Publications by authors named "Kurt Kroenke"

277 Publications

Continuing Research During a Crisis.

J Gen Intern Med 2021 Feb 8. Epub 2021 Feb 8.

Division of General Internal Medicine and Geriatrics, Department of Medicine, Indiana University School of Medicine, Indianapolis, USA.

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http://dx.doi.org/10.1007/s11606-021-06636-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7870021PMC
February 2021

Responsiveness of PROMIS and Patient Health Questionnaire (PHQ) Depression Scales in three clinical trials.

Health Qual Life Outcomes 2021 Feb 4;19(1):41. Epub 2021 Feb 4.

Department of Biostatistics, Indiana University Fairbanks School of Public Health and School of Medicine, Indianapolis, IN, USA.

Background: The PROMIS depression scales are reliable and valid measures that have extensive normative data in general population samples. However, less is known about how responsive they are to detect change in clinical settings and how their responsiveness compares to legacy measures. The purpose of this study was to assess and compare the responsiveness of the PROMIS and Patient Health Questionnaire (PHQ) depression scales in three separate samples.

Methods: We used data from three clinical trials (two in patients with chronic pain and one in stroke survivors) totaling 651 participants. At both baseline and follow-up, participants completed four PROMIS depression fixed-length scales as well as legacy measures: Patient Health Questionnaire 9-item and 2-item scales (PHQ-9 and PHQ-2) and the SF-36 Mental Health scale. We measured global ratings of depression change, both prospectively and retrospectively, as anchors to classify patients as improved, unchanged, or worsened. Responsiveness was assessed with standardized response means, statistical tests comparing change groups, and area-under-curve analysis.

Results: The PROMIS depression and legacy scales had generally comparable responsiveness. Moreover, the four PROMIS depression scales of varying lengths were similarly responsive. In general, measures performed better in detecting depression improvement than depression worsening. For all measures, responsiveness varied based on the study sample and on whether depression improved or worsened.

Conclusions: Both PROMIS and PHQ depression scales are brief public domain measures that are responsive (i.e., sensitive to change) and thus appropriate as outcome measures in research as well as for monitoring treatment in clinical practice. Trial registration ClinicalTrials.gov ID: NCT01236521, NCT01583985, NCT01507688.
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http://dx.doi.org/10.1186/s12955-021-01674-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7860196PMC
February 2021

Estimates From Heterogeneous Studies of Opioid-Related Morbidity.

JAMA Pediatr 2021 Feb 1. Epub 2021 Feb 1.

Department of Psychological and Brain Sciences, Indiana University, Bloomington.

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http://dx.doi.org/10.1001/jamapediatrics.2020.5625DOI Listing
February 2021

Psychological Processes and Symptom Outcomes in Mindfulness-Based Stress Reduction for Cancer Survivors: A Pilot Study.

Mindfulness (N Y) 2020 Apr 14;11(4):905-916. Epub 2020 Jan 14.

Department of Medicine, Indiana University School of Medicine, Indianapolis, IN.

Objectives: Growing evidence supports the efficacy of mindfulness-based interventions for symptoms in cancer survivors. Identifying theory-based psychological processes underlying their effects on symptoms would inform research to enhance their efficacy and cost-effectiveness. We conducted secondary analyses examining the effect of mindfulness-based stress reduction (MBSR) for cancer-related fatigue on mindfulness facets, self-compassion, and psychological inflexibility. We also examined whether changes in these processes were associated with the symptom outcomes of fatigue interference, sleep disturbance, and emotional distress.

Methods: Thirty-five persistently fatigued cancer survivors (94% female, 77% breast cancer survivors) were randomized to either MBSR for cancer-related fatigue or a waitlist control (WC) condition. Self-report measures were administered at pre-intervention, post-intervention, and 1-month follow-up. Then the WC group received MBSR and completed a post-intervention follow-up.

Results: Linear mixed modeling analyses of the first three time points showed steady increases over time for certain mindfulness facets (observing, acting with awareness, and nonjudging) and self-compassion in favor of the MBSR group. When analyzing pre- and post-intervention data across study conditions, none of the psychological processes predicted change in fatigue interference. However, increased nonjudging was associated with decreased sleep disturbance ( = -.39, = .003), and increased acting with awareness was associated with decreased emotional distress ( = -.36, = .003). Self-compassion did not predict change in symptom outcomes.

Conclusions: Results point to specific psychological processes that may be targeted to maximize the efficacy of future MBSR interventions for cancer survivors.
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http://dx.doi.org/10.1007/s12671-019-01299-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7810211PMC
April 2020

PHQ-9: global uptake of a depression scale.

Authors:
Kurt Kroenke

World Psychiatry 2021 Feb;20(1):135-136

Indiana University School of Medicine and Regenstrief Institute, Indianapolis, IN, USA.

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http://dx.doi.org/10.1002/wps.20821DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7801833PMC
February 2021

Balancing the Risks and Benefits of Benzodiazepines.

JAMA 2021 Jan;325(4):347-348

Department of Medicine, Indiana University School of Medicine, Indianapolis.

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http://dx.doi.org/10.1001/jama.2020.22106DOI Listing
January 2021

Screening for perinatal depression with the Patient Health Questionnaire depression scale (PHQ-9): A systematic review and meta-analysis.

Gen Hosp Psychiatry 2021 Jan-Feb;68:74-82. Epub 2020 Dec 21.

Department of Biostatistics, Indiana University, Fairbanks School of Public Health and School of Medicine, Indianapolis, IN, USA.

Objectives: Perinatal depression (PND) is a prevalent and disabling problem both during pregnancy and the postpartum period. The legacy screening measure has been the Edinburgh Postnatal Depression Scale (EPDS). This systematic review examines the validity of the PHQ-9 as a screener for PND.

