PROMIS Physical Function Computer Adaptive Test Compared With Other Upper Extremity Outcome Measures in the Evaluation of Proximal Humerus Fractures in Patients Older Than 60 Years

Utility of PROMIS computerized adaptive testing for assessing mobility in lower extremity fracture patients

INTRODUCTION

Assessment of mobility in orthopaedic trauma patients is commonly performed using the Lower Extremity Functional Assessment (LEFS). Computerized adaptive testing (CAT) utilizing the Patient-Reported Outcomes Measurement Information System (PROMIS) is an advanced method for assessing multiple aspects of patient-reported health and may provide an effective alternative for this purpose. The objective of this study was to correlate and psychometrically compare PROMIS (Mobility (MOB) and Physical Function (PF)) CATs to legacy mobility PROMs (Lower Extremity Functional Scale (LEFS)/ Short Musculoskeletal Function Assessment (SMFA)), and to evaluate factors associated with worse mobility.

PATIENTS AND METHODS

In this Cross-sectional study performed in a single Level-I trauma center, 123 patients were recruited who were treated for a lower-extremity fracture (October 1, 2021-July 1, 2023). Correlations (Pearson), known-group validity (Two-sample T test), reliability (Standard error (SE) and Cronbach's alpha), items and completion time, and floor/ceiling effects were assessed. Factors associated with PROMIS-MOB scores were also identified based on multivariable regression analysis.

RESULTS

PROMIS-MOB and LEFS/SMFA (0.75/0.86), PROMIS-PF and LEFS/SMFA (0.76/0.84), and both PROMIS-CATs (0.88) were highly correlated. Regarding know-group validity, all PROM scores were worse among patients with moderate-extreme pain. Only PROMIS-CATs scores were worse among older (≥65 years) and short-term follow-up (3≤months) patients. Reliability was very high for PROMIS-MOB (SE2.1), PROMIS-PF (SE2.0), LEFS (alpha0.97) and SMFA (apha0.97). Fewer items were needed for PROMIS-MOB (6) and PROMIS-PF (5) compared to LEFS (20) and SMFA (34). Completion time (mean seconds) of PROMIS-MOB (65) and PROMIS-PF (70) was less compared to LEFS (338) and SMFA (367) (p<0.001). Neither PROMIS-CATs nor LEFS/SMFA exhibited floor/ceiling effects. Advancing age, depression, pain intensity, shorter follow-up were associated with worse PROMIS-MOB scores.

CONCLUSION

PROMIS-MOB and PROMIS-PF CATs exhibited a strong correlation with the LEFS and SMFA, indicating that they offer the same information regarding mobility and general physical functioning. Nonetheless, CATs took less time to complete and were better able to detect (subtle) differences between certain groups than traditionally used PROMs. Given that both PROMIS-MOB and PROMIS-PF CATs were also highly correlated, it is questionable whether the more specific mobility CAT provides distinct information in lower extremity fracture patients.

LEVELS OF EVIDENCE

Diagnostic study, Level II.

Exploring the Validity of Measures of Health-Related Quality of Life in Older Adults at Increased Risk of Falls and/or Fractures in Exercise Clinical Trials

Exercise targeting physical function and body composition may mitigate falls and fracture risk among older adults. This study aimed to identify the most valid instrument(s) to assess quality of life (QoL) in this context by comparing the psychometric properties of the EQ-5D-3L, EQ-5D-5L, CDC Healthy Days measure, Modified Falls Efficacy Scale (MFES), and Work Productivity and Activity Impairment Questionnaire. Data from four exercise trials (n = 210, mean age 64.8 ± 7.4, 79.0% female) were analyzed. Construct validity and responsiveness were compared. There was moderate to strong convergence between the EQ-5D (-3L and -5L) and MFES, and EQ-5D-3L and CDC index (correlation: 0.45-0.61). Only the EQ-5D-3L demonstrated good known-group validity (effect size: 0.98-3.7). Responsiveness was low across all instruments (standardized response mean: -0.33-0.49). The instruments are valid for assessing QoL in older adults at risk of falls and/or fractures. However, variation in their psychometric properties should be considered when selecting instruments for exercise trials.

Patient-Reported Outcomes Can Serve as a Functional Substitute for Grip Strength

Background  Grip strength has traditionally been seen as an objective measurement of hand function, while the Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE) has emerged recently as a common patient-reported outcome metric for similar purposes. The primary objective of this study was to determine if a correlation exists between grip strength, PROMIS UE, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores in hand and upper extremity clinic patients. Methods  PROMIS UE, Pain Interference (PI), and Depression (D), as well as QuickDASH were prospectively administered to patients from July 16 to September 3, 2020. A grip strength ratio (GSR), calculated by dividing the grip strength of the injured hand by that of the noninjured hand, was recorded for each individual to control for personal differences in grip strength. Data were analyzed using Spearman's correlation coefficients with the significance level at p  < 0.05. Results  Fifty patients participated in this study. The median GSR was 0.55. QuickDASH demonstrated strong correlations with both PROMIS UE and PI ( r (48) = -0.81, p  < 0.05; r (48) = 0.86, p  < 0.05). GSR correlated moderately with PROMIS UE ( r (48) = 0.63, p  < 0.05). Finally, GSR and QuickDASH also exhibited moderate correlation with each other ( r (48) = -0.62, p  < 0.05). Conclusion  PROMIS UE and QuickDASH are shown to correlate moderately with GSR. This suggests the PROMIS UE forms as an effective measure of hand/wrist function in hand clinic patients and may be substituted for grip strength measurements.

Minimally Invasive Method for Treatment of Syndromic Congenital Vertical Talus Deformity in Children

BACKGROUND

Congenital Vertical Talus (CVT) is a rare form of rigid flatfoot commonly seen in patients with underlying neurologic syndromes. This study aims to evaluate the long-term effectiveness of the minimally invasive method for correcting CVT deformity in a large cohort of syndromic patients.

METHODS

A single author recorded preoperative, 2-week postoperative, 1-year postoperative, and most recent radiographic measurements and complications for 25 patients treated with the minimally invasive method from 2006 to 2021. Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaires were administered for 12 patients after January 1, 2015, when the institution began collecting PROMIS in all orthopaedic patients. Average follow-up was 55 months (13-111); 18 patients had minimum 24-month follow-up.

RESULTS

Forty feet in 25 patients were analyzed. The average preoperative lateral talar axis-first metatarsal base angle (TAMBA) was 68.7 ± 21.3 vs 12.1 ± 8.9 after initial surgical intervention (P < .0001). There was a statistically significant increase in the lateral TAMBA between the initial postoperative and final follow-up visits (13.0 vs 21.6, P = .02). Radiographic recurrence of talonavicular deformity was noted in 12 feet (30.9%); 7 (15.55%) required corrective surgery. Larger preoperative lateral TAMBA was predictive of recurrence. Notably, patients with arthrogryposis experienced higher radiographic recurrence than other syndromic patients (45.0% vs 14.3%, P = .0384). PROMIS scores were within population norms.

CONCLUSION

The study suggests that less than one-third of syndromic CVT patients experienced a radiographic recurrence of talonavicular deformity, with 15% requiring further surgical intervention at an average of 55 months following the initial procedure. A higher incidence of radiographic recurrence occurred in patients with distal arthrogryposis. These findings, along with the satisfactory patient-reported outcomes, suggest that the minimally invasive technique is an effective treatment method for syndromic CVT, underscoring the necessity for clinicians to provide detailed prognoses and consider more intensive follow-up for those at higher risk.

Enhancing the Evaluation of Physical Function Following Orthopaedic Trauma Care: Comparison of PROMIS Computerized Adaptive Testing and Short Musculoskeletal Function Assessment

OBJECTIVES

To compare measurement properties of Patient-Reported Outcomes Measurement Information System (PROMIS) (physical function [PF] and pain interference [PI]) computerized adaptive testing to traditional Short Musculoskeletal Function Assessment (SMFA) (dysfunction index [DI] and bother index [BI]). To explore factors associated with PROMIS scores.

METHODS

DESIGN

Cross-sectional study.

SETTING

Level I Trauma Center.

PATIENT SELECTION CRITERIA

Isolated upper/lower extremity fracture patients were recruited from the orthopaedic trauma outpatient clinic (October 1, 2021 to January 1, 2023).

OUTCOME MEASURES

Correlations (Pearson), reliability (standard error [SE] [T score]), efficiency (amount of information per item [1 - SE2/Nitems]), and floor/ceiling effects were assessed. An r > 0.7 represented high correlation, and SE ≤ 2.2 represented sufficient reliability. Factors associated with worse PROMIS scores were also identified.

RESULTS

In total, 202 patients completed PROMs at median 98 days follow-up. Correlations between PROMIS-PF and SMFA-DI, and PROMIS-PI and SMFA-BI were -0.84 and 0.65. Reliability was very high for both instruments (mean SE 2.0 [PROMIS-PF], SE 2.1 [PROMIS-PI], and SE 1.2 [SMFA-DI], SE 1.8 [SMFA-BI]). Relative efficiency for PROMIS-PF versus SMFA-DI, and PROMIS-PI versus SMFA-BI was 7.8 (SD 2.5) and 4.1 (SD 1.7), respectively. Neither PROMIS nor SMFA exhibited floor/ceiling effects. In the multivariable regression analyses, elevated levels of depression, among other factors, showed an (independent) association with worse PROMIS-PF and PROMIS-PI scores.

CONCLUSIONS

PROMIS-PF and PROMIS-PI CATs showed a (high and moderate) correlation with SMFA and hence measure a comparable construct of physical function and discomfort. As computerized adaptive tests are much more efficient to administer, they present a compelling alternative to SMFA for evaluating impact of fracture treatment. The relation between symptoms of depression and PROMIS scores emphasizes the importance of psychosocial aspects of health in orthopaedic trauma patients.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Crosswalk between the PROMIS physical function CAT and PROMIS upper extremity CAT v1.2 in a hand surgery population

BACKGROUND

There is no gold standard patient-reported outcome measure (PROM) in hand surgery. As a result, a diverse array of PROM instruments have been utilized across centers over time. Lack of score interchangeability limits the ability to compare or conglomerate scores when new instruments are introduced. Our aim was to develop a linkage for the PROMIS UE CAT v1.2 and PROMIS PF CAT scores and develop crosswalk tables for interconversion between these PROMs.

METHODS

Retrospective review was conducted to identify adult (≥ 18y) patients seen by orthopaedic hand surgeons at a single academic tertiary care hospital who had completed PROMIS UE CAT v1.2 and PROMIS PF CAT score at the same visit. For those with multiple visits, only one randomly selected visit was included in the analyses. Pearson's correlation was calculated to determine the linear relationship between the scores. Linkage from PF to UE was performed utilizing several commonly utilized equating models (identity, mean, linear, equipercentile and circle-arc methods). The performance of the models was assessed using intraclass correlation (ICC) between observed PROMIS UE CAT v1.2 and estimated PROMIS UE CAT v1.2 scores generated using the model as well as Root Mean Square Error (RMSE). The model chosen as the 'best' was further assessed for population invariance using root expected mean squared difference (REMSD) where < 0.08 were considered good.

