Health-Related Quality of Life for Patients with Post-Acute COVID-19 Syndrome: Identification of Symptom Clusters and Predictors of Long-Term Outcomes

BACKGROUND

Following COVID-19 infection, as many as a third of patients have long-term symptoms, known as post-acute sequelae (PASC). The mechanisms contributing to PASC remain largely unknown and, due to the heterogeneity of symptoms, treating PASC provides unique challenges.

OBJECTIVE

Our study sought to (1) identify clinical symptom profiles based on PROMIS Global Health (GH) items, (2) evaluate demographic and clinical differences across profiles, and (3) identify predictors of change in health-related quality of life (HRQL) over time.

DESIGN

This was an observational cohort study of patients with PASC who completed PROMIS-GH between 2/11/21 and 12/3/21 as part of routine care, with data extracted from the electronic health record.

PARTICIPANTS

There were 1407 adult patients (mean age 49.6 ± 13.7, 73% female, 81% White race) with PASC seen in the recovery clinic between 2/11/21 and 12/3/21, with 1129 (80.2%) completing PROMIS-GH as routine care.

MAIN MEASURES

HRQL was measured with PROMIS-GH at initial visit and after 12 months.

KEY RESULTS

Latent profile analysis identified symptom classes based on five PROMIS-GH items (mental health, ability to carry out physical activities, pain, fatigue, and emotional problems). Four latent profiles were identified: (1) "Poor HRQL" (n = 346), (2) "Mixed HRQL: good mental/poor physical" (n = 232), (3) "Mixed HRQL: poor mental/good physical" (n = 324), and (4) "Good HRQL" (n = 227). Demographics and comorbidities varied significantly across profile with patients with more severe COVID-19 infection more likely to be in profiles 1 and 2. Overall, patients improved 2 T-score points on PROMIS-GH after 12 months, with differences by profile. Predictors of improved HRQL included profile, lower body mass index, and fewer COVID symptoms.

CONCLUSIONS

Patients with PASC have distinct HRQL symptom profiles which were able to differentiate across COVID-19 severity and symptoms. Improvement over 12 months differed by profile. These profiles may be used to better understand the mechanisms behind PASC. Future research should evaluate their ability to guide treatment decisions to improve HRQL.

Comparison of stratification techniques for optimal management of patients with chronic low back pain in spine clinics

BACKGROUND CONTEXT

Identifying optimal stratification techniques for subgrouping patients with low back pain (LBP) into treatment groups for the purpose of identifying optimal management and improving clinical outcomes is an important area for further research.

PURPOSE

Our study aimed to compare performance of the STarT Back Tool (SBT) and 3 stratification techniques involving PROMIS domain scores for use in patients presenting to a spine clinic for chronic LBP.

STUDY DESIGN

Retrospective cohort study.

PATIENT SAMPLE

Adult patients with chronic LBP seen in a spine center between November 14, 2018 and May 14, 2019 who completed patient-reported outcomes (PROs) as part of routine care, and were followed up with completed PROs 1 year later.

OUTCOME MEASURES

Four stratification techniques, including SBT, and 3 PROMIS-based techniques: the NIH Task Force recommended Impact Stratification Score (ISS), symptom clusters based on latent class analysis (LCA), and SPADE symptom clusters.

METHODS

The 4 stratification techniques were compared according to criterion validity, construct validity, and prognostic utility. For criterion validity, overlap in characterization of mild, moderate, and severe subgroups were compared to SBT, which was considered the gold standard, using quadratic weighted kappa statistic. Construct validity compared techniques' ability to differentiate across disability groups defined by modified Oswestry LBP Disability Questionnaire (MDQ), median days in the past month unable to complete activities of daily living (ADLs), and worker's compensation using standardized mean differences (SMD). Prognostic utility was compared based on the techniques' ability to predict long-term improvement in outcomes, defined as improvement in global health and MDQ at 1-year.

RESULTS

There were 2,246 adult patients with chronic LBP included in our study (mean age 61.0 [SD 14.0], 55.0% female, 83.4% white). All stratification techniques resulted in roughly a third of patients grouped into mild, moderate, and severe categories, with ISS and LCA demonstrating substantial agreement with SBT, while SPADE had moderate agreement. Construct validity was met for all techniques, with large effects demonstrated between mild and severe categories for differentiating MDQ, ADLs, and worker's compensation disability groups (SMD range 0.57-2.48). All stratification techniques demonstrated ability to detect improvement by 1-year, with severe groups experiencing the greatest improvement in multivariable logistic regression models.

CONCLUSIONS

All 4 stratification techniques demonstrated validity and prognostic utility for subgrouping patients with chronic LBP based on risk of long-term disability. ISS and LCA symptom clusters may be the optimal methods given the improved feasibility of including only a few relevant PROMIS domains. Future research should investigate multidisciplinary treatment approaches to target mild, moderate, and severe patients based on these techniques.

Utilities Estimated from PROMIS Scales for Cost-Effectiveness Analyses in Stroke

BACKGROUND

The EQ-5D and Health Utilities Index Mark 3 (HUI-3) are preference-based measures used in cost-effectiveness studies. The Patient Reported Outcomes Measurement Information System (PROMIS) Preference scoring system (PROPr) is a new preference-based measure. In addition, algorithms were previously developed to map PROMIS Global Health (PROMIS-GH) items to HUI-3 using linear equating (HUILE) and 3-level EQ-5D using linear (EQ5DLE). We sought to evaluate and compare estimated utilities based on PROPr and PROMIS-GH in adult stroke survivors.

METHODS

We performed a retrospective cohort study of adults diagnosed with 1 of ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage seen in an outpatient clinic between 2015 and 2019. Patients completed PROMIS scales and other measures. We computed a modified version of PROPr (mPROPr) and compared the distributional characteristics and correlations with stroke outcomes for mPROPr, HUILE, and EQ5DLE.

RESULTS

T toal of 4,159 stroke survivors (average age 62.7 ± 14.7 y, 48.4% female, 77.6% ischemic stroke) were included. Mean utility estimates for mPROPr, EQ5DLE, and HUILE were 0.333 ± 0.244, 0.739 ± 0.201, and 0.544 ± 0.301, respectively. Correlations between the modified Rankin Scale and each of mPROPr and HUILE were both -0.48 and -0.43 for EQ5DLE. Regression analyses indicated that mPROPr scores may be too low for stroke patients in good health and that EQ5DLE scores may be too high for stroke patients in poor health.

CONCLUSIONS

All 3 PROMIS-based utilities were associated with measures of stroke disability and severity, but the distributions of utilities were very different. Our study highlights the problem cost-effectiveness researchers face of valuing health states with certainty. For researchers using utilities estimated from PROMIS scales, our study indicates that mapping PROMIS-GH item scores to HUI-3 via linear equating may be most appropriate in stroke patients.

HIGHLIGHTS

A new preference-based measure has been developed from the Patient Reported Outcomes Measurement Information System (PROMIS), known as the PROMIS-Preference (PROPr) scoring system, and published equations mapping PROMIS Global Health (PROMIS-GH) items to the Health Utilities Index Mark 3 (HUI-3) and EQ-5D-3L are available for use in cost-effectiveness studies.Our study provides distributional characteristics and comparisons of utilities estimated using a modified version of PROPr and equations mapping PROMIS-GH items to EQ-5D-3L and HUI-3 in a sample of stroke survivors.The results of our study show large differences in the distributions of utilities estimated using the different health state measures, and these differences highlight the ongoing difficulty researchers face in valuing health states with certainty.

Clinical characteristics and patient-reported outcomes of chronic and episodic migraine patients at a US tertiary headache center: A retrospective observational study

OBJECTIVE

To describe differences in clinical and demographic characteristics between patients with episodic migraine (EM) or chronic migraine (CM) and determine the effect of migraine subtype on patient-reported outcome measures (PROM).

BACKGROUND

Prior studies have characterized migraine in the general population. While this provides a basis for our understanding of migraine, we have less insight into the characteristics, comorbidities, and outcomes of migraine patients who present to subspecialty headache clinics. These patients represent a subset of the population that bears the greatest burden of migraine disability and are more representative of migraine patients who seek medical care. Valuable insights can be gained from a better understanding of CM and EM in this population.

METHODS

We conducted a retrospective observational cohort study of patients with CM or EM seen in the Cleveland Clinic Headache Center between January 2012 and June 2017. Demographics, clinical characteristics, and patient-reported outcome measures (3-Level European Quality of Life 5-Dimension [EQ-5D-3L], Headache Impact Test-6 [HIT-6], Patient Health Questionnaire-9 [PHQ-9]) were compared between groups.

RESULTS

Eleven thousand thirty-seven patients who had 29,032 visits were included. More CM patients reported being on disability 517/3652 (14.2%) than EM patients 249/4881 (5.1%) and had significantly worse mean HIT-6 (67.3 ± 7.4 vs. 63.1 ± 7.4, p < 0.001) and median [interquartile range] EQ-5D-3L (0.77 [0.44-0.82] vs. 0.83 [0.77-1.00], p < 0.001), and PHQ-9 (10 [6-16] vs. 5 [2-10], p < 0.001).

CONCLUSIONS

There are multiple differences in demographic characteristics and comorbid conditions between patients with CM and EM. After adjustment for these factors, CM patients had higher PHQ-9 scores, lower quality of life scores, greater disability, and greater work restrictions/unemployment.

Cognitive Impairment After Ischemic and Hemorrhagic Stroke: A Scientific Statement From the American Heart Association/American Stroke Association

PURPOSE

Cognitive impairment is a common consequence of stroke and has direct implications for poststroke functioning and quality of life, including the ability to maintain a job, live independently, sustain interpersonal relationships, and drive a vehicle. In this scientific statement, we critically appraise the literature on the prevalence, diagnosis, and management of poststroke cognitive impairment (PSCI) and provide a framework for clinical care while highlighting gaps that merit further study.

METHODS

We performed a scoping literature review of randomized controlled clinical trials, prospective and retrospective cohort studies, case-control studies, clinical guidelines, review articles, and editorials on the incidence and prevalence, natural history, diagnosis, and management of PSCI. Scoping reviews determine the scope of a body of literature on a given topic to indicate the volume of literature and the studies currently available and provide an overview of its focus.

