretroviral therapy (ART) remains common. Patient-centered tools are needed to comprehensively assess adherence barriers in HIV clinical practice. Thus, we conducted a research synthesis to produce a conceptual framework for a new patient-reported outcome measure (PRO) for use in routine HIV care in Canada and France. A PRO's conceptual framework graphically represents the concepts to be measured and the potential relationships between them. Towards ensuring the framework's relevance to the target populations' concerns, qualitative studies with HIV-positive adults on barriers to ART adherence in developed countries were synthesized with thematic analysis, attending to the cross-study prevalence and interrelationships of barrier themes. In March 2016, searches within Medline, PsychINFO, and Embase produced 5,284 records. Two reviewers determined the final sample (n = 41). Analysis generated three levels of ART adherence barrier themes. Twenty Level 2 themes and their component subthemes (Level 3) were organized into 6 higher-order themes (Level 1): Cognitive and emotional aspects (100% of studies contributing content -prevalence), Lifestyle factors (95%), Social and material context (95%), Characteristics of ART (90%), Health experience and state (73%), and Healthcare services and system (66%). As to interrelationships, study authors articulated relationships between all higher-order themes (Level 3). Linkages between Level 2 barrier themes showed great variability, from 21% to 95%. Overall, this synthesis contributes an exceptionally detailed conceptual framework and report of ART adherence barriers, applicable to a wide range of PLHIV. It suggests that a key to understanding many barriers is through their interconnections. It also identifies gaps in barrier research. Concerning the new PRO's development, comprehensiveness will need to be weighed against other concerns (e.g., respondent burden) and the provision of barrier-specific guidance for clinically addressing its scores seems essential.

Improving multiple sclerosis management and collecting safety information in the real world: the MSDS3D software approach

INTRODUCTION

For safety evaluation, randomized controlled trials (RCTs) are not fully able to identify rare adverse events. The richest source of safety data lies in the post-marketing phase. Real-world evidence (RWE) and observational studies are becoming increasingly popular because they reflect usefulness of drugs in real life and have the ability to discover uncommon or rare adverse drug reactions.

AREAS COVERED

Adding the documentation of psychological symptoms and other medical disciplines, the necessity for a complex documentation becomes apparent. The collection of high-quality data sets in clinical practice requires the use of special documentation software as the quality of data in RWE studies can be an issue in contrast to the data obtained from RCTs. The MSDS3D software combines documentation of patient data with patient management of patients with multiple sclerosis. Following a continuous development over several treatment-specific modules, we improved and expanded the realization of safety management in MSDS3D with regard to the characteristics of different treatments and populations.

EXPERT OPINION

eHealth-enhanced post-authorisation safety study may complete the fundamental quest of RWE for individually improved treatment decisions and balanced therapeutic risk assessment. MSDS3D is carefully designed to contribute to every single objective in this process.

"Back on Track": A Mobile App Observational Study Using Apple's ResearchKit Framework

Background

In March 2015, Apple Inc announced ResearchKit, a novel open-source framework intended to help medical researchers to easily create apps for medical studies. With the announcement of this framework, Apple presented 5 apps built in a beta phase based on this framework.

Objective

The objective of this study was to better understand decision making in patients with acute anterior cruciate ligament (ACL) ruptures. Here, we describe the development of a ResearchKit app for this study.

Methods

A multilanguage observatory study was conducted. At first a suitable research topic, target groups, participating territories, and programming method were carefully identified. The ResearchKit framework was used to program the app. A secure server connection was realized via Secure Sockets Layer. A data storage and security concept separating personal information and study data was proposed. Furthermore, an efficient method to allow multilanguage support and distribute the app in many territories was presented. Ethical implications were considered and taken into account regarding privacy policies.

Results

An app study based on ResearchKit was developed without comprehensive iPhone Operating System (iOS) development experience. The Apple App Store is a major distribution channel causing significant download rates (>1.200/y) without active recruitment. Preliminary data analysis showed moderate dropout rates and a good quality of data. A total of 180 participants were currently enrolled with 107 actively participating and producing 424 completed surveys in 9 out of 24 months.

