Date Published: July 10, 2017
Publisher: Public Library of Science
Author(s): Joel Raffel, Alison Wallace, Djordje Gveric, Richard Reynolds, Tim Friede, Richard Nicholas, Sanjay Basu
Abstract: BackgroundThere is increasing emphasis on using patient-reported outcomes (PROs) to complement traditional clinical outcomes in medical research, including in multiple sclerosis (MS). Research, particularly in oncology and heart failure, has shown that PROs can be prognostic of hard clinical endpoints such as survival time (time from study entry until death). However, unlike in oncology or cardiology, it is unknown whether PROs are associated with survival time in neurological diseases. The Multiple Sclerosis Impact Scale–29 (MSIS-29) is a PRO sensitive to short-term change in MS, with questions covering both physical and psychological quality of life. This study aimed to investigate whether MSIS-29 scores can be prognostic for survival time in MS, using a large observational cohort of people with MS.Methods and findingsFrom 15 July 2004 onwards, MSIS-29 questionnaires were completed by people with MS registered with the MS Society Tissue Bank (n = 2,126, repeated 1 year later with n = 872 of the original respondents). By 2014, 264 participants (12.4%) had died. Higher baseline MSIS-29 physical (MSIS-29-PHYS) score was associated with reduced survival time (subgroup with highest scores versus subgroup with lowest scores: hazard ratio [HR] 5.7, 95% CI 3.1–10.5, p < 0.001). Higher baseline MSIS-29 psychological score was also associated with reduced survival time (subgroup with highest scores versus subgroup with lowest scores: HR 2.8, 95% CI 1.8–4.4, p < 0.001). In those with high baseline MSIS-29 scores, mortality risk was even greater if the MSIS-29 score worsened over 1 year (HR 2.3, 95% CI 1.2–4.4, p = 0.02). MSIS-29-PHYS scores were associated with survival time independent of age, sex, and patient-reported Expanded Disability Status Scale score in a Cox regression analysis (per 1-SD increase in MSIS-29-PHYS score: HR 1.8, 95% CI 1.1–2.9, p = 0.03). A limitation of the study is that this cohort had high baseline age and disability levels; the prognostic value of MSIS-29 for survival time at earlier disease stages requires further investigation.ConclusionsThis study reports that PROs can be prognostic for hard clinical outcomes in neurological disease, and supports PROs as a meaningful clinical outcome for use in research and clinical settings.
Partial Text: Patient-reported outcomes (PROs) are defined as ‘any report of the status of a patient’s health condition that comes directly from the patient, without interpretation of the patient’s response by a clinician or anyone else’ . They can offer significant advantages over assessment by a physician: they better capture the impact of disease on the person; they are often easier and cheaper to administer; and they can often be completed from the home environment, potentially allowing for long-term, geographically diverse, and large-scale observational and interventional studies . They can also enhance routine clinical care in areas such as symptom screening, monitoring treatment response, care coordination, care systems assessment, and improving communication in the doctor–patient clinical encounter [3–6].
This study reports that higher MSIS-29 score is associated with reduced survival time in a large observational cohort of people with MS. MSIS-29-PHYS and MSIS-29-PSYCH scores were both associated with survival time, although MSIS-29-PHYS score has stronger prognostic value, and associates with survival time independently of age, sex, and prEDSS score in a Cox regression model. In addition, in the subgroup with initial MSIS-29-PHYS score 85–100, a 1-year longitudinal worsening of MSIS-29-PHYS score is associated with an even worse prognosis. This finding shows that how a person with MS answers these questions is important and relates to how well they may do in terms of health in the future. To our knowledge, this is the first study to associate PROs with survival outcomes in any neurological disease.