Key considerations to reduce or address respondent burden in patient-reported outcome (PRO) data collection

Estimating depression severity in narrative clinical notes using large language models

BACKGROUND

Depression treatment guidelines emphasize measurement-based care using patient-reported outcome measures, yet their impact on narrative documentation quality remains underexplored.

METHODS

We sampled 15,000 narrative clinical outpatient notes from the electronic health record of a large academic medical center, reflecting visits between January 2, 2019 and January 30, 2024, for which a 9-item Patient Health Questionnaire (PHQ-9) was completed at the same time. After censoring PHQ-9 scores from notes, we estimated severity of depressive symptoms with a foundational large language model (gpt4o-08-06) in a HIPAA-compliant enclave. We estimated correlation between true PHQ-9 and model-estimated score and examined the predictive performance of the model for moderate or greater depressive symptoms.

RESULTS

Mean age was 46.3 years (SD 14.9); 9083 (60.6 %) identified as female. 925 (6.2 %) identified as Asian, 638 (4.3 %) as Black, 853 (5.7 %) as another race, and 12,187 (81.2 %) as White. A total of 1044 (7.0 %) identified as Hispanic ethnicity, while 12,699 (84.7 %) were non-Hispanic. Mean measured PHQ-9 score was 1.23 (SD 3.45); 721 (4.8 %) met criteria for moderate or greater depressive symptoms. LLM-predicted PHQ-9 scores were modestly correlated with actual scores (r2 = 0.264 (95 % CI 0.252-0.276)); PPV for moderate or greater depression was 0.309 (95 % CI 0.302-0.317). Performance was consistent across demographic subgroups, with modest differences identified by race, ethnicity, and sex.

CONCLUSION

A foundational LLM performed poorly but consistently across subgroups in imputing PHQ-9 scores from notes when actual PHQ-9 reporting was ablated. This result suggests the extent to which inclusion of PROMs may impoverish documentation of psychiatric symptoms.

Transforming Patient-Reported Outcome Measurement With Digital Health Technology

Healthcare is shifting from a provider-centric to a patient-centric model, emphasizing the integration of patient-reported outcome measures (PROMs) into routine practice. PROMs enhance shared decision-making and provide valuable insights into patient well-being, yet their widespread implementation is hindered by logistical challenges, time constraints, and infrastructure limitations. Digital health solutions offer a promising approach to overcoming these barriers by streamlining PROM administration, improving accessibility, and optimizing clinical integration. This article explores the transition from paper-based to digital PROM administration, the advantages of computerized adaptive testing (CAT), and the broader considerations necessary to ensure effective implementation. By leveraging digital tools and informatics strategies, healthcare systems can facilitate the meaningful adoption of PROMs to improve patient-centred care. This article can be used to advance PROM implementation across various clinical settings.

Systematic evaluation of patient-reported outcomes in clinical trials of digital health in cardiovascular diseases

The integration of patient-reported outcomes (PROs) in digital health (DH) trials for cardiovascular diseases (CVDs) remains unknown. We searched ClinicalTrials.gov for randomized trials that tested DH interventions in CVDs from 2004 to 2024. The search identified 8037 trials, with 673 eligible trials included in the analysis. Among these, 321 trials (48%) incorporated PROs. The number of DH trials and the use of PROs have shown a significant upward trend. Phone-based interventions predominated (38%), mostly targeting hypertension (38%) and heart failure (27%). Behavioral interventions showed higher prevalence of PROs' usage (1.24 [1.04-1.48]), while trials for diagnostic or screening purpose (0.39 [0.20-0.77]) utilized PROs less frequently. Only 15% of trials reported results on ClinicalTrials.gov, while 58% were published in PubMed after completion. Despite DH trial expansion, PRO integration remains insufficient, especially in trials where clinical and patient perspectives are important in informing treatment decisions. Timely results dissemination is critical to improving transparency.

Development, Rasch analysis and validation of the kidney symptom burden questionnaire (KSB-Q)

Background

Increasingly, patient-reported outcome measures (PROMs) are used to monitor chronic kidney disease (CKD) symptoms in routine clinical practice. However, such symptom measurement currently requires completion of multiple, often lengthy, PROMs, which may lead to questionnaire fatigue, lower levels of completion, and missing data. Moreover, many CKD-specific PROMs lack evidence of important measurement properties and few were developed using contemporary psychometric methods. The study objective was to develop and validate a short-form kidney symptom burden questionnaire (KSB-Q).

Methods

A cross-sectional item pool survey was distributed to adults (≥18 years) with CKD stages 3-5 [including individuals not receiving kidney replacement therapy (KRT), those receiving dialysis and those with a functioning kidney transplant] in England (Birmingham, London, Sheffield, and Nottingham) from March to September 2022. Rasch measurement was used to assess the psychometric properties of the item pool. Cognitive debriefing interviews were conducted to evaluate content validity.

Results

In total, 419/1464 participants responded (29% response rate), with 28% receiving dialysis and 30% in receipt of a kidney transplant. Rasch analysis indicated that nine items, one for each of nine symptom domains (fatigue, pain, memory/concentration, poor sleep, skin problems, gastrointestinal problems, dizziness, restless legs, and shortness of breath), formed a PROM with strong psychometric properties (including statistically acceptable reliability, test-retest reliability, and validity). Cognitive debriefing and survey responses confirmed content validity encompassing relevance, comprehensiveness, and clarity.

Conclusions

The KSB-Q is a nine-item PROM measuring somatic symptoms. The KSB-Q demonstrates strong psychometric properties in patients with CKD stages 3-5, including those not receiving KRT, individuals receiving dialysis, and those with a functioning kidney transplant.

Revolutionizing Patient-Reported Outcomes Analysis for Oncology Drug Development Using Population Models

Patient-reported outcomes (PRO) play a crucial role as clinical endpoint in oncology trials. Traditional statistical methods, such as hypothesis testing, have been commonly used by pharmaceutical industry and regulators to evaluate treatment efficacy on PRO endpoints. However, the analysis of PRO data remains challenging because of high variability and missing data issues. In this study, we will present examples in which inappropriate statistical analyses of PRO data can confound treatment efficacy analyses. To overcome these challenges, we propose the application of individual participant data and population models. Population models have been extensively used in pharmacokinetics and pharmacodynamics analyses and are well accepted by regulators. However, their potential in PRO data analyses, particularly in the field of oncology, remains largely untapped. This perspective article aims to highlight the value of population modeling approaches in PRO data analyses for oncology clinicians and researchers. Population models integrate individual participant data and can effectively handle the substantial variability in PRO measurements by incorporating covariates, between-subject variability, and accounting for measurement noise. By leveraging information from the population, this approach also provides accurate estimations for participants with missing data or sparse sampling. Moreover, these models could be applied to predict long-term PRO dynamics. If used appropriately, population modeling approaches could revolutionize the analysis of PRO data in oncology drug development, enabling a more comprehensive understanding of the impact of treatment on patients' lives. Our aim is to encourage stakeholders to consider population modeling as a standard and effective tool to enhance decision-making and ultimately improve patient care.

Patient involvement in the development of patient-reported outcome measures used following hip or knee arthroplasty: a scoping review

PURPOSE

Involving patients in developing patient-reported outcome measures (PROMs) is essential for accurately capturing their perspectives. However, understanding how patients were involved in developing PROMs used after hip or knee arthroplasty is limited. This scoping review aimed to evaluate whether patients were involved in the development of these PROMs and how they were involved.

METHODS

Two independent reviewers documented patient involvement in item development and comprehensibility testing for 50 PROMs used after hip or knee arthroplasty. Trends in patient involvement over time were analyzed using binary logistic regression.

RESULTS

There was no documentation of patient involvement in a collaborative role during the PROM development processes. Regarding the consultative role, of these 26 PROMs, they contributed to item development in 13 PROMs (26%) and comprehensibility testing in four PROMs (8%) and both item development and comprehensibility testing in nine PROMs (18%). Patients who underwent arthroplasty were involved in one or both phases in ten PROMs (20%), while patients with other lower extremity conditions were involved in 16 PROMs (32%). Patients who underwent arthroplasty contributed to both phases in five PROMs: Oxford Knee Score-Activity and Participation Questionnaire, Patient's Knee Implant Performance Questionnaire, Patient-Reported Outcomes Measurement Information System R-Plus-Osteoarthritis of the Knee, Oxford Arthroplasty Early Recovery Score and Oxford Arthroplasty Early Change Score. In addition, our analysis revealed no significant change in patient involvement in a consultative role during either item development or comprehensibility evaluation over time since 1982, when the first PROM included in this review was developed (p = 0.21).

CONCLUSIONS

Almost half of PROMs used after arthroplasty did not involve patients in their development, highlighting the need to address this gap in development of PROMs. There is also a need to analyze PROMs to ensure they accurately reflect the outcomes that matter to patients.

Sponsor- vs. FDA-Initiated Changes to Pediatric Clinical Trial Protocols: A Comparison of Associated Participant Burden

INTRODUCTION

Risks associated with clinical trial participation are a foremost consideration during protocol development whereas trial-associated burdens receive less focus despite their measurable impact on enrollment and retention. Of late, the U.S. Food and Drug Administration (FDA) has elevated discussions on barriers to research participation resulting from overly burdensome trials. Given the agency's role in shaping clinical protocol design, this study examined the perceived burden associated with FDA-proposed study changes in the context of pediatric, off-patent, labeling studies.

