PROMIS measures of pain, fatigue, negative affect, physical function, and social function demonstrated clinical validity across a range of chronic conditions

Predictors of survey non-response two years after hip arthroscopy: Results from an institutional prospective registry

Purpose

Survey-based studies are inherently subject to non-response bias. A comprehensive understanding of the factors contributing to non-response is important for minimizing attrition bias and ensuring generalizability of results. The purpose of this study was to determine the preoperative factors associated with survey non-response 2 years after hip arthroscopy.

Methods

Patients undergoing hip arthroscopy at a single center between October 2015 and March 2020 were approached for enrollment in a prospective registry. Patients were emailed an electronic survey at baseline and at 1 and 2 years postoperatively. The primary outcome was response to the 2-year postoperative survey. Patients who failed to complete any part of the 2-year postoperative survey after a series of standardized email, text message, and phone call reminders were considered non-responders. Baseline sociodemographics and patient-reported outcomes (PROs) were compared between the groups using Pearson Chi-Squared or Wilcoxon Rank-Sum tests. Logistic regression was used to identify predictors of non-response.

Results

Ninty-nine patients were enrolled and completed the baseline survey. There were 25 non-responders (25 %) at 2 years. Non-responders demonstrated a higher proportion of patients who were male, identified as non-white, and did not respond to the 1-year postoperative survey. There were no differences in baseline PROs between responders and non-responders. When controlling for age and sex, patients who did not identify as white (OR = 4.3, 95 % CI [1.3, 14.4]) and patients who did not respond to the 1-year postoperative survey (OR = 4.5, 95 % CI [1.5, 13.8]) were more likely to be non-responders at 2 years.

Conclusion

Not responding to 1 year postoperative survey and non-white race are independent predictors of non-response at 2 years after hip arthroscopy. Baseline PROs do not differ between responders and non-responders.

Combining preoperative expectations and postoperative met expectations to predict patient-reported outcomes after knee surgery

Introduction

Both preoperative expectations and postoperative met expectations can independently influence patient-reported outcomes (PROs), however, their combined effect on PROs is not well understood. This study aimed to determine the prognostic significance of categorizing non-arthroplasty knee surgery patients into clusters based on both preoperative expectations and postoperative met expectations.

Methods

638 patients who underwent non-arthroplasty knee surgery from June 2015 to May 2021 at a single academic institution were analyzed. Patients were grouped based on both preoperative expectations and two-year postoperative met expectations scores using cluster analysis. Four distinct expectations cluster groups were formed: high preoperative-high met expectations (HIGH-HIGH), low preoperative-high met expectations (LOW-HIGH), high preoperative-low met expectations (HIGH-LOW), and low preoperative-low met expectations (LOW-LOW). Socioeconomic data and PROs were compared based on cluster group, and logistic regression was performed to determine the likelihood of achieving a patient-perceived "completely better" status based on cluster group.

Results

Patients with high met expectations, regardless of preoperative expectations, reported better two-year PROs compared to patients with low met expectations. Patients with high preoperative expectations achieved better outcomes only when those expectations were met postoperatively. Low preoperative expectations did not preclude patients from achieving good outcomes, as long as those expectations were met. The HIGH-HIGH group had increased odds of achieving completely better status compared to the LOW-HIGH group (OR = 1.68, p = .02), HIGH-LOW group (OR = 16.69, p < .001), and LOW-LOW group (OR = 5.17, p < .001). The HIGH-LOW group had decreased odds of achieving completely better status compared to the LOW-LOW group (OR = .31, p = .01).

Conclusion

Met expectations may be a stronger predictor of postoperative outcomes than preoperative expectations in non-arthroplasty knee surgery. This study highlights the importance of setting realistic preoperative expectations and focusing on achieving expectations postoperatively. These findings offer valuable insights for clinicians to manage patient expectations effectively based on individual characteristics and expected treatment outcomes.

Use of Patient-Reported Outcomes Measurement Information System Measures in Orthopaedic Specialties: Results of a Scoping Review for 2018 to 2022

The Patient-Reported Outcomes Measurement Information System (PROMIS) is a collection of patient-reported outcome measures assessing physical, mental, and social health that are relevant across a variety of conditions. The use of PROMIS measures in capturing important symptoms and functions has increased over time, yet detail on more recent use of PROMIS measures in orthopaedics and its specialties has been lacking. The goal of this scoping review is to characterize and quantify the use of PROMIS measures in orthopaedic populations across published studies from 2018 through 2022 to inform opportunities for expansion of PROMIS across orthopaedics in research and clinical practice. We identified 699 published studies with 1,835 PROMIS measures. Publications were distributed across orthopaedic subspecialties, including 27% (185 studies) in spine patient populations, 21% (143 studies) in hand/shoulder/elbow, 11% (80 studies) in arthroplasty, 9% (65 studies) in foot/ankle, and 9% (65 studies) in sports medicine. The most commonly used PROMIS measures across all orthopaedic publications assessed physical function (63%), pain interference (55%), and depression (30%). We observed an overall increase in orthopaedic publications using and reporting on PROMIS measures. PROMIS measures are efficient, and precise tools and their use is expected to continue to increase across medical and surgical specialties.

Higher preoperative patient expectations predict better patient-reported psychosocial health outcomes after hip arthroscopy

Introduction

Preoperative expectations are a determinant of patient-reported outcomes (PROs) within several orthopaedic subspecialties. However, the impact on outcomes after hip arthroscopy is unclear. The aim of this study was to explore the relationship between preoperative patient expectations and PROs after hip arthroscopy.

Methods

Patients who underwent hip arthroscopy at a single institution were included. Patient expectations were measured preoperatively using the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) expectations domain. Patient-Reported Outcomes Measurement Information System (PROMIS) domains, a numeric pain scale (NPS), and the Marx activity rating scale (MARS) were assessed 2 years postoperatively. Spearman's coefficient was used to assess the correlation between preoperative expectations and 2-year PROs. Linear regression was used to ascertain the effect of preoperative expectations on 2-year PROs.

Results

105 patients were included, and 78 (74 %) completed 2-year follow-up. The mean (SD) preoperative expectations score was 88.3 (15.3). Higher expectations correlated with better postoperative fatigue, anxiety, depression, pain, and activity levels, as well as more improvement in fatigue, pain, and activity. Expectations scores were higher for patients who achieved minimal clinically important difference (MCID) for PROMIS Fatigue (92.6 vs 82.0, p = .003) and MARS activity (95.3 vs 86.2, p = .014). When controlling for possible confounders, higher expectations independently predicted better postoperative PROMIS Fatigue (β = -0.26, SE = 7.23), Social Satisfaction (β = 0.24, SE = 0.09), and Anxiety (β = -0.24, SE = 0.08).

Conclusion

Higher preoperative expectations are an independent predictor of better psychosocial outcomes 2 years after hip arthroscopy. Setting positive expectations preoperatively may be important for enhancing psychosocial health postoperatively.

Preventing "tipping points" in high comorbidity patients: A lifeline from health coaches - rationale, design and methods

BACKGROUND

This paper describes an innovative cluster randomized controlled trial design to evaluate the comparative effectiveness of two approaches to preventing significant destabilization, leading to unplanned hospitalization and increased disability for patients with high comorbidity, that is, multiple chronic diseases defined by an enhanced Charlson Comorbidity Index ≥4.

METHODS

A total of 1974 patients were randomized in four waves at each of the sixteen Federally Qualified Health Centers (FQHCs) in four health systems -two in New York and two in Chicago. The two interventions compared 1) Patient-Centered Medical Home (PCMH) as implemented by the FQHCs (usual care control); or 2) PCMH plus a coaching intervention delivered by Health Coaches (experimental) helping patients identify life goals to encourage self-management enhanced by a positive affect/self-affirmation strategy. The two primary patient-centered clinical outcomes are 1) Unplanned hospitalizations; and 2) Within-patient changes in quality of life and disability, as measured by the World Health Organization Disability Assessment Scale 2 (WHODAS 2.0). The hypotheses are: 1) intervention patients will have a 5 % relative reduction in unplanned hospitalizations as compared to control patients; and 2) reduced disability measured by WHODAS2.0; 3) destabilization or 'tipping points' leading to hospitalization will be more often triggered by psychosocial issues than by medical Issues.

CONCLUSION

This cluster RCT has the potential to transform the care for patients with high comorbidity by helping motivate patients to engage in self-management and to successfully navigate the barriers, challenges, and stresses leading to destabilization, hospitalization, and increased disability.

CLINICALTRIALS

gov registration number: NCT04176510.

Comparing Approaches to Link SF-36 PF-10 Scores to PROMIS Physical Function: A Validation Study in Three Clinical Samples

BACKGROUND

Physical function (PF) is a central patient-reported outcome (PRO) in many clinical conditions. However, the variety of existing PRO measures (PROMs) yield scores on different scales, limiting the score comparability and interpretability. To overcome this gap, the Patient-Reported Outcomes Measurement Information System (PROMIS®) established a standardized T-score metric using item response theory (IRT). As such, different PROMs measuring PF can be linked to this common metric, allowing for efficient harmonization of scores. Linking algorithms allow conversion of SF-36 PF-10 scores to the PROMIS-PF metric, but these methods have not been validated in independent clinical samples.

OBJECTIVE

To validate and compare two established linking methods for the translation of SF-36 PF-10 scores to the PROMIS-PF metric in clinical populations.

DESIGN

Two previously proposed linking approaches were applied to estimate PROMIS-PF T-scores based on the SF-36 PF-10: 1. Item-level linking, 2. Cross-walk tables. The directly observed T-scores from the 20-item PROMIS-PF short form (PROMIS-PF20a) served as a benchmark against which the linked T-scores from the SF-36 PF-10 were compared. Results were compared to a newly estimated IRT-model based on the study's dataset.

PARTICIPANTS

Patients from cardiology (n = 185), rheumatology (n = 172), and psychosomatic medicine (n = 262), who completed both the PROMIS-PF20a and the SF-36 PF-10.

MAIN MEASURES

PROMIS-PF20a, SF-36 PF-10.

KEY RESULTS

All linking approaches demonstrated high association with observed PROMIS-PF20a T-scores (Pearson correlation ≥ 0.84) and indicated negligible practical differences at the group level (standardized mean difference < 0.2).

CONCLUSIONS

Two currently available linking approaches can reliably translate SF-36 PF-10 scores to standardized PROMIS-PF T-scores across different clinical samples, eliminating the need for re-estimating models in new datasets. As all linking algorithms ultimately presented highly comparable results, cross-walk tables may be preferred as the most practicable approach, allowing for score conversion without complex statistical modeling.

Bedtime media use, psychological distress, and fatigue: a study of college students in Shaanxi Province, China

Background

Numerous studies have linked psychological distress to fatigue, yet few have explored how bedtime media use mediates this relationship. This study examines whether using visual or auditory stimuli at bedtime mediates the relationship between psychological distress and fatigue among college students.

Methods

A total of 1,831 Chinese college students (927 males and 904 females; mean age = 20.36 years, SD 1.26) from universities in Shaanxi Province, China, participated in the study. Data were collected using an electronic questionnaire that assessed psychological distress, bedtime media use, and fatigue. The bootstrap method was employed to test the mediating effects, with 5,000 random samples and a 95% confidence interval.

