Are Social Deprivation and Low Traditional Health Literacy Associated With Higher PROMIS CAT Completion in Orthopaedic Surgery?

The Patient-Reported Outcomes Measurement Information System® (PROMIS®) may be used to assess an individual patient's perspective of their physical, mental, and social health through either standard or computer adaptive testing (CAT) patient questionnaires. These questionnaires are used across disciplines; however, they have seen considerable application in orthopaedic surgery. Patient characteristics associated with PROMIS CAT completion have not been examined within the context of social determinants of health, such as social deprivation or health literacy, nor has patient understanding of the content of PROMIS CAT been assessed. (1) What patient demographics, including social deprivation, are associated with completion of PROMIS CAT questionnaires? (2) Is health literacy level associated with completion of PROMIS CAT questionnaires? (3) Do patients with lower health literacy have a higher odds of completing PROMIS CAT without fully understanding the content? Between June 2022 and August 2022, a cross-sectional study was performed via a paper survey administered to patients at a single, urban, quaternary academic medical center in orthopaedic subspecialty clinics of foot and ankle, trauma, and hand/upper extremity surgeons. We considered all English-speaking patients aged 18 or older, including those with limited reading and/or writing abilities, as eligible provided they received an iPad in clinic to complete the PROMIS CAT questionnaire as part of their routine standard clinical care or they completed the questionnaire via a patient portal before the visit. In all, 946 patients were considered eligible during the study period and a convenience sample of 36% (339 of 946) of patients was approached for inclusion due to clinic time constraints. Fifteen percent (52 of 339) declined to participate, leaving 85% (287 of 339) of patients for analysis here. Median (range) age of study participants was 49 years (35 to 64). Fifty-eight percent (167 of 287) of study participants self-identified as non-Hispanic Black or African American and 26% (75 of 287) as non-Hispanic White. Even proportions were observed across education levels (high school graduate or less, 29% [82 of 287]; some college, 25% [73 of 287]; college graduate, 25% [71 of 287]; advanced degree, 20% [58 of 287]). Eighteen percent (52 of 287) of patients reported an annual income bracket of USD 0 to 13,000, and 17% (48 of 287) reported more than USD 120,000. Forty-six percent (132 of 287) of patients worked full-time, 21% (59 of 287) were retired, and 23% (66 of 287) were unemployed or on disability. The primary outcome of interest was self-reported PROMIS CAT questionnaire completion grouped as: fully completed, partially completed, or no part completed. Overall, self-reported PROMIS CAT questionnaire completion proportions were: 80% (229 of 287) full completion, 13% (37 of 287) partial completion, and 7% (21 of 287) no part completed. We collected the National Area Deprivation Index (ADI) score and the Brief Health Literacy Screening Tool (BRIEF) as part of the study survey to associate with level of completion. Additionally, patient understanding of PROMIS CAT was assessed through Likert-scaled responses to a study survey question that directly asked whether the patient understood all of the questions on the PROMIS CAT questionnaire. Responses to this question may have been limited by social desirability bias, and hence may overestimate how many individuals genuinely understood the questionnaire content. However, the benefit of this approach was it efficiently allowed us to estimate the ceiling effect of patient comprehension of PROMIS CAT and likely had a high degree of specificity for detecting lack of comprehension. ADI score adjusted for age was not associated with PROMIS CAT completion (partial completion OR 1.00 [95% CI 0.98 to 1.01]; p = 0.72, no part completed OR 1.01 [95% CI 0.99 to 1.03]; p = 0.45). Patients with lower health literacy scores, however, were more likely to not complete any part of their assigned questionnaires than patients with higher scores (no part completed OR 0.85 [95% CI 0.75 to 0.97]; p = 0.02). Additionally, 74% (26 of 35) of patients who did not fully understand all of the PROMIS CAT questionnaire questions still fully completed them-hence, 11% (26 of 229) of all patients who fully completed PROMIS CAT did not fully understand the content. Among patients self-reporting full completion of PROMIS CAT with health literacy data (99% [227 of 229]), patients with inadequate/marginal health literacy were more likely than patients with adequate health literacy to not fully understand all of the questions (21% [14 of 67] versus 8% [12 of 160], OR 3.26 [95% CI 1.42 to 7.49]; p = 0.005). Within an urban, socioeconomically diverse, orthopaedic patient population, health literacy was associated with PROMIS CAT questionnaire completion. Lower health literacy levels increased the likelihood of not completing any part of the assigned PROMIS CAT questionnaires. Additionally, patients completed PROMIS CAT without fully understanding the questions. This indicates that patient completion does not guarantee comprehension of the questions nor validity of their scores, even more so among patients with low health literacy. This is a substantive concern for fidelity of data gathered from PROMIS CAT. Clinical implementation of the PROMIS CAT in orthopaedic populations will benefit from further research into health literacy to increase questionnaire completion and to ensure that patients understand the content of the questions they are answering, which will increase the internal validity of the outcome measure.

