Multidisciplinary Specialty Teams: A Self-Management Program for Patients With Advanced Cancer

Self-management has been shown to be an effective intervention to enable and empower patients with chronic illness to manage their health. Taking Early Action to Manage Self (TEAMS) is such an intervention, providing education and support to patients with advanced solid tumors to develop self-management skills. We conducted a study and surveyed health-care providers about their perceptions of multidisciplinary teams on the outcomes of this TEAMS intervention as well as factors that may influence its adoption into practice. The majority of respondents reported that the TEAMS program was feasible to practice and well suited to their patient population. In this article, the full results of this survey are presented, along with the emerging themes of empowerment and improved communication between patients and providers. In addition, facilitators and barriers to its adoption are explored. Although providers supported the adoption of the TEAMS program, provider resources to implement and maintain it need to be addressed prior to its widespread adoption.

Point-of-care clinical decision support for cancer symptom management: Results of a group randomized trial

1

Background: Integration of palliative care into oncology is recommended for quality care. Clinicians may benefit from assistance in assessing and managing multiple symptoms. Palliative care clinicians have the expertise but may not be available or are not consulted early in the course of a patient’s disease. Clinical decision support (CDS) offers an innovative way to deliver symptom management and trigger palliative care referrals at the point-of-care. Methods: Twenty clinicians and their patients were randomized to usual care (UC) or CDS using the symptom assessment and management intervention (SAMI), which provided tailored suggestions for pain, fatigue, depression, anxiety and/or dyspnea. One-hundred seventy-nine patients completed a Web-based symptom assessment prior to each visit for 6 months. A tailored report provided a longitudinal symptom report and suggestions for management were provided to clinicians in the SAMI arm prior to the visit. Standardized questionnaires were administered to patients at baseline, 2, 4 and 6 months later to measure communication about symptoms and health-related quality of life (HR-QOL). The treatment outcome index (TOI) was the primary outcome for HR-QOL. Management of the target symptoms was assessed through chart review. Linear mixed models and logistic regression were used for analyses. Results: Patient characteristics were: mean age of 63 years, 58% female, 88% white, and 32% had < HS education. No differences were noted in communication between patients and their clinicians. Significant differences were noted in physical well-being (p = 0.007, 0.08 adjusted for baseline) and a clinically significant difference in the TOI (62 vs. 68) at 4 months in SAMI as compared to UC. The odds of managing depression (1.6, 90% CI, 1.0-2.5), anxiety (1.7, 90% CI, 1.0-3.0) and fatigue (1.6, 90% CI, 1.1-2.5) were higher in SAMI as compared to UC. The odds of palliative care consults for pain (3.2, 90% CI, 0.7-13.4) appear to be higher in SAMI as compared to UC. Conclusions: Enhanced HR-QOL was noted among patients in the SAMI arm at 4 months. SAMI increased management of depression, fatigue and anxiety and appeared to increase palliative care consults for pain. Clinical trial information: NCT00852462.

Development of a frailty measure for older adults: the frailty index for elders

BACKGROUND AND PURPOSE

Frailty is a significant challenge for health care. Therefore, it is important to identify frail individuals. Theoretical Framework: The Vulnerability/Risk/Human Response/Care Model. The purpose of this study was to develop and validate a measure to identify frail older adults.

METHODS

Instrument development encompassed the following: delineation of content domains, item generation, content validity, quantitative content validity analysis, and psychometric analysis.

RESULTS

Findings indicated the following: (a) Frailty is a complex concept, (b) the Frailty Index for Elders (FIFE) is composed of 10 items, (c) FIFE was able to predict depression, and (d) FIFE was able to differentiate differences in demographic profiles by social support environment.

CONCLUSIONS

FIFE is a valid instrument. FIFE can be used to study the relationships among frailty determinants, provide standardized measurement, and develop and measure interventional studies.

Impact of Financial Burden of Cancer on Survivors' Quality of Life

Increased financial burden as a result of cancer care costs is the strongest independent predictor of poor quality of life among cancer survivors.

Cancer family caregiver depression: are religion-related variables important?