RESULTS

PSCI is common after stroke, especially in the first year, and ranges from mild to severe. Although cognitive impairment is reversible in some cases early after stroke, up to one-third of individuals with stroke develop dementia within 5 years. The pathophysiology is not yet fully elucidated but is likely attributable to an acute stroke precipitating a series of pathological events, often in the setting of preexisting microvascular and neurodegenerative changes. Screening for associated comorbidities and interdisciplinary management are integral components of the care of individuals with PSCI. There is a need for prospective studies evaluating the individual trajectory of PSCI and the role of the acute vascular event in the predisposition for Alzheimer disease and related dementias, as well as high-quality, randomized clinical trials focused on PSCI management.

Impact of acute symptomatic seizures and their management on patient-reported outcomes after stroke

OBJECTIVE

Acute symptomatic seizures (ASyS) after stroke are not uncommon. However, the impact of ASyS and its management with anti-seizure medications (ASMs) on patient-reported outcome measures (PROMs) remains poorly investigated. The objective of our study is to evaluate the association between PROMs and ASyS and ASMs following stroke.

METHODS

We performed a retrospective cohort study of all stroke patients who underwent inpatient continuous EEG (cEEG) monitoring performed due to suspected ASyS, including the ones with observed convulsive ASyS, from 04/01/2012 to 03/31/2018, who completed PROMs within 6 months of hospital discharge. Patient-reported outcome measures, including one Neuro-QoL and six PROMIS v1.0 domain scales, were completed by patients as the standard of care in ambulatory stroke clinics. Since ASMs are sometimes used without clearly diagnosed ASyS, we performed group comparisons based on ASM status at discharge, irrespective of their ASyS status. T-tests or Wilcoxon rank sum tests compared continuous variables across groups and chi-square tests or Fisher's exact tests were used for categorical variables.

RESULTS

A total of 508 patients were included in the study [mean age 62.0 ± 14.1 years, 51.6% female; 244 (48.0%) ischemic stroke, 165 (32.5%) intracerebral hemorrhage, and 99 (19.5%) subarachnoid hemorrhage]. A total of 190 (37.4%) patients were discharged on ASMs. At the time of the first PROM, conducted a median of 47 (IQR = 33-78) days after the suspected ASyS, and 162 (31.9%) were on ASMs. ASM use was significantly higher in patients diagnosed with ASyS. Physical Function and Satisfaction with Social Roles and Activities were the most affected health domains. Patient-reported outcome measures were not significantly different between groups based on ASyS (electrographic and/or convulsive), ASM use at hospital discharge, or ASM status on the day of PROM completion.

SIGNIFICANCE

There were no differences in multiple domain-specific PROMs in patients with recent stroke according to ASyS status or ASM use suggesting the possible lack of the former's sensitivity to detect their impact. Additional research is necessary to determine if there is a need for developing ASyS-specific PROMs.

Stratification of Spine Patients based on Self-Reported Clinical Symptom Classes: Evaluation of Long-Term Outcomes and Subsequent Interventions

Background

Prior work by our group developed a stratification tool based on four PROMIS domains for patients with low back pain (LBP). Our study aimed to evaluate the ability of our previously developed symptom classes to predict long-term outcomes, and determine whether there were differential treatment effects by intervention.

Methods

This was a retrospective cohort study of adult patients with LBP seen in spine clinics in a large health system between November 14, 2018 and May 14, 2019 who completed patient-reported outcomes as part of routine care at baseline and again at 12-months follow-up. Latent class analysis identified symptom classes based on PROMIS domain scores (physical function, pain interference, social role satisfaction, and fatigue) that were ≥1 standard deviation worse (meaningfully worse) than the general population. The ability of the profiles to predict long-term outcomes at 12-months was evaluated through multivariable models. Differences in outcomes by subsequent treatments (physical therapy, specialist visits, injections, and surgery) were investigated.

Results

There were 3,236 adult patients (average age 61.1 ± 14.2, 55.4% female) included in the study with three distinct classes identified: mild symptoms (n = 986, 30.5%), mixed (n = 798, 24.7%) with poor scores on physical function and pain interference but better scores on other domains, and significant symptoms (n = 1,452, 44.9%). The classes were significantly associated with long-term outcomes, with patients with significant symptoms improving the most across all domains. Utilization differed across classes, with the mixed symptom class receiving more PT and injections and significant symptom class receiving more surgeries and specialist visits.

Conclusions

Patients with LBP have distinct clinical symptom classes which could be utilized to stratify patients into groups based on risk of future disability. These symptom classes can also be used to provide estimates of the effectiveness of different interventions, further increasing the clinical utility of these classes in standard care.

PROMIS global health: potential utility as a screener to trigger construct-specific patient-reported outcome measures in clinical care

PURPOSE

Patient-reported outcome measures (PROMs), including global health and construct-specific measures, are collected across healthcare systems. Efforts should be made to reduce data collection burden and individualize survey administration to patient needs. Our study evaluated the ability of utilizing items on a global health measure to identify patients who may require additional screening.

METHODS

A cross-sectional study was conducted of patients who completed PROMIS Global Health (GH) as part of routine care, as well as additional construct-specific surveys, in a large healthcare system from 1/1/2016 to 12/31/2018. Receiver operating characteristic (ROC) analysis identified optimal thresholds for PROMIS GH items identifying clinically meaningful thresholds on construct-specific PROMs: PHQ-9 score ≥10, Neuro-QoL Cognitive Function, PROMIS Physical Function, and Satisfaction with Social Roles and Activities T-score ≤40, PROMIS Anxiety, Fatigue, Sleep Disturbance, and Pain Interference T-score ≥60.

RESULTS

There were 206,685 patients who completed PROMIS GH and additional construct-specific surveys. Scores ≤3 on PROMIS GH item 10 (emotional problems) had 90.0% sensitivity (area under the curve (AUC) = 0.821) for identifying patients with moderate-severe depressive symptoms on PHQ-9. Similarly high sensitivities and AUCs were demonstrated for PROMIS GH items assessing mental and physical health, fatigue, and pain to identify poor scores on their corresponding construct-specific PROMs.

CONCLUSIONS

Our study provides preliminary support for the ability of utilizing PROMIS GH items as screening tools to identify patients with poor scores on additional construct-specific PROMs. Through directing construct-specific PROMs to patients for whom they are most applicable, survey burden could be reduced for many patients, allowing a more efficient and targeted use of PROMs in healthcare decision-making.

Mapping PROMIS physical function and pain interference to the modified low back pain disability questionnaire

PURPOSE

The Modified Low Back Pain Disability Questionnaire (MDQ) is a commonly used tool to assess functioning of patients with low back pain (LBP). Recently, the Patient-Reported Outcomes Measurement Information System (PROMIS) was suggested as an alternative platform to assess LBP patient-reported health. We sought to map between the MDQ and PROMIS Physical Function (PROMIS-PF) and Pain Interference (PROMIS-PI) scales using multiple methods.

METHODS

In a retrospective analysis of LBP patients seen at Cleveland Clinic 11/14/18-12/11/19, T-scores from each PROMIS scale were mapped to MDQ total score individually and together. MDQ item and total scores were mapped to each PROMIS scale. Linear regression as well as linear and equipercentile equating were used. Split sample internal validation using root mean squared error (RMSE), mean absolute error (MAE), and correlations were used to assess accuracy of mapping equations.

RESULTS

13585 patients completed the three scales. In the derivation cohort, average age was 59.0 (SD = 15.8); 53.3% female and 82.9% white. Average MDQ total, PROMIS-PF, and PROMIS-PI T-scores were 40.3 (SD = 19.0), 37.2 (SD = 7.6), and 62.9 (SD = 7.2), respectively. For estimating MDQ total scores, methods that used both PROMIS-PF and PROMIS-PI had closest estimated means, lowest RMSE and MAE, and highest correlations. For estimating each of PROMIS-PF and PROMIS-PI T-scores, the best performing method was equipercentile equating using the MDQ items.

CONCLUSIONS

We created and internally validated maps between MDQ and PROMIS-PF and PROMIS-PI using linear regression, linear and equipercentile equating. Our equations can be used by researchers wishing to translate scores between these scales.

Optimal Methods for Reducing Proxy-Introduced Bias on Patient-Reported Outcome Measurements for Group-Level Analyses

BACKGROUND

Caregivers, or proxies, often complete patient-reported outcomes (PROs) on behalf of patients; yet, research has demonstrated proxies rate patient outcomes worse than patients rate their own outcomes. To improve interpretability of PROs in group-level analyses, our study aimed to identify optimal approaches for reducing proxy-introduced bias in the analysis of PROs.

METHODS

Data were simulated based on 200 patients with stroke and their proxies who both completed 9 PROMIS domains as part of a cross-sectional study. The sample size was varied as 50, 100, 200, and 500, and the proportion of patients with proxy-respondents was varied as 10%, 20%, and 50%. Six methods for handling proxy-completions were investigated: (1) complete case analysis; (2) proxy substitution; (3) Method 2 plus proxy adjustment; (4) Method 3 including inverse-probability of treatment weighting; (5) multiple imputation; (6) linear equating. These methods were evaluated by comparing average bias in PROMIS T-scores (estimated versus observed patient-only responses), as well as by comparing estimated regression coefficients to models using patient-only responses.

RESULTS

Overall mean T-score differences ranged from 0 to 1.75. The range of mean differences varied by the 6 methods with methods 1 and 5 providing estimates closest to the observed mean. In regression models, all but inverse-probability of treatment weighting resulted in low bias when proxy-completions were 10% to 20%. With 50% proxy-completions, method 5 resulted in less accurate estimations while methods 1 to 3 provided less proxy-introduced bias. Bias remained low across domain and varying sample sizes but increased with larger percentages of proxy-respondents.

CONCLUSIONS

Our study found modest proxy-introduced bias when estimating PRO scores or regression estimates across multiple domains of health. This bias remained low, even when sample size was 50 and there were large proportions of proxy-completions. While many of these methods can be chosen for including proxies in stroke PRO research with <20% proxy-respondents, proxy substitution with adjustment resulted in low bias with 50% proxy-respondents.

Evidence of Stability in Patient-Reported Global Health During the COVID-19 Pandemic

OBJECTIVES

Measures of health-related quality of life (HRQOL) are collected throughout healthcare systems and used in clinical, economic, and outcomes studies to direct patient-centered care and inform health policy. Studies have demonstrated increases in stressors unique to the COVID-19 pandemic, however, their effect on HRQOL is unknown. Our study aimed to assess the change in self-reported global health during the pandemic for patients receiving care in a large healthcare system compared with 1 year earlier.

