The Problem of Collinearity in Mental Health and Patient Reported Outcome Research

Teunis, Teun; Jayakumar, Prakash; Ring, David

doi:10.1016/j.jhsa.2020.10.024

Cited by 9 publications

(5 citation statements)

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“…We think this is unlikely because we used short forms and computer adaptive tests to make the total time to complete the questionnaire less than 10 minutes. Although none of the variables met the traditional criteria for multicollinearity, we were thoughtful about the potential for multiple variables to attenuate associations in multivariable models [37]. Even though this merits additional study, the likely result of a better strategy for potential collinearity would likely strengthen the observed associations, which bolsters our confidence in the findings.…”

Section: Discussionmentioning

confidence: 96%

In Orthopaedic Speciality Care, Longer Explanations Are Not More Caring or More Satisfying

Maren

Brown²,

Cremers

et al. 2021

Clin Orthop Relat Res

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Background Research consistently documents no correlation between the duration of a musculoskeletal specialty care visit and patient experience (perceived empathy of the specialist and satisfaction with care). Based on a combination of clinical experience and other lines of research, we speculate that longer visits are often related to discordance between specialist and patient interpretation of symptoms and weighting of available test and treatment options. If this is true, then the specific duration of time discussing the specialist’s interpretations and options with the patient (expertise transfer) might correlate with satisfaction with care and perceived empathy of the clinician even if the total visit time does not. Questions/purposes (1) What demographic or mental health factors are associated with the duration of expertise transfer? (2) What factors, including the duration of expertise transfer, are associated with the patient’s satisfaction with the visit and perceived clinician empathy? Methods In a cross-sectional study, 128 new and returning English-speaking adult outpatients seeking care from one of three orthopaedic specialists in two urban practices between September and November 2019 were enrolled and agreed to audio recording of the visit. A total of 92% (118) of patients completed the questionnaire and had a usable recording. Participants completed a sociodemographic survey, the Patient-Reported Outcome Measure Information System Depression computer adaptive test (PROMIS Depression CAT; a measure of symptoms of depression), the Short Health Anxiety Index (SHAI-5; a measure of symptoms of hypochondriasis, a form of symptoms misinterpretation), the Pain Catastrophizing Scale (PCS-4; a measure of misinterpretation of symptoms), an ordinal measure of patient satisfaction (dichotomized into satisfied or not because of strong ceiling effects), and the Jefferson Scale of Patient Perception of Physician Empathy (JSPPPE; a measure of perceived clinician empathy). The duration of expertise transfer and the total duration of the visit were measured by two raters with acceptable reliability using software that facilitates segmentation of the visit audio recording. To determine factors associated with the duration of expertise transfer, satisfaction, and empathy, we planned a multivariable analysis controlling for potential confounding variables identified in exploratory bivariable analysis. However, there were insufficient associations to merit multivariable analysis. Results A longer duration of expertise transfer had a modest correlation with catastrophic thinking (r = 0.24; p = 0.01). Complete satisfaction with the visit was associated with less health anxiety (6 [interquartile range 5 to 7] for complete satisfaction versus 7 [5 to 7] for less than complete satisfaction; p = 0.02) and catastrophic thinking (4 [1 to 7] versus 5 [3 to 11]; p = 0.02), but not with the duration of expertise transfer. Greater perceived clinician empathy had a slight correlation with less health anxiety (r = -0.19; p = 0.04). Conclusion Patients with greater misinterpretation of symptoms experience a slightly less satisfying visit and less empathetic relationship with a musculoskeletal specialist despite a longer duration of expertise transfer. This supports the concept that directive strategies (such as teaching healthy interpretation of symptoms) may be less effective then guiding strategies (such as nurturing openness to alternative, healthier interpretation of symptoms using motivational interviewing tactics, often over more than one visit or point of contact). Level of Evidence Level II, therapeutic study.

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Section: Discussionmentioning

confidence: 96%

In Orthopaedic Speciality Care, Longer Explanations Are Not More Caring or More Satisfying

Maren

Brown²,

Cremers

et al. 2021

Clin Orthop Relat Res

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“…One benefit of the OSPRO-YF is that in addition to score estimates for each of the 11 full-length psychologic questionnaires, it indicates which of the score estimates is in the highest quartile of population scores for those questionnaires. This function flags high scores, essentially notifying busy clinicians which psychologic constructs (including measures of coping) are of the highest concern [52].…”

Section: Discussionmentioning

confidence: 99%

“…For instance, if clinicians can understand which constructs are most strongly associated with capability, and therefore warrant particular attention, they can prioritize their approach to assessment and intervention, accounting for mindset. Statistically, methods such as factor analysis can group mental health characteristics into factors that can minimize redundancy, be incorporated in multivariable regression analyses, and address multicollinearity, where highly correlated variables entered into the same model may lead to false-negative results [23,52].…”

Section: Introductionmentioning

confidence: 99%

What Are the Underlying Mental Health Constructs Associated With Level of Capability in People With Knee and Hip Osteoarthritis?

