Assessment Tools

Assessment Tools

The following tools can be used for symptom assessment in clinical practice. With increased emphasis on patient and family engagement in care and healthcare decision making, the importance of assessment using patient-reported outcomes (PROs) to achieve high-quality care is well recognized. With a project team of ONS member volunteers, ONS has established criteria for ONS-recommended PRO assessment tools. An initial set of instruments meeting these criteria is available to download. These tools are intended for use in clinical practice and quality-improvement efforts; any use for research purposes requires permission from developers of the instruments.

Assessment tools for the following symptoms can be downloaded and where available are provided in both English and Spanish versions. Instruments in additional languages and availability in different formats can be found at the links for further information provided for each tool.

Multiple Symptom Assessment

MD Anderson Symptom Inventory (MDASI) – English
MD Anderson Symptom Inventory (MDASI) – Spanish

Description: Measurement of 13 common symptoms for severity and interference with aspects of daily life on 10-point numeric rating scales. Average time to complete: 4.8 minutes. Interpretation: Scores of 56 are considered moderate, and scores of 710 are considered severe. Minimally important difference or score change ranges 0.981.21 (Cleeland, 2016). Additional translations are available. Browse additional information.

Anxiety

General Anxiety (GAD 7) – English
General Anxiety (GAD 7) – Spanish

Description: Measurement of seven anxiety symptoms on 4-point scales. Average time to complete: 3 minutes. Interpretation: Total scores of 5, 10, and 15 represent cutpoints for mild, moderate, and severe anxiety. Multiple translations are available. Browse additional information.

PROMIS SF v.10 Anxiety 6a – English
PROMIS SF v.10 Anxiety 6a – Spanish

Description: Measurement of six items on 5-point scales. Average time to complete: 1.6 minutes. Interpretation and scoring: Calculate total score as [(sum of items x 6) ÷ number items answered]. The higher the total score, the more severe the symptom. The minimally important difference (MID) of the total score for a nine-item PROMIS anxiety tool is estimated at 34.5 (Yost, 2011), suggesting a 30% difference as clinically meaningful. Multiple translations are available. Some PROMIS forms are imbedded in electronic systems. Browse additional information and resourcses.

Depression

Patient Health Questionnaire-9 (PHQ9) – English
Patient Health Questionnaire-9 (PHQ9) – Spanish

Description: Nine items on 4-point scales and 4-point scale for impact on daily life. Average time to complete: 3.6 minutes. Interpretation: Scores of 5, 10, 15, and 20 represent cutpoints for mild, moderate, moderately severe, and severe depression. Score 5: Repeat at followup and monitor. Score 1014: Initiate a treatment plan. Score 1519: Active treatment with psychotherapy or pharmacotherapy. Score 2027: Immediate pharmacotherapy and specialist referral. (Instruction manual) Multiple translations are available. Browse additional information.

PROMIS SF v.1.0 Depression 6a – English
PROMIS SF v.1.0 Depression 6a – Spanish

Description: Measurement of six items on 5-point scales. Average time to complete: 1.6 minutes. Interpretation and scoring: Calculate the total score as [(sum of items x 6) ÷ number items answered]. The higher the total score, the more severe the symptom. The MID of the total score for a 10-item PROMIS depression tool is estimated at 3.04.5 (Yost, 2011) suggesting a 30% difference as clinically meaningful. Multiple translations are available. Some PROMIS forms are imbedded in electronic systems. Browse additional information and resources.

Fatigue

PROMIS SFv1.0 6a Fatigue – English
PROMIS SFv1.0 8a Fatigue – Spanish

Description: Measurement of six to eight items on 5-point scales. Average time to complete: 2.25 minutes. Interpretation and scoring: Calculate the total score as [(sum of items x number of items on tool) ÷ number items answered]. The higher the total score, the more severe the symptom. The MID of the total score for a seven-item PROMIS fatigue tool is estimated at 35 (Yost, 2011), suggesting a change score of about 40% is meaningful. Multiple translations are available. Some PROMIS forms are imbedded in electronic systems. Browse additional information and resources.

Brief Fatigue Inventory – English
Brief Fatigue Inventory – Spanish

Description: Measurement of nine items on 10-point numeric scales for fatigue level and interference with daily life. Average time to complete: 2.67 minutes. Interpretation: Cutpoints for fatigue level suggested are 13 (mild), 47 (moderate), and 810 (severe) (Chang, 2007). Levels of 4 or greater suggest a need for intervention beyond activities for prevention. Browse additional information.

Pain

PROMIS v1.0 Pain Intensity 3a – English
PROMIS v1.0 Pain Intensity 3a – Spanish

Description: Measurement of three items on 5-point scales. Average time to complete: 1 minute. Interpretation and scoring: The higher the total score, the more severe the symptom. Multiple translations are available. Some PROMIS forms are imbedded in electronic systems. Browse additional information and resources.

