Joan E. Broderick

Patient compliance with paper and electronic diaries

Paper diaries are commonly used in health care and clinical research to assess patient experiences. There is concern that patients do not comply with diary protocols, possibly invalidating the benefit of diary data. Compliance with paper diaries was examined with a paper diary and with an electronic diary that incorporated compliance-enhancing features. Participants were chronic pain patients and they were assigned to use either a paper diary instrumented to track diary use or an electronic diary that time-stamped entries. Participants were instructed to make three pain entries per day at predetermined times for 21 consecutive days. Primary outcome measures were reported vs actual compliance with paper diaries and actual compliance with paper diaries (defined by comparing the written times and the electronically-recorded times of diary use). Actual compliance was recorded by the electronic diary. Participants submitted diary cards corresponding to 90% of assigned times (+/-15 min). However, electronic records indicated that actual compliance was only 11%, indicating a high level of faked compliance. On 32% of all study days the paper diary binder was not opened, yet reported compliance for these days exceeded 90%. For the electronic diary, the actual compliance rate was 94%. In summary, participants with chronic pain enrolled in a study for research were not compliant with paper diaries but were compliant with an electronic diary with enhanced compliance features. The findings call into question the use of paper diaries and suggest that electronic diaries with compliance-enhancing features are a more effective way of collecting diary information.

A snapshot of the age distribution of psychological well-being in the United States

Psychological well-being (WB) includes a persons overall appraisal of his or her life (Global WB) and affective state (Hedonic WB), and it is considered a key aspect of the health of individuals and groups. Several cross-sectional studies have documented a relation between Global WB and age. Little is known, however, about the age distribution of Hedonic WB. It may yield a different view of aging because it is less influenced by the cognitive reconstruction inherent in Global WB measures and because it includes both positive and negative components of WB. In this study we report on both Global and Hedonic WB assessed in a 2008 telephone survey of 340,847 people in the United States. Consistent with prior studies, Global WB and positive Hedonic WB generally had U-shaped age profiles showing increased WB after the age of 50 years. However, negative Hedonic WB variables showed distinctly different and stronger patterns: Stress and Anger steeply declined from the early 20s, Worry was elevated through middle age and then declined, and Sadness was essentially flat. Unlike a prior study, men and women had very similar age profiles of WB. Several measures that could plausibly covary with the age-WB association (e.g., having children at home) did not alter the age-WB patterns. Global and Hedonic WB measures appear to index different aspects of WB over the lifespan, and the postmidlife increase in WB, especially in Hedonic WB, deserves continued exploration.

Intensive momentary reporting of pain with an electronic diary: reactivity, compliance, and patient satisfaction

&NA; Patient self‐reports are the primary method for capturing the experience of pain, and diaries are often used to collect patient self‐reports. This study was designed to determine if momentary monitoring of pain with an electronic diary affected pain levels over time, if it affected weekly recall of pain, and if daily sampling density affected compliance rates and patients’ reactions to the study. Ninety‐one patients with chronic pain were randomized into four groups with differing levels of momentary monitoring over 2 weeks. Little support was found for reactivity defined as temporal shifts in pain over the study or as changes in recalled weekly pain due to momentary monitoring. Compliance with the electronic diary protocol was 94% or better, and was not related to sampling density. Patients reported little difficulty with the diary procedures and were not unduly burdened by the protocol.

Understanding recall of weekly pain from a momentary assessment perspective: absolute agreement, between- and within-person consistency, and judged change in weekly pain

&NA; To better understand the association between pain recalled over a previous week and the average of multiple momentary reports of pain taken during the same period, 68 patients with chronic pain completed both weekly recall and momentary reports over a 2‐week period and assessed their change in pain over the 2 weeks. Pearson correlations and intraclass correlation coefficients were computed to index three different ways of comparing the measures on both a between‐person and within‐person basis. Between‐person correspondence between weekly and momentary reports was generally moderate to high, but within‐person correspondence was low. Judged change was only weakly related to changes over a week computed from weekly recall or from average momentary reports. Given the importance of within‐person change for treatment studies, these results indicate a serious nonequivalence in weekly recall and averaged momentary reports of pain.

The accuracy of pain and fatigue items across different reporting periods

Abstract The length of the reporting period specified for items assessing pain and fatigue varies among instruments. How the length of recall impacts the accuracy of symptom reporting is largely unknown. This study investigated the accuracy of ratings for reporting periods ranging from 1 day to 28 days for several items from widely used pain and fatigue measures (SF36v2, Brief Pain Inventory, McGill Pain Questionnaire, Brief Fatigue Inventory). Patients from a community rheumatology practice (N = 83) completed momentary pain and fatigue items on average of 5.4 times per day for a month using an electronic diary. Averaged momentary ratings formed the basis for comparison with recall ratings interspersed throughout the month referencing 1‐day, 3‐day, 7‐day, and 28‐day periods. As found in previous research, recall ratings were consistently inflated relative to averaged momentary ratings. Across most items, 1‐day recall corresponded well to the averaged momentary assessments for the day. Several, but not all, items demonstrated substantial correlations across the different reporting periods. An additional 7 day‐by‐day recall task suggested that patients have increasing difficulty actually remembering symptom levels beyond the past several days. These data were collected while patients were receiving usual care and may not generalize to conditions where new interventions are being introduced and outcomes evaluated. Reporting periods can influence the accuracy of retrospective symptom reports and should be a consideration in study design.

Written emotional expression produces health benefits in fibromyalgia patients.

