What Is the Interversion Reliability and Agreement Between the Decision Tree Patient-rated Wrist Evaluation and the...

A frequently used strategy to improve patient-reported outcome measure (PROM) response rates and reduce patients' burden with PROM completion is item reduction. In this context, a shortened decision tree version of the patient-rated wrist evaluation (DT-PRWE) was developed, reducing the number of items from 15 to 5. The DT-PRWE demonstrated excellent psychometric properties in simulated data; however, its psychometric properties have not yet been evaluated in a real-world clinical setting.

(1) What is the interversion reliability and agreement between the DT-PRWE and the patient-rated wrist evaluation (PRWE) in a clinical setting? (2) What is the difference in completion time between the DT-PRWE and the PRWE?

We conducted a prospective study at Xpert Clinics in the Netherlands, a multicenter, referral-based outpatient practice, with both urban and regional locations, that specializes in hand and wrist surgery and hand therapy to assess the interversion reliability and agreement between the PRWE and the DT-PRWE. Between January and April 2025, a total of 427 adult patients were treated for wrist-related conditions and completed the PRWE at baseline as part of routine outcome measurement at our clinic. Subsequently, we asked patients to complete the DT-PRWE again 5 to 10 days after the initial assessment. Of those, we considered adult patients with wrist conditions who completed both versions of the PRWE to be potentially eligible. Based on this, 55% (235 of 427) were potentially eligible; a further 27% (116) were excluded because of intervening treatment before completion of the PRWE and the DT-PRWE, including corticosteroid injection (11% [45]), surgery before completion of both versions (6% [25]), other treatment before completion of both versions (5% [23]), and concomitant treatment (5% [23]), leaving 28% (119) for analysis here. Primarily, we evaluated interversion reliability using intraclass correlation coefficients (ICC) as the main outcome; an ICC > 0.75 was considered acceptable for clinical use. We also calculated Pearson correlation coefficients. We assessed the agreement by evaluating paired between-version mean differences, standard error of measurement (SEM), and Bland-Altman plots. Additionally, we compared the SEM values with the minimum important change (MIC) thresholds of the PRWE to assess the level of agreement. Finally, we calculated the median (IQR) completion time and compared completion efficiency between versions using the paired Wilcoxon signed-rank test.

The DT-PRWE demonstrated good interversion reliability compared with the PRWE for total score (ICC 0.88 [95% confidence interval (CI) 0.83 to 0.91]), pain subscore (ICC 0.78 [95% CI 0.69 to 0.84]), and hand function subscore (ICC 0.83 [95% CI 0.77 to 0.88]). Additionally, the scores of the PRWE and DT-PRWE were highly correlated (total score r = 0.88 [95% CI 0.83 to 0.92], pain subscore r = 0.81 [95% CI 0.74 to 0.87], hand function subscore r = 0.83 [95% CI 0.77 to 0.88]). The agreement between versions was high, with between-version mean differences of -5.3 (95% CI -7.2 to -3.5) on the total score (score range 0 to 100), -3.4 (95% CI -4.6 to -2.2) on the pain subscore (score range 0 to 50), and -2.0 (95% CI -3.2 to -0.7) on the hand function subscore (score range 0 to 50). The SEM values were 7.1 for the total score, 4.6 for the pain subscore, and 4.9 for the hand function subscore, all falling below the MIC thresholds. The Bland-Altman plots indicated high agreement. The median (IQR) time to complete the PRWE was 3 minutes 33 seconds (2 minutes 20 seconds to 7 minutes 18 seconds), whereas for the DT-PRWE it was 1 minute 5 seconds (50 seconds to 1 minute 29 seconds), representing a 70% reduction with a median difference of 2 minutes 28 seconds (p < 0.001).

The DT-PRWE is a reliable alternative to the full-length version, requiring substantially less time for patients to complete. While preserving both pain and function subscores, its simple digital implementation and comparability with existing PRWE data make the DT-PRWE well suited to replace the PRWE in routine clinical practice and for research applications. Future research should focus on cross-cultural validation of the DT-PRWE and test-retest reliability. Also, future research may investigate whether implementing shortened PROMs, such as the DT-PRWE, improves compliance with PROMs.

Level I, diagnostic study.