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Editorial Commentary: Preoperative Patient-Reported Outcomes Measurement Information System Scores Vary Over Time

      Abstract

      Patient-Reported Outcomes Measurement Information System (PROMIS) scores have considerable potential to both streamline the collection of outcome data and provide a common set of metrics to compare and benchmark patient-reported outcomes after orthopaedic procedures. An analysis of PROMIS scores collected at the preoperative clinical visit and the day of surgery found considerable changes in upper- and lower-extremity physical function, pain interference, and depression. These findings suggest that health status may vary between the day of operative consent and the day of surgery. Given the importance of patient-reported outcomes in clinical research, quality assurance, and value-based health care, the potential for large changes in scores leading up to the procedure warrants attention toward the timing of PROMIS administration to ensure that the health status of the patient—and its variation—is accurately captured.
      In the article “Trends in Patient-Reported Outcomes Measurement Information System Scores Exist Between Day of Surgical Scheduling and Day of Surgery,” Cross, Yedulla, Ziedas, Elhage, Guo, Hessburg, Moutzouros, Muh, and Makhni
      • Cross A.G.
      • Yedulla N.R.
      • Ziedas A.C.
      • et al.
      Trends in Patient-Reported Outcomes Measurement Information System scores exist between day of surgical scheduling and day of surgery.
      examined trends in Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing (CAT) score reporting completed in the preoperative ambulatory setting at the time of surgical scheduling, as well as in the perioperative setting on the day of surgery. PROMIS assessment has been used across various orthopaedic specialties to provide a generalized, uniform system for reporting patient outcomes.
      • Brodke D.J.
      • Saltzman C.L.
      • Brodke D.S.
      PROMIS for orthopaedic outcomes measurement.
      ,
      • Lizzio V.A.
      • Gulledge C.M.
      • Meta F.
      • Franovic S.
      • Makhni E.C.
      Using a web-based data collection platform to implement an effective electronic patient-reported outcome registry.
      CAT implements software that focuses these questionnaires on patient-reported outcome measures (PROMs) into patient-specific, short-item surveys using well-defined questions representing symptoms or dysfunction. CAT software adapts to the patient in real time by continually evaluating responses to previously answered items to determine appropriate future questions, such that a meaningful and accurate assessment of the PROM data can be gathered efficiently.
      • Lizzio V.A.
      • Gulledge C.M.
      • Meta F.
      • Franovic S.
      • Makhni E.C.
      Using a web-based data collection platform to implement an effective electronic patient-reported outcome registry.
      ,
      • Cella D.
      • Gershon R.
      • Lai J.S.
      • Choi S.
      The future of outcomes measurement: Item banking, tailored short-forms, and computerized adaptive assessment.
      This is an intriguing new tool and is a way for surgeons to be able to track clinical outcomes and collect follow-up data effectively and routinely.
      In a cohort of patients undergoing orthopaedic sports medicine procedures, Cross et al.
      • Cross A.G.
      • Yedulla N.R.
      • Ziedas A.C.
      • et al.
      Trends in Patient-Reported Outcomes Measurement Information System scores exist between day of surgical scheduling and day of surgery.
      compared preoperative PROMIS CAT scores collected in the ambulatory clinic with perioperative PROMIS CAT scores obtained on the day of surgery.
      • Cross A.G.
      • Yedulla N.R.
      • Ziedas A.C.
      • et al.
      Trends in Patient-Reported Outcomes Measurement Information System scores exist between day of surgical scheduling and day of surgery.
      Their results showed changes in PROMIS scores based on different periods in the preoperative window. Potential reasons for score differences are multifactorial and include both patient- and surgeon-related factors; however, the absolute change in score was considerable and may reflect that health status varies leading up to the day of surgery. Given that surgical decision making is often based on brief clinical encounters, these findings encourage surgeons to consider the trends in PROMIS CAT scores over time and to collect these patient-reported data at different time points in care, when feasible, in an effort to understand the underlying health status of the patient.
      How does this study contribute to what we know about PROMIS CAT in orthopaedics? PROMIS scores have been shown to be valid, efficient, and effective in predicting success in various orthopaedic specialties, including shoulder surgery, knee arthroscopy, hip arthroscopy, hand surgery, and trauma.
      • Bernstein D.N.
      • Houck J.R.
      • Mahmood B.
      • Hammert W.C.
      Minimal clinically important differences for PROMIS Physical Function, Upper Extremity, and Pain Interference in carpal tunnel release using region- and condition-specific PROM tools.
      • Franovic S.
      • Kuhlmann N.A.
      • Pietroski A.
      • et al.
      Preoperative patient-centric predictors of postoperative outcomes in patients undergoing arthroscopic meniscectomy.
      • Rubery P.T.
      • Houck J.
      • Mesfin A.
      • Molinari R.
      • Papuga M.O.
      Preoperative Patient Reported Outcomes Measurement Information System scores assist in predicting early postoperative success in lumbar discectomy.
      • Bernstein D.N.
      • Houck J.R.
      • Gonzalez R.M.
      • et al.
      Preoperative PROMIS scores predict postoperative PROMIS score improvement for patients undergoing hand surgery.
      • Childs S.
      • Canham C.
      • Kenney R.
      • Silas D.
      • Adler K.
      • Giordano B.
      Correlation of PROMIS CAT with validated hip outcome scores in patients undergoing hip arthroscopy.
      • Anthony C.A.
      • Glass N.
      • Hancock K.
      • Bollier M.
      • Hettrich C.M.
      • Wolf B.R.
      Preoperative performance of the Patient-Reported Outcomes Measurement Information System in patients with rotator cuff pathology.
      • Matar R.N.
      • Shah N.S.
      • Grawe B.M.
      Patient-Reported Outcomes Measurement Information System scores are inconsistently correlated with legacy patient-reported outcome measures in shoulder pathology: A systematic review.