Methods: The following databases were searched from January 2001 (when the PHQ-9 was first published) through June 2020: MEDLINE, Embase, and PsychInfo. Studies that compared the PHQ-9 to a criterion standard psychiatric interview were used to determine the operating characteristics of sensitivity, specificity and area under the curve (AUC). Studies comparing the PHQ-9 to the EPDS and other depression scales evaluated convergent validity.

Results: A total of 35 articles were eligible for criterion (n = 10) or convergent (n = 25) validity. Meta-analysis of the 7 criterion validity studies using the standard PHQ-9 cut point ≥10 showed a pooled sensitivity, specificity and AUC of 0.84, 0.81 and 0.89, respectively. Operating characteristics of the PHQ-9 and EPDS were nearly identical in head-to-head comparison studies. The median correlation between the PHQ-9 and EPDS was 0.59, and categorical agreement was moderate.

Conclusions: The PHQ-9 appears to be a viable option for perinatal depression screening with operating characteristics similar to the legacy EPDS.
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http://dx.doi.org/10.1016/j.genhosppsych.2020.12.007DOI Listing
December 2020

COVID-19 Status Differentially Affects Olfaction: A Prospective Case-Control Study.

OTO Open 2020 Oct-Dec;4(4):2473974X20970176. Epub 2020 Nov 2.

Department of Otolaryngology-Head and Neck Surgery, Indiana University, Indianapolis, Indiana, USA.

Objective: The symptoms and long-term sequelae of SARS-CoV-2 infection have yet to be determined, and evaluating possible early signs is critical to determine which patients should be tested and treated. The objective of this ongoing study is to evaluate initial and short-term rhinologic symptoms, olfactory ability, and general quality of life in patients undergoing SARS-CoV-2 testing.

Study Design: Prospective case-control.

Setting: Academic institute.

Methods: Adult patients tested for SARS-CoV-2 were prospectively enrolled and separated into positive and negative groups. Each participant completed 4 validated patient-reported outcome measures. The UPSIT (University of Pennsylvania Smell Identification Test) was distributed to patients who were SARS-CoV-2 positive.

Results: The positive group reported significantly decreased sense of smell and taste on the 22-item Sinonasal Outcome Test (SNOT-22) as compared with the negative group (mean ± SD: 3.4 ± 1.7 vs 1.2 ± 1.4, < .001). The positive group had a much higher probability of reporting a decrease in smell/taste as "severe" or "as bad as it can be" (63.3% vs 5.8%) with an odds ratio of 27.6 (95% CI, 5.9-128.8). There were no differences between groups for overall SNOT-22 domain scores, PHQ-4 depression/anxiety (Patient Health Questionnaire-4), and 5-Level EQ-5D quality-of-life scores. Mean Self-MOQ (Self-reported Mini Olfactory Questionnaire) scores were 7.0 ± 5.6 for the positive group and 1.8 ± 4.0 for the negative group ( < .001). The mean UPSIT score was 28.8 ± 7.2 in the positive group.

Conclusion: Symptomatic patients who are SARS-CoV-2 positive report severe olfactory and gustatory dysfunction via the Self-MOQ and SNOT-22 as compared with symptomatic patients testing negative.
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http://dx.doi.org/10.1177/2473974X20970176DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7649865PMC
November 2020

SymTrak-8 as a Brief Measure for Assessing Symptoms in Older Adults.

J Gen Intern Med 2020 Nov 10. Epub 2020 Nov 10.

School of Medicine, Indiana University, 410 W. Tenth St., Suite 3000, Indianapolis, IN, 46202-3002, USA.

Background: Patient- and caregiver-reported 23-item SymTrak scales were validated for monitoring clinically actionable symptoms and impairments associated with multiple chronic conditions (MCCs) in older adults. Items capture physical and emotional symptoms and impairments in physical and cognitive functioning. An abbreviated SymTrak is desirable when response burden is a concern.

Objective: Develop and validate the 8-item SymTrak.

Design And Participants: Secondary analysis of SymTrak validation study; 600 participants (200 patient-caregiver dyads; 200 patients without an identified caregiver).

Main Measures: Demographic questions, SymTrak, and Health Utility Index Mark 3 (HUI3).

Key Results: SymTrak-8 demonstrated good fit to a one-factor model using confirmatory factor analysis (CFA). Concurrent criterion validity was supported by high standardized linear regression coefficients (STB) between baseline SymTrak-8 total score (independent variable) and baseline HUI3 preference-based overall HRQOL utility score (dependent variable; 0 = death, 1 = perfect health), after adjusting for demographics, comorbid conditions, and medications, with strength comparable to SymTrak-23 (STB = - 0.81 and - 0.84, respectively, for SymTrak-8 and SymTrak-23, when patient-reported; and - 0.60 and - 0.62, respectively, when caregiver-reported). Coefficient alpha (0.74; 0.76) and 24-h test-retest reliability (0.83; 0.87) were high for SymTrak-8 for patients and caregivers, respectively. The convergent correlation between brief and parent SymTrak scales was high (0.94). SymTrak-8 demonstrated approximate normality and a linear relationship with SymTrak-23 and HUI3. Importantly, a 3-month change in SymTrak-8 was sensitive to detecting the criterion (3-month reliable change categories; improved, stable, declined in HUI3 overall utility), with results comparable to SymTrak-23.

Conclusions: SymTrak-8 total score demonstrates internal reliably, test-retest reliability, criterion validity, and sensitivity to change that are comparable to SymTrak-23. Thus, patient- or caregiver-reported SymTrak-8 is a viable option for identifying and monitoring the aggregate effect of symptoms and functional impairments in patients with multimorbidity when response burden is a concern.
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http://dx.doi.org/10.1007/s11606-020-06329-5DOI Listing
November 2020

Patient race and opioid misuse history influence provider risk perceptions for future opioid-related problems.

Am Psychol 2020 09;75(6):784-795

Department of Medicine, Indiana University School of Medicine.