Conclusions

ResearchKit is an easy-to-use framework and powerful tool to create medical studies. Advantages are the modular built, the extensive reach of iOS devices, and the convenient programming environment.

Implementation of a mobile inpatient quality of life (QoL) assessment for oncology nursing

PURPOSE

Cancer patients suffer from a variety of symptoms, but little is known about changes during hospitalization and symptom burden at discharge. We implemented an electronic quality of life (QoL) assessment used by the nursing team in routine inpatient care. Feasibility, acceptance, and the course of QoL were investigated.

METHODS

A self-administered electronic questionnaire based on the EQ-5D and the EORTC QLQ-C30 was applied in clinical routine. Cancer patients were approached by the nursing staff to complete the QoL assessment twice, at admission and at the day of discharge. Both the feedback of the nursing staff as well as characteristics of participants were used to evaluate the electronic assessment.

RESULTS

Out of 210 patients from an oncologic ward, 85 patients (40 %) were invited to participate, 95 % of whom (n = 81) agreed to participate. Participation rate depended on the day of admission, the presence of the coordinating nurse, the overall morbidity assessed by patient clinical complexity level, and the patient age. Forty-six patients (56 %) asked for assistance in completing the questionnaire. Patients older than 53 years and male patients were more likely to need assistance. Twenty-two percent of the nursing staff (n = 5) use the information assessed for individual patient care. Fifty-two percent (n = 12) rated the additional workload as very little or little and 68 % (n = 15) agreed that handling for the patient was easy. Global QoL improved during the stay. Most severe symptoms at admission included fatigue, pain, appetite loss, and insomnia.

CONCLUSIONS

The results of this study indicate that it is feasible to implement and use an electronic QoL assessment by the nursing staff in routine inpatient cancer care. Obstacles and worries of staff members have to be considered when further developing this program.

Detecting short-term change and variation in health-related quality of life: within- and between-person factor structure of the SF-36 health survey

Background

A major goal of much aging-related research and geriatric medicine is to identify early changes in health and functioning before serious limitations develop. To this end, regular collection of patient-reported outcome measure (PROMs) in a clinical setting may be useful to identify and monitor these changes. However, existing PROMs were not designed for repeated administration and are more commonly used as one-time screening tools; as such, their ability to detect variation and measurement properties when administered repeatedly remain unknown. In this study we evaluated the potential of the RAND SF-36 Health Survey as a repeated-use PROM by examining its measurement properties when modified for administration over multiple occasions.

Methods

To distinguish between-person (i.e., average) from within-person (i.e., occasion) levels, the SF-36 Health Survey was completed by a sample of older adults (N = 122, M_age = 66.28 years) daily for seven consecutive days. Multilevel confirmatory factor analysis (CFA) was employed to investigate the factor structure at both levels for two- and eight-factor solutions.

Results

Multilevel CFA models revealed that the correlated eight-factor solution provided better model fit than the two-factor solution at both the between-person and within-person levels. Overall model fit for the SF-36 Health Survey administered daily was not substantially different from standard survey administration, though both were below optimal levels as reported in the literature. However, individual subscales did demonstrate good reliability.

Conclusions

Many of the subscales of the modified SF-36 for repeated daily assessment were found to be sufficiently reliable for use in repeated measurement designs incorporating PROMs, though the overall scale may not be optimal. We encourage future work to investigate the utility of the subscales in specific contexts, as well as the measurement properties of other existing PROMs when administered in a repeated measures design. The development and integration of new measures for this purpose may ultimately be necessary.

