Explaining age differences in the memory-experience gap.

Emotions and symptoms are often overestimated in retrospective ratings, a phenomenon referred to as the "memory-experience gap." Some research has shown that this gap is less pronounced among older compared to younger adults for self-reported negative affect, but it is not known whether these age differences are evident consistently across domains of well-being and why these age differences emerge. In this study, we examined age differences in the memory-experience gap for emotional (positive and negative affect), social (loneliness), and physical (pain, fatigue) well-being. We also tested four variables that could plausibly explain age differences in the gap: (a) episodic memory and executive functioning, (b) the age-related positivity effect, (c) variability of daily experiences, and (d) socially desirable responding. Adults (n = 477) from three age groups (21-44, 45-64, 65+ years old) participated in a 21-day diary study. Participants completed daily end-of-day ratings and retrospective ratings of the same constructs over different recall periods (3, 7, 14, and 21 days). Results showed that, relative to young and middle-aged adults, older adults had a smaller memory-experience gap for negative affect and loneliness. Lower day-to-day variability partly explained why the gap was smaller for older adults. There was no evidence that the magnitude of the memory-experience gap for positive affect, pain or fatigue depended on age. We recommend that future research considers how variability in daily experiences can impact age differences in retrospective self-reports of well-being. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Beyond Average: Providers' Assessments of Indices for Measuring Pain Intensity in Patients With Chronic Pain.

Introduction: Effective clinical care for chronic pain requires accurate, comprehensive, meaningful pain assessment. This study investigated healthcare providers' perspectives on seven pain measurement indices for capturing pain intensity. Methods: Semi-structured telephone interviews were conducted with a purposeful sample from four US regions of 20 healthcare providers who treat patients with chronic pain. The qualitative interview guide included open-ended questions to address perspectives on pain measurement, and included quantitative ratings of the importance of seven indices [average pain, worst pain, least pain, time in no/low pain, time in high pain, fluctuating pain, unpredictable pain]. Qualitative interview data were read, coded and analyzed for themes and final interpretation. Standard quantitative methods were used to analyze index importance ratings. Results: Despite concerns regarding 10-point visual analog and numeric rating scales, almost all providers used them. Providers most commonly asked about average pain, although they expressed misgivings about patient reporting and the index's informational value. Some supplemented average with worst and least pain, and most believed pain intensity is best understood within the context of patient functioning. Worst pain received the highest mean importance rating (7.60), average pain the second lowest rating (5.65), and unpredictable pain the lowest rating (5.20). Discussion: Assessing average pain intensity obviates obtaining clinical insight into daily contextual factors relating to pain and functioning. Pain index use, together with timing, functionality and disability, may be most effective for understanding the meaning to patients of high pain, how pain affects their life, how life affects their pain, and how pain changes and responds to treatment.

I. Indices of Pain Intensity Derived From Ecological Momentary Assessments: Rationale and Stakeholder Preferences.

Pain assessment that fully represents patients' pain experiences is essential for chronic pain research and management. The traditional primary outcome measure has been a patient's average pain intensity over a time period. In this series of 3 articles, we examine whether pain assessment can be enhanced by considering additional outcome measures capturing temporal aspects of pain, such as pain maxima, duration, and variability. Ecological momentary assessment makes the assessment of such indices readily available. In this first article, we discuss the rationale for considering additional pain indices derived from ecological momentary assessment and examine which are most important to stakeholders. Patients (n = 32), clinicians (n = 20), and clinical trialists (n = 20) were interviewed about their preference rankings for Average, Worst, and Least Pain, Time in High Pain, Time in No/Low Pain, Pain Variability, and Pain Unpredictability. Each stakeholder group displayed a distinct preference hierarchy for different indices, and there were few commonalities between groups. Patients favored Worst Pain and Time in High Pain, followed by Pain Variability and Unpredictability. Trialists favored Average Pain, whereas clinicians favored Worst Pain. Results suggest that multiple temporal aspects of pain are relevant for stakeholders and should be considered when evaluating the efficacy of pain management. PERSPECTIVE: Examining which aspects of pain are most important to measure from the perspective of different stakeholders can facilitate efforts to include all relevant treatment outcomes. Our study suggests that multiple temporal aspects of pain intensity are important to stakeholders. This should be considered when evaluating the efficacy of pain management.