Results

Psychological distress (r = 0.256, p < 0.001), visual stimuli of bedtime media use (r = 0.114, p < 0.001), and auditory stimuli of bedtime media use (r = 0.109, p < 0.005) were all positively related to fatigue. Among students with normal levels of psychological distress, the relationship between psychological distress and fatigue was partially mediated by the visual stimuli of bedtime media use. In contrast, for students with severe psychological distress, the auditory stimuli of bedtime media use mediated the relationship between psychological distress and fatigue.

Conclusion

Based on the findings, psychological distress is indirectly associated with fatigue through the visual or auditory stimuli of bedtime media use. The visual and auditory stimuli exhibit different mediating effects among students with normal versus severe psychological distress. Interventions should focus on limiting bedtime media use to enhance health and reduce fatigue among college students experiencing psychological distress. Future studies may use longitudinal designs to establish causality or explore the reverse relationship between psychological distress and fatigue for a more robust finding.

Post-exertional malaise in Long COVID: subjective reporting versus objective assessment

Background

Post-exertional malaise (PEM) is a central feature of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and has emerged as a prominent feature of Long COVID. The optimal clinical approach to PEM is inconclusive, and studies of the impact of exercise have yielded contradictory results.

Objective

The objective of this study was to examine PEM in Long COVID by assessing the prevalence of self-reported PEM across study cohorts and symptom responses of Long COVID patients to a standardized exercise stressor. Secondarily, Long COVID symptom responses to exercise were compared to those of ME/CFS and healthy volunteers.

Methods

Data from three registered clinical trials comprised four cohorts in this study: Long COVID Questionnaire Cohort (QC; n = 244), Long COVID Exercise Cohort (EC; n = 34), ME/CFS cohort (n = 9), and healthy volunteers (HV; n = 9). All cohorts completed questionnaires related to physical function, fatigue, and/or PEM symptoms. EC also performed a standardized exercise test (cardiopulmonary exercise test, CPET), and the PEM response to CPET was assessed using visual analog scales and qualitative interviews (QIs) administered serially over 72 h. EC PEM measures were compared to ME/CFS and HV cohorts. A secondary analysis of QI explored positive responses to CPET among EC, ME/CFS and HV.

Results

Self-reported PEM was 67% in QC and estimated at 27% in EC. Only 2 of 34 EC patients (5.9%) were observed to develop PEM after a CPET. In addition, PEM responses after CPET in Long COVID were not as severe and prolonged as those assessed in ME/CFS. Twenty-two of 34 EC patients (64.7%) expressed at least one of 7 positive themes after the CPET.

Conclusion

Self-report of PEM is common in Long COVID. However, observable PEM following an exercise stressor was not frequent in this small cohort. When present, PEM descriptions during QI were less severe in Long COVID than in ME/CFS. Positive responses after an exercise stressor were common in Long COVID. Exercise testing to determine the presence of PEM may have utility for guiding clinical management of Long COVID.

Pre-Pandemic Physical Activity and Early COVID-19 Pandemic Depressive Symptoms in Older Adults

Importance: Pre-pandemic physical activity (PA) levels may be associated with a lower risk of experiencing depressive symptoms in the context of psychosocial resilience during a global crisis. Objective: To investigate the association between self-reported pre-pandemic PA levels and the risk of experiencing depressive symptoms during the beginning of the COVID-19 pandemic in older U.S. adults. Design, Setting, and Participants: We combined three large ongoing prospective cohorts of US adults who provided pre-pandemic baseline self-reports of leisure-time PA and other risk factors using the most recent questionnaire completed as of December 2019. In June 2020, participants reported in a survey whether they had experienced depressive symptoms in the last 7 days. Exposure: Pre-pandemic PA data were categorized by validated criteria into three groups by metabolic equivalent hours per week (MET-hr/wk): inactive (0-3.5), insufficiently active (>3.5 to <7.5), and sufficiently active (≥7.5). Main Outcome and Measures: Our primary outcome was depressive symptoms experienced during the beginning of the COVID-19 pandemic in 2020, assessed by the PROMIS-29 depression domain. We used multivariate logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association of each of the two upper pre-pandemic PA categories versus the lowest PA category with depressive symptoms during the early pandemic. Results: In total, 35,320 older U.S. adults comprised the pooled cohort (mean [standard deviation] age, 74.9[5.9] years; 66.8% female). For PA categories, 15.8% were inactive; 10.4% insufficiently active; and 73.8%, sufficiently active. A total of 1668 participants reported experiencing depressive symptoms in June 2020. After controlling for demographics, lifestyle factors, comorbidities, medications, and pre-pandemic depression at the beginning of the COVID-19 pandemic, compared with the inactive group, those sufficiently active had significantly lower odds of experiencing depressive symptoms (OR, 0.75; 95% CI, 0.66-0.86). In subgroup analyses, the association between PA and depressive symptoms differed by ethnic group. Conclusion and Relevance: In this cohort of older U.S. adults, those who achieved at least 7.5 MET-hr/wk of pre-pandemic PA had lower odds of exhibiting depressive symptoms during the early months of the pandemic. Hence, higher pre-pandemic PA levels may be associated with lower odds of experiencing depressive symptoms during exceptional global crises, such as the COVID-19 pandemic.

Exploratory analysis of electronic patient-reported outcomes collection: comparing online and in-clinic modalities in cancer care

PURPOSE

Patient reported outcome measures (PROMs) have been shown to improve cancer survival but are generally underutilized in cancer care. It is unclear whether electronic-PROMS (ePROMs) modality (online vs. in-clinic) may address barriers to completion. We examined whether patient sociodemographic and clinical factors differed by completion modality.

METHODS

Patients with cancer who had an oncologic provider visit from January 2021 to March 2023 at a tertiary cancer center were assigned the National Institute of Health's computer adaptive technology Patient-Reported Outcomes Measurement Information System instruments. Patients completed ePROMs either through online patient portal (online) up to 7 days before the visit or used a tablet at the clinic visit (in-clinic) if not completed online. Multivariable logistic regression model estimated associations between patient sociodemographic and clinical factors and completion modality.

RESULTS

A total of 8556 patients completed ePROMs (43.3% completed in-clinic). Females were less likely than males to complete ePROMs in-clinic (aOR = 0.89, 0.84-0.93) as were patients with commercial insurance (aOR = 0.83, 0.77-0.89) vs. Medicare; or saw radiation oncologist (aOR = 0.89, 0.83-0.96) vs. medical oncologist. However, patients were more likely to complete ePROMs in-clinic if they identified as Black race (aOR = 1.41, 1.33-1.49) vs. White; were single (aOR = 1.21, 1.14-1.29) or divorced/separated/widowed (aOR = 1.11, 1.04-1.18) vs. married; or saw a provider located in rural (aOR = 1.33, 1.25-1.42) vs. urban area.

CONCLUSIONS

Patients who were males, Blacks, unmarried, Medicare insured or saw providers located in rural area were more likely to complete ePROMs in-clinic. Given the preference for online completion before visits for real-time symptom monitoring, targeted efforts are needed to boost online PROMs completion.

PLAIN MESSAGE

This is a cross-sectional analysis of the associations between sociodemographic and clinical factors with two electronic patient reported outcome measures completion modalities. The results indicate that about half of patients completed online and half completed in-clinic, with males, Blacks, patients who were divorced/separated/widowed, had Medicare insurance and saw a medical oncologist completing electronic patient reported outcome measures in-clinic. We support offering both options while addressing barriers to either modality.

Metabolic Risk Factors Relate to Worse Tendon Health in Individuals With Achilles Tendinopathy

A high proportion of individuals with Achilles tendinopathy continue to demonstrate long-term symptoms and functional impairments after exercise treatment. Thus, there is a need to delineate patient presentations that may require alternative treatment. The objective of this study was to evaluate if the presence of metabolic risk factors relates to tendon symptoms, psychological factors, triceps surae structure, and lower limb function in individuals with Achilles tendinopathy. One hundred and fifty-eight individuals (88 female) with diagnosed midportion Achilles tendinopathy were divided into three groups based on the number of metabolic risk factors linked to cardiovascular disease present at baseline: two or more factors, one factor, no factors. Metabolic risk factors were determined by clinical evaluation and past medical history. Achilles tendinopathy symptoms (Victorian Institute of Sport Assessment-Achilles, Patient Reported Outcome Measurement Information System, movement-evoked pain ratings), psychological factors (Tampa Scale for Kinesiophobia), triceps surae structure (B-mode ultrasound of tendon and muscle morphology, continuous shear wave elastography of tendon mechanical properties), and lower limb function (test battery) were compared among groups. Individuals with two or more metabolic risk factors had worse symptoms with loading (p = 0.011), smaller Achilles tendon size relative to body mass (p = 0.002), and worse lower limb function compared to individuals without metabolic risk factors (p < 0.02). No differences were observed between individuals with one metabolic risk factor and those without metabolic risk factors. Future consideration of multiple metabolic risk factors for individuals with Achilles tendinopathy could facilitate understanding the underlying impairments of tendon pathology and recovery that may be addressed with treatment.

A New Measure of Quantified Social Health Is Associated With Levels of Discomfort, Capability, and Mental and General Health Among Patients Seeking Musculoskeletal Specialty Care

BACKGROUND

A better understanding of the correlation between social health and mindsets, comfort, and capability could aid the design of individualized care models. However, currently available social health checklists are relatively lengthy, burdensome, and designed for descriptive screening purposes rather than quantitative assessment for clinical research, patient monitoring, or quality improvement. Alternatives such as area deprivation index are prone to overgeneralization, lack depth in regard to personal circumstances, and evolve rapidly with gentrification. To fill this void, we aimed to identify the underlying themes of social health and develop a new, personalized and quantitative social health measure.

QUESTIONS/PURPOSES

(1) What underlying themes of social health (factors) among a subset of items derived from available legacy checklists and questionnaires can be identified and quantified using a brief social health measure? (2) How much of the variation in levels of discomfort, capability, general health, feelings of distress, and unhelpful thoughts regarding symptoms is accounted for by quantified social health?

