Ability of Patient-Reported Outcomes to Characterize Patient Acceptable Symptom State (PASS) After Attending a Primary Care Physical Therapist and Medical Doctor Collaborative Service: A Cross-Sectional Study

Published:September 12, 2018DOI:


      • A set of Patient Reported Outcome Measurement Information System (PROMIS) scales and a global rating of normal function (GRNF) were associated with patient status (patient acceptable symptom state [PASS]) in musculoskeletal patients seen in primary care.
      • Self-efficacy of managing symptoms was equally associated with patient status as other health domains typically associated with musculoskeletal problems (ie, physical function, pain interference).
      • Individual PROMIS scales and GRNF were successful at identifying up to ∼70% of patients with ∼70% accuracy.
      • Further studies are needed to evaluate whether combinations of PROMIS scales or other generic health scales can be combined to improve accuracy of determining patient status.
      • This analysis identifies thresholds associated with PROMIS physical function, pain interference, and GRNF scales that may assist providers with clinical decisions.



      To determine if the Patient-Reported Outcome Measurement Information System (PROMIS) physical function, pain interference, self-efficacy, and global rating of normal function (GRNF) scales are able to accurately characterize a patient’s acceptable symptom state (PASS).


      A cross-sectional analysis, using receiver operator curves and chi-square analysis to explore criteria to determine thresholds (80% and 95% sensitivity/specificity) for PASS that are applicable to PROMIS and GRNF scales.


      Phone survey after primary care.


      Patients (N=94) attending primary care for musculoskeletal problems.


      Not applicable.

      Main Outcomes Measures

      Accuracy and proportion of patients classified as PASS Yes or No.


      Receiver operator curve analysis showed significant area under the curve (AUC) values for each PROMIS scale (AUC>.72) and the GRNF rating (AUC=.74). Identified PROMIS thresholds suggested PASS was achieved when scores were at or slightly worse than the US population average. A score of ≥7 and ≤4 characterized patients that were PASS Yes and No, respectively, on the GRNF rating. A moderate (80%) specificity/sensitivity criteria yielded 72.3%-73.5% accuracy for a majority of participants (>69.9%).


      This analysis suggests the PROMIS and GRNF scales are able to characterize PASS status with moderate accuracy (∼70%) for a large portion of patients (∼70%). New to this study is the association of self-efficacy with PASS status. PROMIS scales at or slightly worse than the US population average characterized PASS status.


      List of abbreviations:

      AUC (area under the curve), GRNF (global rating of normal function), PASS (patient acceptable symptom state), PF (physical function), PI (pain interference), PROMIS (Patient-Reported Outcome Information System), SE (self-efficacy)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Broderick J.E.
        • DeWitt E.M.
        • Rothrock N.
        • Crane P.K.
        • Forrest C.B.
        Advances in patient-reported outcomes: the NIH PROMIS(®) Measures.
        EGEMS (Wash DC). 2013; 1: 1015
        • Hong I.
        • Velozo C.A.
        • Li C.Y.
        • Romero S.
        • Gruber-Baldini A.L.
        • Shulman L.M.
        Assessment of the psychometrics of a PROMIS item bank: self-efficacy for managing daily activities.
        Qual Life Res. 2016; 25: 2203-2214
        • Hung M.
        • Baumhauer J.F.
        • Latt L.D.
        • Saltzman C.L.
        • Soohoo N.F.
        • Hunt K.J.
        Validation of PROMIS® physical function computerized adaptive tests for orthopaedic foot and ankle outcome research.
        Clin Orthop Relat Res. 2013; 471: 3466-3474
        • Rose M.
        • Bjorner J.B.
        • Gandek B.
        • Bruce B.
        • Fries J.F.
        • Ware J.E.
        The PROMIS Physical Function item bank was calibrated to a standardized metric and shown to improve measurement efficiency.
        J Clin Epidemiol. 2014; 67: 516-526
        • Cook K.F.
        • Jensen S.E.
        • Schalet B.D.
        • et al.
        PROMIS measures of pain, fatigue, negative effect, physical function and social function demonstrate clinical validity across a range of chronic conditions.
        J Clin Epidemiol. 2016; 73: 89-102
        • Hung M.
        • Baumhauer J.F.
        • Brodsky J.W.
        • et al.
        Psychometric comparison of the PROMIS physical function CAT with the FAAM and FFI for measuring patient-reported outcomes.
        Foot Ankle Int. 2014; 35: 592-599
        • Cella D.
        • Riley W.
        • Stone A.
        • et al.
        The patient-reported outcomes measurement information system (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005-2008.
        J Clin Epidemiol. 2010; 63: 1179-1194
        • Ho B.
        • Houck J.R.
        • Flemister A.S.
        • et al.
        Preoperative PROMIS scores predict postoperative success in foot and ankle patients.
        Foot Ankle Int. 2016; 37: 911-918
        • Papuga M.O.
        • Beck C.A.
        • Kates S.L.
        • Schwarz E.M.
        • Maloney M.D.
        Validation of GAITRite and PROMIS as high-throughput physical function outcome measures following ACL reconstruction.
        J Orthop Res. 2014; 32: 793-801
        • Gruber-Baldini A.L.
        • Velozo C.
        • Romero S.
        • Shulman L.M.
        Validation of the PROMIS® measures of self-efficacy for managing chronic conditions.
        Qual Life Res. 2017; 26: 1915-1924
      1. Frogner BK, Harwood K, Pines J, Andrilla H, Schwartz M, Washington TG. Does unrestricted direct access to physical therapy reduce utilization and health spending? Health Care Cost Institute and National Academy for State Health Policy State Health Grant Program. Washington, DC: Health Care Cost Institute, January 2016.