II. Indices of Pain Intensity Derived From Ecological Momentary Assessments and Their Relationships With Patient Functioning: An Individual Patient Data Meta-analysis.

Pain intensity is a complex and dynamic experience. A focus on assessing patients' average pain levels may miss important aspects of pain that impact functioning in daily life. In this second of 3 articles investigating alternative indices of pain intensity derived from Ecological Momentary Assessments (EMA), we examine the indices' associations with physical and psychosocial functioning. EMA data from 10 studies (2,660 patients) were reanalyzed to construct indices of Average Pain, Maximum Pain, Minimum Pain, Pain Variability, Time in High Pain, Time in Low Pain, Pain after Wake-up. Three sets of individual patient data meta-analyses examined 1) the test-retest reliability of the pain indices, 2) their convergent validity in relation to physical functioning, fatigue, depression, mental health, and social functioning, and 3) the incremental validity of alternative indices above Average Pain. Reliabilities approaching or exceeding a level of .7 were observed for all indices, and most correlated significantly with all functioning domains, with small to medium effect sizes. Controlling for Average Pain, Maximum Pain and Pain Variability uniquely predicted all functioning measures, and Time in High Pain predicted physical and social functioning. We suggest that alternative pain indices can provide new perspectives for understanding functioning in chronic pain. PERSPECTIVE: Alternative summary measures of pain intensity derived from EMA have the potential to help better understand patients' pain experience. Utilizing EMA for the assessment of Maximum Pain, Pain Variability, and Time in High Pain may provide an enhanced window into the relationships between pain and patients' physical and psychosocial functioning.

III. Detecting Treatment Effects in Clinical Trials With Different Indices of Pain Intensity Derived From Ecological Momentary Assessment.

Pain intensity represents the primary outcome in most pain clinical trials. Identifying methods to measure aspects of pain that are most sensitive to treatment may facilitate discovery of effective interventions. In this third of 3 articles examining alternative indices of pain intensity derived from ecological momentary assessments (EMA), we compare treatment effects based on Average Pain, Maximum Pain, Minimum Pain, Pain Variability, Time in High Pain, Time in Low Pain, and Pain After Wake-Up. We also examine which indices contribute to Patient Global Impressions of Change (PGIC). Data came from 2 randomized, double-blind, placebo-controlled trials examining the efficacy of milnacipran for fibromyalgia treatment; 2,084 patients provided >1 million EMA pain intensity ratings over 24 (Study 1) or 26 (Study 2) treatment weeks. Pain Variability and Time in High Pain produced significantly smaller treatment effects than Average Pain; other pain indices showed effects that were numerically smaller, but not significantly different from Average Pain. Changes in all pain indices were significantly associated with PGIC, with improvements in Maximum Pain and in Pain Variability offering small incremental contributions to understanding PGIC over Average Pain. Results suggest that different pain indices could be used to detect treatment effects in pain clinical trials. PERSPECTIVE: Alternative summary measures of pain intensity derived from EMA may broaden the scope of outcomes useful in pain clinical trials. In this analysis of a pharmacological treatment for fibromyalgia, most pain summary measures indicated similar effects; improvements in Maximum Pain and Pain Variability contributed to understanding PGIC over Average Pain.

Age patterns in subjective well-being are partially accounted for by psychological and social factors associated with aging.

Subjective well-being has captured the interest of scientists and policy-makers as a way of knowing how individuals and groups evaluate and experience their lives: that is, their sense of meaning, their satisfaction with life, and their everyday moods. One of the more striking findings in this literature is a strong association between age and subjective well-being: in Western countries it has a U-shaped association over the lifespan. Despite many efforts, the reason for the curve is largely unexplained, for example, by traditional demographic variables. In this study we examined twelve social and psychological variables that could account for the U-shaped curve. In an Internet sample of 3,294 adults ranging in age from 40 to 69 we observed the expected steep increase in a measure of subjective well-being, the Cantril Ladder. Regression analyses demonstrated that the social-psychological variables explained about two-thirds of the curve and accounting for them significantly flattened the U-shape. Perceived stress, distress-depression, an open perspective about the future, wisdom, satisfaction with social relationships, and family strain were measures that had pronounced impacts on reducing the curve. These findings advance our understanding of why subjective well-being is associated with age and point the way to future studies.

How Physicians Spend Their Work Time: an Ecological Momentary Assessment.