The Key to Individualized Addiction Treatment is Comprehensive Assessment and Monitoring of Symptoms and Behavioral Change

Modern health services now strive for individualized treatment. This approach has been enabled by the increase in knowledge derived from neuroscience and genomics. Substance use disorders are no exception to individualized treatment even though there are no gene-specific medications yet available. What is available is the ability to quickly and precisely assess and monitor biopsychosocial variables known to vary during addiction recovery and which place addicts at increased risk of relapse. Monitoring a broad spectrum of biopsychosocial health enables providers to address diverse genome-specific changes that might trigger withdrawal from treatment or recovery relapse in time to prevent that from occurring. This paper describes modern measurement tools contained in the NIH Patient-Reported Outcomes Measurement Information System (PROMIS) and the NIH Toolbox and suggests how they might be applied to support recovery from alcohol and other substance use disorders in both pharmacological and abstinence-oriented modalities of care.

A psychometric assessment of the St. George's respiratory questionnaire in patients with COPD using Rasch model analysis

BACKGROUND

The St. George's Respiratory Questionnaire (SGRQ) was a widely used tool to assess disease impact on patients with obstructive airways disease. Although traditional methods have generally supported construct validity and internal consistency reliability of SGRQ, such methods cannot facilitate the evaluation of whether items are equivalent to different individuals. The purpose of this study is to rigorously examine the psychometric properties of the SGRQ in patients with chronic obstructive pulmonary disease (COPD) using Rasch model analysis.

METHODS

A methodological research was conducted on SGRQ in a sample of 240 male patients with COPD recruited from the outpatient services in Central Taiwan. The psychometric properties of the SGRQ were examined using Rasch model analysis with a mixed rating scale and partial credit mode by Winsteps software. The level of matching between the item's difficulty and person's ability was analyzed by item-person targeting as well as ceiling and floor effects. Item-person maps were also examined for checking the location of the item's difficulty and person's measures along the same scale. Finally, the differential item functioning (DIF) was examined to measure group equivalence associated with age and disease's severity.

RESULTS

Each of the three domains (Symptom, Activity, Impact) of the SGRQ was found to be unidimensionality. The person separation index ranged from 1.21 (Symptom domain) to 2.50 (Activity domain). There was a good targeting for the SGRQ domains, except the Impact domain (1.36). The percentage of ceiling and floor effects were below 10%, except the ceiling effect in the Impact domain (26.25%). From item-person maps, gaps of location of item corresponded to patient's ability were identified. The results have also showed that many items in SGRQ revealed age or severity related DIF.

CONCLUSIONS

Except the Symptom domain of SGRQ, the others have a reliabile internal consistency and a good hierarchical structure. The results of Rasch model analysis can highlight aspects for scale improvement, such as gap, duplicate items or scale responses. There was some age or severity related DIF indicating somewhat unstable across different characteristics of group. IRB No.: DMR94-IRB-179.

Use of SMS and tablet computer improves the electronic collection of elective orthopaedic patient reported outcome measures

INTRODUCTION

Electronic patient reported outcome measures (PROMs) enable real time reporting back to the patient and medical team, comparison between similar patient cohorts and long-term cost effective outcome measurement. The primary objective of this three-phase pilot study was to measure uptake using a web-based PROM system following the introduction of two separate process improvements.

METHODS

Eighty consecutive new elective orthopaedic patients in a single surgeon's practice were recruited for the study. Patients in Group 1 (n=26) received only a letter reminding them to complete a symptom score. Those in Group 2 (n=31) also received a reminder SMS (short message service) message via their mobile or home telephone and those in Group 3 (n=23) also had access to a tablet computer in clinic.

RESULTS

The mean patient age in Group 1 was 55 years (range: 24-80 years), in Group 2 it was 60 years (range: 23-85 years) and in Group 3 it was 58 years (range: 37-78 years) (p>0.05). Overall, 79% of patients had internet access, and 35% of Group 1, 55% of Group 2 and 74% of Group 3 recorded an electronic PROM score (p=0.02). In Group 3, 94% of patients listed for an operation completed an electronic PROM score (p=0.006).

CONCLUSIONS

Collecting PROM data effectively in everyday clinical practice is challenging. Electronic collection should meet that challenge and improve healthcare delivery but it is in its infancy. This pilot study shows that the combination of an SMS reminder and access to a Wi-Fi enabled tablet computer in the clinic setting enabled 94% of patients listed for an operation to complete a score on a web-based clinical outcomes system. Additional staff training and telephone call reminders may further improve uptake.

