Evidence on the relationship between PROMIS-29 and EQ-5D: a literature review

Chair-based yoga programme for older adults with multimorbidity: RCT with embedded economic and process evaluations

Background

Older adults with multimorbidity experience impaired health-related quality of life and treatment burden. Yoga has the potential to improve several aspects of health and well-being. The British Wheel of Yoga's Gentle Years Yoga© programme was developed specifically for older adults, including those with chronic conditions. A pilot trial demonstrated feasibility of using Gentle Years Yoga in this population, but there was limited evidence of its effectiveness and cost-effectiveness.

Objective

To determine the effectiveness and cost-effectiveness of the Gentle Years Yoga programme in addition to usual care versus usual care alone in older adults with multimorbidity.

Design

Pragmatic, multisite, individually randomised controlled trial with embedded economic and process evaluations.

Setting

Participants were recruited from 15 general practices in England and Wales from July 2019 with final follow-up in October 2022.

Participants

Community-dwelling adults aged 65 years and over with multimorbidity, defined as two or more chronic health conditions from a predefined list.

Interventions

All participants continued with any usual care provided by primary, secondary, community and social services. The intervention group was offered a 12-week programme of Gentle Years Yoga.

Main outcome measures

The primary outcome and end point were health-related quality of life measured using the EuroQol-5 Dimensions, five-level version utility index score over 12 months. Secondary outcomes were health-related quality of life, depression, anxiety, loneliness, incidence of falls, adverse events and healthcare resource use.

Results

The mean age of the 454 randomised participants was 73.5 years; 60.6% were female, and participants had a median of three chronic conditions. The primary analysis included 422 participants (intervention, n = 227 of 240, 94.6%; usual care, n = 195 of 214, 91.1%). There was no statistically or clinically significant difference in the EuroQol-5 Dimensions, five-level version utility index score over 12 months: the predicted mean score for the intervention group was 0.729 (95% confidence interval 0.712 to 0.747) and for usual care it was 0.710 [95% confidence interval (CI) 0.691 to 0.729], with an adjusted mean difference of 0.020 favouring intervention (95% CI -0.006 to 0.045, p = 0.14). No statistically significant differences were observed in secondary outcomes, except for the pain items of the Patient-Reported Outcomes Measurement Information System-29. No serious, related adverse events were reported. The intervention cost £80.85 more per participant (95% CI £76.73 to £84.97) than usual care, generated an additional 0.0178 quality-adjusted life-years per participant (95% CI 0.0175 to 0.0180) and had a 79% probability of being cost-effective at the National Institute for Health and Care Excellence threshold of £20,000 per quality-adjusted life-year gained. The intervention was acceptable to participants, with seven courses delivered face to face and 12 online.

Limitations

Self-reported outcome data raise the potential for bias in an unblinded trial. The COVID-19 pandemic affected recruitment, follow-up and the mode of intervention delivery.

Conclusions

Although the Gentle Years Yoga programme was not associated with any statistically significant benefits in terms of health-related quality of life, mental health, loneliness or falls, the intervention was safe, acceptable to most participants and highly valued by some. The economic evaluation suggests that the intervention could be cost-effective.

Future work

Longer-term cost-effectiveness modelling and identifying subgroups of people who are most likely to benefit from this type of intervention.

Trial registration

This trial is registered as ISRCTN13567538.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/94/36) and is published in full in Health Technology Assessment; Vol. 28, No. 53. See the NIHR Funding and Awards website for further award information.

Population Norms for the EQ-5D-5L, PROPr and SF-6D in Hungary

OBJECTIVES

This study aimed to develop population norms for three preference-accompanied measures [EQ-5D-5L, Patient-Reported Outcomes Measurement Information System (PROMIS)-preference scoring system (PROPr) and Short-Form Six-Dimension (SF-6D)] in Hungary.

