Emergency department utilization among patients who receive outpatient specialty care for headache: A retrospective cohort study analysis.

OBJECTIVES: To compare clinical characteristics among outpatient headache clinic patients who do and do not self-report visiting the emergency department for headache. BACKGROUND: Headache is the fourth most common reason for emergency department visits, compromising 1%-3% of visits. Limited data exist about patients who are seen in an outpatient headache clinic but still opt to frequent the emergency department. Clinical characteristics may differ between patients who self-report emergency department use and those who do not. Understanding these differences may help identify which patients are at greatest risk for emergency department overutilization. METHODS: This observational cohort study included adults treated at the Cleveland Clinic Headache Center between October 12, 2015 and September 11, 2019, who completed self-reported questionnaires. Associations between self-reported emergency department utilization and demographics, clinical characteristics, and patient-reported outcome measures (PROMs: Headache Impact Test [HIT-6], headache days per month, current headache/face pain, Patient Health Questionnaire-9 [PHQ-9], Patient-Reported Outcomes Measurement Information System [PROMIS] Global Health [GH]) were evaluated. RESULTS: Of the 10,073 patients (mean age 44.7 ± 14.9, 78.1% [7872/10,073] female, 80.3% [8087/10,073] White patients) included in the study, 34.5% (3478/10,073) reported visiting the emergency department at least once during the study period. Characteristics significantly associated with self-reported emergency department utilization included younger age (odds ratio = 0.81 [95% CI = 0.78-0.85] per decade), Black patients (vs. White patients) (1.47 [1.26-1.71]), Medicaid (vs. private insurance) (1.50 [1.29-1.74]), and worse area deprivation index (1.04 [1.02-1.07]). Additionally, worse PROMs were associated with greater odds of emergency department utilization: higher (worse) HIT-6 (1.35 [1.30-1.41] per 5-point increase), higher (worse) PHQ-9 (1.14 [1.09-1.20] per 5-point increase), and lower (worse) PROMIS-GH Physical Health T-scores (0.93 [0.88-0.97]) per 5-point increase. CONCLUSION: Our study identified several characteristics associated with self-reported emergency department utilization for headache. Worse PROM scores may be helpful in identifying which patients are at greater risk for utilizing the emergency department.

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.

Quality of life after epilepsy surgery: How domain-specific cognitive changes impact QOL within the context of seizure outcome.

PURPOSE: Neurosurgery is an effective treatment option for pharmacoresistant epilepsy. Although post-surgical seizure freedom is considered the primary goal of epilepsy surgery, other factors that impact Quality of Life (QOL) are also important to consider, including post-surgical cognitive changes. This study aimed to examine the impact of post-surgical cognitive changes on QOL in the context of seizure outcomes. METHODS: Participants were 196 adults with focal epilepsy who underwent either frontal (n = 27) or temporal (n = 169) lobe resection. Each participant completed pre- and post-surgical neuropsychological evaluations, and cognitive composites were constructed for the following domains: language, attention/processing speed, memory, executive function, and visuospatial skill. The Quality of Life in Epilepsy (QOLIE-10) questionnaire was used to assess QOL. Seizure outcome was determined by seizure status six months post-surgery. RESULTS: Eighty-one percent of patients were seizure-free post-surgery and generally reported improved QOL. While a significant portion of patient's demonstrated declines in language and verbal memory following surgery, only a decline in verbal memory was associated with worse QOL; however, this relationship was no longer significant after controlling for seizure outcome. Instead, reduced post-surgical QOL was primarily observed in those who experienced both seizure recurrence and a decline in executive function. Notably, depression was a significant covariate in all of the models. CONCLUSIONS: The findings from this study improve our ability to counsel patients about the trade-off between cognitive decline and seizure remittance in the greater context of overall QOL. Reassuringly, it appears that QOL is improved regardless of cognitive changes when patients have good seizure outcomes. However, for those that experience a "double hit" (i.e., cognitive decline without seizure remission), post-surgical QOL may be reduced. Changes in depression also appear to play a crucial role in QOL outcomes.

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.

Telepsychology May Improve Treatment Adherence in Patients with Psychogenic Nonepileptic Seizures.