METHODS

An observational cross-sectional study of 2 periods was conducted including adult patients who had a healthcare appointment and completed the Patient-Reported Outcomes Measurement Information System Global Health (PROMIS GH) as standard care during the COVID-19 pandemic and a year earlier. The effect of time on PROMIS global mental health (GMH) and global physical health (GPH) was evaluated through multiple statistical methods.

RESULTS

There were 38 037 patients (mean age 56.1 ± 16.6 years; 61% female; 87% white) who completed the PROMIS GH during the pandemic (August 2020) and 33 080 (age 56.7 ± 16.5 years; 61% female; 86% white) who had completed it 1 year earlier (August 2019). GMH was significantly worse, whereas GPH was similar during the pandemic compared with a year earlier (adjusted estimate [standard error]: -1.21 (0.08) and 0.11 (0.08) T-score points, respectively).

CONCLUSIONS

Our study found modest, nonclinically meaningful decreases in GMH and similar GPH during the COVID-19 pandemic compared with a year earlier in patients cared for in a large healthcare system. Nevertheless, healthcare systems are likely seeing a biased sample of patients during these times. Findings from our study have implications for the interpretation of HRQOL during this pandemic.

Patient-proxy agreement on change in acute stroke patient-reported outcome measures: a prospective study

Objectives

Research has indicated proxies overestimate symptoms on patients’ behalves, however it is unclear whether patients and proxies agree on meaningful change across domains over time. The objective of this study is to assess patient-proxy agreement over time, as well as agreement on identification of meaningful change, across 10 health domains in patients who underwent acute rehabilitation following stroke.

Methods

Stroke patients were recruited from an ambulatory clinic or inpatient rehabilitation unit, and were included in the study if they were undergoing rehabilitation. At baseline and again after 30 days, patients and their proxies completed PROMIS Global Health and eight domain-specific PROMIS short forms. Reliability of patient-proxy assessments at baseline, follow-up, and the change in T-score was evaluated for each domain using intra-class correlation coefficients (ICC(2,1)). Agreement on meaningful improvement or worsening, defined as 5+ T-score points, was compared using percent exact agreement.

Results

Forty-one patient-proxy dyads were included in the study. Proxies generally reported worse symptoms and functioning compared to patients at both baseline and follow-up, and reported less change than patients. ICCs for baseline and change were primarily poor to moderate (range: 0.06 (for depression change) to 0.67 (for physical function baseline)), and were better at follow-up (range: 0.42 (for anxiety) to 0.84 (for physical function)). Percent exact agreement between indicating meaningful improvement versus no improvement ranged from 58.5–75.6%. Only a small proportion indicated meaningful worsening.

Conclusions

Patient-proxy agreement across 10 domains of health was better following completion of rehabilitation compared to baseline or change. Overall change was minimal but the majority of patient-proxy dyads agreed on meaningful change. Our study provides important insight for clinicians and researchers when interpreting change scores over time for questionnaires completed by both patients and proxies.

Changes in Health-Related Quality of Life After Transient Ischemic Attack

IMPORTANCE

Numerous studies have found that patients diagnosed with TIA have decreased health-related quality of life, which has been interpreted as suggesting that patients with TIA have residual symptoms after the event. Studies assessing health status in the same patients before and after an event are lacking but may allow a direct determination of the association of TIA with postevent health status.

OBJECTIVE

To examine patient-reported health before transient ischemic attack (TIA) among individuals diagnosed with this event and evaluate change in patient-reported health after the event overall and by TIA characterization subgroups.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted among 236 patients with a clinical diagnosis of TIA from October 2015 to December 2017 in a large US health system that collects a patient-reported outcome measure in ambulatory setting as part of routine care. Included patients had patient-reported global health scale assessments completed as part of routine care before and after a TIA event. Data were analyzed from March through July 2020.

MAIN OUTCOMES AND MEASURES

The main outcome was Patient-Reported Outcome Measurement Information System Global Health (PROMIS GH) scale score before and after TIA. A change of 5 or more points in this score is considered clinically relevant. The secondary outcomes included change in patient-reported global health by clinical impression of the probability of a TIA event, pattern of neurological deficits, and short-term risk of stroke, as assessed by the ABCD2 score.

RESULTS

Among 263 patients who experienced TIA, mean (SD) age was 67.9 (13.4) years and 138 (52.5%) were women. The median (interquartile range) time between patient-reported global health scores was 152 (94-284) days. Mean (SD) baseline patient-reported global physical health and mental health scale summary scores were 43.4 (8.2) and 47.7 (9.7), respectively, and were statistically significantly decreased compared with the general population mean (SD) scores of 50 (10; P < .001) for physical and mental health. The difference between physical health summary score among study participants and the general population was clinically relevant. Mean (SD) summary scores were not statistically significantly different after the event compared with before the event overall (physical health: 44.1 [8.2], for a mean [SE] improvement of 0.65 [0.38] points; P = .09; mental health: 47.4 [9.1], for a mean [SE] worsening of 0.25 [0.38] points; P = .51) or within subgroups.

CONCLUSIONS AND RELEVANCE

These findings suggest that impaired health status among patients diagnosed with TIA reflect, at least in part, an impaired premorbid state of health. This study did not find that TIA events were associated with worsening of health status overall or within subgroups.

Sleep disturbance predicts future health status after stroke

STUDY OBJECTIVES

We evaluated factors associated with the presence of sleep disturbance in patients with stroke and whether sleep disturbance predicted change in other patient-reported domains of health over time.

METHODS

Observational cohort study of 2,190 patients with stroke seen in a cerebrovascular clinic February 17, 2015 to July 5, 2017 who completed patient-reported outcome measures (PROMs) at ≥ 1 visit, including the Patient Health Questionnaire-9 depression screen, Quality of Life in Neurological Disorders (NeuroQoL) cognitive function and Patient-Reported Outcomes Information Measurement System (PROMIS) sleep disturbance, fatigue, anxiety, social role satisfaction, physical function, and pain interference. Separate multivariable models were constructed with PROMIS sleep disturbance as the dependent variable. Covariates included clinical and demographic variables, the Patient Health Questionnaire-9 depression screen scored on the PROMIS metric, and 1 of the 6 other PROMs. Among the 476 patients with ≥ 2 visits, linear regression models were constructed to determine the association of baseline sleep disturbance with follow-up PROMs after adjustment for the corresponding baseline PROMIS/NeuroQol scores, depression score, and clinical variables.

RESULTS

Younger age and all PROM scores were associated with sleep disturbance; depression had the greatest association among PROMs (beta estimate 0.53, 95% confidence interval, 0.49, 0.57), physical function had the least (-0.06, 95% confidence interval, -0.11, -0.01). Baseline PROMIS sleep disturbance score was associated with worse adjusted follow-up scores for depression, fatigue, social role satisfaction, and physical function.

CONCLUSIONS

Younger age and all 8 PROMs were associated with sleep disturbance in patients with stroke. The degree of sleep disturbance predicted future patient-reported outcomes for multiple domains of health. Further study is warranted to determine if interventions shown to improve sleep symptoms will also improve other outcomes.

Group-level analyses involving scores linked from legacy scales to PROMIS scales: A novel alternative using imputation

As the implementation of Patient-Reported Outcomes Measurement Information System (PROMIS) scales has increased, so has the number of studies linking legacy scale scores to PROMIS scale scores. Variability in linked scores for a given PROMIS score can be considerable, leading to potential bias. An alternative method is imputation using a bridge study. We sought to compare linking to this alternative novel method in group-level analyses using linked legacy scores. Adult patients who completed PROMIS Depression and Patient Health Questionnaire (PHQ-9) were included. We randomly allocated data samples to be missing either PROMIS Depression or PHQ-9. We estimated PROMIS T scores using six methods: Linking methods by Choi et al. (2014), linking in our internal data, imputation using bridge study data from external data and from our internal data, each with and without patient demographics. Estimated mean PROMIS T scores using the linking and imputation methods were compared to actual PROMIS T scores across varying proportions of missingness and sample size. We also compared regression coefficients for the six estimation methods to a model using actual PROMIS T scores. Mean estimated versus actual PROMIS T scores varied between 1 and 4 points for the linking methods and within 0.4 points for the imputation method using internal data with patient demographics. The imputation methods had estimated regression coefficients closer to that of the model using actual scores as compared to the linking methods. For group-level analyses, imputation using a bridge study may be a feasible alternative to using linked scores or can be used as a sensitivity analysis. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Somatic symptoms have negligible impact on Patient Health Questionnaire-9 depression scale scores in neurological patients

BACKGROUND AND PURPOSE

There is concern that the Patient Health Questionnaire-9 (PHQ-9) depression scale may be impacted by the presence of somatic symptoms (differential item functioning [DIF]) in patients with neurological conditions. We evaluated the PHQ-9 for the presence and impact of DIF in large clinical samples of neurological patients.

METHODS

We conducted a cross-sectional study of patients seen at the Cleveland Clinic Cerebrovascular, Headache, Movement Disorder, and Neuromuscular clinics who completed the PHQ-9 and patient-reported disease severity measures as part of standard care between 29 July 2008 and 21 February 2013. We evaluated PHQ-9 items for DIF with respect to disease-specific severity for each condition. Salient DIF impact was characterized as a difference between DIF-adjusted and unadjusted PHQ-9 scores.

RESULTS

Included in the study were 2112 patients with stroke, 8221 with migraine, 440 with amyotrophic lateral sclerosis (ALS), and 5022 with Parkinson disease (PD). Several PHQ-9 items demonstrated DIF with respect to disease-specific severity, although salient DIF was present in very few patients (stroke, n = 0; migraine, n = 1; ALS, n = 13; PD, n = 1).

CONCLUSIONS

PHQ-9 items function consistently across disease severity, with salient levels of DIF impact found only for a very small proportion of people. These results suggest that the PHQ-9 provides a consistent measure of depression severity among people with neurological conditions associated with somatic symptoms that overlap with depression.

Patient-Reported Outcomes Predict Future Emergency Department Visits and Hospital Admissions in Patients With Stroke

Background

Identification of stroke patients at increased risk of emergency department (ED) visits or hospital admissions allows implementation of mitigation strategies. We evaluated the ability of the Patient‐Reported Outcomes Information Measurement System (PROMIS) patient‐reported outcomes (PROs) collected as part of routine care to predict 1‐year emergency department (ED) visits and admissions when added to other readily available clinical variables.

