A Multimedia Self-management Intervention to Prepare Cancer Patients and Family Caregivers for Lung Surgery and Postoperative Recovery

BACKGROUND

The purpose of this study was to evaluate the feasibility and acceptability of a multimedia self-management (MSM) intervention to prepare patients and family caregivers for lung surgery.

PATIENTS AND METHODS

This is a quasi-experimental, 2-group, sequential enrollment pilot study of a 4-session multimedia intervention (audio/visual + print) to enhance self-management and quality of life (QOL) for patients and family caregivers. The intervention, Preparing for Lung Surgery, begins before surgery, and continues through hospitalization and discharge, with 2 telephone support sessions after discharge. Outcomes were assessed before surgery (preintervention), at discharge, and 2 to 4 weeks postdischarge (postintervention). Patient outcomes were assessed using the Functional Assessment of Cancer Therapy-General (QOL), MD Anderson Symptom Inventory and Functional Assessment of Cancer Therapy-Pulmonary Symptom Index (symptoms), self-efficacy, surgery-related knowledge, and patient activation. Family caregiver outcomes included City of Hope-QOL-Family (QOL), Caregiver Burden Scale, and knowledge. Paired t tests were used for exploratory evaluations of score changes from pre- to postintervention.

RESULTS

Sixty participants (38 patients, 22 family caregivers) enrolled in the study (70% accrual). Postintervention scores were significantly improved for patients' emotional QOL (P = .001). Trends for improvements were observed for patient self-efficacy, surgery-related knowledge, and activation. Family caregivers' surgery-related knowledge was significantly improved (P = .02). Overall, participants were highly satisfied with the acceptability/usability of the intervention (3.6-3.7 of 4.0).

CONCLUSION

A standardized MSM intervention was feasible and acceptable in supporting readiness and preparedness for lung surgery and postoperative recovery. A larger randomized trial is needed to verify the impact of the MSM intervention on patient/family caregiver outcomes and health care resource use.

The Measurement of Transitions in Cancer Scale

BACKGROUND AND PURPOSE

Health-illness transitions are changes in life phase, situation, or status related to shifts between health and illness. We report on the development and psychometric evaluation of the Measurement of Transitions in Cancer Scale (MOT-CA), a 7-item instrument that assesses extent and management of a range of transitions experienced by cancer patients.

METHODS

We identified content domains, developed operational definitions, generated items, conducted expert review (n = 7) and cognitive interviews (n = 13), and tested MOT-CA with our target population (n = 105).

RESULTS

MOT-CA has content and convergent validity and a 2-factor structure consisting of Personal Transitions (physical, emotional, social, spiritual; eigenvalue = 2.994) and Care Transitions (cancer status, treatment, approach to care; eigenvalue = 1.444).

CONCLUSION

Although additional testing is indicated, the MOT-CA is valid, brief, and acceptable.

Quality of life and self-management strategies after gastroesophageal cancer surgery

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Background: Gastroesophageal cancer surgery can result in significant morbidity and decreased quality of life (QOL). The profound physical changes and symptoms that affect eating/digestion can substantially alter psychological and social well-being. We aimed to describe QOL and dietary/behavioral self-management strategies after gastroesophageal cancer surgery. Methods: Patients who were 6-12 months post-resection completed surveys for QOL (EORTC-QLQ-C30), symptoms (EORTC-QLQ-OES18 or QLQ-STO22), diet modifications, and behavioral adjustments. Scores for validated measures were calculated according to guidelines, and summarized using descriptive statistics. Results: 31 patients (11 esophagectomy, 20 gastrectromy) participated in the study. Surgical approach was 71% minimally invasive (laparoscopic, robotic). Patients reported clinically meaningful (≥10 point difference) worse mean scores compared to reference population means for physical (73.3/100 esophagectomy, 78.3/100 gastrectomy vs. 89.8/100 reference populations), role (63.6/100, 73.3/100 vs. 84.7/100), and social functioning (62.1/100, 75.0/100 vs. 87.5/100). Eating problems (48.5/100) was the worst symptom for esophagectomy patients. Thereafter, problems with taste, cough, reflux, and dysphagia were reported frequently. For gastrectomy patients, eating problems was also the worst symptom (28.2/100), followed by body image disturbance, dry mouth, and pain. Time to comfort with eating after surgery was between 3-12 months. The most common behavioral adjustments include chewing food completely (96%), eating multiple meals per day (90%), controlling meal portions (87%), staying or sitting upright after meals (71%), staying at or close to home more (64%), and eating out less (55%). Conclusions: QOL is greatly reduced after gastroesophageal cancer surgery. Eating problems and associated symptoms persist 6-12 months after surgery. Patients used multiple self-management strategies to control eating problems and symptoms. These strategies varied greatly, suggesting that personalized interventions are necessary to help patients adjust to eating after surgery and improve QOL.

