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PROMIS – Global Health

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Purpose

Domain focused, self-reported and parent-reported measures of global, physical, mental, and social health for adults and children in the general population and those living with a chronic condition.

Link to Instrument

Instrument Details

Acronym PROMIS-GH

Area of Assessment

General Health
Quality of Life

Assessment Type

Patient Reported Outcomes

Cost

Free

Actual Cost

$0.00

Cost Description

Free to use, however NIH Toolbox app is $499.99 per year.

CDE Status

Availability

The instrument is freely available here: PROMIS website.

See General Page for currently available PROMIS Bank CDE Details.

Classification

Supplemental - Highly Recommended: Stroke, Congenital Muscular Dystrophy (CMD) in studies of psychosocial functioning, quality-of-life, outcome, and long-term adjustment studies.

 Supplemental: Traumatic Brain Injury (TBI), Amyotrophic Lateral Sclerosis (ALS), Chiari I Malformation (CM), Epilepsy, Friedreich's Ataxia (FA), Headache, Huntington's Disease (HD), Mitochondrial Disease (Mito), Multiple Sclerosis (MS), Myasthenia Gravis (MG), Neuromuscular Diseases (NMD), Duchenne/Becker Muscular Dystrophy (DMD/BMD), Spinal Muscular Atrophy (SMA), Parkinson's Disease (PD), Stroke, and Spinal Cord Injury (SCI), and Unruptured Cerebral Aneurysms and Subarachnoid Hemorrhage (SAH)

Exploratory: Cerebral Palsy (CP) Myotonic Muscular Dystrophy (DM) and Facioscapulohumeral Muscular Dystrophy (FSHD) and Sport-Related Concussion (SRC)

*Headache specific subtest recommendations : Anxiety (Adult/Pediatric), Depression (Adult/Pediatric), Sleep (Adult)

Key Descriptions

  • Subcategories are physical and mental global health
  • Short Form, CAT, or Profile administration methods
  • Minimum and maximum scores depends on the form being used
  • Scoring: Item-levels are scored numerically for an individual's response to each question. PROMIS recommends the best way to find the total raw score is using the free HealthMeasures Scoring Service
    (https://www.assessmentcenter.net/ac_scoringservice) or a tool that can automatically calculate scores. Scores can also be added up by hand to find the total raw score.
    Then the raw score is converted to a T-score using the table in the Appendix of the link below. This standardizes the score with a mean of 50 and standard deviation of 10.
    Being above or below the standard deviation could be desirable or undesirable based on the domain being measured.
  • Higher scores means more of the concept being measured. Example = more health.

Number of Items

Item Bank: 10

Equipment Required

  • Digital Assessment

Time to Administer

2-5 minutes

Variable but design based on item-response theory algorithms to minimize time.

Required Training

No Training

Age Ranges

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Holly O’Hearn, SPT

Jensyn Bradley SPT, ATC, LAT

Chi-Lun Chiao, SPT

Holt McPherson, SPT

Kenna Peters, SPT

Corinne Woodbine, SPT

Duke University, School of Medicine, Division of Physical Therapy.

ICF Domain

Body Function

Measurement Domain

General Health

Considerations

  • PROMIS measures can be used in the general population and with adults and pediatric populations with a chronic condition(s)
  • PROMIS measures have a larger range of measurement than most conventional measures, decreasing floor and ceiling effects as a result
  • PROMIS measures have fewer items than conventional measures, thereby decreasing respondent burden. When used as computer adaptive tests, PROMIS measures usually require 4-6 items for precise measurement of health-related constructs
  • Translations: The assessments are available via PDF in Spanish and can be obtained in other languages by contacting translations@Healthmeasures.net

Joint Pain and Fractures

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Normative Data

Knee Arthroscopy

Oak et al 2016, n=50; mean age=41 (13.9): 45 patients followed up post-op, observed over a mean of 3.6 months

  • Mean T score= 50 (SD of 10)

PROMIS

Measure

n

Preoperative

Postoperative

Difference

PROMIS 10

physical

44

43.88 ± 8.69

48.54 ± 8.91

4.4 ± 6.11

PROMIS 10

mental

45

50.97 ± 9.42

51.52 ± 10.44

0.54 ± 6.54

 

Criterion Validity (Predictive/Concurrent)