MATERIALS AND METHODS

Pediatric Trials Network (PTN) studies conducted between 2013 and 2023 for which there existed a record of formal communication between the PTN and FDA were evaluated. All protocol versions and regulatory communications were reviewed, and every protocol change with the potential to alter participant burden was extracted and attributed to the PTN Sponsor or FDA. Changes were grouped into 11 themes (e.g. change in the number of visits, change in invasive procedures) and each change assigned a perceived burden score on an 11-point Likert scale by pediatric clinical trialists who were blinded to attribution. An abbreviated list of protocol changes were reviewed and scored by children to examine their concordance with adult scores. Quantitative and qualitative differences between changes introduced by Sponsors and the FDA were compared.

RESULTS

Twenty-one studies (94 protocol versions) met the criteria for inclusion (18 drug, 3 device). Half of the protocol versions incorporated changes (n = 123) that could perceivably affect participant burden (77 initiated by the sponsor, 46 proposed by the FDA). Changes classified as introducing, increasing, or extending protocol features occurred almost twice as often (64%) as changes that reduced, removed, or restricted features of the protocol (36%), the latter also occurring later in the life of the protocol (1.2 vs. 2.0 year, p < 0.01). Changes recommended by the FDA were primarily related to ensuring safety (77%), optimizing trial design (16%) and adequately capturing effectiveness (7%) and, on average, were associated with statistically higher burden scores. Modifications driven by sponsors reflected trial design refinements (34%), safety assessment (32%), expansion of primary/secondary scientific questions (22%), and effectiveness evaluation (12%). Burden scores demonstrated strong concordance between trialists and children (r = 0.7).

CONCLUSIONS

Half of all protocol amendments are associated with changes that conceivably alter the burden of clinical trial participation, and these changes are twice as likely to add to (vs. reduce) participant burden. Given the time and effort involved with protocol amendments, we suggest that modifications to trial protocols be accompanied by a reassessment of the role and utility of all existing protocol elements at the time of resubmission.

An Evaluation of Time Spent Completing Electronically Collected Patient-Reported Outcomes in Clinical Trials

OBJECTIVES

Patient-reported outcomes (PROs) are important measures of efficacy in the context of clinical trials but are sometimes identified as time and resource intensive to study participants and site personnel. The objective of this research was to evaluate the amount of time that participants spend completing PROs via an electronic device in phase 2 and 3 clinical trials across several disease areas.

METHODS

The electronic Clinical Outcome Assessment (eCOA) data were obtained from Johnson & Johnson clinical trials across various disease areas from 2016 to 2023. Data were acquired from internal and external sources including clinical trial sites and eCOA partners. In total, 82 trials were analyzed, containing data from 33,633 unique participants, and 1,083,994 measurements of completed electronic PRO instruments. After data cleaning, descriptive and multivariate analyses were performed. Electronic PRO completion time was examined in two ways: by time-per-item and time-per-instrument for each PRO.

RESULTS

On average, participants spend about 16 s per item and an average of 2 min to complete a PRO instrument electronically. The average time to complete PRO instruments varied significantly by disease area and most eCOA were completed on study site tablets (68%) or personal handheld devices (31%).

CONCLUSIONS

Overall, patients spend an average of 16 s per item and 2 min per PRO instrument in clinical trial studies. PROs are a crucial component of clinical trial outcomes data and can be efficiently completed electronically by participants in clinical trials in a short amount of time.

Patient preferences for key organizational features of primary cardiovascular care in Quebec: a discrete choice experiment

BACKGROUND

Cardiovascular diseases and their risk factors are leading causes of morbidity and mortality worldwide, and are among the top reasons for primary care visits. Little is known about patient preferences for primary care in the context of chronic conditions. This study aimed to investigate the effect of key organizational features identified by patients and providers on patients' choice of a preferred primary care practice to receive cardiovascular care.

METHODS

A discrete choice experiment survey was completed by a weighted online sample of 501 Quebec residents having or being at risk of cardiovascular disease. Respondents completed one of two blocks of nine choice sets by indicating, among three hypothetical primary care practice alternatives in each choice set, their preferred and second-most preferred options. Alternatives were differentiated on the basis of five key attributes identified as priorities in an earlier Delphi study: listening to and respecting care preferences; providing personalized information; 24-to- 48-h accessibility in the event of a problem; continuity of care; and up-to-date clinical skills. Each attribute could be assigned a best, moderate, or worst level. Choices were analyzed using generalized multinomial logit modeling. Marginal effects and choice probabilities for policy-relevant scenarios were estimated.

RESULTS

All five attributes significantly influenced choices of primary care practice. The marginal effects of worst attribute levels were of much greater magnitude than those of best levels for all attributes. Improving short-term accessibility from worst to moderate level had the largest average incremental effect on the probability of patients choosing a practice. Best continuity of care was more valued by older patients and those in poorer general health, but had nonsignificant impact unless it was coupled with enhanced short-term accessibility.

CONCLUSIONS

A balanced approach across the key organizational features covered seems more advantageous for primary care practices than focusing solely on achieving excellence in any single attribute. The interactions between patient preferences for short-term accessibility and continuity of care should be taken into account when planning and implementing organizational change in primary care. Whether these preferences are generalizable to other jurisdictions and subsets of primary care patients deserves further exploration.

Implementing value-based healthcare: a scoping review of key elements, outcomes, and challenges for sustainable healthcare systems

Introduction

Value-Based Health Care (VBHC) is an increasingly important healthcare paradigm that focuses on maximizing health outcomes relative to the cost of care delivered. Various healthcare organizations have adopted VBHC principles, but significant barriers remain in adapting care models, engaging stakeholders, and measuring outcomes. Moreover, the lack of standardized methods for measuring outcomes and financial sustainability further complicates the transition to VBHC. Understanding the factors that facilitate or hinder VBHC adoption is crucial to informing policy and practice for broader implementation. The objective is to map the literature addressing VBHC concerning population, study characteristics, funding models, outcome measures, and barriers and facilitators.

Methods

Following the JBI methodology and the PRISMA-ScR reporting guidance, a scoping review was undertaken to include primary and secondary research on VBHC across various healthcare settings. Searches were undertaken in nine relevant databases. Peer-reviewed quantitative and qualitative studies published in English were included and analyzed. A total of 145 studies were included after screening 2,725 studies.

Results

The findings show that the United States leads VBHC research, contributing 65% of the studies, followed by European countries. Cohort and cross-sectional studies were predominant, focusing on various populations, including hospitals, surgical patients, and cancer patients. Key findings highlight that Value-Based Purchasing and Time-Driven Activity-Based Costing models were the most frequently reported funding models. Traditional in-hospital care remains the dominant delivery model, with increasing interest in telemedicine. Outcome measure were diverse, ranging from patient-reported outcomes to cost savings for both patients and providers. Barriers to VBHC implementation include insufficient funding, fee-for-service model persistence, and resistance from healthcare professionals. Facilitators included strong leadership, multidisciplinary collaboration, and the use of digital tools.

Conclusion

The review highlights the need for consistent outcome measurements, financial incentives, and improved data transparency to ensure the successful and scalable implementation of VBHC across healthcare systems. While VBHC shows promise in improving healthcare efficiency and quality, challenges remain in aligning financial and operational structures to fully support this paradigm shift.

Prognostic value of baseline EORTC QLQ-C30 scores for overall survival across 46 clinical trials covering 17 cancer types: a validation study

Background

A pooled data analysis by Quinten et al. (2009) found three European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) health-related quality of life (HRQoL) scales to be prognostic for survival: physical functioning, pain and appetite loss. This study aims to replicate these findings in an independent data set comprising a broader cancer population.

Methods

Data were obtained from 46 clinical trials across three cancer research networks conducted between 1996 and 2013 that assessed HRQoL using the EORTC QLQ-C30. A stratified Cox proportional hazards model was employed to assess the prognostic significance of baseline QLQ-C30 scale scores on overall survival, adjusting for socio-demographic and clinical variables. Stepwise model selection was done at 5% significance level. Model stability and prognostic accuracy were evaluated via bootstrapping and the C index respectively.

Findings

Data from 16,210 patients reporting HRQoL at baseline, spanning 17 cancer types, was used. The stratified multivariable model confirmed that better physical functioning (hazard ratio [HR], 0.94; 95% confidence interval [CI], 0.93-0.96), lower pain (HR, 1.02; 95% CI, 1.01-1.03), and appetite loss (HR, 1.04; 95% CI, 1.03-1.05) were significantly associated with survival. Additionally, global health status/QoL, dyspnoea, emotional and cognitive functioning were found to be prognostic for survival. This final model, encompassing sociodemographic, clinical, and HRQoL variables, achieved a corrected C index of 0.74, marking a 48% enhancement in discriminatory ability. Bootstrap evaluation indicated no major instability issues.

Interpretation

These results support previous findings that baseline physical functioning, pain, and appetite loss scores, along with four other scales from the EORTC QLQ-C30, predict survival in cancer patients.

Funding

EORTC Quality of Life Group.

Patient reported outcome measures: from the classics to AI

With its basis in the development of intelligence testing, classical test theory paved the way to develop patient-reported outcome measures - tools capable of quantifying otherwise immeasurable traits. In hand surgery, many of the popular outcome measures were developed using classical test theory. However, these techniques are increasingly being superseded by novel mathematical approaches. This review article will chart the progress from established scientific methods through to modern day item response theory and computerized adaptive testing, and explore the opportunities that artificial intelligence may afford.Level of evidence: V.

Missing data and long-term outcomes from nutrition research in the critically ill

PURPOSE OF REVIEW

The use of functional outcomes in critical care nutrition research is increasingly advocated; however, this inevitably gives rise to missing data. Consequently there is a need to adopt modern approaches to the foreseeable problem of missing functional and survival outcomes in research trials.