Measurement equivalence and feasibility of the EORTC QLQ-PR25: paper-and-pencil versus touch-screen administration

OBJECTIVE

We assessed the measurement equivalence and feasibility of the paper-and-pencil and touch-screen modes of administration of the Taiwan Chinese version of the EORTC QLQ-PR25, a commonly used questionnaire to evaluate the health-related quality of life (HRQOL) in patients with prostate cancer in Taiwan.

METHODS

A cross-over design study was conducted in 99 prostate cancer patients at an urology outpatient clinic. Descriptive exact and global agreement percentages, intraclass correlation, and equivalence test based on minimal clinically important difference (MCID) approach were used to examine the equity of HRQOL scores between these two modes of administration. We also evaluated the feasibility of computerized assessment based on patients' acceptability and preference. Additionally, we used Rasch rating scale model to assess differential item functioning (DIF) between the two modes of administration.

RESULTS

The percentages of global agreement in all domains were greater than 85% in the EORTC QLQ-PR25. All results from equivalence tests were significant, except for Sexual functioning, indicating good equivalence. Only one item exhibited DIF between the two modes. Although nearly 80% of the study patients had no prior computer-use experience, the overall proportion of acceptance and preference for the touch-screen mode were quite high and there was no significant difference across age groups or between computer-use experience groups.

CONCLUSIONS

The study results showed that the data obtained from the modes of administration were equivalent. The touch-screen mode of administration can be a feasible and suitable alternative to the paper-and-pencil mode for assessment of patient-reported outcomes in patients with prostate cancer.

Feasibility of computerized adaptive testing for collection of patient-reported outcomes after inpatient rehabilitation

OBJECTIVE

To evaluate the feasibility of computer adaptive testing (CAT) using an Internet or telephone interface to collect patient-reported outcomes after inpatient rehabilitation and to examine patient characteristics associated with completion of the CAT-administered measure and mode of administration.

DESIGN

Prospective cohort study of patients contacted approximately 4 weeks after discharge from inpatient rehabilitation. Patients selected an Internet or telephone interface.

SETTING

Rehabilitation hospital.

PARTICIPANTS

Patients (N=674) with diagnoses of neurologic, orthopedic, or medically complex conditions.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

CAT version of the Community Participation Indicators (CAT-CPI).

RESULTS

From an eligible pool of 3221 patients, 674 (21%) agreed to complete the CAT-CPI. Patients who agreed to complete the CAT-CPI were younger and reported slightly higher satisfaction with overall care than those who did not participate. Among these patients, 231 (34%) actually completed the CAT-CPI; 141 (61%) selected telephone administration, and 90 (39%) selected Internet administration. Decreased odds of completing the CAT-CPI were associated with black and other race; stroke, brain injury, or orthopedic and other impairments; and being a Medicaid beneficiary, whereas increased odds of completing the CAT-CPI were associated with longer length of stay and higher discharge FIM cognition measure. Decreased odds of choosing Internet administration were associated with younger age, retirement status, and being a woman, whereas increased odds of choosing Internet administration were associated with higher discharge FIM motor measure.

CONCLUSIONS

CAT administration by Internet and telephone has limited feasibility for collecting postrehabilitation outcomes for most rehabilitation patients, but it is feasible for a subset of patients. Providing alternative ways of answering questions helps assure that a larger proportion of patients will respond.

Barriers to completion of Patient Reported Outcome Measures

Patient Reported Outcomes Measures (PROMs) are commonly used in total joint arthroplasty (TJA) to assess surgical outcomes. However certain patient populations may be underrepresented due to lower survey completion rates. The purpose of this study is to evaluate factors that influence PROM completion rates for 1997 TJA patients between 7/1/2007 and 12/31/2010. Completion rates were lower among patients who were over 75, Hispanic or Black, had Medicare or Medicaid, TKA patients and revision TJA patients (P<0.05 for all comparisons). Having multiple risk factors further reduced completion rates (P<0.001). Overall participation increased significantly during the study period, after electronic data capture methods were introduced. Awareness of these factors may help physicians and researchers improve participation of all patient populations so they are well represented in TJA outcomes research.