Objective: Written expression of traumatic experiences, an intervention found to have health benefits in rheumatoid arthritis, asthma, and breast cancer, was tested in a randomized, controlled trial with female fibromyalgia patients. It was hypothesized that relative to controls, patients engaging in the writing intervention would experience improved status on psychological well-being and physical health variables. Methods: Patients (N = 92) were randomized into a trauma writing group, a control writing group, or usual care control group. The two writing groups wrote in the laboratory for 20 minutes on 3 days at 1-week intervals. Psychological well-being, pain, and fatigue were the primary outcome variables. Assessments were made at pretreatment, posttreatment, 4-month follow-up, and 10-month follow-up. Results: The trauma writing group experienced significant reductions in pain (effect size [ES] = 0.49) and fatigue (ES = 0.62) and better psychological well-being (ES = 0.47) at the 4-month follow-up relative to the control groups. Benefits were not maintained at the 10-month follow-up. Conclusion: Fibromyalgia patients experienced short-term benefits in psychological and health variables through emotional expression of personal traumatic experiences. ED = written emotional disclosure; RA = rheumatoid arthritis; QOL = Quality of Life Scale; STAI-S = state version, State-Trait Anxiety Inventory; BDI = Beck Depression Inventory; MOS = Medical Outcome Study; CLINHAQ = Clinical Health Assessment Questionnaire; FIQ = Fibromyalgia Impact Questionnaire; VAS = visual analogue scale; NW = neutral writing group; UC = usual-care control group; ANOVA = analysis of variance; ES = effect size.

Variability of Momentary Pain Predicts Recall of Weekly Pain: A Consequence of the Peak (or Salience) Memory Heuristic

Patients’ recall of their recent pain is commonly assessed by both researchers and clinicians. However, concerns have been raised about differences between recalled pain and the average of real-time recordings of pain taken over the same period, in part because of the possibility that memory processes affect how retrospective pain is reported. It was hypothesized that memory processes affect the accuracy of recall, such that those with higher versus lower variability of real-time pain will recall pain at higher levels, relative to their average momentary pain. Sixty-eight chronic pain patients with rheumatologic conditions reported their pain several times a day for 2 weeks and also recalled their weekly pain at the end of each of those 2 weeks. The hypothesis was confirmed and it was concluded that variability of real-time pain affects the recall of pain.

Signaling does not adequately improve diary compliance

Hypothesis: Compliance with a paper diary protocol would be improved by using auditory signaling.Background: Prior research has demonstrated that compliance with the reporting schedule in paper diary protocols is poor.Methods: Adults with chronic pain (N = 27) were recruited from the community to participate in a 24-day experience sampling protocol of 3 pain assessments per day (10:00 a.m., 4:00p.m., 8:00p.m.). Diaries were instrumented to record openings and closings, thereby permitting determination of date and time when the participant could have made diary entries. Participants were signaled with a programmed wristwatch at the onset of each 30-min assessment window. Two compliance windows were defined: ± 15 min and ± 45 min of the targeted assessment time.Results: Self-reported compliance based on participants’ paper diaries was 85% and 91% for the 30- and 90-min windows. Verified compliance was 29% and 39% for the two windows. Signaling produced a significant increment in verified compliance when compared with an identical trial without signaling. A significant eroding of verified compliance was observed across the 3 weeks of the study.Conclusions: Self-report dating of diary entries may be misleading investigators about compliance with diary protocols. Although auditory signaling enhances compliance, the result is still unsatisfactory.

Reactive effects of diary self-assessment in chronic pain patients.

&NA; Several studies of experimental and acute clinical pain have indicated reactive effects of self‐assessment on pain intensity and tolerance. A recent study of chronic pain patients (vonBaeyer 1994), however, failed to show these effects. The present investigation sought to determine whether reactive effects can be produced in chronic pain patients by an intensive self‐assessment protocol. Using the methodology of ecological momentary assessment (EMA; Stone and Shiffman 1994), thirty‐five chronic rheumatoid arthritis patients completed diaries of pain and mood seven times a day for 1 wk. Eighteen patients were included in the final sample because they responded to at least half of the number of hourly prompts for each of the 7 days. Using repeated measures analysis of the daily means, no significant effects of time were found for any measures. Reactive effects that result in an average change in pain levels over time, therefore, do not appear to be produced by intensive self‐assessment in a naturalistic context. Results are discussed in terms of cognitive and behavioral theories of pain reactivity.

Obesity and Pain Are Associated in the United States

Recent small‐scale studies have shown a positive association between central obesity and self‐reported pain levels. This study attempts to replicate the finding in a survey of over 1,000,000 individuals in the United States. The Gallup Organization conducted a proprietary survey between 2008 through 2010 where 1,062,271 randomly selected individuals in the United States participated in a telephone interview. Survey questions included height and weight, from which BMI was computed, questions about pain conditions in the past year, and a question about pain experience yesterday. Only 19.2% of the sample was classified as Low‐Normal BMI, 21.4 were classified as Overweight, and the remainder was in the three categories of Obese. BMI and pain yesterday were reliably associated when demographic variables were controlled: the overweight group reported 20% higher rates of pain than Low‐Normal group, 68% higher for Obese I group, 136% higher for Obese II group, and 254% higher for Obese III group. The association held for both men and women and it became stronger in older age groups. Controlling the associations for other pain‐related medical conditions substantially reduced the associations, but they remained substantial for the Obese groups. We conclude that BMI and daily pain are positively correlated in the United States: people who are obese are considerably more prone to having daily pain. The association is robust and holds after controlling for several pain conditions and across gender and age. The increasing BMI‐pain association with older ages suggests a developmental process that, along with metabolic hypotheses, calls out for investigation.