BACKGROUND: Little is known about how physicians spend their work time. OBJECTIVE: To determine how physicians in outpatient care spend their time at work, using an innovative method: ecological momentary assessment (EMA). DESIGN: Physician activity was measured via EMA, using a smartphone app. PARTICIPANTS: Twenty-eight practices across 16 US states. Sixty-one physicians: general internal medicine, family medicine, non-interventional cardiology, orthopedics. MAIN MEASURES: Proportions of time spent on 14 activities within 6 broad categories of work: direct patient care (including both face-to-face care and other patient care-related activities), electronic health record (EHR) input, administration, teaching/supervising, personal time, and other. KEY RESULTS: After excluding personal time, physicians spent 66.5% of their time on direct patient care (23.6% multitasking with use of the EHR and 42.9% without the EHR), 20.7% on EHR input alone, 7.7% on administrative activities, and 5.0% on other activities (0.6% using the EHR). In total, physicians spent 44.9% of their time on the EHR. LIMITATIONS: Unable to measure time spent at home on the EHR or other work tasks; participating physicians were not a random sample of US physicians. CONCLUSIONS: The efficiency of highly trained professionals spending only two-thirds of their time on direct patient care may be questioned. EHR use continues to account for a large proportion of physician time. Further attempts should be made to redesign both EHRs and physician work processes.

Age Effects of Frames of Reference in Self-reports of Health, Well-being, Fatigue and Pain.

RATIONALE: Self-reports of health and well-being are central for population monitoring, so it is paramount that they are measured accurately. The goal of this study was to examine the impact of age on the use of the comparison standards or frames of reference (FoRs) in self-reports of health, life-satisfaction, fatigue, and pain, and to determine if the age-health outcome associations were affected by age differences in FoRs. METHODS: Respondents (n = 2000) selected from the U.S. general population self-rated their life-satisfaction and health outcomes. Following this, they were asked to indicate if they used any comparisons (FoRs) when making their rating and the direction of these comparisons (upward, lateral or downward). Analyses examined (a) whether age groups differed in the type and direction of FoRs, and (b) whether age patterns in health, life-satisfaction, fatigue, and pain were altered when FoRs were statistically controlled. RESULTS: Compared to middle-aged and older people, younger respondents were more likely to compare themselves with other people when self-rating their health and life-satisfaction. They were also more likely to use a hypothetical situation when evaluating their pain and fatigue. Younger participants used lateral comparisons less often and downward comparisons more often than middle-aged and older participants. When these age differences in FoRs were statistically controlled, the observed age patterns in self-reported health outcomes were somewhat reduced. CONCLUSIONS: The results show that people of different ages use different FoRs when self-reporting their life-satisfaction and health outcomes.

Patient reported outcomes can improve performance status assessment: a pilot study.

BACKGROUND: Patient performance status is routinely used in oncology to estimate physical functioning, an important factor in clinical treatment decisions and eligibility for clinical trials. However, validity and reliability data for ratings of performance status have not been optimal. This study recruited oncology patients who were about to begin emetogenic palliative or adjuvant chemotherapy for treatment of solid tumors. We employed actigraphy as the gold standard for physical activity level. Correspondences between actigraphy and oncologists' and patients' ratings of performance status were examined and compared with the correspondences of actigraphy and several patient reported outcomes (PROs). The study was designed to determine feasibility of the measurement approaches and if PROs can improve the accuracy of assessment of performance status. METHODS: Oncologists and patients made performance status ratings at visit 1. Patients wore an actigraph and entered weekly PROs on a smartphone app. Data for days 1-14 after visit 1 were analyzed. Chart reviews were conducted to tabulate all unexpected medical events across days 1-150. RESULTS: Neither oncologist nor patient ratings of performance status predicted steps/hour (actigraphy). The PROMIS® Physical Function PRO (average of Days 1, 7, 14) was associated with steps/hour at high (for men) and moderate (for women) levels; the PROMIS® Fatigue PRO predicted steps for men, but not for women. Unexpected medical events occurred in 57% of patients. Only body weight in female patients predicted events; oncologist and patient performance status ratings, steps/hour, and other PROs did not. CONCLUSIONS: PROMIS® Physical Function and Fatigue PROs show good correspondence with steps/hour making them easy, useful tools for oncologists to improve their assessment of performance status, especially for male patients. Female patients had lower levels of steps/hour than males and lower correlations among the predictors, suggesting the need for further work to improve performance status assessment in women. Assessment of pre-morbid sedentary behavior alongside current Physical Functioning and Fatigue PROs may allow for a more valid determination of disease-related activity level and performance status.