Litvak AL ，Lin NA ，Hynes KK ，Strelzow JA ，Conti Mica MA ，Stepan JG ... -  《-》

Being a medical trainee in Greece: Aims and key aspects of the Greek Survey of Medical Work and Education.

Stringaris A ，Peiou P ，Rokas IM ，Saridis N ，Asimakopoulos LO ... -  《-》

Effectiveness of interventions for improving educational outcomes for people with disabilities in low- and middle-income countries: A systematic review.

People with disabilities are consistently falling behind in educational outcomes compared to their peers without disabilities, whether measured in terms of school enrolment, school completion, mean years of schooling, or literacy levels. These inequalities in education contribute to people with disabilities being less likely to achieve employment, or earn as much if they are employed, as people without disabilities. Evidence suggests that the gap in educational attainment for people with and without disabilities is greatest in low- and middle-income countries (LMICs). Exclusion of people with disabilities from mainstream education, and low rates of participation in education of any kind, are important issues for global equity. Interventions which might have a positive impact include those that improve educational outcomes for people with disabilities, whether delivered in specialist or inclusive education settings. Such interventions involve a wide range of initiatives, from those focused on the individual level - such as teaching assistance to make mainstream classes more accessible to children with specific learning needs - to those which address policy or advocacy. The objectives of this review were to answer the following research questions: (1) What is the nature of the interventions used to support education for people with disabilities in LMICs? (2) What is the size and quality of the evidence base of the effectiveness of interventions to improve educational outcomes for people with disabilities in LMICs? (3) What works to improve educational outcomes for people with disabilities in LMICs? (4) Which interventions appear to be most effective for different types of disability? (5) What are the barriers and facilitators to the improvement of educational outcomes for people with disabilities? (6) Is there evidence of cumulative effects of interventions? The search for studies followed two steps. Firstly, we conducted an electronic search of databases and sector-specific websites. Then, after initial screening, we examined the reference lists of all identified reviews and screened the cited studies for inclusion. We also conducted a forward search and an ancestral search. No restrictions in terms of date or format were placed on the search, but only English-language publications were eligible for inclusion. In our review, we included studies on the basis that they were able to detect intervention impact. Descriptive studies of various designs and methodologies were not included. We also excluded any study with a sample size of fewer than five participants. We included studies which examined the impact of interventions for people with disabilities living in LMICs. There were no restrictions on comparators/comparison groups in included studies. However, to be eligible for inclusion, a study needed to have both an eligible intervention and an eligible outcome. Any duration of follow-up was eligible for inclusion. We used EppiReviewer for bibliographic management, screening, coding, and data synthesis. Eligibility was assessed using a predesigned form based on the inclusion criteria developed by the authors. We piloted all coding sheets with at least five studies before use. The form allowed for coding of multiple intervention domains and multiple outcomes domains. The entire screening process was reported using a PRISMA flow chart. We screened all unique references from our search title and abstract, with two independent reviewers determining relevance, and repeated this process for full texts. Data was extracted from studies according to a coding sheet. Coding included: (1) extraction of basic study characteristics, (2) a narrative summary of procedures and findings (including recording of iatrogenic effects), (3) a summary of findings/results table, (4) an assessment of confidence in study findings, and (5) creation of a forest plot of effect sizes. A third data collector, a research associate, checked the results of this process. Confidence in study findings was assessed using a standardised tool. All coding categories were not mutually exclusive and so multiple coding was done where an intervention covered more than one category of intervention. Twenty-eight studies were included in this review. Most studies (n = 25) targeted children with disabilities. Only two studies directly targeted family members, and the remaining three focused on service providers. Individuals with intellectual or learning and developmental impairments were most frequently targeted by interventions (n = 17). The category of interventions most represented across studies was 'Educational attainment support', for instance, a reading comprehension intervention that combined strategy instruction (graphic organisers, visual displays, mnemonic illustrations, computer exercises, predicting, inference, text structure awareness, main idea identification, summarisation, and questioning) for children with dyslexia. The second most common category of intervention was 'Accessible learning environments', for instance, programmes which aimed to improve social skills or to reduce rates of victimisation of children with disabilities in schools. Regarding intervention effects, included studies concerned with 'Conditions for inclusion of people with disabilities in education' showed a moderately significant effect, and one study concerned with teacher knowledge showed a significant effect size. Among the 18 studies included in the analysis of intervention effects on 'Skills for learning', 12 interventions had a significant effect. When considering the effect of interventions on different outcomes, we see that the effect on literacy, cognitive skills, handwriting, and numeracy are significant. All these effects are large but are based on a low number of studies. The studies concerned with speech and school behaviour show no significant effect of intervention. Across studies, heterogeneity is high, and risk of publication bias varies but was frequently high. All but one study received an overall rating of low confidence in study findings. However, this lack of confidence across studies was largely due to the use of low-rigour study designs and was not always reflective of multiple points of weakness within a given study. Children with disabilities fall behind in educational outcomes as the current school systems are not set up to teach children with different impairment types. There is no one 'magic bullet' intervention which can equalise health outcomes for this group. A twin-track approach is needed, which both addresses the specific needs of children with disabilities but also ensures that they are included in mainstream activities (e.g., through improving the skills of teachers and accessibility of the classroom). However, currently most interventions included in this systematic review targeted individual children with disabilities in an attempt to improve their functioning, skills, and competencies, but did not focus on mainstreaming these children into the school by system-level or school-level changes. Consequently, a focus on evaluation of interventions which target not just the individual with a disability but also their broader environment, are needed.

