Assessment of patients' understanding of and adherence to oral anticancer medication (OAM): Results of a cross-sectional institutional pilot study

BACKGROUND

Although oral anticancer medications (OAM) provide opportunity for treatment at home, challenges include prescription filling, monitoring side effects, safe handling, and adherence. We assessed understanding of and adherence to OAM in vulnerable patients.

METHODS

This 2018 pilot study defined vulnerable patients based on Chinese language, older age (≥65 years), and subsidized insurance. All participants had a cancer diagnosis and were taking an OAM filled through the hospital's specialty pharmacy. Participants reported on OAM taking (days per week, times per day, special instructions) and handling (handling, storage, disposal). The specialty pharmacist classified patient-reported responses about OAM taking and handling as adequate or inadequate. OAM regimens were classified by complexity.

RESULTS

Of 61 eligible patients, 55 participated. Mean age was 68 years (standard deviation [SD] = 12) and 53% were female. Patient subgroups were: 27% Chinese, 64% ≥65 years, and 9% subsidized insurance. Forty-nine percent were on frontline therapy and median time on OAM was 1 year (Quartile 1 = 0.4, Quartile 3 = 1.7). Adequacy of OAM taking (30%) and handling (15%) were low; 15% had adequacy in both. Adequacy of OAM taking and handling did not vary by patient subgroup or regimen complexity. Mean patient-reported adherence was high (5.4, SD = 1, possible range 1-6) and did not vary by adequacy of OAM taking or handling.

CONCLUSIONS

Understanding of OAM taking and handling in this group of vulnerable patients was low and did not align with patient-reported adherence. Future interventions should ensure that patients understand how to safely take and handle OAM, thereby optimizing their therapeutic potential.

Enhancing patients' understanding of and adherence to oral anticancer medication: Results of a longitudinal pilot intervention

BACKGROUND

Oral anticancer medications (OAM) make administration more convenient for patients, but shifts the responsibility of care from clinical providers to the patients themselves. Following an institutional pilot study showing inadequate understanding and adherence among vulnerable patients taking OAM, a longitudinal intervention was developed using an oncology specialty pharmacist and medication navigators to enhance OAM understanding and adherence.

METHODS

Patients initiating OAM were approached for four formalized teaching and check-in sessions, supplemented with medication information sheets and individualized calendars. At each session, participants were assessed on their OAM understanding and adherence using teach-back and validated measures. A study evaluation elicited feedback from participants on the usefulness of the intervention.

RESULTS

Of 80 eligible patients, 58 (72.5%) received formal OAM teaching from the specialty pharmacist. Of those, 54 (93.1%) enrolled in the study with 39 (72%) completing the intervention for final analysis. At study completion, all participants adequately understood OAM taking, but 41.0% had inadequate understanding of OAM handling. Throughout the study, participants reported issues that were addressed by the intervention team (28.2% to 31.6%) as well as those requiring additional assistance from the treatment team (26.3% to 38.5%), Most participants found the intervention to be very beneficial (initial evaluation, 86.5%; final evaluation, 76.9%).

CONCLUSIONS

This pilot intervention addressed gaps identified by our institutional assessment through formalized OAM teaching and follow-up. Improved understanding of taking and handling OAM through this subsequent study illustrated the enhanced effect of a multidisciplinary and multicomponent intervention to better educate and support patients on OAM.

First-line treatment in older patients with Hodgkin lymphoma: a Surveillance, Epidemiology, and End Results (SEER)-Medicare population-based study

While Hodgkin lymphoma (HL) is highly curable in younger patients, older patients have higher relapse and death rates, which may reflect age-related factors, distinct disease biology and/or treatment decisions. We described the association between patient, disease and geographic factors and first-line treatment in older patients (≥65 years) with incident HL using Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 1999 to 2014 (n = 2825). First-line treatment initiated at ≤4 months after diagnosis was categorised as: full chemotherapy regimen (n = 699, 24·7%); partial chemotherapy regimen (n = 1016, 36·0%); single chemotherapy agent or radiotherapy (n = 382, 13·5%); and no treatment (n = 728, 25·8%). Among the fully treated, ABVD [doxorubicin (Adriamycin), bleomycin, vinblastine, dacarbazine]/AVD was most common (n = 635, 90·8%). Adjusted multinomial logistic regression identified factors associated with treatment. Older age, Medicaid dual eligibility, not married, frailty, cardiac comorbidity, prior cancer, earlier diagnosis date, histology, advanced disease Stage, B symptoms and South region were independently associated with increased odds of not receiving full chemotherapy regimens. In conclusion, we found variability in first-line HL treatment for older patients. Treatment differences by Medicaid and region may indicate disparities. Even after adjusting for frailty and cardiac comorbidity, age was associated with treatment, suggesting factors such as end-of-life care or shared decision-making may influence treatment in older patients.