The Computer-based Health Evaluation Software (CHES): a software for electronic patient-reported outcome monitoring

BACKGROUND

Patient-reported Outcomes (PROs) capturing e.g., quality of life, fatigue, depression, medication side-effects or disease symptoms, have become important outcome parameters in medical research and daily clinical practice. Electronic PRO data capture (ePRO) with software packages to administer questionnaires, storing data, and presenting results has facilitated PRO assessment in hospital settings. Compared to conventional paper-pencil versions of PRO instruments, ePRO is more economical with regard to staff resources and time, and allows immediate presentation of results to the medical staff.The objective of our project was to develop software (CHES - Computer-based Health Evaluation System) for ePRO in hospital settings and at home with a special focus on the presentation of individual patient's results.

METHODS

Following the Extreme Programming development approach architecture was not fixed up-front, but was done in close, continuous collaboration with software end users (medical staff, researchers and patients) to meet their specific demands. Developed features include sophisticated, longitudinal charts linking patients' PRO data to clinical characteristics and to PRO scores from reference populations, a web-interface for questionnaire administration, and a tool for convenient creating and editing of questionnaires.

RESULTS

By 2012 CHES has been implemented at various institutions in Austria, Germany, Switzerland, and the UK and about 5000 patients participated in ePRO (with around 15000 assessments in total). Data entry is done by the patients themselves via tablet PCs with a study nurse or an intern approaching patients and supervising questionnaire completion.

DISCUSSION

During the last decade several software packages for ePRO have emerged for different purposes. Whereas commercial products are available primarily for ePRO in clinical trials, academic projects have focused on data collection and presentation in daily clinical practice and on extending cancer registries with PRO data. CHES includes several features facilitating the use of PRO data for individualized medical decision making. With its web-interface it allows ePRO also when patients are home. Thus, it provides complete monitoring of patients'physical and psychosocial symptom burden.

Spinal cord injury-functional index: item banks to measure physical functioning in individuals with spinal cord injury

OBJECTIVES

To develop a comprehensive set of patient-reported items to assess multiple aspects of physical functioning relevant to the lives of people with spinal cord injury (SCI), and to evaluate the underlying structure of physical functioning.

DESIGN

Cross-sectional.

SETTING

Inpatient and community.

PARTICIPANTS

Item pools of physical functioning were developed, refined, and field tested in a large sample of individuals (N=855) with traumatic SCI stratified by diagnosis, severity, and time since injury.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Spinal Cord Injury-Functional Index (SCI-FI) measurement system.

RESULTS

Confirmatory factor analysis (CFA) indicated that a 5-factor model, including basic mobility, ambulation, wheelchair mobility, self-care, and fine motor function, had the best model fit and was most closely aligned conceptually with feedback received from individuals with SCI and SCI clinicians. When just the items making up basic mobility were tested in CFA, the fit statistics indicated strong support for a unidimensional model. Similar results were demonstrated for each of the other 4 factors, indicating unidimensional models.

CONCLUSIONS

Though unidimensional or 2-factor (mobility and upper extremity) models of physical functioning make up outcomes measures in the general population, the underlying structure of physical function in SCI is more complex. A 5-factor solution allows for comprehensive assessment of key domain areas of physical functioning. These results informed the structure and development of the SCI-FI measurement system of physical functioning.

Neuro-QOL: brief measures of health-related quality of life for clinical research in neurology

OBJECTIVE

To address the need for brief, reliable, valid, and standardized quality of life (QOL) assessment applicable across neurologic conditions.

METHODS

Drawing from larger calibrated item banks, we developed short measures (8-9 items each) of 13 different QOL domains across physical, mental, and social health and evaluated their validity and reliability. Three samples were utilized during short form development: general population (Internet-based, n = 2,113); clinical panel (Internet-based, n = 553); and clinical outpatient (clinic-based, n = 581). All short forms are expressed as T scores with a mean of 50 and SD of 10.

