Is the Patient Activation Measure a valid measure of osteoarthritis self-management attitudes and capabilities? Results of a Rasch analysis

Abstract

Background The Patient Activation Measure (PAM-13) was developed using Rasch analysis to assess knowledge, skills and confidence in the management of one’s health. Previous studies report positive relationships between PAM-13 scores, self-management behaviours and longitudinal health outcomes in adults with chronic disease. There is little extant measurement property evidence for the use of PAM-13 in specific osteoarthritis (OA) populations. This study tested measurement properties of the PAM-13 in people living with hip and knee OA. Methods Item response frequency analysis was conducted. Rasch analysis evaluated the fit of the PAM-13 data to the Rasch model. Model-data fit was evaluated using infit and outfit statistics; person/item reliability and person separation indices were computed. Unidimensionality was evaluated using Principal Components Analysis of Rasch residuals and the data were assessed for item redundancy. Differential Item Functioning (DIF) examined bias in respondent subgroups and correlations tested relationships between PAM-13 and other patient-reported outcomes. Results Two-hundred-and-seventeen PAM-13 surveys were completed; there were no missing responses, floor or ceiling effects. Person and item reliability were acceptable (0.98 and 0.87 respectively) with good separation (person separation index 2.58). Unidimensionality was evaluated, with 49.4% of the variance explained by the first eigenvector. There was evidence of potential local response-dependence. The Rasch fit statistics were acceptable (except for item-2). There were some issues identified with targeting of the PAM-13 items to people with higher ability and the item difficulty order was different to that proposed in original cohorts. Significant DIF was identified for sex and educational level for a small number of items. PAM-13 scores were moderately correlated with depressive symptoms on the Depression Anxiety Stress Scale and Assessment of Quality of Life-6D. There were small correlations between PAM-13 and Knee injury and Osteoarthritis Outcome Score pain and activities of daily living scores. Conclusions This study provides some evidence of adequate person and item reliability, unidimensionality, and construct validity to support the use of PAM-13 to measure patient activation in people living with hip and knee OA. Possible limitations regarding targeting, different item difficulty order, DIF and local response dependence should be investigated in future research.

Measures of Patient Activation and Self‐Efficacy

“…No floor or ceiling effect (1% and 3%, respectively) was detected among 217 patients with osteoarthritis who were participants of an osteoarthritis management program in Australia (24). At the individual‐item level, all items of the Italian version have displayed a low floor effect and a moderate to large ceiling effect (25).…”

“…Cronbach’s α was high for all versions and varied from 0.80 to 0.92. (8,9,13–16,18,19,21,24–31) Using Rasch analysis, the item reliability index was 0.98 (greater than 0.80 criterion value) for the 217 patients with osteoarthritis from Australia (24).…”

“…Validation studies report a low percentage of missing items, generally below 3.5% (13,20). “Not applicable” response was moderate (greater than 10%) for a small number of items (13,24). A “not applicable” response was reported by 0% to 8% of the 217 patients with arthritis for each item of the PAM‐13 (24).…”

“…“Not applicable” response was moderate (greater than 10%) for a small number of items (13,24). A “not applicable” response was reported by 0% to 8% of the 217 patients with arthritis for each item of the PAM‐13 (24). Young people in digital consulting with long‐term conditions found 11 of 13 item to be relevant, whereas four of seven clinicians found all items to be relevant (32).…”

“…Statistically significant Pearson’s and Spearman’s correlation coefficients of PAM‐13 total scores to other instruments are as follows (with reference citations in parentheses): For correlations with measures of mood: Beck Depression Inventory II: 0.43 (20). Depression, Anxiety, and Stress Scale: −0.26 (24). Patient Health Questionnaire–9: 0.35 (10) and −0.16 (14).…”