In response to the dual public health crises of chronic pain and opioid use, providers have become more vigilant about assessing patients for risk of opioid-related problems. Little is known about how providers are making these risk assessments. Given previous studies indicating that Black patients are at increased risk for suboptimal pain care, which may be related to stereotypes about drug abuse, the current study examined how patient race and previous opioid misuse behaviors impact providers' risk assessments for future prescription opioid-related problems. Physician residents and fellows (N = 135) viewed videos and read vignettes about 8 virtual patients with chronic pain who varied by race (Black/White) and history of prescription opioid misuse (absent/present). Providers rated patients' risk for future prescription opioid-related adverse events, misuse/abuse, addiction, and diversion, and also completed measures of implicit racial attitudes and explicit beliefs about race differences in pain. Two significant interactions emerged indicating that Black patients were perceived to be at greater risk for future adverse events (when previous misuse was absent) and diversion (when previous misuse was present). Significant main effects indicated that Black patients and patients with previous misuse were perceived to be at greater risk for future misuse/abuse of prescription opioids, and that patients with previous misuse were perceived to be at greater risk of addiction. These findings suggest that racial minorities and patients with a history of prescription opioid misuse are particularly vulnerable to any unintended consequences of efforts to stem the dual public health crises of chronic pain and opioid use. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/amp0000636DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7490831PMC
September 2020

Two Birds with One Stone: Joint Screening for Perinatal Depression and Anxiety.

Authors:
Kurt Kroenke

J Womens Health (Larchmt) 2020 Jul 23. Epub 2020 Jul 23.

Indiana University School of Medicine and Regenstrief Institute, Indianapolis, Indiana, USA.

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http://dx.doi.org/10.1089/jwh.2020.8643DOI Listing
July 2020

Brief educational video plus telecare to enhance recovery for older emergency department patients with acute musculoskeletal pain: study protocol for the BETTER randomized controlled trial.

Trials 2020 Jul 6;21(1):615. Epub 2020 Jul 6.

Department of Psychology and Neuroscience, Duke University, Durham, NC, USA.

Background: Chronic musculoskeletal pain (MSP) affects more than 40% of adults aged 50 years and older and is the leading cause of disability in the USA. Older adults with chronic MSP are at risk for analgesic-related side effects, long-term opioid use, and functional decline. Recognizing the burden of chronic MSP, reducing the transition from acute to chronic pain is a public health priority. In this paper, we report the protocol for the Brief EducaTional Tool to Enhance Recovery (BETTER) trial. This trial compares two versions of an intervention to usual care for preventing the transition from acute to chronic MSP among older adults in the emergency department (ED).

Methods: Three hundred sixty patients from the ED will be randomized to one of three arms: full intervention (an interactive educational video about pain medications and recovery-promoting behaviors, a telecare phone call from a nurse 48 to 72 h after discharge from the ED, and an electronic communication containing clinical information to the patient's primary care provider); video-only intervention (the interactive educational video but no telecare or primary care provider communication); or usual care. Data collection will occur at baseline and at 1 week and 1, 3, 6, and 12 months after study enrollment. The primary outcome is a composite measure of pain severity and interference. Secondary outcomes include physical function, overall health, opioid use, healthcare utilization, and an assessment of the economic value of the intervention.

Discussion: This trial is the first patient-facing ED-based intervention aimed at helping older adults to better manage their MSP and reduce their risk of developing chronic pain. If effective, future studies will examine the effectiveness of implementation strategies.

Trial Registration: ClinicalTrials.gov NCT04118595 . Registered on 8 October 2019.
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http://dx.doi.org/10.1186/s13063-020-04552-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7336469PMC
July 2020

Predictors of depression outcomes in adults with cancer: A 12 month longitudinal study.

J Psychosom Res 2020 09 11;136:110169. Epub 2020 Jun 11.

Indiana University School of Medicine, Indianapolis, IN, USA; Center for Health Services Research, Regenstrief Institute, Inc., Indianapolis, IN USA; Charles Warren Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis, IN USA; Research in Palliative and End of Life Communication and Training Center, Indiana University Purdue University Indianapolis, Indianapolis, IN USA.

Objectives: The prevalence of depression in patients with cancer ranges from 8% to 24% within the first year of receiving a cancer diagnosis. Identifying predictors of depression outcomes may facilitate tailored or more intensive treatment in patient subgroups with a poorer prognosis for depression improvement. The objective of this study was to determine predictors of depression severity and improvement over 12 months among adults with cancer.

Methods: Longitudinal analysis of data from the Indiana Cancer Pain and Depression trial was performed in 309 patients (n = 309) with cancer-related depression. Depression outcomes were assessed at baseline, 1, 3, 6, and 12 months and included depression severity (Hopkins Symptom Checklist-20) and global improvement (Depression Global Rating of Improvement (DGRI)). Multivariable repeated measures analyses, adjusting for treatment group, baseline depression, and time point, were conducted to determine symptom (pain), demographic, and clinical predictors of depression outcomes over 12 months.

Results: Pain was particularly important, with a clinically meaningful reduction in pain predicting a 12-24% greater odds of depression global improvement. Other factors that independently predicted better depression outcomes over 12 months included female sex, newly-diagnosed or maintainence/disease-free cancer, fewer comorbid medical conditions, and higher socioeconomic status. As expected, the three covariates adjusted for in the model (treatment group, passage of time, and baseline depression severity) also predicted depression outcomes.

Conclusion: Pain as well as several demographic and clinical factors predict depression outcomes over 12 months. These findings may help identify patient subgroups requiring closer monitoring and more intensive or tailored depression treatment. Trial Registration clinicaltrials.gov Identifier: NCT00313573.
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http://dx.doi.org/10.1016/j.jpsychores.2020.110169DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7484175PMC
September 2020

Disentangling trait versus state characteristics of the Pain Catastrophizing Scale and the PHQ-8 Depression Scale.