RESULTS

Internal consistency (Cronbach α) of the 13 short forms ranged from 0.85 to 0.97. Correlations between short form and full-length item bank scores ranged from 0.88 to 0.99 (0.82-0.96 after removing common items from banks). Online respondents were asked whether they had any of 19 different chronic health conditions, and whether or not those reported conditions interfered with ability to function normally. All short forms, across physical, mental, and social health, were able to separate people who reported no health condition from those who reported 1-2 or 3 or more. In addition, scores on all 13 domains were worse for people who acknowledged being limited by the health conditions they reported, compared to those who reported conditions but were not limited by them.

CONCLUSION

These 13 brief measures of self-reported QOL are reliable and show preliminary evidence of concurrent validity inasmuch as they differentiate people based upon number of reported health conditions and whether those reported conditions impede normal function.

Content-balancing strategy in bifactor computerized adaptive patient-reported outcome measurement

PURPOSE

Most multidimensional patient-reported outcomes (PRO) measures are lengthy to complete. Computerized adaptive testing (CAT) that selects the most informative items can potentially reduce respondent burden without sacrificing measurement accuracy. The commonly used maximum Fisher information item selection method has been reported to lead to highly unbalanced item bank usage and potentially imprecise trait estimation. This study employs the content-balancing strategy in a bifactor-modeled CAT item selection and examines its impact on measurement accuracy and item bank usage.

METHODS

Item responses from a population-based SF-36 survey were first calibrated using the bifactor graded response model. Four post hoc CATs using items and responses from the SF-36 data set were then created. The content-balancing strategy was adopted in the item selection procedure of the bifactor-modeled CAT. The measurement accuracy and usage of items of the CAT were compared between the tests with and without the content-balancing strategy.

RESULTS

The results indicate that the CAT implemented with the content-balancing strategy offers a better overall measurement accuracy of both the general health status and the two health domains (physical and mental) of the SF-36.

CONCLUSIONS

The content-balancing strategy helps the CAT-PRO to balance the selection of items and achieve improved measurement accuracy. Its implementation in real-time CAT administration to measure multidimensional PRO traits merits further studies.

[Modern testing theory and its application in the field of health measurement]

This paper briefly introduces item response theory (IRT) as a typical representation of modern testing theory (MTT), and systematically reviews the processes and contents of the application of IRT in the area of health measurement, including, for example, item bank development, scale revision and computerized adaptive testing. The author presents the potential benefits and the notable problems during health measuring by IRT. Then, the author asserts the need for thorough assessment of feasibility when using the IRT in patient-reported outcome research. Further research based on IRT and computerized adaptive testing in health measurement will be carried out in the field of medical care including traditional Chinese medicine and integrative medicine.

Qualitative and quantitative evaluation of EHR-integrated mobile patient questionnaires regarding usability and cost-efficiency

OBJECTIVES

The objective of this evaluation study is to assess a web-based application, currently available on iPad, to document questionnaires regarding patient reported outcomes such as quality of life. Based on the single source approach, the results of these questionnaires are available in the electronic health record to be used for treatment and research purposes. The assessment focuses on the usability and efficiency of the system.

METHODS

The system usability scale questionnaire with seven additional items was used to rate the usability by the patients. It was formally validated by a Cronbach Alpha test. In addition, semi-structured interviews were conducted with patients and medical staff. Time and cost measures, based on official tables of costs, were taken through workflow observations. This study was conducted in the department of dermatology at the University Hospital of Münster, Germany from April to June 2011.

RESULTS

Using the web-based application questionnaire, results about patient reported outcomes like quality of life are immediately available in the electronic health record and can be used for treatment or research purposes. 118 patients and four staff members participated in the study. The usability score reached 80 from 100 points and patients as well as medical staff stated in the interviews that the usability of the web-based system was high, and they preferred it to the previously used paper-based questionnaires. In the setting of our pilot department the mobile devices amortized their costs after 6.7 months. In general, depending on the professional group who are going to post process the paper-based forms, the earliest break-even point to use mobile questionnaires is at 1737 paper sheets per year.

