Systematic Review of the Use of Patient Reported Outcome Measures in Studies of Electively-Managed Hand Conditions

Developing a multimedia patient-reported outcomes measure for low literacy patients with a human-centered design approach

INTRODUCTION

Almost all patient-reported outcomes measures (PROMs) are text-based, which impedes accurate completion by low and limited literacy patients. Few PROMs are designed or validated to be self-administered, either in clinical or research settings, by patients of all literacy levels. We aimed to adapt the Patient Reported Outcomes Measurement Information System Upper Extremity Short Form (PROMIS-UE) to a multimedia version (mPROMIS-UE) that can be self-administered by hand and upper extremity patients of all literacy levels.

METHODS

Our study in which we applied the Multimedia Adaptation Protocol included seven phases completed in a serial, iterative fashion: planning with our community advisory board; direct observation; discovery interviews with patients, caregivers, and clinic staff; ideation; prototyping; member-checking interviews; and feedback. Direct observations were documented in memos that underwent rapid thematic analysis. Interviews were audio-recorded and documented using analytic memos; a rapid, framework-guided thematic analysis with both inductive and deductive themes was performed. Themes were distilled into design challenges to guide ideation and prototyping that involved our multidisciplinary research team. To assess completeness, credibility, and acceptability we completed additional interviews with member-checking of initial findings and consulted our community advisory board.

RESULTS

We conducted 12 hours of observations. We interviewed 17 adult English-speaking participants (12 patients, 3 caregivers, 2 staff) of mixed literacy. Our interviews revealed two distinct user personas and three distinct literacy personas; we developed the mPROMIS-UE with these personas in mind. Themes from interviews were distilled into four broad design challenges surrounding literacy, customizability, convenience, and shame. We identified features (audio, animations, icons, avatars, progress indicator, illustrated response scale) that addressed the design challenges. The last 6 interviews included member-checking; participants felt that the themes, design challenges, and corresponding features resonated with them. These features were synthesized into an mPROMIS-UE prototype that underwent rounds of iterative refinement, the last of which was guided by recommendations from our community advisory board.

DISCUSSION

We successfully adapted the PROMIS-UE to an mPROMIS-UE that addresses the challenges identified by a mixed literacy hand and upper extremity patient cohort. This demonstrates the feasibility of adapting PROMs to multimedia versions. Future research will include back adaptation, usability testing via qualitative evaluation, and psychometric validation of the mPROMIS-UE. A validated mPROMIS-UE will expand clinicians' and investigators' ability to capture patient-reported outcomes in mixed literacy populations.

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.

Linking QuickDASH and PROMIS Upper-Extremity Computer-Adaptive Test Scores in Hand Surgery: A Crosswalk Study

PURPOSE

Assessment of patient-reported outcome measures (PROMs) for hand and upper-extremity surgery patients using measures such as the Quick Disabilities of the Arm, Shoulder, and Hand (qDASH), as well as general measures including the Patient-Reported Outcomes Measurement Information System Upper Extremity Physical Function domain via a Computer-Adaptive Test (PROMIS UE CAT), has become commonplace. The aim of this study was to link, for crosswalking, the qDASH measure to both versions of the PROMIS UE CAT (v1.2 and v2.0).

METHODS

We included 18,944 hand and upper-extremity patients who completed both versions of the PROMIS UE CAT and the qDASH at the same clinical encounter. Shoulder pathology was excluded. Score linkage was performed using the R package equate, and multiple equating models (linear regression, identity, mean, linear, equipercentile, and circle-arc models) were used to establish crosswalk tables.

RESULTS

Mean qDASH and PROMIS UE CAT v1.2 scores were 38.2 (SD = 23.1) and 36.6 (SD = 9.8), respectively. Mean qDASH and PROMIS UE CAT v2.0 scores were 37.3 (SD = 21.8) and 38.3 (SD = 10.4), respectively. Pearson correlations had very strong linear relationships between the qDASH and the PROMIS UE CAT v1.2 and PROMIS UE CAT v2.0 (r = -0.83 [-0.84, -0.92] and r = -0.80 [-0.81, -0.80], respectively). For the equipercentile equating models, the intraclass correlation coefficient (ICC) had very strong positive relationships to linking measures with ICC = 0.85 (0.84, 0.86) for the qDASH-UE CAT v1.2 crosswalk and ICC = 0.83 (0.82, 0.84) for the qDASH-UE CAT v2.0 crosswalk.

