A mixed-methods evaluation of health-related quality of life for male veterans with and without intestinal stomas

PURPOSE

Intestinal stomas have a major impact on Cases' lives. It is essential to better understand the areas in which interventions may help to minimize the negative consequences.

METHODS

This was a case-control survey study using validated instruments (City of Hope Quality of Life-Ostomy and Short Form 36 for Veterans). Cases were accrued from Veterans Affairs Medical Centers in Tucson, Indianapolis, and Los Angeles. Eligibility included a major intra-abdominal surgical procedure that led to an ostomy (cases), or a similar procedure that did not mandate a stoma (controls). Analysis included quantitative and qualitative responses.

RESULTS

The response rate was 48 percent (511/1,063). Cases and controls had relatively similar demographic characteristics. Because of low numbers of female respondents (13 cases and 11 controls), only results for males are reported. Based on both the City of Hope Quality of Life-Ostomy and Short Form 36 for Veterans, cases reported significantly poorer scores on scales/domains reflecting psychologic and social functioning and well being. Additionally, cases reported poorer scores on Short Form 36 for Veterans scales reflecting physical functioning and significantly lower scores on multiple items in the social domain of the City of Hope Quality of Life-Ostomy compared with controls. Two-thirds of cases replied to an open-ended question on their "greatest challenge" related to their ostomy, which led to further clarification of major issues.

CONCLUSIONS

Multiple health-related quality of life problems were reported by male veterans with intestinal stomas. The greatest differences between cases and controls were observed in the social and psychologic domains/scales. Findings from this study provide a greater understanding of the challenges faced by ostomates and will inform the development and evaluation of urgently needed intervention strategies.

Breast cancer Internet information and support (BCIIS): How are older persons different?

The Breast Cancer Internet Information and Support study (BCIIS) is an online needs assessment that asks persons with breast cancer what types of informational and support features they would most prefer in Internet-based programming related to breast cancer. Preliminary analyses indicate significant differences in characteristics of older respondents related to physical and mental health as well as online support needs.

A Single-Item Approach to Screening Elders for Oral Health Assessment

BACKGROUND

Oral health contributes significantly to overall health. Finding a single item that can be used by primary care providers to screen elders who are in need of oral care is important.

OBJECTIVES

The objective of this article was to evaluate usefulness of the item: "Do you have regular dental checkups?" as a means to decide whether an oral health assessment or further referral is indicated. Answering no is postulated as a positive predictor of poor oral health and need for care.

METHODS

This study was a secondary analysis of a nutritional survey of 240 community-dwelling elders. Examiner-rated Kayser-Jones Brief Oral Health Status Examination; self-reported General Oral Health Assessment Index; number of remaining teeth; and pattern of checkups (regular vs. irregular) were evaluated by a trained gerontological nurse practitioner during an in-home assessment.

RESULTS

A dental visit within the past year for any reason was reported by 132 subjects (55.0%), but only 81 (33.8%) reported some sort of regular dental checkups. For dentate elders (n = 147), an irregular checkup was associated with lower educational level, Protestant faith, and Black race. People with irregular checkups scored significantly lower on all three oral indices. The negative predictive values and likelihood ratio negative values ranged 98.7-100.0% and 0.00-0.98, respectively, indicating that this item of interest is valid for ruling-out dentate subjects with good oral health. For edentulous elders (n = 93), the item was less effective.

DISCUSSION

A single item, "Do you have regular dental checkups?" can be used effectively to rule out dentate elders with good oral health and identify those who are in need of further oral health assessment or referrals.

Symptom management for cancer patients: a trial comparing two multimodal interventions

The results of a randomized controlled trial that tested the effects of eight-week, six-contact multidimensional interactive interventions for symptom management are presented. Four hundred and thirty-five cancer patients with solid tumors undergoing chemotherapy were randomized to receive either nurse-assisted symptom management (NASM) or automated telephone symptom management (ATSM). A prior trial established the effectiveness of NASM compared with conventional care. Seventeen symptoms commonly experienced by patients undergoing chemotherapy were rated on a scale from 0 to 10 and were evaluated at baseline, at each of the six intervention contacts, and postintervention observation at 10 weeks. Both groups achieved significant reduction in symptom severity over baseline, and there was no difference between groups on symptom severity at 10 weeks. Randomization accounted for possible reductions in severity due to response shifts. Severity of symptoms reported by patients at each of the six intervention contacts was measured using a Rasch model. Symptom pattern was different for lung and non-lung cancer patients, and they were analyzed separately. Longitudinal analyses revealed that lung cancer patients with greater symptom severity withdrew from later intervention contacts of the ATSM. The results suggest that both NASM and ATSM achieved a clinically significant reduction in symptom severity. The NASM may be more effective than ATSM in retaining lung cancer patients in the intervention. Further testing of ATSM supplemented by NASM for patients with severe symptoms is warranted.