Methods and Results

This was a cohort study of 1696 patients with ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, or transient ischemic attack seen in a cerebrovascular clinic from February 17, 2015, to June 11, 2018, who completed the following PROs at the visit: Patient Health Questionnaire‐9, Quality of Life in Neurological Disorders cognitive function, PROMIS Global Health, sleep disturbance, fatigue, anxiety, social role satisfaction, physical function, and pain interference. A series of logistic regression models was constructed to determine the ability of models that include PRO scores to predict 1‐year ED visits and all‐cause and unplanned admissions. In the 1 year following the PRO encounter date, 1046 ED visits occurred in 548 patients; 751 admissions occurred in 453 patients. All PROs were significantly associated with future ED visits and admissions except PROMIS sleep. Models predicting unplanned admissions had highest optimism‐corrected area under the curve (range, 0.684–0.724), followed by ED visits (range, 0.674–0.691) and then all‐cause admissions (range, 0.628–0.671). PROs measuring domains of mental health had stronger associations with ED visits; PROs measuring domains of physical health had stronger associations with admissions.

Conclusions

PROMIS scales improve the ability to predict ED visits and admissions in patients with stroke. The differences in model performance and the most influential PROs in the prediction models suggest differences in factors influencing future hospital admissions and ED visits.

Abstract P238: Importance of Self-Efficacy in the Patient-Reported Physical Function of Patients With Stroke

Background: Self-efficacy is the belief that one is able to respond to demands of a stressful situation and it has both direct and indirect effects on health. The study objective is to investigate the amount of variance in patient-reported physical function (PF) that is explained by self-efficacy compared to clinician-reported disability and other patient-reported domains of health, and evaluate whether self-efficacy mediates the relationship between PF and other domains of health.

Methods: Observational cohort study of 248 patients who were seen in a cerebrovascular clinic 3/18/20 - 7/7/20 and completed the following patient-reported outcome measures (PROMs) as part of the routine office visit: PROMIS PF, general self-efficacy, fatigue, and pain interference. Linear regression models were constructed to determine the amount of variance (adjusted R 2 ) in PROMIS PF score explained by the modified Rankin Scale (mRS) and additional PROM scores. The mRS and individual PROMs were added separately to a base model adjusted for demographic characteristics. Mediation analysis was conducted to determine the extent to which self-efficacy mediated the relationship between PF and other PROMs.

Results: Mean age of study cohort was 61.5 (SD=13.5) years and 48.4% were female. The base model explained 4.5% of the variance of PF. Adding PROMIS fatigue resulted in the largest increase in the proportion of variance explained (adj R 2 = 47.7%), followed by PROMIS self-efficacy (40.7%), PROMIS pain interference (38.7%), and mRS (26.6%). Self-efficacy significantly mediated the relationship between fatigue and PF (standardized indirect effect: 0.11 (bias-corrected 95% CI: 0.05-0.18), 20.9% of total effect) and pain interference and PF (standardized indirect effect 0.10 (95% CI: 0.06-0.17), 27.1% of total effect).

Conclusion: PROMIS self-efficacy explains more variance in stroke patients’ perceived physical function than their disability. This suggests that interventions to improve self-efficacy could have a significant effect on patient’s perceived health. Patients’ fatigue, despite being partially mediated by self-efficacy, was a large contributor to self-reported PF and should be included as part of an evaluation of patient’s physical health.

The validity of proxy responses on patient-reported outcome measures: Are proxies a reliable alternative to stroke patients' self-report?

PURPOSE

Caregivers, or proxies, often complete patient-reported outcome measures (PROMs) on behalf of patients with stroke. The objective of our study was to assess the validity and responsiveness of proxy-responses compared to patient-responses across multiple domains of health.

METHODS

Stroke patients and their proxies were recruited to complete PROMs between 7/2018-11/2019. PROMs included Neuro-QoL cognitive function, PROMIS physical function, satisfaction with social roles, anxiety, fatigue, pain interference, sleep disturbance, Global Health, and PHQ-9. Internal consistency and convergent validity were compared between patient- and proxy-reported measures. Known-groups validity was assessed across levels of stroke disability. Internal responsiveness was evaluated using paired t-tests for a subset of patients who attended rehabilitation following stroke. Analyses were stratified by patients ≤ 3 vs > 3 months from stroke.

RESULTS

This cross-sectional study included 200 stroke patients (age 62.2 ± 13.3, 41.5% female) and their proxies (age 56.5 ± 13.9, 70% female, 72% spouses). PROMs had high internal consistency and were significantly correlated for patients and proxies. Patient- and proxy-reported measures worsened with increasing stroke disability. For 34 (17%) patients who attended rehabilitation, patients self-reported improvement on 5 domains whereas proxies reported no improvement. Compared to patient self-reports, validity was worse for proxy-reports on patients ≤ 3 months but better > 3 months from stroke.

CONCLUSIONS

Both patient- and proxy-reported PROMs demonstrated strong validity. Only patient-reported PROMs were responsive to change, and proxies had worse validity for patients ≤ 3 months from stroke but better validity for patients > 3 months from stroke. These findings justify the utilization of proxy responses in stroke patients > 3 months from stroke.

A Cost-Effectiveness Framework for Amyotrophic Lateral Sclerosis, Applied to Riluzole

OBJECTIVES

Reexamine cost-effectiveness of riluzole in the treatment of amyotrophic lateral sclerosis (ALS) in light of recent advances in disease staging and understanding of stage-specific drug effect.

METHODS

ALS was staged according to the "fine'til 9" (FT9) staging method. Stage-specific health utilities (EQ-5D, US valuation) were estimated from an institutional cohort, whereas literature informed costs and transition probabilities. Costs at 2018 prices were disaggregated into recurring costs (RCs) and "one-off" transition/"tollgate" costs (TCs). Five- and 10-year horizons starting in stage 1 disease were examined from healthcare sector and societal perspectives using Markov models to evaluate riluzole use, at a threshold of $100 000/quality-adjusted life year (QALY). Probabilistic and deterministic sensitivity analyses were conducted.

RESULTS

Mean EQ-5D utilities for stages 0 to 4 were 0.79, 0.74, 0.63, 0.54, and 0.46, respectively. From the healthcare sector perspective at the 5-year horizon, riluzole use contributed to 0.182 QALY gained at the cost difference of $12 348 ($5403 riluzole cost, $8870 RC and -$1925 TC differences), translating to an incremental cost-effectiveness ratio (ICER) of $67 658/QALY. Transition probability variation contributed considerably to ICER uncertainty (-30.2% to +90.0%). ICER was sensitive to drug price and RCs, whereas higher TCs modestly reduced ICER due to delayed tollgates.

CONCLUSION

This study provides a framework for health economic studies of ALS treatments using FT9 staging. Prospective stage-specific and disaggregated cost measurement is warranted for accurate future cost-effectiveness analyses. Appropriate separation of TCs from RCs substantially mitigates the high burden of background cost of care on the ICER.

Magnitude and Variability of Stroke Patient-Proxy Disagreement Across Multiple Health Domains

OBJECTIVES

To quantify the extent and variability of bias introduced when caregivers, or proxies, complete patient-reported outcome measures (PROM) on behalf of stroke patients.

DESIGN

Cross-sectional survey study conducted between July 2018 and November 2019.

SETTING

Ambulatory clinic of a cerebrovascular center or rehabilitation unit.

PARTICIPANTS

A consecutive sample of stroke patients (N=200) and their proxies who were able and willing to complete PROMs. Proxies completed PROMs as they believed the patient would answer.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

PROMs included Neuro-QoL cognitive function, PROMIS physical function, social role satisfaction, anxiety, fatigue, pain interference, sleep disturbance, Patient Health Questionnaire-9 translated to PROMIS Depression, and PROMIS Global Health.

RESULTS

The study included 200 stroke patients (age, 62.2±13.3; 41.5% women) and their proxies (age 56.5±13.9; 70% women, 72% spouses). Proxies reported worse functioning and more symptoms across all PROM domains compared with patients (average difference, 0.3-3.0 T score points). Reliability between dyad responses was moderate across all domains (intraclass correlation coefficients (2,1), 0.49-0.76) and effect sizes were small (d=0.04-0.35). Cognitive function, anxiety, and depression had the lowest agreement, whereas physical function, pain, and sleep had the highest agreement based on the Bland-Altman method. At the individual level, a large proportion of dyads had meaningfully different scores across domains (range, 40%-57%; dyads differed >5 T score points). Few predictors of disagreement were identified through multinomial regression models.

CONCLUSIONS

At the aggregate level, small differences were detected between stroke patient-proxy pairs, with lower agreement on more subjective domains. At the individual level, a large proportion of dyads reported meaningfully different scores on all domains, affecting the interpretability of proxy responses on PROMs in a clinical setting.

Clinical Symptom Profiles After Mild-Moderate Stroke

Background

There is heterogeneity in the severity of domains affected in patients with stroke, resulting in differences in health‐related quality of life (hrQoL). Identifying different clinical profiles of stroke patients may provide a means for selecting patients for tailored interventions to improve hrQoL.

Methods and Results

This was an observational study of 496 patients with ischemic stroke or intracerebral hemorrhage seen in a cerebrovascular clinic from October 12, 2015, through June 11, 2018, who completed patient‐reported outcome measures using Patient‐Reported Outcome Measurement Information System (PROMIS) tools within 1 month of stroke. Latent profile analysis identified groups based on PROMIS domain scores—pain, depression, cognitive function, fatigue, social role satisfaction, and physical function—as well as clinician‐reported modified Rankin Scale (mRS). Five distinct profiles were identified. Group 1 (“excellent hrQoL,” n=106) had fewer symptoms in all domains than the general population. Group 2 (“disabled with mixed hrQoL,” n=17) had fewer symptoms than the general population in all domains except social role satisfaction and physical function, despite having moderate disability (median mRS score: 3). Group 3 (“mild limitations with average hrQoL,” n=189) had scores similar to the general population for all domains and minimal disability (median mRS score: 1). Group 4 (“mild limitations with poor hrQoL,” n=152) also had a median mRS score of 1 but had worse scores than group 3 on all domains. Group 5 (“disabled with poor hrQoL,” n=32) had worse symptoms than patients in the other profiles and a median mRS score of 3.

Conclusions

Patients with recent stroke have distinct clinical symptom profiles, even with similar levels of clinician‐reported disability. Symptom profiles provide a means of understanding patterns of outcomes in patients with stroke.