METHODS

In November 2020, an online cross-sectional survey was conducted among a representative sample of the Hungarian adult general population (n = 1631). Respondents completed the Hungarian versions of the EQ-5D-5L, PROMIS-29+2 version 2.1 and 36-item Short Form Survey version 1 (SF-36v1). The association of utilities with sociodemographic and health-related characteristics of respondents was analysed using multivariate regressions.

RESULTS

The proportion of respondents reporting problems ranged from 8 to 44% (self-care to pain/discomfort) on the EQ-5D-5L, 39-94% (physical function to sleep) on PROPr and 38-87% (role limitations to vitality) on the SF-6D. Problems related to physical function, self-care, usual activities/role limitations and pain increased with age, while mental health problems decreased in all three measures. In almost all corresponding domains, respondents indicated the fewest problems on the EQ-5D-5L and the most problems on the SF-6D. The mean EQ-5D-5L, PROPr and SF-6D utilities were 0.900, 0.535 and 0.755, respectively. Female gender (PROPr, SF-6D), a lower level of education (EQ-5D-5L, PROPr), being unemployed or a disability pensioner (EQ-5D-5L), being underweight or obese (SF-6D), lack of physical exercise (all) and polypharmacy (all) were associated with significantly lower utilities. PROPr yielded the lowest and EQ-5D-5L the highest mean utilities in 28 of 30 chronic health conditions.

CONCLUSIONS

This study presents the first set of Hungarian population norms for the EQ-5D-5L, PROPr and SF-6D. Our findings can serve as reference values in clinical trials and observational studies and contribute to the monitoring of population health and the assessment of disease burden in Hungary.

A Swiss digital Delphi study on patient-reported outcomes

AIMS OF THE STUDY

Health-related quality of life (HRQoL) indicators are patient-reported outcomes (PROs). PROs are defined as any report of the status of a patient's health condition or health behaviour that comes directly from the patient, without interpretation of the patient's response by a clinician or anyone else. Despite Swiss national bodies (FOPH, FMH) recognising the potential of PRO measures (PROMs) for improving the health system, no consensus has yet emerged regarding a generic PROM framework or specific domains for practical uptake. The aim of the present digital Delphi study was to generate a consensual Swiss expert opinion on a generic PROM framework, measurement domains and items from a validated instrument (PROMIS [Patient-Reported Outcome Measurement Information System]) as well as on the role and implementation of PROs in the Swiss healthcare system via PRO consensus statements.

METHODS

A 4-round digital Delphi study was conducted among Swiss PRO stakeholders. A total of n = 21 Swiss PROM stakeholders completed round 1 surveys on the PROM framework. During the stakeholder meeting, n = 11 stakeholders completed round 2 and round 3 surveys pertaining to measurement domains and items, respectively. In-meeting key questions and discussion items were extracted, consolidated into statements and subjected to consensus voting in a round 4, post-meeting survey. Consensus was defined as ≥70% agreement.

RESULTS

Pre-meeting, agreement was reached for the tripartite framework of physical, mental and social health (95-100%). During the meeting, agreement was reached on all seven measurement domains of a generic PROM (PROMIS-29), ranging from 80% (Anxiety, Sleep Disturbance) to 100% (Pain Interference, Depression, Ability to Participate in Social Roles). Consensus was also reached for all PROMIS-29 items, with average domain consensus ranging from 83% (Sleep Disturbance, Ability to Participate in Social Roles) to 100% (Depression). Finally, four post-meeting consensus statements regarding PROs in Switzerland reached agreement.

CONCLUSIONS

A Delphi method can help identify areas of need regarding PROMs in Switzerland. The current study identified a generic PROM as a missing quality indicator for the Swiss national health system's value. A pre-meeting informational briefing, expert presentations and moderation supported three voting rounds to help identify PROMIS-29 as a PROM framework (round 1), measurement domains (round 2) and items (round 3) as a basis for further validation research. The empirical agreement among diverse stakeholders supports broad consensus towards preliminary feasibility of integrating generic PROMs into the Swiss health system based on content relevance.