Using a conceptual model in nursing research--mitigating fatigue in cancer patients

AIM

This paper is a discussion of the use of the Levine Conservation Model to guide the investigation of an exercise intervention to mitigate cancer-related fatigue.

BACKGROUND

Researchers use conceptual models or theoretical frameworks to provide an organizing structure for their studies, to guide the development and testing of hypotheses, and to place research finding within the context of science. Selection of an appropriate and useful framework is an essential step in the development of a research project.

METHOD

A descriptive approach is used to present the components of the conceptual model and details of the articulation of the study intervention and outcomes with the model.

FINDINGS

The Levine Conservation Model provided a useful framework for this investigation, conducted in 2002-2006, of the effects of exercise on fatigue and physical functioning in cancer patients. The four conservation principles of the model guided the development of the exercise intervention, the identification of salient outcomes for patients, and the selection of appropriate instruments to measure study variables. The model is also proving useful in the analysis and interpretation of data in relation to the conservation principles.

CONCLUSION

Use of an appropriate conceptual model facilitates the design and testing of theory-based interventions and the development of science to support nursing practice.

Effects of advanced practice nursing on patient and spouse depressive symptoms, sexual function, and marital interaction after radical prostatectomy

A secondary analysis of a prospective randomized clinical trial with repeated measures was conducted to examine the effects of a standardized nursing intervention on patient and spouse depressive symptoms, sexual function, and marital interaction. Another purpose of this study was to determine if, over time, differences existed in men and their spouses' levels of depressive symptoms, sexual function, and marital interaction following radical prostatectomy. Spouses reported significantly higher levels of depressive symptoms and significantly more marital interaction distress compared to patients. Patients reported significantly more distress pertaining to sexual function than their spouses.

Remedies and life changes among invasive cervical cancer survivors

This study addresses health practices and perceived disease impact among long-term survivors of invasive cervical cancer. Little is now known about how these women adapt and how often positive changes may result from their experience. Interviews were conducted with 208 individuals 6 to 29 years post-invasive cervical cancer diagnosis identified through the Connecticut Tumor Registry. Questioning focused on alternative remedies used, health practices, life priorities, and health status. Despite the challenges associated with a history of cervical cancer, women interviewed in this study found opportunities for adaptation and growth. Health professionals should inform cervical cancer patients about remedies that women have found valuable in promoting recovery, as well as share information about how survivors have grown personally through the disease experience.

Goal setting as a shared decision making strategy among clinicians and their older patients

OBJECTIVE

Older adults are less likely than other age groups to participate in clinical decision-making. To enhance participation, we sought to understand how older adults consider and discuss their life and health goals during the clinical encounter.

METHODS

We conducted six focus groups: four with community-dwelling older persons (n=42), one with geriatricians and internists (n=6), and one with rehabilitation nurses (n=5). Participants were asked to discuss: patients' life and health goals; communication about goals, and perception of agreement about health goals. Group interactions were tape-recorded, transcribed, and analyzed using content analysis.

RESULTS

All participants were willing to discuss goals, but varied in the degree to which they did so. Reasons for non-discussion included that goal setting was not a priority given limited time, visits focused on symptoms, mutual perception of disinterest, and the presumption that all patients' goals were the same.

CONCLUSION

Interventions to enhance goal setting need to address key barriers to promoting goals discussions. Participants recognized the benefits of goal setting, however, training and instruments are needed to integrate goal setting into medicine.

PRACTICE IMPLICATIONS

Setting goals initially and reviewing them periodically may be a comprehensive, time-efficient way of integrating patients' goals into their care plans.

Testing the effects of treatment complications on a cognitive-behavioral intervention for reducing symptom severity

Patients (n = 231) diagnosed with solid tumors and undergoing chemotherapy were randomly assigned to the experimental arm (n = 114) or to conventional care (n = 117). A symptom severity index based on summed severity scores across 15 symptoms was the primary outcome. Building on previously published work, an analysis was undertaken to determine the effects of patient characteristics and treatment complications on reductions in symptom severity achieved by a trial of a cognitive-behavioral intervention (CBI). The impact of the intervention on symptom severity differed by the occurrence of neutropenic events, chemotherapy dose delays or dose reductions, and number of comorbid conditions. Patients with more comorbid conditions, as well as those who did not experience neutropenia or dose delay/reduction, who received the intervention reported lower severity at 20 weeks compared to those who received conventional care. This research begins to specify the clinical conditions under which CBIs are effective in lowering symptom severity.