RECENT FINDINGS

Analyses that ignore unobserved or missing data will often return biased effect estimates. An improved approach is to routinely anticipate the types and extent of missing data, and consider the likely mechanisms of that missingness. The researcher and their statistical advisor may then choose from a number of modern strategies to assess the sensitivity of the research conclusions to the patterns of missingness contained in these research data. Methods widely employed include multiple imputation of missing observations, mixed regression models, use of composite outcome variables with patients who die being attributed a value reflecting the lack of ability to function, and selected Bayesian methodology.

SUMMARY

Conclusions from clinical research in critical care nutrition will become more clinically interpretable and generalizable with the adoption of modern methods for the statistical handling of missing data.

Value-based health care definition and characteristics: an evidence-based approach

Objective The aim of this study was to develop a concise, accessible definition of value-based health care (VBHC) and identify its main characteristics through a comprehensive analysis of existing literature. Methods A scoping review methodology was employed to map definitions and characteristics of VBHC from nine databases, including JBI EBP Database, Cochrane Reviews, Embase, Ovid MEDLINE(R), APA PsycINFO, and others, from inception until November 2023. The scoping review aimed to clarify existing concepts and identify gaps in VBHC definitions and frameworks across various geographical contexts. Additionally, qualitative data on VBHC were analysed from the included studies using a word cloud generated via an online tool and a word frequency table generated from Excel. This dual analysis informed the creation of a simplified, data-driven definition of VBHC along with its key characteristics. Results The word frequency analysis highlighted common themes, including 'care,' 'outcomes,' 'quality,' 'efficiency,' and 'cost.' Based on these frequently mentioned terms, a simplified definition of VBHC was formulated, focusing on patient-centred care that aims to improve health outcomes relative to costs. Comparisons with existing literature revealed that while the derived definition is more accessible and concise, it lacks the depth of the academic definitions, which emphasise strategic implementation, interdisciplinary collaboration, and nuanced measurement of outcomes. Conclusion This study provides a simplified, data-driven definition of VBHC that can facilitate understanding and implementation among practitioners and stakeholders. Integrating this accessible definition can bridge the gap between theory and practice, ultimately supporting better health outcomes and system sustainability.

Best practices and pragmatic approaches for patient-reported outcomes and quality of life measures in cancer clinical trials

Patient-reported outcomes (PROs) are often collected in cancer clinical trials. Data obtained from trials with PROs are essential in evaluating participant experiences relating to symptoms, financial toxicity, or health-related quality of life. Although most features of clinical trial design, implementation, and analyses apply to trials with PROs, several considerations are unique. In this paper, we focus on specific issues such as selection of the tool, timing and frequency of assessments, and data collection methods. We discuss how the estimand framework can be used in connection with PROs, properties of common estimation methods, and handling of missing outcomes. With a plethora of literature available, we aim to summarize best practices and pragmatic approaches to the design and analysis of the studies incorporating PROs.

A Hierarchical Framework for Selecting Reference Measures for the Analytical Validation of Sensor-Based Digital Health Technologies

Sensor-based digital health technologies (sDHTs) are increasingly used to support scientific and clinical decision-making. The digital clinical measures they generate offer enormous benefits, including providing more patient-relevant data, improving patient access, reducing costs, and driving inclusion across health care ecosystems. Scientific best practices and regulatory guidance now provide clear direction to investigators seeking to evaluate sDHTs for use in different contexts. However, the quality of the evidence reported for analytical validation of sDHTs-evaluation of algorithms converting sample-level sensor data into a measure that is clinically interpretable-is inconsistent and too often insufficient to support a particular digital measure as fit-for-purpose. We propose a hierarchical framework to address challenges related to selecting the most appropriate reference measure for conducting analytical validation and codify best practices and an approach that will help capture the greatest value of sDHTs for public health, patient care, and medical product development.

Health-related Quality of Life Assessment in Renal Cell Cancer: A Scoping Review

BACKGROUND AND OBJECTIVE

In oncology, patient-reported outcome measures (PROMs) capturing health-related quality of life (HRQOL) play an increasing role in clinical trials, drug approval, and policy making. This scoping review aimed to identify and elaborate on HRQOL-focussed PROMs used in renal cell cancer (RCC) clinical trials.

METHODS

MEDLINE, Web of Science, PsychINFO, Academic Search Elite, CINAHL, Embase, and the Cochrane Library were searched systematically for original peer-reviewed articles on clinical trials including RCC patients and using PROMs, published between 1950 and 2023. Prespecified trial characteristics and information on the PROMs used were extracted. Frequencies and proportions of categorical data, and ranges and medians of continuous variables were calculated.

KEY FINDINGS AND LIMITATIONS

Of the 48 unique studies included, the majority followed a randomised controlled design (34, 71%) and evaluated systemic treatments (38, 79%). The trials used 27 different PROMs (max = 6, median = 2), of which only 4 (15%) were developed specifically for kidney cancer patients. Of the trials, 46% did not use any RCC-specific PROM. European Quality of Life-5 Dimensions (EQ-5D), European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30), Functional Assessment of Cancer Therapy Kidney Symptom Index (FKSI) -15/19-item version, FKSI-Disease Related Symptoms, and Functional Assessment of Cancer Therapy-General (FACT-G) were the most frequently used questionnaires, with pain, ability to work, fatigue, worry, and sleep quality being the most commonly assessed issues.

CONCLUSIONS AND CLINICAL IMPLICATIONS

A variety of PROMs are used in RCC patients, hindering interpretability across trials. The PROMs used differ in terms of both the domains assessed and how the issues are translated into questionnaire items. Though RCC-specific PROMs exist, these have flaws in terms of relevance to patients. To answer predefined relevant HRQOL research questions, revised RCC-specific PROMs and standardisation of their integration into clinical trials are warranted.

PATIENT SUMMARY

Researchers are more and more interested in the health-related quality of life of kidney cancer patients and use questionnaires to measure it. This review shows that there are many different health-related quality of life questionnaires that are used in different combinations in clinical trials for kidney cancer patients. This makes it very difficult to compare these study results and draw reliable conclusions for the actual clinical treatment. It was even found that some of the questionnaires used do not capture things that patients actually consider important (eg, emotional issues such as dealing with thoughts about cancer and depression). Therefore, more work needs to be done to develop questionnaires that ask what is really important to kidney cancer patients' health-related quality of life. If these questionnaires are used in a consistent way in clinical trials, the results can be better compared. This will help treat kidney cancer patients in the best possible way.

Personalizing rehabilitation for individuals with musculoskeletal impairments: Feasibility of implementation of the Measures Associated to Prognostic (MAPS) tool

INTRODUCTION

The Measures Associated to PrognoStic (MAPS) tool is a standardized questionnaire that integrates validated prognostic tools to detect the presence of biopsychosocial prognostic factors in patients consulting for musculoskeletal disorders.

PURPOSE

The objectives were to assess the: 1) feasibility of implementation of the MAPS tool, 2) clinicians' acceptability of the dashboard, and 3) patients' acceptability of the MAPS tool.

METHODS

Twenty physiotherapists and two occupational therapists from seven outpatient musculoskeletal clinics were recruited to implement the MAPS tool during a 3-month timeframe, where new patients completed the questionnaire upon initial assessment. The results were presented to the clinicians via a dashboard. Surveys and semi-structured interviews were conducted to measure feasibility and acceptability.

RESULTS

Six out of 11 feasibility criteria (55%) and 21 out of 24 acceptability criteria (88%) reached the a priori threshold for success. The interviews allowed us to identify three main themes to facilitate implementation: 1) limiting the burden, 2) ensuring patients' understanding of the tool's purpose, and 3) integrating the dashboard as a clinical information tool.

CONCLUSION

Our quantitative and qualitative results support the feasibility of implementation and acceptability of the MAPS tool pending minor adjustments. Depicting the patients' prognostic profile has the potential to help clinicians optimize their interventions for patients presenting with musculoskeletal disorders.

Exploring the Impact of the Multimodal CAPABLE eHealth Intervention on Health-Related Quality of Life in Patients With Melanoma Undergoing Immune-Checkpoint Inhibition: Prospective Pilot Study

Background

Patients with melanoma receiving immunotherapy with immune-checkpoint inhibitors often experience immune-related adverse events, cancer-related fatigue, and emotional distress, affecting health-related quality of life (HRQoL) and clinical outcome to immunotherapy. eHealth tools can aid patients with cancer in addressing issues, such as adverse events and psychosocial well-being, from various perspectives.

Objective

This study aimed to explore the effect of the Cancer Patients Better Life Experience (CAPABLE) system, accessed through a mobile app, on HRQoL compared with a matched historical control group receiving standard care. CAPABLE is an extensively tested eHealth app, including educational material, remote symptom monitoring, and well-being interventions.

Methods

This prospective pilot study compared an exploratory cohort that received the CAPABLE smartphone app and a multisensory smartwatch for 6 months (intervention) to a 2:1 individually matched historical prospective control group. HRQoL data were measured with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 at baseline (T0), 3 months (T1), and 6 months (T2) after start of treatment. Mixed effects linear regression models were used to compare HRQoL between the 2 groups over time.

Results

From the 59 eligible patients for the CAPABLE intervention, 31 (53%) signed informed consent to participate. Baseline HRQoL was on average 10 points higher in the intervention group compared with controls, although equally matched on baseline and clinical characteristics. When correcting for sex, age, disease stage, and baseline scores, an adjusted difference in fatigue of -5.09 (95% CI -15.20 to 5.02, P=.32) at month 3 was found. No significant nor clinically relevant adjusted differences on other HRQoL domains over time were found. However, information satisfaction was significantly higher in the CAPABLE group (β=8.71, 95% CI 1.54-15.88, P=.02).