CONCLUSIONS

The linkages establish crosswalk tables using equipercentile equating models to convert the PROMIS UE CAT v1.2 and v2.0 scores to the qDASH and vice versa.

CLINICAL RELEVANCE

This study provides crosswalk tables for commonly collected PROMs in hand surgery, increasing the comparability of results between centers using different PROMs to study the same conditions or treatments.

Modified Scoring of the QuickDASH Can Achieve Previously-unattained Interval-level Measurement in Dupuytren Disease and Carpal Tunnel Syndrome

Background

Rasch measurement theory can be used to identify scales within questionnaires and to map responses to more precise continuous scales. The aim of this article was to use RMT to refine the scoring of the QuickDASH in patients with Dupuytren disease and carpal tunnel syndrome (CTS).

Methods

Data were collected between 2013 and 2019 from a single center in the UK. Preoperative QuickDASH responses from patients diagnosed with Dupuytren disease and CTS were used. RMT was used to reduce the number of items in the QuickDASH and examine the reliability and validity of each subscale.

Results

The preoperative QuickDASH responses of 750 patients with Dupuytren disease and 1916 patients with CTS were used. The median age of participants was 61 years, and 46% were men. Exploratory factor analysis suggested two distinct subscales within the QuickDASH: task items 1-6 and symptom items 9-11. These items were fitted to the Rasch model, and disordered response thresholds were collapsed. In Dupuytren disease, the two worst responses or each item were disordered. After collapsing these options, good Rasch model fit was demonstrated. CTS responses fitted without modification. Item targeting was more appropriate for CTS than Dupuytren disease.

Conclusions

This study proposes a modification to the scoring system for the QuickDASH that provides high-quality, continuous, and condition-specific scales for the QuickDASH. The identification of distinct subscales within the QuickDASH can be used to identify distinct improvements in hand function and/or symptoms in previous, current, and future work.

PROMIS Global Physical Health Subscale Strongly Correlates and Performs Similarly to the QuickDASH in Hand and Upper Extremity Patients

BACKGROUND

The Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) is a validated, static hand and upper extremity patient-reported outcome measure (PROM) commonly used. However, with the growth of PROM implementation across orthopedic and plastic surgery clinics, it is beneficial to determine whether a more general PROM can be used to capture the same insights. This would ease implementation broadly. There is a paucity of literature assessing whether the QuickDASH and Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 are correlated and perform similarly.

METHODS

Between June 2016 and December 2020, hand and upper extremity patients seeking care at clinics associated with a single quaternary academic medical center were identified. Those who completed the PROMIS Global-10 and QuickDASH as part of routine care were identified. The PROMIS Global-10 is divided into the PROMIS Global Physical Health and PROMIS Global Mental Health subscores. Spearman rho (ρ) correlations were calculated across PROMs, and ceiling and floor effects were determined.

RESULTS

Across the 18 744 included patients, there was a strong correlation and strong-moderate correlation found between the QuickDASH and PROMIS Global Physical Health (ρ = 0.70, P < .001) and PROMIS Global Mental Health (ρ = 0.69, P < .001), respectively. Although small, QuickDASH demonstrates the worst floor effect (2.6%, [n = 478]), whereas PROMIS Global Mental Health demonstrated a much more notable ceiling effect (11%, [n = 2034]).

CONCLUSIONS

The PROMIS Global-10 can be used to assess the functional status of patients presenting for hand and upper extremity concerns, while also capturing aspects of mental health. The PROMIS Global-10 may ease PROM implementation broadly.

Toward System-Wide Implementation of Patient-Reported Outcome Measures: A Framework for Countries, States, and Regions

OBJECTIVES

This study aimed to develop a framework facilitating (1) the maturity assessment of healthcare systems regarding patient-reported outcome measure (PROM) implementation and (2) the comparison of different healthcare systems' PROM implementation levels to guide discussions and derive lessons for regional, state-level, and national PROM initiatives.

METHODS

Guided by the grounded theory methodology, a PROM healthcare system implementation framework was developed following multiple steps. Based on interviews with 28 experts from 12 countries and a literature review, a framework was drafted and refined through 29 additional validation interviews.

RESULTS

The resulting framework comprises 5 implementation stages along 7 dimensions. Implementation stages range from "first experimentation" to "system-wide adoption and a vibrant ecosystem." The dimensions are grouped into patient-reported outcome (PRO) measurement and PRO utilization, the former with the dimensions "scope and condition coverage," "metric and process standardization," and "tools and information technology-based solutions" and the latter with "patient empowerment and clinical decision support," "reporting and quality improvement," and "rewarding and contracting." The "culture and stakeholder involvement" dimension connects both groups. Although a concerted implementation approach across dimensions can be observed in advanced countries, others show a more uneven adoption.