OBJECTIVE

Prevalence estimates for clinical depression among cancer family caregivers (CFC) range upwards to 39%. Research inconsistently reports risk for CFC depressive symptoms when evaluating age, gender, ethnicity, or length of time as caregiver. The discrepant findings, coupled with emerging literature indicating religiosity may mitigate depression in some populations, led us to investigate religion-related variables to help predict CFC depressive symptoms.

METHODS

We conducted a cross-sectional study of 150 CFC. Explanatory variables included age, gender, spousal status, length of time as caregiver, attendance at religious services, and prayer. The outcome variable was the Center for Epidemiological Studies Depression Scale score.

RESULTS

Compared with large national and state datasets, our sample has lower representation of individuals with no religious affiliation (10.7% vs. 16.1% national, p = 0.07 and 23.0% state, p = 0.001), higher rate of attendance at religious services (81.3% vs. 67.2% national, p < 0.001 and 30.0% state, p < 0.001), and higher rate of prayer (65.3% vs. 42.9% national, p < 0.001; no state data available). In unadjusted and adjusted models, prayer is not significantly associated with caregiver depressive symptoms or clinically significant depressive symptomology. Attendance at religious services is associated with depressive symptoms (p = 0.004) with an inversely linear trend (p = 0.002).

CONCLUSION

The significant inverse association between attendance at religious services and depressive symptoms, despite no association between prayer and depressive symptoms, indicates that social or other factors may accompany attendance at religious services and contribute to the association. Clinicians can consider supporting a CFC's attendance at religious services as a potential preventive measure for depressive symptoms.

Testing the differential effects of symptom management interventions in cancer

OBJECTIVE

The purpose of this study was to test for moderating effects of patient characteristics on self-management interventions developed to address symptoms during cancer treatment. Patient's age, education, and depressive symptomatology were considered as potential moderators.

METHODS

A secondary analysis of data of 782 patients from two randomized clinical trials was performed. Both trials enrolled patients with solid tumors undergoing chemotherapy. After completing baseline interviews, patients were randomized to a nurse-delivered intervention versus intervention delivered by a 'coach' in trial I and to a nurse-delivered intervention versus an intervention delivered by an automated voice response system in trial II. In each of the two trials, following a six-contact 8-week intervention, patients were interviewed at week 10 to assess the primary outcome of symptom severity.

RESULTS

Although nurse-delivered intervention proved no better than the coach or automated system in lowering symptom severity, important differences in the intervention by age were found in both trials. Patients aged ≤45 years responded better to the coach or automated system, whereas those aged ≥75 years favored the nurse. Education and depressive symptomatology did not modify the intervention effects in either of the two trials. Depressive symptomatology had a significant main effect on symptom severity at week 10 in both trials (p = 0.03 and p < 0.01, respectively). Education was not associated with symptom severity over and above age and depressive symptomatology.

CONCLUSIONS

Clinicians need to carefully consider the age of the population when using or testing interventions to manage symptoms among cancer patients.

National hospice survey results: for-profit status, community engagement, and service

IMPORTANCE The impact of the substantial growth in for-profit hospices in the United States on quality and hospice access has been intensely debated, yet little is known about how for-profit and nonprofit hospices differ in activities beyond service delivery. OBJECTIVE To determine the association between hospice ownership and (1) provision of community benefits, (2) setting and timing of the hospice population served, and (3) community outreach. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional survey (the National Hospice Survey), conducted from September 2008 through November 2009, of a national random sample of 591 Medicare-certified hospices operating throughout the United States. EXPOSURES For-profit or nonprofit hospice ownership. MAIN OUTCOMES AND MEASURES Provision of community benefits; setting and timing of the hospice population served; and community outreach. RESULTS A total of 591 hospices completed our survey (84% response rate). For-profit hospices were less likely than nonprofit hospices to provide community benefits including serving as training sites (55% vs 82%; adjusted relative risk [ARR], 0.67 [95% CI, 0.59-0.76]), conducting research (18% vs 23%; ARR, 0.67 [95% CI, 0.46-0.99]), and providing charity care (80% vs 82%; ARR, 0.88 [95% CI, 0.80-0.96]). For-profit compared with nonprofit hospices cared for a larger proportion of patients with longer expected hospice stays including those in nursing homes (30% vs 25%; P = .009). For-profit hospices were more likely to exceed Medicare's aggregate annual cap (22% vs 4%; ARR, 3.66 [95% CI, 2.02-6.63]) and had a higher patient disenrollment rate (10% vs 6%; P &lt; .001). For-profit were more likely than nonprofit hospices to engage in outreach to low-income communities (61% vs 46%; ARR, 1.23 [95% CI, 1.05-1.44]) and minority communities (59% vs 48%; ARR, 1.18 [95% CI, 1.02-1.38]) and less likely to partner with oncology centers (25% vs 33%; ARR, 0.59 [95% CI, 0.44-0.80]). CONCLUSIONS AND RELEVANCE Ownership-related differences are apparent among hospices in community benefits, population served, and community outreach. Although Medicare's aggregate annual cap may curb the incentive to focus on long-stay hospice patients, additional regulatory measures such as public reporting of hospice disenrollment rates should be considered as the share of for-profit hospices in the United States continues to increase.