Conclusions

The intervention showed a limited effect on HRQoL, although there was a small improvement in fatigue at 3 months, as well as information satisfaction. When aiming at personalized patient and survivorship care, further optimization and prospective investigation of eHealth tools is warranted.

Enhancing Patient Response to Patient-Reported Outcome Measures: Insights From a Leading Dutch University Hospital

OBJECTIVES

Engaging patients with patient-reported outcome measures (PROMs) is a widely recognized and pressing challenge, yet our understanding of how to achieve this is limited. This study investigated strategies implemented by a Dutch university hospital aimed at enhancing response rates among outpatients from nearly 70 subdepartments. Response rates improved, but remained below desired levels. To deepen understanding and inform future strategies, we identified patient and consultation characteristics associated with response behavior.

METHODS

We investigated strategies and their underlying rationales through a document analysis of internal hospital documentation (2020-2023) using the COM-B model. We exploited electronic health record data to identify patient and consultation characteristics associated with PROMs completion, estimating a multivariate logistic regression model (n = 46 468 outpatient consultations).

RESULTS

Thirteen strategies targeted outpatients' capability, opportunity, and motivation to complete PROMs. In 2023, PROMs were completed in more than half of the 46 468 unique consultations (56%) for which a PROM was sent. Challenges persisted in establishing effective feedback mechanisms and accommodating non-Dutch-speaking patients. The multivariate analysis showed a significantly higher response among patients of high or middle socioeconomic status and those with an in-person consultation, ie, not using telehealth. Women, patients attending a follow-up visit, or those having their consultation on a Friday were slightly less likely to complete PROMs.

CONCLUSIONS

Response rates to PROMs improved but remained below desired levels, despite multiple strategies. Hospitals may benefit from effective patient feedback on PROMs and tailoring strategies to engage specific patient groups. These approaches can enhance successful implementation and promote equity in value-based healthcare.

Patient-reported outcome measures for paediatric gender-affirming care: A systematic review

Objectives

Patient needs must be comprehensively measured to offer paediatric gender-affirming care in line with clinical standards. Patient-reported outcome measures (PROMs) are self-report tools that measure outcomes deemed to be of importance to patients. PROMs may assess a single outcome or multiple outcomes simultaneously, such as symptoms, functional ability, and quality of life. This study aims to identify PROMs for paediatric gender-affirming care.

Methods

This systematic review is PRISMA-compliant and was prospectively registered on PROSPERO (CRD42023461959). Six databases were searched: PubMed, Embase, MEDLINE, PsycINFO, CINAHL, and Web of Science from inception to December 16, 2022. Articles meeting the following criteria were included: 1) Original article; 2) Administers a formally-developed PROM; 3) Focuses on gender-affirming care; and 4) Focuses on paediatric populations. Screening and data extraction occurred independently and in duplicate. Data extracted include study/demographic information, and details of PROM used.

Results

In total, 20 articles were included, representing a total of 5793 paediatric patients undergoing gender-affirming care. Most studies (13, 65%) focused on hormonal gender-affirming care. A total of 38 different PROMs for paediatric gender-affirming care were identified, ranging from 4 to 120 items each (mean 23 items; median 14 items). Most PROMs (n = 22) measured psychological functioning, with eight PROMs measuring quality of life, and three PROMs measuring gender-related concepts (i.e., gender dysphoria/euphoria). Commonly used PROMs include the Utrecht Gender Dysphoria Scale (n = 4; 20%), Body Image Scale (n = 5;25%), and Youth Self-Report (n = 8; 40%).

Conclusions

A total of 38 PROMs were identified measuring a range of concepts for paediatric gender-affirming care.

Improving completion rates of patient-reported outcome measures in cancer clinical trials: Scoping review investigating the implications for trial designs

BACKGROUND

Patient-reported outcomes (PROs) play a crucial role in cancer clinical trials. Despite the availability of validated PRO measures (PROMs), challenges related to low completion rates and missing data remain, potentially affecting the trial results' validity. This review explored strategies to improve and maintain high PROM completion rates in cancer clinical trials.

METHODOLOGY

A scoping review was performed across Medline, Embase and Scopus and regulatory guidelines. Key recommendations were synthesized into categories such as stakeholder involvement, study design, PRO assessment, mode of assessment, participant support, and monitoring.

RESULTS

The review identified 114 recommendations from 18 papers (16 peer-reviewed articles and 2 policy documents). The recommendations included integrating comprehensive PRO information into the study protocol, enhancing patient involvement during the protocol development phase and in education, and collecting relevant PRO data at clinically meaningful time points. Electronic data collection, effective monitoring systems, and sufficient time, capacity, workforce and financial resources were highlighted.

DISCUSSION

Further research needs to evaluate the effectiveness of these strategies in various context and to tailor these recommendations into practical and effective strategies. This will enhance PRO completion rates and patient-centred care. However, obstacles such as patient burden, low health literacy, and conflicting recommendations may present challenges in application.

Quick MSA-QoL: A validated, abbreviated health-related quality of life questionnaire for use in Multiple System Atrophy

BACKGROUND

Health-related quality of life is an important patient-reported outcome, which can be assessed using instruments such as the Multiple System Atrophy (MSA) Quality of Life (MSA-QoL) scale. However, at 40-items its length can prove burdensome, particularly to patients with a disease such as MSA. This can contribute to respondent burden and poor-quality response data.

OBJECTIVE

The objective of this study was to develop an abbreviated MSA-QoL scale for use in clinical practise and trials (Quick MSA-QoL).

METHODS

A single-factor 15-item scale was developed with data from 310 patients with MSA, using exploratory factor analysis (EFA). A separate dataset (n = 279) was used for analysis of psychometric properties and for confirmatory factor analysis.

RESULTS

Missing data was minimal, with even distribution of scores and negligible floor/ceiling effects (0/0.4%). Reliability was high (Cronbach alpha 0.870, test-retest reliability 0.950). Good item-total scale correlations were observed (r = 0.402-0.618), and the overall scale correlated well with other validated questionnaires including the original MSA-QoL (r = 0.862). Confirmatory factor analysis demonstrated acceptable model fit indices. Responsiveness data from re-administration of the Quick MSA-QoL 10 months from baseline testing found the overall scale to be sensitive to change.

CONCLUSIONS

These data suggest that the Quick MSA-QoL is a suitable and efficient scale for use in clinical trials, minimising respondent burden and maintaining data quality.

Enhancing Clinicians' Use of Electronic Patient-Reported Outcome Measures in Outpatient Care: Mixed Methods Study

BACKGROUND

Despite the increasing use of patient-reported outcome measures (PROMs) for collecting self-reported data among hospital outpatients, clinicians' use of these data remains suboptimal. Insight into this issue and strategies to enhance the use of PROMs are critical but limited.

OBJECTIVE

This study aimed to examine clinicians' use of PROM data for value-based outpatient consultations and identify efforts to enhance their use of PROMs in a Dutch university hospital. First, we aimed to investigate clinicians' use of outpatients' PROM data in 2023, focusing on adoption, implementation, and maintenance. Second, we aimed to develop insights into the organizational-level strategies implemented to enhance clinicians' use of PROM data from 2020 to 2023. This included understanding the underlying rationales for these strategies and identifying strategies that appeared to be missing to address barriers or leverage facilitators. Third, we aimed to explore the key factors driving and constraining clinicians' use of PROMs in 2023.

METHODS

We integrated data from 4 sources: 1-year performance data on clinicians' use of PROMs (n=70 subdepartments), internal hospital documents from a central support team (n=56), a survey among clinicians (n=47), and interviews with individuals contributing to the organizational-level implementation of PROMs (n=20). The Reach, Effectiveness, Adoption, Implementation, and Maintenance framework was used to analyze clinicians' adoption, implementation, and maintenance of PROMs. Strategies were analyzed using the Expert Recommendations for Implementing Change taxonomy, and results were structured around the constructs of capability, opportunity, and motivation.

RESULTS

On average, around 2023, clinicians accessed PROM data for approximately 3 of 20 (14%) patients during their outpatient consultation, despite numerous strategies to improve this practice. We identified issues in adoption, implementation, and maintenance. The hospital's strategies, shaped organically and pragmatically, were related to 27 (37%) out of 73 Expert Recommendations for Implementing Change strategies. These strategies focused on enhancing clinicians' capability, opportunity, and motivation. We found shortcomings in the quality of execution and completeness of strategies in relation to addressing all barriers and leveraging facilitators. We identified variations in the factors influencing the use of PROMs among frequent PROM users, occasional users, and nonusers. Challenges to effective facilitation were apparent, with certain desired strategies being unfeasible or impeded.

CONCLUSIONS

Enhancing clinicians' use of PROMs has remained challenging despite various strategies aimed at improving their capability, opportunity, and motivation. The use of PROMs may require more substantial changes than initially expected, necessitating a shift in clinicians' professional attitudes and practices. Hospitals can facilitate rather than manage clinicians' genuine use of PROMs. They must prioritize efforts to engage clinicians with PROMs for value-based outpatient care. Specific attention to their professionalization may be warranted. Tailored strategies, designed to address within-group differences in clinicians' needs and motivation, hold promise for future efforts.

Sparse item testing of clinical scales in neurology trials to alleviate burden to patients

BACKGROUND

Neurology trials typically rely on composite scales for measuring symptom severity. Completing all items in a long scale can be burdensome for patients, caregivers, and trial personnel.

OBJECTIVES

To test the hypothesis that sparse item testing, aided by item-response modelling, can preserve the power for detecting treatment effect in a controlled trial.