Pediatric Lipid Screening and Treatment in Canada: Practices, Attitudes, and Barriers

The pediatric lipid screening and treatment practices, attitudes, and perceived barriers of Canadian pediatricians are not known. We sought to evaluate this in a survey of pediatricians through the Canadian Pediatric Surveillance Program (CPSP) in March 2019. The survey included an assessment of lipid screening of 9- to 11-year-old youth and a hypothetical case of persistent severe dyslipidemia to ascertain management practices. There were 759 respondents (28% response rate, 759 of 2742), of whom 236 provided outpatient primary care to 9- to 11-year-old youth as part of their routine clinical practice. Among primary care-providing pediatricians, universal lipid screening of healthy 9- to 11-year-old youth most or all of the time was reported by 3% (8 of 230). Reported screening practices most or all of the time were more common for youth with risk factors such as overweight and obesity (54%, 127 of 235) and a family history of premature cardiovascular disease (39%, 85 of 217). Most respondents would refer a child with severe persistent dyslipidemia to dieticians (69%, 152 of 220) and a lipid specialist (64%, 144 of 220) most or all of the time, whereas 7% (16 of 220) would start statin therapy themselves. A lack of Canadian pediatric lipid guidelines was reported as a major barrier for 49% (114 of 233) and minor barrier for 40% (93 of 213). The rate of routine lipid screening of healthy 9- to 11-year-old youth among Canadian primary care-providing pediatricians is low and at odds with current US guidelines. This discrepancy may be due at least in part to a lack of Canadian guidelines on pediatric dyslipidemia, the development of which may address certain perceived barriers and influence future attitudes.

Lifelong disease burden of chemotherapy in Hodgkin lymphoma (HL): A simulation study from the St. Jude Lifetime (SJLIFE) Cohort and HL International Study for Individual Care (HoLISTIC)

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Background: Current emphasis for childhood and young adults with HL is to maintain high cure rates while concurrently identifying regimens to reduce excess long-term mortality/morbidity. Thus, understanding the late effects (LE) of contemporary clinical trials (CCT) for HL is critical. Methods: We used simulation to estimate the projected life expectancy (LExp), quality adjusted life-expectancy (QALE) & cause of death (COD) in a large cohort of HL CCT patients (pts) in the recently established HoLISTIC consortium by linking long-term risk models from the SJLIFE cohort. Individual patient data (IPD) on bleomycin, alkylating agents and anthracycline were extracted & harmonized for 982 HL pts in 5 prospective CCT (mean diagnosis age 19y, range 3-30y; 51% male; all treated with chemotherapy only; progression-free survival [PFS] >5y) in the HoLISTIC database. LExp, QALE & COD were projected using a previously developed microsimulation model (Bhakta, Blood [Supplement], 2019) that incorporated mortality & incidence of LEs by diagnosis age, sex, race, treatment exposures & attained age estimated from 5,522 adult 10-y survivors of childhood cancers in the SJLIFE cohort (56% male; mean age at last follow-up 35y, range 19-68). Microsimulation was applied to 10,000 randomly selected survivors of HL CCT cohort, from 10y after HL diagnosis until death to project the LExp, QALE & COD. Results: Assuming 10-y PFS, LExp and QALEs projected for the HL CCT cohort using adjusted US general population rates linked with the SJLIFE microsimulation model, COD and trial-specific exposures are shown in the Table. Conclusions: A novel lifetime simulation approach was used to project LExp, QALE & COD by linking together IPD from CCTs with the long-term risk model of the SJLIFE survivorship cohort. Despite differences in PFS, reflecting in part the variation in risk/stage status, the projected long-term outcomes were similar. Our approach highlights a new opportunity to inform future clinical trial design and aid provider & patient decision-making. [Table: see text]

The Hodgkin lymphoma international study for individual care (HoLISTIC): Enhancing decision making in pediatric and adult Hodgkin lymphoma (HL)

