Sunday, August 30, 2015

Is there sufficient PROMIS to re-invent the wheel?

Psychometric evaluation of the PROMIS Physical Function Computerized Adaptive Test in comparison to the American Shoulder and Elbow Surgeons score and Simple Shoulder Test in patients with rotator cuff disease

The National Institutes of Health has recently developed the Patient-Reported Outcomes Measurement System (PROMIS) Computer Adaptive Test (CAT) that applies technology of computerized adaptive testing used in examinations like the Graduate Records Examinations.
With CAT, questions are sequentially administered from a large item ‘‘bank’’ until predetermined reliability criteria are met. Each question response produces a probability curve of the respondent’s estimated ability. For example, a patient who can throw a ball with ease has a high probability of having upper-end physical function. Subsequent questions can then be chosen by the CAT ‘‘engine’’ that will further discriminate the respondent’s estimated ability while uninformative and repetitive questions are omitted.

These authors studied 187 patients with clinical diagnosis of rotator cuff disease completed the American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST), and PF CAT.

Responses from 187 patients were analyzed. The PF CAT required fewer questions than the ASES or SST (PF CAT, 4.3; ASES, 11; SST, 12). Correlation between all instruments was moderately high. Item reliability was excellent for all instruments, but person reliability of the PF CAT was superior (0.93, excellent) to the SST (0.71, moderate) and ASES (0.48, fair). Ceiling effects were similar among all instruments (PF CAT, 0.53%; SST, 6.1%; ASES, 2.3%). Floor effects were found in 21% of respondents to the SST but in only 3.2% of PF CAT and 2.3% of ASES respondents.

Comment: Unfortunately the CAT requires the patient to be at a computer or tablet that carries the program. It cannot be completed on paper and thus is not amenable to follow-up mailings. The authors did not measure the time to complete the PROMIS nor its relative convenience or user-friendliness. They did not study the ability of the PROMIS responses to be translated into terms that patients can easily grasp. It is 'the new kid on the block' so that its results cannot be compared to data collected in the past.

By contrast the user-friendly Simple Shoulder Test can be completed on paper anywhere in the world in under two minutes and requires nothing other than a pencil. The SST has been utilized in over 650 publications according to a recent PubMed search. As early as ten years ago, it was recognized that this simple 12 item questionnaire had the ability to characterize (1) the function of normal shoulders, (2)  the functional deficits for many different diagnoses, and (3) the different responses of male and female patients. Here are some figures from that article that was based on 2674 patients.

Self-assessed outcome at two to four years after shoulder hemiarthroplasty with concentric glenoid reaming.

Shoulder scoring scales for the evaluation of rotator cuff repair.

It can be easily used to track patients' recovery over time.

As well as its use in multiple languages, for example

Validation and reliability of a Spanish version of Simple Shoulder Test (SST-Sp)

Finally, and perhaps most importantly, while the PROMIS score is a number without particular meaning to a patient, the results of the SST can be easily communicated:

We are not sure that the PROMIS is progress.


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