Item Generation and Reduction Toward Developing a Patient-reported Outcome for Pediatric Ulcerative Colitis (TUMMY-UC)

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Patient-Reported Outcomes Measurement Information System as a Clinical Tool for Capturing the Patient Perspective in Pediatric Inflammatory Bowel Disease: A Narrative Review

Inflammatory bowel disease (IBD) is an immune-mediated chronic disease with a significant impact on quality of life. In pediatric patients, diagnosing and managing IBD is particularly challenging, and IBD often presents as a more severe and progressive disease. Patient-reported outcomes (PROs) are measures of treatment and disease management outcomes reported by patients and/or caregivers. These measures evaluate several aspects of disease management from the patient/caregiver perspective, emphasizing the patient's real-life experience with the disease and its treatment. PROs represent a model of patient-centered care, facilitating better-informed healthcare decisions. The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed to promote the use of PROs among patients with chronic conditions. Its primary objective is to provide PROs for research and clinical practice throughout the lifespan. The PROMIS is a non-disease-specific instrument for both adults and pediatric patients assessing domains of physical, psychological, and social health, as well as quality of life (QOL). These instruments are designed to be applicable to a wide range of chronic diseases. Despite the initial expectation concerning PROs in assessing pediatric IBD outcomes, objective data in this area have only recently begun to emerge. This narrative review, based on a selection of reliable articles recognized by PubMed and Cochrane Library, aimed to identify and summarize previously published evidence of the usefulness of PROs, particularly the PROMIS, in IBD patients and in the pediatric population. We present an updated perspective, including identification of their general applications and most relevant previous studies, in the mentioned areas and identify knowledge gaps.

Fatigue in pediatric inflammatory bowel diseases: A systematic review and a single center experience

OBJECTIVES

We aimed to review the literature on fatigue in pediatric inflammatory bowel diseases (PIBD), to explore how it is measured, and approximate its rate in an inception pediatric cohort.

METHODS

Studies on fatigue were systematically reviewed and selected by two authors. Next, we retrieved the two fatigue-related questions of the IMPACT-III questionnaire at 4 and 12 months after diagnosis from a prospectively maintained cohort of PIBD patients, each scoring 0-100 (lower scores imply more fatigue), and 44 healthy controls.

RESULTS

The systematic review identified 14 studies reporting fatigue in children, of which nine had fatigue as the primary outcome and only two provided rates of fatigue. No standalone index was identified for measuring fatigue specifically for PIBD. Of 80 children included in the inception cohort, 62 (78%) scored an average of ≤75 on the two IMPACT-III questions (approximating at least mild fatigue), 26 (33%) scored ≤50 (at least moderate fatigue) and nine (11%) scored ≤25 (severe fatigue). In comparison, only four (9%) healthy children scored at least moderate fatigue (p = 0.007). Fatigue rates at 12 months were only slightly and nonsignificantly lower. Fatigue of any severity was reported in 92% children with active disease versus 63% of those in clinical remission (p = 0.01).

CONCLUSION

Literature reporting on fatigue in PIBD is scarce, and no PIBD-specific tool is available to measure fatigue. In our cohort, fatigue-related questions were frequently scored low in children with IBD, mainly among children with active disease but also during clinical remission.

Development and Validation of the TUMMY-UC: A Patient-Reported Outcome for Pediatric Ulcerative Colitis

BACKGROUND & AIMS

The TUMMY-UC is a patient-reported outcome measure for pediatric ulcerative colitis (UC) with an observer-reported outcome version for children aged <8 years. It includes eight items selected by concept elicitation interviews. We aimed to finalize the TUMMY-UC by cognitive interviews (stage 2) and to evaluate the index for its psychometric properties (stage 3).

METHODS

The TUMMY-UC items were first finalized during 129 cognitive debriefing interviews. Then, in a prospective, multicenter validation study, 84 children who underwent colonoscopy or provided stool for calprotectin completed the TUMMY-UC and various measures of disease activity. Assessments were repeated after 7 and 21 days for evaluating reliability and responsiveness.