CONCLUSIONS

The framework and its preliminary application to different healthcare systems demonstrate (1) the importance of coherent progress across complementing dimensions and (2) the relevance of PROM integration across clinical specialties and care sectors to strengthen patient-centered care. Overall, the framework can facilitate dialogues between stakeholders to analyze the current PROM implementation status and strategies to advance it.

Bringing Patient-Reported Outcome Measures (PROMs) Into Practice: A Review of the Latest Developments in PROM Use in the Evaluation and Treatment of Carpal Tunnel Syndrome

As health care systems globally shift toward optimizing value, defined as health outcomes achieved per dollar spent across a full cycle of care, there has been increasing focus on using patient-reported outcome measures (PROMs) to gauge success. Patient-reported outcome measures are validated questionnaires that allow patients to share their health status across several domains (eg, pain or physical function). This trend has been particularly notable in hand surgery, with PROM use investigated for many common hand conditions, including carpal tunnel syndrome, Dupuytren contracture, trigger finger, osteoarthritis, and wrist ganglion. The purpose of this article is to review recent developments in the use of PROM instruments, including the Boston Carpal Tunnel Questionnaire; Michigan Hand Outcomes Questionnaire; Disabilities of the Arm, Shoulder, and Hand; and Patient-Reported Outcomes Measurement Information System, for the evaluation and treatment of patients with carpal tunnel syndrome. The considerable progress in establishing PROMs for use in carpal tunnel syndrome is reviewed, and future improvements are proposed to standardize PROM use and bring PROMs into day-to-day clinical practice for individualized patient treatment decision-making and counseling.

A comparative analysis of multidimensional computerized adaptive testing for the DASH and QuickDASH scores in Dupuytren's disease

The QuickDASH is a short-form version of the DASH questionnaire, the most widely used patient-reported outcome measure in hand surgery. Multidimensional computerized adaptive testing (MCAT) can produce shorter and more precise testing than static short forms, like QuickDASH. We used DASH responses from 507 patients with Dupuytren's disease to develop a MCAT. The algorithm was evaluated in a Monte Carlo simulation, where the standard error of measurement (SEm) of scores obtained from the 11-item QuickDASH was compared with scores obtained from an MCAT that could administer up to 11 items from the full 30-item DASH. The MCAT asked a mean of 8.51 items (SD 2.93) and 265/1000 simulated respondents needed to complete ≤five items. Median SEms were better for DASH MCAT: 0.299 (hand function) and 0.256 (sensory symptoms) versus 0.320 and 0.290, respectively, for QuickDASH. Our study showed that the DASH MCAT can produce more precise DASH measurement than the QuickDASH, from fewer items.

Outcome measurement in adult flexor tendon injury: A systematic review

BACKGROUND

Defining the optimal, evidence-based management of flexor tendon injury remains challenging. Lack of consensus on which measures to use to assess the outcome of interventions is a key issue, especially with regard to patient-reported outcome measures (PROMs). This systematic review defines the landscape of outcome measurement in studies on interventions for flexor tendon injuries to guide future research.

METHODS

A PRISMA-compliant systematic review was conducted using bespoke search strategies applied to MEDLINE, EMBASE, PsycINFO, CENTRAL, CINAHL and AMED. A protocol was developed and registered prospectively (CRD42020186780). We identified all studies describing adult patients undergoing interventions for acute hand flexor tendon injuries.

RESULTS

Of the 4844 studies, 114 studies met the final inclusion criteria for evaluating the outcomes of 8127 participants with 9071 injured digits. Studies included 24 randomised controlled trials, 19 cohort studies and 61 case series. Nine different PROMs were used in 24 studies (22%): three site-specific PROMs, one generic quality-of-life measure and four visual analogue scales. Clinician-reported outcome measures were used in 103 studies (96%), such as the range of motion reported in 102 studies (94%). Adverse outcomes were reported in 96 studies (89%), with the most frequently reported adverse outcomes being tendon rupture and infection. Re-operation was reported in 21 studies (19%). The most frequently reported health economic outcome measure was the length of work absence, reported in ten studies (9%).