Frailty determinants in two long-term care settings: Assistant living facilities and home and community-based programs

There is limited knowledge on differences in frailty among residents in assisted living facilities (ALF) and home and community-based services (HCBS). This study used a retrospective cross-sectional design to compare frailty determinants in two long-term care settings. The HCBS setting had a greater proportion of positive responses to 9 of 14 frailty indicators. The ALF setting had a greater proportion to only 2 of the 14 frailty indicators. The finding that the HCBS setting had a significantly greater proportion of participants with positive frailty indicators as compared to the ALF setting suggests the degree of frailty risk is different by health care setting.

Missing Domains of Lung Transplant Patient Selection

The goal of consistent, predictable, and improved outcomes has continued to elude the scientific community in the 30 years since lung transplantation became the procedure of choice for patients with terminal, nonmalignant lung disease.

Background:

Although there is consensus regarding disease-specific indications for lung transplant, ambiguity remains regarding how patient-specific attributes should influence lung transplant candidacy. This study had 3 aims (1) to establish the missing domains of the interdisciplinary assessment of the lung transplant candidate, (2) to have these domains validated by an international panel of lung transplant experts, and (3) to recommend the next step for inclusion of these domains into the lung transplant candidate selection process.

Methods:

Three levels of evidence were reviewed. A search for standards and guidelines, a comprehensive literature review, and a validation of domains by experts were conducted.

Results:

Seven domains of patient attributes were identified as relevant to lung transplant patient selection: cognitive performance, frailty, psychological factors, self-efficacy, social support, quality of life, and sociodemographic factors. Within each domain, several elements were identified to be incorporated in the process of patient assessment.

Conclusion:

Assessment of the missing domains and elements should be incorporated into the interdisciplinary lung transplant evaluation process. Standardized recognition and reporting of the patient-specific attributes will inform the work of individual transplant programs and the international transplant community. Further study is needed to associate these patient attributes with transplant outcomes. Improved understanding is needed regarding how nurses assess lung transplant candidates and how they communicate their findings within interdisciplinary settings.

Application of Community-Based Participatory Research Methods to a Study of Complementary Medicine Interventions at End of Life

Community-based participatory research (CBPR) principles can be successfully applied to the design and implementation of a complementary medicine study for adults with end-stage AIDS. The Yale Prevention Research Center partnered with Leeway, Inc., an AIDS-dedicated nursing facility, and other academic and clinical entities to conduct a randomized, controlled pilot trial of meditation and massage on quality of life at the end of life. Using CBPR principles, a methodology was developed that was scientifically rigorous, highly respectful, and acceptable to the 91% minority study population. Using continuous, open communication among all involved parties, challenges were satisfactorily addressed in a timely manner. Fifty-eight residents (97% of those eligible) with end-stage AIDS participated from November 2001 to September 2003. Subjects received 1-month interventions of meditation, massage, combined meditation and massage, or standard care. The study of quality-of-life in end-stage AIDS poses unique challenges well met by applying CBPR principles to an academic-community research partnership.

Health information needs and preferences in relation to survivorship care plans of long-term cancer survivors in the American Cancer Society's Study of Cancer Survivors-I

PURPOSE

Survivorship care plans (SCPs) provide cancer patients and health care providers with a treatment summary and outline of recommended medical follow-up. Few studies have investigated the information needs and preferred sources among long-term cancer survivors.

METHODS

Cancer survivors of the ten most common cancers enrolled in the longitudinal Study of Cancer Survivors-I (SCS-I) completed a survey 9 years post-diagnosis (n = 3138); at time of diagnosis of the SCS-I cohort, SCPs were not considered usual care. We assessed participants' current desire and preferred sources for information across ten SCP items and evaluated factors associated with information need 9 years after diagnosis.

RESULTS

The proportion of long-term cancer survivors endorsing a need for cancer and health information 9 years post-diagnosis ranged from 43 % (cancer screening) to 9 % (consequences of cancer on ability to work). Print media and personalized reading materials were the most preferred information sources. Younger age, higher education, race other than non-Hispanic white, later cancer stage, having breast cancer, having ≥2 comorbidities, and self-reporting poor health were associated with greater informational need (p < 0.05).