RESULTS

Of 10,081 included patients, mean age was 48.3 (SD = 17.0), and 54% were female (5,477/10,081). Mean UE CAT v1.2 and PF CAT scores were 37 (SD = 9.8) and 46 (SD = 10.0), respectively. There was a strong correlation between the scores (Pearson correlation r = 0.70). All methods performed acceptably (ICC ≥ 0.66 and RMSE < = 7.52 for all). The equipercentile method had the highest ICC (ICC = 0.70 (95% CI 0.69-0.71)) while the mean and circle arc methods had the lowest RMSE. The circle arc method is the most reliable with the smallest standard error and has satisfactory population invariance across age group (REMSD 0.065) and sex (REMSD 0.036).

CONCLUSIONS

Crosswalk tables to be used for bidirectional conversion between scores were created.

LEVEL OF EVIDENCE

III.

Evaluation of the trajectory of recovery following surgically treated acetabular fractures

Aims

Acetabular fractures are associated with long-term morbidity. Our prospective cohort study sought to understand the recovery trajectory of this injury over five years.

Methods

Eligible patients at a level I trauma centre were recruited into a longitudinal registry of surgical acetabular fractures between June 2004 and August 2019. Patient-reported outcome measures (PROMs), including the 36-Item Short Form Health Survey (SF-36) physical component summary (PCS), were recorded at baseline pre-injury recall and six months, one year, two years, and five years postoperatively. Comparative analyses were performed for elementary and associated fracture patterns. The proportion of patients achieving minimal clinically important difference (MCID) was determined. The rate of, and time to, conversion to total hip arthroplasty (THA) was also established.

Results

We recruited 251 patients (253 fractures), with a 4:1 male to female ratio and mean age of 46.1 years (SD 16.4). Associated fracture patterns accounted for 56.5% of fractures (n = 143). Trajectory analysis showed all timepoints had significant disability versus baseline, including final follow-up (p < 0.001). Elementary fractures had higher SF-36 PCS at six months (p = 0.023) and one year (p = 0.007) compared to associated fractures, but not at two years (p = 0.135) or five years (p = 0.631). The MCID in SF-36 PCS was observed in 37.3% of patients (69/185) between six months and one year, 26.9% of patients (39/145) between one and two years, and 23.3% of patients (20/86) between two and five years, highlighting the long recovery potential of these injuries. A significant proportion of patients failed to attain the MCID after five years (38.1%; 40/105). Conversion to THA occurred in 13.1% of patients (11/110 elementary and 22/143 associated fractures). Approximately two-thirds of THAs (21/33 patients; 63.6%) were performed within two years of index surgery.

Conclusion

Acetabular fractures significantly impact physical function. Recovery trajectory is often elongated beyond one year, with two-thirds of our patients displaying persistent clinically relevant long-term disability.

Minimal Clinically Important Differences of Patient-Reported Outcomes Measurement Information System Physical Function in Patients With Tibial Shaft Fracture

OBJECTIVE

To calculate the minimal clinically important differences (MCIDs) of patient-reported outcomes measurement information system physical function (PROMIS PF) scores for patients with operatively treated tibial shaft fractures.

DESIGN

Retrospective Cohort Study.

SETTING

A Level 1 trauma center.

PATIENTS

All operatively treated tibial shaft fractures identified by Current Procedural Terminology codes.

INTERVENTION

Enrolled patients treated acutely with operative fixation of their tibia.

MAIN OUTCOME MEASUREMENTS

MCIDs were calculated by distribution-based and anchor-based methods, calculated from PROMIS PF scores completed at least at two-time points postoperatively. MCIDs were calculated at different time points including overall, 7-12 weeks, 3-6 months, and 6-24 months. MCIDs were calculated for different subgroups including open fractures, closed fractures, any complications, and no complications.

RESULTS

MCID for PROMIS PF scores was 5.7 in the distribution-based method and 7.84 (SD 18.65) in the anchor-based method. At 6-24 postoperatively, the months the distribution-based MCID was 5.95 from a postoperative baseline 27.83 (8.74) to 42.85 (9.61), P < 0.001. At 6-24 months, the anchor-based MCID was 10.62 with a score difference between the improvement group of 16.03 (10.73) and the no improvement group of 5.41 (15.75), P < 0.001. Patients with open fractures (distribution-based 6.22 and anchor-based 8.05) and any complications (distribution-based 5.71 and anchor-based 9.29) had similar or higher MCIDs depending on the methodology used than the overall cohort MCIDs.

CONCLUSION

This study identified distribution-based MCID of 5.7 and anchor-based MCID of 7.84 calculated from PROMIS PF scores in operative tibial shaft fractures. Distribution-based methods yielded smaller MCIDs than anchor-based methods. These MCID scores provide a standard to compare clinical and investigational outcomes.

Concurrent Validity of PROMIS With DASH and DVPRS in Transhumeral Amputees

BACKGROUND

We sought to assess whether select domains of the Patient-Reported Outcomes Measurement Information System (PROMIS) significantly correlate with the Disabilities of the Arm, Shoulder, and Hand (DASH) score and the Defense and Veterans Pain Rating Scale (DVPRS) among transhumeral amputees.

METHODS

We prospectively administered DASH, DVPRS, and PROMIS (including Upper Extremity, Pain Interference, and Pain Behavior domains) testing to patients presenting for consideration of osseointegration after transhumeral amputation. Concurrent validity was assessed via Pearson correlation testing.

RESULTS

The mean DASH score of the cohort was 32.8. The mean DVPRS score was 1.8. The mean PROMIS scores were 33.8, 50.5, and 50.6 for Upper Extremity, Pain Interference, and Pain Behavior domains, respectively. Pearson testing demonstrated a significant, inverse correlation between DASH and PROMIS Upper Extremity scores (r = -0.85, P = .002). There was also significant correlation between DVPRS and PROMIS Pain Interference scores (r = 0.69, P = .03). The PROMIS Pain Behavior domain did not significantly correlate with either DASH or DVPRS.

CONCLUSIONS

Patient-Reported Outcomes Measurement Information System Upper Extremity and Pain Interference scores demonstrated significant concurrent validity with traditional measures (DASH and DVPRS) of patient-reported outcome in our population of transhumeral amputees.

The Current Utilization of Patient-reported Outcome Measurement Information System in Shoulder, Elbow, and Sports Medicine

Clinical research using patient-reported outcome measures has been critical within the field of shoulder, elbow, and sports medicine in helping clinicians deliver evidence-based and value-based medicine. Recently, however, clinicians have advocated for improving the process of obtaining clinically meaningful information from patients while decreasing survey fatigue and increasing compliance. To that end, the National Institutes of Health created the Patient-Reported Outcome Measures Information System (PROMIS) in which a number of institutions and research investigations have adopted for reporting outcomes. A special focus has also been placed on PROMIS Computer Adaptive Testing forms, which tailor questioning through item response theory. The purpose of this study was to provide insight into the utilization, advantages, and disadvantages of PROMIS within the field of shoulder, elbow, and sports medicine and provide a comparison with legacy patient-reported outcome measure measurements.

Measurement Properties of the Patient-Specific Functional Scale and Its Current Uses: An Updated Systematic Review of 57 Studies Using COSMIN Guidelines

OBJECTIVE

To systematically review measurement properties, including acceptability, feasibility, and interpretability, and current uses of the Patient-Specific Functional Scale (PSFS).

DESIGN

Systematic review of a patient-reported outcome measure using the COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) guidelines.

LITERATURE SEARCH

We searched 11 databases from January 2010 to July 2020 for articles on measurement properties or use of PSFS.

STUDY SELECTION CRITERIA

Published primary articles without language restrictions.

DATA SYNTHESIS

Two independent reviewers screened all records, extracted data, and performed risk of bias assessments using COSMIN guidelines. We qualitatively synthesized findings for each measurement property in musculoskeletal and nonmusculoskeletal conditions, and 2 reviewers independently performed Grading of Recommendations Assessment, Development and Evaluation assessments. This study was preregistered with the Open Science Framework (https://doi.org/10.17605/OSF.IO/42UZT).

RESULTS

Of the 985 articles screened, we included 57 articles on measurement properties and 255 articles on the use of PSFS. The PSFS had sufficient test-retest reliability in musculoskeletal (22 studies, 845 participants, low-to-moderate certainty) and nonmusculoskeletal conditions (6 studies, 197 participants, very low certainty), insufficient construct validity as a measure of physical function (21 studies, 2 945 participants, low-to-moderate certainty), and sufficient responsiveness (32 studies, 13 770 participants, moderate-to-high certainty). The standard error of measurement ranged from 0.35 to 1.5. The PSFS was used in 87 unique health conditions, some without prior evidence of validity.

CONCLUSION

The PSFS is an easy-to-use, reliable, and responsive scale in numerous musculoskeletal conditions, but the construct validity of PSFS remains uncertain. Further study of the measurement properties of the PSFS in nonmusculoskeletal conditions is necessary before clinical use. J Orthop Sports Phys Ther 2022;52(5):262-275. Epub: 05 Feb 2022. doi:10.2519/jospt.2022.10727.

Impact of Renal Replacement Therapy on Mortality and Renal Outcomes in Critically Ill Patients with Acute Kidney Injury: A Population-Based Cohort Study in Korea between 2008 and 2015

The outcomes depending on the type of renal replacement therapy (RRT) or pre-existing kidney disease in critically ill patients with acute kidney injury (AKI) have not been fully elucidated. All adult intensive care unit patients with AKI in Korea from 2008 to 2015 were screened. A total of 124,182 patients, including 21,165 patients with pre-existing kidney disease, were divided into three groups: control (no RRT), dialysis, and continuous RRT (CRRT). In-hospital mortality and progression to end-stage kidney disease (ESKD) were analyzed according to the presence of pre-existing kidney disease. The CRRT group had a higher risk of in-hospital mortality. Among the patients with pre-existing kidney disease, the dialysis group had a lower risk of in-hospital mortality compared to other groups. The risk of ESKD was higher in the dialysis and CRRT groups compared to the control group. In the CRRT group, the risk of ESKD was even higher in patients without pre-existing kidney disease. Although both dialysis and CRRT groups showed a higher incidence of ESKD, in-hospital mortality was lower in the dialysis group, especially in patients with pre-existing kidney disease. Our study supports that RRT and pre-existing kidney disease may be important prognostic factors for overall and renal outcomes in patients with AKI.