Rotator Cuff Disease

Nicholson et al 2019, n=323; mean age=57.7(13.8):

  • Excellent correlation between Global-10 and  EQ-5D (r=0.70, p<0.0001)
  • Excellent-good correlation between Global-Physical and ASES (r=0.62, p<0.0001)
  • Good correlation between Global-Physical and WORC (r=0.41, p<0.0001)
  • Good correlation between Global-Physical and SANE (r=0.41, p<0.0005)
  • Poor correlation between Global-Mental and ASES (r=0.34, p<0.0001)
  • Poor correlation between Global-Mental and WORC (r=0.32, p=0.0016)
  • Poor correlation between Global-Mental and SANE (r=0.24, p<0.0001)

Construct Validity

Primary Joint Arthroplasty

Kohring et al 2018, n=540; mean age = 64: knee and hip arthroplasty:

  • Poor correlation between the PROMIS Global Mental and Press Gane Outpatient Medical Practice Survey (r=0.13)
  • Poor correlation between the PROMIS Global Physical and Press Ganey Outpatient Medical Practice Survey (r=0.02)

Floor/Ceiling Effects

Rotator Cuff Disease

  • Nicholson et al (2019): No floor or ceiling effects found for either PROMIS physical or mental health scores.

Responsiveness

Knee Arthroscopy

Oak et al (2016): n=50; mean age=41 (13.9): 45 patients followed up post-op, observed over a mean of 3.6 months

  • Significant internal responsiveness for PROMIS 10 physical (p<0.001, Cohen d=0.507, SRM=0.721)
  • Insignificant Internal responsiveness for PROMIS 10 mental (p=0.58, Cohen d=0.058, SRM=0.083)
  • Significant external responsiveness for change in pre to postoperative PROMIS 10 physical score with change in KOOS-Pain Score: (Correlation=0.77, p<0.001).
  • Significant external responsiveness for change in pre to postoperative PROMIS 10 mental score with change in KOOS-Pain Score (Correlation=0.39, p<.008). 

Non-Specific Patient Population

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Normative Data

General Population (ACO members)

Blumenthal et al 2017, n=2639; mean age = 48.0

Global-Physical

  -Q1 n=658

  -Q2-4 n=1981

  -Lowest quartile (Q1) of GPH were significantly older, more likely to be

   female, and more likely to live in an area with a higher level of poverty;

   less likely to be commercially insured

 

Global-Mental

 - Q1 n=579

 - Q2-4 n=2060

 - Lowest quartile (Q1) of the GMH score were younger than those in the

   other three quartiles.

 

Rates and Unadjusted Rate Ratios of ED Visits and Hospitalizations for Lowest Quartile of Global Physical Health and Global Mental Health Scores Compared to All Others:

 

 

ED Visits

Hospitalizations

Rate per 100 person-years

Rate ratio (95% CI)

P value

Rate per 100 person-years

Rate ratio (95% CI)

P value

GPH

Q1

9.8

.34 (0.95, 1.90)

0.10

7.8

5.14 (2.37, 11.15)

<0.001

Q2–4 (Ref)

14.8

1.5

GMH

Q1

20.2

1.35(0.94, 1.95)

0.11

5.5

2.27 (1.06, 4.85)

0.03

Q2–4 (Ref)

14.9

2.4

Criterion Validity (Predictive/Concurrent)

General Population (ACO members)

Blumenthal et al (2017)

  • Patients with the lowest quartile of self-reported physical health scores had significantly higher rates of subsequent hospitalizations
  • Self-reported physical and mental health were not associated with the risk of ED visits, and the overall sensitivity of the models in predicting patients in the top 5% of ED utilization was fairly low

Construct Validity

Patients with Upper Extremity Illness

Stoop et al 2017, n=112; mean age=50 (16)

  • Moderate correlation between Global-Physical and QuickDASH (r = −0.47, P < .001).
  • No correlation between the PROMIS Global Mental Health subscale and QuickDASH (r= -0.09, P=0.34)
  • Moderate correlation between the mental and physical PROMIS Global Health subscales (r = 0.47, P < .0001)

Cancer

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Normative Data

Breast or Prostate Cancer

(Seneviratne et al 2019), prostate n =2118 and breast n=4199; prostate mean age = 70.1 (9) and mean breast age = 58.1 (15)