CONCLUSIONS/IMPLICATIONS FOR CANCER SURVIVORS

Long-term cancer survivors continue to report health information needs for most SCP items and would prefer a print format; however, level of need differs by socio-demographic and cancer characteristics. Cancer survivors who did not previously receive a SCP may still benefit from receiving SCP content, and strategies for enabling dissemination to long-term survivors warrant further investigation.

Evolution of a 90-day model of care for bundled episodic payments for congestive heart failure in home care

The Centers for Medicare and Medicaid Services Innovation Center's Episode-Based Payment initiatives propose a large opportunity to reduce cost from waste and variation and stand to align hospitals, physicians, and postacute providers in the redesign of care that achieves savings and improve quality. Community-based organizations are at the forefront of this care redesign through innovative models of care aimed at bridging gaps in care coordination and reducing hospital readmissions. This article describes a community-based provider's approach to participation under the Bundled Payments for Care Improvement initiative and a 90-day model of care for congestive heart failure in home care.

Design of an Evidence-Based "Second Victim" Curriculum for Nurse Anesthetists

The "second victim" phenomenon--when a healthcare provider experiences adverse events because of the adverse events of a patient--is not well known or understood among healthcare professionals, including Certified Registered Nurse Anesthetists (CRNAs). No published research is currently available on the impact of second victim specifically in CRNAs, but it is known that second victim poses major challenges for healthcare professionals. Therefore, it is important to acknowledge its occurrence and to develop an educational curriculum based on the available evidence in order to promote peer and organizational support infrastructures. A comprehensive literature review was conducted, 6 educational domains on second victim were developed, and an expert panel validated the content.

A chronic care ostomy self-management program for cancer survivors

BACKGROUND

Individuals with ostomies experience extensive changes in health-related quality of life (HRQOL) and daily routine. Patients and families are typically forced to use trial and error to improve self-management.

METHODS

This is a longitudinal one-group design pilot study of a five-session ostomy self-care curriculum based on the Chronic Care Model to improve HRQOL and self-management for cancer survivors with ostomies. Participants were surveyed to evaluate each session. Multiple instruments were administered to examine outcomes at baseline, post-intervention, and at 6-month follow-up (Patient Activation Measure, self-efficacy, Hospital Anxiety and Depression Scale, Ways of Coping, Group Health Association of America Satisfaction with ostomy care survey, and the City of Hope Quality of Life Ostomy). Changes from pre-intervention to post-intervention and pre-intervention to follow-up were evaluated with paired t-tests. Text responses were coded and evaluated for important themes and recommendations.

RESULTS

Thirty-eight subjects participated in the study. Most had a history of rectal cancer (60.5%) or bladder cancer (28.9%). Participants rated the overall program high (4.4-4.8 on 5-point scale). Text feedback indicated that participants enjoyed the group forums, wanted more participants, and more hands-on training. Scores on multiple surveys were shown to be improved and sustained, including patient activation (p = 0.0004), self-efficacy (p = 0.006), total HRQOL (p = 0.01), physical well-being (p = 0.005), and social well-being (p = 0.002). Survivor anxiety was significantly reduced by follow-up (p = 0.047).

CONCLUSIONS

This self-management ostomy program can help cancer survivors with ostomies adapt to their stoma. Initiating this program in the community setting would be beneficial to many cancer survivors.

The five steps of comprehensive psychosocial distress screening

Despite the growing recognition of the impact psychosocial distress has on the quality of life of patients with cancer, the implementation of the National Comprehensive Cancer Network (NCCN) Distress Management Guidelines and the mandate of evidence-based policy for routine distress screening continue to lag. To speed adoption of the guideline, the American Psychosocial Oncology Society (APOS) and Yale School of Nursing (YSN) launched the Screening for Psychosocial Distress Program in 2014. The program resulted in the development of five steps necessary to carry out routine psychosocial distress screening. The steps are consistent with the NCCN Distress Management Guidelines and the new criterion for accreditation by the American College of Surgeons (ACS) Commission on Cancer as of 2015. These five steps are as follows: (1) screening, (2) evaluating, (3) referring, (4) following up, and (5) documenting and quality improvement. The purpose of this article is to summarize the detailed procedure of the five steps for cancer care professionals-including oncologists, nurses, psychiatrists, psychologists, and social workers-so they can manage psychosocial distress efficiently in their own clinical environments.

An Advanced Practice Nurse Coordinated Multidisciplinary Intervention for Patients with Late-Stage Cancer: A Cluster Randomized Trial

BACKGROUND

Early palliative care provided through a palliative care consultative service is effective in enhancing patient outcomes. However, it is unknown whether the integration of palliative care as part of routine comprehensive cancer care improves patients' self-reported clinical outcomes.