There are more things in physical function and pain: a systematic review on physical, mental and social health within the orthopedic fracture population using PROMIS

Background

The Patient-Reported Outcomes Information System (PROMIS®) is more and more extensively being used in medical literature in patients with an orthopedic fracture. Yet, many articles studied heterogeneous groups with chronic orthopedic disorders in which fracture patients were included as well. At this moment, there is no systematic overview of the exact use of PROMIS measures in the orthopedic fracture population. Therefore this review aimed to provide an overview of the PROMIS health domains physical health, mental health and social health in patients suffering an orthopedic fracture.

Methods

This systematic review was documented according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. We searched Embase, Medline, Web of Science Core Collection, and Cochrane Central Register of controlled Trials, CINAHL and Google Scholar in December 2020 using a combination of MeSH terms and specific index terms related to orthopedic fractures and PROMIS questionnaires. Inclusion criteria were available full text articles that were describing the use of any PROMIS questionnaires in both the adult and pediatric extremity fracture population.

Results

We included 51 relevant articles of which most were observational studies (n = 47, 92.2%). A single fracture population was included in 47 studies of which 9 involved ankle fractures (9/51; 17.6%), followed by humeral fractures (8/51; 15.7%), tibia fractures (6/51; 11.8%) and radial -or ulnar fractures (5/51; 9.8%). PROMIS Physical Function (n = 32, 32/51 = 62.7%) and PROMIS Pain Interference (n = 21, 21/51 = 41.2%) were most frequently used questionnaires. PROMIS measures concerning social (n = 5/51 = 9.8%) and mental health (10/51 = 19.6%) were much less often used as outcome measures in the fracture population. A gradually increasing use of PROMIS questionnaires in the orthopedic fracture population was seen since 2017.

Conclusion

Many different PROMIS measures on multiple domains are available and used in previous articles with orthopedic fracture patients. With physical function and pain interference as most popular PROMIS measures, it is important to emphasize that other health-domains such as mental and social health can also be essential to fracture patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00440-3.

Predictors of PROMIS Physical Function at 2 Years following Knee Surgery

The purpose of this study was to evaluate Patient-Reported Outcomes Measurement Information System physical function (PROMIS PF) 2 years following knee surgery, and identify preoperative factors associated with postoperative PROMIS PF. Three hundred and sixty-five patients, age 17 years and older, undergoing knee surgery at one institution were studied. Patients completed multiple questionnaires prior to surgery and again 2 years postoperatively including PROMIS PF, International Knee Documentation Committee (IKDC), joint and body numeric pain scales (NPS), Tegner's activity scale (TAS), and Marx's activity rating scale (MARS). Mean PROMIS PF improved from 41.4 to 50.9 at 2 years postoperatively (p < 0.001) and was strongly correlated with 2-year IKDC scores. Older age, female gender, non-Hispanic ethnicity, unemployment, lower income, government insurance, smoking, preoperative opioid use, having a legal claim, comorbidities, previous surgeries, higher body mass index (BMI), and knee arthroplasty were associated with worse 2-year PROMIS PF. Multivariable analysis confirmed that lower BMI, less NPS body pain, and higher MARS were independent predictors of greater 2-year PROMIS PF and better improvement in PROMIS PF. In this large, broad cohort of knee surgery patients, multiple preoperative factors were associated with PROMIS PF 2 years postoperatively. PROMIS PF scores improved significantly, but worse 2 year PROMIS PF scores and less improvement from baseline were independently predicted by higher BMI, greater NPS body pain, and lower MARS activity level. PROMIS PF can be implemented as an efficient means to assess outcomes after knee surgery.

The performance of PROMIS computer adaptive testing for patient-reported outcomes in hip fracture surgery: a pilot study

INTRODUCTION

Patient-reported outcome measures (PROMs) are essential to patient-centered care in orthopaedics. PROMIS measures have demonstrated reliability, validity, responsiveness, and minimal floor and ceiling effects in various populations of patients receiving orthopaedic care but have not yet been examined in hip fracture patients. This pilot study sought to evaluate the psychometric performance of the PROMIS Physical Function (PROMIS PF) and Pain Interference (PROMIS PI) computer adaptive tests and compare these instruments with legacy outcome measures in hip fracture patients.

METHODS

This study included 67 patients who were 27-96 years old (median 76) and underwent osteosynthesis for a proximal femoral fracture. At 3, 6, and/or 12 months follow-up, patients completed both legacy (mHHS, SF-36-PCS, and VAS for pain) and PROMIS questionnaires (PROMIS PF and PROMIS PI). Respondent burden and floor/ceiling effects were calculated for each outcome measure. Correlation was calculated to determine concurrent validity between related constructs.

RESULTS

A strong correlation was found between PROMIS PF and mHHS (rho = 0.715, p < 0.001) and moderately strong correlation between PROMIS PF and SF-36 PCS (rho = 0.697, p < 0.001). There was also a moderately strong correlation between the VAS and the PROMIS PI (rho = 0.641, p < 0.001). Patients who completed PROMIS PF were required to answer significantly fewer questions as compared with legacy PROMs (mHHS, SF-36). For the PROMIS measures, 1% of patients completing PROMIS PF achieved the highest allowable score while 34% of patients completing PROMIS PI achieved the lowest allowable score. Of the legacy outcome measures, 31% of patients completing the VAS for pain achieved the lowest allowable score and 7% of patients completing the mHHS achieved the highest allowable score.

CONCLUSIONS

The results of this study support the validity of PROMIS CATs for use in hip fracture patients. The PROMIS PF was significantly correlated with SF-36 PCS and mHHS while requiring fewer question items per patient relative to the legacy outcome measures.

Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Instruments Compare Favorably With Legacy Patient-Reported Outcome Measures in Upper- and Lower-Extremity Orthopaedic Patients: A Systematic Review of the Literature

PURPOSE

To compare Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) with traditional ("legacy") patient-reported outcome measures (PROMs) in regard to correlations, ease of use, and quality criteria for upper (UE) and lower extremity (LE) orthopaedic conditions.

METHODS

A systematic search of the PubMed/MEDLINE database was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify published articles that referenced the various PROMIS PF measures. Two authors independently reviewed selected studies. The search returned 857 studies, 85 of which were selected for independent review by 2 authors. Of these, 54 were selected for inclusion. Mixed linear models were performed to assess for differences between legacy PROMs and PROMIS measures.

RESULTS

The combined sample size of all included studies yielded 6,074 UE and 9,366 LE patients. Overall, PROMIS PF measures demonstrated strong correlations with legacy PROMs among UE (weighted Pearson correlation, 0.624, standard error [SE] = 0.042; weighted Spearman correlation, 0.566, SE = 0.042) and LE patients (weighted Pearson correlation, 0.645, SE = 0.062; weighted Spearman correlation, 0.631, SE = 0.041). PROMIS PF questionnaires completed by UE patients had fewer questions than legacy PROMs (5.9 vs 17.7, P = .0093) and were completed in less time (90.5 vs 223.8 seconds, P = .084). PROMIS PF questionnaires completed by LE patients had fewer questions than legacy PROMs (4.81 vs 15.33, P < .001) and were completed in less time (63.6 vs 203.2 seconds, P = .0063). The differences for the reliability measures were not significant.

CONCLUSIONS

PROMIS PF scores correlate strongly with commonly used legacy PROMs in orthopaedics, particularly in UE and LE patients. PROMIS PF forms can be administered efficiently and to a broad patient population while remaining highly reliable. Therefore, they can be justified for standardized use among orthopaedic patients with UE and LE conditions, improving the ability to aggregate and compare outcomes in orthopaedic research.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV evidence.

Patient-Reported Outcomes for Fractures of the Acetabulum: A Comparison Between Patient-Reported Outcomes Information System and Traditional Instruments

INTRODUCTION

The objective of this study was to compare instruments from the Patient-Reported Outcomes Information System (PROMIS) with previously validated acetabulum fracture outcome instruments.

METHODS

This study included adult patients presenting for routine follow-up at least 3 months after surgical treatment of an acetabulum fracture. Participants completed four different patient-reported outcomes in a randomized order: PROMIS Mobility, PROMIS Physical Function, Short Form 36 (SF-36), and Short Musculoskeletal Functional Assessment (SMFA). Primary outcomes were the correlations between instruments, floor/ceiling effects, and survey completion time. The effects of age, education, and race on survey completion time were also evaluated.

RESULTS

Overall strong correlations were observed between PROMIS instruments and the SMFA/SF-36 (r = 0.73 to 0.86, P < 0.05) with weaker, more moderate correlations in those with >18 months of follow-up (r = 0.41 to 0.76, P < 0.05). No instruments demonstrated notable floor or ceiling effects. The PROMIS outcomes required less time to complete (PROMIS [56 to 59 seconds] than SF-36 [5 minutes 22 seconds] and SMFA [6 minutes 35 seconds]; P < 0.001). Older individuals required more time to complete the PROMIS PF (0.5 s/yr, P = 0.03), SF-36 (2.35 s/yr, P = 0.01), and SMFA (3.85 s/yr, P < 0.01). Level of education did not affect completion time; however, African Americans took significantly longer than Caucasians to complete the SMFA and SF-36 by 151 and 164 seconds (P < 0.01).

CONCLUSION

This study supports that the PROMIS Mobility and Physical Function surveys are much more efficient instruments for evaluating patients with acetabulum fractures when compared with the SMFA and SF-36. Convergent validity of the PROMIS instruments was overall strong but weaker and more moderate in those with a long-term follow-up, and additional study is suggested for longer-term outcomes. Level of education did not influence survey completion time; however, it took markedly longer time for older individuals and African Americans to complete the SMFA and SF-36.

Patients Require Less Time to Complete Preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Than Legacy Patient-Reported Outcome Measures

Purpose

To analyze time to completion of preoperative legacy patient-reported outcomes (PROs) and more recent computer adaptive Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaires in patients with symptomatic femoroacetabular impingement syndrome undergoing primary hip arthroscopy.

Methods

A retrospective analysis was conducted on patients undergoing hip arthroscopy by a single fellowship-trained hip arthroscopist. Inclusion criteria were patients undergoing primary arthroscopic hip surgery and completion of at least 1 legacy PRO or PROMIS questionnaire at the preoperative time point. Exclusion criteria were history of contralateral or ipsilateral hip surgery, non-English-speaking patients, patients who completed PROs by phone or by paper form, and patients who did not complete preoperative PROs. Legacy PROs included modified Harris Hip Score (mHHS), Hip Outcome Score (HOS), International Hip Outcome Tool (iHOT-12), and Hip Pain Visual Analog Scale (VAS-Pain). PROMIS PROs included Physical Function (PROMIS-PF), Pain Interference (PROMIS-PI), and Depression (PROMIS-D). Only preoperative PROs were included in the analysis. Completion time was calculated using the questionnaire start and stop time reported by the survey collecting software. The median and interquartile range of each PRO were reported for analysis of central tendency and statistical dispersion, respectively.