Gender differences in the evolution of illness understanding among patients with advanced cancer

BACKGROUND

Patient understanding of advanced metastatic disease is central to decisions about care near death. Prior studies have focused on gender differences in communication style rather than on illness understanding.

OBJECTIVES

: To evaluate gender differences in terminal illness acknowledgement (TIA), understanding that the disease is incurable and the advanced stage of the disease. To evaluate gender differences in patients' reports of discussions of life expectancy with oncology providers and its effect on differences in illness understanding.

METHODS

Coping with Cancer 2 patients (N = 68) were interviewed before and after a visit with their oncology providers to discuss scan results.

RESULTS

At the prescan interview, there were no statistically significant gender differences in patient measures of illness understanding. At the postscan interview, women were more likely than men to recognize that their illness was incurable (Adjusted Odds Ratio, [AOR] = 5.29; P = .038), know that their cancer was at an advanced stage (AOR = 6.38; P = .013), and report having had discussions of life expectancy with their oncologist (AOR = 4.77; P = .021). Controlling discussions of life expectancy, women were more likely than men to report that their cancer was at an advanced stage (AOR = 9.53; P = .050). Controlling for gender, discussions of life expectancy were associated with higher rates of TIA (AOR = 4.65; P = .036) and higher rates of understanding that the cancer was incurable (AOR = 4.09; P = .085).

CONCLUSIONS

Due largely to gender differences in communication, women over time have a better understanding of their illness than men. More frequent discussions of life expectancy should enhance illness understanding and reduce gender differences.

Nurse navigators in early cancer care: a randomized, controlled trial

PURPOSE

To determine whether a nurse navigator intervention improves quality of life and patient experience with care for people recently given a diagnosis of breast, colorectal, or lung cancer.

PATIENTS AND METHODS

Adults with recently diagnosed primary breast, colorectal, or lung cancer (n = 251) received either enhanced usual care (n = 118) or nurse navigator support for 4 months (n = 133) in a two-group cluster randomized, controlled trial with primary care physicians as the units of randomization. Patient-reported measures included the Functional Assessment of Cancer Therapy-General (FACT-G) Quality of Life scale, three subscales of the Patient Assessment of Chronic Illness Care (PACIC), and selected subscales from a cancer adaptation of the Picker Institute's patient experience survey. Self-report measures were collected at baseline, 4 months, and 12 months. Automated administrative data were used to assess time to treatment and total health care costs.

RESULTS

There were no significant differences between groups in FACT-G scores. Nurse navigator patients reported significantly higher scores on the PACIC and reported significantly fewer problems with care, especially psychosocial care, care coordination, and information, as measured by the Picker instrument. Cumulative costs after diagnosis did not differ significantly between groups, but lung cancer costs were $6,852 less among nurse navigator patients.

CONCLUSION

Compared with enhanced usual care, nurse navigator support for patients with cancer early in their course improves patient experience and reduces problems in care, but did not differentially affect quality of life.

Hospices' enrollment policies may contribute to underuse of hospice care in the United States

Hospice use in the United States is growing, but little is known about barriers that terminally ill patients may face when trying to access hospice care. This article reports the results of the first national survey of the enrollment policies of 591 US hospices. The survey revealed that 78 percent of hospices had at least one enrollment policy that may restrict access to care for patients with potentially high-cost medical care needs, such as chemotherapy or total parenteral nutrition. Smaller hospices, for-profit hospices, and hospices in certain regions of the country consistently reported more limited enrollment policies. We observe that hospice providers' own enrollment decisions may be an important contributor to previously observed underuse of hospice by patients and families. Policy changes that should be considered include increasing the Medicare hospice per diem rate for patients with complex needs, which could enable more hospices to expand enrollment.