        • Irrgang J.J.
        • Anderson A.F.
        • Boland A.L.
        • et al.
        Development and validation of the international knee documentation committee subjective knee form.
        Am J Sports Med. 2001; 29: 600-613
        • Martin R.L.R.
        • Irrgang J.J.J.
        • Burdett R.G.
        • Conti S.F.
        • Van Swearingen J.M.
        Evidence of validity for the Foot and Ankle Ability Measure (FAAM).
        Foot Ankle Int. 2005; 26: 968-983
        • Aas I.H.M.
        Guidelines for rating Global Assessment of Functioning (GAF).
        Ann Gen Psychiatry. 2011; 10: 2
        • Noble P.C.
        • Dwyer M.
        • Brekke A.
        Commonalities, differences, and challenges with patient-derived outcome measurement tools: function/activity scales.
        Clin Orthop and Relat Res. 2013; 471: 3457-3465
        • Noble P.C.
        • Fuller-Lafreniere S.
        • Meftah M.
        • Dwyer M.K.
        Challenges in outcome measurement: discrepancies between patient and provider definitions of success.
        Clin Orthop Relat Res. 2013; 471: 3437-3445
        • Kvien T.K.
        • Heiberg T.
        • Hagen B.
        Minimal clinically important improvement/difference (MCII/MCID) and patient acceptable symptom state (PASS): what do these concepts mean?.
        Ann Rheum Dis. 2007; 66: 40-41
        • Salaffi F.
        • Carotti M.
        • Gutierrez M.
        • Carlo M.D.
        • Angelis R.D.
        Patient acceptable symptom state in self-report questionnaires and composite clinical disease index for assessing rheumatoid arthritis activity: identification of cut-off points for routine care.
        Biomed Res Int. 2015; 2015: 930756
        • Tashjian R.Z.
        • Deloach J.
        • Porucznik C.A.
        • Powell A.P.
        Minimal clinically important differences (MCID) and patient acceptable symptomatic state (PASS) for visual analog scales (VAS) measuring pain in patients treated for rotator cuff disease.
        J Shoulder Elbow Surg. 2009; 18: 927-932
        • Wright A.A.
        • Hensley C.P.
        • Gilbertson J.
        • Leland J.M.
        • Jackson S.
        Defining patient acceptable symptom state thresholds for commonly used patient reported outcomes measures in general orthopedic practice.
        Man Ther. 2015; 20: 814-819
        • Levy D.M.
        • Kuhns B.D.
        • Chahal J.
        • Philippon M.J.
        • Kelly B.T.
        • Nho S.J.
        Hip arthroscopy outcomes with respect to patient acceptable symptomatic state and minimal clinically important difference.
        Arthroscopy. 2016; 32: 1877-1886
        • Muller B.
        • Yabroudi Ma
        • Lynch A.
        • et al.
        Defining thresholds for the patient acceptable symptom state for the IKDC Subjective Knee Form and KOOS for patients who underwent ACL reconstruction.
        Am J Sports Med. 2016; 1: 9-11
        • Andersen N-bDV.
        • Kent P.
        • Hjort J.
        • Christiansen D.H.
        Clinical course and prognosis of musculoskeletal pain in patients referred for physiotherapy: does pain site matter?.
        BMC Musculoskelet Disord. 2017; : 1-11
        • Hung M.
        • Franklin J.D.
        • Hon S.D.
        • Cheng C.
        • Conrad J.
        • Saltzman C.L.
        Time for a paradigm shift with computerized adaptive testing of general physical function outcomes measurements.
        Foot Ankle Int. 2014; 35: 1-7
        • Martin R.L.
        • Irrgang J.J.
        A survey of self-reported outcome instruments for the foot and ankle.
        Journal Orthop Sports Phys Ther. 2007; 37: 72-84
        • Gortmaker S.
        • Hosmer D.
        • Lemeshow S.
        Applied logistic regression.
        Contemp Sociol. 1994; 23: 159