Results

A total of 1,901 patients and 269 patients were included in the legacy and PROMIS groups, respectively. The median time required for completion of each PRO in (minutes: seconds) format was as follows: mHHS (1:29), HOS (3:58), iHOT (2:11), VAS-Pain (0:32), PROMIS-PF (0:46), PROMIS-PI (0:37), and PROMIS-D (0:43). The interquartile range of the middle 50% of respondents was as follows; mHHS (0:58), HOS (2:46), iHOT (1:22), VAS-Pain (0:28), PROMIS-PI (0:19), PROMIS-D (0:29), and PROMIS-PF (0:20).

Conclusions

This study supports that preoperative PROMIS forms require less time to complete than preoperative legacy PROs and are not significantly influenced by age, race, or workers compensation status.

Level of Evidence

Level IV, case series.

Fracture-related infection in long bone fractures: A comprehensive analysis of the economic impact and influence on quality of life

OBJECTIVES

Fracture-related infection (FRI) is a feared complication with substantial clinical and economic consequences. The main objective of this study was to compare direct and indirect healthcare costs related to long bone fractures in patients with and without FRI and to assess its impact on the patient's quality of life (QoL).

PATIENTS AND METHODS

Between January 2015 and March 2019, 175 patients with FRI were treated at the University Hospitals Leuven (Belgium). Using a matched-pair analysis, patients with an FRI were matched by age, sex, and fracture location (humeral, femoral, or tibial shaft) to a non-FRI cohort treated during the same time period. Clinical and process-related variables, direct hospital-related healthcare costs, and indirect costs due to absenteeism were compared between the two groups. Furthermore, the patient's QoL was evaluated using Patient-Reported Outcomes Measurement Information System (PROMIS) physical function and pain interference.

RESULTS

After matched-pair analysis, 15 patients in both the FRI and non-FRI group were included. FRI was associated with direct hospital-related costs being eight times that of non-FRI patients (€ 47,845 [€ 43,072-€ 82,548] vs. € 5,983 [€ 4,519-€ 8,428], p < 0.001). Furthermore, FRI was associated with prolonged absenteeism (340 [340-676] vs. 86 [65-216] days, p = 0.007) and a median indirect cost that was nearly four times that of patients without FRI (€ 77,909 vs. € 19,706). Lastly, FRI patients showed significantly poorer outcomes on both physical function (35.6 vs. 48.4, p < 0.001) and pain interference (60.4 vs. 46.3, p < 0.001) PROMIS scales.

CONCLUSION

Direct hospital-related healthcare costs of FRI are eight times that of non-FRI long bone fractures. Total healthcare costs are mainly driven by hospitalisation costs, wherein FRI is associated with prolonged length of stay. To the best of our knowledge, this study is the first to demonstrate that FRI is also associated with substantial absenteeism, which is almost four times higher compared to non-FRI patients. In addition to this economic impact, FRI significantly deteriorates QoL. Generalizing the outcome of this study should be done cautiously due to the small sample size of 15 patients in both the FRI and non-FRI group after matched-pair analysis.

Age Significantly Affects Response Rate to Outcomes Questionnaires Using Mobile Messaging Software

Purpose

To investigate the demographic factors that influence time to respond (TTR), time to completion (TTC), and response rate when using a text messaging-based system and to determine the feasibility and applicability of mobile messaging-based services for collection of patient-reported outcomes among orthopaedic sports medicine patients.

Methods

On the day of surgery, patient mobile phone number was collected and the automated mobile messaging service (MOSIO, Seattle, WA) messaged patients for 10 ``days postoperatively. Patient visual analog scale (VAS) scores were collected 3 times daily, side effects were asked each evening, and Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) Short Form was collected on postoperative day 3 and 7.

Results

A total of 177 patients were enrolled in the study. The overall response rate to the survey questions was 75.0%. For all patients, the average TTR of questions was 35.09 ± 12.57 minutes. The TTC was 2.75 ± 3.56 minutes for PROMIS-PI, 3.51 ± 1.26 minutes for VAS, and 3.80 ± 6.87 for side-effect questions. When patients were stratified into age groups, the youngest group, 16 to 32 years, had the greatest response rate of 85.2% and patients in the 49 to 59 years group had the lowest response rate of 68.4% and 69.1%, respectively (P < .001). There was no significant difference in the TTR or TTC for VAS, PROMIS-PI, or side-effect questions when patients were stratified by age or sex groups (P > .05).

Conclusions

Collectively, all age groups successfully achieved a mean response rate of 75%; however, significantly lower response rates were observed for patients >49 years old. Differences in age and sex did not impact the overall TTR or TTC for VAS, PROMIS-PI, or side-effect questions. Mobile-based applications present as an emerging opportunity to track postoperative outcome scores and reduce clinic survey load.

Level of Evidence

Case series, level of evidence IV.

Establishing Age-calibrated Normative PROMIS Scores for Hand and Upper Extremity Clinic

The purpose of our study is to investigate differences in normative PROMIS upper extremity function (PROMIS-UE), physical function (PROMIS-PF), and pain interference (PROMIS-PI) scores across age cohorts in individuals without upper extremity disability.

Patient-Reported Outcome Measurement Information System (PROMIS) in Orthopaedic Trauma Research

This review describes the development, advantages and disadvantages, and applications of the Patient-Reported Outcome Measurement Information System (PROMIS) in orthopaedic trauma. PROMIS is a useful tool for quantifying outcomes in orthopedic trauma. It allows measurement of outcomes across multiple domains while minimizing administration time. PROMIS also reliably identifies clinical, social, and psychological risk factors for poor outcomes across a variety of orthopaedic injuries and disease states. However, PROMIS lacks specificity for certain anatomic regions and validation for mental health outcomes. It also is limited by ceiling effects in certain active patient populations. Orthopaedic traumatologists should be familiar with PROMIS, as its use is increasing and it is a valuable tool that can aid in clinical decision making.

Preoperative opioid use in patients undergoing shoulder surgery

BACKGROUND

Opioids are commonly used to manage pain from acute injury or chronic degenerative diseases. The objective of this study was to assess the prevalence of preoperative opioid use in patients undergoing shoulder surgery and the clinical factors associated with preoperative opioid use.

METHODS

This was an analytical cross-sectional study of 175 patients undergoing shoulder surgery at an urban hospital from June 2015 to June 2017. Multivariable regression models were used to determine independent associations.

RESULTS

Fifty-three patients reported preoperative opioid use, which was significantly associated with primary procedure performed (Current Procedural Terminology [CPT]), higher body mass index (BMI), unemployment, lower income, smoking, higher American Society of Anesthesiologists score, greater number of previous surgeries, higher comorbidity burden, and decreased expectations to exercise and do recreational activities (p < 0.05). Preoperative opioid use was independently associated with worse scores on the: Numeric Pain Scale, ASES, IPAQ, and PROMIS domains of Physical Function, Pain Interference, and Social Satisfaction (p < 0.05).

CONCLUSION

More than one in four patients reported preoperative opioid use. Several health measures, including worse pain, function, and social satisfaction were independently associated with preoperative opioid use. These findings suggest that orthopaedic surgeons need to identify patients using opioids preoperatively in order to effectively establish and execute a plan for pain management, which may include weaning off opioids prior to surgery, managing psychological distress, and optimizing coping strategies.Level of Evidence: III.

Patient-Reported Outcomes Measurement Information System Scores Are Inconsistently Correlated With Legacy Patient-Reported Outcome Measures in Shoulder Pathology: A Systematic Review

PURPOSE

To evaluate the current literature regarding Patient-Reported Outcomes Measurement Information System (PROMIS) and its correlation to legacy patient-reported outcomes measures (PROMs) in 5 domains: (1) rotator cuff disease, (2) shoulder instability, (3) shoulder arthroplasty, (4) proximal humerus fractures, and (5) glenohumeral arthritis. The secondary purpose is to evaluate the floor and ceiling effects, the number of questions, and time needed to complete PROMIS and legacy PROMs in shoulder care.

METHODS

A systematic review of the available literature on PROMIS scores in shoulder care was performed. This review was accomplished per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines.

RESULTS

A total of 11 studies that reported data on 1485 patients met inclusion criteria. There was a strong correlation between general function PROMs and the PROMIS PF for patients with rotator cuff disease, shoulder instability, shoulder arthroplasty, and proximal humerus fractures. In addition, there was a strong correlation between PROMIS UE and legacy PROMs in patients with rotator cuff injury and shoulder instability. PROMIS instruments asked fewer questions than legacy PROMs (9.46 vs 12.99, respectively), took less time to complete (88.21 vs 96.53 seconds, respectively), had less floor effects in both PROMIS PF and UE (0.17% and 0.62% vs 2.89%, respectively), and had lower ceiling effects for PROMIS PF but not PROMIS UE assessments (0.17% and 6.37% vs 1.89%, respectively).

CONCLUSIONS

This systematic review demonstrated PROMIS instruments have varying correlations with legacy PROMs measures for patients with rotator cuff disease, shoulder instability, shoulder arthroplasty, and glenohumeral arthritis. PROMIS instruments do measure clinical outcomes faster and with fewer questions. Other than PROMIS UE v1.2 ceiling effects, PROMIS instruments have lower rates of floor and ceiling effects.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II-IV studies.

The PROMIS Upper Extremity Computer Adaptive Test Correlates With Previously Validated Metrics in Patients With Carpal Tunnel Syndrome

Background: The Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE) computer adaptive test was developed to improve precision and reduce question burden. We hypothesized that in patients with carpal tunnel syndrome (CTS): (1) PROMIS UE would correlate with established patient-reported outcome measures (PROs); (2) the time and number of questions required would be lower than current metrics; (3) there would be no floor or ceiling effects; and (4) PROMIS UE would not correlate with disease severity. Methods: Patients undergoing electrodiagnostic evaluation found to have a primary diagnosis of unilateral CTS prospectively completed PROMIS UE, Quick Disabilities of the Arm, Shoulder and Hand (qDASH), and Boston Carpal Tunnel Syndrome Questionnaire (BCTQ). Electrophysiologic and clinical severity was recorded. The relationships among PROs were described with Spearman coefficients. A floor or ceiling effect was confirmed if >15% of patients achieved the lowest or highest possible score, respectively. Results: Fifty-one patients (average, 53.9 years) were enrolled. An excellent correlation was identified between PROMIS UE and qDASH (R = -0.76, P < .001). There was a good correlation between PROMIS UE and BCTQ (R = -0.58, P < 0.001). The PROMIS UE required less time and fewer questions than qDASH and BCTQ (P = .02 and P < .001). There were no floor or ceiling effects. Neither neurophysiologic nor clinical severity correlated with PROMIS UE (R = 0.24, P > .05 and R = -0.18, P > .05). Conclusions: The PROMIS UE has an excellent correlation with qDASH and a good correlation with BCTQ in patients with CTS. Furthermore, PROMIS UE required less time and fewer questions than established PROs. Used as a single PRO, PROMIS UE represents a practical alternative to current metrics in patients with CTS.