The promise of clinical interventions for hepatocellular carcinoma from the west to mainland China

OBJECTIVE

Hepatocellular carcinoma (HCC) presents a major health problem with its steadily increasing incidence in Western countries, and persistent high fatality rates worldwide. The well-recognized complexity and toxicity of its treatment as well as inadequate care and limited resources in mainland China exacerbate the difficulty of maintaining quality of remaining life of patients living with this illness. The goal of this comprehensive literature review was to identify promising clinical interventions for improving quality of life (QOL) of people with advanced HCC in mainland China.

METHOD

A comprehensive literature review was performed in China Academic Journals (CAJ), Cochrane, and PubMed databases. The review was confined to studies of randomized controlled trials (RCT) for adults, in Chinese and English, from 1980 to 2012.

RESULTS

A total of 676 studies in Chinese and 391 studies in English were identified. Eighteen RCTs were selected for the final review, among which three were conducted in mainland China.

SIGNIFICANCE OF RESULTS

Nurse-led home-based comprehensive interventions using a collaborative care approach addressing multiple dimensions of QOL show promise for enhancing clinical outcomes for people with advanced HCC in mainland China. Education and psychosocial support combined with symptom management early in the illness trajectory and ongoing close attention to physical symptoms, emotional distress, as well as spiritual well-being are crucial for maintaining QOL of people with advanced HCC. Telephone monitoring appears to be a feasible way in rural as well as urban areas. Families are advised to be part of overall interventions. It is warranted that promising interventions aiming at improving QOL for advanced cancer patients reported in Western literature be further tested in mainland China.

An oncology nurse navigator program designed to eliminate gaps in early cancer care

Although the burden of a cancer diagnosis for patients is profound, healthcare systems often fail to address patients' and families' psychosocial, information, and care coordination needs. The authors of this article designed an oncology nurse navigator program to proactively address these care gaps and tested the program's effectiveness in providing high-quality cancer care through a randomized, controlled trial. The program's model was informed by research synthesizing the perspectives of patients, families, clinicians, and experts throughout the country. The authors systematically incorporated feedback from participating clinical departments to improve the effectiveness of the program. This article details the intervention to help inform other systems interested in implementing an oncology nurse navigator program.

Functional impairments as symptoms in the symptom cluster analysis of patients newly diagnosed with advanced cancer

CONTEXT

Symptoms and subsequent functional impairment have been associated with the biological processes of disease, including the interaction between disease and treatment in a measurement model of symptoms. However, hitherto cluster analysis has primarily focused on symptoms.

OBJECTIVES

This study among patients within 100 days of diagnosis with advanced cancer explored whether self-reported physical symptoms and functional impairments formed clusters at the time of diagnosis.

METHODS

We applied cluster analysis to self-reported symptoms and activities of daily living of 111 patients newly diagnosed with advanced gastrointestinal (GI), gynecological, head and neck, and lung cancers. Based on content expert evaluations, the best techniques and variables were identified, yielding the best solution.

RESULTS

The best cluster solution used a K-means algorithm and cosine similarity and yielded five clusters of physical as well as emotional symptoms and functional impairments. Cancer site formed the predominant organizing principle of composition for each cluster. The top five symptoms and functional impairments in each cluster were Cluster 1 (GI): outlook, insomnia, appearance, concentration, and eating/feeding; Cluster 2 (GI): appetite, bowel, insomnia, eating/feeding, and appearance; Cluster 3 (gynecological): nausea, insomnia, eating/feeding, concentration, and pain; Cluster 4 (head and neck): dressing, eating/feeding, bathing, toileting, and walking; and Cluster 5 (lung): cough, walking, eating/feeding, breathing, and insomnia.

CONCLUSION

Functional impairments in patients newly diagnosed with late-stage cancers behave as symptoms during the diagnostic phase. Health care providers need to expand their assessments to include both symptoms and functional impairments. Early recognition of functional changes may accelerate diagnosis at an earlier cancer stage.