Spousal responses to prostate cancer: an integrative review

Prostate cancer is the most frequently diagnosed cancer in the United States. Survival rates of localized cancer are excellent, with more than 96 percent of men surviving 5 years after diagnosis. However, treatment such as radical prostatectomy may leave the patients and their spouses to deal with long-term side effects, including impotence and urinary incontinence. While previous studies have shown how men react to these treatment effects, studies are now emerging that focus on the responses of their spouses to diagnosis and treatment side effects. This integrative literature review examines the psychosocial responses of spouses whose husbands have undergone prostatectomy. Studies that report on spouses' responses to diagnosis, treatment, and side effects were reviewed. The literature shows that spouses are significantly more distressed overall than are patients. Sources of distress include lack of information, fear of the unknown, fear of what the future will hold, and treatment-related concerns. Only one controlled intervention study was found that attempted to address these concerns. Further controlled studies are needed to address spousal distress.

The VA Ostomy Health-Related Quality of Life Study: objectives, methods, and patient sample

OBJECTIVE

To present the design and methods of a multisite study of health-related quality of life (HR-QOL) in veterans living with ostomies.

RESEARCH DESIGN AND METHODS

Veterans from Tucson, Indianapolis, and Los Angeles VA Medical Centers were surveyed using the validated City of Hope ostomy-specific tool (mCOH-QOL-Ostomy) and the SF-36V. Cases (ostomates) had a major gastrointestinal procedure that required an intestinal stoma, while controls had similar procedures for which an ostomy was not required. Ostomy subjects were recruited for four focus groups in each of two sites divided by ostomy type (colostomy versus ileostomy) and overall mCOH-QOL-Ostomy HR-QOL score (highest versus lowest quartile). The focus groups further evaluated barriers, concerns, and adaptation methods and skills.

MAIN OUTCOME MEASURES

This report presents recruitment results, reliability of survey instruments, and demographic characteristics of the sample.

RESULTS

The overall response (i.e., recruitment) rate across all sites was 48% and by site was 53%, 57%, and 37%, respectively (p < 0.001). Internal consistency reliability estimates indicated that both instruments remain reliable in this population (Cronbach's alpha for HR-QOL domains/scales: 0.71-0.96). Cases and controls were similar in demographic characteristics. Proportions of minority subjects matched projections from the site patient populations. Subjects with ostomies had significantly longer time since surgery than controls (p < 0.001). Focus groups were comprised of two to six subjects per group and demonstrated racial diversity at the Los Angeles site.

CONCLUSIONS

The unique design of our study of VA patients with ostomies is an illustration of a successful mixed methods approach to HR-QOL research. We collected meaningful quantitative and qualitative data that will be used in the development of new approaches to care that will lead to improved functioning and well-being in persons living with ostomies. Subsequent reports will provide the results of this research project.

Factors related to depressive symptoms among long-term survivors of cervical cancer

In this article we describe depressive symptoms among survivors of cervical cancer. Study participants were previously diagnosed and treated with cervical cancer 5 to 25 years prior to the completion of a telephone survey. Through a population-based survey of women identified via a state tumor registry in southern New England, the investigators learned that depressive symptoms are prevalent among a subgroup of long-term survivors long after diagnosis and treatment. The at-risk participants included those who were at a lower economic status and whose marital status and ability to work had changed, and who continued to experience pain and diarrhea caused by radiotherapy. Findings from this study warrant additional research with this potentially vulnerable group of women.

Symptom assessment in community-dwelling older adults with advanced chronic disease

Brief symptom instruments are designed to assess symptoms while maintaining low respondent burden, but they may omit important information. Our objective was to determine whether a representative brief symptom instrument effectively captures the full symptom experience of older adults with advanced diseases. In this cross-sectional study, we interviewed 90 community-dwelling adults with cancer, congestive heart failure, or chronic obstructive pulmonary disease regarding the presence of symptoms in the prior 24 hours. Participants rated the intensity and bothersome nature of 15 symptoms--10 symptoms were included in the Edmonton Symptom Assessment Scale (ESAS) plus 5 supplemental symptoms. Participants reported similar proportions of ESAS and supplemental symptoms. Intensity and "bothersomeness" ratings frequently differed. Brief symptom instruments only provide a limited assessment of the respondent's symptom experience. The benefit obtained from incorporating both the intensity and bothersome nature of a longer list of symptoms may outweigh the potential increase in respondent burden.

Mixed models incorporating intra-familial correlation through spatial autoregression

Family researchers are challenged by the need to account for the special forms of statistical dependence that can exist in family data. To address this issue, mixed modeling methods were adapted to account for dependence of continuous outcomes measured across multiple family members. This was accomplished using a spatial autoregressive approach that accounts for dependence on direction as well as on distance apart. For family data, the dimensions underlying direction can correspond to different family members, thereby accounting for different correlations between family members. When the data are also longitudinal, a dimension representing distance apart in time also can be included to account for temporal correlation. Fixed effects involving general linear models can be included as well. Example analyses were conducted to demonstrate the use of the spatial autoregressive approach for modeling intra-familial correlation.