Reporting and utilization of Patient-Reported Outcomes Measurement Information System® (PROMIS®) measures in orthopedic research and practice: a systematic review

BACKGROUND

The Patient-Reported Outcomes Measurement Information SystemⓇ (PROMISⓇ) is a dynamic system of psychometrically sound patient-reported outcome (PRO) measures. There has been a recent increase in the use of PROMIS measures, yet little has been written about the reporting of these measures in the field of orthopedics. The purpose of this study was to conduct a systematic review to determine the uptake of PROMIS measures across orthopedics and to identify the type of PROMIS measures and domains that are most commonly used in orthopedic research and practice.

METHODS

We searched PubMed, Embase, and Scopus using keywords and database-specific subject headings to capture orthopedic studies reporting PROMIS measures through November 2018. Our inclusion criteria were use of PROMIS measures as an outcome or used to describe a population of patients in an orthopedic setting in patients ≥ 18 years of age. We excluded non-quantitative studies, reviews, and case reports.

RESULTS

Our final search yielded 88 studies published from 2013 through 2018, with 57% (50 studies) published in 2018 alone. By body region, 28% (25 studies) reported PROMIS measures in the upper extremity (shoulder, elbow, hand), 36% (32 studies) reported PROMIS measures in the lower extremity (hip, knee, ankle, foot), 19% (17 studies) reported PROMIS measures in the spine, 10% (9 studies) reported PROMIS measures in trauma patients, and 6% (5 studies) reported PROMIS measures in general orthopedic patients. The majority of studies reported between one and three PROMIS domains (82%, 73 studies). The PROMIS Computerized Adaptive Test (CAT) approach was most commonly used (81%, 72 studies). The most frequently reported PROMIS domains were physical function (81%, 71 studies) and pain interference (61%, 54 studies).

CONCLUSION

Our review found an increase in the reporting of PROMIS measures over the recent years. Utilization of PROMIS measures in orthopedic populations is clinically appropriate and can facilitate communication of outcomes across different provider types and with reduced respondent burden.

REGISTRATION

The protocol for this systematic review was designed in accordance with the PRISMA guidelines and is registered with the PROSPERO database (CRD42018088260).

Outcome measures reported for the management of proximal humeral fractures: a systematic review

BACKGROUND

The American Shoulder and Elbow Surgeons multicenter taskforce studying proximal humerus fractures reached no consensus on which outcome measures to include in future studies, and currently no gold standard exists. Knowledge of commonly used outcome measures will allow standardization, enabling more consistent proximal humerus fracture treatment comparison. This study identifies the most commonly reported outcome measures for proximal humerus fracture management in recent literature.

METHODS

A systematic review identified all English-language articles assessing proximal humerus fractures from 2008 to 2018 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Review articles, meta-analyses, revision surgery, chronic injuries, studies with <15 patients, studies with <12 month follow-up, anatomic/biomechanical studies, and technique articles were excluded. Included studies were assessed for patient demographics and outcome scores, patient satisfaction, complications, range of motion, and strength.

RESULTS

Of 655 articles, 74 met inclusion criteria. The number of proximal humerus fractures averaged 74.2 per study (mean patient age, 65.6 years). Mean follow-up was 30.7 months. Neer type 1, 2, 3, and 4 fractures were included in 8%, 51%, 81%, and 88% of studies, respectively. Twenty-two patient-reported outcome instruments were used including the Constant-Murley score (65%), Disabilities of the Arm, Shoulder, and Hand score (31%), visual analog scale pain (27%), and American Shoulder and Elbow Surgeons score (18%). An average of 2.2 measures per study were reported.

CONCLUSION

Considerable variability exists in the use of outcome measures across the proximal humerus fracture literature, making treatment comparison challenging. We recommend that future literature on proximal humerus fractures use at least 3 outcomes measures and 1 general health score until the optimal scores are determined.

Usage Trends of Patient-reported Outcome Measures in Shoulder Literature

INTRODUCTION

Quantifying patient outcomes is integral in orthopaedic practice, and patient-reported outcome measures (PROMs) assist with this goal and assist clinicians in assessing subjective outcomes (pain, satisfaction, etc.). This study seeks to identify the most highly used PROMs in the shoulder literature and analyze their usage trends.

METHODS

PubMed was queried for all shoulder-based articles published in eight selected journals from 2007 to 2017. Articles were assessed for PROM usage, surgical approach, surgical procedure, and disease pathology. Frequency analyses identified the most used PROMs overall, and for each approach, procedure, and pathology. Last, usage trends, question number, validation, and clinician dependence of PROMs with ≥20 uses were analyzed.

RESULTS

In total, 1,740 of 2,462 articles (71%) used 105 unique PROMs 4,394 times during the study. PROM usage increased 18%, and the use of multiple PROMs increased by 20%. PROMs with a clinician component increased 21% slower than the baseline. Twenty-two PROMs (17%) had >20 uses, with the most used PROMs being the Constant-Murley Score (783), American Shoulder and Elbow Surgeons Shoulder Score (731), Visual Analog Scale (685), Simple Shoulder Test (372), and the University of California, Los Angeles, Shoulder Rating Scale (274). PROMs demonstrating the greatest usage increase were the EuroQol 5-Dimensions Questionnaire (1,282%), Shoulder Pain and Disability Index (638%), Western Ontario Rotator Cuff Index (632%), Western Ontario Osteoarthritis of the Shoulder Index (582%), and Oxford Shoulder Score (462%)-all without a clinician component.

DISCUSSION

PROM usage is increasing, often with multiple PROMs being used to evaluate patient outcomes. PROMs without a clinician component are growing at higher rates than their clinician-dependent counterparts, highlighting an emphasis on patient reporting of outcomes. This study suggests that the American Shoulder and Elbow Surgeons Shoulder Score, Oxford Shoulder Score, Visual Analog Scales-all without a mandatory clinician component and high levels of use-will be the most highly used PROMs moving forward to assess shoulder function.

General treatment principles for fracture-related infection: recommendations from an international expert group

Fracture-related infection (FRI) remains a challenging complication that creates a heavy burden for orthopaedic trauma patients, their families and treating physicians, as well as for healthcare systems. Standardization of the diagnosis of FRI has been poor, which made the undertaking and comparison of studies difficult. Recently, a consensus definition based on diagnostic criteria for FRI was published. As a well-established diagnosis is the first step in the treatment process of FRI, such a definition should not only improve the quality of published reports but also daily clinical practice. The FRI consensus group recently developed guidelines to standardize treatment pathways and outcome measures. At the center of these recommendations was the implementation of a multidisciplinary team (MDT) approach. If such a team is not available, it is recommended to refer complex cases to specialized centers where a MDT is available and physicians are experienced with the treatment of FRI. This should lead to appropriate use of antimicrobials and standardization of surgical strategies. Furthermore, an MDT could play an important role in host optimization. Overall two main surgical concepts are considered, based on the fact that fracture fixation devices primarily target fracture consolidation and can be removed after healing, in contrast to periprosthetic joint infection were the implant is permanent. The first concept consists of implant retention and the second consists of implant removal (healed fracture) or implant exchange (unhealed fracture). In both cases, deep tissue sampling for microbiological examination is mandatory. Key aspects of the surgical management of FRI are a thorough debridement, irrigation with normal saline, fracture stability, dead space management and adequate soft tissue coverage. The use of local antimicrobials needs to be strongly considered. In case of FRI, empiric broad-spectrum antibiotic therapy should be started after tissue sampling. Thereafter, this needs to be adapted according to culture results as soon as possible. Finally, a minimum follow-up of 12 months after cessation of therapy is recommended. Standardized patient outcome measures purely focusing on FRI are currently not available but the patient-reported outcomes measurement information system (PROMIS) seems to be the preferred tool to assess the patients' short and long-term outcome. This review summarizes the current general principles which should be considered during the whole treatment process of patients with FRI based on recommendations from the FRI Consensus Group.Level of evidence: Level V.

Patients undergoing shoulder surgery have high preoperative expectations

PURPOSE

The primary aims of this study were to (1) assess the preoperative expectations of patients undergoing shoulder surgery, and (2) determine the relationship between preoperative patient demographics, PROs, and preoperative patient expectations. It was hypothesized that younger patients with worse function and worse health status had higher expectations of shoulder surgery.

METHODS

Data from a total of 319 patients (319 shoulders) from 2015-2018 were analyzed. Patients completed a series of questionnaires covering demographics and patient-reported outcome measures. Expectations of treatment were evaluated using the Musculoskeletal Outcomes Data Evaluation and Management System. Bivariate analyses were performed to determine the significance of identified associations.

RESULTS

The study population consisted of 186 males and 133 females. The mean age was 46.9 (± 17.2), and the mean BMI was 30.1 (± 6.8). Overall, patients had high expectations of shoulder surgery, with a mean score of 84.7 (± 19.3). The most commonly performed procedure in the study population was arthroscopic rotator cuff repair. There was a significant association between pre-treatment expectations and ethnicity, previous shoulder surgery, employment status, income level, tobacco use, preoperative opioid use, depression, and ASA score.

CONCLUSION

The findings suggest that patients undergoing shoulder surgery have high overall preoperative expectations, which were significantly associated with ethnicity, surgical history, opioid use, and employment status, and with multiple patient-reported outcome measures including physical function, pain interference, fatigue, and depression. Nevertheless, by discussing expectations preoperatively, orthopaedic surgeons can help patients develop high but realistic expectations to improve outcomes and satisfaction.

LEVEL OF EVIDENCE

IV.

Use of the Patient-Reported Outcomes Measurement Information System (PROMIS) for Operative Shoulder Outcomes

Background:

Few studies have investigated the relationship between the Patient-Reported Outcomes Measurement Information System (PROMIS) and legacy patient-reported outcome (PRO) measurements.

Purpose:

To compare patient-reported outcomes from the PROMIS physical function (PF) and upper extremity (UE) platforms against one another and against legacy PRO measurements to assess the potential strengths and weaknesses of the National Institutes of Health PROMIS initiative and expand on the use of PRO measurements in clinical orthopaedic practice.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic search of the PubMed, Embase, and Cochrane Library databases was conducted following PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. All English-language studies published between 2017 and 2019 using PROMIS to evaluate patients for shoulder surgery were analyzed. PROs were compared based on survey administered and the shoulder condition being investigated. Study quality was evaluated using the Modified Coleman Methodology Score and the Methodological Index for Non-Randomized Studies score.