Racial/ethnic differences in end-of-life (EoL) treatment preferences: The role of religious beliefs about care

6529

Background: Racial/ethnic minorities and patients who turn to religion to cope receive more aggressive EOL care. Beliefs underlying these associations are unknown. Methods: Coping with Cancer is an ongoing, multi-site, NCI-funded study examining factors influencing racial/ethnic EoL disparities. From 11/2010-10/2012, 133 advanced cancer patients underwent baseline interviews, including 7 items assessing religious beliefs about EoL care (RBEC). Univariate analyses assessed racial/ethnic differences in RBEC and EoL treatment preferences. Multivariable analyses (MVA) modeled mean RBEC score as a function of race/ethnicity, controlling for confounders, and assessed the relationship of race/ethnicity and RBEC to treatment preferences. Results: Religious beliefs about EoL care are common and more often held by racial/ethnic minorities (Table); racial/ethnic differences persisted in MVA (p<.0001). Black patients were more likely than Whites to prefer aggressive EOL care (OR=5.03, p=.02), whereas Latino’s EOL preferences did not differ from Whites (p=.87). In MVA including race and RBEC score, Black race was not related to EOL care preferences (OR 1.61, p=0.55), whereas greater RBEC score was associated with greater preference for aggressive care (OR 2.48, p=0.003). Conclusions: Religious beliefs about EoL care are common and significantly more so among racial/ethnic minorities. Preliminary data suggest these beliefs mediate the relationship between race/ethnicity and EoL treatment preferences. [Table: see text]

Do healthcare professionals discuss the emotional impact of cancer with patients?

BACKGROUND

It is known that cancer may affect patients' emotions and their relationships with other people and that those with strong emotional support may enjoy improved outcomes. We sought to determine the frequency with which healthcare professionals discuss the impact of cancer on patients' emotions and relationships with others.

METHODS

Data regarding healthcare professionals' discussions of the emotional impact of cancer and relevant covariates were obtained from the 2010 National Health Interview Survey. Statistical analyses were performed using sudaan software (Research Triangle Institute, Raleigh, NC, USA).

RESULTS

Of the 2074 people with a prior diagnosis of cancer surveyed, 701 (33.8%) claimed that a doctor, nurse, or other healthcare professional had discussed with them 'how cancer could affect their emotions or relationships with others'. Of these, 586 (84.5%) reported that they were 'very satisfied' with how well their emotional and social needs were met; 73.4% of those who had not had this discussion reported being very satisfied. Patients with leukemia/lymphoma, younger patients, African Americans, and those with a lower degree of education were most likely to report having discussions about emotional issues. Gender was not correlated with these discussions (30.6% in men vs. 33.3% in women). On multivariate analysis, age, race, and cancer type remained independent significant predictors of having a discussion regarding the emotional impact of cancer.

CONCLUSION

Only a third of cancer patients discussed the emotional impact of a cancer diagnosis with their healthcare professional. Age, race, and type of malignancy affect the likelihood of having these discussions.

Development of a chronic care ostomy self-management program

Each year a percentage of the 1.2 million men and women in the United States with a new diagnosis of colorectal cancer join the 700,000 people who have an ostomy. Education targeting the long-term, chronic care of this population is lacking. This report describes the development of a Chronic Care Ostomy Self-Management Program, which was informed by (1) evidence on published quality-of-life changes for cancer patients with ostomies, (2) educational suggestions from patients with ostomies, and (3) examination of the usual care of new ostomates to illustrate areas for continued educational emphases and areas for needed education and support. Using these materials, the Chronic Care Ostomy Self-Management Program was developed by a team of multi-disciplinary researchers accompanied by experienced ostomy nurses. Testing of the program is in process. Pilot study participants reported high satisfaction with the program syllabus, ostomy nurse leaders, and ostomate peer buddies.