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Background: Decision making in HL is complicated by clinical trial results that differ, a growing range of treatment options, and the absence of ideal, objective information on long term outcomes from modern therapy. Methods: We formed an international consortium, HoLISTIC, consisting of 50+ pediatric & adult HL providers, decision scientists, statisticians, epidemiologists, and patient (pt) advocates and are creating a data repository of individual pt data (IPD) from 16 contemporary, pediatric & adult clinical trials for newly diagnosed pts with HL, and 6 large HL registries/survivorship cohorts, the latter enriched with LE data (Table). We will enhance our prior decision model (DM) from group-level data (Parsons S et al. B J Haem 2018) to establish a dynamic HL DM from IPD. Using statistical and simulation modeling of IPD, the enhanced DM will project outcomes of interest, including quality-adjusted life years (QALYs), reflecting both mortality and morbidity. Results will be validated and calibrated against prominent external cohorts (e.g., St. Jude LIFE Cohort, Dutch HL registry). The DM then will be converted to a web-based platform that we will test and evaluate among HL providers and pts at the point of care. Results: To date, we have harmonized IPD from 10 trials (~8,000 HL pts), ranging in size from 165-1925 pts. At diagnosis, median age was 26 y (IQR 18-38); 51.5% were male. 43% had B symptoms, 34% had mediastinal bulk, and 79% had nodular sclerosis histology. Median follow up was 5.0 y (IQR 3.5-7.4). IPD harmonization is ongoing, which will be followed by creation of the enhanced DM. Conclusions: HoLISTIC capitalizes on a multidisciplinary pediatric & adult oncology collaborative, harmonizing extensive IPD by linking data from clinical trials and real world registries/survivorship cohorts. This work will inform questions about the influence of Tx options on both acute and potential long term events and how those options align with pt values and preferences. [Table: see text]

Assessment of health-related quality of life among adults hospitalized with sickle cell disease vaso-occlusive crisis

Sickle cell disease (SCD) is characterized by painful vaso-occlusive crises (VOCs). Self-reported pain intensity is often assessed with the Numeric Rating Scale (NRS), whereas newer patient-reported outcome measures (PROMs) assess multidimensional pain in SCD. We describe pain experiences among hospitalized adults with VOCs, using 2 PROMs: the Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health and the Adult Sickle Cell Quality of Life Measurement System (ASCQ-Me). Adults with SCD hospitalized with VOCs at 2 academic centers in Boston, Massachusetts, from April 2016 to October 2017 were eligible. Participants completed the NRS and PROMs at admission and 7 days postdischarge. PROM scores were described and compared with population norms. Length of stay (LOS) and 30-day readmission rates were assessed. Forty-two (96%) of 44 eligible patients consented and completed admission assessments. Mean age was 30.2 years (standard deviation, 9.1), 60% were women, 76% were non-Hispanic black, and 64% had hemoglobin SS. Twenty-seven participants (64%) completed postdischarge assessments. Sixty percent had ≥4 VOCs in the last year. Nearly all PROMIS Global Health and ASCQ-Me scores were worse than population norms. NRS and PROMIS Global Physical Health scores improved after discharge, the latter driven principally by improvements in pain. Overall median LOS was 7 days, and 30-day readmission rate was 40.5%. Administration of PROMs among adults with SCD hospitalized for VOCs is feasible and demonstrates participants experienced recurrent, prolonged, and severe VOCs. PROMIS Global and ASCQ-Me scores indicated substantial suffering, and the striking 30-day readmission rate highlights the vulnerability of these patients.

Pilot study to assess a pharmacist- and medication navigator-led intervention of oral anticancer medication (OAM) adherence

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Background: While advances in OAM make treatment more convenient for patients, OAM must be taken and handled correctly. Studies show gaps in patients’ knowledge of taking/handling OAM, suboptimal adherence, and worse outcomes. A prior study at our institution showed low patient understanding of OAM taking (30%) and handling (15%). Other pharmacist (RPh)- or nurse-led interventions have included patient education, short-term follow-up, and reminder tools. No studies have examined multisession interventions co-led by an RPh and medication navigator (MN). This ongoing pilot study assesses the feasibility of such an intervention, its impact on patients’ understanding and adherence, and patient acceptability. Methods: Patients at our institution met with an RPh and MN for an education and teach-back session at OAM initiation (T1). Patients were given a Drug Information Sheet and Medication Calendar as educational tools. Patients were then invited to enroll in a multisession intervention, including an RPh-led re-education at the first refill (T3) and MN-led boosters (T2, T4). At each session, teach-back responses were recorded and participants completed study measures and evaluations. Preliminary results on T1 and T2 are presented. Results: To date, 37 (95%) patients enrolled at T1 and 33 completed the MN-led booster a week later (T2). At T1 and T2, 85% of participants demonstrated sufficient understanding of OAM taking and handling. However, despite high levels of self-reported adherence, 48% lacked knowledge about when or where to get a refill. At T1 (32%) and T2 (60%), of patients raised issues that were not previously shared with their clinical team. Patients were highly satisfied with the intervention and found the education session, booster, and educational tools useful. Conclusions: While data collection is ongoing, preliminary results suggest this intervention is feasible, enhances patient understanding and adherence to their medications, and is acceptable to patients undergoing OAM treatment. Integration of RPh and MN into oncology teams can enhance care delivery and provide timely assistance for OAM-related issues, providing insight into future models of care.

