Suitability of the animated activity questionnaire for use as computer adaptive test: establishing the AAQ-CAT

Purpose The animated activity questionnaire (AAQ) is a computer-based measure of activity limitations. To answer a question, patients choose the animation of a person performing an activity that matches their own level of limitation. The AAQ has not yet been tested for suitability to be applied as computer-adaptive test (CAT). Thus, the objective of this study was to develop and evaluate an AAQ-based CAT to facilitate the application of the AAQ in daily clinical care. Methods Patients (n = 1408) with hip/knee osteoarthritis from Brazil, Denmark, France, The Netherlands, Norway, Spain, and the UK responded to all 17 AAQ items. Assumptions of item-response theory (IRT) modelling were investigated. To establish item parameters for the CAT, a graded response model was estimated. To evaluate the performance of post-hoc simulated AAQ-based CATs, precision, test length, and construct validity (correlations with well-established measures of activity limitations) were evaluated. Results Unidimensionality (CFI = 0.95), measurement invariance (R2-change < 2%), and IRT item fit (S-X2 p > .003) of the AAQ were supported. Performing simulated CATs, the mean test length was more than halved (≤ 8 items), while the range of precise measurement (standard error ≤ 0.3) was comparable to the full AAQ. The correlations between original AAQ scores and three AAQ-CAT versions were ≥ 0.95. Correlations of AAQ-CAT scores with patient-reported and performance measures of activity limitations were ≥ 0.60. Conclusion The almost non-verbal AAQ-CAT is an innovative and efficient tool in patients with hip/knee osteoarthritis from various countries, measuring activity limitations with lower respondent burden, but similar precision and construct validity compared to the full AAQ. Supplementary Information The online version contains supplementary material available at 10.1007/s11136-023-03402-4.


Introduction
Osteoarthritis is a highly prevalent chronic disease and a major cause of activity limitations in affected patients [1,2]. With hip and knee being two of the most affected joints [1], patients are often particularly limited in lower body functions and associated activities of daily living (ADL). Consequently, limitations in performing physical activities is an important outcome in the field of hip and knee osteoarthritis [3].
By now, many different measures of activity limitations have been developed [4], with patient-reported outcome (PRO) and performance-based outcome (PerfO) measures being the most frequently used assessment types [4,5]. In PRO measures, respondents rate their perceived level of activity limitations by responding to self-report items in a questionnaire, while PerfO measures assess a patient's performance of physical tasks in a standardized test environment [4]. PRO measures are easy to use and cheap but subjective with regard to the interpretation of the terms used in the questionnaire (i.e., 'difficulty') and to the adopted reference frame of the respondent (i.e., the situation or status the subject relates) [6]. It has been shown that PRO measures are more influenced by subjective patient variables than PerfO assessments [6][7][8][9]. In contrast, PerfO measures lead to more objective assessments, but are more resource-intense and burdensome to the patients [10]. Moreover, while PRO measures allow to capture a broad range of different activities, PerfO measures usually focus on a very specific activity and are often used as single-task measures [11]. In sum, several previous research findings indicate that PRO and PerfO measures may assess related but yet different constructs, and that respective results should only be compared with caution [12,13].
To combine the advantages of PRO and PerfO measures within one instrument, the animated activity questionnaire (AAQ) was developed [14,15]. The AAQ is an online-based measure of activity limitations for patients with hip and knee osteoarthritis. Each of its 17 items consists of several videos of an animated avatar performing a specific ADL task. To answer an item, patients choose the animation that best matches their own activity limitation level. Resourceintensity of the AAQ is comparable to computer-based PRO measures. At the same time, by showing animations of activities in a standardized real life situation and environment, the influence of the patient's reference frame is expected to be minimized [14,16]. Moreover, the AAQ is almost non-verbal, potentially reducing validity problems due to differences in literacy across patients, and allows for crosslanguage application with little translational efforts [16,17]. Thus, the AAQ is being discussed as a suitable alternative for PerfO measures in largescale studies [14].
Several studies indicated good psychometric characteristics of the AAQ [14,[16][17][18][19]. However, item response theory (IRT) methods, allowing for validating an instrument on item-level [20], has not yet been applied to psychometrically evaluate the AAQ. Using IRT, ability estimates can be assessed on an interval scale and statistical precision and power can be improved [20]. Estimating an IRT model provides individual parameters for each item of a measure [21][22][23]. A major advantage of using IRT item parameters for scoring is that item sets can be optimized by administering only the most relevant and precise items for a given ability level. One method of item set optimization is the application of computerized adaptive tests (CAT) [23]. In a CAT, a computer algorithm automatically selects the most informative items for an individual respondent, based on her or his answers given on previous items [23]. These algorithms are based on item parameters reflecting the individual statistical relationship between the latent construct of a measure and the responses to a given item. The application of CATs usually leads to a significant reduction in the number of items to be answered and in the time required to complete a questionnaire [21,23,24]. This seems to be particularly useful even for relatively short instruments, as study participants often have to complete not only a single questionnaire, but entire batteries of questionnaires, which can be very burdensome for patients and resource-intensive for those conducting these studies [24]. Moreover, to answer an AAQ item, patients must watch multiple videos simultaneously, which requires a certain level of concentration and attention. Therefore, administration as a CAT could lead to a significant reduction in patient burden.
Considering its computer-based nature, the AAQ seems to be very well-suited for being used as a CAT. Thus, the aims of this study were (1) to investigate if the items of the AAQ fulfill psychometric criteria for IRT modelling and (2) to establish IRT item parameters which can be used for the application as CAT. Moreover, (3) the performance of different CAT versions in terms of test length, precision, and construct validity will be evaluated based on post-hoc simulations.