Eur J Pain 2020 09 27;24(8):1624-1634. Epub 2020 Jun 27.

Departments of Physical Therapy, Orthopaedic Surgery and Rheumatology, Virginia Commonwealth University, Richmond, VA, USA.

Background: Research on the role of trait versus state characteristics of a variety of measures among persons experiencing pain has been a focus for the past few decades. Studying the trait versus state nature of the Pain Catastrophizing Scale (PCS) and the Patient Health Questionnaire (PHQ-8) depression scale would be highly informative given both are commonly measured in pain populations and neither scale has been studied for trait/state contributions.

Methods: The PHQ-8 and PCS were obtained on persons undergoing knee arthroplasty at baseline, 2-, 6- and 12-month post-surgery (N = 402). The multi-trait generalization of the latent trait-state model was used to partition trait and state variability in PCS and PHQ-8 item responses simultaneously. A set of variables were used to predict trait catastrophizing and trait depression.

Results: For total scores, the latent traits and latent states explain 63.2% (trait = 43.2%; state = 20.0%) and 50.2% (trait = 29.4%; state = 20.8%) of the variability in PCS and PHQ-8, respectively. Patients with a high number of bodily pain sites, high levels of anxiety, young patients and African-American patients had high levels of trait catastrophizing and trait depression. The PCS and the PHQ-8 consist of both enduring trait and dynamic state characteristics, with trait characteristics dominating for both measures.

Conclusion: Clinicians and researchers using these scales should not assume the obtained measurements solely reflect either trait- or state-based characteristics.

Significance: Clinicians and researchers using the PCS or PHQ-8 scales are measuring both state and trait characteristics and not just trait- or state-based characteristics.
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http://dx.doi.org/10.1002/ejp.1619DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7686072PMC
September 2020

Short-Term Psychodynamic Psychotherapy for Functional Somatic Disorders: A Meta-Analysis of Randomized Controlled Trials.

Psychother Psychosom 2020 19;89(6):363-370. Epub 2020 May 19.

Centre for Emotions and Health, Dalhousie University, Halifax, Nova Scotia, Canada.

Introduction: Functionalsomatic disorders (FSD) are common and costly, thereby driving the need for the development of effective brief treatment options. Short-term psychodynamic psychotherapy (STPP) is one candidate treatment method.

Objective: To review and meta-analyze, where possible, randomized controlled trials (RCTs) of STPP for FSD.

Methods: Following a systematic search of the literature, we performed a meta-analysis of available RCT groups to determine the effects of STPP on a range of outcomes after treatment, and medium- and long-term follow-ups.

Results: In meta-analyses of 17 RCTs, STPP significantly outperformed minimal treatment, treatment as usual, or waiting list controls on somatic symptom measures at all time frames, with small to large magnitude effect sizes. Descriptive reviews of 5 RCTs suggest that STPP performed at least as well as other bona fide psychological therapies. Limitations of this meta-analysis include small samples of studies and possible publication bias.

Conclusions: STPP is a valid treatment option for diverse FSD conditions resulting in somatic symptom reductions that persist over time. STPP should be included in FSD treatment guidelines.
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http://dx.doi.org/10.1159/000507738DOI Listing
May 2020

Minimally important differences and severity thresholds are estimated for the PROMIS depression scales from three randomized clinical trials.

J Affect Disord 2020 04 23;266:100-108. Epub 2020 Jan 23.

Department of Biostatistics, Indiana University Fairbanks School of Public Health and School of Medicine, Indianapolis, IN, USA.

Background: Patient Reported Outcomes Measurement Information Systems (PROMIS) scales are increasingly being used to measure symptoms in research and practice. The purpose of this study was to determine the minimally important difference (MID) and severity thresholds (cut-points) for the four fixed-length PROMIS depression scales.

Methods: The study sample was adult participants in three randomized clinical trials (N=651). MID was estimated using multiple distribution- and anchor-based approaches including assessing correspondence between Patient Health Questionnaire (PHQ-9) and PROMIS depression scores.

Results: The best MID estimate was a PROMIS depression T-score of 3.5 points with most methods producing an MID in the 3 to 4 point range across all three samples. MID estimates were similar for all four PROMIS scales. A PHQ-9 1-point change equated to a PROMIS 1.25-point T-score change. PROMIS T-scores of 55, 60, 65, and 70 appeared to be reasonable thresholds for mild, moderate, moderately severe, and severe depression, respectively.

Limitations: The study sample was predominantly male veterans with either chronic pain (2 trials) or previous stroke (1 trial). The severity of depression was mild to moderate.

Conclusion: A T-score of 3 to 4 points is a reasonable MID for PROMIS depression scales and can be used to assess treatment effects in both practice and research as well to calculate sample sizes for clinical trials. Severity cut-points can help interpret the meaning of scores and action thresholds for treatment decisions.
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http://dx.doi.org/10.1016/j.jad.2020.01.101DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7103541PMC
April 2020

Patients' Experiences with Telecare for Chronic Pain and Mood Symptoms: A Qualitative Study.

Pain Med 2020 10;21(10):2137-2145

VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana.

Objective: Pain, anxiety, and depression commonly co-occur, can have reciprocal effects, and are associated with substantial disability and health care costs. However, few interventions target treatment of pain and mood disorders as a whole. The Comprehensive vs. Assisted Management of Mood and Pain Symptoms (CAMMPS) trial was a randomized trial comparing two pragmatic telecare interventions, a high- vs low-resource approach to pain and anxiety/depression treatment. The purpose of the current study is to better understand patients' perspectives on both intervention approaches, including intervention components, delivery, patient experiences, and patient outcomes.

Design: Qualitative, semistructured interviews.

Setting: A Veterans Affairs Medical Center.

Subjects: Twenty-five patients were purposefully sampled from both study arms.