Response styles confound the age gradient of four health and well-being outcomes.

OBJECTIVES: Accurate representation of the association of health and well-being outcomes over age can inform us about how well the population is doing, where segments of the population may be in need, and allow hypothesis generation about correlates and causes of observed gradients. In this paper, we examine the possibility that response styles can impact associations between respondent age and four common, self-report variables: overall health; life satisfaction; pain intensity; and, fatigue level. Response styles (RSs) are defined as tendencies for people to use certain locations on response scales (e.g., extremes, middle) regardless of scale content. Although RSs have been shown in some circumstances to bias self-reports, often little attention is paid to this source of bias. METHODS: A sample of 2000 Internet panelists completed an online questionnaire that included a set of heterogeneous items to compute measures of the following RSs: acquiescence, disacquiescence, midpoint responding, and extreme responding. RESULTS: A total of 1839 participants formed the analytic sample and they had an average age of 54.4 (range: 21-89). RSs were associated with age and with the outcome variables. Moreover, the age pattern of the health and well-being variables was considerably altered when RSs were controlled. An alternative, item-response theory-based method of deriving measures of RSs confirmed many of the associations from the primary method of computing RS variables. Across the different self-report outcomes, disacquiescence had the greatest effect on the age patterns, and pain and fatigue were the outcomes most impacted by controlling for RSs. DISCUSSION: In accord with prior research, we recommend greater consideration be given to RSs in aging research.

Frames of Reference in Self-Reports of Health, Well-being, Fatigue, and Pain: A Qualitative Examination.

OBJECTIVES: Self-reports in survey research can be affected by internal comparison standards, or Frames of Reference (FoRs), that people apply when making their ratings. The goal of this study was to determine which FoRs people naturally use when rating their health, subjective well-being, fatigue, and pain. We further examined whether FoRs varied by content domain and age group. METHODS: One hundred adults from a community sample of the US general population participated in individual semi-structured qualitative interviews. Participants provided self-report ratings on two of the four content domains and were then systematically queried about FoRs. Interview responses were summarized and coded into broad FoR categories. RESULTS: Four broad FoR categories emerged: References to (1) Other People, (2) an Earlier Time in Life, (3) an Important Event in the Past, and (4) a Hypothetical Situation. FoRs were reported in the majority (80.5%) of responses and multiple FoRs were reported in 34% of responses. The reporting of FoRs was evident for all domains, but was more prevalent for well-being compared to pain. References to a Hypothetical Situation were only mentioned in the well-being and health domains. For health, references to Other People were more frequently reported at older compared to younger ages. DISCUSSION: Our results extend prior work by demonstrating that participants' reporting of FoRs is evident in ratings of various content domains. They further suggest that a limited number of FoRs are used and that their identification holds promise for understanding and controlling systematic group differences in FoRs.

Partners' Overestimation of Patients' Pain Severity: Relationships with Partners' Interpersonal Responses.

Objectives: The present study examined whether concordance between patients' and their partners' reports of patient pain severity relates to partners' social support and behavioral responses in couples coping with chronic pain. Methods: Fifty-two couples completed questionnaires about the patient's pain severity. Both dyad members also rated the partner's social support and negative, solicitous, and distracting responses toward the patient when in pain. Results: Bivariate correlations showed moderate correspondence between patient and partner ratings of pain severity (r = 0.55) and negative (r = 0.46), solicitous (r = 0.47), and distracting responses (r = 0.53), but lower correspondence for social support (r = 0.28). Twenty-eight couples (54%) were concordant in their perceptions of patient pain; partners overestimated pain in 14 couples (27%), and partners underestimated pain in 10 couples (19%). Couple concordance in pain perceptions was not related to patients' reports; however, it significantly predicted partners' reports: Partners who overestimated pain reported giving more social support (ß = 0.383, P = 0.016), fewer negative responses (ß = -0.332, P = 0.029), and more solicitous responses (ß = 0.438, P = 0.016) than partners who were in agreement or who underestimated pain. Discussion: Partner overestimation of pain severity is associated with partner-reported but not with patient-reported support-related responses. This finding has important clinical implications for couple interventions in chronic pain.