Animated activity questionnaire (AAQ)
The AAQ is an online animated questionnaire containing 17 items of single ADL tasks [14,15]. The development and selection of items was based on conceptual and theoretical considerations as well as focus groups with patients [14]. Each item simultaneously shows 3 to 5 animated videos of an avatar performing an ADL task. Patients select the animation that best matches their performance of the task in the past week, or "Not possible" (http:// www. kmin-vumc. nl/_ 16_0. html). Responses are scored from 1 to 4/5/6 (depending on the number of response options), with higher response categories indicating more activity limitations. The AAQ is currently available in eleven languages at https:// anima tedac tivit yques tionn aire. com/. The AAQ showed high test-retest reliability (intraclass correlation = 0.97) and internal consistency (Cronbach's alpha = 0.95) [14], next to other satisfactory psychometric properties with regard to responsiveness [19], construct validity, and cross-cultural validity [17]. AAQ scores are transformed to a 0-100 metric with higher scores indicating less activity limitations.

H/KOOS ADL subscale and PerfO measures
To investigate construct validity of the IRT-calibrated AAQ measure and related CAT scores, a disease-specific PRO and three PerfO measures were administered. As PRO measure, the ADL subscale of the hip disability and osteoarthritis outcome score (HOOS) [25] or knee injury and osteoarthritis outcome score (KOOS) [26] was used. The ADL subscales of the HOOS and KOOS are identical, therefore the same scale was used for both hip and knee patients (H/KOOS). The H/KOOS contains 17 questions about perceived difficulty in executing ADL tasks in the past week due to hip or knee problems, on a 5-point scale. A total H/KOOS score was calculated and transformed into a score ranging from 0 to 100, with higher scores indicating less activity limitation. In addition, three single-item PerfO measures were executed by a subsample of participants: the Stair Climbing Test (SCT; n = 324) [27], and the Timed Up and Go test (TUG; n = 396) [28], both measuring the time in which the activity is performed, and the 30 s Chair Stands Test (CST; n = 325) [29], which takes the number of sit to stands that was performed within 30 s. These measures were chosen from the most feasible, reliable and responsive measures recommended by OsteoArthritis Research Society International [30].