METHODS

In this two-stage, cross-sectional study among people seeking musculoskeletal specialty care in an urban area in the United States, all English and Spanish literate adults (ages 18 to 89 years) were invited to participate in two separate cohorts to help develop a provisional new measure of quantified social health. In a first stage (December 2021 to August 2022) , 291 patients rated a subset of items derived from commonly used social health checklists and questionnaires (Tool for Health and Resilience in Vulnerable Environments [THRIVE]; Protocol for Responding to and Assessing Patient Assets, Risks and Experiences [PRAPARE]; and Accountable Health Communities Health-Related Social Needs Screening Tool [HRSN]), of whom 95% (275 of 291; 57% women; mean ± SD age 49 ± 16 years; 51% White, 33% Hispanic; 21% Spanish speaking; 38% completed high school or less) completed all items required to perform factor analysis and were included. Given that so few patients decline participation (estimated at < 5%), we did not track them. We then randomly parsed participants into (1) a learning cohort (69% [189 of 275]) used to identify underlying themes of social health and develop a new measure of quantified social health using exploratory and confirmatory factor analysis (CFA), and (2) a validation cohort (31% [86 of 275]) used to test and internally validate the findings on data not used in its development. During the validation process, we found inconsistencies in the correlations of quantified social health with levels of discomfort and capability between the learning and validation cohort that could not be resolved or explained despite various sensitivity analyses. We therefore identified an additional cohort of 356 eligible patients (February 2023 to June 2023) to complete a new extended subset of items directed at financial security and social support (5 items from the initial stage and 11 new items derived from the Interpersonal Support Evaluation List, Financial Well-Being Scale, Multidimensional Scale of Perceived Social Support, Medical Outcomes Study Social Support Survey, and 6-item Social Support Questionnaire, and "I have to work multiple jobs in order to finance my life" was self-created), of whom 95% (338 of 356; 53% women; mean ± SD age 48 ± 16 years; 38% White, 48% Hispanic; 31% Spanish speaking; 47% completed high school or less) completed all items required to perform factor analysis and were included. We repeated factor analysis to identify the underlying themes of social health and then applied item response theory-based graded response modeling to identify the items that were best able to measure differences in social health (high item discrimination) with the lowest possible floor and ceiling effects (proportion of participants with lowest or highest possible score, respectively; a range of different item difficulties). We also assessed the CFA factor loadings (correlation of an individual item with the identified factor) and modification indices (parameters that suggest whether specific changes to the model would improve model fit appreciably). We then iteratively removed items based on low factor loadings (< 0.4, generally regarded as threshold for items to be considered stable) and high modification indices until model fit in CFA was acceptable (root mean square of error approximation [RMSEA] < 0.05). We then assessed local dependencies among the remaining items (strong relationships between items unrelated to the underlying factor) using Yen Q3 and aimed to combine only items with local dependencies of < 0.25. Because we exhausted our set of items, we were not able to address all local dependencies. Among the remaining items, we then repeated CFA to assess model fit (RMSEA) and used Cronbach alpha to assess internal consistency (the extent to which different subsets of the included items would provide the same measurement outcomes). We performed a differential item functioning analysis to assess whether certain items are rated discordantly based on differences in self-reported age, gender, race, or level of education, which can introduce bias. Last, we assessed the correlations of the new quantified social health measure with various self-reported sociodemographic characteristics (external validity) as well as level of discomfort, capability, general health, and mental health (clinical relevance) using bivariate and multivariable linear regression analyses.

RESULTS

We identified two factors representing financial security (11 items) and social support (5 items). After removing problematic items based on our prespecified protocol, we selected 5 items to address financial security (including "I am concerned that the money I have or will save won't last") and 4 items to address social support (including "There is a special person who is around when I am in need"). The selected items of the new quantified social health measure (Social Health Scale [SHS]) displayed good model fit in CFA (RMSEA 0.046, confirming adequate factor structure) and good internal consistency (Cronbach α = 0.80 to 0.84), although there were some remaining local dependencies that could not be resolved by removing items because we exhausted our set of items. We found that more disadvantaged quantitative social health was moderately associated with various sociodemographic characteristics (self-reported Black race [regression coefficient (RC) 2.6 (95% confidence interval [CI] 0.29 to 4.9)], divorced [RC 2.5 (95% CI 0.23 to 4.8)], unemployed [RC 1.7 (95% CI 0.023 to 3.4)], uninsured [RC 3.5 (95% CI 0.33 to 6.7)], and earning less than USD 75,000 per year [RC 2.7 (95% CI 0.020 to 5.4) to 6.8 (95% CI 4.3 to 9.3)]), slightly with higher levels of discomfort (RC 0.055 [95% CI 0.16 to 0.093]), slightly with lower levels of capability (RC -0.19 [95% CI -0.34 to -0.035]), slightly with worse general health (RC 0.13 [95% CI 0.069 to 0.18]), moderately with higher levels of unhelpful thoughts (RC 0.17 [95% CI 0.13 to 0.22]), and moderately with greater feelings of distress (RC 0.23 [95% CI 0.19 to 0.28]).

CONCLUSION

A quantitative measure of social health with domains of financial security and social support had acceptable psychometric properties and seems clinically relevant given the associations with levels of discomfort, capability, and general health. It is important to mention that people with disadvantaged social health should not be further disadvantaged by using a quantitative measure of social health to screen or cherry pick in contexts of incentivized or mandated reporting, which could worsen inequities in access and care. Rather, one should consider disadvantaged social health and its associated stressors as one of several previously less considered and potentially modifiable aspects of comprehensive musculoskeletal health.

CLINICAL RELEVANCE

A personalized, quantitative measure of social health would be useful to better capture and understand the role of social health in comprehensive musculoskeletal specialty care. The SHS can be used to measure the distinct contribution of social health to various aspects of musculoskeletal health to inform development of personalized, whole-person care pathways. Clinicians may also use the SHS to identify and monitor patients with disadvantaged social circumstances. This line of inquiry may benefit from additional research including a larger number of items focused on a broader range of social health to further develop the SHS.

Development of Prediction Models for Severe Pain and Urinary Symptoms After Ureteroscopy With Ureteral Stent Placement: Results From the STENTS Study and Initial Validation of Pain Interference

PURPOSE

We developed prediction models for severe pain and urinary symptoms after ureteroscopy with ureteral stent placement.

MATERIALS AND METHODS

The development cohort included 424 adults and adolescents enrolled in the multicenter STENTS prospective cohort study who underwent ureteroscopy with stent placement for urinary stones. The validation cohort was an independent prospective cohort of 115 adults. The outcomes were severe pain intensity and pain interference, measured by the Patient-Reported Outcomes Measurement Information System, and severe urinary symptoms, measured by the Ureteral Stent Symptom Questionnaire. The top quartile of symptoms on postoperative days 1 and 3 was defined as severe. Generalized estimating equation models were used to predict severe symptoms on postoperative days 1, 3, 5, and 7 to 9 in the development cohort and severe pain interference on days 1 and 7 in the validation cohort.

RESULTS

Female sex, younger age, higher BMI, baseline pain interference, number of chronic pain conditions, renal stone location, and history of anxiety predicted severe pain. In the development cohort, the C statistics were 0.83 (95% CI 0.80-0.85) for severe pain interference and 0.82 (95% CI 0.79-0.84) for severe pain intensity. A model in which baseline urinary symptoms replaced pain interference had excellent discrimination for severe urinary symptoms (C statistic 0.83; 95% CI 0.81-0.85). In the validation cohort, the C statistic was 0.7 for severe pain interference (95% CI 0.54-0.78).

CONCLUSIONS

Preoperative characteristics accurately predicted severe pain and urinary symptoms after ureteroscopy with stent placement. On further validation, these models could guide clinical decisions to improve surgical outcomes.

The Johns Hopkins Hope at Hopkins Clinic: supporting the comprehensive needs of individuals with metastatic breast cancer

PURPOSE

Individuals with metastatic breast cancer (MBC) may live with their disease for many years. We initiated the Johns Hopkins Hope at Hopkins Clinic to assess the needs and optimize the care of these patients.

PATIENTS AND METHODS

Patients with MBC who agreed to participate in the Clinic in addition to usual care completed patient-reported outcome (PRO) surveys. They met with a navigator and underwent core consults (cancer rehabilitation, integrative medicine, supportive and palliative care, social work, and nutrition), clinical trial eligibility assessment, and optional services based on PRO responses and selection from a Clinic Menu. A medical oncologist provided a Care Plan during a final consult. Participants were asked to complete 3- and 6-month follow-up PRO surveys. We report on initial Clinic implementation, participant characteristics, and baseline PROs.

RESULTS

From 11/2020 to 6/2022, 45 patients completed baseline surveys and participated in the Clinic. Median age was 58 (32-86); the majority (71%) were white and had estrogen receptor-positive (84%) tumors. Baseline physical and mental health were not good for ≥ 14 days of the past month for 22 and 10%, respectively. PROMIS measure scores were > 1 standard deviation worse than average for 32% for Physical Health, 16% for Mental Health, and 23% for Physical Function. PHQ-8 and GAD-7 scores suggested depression and anxiety for 22 and 7%, respectively. More than 80% of participants received specific recommendations from the core consultants. Only 20% of participants completed follow-up surveys.

CONCLUSION

Patients living with MBC have multiple needs. We used our results to implement routine PRO assessments and to expand services for patients with MBC. Our experience can serve as a model for coordinated care in other systems.

Neurocognitive and Psychosocial Outcomes in Older Adults with Obstructive Sleep Apnea Following Hypoglossal Nerve Stimulation

OBJECTIVES

To assess the impact of hypoglossal nerve stimulation (HNS) on neurocognitive, psychological, and sleep outcomes in older adults with obstructive sleep apnea (OSA).

METHODS

A retrospective analysis of 42 patients aged 50 years and older who underwent HNS for OSA was conducted. Patient-reported outcomes were collected using validated tools, including the Insomnia Severity Index (ISI), PROMIS measures (Sleep-Related Impairment, Cognitive Function, Depression, Anxiety, Anger, Physical Function), Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire (FOSQ-10), and NIH Toolbox Loneliness survey. Pre- and post-HNS scores were compared using paired t-tests and Wilcoxon tests.

RESULTS

Significant improvements were observed in apnea-hypopnea index (AHI) (-17.6, P < .0001), ISI (-7.02, P < .0001), ESS (-3.4, P < .0001), and FOSQ (4.05, P < .0001). PROMIS measures showed significant posttreatment improvements in sleep impairment, cognitive function, depression, anxiety, anger, and loneliness (all P < .01). Physical function and pain did not change.

CONCLUSION

HNS significantly improves sleep characteristics, cognitive function, and psychosocial outcomes in older adults with OSA. Future studies should include larger and more diverse samples with longer follow-up, as well as a control condition.

Implementation of the American- College of Physicians Guideline for Low Back Pain (IMPACt-LBP): protocol for a healthcare systems embedded multisite pragmatic cluster-randomised trial

INTRODUCTION

Low back pain (LBP) is a key source of medical costs and disability, impacting over 31 million Americans at any given time and resulting in US$100-US$200 billion per year in total healthcare costs. LBP is one of the leading causes of ambulatory care visits to US physicians; problematically, these visits often result in treatments such as opioids, surgery or advanced imaging that can lead to more harm than benefit. The American College of Physicians (ACP) Guideline for Low Back Pain recommends patients receive non-pharmacological interventions as a first-line treatment. Roadmaps exist for multidisciplinary collaborative care that include well-trained primary contact clinicians with specific expertise in the treatment of musculoskeletal conditions, such as physical therapists and doctors of chiropractic, as first-line providers for LBP. These clinicians, sometimes referred to as primary spine practitioners (PSPs) routinely employ many of the non-pharmacological approaches recommended by the ACP guideline, including spinal manipulation and exercise. Important foundational work has demonstrated that such care is feasible and safe, and results in improved physical function, less pain, fewer opioid prescriptions and reduced utilisation of healthcare services. However, this treatment approach for LBP has yet to be widely implemented or tested in a multisite clinical trial in real-world practice.

METHODS AND ANALYSIS

The Implementation of the American College of Physicians Guideline for Low Back Pain trial is a health system-embedded pragmatic cluster-randomised trial that will examine the effect of offering initial contact with a PSP compared with usual primary care for LBP. Twenty-six primary care clinics within three healthcare systems were randomised 1:1 to PSP intervention or usual primary care. Primary outcomes are pain interference and physical function using the Patient-Reported Outcomes Measurement Information System Short Forms collected via patient self-report among a planned sample of 1800 participants at baseline, 1, 3 (primary end point), 6 and 12 months. A subset of participants enrolled early in the trial will also receive a 24-month assessment. An economic analysis and analysis of healthcare utilisation will be conducted as well as an evaluation of the patient, provider and policy-level barriers and facilitators to implementing the PSP model using a mixed-methods process evaluation approach.