Psychological stress declines rapidly from age 50 in the United States: Yet another well-being paradox.

OBJECTIVES: Although there is evidence that evaluative subjective well-being (e.g., life satisfaction) shows a U-shaped pattern with highest satisfaction in the youngest and oldest years and lowest in the middle years of adulthood, much less is known about experiential well-being. We explore a negative indicator of experiential well-being (perceived stress), examine its association with age, and explore possible determinants of the age pattern. METHODS: Using Gallup-Healthways survey data of over 1.5 million U.S. respondents, we analyzed a question asking about stress yesterday and demographic determinants of the pattern. To confirm this pattern, data on stress was analyzed from the American Time Use Survey and data on distress was analyzed from the Health and Retirement Survey. RESULTS: We show that ratings of daily, perceived stressfulness yield a paradox, with high levels from the 20's through about age 50, followed by a precipitous decline through the 70's. Data from the other two surveys confirmed the age pattern for stress. Regressions with the Gallup-Healthways data statistically controlled several third-variables, yet none substantially altered the pattern. CONCLUSION: We argue that this new experiential well-being pattern informs us about aging in the US and the "paradox" calls out for explanation.

Linguistic Indicators of Pain Catastrophizing in Patients With Chronic Musculoskeletal Pain.

The present study examined markers of pain catastrophizing in the word use of patients with chronic pain. Patients (N = 71) completed the Pain Catastrophizing Scale and wrote about their life with pain. Quantitative word count analysis examined whether the essays contained linguistic indicators of catastrophizing. Bivariate correlations showed that catastrophizing was associated with greater use of first person singular pronouns, such as "I" (r = .27, P ≤ .05) and pronouns referencing other people (r = .28, P ≤ .05). Catastrophizing was further significantly associated with greater use of sadness (r = .35, P ≤ .01) and anger (r = .30, P ≤ .05) words. No significant relationships with positive emotion and cognitive process words were evident. Controlling for patients' engagement in the writing task, gender, age, pain intensity, and neuroticism in multiple regression, the linguistic categories together uniquely explained 13.6% of the variance in catastrophizing (P ≤ .001). First person singular pronouns (ß = .24, P ≤ .05) and words relating to sadness (ß = .25, P ≤ .05) were significant, and pronouns referencing other people (ß = .19, P ≤ .10) were trending. The results suggest that pain catastrophizing is associated with a "linguistic fingerprint" that can be discerned from patients' natural word use. PERSPECTIVE: Quantitative word count analysis examined whether pain catastrophizing is reflected in patients' written essays about living with pain. Catastrophizing was associated with more first person singular pronouns, more pronouns referencing other people, and more expressions of sadness and anger. The results can help understand how catastrophizing translates into communicative behaviors.

Etiologic specificity of waking Cortisol: Links with maternal history of depression and anxiety in adolescent girls.

BACKGROUND: Many previous studies have indicated that individuals who are depressed or at risk for depression are characterized by increased levels of morning cortisol and a greater cortisol awakening response (CAR). However, despite the high comorbidity between depressive and anxiety disorders, fewer studies have examined whether these diurnal cortisol abnormalities are also characteristic of anxiety or risk for anxiety. METHODS: In the present study we examined cortisol in a community sample of 476 female adolescents and related it to maternal history of depression and/or anxiety disorders. Salivary cortisol was collected at waking, 30min post waking, and in the evening on three weekdays. RESULTS: Contrary to prior results, offspring at risk for depression did not have increased morning cortisol or CAR. However, offspring at risk for anxiety disorders had elevated 30min cortisol and total cortisol produced throughout the day; this effect was primarily driven by offspring of mothers with panic disorder or agoraphobia. Additionally, levels of cortisol were highest among offspring of mothers with multiple anxiety diagnoses. LIMITATIONS: The study is limited to female adolescents and maternal diagnostic history. Additionally, some diagnoses could not be examined as a result of too few cases (e.g. GAD). CONCLUSIONS: Overall, these results underscore the importance of considering anxiety when examining the association of diurnal cortisol abnormalities with risk for psychopathology, as it may have influenced prior observations of elevated morning cortisol in depression.