Understanding the measurement relationship between EQ-5D-5L, PROMIS-29 and PROPr

PURPOSE

Many generic patient-reported instruments are available for the measurement of health outcomes, including EQ-5D-5L, and the Patient-Reported Outcome Measurement Information System (PROMIS). Assessing their measurement characteristics informs users about the consistency between, and limits of, evidence produced. The aim was to assess the measurement relationship between the EQ-5D-5L descriptive system and value sets, the PROMIS-29 and PROPr (PROMIS value set).

METHODS

Data were extracted from a cross-sectional survey administering measures of quality of life online in Australia. Descriptive analysis, agreement and construct validity assessment methods were used to compare instruments at the item, domain and value set level.

RESULTS

In total, 794 Australians completed the survey. Convergent validity analysis found that similar dimensions across instruments were highly correlated (> 0.50), but the PROMIS-29 assesses additional health concepts not explicitly covered by EQ-5D (sleep and fatigue). Known-group assessment found that EQ-5D-5L and PROPr were able to detect those with and without a condition (ES range 0.78-0.83) but PROPr could more precisely detect differing levels of self-reported health. Both instruments were sensitive to differences in levels of pain.

DISCUSSION

There is some consistency in what the EQ-5D-5L, PROMIS-29 and PROPr measure. Differences between value set characteristics can be linked to differences what is measured and the valuation approaches used. This has implications for the use of each in assessing health outcomes, and the results can inform decisions about which instrument should be used in which context.

Scale agreement, ceiling and floor effects, construct validity, and relative efficiency of the PROPr and EQ-5D-3L in low back pain patients

BACKGROUND

The PROMIS Preference score (PROPr) is a new health state utility (HSU) score that aims to comprehensively incorporate the biopsychosocial model of health and apply favorable psychometric properties from the descriptive PROMIS system to HSU measurements. However, minimal evidence concerning comparisons to the EQ-5D-3L and the PROPr's capability to differentiate clinical severity are available. Therefore, the aim of this study was to compare the PROPr to the EQ-5D-3L in terms of scale agreement, ceiling/floor effects, distribution, construct validity, discriminatory power, and relative efficiency (RE) in terms of the Oswestry Disability Index (ODI) for patients with low back pain (LBP).

METHODS

We used intra-class correlation coefficients (ICC) and Bland-Altman plots to compare the PROPr and EQ-5D-3L with regared to scale agreement in a cross-sectional routine sample of LBP patients. For distribution, we used the Pearson's coefficient for skewness and for ceiling/floor effects, a 15%-top/bottom threshold. For convergent validity, we used Pearson's correlation coefficients. For known-groups validity, we applied a linear regression with interaction terms (predictors sex, age, and ODI level) and an analysis of variance (ANOVA). For discriminatory power, we calculated the effect size (ES) using Cohen's d and the ratio of the area under the receiver-operating characteristics curves (AUROC-ratio = AUROCPROPr/AUROCEQ-5D-3L). RE was measured using the ratio of F-values (RE = FPROPr/FEQ-5D-3L).

RESULTS

Of 218 LBP patients, 50.0% were female and the mean age was 61.8 years. The mean PROPr (0.20, 95%CI: 0.18; 0.22) and EQ-5D-3L scores (0.55, 95%CI: 0.51; 0.58) showed low agreement (d = 0.35, p < 0.001; ICC 0.27, 95%CI: -0.09; 0.59). The PROPr's distribution was positively skewed, whereas the EQ-5D-3L's was negative. Neither tool showed ceiling/floor effects, but all EQ-5D-3L dimensions did. Pearson correlation was r = 0.66 (95%CI: 0.58; 0.73). Differences were invariant to sex and age but not to ODI severity: ESEQ-5D-3L > ESPROPr and RE < 1 in higher ODI severity; ESEQ-5D-3L < ESPROPr and RE > 1 in lower ODI severity. AUROC-ratios did not show significant differences in terms of ODI severity.