The role of frailty and comorbidity in treatment (tx) of elderly patients with Hodgkin lymphoma (HL)

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Background: While HL is highly curable in younger patients, older patients have higher rates of tx failure and death, which may reflect age-related factors, tx decisions, or disease biology. We described first-line tx in elderly patients with HL by frailty, comorbidity, and age. Methods: We analyzed Surveillance, Epidemiology and End Results (SEER)-Medicare data from 1999-2014. Patients with incident classical HL and Medicare Part A and B fee for service were included. First-line tx within 4 months of diagnosis (dx) was determined from inpatient, outpatient, and physician/supplier claims using chemotherapy J-codes, HCPCS codes, and DRG codes and was categorized as standard regimen, any other tx, and no tx. Pre-existing frailty and comorbidity ≤6 months prior to dx were separately defined using validated claims-based algorithms. Multinomial logistic regression estimated adjusted odds ratios (aOR) and 95% confidence intervals (CI) to identify whether frailty, comorbidity, or age at dx were associated with first-line tx; their 3- and 2-way interactions were tested and removed if p < 0.1. We adjusted for race/ethnicity, Medicaid dual enrollment, population density, histology, stage, B symptoms, year (yr) of dx, and SEER registry. Results: Analyses included 2789 patients: median age was 76 yrs. 65% were frail, 79% of patients had ≥1 comorbidity, and 61% were frail and had comorbidity. 41% received a standard regimen, 32% received other tx, and 27% received no tx. No interactions were significant. Frailty, comorbidity, and older age were associated more use of other tx or no tx then standard regimens (Table). Conclusions: Frailty, comorbidity, and age were associated with first-line tx in elderly patients with HL. This may reflect physician tx decision, end-of-life care, or unique disease biology in older patients. Future research will study the relationships between first-line tx and outcomes. [Table: see text]

Performance of FACT-GOG-Ntx to assess chemotherapy-induced peripheral neuropathy (CIPN) in pediatric Hodgkin lymphoma (HL) patients

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Background: CIPN is a common, but under-recognized complication of tubulin toxins, which are key to curative therapy for HL. In the absence of validated, self- or proxy-report measures for children, CIPN reporting has depended on clinical grading scales. The goal of this study was to assess the psychometric properties of the FACT-GOG-Ntx measure in a pediatric population. Methods: Youth (11+ yrs) and parents of all children (5-18 yrs) with newly diagnosed high risk HL, enrolled on AHOD1331 (NCT02166463), serially completed the FACT-GOG-Ntx, a validated measure of CIPN in adults. Cronbach’s alpha coefficient (reliability) and intra-class coefficients (ICC) were calculated. FACT-GOG-Ntx total scale and 4-item sensory subscale scores (Ntx4) at Cycle 5 (dose peak) and 6-8 weeks after last cycle (End Rx) were compared to mandatory clinical grading, using the Balis Scale with any neuropathy defined as > grade 1 on Balis. Results: 279 youth and 291 parents completed study measures. Cronbach’s alpha exceeded 0.80 for both raters. Inter-rater agreement was strong (ICC=0.89). Sixty (20%) patients had any neuropathy on Balis. Those with CIPN had significantly lower total and Ntx4 scores than those without at cycle 5 and End Rx and for both raters (p<0.05) (Table). Conclusions: This is the first application of the FACT-GOG-Ntx in a pediatric HL trial. We demonstrate that the measure was reliable for both raters and had strong intra-rater agreement. Validity was demonstrated by significantly lower FACT-GOG-Ntx scores among patients with evidence of CIPN on clinical exam. Comparisons between study arms will be evaluated after study accrual is completed. [Table: see text]

Patients’ understanding and adherence to oral anti-cancer medication (OAM): Results of an institutional pilot study