ETHICS AND DISSEMINATION

The study received ethics approval from Advarra, Duke University, Dartmouth Health and the University of Iowa Institutional Review Boards. Study data will be made available on completion, in compliance with National Institutes of Health data sharing policies.

TRIAL REGISTRATION NUMBER

NCT05626049.

Web-based psychoeducational intervention for bereaved parents

BACKGROUND

There is a lack of theoretically sound, scientifically-tested interventions for bereaved parents.

AIMS

To describe the acceptability and feasibility testing of an online grief-support-resource platform for bereaved parents.

METHODS

Participants included 20 parents of children who had died from a disease. The study involved a quasi-experimental treatment-only two-site design.

FINDINGS

The study was not able to recruit the intended number of participants. The website designed to support parents during grieving was found to be helpful by participants (43% enrolment rate), though not feasible. Lessons learned from this trial include: to use a well-defined eligibility criteria; follow a model for behavioural intervention development in a stepwise fashion, not exceed the individual stage's purpose; cautiously approach bereaved parents less than 6 months after a child's death; and comprehensive parent orientation to the grief-support-resource platform.

CONCLUSION

Transparent sharing of lessons learned provide opportunities for investigators who are planning studies to learn from this team's experience.

The Moderating Role of Ethnicity on Depressive and Anxiety Symptoms and Pain Catastrophizing in Hispanic/Latinx and Non-Hispanic/Latinx White Youth With Chronic Pain

OBJECTIVES

Chronic pain (CP) significantly impacts emotional and physical well-being and overall quality of life across diverse populations in the United States (US). Notably, under-represented minoritized (URM) groups, such as Hispanic/Latinx (H/L) youth, may experience disproportionate effects due to health disparities and lack of access to quality health care. However, this remains understudied. This study aimed to examine the association between CP and its related psychosocial factors-depressive and anxiety symptoms, and pain catastrophizing-in H/L youth, as compared with Non-Hispanic White (NHW) youth.

METHODS

The current study sample included 58 self-identifying H/L and 58 NHW youth seeking CP treatment at a large Northeastern tertiary pain clinic, ages 12 to 18 years old, (M=15.49, SD=1.71), of which 88% identified as biologically female. Participant samples for each group were age and-sex-matched.

RESULTS

Significant associations were found between anxiety and depressive symptoms and pain catastrophizing for youth in both groups. Ethnicity significantly moderated the associations between pain catastrophizing and depressive symptoms and between anxiety and depressive symptoms, with NHW youth with pain exhibiting stronger relations between these constructs when compared with H/L youth with pain.

DISCUSSION

Our results suggested that for NHW youth with CP, greater tendencies toward catastrophizing and experiences of anxiety may more strongly contribute to depressive symptoms, when compared with their Hispanic/Latinx youth counterparts. Further investigation of pain-coping mechanisms among H/L youth and other youth from historically marginalized populations (e.g., racial/ethnic minoritized groups) will help advance clinical understanding of sociocultural variability in links between pain-related psychosocial outcomes in the CP experience.

Effect of an Innovative Online Ayurveda Program for Detox and Lifestyle on Mental and Physical Health in Home-Based Adults: A Pilot Study

Background and Objective: Mental health complaints have significantly increased in Europe over recent years. This study evaluated the effects and safety of a 4-month online, multimodal, complementary intervention on the mental and physical health of home-based adults. Method: Ninety-eight home-based adults with mild to severe mental health and related physical symptoms were recruited across Europe through digital advertisements. This single-arm repeated-measures study utilized three individualized treatment groups to evaluate the impact of the Ayurveda Program for Detox and Lifestyle. The online program included a personalized Ayurveda diet, daily routine, yoga exercise, herbal detoxification procedures, and herbal preparations. Standardized online tests were administered monthly for 4 months to assess anxiety, depression, physical symptoms (Patient Health Questionnaire for Somatic, Anxiety, and Depressive Symptoms), fatigue (PROMIS), and body mass index (BMI). Results: The study population was predominantly female (85%), with a mean age of 58 years. By the end of the fourth month, primary outcomes indicated a significant decrease in anxiety (55%, p < 0.001) and depression symptoms (45%, p < 0.001). The secondary outcomes showed a significant reduction in physical symptoms, including musculoskeletal, neurological, and digestive issues (42%, p < 0.001); fatigue (31%, p < 0.001); and BMI (2%, p < 0.001). Improvements were consistent across all treatment groups, with no significant differences observed. The intervention was feasible and generally safe, with 91% retention, 70% compliance, and 6% adverse effects. Conclusion: The initial results suggest that the Ayurveda Program for Detox and Lifestyle is safe and is associated with significant improvements in the mental and physical health of participants. This trial highlights the potential benefits of integrating complementary lifestyle protocols into standard primary and mental health care practices. Future randomized controlled trials are recommended to control for confounding factors and validate these findings in larger clinical populations.

Supported biopsychosocial self-management for back-related leg pain: a randomized feasibility study integrating a whole person perspective

BACKGROUND

There is limited high-quality research examining conservative treatments for back-related leg pain (BRLP). This feasibility study was done in preparation for a full-scale trial comparing a whole-person supported self-management intervention to medical care for chronic BRLP.

METHODS

Participants were randomized to 12 weeks of individualized supported self-management delivered by physical therapists and chiropractors or medical care consisting of guideline-based pharmacologic care. Supported self-management was based on a behavioral model that used a whole person approach to enhance participants capabilities, opportunities, and motivations to engage in self-care. It combined BRLP education with psychosocial strategies (e.g., relaxed breathing, progressive muscle relaxation, guided imagery, communication skills) and physical modalities such as exercise and spinal manipulation therapy. Providers were trained to address participants' individualized needs and use behavior change and motivational communication techniques to develop a therapeutic alliance to facilitate self-management. Feasibility was assessed using pre-specified targets for recruitment and enrollment, intervention delivery, and data collection over the six-month study period. In addition, areas for potential refinement and optimization of processes and protocols for the full-scale trial were assessed.

RESULTS

We met or exceeded nearly all feasibility targets. Forty-two participants were enrolled over a six-month period in 2022 and very few individuals declined participation due to preferences for one treatment. All but one participant received treatment and 95% of participants attended the minimum number of visits (self-management = 6, medical care = 2). At 12 weeks, 95% of participants in the self-management group reported engaging in self-management practices learned in the program and 77% of medical care participants reported taking medications as prescribed. Satisfaction with the self-management intervention was high with 85% of participants reporting satisfaction with the program overall. Self-management intervention providers delivered all required activities at 72% of visits. Providers also noted some challenges navigating the shared decision-making process and deciding what self-management tools to prioritize. Over the six-month study period, completion rates were 91% for monthly surveys and 86% for weekly surveys.

CONCLUSION

We were able to demonstrate that a full-scale randomized trial comparing a whole-person supported self-management intervention to medical care for chronic BRLP is feasible and identified important areas for optimization.

Current status and future directions in food protein-induced enterocolitis syndrome: An NIAID workshop report of the June 22, 2022, virtual meeting

Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated gastrointestinal food allergy characterized by delayed, protracted vomiting and accompanied by lethargy and pallor, usually 1 to 4 hours after ingesting the food allergen. The pathophysiology of FPIES remains unknown, and currently there are no diagnostic biomarkers available to assess disease activity or its resolution. Over the last 2 decades, FPIES has become increasingly recognized in both pediatric and adult patients. Forty years after the initial FPIES description, the first FPIES code appeared in the International Classification of Diseases, Tenth Revision (ICD-10), and the first international consensus guidelines for the diagnosis and management of FPIES were published. On June 22, 2022, the National Institute of Allergy and Infectious Diseases (NIAID) held its first virtual multidisciplinary workshop on FPIES. Various clinical and translational aspects of FPIES as well as important areas of unmet needs were discussed as priorities for future research during this 2-day virtual workshop. Our report provides a summary of content of the workshop, including updated literature on the topic areas, and also provides critical commentary on the state of FPIES.

Mid to long term follow up of early weightbearing after open reduction internal fixation of ankle fractures

INTRODUCTION

Studies have demonstrated successful outcomes with early weightbearing following open reduction internal fixation (ORIF) of specific ankle fractures. The external validity of an early weightbearing protocol and its effects on patient-reported outcome information scores (PROMIS) has yet to be investigated. This study aimed to investigate the effects of an early weightbearing protocol for all operatively treated ankle fractures and its impact on clinical outcomes and complications.

METHODS

This retrospective cohort study included 229 patients (≥ 16 years) with OTA/AO 44 A-C fractures who underwent open reduction and internal fixation (ORIF). Patients were divided into groups based on early (2-3 weeks postoperative) or delayed (>6 weeks postoperative) weightbearing protocols. Primary outcomes included PROMIS score subsets including physical function, depression, and pain interference and ankle range of motion (ROM) at each follow up visit. Secondary outcomes included complications such as implant removal for pain, prominence, or surgical site infection, revision surgery for failure of fixation or loss of reduction, and post-operative sensory or motor deficits.

RESULTS

There were 96 patients in the early weightbearing cohort and 133 patients in the delayed weightbearing cohort. The median follow-up time of the early weightbearing cohort was 471.47 ± 389.69 days while the delayed cohort was 459.82 ± 358.21 days. Demographics and comorbidities were distributed equally between both groups, except the presence of peripheral neuropathy which was observed more frequently in the delayed weightbearing cohort (8 versus 0, p = 0.022). Results indicated no statistically significant differences in PROMIS scores at final follow up, ankle ROM, or post-operative complications between the early and delayed weightbearing cohorts. Multivariable regression analysis identified smoking as a factor associated with worse ankle ROM at final follow-up.

CONCLUSIONS

This study found that early weightbearing after ORIF of unstable ankle fractures leads to similar PROMIS scores and ankle ROM without increased complications. In addition, smokers were found to have worse ankle ROM when compared to nonsmokers at final follow-up.

Performance-based and patient-reported outcome measures for custom ankle-foot orthosis users: reliability, validity, and sensitivity evidence

PURPOSE

To evaluate the psychometric properties of performance and patient-reported outcome measures (PROMs) for custom ankle-foot orthosis (AFOs) users.

MATERIALS AND METHODS

Current AFO users completed two assessments one week apart; new AFO users completed an assessment before device delivery and at one- and two-months post-delivery.

RESULTS

Seventy current and 31 new users consented and provided data. We found evidence of minimal floor and ceiling effects for most PROMs; the exceptions were measures of service satisfaction. The Orthotics and Prosthetics Users' Survey (OPUS) Lower Extremity Functional Status (LEFS) measure demonstrated excellent test-retest reliability; the 5-level EuroQol (EQ-5D-5L), OPUS Health-Related Quality of Life, Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST 2.0), and PROMIS Physical Function measures demonstrated good reliability. Evidence of known-groups validity is provided by associations between obesity and walking speed. PROMs measuring physical function (LEFS, Rivermead Mobility Index (RMI), PROMIS Physical Function) correlated at least moderately with performance instruments. We observed moderate to large correlations between PROM and performance instrument changes for the EQ-5D-5L, LEFS, RMI, and PROMIS Physical Function.

CONCLUSIONS

Results provide evidence of test-retest reliability, construct validity, and sensitivity to change for some PROMs. PROMs and performance instruments provide overlapping but complementary evidence regarding the benefits of custom AFOs.