OBJECTIVE

The objective of this study was to evaluate the effects of a multidisciplinary coordinated intervention by advanced practice nurses at the clinic level on outcomes with patients newly diagnosed with late-stage cancer.

METHODS

A clustered, randomized, controlled trial design was used. Four disease-specific multidisciplinary clinics were randomized to the 10-week intervention (gynecologic and lung clinics) or to enhanced usual care (head and neck and gastrointestinal clinics). Patient primary outcomes (symptoms, health distress, depression, functional status, self-reported health) were collected at baseline and one and three months, and secondary outcomes were collected one and three months postbaseline. General linear mixed model analyses with a covariance structure of within-subject correlation was used to examine the intervention's effect.

RESULTS

The sample included 146 patients with newly diagnosed late-stage cancers. We found no differences between the two groups on the primary patient-reported outcomes at one and three months postbaseline; however, physical and emotional symptoms remained stable or significantly improved from baseline for both groups. Overall, secondary outcomes remained stable within the groups.

CONCLUSION

In this translational study, we demonstrated that if patients newly diagnosed with late-stage cancer were managed by disease-specific multidisciplinary teams who palliated their symptoms, providing whole-patient care, patient outcomes remained stable or improved.

Supporting commission on cancer-mandated psychosocial distress screening with implementation strategies

PURPOSE

The American College of Surgeons Commission on Cancer (CoC) has set psychosocial distress screening as a new patient care standard to be met by 2015. The standard requires CoC-accredited cancer centers to integrate and monitor distress screening and, when needed, refer patients to psychosocial health care services. We describe the uptake of distress screening reported by applicants to a distress screening cancer education program and the degree of and barriers to implementation of distress screening programs reported by selected participants.

MATERIALS AND METHODS

This cross-sectional study collected quantitative data online from applicants to the program between August 1 and November 15, 2013, described by frequencies, percentages, and measures of central tendency, and qualitative data in person from accepted participants on February 13, 2014, analyzed using an integrated approach to open-ended data.

RESULTS

Applications were received from 70 institutions, 29 of which had started distress screening. Seven of 18 selected applicant institutions had not begun screening patients for distress. Analysis of qualitative data showed that all participants needed to create buy-in among key cancer center staff, including oncologists; to decide how to conduct screening in their institution in a way that complied with the standard; and to pilot test screening before large-scale rollout.

CONCLUSION

Fourteen months before the compliance deadline, fewer than half of applicant institutions had begun distress screening. Adding implementation strategies to mandated quality care standards may reduce uncertainty about how to comply. Support from key staff members such as oncologists may increase uptake of distress screening.

Incorporating patient-reported outcomes to improve emotional distress screening and assessment in an ambulatory oncology clinic

PURPOSE

Assessment of distress and well-being of patients with cancer is not always documented or addressed in a clinical visit, reflecting a need for improved psychosocial screening.

METHODS

A multidisciplinary team completed process mapping for emotional distress assessment in two clinics. Barriers were identified through cause-and-effect analysis, and an intervention was chosen. Patient-reported outcomes were collected over 6 months using the validated National Comprehensive Cancer Network Emotional Distress Thermometer (EDT) paper tool. The American Society of Clinical Oncology Quality Oncology Practice Initiative (QOPI) measures were compared before and after intervention.

RESULTS

During 6 months, a total of 864 tools were collected from 1,344 patients in two ambulatory clinics (64%). Electronic medical record documentation of distress increased from 19.2% to 34% during the 6 months before and after intervention. QOPI measures showed an increase in emotional well-being documentation. Of 29 new and 835 return patients, 62% indicated mild distress (EDT, 0 to 3), 18% moderate (EDT, 4 to 6), and 11% severe (EDT, 7 to 10). The average distress score of new patients was significantly higher than that of return patients (5.39 [n = 26] v 2.52 [n = 754]; P < .001). The top problems for patients with moderate and severe distress were worry, fatigue, pain, and nervousness; depression and sadness were particularly noted in patients reporting severe distress. Eleven percent of patients were referred to the social worker on site.

CONCLUSION

A pilot intervention collecting Patient-reported outcomes in two ambulatory clinics led to increase in psychosocial distress screening followed by sustained improvement, indicated by both process and QOPI measures.

Do depressed newly diagnosed cancer patients differentially benefit from nurse navigation?

OBJECTIVE

To examine whether the effects of a nurse navigator intervention for cancer vary with baseline depressive symptoms.