CONCLUSION

The mobile patient questionnaires, integrated into the electronic health record, were well accepted in our pilot setting with high usability scores from patients and medical staff alike. The system has also proved to be cost-efficient compared to the paper-based workflow, given that a certain number of questionnaires is used per year.

An interactive voice response diary for patients with non-dystrophic myotonia

INTRODUCTION

Non-dystrophic myotonia (NDM) is caused by mutations in muscle chloride and sodium channels. Currently, there is no standardized instrument for documenting symptom frequency and severity in NDM.

METHODS

Subjects used an automated, interactive, telephone-based voice response diary (IVR) to record frequency and severity of stiffness, weakness, pain, and tiredness once a week for 8 weeks, after their baseline visits.

RESULTS

We describe the IVR and report data on 76 subjects for a total of 385 person-weeks. Overall there were 5.1 calls per subject. Forty-eight subjects called in 5 or more times, and 14 called in 8 times. Stiffness was both the most frequent and severe symptom. Warm-up and handgrip myotonia were associated with higher severity scores for stiffness.

CONCLUSIONS

IVR is a convenient technology to allow patient reporting of repeated and real-time symptom frequency and severity, and it is presently being used in a trial of mexiletine in NDM.

Health span or life span: the role of patient-reported outcomes in informing health policy

OBJECTIVES

Population ageing and the increasing burden of chronic conditions challenge traditional metrics of assessing the efficacy of health care interventions and as a consequence policy and planning. Using chronic heart failure (CHF) as an exemplar this manuscript seeks to describe the importance of patient-reported outcomes to inform policy decisions.

METHODS

The method of an integrative review has been used to identify patient-reported outcomes (PROs) in assessing CHF outcomes. Using the Innovative Care for Chronic Conditions the case for developing a metric to incorporate PROs in policy planning, implementation and evaluation is made.

RESULTS

In spite of the increasing use of PROs in assessing CHF outcomes, their incorporation in the policy domain is limited.

CONCLUSIONS

Effective policy and planning is of health care services is dependent on the impact on the individual and their families. Epidemiological transitions and evolving treatment paradigms challenge traditional metrics of morbidity and mortality underscoring the importance of assessing PROs.

The development of a clinical outcomes survey research application: Assessment Center

INTRODUCTION

The National Institutes of Health sponsored Patient-Reported Outcome Measurement Information System (PROMIS) aimed to create item banks and computerized adaptive tests (CATs) across multiple domains for individuals with a range of chronic diseases.

PURPOSE

Web-based software was created to enable a researcher to create study-specific Websites that could administer PROMIS CATs and other instruments to research participants or clinical samples. This paper outlines the process used to develop a user-friendly, free, Web-based resource (Assessment Center) for storage, retrieval, organization, sharing, and administration of patient-reported outcomes (PRO) instruments.

METHODS

Joint Application Design (JAD) sessions were conducted with representatives from numerous institutions in order to supply a general wish list of features. Use Cases were then written to ensure that end user expectations matched programmer specifications. Program development included daily programmer "scrum" sessions, weekly Usability Acceptability Testing (UAT) and continuous Quality Assurance (QA) activities pre- and post-release.

RESULTS

Assessment Center includes features that promote instrument development including item histories, data management, and storage of statistical analysis results.

CONCLUSIONS

This case study of software development highlights the collection and incorporation of user input throughout the development process. Potential future applications of Assessment Center in clinical research are discussed.

Technology and quality of life outcomes

OBJECTIVES

To discuss recent technological advances in quality of life (QOL) data collection and guidance for use in research and clinical practice. The use of telephone-, computer-, and web/internet-based technologies to collect QOL data, reliability and validity issues, and cost will be discussed, along with the potential pitfalls associated with these technologies.

DATA SOURCES

Health care literature and web resources.

CONCLUSION

Technology has provided researchers and clinicians with an opportunity to collect QOL data from patients that were previously not accessible. Most technologies offer a variety of options, such as language choice, formatting options for the delivery of questions, and data management services. Choosing the appropriate technology for use in research and/or clinical practice primarily depends on the purpose for QOL data collection.