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Background: Advancements in biopharmaceuticals have led to increasing availability and use of OAM. While oral medications allow patients (pts) to receive treatment at home, OAM use introduces new challenges related to prescription filling, monitoring for and reporting of side effects, safe medication handling, and adherence. We assessed understanding of and adherence to OAM in pts vulnerable to these home-based challenges. Methods: This 2018 pilot study defined vulnerable pts based on spoken language (Chinese), older age (≥65 yrs), and public insurance ( < 65 yrs). All pts had a cancer diagnosis, had been taking an OAM, and received prescriptions through the hospital’s specialty pharmacy. Prior to a clinic visit, pts completed patient-reported measures about OAM taking and handling. Clinical characteristics were extracted from medical records; medication information was extracted from pharmacy records. The study team’s specialty pharmacist (DH) classified patient-reported responses about OAM taking (days per week, times per day, special instructions) and handing (handling, storage, disposal) as adequate or inadequate. OAM regimens were classified by complexity based on number of drugs and schedule. Results: Of 61 eligible pts, 55 participated (90%). Mean age was 68 yrs (SD 12) and 53% were female. Pt subgroups were: 27% Chinese, 64% ≥65 yrs, and 9% < 65 yrs with public insurance. 33% had solid tumor and 67% had hematologic malignancy; tyrosine kinase inhibitor was the most OAM type (42%). 49% of pts were on front-line therapy and overall median time on OAM was 1 year (Q1 0.4, Q3 1.7). Adequacy of OAM taking (30%) and handling (15%) were low; only 15% had adequacy in both. Pt subgroup and regimen complexity did not vary by adequacy of OAM taking or handling. Patient-reported adherence was high 5.4 (SD 1) (possible range 1-6) and did not vary by adequacy of OAM taking or handling. Conclusions: Understanding of how OAM should be taken and handled in a group of vulnerable pts was strikingly low and did not align with pts’ self-reports of adherence. Future interventions are needed to ensure that pts understand how to safely take and handle OAM, thereby optimizing their therapeutic potential.

Prevalence and Predictors of Cholesterol Screening, Awareness, and Statin Treatment Among US Adults With Familial Hypercholesterolemia or Other Forms of Severe Dyslipidemia (1999-2014)

BACKGROUND

Familial hypercholesterolemia (FH) and other extreme elevations in low-density lipoprotein cholesterol significantly increase the risk of atherosclerotic cardiovascular disease; however, recent data suggest that prescription rates for statins remain low in these patients. National rates of screening, awareness, and treatment with statins among individuals with FH or severe dyslipidemia are unknown.

METHODS

Data from the 1999 to 2014 National Health and Nutrition Examination Survey were used to estimate prevalence rates of self-reported screening, awareness, and statin therapy among US adults (n=42 471 weighted to represent 212 million US adults) with FH (defined using the Dutch Lipid Clinic criteria) and with severe dyslipidemia (defined as low-density lipoprotein cholesterol levels ≥190 mg/dL). Logistic regression was used to identify sociodemographic and clinical correlates of hypercholesterolemia awareness and statin therapy.

RESULTS

The estimated US prevalence of definite/probable FH was 0.47% (standard error, 0.03%) and of severe dyslipidemia was 6.6% (standard error, 0.2%). The frequency of cholesterol screening and awareness was high (>80%) among adults with definite/probable FH or severe dyslipidemia; however, statin use was uniformly low (52.3% [standard error, 8.2%] of adults with definite/probable FH and 37.6% [standard error, 1.2%] of adults with severe dyslipidemia). Only 30.3% of patients with definite/probable FH on statins were taking a high-intensity statin. The prevalence of statin use in adults with severe dyslipidemia increased over time (from 29.4% to 47.7%) but not faster than trends in the general population (from 5.7% to 17.6%). Older age, health insurance status, having a usual source of care, diabetes mellitus, hypertension, and having a personal history of early atherosclerotic cardiovascular disease were associated with higher statin use.

CONCLUSIONS

Despite the high prevalence of cholesterol screening and awareness, only ≈50% of adults with FH are on statin therapy, with even fewer prescribed a high-intensity statin; young and uninsured patients are at the highest risk for lack of screening and for undertreatment. This study highlights an imperative to improve the frequency of cholesterol screening and statin prescription rates to better identify and treat this high-risk population. Additional studies are needed to better understand how to close these gaps in screening and treatment.

Understanding the Relationship Between Child Health-Related Quality of Life and Parent Emotional Functioning in Pediatric Hematopoietic Stem Cell Transplant

Objective

Explore interrelationships between domains of child health-related quality of life (HRQL) and parent emotional functioning using parent-proxy and child report in the context of hematopoietic stem cell transplant (HSCT).