Sleep-related symptoms in patients with mild stroke

STUDY OBJECTIVES

Treatable sleep-related conditions are frequent in stroke patients, although their prevalence across stroke types and ideal method for screening is not clear. The objectives of this study were to evaluate the prevalence of sleep disturbance across different stroke types and identify approaches to the collection of sleep-related measures in clinical practice.

METHODS

We performed an observational cohort study of 2,213 patients with ischemic stroke, intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), or transient ischemic attack seen in a cerebrovascular clinic February 17, 2015 through July 5, 2017 who completed at least one of the following sleep-related questionnaires: Patient-Reported Outcomes Measurement Information System (PROMIS) sleep disturbance, Insomnia Severity Index (ISI), Sleep Apnea Probability Scale (SAPS), and sleep duration. Prevalence of abnormal scores were calculated using the following thresholds: PROMIS sleep disturbance ≥ 55, ISI ≥ 15, SAPS score ≥ 0.50, and sleep duration fewer than 6 or more than 9 hours. Sensitivity, specificity, and positive and negative predictive values of PROMIS sleep disturbance T-score ≥ 55 to identify patients with moderate-severe insomnia (ISI ≥ 15) were computed.

RESULTS

In the cohort, 28.6% patients (624/2183) had PROMIS sleep disturbance score ≥ 55, 17.6% (142/808) had ISI ≥ 15, and 61.3% (761/1241) had a positive SAPS screen. The frequency of abnormal sleep scale scores was similar across time periods and stroke types. The sensitivity and specificity of PROMIS sleep disturbance T-score ≥ 55 to identify patients with ISI ≥ 15 were 0.89 (95% confidence interval 0.83-0.94) and 0.81 (95% confidence interval 0.78-0.84), respectively.

CONCLUSIONS

The prevalence of sleep-related symptoms in patients with mild stroke are similar across stroke types and time periods after stroke. Potential approaches to screening for sleep disturbance in stroke patients are provided.

Impact of Positive Airway Pressure on International Restless Legs Syndrome Score in Sleep Disordered Breathing

Study Objective: Studies have shown increased prevalence of restless legs syndrome (RLS) in sleep disordered breathing (SDB), however limited data have focused on the impact of SDB therapy on RLS. We hypothesize that positive airway pressure (PAP) will improve the International Restless Legs Syndrome (IRLS) score among SDB patients compared to patients without PAP. Methods: Patients with AHI ≥ 5 who responded positively to a RLS qualifier question from January 2010 to May 2015 were included in this retrospective study. IRLS score was used to measure RLS symptom severity. Two-sample t-tests and one-way analysis of variance were used to compare changes in IRLS score and linear regression models were created to examine IRLS change with PAP use and PAP adherence (PAP usage ≥4 h nightly for ≥70% of nights), adjusting for potential confounders. Results: In 434 patients (51.9 ± 13.4years, 50.5% female, 77.6% Caucasian; 325 PAP, 109 control), IRLS scores improved from baseline to follow-up, with the PAP group achieving significant improvement after adjustment for covariates (difference in IRLS: −1.8 (CI −3.6,0.00), p = 0.050). In self-reported PAP adherent patients, IRLS improvement was greater than controls (−5.3 ± 7.4 vs. −2.7 ± 7.6 respectively, p = 0.045), and comparable to non-adherent patients (−5.3 ± 7.4 vs. −3.0 ± 7.0, p = 0.091). Conclusions: Among SDB patients with a positive RLS qualifier, those who used PAP therapy achieved significantly greater improvement in IRLS scores than patients who did not use PAP, with more significant changes in the PAP adherent group. This is the first large clinical study to examine these relationships, providing a basis for future prospective interventional trials and informing clinicians of expected improvement in IRLS score in PAP treated SDB populations.

Ultrasound Criteria for Assessment of Vertebral Artery Origins

BACKGROUND AND PURPOSE

We sought to validate ultrasound as a reliable means of assessing vessel stenosis of vertebral artery origins.

METHODS

We reviewed 1,135 patient charts with ultrasound of the posterior circulation performed in 2008-2015 in a single hospital. Inclusion criteria for native vessels consisted of ultrasound and digital subtraction angiography (DSA) performed within 3 months. Patients with indwelling stents were analyzed separately from native vessels. Using DSA as the gold standard, we determined sensitivity and specificity of ultrasound in detecting occlusion at vertebral artery origin. All patients with nonoccluded native vertebral artery origins were evaluated for degree of stenosis on DSA, and compared to mean flow velocity (MFV), peak systolic velocity (PSV), and end-diastolic velocity (EDV) on ultrasound.

RESULTS

Among 218 vertebral artery origins in 139 patients evaluated, ultrasound showed sensitivity of 85.7% (95% confidence interval (CI): 69.7-95.2%) for occlusion and specificity of 99.5% (95%CI: 96.9-99.9%). Among 126 arteries without occlusion, <50% stenosis had average MFV (39 ± 19 cm/s), 50-69% stenosis had average MFV (68 ± 35 cm/s), and severe (70-99%) stenosis had average MFV (120 ± 93 cm/s) (P < .001). MFV cutoff value of 44 cm/s corresponded to 77% sensitivity and 70% specificity to detect vertebral artery origin stenosis >50% (C-statistic: .81). PSV value of 97 cm/s corresponded with 72% sensitivity and 70% specificity to detect >50% stenosis (C-statistic: .77). MFV cutoff value of 60 cm/s corresponded with 70% sensitivity and 82% specificity to predict 70-99% stenosis (C-statistic: .83). PSV cutoff value of 110 cm/s corresponded with 80% sensitivity and 72% specificity to predict 70-99% stenosis (C-statistic: .84).

CONCLUSION

Ultrasound has good sensitivity and excellent specificity for detecting vertebral origin occlusion. Flow velocity can be used to screen for severe stenosis of vertebral artery at origin.

PROMIS Global Health item nonresponse: is it better to impute missing item responses before computing T-scores?

PURPOSE

Item response theory (IRT) scoring provides T-scores for physical and mental health subscales on the Patient-Reported Outcomes Measurement Information System Global Health questionnaire (PROMIS-GH) even when relevant items are skipped. We compared different item- and score-level imputation methods for estimating T-scores to the current scoring method.

METHODS

Missing PROMIS-GH items were simulated using a dataset of complete PROMIS-GH scales collected at a single tertiary care center. Four methods were used to estimate T-scores with missing item scores: (1) IRT-based scoring of available items (IRT_avail), (2) item-level imputation using predictive mean matching (PMM), (3) item-level imputation using proportional odds logistic regression (POLR), and (4) T-score-level imputation (IMP_direct). Performance was assessed using root mean squared error (RMSE) and mean absolute error (MAE) of T-scores and comparing estimated regression coefficients from the four methods to the complete data model. Different proportions of missingness and sample sizes were examined.

RESULTS

IRT_avail had lowest RMSE and MAE for mental health T-scores while PMM had lowest RMSE and MAE for physical health T-scores. For both physical and mental health T-scores, regression coefficients estimated from imputation methods were closer to those of the complete data model.

CONCLUSIONS

The available item scoring method produced more accurate PROMIS-GH mental but less accurate physical T-scores, compared to imputation methods. Using item-level imputation strategies may result in regression coefficient estimates closer to those of the complete data model when nonresponse rate is high. The choice of method may depend on the application, sample size, and amount of missingness.

Association Between Patient Experience With Patient-Reported Outcome Measurements and Overall Satisfaction With Care in Neurology

BACKGROUND

There has been increasing focus on both patient-reported outcome measurement (PROM) collection and patient satisfaction ratings; nevertheless, little is known about their relationship.

OBJECTIVES

To determine the association between patient experience with PROM collection and visit satisfaction and to identify characteristics of better ratings for each.

METHODS

This cross-sectional observational study included all patients seen in 15 neurological clinics who completed PROMs as well as 6 questions on the patient experience with PROMs at least once from October 1, 2015 to December 31, 2016. Visit satisfaction was evaluated using a composite measure of physician communication, overall physician rating, and the likelihood of recommending that physician as indicated on the Clinician and Group Consumer Assessment of Healthcare Providers and Systems survey. Predictors of PROM experience and satisfaction were identified using proportional odds and logistic regression models, respectively.

RESULTS

There were 6454 patients (average age 58 ± 15 years, 59% women) who completed PROMs and responded to the Clinician and Group Consumer Assessment of Healthcare Providers and Systems survey. There were significant positive associations between each PROM experience question and visit satisfaction (r = 0.11-0.19; P<.010), although factors predicting visit satisfaction differed from those predicting PROM experience. A differential effect of PROMs on visit satisfaction was identified for patients who were nonwhite, had lower income, and had more comorbidities.

CONCLUSIONS

Although there was a significant association between better PROM experience and higher visit satisfaction, relationships with clinical characteristics differed, providing insights into how PROMs may be associated with patients' visit satisfaction. Further research is necessary to confirm whether PROMs can be used to improve visit satisfaction, particularly in patients who historically have reported lower quality of care.

The use of STarT back screening tool to predict functional disability outcomes in patients receiving physical therapy for low back pain

BACKGROUND CONTEXT

The STarT Back Screening Tool (SBST) categorizes risk of future disability in patients with low back pain (LBP). Previous studies evaluating the use of SBST in physical therapy (PT) populations do not reflect the ethnic and socioeconomic diversity occurring in clinical practice and lack statistical power to evaluate factors associated with outcomes within each SBST risk category.

PURPOSE

The purpose of this study is to further refine SBST risk categorization for predicting improvements in functional disability with attention toward patient level factors that might guide SBST use in routine outpatient physical therapy practice.

STUDY DESIGN/SETTING

This was a retrospective cohort study that took place within a large academic, tertiary-care health system.

PATIENT SAMPLE

The study cohort consisted of 1,169 patients with LBP who completed a course of outpatient physical therapy from June 1, 2014 to May 31, 2015 and who completed the patient-reported SBST and modified low back pain disability questionnaire (MDQ) questionnaires as part of standard of care.

OUTCOME MEASURES

Improvement in functional disability defined as decrease in 10 or more points in the MDQ.

METHODS

Multivariable logistic regression was performed to evaluate independent predictors of improvement after PT, which included SBST risk category, baseline MDQ, a two-way interaction term between SBST category and baseline MDQ, prior level of function (independent vs. required assistance), demographic characteristics, number of completed PT visits, and duration of PT episode of care. In exploratory analyses, additional two-way interaction terms between SBST category and the significant predictors were added to the regression model.

