Using DVPRS as a single-item screening tool for postoperative sleep disturbance Albert Hsu, MD1; Christian Calilung, MSc3,4; Winifred Rojas, BSN, RN, CCRP3,4; Krista Highland, PhD2,3,4; Chester Buckenmaier III, MD2,3; Michael Kent, MD1 1Department of Anesthesiology, Walter Reed National Military Medical Center; Bethesda, MD 2Uniformed Services University of the Health Sciences; Bethesda, MD 3Defense and Veterans Center for Integrative Pain Management; Rockville, MD 4Henry M. Jackson Foundation for the Advancement of Military Medicine; Bethesda, MD

Background Pain and sleep inextricably interwoven in perioperative period Often, intensity of pain alone assessed when evaluating for pain Important to assess sleep in perioperative period Numerous measures of sleep Many are cumbersome, give composite score vs. measuring specific dimension It seems obvious that pain and sleep are deeply interwoven in the perioperative period. Numerous studies have demonstrated just this. In addition, as pain may prevent a post-surgical patient from having a good night of sleep, and thus how well a patient sleeps allows us to gauge how well his pain is controlled.   However, intensity of pain alone is often assessed when evaluating someone’s pain. It’s important to assess sleep in perioperative period, as it adds to a multidimensional evaluation of perioperative pain. Currently there are numerous measures of sleep- Pittsburgh qualitiy of sleep index, quality of recovery index, functional outcomes of sleep questionnaire. Many of these are cumbersome, and many have applicability mainly in the research setting, not necessarily the clinical setting

[*MORE HERE RE: PROMIS] Include cut-off explanation. This is the DVPRS- the Defense and Veteran’s Pain Rating Scale. It is a five-item questionnaire that is used ubiquitously in the DoD and VA system at assessing pain. What’s nice about it is it not only helps us assess for intensity of pain, but also how pain affects their functioning in these four domains.   One of the domains is sleep interference, boxed in this slide. “Choose a number over the past 24hrs that describes how pain has interfered with your sleep”. Patients can choose a response between 0 and 10, with cutoff of 3 or 4 being the demarcation between mild and moderate. [*MORE HERE RE: PROMIS] Include cut-off explanation.

Objective Assess the degree of congruence between DVPRS Sleep Interference item and PROMIS Sleep Disturbances scale Assess performance of DVPRS Sleep Interference item in relation to the PROMIS Sleep Disturbances scale score at detecting moderate-severe disturbances in sleep For this study, we assessed the ability of the DVPRS-SI perform at detecting moderate-severe sleep disturbances in perioperative period. As noted previously, a simplified measure could provide significant clinical impact. To figure this out, we compared the DVPRS to PROMIS. The PROMIS- Patient Reported Outcomes Measurement Information System – is a system of highly precise measures of patient-reported health status for physical, mental, and social well-being. It has several different tools/questionnaires that are used at least in the research world to assess various domains of health, one of them being sleep disturbance. How PROMIS works is beyond the scope of this talk, but just know that we tested the degree DVPRS-SI item using the PROMIS-SD

Methods Adult patients at WRNMMC undergoing a variety of surgeries (Ortho/Gen/Neuro/CT) completed DVPRS and PROMIS-SD preoperatively (BL) and POD7 (D7) PROMIS-Sleep Disturbances scale was used as the reference measure Spearman correlations assessed the correlation between DVPRS Sleep Interference Item and PROMIS Sleep Disturbances t-score before surgery and seven days post-surgery Area Under the Receiving Operating Curve analyses assessed the screening properties of DVPRS Sleep Interference item in relation to PROMIS Sleep Disturbances So what we did is have patients undergoing these surgeries complete the DVPRS and PROMIS at pre op and POD7. Spearman correlations used to assess correlation between DVPRS-SI and PROMIS-SD. AUROC used to describe screening properties of DVPRS-SI in relation to PROMIS-SD For the AUROC analyses, sensitivity and specificity of 80% or greater are generally considered to be good indications of measurement properties. Define mild/mod/sev for DVPRS and PROMIS, focusing specifically on ability of DVPRS to pick up mod-sever

Methods DVPRS – Sleep Interference Item Mild  0-3 Moderate  4-6 Severe  7-10 PROMIS – Sleep Disturbances t-score Mild  55-60 Moderate  60-70 Severe  >70 patients undergoing these surgeries complete the DVPRS and PROMIS at pre op and POD7. Spearman correlations used to assess correlation between DVPRS-SI and PROMIS-SD. AUROC used to describe screening properties of DVPRS-SI in relation to PROMIS-SD Define mild/mod/sev for DVPRS and PROMIS, focusing specifically on ability of DVPRS to pick up mod-sever

Results 160 and 117 patients completed the two questionnaires before surgery and seven days post-surgery, respectively Moderate-strong correlations between DVPRS-Sleep Interference item score and PROMIS-Sleep Disturbances t-score before surgery (Spearman rho=.50, p<.001) and seven days post-surgery (Spearman rho=.59, p<.001) ROC analysis Before surgery: there was not an adequate cut-off with sensitivity and specificity > 80% Seven days post-surgery: a cut-off of moderate-severe (i.e., score 4 or greater) on the DVPRS – Sleep Interference item provided good sensitivity 82% and adequate specificity 69%

Conclusions DVPRS–Sleep Interference item displayed improved performance post-operatively compared to preoperatively, with a score of 4 or greater indicating significant sleep disturbance. DVPRS Sleep Interference item may be useful for sleep disturbance screening in the immediate postoperative period to further guide bedside/clinical evaluation.

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