Methods

Data on 258 parent-child dyads were used from two longitudinal studies. Domains of HRQL included physical, emotional, and role functioning, and HSCT-related worry. We used structural equation modeling to model the outcome of parent emotional functioning using primary and alternative conceptual models.

Results

Parent-proxy raters reported lower child HRQL than child raters. Structural equation models demonstrated relationships between child emotional functioning, child HSCT-related worry, and parent emotional functioning, with some differences by raters.

Conclusions

Relationships between child HRQL and parent emotional functioning within the context of HSCT are complex. To optimize the child's health outcomes, providing psychosocial support for children and their families may be necessary, especially for those experiencing distress or facing treatment complications.

Risk factors for length of stay and charge per day differ between older and younger hospitalized patients with AML

Acute myeloid leukemia (AML) is associated with frequent hospitalizations. We evaluated factors associated with length of stay (LOS) and charge per day (CPD) for admissions in older (≥60 years) and younger patients (<60 years). We identified patients with ICD‐9‐CM codes for AML or myeloid sarcoma in the 2012 HCUP‐NIS. In separate models based on age, we examined patient (sex, race, income, insurance payer, chronic conditions, chemotherapy administration, death) and hospital (type, geography) characteristics. Multivariable negative binomial regression estimated factor effects on LOS and CPD using rate ratios, with HCUP‐NIS weights. In 43,820 discharges, LOS was longer in patients <60 than ≥60 (6.8 vs. 5.4 days). For patients <60, longer LOS was seen with more chronic conditions (RR = 1.10), Black race (RR = 1.16), chemotherapy (RR = 2.27), and geography; shorter LOS was associated with older age (RR = 0.93), Medicare (RR = 0.83), and hospital type. For patients ≥60, longer LOS associated with chronic conditions (RR = 1.07) and Asian race (RR = 1.33). Shorter LOS associated with older age (RR = 0.86), higher income (RR = 0.93), and hospital type. For patients <60, higher CPD associated with chronic conditions (RR = 1.05), death (RR = 1.93), and geography; lower CPD associated with increasing age (RR = 0.96), Medicaid (RR = 0.93), and rural hospitals (RR = 0.65). For patients ≥60, higher CPD associated with Medicare (RR = 1.05), more chronic conditions (RR = 1.02), younger age (RR = 1.1), west geography (RR = 1.37), death (RR = 1.45), and Hispanic race (RR = 1.15). We identify predictors for increased healthcare utilization in hospitalized patients with AML, which differ within age groups. Future efforts are needed to link utilization outcomes with clinical treatments and response.

Leveraging pediatric PROMIS item banks to assess physical functioning in children at risk for severe functional loss

Background

Pediatric neuromuscular illnesses often result in decreased health-related quality of life (HRQL), notably in physical functioning. Generic HRQL measures have been developed for use in general populations, but may not adequately assess patients with severe functional loss. To address this measurement gap, we created two custom parent-proxy physical functioning short forms for use among children at risk for low levels of functioning, using pediatric Patient Reported Outcomes Measurement Information System (PROMIS) item banks for Upper Extremity and Mobility.

Methods

Two custom short forms from PROMIS Upper Extremity (13 items) and Mobility (13 items) parent-proxy item banks were created and administered to parents of children (ages 5 - 22 years) enrolled in an integrated care program for management of chronic respiratory insufficiency, largely due to neuromuscular illnesses. Standardized PROMIS T-scores have a mean of 50 (SD = 10); higher scores indicate better functioning. Physicians rated clinical severity. Single proxy-rated items on mental and physical health from the Child Health Rating Inventories (CHRIs) global health scale were completed by parents. Psychometric properties, including known groups comparisons, were explored.

Results

Fifty-seven parents completed the parent-proxy custom PROMIS short forms. The mean Upper Extremity T-score was 21 (SD = 13); the mean Mobility T-score was 22 (SD = 11). Some participants scored at the measurement floor; two items on assistive devices did not perform well in this sample and were excluded from the Mobility T-score. Known groups comparisons showed that those with lower clinical severity had better median Upper Extremity (22 vs. 14, p < 0.001) and Mobility (28 vs. 16, p = 0.004) function than those with worse clinical severity. Both Upper Extremity and Mobility T-scores were higher in the subgroups defined by better physical and mental health, as measured by the CHRIs.