RESULTS

Mean age of patients in the study cohort was 55.1 years (SD 16.1); 657 (56.2%) were female, 117 (10.0%) were black race, 127 (10.9%) had Medicaid insurance, and 353 (30.2%) had previously received PT for back pain. In all, 35.8% (n=419) patients categorized as low risk SBST category, 40.7% (n=476) medium risk SBST category, and 23.4% (n=274) high risk SBST category. There was an interaction between baseline MDQ and SBST risk category and improvement with PT. For all three SBST categories, higher baseline MDQ was associated with higher probability of improvement, but the effect was less pronounced as SBST risk category increased. Additional factors independently associated with reduced odds of improvement after PT included black race (odds ratio [OR] 0.44, 95% confidence interval [CI] 0.28-0.72), Medicaid insurance (OR=0.58, 95% CI 0.36-0.95), and prior PT (OR=0.48, 95% CI 0.34-0.67). In exploratory analyses, there was a significant interaction between insurance type and SBST risk category in predicting functional improvement after PT. Patients with Medicare and Medicaid insurance had similar rates of improvement in low and high risk SBST categories but different rates of improvement in the medium risk categories.

CONCLUSIONS

The SBST tool predicts outcomes of PT in a cohort of patients receiving outpatient PT for LBP. The odds of improvement varied according to baseline disability and SBST risk status. Race, insurance type, and history of previous PT influenced prediction independent of SBST risk status. Incorporating these variables and the interaction between SBST and baseline disability in outcome models has the potential to refine prediction of outcomes after PT.

Quality of life outcomes in patients presenting for evaluation of CNS tumors

Background

We describe patient-reported outcomes (PROs) in adults with CNS tumors and evaluate their correlation with physician-reported functional status.

Methods

We completed a retrospective cohort study of patients managed at a high-volume CNS tumor institute between September 2013 and September 2014. PROs were measured using 6 domains from the PROs Measurement Information System (PROMIS): anxiety, physical function, pain interference, sleep disturbance, fatigue, and satisfaction with social roles. Physician-reported outcomes were measured using the Eastern Cooperative Oncology Group Scale of Performance Status (ECOG). We compared differences in PROMIS scores across tumor types using analysis of variance and measured the correlation between PROMIS scores and ECOG scores using spearman correlations. Finally, we compared the range of PROMIS physical function scores within each ECOG level.

Results

In a cohort of 2,828 patients, 1,284 (45.4%) completed all 6 PROMIS domains. There were significant differences in PROMIS scores across tumor types for all domains except anxiety. The strength of the correlation between PROMIS and ECOG scores was weak to moderate for all PROMIS domains (all p < 0.001). The correlation was the strongest between the physical function domain and ECOG score (ρ = -0.54), although there was a broad distribution of physical function scores within ECOG level, with scores spanning nearly 5 SDs within most ECOG levels.

Conclusions

Symptom burden was associated with tumor type. There were only weak to moderate correlations between PROMIS and ECOG scores, underscoring the importance of integrating PROs into clinical practice for patients with CNS tumors.

Sensitivity and specificity of patient-entered red flags for lower back pain

BACKGROUND CONTEXT

Red flags are questions typically ascertained by providers to screen for serious underlying spinal pathologies. The utility of patient-reported red flags in guiding clinical decision-making for spine care, however, has not been studied.

PURPOSE

The aim of this study was to quantify the sensitivity and specificity of patient-reported red flags in predicting the presence of serious spinal pathologies.

STUDY DESIGN

This was a retrospective nested case-control study.

PATIENT SAMPLE

This study consisted of 120 patients with International Classification of Diseases, Ninth Revision, Clinical Modification codes for spinal pathologies and 380 randomly selected patients, from a population of 4,313 patients seen at a large tertiary care spine clinic between October 9, 2013 and June 30, 2014.

OUTCOME MEASURES

The presence of patient-reported red flags and red flags obtained from medical records was verified for chart review. The spinal pathology (ie, malignancy, fractures, infections, or cauda equina syndrome) was noted for each patient.

METHODS

The sensitivity and specificity of patient-reported red flags for detecting serious spinal pathologies were calculated from data obtained from the 500 patients. Youden's J was used to rank performance. Agreement between patient-reported red flags and those obtained from medical record review was assessed via Cohen's kappa statistic.

RESULTS

"History of cancer" was the best performing patient-reported red flag to identify malignancy (sensitivity=0.75 [95% confidence intervals, CI 0.53-0.90], specificity=0.79 [95% CI 0.75-0.82]). The best performing patient-reported red flag for fractures was the presence of at least one of the following: "Osteoporosis," "Steroid use," and "Trauma" (sensitivity=0.59 [95% CI 0.44-0.72], specificity=0.65 [95% CI 0.60-0.69]). The prevalence of infection and cauda equina diagnoses was insufficient to gauge sensitivity and specificity. Red flags from medical records had better performance than patient-reported red flags. There was poor agreement between patient red flags and those obtained from medical record review.

CONCLUSIONS

Patient-reported red flags had low sensitivity and specificity for identification of serious pathologies. They should not be used in insolation to make treatment decisions, although they may be useful to prompt further probing to determine if additional investigation is warranted.

Patient-reported outcomes across cerebrovascular event types: More similar than different

OBJECTIVES

To compare the degrees to which 8 domains of health are affected across types of cerebrovascular events and to identify factors associated with domain scores in different event types.

METHODS

This was an observational cohort study of 2,181 patients with ischemic stroke, intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), or TIA in a cerebrovascular clinic from February 17, 2015, to June 2, 2017 who completed Quality of Life in Neurologic Disorders executive function and the following Patient-Reported Outcomes Measurement Information System scales as part of routine care: physical function, satisfaction with social roles, fatigue, anxiety, depression, pain interference, and sleep disturbance.

RESULTS

All health domains were affected to similar degrees in patients with ICH, SAH, and ischemic stroke after adjustment for disability and other clinical factors, whereas patients with TIA had worse adjusted scores for 5 of the 8 domains of health. Female sex, younger age, lower income, and event <90 days were associated with worse scores in multiple domains. Factors associated with health domain scores were similar for all cerebrovascular events. Most affected domains for all were physical function, satisfaction with social roles, and executive function.

CONCLUSIONS

The subtype of stroke (ischemic stroke, ICH, and SAH) had similar effects in multiple health domains, while patients with TIA had worse adjusted outcomes, suggesting that the mechanisms for outcomes after TIA may differ from those of other cerebrovascular events. The most affected domains across all event types were physical function, satisfaction with social roles, and executive function, highlighting the need to develop effective interventions to improve these health domains in survivors of these cerebrovascular events.

Accuracy of Linking VR-12 and PROMIS Global Health Scores in Clinical Practice

OBJECTIVES

To examine the accuracy of general health cross-walk tables in a clinical sample of patients with spine disorders. Published tables (Schalet BD, Rothrock NE, Hays RD, et al. Linking physical and mental health summary scores from the Veterans RAND 12-Item Health Survey (VR-12) to the PROMIS(®) Global Health Scale. J Gen Intern Med 2015;30:1524-30) link scores from the Veterans RAND 12-Item Health Survey (VR-12) to the 10-Item Patient-Reported Outcome Measurement Information System (PROMIS), a global health scale metric for both mental (GMH) and physical (GPH) summary scores.

METHODS

We assessed the accuracy of administered PROMIS and VR-12 scores with scores predicted by cross-walks in 4606 adult patients seen in a spine clinic from October 2015 to 2016. Accuracy of linking scores was evaluated using Pearson correlation, intraclass correlation coefficients, and mean and SD of score differences. Bland-Altman plots were used to graphically assess the levels of agreement. The consistency in scores' discrimination across levels of pain severity, depression, and other patient characteristics was assessed. Bootstrap methods estimated linking precision across varying sample sizes.

RESULTS

Actual and cross-walked PROMIS scores showed moderate correlation (ICC(3,1): GMH 0.73; GPH 0.81), with Bland-Altman plots suggesting smaller differences between scores in patients with lower and higher general health. Significant discrimination between patient subgroups was demonstrated reliably by both actual and estimated scores. Bootstrapped resamples indicated adequate precision for 200 patients (95% confidence interval for mean difference: GMH -1.38 to 0.60; GPH 0.39 to 1.93).

CONCLUSIONS

VR-12 and PROMIS global health scores can be accurately linked within a sample of patients with spine disorders; nevertheless, bias is high and precision is low for linking on the patient level. Linked scores at the group level for more than 200 patients can be used in comparative effectiveness research and for comparing results across studies.

Patient experience with patient-reported outcome measures in neurologic practice

OBJECTIVE

To quantify the neurologic patient experience with patient-reported outcome measures (PROMs) and identify factors associated with a positive PROMs experience.

METHODS

This retrospective study included all patients seen in 6 neurologic clinics who completed patient experience questions at least once between October 2015 and September 2016. Questions assessed overall satisfaction with PROMs, as well as 4 facets of the PROM experience: usefulness of questions, ease of understanding, effect on communication with provider, and effect on control of their own care. Clinic and patient characteristics were summarized across questions and predictors of response were identified using multivariable proportional odds models.

RESULTS

A total of 16,157 patients answered generic and condition-specific PROMs, as well as questions on their experience with completing PROMs. The majority of patients agreed/strongly agreed questions were easy to understand (96%), useful (83%), and improved communication (78%) and control (71%). After adjustment for other factors, being younger, black, or depressed, or having lower household income, were independent predictors of high satisfaction with PROMs. Patients who indicated the system improved communication and control of care were more often male, black, and lower income. Variability in responses was shown by clinic.

CONCLUSION

Given the growing importance of patient satisfaction in health care, the patient experience with PROMs is a critical component of their successful implementation and utilization. Findings from this study support the feasibility of collecting PROMs in neurologic practice and the potential as a tool to optimize patient-centered neurologic care.

Impact of Stroke Call on the Stroke Neurology Workforce in the United States: Possible Challenges and Opportunities

BACKGROUND

The Stroke & Vascular Neurology Section of the American Academy of Neurology was charged to identify challenges to the recruitment and retention of stroke neurologists and to make recommendations to address any identified problems. The Section initiated this effort by determining the impact of stroke on-call requirements as a barrier to the recruitment and retention of vascular neurologists.

METHODS

This is a cross-sectional survey of a sample of US Neurologists providing acute stroke care.