The technical expert/clinical user/patient panel (TECUPP): centering patient and family perspectives in patient-reported measure development

Patient and caregiver perspectives are increasingly incorporated into health care research and policymaking, but their inclusion in the quality measure development process often is not robust. We describe a stakeholder panel model for incorporating patient/caregiver voices in the development of patient-reported measures, the Technical Expert/Clinical User/Patient Panel (TECUPP) model. This model is characterized by significant or equal representation of people with lived experience of the disease or condition (as patients or caregivers) to the clinicians and others with technical expertise who typically comprise technical expert panels. We report key design features of the TECUPP model and how we used this model to develop survey-based patient experience measures of timeliness of cancer diagnosis. We describe benefits and challenges of using the TECUPP model and considerations to guide others who might use it as part of developing patient-centered quality measures, based on our experience convening a TECUPP to inform development of a patient-reported measure on timeliness of cancer diagnosis. Benefits include creating space for significant contributions from patients/caregivers and development of a shared understanding of patient experiences and observability of measure domains between clinicians and patients/caregivers. Challenges include time management and managing conversations outside the project scope. Measure development efforts implementing this model should consider recruiting diverse individuals, scheduling short and frequent meetings, enabling participation from all TECUPP members, developing accessible pre-read materials, anchoring meetings with patient stories, and encouraging multiple communication modes. The TECUPP model promotes discussion and understanding by patients/caregivers and clinicians/measure experts helpful for development of survey-based patient-reported measures.

The problem of pain in systemic lupus erythematosus: A comprehensive analysis of pain distribution using the CHOIR body map and PROMIS measures

BACKGROUND

Our study investigates the associations between pain distribution, biopsychosocial factors, and Patient-Reported Outcomes Measurement Information System (PROMIS) measures in patients with systemic lupus erythematosus (SLE). Employing self-reported pain body maps, we aim to characterize the distribution of pain and its impact on biopsychosocial measures.

METHODS

We retrospectively analyzed the electronic health records (EHR) of 332 adult patients with SLE attending pain clinics at an academic medical center. The study included demographics, pain distribution assessed via self-reported body maps, and PROMIS assessments of biopsychosocial experiences. We used linear regression models adjusted for age and sex to investigate associations between pain distribution and PROMIS outcomes.

RESULTS

Men, on average, indicated pain in 3.2 regions, whereas women reported pain in 5.6 regions. Women predominantly highlighted the hip, buttock, and leg region, whereas men primarily emphasized the shoulder and arm region. We found a positive correlation between pain widespreadness and worse PROMIS measures, including pain interference, behavior, fatigue, depression, anxiety, sleep disturbance, and social isolation. Additionally, widespread pain was associated with lower physical function, emotional support, and satisfaction in roles and activities. Female patients reported higher levels of pain and PROMIS measures compared to males.

CONCLUSION

Our findings highlight the multidimensional impact of pain on SLE patients' lives underscoring the need for holistic pain management approaches. The intricate associations between pain distribution and biopsychosocial factors emphasize the importance of considering spatial dimensions of pain in clinical interventions. Further research is warranted to explore effective interventions addressing psychosocial aspects of pain in SLE, aiming to enhance patient symptom management and quality of life.

Social Anxiety, Negative Affect, and Hearing Difficulties in Adults

Subjective ratings of communication function reflect both auditory sensitivity and the situational, social, and emotional consequences of communication difficulties. Listeners interact with people and their environment differently, have various ways of handling stressful situations, and have diverse communication needs. Therefore, understanding the relationship between auditory and mental health factors is crucial for the holistic diagnosis and treatment of communication difficulty, particularly as mental health and communication function may have bidirectional effects. The goal of this study was to evaluate the degree to which social anxiety and negative affect (encompassing generalized anxiety, depression, and anger) contributed to subjective communication function (hearing handicap) in adult listeners. A cross-sectional online survey was administered via REDCap. Primary measures were brief assessments of social anxiety, negative affect, and subjective communication function measures. Participants were 628 adults (408 women, 220 men), ages 19 to 87 years (mean = 43) living in the United States. Results indicated that individuals reporting higher social anxiety and higher negative affect also reported poorer communication function. Multiple linear regression analysis revealed that both negative affect and social anxiety were significant and unique predictors of subjective communication function. Social anxiety and negative affect both significantly, and uniquely, contribute to how much someone feels a hearing loss impacts their daily communication function. Further examination of social anxiety and negative affect in older adults with hearing loss may help researchers and clinicians understand the complex interactions between mental health and sensory function during everyday communication, in this rapidly growing clinical population.

Examining the Influence of Optimal Guideline-Directed Medical Therapy on Patient-Reported Outcomes in Adults With Heart Failure

BACKGROUND

Multidrug, guideline-directed medical therapy (GDMT) improves mortality and hospitalizations for heart failure (HF), but little is known about how optimization of multidrug GDMT influences patient-reported outcomes. Trials of single GDMT medications demonstrate improvements in patient-reported outcomes; however, the effect of the multidrug GDMT regimen on patient-reported outcomes is unclear.

OBJECTIVE

The objective of this study is to determine how multidrug optimization during a multidisciplinary, advanced practice provider HF clinic impacted patient-reported symptoms and quality of life in adults with HF.

METHODS

This retrospective cohort study examined patient-reported outcomes at baseline and 12 weeks during a multidrug GDMT optimization clinic for HF. Outcomes were compared across time and male and female sex. Quality of life was measured with the EQ5D. Symptoms were measured using the PROMIS-29 and PROMIS-Dyspnea Severity score. Descriptive statistics describe sample characteristics. Paired and independent t tests were used for comparisons.

RESULTS

Of 301 adults with HF enrolled in a clinic, 101 completed patient-reported outcome measures at baseline and 12 weeks. Patients (predominantly White/Caucasian males; mean age, 59 years) reported significant improvement in the EQ5D domains of mobility and performance of usual activities, and PROMIS-29 subscales for physical function, fatigue, and ability to participate in social roles. Sex differences were noted for pain and depression, with females reporting improved pain and males reporting slightly less depression.

CONCLUSIONS

Multidisciplinary, advanced practice provider-led optimization clinics can promote optimization of multidrug GDMT that can improve patient-reported outcomes in adults with HF. Future studies are needed to comprehensively examine sex differences in patient-reported response to GDMT and patient-reported response to updated, "quadruple-therapy" GDMT recommendations.

Validation of PROMIS-PI in a Lumbar Decompression Cohort Through Correlation to Established Pain and Disability Metrics

STUDY DESIGN

Retrospective review.

OBJECTIVE

To validate using patient-reported outcome measurement information system-pain interference (PROMIS-PI) to assess outcomes in patients undergoing lumbar decompression surgery compared with well-established pain and disability measures.

SUMMARY OF BACKGROUND DATA

PROMIS outcomes provide valuable information, but the PROMIS-PI measure has not been validated in lumbar decompression.

METHODS

Patient data from a single-surgeon registry were queried to identify patients undergoing elective, primary lumbar decompression for disc herniation. Exclusion criteria included records missing patient-reported outcome measures (PROMs). PROMs included: PROMIS-PI, visual analog scale (VAS)-back, VAS-leg, and Oswestry disability index (ODI). The association between PROMIS-PI and the other PROMs was determined at preoperative, 6-week, 12-week, 6-month, 1-year, and 2-year time points using the Pearson paired correlation tests. MCID achievement rates were determined for all PROMs and correlations were calculated between PROMIS-PI MCID achievement rates and achievement rates for VAS-B, VAS-L, and ODI.

RESULTS

A total of 102 patients were included. PROMIS-PI demonstrated a significant correlation to VAS-B at all periods (P<0.0048, all) with a magnitude of correlation (|r|) ranging from 0.535 to 0.907. PROMIS-PI demonstrated a significant correlation to VAS-L at all periods (P<0.0048, all) with a magnitude of correlation (|r|) ranging from 0.393 to 0.907. PROMIS-PI demonstrated a significant correlation to ODI (P<0.0010, all) with a magnitude of correlation (|r|) ranging from 0.664 to 0.925. There were moderate correlations between MCID achievement rates between PROMIS-PI and all other PROMs studied (P<0.0019, all) with correlation coefficients ranging from 0.367 to 0.406.

CONCLUSION

PROMIS-PI demonstrated a significant correlation to VAS-back, VAS-L, and ODI metrics at preoperative and all postoperative follow-up periods. PROMIS-PI as a valid tool for the evaluation of patient-reported pain provides an additional metric that can guide pain management in patients undergoing spine surgery.

A Remotely Delivered Light-Intensity Physical Activity Intervention for Older Cancer Survivors: Protocol for a Feasibility Randomized Controlled Trial

BACKGROUND

Older cancer survivors face age- and treatment-related comorbidities, including physical functional impairment, which are exacerbated by physical inactivity and sedentary behavior. Regular physical activity can reduce this risk, yet less than 30% of older cancer survivors meet the recommended guidelines for physical activity.

OBJECTIVE

This study aims to describe the design, methods, and rationale for a remotely delivered intervention that uses a whole-of-day approach to physical activity in older cancer survivors. This approach focuses on the accumulation of intermittent bouts of light-intensity activity throughout the entire day by disrupting and reducing sedentary activity. The intervention was guided by social cognitive and self-determination theories and incorporated motivational interviewing.

METHODS

The 12-week Move for Your Health trial randomly assigned 64 older cancer survivors to a theory-based physical activity intervention or a waitlist control. A Fitbit (Google) activity tracker and smartphone app were used to promote awareness of activity levels and enable self-monitoring of both activity and inactivity in tandem with health coaching phone calls. Motivational interviewing was used to engage participants and tailor strategies to achieve goals during the 12-week intervention. Data were collected at baseline, immediately after the intervention, and at longer-term follow-up (3 months thereafter). Feasibility outcomes included recruitment, retention, adherence, adverse events, and acceptability. Other outcomes included obtaining the parameter estimates for changes in physical function, physical performance, physical activity, sedentary behavior, and quality of life.

RESULTS

Recruitment for the Move for Your Health randomized controlled trial was completed in June 2023. Data collection was completed in March 2024. Data analyses are ongoing.

CONCLUSIONS

The results of this trial will provide information on the feasibility of implementing this intervention in the target patient population, as well as data that will provide information about the potential impact of the intervention on the outcomes. Both of these outcomes will inform the design of a larger randomized controlled trial to more fully test a physical activity intervention in an older cancer survivor population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05582889; https://clinicaltrials.gov/study/NCT05582889.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/59504.

Fatigue, impaired physical function and mental health in cancer survivors: the role of social isolation

PURPOSE

Cancer survivors experience an array of physical, psychological, and social problems after treatment has ended. Perceived social isolation may exacerbate the effects of physical problems on mental health. We examined the association between physical health (cancer-related fatigue and physical function) and mental health (depression and anxiety symptoms) in cancer survivors in the first year of survivorship (i.e., up to one year after the end of treatment with curative intent), as well as the moderating role of perceived social isolation.

METHODS

Survey data were collected from 118 cancer survivors who completed treatment with curative intent in the last year. We assessed mental and physical health symptoms, as well as perceived social isolation.

RESULTS

In multivariable analyses, fatigue was significantly associated with both depression (β = 0.279, 95% CI: 0.193,0.362) and anxiety symptoms (β = 0.189, 95% CI: 0.106,0.272). Social isolation moderated the effect of fatigue on depression and anxiety such that higher social isolation exacerbated the association of fatigue with mental health.

