Two-Step Screening for Anxiety Symptoms Among Kidney and Kidney-Pancreas Transplant Recipients

Background: Anxiety among Kidney and Kidney-Pancreas transplant recipients (KTR, KPTR) is associated with poor outcomes. Systematic screening using patient-reported outcome measures (PROM) may identify individuals needing further assessment. We assessed the accuracy and efficiency of two-step screening approaches to identify potentially clinically relevant anxiety among KTR and KPTR. Methods: Adult, stable KTR, and KPTR in Toronto, Canada completed the Patient-Reported Outcomes Measurement Information System - Anxiety (PROMIS-A) Computer Adaptive Test, and Generalized Anxiety Disorder-7 (GAD7) questionnaires. Moderate/severe anxiety was defined as GAD7 ≥10. We simulated two-step screening scenarios, as if participants first completed an ultra-brief pre-screener (GAD2; or PROMIS-A screener) followed by PROMIS-A onlu if pre-screened positive. Different pre-screener cutoffs (GAD2 2 and 3; PROMIS-A screener ≥1), and PROMIS-A cut-offs (PROMIS-A 55-60) were evaluated. Screening performance was assessed using sensitivity, specificity (>80% benchmark). Item burden was assessed for each scenario. Results: Among 283 participants (241 KTR, 42 KPTR), mean(SD) age was 53(12) years; 58% male; GAD7 ≥10 in 13%. The GAD-2 ≥3 followed by PROMIS-A ≥55 scenario yielded the best performance (sensitivity 0.81, specificity 0.97). The PROMIS-A screener ≥1 followed by PROMIS-A ≥58 also performed well (sensitivity 0.86, specificity 0.75). GAD7 had the highest item burden, with 1,981 items completed by the study sample (7/person). PROMIS-A, participants completed 1,415 items (5/per person). Of the two-step scenarios, PROMIS-A screener ≥1 followed by PROMIS-A reduced burden (876 items completed, 3/person) by 56% and 38%, compared to GAD7 and PROMIS-A, respectively. The GAD2 ≥3 followed by PROMIS-A scenario reduced burden (709 items completed, 3/person) by 64% and 50%, compared to GAD7 and PROMIS-A, respectively. Conclusion: The proposed two-step screening scenarios demonstrated acceptable screening performance with low item burden. Patients who screen positive will need clinical assessment. These results need to be confirmed using clinical diagnosis as the referent - the overlap between GAD2 and GAD7 may have inflated the results of the scenarios including GAD2 Funding: Private Foundation Support, Government Support – Non-U.S.