Participants and data collection
The present study used data from various research projects on the development, translation and evaluation of the AAQ, which were collected between 2013 and 2019 [14,[16][17][18][19]31]. The largest of these projects with 1239 participants was conducted to establish cross-cultural validity of the AAQ in 7 European countries, namely Denmark, France, Italy, the Netherlands, Norway, Spain, and United Kingdom [17]. However, Italian AAQ data (n = 203) were not considered for the present study because problems with cross-cultural validity have been identified [17]. In addition to the data mentioned above, Brazilian data were analysed that were collected as part of another AAQ validation project [31]. In all participating countries, patients aged over 18 years with a diagnosis of hip and/or knee OA according the ACR criteria [32] were invited to participate in the study, either by phone or when they visited the clinic where they receive treatment. If they agreed to participate, an information leaflet, an informed consent form, and a pre-stamped, pre-addressed envelope were sent or given to them personally. A consecutive sample of patients was recruited from different health care settings such as primary care, in-patient rehabilitation, and hospitals. The participants were sent a link to the online questionnaire. They completed the AAQ and the H/KOOS ADL subscale in consecutive order. A random subgroup was invited to visit the outpatient clinic to execute three performance-based tests after the AAQ and the H/KOOS were completed.

Statistical analysis
To describe the characteristics of the study sample, descriptive statistics were used (see Table 1). Psychometric analyses were conducted following the analysis plan of the Patient-Reported Outcomes Measurement Information System (PROMIS) [33]. Table 2 provides an overview of psychometric properties and related research questions that were investigated, including analyses and statistics, criteria, and applied software.
Before IRT-based AAQ item parameters were estimated, assumptions of IRT modelling were checked [34]. We conducted a confirmatory factor analysis (CFA) of a one-factor model with a weighted least squares means and variance adjusted (WLSMV) estimator, which is a robust (scaled) variant of the diagonally weighted least squares estimator [33,35]. Unidimensional model fit was evaluated by calculating the comparative fit index (CFI), the Tucker-Lewis index (TLI), the root mean square error of approximation (RMSEA), and the standardized root mean square residual (SRMSR) [33]. Since strictly unidimensional models have been discussed as too restrictive when applied to patientreported data, the explained common variance (ECV) as well as Omega H, resulting from an exploratory bifactor model with one general and three specific group factors, were additionally used to evaluate 'sufficient' unidimensionality [33,36,37]. Residual correlations were calculated for each pair of items to investigate locale independence. Low residual correlations indicate that all covariation between items is explained by the common factor. Monotonicity, meaning that subjects with more severe activity limitation are more likely to score higher on each AAQ item, was evaluated using Mokken scale analysis [38]. Loevinger's homogeneity coefficient H was used as an indicator of scalability for the total AAQ scale. For determining the discriminative power of each AAQ item, item specific H j values were calculated [38]. Differential item functioning (DIF) analysis was used to examine measurement invariance across patient groups regarding age, gender, and country. With regard to DIF by country, we compared Brazilin data versus all other countries, because measurement invariance across the other 6 countries was demonstrated before [17]. To identify DIF, ordinal logistic regression was applied [39].
Since we did not assume all items to have equal discrimination based on the results of a previous study [14], a two-parameter IRT model, namely the graded response model (GRM), was fitted to estimate item parameters [40]. In GRMs, one slope and several (number of response options minus 1) threshold parameters are estimated for each item. While the slope parameter (a) specifies how strong an item is associated with the latent trait (discrimination), threshold parameters (b j ) define the locations on the latent trait continuum at which item responses are most informative. Data from all countries were modelled together. Item fit was evaluated using the S-X 2 statistic, assessing the discrepancy between observed and modelpredicted item responses [41]. Item characteristic curves were checked for disordered thresholds [42].
To investigate the performance of applying the AAQ items as CAT, post-hoc simulations were conducted [43], based on the responses of the participants to the full set of AAQ items and the established GRM item parameters. The maximum Fischer Information (MFI) method was used to automatically select the most informative items [43]. For estimating scores indicating the individual level of activity limitations (theta), expected a posteriori (EAP) estimation was applied [43].
IRT-based AAQ scores (theta) were initially calibrated to the total sample mean of 0 and a standard deviation of 1, with higher scores indicating more activity limitations. In a second step, to enable comparisons with the original AAQ measure, expected sum scores were calculated based on the fitted IRT model [44] and subsequently transformed to the original 0-100 metric, with higher scores indicating less activity limitations.
The performance of three versions of the AAQ-CAT was compared to the full AAQ measure. The three CAT versions differed in the pre-specified stopping rule: The root mean square error (RMSE) and the mean difference to original AAQ scores (bias) were calculated for the IRT-calibrated AAQ measure and the CAT versions. Mean test lengths (i.e., number of items administered) and precision (i.e., standard error) in dependence of a given activity limitation level was calculated for the different CAT versions and inspected graphically.
To investigate construct validity, AAQ scores were correlated with the H/KOOS ADL, the SCT, the TUG, and the CST. We hypothesized that correlation coefficients would be ≥ 0.60 [17].