Methods: Patients were interviewed about their experiences with pain and mood treatment, perceived benefits and changes, and experiences with the intervention model to which they were randomized. The constant comparison method guided analysis.

Results: Pain was more important than mood for most participants. Participants described developing increased awareness of their symptoms, including connecting pain and mood, which enabled better management. Participants in the high-resource intervention described the added value of the study nurse in their symptom management.

Conclusions: Patients in a telecare intervention for chronic pain and mood symptoms learned to connect pain and mood and be more aware of their symptoms, enabling more effective symptom management. Patients in the high-resource intervention described the added benefits of a nurse who provided informational and motivational support. Implications for tradeoffs between resource intensity and patient outcomes are discussed.
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http://dx.doi.org/10.1093/pm/pnz345DOI Listing
October 2020

A Time Motion Study Evaluating the Impact of Geographic Cohorting of Hospitalists.

J Hosp Med 2020 06;15(6):338-344

Indiana University School of Medicine, Indianapolis, Indiana.

Background: Geographic cohorting (GCh) localizes hospitalists to a unit. Our objective was to compare the GCh and non-GCh workday.

Methods: In an academic, Midwestern hospital we observed hospitalists in GCh and non-GCh teams. Time in patient rooms was considered direct care; other locations were considered 'indirect' care. Geotracking identified time spent in each location and was obtained for 17 hospitalists. It was supplemented by in-person observation of four GCh and four non-GCh hospitalists for a workday each. Multilevel modeling was used to analyze associations between direct and indirect care time and team and workday characteristics.

Results: Geotracking yielded 10,522 direct care episodes. GCh was associated with longer durations of patient visits while increasing patient loads were associated with shorter visits. GCh, increasing patient loads, and increasing numbers of units visited were associated with increased indirect care time. In-person observations yielded 3,032 minutes of data. GCh hospitalists were observed spending 56% of the day in computer interactions vs non-GCh hospitalists (39%; P < .005). The percentage of time spent multitasking was 18% for GCh and 14% for non-GCh hospitalists (P > .05). Interruptions were pervasive, but the highest interruption rate of once every eight minutes in the afternoon was noted in the GCh group.

Conclusion: GCh may have the potential to increase patient-hospitalist interactions but these gains may be attenuated if patient loads and the structure of cohorting are suboptimal. The hospitalist workday is cognitively intense. The interruptions noted may increase the time taken for time-intensive tasks like electronic medical record interactions.
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http://dx.doi.org/10.12788/jhm.3339DOI Listing
June 2020

Benzodiazepine and unhealthy alcohol use among adult outpatients.

Am J Manag Care 2019 12 1;25(12):e358-e365. Epub 2019 Dec 1.

Department of Psychiatry and the UCSF Weill Institute for Neurosciences, University of California, San Francisco, 401 Parnassus Ave, Box 0984, San Francisco, CA 94143. Email:

Objectives: Concomitant excessive alcohol consumption and benzodiazepine use is associated with adverse health outcomes. We examined associations of unhealthy alcohol use and other patient characteristics with benzodiazepine use.

Study Design: A cross-sectional analysis of 2,089,525 Kaiser Permanente of Northern California outpatients screened for unhealthy alcohol use in primary care between November 1, 2014, and December 31, 2016.

Methods: We fit multivariable generalized linear models to estimate the associations between unhealthy alcohol use and benzodiazepine dispensation and, among patients who were dispensed a benzodiazepine, mean doses (in mean lorazepam-equivalent daily doses [LEDDs]) and prescription durations. We controlled for patient sex, age, race/ethnicity, estimated household income, Charlson Comorbidity Index (CCI) score, anxiety disorder, alcohol use disorder, insomnia, musculoskeletal pain, and epilepsy.

Results: In the 12 months centered around (6 months before and 6 months after) the first alcohol-screening visit, 7.5% of patients used benzodiazepines. The following characteristics were independently associated with higher rates of benzodiazepine use, higher LEDD, and longer prescription duration: older age, white race/ethnicity, lower estimated household income, higher CCI score, and the presence of an anxiety disorder, insomnia, musculoskeletal pain, or epilepsy. Women and patients with an alcohol use disorder or unhealthy alcohol use, compared with men and patients with low-risk drinking or abstinence, were more likely to use a benzodiazepine; however, their LEDDs were lower and their prescription durations were shorter.

Conclusions: Benzodiazepine use in primary care was associated with older age, female sex, white race/ethnicity, lower socioeconomic status, and unhealthy alcohol use. These findings may be applied to develop policies and interventions to promote judicious benzodiazepine use.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7217068PMC
December 2019

A randomized controlled trial testing a virtual perspective-taking intervention to reduce race and socioeconomic status disparities in pain care.

Pain 2019 10;160(10):2229-2240

Department of Psychology, Indiana University-Purdue University Indianapolis, Indianapolis, IN, United States.

We conducted a randomized controlled trial of an individually tailored, virtual perspective-taking intervention to reduce race and socioeconomic status (SES) disparities in providers' pain treatment decisions. Physician residents and fellows (n = 436) were recruited from across the United States for this two-part online study. Providers first completed a bias assessment task in which they made treatment decisions for virtual patients with chronic pain who varied by race (black/white) and SES (low/high). Providers who demonstrated a treatment bias were randomized to the intervention or control group. The intervention consisted of personalized feedback about their bias, real-time dynamic interactions with virtual patients, and videos depicting how pain impacts the patients' lives. Treatment bias was re-assessed 1 week later. Compared with the control group, providers who received the tailored intervention had 85% lower odds of demonstrating a treatment bias against black patients and 76% lower odds of demonstrating a treatment bias against low SES patients at follow-up. Providers who received the intervention for racial bias also showed increased compassion for patients compared with providers in the control condition. Group differences did not emerge for provider comfort in treating patients. Results suggest an online intervention that is tailored to providers according to their individual treatment biases, delivers feedback about these biases, and provides opportunities for increased contact with black and low SES patients, can produce substantial changes in providers' treatment decisions, resulting in more equitable pain care. Future studies should examine how these effects translate to real-world patient care and the optimal timing/dose of the intervention.
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http://dx.doi.org/10.1097/j.pain.0000000000001634DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6784848PMC
October 2019

Sleep Disturbance Predicts Less Improvement in Pain Outcomes: Secondary Analysis of the SPACE Randomized Clinical Trial.