Introduction: Access to mental health care is a significant challenge in patients with psychogenic nonepileptic seizures (PNES). Telepsychology can curb the access barriers and improve adherence but the role of telepsychology in improving adherence has not been well investigated. The current study examines the utility of telepsychology during the COVID-19 pandemic and treatment adherence in PNES patients. Materials and Methods: Patients with PNES admitted to a 12-week counseling program were offered two visit types: telepsychology and in-office. Visit type, visit status, and demographic information were obtained from department database. Follow-up visits in 6 months were used to examine the effect of visit type on visit status. Adherence to treatment was measured by higher attendance of scheduled visits and less cancellation and no-show rates. Results: Two hundred fifty-seven (n) patients who scheduled virtual or telepsychology visits were included in the study. After adjusting for demographic variables, and accounting for repeated measures, telepsychology visits were significantly more likely to be attended (odds ratio [OR] = 2.40, 95% confidence interval [CI] = 1.69-3.41, p < 0.001) and were significantly less likely to be canceled (OR = 0.43, 95% CI = 0.29-0.64, p < 0.001). The regression model showed patients in the telepsychology visit group attended more than three times as many visits as in-office patients (incidence rate ratios = 3.16, 95% CI = 2.13-4.73, p < 0.001). Conclusions: Patients with PNES have logistical and psychological barriers that can impede their ability to attend counseling treatment. Receiving care remotely may have been associated with higher engagement with mental health treatment compared to having to travel to counseling clinics. Considering the symptom-related restrictions patients with PNES have and the barriers presented by the COVID-19 pandemic, telepsychology played a key role for continuation of mental health treatment.

Patient reported outcomes and performance metrics at diagnosis of secondary progressive multiple sclerosis.

BACKGROUND: Relapsing-remitting multiple sclerosis (RRMS) usually evolves into secondary progressive multiple sclerosis (SPMS). Recognition of SPMS is important because of prognostic and treatment implications. OBJECTIVE: The objective of this study is to determine distributions of patient-reported outcomes (PROs) and the Timed 25-Foot Walk (T25FW) at SPMS diagnosis and describe the evolution of these metrics in patients with SPMS. METHODS: A tertiary MS center clinical database was queried to identify patients with RRMS and SPMS. PRO data including performance scales (PS), Patient Health Questionnaire-9 (PHQ-9), European Quality of Life-5-Dimensions (EQ-5D), and the T25FW were extracted. Descriptive statistics were calculated at SPMS diagnosis, and score trajectories were modeled. Cox proportional hazards modeling was used to estimate hazard ratios for time to SPMS diagnosis. RESULTS: Among 5,558 patients identified, 164 were diagnosed with SPMS between January 2008 and June 2016. At SPMS diagnosis, the mean outcome values were T25FW = 12.5 seconds (standard deviation, SD = 10.7), PS = 15.6 (SD = 6.5), PHQ-9 = 6.8 (SD = 4.2), and EQ-5D = 0.63 (SD = 0.20). Distinct patterns were observed in the measures leading up to SPMS diagnosis. Higher age, male gender, longer disease duration, and greater disability were associated with an increased hazard of SPMS diagnosis. CONCLUSION: Longitudinal monitoring of PROs and performance metrics may help identify those at higher risk of near-term SPMS.

Outcomes in the treatment of psychogenic nonepileptic seizures (PNES) with CBTip: Response in seizure frequency, depression, anxiety, and quality of life.