PROMIS Pain Interference Short Form 6a – English
PROMIS Pain Interference Short Form 6a – Spanish

Description: Measurement of six items on 5-point scales for pain interference on aspects of daily life. Average time to complete: 1.6 minutes. Interpretation and scoring: Calculate the total score as [(sum of items x 6) ÷ number items answered]. The higher the total score, the more severe the symptom. The MID of the total score for a 10-item PROMIS pain interference tool is estimated at 46 (Yost, 2011), suggesting a change score of about 60% is meaningful. A raw score greater than 7 is higher than people in the general population (Cleeland, 2016). Multiple translations are available. Some PROMIS forms are imbedded in electronic systems. Browse additional information and resources.

Brief Pain Inventory – English
Brief Pain Inventory – Spanish

Description: Questions for presence of pain; use of pain medication; diagram to identify pain location; four items to rate worst, least, average, and current pain intensity on 10-point numeric scales; questions for relief from treatment for pain and pain description. Average time to complete: 9.8 minutes. Interpretation and scoring: Four items for intensity can be used alone. A two-point difference in intensity rating has been suggested as a MID for this tool (Mathias, 2011). This tool is not suggested for initial pain screening but is seen as useful for more comprehensive follow-up assessment for individuals who report having pain. Browse additional information.

Sleep

PROMIS SF v1.0 Sleep Disturbance 8a – English
PROMIS SF v1.0 Sleep Disturbance 8a – Spanish

Description: Measurement of eight items for sleep quality on 5-point scales. Average time to complete: 1.5 minutes. Interpretation and scoring: Calculate the total score as [(sum of items x 8) ÷ number items answered]. The higher the total score, the more severe the symptom. Total scores less than 24 suggest no to slight sleep disturbance, 2428 suggest mild disturbance, 2938 moderate disturbance, and greater than 38 severe sleep disturbance. Browse additional information and resources.

PROMIS SF v1.0 Sleep Related Impairment 8a – English
PROMIS SF v1.0 Sleep Related Impairment 8a – Spanish

Description: Measurement of eight items on 5-point scales to rate the frequency of problems related to insufficient sleep in the past seven days. Average time to complete: 2 minutes. Interpretation and scoring: Calculate the total score as [(sum of items x 8) ÷ number items answered]. The higher the total score, the more severe the problem. Browse additional information and resources.

Insomnia Severity Index (ISI) – English

Description: Measurement of seven items regarding the insomnia problem, interference with functioning, related distress, and sleep satisfaction. Average time to complete: 3 minutes. Interpretation: Scoring interpretation is shown on the tool. Individuals with moderate (scores 1521) or severe (scores 2228) insomnia should be considered for specialized follow up and interventions. A six-point change in score has been suggested as a minimally clinical important difference for the ISI (Yang, 2009).

ONS Criteria for Assessment Tool Recommendation

Criteria were established by the project team, and selected tools were evaluated according to these criteria.

  • Acceptable reliability
  • Content validity established by oncology content experts or previous validation or use in patients with cancer
  • Practical for clinical application, including brief, ease of use, scoring and interpretation
  • Potential for incorporation into electronic health records
  • Direct availability via the ONS website

Preferred characteristics include

  • Information regarding tool responsiveness to change
  • Information regarding clinically important and meaningful difference (that difference that show a meaningful change for improvement or decline)
  • Availability in multiple languages.

Benefits of PRO Measurement

  • Assessment tools that present measurement of patient-reported outcomes provide a mechanism for clinicians to engage patients and caregivers in care planning.
  • These tools can be used to provide more detailed initial level of symptom assessment for individuals who indicate symptom distress in overall distress screening. 
  • PROs can be used to facilitate objective goal setting with patients to identify desired levels of symptom improvement. Repeated use enables evaluation of effectiveness of interventions provided.
  • Numeric results from tools can be incorporated into electronic health records, and some instruments are already designed for electronic use. Incorporation into electronic health records can meet current meaningful use requirements.

For questions about use or interpretation, please contact research@ons.org

References

Chang, Y.J., Lee, J.S., Lee, C.G., Lee, W.S., Lee, K.S., . . . Yun, Y.H. (2007). Assessment of clinical relevant fatigue level in cancer. Supportive Care in Cancer, 17, 891–896. doi:10.1007/s00520-007-0219-x

Cleeland, C.S. (2016). The M.D. Anderson Symptom Inventory User Guide, Version 1. Houston, TX: University of Texas MD Anderson Cancer Center.

Mathias, S.D., Crosby, R.D., Qian, Y., Jiang, Q., Dansey, R., & Chung, K. (2011). Estimating minimally important differences for the worst pain rating of the Brief Pain Inventory, short form. Journal of Supportive Oncology, 9, 72–78. doi:10.1016/j.suponc.2010.12.004

Yang, M., Morin, CM., Schaefer, K., & Wallenstein, GV. (2009). Interpreting score differences in the insomnia severity index: Using health related outcomes to define the minimally important difference. Current Medical Research and Opinion, 25, 2487–2494. doi:10.1185/03007990903167415

Yost, K.J., Eton, D.T., Garcia, S.F.Y., & Cella, D. (2011). Minimally important differences were estimated for six PROMIS-Cancer scales in advanced stage cancer patients. Journal of Clinical Epidemiology, 54, 507–516. doi:10.1016/jclinepi.2010.11.018

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