Results:

We included 9 studies (5 studies were level 2; 3 studies were level 3; 1 study was level 4) encompassing a total of 1130 patients (60.2% male; mean age, 52.6 ± 16.5 years; mean BMI, 29.8 ± 2.8 kg/m²). Of these, 6 studies administered the PROMIS PF, and 6 studies administered the PROMIS UE. The strongest correlation was between PROMIS PF computer adaptive test and the 36-Item Short Form Health Survey Global Health (SF-36 GH) (r = 0.75). The highest overall correlation with the PROMIS UE was found with the American Shoulder and Elbow Surgeons (ASES) Shoulder Score (r = 0.70). The lowest correlations were found between PROMIS PF and the Marx Shoulder Activity Scale (r = 0.08) and the PROMIS UE and the Marx Shoulder Activity Scale (r = 0.18).

Conclusion:

From available data, the PROMIS PF and PROMIS UE were most closely correlated with outcomes measured by the SF-36 GH. The PROMIS UE alone was most correlated with ASES Shoulder Score. Thus, either PROMIS PF or UE may provide a possible alternative to legacy PRO measurements but with a lower overall number of questions and higher generalizability. Future research should compare the time and question burden of the various PROMIS platforms with a more consistent evaluation of standard PRO measurements.

Patient-reported Outcome Measures in Emergency Care Research: A Primer for Researchers, Peer Reviewers, and Readers

Patient-reported outcomes (PROs) are of increasing importance in clinical research because they capture patients' experience with well-being, illness, and their interactions with health care. Because PROs tend to focus on specific symptoms (e.g., pain, anxiety) or general assessments of patient functioning and quality of life that offer unique advantages compared to traditional clinical outcomes (e.g., mortality, emergency department revisits), emergency care researchers may benefit from incorporation of PRO measures into their research design as a primary or secondary outcome. Patients may also benefit from the ability of PROs to inform clinical practice and facilitate patient decision making, as PROs are obtained directly from the lived experience of other patients with similar conditions or health status. This review article introduces and defines key terminology relating to PROs, discusses reasons for utilizing PROs in clinical research, outlines basic psychometric and practical assessments that can be used to select a specific PRO measure, and highlights examples of commonly utilized PRO measures in emergency care research.

Is PROMIS the new standard for patient-reported outcomes measures in orthopaedic trauma research?

This review describes some of the benefits of the Patient-Reported Outcomes Measurement Information System (PROMIS) architecture, determined how frequently PROMIS measures were used in the current orthopaedic trauma literature, and compared the features of PROMIS instruments with other frequently used patient-reported outcomes measures (PROMs). PROMIS instruments have several unique elements to their architecture, such as item response theory, computerized adaptive testing options, and scaling using T-scores, that differentiate the instruments from many other PROMs. Over the past five years, 108 different PROMs were reported in 319 studies published in high-impact orthopaedic journals. PROMIS measures, including PROMIS Physical Function, Pain Interference, and Upper Extremity Function, were only used in seven studies (2%). PROMIS measures were found to be comparable to other more common PROMs with respect to respondent burden, administration options, and psychometric assessments specific to fracture patients. Likely, the limited familiarity and interpretability of PROMIS measures in the fracture population remain the most substantial barriers to broader adoption in orthopaedic trauma research.

What Are the Floor and Ceiling Effects of Patient-Reported Outcomes Measurement Information System Computer Adaptive Test Domains in Orthopaedic Patients? A Systematic Review

PURPOSE

To perform a systematic review to answer the following: (1) What are the floor and ceiling (F/C) effects of the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive test (CAT) domains of physical function (PF), upper extremity physical function (UE), pain interference (PI), and depression (D) in adult orthopaedic patients? (2) Do the PROMIS-PF and PROMIS-PI domains have differing F/C effects depending on use in upper extremity, lower extremity, spine, neck, and back, or trauma patients?.

METHODS

(Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines were followed, the review was registered on PROSPERO, and the methodological index for non-randomized studies was used for this systematic review. Studies reporting the F/C effects of at least 1 of 4 PROMIS CAT domains in orthopaedic patient cohorts accessed through PubMed and Embase on October 30, 2018, were included. F/C effects for each study were reported within forest plots.

RESULTS

Forty-three studies were included. Generally, varying cohorts demonstrated no F/C effects for PROMIS-PF (0%-9.0%), variable ceiling effects for PROMIS-UE (lower in v2.0; 0%-28.2%), variable floor effects for PROMIS-PI (0%-19.0%), and significant floor effects for PROMIS-D (0.4%-23.4%).

CONCLUSIONS

The orthopaedic literature demonstrated generally favorable floor and ceiling effects for PROMIS CAT domains, with the exception of variable ceiling effects for PROMIS-UE (the newer version exhibits only minor effects), variable floor effects for PROMIS-PI, and significant floor effects for PROMIS-D. In addition, the F/C effects of PROMIS-PF did not vary based on patient population. Although the floor effects of PROMIS-PI did vary based on patient population, the variability does not appear to be based solely on anatomic location. The PROMIS-PF and PROMIS-UE v2.0 demonstrate consistently low floor and ceiling effects. However, the PROMIS-PI and PROMIS-D may need modification before widespread adoption for clinical and research purposes.

LEVEL OF EVIDENCE

III; systematic review of Level I-III studies.

PROMIS PF correlates with HOOS, JR in patients with hip pain

Background

Patient-reported outcome measures (PROMs) are increasingly integrated into reporting requirements tied to reimbursement. There may be advantages to computer adaptive tests that apply to many different anatomical regions and diseases, provided that important information is not lost.

Questions

1) Does the Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF) computer adaptive test correlate with the Hip injury and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR: a hip-specific PROM); 2) Is there any difference in the amount of variation explained by various factors (e.g. age, BMI, presence of concomitant knee pain) for both measures?

Methods

In this prospective, cross-sectional study of 213 patients, we assessed the Pearson correlation of PROMIS PF and HOOS, JR. To investigate the variation explained by various patient-level factors, we constructed two multivariable linear regression models.

Results

We found a large correlation between PROMIS PF and HOOS, JR (r 0.58, P < 0.001). Disabled or unemployed status was independently associated with both lower PROMIS PF and HOOS, JR scores (regression coefficient [β] -3.4; 95% confidence interval [CI] -5.8 to -1.0; P = 0.006 and β -11; 95% CI -17 to -5.0; P < 0.001, respectively). Private rather than public insurance was associated with both higher PROMIS PF and HOOS, JR scores (β 4.5; 95% CI 2.2 to 6.8; P < 0.001 and β 6.4; 95% CI 0.49 to 12; P = 0.034, respectively). No floor or ceiling effects were observed for PROMIS PF. HOOS, JR scores showed 4.2% floor and 0.5% ceiling effect.

Conclusions

This study adds to the evidence that general measures of physical limitations may provide similar information as joint- or region-specific measures.

Level of evidence

Level III.

PROMIS CAT forms demonstrate responsiveness in patients following arthroscopic rotator cuff repair across numerous health domains

BACKGROUND

Recent studies of patients with rotator cuff tears have demonstrated improved efficiency with Patient-Reported Outcomes Measurement Information System (PROMIS) when compared with traditional patient-reported outcome measures (PROM). However, these studies have been cross-sectional in nature and the responsiveness of PROMIS computer adaptive test (CAT) forms has not been evaluated. The purpose of this study was to determine the responsiveness of PROMIS CAT assessments in patients undergoing arthroscopic rotator cuff repair.

METHODS

All patients undergoing arthroscopic rotator cuff repair by one of 3 fellowship-trained surgeons were included in the study. PROMIS CAT upper extremity physical function ("PROMIS-UE"), pain interference ("PROMIS-PI"), and depression ("PROMIS-D") scores from preoperative and 6-month postoperative visits were collected and analyzed. Patient-centric demographic factors, tear size, and biceps involvement were also correlated to preoperative and postoperative PROMIS scores.

RESULTS

A total of 101 patients were enrolled in the study. The average age was 59.8 ± 8.9 years with 51 males (50.5%). Preoperative PROMIS-UE, PROMIS-PI, and PROMIS-D CAT scores improved significantly from 29.8 ± 6.0, 62.6 ± 5.1, and 48.4 ± 8.7, respectively, to 40.9 ± 9.8, 51.2 ± 9.3, and 42.9 ± 9.0, respectively, at 6-month follow-up (P < .001). Preoperative correlations were found between PROMIS-UE and PROMIS-PI scores (P < .001) and between PROMIS-PI and PROMIS-D scores (P = .001). No significant correlation was found between PROMIS-UE and PROMIS-D scores (P = .08), preoperatively. Preoperative PROMIS-UE, PROMIS-PI, or PROMIS-D scores were not correlated with rotator cuff tear size (P = .4).

CONCLUSION

PROMIS CAT forms demonstrate responsiveness in patients undergoing arthroscopic rotator cuff repair across numerous domains.

Mental Health and Tobacco Use Are Correlated With Physical Function Outcomes in Patients With Knee Pain and Injury

PURPOSE

To examine the relation between the Patient-Reported Outcomes Measurement Information System (PROMIS) domains of Pain Interference (PROMIS-PI), Depression (PROMIS-D), and Physical Function (PROMIS-PF) for nonoperative patients presenting to our ambulatory sports orthopaedic clinic with knee complaints and to determine whether patient demographic characteristics influence PROMIS scores, particularly tobacco use.

METHODS

All patients treated nonoperatively for a primary complaint of knee pain were recruited for participation. Patients were included if they completed all 3 PROMIS questionnaires prior to their clinical evaluation. Patients were excluded if their treatment plan determined that surgical intervention was warranted. Survey results were compiled, and statistical correlations were run between PROMIS domains and patient demographic characteristics.

RESULTS

A total of 527 PROMIS questionnaire sets were included. PROMIS-PF had a strong negative correlation with PROMIS-PI (R = -0.75, P < .001) and a nearly moderate negative correlation with PROMIS-D (R = -0.47, P < .001). When evaluating patient demographic characteristics, we found a significant decrease in physical function scores and increases in pain and depression scores in both current and former tobacco users compared with nonsmokers. Differences in all PROMIS domains between smokers and nonsmokers exceeded minimal clinically important differences.

CONCLUSIONS

Our study showed an inverse correlation between PROMIS-PI and PROMIS-PF, as well as between PROMIS-D and PROMIS-PI, in patients seen in the ambulatory setting for knee complaints treated nonoperatively. A positive correlation was found between PROMIS-PI and PROMIS-D. Tobacco use was a patient demographic factor found to significantly impact PROMIS scores leading to minimal clinically important differences across all 3 PROMIS domains. The findings of this study may be used to identify patients at high risk of poor outcomes.