METHODS

UPDRS (Unified Parkinson's Disease Rating Scale) Part III (motor examinations) data from a placebo-controlled trial (N = 391) of ropinirole were analysed with a longitudinal item-response model. Symptom severity was estimated directly from item scores as a latent variable, without needing the total score. This enabled sparse item testing. With the symptom severity as a clinical endpoint, the potential power loss for detecting treatment effect due to the sparse testing was assessed by simulation.

RESULTS

When each patient took 18 of all 27 tests in UPDRS Part III at each study visit, there was no appreciable power loss. Reducing four visits to three also had negligible effects on power. A threefold reduction of the total tests that each patient needed to do throughout the trial, from 108 to 27, only compromised power slightly, e.g., from 92 to 87% at N = 160.

CONCLUSIONS

These findings show that using the symptom severity derived from item scores as the endpoint allows sparse testing to drastically reduce trial burden without incurring major power loss. This benefit would multiply for indications like Alzheimer's disease where modern trials often require patients to be tested on multiple scales at several times.

Patients with axial spondyloarthritis reported willingness to use remote care and showed high adherence to electronic patient-reported outcome measures: an 18-month observational study

Remote monitoring using electronic patient reported outcomes (ePROs) in axial spondyloarthritis (axSpA) may improve self-management and reduce the need for consultations. However, knowledge regarding patients' willingness to use remote care and adherence to reporting ePROs is scarce. The objective of this study was to assess axSpA patients' willingness to use remote care and adherence to reporting of ePROs. The study was part of a three-armed randomized controlled trial testing digital follow-up strategies (The ReMonit study, NCT: 05031767). AxSpA patients in low disease activity were randomized to usual care, remote monitoring, or patient-initiated care. Demographics, clinical data, and patients' willingness to use remote care were collected at baseline. EPROs were reported either monthly or quarterly by the remote monitoring- and patient-initiated care group over 18 months, respectively. Adherence to reporting was calculated as number of ePROs completed divided by the total number requested. Mixed model logistic regression was utilized to assess factors associated with adherence to reporting of ePROs. In total 242 patients (median age 43 years, 75% males) were included. The majority (96%) reported high willingness to use remote care. Adherence to reporting ePROs remained high over 18 months by remote monitoring and patient-initiated care groups [median (IQR): 88% (77-100) vs. 83% (66-100)]. No patient characteristics were significantly associated with adherence to reporting of ePROs. The high degree of willingness and adherence to reporting ePROs over time indicates that the majority of axSpA patients with low disease activity are motivated to use remote care.

Behavioural digital biomarkers enable real-time monitoring of patient-reported outcomes: a substudy of the multicentre, prospective observational SafeHeart study

AIMS

Patient-reported outcome measures (PROMs) serve multiple purposes, including shared decision-making and patient communication, treatment monitoring, and health technology assessment. Patient monitoring using PROMs is constrained by recall and non-response bias, respondent burden, and missing data. We evaluated the potential of behavioural digital biomarkers obtained from a wearable accelerometer to achieve personalized predictions of PROMs.

METHODS AND RESULTS

Data from the multicentre, prospective SafeHeart study conducted at Amsterdam University Medical Center in the Netherlands and Copenhagen University Hospital, Rigshospitalet in Copenhagen, Denmark, were used. The study enrolled patients with an implantable cardioverter defibrillator between May 2021 and September 2022 who then wore wearable devices with raw acceleration output to capture digital biomarkers reflecting physical behaviour. To collect PROMs, patients received the Kansas City Cardiomyopathy Questionnaire (KCCQ) and EuroQoL 5-Dimensions 5-Level (EQ5D-5L) questionnaire at two instances: baseline and after six months. Multivariable Tobit regression models were used to explore associations between digital biomarkers and PROMs, specifically whether digital biomarkers could enable PROM prediction. The study population consisted of 303 patients (mean age 62.9 ± 10.9 years, 81.2% male). Digital biomarkers showed significant correlations to patient-reported physical and social limitations, severity and frequency of symptoms, and quality of life. Prospective validation of the Tobit models indicated moderate correlations between the observed and predicted scores for KCCQ [concordance correlation coefficient (CCC) = 0.49, mean difference: 1.07 points] and EQ5D-5L (CCC = 0.38, mean difference: 0.02 points).

CONCLUSION

Wearable digital biomarkers correlate with PROMs, and may be leveraged for real-time prediction. These findings hold promise for monitoring of PROMs through wearable accelerometers.

Intakes of Lean Proteins and Processed Meats and Differences in Mental Health between Rural and Metro Adults 50 Years and Older

Mental health disparities exist between rural and metro areas of the United States. Differences in dietary intake may contribute to these disparities. We examined differences in dietary intake and mental health between those 50 years and older (n = 637) living in rural counties to those living in metro counties in North Dakota and the relationship between dietary intake to days with depression or anxiety. A survey was conducted throughout North Dakota. Items were modified from other surveys, such as the Behavioral Risk Factor Surveillance System questionnaires and the National Health Interview Survey Cancer Control Supplement Dietary Screener Questionnaire. Comparing medians, individuals more likely to be unable to perform normal daily activities due to mental health (p = 0.009) resided in rural areas instead of metro areas. Those living rurally also ate more processed meats (p = 0.005), while trending toward less lean protein intake (p = 0.056). Multinomial regression analyses controlling for covariates revealed that lean protein intake and fruit intake were inversely associated with days with depression and anxiety (all p < 0.05), whereas processed meat intake was positively associated with anxiety (p = 0.005). Clinicians working with older adults residing in rural areas should emphasize substituting lean proteins for processed meats.

Correspondence between the Simple Physical Activity Questionnaire (SIMPAQ) and accelerometer-based physical activity in inpatients treated for major depressive disorders in comparison to non-depressed controls

Introduction

Major depressive disorders (MDD) are a leading health concern worldwide. While first line medication treatments may fall short of desired therapeutic outcomes, physical activity (PA) interventions appear to be a promising and cost-effective add-on to improve symptoms of depression. This study aimed to address challenges in the assessment of PA in inpatients treated for MDD by examining the correspondence of self-reported and accelerometer-based PA.

Methods

In 178 inpatients treated for MDD (mean age: M = 41.11 years, SD = 12.84; 45.5% female) and 97 non-depressed controls (mean age: M = 35.24 years, SD = 13.40; 36.1% female), we assessed self-reported PA via the Simple Physical Activity Questionnaire (SIMPAQ) for one week, followed by a week where PA was monitored using an accelerometer device (Actigraph wGT3x-BT). Additionally, we examined correlations between PA levels assessed with the SIMPAQ and exercise determinants in both groups.

Results

Descriptively, inpatients treated for MDD showed lower levels of light PA on accelerometer-based measures, whereas they self-reported increased levels of certain types of PA on the SIMPAQ. More importantly, there was only a small degree of correspondence between self-reported and actigraphy-based PA levels in both in patients (r = 0.15, p < 0.05) and controls (r = 0.03, ns). Only few significant correlations were found for self-reported PA (SIMPAQ subscores) and perceived fitness, whereas self-reported PA and estimated VO2max were unrelated. Furthermore, only weak (and mostly statistically non-significant) correlations were found between exercise determinants and SIMPAQ-based exercise behavior in both populations.

Discussion

Our findings emphasize the intricate challenges in the assessment of PA, not only in inpatients treated for MDD, but also in non-depressed controls. Our findings also underline the necessity for a diversified data assessment. Further efforts are needed to refine and improve PA questionnaires for a more accurate data assessment in psychiatric patients and healthy controls.

Clinimetric Properties of the Working Alliance Inventory and Credibility Expectancy Questionnaire: Screening Options for Musculoskeletal Pain

OBJECTIVE

To investigate clinimetric properties of 2 surveys used to evaluate common factors in the patient-provider relation and present screener options for the assessment of common factors and report their correlation with pain and functional outcomes.

DESIGN

Observational cohort.

SETTING

Outpatient physical therapy.

PARTICIPANTS

100 individuals (58% women, mean age=34, SD=15; N=100) presenting to physical therapy with musculoskeletal pain in the following regions: 44% lower extremity, 36% spine, 19% upper extremity, 1% undetermined.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Participants completed the Working Alliance Inventory (WAI) and the Credibility and Expectancy Questionnaire (CEQ). Exploratory factor analysis (EFA) explored factor structure of the WAI and CEQ. Internal consistency was evaluated for scales derived from items retained based on factor loadings. Finally, options for screener tools were proposed and assessed based on their correlation to original surveys as well as pain and functional outcomes.

RESULTS

The data supported a 4-factor structure for the surveys. Some WAI items were excluded due to cross-loading. The derived four-factor scales demonstrated strong correlations with the original surveys (r=.89-.99) and exhibited good internal consistency (α=.824-.875). Two screening options were suggested: 1 retaining 11 of the original 18 items and the other comprising just 3 items. Both screening tools correlated with the original surveys and showed associations with improvements in pain and functional outcomes (r=-.21-.34).

CONCLUSION

The proposed screeners provide concise measurement options to facilitate use in clinical practice. These tools can aid in facilitating patient communication specifically addressing patient expectation and understanding the tasks required to enact behavior change.

Measuring health related quality of life (HRQoL) in Lysosomal Storage Disorders (LSDs): a rapid scoping review of available tools and domains

BACKGROUND

Lysosomal storage diseases (LSDs) are a group of rare inherited metabolic disorders, consisting of over 70 diseases that are characterised by lysosomal dysfunction. Due to their varied and progressive symptoms, LSDs have a continual impact on patients' health-related quality of life (HRQoL). Several recently published studies have provided insight into the HRQoL of individuals with LSDs. However, it is challenging to meaningfully synthesise this evidence, since studies often focus upon a particular type of LSD and / or utilise different self-report questionnaires or patient-reported outcome measures (PROMs) to assess HRQoL.