RATIONALE: Psychogenic Nonepileptic Seizures (PNES) are seizure-like episodes without EEG abnormality, and are of psychological origin. Cognitive Behavioral Therapy (CBT), a type of psychological counseling, is known to be the best intervention to treat PNES and the underlying psychiatric symptoms. Yet, many remain untreated because of limited access to specialized counseling programs. In this study, first we intended to see if the positive outcomes of the CBTip can be replicated in our patient population using within-group comparison. We also aimed to examine the outcomes of patients who received a variable dose of treatment than the established treatment protocol. METHOD: We obtained retrospective patient reported outcomes (PRO) data from patients treated with Cognitive Behavioral Therapy-informed psychotherapy (CBT-ip) from January 2015 to January 2020 in an outpatient tertiary care epilepsy center. The CBTip program is a 12-session intervention delivered weekly by a seizure counselor. Although the program comprises 12 sessions of treatment, we included patients who attended at least 7 sessions consistent with previous research that used a similar cutoff. We had a total of 160 patient PROs included in the analysis. Outcome variables including seizure frequency, depression, anxiety, and quality of life were examined using self-report outcome scores. Demographic and other clinical and psychosocial confounding variables were controlled. RESULTS: In the first analysis in which we compared pre-treatment scores with 3-month posttreatment scores, there was no significant change in seizure frequency, depression, anxiety, and quality-of-life outcomes. In the second analysis when we compared pre- and posttreatment scores in patients who completed the treatment in longer than 3-month time, there were significant improvement in primary and secondary outcomes. For seizure frequency, 10 patients had data for "seizures per day in the last 6 months" and 5 participants (50%) improved by 50% or more in the number of seizures per day. There were also significant reductions in depression and anxiety scores but not in quality of life. IMPLICATION AND CONCLUSIONS: Our analysis showed that patients treated with CBTip with a minimum of 7 sessions in 3 months did not have significant improvement. However, attending at least 7 sessions of CBTip in longer than 3 months was effective for seizure control, depression, and anxiety. The observational and exploratory nature of our study, however, limits the generalizability of our findings outside of the single tertiary clinical care setting.

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.

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.

Metabolic Syndrome Rather Than Body Mass Index Is Associated With Treatment Response to Ketamine Infusions.

PURPOSE: There is a practical need for the identification of pretreatment clinical and epidemiological response predictors to repeat ketamine infusions. Response predictors can serve to guide clinical inclusion of patients and weigh risks versus benefits for those receiving maintenance ketamine. Previous studies indicate a link between obesity, depression, and treatment response. We sought to investigate if body mass index (BMI) or metabolic syndrome could predict treatment response to ketamine. METHODS: Patients aged 18 to 72 years who were electroconvulsive therapy nonresponders were given a subanesthetic ketamine hydrochloride dose of 0.5 mg/kg delivered intravenously for 40 minutes for an acute series of 3 to 6 infusions every other day. If patients reported at least a 50% decrease in depression symptoms after the acute series, they were moved to a maintenance series of infusions, on an individualized basis. To assess if BMI or metabolic syndrome could predict response, logistic regression models were run to analyze initial responders, sustained responders, and nonresponders. Models were adjusted for age, sex, and baseline depression severity. RESULTS: Of the 150 patients analyzed, 56 did not respond to the acute phase, 38 initially responded to the acute phase but relapsed during the maintenance phase, and 56 sustained their response for 1 year. In unadjusted models, BMI was not shown to be a predictor of initial or sustained response. Alternatively, metabolic syndrome defined by a diagnosis of hypertension, hyperglycemia, or hyperlipidemia was determined to be significantly associated with diminished initial response but not sustained response. CONCLUSIONS: In our patient group, results support the literature that outcome in antidepressant therapy is affected by the presence of metabolic syndrome rather than obesity itself. Although BMI did not predict initial response to ketamine, the presence of metabolic syndrome was significantly negatively associated with the initial response to an acute series of ketamine infusions.

Quality of life before and after epilepsy surgery: Age is just a number.

BACKGROUND: In a rapidly aging population, it is critical to analyze if the quality of life (QOL) in patients with drug-resistant epilepsy (DRE) and the change in it after epilepsy surgery is dependent on the age at operation. METHODS: A prospective registry-based retrospective cohort study including adults with a completed pre- and post-surgery Quality of Life in Epilepsy 10 (QOLIE-10) survey. Multivariable linear regression models analyzed the baseline, postoperative, or change in QOLIE-10 score. RESULTS: We analyzed 416 patients (51% females) with the mean age of 39.6 (SD = 12.6) years at the time of surgery, including 100 (24%) individuals 50 years or older. The younger and older adults (dichotomized as <50 vs. ≥50 and <60 vs. ≥60) had comparable pre- and post-surgery QOLIE 10 total scores. The change in total and individual QOLIE-10 items score were comparable between the groups as well. Within group improvements in total QOLIE-10 score post-surgery was in younger as well as older groups. The linear regression models showed that age, regardless of parameterization (linear or dichotomized), was not related to pre-surgery, post-surgery, and change in QOLIE-10 score, both before and after adjustment for covariates. The change in QOLIE-10 score did not show correlation with age, whether seizure freedom or relative seizure reduction was used in the model. CONCLUSION: With QOL, before or after surgery, being independent of a patient's age, our findings suggest that well-selected older adults and the elderly should be offered epilepsy surgery without concern for an inferior improvement in QOL compared to their younger counterparts.