RESULTS

During stage 2, the items were formatted with identical structure to ensure conceptual equivalence and weighted based on ranking of importance. In stage 3, the TUMMY-UC total score had excellent reliability in repeated assessments (intraclass correlation coefficient, 0.90; 95% confidence interval, 0.84-0.94). It also had moderate to strong correlations with all constructs of disease activity: r = 0.70 with UC endoscopic index of severity, r = 0.63 with the IMPACT-III questionnaire, r = 0.43 with calprotectin, r = 0.80 with the Pediatric Ulcerative Colitis Activity Index, r = 0.75 with global assessment of disease activity, and r = 0.46 with C-reactive protein (all P < .015). The index had excellent discrimination of disease activity, with a score of <9 defining remission (area under the receiver operating characteristic curve, 0.95; 95% confidence interval, 0.93-0.99). The ΔTUMMY-UC showed high responsiveness and differentiated well between children who experienced changed from those with no change.

CONCLUSIONS

The TUMMY-UC, constructed from patient-reported outcome and observer-reported outcome versions, is a reliable, valid and responsive index that can be now used in practice and clinical trials.

Antibiotics in pediatric inflammatory bowel diseases: a systematic review

Introduction: Current therapies in pediatric Inflammatory Bowel Diseases (IBD) target the immune system and often fail to sustain long-term remission. There is a high need for development of alternative treatment strategies such as antibiotics in pediatric IBD.Areas covered: This study systematically assessed efficacy and safety of antibiotics in pediatric IBD. CENTRAL, EMBASE, and Medline were searched for Randomized Controlled Trials (RCTs). Quality assessment was conducted with the Cochrane risk-of-bias tool.Expert opinion: Two RCTs (n = 101, 4.4-18 years, 43% male) were included. Both studies had overall low risk of bias. In mild-to-moderate Crohn's disease, azithromycin+metronidazole (AZ+MET) (n = 35) compared to metronidazole (MET) alone (n = 38) did not induce a significantly different response (PCDAI drop ≥12.5 or remission) (p = 0.07). For induction of remission (PCDAI≤10), AZ+MET was more effective than MET (p = 0.025). In Acute Severe Colitis, mean 5-day-PUCAI was significantly lower in the antibiotic (vancomycin, amoxicillin, metronidazole, doxycycline)+intravenous-corticosteroids group (AB+IVCS) (n = 16) compared to IVCS alone (n=12) (p = 0.037), whereas remission (PUCAI<10) did not differ (p = 0.61). No significant drug-related adverse events were reported. Results of this systematic review of antibiotic use highlight the lack of evidence in pediatric IBD. More evidence is needed before widespread implementation in daily practice.

Overview of Self-Management Skills and Associated Assessment Tools for Children with Inflammatory Bowel Disease

Self-management is a multi-modal approach for managing chronic conditions that encompasses a number of different elements; knowledge, adherence, self-regulation, communication, and cognitive factors. Self-management has been shown to be beneficial for adults with inflammatory bowel disease (IBD), and for children with IBD it may help them learn to take control of their complex treatment regimens and lead to positive disease outcomes. The development of self-management skills for children with IBD is vital in order to maximize their potential for health autonomy, but it is still an emergent field in this population. This review provides an over-arching view of the self-management elements specific to children with IBD, and highlights outcome measures that may be used to assess skills within each field as well as the efficacy of targeted interventions.

Treat-to-Target in Pediatric Inflammatory Bowel Disease: What Does the Evidence Say?

The traditional management of inflammatory bowel disease, based on treatment intensification guided by clinical activity alone, has been revised in the last 10 years and a treat-to-target approach has been proposed and is currently under evaluation as a disease-modifying strategy. Treat-to-target focuses on objective and scheduled measures to monitor intestinal damage, with consequent therapeutic adjustments in case of failure to achieve pre-defined targets. Identification of targets has been set out by the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) committee in 2015. Mucosal healing is universally accepted as the main target both in Crohn's disease and ulcerative colitis, given its proven association with better long-term outcomes than clinical remission alone. Equally important is to ensure patients' clinical remission and improve patient-reported outcomes. Transmural healing (for Crohn's disease) and histological remission (for ulcerative colitis), listed as adjunctive targets, are likely to become primary targets in the near future. The ultimate goal of this approach is to modify the natural history of inflammatory bowel diseases by trying to block bowel damage progression, with interventions in the pre-clinical stage. In this review, we will discuss the current recommended therapeutic targets, as well as those that are considered adjunctive targets, with a focus on the limited pediatric literature available. Prospective long-term trials are warranted in order to identify the most appropriate target for the pediatric population and its specific issues. Identification of reliable predictors of disease course, outcome, and response to treatment will help to individually adapt each step of this monitoring algorithm and consequent therapeutic decision.