AIMS

The aim of this study was to review the published literature in LSDs, to identify the PROMs which have been used to assess HRQoL and generate a conceptual map of HRQoL domains measured in individuals diagnosed with LSDs.

METHODS

Three electronic databases were searched in March 2022. Primary studies of any design which utilised multi-item PROMs to assess at least one aspect of HRQoL in individuals with LSDs since 2017 were identified. Data were extracted to assess both the characteristics of each study and of the PROMs utilised within each study. The extraction of HRQoL domains and synthesis were informed by an a priori framework, inductively modified to reflect data emerging from the identified literature. Selection and extraction was undertaken independently by two reviewers; discrepancies were ratified by a third reviewer.

RESULTS

Sixty nine studies were identified which were published 2017-2022, with a combined total of 52 PROMs (71 variants) used to assess HRQoL in individuals with LSDs. The final extracted HRQoL framework included 7 domains (Activities; Physical sensations; Autonomy; Cognition; Feelings and emotions; Self-identity; Relationships), characterised by 37 sub-domains.

CONCLUSIONS

This review highlights the breadth and variety of HRQoL domains assessed in individuals with LSDs, across three broad domains of physical, psychological and social functioning. The resultant framework and mapped PROMs will aid researchers and clinicians in the selection of PROMs to assess aspects of HRQoL in people living with LSDs, based on their conceptual coverage.

Implementing Systematic Patient-Reported Measures for Chronic Conditions Through the Naveta Value-Based Telemedicine Initiative: Observational Retrospective Multicenter Study

BACKGROUND

Patient-reported outcome and experience measures can play a critical role in providing patient-centered and value-based health care to a growing population of patients who are chronically ill. Value-based telemedicine platforms such as the Naveta initiative may facilitate the effective integration of these tools into health care systems.

OBJECTIVE

This study aims to evaluate the response rate to electronic patient-reported outcome measures (ePROMs) and electronic patient-reported experience measures (ePREMs) among patients participating in the Naveta telemedicine initiative and its correlations with sociodemographic and clinical characteristics, as well as the evolution of the response rates over time.

METHODS

Between January 1, 2021, and June 30, 2023, a total of 53,364 ePREMs and ePROMs for 20 chronic conditions were administered through the Naveta-Phemium platform. Descriptive statistics were used to summarize continuous and categorical variables. Differences in response rates within each sociodemographic variable were analyzed using logistic regression models, with significance assessed via chi-square and post hoc Tukey tests. Two-way ANOVA was used to examine the interaction between time interval and disease type on response rate evolution.

RESULTS

A total of 3372 patients with severe chronic diseases from 64 public hospitals in Spain participated in the Naveta health questionnaire project. The overall response rate to ePROMs and ePREMs during the first 2.5 years of the Naveta initiative was 46.12% (24,704/53,364), with a baseline rate of 53.33% (7198/13,496). Several sociodemographic factors correlated with lower response rates, including male gender, older age, lower education level, frequent alcohol use, being a student, and not being physically active. There were also significant variations in response rates among different types of chronic conditions (P<.001), with the highest rates being for respiratory (433/606, 71.5%), oncologic (200/319, 62.7%), digestive (2247/3601, 62.4%), and rheumatic diseases (7506/12,982, 57.82%) and the lowest being for HIV infection (7473/22,695, 32.93%). During the first 6 months of follow-up, the response rates decreased in all disease types, except in the case of the group of patients with oncologic disease, among whom the response rate increased up to 100% (6/6). Subsequently, the overall response rate approached baseline levels.

CONCLUSIONS

Recognizing the influence of sociodemographic factors on response rates is critical to identifying barriers to participation in telemonitoring programs and ensuring inclusiveness in patient-centered health care practices. The observed decline in response rates at follow-up may be due to survey fatigue, highlighting the need for strategies to mitigate this effect. In addition, the variation in response rates across chronic conditions emphasizes the importance of tailoring telemonitoring approaches to specific patient populations.

Accuracy, Acceptability, and Burden of an Integrated Screening Approach to Facilitate the Delivery of Tailored Sexual Assault Prevention in the U.S. Air Force

This paper examines accuracy, acceptability, and respondent burden of integrated screening to facilitate tailored sexual assault (SA) prevention program delivery in a basic military training (BMT) environment. Trainees (n = 5,951) received tailored prevention content based on self-reported sex, sexual orientation, prior SA victimization and perpetration, and past-month post-traumatic stress symptoms. Bivariate analyses examined trainee-reported screener accuracy, acceptability, and burden, including differences by tailoring-targeted subgroups (e.g. men/women). Overall accuracy and acceptability were high (>90%) despite significant subgroup variability. Screening time averaged 10.55 (SD = 1.95) minutes; individuals with prior SA took longer. Missingness increased linearly throughout the screener. Integrated screening is an accurate, acceptable way to deploy tailored SA prevention in BMT. Findings inform data-driven screening improvements and novel applications.

A review of patient recruitment in randomised controlled trials of preoperative exercise

BACKGROUND

Randomised controlled trials (RCTs) are considered the gold standard design to determine the effectiveness of an intervention, as the only method of decreasing section bias and minimising random error. However, participant recruitment to randomised controlled trials is a major challenge, with many trials failing to recruit the targeted sample size accordingly to the planned protocol. Thus, the aim of this review is to detail the recruitment challenges of preoperative exercise clinical trials.

METHODS

A comprehensive search was performed on MEDLINE, Embase, The Cochrane Library, CINAHL, AMED and PsycINFO from inception to July 2021. Randomised controlled trials investigating the effectiveness of preoperative exercise on postoperative complication and/or length of hospital stay in adult cancer patients were included. Main outcomes included recruitment rate, retention rate, number of days needed to screen and recruit one patient and trial recruitment duration. Descriptive statistics were used to summarise outcomes of interest.

RESULTS

A total of 27 trials were identified, including 3656 patients screened (N = 21) and 1414 randomised (median recruitment rate (interquartile range) = 53.6% (25.2%-67.6%), N = 21). The sample size of the included trials ranged from 19 to 270 (median = 48.0; interquartile range = 40.0-85.0) and the duration of trial recruitment ranged from 3 to 50 months (median = 19.0 months; interquartile range = 10.5-34.0). Overall, a median of 3.6 days was needed to screen one patient, whereas 13.7 days were needed to randomise one participant. Over the trials duration, the median dropout rate was 7.9%. Variations in recruitment outcomes were observed across trials of different cancer types but were not statistically significant.

CONCLUSION

The recruitment of participants to preoperative exercise randomised controlled trials is challenging, but patient retention appears to be less of a problem. Future trials investigating the effectiveness of a preoperative exercise programme following cancer surgery should consider the time taken to recruit patients. Strategies associated with improved recruitment should be investigated in future studies.

Patient adherence and response time in electronic patient-reported outcomes: insights from three longitudinal clinical trials

PURPOSE

Patient-reported outcome measures (PROMs) are used to collect data on disease symptoms in support of clinical trial endpoints. Clinical studies can last a year or more, and the patients' adherence and response time to daily at-home questionnaires may vary significantly over time. The aim of this study was to understand patterns and changes in patients' completion of daily PROMs during longitudinal clinical studies.

METHODS

Data were collected from 1342 patients randomized into three respiratory clinical trials (NCT03401229, NCT03347279, and NCT03406078). PROMs were completed by patients using electronic handheld devices that collected the starting and completion times. A Bayesian generalized linear mixed-effects model was used to identify unbiased coefficients associated with PROM adherence and response time using patient, site, and calendar features as covariates.

RESULTS

Adherence decreased over time after randomization, and the rate of decrease was higher in younger patients. The 14-day pre-randomization adherence was correlated with adherence throughout the study. Patients were also more adherent during working days compared to non-working days. Oldest patients took twice as long to complete PROMs throughout the study; however, the response time for all patients decreased during the first month of the study regardless of age. Response time increased 7 days before and after the date of a scheduled clinic visit and when a patient-reported higher symptom burden.

CONCLUSION

Detailed analyses of adherence and response time for daily PROMs in clinical trials can provide significant insights about trends of patient behavior in longitudinal clinical studies with high baseline adherence.

Missingness mechanisms and generalizability of patient reported outcome measures in colorectal cancer survivors - assessing the reasonableness of the "missing completely at random" assumption

BACKGROUND

Patient-Reported Outcome Measures (PROM) provide important information, however, missing PROM data threaten the interpretability and generalizability of findings by introducing potential bias. This study aims to provide insight into missingness mechanisms and inform future researchers on generalizability and possible methodological solutions to overcome missing PROM data problems during data collection and statistical analyses.

METHODS

We identified 10,236 colorectal cancer survivors (CRCs) above 18y, diagnosed between 2014 and 2018 through the Danish Clinical Registries. We invited a random 20% (2,097) to participate in a national survey in May 2023. We distributed reminder e-mails at day 10 and day 20, and compared Initial Responders (response day 0-9), Subsequent Responders (response day 10-28) and Non-responders (no response after 28 days) in demographic and cancer-related characteristics and PROM-scores using linear regression.

RESULTS

Of the 2,097 CRCs, 1,188 responded (57%). Of these, 142 (7%) were excluded leaving 1,955 eligible CRCs. 628 (32%) were categorized as initial responders, 418 (21%) as subsequent responders, and 909 (47%) as non-responders. Differences in demographic and cancer-related characteristics between the three groups were minor and PROM-scores only marginally differed between initial and subsequent responders.