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 (IRTavail), (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 (IMPdirect). 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: IRTavail 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.

Patient versus proxy response on global health scales: no meaningful DIFference.

PURPOSE: Assessment of outcomes from a proxy is often substituted for the patient's self-report when the patient is unable or unwilling to report their status. Research has indicated that proxies over-report symptoms on the patient's behalf. This study aimed to quantify the extent of proxy-introduced bias on the Patient-Reported Outcomes Measurement Information System Global Health (PROMIS GH) scale for mental (GMH) and physical (GPH) scores. METHODS: This retrospective cohort study included incident stroke patients seen in a cerebrovascular clinic who completed PROMIS GH between 10/12/15 and 6/6/18. Differential item functioning (DIF) evaluated measurement invariance of patient versus proxy responses. DIF impact was assessed by comparing the initial score to the DIF-adjusted score. Subgroup analyses evaluated DIF within strata of stroke severity, measured by modified Rankin Scale (≤ 1, 2, 3+), and time since stroke (≤ 30, 31-90, > 90 days). RESULTS: Of 1351 stroke patients (age 60.5 ± 14.9, 45.1% female), proxy help completing PROMIS GH was required by 406 patients (30.1%). Proxies indicated significantly worse response to all items. No items for GMH or GPH were identified as having meaningful DIF. In subgroup analyses, no DIF was found by severity or 31-90 days post-stroke. In patients within 30 and > 90 days of stroke, DIF was detected for 2 items. Accounting for DIF had negligible effects on scores. CONCLUSIONS: Our findings revealed the overestimation of symptoms by proxies is a real difference and not the result of measurement non-invariance. PROMIS GH items do not perform differently or have spuriously inflated severity estimates when administered to proxies instead of patients.

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.

Prevalence and Predictors of Depression Among Patients With Epilepsy, Stroke, and Multiple Sclerosis Using the Cleveland Clinic Knowledge Program Within the Neurological Institute.

BACKGROUND: Neurological conditions carry a high risk of depression. Given this risk, the Neurological Institute (NI) at Cleveland Clinic has initiated systematic screening for depression using the 9-item Patient Health Questionnaire-9 (PHQ-9) embedded within its electronic medical record and its data capture system, the Knowledge Program (KP)1. OBJECTIVE: We sought to (1) estimate the prevalence of depression among patients with epilepsy, stroke, and multiple sclerosis (MS); (2) identify risk factors for depression within each disease; and (3) determine differential risks and predictors across neurological disorders. METHODS: The KP1 database provided information on approximately 23,000 visits involving 7946 outpatients with epilepsy, stroke, or MS seen in neurology specialty clinics. The primary outcome measure was depression as defined as a PHQ-9 ≥ 10. RESULTS: Overall, the point prevalence of depression was 29.0%. For stroke, epilepsy, and MS, prevalence of depression was 23% (95% CI: 21-25%), 33% (95% CI: 31-35%), and 29% (95% CI: 28-30%), respectively. For all 3 conditions, increasing disease severity and decreased health-related quality of life were independent predictors of depression. In multivariable models, there was a significant interaction between age and condition, and condition with disease severity. In stroke and MS, increasing age was associated with reduced odds for depression, whereas in epilepsy, increasing age was associated with an increased odds for depression. CONCLUSIONS: Although depression is common among patients with neurological disorders, our data suggest that predictors of depression such as age and disease severity varied by condition, supporting important possible phenomenological and pathophysiological differences of depression across these neurological conditions.

Depression score changes in response to sleep disordered breathing treatment with positive airway pressure in a large clinic-based cohort.