Sample characteristics
AAQ data from 1408 patients with hip/knee osteoarthritis from Brazil (n = 200), Denmark (n = 201), France (n = 190), The Netherlands (n = 425), Norway (n = 91), Spain (n = 99), and the UK (202) were included. Further demographic and clinical characteristics of the study sample regarding gender, age, body mass index (BMI), affected joint(s) and joint replacement are presented in Table 1.

Criteria for IRT modelling
Results with regard to IRT-model assumptions are presented in Table 2. While results of the CFA were somewhat contradictory, bifactor analysis supported sufficient unidimensionality of the AAQ for IRT analysis. Residual correlations were lower than 0.2 in 97% of item pairs, supporting local independence and, thereby, indicating that one common factor explains almost all covariation across items. Monotonicity and IRT model fit were supported for all AAQ items. DIF analysis confirmed measurement invariance regarding age, gender, and country.

Item characteristics
As IRT assumptions were fulfilled, legitimating IRT modelling, a GRM was estimated for all 17 AAQ items. Item parameters as well as detailed characteristics regarding scalability and fit statistics are presented in Table 3. While slopes of most items were (close to) a = 2 or above, slopes for item 16 ('putting on shoes') and item 17 ('taking off shoes') were considerably lower (a = 1.40 and a = 1.29, respectively). Threshold parameters ranged from − 1.56 (b1 of item 16; 'putting on shoes') to 3.69 (b4 of item 11; 'sitting down on a chair'). Disordered thresholds were detected in four items (see Online Appendix Fig. A1). After collapsing the affected response categories and reanalyzing the data using a GRM, the newly estimated theta values matched the theta values of the original model (Pearson's r = 1.00), indicating that the recoding of the items had no effect. Since a satisfactory fit of the items was found for the original model, we decided to retain the original response categories for all items. A test information plot is provided in Online Appendix Fig. A2, indicating highly reliable measurements (defined as marginal reliability ≥ 0.9 ≈ test information ≥ 10) between theta = -1 and theta = 4.

Performance of the AAQ CAT
Results of the IRT-calibrated AAQ measure and each AAQ-CAT version regarding measurement characteristics and construct validity in comparison to original AAQ scores are summarized in Table 4. Scores derived from the IRTcalibrated AAQ measure as well as score estimates from all CAT versions were very close to original AAQ scores, with Pearson correlations of r ≥ 0.95. RMSE and bias were comparable between the different CAT versions. Items 4, 6, 7, 12, 13, and 14 had the highest exposure rates in each CAT version, indicating that these items are the most informative items for the sample. This is in line with Table 3, showing that all of these items had comparatively high slopes.
With regard to construct validity, AAQ full measure and CAT scores were highly correlated with PRO (H/KOOS ADL), and PerfO measures (SCT, TUG, and CST), with |r| Table 3 AAQ item characteristics H i Loevinger's Homogeneity coefficient (on item level), GRM graded response model a In GRMs, one slope and several (number of response options minus 1) threshold parameters are estimated for each item. While the slope parameter (a) specifies how strong an item is associated with the latent trait, threshold parameters (b j ) define the locations on the latent trait continuum at which an item responses are most informative b S-X 2 item fit statistics were evaluated after adjusting for multiple testing (p < 0.003)