CONCLUSIONS

All PROPr and EQ-5D-3L biopsychosocial dimensions of health showed impairment in LPB patients. The capability of EQ-5D-3L and PROPr to differentiate ODI levels depends on ODI severity. Joint application of both tools may provide additional information.

A Direct Comparison of the Measurement Properties of EQ-5D-5L, PROMIS-29+2 and PROMIS Global Health Instruments and EQ-5D-5L and PROPr Utilities in a General Population Sample

OBJECTIVES

We aimed to compare measurement properties of the 5-level version of EQ-5D (EQ-5D-5L) and 2 Patient-Reported Outcomes Measurement Information System (PROMIS) short forms, PROMIS-29+2 and PROMIS Global Health (PROMIS-GH-10), and of EQ-5D-5L and PROMIS-preference scoring system (PROPr) utilities.

METHODS

A cross-sectional survey was conducted in a general population sample in Hungary (N = 1631). We compared the following measurement properties at the level of items, domains, and utilities, the latter using corresponding US value sets: ceiling and floor, informativity (Shannon's indices), agreement, convergent, and known-group validity. For the analyses, PROMIS items/domains were matched to EQ-5D-5L domains that cover similar concepts of health.

RESULTS

The majority of PROMIS items showed enhanced distributional characteristics, including lower ceilings and higher informativity than the EQ-5D-5L. Good convergent validity was established between EQ-5D-5L and PROMIS domains capturing similar aspects of health. Mean EQ-5D-5L utilities were substantially higher than those of PROPr (0.864 vs 0.535). EQ-5D-5L utilities correlated moderately or strongly with PROPr (r = 0.61), PROMIS-GH-10 physical (r = 0.68), and mental health summary scores (r = 0.53). EQ-5D-5L utilities decreased with age, whereas PROPr utilities slightly increased with age. EQ-5D-5L utilities discriminated significantly better in 12/28 (ratio of F-statistics) and 18/26 (area under the receiver-operating characteristics curve ratio) known groups defined by age, self-perceived health status, and self-reported physician-diagnosed health conditions, including hypertension, diabetes, coronary heart disease, chronic kidney disease, and stroke.

CONCLUSIONS

This study provides comparative evidence on the measurement properties of EQ-5D-5L, PROMIS-29+2, and PROMIS-GH-10 and informs decisions about the choice of instruments in population health surveys for assessment of patients' health and for cost-utility analyses.

Mapping the Patient-Reported Outcomes Measurement Information System (PROMIS-29) to EQ-5D-5L

BACKGROUND AND OBJECTIVE

The Patient-Reported Outcomes Measurement Information System (PROMIS-29) is gaining popularity as healthcare system funders increasingly seek value-based care. However, it is limited in its ability to estimate utilities and thus inform economic evaluations. This study develops the first mapping algorithm for estimating EuroQol 5-Dimension 5-Level (EQ-5D-5L) utilities from PROMIS-29 responses using a large dataset and through extensive comparisons between econometric models.

METHODS

An online survey was conducted to collect responses to PROMIS-29 and EQ-5D-5L from the general Australian population (N = 3013). Direct and indirect mapping methods were explored, including linear regression, Tobit, generalised linear model, censored regression model, beta regression (Betamix), the adjusted limited dependent variable mixture model (ALDVMM) and generalised ordered logit. The most robust model was selected by assessing the performance based on average ten-fold cross-validation geometric mean absolute error and geometric mean squared error, the predicted mean, maximum and minimum utilities, as well as the fitting across the entire distribution.

RESULTS

The direct approach using ALDVMM was considered the preferred model based on lowest geometric mean absolute error and geometric mean squared error in cross-validation (0.0882, 0.0299) and its superiority in predicting the actual observed mean, full health states and lower utility extremes. The robustness and precision in prediction across the entire distribution of utilities with ALDVMM suggest it is an accurate and valid mapping algorithm. Moreover, the suggested mapping algorithm outperformed previously published algorithms using Australian data, indicating the validity of this model for economic evaluations.