Jayakumar,

Crijns,

Misciagna

et al. 2024

Clin Orthop Relat Res

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Background Mental health characteristics such as negative mood, fear avoidance, unhelpful thoughts regarding pain, and low self-efficacy are associated with symptom intensity and capability among patients with hip and knee osteoarthritis (OA). Knowledge gaps remain regarding the conceptual and statistical overlap of these constructs and which of these are most strongly associated with capability in people with OA. Further study of these underlying factors can inform us which mental health assessments to prioritize and how to incorporate them into whole-person, psychologically informed care. Questions/purposes (1) What are the distinct underlying factors that can be identified using statistical grouping of responses to a multidimensional mental health survey administered to patients with OA? (2) What are the associations between these distinct underlying factors and capability in knee OA (measured using the Knee Injury and Osteoarthritis Outcome Score, Joint Replacement [KOOS JR]) and hip OA (measured using Hip Disability and Osteoarthritis Outcome Score, Joint Replacement [HOOS JR]), accounting for sociodemographic and clinical factors? Methods We performed a retrospective cross-sectional analysis of adult patients who were referred to our program with a primary complaint of hip or knee pain secondary to OA between October 2017 and December 2020. Of the 2006 patients in the database, 38% (760) were excluded because they did not have a diagnosis of primary osteoarthritis, and 23% (292 of 1246) were excluded owing to missing data, leaving 954 patients available for analysis. Seventy-three percent (697) were women, with a mean age of 61 ± 10 years; 65% (623) of patients were White, and 52% (498) were insured under a commercial plan or via their employer. We analyzed demographic data, patient-reported outcome measures, and a multidimensional mental health survey (the 10-item Optimal Screening for Prediction of Referral and Outcome-Yellow Flag [OSPRO-YF] assessment tool), which are routinely collected for all patients at their baseline new-patient visit. To answer our first question about identifying underlying mental health factors, we performed an exploratory factor analysis of the OSPRO-YF score estimates. This technique helped identify statistically distinct underlying factors for the entire cohort based on extracting the maximum common variance among the variables of the OSPRO-YF. The exploratory factor analysis established how strongly different mental health characteristics were intercorrelated. A scree plot technique was then applied to reduce these factor groupings (based on Eigenvalues above 1.0) into a set of distinct factors. Predicted factor scores of these latent variables were generated and were subsequently used as explanatory variables in the multivariable analysis that identified variables associated with HOOS JR and KOOS JR scores. Results Two underlying mental health factors were identified using exploratory factor analysis and the scree plot; we labeled them “pain coping” and “mood.” For patients with knee OA, after accounting for confounders, worse mood and worse pain coping were associated with greater levels of incapability (KOOS JR) in separate models but when analyzed in a combined model, pain coping (regression coefficient -4.3 [95% confidence interval -5.4 to -3.2], partial R2 0.076; p < 0.001) had the strongest relationship, and mood was no longer associated. Similarly, for hip OA, pain coping (regression coefficient -5.4 [95% CI -7.8 to -3.1], partial R2 0.10; p < 0.001) had the strongest relationship, and mood was no longer associated. Conclusion This study simplifies the multitude of mental health assessments into two underlying factors: cognition (pain coping) and feelings (mood). When considered together, the association between capability and pain coping was dominant, signaling the importance of a mental health assessment in orthopaedic care to go beyond focusing on unhelpful feelings and mood (assessment of depression and anxiety) alone to include measures of pain coping, such as the Pain Catastrophizing Scale or Tampa Scale for Kinesiophobia, both of which have been used extensively in patients with musculoskeletal conditions. Level of Evidence Level III, prognostic study.

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“…Due to multicollinearity (intercorrelation) between the mental health variables (Appendix 1), we decided to run multiple models with one mental health variable at the time and to only include the model that had the best model fit (lowest Akaike Information Criterion). 28 The model with NPTQ-4 had the best fit and was selected, and other mental health variables were excluded. ACEs were not moved to multivariable analysis since the P value was above the .10 threshold in bivariate analysis.…”

Section: Methodsmentioning

confidence: 99%

Magnitude of Incapability and Pain Intensity are Associated More with Unhelpful Thoughts Than Stressful Life Events

et al. 2023

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Prior studies show that stressful life events are associated with greater magnitude of incapability and symptom intensity. We sought to understand the association of such events (i.e., both adverse childhood experiences and recent difficult life events [DLEs]) alongside feelings of worry or despair and unhelpful, on the magnitude of incapability and symptom intensity in musculoskeletal patients. One hundred and thirty-six patients presenting for musculoskeletal specialty care completed measures of incapability, pain intensity, adverse childhood experiences, DLEs in the last year, unhelpful thoughts, symptoms of anxiety and depression, and sociodemographic factors. Factors associated with the magnitude of incapability and pain intensity were sought in multivariable analysis. Accounting for potential confounders, greater incapability was associated with greater unhelpful thoughts (RC = −0.81; 95% CI = −1.2 to −0.42; P ≤ .001), but not with stressful life events (either during childhood or more recently). Greater pain intensity was associated with greater unhelpful thoughts(RC = 0.25; 95% CI = 0.16 to 0.35; P ≤ .001) and being divorced or widowed (RC = 1.8; 96% CI = 0.43 to 3.2; P = .011), but again, not with stressful life events. The strong association of unhelpful thoughts with magnitude of incapability and pain intensity can motivate musculoskeletal specialists to anticipate patients expressing negative pain thoughts and behaviors. Future studies might account for social and environmental context behind stressful life events and the influence of resiliency and pain-coping strategies on these interactions. Level of Evidence: Level III, prognostic study

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The Problem of Collinearity in Mental Health and Patient Reported Outcome Research

Cited by 9 publications

References 1 publication

In Orthopaedic Speciality Care, Longer Explanations Are Not More Caring or More Satisfying

In Orthopaedic Speciality Care, Longer Explanations Are Not More Caring or More Satisfying

What Are the Underlying Mental Health Constructs Associated With Level of Capability in People With Knee and Hip Osteoarthritis?

Magnitude of Incapability and Pain Intensity are Associated More with Unhelpful Thoughts Than Stressful Life Events

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