METHOD

Participants were enrolled in a randomized controlled trial of a nurse navigation intervention for patients newly diagnosed with lung, breast or colorectal cancer (N=251). This exploratory analysis used linear regression models to estimate the effect of a nurse navigator intervention on patient experience of care. Models estimated differential effects by including interactions between randomization group and baseline depressive symptoms. Baseline scores on the 9-item Patient Health Questionnaire (PHQ) were categorized into 3 groups: no depression (PHQ=0-4, N=138), mild symptoms of depression (PHQ=5-9, N=76) and moderate to severe symptoms (PHQ=10 or greater, N=34). Patient experience outcomes were measured by subscales of the Patient Assessment of Chronic Illness Care (PACIC) and subscales from an adaptation of the Picker Institute's patient experience survey at 4-month follow-up.

RESULTS

With the exception of the PACIC subscale of delivery system/practice design, interaction terms between randomization group and PHQ-9 scores were not statistically significant.

CONCLUSIONS

The intervention was broadly useful; we found that it was equally beneficial for both depressed patients and patients who were not significantly depressed in the first 4 months postdiagnosis. However, because of the small sample size, we cannot conclude with certainty that patients with depressive symptoms did not differentially benefit from the intervention.

Feasibility of using algorithm-based clinical decision support for symptom assessment and management in lung cancer

CONTEXT

Distressing symptoms interfere with the quality of life in patients with lung cancer. Algorithm-based clinical decision support (CDS) to improve evidence-based management of isolated symptoms seems promising, but no reports yet address multiple symptoms.

OBJECTIVES

This study examined the feasibility of CDS for a Symptom Assessment and Management Intervention targeting common symptoms in patients with lung cancer (SAMI-L) in ambulatory oncology. The study objectives were to evaluate completion and delivery rates of the SAMI-L report and clinician adherence to the algorithm-based recommendations.

METHODS

Patients completed a web-based symptom assessment and SAMI-L created tailored recommendations for symptom management. Completion of assessments and delivery of reports were recorded. Medical record review assessed clinician adherence to recommendations. Feasibility was defined as 75% or higher report completion and delivery rates and 80% or higher clinician adherence to recommendations. Descriptive statistics and generalized estimating equations were used for data analyses.

RESULTS

Symptom assessment completion was 84% (95% CI=81-87%). Delivery of completed reports was 90% (95% CI=86-93%). Depression (36%), pain (30%), and fatigue (18%) occurred most frequently, followed by anxiety (11%) and dyspnea (6%). On average, overall recommendation adherence was 57% (95% CI=52-62%) and was not dependent on the number of recommendations (P=0.45). Adherence was higher for anxiety (66%; 95% CI=55-77%), depression (64%; 95% CI=56-71%), pain (62%; 95% CI=52-72%), and dyspnea (51%; 95% CI=38-64%) than for fatigue (38%; 95% CI=28-47%).

CONCLUSION

The CDS systems, such as SAMI-L, have the potential to fill a gap in promoting evidence-based care.

A differential item function analysis of somatic symptoms of depression in people with cancer

BACKGROUND

The overlap of somatic symptoms of depression with symptoms of cancer treatment is widely acknowledged and studied. However, this literature provides little guidance for clinicians as to whether these items should be used in assessing depression. The current study examined the appropriateness of using somatic items for assessment of depression in people with cancer.

METHODS

People with newly diagnosed breast, lung or colorectal cancer (n=251) completed the Patient Health Questionnaire-9 (PHQ9) shortly after cancer diagnosis but before cancer treatment (baseline), 4 months later, typically during or shortly after treatment, and 12 months later. Pharmacy data was used to classify participants as having low somatic symptoms or high somatic symptoms. Differential item function (DIF) compared the functioning of the somatic items of the PHQ9 in the low vs. high symptom groups and the chemotherapy vs. no chemotherapy groups at the 4-month assessment.

RESULTS

Significant DIF was not found on any of the four somatic items of the PHQ9 and differences in the item parameters of the somatic items were not consistent across the groups. However, fatigue and sleep indicated only mild depression. Only removing the fatigue item greatly affected the number screening positive for depression at 4 months (8.3%) but removing the other somatic items did not have as large an effect. Only one participant at baseline screened positive for depression by somatic symptoms alone (no psychological symptoms) and no participants screened positive by somatic symptoms alone at 4 months and 12 months.

LIMITATIONS

The sample size was small for DIF and consisted of mostly women with breast cancer.

CONCLUSIONS

Somatic symptoms of depression can continue to be administered to people with cancer, however the fatigue and sleep items should be used with caution.