CONCLUSIONS

Cancer survivors who continue to experience fatigue after curative treatment are at risk for mental health problems, including depression and anxiety symptoms. For cancer survivors who feel socially isolated, the association between fatigue and mental health may be stronger. The current standard of care for survivorship does not sufficiently address psychosocial needs. Future research should evaluate the inclusion of social support interventions in early-term survivorship care.

A common metric for questionnaires on health anxiety in cancer patients

After a cancer diagnosis, life is accompanied by worries, concerns and fears that the disease will recur or worsen. These can be normal and useful reactions but may also become so severe that they interfere with everyday functioning. A challenge for patient care is that the theoretical similarity of these reactions, is not consistently conceptualized in practice, hence the empirical comparability of their measures is unclear. Here we intend to show that the theoretical similarity is also empirically justified, and we present a common metric in graphical form that allows direct comparisons between different questionnaires. A total of 1,733 cancer patients completed the Fear of Progression Questionnaire Short Form, Questionnaire on Stress in Cancer Patients-revised version, Concerns About Recurrence Questionnaire, the subscales Health Distress and Negative Health Outlook of the EORTC QLQ-SURV100, and the Whiteley Index. Using a model based on item response theory, we linked the score values of the individual questionnaires. The main outcome of this study is a diagram that can be used to convert the respective values of eight questionnaires on health anxiety to another. All instruments showed a reliability above 0.75 near the mean health anxiety level. The common metric can be used to compare measurements with these questionnaires in terms of the level of health anxiety. Additionally, the reliability of the instruments can be judged at different levels of anxiety. This allows for a better comparability of test results and facilitates communication about the results among experts and with patients.

Pressurizing or encouraging: Health behaviors among long-distance couples

Couples in long-distance relationships face unique challenges that affect their health outcomes and relationship dynamics in ways that are different from couples in close proximal relationships (PR). The results of previous literature analyzing health outcomes for long-distance relationship (LDR) couples have been mixed, and factors such as couple satisfaction and gender of the individuals contribute to the variance. This study examined the good health practices of couples in LDRs, the ways in which partners influence each other's health, and the health outcomes of these couples as compared to couples in PRs. Multilevel multivariate analysis showed that couples in LDRs had better health practices than those in PRs, and men overall had poorer health practices than women. There was no main effect seen for LDRs when we examined strategies used for influencing health. There was a main effect for gender, though, and we found that women tend to use more collaborative and pressurizing strategies for influencing their partner's health. On health indices, we found that LDR couples tended to have lower levels of fatigue and sleep disturbance as compared to PR couples. In the adjusted model with covariates, which included age, income, couple satisfaction, and married or unmarried couples, we found that lower couple satisfaction and lower income significantly predicted poorer health on all health indices. These results are discussed in light of unequal gender roles, social control, and positive aspects of LDRs on health in an attempt to understand LDRs better and destigmatize the narrative of these relationships as 'less than' PRs. Implications for health and mental health practitioners are also discussed.

Phenotypes of sleep health among adults with chronic heart failure in a randomized controlled trial of cognitive behavioral therapy for insomnia

BACKGROUND

Poor sleep contributes to adverse health in heart failure. However, studies are limited to isolated sleep characteristics.

PURPOSES

To evaluate changes in sleep health phenotypes after cognitive behavioral therapy for insomnia or attention control and associations between sleep health phenotypes, symptoms, stress, functional performance, and emergency department visits and hospitalizations.

METHODS

Secondary analysis of a randomized controlled trial of cognitive behavioral therapy for insomnia among adults with heart failure. We measured sleep (rest-activity rhythms, sleep duration, quality, and efficiency, insomnia severity, daytime sleepiness), symptoms, cognitive ability, vigilance, and 6-minute walk distance at baseline and 3-, 6-, and 12-month postintervention and collected hospitalizations and emergency department visits. We used K-means cluster analysis and generalized linear mixed models, generalized estimating equations, and Cox proportional hazard models.

RESULTS

Among 166 participants (M age=63.2 (SD=12.6) years; 57% male; 23% New York Heart Association Class III/IV), there were four sleep health phenotypes ("Unstable Sleep" (15%); "Short Sleep" (39%); "Low Sleep Efficiency" (25%); and "Good Sleep" (21%)) at baseline. The healthiest phenotype was associated with the lowest fatigue. The proportions of participants in the healthiest sleep group increased from pre- to post-treatment. Low sleepiness (p = .0188) and a robust circadian quotient (p = .007) predicted transition to the healthiest phenotype. The poorest sleep phenotype at baseline predicted time to hospitalizations and emergency department visits (hazard ratios 0.35-0.60) after adjusting for covariates.

CONCLUSION

Sleep phenotypes predict heart failure outcomes. Tailored interventions targeting phenotypes may be more effective than approaches that focus on single sleep characteristics.

Patient-Reported Outcomes Associated With "Completely Better" Status at 2 Years After Hip Arthroscopy

Background

Measures such as the Patient Acceptable Symptom State and minimum clinically important difference have been used to contextualize patient-reported outcomes (PROs). Assessment of patients' perception of being "completely better" (CB) after hip arthroscopy has not been studied.

Purposes

To (1) determine the prevalence and characteristics of patients who report being CB at 2 years after hip arthroscopy; (2) determine whether PROs measuring function, pain, and mental health are associated with CB status; and (3) determine threshold values for PROs predictive of achieving CB status.

Study Design

Case-control study; Level of evidence, 3.

Methods

Patients undergoing hip arthroscopy at a single institution from October 2015 to January 2020 were administered electronic surveys assessing sociodemographic variables and PROs at baseline and 2 years postoperatively. The CB anchor question was "Is the condition for which you underwent surgery completely better now?" Threshold values for PROs associated with achieving CB status at 2 years postoperatively were identified with 90% specificity. Variables with an area under the curve of >0.80 on a receiver operating characteristic curve were selected for multivariate analysis.

Results

Overall, 29 of 62 patients (47%) achieved CB status. There were no differences in age, sex, body mass index, race, prior hip surgery, preoperative opioid use, smoking status, or preoperative expectations between the CB and no-CB groups. The CB group had better 2-year postoperative and pre- to postoperative change values on all PROs (P < .05 for all) except for the Patient-Reported Outcomes Measurement Information System (PROMIS)-Depression and the Numeric Pain Scale (NPS) for whole-body pain. Two-year postoperative PRO thresholds for achieving CB status were determined as PROMIS-Physical Function (PF) ≥51.3 or increase in PROMIS-PF ≥12 points, PROMIS-Pain Interference ≤46.6 or decrease in PROMIS-Pain Interference ≥12.2 points, NPS for operative hip pain of ≤1.0, Musculoskeletal Outcomes Data Evaluation and Management System-expectations met ≥95.0, and Surgical Satisfaction Questionnaire (SSQ-8) ≥87.5. Multivariate analysis demonstrated that higher SSQ-8 score and greater improvement on the PROMIS-PF were independent predictors of achieving CB status.

Conclusion

Almost half of the study patients perceived being CB at 2 years after hip arthroscopy. Multiple postoperative PROs scores were associated with achieving CB status.

Symptom management interventions influence unscheduled health services use among cancer survivors and caregivers

PURPOSE

Three sequences of telephone symptom management interventions were tested on use of unscheduled health services among cancer survivors with depressive or anxiety symptoms during treatment (N = 334) and their informal caregivers (N = 333).

METHODS

The three 12-week intervention sequences were as follows: (1) Symptom Management and Survivorship Handbook (SMSH), (2) a combined 8-week SMSH + Telephone Interpersonal Counseling (TIPC) followed by SMSH for 4 weeks, and (3) SMSH for 4 weeks followed by a combined SMSH + TIPC if no response to SMSH alone. Survivor-caregiver dyads were first randomized to SMSH or a combined SMSH + TIPC. If the survivor's depressive or anxiety symptoms persisted after 4 weeks of SMSH alone, the dyad was randomized the second time to continue with SMSH alone or TIPC was added to SMSH. All participants were assessed at baseline and 13 and 17 weeks. Health service use was compared between randomized groups and among the three sequences.

RESULTS

Survivors were 60.2 years of age, 79% were female, and 41% were Hispanic. Caregivers were 54.8 years of age; 67% were female. The significantly lower rate of emergency department (ED) or urgent care visits for survivors was found in the SMSH + TIPC intervention sequence compared to the SMSH alone in the second randomization and for the third intervention sequence compared to the first.

CONCLUSIONS

Adding TIPC to SMSH after week 4 when survivors experienced persisting depressive or anxiety symptoms reduced ED/urgent care visits compared to SMSH alone.

IMPLICATIONS FOR CANCER SURVIVORS

Managing depression and anxiety symptoms may help prevent ED/urgent care visits and worsening of other symptoms.

Length of Time to Clinical Improvement After Orthopedic Oncology Surgery in Patients With Metastatic Cancer: A Multi-Institution Patient-Reported Outcome Study

BACKGROUND

Currently, there is a paucity of data that describes the length of time required to realize improvement in pain and function following surgery for patients with metastatic cancer to bone.

METHODS

One hundred patients with impending or completed pathologic fractures due to metastatic cancer to bone were enrolled in this prospective cohort study. Outcomes were measured with a Computer Adaptive Test of Patient Reported Outcomes for Pain Interference and Physical Function domains, to determine the time required to achieve a Minimal Clinically Important Difference (MCID) in the tested domains.

RESULTS

Eighty-one patients were included in the analysis. Thirty-two patients (39.5%) survived and completed the follow-up to 1 year, while 23 (28.4%) died before the end of the data collection. Fifty-one patients (63.0%) achieved at least a 5-point improvement in Physical Function and 59 (72.8%) achieved at least a 5-point improvement in Pain Interference. The time to achieve the MCID was 6 weeks for the Physical Function and 4 weeks for the Pain Interference domain.

CONCLUSION

The majority of patients with impending or completed pathologic fractures due to metastatic cancer see clinically important improvements in pain and function after surgery in an average of 4 and 6 weeks, respectively.

Decision Support and Behavioral Health for Reducing High-Dose Opioids in Comorbid Chronic Pain, Depression and Anxiety: Stepped-Wedge Cluster Randomized Trial

BACKGROUND

High prevalence of depression or anxiety with opioid use for chronic pain complicates co-management and may influence prescribing behaviors.

OBJECTIVE

Compare clinical effectiveness of electronic medical record clinical decision support (EMR-CDS) versus additional behavioral health (BH) care management for reducing rates of high-dose opioid prescriptions.

DESIGN

Type 2 effectiveness-implementation hybrid stepped-wedge cluster randomized trial in 35 primary care clinics within a health system in LA, USA.

PARTICIPANTS

Patients aged 18+ receiving chronic opioid therapy for non-cancer pain with depression or anxiety and matched controls.

INTERVENTION

EMR-CDS included opioid risk mitigation procedures. BH care included cognitive behavioral therapy; depression or anxiety medication adjustments; and case management.

MAIN MEASURES

Outcomes of interest included difference-in-difference (DID) estimate of changes in probability for prescribing high-dose morphine equivalent daily dose (MEDD ≥50 mg/day and MEDD ≥90), average MEDD, and rates of hospitalization, emergency department use, and opioid risk mitigation.

KEY RESULTS

Most participants were female with 3+ pain syndromes. Data analysis included 632 patients. Absolute risk differences for MEDD≥50 and ≥90 decreased post-index compared to pre-index (DID of absolute risk difference [95%CI]: -0.036 [-0.089, 0.016] and -0.029 [-0.060, 0.002], respectively). However, these differences were not statistically significant. The average MEDD decreased at a higher rate for the BH group compared to EMR-CDS only (DID rate ratio [95%CI]: 0.85 [0.77, 0.93]). There were no changes in hospitalization and emergency department utilization. The BH group had higher probabilities of new specialty referrals and prescriptions for naloxone and antidepressants.