Hunt X ，Saran A ，White H ，Kuper H ... -  《-》

Mortality impact, risks, and benefits of general population screening for ovarian cancer: the UKCTOCS randomised controlled trial.

Menon U ，Gentry-Maharaj A ，Burnell M ，Ryan A ，Kalsi JK ，Singh N ，Dawnay A ，Fallowfield L ，McGuire AJ ，Campbell S ，Skates SJ ，Parmar M ，Jacobs IJ ... -  《-》

A New Measure of Quantified Social Health Is Associated With Levels of Discomfort, Capability, and Mental and General Health Among Patients Seeking Musculoskeletal Specialty Care.

A better understanding of the correlation between social health and mindsets, comfort, and capability could aid the design of individualized care models. However, currently available social health checklists are relatively lengthy, burdensome, and designed for descriptive screening purposes rather than quantitative assessment for clinical research, patient monitoring, or quality improvement. Alternatives such as area deprivation index are prone to overgeneralization, lack depth in regard to personal circumstances, and evolve rapidly with gentrification. To fill this void, we aimed to identify the underlying themes of social health and develop a new, personalized and quantitative social health measure. (1) What underlying themes of social health (factors) among a subset of items derived from available legacy checklists and questionnaires can be identified and quantified using a brief social health measure? (2) How much of the variation in levels of discomfort, capability, general health, feelings of distress, and unhelpful thoughts regarding symptoms is accounted for by quantified social health? In this two-stage, cross-sectional study among people seeking musculoskeletal specialty care in an urban area in the United States, all English and Spanish literate adults (ages 18 to 89 years) were invited to participate in two separate cohorts to help develop a provisional new measure of quantified social health. In a first stage (December 2021 to August 2022), 291 patients rated a subset of items derived from commonly used social health checklists and questionnaires (Tool for Health and Resilience in Vulnerable Environments [THRIVE]; Protocol for Responding to and Assessing Patient Assets, Risks and Experiences [PRAPARE]; and Accountable Health Communities Health-Related Social Needs Screening Tool [HRSN]), of whom 95% (275 of 291; 57% women; mean ± SD age 49 ± 16 years; 51% White, 33% Hispanic; 21% Spanish speaking; 38% completed high school or less) completed all items required to perform factor analysis and were included. Given that so few patients decline participation (estimated at < 5%), we did not track them. We then randomly parsed participants into (1) a learning cohort (69% [189 of 275]) used to identify underlying themes of social health and develop a new measure of quantified social health using exploratory and confirmatory factor analysis (CFA), and (2) a validation cohort (31% [86 of 275]) used to test and internally validate the findings on data not used in its development. During the validation process, we found inconsistencies in the correlations of quantified social health with levels of discomfort and capability between the learning and validation cohort that could not be resolved or explained despite various sensitivity analyses. We therefore identified an additional cohort of 356 eligible patients (February 2023 to June 2023) to complete a new extended subset of items directed at financial security and social support (5 items from the initial stage and 11 new items derived from the Interpersonal Support Evaluation List, Financial Well-Being Scale, Multidimensional Scale of Perceived Social Support, Medical Outcomes Study Social Support Survey, and 6-item Social Support Questionnaire, and "I have to work multiple jobs in order to finance my life" was self-created), of whom 95% (338 of 356; 53% women; mean ± SD age 48 ± 16 years; 38% White, 48% Hispanic; 31% Spanish speaking; 47% completed high school or less) completed all items required to perform factor analysis and were included. We repeated factor analysis to identify the underlying themes of social health and then applied item response theory-based graded response modeling to identify the items that were best able to measure differences in social health (high item discrimination) with the lowest possible floor and ceiling effects (proportion of participants with lowest or highest possible score, respectively; a range of different item difficulties). We also assessed the CFA factor loadings (correlation of an individual