RESULTS

Of the 900 neurologists who were sent surveys, 313 (35%) responded. Of respondents from institutions providing stroke coverage, 71% indicated that general neurologists and 45% indicated that vascular neurologists provided that service. Of those taking stroke call, 36% agreed with the statement, "I spent too much time on stroke call," a perception that was less common among those who took less than 12-hour shifts (P < .0001); 21% who participated in stroke call were dissatisfied with their current job. Forty-six percent indicated that their stroke call duties contributed to their personal feeling of "burnout."

CONCLUSIONS

Although the reasons are likely multifactorial, our survey of neurologists providing stroke care suggests that over-burdensome on-call responsibilities may be contributing to the vascular neurology workforce burnout and could be affecting recruitment and retention of vascular neurologists. Strategies to reduce the lifestyle impact of stroke call may help address this problem.

The most affected health domains after ischemic stroke

OBJECTIVES

(1) Examine 8 patient-reported domains of health across levels of disability compared to the US general population; and (2) identify factors associated with domain scores in patients with ischemic stroke.

METHODS

Observational cohort study of 1,195 patients in a cerebrovascular clinic from February 17, 2015, to January 27, 2017, who completed Neuro-QoL (Quality of Life in Neurological Disorders) executive function or the following PROMIS (Patient-Reported Outcomes Measurement Information System) scales as part of routine care: physical function, satisfaction with social roles, fatigue, anxiety, depression, pain interference, and sleep disturbance.

RESULTS

Mean age was 62 (±15) years, and 81% were white. Median modified Rankin Scale (mRS) score at the clinic visit was 1 (interquartile range 0-2). Percentage of patients with scores meaningfully worse than the general population ranged from 28% (sleep disturbance) to 63% (physical function). Scores were worse in patients with higher mRS levels, although correlation between scores and mRS level varied (sleep disturbance r = 0.16 to physical function r = 0.52). Most affected domains were physical function (T score = 58.8), satisfaction with social roles (T score = 55.4), and executive function (T score = 53.4). Disability, lower income, and female sex were associated with worse scores in multiple domains. Age was associated with worse physical function but lower anxiety, depression, and sleep disturbance.

CONCLUSIONS

Patients with ischemic stroke reported symptoms in multiple domains that increase to variable degrees at higher levels of disability. Physical function, satisfaction with social roles, and executive function were most affected. This information improves our understanding of the well-being of patients with ischemic stroke and brings attention to the importance of social roles and executive function for stroke survivors.

Neurologic provider views on patient-reported outcomes including depression screening

Background

We sought to assess neurologic provider satisfaction with the systematic electronic collection of patient-reported outcome measures (PROMs) for both disease-specific measures and depression screening (Patient Health Questionnaire [PHQ-9]).

Methods

A web-based survey was sent to 299 staff physicians and advanced practice providers on the staff email list of a large group neurologic practice, of whom 206 used the PROM system. The survey consisted of 11 questions with Likert response options regarding perceived usefulness of PROM collection; usefulness of PROM data for clinical care, quality, and research activities according to provider age group and type; and perceived usefulness between disease-specific information and the PHQ-9 depression screen.

Results

Of those who use the PROM system, 73.3% (151/206) responded. PROM collection was useful for patient care (strongly agree or agree 59.6%), research (strongly agree or agree 68.5%), and to a lesser extent, quality improvement (strongly agree or agree 48.6%). Providers aged 66-75 years believed PROM data were less useful for research (p < 0.01). PROM collection affected patient interactions or clinical management (always or usually 34.6% for disease-specific information and 31.3% for the PHQ-9). Responses were similar concerning perceived clinical usefulness (strongly agree or agree 67.3%) for center-selected disease-specific PROMs and the mandated PHQ-9 (69.8%).

Conclusions

Providers favorably viewed systematic electronic collection of PROMs in neurologic patients. A mandated depression screening was perceived as favorably as center-selected disease-specific information and should be considered when implementing PROMs in neurologic practice.

PROMIS GH (Patient-Reported Outcomes Measurement Information System Global Health) Scale in Stroke

Background and Purpose—

The International Consortium for Health Outcomes Measurement recently included the 10-item PROMIS GH (Patient-Reported Outcomes Measurement Information System Global Health) scale as part of their recommended Standard Set of Stroke Outcome Measures. Before collection of PROMIS GH is broadly implemented, it is necessary to assess its performance in the stroke population. The objective of this study was to evaluate the psychometric properties of PROMIS GH in patients with ischemic stroke and intracerebral hemorrhage.

Methods—

PROMIS GH and 6 PROMIS domain scales measuring same/similar constructs were electronically collected on 1102 patients with ischemic and hemorrhagic strokes at various stages of recovery from their stroke who were seen in a cerebrovascular clinic from October 12, 2015, through June 2, 2017. Confirmatory factor analysis was performed to evaluate the adequacy of 2-factor structure of component scores. Test–retest reliability and convergent validity of PROMIS GH items and component scores were assessed. Discriminant validity and responsiveness were compared between PROMIS GH and PROMIS domain scales measuring the same or related constructs. Analyses were repeated stratified by stroke subtype and modified Rankin Scale score <2 versus ≥2.

Results—

There was moderate internal reliability (ordinal α, 0.82–0.88) and marginal model fit for the 2-factor solution for component scores (root mean square error of approximation, 0.11). Convergent validity was good with significant correlations between all PROMIS GH items and PROMIS domain scales ( P <0.001 for all). There was excellent discrimination for all PROMIS GH items and component scores across modified Rankin Scale levels. Good responsiveness (effect size, >0.5) was demonstrated for 8 of the 10 PROMIS GH items. Reliability and validity remained consistent across stroke subtype and disability level (modified Rankin Scale, <2 versus ≥2).

Conclusions—

PROMIS GH exhibits acceptable performance in patients with stroke. Our findings support International Consortium for Health Outcomes Measurement recommendation to use PROMIS GH as part of the standard set of outcome measures in stroke.

Mapping PROMIS Global Health Items to EuroQol (EQ-5D) Utility Scores Using Linear and Equipercentile Equating

BACKGROUND

Mapping Patient-Reported Outcomes Measurement Information System-Global Health (PROMIS-GH) to EuroQol 5-dimension, three-level version (EQ-5D-3L) provides a utility score for use in quality-of-life and cost-effectiveness analyses. In 2009, Revicki et al. mapped the PROMIS-GH items to EQ-5D-3L utilities using linear regression (REV_Reg). More recently, regression was shown to be ill-suited for mapping to preference-based measures due to regression to the mean. Linear and equipercentile equating are alternative mapping methods that avoid the issue of regression to the mean. Another limitation of the prior models is that ordinal predictors were treated as continuous.

METHODS

Using data collected from the PROMIS Wave 1 sample, we refit REV_Reg, treating the PROMIS-GH items as categorical variables (CAT_Reg). We applied linear and equipercentile equating to the REV_Reg model (REV_LE, REV_equip) and the CAT_Reg model (CAT_LE, CAT_equip). We validated and compared the predictive accuracy of these models in a large sample of neurological patients at a single tertiary-care hospital.

RESULTS

In the neurological disease patient sample, CAT_LE produced the strongest correlations between estimated and observed EQ-5D-3L scores and had the lowest mean squared error. The CAT_equip model had the lowest mean absolute error and had estimated scores that best matched the overall distribution of observed scores.

CONCLUSIONS

Using linear and equipercentile equating, we created new models mapping PROMIS-GH items to EQ-5D-3L utility scores. EQ-5D-3L utility scores can be more accurately estimated using our models for use in cost-effectiveness studies or studies examining overall health-related quality of life.

Minimally Clinically Important Change in the Activity Measure for Post-Acute Care (AM-PAC), a Generic Patient-Reported Outcome Tool, in People With Low Back Pain

BACKGROUND

The Activity Measure for Post-Acute Care (AM-PAC) is a generic metric of patient-reported functional status. The minimal clinically important difference (MCID) in the AM-PAC score has not been determined.

OBJECTIVE

The study objective was to determine the MCID for AM-PAC in people with low back pain.

DESIGN

This was a retrospective cohort study.

METHODS

Anchor-based and distribution-based methods were used to estimate the MCID. The Modified Low Back Pain Disability Questionnaire was used as the anchor. Adults who had a primary ICD-9 code for low back pain in at least 1 outpatient physical therapist visit during an episode of care and who completed both the AM-PAC and the Modified Low Back Pain Disability Questionnaire in at least 2 visits during the care episode were included. The MCID was calculated for the AM-PAC basic mobility version as well its adapted version, which the Cleveland Clinic uses for patients 65 years old or older.

RESULTS

A total of 1,271 participants were eligible for study. For the AM-PAC basic mobility version, anchor-based methods yielded MCID estimates of between 3.4 and 5.1, whereas distribution-based methods yielded estimates of 1.7 to 4.2. The minimal detectable change (MDC) for the AM-PAC basic mobility version was 3.3. For the adapted AM-PAC basic mobility version, the MCID was estimated to be between 2.9 and 4.0 via anchor-based methods and between 1.2 to 3.5 via distribution-based methods. The MDC for the adapted AM-PAC basic mobility version was 3.5.

LIMITATIONS

The estimated MCID was designed for people with low back pain only.

CONCLUSIONS

The MCID ranged from 3.3 to 5.1 for the AM-PAC basic mobility version and 3.5 to 4 for the adapted version, with the MDC as the lower limit. Changes in the AM-PAC for people with low back pain may be interpreted using the estimated MCID. Future studies are needed to determine the AM-PAC MCID for populations other than those with low back pain.

Scale Linking to Enable Patient-Reported Outcome Performance Measures Assessed with Different Patient-Reported Outcome Measures

BACKGROUND

Patient-reported outcome performance measures (PRO-PMs) incorporate outcomes from the patient's perspective into performance measures and may have great potential to impact health care. The various patient-reported outcome measures (PROMs) used to assess the same outcome challenge widespread use of PRO-PMs. A potential solution is to statistically link PROMs to provide equivalent PRO-PM conclusions to be drawn regardless of which PROM was used.

OBJECTIVES

To determine the level of agreement in the performance of two depression-related PRO-PMs assessed using the nine-item Patient Health Questionnaire (PHQ-9) depression scale and the eight-item Patient-Reported Outcomes Measurement Information System (PROMIS) Depression short form and the PHQ-9 cocalibrated on the PROMIS metric.