CONCLUSION

In this study of long-term colorectal cancer survivors, we showed that initial responders, subsequent responders, and non-responders exhibit comparable demographic and cancer-related characteristics. Among respondents, Patient-Reported Outcome Measures were also similar, indicating generalizability. Assuming Patient-Reported Outcome Measures of subsequent responders represent answers by the non-responders (would they be available), it may be reasonable to judge the missingness mechanism as Missing Completely At Random.

Toward a more patient-centered drug development process in clinical trials for patients with myelodysplastic syndromes/neoplasms (MDS): Practical considerations from the International Consortium for MDS (icMDS)

Notable treatment advances have been made in recent years for patients with myelodysplastic syndromes/neoplasms (MDS), and several new drugs are under development. For example, the emerging availability of oral MDS therapies holds the promise of improving patients' health-related quality of life (HRQoL). Within this rapidly evolving landscape, the inclusion of HRQoL and other patient-reported outcomes (PROs) is critical to inform the benefit/risk assessment of new therapies or to assess whether patients live longer and better, for what will likely remain a largely incurable disease. We provide practical considerations to support investigators in generating high-quality PRO data in future MDS trials. We first describe several challenges that are to be thoughtfully considered when designing an MDS-focused clinical trial with a PRO endpoint. We then discuss aspects related to the design of the study, including PRO assessment strategies. We also discuss statistical approaches illustrating the potential value of time-to-event analyses and their implications within the estimand framework. Finally, based on a literature review of MDS randomized controlled trials with a PRO endpoint, we note the PRO items that deserve special attention when reporting future MDS trial results. We hope these practical considerations will facilitate the generation of rigorous PRO data that can robustly inform MDS patient care and support treatment decision-making for this patient population.

Patient-Reported Outcomes to Achieve Person-Centered Care for Aging People With Kidney Disease

Person-centered care is a system of care delivery that supports effective patient-clinician communication and empowers patients to partner with their clinical providers to develop goal-concordant treatment plans. Models of person-centered care often involve the implementation of patient-reported outcomes (PROs) to measure patients' symptoms and quality of life as they navigate complex chronic health conditions. Models of person-centered care have been particularly effective in improving the quality of care delivery for older adults as well as younger adults with aging-associated conditions such as physical function decline. Though PROs have been developed and validated in kidney disease, they are not routinely implemented in clinical practice. Most individuals with kidney disease are 65 and older, but many younger individuals with kidney disease also experience aging-associated conditions earlier than in the general population. Thus, PROs represent an important tool for achieving person-centered care in groups with kidney disease who are the most vulnerable to adverse health outcomes and excess health care utilization. In this article, we aim to move toward more routine implementation of PROs in kidney care for aging adults. To identify the most clinically relevant PROs for this group and understand the ideal mode and context in which to implement PROs, we will (1) provide an evidence-based summary of PROs with the greatest prognostic significance in the general population and in kidney disease, including those specific to older adults; (2) describe barriers to the implementation of PROs in kidney care with a special focus on the needs of older adults and younger adults with aging-associated conditions; and (3) conclude with our evidence-based recommendations for the content, time, and context in which PROs should be implemented to achieve person-centered kidney care for aging adults.

Administering selected subscales of patient-reported outcome questionnaires to reduce patient burden and increase relevance: a position statement on a modular approach

Patient-reported outcome (PRO) questionnaires considered in this paper contain multiple subscales, although not all subscales are equally relevant for administration in all target patient populations. A group of measurement experts, developers, license holders, and other scientific-, regulatory-, payer-, and patient-focused stakeholders participated in a panel to discuss the benefits and challenges of a modular approach, defined here as administering a subset of subscales out of a multi-scaled PRO measure. This paper supports the position that it is acceptable, and sometimes preferable, to take a modular approach when administering PRO questionnaires, provided that certain conditions have been met and a rigorous selection process performed. Based on the experiences and perspectives of all stakeholders, using a modular approach can reduce patient burden and increase the relevancy of the items administered, and thereby improve measurement precision and eliminate wasted data without sacrificing the scientific validity and utility of the instrument. The panelists agreed that implementing a modular approach is not expected to have a meaningful impact on item responses, subscale scores, variability, reliability, validity, and effect size estimates; however, collecting additional evidence for the impact of context may be desirable. It is also important to recognize that adequate rationale and evidence (e.g., of fit-for-purpose status and relevance to patients) and a robust consensus process that includes patient perspectives are required to inform selection of subscales, as in any other measurement circumstance, is expected. We believe that the considerations discussed within (content validity, administration context, and psychometric factors) are relevant across multiple therapeutic areas.

Patient-Reported Outcome Measures for Patients With CKD: The Case for Patient-Reported Outcomes Measurement Information System (PROMIS) Tools

Chronic kidney disease (CKD), kidney failure, and kidney replacement therapies are associated with high symptom burden and impaired health-related quality of life (HRQOL). Symptoms change with disease progression or transition between treatment modalities and frequently go unreported and unmanaged. Tools that reliably monitor symptoms may improve the management of patients with CKD. Patient-reported outcome measures (PROMs) assess symptom severity; physical, psychological, social, and cognitive functioning; treatment-related side effects; and HRQOL. Systematic use of PROMs can improve patient-provider communication, patient satisfaction, clinical outcomes, and HRQOL. Potential barriers to their use include a lack of engagement, response burden, and limited guidance about PROM collection, score interpretation, and workflow integration. Well-defined, acceptable, and effective clinical response pathways are essential for implementing PROMs. PROMs developed by the Patient-Reported Outcomes Measurement Information System (PROMIS) address some challenges and may be suitable for clinical use among patients with CKD. PROMIS tools assess multiple patient-valued, clinically actionable symptoms and functions. They can be administered as fixed-length, customized short forms or computer adaptive tests, offering precise measurement across a range of symptom severities or function levels, tailored questions to individuals, and reduced question burden. Here we provide an overview of the potential use of PROMs in CKD care, with a focus on PROMIS.

Developing a shortened spine functional index (SFI-10) for patients with sub-acute/chronic spinal disorders: a cross-sectional study

BACKGROUND

Brief whole-spine patient-reported outcome measures (PROMs) provide regional solutions and future directions for quantifying functional status, evidence, and effective interventions. The whole-spine regional Spine Functional Index (SFI-25) is used internationally in clinical and scientific contexts to assess general sub-acute/chronic spine populations. However, to improve structural validity and practicality a shortened version is recommended. This study developed a shortened-SFI from the determined optimal number of item questions that: correlated with criteria PROMs being highly with whole-spine, moderately with regional-spine, condition-specific and patient-specific, and moderately-low with general-health and pain; retained one-dimensional structural validity and high internal consistency; and improved practicality to reduce administrative burden.

METHODS

A cross-sectional study (n = 505, age = 18-87 yrs., average = 40.3 ± 10.1 yrs) of sub-acute/chronic spine physiotherapy outpatients from an international sample of convenience. Three shortened versions of the original SFI-25 were developed using 1) qualitative 'content-retention' methodology, 2) quantitative 'factorial' methodology, and 3) quantitative 'Rasch' methodology, with a fourth 'random' version produced as a comparative control. The clinimetric properties were established for structural validity with exploratory (EFA) and confirmatory (CFA) factorial analysis, and Rasch analysis. Criterion validity used the: whole-spine SFI-25 and Functional Rating Index (FRI); regional-spine Neck Disability Index (NDI), Oswestry Disability Index (ODI), and Roland Morris Questionnaire (RMQ), condition-specific Whiplash Disability Questionnaire (WDQ); and patient-specific functional scale (PSFS); and determined floor/ceiling effect. A post-hoc pooled international sub-acute/chronic spine sample (n = 1433, age = 18-91 yrs., average = 42.0 ± 15.7 yrs) clarified the findings and employed the general-health EuroQuol-Index (EQ-5D), and 11-point Pain Numerical Rating Scale (P-NRS) criteria.

RESULTS

A 10-item SFI retained structural validity with optimal practicality requiring no computational aid. The SFI-10 concept-retention-version demonstrated preferred criterion validity with whole-spine criteria (SFI-25 = 0.967, FRI = 0.810) and exceeded cut-off minimums with regional-spine, condition-specific, and patient-specific measures. An unequivocal one-dimensional structure was determined. Internal consistency was satisfactory (α = 0.80) with no floor/ceiling effect. Post-hoc analysis of the international sample confirmed these findings.

CONCLUSION

The SFI-10 qualitative concept-retention version was preferred to quantitative factorial and Rasch versions, demonstrated structural and criterion validity, and preferred correlation with criteria measures. Further longitudinal research is required for reliability, error, and responsiveness, plus an examination of the practical characteristics of readability and administrative burden.

Recommendations to address respondent burden associated with patient-reported outcome assessment

Patient-reported outcomes (PROs) are increasingly used in healthcare research to provide evidence of the benefits and risks of interventions from the patient perspective and to inform regulatory decisions and health policy. The use of PROs in clinical practice can facilitate symptom monitoring, tailor care to individual needs, aid clinical decision-making and inform value-based healthcare initiatives. Despite their benefits, there are concerns that the potential burden on respondents may reduce their willingness to complete PROs, with potential impact on the completeness and quality of the data for decision-making. We therefore conducted an initial literature review to generate a list of candidate recommendations aimed at reducing respondent burden. This was followed by a two-stage Delphi survey by an international multi-stakeholder group. A consensus meeting was held to finalize the recommendations. The final consensus statement includes 19 recommendations to address PRO respondent burden in healthcare research and clinical practice. If implemented, these recommendations may reduce PRO respondent burden.