LEVEL OF EVIDENCE

Level III, observational study.

PROMIS correlation with NDI and VAS measurements of physical function and pain in surgical patients with cervical disc herniations and radiculopathy

OBJECTIVE

The aim of this study was to compare the patient-reported outcome measures Neck Disability Index (NDI) and visual analog scale (VAS) with the Patient Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) measures, respectively, and to determine their correlations in a surgical population longitudinally.Legacy outcome measures such as NDI and VAS are essential for analyzing treatments in spine surgery for cervical disc herniations with radiculopathy. Despite their usefulness, administrative burdens impose limits on completion of these measures. PROMIS was developed as a patient outcome measure in order to improve reporting of patient symptoms and function and to reduce administrative burden. Despite early positive results of PROMIS in orthopedics, NDI and VAS scores have not been compared with PROMIS scores in patients with cervical disc herniations with radiculopathy.

METHODS

Eighty patients undergoing surgery for cervical disc herniations with radiculopathy were included. All patients were treated at the same tertiary spine center. Patients were seen and PROMIS PF and PI, NDI, and VAS arm and neck pain scores were collected preoperatively and at 1 year postoperatively. Correlations between NDI, VAS, and PROMIS PF and PI were quantified using Pearson correlation coefficients. Two-tailed Student t-tests were used to demonstrate correlation significance, with alpha = 0.05.

RESULTS

All 80 (100%) patients completed all preoperative questionnaires. Fifty-seven (72%) and 75 (94%) patients completed all questionnaires at baseline and at the 6-month and 1-year follow-ups, respectively. PROMIS PF and NDI scores demonstrated a strong negative correlation, with Pearson r values of -0.81, -0.77, and -0.75 at baseline, 6 months, and 1 year. PROMIS PI and VAS neck pain scores demonstrated a moderately positive correlation, with Pearson r values of 0.51, 0.61, and 0.6. PROMIS PI and VAS arm pain scores demonstrated a moderately positive correlation, with Pearson r values of 0.46, 0.47, and 0.45.

CONCLUSIONS

PROMIS PF scores have a strong negative correlation with NDI scores at baseline and in the postoperative course in patients undergoing surgery for cervical disc herniations with radiculopathy. PROMIS PI scores have a moderately positive correlation with VAS neck and arm pain scores at baseline and in the postoperative course. Surgeons may factor these correlation results into the interpretation of patient-reported outcome measures in patients with cervical radiculopathy. Use of PROMIS PF and PI for this patient population may reduce administrative burden while providing reliable outcomes data.

A Comparison of PROMIS UE Versus PF: Correlation to PROMIS PI and Depression, Ceiling and Floor Effects, and Time to Completion

PURPOSE

This study aimed to (1) determine the correlation of Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) with PROMIS Upper Extremity (UE) and compare the correlations of PF and UE with PROMIS Pain Interference (PI) and PROMIS Depression; (2) compare the ability of PF and UE to capture health outcomes across the spectrum in patients seeking hand care; and (3) compare the time to completion for PROMIS PF to that for PROMIS UE.

METHODS

Patients presenting to a hand clinic between October, 2015 and October, 2017 were asked to complete PROMIS PF, UE, PI, and Depression computerized adaptive tests. Spearman correlation coefficients (ρ) were calculated between the domains. Ceiling and floor effects and time to completion of each domain were compared.

RESULTS

A total of 20,489 unique visits representing 10,344 patients met inclusion criteria. On average, PROMIS UE demonstrated more functional disability than did PROMIS PF (PF: 43.9 [95% confidence interval (CI), 43.7-44.0] vs UE: 38.5 [95% CI, 38.4-38.7]). PROMIS PF and UE were positively correlated (ρ = 0.79) and both were inversely correlated with PROMIS PI (PF: ρ = -0.72; UE: ρ = -0.72). PROMIS PF and UE were both inversely correlated with PROMIS Depression (PF: ρ = -0.44; UE: ρ = -0.44). PROMIS PF demonstrated better ceiling (0.6% vs 7.5%) and floor effects (0.07% vs 0.4%). The PROMIS UE CAT was completed in about the same time as the PROMIS PF CAT (UE: 59.8 seconds [95% CI, 59.3-60.3 seconds] vs PF: 54.1 seconds [95% CI, 53.8-54.5 seconds]).

CONCLUSIONS

PROMIS PF captures functional outcomes similar to those of the UE domain with better performance (ie, ceiling and floor effects) in patients with hand pathologies.

CLINICAL RELEVANCE

Hand surgeons should consider the trade-off of using PROMIS PF instead of PROMIS UE or vice versa when selecting a domain for patient care. Although PROMIS PF may capture slight variations in function at the extremes better than the current PROMIS UE, this may not be as clinically important as capturing large changes in upper-extremity function more specifically, which PROMIS UE accomplishes.

Patient-Reported Outcomes Measurement Information System physical function correlates with Toronto Extremity Salvage Score in an orthopaedic oncology population

BACKGROUND

The National Institute of Health's Patient-Reported Outcomes Measurement Information System (PROMIS) uses computerised-adaptive testing to reduce survey burden and improve sensitivity. PROMIS is being used across medical and surgical disciplines but has not been studied in orthopaedic oncology.

QUESTIONS/PURPOSES

The aim of the study was to compare PROMIS measures with upper extremity (UE) and lower extremity (LE) Toronto Extremity Salvage Score (TESS) by assessing the following: (1) responder burden, (2) correlation between scores and (3) floor/ceiling effects.

PATIENTS AND METHODS

This cross-sectional trial analysed all 97 adult patients treated surgically for a bone or soft tissue tumour at a tertiary institution between November 2015 and March 2016. TESS (UE or LE) and PROMIS (Physical Function, Pain Interference and Depression) surveys were administered preoperatively. Pearson correlations between each PROMIS domain and TESS were calculated, as were floor/ceiling effects of each outcome measure.

RESULTS

(1) Completion of three PROMIS questionnaires required a mean total of 16.8 (+/- 5.8 standard deviation) questions, compared with 31 and 32 questions for the LE and UE TESS questionnaires, respectively. (2) The PROMIS Physical Function scores demonstrated a strong positive correlation with the LE TESS (r = 0.84; 95% confidence interval [CI], 0.72-0.91; p < 0.001) and moderate positive correlation with the UE TESS (r = 0.64; 95% CI, 0.34-0.83; p = 0.055). The PROMIS Depression scores demonstrated a weak negative correlation with both the LE TESS (r = -0.38; 95% CI, -0.61 to -0.10; p = 0.010) and with UE TESS (r = -0.38; 95% CI, -0.67 to -0.01; p = 0.055). The PROMIS Pain Interference scores demonstrated a strong negative correlation with the LE TESS (r = -0.71; 95% CI, -0.83 to -0.52; p < 0.001) and a moderate negative correlation with the UE TESS (r = -0.62; 95% CI, -0.81 to -0.30; p = 0.001). (3) The UE TESS had a range of scores from 16 to 100 with a 27% ceiling effect and no floor effect, and the LE TESS had a range from 10 to 98 with no floor or ceiling effect. There was no floor or ceiling effect for any PROMIS measures.

CONCLUSIONS

In an orthopaedic oncology population, the PROMIS Physical Function and Pain Interference scores correlate with the TESS and have the benefit of reduced survey burden and ceiling effect. The PROMIS Depression scores may provide additional information regarding patient outcomes not captured by the TESS.

LEVEL OF EVIDENCE

Level III.

THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE

Patient reported outcome measures asses patients' symptoms, function and health-related quality of life and are designed to capture more clinical information than can be gathered by objective medial testing alone. As reimbursements and the understanding of patient outcomes are becoming tied to performance on PROMIS measures, it is an important step to establish how PROMIS measures correlate and compare to traditional legacy measures.

PROMIS physical function underperforms psychometrically relative to American Shoulder and Elbow Surgeons score in patients undergoing anatomic total shoulder arthroplasty

BACKGROUND

The purpose of this study was to evaluate the psychometric properties of the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function computer adaptive test (PF-CAT) relative to the American Shoulder and Elbow Surgeons (ASES) score in patients with glenohumeral osteoarthritis undergoing primary anatomic total shoulder arthroplasty (TSA).

METHODS

A retrospective study of an institutional TSA registry was performed. Preoperative PROMIS PF-CAT and ASES scores were collected. Floor and ceiling effects were determined, and convergent validity was established through Pearson correlations. Rasch partial credit modeling was used for psychometric analysis of the validity of PF-CAT and ASES question items. Person-item maps were generated to characterize the distribution of question responses along the latent dimension of shoulder disability.

RESULTS

Responses from 179 patients (184 shoulders) were included. PF-CAT had a moderate correlation to ASES (r = 0.487; P < .001), with no floor or ceiling effects; ASES had a 1.1% floor effect and no ceiling effect. With iterative Rasch model item-reduction analysis eliminating poorly fitting question items, all possible PF-CAT items were eliminated after 6 iterations. With ASES, just 1 function question item was dropped. Person-item maps showed ASES to be superior to PROMIS PF-CAT psychometrically, with sequential and improved coverage of the latent dimension of shoulder disability.

CONCLUSION

Despite moderate correlation with ASES, PROMIS PF-CAT demonstrated inferior validity and psychometric properties in patients undergoing TSA. PF-CAT should not replace the ASES in this population of patients.

Validation of PROMIS Physical Function Instruments in Patients With an Orthopaedic Trauma to a Lower Extremity

OBJECTIVES

To evaluate the reliability, convergent validity, known-groups validity, and responsiveness of the Patient-Reported Outcomes Measurement Information System (PROMIS) Mobility Computer Adaptive Test (CAT) and PROMIS Physical Function 8a Short Form.

DESIGN

Prospective cohort study.

SETTING

Two Level-I trauma centers.

PATIENTS

Eligible adults with an isolated lower extremity trauma injury receiving treatment were approached consecutively (n = 402 consented at time 1, median = 80 days after treatment). After 6 months, 122 (30.3%) completed another assessment.

INTERVENTION

Cross-sectional and longitudinal monitoring of patients.

MAIN OUTCOME MEASUREMENTS

Floor and ceiling effects, reliability (marginal reliability and Cronbach's alpha), convergent validity, known-groups discriminant validity (weight-bearing status and fracture severity), and responsiveness (Cohen's d effect size) were evaluated for the PROMIS Mobility CAT, PROMIS Physical Function 8a Short Form, and 5 other measures of physical function.

RESULTS

PROMIS PFSF8a and Foot and Ankle Ability Measure Activities of Daily Living Index had ceiling effects. Both PROMIS measures demonstrated excellent internal consistency reliability (mean marginal reliability 0.94 and 0.96; Cronbach's alpha = 0.96). Convergent validity was supported by high correlations with other measures of physical function (r = 0.70-0.87). Known-groups validity by weight-bearing status and fracture severity was supported as was responsiveness (Mobility CAT effect size = 0.81; Physical Function Short Form 8a = 0.88).