Pain Med 2020 06;21(6):1162-1167

Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota.

Objective: Sleep disturbance may limit improvement in pain outcomes if not directly addressed in treatment. Moreover, sleep problems may be exacerbated by opioid therapy. This study examined the effects of baseline sleep disturbance on improvement in pain outcomes using data from the Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) trial, a pragmatic 12-month randomized trial of opioid vs nonopioid medication therapy.

Design: Participants with chronic back pain or hip or knee osteoarthritis pain were randomized to either opioid therapy (N = 120) or nonopioid medication therapy (N = 120).

Methods: We used mixed models for repeated measures to 1) test whether baseline sleep disturbance scores modified the effect of opioid vs nonopioid treatment on pain outcomes and 2) test baseline sleep disturbance scores as a predictor of less improvement in pain outcomes across both treatment groups.

Results: The tests for interaction of sleep disturbance by treatment group were not significant. Higher sleep disturbance scores at baseline predicted less improvement in Brief Pain Inventory (BPI) interference (β = 0.058, P = 0.0002) and BPI severity (β = 0.026, P = 0.0164).

Conclusions: Baseline sleep disturbance adversely affects pain response to treatment regardless of analgesic regimen. Recognition and treatment of sleep impairments that frequently co-occur with pain may optimize outcomes.
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http://dx.doi.org/10.1093/pm/pnz221DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7069777PMC
June 2020

Designing the relational team development intervention to improve management of mental health in primary care using iterative stakeholder engagement.

BMC Fam Pract 2019 09 6;20(1):124. Epub 2019 Sep 6.

Lowry Family Health Center, Denver Health, Denver, CO, USA.

Background: Team-based models of care are efficacious in improving outcomes for patients with mental and physical illnesses. However, primary care clinics have been slow to adopt these models. We used iterative stakeholder engagement to develop an intervention to improve the implementation of team-based care for this complex population.

Methods: We developed the initial framework for Relational Team Development (RELATED) from a qualitative study of Primary Care Providers' (PCPs') experiences treating mental illness and a literature review of practice facilitation and psychology clinical supervision. Subsequently, we surveyed 900 Colorado PCPs to identify factors associated with PCP self-efficacy in management of mental illness and team-based care. We then conducted two focus groups for feedback on RELATED. Lastly, we convened an expert panel to refine the intervention.

Results: We developed RELATED, a two-part intervention delivered by a practice facilitator with a background in clinical psychology. The facilitator observes PCPs during patient visits and provides individualized coaching. Next, the facilitator guides the primary care team through a practice change activity with a focus on relational team dynamics.

Conclusion: The iterative development of RELATED using stakeholder engagement offers a model for the development of interventions tailored to the needs of these stakeholders.

Trial Registration: Not applicable.
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http://dx.doi.org/10.1186/s12875-019-1010-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6728939PMC
September 2019

Comparative Responsiveness and Minimally Important Difference of Common Anxiety Measures.

Med Care 2019 11;57(11):890-897

Department of Biostatistics, Indiana University Fairbanks School of Public Health, Indianapolis, IN.

Background: Anxiety is one of the most prevalent mental disorders and accounts for substantial disability as well as increased health care costs. This study examines the minimally important difference (MID) and responsiveness of 6 commonly used anxiety scales.

Methods: The sample comprised 294 patients from 6 primary care clinics in a single VA medical center who were enrolled in a telecare trial for treatment of chronic musculoskeletal pain and comorbid depression and/or anxiety. The measures assessed were the Patient Reported Outcomes Measurement Information System (PROMIS) 4-item, 6-item, and 8-item anxiety scales; the Generalized Anxiety Disorder 7-item scale (GAD-7); the Symptom Checklist anxiety subscale (SCL); the Posttraumatic Stress Disorder Checklist (PCL); the Short Form (SF)-36 Mental Health subscale; and the SF-12 Mental Component Summary (MCS). Validity was assessed with correlations of these measures with one another and with measures of quality of life and disability. MID was estimated by triangulating several methods. Responsiveness was evaluated by comparing: (a) the standardized response means for patients who reported their mood as being better, the same, or worse at 3 months; (b) the area under the curve for patients who had improved (better) versus those who had not (same/worse).

Results: Convergent and construct validity was supported by strong correlations of the anxiety measures with one another and moderate correlations with quality of life and disability measures, respectively. All measures differentiated patients who reported global improvement at 3 months from those who were unchanged, but were less able to distinguish worsening from no change. The area under the curves showed comparable responsiveness of the scales. The estimated MID was 4 for the PROMIS scales; 3 for the GAD-7; 6 for the PCL; 9 for the SF-36 mental health subscale; 5 for the MCS score, and 0.3 for the SCL anxiety scale.

Conclusions: Six commonly used anxiety scales demonstrate similar responsiveness, and estimated MIDs can be used to gauge anxiety change in clinical research and practice.
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http://dx.doi.org/10.1097/MLR.0000000000001185DOI Listing
November 2019

Measurement invariance of the patient health questionnaire-9 (PHQ-9) depression screener in U.S. adults across sex, race/ethnicity, and education level: NHANES 2005-2016.

Depress Anxiety 2019 09 29;36(9):813-823. Epub 2019 Jul 29.

Department of Psychology, Indiana University-Purdue University Indianapolis (IUPUI), Indianapolis, Indiana.