Electronic adaptation and danish cross-cultural translation of PEmb-QoL and VEINES-QoL/Sym for patients with venous thromboembolism

PURPOSE

Most patient-reported outcome (PROs) used in thrombosis research and clinical practice are delivered using technology like online questionnaires. However, only few have undergone formal electronic adaptation from paper to digital versions, threatening the validity and reliability of the PROs. The present study aimed to perform an electronic adaption and cross-cultural translation of two PROs measuring health-related quality of life in a Danish cohort of patients with venous thrombosis (VTE), specifically the VEINES-QoL/Sym questionnaire and the PEmb-QoL questionnaire.

METHODS

The electronic adaption and cross-cultural translation processes followed the international guidelines recommended by ISPOR. The migration of the questionnaires from paper to electronic versions was conducted in the Research Electronic Data Capture (REDCap). Following approval of the electronically adapted and translated versions, a pretest of the questionnaires was performed by cognitive interviewing patients with VTE recruited from a hospital setting.

RESULTS

Nine men and ten women between the age of 19 and 73 years participated in cognitive interviews. The questionnaires were successfully adapted from paper to electronic versions, and during the migration process only a few modifications to the content and format were made. Most comments were related to technicalities, e.g. touch functions and checkboxes. The cross-cultural translation of both questionnaires was satisfactory, as only minor rephrasing was required.

CONCLUSIONS

The original and Danish version of VEINES-QoL/Sym and PEmb-QoL were successfully adapted into electronic versions and are ready to share for REDCap users. Furthermore, the Danish versions of the two questionnaires have shown satisfactory face validity.

[Special issue PRO] Considering endpoints for comparative tolerability of cancer treatments using patient report given the estimand framework

Regulatory agencies are advancing the use of systematic approaches to collect patient experience data, including patient-reported outcomes (PROs), in cancer clinical trials to inform regulatory decision-making. Due in part to clinician under-reporting of symptomatic adverse events, there is a growing recognition that evaluation of cancer treatment tolerability should include the patient experience, both in terms of the overall side effect impact and symptomatic adverse events. Methodologies around implementation, analysis, and interpretation of "patient" reported tolerability are under development, and current approaches are largely descriptive. There is robust guidance for use of PROs as efficacy endpoints to compare cancer treatments, but it is unclear to what extent this can be relied-upon to develop tolerability endpoints. An important consideration when developing endpoints to compare tolerability between treatments is the linkage of trial design, objectives, and statistical analysis. Despite interest in and frequent collection of PRO data in oncology trials, heterogeneity in analyses and unclear PRO objectives mean that design, objectives, and analysis may not be aligned, posing substantial challenges for the interpretation of results. The recent ICH E9 (R1) estimand framework represents an opportunity to help address these challenges. Efforts to apply the estimand framework in the context of PROs have primarily focused on efficacy outcomes. In this paper, we discuss considerations for comparing the patient-reported tolerability of different treatments in an oncology trial context.

Co-design for stroke intervention development: Results of a scoping review

BACKGROUND

Co-design methodology seeks to actively engage end-users in developing interventions. It is increasingly used to design stroke interventions; however, limited guidance exists, particularly with/for individuals with stroke who have diverse cognitive, physical and functional abilities. Thus, we describe 1) the extent of existing research that has used co-design for stroke intervention development and 2) how co-design has been used to develop stroke interventions among studies that explicitly used co-design, including the rationale, types of co-designed stroke interventions, participants involved, research methodologies/approaches, methods of incorporating end-users in the research, co-design limitations, challenges and potential strategies reported by researchers.

MATERIALS AND METHODS

A scoping review informed by Joanna Briggs Institute and Arksey & O'Malley methodology was conducted by searching nine databases on December 21, 2022, to locate English-language literature that used co-design to develop a stroke intervention. Additional data sources were identified through a hand search. Data sources were de-duplicated, and two research team members reviewed their titles, abstracts and full text to ensure they met the inclusion criteria. Data relating to the research objectives were extracted, analyzed, and reported numerically and descriptively.

RESULTS

Data sources used co-design for stroke intervention development with (n = 89) and without (n = 139) explicitly using the term 'co-design.' Among studies explicitly using co-design, it was commonly used to understand end-user needs and generate new ideas. Many co-designed interventions were technology-based (65%), and 48% were for physical rehabilitation or activity-based. Co-design was commonly conducted with multiple participants (82%; e.g., individuals with stroke, family members/caregivers and clinicians) and used various methods to engage end-users, including focus groups and workshops. Limitations, challenges and potential strategies for recruitment, participant-engagement, contextual and logistical and ethics of co-designed interventions were described.

CONCLUSIONS

Given the increasing popularity of co-design as a methodology for developing stroke interventions internationally, these findings can inform future co-designed studies.

Pilot Study on the Efficacy and Safety of Long-Term Oral Imepitoin Treatment for Control of (Thunder)Storm-Associated Noise Phobia/Noise Aversion in Dogs Using an Individualized-Dose Titration Approach

Imepitoin is a low-affinity partial agonist for benzodiazepine binding sites of gamma-aminobutyric acid receptors with anxiolytic effects. It has been shown to reduce anxiety during noise-related events in dogs when given at 30 mg/kg PO BID, although this dose was associated with ataxia and increased appetite in some cases. The objective of this study was to assess its safety and efficacy for storm anxiety when started at 10 mg/kg PO BID and titrated to effect up to 30 mg/kg PO BID during storm season. Significant decreases in anxiety scores were seen in weekly surveys and storm logs (SLs) at 10, 20 and 30 mg/kg PO BID. Serious adverse events (AEs) were not reported in any subject. Ataxia was the most commonly reported non-serious AE (14/33), followed by increased hunger (13/33). The frequency of AEs was higher in the 20 mg/kg PO BID group than in the 10 mg/kg group PO BID. No clinically significant changes were seen in lab work pre- and post-study. In conclusion, Imepitoin given during storm season at doses ranging from 10 to 30 mg/kg PO BID reduced clinical signs of fear and anxiety during storms for the dogs in this study. These findings support the use of an individually titrated dose.

Patient-Reported Outcome-Based Performance Measures in Alternative Payment Models: Current Use, Implementation Barriers, and Principles to Succeed

OBJECTIVES

Patient-reported outcome (PRO)-based performance measures (PRO-PMs) offer opportunities to aggregate survey data into a reliable and valid assessment of performance at the entity-level (eg, clinician, hospital, and accountable care organization). Our objective was to address the existing literature gap regarding the implementation barriers, current use, and principles for PRO-PMs to succeed.

METHODS

As quality measurement experts, we first highlighted key principles of PRO-PMs and how alternative payment models (APMs) may be integral in promoting more widespread use. In May 2023, we reviewed the Centers for Medicare and Medicaid Services (CMS) Measures Inventory Tool for active PRO-PM usage within CMS programs. We finally present principles to prioritize as part PRO-PMs succeeding within APMs.

RESULTS

We identified 5 implementation barriers to PRO-PM use: original development of instrument, response rate sufficiency, provider burden, hesitancy regarding fairness, and attribution of desired outcomes. There existed 54 instances of active PRO-PM usage across CMS programs, including 46 unique PRO-PMs within 14 CMS programs. Five principles to prioritize as part of greater PRO-PM development and incorporation within APMs include the following: (1) clinical salience, (2) adequate sample size, (3) meaningful range of performance among measured entities and the ability to detect performance change in a reasonable time frame, (4) equity focus, and (5) appropriate risk adjustment.

CONCLUSIONS

Identified barriers and principles to prioritize should be considered during PRO-PM development and implementation phases to link available and novel measures to payment programs while ensuring provider and stakeholder engagement.

The biosocial correlates and predictors of emotion dysregulation in autistic adults compared to borderline personality disorder and nonclinical controls

BACKGROUND

Emotion dysregulation (ED) is a core symptom of borderline personality disorder (BPD), whose aetiology has been attributed to biosocial factors. In autism spectrum condition (ASC), although ED is prevalent and is associated with decreased well-being (e.g. self-harm, suicidality), it has been understudied, especially in adults. It is therefore crucial to further understand ED in autistic adults to improve its treatment. Our study investigates ED, its behavioural correlates (e.g. self-harm, suicidality) and biosocial predictors in autistic adults relative to BPD and nonclinical controls (NC).

METHODS

A total of 724 participants (ASC = 154; BPD = 111; NC = 459) completed 11 self-reported questionnaires assessing ED, ASC and BPD traits, co-occurring disorders, alexithymia, emotional vulnerability and invalidating experiences (e.g. bullying, autistic camouflaging). The occurrence of ED behavioural correlates (i.e. self-harm, history of suicide attempts, and psychiatric hospitalizations) was collected. In addition, between-groups analyses, linear regressions and machine learning (ML) models were used to identify ED predictors in each group.

RESULTS

ED and its behavioural correlates were higher in ASC compared to NC, but milder than in BPD. While gender did not predict ED scores, autistic women had increased risk factors to ED, including sexual abuse and camouflaging. Interestingly, BPD traits, emotional vulnerability and alexithymia strongly predicted ED scores across the groups. Using ML models, sensory sensitivity and autistic camouflaging were associated with ED in ASC, and ADHD symptoms with ED in BPD.

LIMITATIONS

ASC and BPD diagnoses were self-reported, which did not allow us to check their accuracy. Additionally, we did not explore the transactional and the moderating/mediating relationships between the different variables. Moreover, our research is cross-sectional and cannot draw conclusions regarding the direction and causality of relationships between ED and other clinical dimensions.

CONCLUSIONS

ED and its behavioural correlates are heightened in BPD compared to ASC and nonclinical controls. In the ASC group, there were no gender differences in ED, despite the heightened exposure of autistic women to ED risk factors. BPD traits, emotional vulnerability, and alexithymia are core to ED regardless of diagnosis. Although less central, sensory sensitivity and autistic camouflaging seem to be specific predictors of ED in autistic adults.