A Symptom Self-report Tool for Children With Inflammatory Bowel Disease (IBDnow)

OBJECTIVES

Clinical symptom evaluation for children with inflammatory bowel disease (IBD) is typically done using composite tools: the Pediatric Crohn's Disease Activity Index (PCDAI) and Pediatric Ulcerative Colitis Activity Index (PUCAI). Both rely on clinician interpretation of child or parent symptom recall. No universal self-report tool has yet been developed for children with IBD to assess and report their symptoms. The research objective was to develop a self-report tool that produced information congruent with that obtained by clinicians using the PUCAI or PCDAI.

METHODS

A children's symptom self-report tool (IBDnow) was developed with picture and text Likert symptom scales. The clinician and child completed their reports during the same outpatient consultation. Agreement levels were calculated at the individual level (identical child and clinician answers), category level (symptom severity), and aggregate level (cohort scores). Internal consistency was measured with Cronbach alpha.

RESULTS

One hundred children from Christchurch (New Zealand) (n = 65), and Sydney (Australia) (n = 35) completed the study (Crohn's Disease (CD):88, ulcerative colitis (UC):12), mean age 13.9 years (±3.6). Mean individual agreement was 0.76 (±0.19). Category severity had very good or good inter-rater reliability for 5 of the 7 symptom scales and overall severity agreement of 76%. Aggregate mean scores were significantly different between clinicians (14.9, ±18.8), and participants (21.6, ±19.4), (P <0.005, confidence interval -9.0, -4.4), but 60 pairs had scores within a 10% margin. Cronbach alpha was 0.74.

CONCLUSIONS

This self-report tool had good proportionate agreement between raters, and good crude agreement for symptom categories. Assigning PUCAI or PCDAI scores caused inter-rater discrepancies to be misleadingly magnified. Pediatric gastroenterologists may consider utilizing IBDnow to elicit symptom self-reports from children with IBD to enable them to communicate meaningful information on their ongoing symptom burden. This would be a positive step in helping children feel included in clinical encounters and promoting self-management, at the same time producing valid, subjective symptom recall.

Do Children and Adolescents With Inflammatory Bowel Disease Complete Clinical Disease Indices Similar to Physicians?

OBJECTIVES

The degree to which children and adolescents with inflammatory bowel disease (IBD) complete clinical disease activity indices in accordance with their physician is indefinite. Therefore, we investigated the agreement between patient- and physician-based clinical indices in children and adolescents with a previous diagnosis of IBD.

METHODS

In this cross-sectional study, IBD patients (8-18 years) were included prospectively. Patients completed a patient-based short Pediatric Crohn's Disease Activity Index (shPCDAI) for Crohn disease or the Pediatric Ulcerative Colitis Activity Index (PUCAI) for ulcerative or indeterminate colitis. Physicians completed the original physician-based shPCDAI or PUCAI. Agreement was calculated with linear weighted kappa.

RESULTS

In total, 154 pairs of clinical indices were collected: 89 pairs of shPCDAI's (median age at assessment 15.6 years, 61% men) and 55 pairs of PUCAI's (median age at assessment 14.0 years, 44% men). The shPCDAI disease activity category only fairly agreed between patient- and physician-based indices (kappa: 0.40 [95% confidence interval 0.24-0.55], P < 0.001), with perfect agreement in 58% of pairs. In the majority of disagreement (81%), patients scored in a higher shPCDAI disease activity category. The PUCAI disease activity category substantially agreed between patient- and physician-based indices (kappa: 0.64 [95% confidence interval 0.45-0.83], P < 0.001), with perfect agreement in 78% of pairs. In the majority of disagreement (75%), patients scored in a higher PUCAI disease activity category.

CONCLUSIONS

Patient- and physician-based shPCDAI and PUCAI do not always agree, particularly the shPCDAI, and therefore, should not be interpreted equivalently in management and research on children and adolescents with IBD.