Thoughts on the Surprising Effect of Priming on 22-Item Sino-Nasal Outcome Test (SNOT-22) Results

On February 8, 2024, Mohammad et al ¹ published an online version of a manuscript entitled “The surprising effect of priming on SNOT-22 results” in the American Journal of Rhinology and Allergy. We are excited to see that other groups are exploring and replicating our intriguing findings, which we presented at the 2022 ARS annual meeting and published last year in Rhinology as “The effects of priming on rhinologic patient reported outcome measures: a randomized controlled trial.”^2,3 Priming, as the authors describe, is a technique used in psychology research whereby the introduction of one stimulus influences how people respond to a subsequent stimulus. Priming works by activating an association, inclination, feeling, or representation just before another stimulus or task is introduced. In the present manuscript, Mohammad et al perform an outstanding study of 206 patients randomized to either positive or negative priming, and the results confirm our finding that priming dramatically impacts subjects’ responses to the SNOT-22. We have also demonstrated a similar impact for the Rhinosinusitis Disability Index and the Mini Rhinoconjunctivitis Quality of Life Questionnaire.

As the investigation into the impact of priming on patient-reported outcome measures (PROMs) is only just beginning, the reader should note a few important considerations when evaluating these data. First, in the Methods, the authors claim to report a randomized controlled trial, but the study did not include a control group (ie, a group that completed the SNOT-22 without priming). Therefore, it is not possible to determine whether the difference in SNOT-22 scores between intervention arms was due to negative priming, positive priming, or both. Second, although the authors mention that neither demographic nor health-related variables were analyzed in this pilot study, the lack of any such patient data presented in Table 1 prevents the reader from knowing whether proper randomization was achieved. Third, priming is traditionally performed with an unrelated stimulus, but the priming in this study was performed with specific descriptions of chronic rhinosinusitis and its impact.

The study by Mohammad et al is a valuable contribution to the exploration of factors that influence PROMs, essential assessment tools in rhinology, and the broader field of patient-centered medical care. Our results and those from this study suggest that physicians using PROMs should carefully consider the impact the administration context may have on reported results. We propose that, just as each PROM has its own scoring system and minimal clinically important difference (CID), these health questionnaires may have a standardized protocol and context for administration, analogous to how a patient must be positioned appropriately and consistently for a proper chest X-ray. Moreover, each PROM score may ultimately require incorporating a “health-related mood” questionnaire and coefficient to reflect the aggregate impact of all intentional and unintentional antecedent stimuli. We hope to see further refinement of PROM protocols evaluated in future studies.