  • The mean T scores (calibrated to a general population mean of 50) for GPH were 48.4 ± 9 for breast cancer and 50.6 ± 9 for prostate Cancer; GMH scores were 52.7 ± 8 and 52.1 ± 9, respectively

Arthritis

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Normative Data

Rheumatoid Arthritis: (Bingham 2019, n=546, age = 57 (14) years old, 81% female, recruited from online patient communities, Computer Adaptive Testing (CAT))

 

N

Mean

SD

Median

25%

75%

Range

Min

Max

Patient Global Disease Activity

547

22.7

29.6

25.0

2.0

49.0

100.0

0.0

100.0

Criterion Validity (Predictive/Concurrent)

Shoulder Arthritis

Saad et al 2018, n=161; mean age=64.5 (13.3):

  • Excellent correlation between the PROMIS Global-10 and the EQ-5D (r=0.72, p<0.0001).
  • Good correlation between the PROMIS Global-Physical and the ASES score (r=0.57,p<0.0001).
  • Poor correlation between the PROMIS Global-Physical and the SANE score (r=0.23, p=0.0045).
  • Poor correlation between the PROMIS Global-Physical and the WOOS score (r=0.11, p<0.3743).
  • Poor correlation between the PROMIS Global-Mental and the ASES score (r=0.26, p=0.0012).
  • Poor correlation between the PROMIS Global-Mental and SANE score (r=0.13, p=0.1004)
  • Poor correlation between the PROMIS Global-Mental and the WOOS score (r=0.09, p=0.4311).

Floor/Ceiling Effects

Shoulder Arthritis

  • Saad at al (2018): No floor or ceiling effects found

Mixed Populations

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Test/Retest Reliability

Systemic Lupus Erythematosus

Shanthini  et al 2018, n=204; mean age=40.0 (13.2): 90 completed 1 week retest

  • High for Global-Physical (ICC = 0.89, SEM=3.24)
  • High for Global-Mental (ICC = 0.85, SEM=3.50)

Internal Consistency

Combined General Population and Chronic Condition Population

Hays et al 2009, n=21,133; mean age=53 (18-100): Clinical sample included individuals with heart disease, cancer, rheumatoid arthritis, osteoarthritis, psychiatric disorders, chronic obstructive pulmonary disease, spinal cord injury, and other medical conditions.

  • Excellent internal consistency with Global Physical (Cronbach’s alpha=0.81)
  • Excellent internal consistency with Global Mental (Cronbach’s alpha = 0.86)

Construct Validity

Systemic Lupus Erythematosus: (Kasturi et al 2018, n=204, age= 40.0 ± 13.2, outpatient, CAT)

 

Convergent and discriminant validity of PROMIS10. Values are Spearman correlations.

Outcome Measures

PROMIS Global Physical Health, n = 199

PROMIS Global Mental Health, n = 187

Physical health

   

  PROMIS physical function CAT

0.77

0.54

  PROMIS mobility CAT

0.75

0.49

  SF-36 physical function

0.76

0.47

  SF-36 role physical

0.60

0.46

  SF-36 PCS

0.77

0.41

  LupusQoL physical health

0.77

0.59

  PROMIS pain behavior CAT

−0.71

−0.59

  PROMIS pain interference CAT

−0.80

−0.59

  SF-36 bodily pain

−0.79

−0.55

  LupusQoL pain

0.74

0.56

  PROMIS fatigue CAT

−0.65

−0.60

  SF-36 vitality

0.53

0.55

  LupusQoL fatigue

0.62

0.62

Emotional health

   

  PROMIS anger CAT

−0.42

−0.57

  PROMIS anxiety CAT

−0.41

−0.61

  PROMIS depression CAT

−0.48

−0.73

  SF-36 mental health

0.42

0.72

  SF-36 role emotional

0.49

0.61

  SF-36 MCS

0.41

0.72

  LupusQoL emotional health

0.52

0.70

Social health

   

  PROMIS ability to participate in social roles CAT

0.74

0.65

  PROMIS satisfaction with participation in social roles CAT

0.61

0.59

  SF-36 social function

0.70

0.66

  LupusQoL planning

0.69

0.62

Other

   