Item
Monoto     and below-average scores (i.e. more severe activity limitation levels). In contrast, for participants with above-average scores (i.e. less severe levels of activity limitations), more items were needed for precise measurement. In accordance with this finding, Fig. 2 shows higher standard errors for patients scoring above-average. When using the 'CAT-5', only participants with AAQ scores lower than 80 could be scored with a precision of SE ≤ 0.3. In contrast, using the CAT versions that allow for administering more than 5 items, the range of precise measurement was comparable to the full AAQ measure.

Discussion
Based on a large international sample of patients with hip and/or knee osteoarthritis, the findings of our study indicate that all items of the AAQ are well-suited for being calibrated on a unidimensional IRT-based scale. Item parameters have been established using graded response modelling. These parameters can be used for applying the AAQ as CAT.
Using post-hoc simulations, good psychometric properties were found for three different CAT versions (without length restrictions, with a maximum of 10 items, with a maximum of 5 items). Statistical analyses indicated that all items of the AAQ fulfill psychometric criteria for IRT modelling. Among others, a core assumption of unidimensional IRT is that all items can be used for the assessment of a common underlying construct (i.e., activity limitations in the case of the AAQ). Although the results of a traditional unidimensional CFA were inconsistent, bifactor analysis as well as individual item analyses supported a unidimensional structure of the AAQ items. That the use of bifactor models might be better suited for evaluating sufficient unidimensionality of self-reported data than traditional CFA criteria has been discussed before [37].
Individual item parameters indicated that the AAQ items are generally best suited for measuring more severe activity limitations. Moreover, items 16 ('putting on shoes') and 17 ('taking off shoes') showed comparably low slopes, indicating low associations of these two items with the underlying construct. In the context of CAT, items with low slopes are generally less informative and, consequently, less likely to be administered by the automated CAT algorithm. Nonetheless, items 16 and 17 appeared to be useful when it comes to scoring individuals with below-average activity limitations and were actually selected by the CAT algorithm for some participants.
Important to consider in relation to CAT administration is that the individual items of the AAQ cover somewhat different aspects of physical activity limitations, i.e., climbing stairs (items 1 and 2), walking (items 3 to 7), rising and sitting down (items 9 to 15), but also activities that require fine motor skills next to hip joint mobility, such as picking up an object from the floor as well as putting on and taking off shoes (items 8, 16, and 17, respectively). Thus, when applied as CAT, content validity of the AAQ might be reduced in case one or more of these aspects are skipped due to the automatized CAT algorithm [39]. Content validity means that a measure represents all aspects of the construct of interest. This issue appeared to be particularly relevant for the 5-item CAT, where as much as five AAQ items were never used for scoring any participant (items 2, 8, 9, 15, and 17). In the 10-item CAT, only one item (item 8) was never used; in the 17-item IRT-based standard error estimates (y-axis) for estimated AAQ score and related theta deciles (x-axis) in the study sample. Higher AAQ scores indicate less activity limitations CAT, all items were used (lowest exposure rate was 17% for item 15). Content balancing has been suggested to be a potential solution when reduced content validity causes systematic bias in CAT assessments, i.e., when the items of a scale appear to measure distinct sub-constructs [23,39]. Nevertheless, our analyses did not indicate any systematic bias when administering the AAQ as CAT. Each CAT version was highly correlated with the full AAQ and the differences to the original AAQ scores were negligible. Moreover, scores of the full AAQ measure and each CAT version were similarly associated with other PRO and PerfO measures of activity limitations. In sum, based on the results of this study, content balancing seems not to be necessary for any version of the AAQ-CAT. Moreover, the correlation between AAQ scores and each of the other measures of activity limitations tended to be higher than the correlations between PRO and PerfO measures. This finding might empirically reflect the original purpose to develop the AAQ as an innovative assessment tool combining the characteristics of PRO and PerfO measures [15].
