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Figure 1. Patients selected for inclusion.
facilitate clinically relevant improvement in care for both
physicians and patients while being efficient and easy to use
clinically.6 The Patient-Reported Outcomes Measurement
Instrumentation System (PROMIS), a validated measure
that uses computerized adaptive testing (CAT) and item
response theory, decreases administration time, avoids floor
and ceiling effects, and achieves high accuracy.7 In head-tohead comparisons, PROMIS scales demonstrate higher
accuracy and efficiency than disease-specific legacy scales
across the spectrum of orthopedics.3,9-12,14,17 The benefits to
applying PROMIS scales in clinical decision making remain
uncertain.
Using PROMIS scales to predict how an individual
patient will respond to a proposed treatment is of great
interest to physicians and patients. Ho et al9 recently
reported preoperative PROMIS scores to be highly predictive in identifying patients who would and would not
improve from foot and ankle surgery. In that study, PROMIS
physical function (PF), pain interference (PI), and depression (D) scores were prospectively collected at an academic
tertiary foot and ankle center. Having the pre- and postoperative data available and defining the minimal clinically
important difference (MCID), the sensitivity (true-positive
rate) and 100 minus specificity (false-positive rate) can be
obtained and plotted on a curve called the receiver operating characteristic (ROC) curve, and predictive percentages
can be determined. ROC curve analysis demonstrated that
Foot & Ankle International 39(7)
preoperative PF, PI, and D scores were predicative of postoperative improvement. Furthermore, patients with poor
preoperative function, high preoperative pain, and high preoperative depression were more likely to reach MCID than
less affected patients, allowing the identification of
PROMIS score thresholds with 95% accuracy. PROMIS PF
scales have been compared with other foot and ankle legacy
scales and found to be more efficient, reliable, and responsive to change.10 The strength of PROMIS scales, which are
global, non-disease-specific scales, in predicting MCID
improvement was surprising given the differences across
procedures, diagnoses, and severity.9 The derived threshold
values from that study have not been validated in a separate
sample of foot and ankle patients and are not known to be
generalizable. Although similar findings of preoperative
PROMIS scores were found to be highly predictive of outcomes from hip,5 knee,4 and shoulder19 arthroplasty patients,
the proposed thresholds relative to foot and ankle surgery
remain speculative when applied to a separate cohort of
patients.
The purpose of this analysis was to assess the validity
and generalizability of previously published preoperative
PROMIS PF and PI t scores as predictors of postoperative
clinically meaningful improvement in foot and ankle
patients in a separate, geographically distinct cohort. We
tested 3 hypotheses: (1) PROMIS scales (PF and PI) would
improve at postoperative follow-up, as in other studies9,14;
(2) preoperative PROMIS PF and PI scores would accurately predict postoperative improvement (MCID), resulting in similar threshold values (specifically, the hypothesis
was that patients with high preoperative pain would be
more likely to reach MCID than those with low preoperative pain and that those with low preoperative function
would be more likely to reach MCID than those with high
preoperative function); and (3) applying the preoperative
PROMIS PF and PI thresholds reported previously to this
data set would successfully identify patients experiencing
postoperative MCID change in this validation sample over
chance alone.
Methods
PROMIS PF and PI scores were prospectively collected
from consecutive patient visits to a multiple-surgeon tertiary foot and ankle clinic between January 2014 and
November 2016. This consisted of 18565 unique patient
visits, of which 1408 were new patient visits. Patients
undergoing elective operative intervention were identified
by Current Procedural Terminology codes. Application of
exclusion criteria identical to those of Ho et al9 (new
patients, elective surgery, complete data sets with a minimum of 6 months of follow-up) resulted in a sample of 61
subjects (Figure 1). PROMIS PF and PI scores were
assessed at initial and follow-up visits (minimum, 6 months;
Table of Contents for the Digital Edition of Foot & Ankle International - July 2018
Contents
Foot & Ankle International - July 2018 - Intro
Foot & Ankle International - July 2018 - Cover1
Foot & Ankle International - July 2018 - Cover2
Foot & Ankle International - July 2018 - i
Foot & Ankle International - July 2018 - ii
Foot & Ankle International - July 2018 - Contents
Foot & Ankle International - July 2018 - iv
Foot & Ankle International - July 2018 - v
Foot & Ankle International - July 2018 - vi
Foot & Ankle International - July 2018 - vii
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Foot & Ankle International - July 2018 - 1A
Foot & Ankle International - July 2018 - 1B
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Foot & Ankle International - July 2018 - 2A
Foot & Ankle International - July 2018 - 2B
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Foot & Ankle International - July 2018 - 3A
Foot & Ankle International - July 2018 - 3B
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Foot & Ankle International - July 2018 - Cover3
Foot & Ankle International - July 2018 - Cover4
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