  SF-36 global health

0.68

0.57

  LupusQoL intimate relationships

0.53

0.46

  LupusQoL burden to others

0.52

0.53

  LupusQoL body image

0.35

0.46

  PGA

−0.31

−0.27

  SELENA-SLEDAI

−0.14

−0.16

  SDI

−0.20

−0.12*

Data in bold with correlations ≥ 0.70 are considered strong. All p values are < 0.0001, except where indicated by *. PROMIS10: 10-item Patient Reported Outcomes Measurement Information System Global Health Short Form; CAT: computerized adaptive tests; SF-36: Medical Outcomes Study Short Form-36; PCS: physical component summary; LupusQoL: Lupus Quality of Life; MCS: mental component summary; PGA: physician’s global assessment; SELENA-SLEDAI: Safety of Estrogens in Lupus Erythematosus National Assessment–Systemic Lupus Erythematosus Disease Activity Index; SDI: Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index.

Content Validity

Systemic Lupus Erythematosus

Shanthini et al (2018): values are Spearman correlations

 

 

Outcome Measures

PROMIS Global Physical Health, n = 199

PROMIS Global Mental Health, n = 187

Physical health

PROMIS physical function CAT

0.77

0.54

PROMIS mobility CAT

0.75

0.49

SF-36 physical function

0.76

0.47

SF-36 role physical

0.6

0.46

SF-36 PCS

0.77

0.41

LupusQoL physical health

0.77

0.59

PROMIS pain behavior CAT

−0.71

−0.59

PROMIS pain interference CAT

−0.80

−0.59

SF-36 bodily pain

−0.79

−0.55

LupusQoL pain

0.74

0.56

PROMIS fatigue CAT

−0.65

−0.60

SF-36 vitality

0.53

0.55

LupusQoL fatigue

0.62

0.62

Emotional health

PROMIS anger CAT

−0.42

−0.57

PROMIS anxiety CAT

−0.41

−0.61

PROMIS depression CAT

−0.48

−0.73

SF-36 mental health

0.42

0.72

SF-36 role emotional

0.49

0.61

SF-36 MCS

0.41

0.72

LupusQoL emotional health

0.52

0.7

Social health

PROMIS ability to participate in social roles CAT

0.74

0.65

PROMIS satisfaction with participation in social roles CAT

0.61

0.59

SF-36 social function

0.7

0.66

LupusQoL planning

0.69

0.62

Other

SF-36 global health

0.68

0.57

LupusQoL intimate relationships

0.53

0.46

LupusQoL burden to others

0.52

0.53

LupusQoL body image

0.35

0.46

PGA

−0.31

−0.27

SELENA-SLEDAI

−0.14

−0.16

SDI

−0.20

−0.12*

 

Combined General Population and Chronic Condition Population

Hays et al, 2009; n=21,133; mean age=53 (18-100):

  • Excellent correlation between Global-Physical and EQ-5D (r=0.76)
  • Adequate correlation between Global-Mental and EQ-5D (r=0.59)

Stroke

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Test/Retest Reliability

Stroke: Katzan et al 2017, n=1102; mean age=60.8 (14.9): median time since stroke 134 days

Test-retest reliability for items and component scores in patients with a repeat visit within 6 months and who indicated no change on corresponding health domains

 

N

Correlation

Coefficient*

Weighted

Kappa (95%CI)

Global01. General Health

40

0.865

0.59 (0.42, 0.76)

Global02. Quality of Life

51

0.845

0.59 (0.43,

0.74)

Global03. Physical Health

41

0.952

0.72 (0.57, 0.87)

Global04. Mental Health

51

0.902

0.65 (0.52, 0.77)

Global05. Social Satisfaction

52

0.895

0.67 (0.54, 0.80)

Global06. Physical Activities

40

0.870

0.60 (0.45, 0.75)

Global07. Pain

59

0.811

0.54 (0.38, 0.70)

Global08. Fatigue

37

0.780

0.57 (0.37, 0.77)

Global09. Social Activities

52

0.862

0.66 (0.52, 0.80)

Global10. Emotional Problems

50

0.504

0.39 (0.19, 0.60)

Component T-Scores

 

 

ICC (95% CI)

Mental Component T-Score

50

0.855

0.86 (0.76, 0.92)

Physical Component T-Score

38

0.880

0.88 (0.78, 0.94)

 

 *Polychoric correlation coefficients between item scores and Pearson correlation coefficients between component scores; ICC = intraclass correlation coefficient; Mean days between visits was 97 (interquartile range: 61-140).