CONCLUSIONS

Incorporation of a multidisciplinary behavioral health care team into primary care did not decrease high-dose prescribing; however, it improved adherence to clinical guideline recommendations for managing chronic opioid therapy for non-cancer pain.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT03889418.

Do mindfulness interventions cause harm? Findings from the Learning to Apply Mindfulness to Pain (LAMP) Pragmatic Clinical Trial

BACKGROUND

Although mindfulness-based interventions (MBIs) are widely used in clinical and nonclinical settings, there has been little systematic study of their potential risks. To address this gap, we examined differences in psychological and physical worsening among participants in the usual care and intervention conditions of a 3-group, randomized pragmatic trial (Learning to Apply Mindfulness to Pain [LAMP]) that tested the effectiveness of 2 approaches to delivering MBIs to patients with chronic pain.

METHODS

The sample consisted of 374 male and 334 female patients with chronic pain enrolled in the LAMP trial who completed a 10-week follow-up survey, 61% of whom had a mental health diagnosis. Psychological and physical worsening was assessed by a checklist asking whether participants experienced specific symptoms since beginning the study. We used multivariable logistic regression models with imputed data to determine whether predicted probabilities of increased symptoms differed between usual care and the 2 MBIs.

RESULTS

Participants in usual care were more likely to report experiencing increased psychological and physical worsening than were those in the MBIs, including an increase in disturbing memories; sadness, anxiousness, and fatigue; isolation and loneliness; and feeling more upset than usual when something reminded them of the past.

CONCLUSIONS

MBIs do not appear to cause harm, in terms of increased symptoms, for this population of patients with chronic pain and high levels of mental health comorbidities.

CLINICAL TRIAL REGISTRATION

Preregistration with an analysis plan at www.ClinicalTrials.gov: NCT04526158. Patient enrollment began December 4, 2020.

Improved quality of life after Ibandronic acid infusion in patients suffering from diffuse sclerosing osteomyelitis of the jaw

BACKGROUND

Quality of life research with respect to patient reported outcomes (PROs) other than pain has not yet been conducted in the field of Diffuse Sclerosing Osteomyelitis. This cross-sectional study aims to investigate changes in quality of life regarding 34 subjective parameters in patients with diffuse sclerosing osteomyelitis after intravenous Ibandronic acid administration (6mg).

MATERIAL AND METHODS

15 patients (11 female, 4 male) with diffuse sclerosing osteomyelitis (DSO) treated with 6mg of Ibandronic acid completed the standardized questionnaires (EORTC QLQ-C30, EORTC QLQ-H&N35, OHIP-G 14) considering quality of life before and two weeks after infusion.

RESULTS

All 15 patients reported a significantly improved quality of life after administration of Ibandronate. Patients reported improvements in oral health associated quality of life as well as reduction of pain and intake of analgesics. In addition patients reported a significant improvement in fatigue, sexuality, social interactions, emotional, cognitive and role functioning. Furthermore patients reported an improvement in mouth opening, weight loss and loss of appetite as well as a reduction of speech and swallowing problems. Moreover, insomnia occurred less frequently after bisphosphonate infusions.

CONCLUSIONS

The study evaluates patients subjectively benefit from a standardized Ibandronic acid regimen. A significantly improved quality of life after administration of Ibandronate was observed in all 15 patients.

Improved Fatigue Management in Primary Sjögren's Syndrome: A Retrospective Analysis of the Efficacy of Methotrexate in Chinese Patients

Objective

To assess the efficacy of methotrexate (MTX) and hydroxychloroquine (HCQ) in improving fatigue symptoms in patients with primary Sjögren's syndrome (pSS).

Methods

A single-center retrospective study was conducted on pSS patients experiencing fatigue symptoms. All patients received either MTX, HCQ, or a combination of MTX + HCQ for a period of six months. Clinical efficacy was measured using the European League Against Rheumatism (EULAR) Sjögren's Syndrome Disease Activity Index (ESSDAI), EULAR Sjögren's Syndrome Patient Reported Index (ESSPRI), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), fatigue severity scale (FSS), and visual analog scale (VAS) score. These measures were assessed at baseline and at 1, 2, 3, and 6 months.

Results

A total of 86 pSS patients with fatigue symptoms were enrolled (27 received MTX, 29 received HCQ, and 30 received MTX + HCQ). Patients receiving MTX and MTX + HCQ showed significant improvements at 6th month in ESSDAI, ESSPRI, FSS, FACIT-F, and VAS scores (all P < 0.01) compared with baseline. Repeated-measures analysis of variance revealed that patients treated with MTX and MTX + HCQ experienced significant improvements in ESSDAI, FSS, FACIT-F, and VAS scores (all P < 0.01) from baseline to the 6th month. The HCQ group did not show significant improvement in FSS, FACIT-F, and VAS scores (all P > 0.05), although their ESSDAI and ESSPRI scores did improve significantly (all P < 0.01). Patients in the MTX group showed the most improvement in mean changes of ESSDAI score, FSS score, FACIT-F score, and VAS score from baseline to the 6th month. And patients received MTX treatment significantly had more fatigue remission numbers (all P < 0.05).

Conclusion

In clinical practice, methotrexate is more effective than hydroxychloroquine in improving fatigue symptoms, as measured by patient-reported fatigue scales (FSS, FACIT-F, and VAS scores) in patients with pSS.

Is There an Association Between Lateralization of Chronic Pain in the Body and Depression?

Depression commonly co-occurs with chronic pain and can worsen pain outcomes. Recent theoretical work has hypothesized that pain localized to the left hemibody is a risk factor for worse depression due to overlap in underlying neural substrates. This hypothesis has not been tested a priori. Using a large sample of treatment-seeking adults with mixed-etiology chronic pain (N = 1,185), our cross-sectional study tested whether patients with left-sided pain endorse worse depressive symptoms. We also examined differences in other pain-related functioning measures. We tested 4 comparisons based on painful body areas using the CHOIR body map: 1) only left-sided (OL) versus any right-sided pain; 2) only right-sided (OR) versus any left-sided pain; 3) OL versus OR versus bilateral pain; and 4) more left-sided versus more right-sided versus equal-sided pain. Analysis of variance models showed OL pain was not associated with worse depression (F = 5.50, P = .019). Any left-sided pain was associated with worse depression, though the effect was small (F = 8.58, P = .003, Cohens d = .29). Bilateral pain was associated with worse depression (F = 8.05, P < .001, Cohens d = .24-.33). Regardless of pain location, more body areas endorsed was associated with greater depression. Although a more rigorous assessment of pain laterality is needed, our findings do not support the hypothesis that left-lateralized pain is associated with worse depression. PERSPECTIVE: Pain lateralized to the left side of the body has been hypothesized as a risk factor for worse depression in chronic pain, despite never being tested in a large, real-world sample of patients with chronic pain. Findings showed that more widespread pain, not pain laterality, was associated with worse depression.

Telehealth Mindfulness-Based Interventions for Chronic Pain: The LAMP Randomized Clinical Trial

Importance

Although mindfulness-based interventions (MBIs) are evidence-based treatments for chronic pain and comorbid conditions, implementing them at scale poses many challenges, such as the need for dedicated space and trained instructors.

Objective

To examine group and self-paced, scalable, telehealth MBIs, for veterans with chronic pain, compared to usual care.

Design, Setting, and Participants

This was a randomized clinical trial of veterans with moderate to severe chronic pain, recruited from 3 Veterans Affairs facilities from November 2020 to May 2022. Follow-up was completed in August 2023.

Interventions

Two 8-week telehealth MBIs (group and self-paced) were compared to usual care (control). The group MBI was done via videoconference with prerecorded mindfulness education and skill training videos by an experienced instructor, accompanied by facilitated discussions. The self-paced MBI was similar but completed asynchronously and supplemented by 3 individual facilitator calls.

Main Outcomes and Measures

The primary outcome was pain-related function using the Brief Pain Inventory interference scale at 3 time points: 10 weeks, 6 months, and 1 year. Secondary outcomes included biopsychosocial outcomes: pain intensity, physical function, anxiety, fatigue, sleep disturbance, participation in social roles and activities, depression, patient ratings of improvement of pain, and posttraumatic stress disorder.

Results

Among 811 veterans randomized (mean [SD] age, 54.6 [12.9] years; 387 [47.7%] women), 694 participants (85.6%) completed the trial. Averaged across all 3 time points, pain interference scores were significantly lower for both MBIs compared to usual care (group MBI vs control difference: -0.4 [95% CI, -0.7 to -0.2]; self-paced vs control difference: -0.7 [95% CI, -1.0 to -0.4]). Additionally, both MBI arms had significantly better scores on the following secondary outcomes: pain intensity, patient global impression of change, physical function, fatigue, sleep disturbance, social roles and activities, depression, and posttraumatic stress disorder. Both group and self-paced MBIs did not significantly differ from one another. The probability of 30% improvement from baseline compared to control was greater for group MBI at 10 weeks and 6 months, and for self-paced MBI, at all 3 time points.

Conclusions and Relevance

In this randomized clinical trial, scalable telehealth MBIs improved pain-related function and biopsychosocial outcomes compared to usual care among veterans with chronic pain. Relatively low-resource telehealth-based MBIs could help accelerate and improve the implementation of nonpharmacological pain treatment in health care systems.

Trial Registration

ClinicalTrials.gov Identifier: NCT04526158.

Thresholds in PROMIS Scores Anchored to Subsequent Unscheduled Health Service Use Among People Diagnosed With Cancer

PURPOSE

To establish thresholds in the Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference, physical function, fatigue, and depression scores on the basis of their association with subsequent use of the emergency department (ED) or urgent care by people diagnosed with cancer.

METHODS

Retrospective data from 952 people seen at Henry Ford Cancer and insured through the Health Alliance Plan were analyzed using generalized linear mixed-effects models. The log odds of ED or urgent care use during 14 or 30 days after each patient-reported outcome (PRO) assessment were related to PRO scores, while adjusting for comorbidity, sociodemographic, and tumor characteristics.

RESULTS

Pain interference and physical function were associated with subsequent ED or urgent care visits, but fatigue and depression were not, and the results for 14- and 30-day visits were similar. Thresholds anchored in the likelihood of these visits differed according to cancer stage. For people with advanced cancer, a pain interference score of 60 or higher (odds ratio [OR] 3.75, [95% CI, 1.53 to 7.87]) and a physical function score lower than 40 (OR 2.94, [95% CI, 1.22 to 7.06]) produced the largest ORs with narrowest CIs for 30-day visits. For people with nonadvanced cancer, the thresholds of 65 for pain interference (OR 2.64, [95% CI, 1.40 to 5.01]) and 35 for physical function (OR 1.87, [95% CI, 1.01 to 3.45]) produced largest ORs with narrowest CIs for 30-day visits.

CONCLUSION

These anchor-based thresholds in PROMIS scores can inform clinicians' actions with the goal of preventing ED or urgent care visits.