      Ziedas AC, Abed V, Swantek AJ, et al. Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function instruments compare favorably with legacy patient-reported outcome measures in upper- and lower-extremity orthopaedic patients: A systematic review of the literature [published online May 27, 2021]. Arthroscopy. https://doi.org/10.1016/j.arthro.2021.05.031.

      Specifically, PROMIS CAT was shown by Childs et al.
      • Childs S.
      • Canham C.
      • Kenney R.
      • Silas D.
      • Adler K.
      • Giordano B.
      Correlation of PROMIS CAT with validated hip outcome scores in patients undergoing hip arthroscopy.
      to be a valid tool when compared with standard PROMs in patients undergoing elective arthroscopic hip procedures. By completing PROMIS CAT assessment at the preoperative evaluation and comparing the scores with previously validated PROMs such as the modified Harris Hip Score, a strong correlation was found, showing its validity and generalizability. In a similar study in a cohort of patients with rotator cuff pathology, Anthony et al.
      • Anthony C.A.
      • Glass N.
      • Hancock K.
      • Bollier M.
      • Hettrich C.M.
      • Wolf B.R.
      Preoperative performance of the Patient-Reported Outcomes Measurement Information System in patients with rotator cuff pathology.
      reported an excellent correlation between PROMIS Upper Extremity and PROMIS Physical Function (PF) CAT scores and legacy shoulder outcome measures, such as the American Shoulder and Elbow Surgeons Shoulder Assessment Form. Although evidence exists supporting the correlation of PROMIS scores with legacy PROMs, it has been shown in a systematic review by Matar et al.
      • Matar R.N.
      • Shah N.S.
      • Grawe B.M.
      Patient-Reported Outcomes Measurement Information System scores are inconsistently correlated with legacy patient-reported outcome measures in shoulder pathology: A systematic review.
      that PROMIS scores can be inconsistently correlated with these legacy outcomes, specifically in patients with shoulder pathology. On the contrary, in another systematic review, Ziedas et al.

      Ziedas AC, Abed V, Swantek AJ, et al. Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function instruments compare favorably with legacy patient-reported outcome measures in upper- and lower-extremity orthopaedic patients: A systematic review of the literature [published online May 27, 2021]. Arthroscopy. https://doi.org/10.1016/j.arthro.2021.05.031.