Internal Consistency

Minor Stroke Attacks: Lam et al 2018, n=75; mean age=68.9 (11.2): assessed 1 year post-stroke

  • Excellent internal consistency for the 4 mental health (MH) items from the Dutch PROMIS-10 measure (Cronbach’s alpha = 0.83)
  • Adequate internal consistency for the 4 physical health (PH) items from the Dutch PROMIS-10 measure (Cronbach’s alpha = 0.79)

Construct Validity

Stroke

Katzan et al 2017, n=1102; mean age=60.8 (14.9): median time since stroke 134 days

Discriminant validity comparing PROMIS Domain Scales versus PROMIS GH Items across level of stroke severity (mild/moderate (modified Rankin <2) versus severe (≥2))

 

PROMIS Domain Scales

PROMIS GH Items

 

 

Cohen’s d Effect Size (95% CI)

 

Cohen’s d Effect Size (95% CI)

P-Value Comparing Cohen’s d

 

 

Physical Function

 

 

1.03 (0.90, 1.17)

Global01. General Health

0.56 (0.44, 0.69)

<0.001

Global03. Physical Health

0.58 (0.46, 0.71)

<0.001

Global06. Physical Activities

0.94 (0.81, 1.06)

0.18

 

 

Satisfaction with Social Roles

 

 

0.77 (0.63, 0.90)

Global02. Quality of Life

0.61 (0.49, 0.74)

0.052

Global05. Social Satisfaction

0.56 (0.43, 0.68)

0.016

Global09. Social Activities

0.74 (0.62, 0.87)

0.38

NeuroQoL Executive Function

0.60 (0.47, 0.74)

Global04. Mental Health

0.45 (0.33, 0.58)

0.062

Pain Interference

0.32 (0.19, 0.45)

Global07. Pain

0.33 (0.20, 0.45)

0.46

Fatigue

0.47 (0.34, 0.60)

Global08. Fatigue

0.35 (0.23, 0.48)

0.10

Anxiety

0.37 (0.24, 0.50)

Global10. Emotional Problems

0.26 (0.14, 0.38)

0.12

Effect size compares scores in mild/moderate versus severe stroke patients. P-value based on Fisher’s z-test.

 

Minor Stroke Attacks

Lam et al (2018)

  • Excellent correlation between the Dutch PROMIS-10 physical health (PH) scores and the RAND-36 physical component scores (PCS) (r=0.81, p<.001)
  • Excellent correlation between Dutch PROMIS-10 mental health (MH) scores and the RAND-36 mental component scores (MCS) (r=0.76, p<.001).

Responsiveness

Stroke: Katzan et al (2017)

Responsiveness to change in PROMIS Domain Scales compared to PROMIS GH Items based on patient perceived improvement versus worsening as indicated on corresponding health domains

PROMIS Domain Scales

PROMIS GH Items

 

 

Cohen’s d Effect Size (95% CI)

 

Cohen’s d Effect Size (95% CI)

P-Value Comparing Cohen’s d

Physical Function

0.76 (0.36, 1.16)

Global01. General Health

0.57 (0.18, 0.97)

0.31

Global03. Physical Health

0.68 (0.23, 1.14)

0.42

Global06. Physical Activities

0.60 (0.20, 1.00)

0.34

Satisfaction with Social Roles

1.49 (0.91, 2.08)

Global02. Quality of Life

0.43 (-0.05, 0.92)

0.006

Global05. Social Satisfaction

0.57 (0.14, 1.01)

0.015

Global09. Social Activities

0.65 (0.13, 1.17)

0.024

NeuroQoL Executive Function

1.31 (0.77, 1.86)

Global04. Mental Health

0.67 (0.10, 1.25)

0.068

Pain Interference

0.41 (-0.02, 0.84)

Global07. Pain

0.30 (-0.13, 0.73)

0.38

Fatigue

1.06 (0.66, 1.46)

Global08. Fatigue

0.65 (0.15, 1.15)

0.11

Anxiety

0.98 (0.56, 1.41)

Global10. Emotional Problems

0.72 (0.08, 1.35)