Clinic Blood Pressure Underestimates Ambulatory Blood Pressure in an Untreated Employer-Based US Population: Results From the Masked Hypertension Study.

BACKGROUND: Ambulatory blood pressure (ABP) is consistently superior to clinic blood pressure (CBP) as a predictor of cardiovascular morbidity and mortality risk. A common perception is that ABP is usually lower than CBP. The relationship of the CBP minus ABP difference to age has not been examined in the United States. METHODS: Between 2005 and 2012, 888 healthy, employed, middle-aged (mean±SD age, 45±10.4 years) individuals (59% female, 7.4% black, 12% Hispanic) with screening BP <160/105 mm Hg and not taking antihypertensive medication completed 3 separate clinic BP assessments and a 24-hour ABP recording for the Masked Hypertension Study. The distributions of CBP, mean awake ABP (aABP), and the CBP-aABP difference in the full sample and by demographic characteristics were compared. Locally weighted scatterplot smoothing was used to model the relationship of the BP measures to age and body mass index. The prevalence of discrepancies in ABP- versus CBP-defined hypertension status-white-coat hypertension and masked hypertension-were also examined. RESULTS: Average systolic/diastolic aABP (123.0/77.4±10.3/7.4 mm Hg) was significantly higher than the average of 9 CBP readings over 3 visits (116.0/75.4±11.6/7.7 mm Hg). aABP exceeded CBP by >10 mm Hg much more frequently than CBP exceeded aABP. The difference (aABP>CBP) was most pronounced in young adults and those with normal body mass index. The systolic difference progressively diminished, but did not disappear, at older ages and higher body mass indexes. The diastolic difference vanished around age 65 and reversed (CBP>aABP) for body mass index >32.5 kg/m2. Whereas 5.3% of participants were hypertensive by CBP, 19.2% were hypertensive by aABP; 15.7% of those with nonelevated CBP had masked hypertension. CONCLUSIONS: Contrary to a widely held belief, based primarily on cohort studies of patients with elevated CBP, ABP is not usually lower than CBP, at least not among healthy, employed individuals. Furthermore, a substantial proportion of otherwise healthy individuals with nonelevated CBP have masked hypertension. Demonstrated CBP-aABP gradients, if confirmed in representative samples (eg, NHANES [National Health and Nutrition Examination Survey]), could provide guidance for primary care physicians as to when, for a given CBP, 24-hour ABP would be useful to identify or rule out masked hypertension.

Cognitive behavioral therapy for chronic pain is effective, but for whom?

Moderator analyses are reported for posttreatment outcomes in a large, randomized, controlled effectiveness trial for chronic pain for hip and knee osteoarthritis (N = 256). Pain Coping Skills Training, a form of cognitive behavioral therapy, was compared to usual care. Treatment was delivered by nurse practitioners in patients' community doctors' offices. Consistent with meta-analyses of pain cognitive behavioral therapy efficacy, treatment effects in this trial were significant for several primary and secondary outcomes, but tended to be small. This study was designed to examine differential response to treatment for patient subgroups to guide clinical decision-making for treatment. Based on existing literature, demographic (age, sex, race/ethnicity, and education) and clinical variables (disease severity, body mass index, patient treatment expectations, depression, and patient pain coping style) were specified a priori as potential moderators. Trial outcome variables (N = 15) included pain, fatigue, self-efficacy, quality of life, catastrophizing, and use of pain medication. Results yielded 5 significant moderators for outcomes at posttreatment: pain coping style, patient expectation for treatment response, radiographically assessed disease severity, age, and education. Thus, sex, race/ethnicity, body mass index, and depression at baseline were not associated with level of treatment response. In contrast, patients with interpersonal problems associated with pain coping did not benefit much from the treatment. Although most patients projected positive expectations for the treatment prior to randomization, only those with moderate to high expectations benefited. Patients with moderate to high osteoarthritis disease severity showed stronger treatment effects. Finally, the oldest and most educated patients showed strong treatment effects, while younger and less educated did not.

PROMIS fatigue, pain intensity, pain interference, pain behavior, physical function, depression, anxiety, and anger scales demonstrate ecological validity.

