We accordingly structure the micro-, meso-, and macro-level implications of response shift based on the following three tenets from Gadamerian hermeneutics: (1) the use of PROMs involves the interpretation of contextual elements (2) interpretation of PROM results is an ongoing dialectical interaction and (3) the integration of PROM data in decision-making requires openness and reflexivity. This interplay constitutes a dialectical process of navigating differences in how patients interpret and respond to questions about their health, and how researchers and clinicians interpret the results. Dialectical processes refer to the interplay between patients’ prior ideas and experiences and the assumptions held by researchers and clinicians about health. hermeneutic circle) that provide insights into how different stakeholders interpret and use PROM results. We specifically drew upon Gadamerian hermeneutics because it draws attention to the dialectical processes (a.k.a. At a foundational level, the use of PROs involves an interpretive process of understanding the meaning of individuals’ responses to PROM items. Our inferences, actions, and decisions made on PROs must therefore take into account the possibility that PROM scores may be influenced by response shift.īuilding on the theoretical premises of measurement validity, we take a hermeneutic philosophical lens to gain further insight into how the meaning of PROM scores may change over time and the consequent implications for micro-, meso-, and macro-level healthcare decision-making. As a consequence, the meaning of the PROM score will not be consistent over time. In other words, response shift occurs when observed scores (i.e., responses to PROM items) do not reflect the construct of interest in the same way at different points in time. Response shift threatens the measurement assumption that the process and frame of reference by which a person responds to PROM items are consistent over time. This view of measurement validity is based on the foundational work by Messick and, subsequently, Zumbo, which has received increasing attention in PRO measurement. From a measurement validity point of view, the impact of response shift on healthcare decision-making ultimately pertains to whether the inferences we make are valid, and subsequent actions and decisions made on PROs are well founded. Our analysis is informed by perspectives of measurement validity, hermeneutic philosophy, and healthcare decision-making. This work is part of an international, interdisciplinary collaboration (see Appendix for the participating members) to synthesize the research on response shift to date. In so doing, we intend to raise awareness and provide guidance for PRO researchers who play an important role in informing healthcare providers, healthcare leaders, health policymakers, and regulators regarding the implications of response shift. Our goal is to provide a framework regarding the impacts of response shift at micro-, meso- and macro-levels of healthcare decision-making. To date, the implications of response shift for healthcare decision-making have rarely been investigated. The possibility of response shift must therefore be considered when measuring changes in PROM scores over time and when comparing differences in PROM scores between people (e.g., when comparing people who experienced response shifts with those who did not). However, if we want to measure change in perceived health status over time, inferences we draw from the observed change in that item may be invalid, leading to ill-informed decisions. For example, when we assess patients’ perceived health status at two time points, we can take their responses to that item at each time point at face value, even if response shift has occurred in the interim. It is therefore important to consider the potential implications of response shift when measures of change in PROs over time are used to inform decisions. Evolving perspectives of measurement validity place increasing emphasis on the inferences, judgements, and decisions based on measurement scores. Response shift is defined as a change in the meaning of one’s self-evaluation as a result of changes in internal standards (recalibration), values (reprioritization), and/or conceptualization of the target construct (reconceptualization), which may result in measurements at two or more time points not being comparable. There is ample evidence that response shift can affect PROs. The decisions that PROs inform can be considered at the level of patient care (micro), the healthcare organization (meso), and health policy (macro). Patient-reported outcomes (PROs), and by extension patient-reported outcome measures (PROMs), are increasingly used to inform healthcare decision-making.
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