Perceptions of roles, practice patterns, and professional growth opportunities: broadening the scope of advanced practice in oncology

Broadening the scope of advanced practice providers (APPs) has been offered as a solution to increasing healthcare costs, workforce shortage, and increased demand. To understand present scope and barriers to broadening it, the authors describe the perceptions and practice patterns of APPs. This cross-sectional study used a computerized self-report survey of 32 targeted nurse practitioners and physician assistants employed in the cancer center of an urban teaching hospital; 31 were included in the quantitative analyses. Survey items covered education and training background, expertise, professional resources and support, duties, certification, and professional development. Respondents practiced in a variety of oncology specialty areas, but all had advanced degrees, most held specialty certifications, and 39% had attended a professional or educational meeting within the last year. They spent a majority of their time on essential patient-care activities, but clerical duties impeded these; however, 64% reported being satisfied with the time they spent with patients and communicating with collaborating physicians. A model of advanced oncology practice needs to be developed that will empower APPs to provide high-quality patient care at the fullest extent of their knowledge and competence.

One step at a time: self-management and transitions among women with ovarian cancer

PURPOSE/OBJECTIVES

To describe experiences of self-management and transitioning among women with ovarian cancer.

RESEARCH APPROACH

Interpretive description.

SETTING

Participants' homes.

PARTICIPANTS

Purposive sample of 10 women with ovarian cancer.

METHODOLOGIC APPROACH

Individual interviews about women's self-management and transition experiences.

MAIN RESEARCH VARIABLES

Self-management, transitions, and ovarian cancer.

FINDINGS

Participants self-managed to increase their sense of control and to self-advocate. They managed their care one step at a time to prevent becoming overwhelmed. Common transitions were diagnosis, surgery and recovery, starting chemotherapy, managing symptoms, and recurrence. Transitions were challenging, even if previously experienced, and influenced the ability and willingness of women to self-manage. Barriers and facilitators to self-management were identified.

CONCLUSIONS

The approach to self-management of one step at a time is somewhat illusory, as women face multiple transitions simultaneously. The short trajectory of ovarian cancer leaves little time between transitions and an awareness of mortality. Women are forced to confront goals of care quickly, which may affect their ability to self-manage.

INTERPRETATION

Women with ovarian cancer need clinical and social support to prioritize and manage transitions. Introducing palliative care shortly after diagnosis could facilitate women's anticipation of and adjustment to transitions.

Validity testing of the stopwatch urine stream interruption test in radical prostatectomy patients

OBJECTIVE

To assess convergent validity of the stopwatch urine stream interruption test (UST). Specific aims were to describe relationships among stopwatch UST scores and 4 common clinical indices of pelvic floor muscle strength: 24-hour urine leakage, confidence in performing pelvic muscle exercise, 24-hour pad count, and daily pelvic muscle exercise count.

DESIGN

Secondary analysis; instrumentation study.

METHODS

The final sample consisted of baseline stopwatch UST scores and measurements of comparison variables from 47 participants in a randomized clinical trial of 3 approaches to pelvic floor training for patients with urinary incontinence following radical prostatectomy. The sample size provided 80% power to detect correlations of moderate strength or higher. The stopwatch UST was conducted in an examination room at the study site by trained study personnel (MP, ADC, JP, SM). Measurements of comparison variables were obtained from 3 instruments: 24-hour pad test, Broome pelvic muscle self-efficacy scale, and 3-day bladder diary. Relationships among study variables were evaluated with Pearson correlation coefficients.

RESULTS

Stopwatch UST scores were moderately correlated with 24-hour urine leakage on the 24-hour pad test (r = 0.35, P < .05), the most robust comparison measure. Correlations between stopwatch UST scores and all other comparison measures were in the appropriate direction, although weak, and did not reach statistical significance.

CONCLUSION

Findings suggest that the stopwatch UST may be a valid index of pelvic floor muscle strength in men following radical prostatectomy. With further testing, the stopwatch UST could become a valuable clinical tool for assessing pelvic floor muscle strength in radical prostatectomy patients with urinary incontinence.

Validity of the end-of-life professional caregiver survey to assess for multidisciplinary educational needs

The National Consensus Project for Quality Palliative Care (NCP) has put forth eight domains of clinical practice guidelines that address the multidisciplinary nature of palliative and end-of-life (EOL) care. Extant surveys to assess education needs of palliative and EOL workers, however, have been constructed for individual professions. Thus we developed the End-of-life Professional Caregiver Survey (EPCS) as an instrument for assessing the palliative and EOL care-specific educational needs of multidisciplinary professionals.