Background: Despite its popularity, little is known about the measurement invariance of the Patient Health Questionnaire-9 (PHQ-9) across U.S. sociodemographic groups. Use of a screener shown not to possess measurement invariance could result in under/over-detection of depression, potentially exacerbating sociodemographic disparities in depression. Therefore, we assessed the factor structure and measurement invariance of the PHQ-9 across major U.S. sociodemographic groups.

Methods: U.S. population representative data came from the 2005-2016 National Health and Nutrition Examination Survey (NHANES) cohorts. We conducted a measurement invariance analysis of 31,366 respondents across sociodemographic factors of sex, race/ethnicity, and education level.

Results: Considering results of single-group confirmatory factor analyses (CFAs), depression theory, and research utility, we justify a two-factor structure for the PHQ-9 consisting of a cognitive/affective factor and a somatic factor (RMSEA = 0.034, TLI = 0.985, CFI = 0.989). On the basis of multiple-group CFAs testing configural, scalar, and strict factorial invariance, we determined that invariance held for sex, race/ethnicity, and education level groups, as all models demonstrated close model fit (RMSEA = 0.025-0.025, TLI = 0.985-0.992, CFI = 0.986-0.991). Finally, for all steps ΔCFI was <-0.004, and ΔRMSEA was <0.01.

Conclusions: We demonstrate that the PHQ-9 is acceptable to use in major U.S. sociodemographic groups and allows for meaningful comparisons in total, cognitive/affective, and somatic depressive symptoms across these groups, extending its use to the community. This knowledge is timely as medicine moves towards alternative payment models emphasizing high-quality and cost-efficient care, which will likely incentivize behavioral and population health efforts. We also provide a consistent, evidence-based approach for calculating PHQ-9 subscale scores.
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http://dx.doi.org/10.1002/da.22940DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6736700PMC
September 2019

PROMIS 4-item measures and numeric rating scales efficiently assess SPADE symptoms compared with legacy measures.

J Clin Epidemiol 2019 11 19;115:116-124. Epub 2019 Jul 19.

Department of Biostatistics, Indiana University Fairbanks School of Public Health and School of Medicine, Indianapolis, IN, USA.

Objective: The 5 SPADE (sleep, pain, anxiety, depression, and low energy/fatigue) symptoms are among the most prevalent and disabling symptoms in clinical practice. This study evaluates the minimally important difference (MID) of Patient-Reported Outcomes Measurement Information System (PROMIS) measures and their correspondence with other brief measures to assess SPADE symptoms.

Study Design And Setting: Three hundred primary care patients completed a 4-item PROMIS scale, a numeric rating scale (NRS), and a non-PROMIS legacy scale for each of the 5 SPADE symptoms. Optimal NRS cutpoints were examined, and cross-walk units for converting legacy measure scores to PROMIS scores were determined. PROMIS scores corresponding to standard deviation (SD) and standard error of measurement (SEM) changes in legacy scores were used to estimate MID.

Results: At an NRS ≥5, the mean PROMIS T-score exceeded 55 (the operational threshold for a clinically meaningful symptom) for each SPADE symptom. Correlations were high (0.70-0.86) between each PROMIS scale and its corresponding non-PROMIS legacy scale. Changes in non-PROMIS legacy scale scores of 0.35 SD and 1 SEM corresponded to mean PROMIS T-scores of 2.92 and 3.05 across the 5 SPADE symptoms, with changes in 0.2 and 0.5 SD corresponding to mean PROMIS T-scores of 1.67 and 4.16.

Conclusion: A 2-step screening process for SPADE symptoms might use single-item NRS scores, proceeding to PROMIS scales for NRS scores ≥5. A PROMIS T-score change of three points represents a reasonable MID estimate, with two to four points approximating lower and upper bounds.
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http://dx.doi.org/10.1016/j.jclinepi.2019.06.018DOI Listing
November 2019

Assessing depression improvement with the remission evaluation and mood inventory tool (REMIT).

Gen Hosp Psychiatry 2019 Sep - Oct;60:44-49. Epub 2019 Jul 12.

Department of Biostatistics, Indiana University Fairbanks School of Public Health, Indianapolis, IN, United States.

Objective: The Remission Evaluation and Mood Inventory Tool (REMIT) was developed as a brief complementary measure to provide a more robust assessment of depression improvement than tracking DSM-V symptom improvement alone. This study provides further validation of the REMIT tool and examines its utility in predicting depression improvement.

Methods: The sample comprised 294 primary care patients enrolled in a telecare trial of pain plus depression and/or anxiety. Assessments collected included: REMIT, PHQ-9 and measures assessing anxiety, pain, sleep, fatigue, somatization, health-related quality of life and disability. Data was analyzed to assess the REMIT's validity, its minimally important difference (MID), and its utility in predicting 6-month depression improvement.

Results: Convergent and construct validity of REMIT was supported by moderate correlations with mental health measures and weaker correlation with physical health measures. MID of approximately 2 points for REMIT was estimated by two metrics: 0.5 standard deviation and 1 standard error of measurement. Both baseline and 3-month change in REMIT scores predicted depression improvement at 6 months. Indeed, REMIT was as good or better predictor than the PHQ-9.

Conclusion: The REMIT measure is a brief 5-item tool that augments core DSM-V symptom-oriented metrics in assessing and predicting recovery from major depression.
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http://dx.doi.org/10.1016/j.genhosppsych.2019.07.007DOI Listing
April 2020

Automated Self-management (ASM) vs. ASM-Enhanced Collaborative Care for Chronic Pain and Mood Symptoms: the CAMMPS Randomized Clinical Trial.

J Gen Intern Med 2019 09 21;34(9):1806-1814. Epub 2019 Jun 21.

VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, USA.

Background: Chronic musculoskeletal pain is often accompanied by depression or anxiety wherein co-occurring pain and mood symptoms can be more difficult to treat than either alone. However, few clinical trials have examined interventions that simultaneously target both pain and mood conditions.