METHODS

We conducted a retrospective cohort study of patients who visited one of eight ambulatory neurological and psychiatric clinics at the Cleveland Clinic between January 23 and June 15, 2012, and who completed both the PHQ-9 and PROMIS Depression scales at the same visit. The level of agreement was measured between PRO-PM performance assessed with standard scoring of the PHQ-9, the PROMIS cocalibrated scoring of the PHQ-9, and the PROMIS score for two depression-related PRO-PMs.

RESULTS

Of the 5736 enrolled patients, 701 had PROMs from two or more visits. Differences in performance of the depression remission PRO-PM ranged from 0.4% to 2.1%, and differences in the progress toward remission PRO-PM ranged from 0.9% to 5.1%, depending on which depression score was used.

CONCLUSIONS

There was a high level of agreement in the PRO-PM for depression when incorporating different PROMs. These findings support the ability to use linkage of scale scores to assess performance of PRO-PMs with different PROMs.

Added Value of Patient-Reported Outcome Measures in Stroke Clinical Practice

Background

There is uncertainty regarding the clinical utility of the data obtained from patient‐reported outcome measures (PROMs) for patient care. We evaluated the incremental information obtained by PROMs compared to the clinician‐reported modified Rankin Scale (mRS).

Methods and Results

This was an observational study of 3283 ischemic stroke patients seen in a cerebrovascular clinic from September 14, 2012 to June 16, 2015 who completed the routinely collected PROMs: Stroke Impact Scale‐16 (SIS‐16), EQ‐5D, Patient Health Questionnaire‐9, PROMIS Physical Function, and PROMIS fatigue. The amount of variation in the PROMs explained by mRS was determined using r² after adjustment for age and level of stroke impairment. The proportion with meaningful change was calculated for patients with ≥2 visits. Concordance with change in the other scales and the ability to discriminate changes in health state as measured by c‐statistic was evaluated for mRS versus SIS‐16. Correlation between PROMs and mRS was highest for SIS‐16 (r=−0.64, P<0.01). The r² ranged from 0.11 (PROMIS fatigue) to 0.56 (SIS‐16). Change in scores occurred in 51% with mRS and 35% with SIS‐16. There was lower agreement and less ability to discriminate change in mRS than in SIS‐16 with change in the other measures.

Conclusions

PROMs provide additional valuable information compared to the mRS alone in stroke patients seen in the ambulatory setting. SIS‐16 may have a better ability to identify change than mRS in health status of relevance to the patient. PROMs may be a useful addition to mRS in the assessment of health status in clinical practice.

Patient Satisfaction with Collection of Patient-Reported Outcome Measures in Routine Care

INTRODUCTION

Systematic collection of patient-reported outcome measures (PROMs) during ambulatory clinic visits can enhance communication between patient and provider, and provide the ability to evaluate outcomes of care. Little is known about patient satisfaction of PROM data collection in routine clinical care. To evaluate patient reaction to the routine collection of PROMs in the ambulatory setting.

METHODS

Before all ambulatory clinic visits at our neurological institute, patients electronically complete health status questionnaires. We administered an 8-question patient satisfaction survey to a sample of patients seen across the institute after their clinical visit.

RESULTS

Of 343 patients approached, 323 agreed to participate. The majority responded that the questionnaire system was easy to use, was an appropriate length, and benefited their care overall (strongly agree or agree = 92.3%, 87.6%, and 77.3%, respectively). Provider review of the PROMs with the patient during the clinic visit was associated with significantly higher positive responses to all questions, even those regarding logistical aspects of the collection process. There were significant age and race differences in response to perceived benefit: those in the Black/other race category had a markedly lower probability of viewing the process favorably with increasing age.

CONCLUSIONS

Systematic collection of PROMs via an electronic questionnaire appears to be well accepted by patients. A minority of patients did not feel the questionnaire content applied to their appointment or that the system was a beneficial feature of the clinical practice. The provider can significantly improve the patient's perception of PROM collection and the patient-physician encounter by reviewing the questionnaire results with the patient.

Chronic Stroke Outcome Measures for Motor Function Intervention Trials: Expert Panel Recommendations

BACKGROUND

About half of survivors with stroke experience severe and significant long-term disability. The purpose of this article is to review the state of the science and to make recommendations for measuring patient-centric outcomes in interventions for motor improvement in the chronic stroke phase.

METHODS AND RESULTS

A 9-member expert panel reviewed evidence to identify measures of upper and lower extremity function used to date as outcomes in trials with patients who experienced a stroke ≥6 months before assessment. Outcome measures were screened using StrokEDGE consensus panel recommendations, and evaluated for availability of a published minimal clinically important difference. Measures meeting these criteria were further evaluated with regard to their level of measurement, psychometric properties, and ability of minimal clinically important difference to capture gains associated with improved function and clinical relevance to patients, to arrive at recommendations. A systematic literature review yielded 115 clinical trials of upper and lower extremity function in chronic stroke that used a total of 34 outcome measures. Seven of these had published minimal clinically important differences and were recommended or highly recommended by StrokEDGE. Those are the Fugl-Meyer Upper Extremity and Lower Extremity scales, Wolf Motor Function Test, Action Research Arm Test, Ten-Meter and Six-Minute Walk Tests, and the Stroke Impact Scale. All had evidence for their psychometric performance, although the strength of evidence for validity varied, especially in populations with chronic stroke Fugl-Meyer Upper and Lower Extremity scales showing the strongest evidence for validity.

CONCLUSIONS

The panel recommends that the Fugl-Meyer Upper and Lower Extremity scales be used as primary outcomes in intervention trials targeting motor function in populations with chronic stroke. The other 6 measures are recommended as secondary outcomes.

The PROMIS physical function scale: A promising scale for use in patients with ischemic stroke

OBJECTIVE

To evaluate the performance of the Patient Reported Outcomes Measurement Information System (PROMIS) physical function (PF) scale compared to the validated Stroke Impact Scale-16 (SIS-16) in ischemic stroke patients seen in an ambulatory cerebrovascular clinic.

METHODS

This was a retrospective cohort study. PROMIS PF (computer adaptive testing version) and SIS-16 measures were electronically collected on 1,946 ischemic stroke patients seen in a cerebrovascular clinic using an electronic platform from September 12, 2012, to June 16, 2015. Distribution of scores was compared to assess ceiling and floor effects. Correlations with other commonly used functional status scales were performed to assess convergent validity.

RESULTS

The SIS-16 and PROMIS PF had a 19.6% and <1% ceiling effect, respectively. Patients completed 16 SIS-16 items and a median of 4 (interquartile range 4-4) PROMIS PF items. Internal consistency of both SIS-16 and PROMIS PF was excellent. The SIS-16 had slightly but significantly higher correlations with the other functional scales than PROMIS PF.

CONCLUSIONS

The use of PROMIS to obtain electronic patient-reported functional status in an ambulatory setting is feasible. PROMIS PF is an option for measurement of physical function in ischemic stroke patients. It had similar test characteristics as the SIS-16 but with lower patient burden and minimal ceiling effect.

ID: 24: BENEFITS AND RISKS OF WARFARIN WITH AND WITHOUT ASPIRIN IN PATIENTS WITH CORONARY ARTERY DISEASE OR CEREBROVASCULAR ACCIDENT: A META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

Background

Previous studies have shown that secondary prophylaxis of non-embolic stroke remains challenging. Randomized controlled trials (RCTs) evaluating warfarin with or without aspirin to prevent stroke have yielded mixed results. We conducted a meta-analysis of RCTs to evaluate the efficacy of warfarin (with and without aspirin) in patients with coronary artery disease (CAD) or ischemic stroke/ transient ischemic attack (TIA).

Methods

We searched 6 electronic databases published from 1980–2014. RCTs reporting the benefits (reduced incidence of stroke) and risks (mortality, intracranial bleeds, major and minor bleeds) of warfarin (with and without aspirin) therapy were included. Trials were stratified by intensity of the therapeutic international normalized ratio (INR): low (INR<2), intermediate (INR 2–3) and high (INR>3). Risk ratios (RRs) were pooled using random-effects models.

Results

Twenty-five RCTs (30,939 patients) met our inclusion criteria. Intermediate intensity warfarin with aspirin compared with aspirin alone significantly reduced the risk of secondary strokes [RR 0.48, 95% confidence interval (CI) 0.29–0.80], but increased the risk of major bleeding (RR 2.54, CI 1.70–3.79); there were no significant differences in mortality (RR 1.00, CI 0.80–1.25) and intracranial bleeding (RR 3.03, CI 0.48–19.20). Intermediate intensity warfarin without aspirin compared with aspirin alone, significantly increased major bleeding (RR 2.11, CI 1.45–3.06); there were no significant differences for stroke (RR 0.84, CI 0.66–1.08), mortality (RR1.21, CI 0.90–1.63) and intracranial bleeding (RR 1.87, CI 0.94–3.70).

Conclusions

Use of intermediate intensity warfarin with aspirin reduced the risk of stroke at the price of increased bleeding. Most anticoagulation increased the risk of major bleeding with no effect on mortality. Studies with oral anticoagulants with aspirin for secondary prevention should be considered.

A screening tool for obstructive sleep apnea in cerebrovascular patients

BACKGROUND

A majority of stroke patients suffer from obstructive sleep apnea (OSA), which can go unrecognized as the current OSA screens do not perform well in stroke patients. The objective of this study is to modify the existing OSA screening tools for use in stroke patients.

METHODS

The cohort study consisted of patients who completed the validated OSA STOP screen and underwent polysomnography within one year. Six prediction models were created and sensitivity and specificity of various cut points were calculated.

RESULTS

There were 208 patients with mean age of 55.4 years; 61.0% had sleep apnea. Models with the highest c-statistics included the STOP items plus BMI, age, and sex (STOP-BAG). Addition of neck circumference and other variables did not significantly improve the models. The STOP-BAG2 model, using continuous variables, had a greater sensitivity of 0.94 (95% CI 0.89-0.98) and specificity 0.60 (95% CI 0.49-0.71) compared to the STOP-BAG model, which used dichotomous variables, and had a sensitivity of 0.91 (95% CI 0.85-0.96) and specificity of 0.48 (95% CI 0.37-0.60).

CONCLUSIONS

The STOP-BAG screen can be used to identify cerebrovascular patients at an increased risk of OSA. The use of continuous variables (STOP-BAG2) is preferable if automated score calculation is available. It can improve the efficiency of evaluation for OSA and lead to improved outcomes of patients with cerebrovascular disease.