Exercise as part of survivorship care in metastatic breast cancer: protocol for the randomized EMBody trial

BACKGROUND

Exercise is associated with improved survival, physical functioning, treatment tolerability, and quality of life in early-stage breast cancer. These same endpoints matter in metastatic breast cancer (MBC). Prior trials in MBC have found exercise to be not feasible or of limited benefit, possibly due to inclusion of patients with heterogeneous disease trajectories. Patients with MBC have variable disease trajectories and supportive care needs; those with indolent MBC have longer life expectancy, lower symptom burden and distinct priorities, and are well-positioned to participate in and benefit from an exercise program. The EMBody trial aims to determine the impact of a multimodal exercise intervention on cardiorespiratory fitness, physical function, body composition, and patient-reported outcomes, specifically in patients with stable, indolent MBC.

METHODS

Eligible patients have MBC with no evidence of disease progression on current therapy in the prior 12 months and cannot be receiving cytotoxic chemotherapy. The trial aims to enroll 100 patients, randomized 1:1 to the exercise intervention versus usual care, stratified by baseline function. The virtually-delivered exercise intervention arm achieves moderate intensity exercise with exercise physiologists 3 days/week for 16 weeks. The 60-minute sessions include aerobic, resistance, balance and stretching exercises. The exercise arm receives informational sessions on the role of exercise in cancer and principles of habit and self-efficacy. The primary endpoint is 16 week change in fitness on a ramp treadmill test between the exercise and control arms. Secondary endpoints include change in a physical function, muscle mass assessed by CT scans, and PROs of fatigue and quality of life. Exploratory analysis includes behavioral modifiers of exercise adherence and effectiveness and serologic measures of inflammatory, metabolic, and immune pathway biomarkers.

DISCUSSION

The EMBody trial evaluates exercise in a unique patient population with indolent, non-progressive MBC. Patients living with MBC experience similar symptom burden to those undergoing therapy for early-stage disease and the benefits achieved with exercise could be similarly impactful. This trial will contribute evidence to support expansion of exercise recommendations, among other survivorship care efforts, to those living with metastatic disease.

CLINICAL TRIAL INFORMATION

NCT05468034.

TRIAL REGISTRATION

NCT05468034. Date of registration: 7/12/2022.

Cognitive function in long-term testicular cancer survivors: impact of modifiable factors

No study has comprehensively examined associated factors (adverse health outcomes, health behaviors, and demographics) affecting cognitive function in long-term testicular cancer survivors (TC survivors). TC survivors given cisplatin-based chemotherapy completed comprehensive, validated surveys, including those that assessed cognition. Medical record abstraction provided cancer and treatment history. Multivariable logistic regression examined relationships between potential associated factors and cognitive impairment. Among 678 TC survivors (median age = 46; interquartile range [IQR] = 38-54); median time since chemotherapy = 10.9 years, IQR = 7.9-15.9), 13.7% reported cognitive dysfunction. Hearing loss (odds ratio [OR] = 2.02; P = .040), neuropathic pain (OR = 2.06; P = .028), fatigue (OR = 6.11; P < .001), and anxiety/depression (OR = 1.96; P = .029) were associated with cognitive impairment in multivariable analyses. Being on disability (OR = 9.57; P = .002) or retired (OR = 3.64; P = .029) were also associated with cognitive decline. Factors associated with impaired cognition identify TC survivors requiring closer monitoring, counseling, and focused interventions. Hearing loss, neuropathic pain, fatigue, and anxiety/depression constitute potential targets for prevention or reduction of cognitive impairment in long-term TC survivors.

A Single-Session, 2-Hour Version of Mindfulness-Oriented Recovery Enhancement (One MORE) Improves Chronic Pain Patients' Pain-Related Outcomes Through 3-Month Follow-Up in a Randomized Controlled Trial

Introduction: Traditional, 8-week, mindfulness-based interventions can effectively treat chronic pain, but require a time and resource investment too burdensome for many patients and providers. The solution to this logistical challenge may be to distill the core, therapeutic elements of an efficacious 8-week, mindfulness-based intervention, Mindfulness-Oriented Recovery Enhancement (MORE), into a 2-h, single-session intervention. Methods: In this study, the authors conducted a waitlist-controlled, randomized clinical trial to assess the impact of a 2-h, single-session adaptation of MORE (i.e., One MORE) on chronic pain patients' (N = 40) pain-related outcomes through 3-month follow-up. Results: Results indicated that One MORE significantly improved chronic pain patients' pain catastrophizing (i.e., primary outcome; F = 9.97, p = 0.002), pain intensity (F = 26.58, p < 0.001), pain interference (F = 39.43, p < 0.001), physical function (F = 16.29, p < 0.001), sleep (F = 16.66, p < 0.001), anxiety (F = 12.54, p < 0.001), and depression (F = 17.48, p < 0.001). One MORE also significantly increased theoretically indicated therapeutic mechanisms through the 3-month follow-up: mindfulness, positive reappraisal, savoring, self-transcendence. Discussion: Study results are promising, and if replicated, would suggest that One MORE is a highly scalable, low-cost (e.g., sustainable), nonpharmacologic treatment for chronic pain. Clinical Trial Registration: NCT05194241.

Using mHealth Technology to Evaluate Daily Symptom Burden among Adult Survivors of Childhood Cancer: A Feasibility Study

BACKGROUND

Cancer therapies predispose survivors to a high symptom burden. This study utilized mobile health (mHealth) technology to assess the feasibility of collecting daily symptoms from adult survivors of childhood cancer to evaluate symptom fluctuation and associations with future health-related quality-of-life (HRQOL).

METHODS

This prospective study used an mHealth platform to distribute a 20-item cancer-related symptom survey (5 consecutive days each month) and an HRQOL survey (the day after the symptom survey) over 3 consecutive months to participants from the Childhood Cancer Survivor Study. These surveys comprised a PROMIS-29 Profile and Neuro-QOL assessed HRQOL. Daily symptom burden was calculated by summing the severity (mild, moderate, or severe) of 20 symptoms. Univariate linear mixed-effects models were used to analyze total, person-to-person, day-to-day, and month-to-month variability for the burden of 20 individual symptoms. Multivariable linear regression was used to analyze the association between daily symptom burden in the first month and HRQOL in the third month, adjusted for covariates.

RESULTS

Out of the 60 survivors invited, 41 participated in this study (68% enrollment rate); 83% reported their symptoms ≥3 times and 95% reported HRQOL in each study week across 3 months. Variability of daily symptom burden differed from person-to-person (74%), day-to-day (18%), and month-to-month (8%). Higher first-month symptom burden was associated with poorer HRQOL related to anxiety (regression coefficient: 6.56; 95% CI: 4.10-9.02), depression (6.32; 95% CI: 3.18-9.47), fatigue (7.93; 95% CI: 5.11-10.80), sleep (6.07; 95% CI: 3.43-8.70), pain (5.16; 95% CI: 2.11-8.22), and cognitive function (-6.89; 95% CI: -10.00 to -3.79) in the third month.

CONCLUSIONS

Daily assessment revealed fluctuations in symptomology, and higher symptom burden was associated with poorer HRQOL in the future. Utilizing mHealth technology for daily symptom assessment improves our understanding of symptom dynamics and sources of variability.

Improving Access to Yoga for Chronic Pain in a Spanish-Speaking Community: A Quality Improvement Initiative

BACKGROUND

The recent increase in opioid misuse and overdose among the Hispanic population signifies the need for an initiative to increase efforts in pain management in the Hispanic population. Yoga is an evidence-based therapeutic intervention that is effective for several pain-associated disorders. However, in the United States, it is primarily taught in English and not always accessible. This quality improvement (QI) project aimed to assess the outcome of implementing a yoga program on pain and quality of life in the Hispanic population.

METHODS

Twenty Spanish-speaking community center members participated in a linguistically-tailored yoga program over the course of 10 weeks that included educational, demonstration, and practice videos. Outcome measures of the QI program included changes in pain interference, physical function, opioid medication use, the overall impression of change in pain, satisfaction with the program, and the likelihood of continuation of yoga practice.

RESULTS

Data collected from participants (n = 16) after the 10-week period indicated that nearly 60% experienced an improvement in their overall impression of change in pain; their reported likelihood of continuation of yoga practice at home or another location were 6.8 and 7.4, respectively, on a 10-point scale. While pain interference was unaffected, there was an improvement in markers of physical function, including a two-fold improvement in general activity without limitations. The mean average intensity of pain decreased by 33%.

CONCLUSION

The use of a linguistically-tailored yoga program improved self-reported overall pain, physical function, average intensity of pain, and initiated an interest in participants in utilizing yoga practice for self-management of pain. This QI project provides results that can be used for further implementation initiatives at other sites and consideration of use in diverse populations.

Increased Pain Variability in Patients With Chronic Pain: A Role for Pain Catastrophizing

Pain is an inherently negative perceptual and affective experience that acts as a warning system to protect the body from injury and illness. Pain unfolds over time and is influenced by myriad factors, making it highly dynamic. Despite this, statistical measures often treat any intraindividual variability in pain ratings as noise or error. This is consequential, especially for research on chronic pain, because pain variability is associated with greater pain severity and depression. Yet, differences in pain variability between patients with chronic pain and controls in response to acute pain has not been fully examined-and it is unknown if dispositional factors such as pain catastrophizing (negative cognitive-affective response to potential or actual pain in which attention cannot be diverted away from pain) relate to pain variability. In the current study, we recruited chronic-pain patients (N = 30) and pain-free controls (N = 22) to complete a 30-second thermal pain task where they continually rated a painful thermal stimulus. To quantify pain variability and capture potential dynamics, we used both a traditional intraindividual standard deviation (iSD) metric of variability and a novel derivatives approach. For both metrics, patients with chronic pain had higher variability in their pain ratings over time, and pain catastrophizing significantly mediated this relationship. This suggests patients with chronic pain experience pain stimuli differently over time, and pain catastrophizing may account for this differential experience. PERSPECTIVE: The present study demonstrates (using multiple variability metrics) that chronic pain patients show more variability when rating experimental pain stimuli, and that pain catastrophizing helps explain this differential experience. These results provide preliminary evidence that short-term pain variability could have utility as a clinical marker in pain assessment and treatment.

Wearable motion-based platform for functional spine health assessment

INTRODUCTION

Low back pain is a significant burden to society and the lack of reliable outcome measures, combined with a prevailing inability to quantify the biopsychosocial elements implicated in the disease, impedes clinical decision-making and distorts treatment efficacy. This paper aims to validate the utility of a biopsychosocial spine platform to provide standardized wearable sensor-derived functional motion assessments to assess spine function and differentiate between healthy controls and patients. Secondarily, we explored the correlation between these motion features and subjective biopsychosocial measures.

METHODS

An observational study was conducted on healthy controls (n=50) and patients with low back pain (n=50) to validate platform utility. The platform was used to conduct functional assessments along with patient-reported outcome assessments to holistically document cohort differences. Our primary outcomes were motion features; and our secondary outcomes were biopsychosocial measures (pain, function, etc).

RESULTS

Our results demonstrated statistically significant differences in motion features between healthy and patient cohorts across anatomical planes. Importantly, we found velocity and acceleration in the axial plane showed the largest difference, with healthy controls having 49.7% and 55.7% higher values, respectively, than patients. In addition, we found significant correlations between motion features and biopsychosocial measures for pain, physical function and social role only.

CONCLUSIONS

Our study validated the use of wearable sensor-derived functional motion metrics in differentiating healthy controls and patients. Collectively, this technology has the potential to facilitate holistic biopsychosocial evaluations to enhance spine care and improve patient outcomes.

TRIAL REGISTRATION NUMBER

NCT05776771.