OBJECTIVES: Ecological validity refers to the degree to which instruments faithfully capture information in respondents' natural environments. We examined the ecological validity of eight instruments from the Patient Reported Outcomes Measurement Information System (PROMIS), most of which use 7-day reporting periods, by comparing PROMIS scores with daily diary data as a standard. STUDY DESIGN AND SETTING: Five groups of approximately 100 respondents each completed daily diaries and weekly PROMIS instruments for 4 consecutive weeks: community residents; osteoarthritis patients; women experiencing premenstrual syndrome; men undergoing hernia surgery; and breast cancer patients receiving chemotherapy. The last three groups experienced events (menses, surgery, or chemotherapy, respectively) at standardized times in the protocol to examine symptom changes attributable to these events. RESULTS: We examined the ability of the PROMIS scales to replicate between-group differences in diaries, to replicate week-to-week changes in diaries, and the correlation between diary and PROMIS scales. As a secondary aim, we examined known-group differences with the PROMIS measures. All three types of ecological validity were strongly confirmed, as was known-group validity for the PROMIS recall scales. CONCLUSION: This study adds to the growing literature supporting the reliability and validity of the family of PROMIS instruments.

Identification of distinct fatigue trajectories in patients with breast cancer undergoing adjuvant chemotherapy.

PURPOSE: The goal of this study was to characterize changes in daily fatigue in women undergoing chemotherapy for breast cancer. We examined whether there are subgroups of patients with distinct fatigue trajectories and explored potential psychosocial and biomedical predictors of these subgroups. METHODS: Participants were 77 women with breast cancer receiving adjuvant chemotherapy with AC-T (2-week cycle) and TC or TCH (3-week cycle) regimens. They completed 28 daily ratings online using an adapted version of the Patient-Reported Outcomes Measurement Information System (PROMIS®) fatigue instrument. RESULTS: Both regimens followed an "inverted-U-shaped" fatigue pattern over approximately 2 weeks. Growth mixture modeling identified three patient subgroups with distinct trajectories. Fatigue scores in the "low fatigue" group (23 %) increased following the infusion and quickly abated. The "transient fatigue" (27 %) group had a very pronounced increase. Patients in the "high fatigue" (50 %) group reported consistently elevated fatigue with a relatively small increase. Demographic and medical variables were not associated with fatigue trajectory. Patients in the "high fatigue" group reported significantly poorer physical, emotional, and social functioning, poorer general health, and more depressed mood than patients in the "low fatigue" group. The "transient fatigue" group reported significantly better physical and social functioning than the "high fatigue" group, but emotional distress and depression similar to the "high fatigue" group. CONCLUSIONS: The identification of patient subgroups with distinct fatigue trajectories during chemotherapy is an essential step for developing preventative strategies and tailored interventions. Our results suggest that different trajectories are associated with patients' psychosocial and general health.

Nurse practitioners can effectively deliver pain coping skills training to osteoarthritis patients with chronic pain: A randomized, controlled trial.

A multisite, randomized, controlled clinical effectiveness trial was conducted for osteoarthritis patients with chronic pain of the knee or hip. Adult health nurse practitioners provided a 10-session intervention, pain coping skills training (PCST), in patients' doctors' offices (N=129 patients); the control group received usual care (N=127 patients). Primary outcomes assessed at baseline, posttreatment, 6-month follow-up, and 12-month follow-up were: pain intensity, physical functioning, psychological distress, self-efficacy, catastrophizing, use of coping strategies, and quality of life. Secondary measures included fatigue, social functioning, health satisfaction, and use of pain medication. Methods favoring external validity, consistent with pragmatic, effectiveness research, were utilized. Primary ITT and secondary per-protocol analyses were conducted. Attrition was within the expected range: 11% at posttreatment and 29% at 12-month follow-up; rates did not differ between groups. Omnibus ITT analyses across all assessment points indicated significant improvement for the PCST group compared with the control group for pain intensity, physical functioning, psychological distress, use of pain coping strategies, and self-efficacy, as well as fatigue, satisfaction with health, and reduced use of pain medication. Treatment effects were robust to covariates (demographics and clinical sites). Trends in the outcomes across the assessments were examined. All outcomes, except for self-efficacy, were maintained through the 12-month follow-up; effects for self-efficacy degraded over time. Per-protocol analyses did not yield greater effect sizes. Comparisons of PCST patients who were more vs less treatment adherent suggested greater effectiveness for patients with high adherence. Results support the effectiveness of nurse practitioner delivery of PCST for chronic osteoarthritis pain.