Identifying clinically meaningful severity categories for PROMIS pediatric measures of anxiety, mobility, fatigue, and depressive symptoms in juvenile idiopathic arthritis and childhood-onset systemic lupus erythematosus



A key limitation to widespread adoption of patient-reported outcome (PRO) measures is the lack of interpretability of scores. We aim to identify clinical severity thresholds to distinguish categories of no problems, mild, moderate, and severe along the PROMIS® Pediatric T-score metric for measures of anxiety, mobility, fatigue, and depressive symptoms for use in populations with juvenile idiopathic arthritis (JIA) and childhood-onset systemic lupus erythematosus (cSLE).


We used a modified standard setting methodology from educational testing to identify clinical severity thresholds (clinical cut scores). Using item response theory-based parameters from PROMIS item banks, we developed a series of clinical vignettes that represented different severity or ability levels along the PROMIS Pediatric T-score metric. In stakeholder workshops, participants worked individually and together to reach consensus on clinical cut scores. Median cut-score placements were taken when consensus was not reached. Focus groups were recorded and qualitative analysis was conducted to identify decision-making processes.


Nine adolescents (age 13–17 years) with JIA (33% female) and their caregivers, five adolescents (age 14–16 years) with cSLE (100% female) and their caregivers, and 12 pediatric rheumatologists (75% female) participated in bookmarking workshops. Placement of thresholds for bookmarks was highly similar across stakeholder groups (differences from 0 to 5 points on the PROMIS t-score metric) for all but one bookmark placement.


This study resulted in clinical thresholds for severity categories for PROMIS Pediatric measures of anxiety, mobility, fatigue, and depressive symptoms, providing greater interpretability of scores in JIA and cSLE populations.

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This study was conducted as part of the Duke PEPR Center, which is funded by the National Institutes of Health through the following grant administered by the National Institute of Arthritis and Musculoskeletal and Skin Diseases: U19AR069519. The research reported is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. We would like to acknowledge the adolescents, parents, and clinicians who participated in this study. We are grateful for their contributions. We would also like to acknowledge the Childhood and Rheumatology Research Alliance (CARRA) and the Arthritis Foundation for their help setting up bookmarking workshops at their annual meetings and conferences.

Author information




All authors substantially contributed to the study conception, design, implementation or analysis. Bryce Reeve, Courtney Mann, Mian Wang, Emily von Scheven, and Laura Schanberg were responsible for conceptualization and study design. Study implementation, including material preparation, participant recruitment, and data collection were performed by Courtney Mann, Mian Wang, Nicole Lucas, Alexy Hernandez, Laura Schanberg, Emily von Scheven, Sarah Ringold, and Bryce Reeve. Data analysis was conducted by Courtney Mann, Nicole Lucas, and Alexy Hernandez and results were interpreted by the full research team. The first draft of the manuscript was written by Courtney Mann and all authors commented on subsequent drafts of the manuscript. All authors read and approved the final manuscript.

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Correspondence to C. M. Mann.

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Conflict of interest

Laura Schanberg, MD, Sarah Ringold, MD, and Emily von Scheven work for the Childhood Arthritis and Rheumatology Research Alliance (CARRA). Dr. Schanberg is a former Board Chair and currently sits on the Registry and Research Oversight Committee along with Dr. Sarah Ringold. Dr. Emily von Scheven will be the next Board Chair for CARRA. All other authors declare no conflict of interest.

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All procedures performed in studies involving human participants were conducted in accordance with ethical standards of the institutional review board (Duke Health IRB, Pro00091284 and UNC IRB #15-2442 and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study. For participants under the age of 18, caregiver consent was obtained in addition to child assent.

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Mann, C.M., Schanberg, L.E., Wang, M. et al. Identifying clinically meaningful severity categories for PROMIS pediatric measures of anxiety, mobility, fatigue, and depressive symptoms in juvenile idiopathic arthritis and childhood-onset systemic lupus erythematosus. Qual Life Res 29, 2573–2584 (2020).

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  • Patient-reported outcomes
  • Juvenile idiopathic arthritis
  • Childhood-onset
  • Systematic lupus erythematosus
  • Reference values