Objective: To determine the comparative effectiveness of automated self-management (ASM) vs. ASM-enhanced collaborative care.

Design: Randomized clinical trial conducted in six primary care clinics in a VA medical center.

Participants: Two hundred ninety-four patients with chronic musculoskeletal pain of at least moderate intensity and clinically significant depressive and/or anxiety symptoms.

Intervention: ASM consisted of automated monitoring and 9 web-based self-management modules. Comprehensive symptom management (CSM) combined ASM with collaborative care management by a nurse-physician team. Both interventions were delivered for 12 months.

Main Measures: Primary outcome was a composite pain-anxiety-depression (PAD) z-score consisting of the mean of the BPI, PHQ-9, and GAD-7 z-scores: 0.2, 0.5, and 0.8 represent potentially small, moderate, and large clinical differences. Secondary outcomes included global improvement, health-related quality of life, treatment satisfaction, and health services use.

Key Results: Both CSM and ASM groups had moderate PAD score improvement at 12 months (z = - 0.65 and - 0.52, respectively). Compared to the ASM group, the CSM group had a - 0.23 (95% CI, - 0.38 to - 0.08; overall P = .003) greater decline in composite PAD z-score over 12 months. CSM patients were also more likely to report global improvement and less likely to report worsening at 6 (P = .004) and 12 months (P = .013).

Conclusions: Two intervention models relying heavily on telecare delivery but differing in resource intensity both produced moderate improvements in pain and mood symptoms. However, the model combining collaborative care led by a nurse-physician team with web-based self-management was superior to self-management alone.

Trial Registration: ClinicalTrials.gov : NCT0175730.
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http://dx.doi.org/10.1007/s11606-019-05121-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6712242PMC
September 2019

Telecare management of pain and mood symptoms: Adherence, utility, and patient satisfaction.

J Telemed Telecare 2020 Dec 20;26(10):619-626. Epub 2019 Jun 20.

VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, USA.

Introduction: Pain, depression, and anxiety are prominent symptoms that frequently co-occur, causing significant debilitation and frequent primary care visits. This paper examines the acceptability of telecare and self-management modules in managing these conditions in a randomized trial.

Methods: The Comprehensive Management of Mood and Physical Symptoms (CAMMPS) trial compared an automated symptom management (ASM) plus self-management intervention with a comprehensive symptom management (CSM) intervention that added telecare facilitation of enhanced services. Data from the CAMMPS trial were analysed to compare the acceptability of these two interventions as indicated by utilization and patient satisfaction surveys.

Results: The mean number of automated reports completed was similar between the CSM and ASM groups (14.5 vs 14.0). Responses designated with clinically relevant "red alerts" (i.e. patient reports warranting an expedited nurse contact) were more frequent in the CSM group (10.2 vs 8.3). The CSM and ASM groups completed a similar number of the nine self-management modules (6.3 vs 5.8). The mean helpfulness score across all modules was higher in the CSM group than in the ASM group (1.8 vs 1.5;  = .003). The most common feedback suggestion from the ASM group was to have more personal interaction, while participants from both groups commonly suggested technical improvements or requests for more flexible timing of calls.

Discussion: Participants generally found both interventions satisfactory, with a trend in satisfaction data suggesting that patients tended to find the CSM intervention more helpful.
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http://dx.doi.org/10.1177/1357633X19856156DOI Listing
December 2020

Ten Principles for More Conservative, Care-Full Diagnosis.

Ann Intern Med 2019 06;170(11):823-824

Usher Institute of Population Health, University of Edinburgh, Edinburgh, Scotland (A.S.).

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http://dx.doi.org/10.7326/L19-0149DOI Listing
June 2019

Reliability and Validity of SymTrak, a Multi-Domain Tool for Monitoring Symptoms of Older Adults with Multiple Chronic Conditions.

J Gen Intern Med 2019 06 18;34(6):908-914. Epub 2019 Apr 18.

School of Medicine, Indiana University, Indianapolis, IN, USA.

Background: A reliable and valid clinically practical multi-domain self-report and caregiver-report tool is needed for tracking actionable symptoms in primary care for elderly patients with multiple chronic conditions (MCCs).

Objective: Assess internal consistency reliability, test-retest reliability, construct validity, and sensitivity to change for SymTrak.

Design And Participants: Among 600 (200 patient-caregiver dyads, 200 patients without an identified caregiver) participants, SymTrak was telephone interviewer-administered at baseline and 3-month follow-up, and at 24 h post-baseline for assessing test-retest reliability in a random subsample of 180 (60 dyads, 60 individual patients) participants.

Main Measures: Demographic questions, SymTrak, Health Utility Index Mark 3 (HUI3).

Key Results: Exploratory factor analysis indicated a single dominant dimension for SymTrak items for both patients and caregivers. Coefficient alpha and 24-h test-retest reliability, respectively, were high for the 23-item SymTrak total score for both patient-reported (0.85; 0.87) and caregiver-reported (0.86; 0.91) scores. Construct validity was supported by monotone decreasing relationships between the mean of SymTrak total scores across the poor-to-excellent categories of physical and emotional general health, and by high correlations with HUI3 overall utility score, even after adjusting for demographic covariates (standardized linear regression coefficient = - 0.84 for patients; - 0.70 for caregivers). Three-month change in the SymTrak total score was sensitive to detecting criterion standard 3-month reliable change categories (Improved, Stable, Declined) in HUI3-based health-related quality of life, especially for caregiver-reported scores.

Conclusions: SymTrak demonstrates good internal consistency and test-retest reliability, construct validity, and sensitivity to change over a 3-month period, supporting its use for monitoring symptoms for older adults with MCCs.
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http://dx.doi.org/10.1007/s11606-018-4780-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6544736PMC
June 2019