0.27

Bibliography

Bingham, C O., Gutierrez, A.K., Butanis, A., Bykerk, V.P., Curtis, J.R., Leong, A., Lyddiatt, A.,  Nowell, W. B., Orbai, A. M., Bartlett, S.J.(2019).  PROMIS Fatigue short forms are reliable and valid in adults with rheumatoid arthritis. Journal of Patient-Reported Outcomes, 3(1):14. doi: 10.1186/s41687-019-0105-6

Blumenthal, K. J., Chang, Y., Ferris, T. G., Spirt, J. C., Vogeli, C., Wagle, N., Metlay, J. P. (2017). Using  a Self-Reported Global Health Measure to Identify Patients at High Risk for Future Healthcare Utilization. Journal of general internal medicine. 32(8): 877–882. doi: 10.1007/s11606-017-4041-y

Hays, R. D., Bjorner, J. B., Revicki, D. A., Spritzer, K. L., & Cella, D. (2009). Development of physical and mental health summary scores from the patient-reported outcomes measurement information system (PROMIS) global items. Quality of life research 18(7), 873–880. doi:10.1007/s11136-009-9496-9

Kasturi, S., Szymonifka, J., Burket, J. C., Berman, J. R., Kirou, K. A., Levine, A. B., Sammaritano, L.R., Mandl, L.A. (2018). Feasibility, Validity, and Reliability of the 10-item Patient Reported Outcomes Measurement Information System Global Health Short Form in Outpatients with Systemic Lupus Erythematosus. The Journal of Rheumatology, 45(3), 397 404. doi:10.3899/jrheum.170590

Katzan, I.L., Lapin, B. (2018). PROMIS GH (Patient-Reported Outcomes Measurement Information System Global Health) Scale in Stroke: A Validation Study. Stroke, 49 (1): 147-154. doi:10.1161/STROKEAHA.117.018766

Kohring, J.M., Pelt, C.E., Anderson, M.B., Peters, C.L., Gililland, J.M. (2018). Press Ganey Outpatient Medical Practice Survey Scores Do Not Correlate With Patient-Reported Outcomes After Primary Joint Arthroplasty. The Journal of Arthroplasty, 33(8):2417-2422. doi: 10.1016/j.arth.2018.03.044.

Lam, K., Kwa, V. (2018). Validity of the PROMIS-10 Global Health assessed by telephone and on paper in minor stroke and transient ischaemic attack in the Netherlands. BMJ Open, 8(7):e019919. doi: 10.1136/bmjopen-2017-019919

Nicholson, A.D., Kassam, H.F., Pan, S.D., Berman, J.E., Blaine, T.A., Kovacevic, D.  (2019). Performance of PROMIS Global-10 Compared With Legacy Instruments for Rotator Cuff Disease. The American Journal of Sports Medicine.  v4 7 issue: 1, page(s): 181-188. https://doi.org/10.1177/0363546518810508

Oak, S. R., Strnad, G.J., Bena, J., Farrow, L.D., Parker, R.D., Jones, M.H., & Spindler, K.  P. (2016). Responsiveness Comparison of the EQ-5D, PROMIS Global Health, and VR-12  Questionnaires in Knee Arthroscopy. Orthopaedic journal of sports medicine, 4(12),  2325967116674714. doi:10.1177/2325967116674714

Saad, M.A., Kassam, H.F., Suriani, R.J., Pan, S.D., Blaine, T.A., Kovacevic, D. (2018). Performance of PROMIS Global-10 compared with legacy instruments in patients with shoulder arthritis. Journal of Shoulder and Elbow Surgery. 27(12):2249-2256. doi: 10.1016/j.jse.2018.06.006

Seneviratne, M.G., Bozkurt, S., Patel, M.I., Seto, T., Brooks, J.D., Blayney, D.W., Kurian, A.W., Hernandez-Boussard, T. (2019). Distribution of global health measures from routinely collected PROMIS surveys in patients with breast cancer or prostate cancer. Cancer, 125(6):943-951. doi: 10.1002/cncr.31895

Stoop, N., Menendez, M.E., Mellema, J.J., Ring, D. (2018). The PROMIS Global Health Questionnaire Correlates With the QuickDASH in Patients With Upper Extremity Illness. Hand (NY), 13(1):118-121. doi: 10.1177/1558944717691127

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