OBJECTIVE: The clinical-population impact of positive airway pressure (PAP) on depressive symptoms in sleep disordered breathing (SDB) awaits clear documentation. We hypothesized that depressive symptoms improve in response to PAP treatment in a large clinical setting, and that lower socio-economic status poses barriers to full therapeutic response. METHOD: We performed a retrospective cohort study of SDB patients attending a tertiary ambulatory sleep center between January 1, 2010 and December 31, 2015. Data extracted from electronic health records included Patient Health Questionnaire-9 (PHQ-9) scores, demographic characteristics, PAP adherence, and medical history. Paired- and two-sample t tests were utilized to assess changes in PHQ-9 score according to PAP adherence. Linear regression models were constructed to evaluate the association of socioeconomic status (SES) and other clinical variables on PHQ-9 scores. RESULTS: The cohort consisted of 1981 SDB patients (56.4 ± 13.3 years; 45.7% female; 76.2% Caucasian). Regardless of adherence, PAP therapy improved PHQ-9 scores (- 2.4 ± 4.6, p < 0.0001), with more robust responses in patients with baseline PHQ-9 scores > 10 (- 4.8 ± 5.7; p < 0.0001). Adherent patients had significantly greater improvement (- 2.8 ± 4.4 vs. 1.6 + 4.2, p < 0.0001), and even greater benefit if baseline PHQ-9 was > 10 (-6.0 ± 5.3 vs. - 3.8 ± 4.9, p < 0.001). Patients from lower socioeconomic status and greater depressive symptom had worse post-PAP PHQ-9 scores. CONCLUSIONS: PAP therapy and adherence were associated with improvement in depressive symptom severity in this clinical cohort. Patients with lower socioeconomic status derived less therapeutic benefit, suggesting that they faced additional barriers to treatment effectiveness.

Influence of hypertension, diabetes, hyperlipidemia, and obstructive lung disease on multiple sclerosis disease course.

BACKGROUND: Comorbidities are known to affect multiple sclerosis (MS) patients in a number of ways, including delaying time to diagnosis and reducing health-related quality of life. OBJECTIVE: To determine the impact of hypertension, hyperlipidemia, diabetes mellitus, and obstructive lung disease on disease course in MS patients. METHODS: The Knowledge Program is a database linked to our electronic medical record allowing capture of patient and clinician reported outcomes. Through Knowledge Program query and chart review, we identified all relapsing-remitting MS patients seen between 1 January 2010 and 29 May 2012 and acquired their magnetic resonance imaging (MRI) results and comorbidities. Linear and logistic regression models with adjustment for important covariates were used to determine whether the comorbidities affected outcomes over a 3-year period. RESULTS: Hypertension, diabetes, and obstructive lung disease, but not hyperlipidemia, impacted clinical outcomes, including walking speed, self-reported disability, and depression. Hypertension had the greatest effect. The presence of multiple comorbidities had a cumulative effect on clinical outcomes. MRI outcomes were unaffected by comorbidities. CONCLUSION: This 3-year longitudinal study revealed that all comorbidities tested except hyperlipidemia impacted clinical outcomes and a cumulative effect with multiple comorbidities was observed. Consideration of comorbid conditions is essential in MS patient care.

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.

Fluorodeoxyglucose Positron Emission Tomography (FDG-PET) Correlation of Histopathology and MRI in Prion Disease.

Creutzfeldt-Jakob disease (CJD) and other prion diseases are rapidly progressive spongiform encephalopathies that are invariably fatal. Clinical features and magnetic resonance imaging, electroencephalogram, and cerebrospinal fluid abnormalities may suggest prion disease, but a definitive diagnosis can only be made by means of neuropathologic examination. Fluorodeoxyglucose positron emission tomography (FDG-PET) is not routinely used to evaluate patients with suspected prion disease. This study includes 11 cases of definite prion disease in which FDG-PET scans were obtained. There were 8 sporadic CJD cases, 2 genetic CJD cases, and 1 fatal familial insomnia case. Automated FDG-PET analysis revealed parietal region hypometabolism in all cases. Surprisingly, limbic and mesolimbic hypermetabolism were also present in the majority of cases. When FDG-PET hypometabolism was compared with neuropathologic changes (neuronal loss, astrocytosis, spongiosis), hypometabolism was predictive of neuropathology in 80.6% of cortical regions versus 17.6% of subcortical regions. The odds of neuropathologic changes were 2.1 times higher in cortical regions than subcortical regions (P=0.0265). A similar discordance between cortical and subcortical regions was observed between FDG-PET hypometabolism and magnetic resonance imaging diffusion weighted imaging hyperintensity. This study shows that there may be a relationship between FDG-PET hypometabolism and neuropathology in cortical regions in prion disease but it is unlikely to be helpful for diagnosis.