CONCLUSIONS

There is variability in the use of outcome measures used to study interventions for flexor tendon injuries. An independent systematic review of the psychometric properties of the identified outcome measures and a specific multi-stakeholder consensus process may support optimal choice and standardisation for future studies.

The HAND-Q: Psychometrics of a New Patient-reported Outcome Measure for Clinical and Research Applications

The perspective of the patient in measuring the outcome of their hand treatment is of key importance. We developed a hand-specific patient-reported outcome measure to provide a means to measure outcomes and experiences of care from the patient perspective, that is, HAND-Q.

Factors Associated with the Development, Progression, and Outcome of Dupuytren Disease Treatment: A Systematic Review

BACKGROUND

The factors typically considered to be associated with Dupuytren disease have been described, such as those in the "Dupuytren diathesis." However, the quality of studies describing them has not been appraised. This systematic review aimed to analyze the evidence for all factors investigated for potential association with the development, progression, outcome of treatment, or recurrence of Dupuytren disease.

METHODS

A systematic review of the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and Cumulative Index to Nursing and Allied Health Literature databases was conducted using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant methodology up to September of 2019. Articles were screened in duplicate. Prognostic studies were quality assessed using the Quality in Prognosis Study tool.

RESULTS

This study identified 2301 records; 51 met full inclusion criteria reporting data related to 54,491 patients with Dupuytren disease. In total, 46 candidate factors associated with the development of Dupuytren disease were identified. There was inconsistent evidence between the association of Dupuytren disease and the presence of "classic" diathesis factors. The quality of included studies varied, and the generalizability of studies was low. There was little evidence describing the factors associated with functional outcome.

CONCLUSIONS

This systematic review challenges conventional notions of diathesis factors. Traditional diathesis factors are associated with disease development and recurrence, although they are not significantly associated with poor outcome following intervention based on the current evidence.

Patient-level barriers and facilitators to completion of patient-reported outcomes measures

PURPOSE

To identify patient-level barriers and facilitators to completion of patient-reported outcomes measures (PROMs) in a hand and upper extremity clinic in Baltimore, Maryland.

METHODS

We conducted 12 h of direct observation of PROM completion (October-November, 2020). Ethnographic observation memos were qualitatively analyzed for barriers and facilitators using rapid thematic analysis. Informed by observation findings, we conducted 17 semi-structured interviews with mixed-literacy patients, caregivers, and clinic staff to understand the patient experience when completing PROMs (November 2020-March 2021). We identified initial themes through inductive and deductive framework analysis and validated findings through subsequent interviews with member-checking.

RESULTS

We identified nine patient-level factors that influence PROM completion: platform design, print literacy, health literacy, technology literacy, language proficiency, physical functioning, vision, cognitive functioning, and time.

CONCLUSIONS

There are multiple distinct patient-level factors that affect PROM completion. Failure to consider these factors in PROM design and implementation may lower completion rates or prevent accurate completion, undermining PROM validity. Because certain factors affect minority populations at disproportionate rates, this may also contribute to existing health disparities.

Pain and numbness one month after carpal tunnel release predict patient-reported outcome measures at sixth months

A number of outcome predictors for carpal tunnel release (CTR) for carpal tunnel syndrome (CTS) have been reported. However, some predictors are controversial, and few studies have referred to the early postoperative outcome prognostic factors after CTR. The aim of this study was to investigate whether pain and numbness at 1 month post-CTR were early postoperative predictors of clinical outcomes 6 months after surgery. Pain and numbness were evaluated using the visual analog scale (VAS) preoperatively and at 1 month post-surgery. Patient-reported outcome measures (PROMs), including the Quick Disabilities of the Arm, Shoulder and Hand (QDASH) measure, the Hand20 questionnaire and the Boston Carpal Tunnel Questionnaire (BCTQ), were recorded for each patient 6 months after surgery. The BCTQ consisted of the Symptom Severity Scale (SSS) and Functional Status Scale (FSS). Multivariable linear regression analysis was performed to investigate the association between the VAS scores and PROMs. We retrospectively identified 93 patients who underwent open carpal tunnel release (OCTR) or endoscopic carpal tunnel release. The mean age of the patients was 67.5 years, and 67 patients (72.0%) were female. Sixty patients were treated by OCTR (65.0%). With multivariable linear regression analysis, we found that pain and numbness, evaluated with VAS 1 month post-surgery had significant correlations with QDASH, Hand20, SSS and FSS 6 months after surgery. In conclusion, pain and numbness 1 month after CTR predict PROMs at 6 months.