      found a strong correlation between the PROMIS Upper Extremity and Lower Extremity scoring systems and legacy PROMs. These contrasting results are likely related to the heterogeneity inherent to any systematic review, in addition to the wide variety of scoring systems for shoulder, upper-extremity, and lower-extremity outcomes. This variation in legacy scores and PROMIS scores was addressed in Arthroscopy by Rossi et al.,
      • Rossi M.J.
      • Sheean A.J.
      • Cote M.P.
      • Brand J.C.
      • Lubowitz J.H.
      The Patient-Reported Outcomes Measurement Information System (PROMIS): Can we finally compare apples to oranges?.
      who eloquently reviewed the differences in PROMIS scores and legacy PROMs, highlighting the importance of defining clinically important differences, patient function, and ultimately, outcomes.
      In addition to its validity, the PROMIS PF CAT assessment has been shown to be efficient and less time-consuming than legacy PROMs. Hung et al.
      • Hung M.
      • Stuart A.R.
      • Higgins T.F.
      • Saltzman C.L.
      • Kubiak E.N.
      Computerized adaptive testing using the PROMIS Physical Function item bank reduces test burden with less ceiling effects compared with the short musculoskeletal function assessment in orthopaedic trauma patients.
      compared a cohort of orthopaedic trauma patients who completed PROMIS PF CAT and the short Musculoskeletal Function Assessment. The PROMIS PF CAT assessment required less time to complete than the traditional short Musculoskeletal Function Assessment while showing high reliability.
      • Rossi M.J.
      • Sheean A.J.
      • Cote M.P.
      • Brand J.C.
      • Lubowitz J.H.
      The Patient-Reported Outcomes Measurement Information System (PROMIS): Can we finally compare apples to oranges?.
      In addition to PROMIS scores being valid and efficient tools for orthopaedic research, recent literature has suggested that PROMIS scores collected preoperatively can be used to help predict postoperative outcomes.
      • Franovic S.
      • Kuhlmann N.A.
      • Pietroski A.
      • et al.
      Preoperative patient-centric predictors of postoperative outcomes in patients undergoing arthroscopic meniscectomy.
      • Rubery P.T.
      • Houck J.
      • Mesfin A.
      • Molinari R.
      • Papuga M.O.
      Preoperative Patient Reported Outcomes Measurement Information System scores assist in predicting early postoperative success in lumbar discectomy.
      • Bernstein D.N.
      • Houck J.R.
      • Gonzalez R.M.
      • et al.
      Preoperative PROMIS scores predict postoperative PROMIS score improvement for patients undergoing hand surgery.
      Franovic et al.
      • Franovic S.
      • Kuhlmann N.A.
      • Pietroski A.
      • et al.
      Preoperative patient-centric predictors of postoperative outcomes in patients undergoing arthroscopic meniscectomy.
      reported that preoperative PROMIS scores predicted postoperative improvement in a cohort of patients undergoing elective knee arthroscopy procedures, whereas Rubery et al.
      • Rubery P.T.
      • Houck J.
      • Mesfin A.
      • Molinari R.
      • Papuga M.O.
      Preoperative Patient Reported Outcomes Measurement Information System scores assist in predicting early postoperative success in lumbar discectomy.
      found that preoperative PROMIS scores combined with clinical factors were able to predict improvement and achievement of the minimally important difference after lumbar discectomy surgery. Similarly, Bernstein et al.
      • Bernstein D.N.
      • Houck J.R.
      • Gonzalez R.M.
      • et al.
      Preoperative PROMIS scores predict postoperative PROMIS score improvement for patients undergoing hand surgery.
      showed that PROMIS PF, Pain Interference, and Depression scores can predict improvement in postoperative PROMIS scores in patients undergoing hand and wrist procedures.
      What has been shown from the existing literature is that PROMIS CAT is valid, is efficient, and when implemented properly, can provide insight into postoperative outcomes. That being said, Cross et al.
      • Cross A.G.
      • Yedulla N.R.
      • Ziedas A.C.
      • et al.
      Trends in Patient-Reported Outcomes Measurement Information System scores exist between day of surgical scheduling and day of surgery.
      showed that PROMIS CAT scores can change considerably—and should be examined over time. From the administration of the PROMIS CAT assessment during the preoperative visit to the perioperative PROMIS CAT assessment collected on the day of surgery, patient health states can worsen or improve. Although the reasoning behind this change is multifactorial, the variation in scores between time points in the preoperative window should be considered when using PROMIS CAT scores. Specifically, this study implores individuals using PROMIS CAT assessment to administer it at multiple time points throughout the patient’s care to improve precision in data collection and analysis. By looking at PROMIS CAT scores as a fluid representation of the patient’s health state over time, we can more accurately assess the relevance of these scores to clinical outcomes postoperatively.
      As the American philosopher Ted Nelson once noted, “The good news about computers is that they do what you tell them to do. The bad news is that they do what you tell them to do.” The evidence supporting PROMIS CAT technology in orthopaedics continues to grow, and this advice behooves surgeons to use this technology accurately, with as many data points as are feasible in clinical practice. The timing of preoperative and perioperative PROMIS CAT data collection is an important consideration and can help maximize the usefulness and application of this clinical tool.

      Supplementary Data

      References

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