CONCLUSIONS

The PROMIS Mobility CAT and Physical Function 8a Short Form demonstrated reliability, convergent and known-groups discriminant validity, and responsiveness in a sample of patients with a lower extremity orthopaedic trauma injury.

Evaluation of the PROMIS Upper Extremity Computer Adaptive Test Against Validated Patient-Reported Outcomes in Patients With Basilar Thumb Arthritis

PURPOSE

The Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) computer adaptive test was developed to reduce test burden and improve precision. We hypothesized that, in patients with thumb basilar joint arthritis (BJA), (1) PROMIS UE would correlate with established patient-outcomes (PROs), (2) PROMIS UE would require less time and fewer questions than current metrics, (3) there would be no floor or ceiling effects, and (4) PROMIS UE would not correlate with radiographic disease severity.

METHODS

Patients presenting with a primary diagnosis of thumb BJA completed the Quick Disabilities of the Arm Shoulder and Hand (QuickDASH), Thumb Disability Examination (TDX), Patient-Rated Wrist Hand Evaluation (PRWHE), and PROMIS UE. Radiographic disease severity as described by the Eaton scoring system was recorded. The relationships among PROs were described with Spearman correlation coefficients. The presence of a floor or ceiling effect was confirmed if greater than 15% of patients achieved the lowest or the highest possible score, respectively.

RESULTS

One hundred patients with thumb BJA formed the sample for this study. A good to excellent correlation was identified between PROMIS UE and QuickDASH. There were good correlations between PROMIS UE and TDX as well as PRWHE. The PROMIS UE was significantly less time consuming (average: 58.5 seconds vs QuickDASH, 92.2; TDX, 62.6; and PRWHE, 144.7), and required fewer questions than current metrics (average: 4.9 questions vs QuickDASH, 11; TDX, 20; and, 15). In addition, there were no appreciable floor or ceiling effects. Radiographic disease severity did not correlate with PROMIS UE.

CONCLUSIONS

The PROMIS UE has a good to excellent correlation with QuickDASH and good correlations with PRWHE and TDX. In addition, PROMIS UE required less time and fewer questions than established PROs. There were no floor or ceiling effects. Used as a single PRO, PROMIS UE may be a practical alternative to legacy scales in patients with thumb BJA.

CLINICAL RELEVANCE

The PROMIS UE PRO instrument may be a valuable addition in the assessment of patients with basilar thumb arthritis.

A Systematic Review and Standardized Comparison of Available Evidence for Outcome Measures Used to Evaluate Proximal Humerus Fracture Patients

OBJECTIVES

To summarize and appraise any patient-reported or clinician-measured outcome measures based on their measurement properties in proximal humerus fracture patients.

DATA SOURCES AND STUDY SELECTION

MEDLINE, EMBASE, and CINAHL were searched from January 2000 to August 2018 to identify all studies of proximal humerus fracture patients that reported a measurement property evaluation of an outcome measure.

DATA EXTRACTION AND SYNTHESIS

Quality appraisal of each measure was completed using the Evaluating the Measurement of Patient-Reported Outcomes (EMPRO) tool. The EMPRO takes into account all studies of each measure, and the overall score is transformed linearly to a range of 0 (lowest) to 100 (best).

RESULTS

Eleven instruments were identified. Intended concepts of the instruments included clinician-measured shoulder function, patient-reported function or disability, and patient-reported general health state. Only the Disabilities of the Arm, Shoulder and Hand (DASH), Oxford Shoulder Score, Constant Score, University of California, Los Angeles Shoulder Score, and EuroQol 5 Dimension (EQ5D) were evaluated in more than 1 study. The Shoulder Function Index (SFINX), DASH, and EQ5D had the highest EMPRO scores (80, 66, and 58, respectively). The SFINX and DASH consistently scored among the top 3 instruments for each attribute.

CONCLUSIONS

Evidence on the measurement properties of outcome measures for proximal humerus fracture patients is limited. With the available evidence, the SFINX is recommended as a clinician-measured functional outcome measure, the DASH as a patient-reported functional outcome measure, and the EQ5D as a general health status measure.

Non-hip/non-vertebral fractures - How to treat best?

Fractures of the extremities in the elderly constitute more than two-thirds of all fragility fractures befalling frail, osteoporotic and sarcopenic patients. Although treatment controversies abound, consensus exists. Upper extremity fractures hinder activities of daily living and are debilitating. Open fractures or displaced fractures will need surgical intervention. Wrist fractures treated operatively allow early use of the hand. Most pelvic fractures are treated conservatively. In the lower extremities, fractures of the long bones, tibia and femur need surgical intervention. Non-displaced fractures around the foot may be treated with immobilisation and avoidance of full weight-bearing. As a rule, fractures take four months for consolidation. Individually tailored solutions are needed for frail patients with comorbidities. Maintaining joint mobility and muscle strength preserves mobility and autonomy. Caring for extremities trauma is team work, involving family and health care providers. Prevention efforts are mandatory.

Variability of PROMIS Scores Across Hand Conditions

PURPOSE

This study aimed to determine whether Patient-Reported Outcome Measurement Information System (PROMIS) Physical Function and Pain Interference scores varied at presentation for specialty care by nontrauma hand condition. The secondary aim was to compare PROMIS scores with a reference standard, the Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH), regarding the magnitude and direction of score differentials among diagnoses.

METHODS

PROMIS Physical Function and Pain Interference scores were analyzed from 1,471 consecutive new adult patient clinic visits at a tertiary orthopedic hand clinic presenting with 1 of 5 nontrauma hand conditions. A 5-point difference on PROMIS assessments was presumed to be clinically relevant. A random sample of 30 QuickDASH scores from each diagnostic group was evaluated for score differentials among groups. We also measured the correlation between PROMIS and QuickDASH scores.

RESULTS

Patients with carpal tunnel syndrome and thumb basal joint arthritis reported worse physical function and more pain interference, whereas those with Dupuytren contractures and ganglion cysts reported less pain and better function. For both domains, patients with trigger fingers averaged PROMIS scores among the other groups. Similar differences were observed in QuickDASH scores because patients with carpal tunnel syndrome and thumb arthritis reported clinically worse upper-extremity function than did patients with ganglion cysts and Dupuytren contracture. A strong correlation was seen between QuickDASH scores with both PROMIS Physical Function scores and Pain Interference scores.

CONCLUSIONS

The PROMIS system is sufficiently able to capture differences in self-reported function and pain interference among patients with different hand conditions. Moreover, PROMIS Physical Function demonstrates construct validity when evaluated against a reference of the QuickDASH across nontrauma hand conditions.

CLINICAL RELEVANCE

The use of PROMIS is expanding, but because PROMIS is not disease-specific, assessment of its construct validity is necessary for hand conditions.

Introducing BREAST-Q Computerized Adaptive Testing: Short and Individualized Patient-Reported Outcome Assessment following Reconstructive Breast Surgery

BACKGROUND

The BREAST-Q is a widely used patient-reported outcome instrument measuring health-related quality-of-life and patient satisfaction in breast surgery. Shorter assessment potentially increases patients' willingness to complete scales, but simply offering a shortened version leads to unacceptable loss in measurement precision. The authors aimed to develop a computerized adaptive test (CAT) to shorten the BREAST-Q's Satisfaction with Breasts scale while maintaining reliability of measurement.

METHODS

The authors created a CAT, which repetitively administered questions from the pool of 16 questions, until prespecified levels of reliability were reached [i.e., standard errors (SE) of 0.32 to 0.55]. In a simulation study, the authors tested the CAT's feasibility for all potential satisfaction scores. In a second study using actual patient data, 5000 breast reconstruction patients who had previously completed the full scale were randomly selected from a large database. Their full-scale satisfaction scores were compared with their CAT-derived scores.

RESULTS

In both studies, by applying CAT, the Satisfaction with Breasts scale could be reduced to an average of 10 questions when using the minimum level of measurement precision for individual-patient measurement (SE, 0.32), compared with four questions when using the minimum precision level for group-based research (SE, 0.55). Score estimates were highly correlated between the CAT assessment and the full scale (0.91 to 0.98 in the simulation study, and 0.89 to 0.98 in the patient data study).

CONCLUSIONS

Applying computerized adaptive testing to the BREAST-Q's Satisfaction with Breasts scale facilitates reliable assessment, with 38 to 75 percent fewer questions than the full version. The novel BREAST-Q CAT version may decrease response burden and help overcome barriers to implementation in routine care.

Reliability of Proxy-reported Patient-reported Outcomes Measurement Information System Physical Function and Pain Interference Responses for Elderly Patients With Musculoskeletal Injury

BACKGROUND

Patient-reported Outcomes Measurement Information System (PROMIS) instruments are useful to evaluate health status, but its use can be challenging for some vulnerable elderly patients, requiring aid from their proxies. Whether the proxies could be accurate informants is unknown. The goal of this study was to compare elderly patients' and their proxies' answers with PROMIS physical function (PF) and pain interference (PI) computer adaptive test for the evaluation of patients' outcomes after musculoskeletal injury. In addition, to correlate patients' reported PF with the Timed Up and Go (TUG) test.

METHODS

This prospective cohort study, from February to September 2016, in the Orthopaedic trauma clinic of two level I Trauma centers, included 273 patients aged 65 years or older, ambulatory, cognitively intact, with a discernible proxy. PROMIS PF and PI, TUG, and the "FRAIL" Questionnaire screening tool were performed. The correlation of PROMIS scores between patients and proxies, and also with the TUG score, was assessed using Spearman rank correlation. The Bland-Altman analysis served to check agreement and bias. Subgroup comparison was tested using probit transformations.

RESULTS

The mean age of patients was 75.7 years, SD 7.5 (62.2 years; SD, 13.8 for proxies), 66.7% women, 57.1% married, and 34% with femoral fractures. A significant correlation and agreement of PROMIS PF and PI scores were found between patients and proxies (Spearman rho for both, PF and PI = 0.73), although proxies tended to overestimate the interference of pain on patient's performance (median difference, -1.7; P < 0.001). The correlation was markedly stronger in nonfrail patients and in those with faster TUG scores. There was also a correlation between patients' PROMIS PF and TUG test (Spearman rho = - 0.58).

CONCLUSIONS

Proxies are good informants of the PF of ambulatory, cognitively intact elderly patients, as evaluated by the PROMIS PF instrument, after musculoskeletal injury, although they tend to slightly overestimate PI. The use of proxy-reported PROs might better characterize functional impairment and pain in a vulnerable patient population, and it could decrease selection bias in outcomes research.

LEVEL OF EVIDENCE

Diagnostic level II.