CONCLUSIONS

This study developed a robust algorithm to estimate EQ-5D-5L utilities from PROMIS-29. Consistent with the recent literature, the ALDVMM outperformed all other econometric models considered in this study, suggesting that the mixture models have relatively better performance and are an ideal candidate model for mapping.

A Comparison of PROPr and EQ-5D-5L Value Sets

OBJECTIVES

The EQ-5D-5L and its value sets are widely used internationally. However, in the US and elsewhere, there is growing use of PROMIS, which has a value set (PROPr) based on the stated preferences of the US population. This paper aims to compare the characteristics of EQ-5D-5L and PROPr value sets and to highlight potential implications for users.

METHODS

US, Australian and English value sets were used for EQ-5D-5L. PROPr utilities were calculated based on PROMIS-29 + 2. We examined, in each case, (i) the characteristics (e.g. range of values, number of unique values) and distribution of all possible 'theoretical' utilities; (ii) dimension/domain importance ranking by the utility of corner states (i.e. health states with the worst level in one domain and the best in all others); (iii) comparisons of utilities for health states hypothesised to be comparable in terms of severity across EQ-5D-5L descriptive systems and PROMIS-29 + 2 domain scores; (iv) the changes in values of adjacent states (i.e. a one-level change in one dimension for EQ-5D-5L and a four-point change in raw scores for PROMIS-29 + 2, with the other dimensions held constant) for dimensions hypothesised to overlap conceptually or be correlated between the two instruments.

RESULTS

EQ-5D-5L and PROPr utilities differ systematically. First, the US EQ-5D-5L utilities range from - 0.573 to 1, whereas PROPr values for PROMIS-29 + 2 range from - 0.022 to 0.954. Second, in the US (and English) EQ-5D-5L value sets, pain is the most important dimension whereas in PROPr pain is one of the least important (apart from sleep disturbance). Third, classified based on severity across EQ-5D-5L descriptive systems and PROMIS-29 + 2 domain scores, PROPr has substantially lower values than EQ-5D-5L values for comparable 'mild' health states, but higher values for more 'severe' health states. Last, when one dimension is considered across its best to worst levels and all other dimensions are held constant at their best or moderate level, in EQ-5D-5L value sets, the greatest changes in utility occur between levels 3 and 4 (moderate and severe) problems; in PROPr that occurred between the most severe states and their descriptively adjacent health states.

CONCLUSION

There are very considerable differences between US EQ-5D-5L and PROPr utilities, despite both in principle representing utility on the same scale anchored at 0 and 1 and both representing the preferences of the US general public. It is important for decision makers and clinical triallists to be aware of these differences. Further work is needed to assess the impact of these differences in value sets using population and patient data, and in longitudinal settings.

Beyond the Knife-Reviewing the Interplay of Psychosocial Factors and Peripheral Nerve Lesions

Peripheral nerve injuries are a common clinical problem. They not only affect the physical capabilities of the injured person due to loss of motor or sensory function but also have a significant impact on psychosocial aspects of life. The aim of this work is to review the interplay of psychosocial factors and peripheral nerve lesions. By reviewing the published literature, we identified several factors to be heavily influenced by peripheral nerve lesions. In addition to psychological factors like pain, depression, catastrophizing and stress, social factors like employment status and worker's compensation status could be identified to be influenced by peripheral nerve lesions as well as serving as predictors of functional outcome themselves, respectively. This work sheds a light not only on the impact of peripheral nerve lesions on psychosocial aspects of life, but also on the prognostic values of these factors of functional outcome. Interdisciplinary, individualized treatment of patients is required to identify patient at risk for adverse outcomes and provide them with emotional support when adapting to their new life situation.