Conclusions

Upper Extremity and Mobility T-scores were nearly three standard deviations below the PROMIS pediatric calibration population mean. Preliminary psychometrics demonstrated the potential to more accurately measure lower physical functioning using items from PROMIS item banks. However, some participants scored at the measurement floor despite targeting items at the lower end of the scale. Further short form refinement, enrichment of the item banks, and larger-scale field testing are needed.

Predicting Health Care Utilization for Children With Respiratory Insufficiency Using Parent-Proxy Ratings of Children's Health-Related Quality of Life

INTRODUCTION

Children with chronic respiratory insufficiency and mechanical ventilation often experience acute illnesses requiring unscheduled hospitalizations. Health-related quality of life (HRQL) may predict future health care utilization.

METHODS

Participants were 30 days to 22 years old with chronic respiratory insufficiency (N = 120). Parent-proxies completed global HRQL and general health measures. Outcomes were total health care (emergency department, outpatient, inpatient) and inpatient days over 6 months. Adjusted negative binomial regression estimated the effects of global HRQL and general health on utilization.

RESULTS

Three quarters of children had any utilization; 32% had hospitalizations. Children with poor/fair global HRQL had 3.7 times more health care days than those with very good/excellent global HRQL. Children with poor/fair global HRQL had 6.3 times more inpatient days than those with very good/excellent global HRQL. Similar relationships existed between general health and utilization.

DISCUSSION

HRQL was associated with health care and inpatient days. Clinical teams can use HRQL as a marker for utilization risk, enabling potentially earlier intervention, better outcomes, and lower costs.

Responsiveness and Minimally Important Differences for 4 Patient-Reported Outcomes Measurement Information System Short Forms: Physical Function, Pain Interference, Depression, and Anxiety in Knee Osteoarthritis

Patient-Reported Outcomes Measurement Information System (PROMIS) instruments can provide valid, interpretable measures of health status among adults with osteoarthritis (OA). However, their ability to detect meaningful change over time is unknown. We evaluated the responsiveness and minimally important differences (MIDs) for 4 PROMIS Short Forms: Physical Function, Pain Interference, Depression, and Anxiety. We analyzed adults with symptomatic knee OA from our randomized trial comparing Tai Chi and physical therapy. Using baseline and 12-week scores, responsiveness was evaluated according to consensus standards by testing 6 a priori hypotheses of the correlations between PROMIS and legacy change scores. Responsiveness was considered high if ≥5 hypotheses were confirmed, and moderate if 3 or 4 were confirmed. MIDs were evaluated according to prospective change for people achieving previously-established MID on legacy comparators. The lowest and highest MIDs meeting a priori quality criteria formed a MID range for each PROMIS Short Form. Among 165 predominantly female (70%) and white (57%) participants, mean age was 61 years and body mass index was 33. PROMIS Physical Function had 5 confirmed hypotheses and Pain Interference, Depression, and Anxiety had 3 or 4. MID ranges were: Depression = 3.0 to 3.1; Anxiety = 2.3 to 3.4; Physical Function = 1.9 to 2.2; and Pain Interference = 2.35 to 2.4. PROMIS Physical Function has high responsiveness, and Depression, Anxiety, and Pain Interference have moderate responsiveness among adults with knee OA. We established the first MIDs for PROMIS in this population, and provided an important standard of reference to better apply or interpret PROMIS in future trials or clinical practice.

PERSPECTIVE

This study examined whether PROMIS Short Form instruments (Physical Function, Pain Interference, Depression, and Anxiety) were able to detect change over time among adults with knee OA, and provided minimally important change estimates for each measure. This standard of reference can help apply or interpret these instruments in the future.

Cholesterol Screening and Treatment Practices and Preferences: A Survey of United States Pediatricians

OBJECTIVES

To determine pediatricians' practices, attitudes, and barriers regarding screening for and treatment of pediatric dyslipidemias in 9- to 11-year-olds and 17- to 21-year-olds.

STUDY DESIGN

American Academy of Pediatrics (AAP) 2013-2014 Periodic Survey of a national, randomly selected sample of 1627 practicing AAP physicians. Pediatricians' responses were described and modeled.

RESULTS

Of 614 (38%) respondents who met eligibility criteria, less than half (46%) were moderately/very knowledgeable about the 2008 AAP cholesterol statement; fewer were well-informed about 2011 National Heart, Lung, and Blood Institute Guidelines or 2007 US Preventive Service Task Force review (both 26%). Despite published recommendations, universal screening was not routine: 68% reported they never/rarely/sometimes screened healthy 9- to 11-year-olds. In contrast, more providers usually/most/all of the time screened based on family cardiovascular history (61%) and obesity (82%). Screening 17- to 21-year-olds was more common in all categories (P?<?.001). Only 58% agreed with universal screening, and 23% felt screening was low priority. Pediatricians uniformly provided lifestyle counseling but access to healthy food (81%), exercise (83%), and adherence to lifestyle recommendations (96%) were reported barriers. One-half of pediatricians (55%) reported a lack of local subspecialists. Although 62% and 89% believed statins were appropriate for children and adolescents with high low-density lipoprotein cholesterol (200?mg/dL) unresponsive to lifestyle, a minority initiated statins (8%, 21%).