item with the identified factor) and modification indices (parameters that suggest whether specific changes to the model would improve model fit appreciably). We then iteratively removed items based on low factor loadings (< 0.4, generally regarded as threshold for items to be considered stable) and high modification indices until model fit in CFA was acceptable (root mean square of error approximation [RMSEA] < 0.05). We then assessed local dependencies among the remaining items (strong relationships between items unrelated to the underlying factor) using Yen Q3 and aimed to combine only items with local dependencies of < 0.25. Because we exhausted our set of items, we were not able to address all local dependencies. Among the remaining items, we then repeated CFA to assess model fit (RMSEA) and used Cronbach alpha to assess internal consistency (the extent to which different subsets of the included items would provide the same measurement outcomes). We performed a differential item functioning analysis to assess whether certain items are rated discordantly based on differences in self-reported age, gender, race, or level of education, which can introduce bias. Last, we assessed the correlations of the new quantified social health measure with various self-reported sociodemographic characteristics (external validity) as well as level of discomfort, capability, general health, and mental health (clinical relevance) using bivariate and multivariable linear regression analyses. We identified two factors representing financial security (11 items) and social support (5 items). After removing problematic items based on our prespecified protocol, we selected 5 items to address financial security (including "I am concerned that the money I have or will save won't last") and 4 items to address social support (including "There is a special person who is around when I am in need"). The selected items of the new quantified social health measure (Social Health Scale [SHS]) displayed good model fit in CFA (RMSEA 0.046, confirming adequate factor structure) and good internal consistency (Cronbach α = 0.80 to 0.84), although there were some remaining local dependencies that could not be resolved by removing items because we exhausted our set of items. We found that more disadvantaged quantitative social health was moderately associated with various sociodemographic characteristics (self-reported Black race [regression coefficient (RC) 2.6 (95% confidence interval [CI] 0.29 to 4.9)], divorced [RC 2.5 (95% CI 0.23 to 4.8)], unemployed [RC 1.7 (95% CI 0.023 to 3.4)], uninsured [RC 3.5 (95% CI 0.33 to 6.7)], and earning less than USD 75,000 per year [RC 2.7 (95% CI 0.020 to 5.4) to 6.8 (95% CI 4.3 to 9.3)]), slightly with higher levels of discomfort (RC 0.055 [95% CI 0.16 to 0.093]), slightly with lower levels of capability (RC -0.19 [95% CI -0.34 to -0.035]), slightly with worse general health (RC 0.13 [95% CI 0.069 to 0.18]), moderately with higher levels of unhelpful thoughts (RC 0.17 [95% CI 0.13 to 0.22]), and moderately with greater feelings of distress (RC 0.23 [95% CI 0.19 to 0.28]). A quantitative measure of social health with domains of financial security and social support had acceptable psychometric properties and seems clinically relevant given the associations with levels of discomfort, capability, and general health. It is important to mention that people with disadvantaged social health should not be further disadvantaged by using a quantitative measure of social health to screen or cherry pick in contexts of incentivized or mandated reporting, which could worsen inequities in access and care. Rather, one should consider disadvantaged social health and its associated stressors as one of several previously less considered and potentially modifiable aspects of comprehensive musculoskeletal health. A personalized, quantitative measure of social health would be useful to better capture and understand the role of social health in comprehensive musculoskeletal specialty care. The SHS can be used to measure the distinct contribution of social health to various aspects of musculoskeletal health to inform development of personalized, whole-person care pathways. Clinicians may also use the SHS to identify and monitor patients with disadvantaged social circumstances. This line of inquiry may benefit from additional research including a larger number of items focused on a broader range of social health to further develop the SHS.

Brinkman N ，Broekman M ，Teunis T ，Choi S ，Ring D ，Jayakumar P ... -  《-》