This study has some limitations. First, the evaluation of the CAT performance was based on post-hoc simulations. The performance of actual AAQ-CAT administrations must be examined in future studies. Nevertheless, findings of previous studies comparing simulated and real CAT data indicated that results might be similar [49]. Moreover, using post-hoc simulations had the advantage that the anticipated performance of different CAT versions could directly be compared to each other and to the full measure. Second, while 11 language versions of the AAQ already exist, data from only 7 countries were used for psychometric evaluations and for establishing IRT parameters in the present study. Three languages (German, Swedish, and Turkish) could not be considered because sufficient data has not yet been collected. Moreover, Italian data were not considered for establishing CAT parameters in the present study because considerable differential item functioning has been identified before [17]. However, it is not known whether these problems were caused by a lack of cross-cultural validity, or whether there was an issue with the specific set of Italian data collected for the AAQ cross-cultural validity study [17]. As long as cross-cultural invariance has not been shown, CAT results should be interpreted with caution for languages not included in the present study. Third, the current AAQ metric ranging from 0 to 100 is arbitrary. It is yet to be decided whether a different metric should be used. For instance, linearly transforming the IRT-based theta metric to a T-score metric with a mean of 50 and a standard deviation of 10 based on a representative sample of a meaningful reference population might lead to increased interpretability of AAQ scores [33]. Original AAQ scores could also be linked to such a metric, allowing for comparisons with AAQ-CAT scores.
With regard to the comparison of different CAT versions, the CAT-10 (with a maximum of 10 items) appeared to be the most efficient version in our sample, with an average of less than 7 administered items but with comparable precision and validity to the full AAQ. Nevertheless, for samples with highly impaired patients, the CAT-5 might also be well-suited.
The AAQ was originally developed to combine the benefits of patient-reported and performance-based measures of activity limitations. In addition, since the AAQ is almost non-verbal, it is applicable in low literacy patients and its items are easy to translate to other languages, which allows for cross-cultural application. Our study clearly supports the suitability of the AAQ to be applied as CAT, measuring activity limitations with lower respondent burden, but similar precision and construct validity compared to the full AAQ measure. Moreover, calibration of the AAQ to an IRT-based scale is the basis for expanding the measurement range by adding new items, e.g., specific items assessing the extremes of the underlying construct, in future developments. To make the CAT accessible to users, it is considered to integrate the AAQ into existing CAT platforms, e.g., the Dutch-Flemish PROMIS Assessment Center.
Author contributions All authors made substantial contributions to study conception and design, acquisition of data, or analysis and interpretation of data, and were involved in drafting of the article or revising it critically for important intellectual content, and gave final approval of the submitted version.
Funding Open Access funding enabled and organized by Projekt DEAL. The study validating the Brazilian version of the AAQ was supported by a Grant from the Conselho Nacional de Desenvolvimento Científico e Tecnológico CNPq (108978/2017-6). All other studies from which the data were used were financially supported by Grants from the European Alliance of Associations for Rheumatology (EULAR, Project No EPI009), the Arthritis Foundation, and the Anna Foundation.
Data availability statement Data sharing is not applicable to this article as no new data were created or analyzed in this study.

Declarations
Competing interests All authors except GL were involved in the development and/or previous validation studies of the AAQ.

Ethical approval
The study validating the Brazilian version of the AAQ was approved by the Ethics Committee of the Universidade Federal dos Vales do Jequitinhonha e Mucuri (2.451.189). All other studies from which the data were used were approved by the Medical Ethics Committee of the VU University Medical Center, Amsterdam. Consent to participate Informed consent was obtained from all individual participants included in the study.
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