IMPLICATIONS FOR NURSING PRACTICE

Technology is changing the way nurses assess QOL in patients with cancer and provide care. As stakeholders in the health care delivery system and patient advocates, nurses must be intimately involved in the evaluation and use of new technologies that impact QOL and/or the delivery of care.

Using Qualitative Research to Inform the Development of a Comprehensive Outcomes Assessment for Asthma

BACKGROUND: Qualitative research can inform the development of asthma patient-reported outcome (PRO) measures and user-friendly technologies through defining measurement constructs, identifying potential limitations in measurement and sources of response error, and evaluating usability. OBJECTIVE: The goal of the current study was to inform the development of a comprehensive asthma PRO assessment with input from patients and clinical experts. METHOD: Self-reported adult asthma sufferers recruited from a 3,000 member New England-area research panel participated in either one of three focus groups (N=21) or individual cognitive item debriefing interviews (N=20) to discuss how asthma impacts their health-related quality of life (HRQOL), and provide feedback on a preliminary set of asthma impact survey items and prototype patient report. Focus groups and cognitive interviews were conducted using traditional research principles (e.g., semi-structured interview guide, probing, and think aloud techniques). An Expert Advisory Panel (N=12) including asthma clinical specialists and measurement professionals was convened to review results from the focus group and cognitive interview studies and make recommendations for final survey and report development. RESULTS: Domains of health impacted by asthma included physical (recreation, play, competitive sports, and exercise), social (activities, family relationships), emotional (anger, upset, frustration, anxiety, worry), sleep, role (recreational/leisure activities; work), and sexual functioning. Most items in the impact survey were easily understood, covered important content, and included relevant response options. Items with contradictory examples and multiple concepts were difficult to comprehend. Suggestions were made to expand survey content by including additional items on physical and sexual functioning, sleep, self-consciousness, stigma, and finances. Reports were considered useful and participants saw value in sharing the results with their doctor. Graphic presentation of scores was not always understood; participants preferred tabular presentation of score levels with associated interpretative text. Display of inverse scores for different measures (higher scores equaling better health on one scale and worse health on another) shown on a single page was confusing. The score history section of the report was seen as helpful for monitoring progress over time, particularly for those recently diagnosed with asthma. Expert panelists agreed that displaying inverse scores in a single summary report may be confusing to patients and providers. They also stressed the importance of comprehensive interpretation guidelines for patients, with an emphasis on what they should do next based on scores. Panelists made recommendations for provider and aggregate-level reports (e.g., "red flags" to indicate significant score changes or cut-points of significance; identification of subgroups that have scored poorly or recently gotten worse). CONCLUSION: Incorporating input from patients, clinicians, and measurement experts in the early stages of product development should improve the construct validity of this PRO measure and enhance its practical application in healthcare.

Building PROMIS item banks: librarians as co-investigators

PURPOSE

There is growing interest in the use of item response theory (IRT) for creation of measures of health-related quality of life (HRQOL). A first step in IRT modeling is development of item banks. Our aim is to describe the value of including librarians and to describe processes used by librarians, in the creation of such banks.

METHOD

Working collaboratively with PROMIS researchers at the University of Pittsburgh, a team of librarians designed and implemented comprehensive literature searches in a selected set of information resources, for the purpose of identifying existing measures of patient-reported emotional distress.

RESULTS

A step-by-step search protocol developed by librarians produced a set of 525 keywords and controlled vocabulary terms for use in search statements in 3 bibliographic databases. These searches produced 6,169 literature citations, allowing investigators to add 444 measurement scales to their item banks.

CONCLUSION

Inclusion of librarians on the Pittsburgh PROMIS research team allowed investigators to create large initial item banks, increasing the likelihood that the banks would attain high measurement precision during subsequent psychometric analyses. In addition, a comprehensive literature search protocol was developed that can now serve as a guide for other investigators in the creation of IRT item banks.