CONCLUSIONS

US pediatricians report lipid screening and treatment practices that are largely at odds with existing recommendations, likely because of lack of knowledge and conflicts among national guidelines, and concern about treatment efficacy and harms. Education regarding pediatric lipid disorders could promote guideline implementation.

Three sides to a story: Child, parent, and nurse perspectives on the child's experience during hematopoietic stem cell transplantation

BACKGROUND

The experience of children undergoing hematopoietic stem cell transplantation (HSCT), including the ways in which different participants (ie, children, parents, and nurses) contribute to the overall picture of a child's experience, is poorly characterized. This study evaluated parent, child, and nurse perspectives on the experience of children during HSCT and factors contributing to interrater differences.

METHODS

Participants were enrolled in a multicenter, prospective study evaluating child and parent health-related quality of life over the year after HSCT. Children (n = 165) and their parents and nurses completed the Behavioral, Affective, and Somatic Experiences Scale (BASES) at baseline (before/during conditioning), 7 days after the stem cell infusion (day+7), and 21 days after the stem cell infusion (day+21). The BASES domains included Somatic Distress, Mood Disturbance, Cooperation, and Getting Along. Higher scores indicated more distress/impairment. Repeated measures models by domain assessed differences by raters and changes over time and identified other factors associated with raters' scores.

RESULTS

Completion rates were high (≥73% across times and raters). Multivariate models revealed significant time-rater interactions, which varied by domain. For example, parent-rated Somatic Distress scores increased from baseline to day+7 and remained elevated at day+21 (P < .001); children's scores were lower than parents' scores across time points. Nurses' baseline scores were lower than parents' baseline scores, although by day+21 they were similar. Older child age was associated with higher Somatic Distress and Mood Disturbance scores. Worse parent emotional functioning was associated with lower scores across raters and domains except for Cooperation.

CONCLUSIONS

Multirater assessments are highly feasible during HSCT. Ratings differ by several factors; considering ratings in light of such factors may deepen our understanding of the child's experience. Cancer 2017;123:3159-66. © 2017 American Cancer Society.

Development of phase-specific breast cancer survivorship care plans (SCPs)

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Background: There are nearly 3 million breast cancer (BC) survivors in the US. Among the recently diagnosed, accrediting organizations (e.g., Commission on Cancer) now require SCPs at the completion of curative therapy. Within the Oncology Care Model, the preparation and delivery of SCPs is recognized as one of the 13 quality metrics. SCPs, combining treatment summaries (TS) and follow-up care plans (FUCPs), assist patients and providers in the delivery of high quality long-term care. BC presents a unique challenge, as the risk of recurrence extends decades past initial treatment; adjuvant risk reduction may extend up to 15 years. Periodic FUCPs provide a mechanism to review updated information and may allow providers to catch up with longer term BC survivors whose care was delivered prior to SCPs. We explored the role of phase-specific SCPs within the heterogeneous BC survivor population. Methods: Oncologists and nurse practitioners (NPs) from the Breast Health and Survivorship Programs at Tufts MC, an academic medical center in Boston, and New England Cancer Specialists, a community-based private oncology practice in Maine--together caring for more than 2,000 BC survivors--convened to develop and test phase-specific survivorship tools. Using an adapted ASCO template for BC, TS were completed at the end of initial therapy by trained NPs. FUCPs for initial, 5-year, and 10-year visits were designed with clinical input, literature reviews, and existing guidelines. Results: FUCPs were pilot tested and refined before incorporation into the electronic health record. Further testing is planned to identify barriers to effective survivorship care, particularly involving documentation of changes in recommendations and the transition from oncologist to primary care physician. Conclusions: SCPs are critical for providing quality health care to BC survivors, but a single SCP, written at the conclusion of curative treatment, might not be sufficient to address changing needs of individuals as they progress through survivorship. Thus, phase-specific SCPs enable providers to focus on salient aspects of care that may change over time. Despite growing recognition of the value of SCPs, implementation remains a challenge across cancer programs.