Dynamics of nutritional health in a community sample of american elders: a multidimensional approach using roy adaptation model

Nutritional health of community-dwelling elders has been shown to be one of the prime indices of health, influencing the elders' ability to live independently. However, little research has been directed toward understanding the dynamics of nutritional health in community-dwelling elders using a multidimensional theory approach. The purpose of this study was to evaluate the dynamics of nutritional health within the context of Roy Adaptation Model. Factors associated with nutritional health of community-dwelling elders were cross-examined. Depressive symptoms, functional status, oral health, and income emerged as independent predictors of nutritional health adjusting for confounders. This finding lends support to the notion that multidimensional biopsychosocial factors contribute to the dynamics of nutritional health.

Discrepancy in the preferences of place of death between terminally ill cancer patients and their primary family caregivers in Taiwan

There is a worldwide common preference for dying at home. However, death at home does not come without significant challenges and potential consequences for families. Given the interactive nature of decisions regarding the place of death, the family's perspective is important and needs to be investigated. The purposes of this study were to compare (1) Taiwanese terminally ill cancer patients' and their family caregivers' preferences for the patient's place of death; and (2) important factors that are considered in choosing the preferred place of death from both points of view. A total of 617 dyads of terminally ill cancer patients and their family caregivers were surveyed. The majority of both terminally ill cancer patients and their family caregivers preferred to die at home (61.0% and 56.9%, respectively). A higher proportion of the family caregivers indicated a preference for hospital death for the patients. There was a moderate association between the two respondents in the preferences of place of death. Results underscore discrepancies between patients and their families in the importance given to cultural concerns, quality of health care, worries of being a burden to others, lack of availability of families, relationships with health care providers, and being surrounded by the home environment. Effective interventions need to be developed which can lighten the caregiving burden and help families retain dying patients at home, avoid unnecessary re-hospitalizations and unfavorable hospital deaths, and improve accordance with the patient's wishes.

A Randomized Controlled Trial of Meditation and Massage Effects on Quality of Life in People with Late-Stage Disease: A Pilot Study

CONTEXT

Certain meditation practices may effectively address spiritual needs near end-of-life, an often overlooked aspect of quality of life (QOL). Among people subject to physical isolation, meditation benefits may be blunted unless physical contact is also addressed.

OBJECTIVE

To evaluate independent and interactive effects of Metta meditation and massage on QOL in people with acquired immunodeficiency syndrome (AIDS).

DESIGN

Randomized controlled blinded factorial pilot trial conducted from November 2001 to September 2003.

SETTING

An AIDS-dedicated skilled nursing facility in New Haven, Connecticut.

PARTICIPANTS

Fifty-eight residents (43% women) with late stage disease (AIDS or comorbidity).

INTERVENTIONS

Residents were randomized to 1 month of meditation, massage, combined meditation and massage, or standard care. The meditation group received instruction, then self-administered a meditation audiocassette daily. A certified massage therapist provided the massage intervention 30 minutes per day 5 days per week.

OUTCOME MEASURE

Changes on Missoula-Vitas QOL Index overall and transcendent (spiritual) scores at 8 weeks.

RESULTS

The combined group showed improvement in overall (p = 0.005) and transcendent (p = 0.01) scores from baseline to 8 weeks, a change significantly greater (p < 0.05) than the meditation, massage, and control groups.

CONCLUSIONS

The combination of meditation and massage has a significantly favorable influence on overall and spiritual QOL in late-stage disease relative to standard care, or either intervention component alone.

Comparison of health-related quality of life questionnaires in ambulatory oncology

The purpose of this study is to compare three commonly used health-related quality of life (HR-QOL) questionnaires for their ease of use, accuracy, and patient preference; identify factors related to patient preference; identify differences in patient completion rates; and to identify factors associated with patient completion of these questionnaires. Three psychometrically sound measures, the Symptom Distress Scale (SDS), Medical Outcome Study Short Form-36 (SF-36), and Functional Assessment of Cancer Therapy (FACT), were tested. Seventy-nine patients completed questionnaires in the ambulatory oncology setting. No significant differences in patient ratings were found in ease of use and accuracy among the questionnaires. All of the questionnaires were rated as easy to use and accurate. Patient ratings on preference were marginally significant (p = 0.07). Forty-six percent of participants indicated that they preferred the SDS, whereas 27% and 39% preferred the SF-36 and the FACT. No significant differences in patient completion rates were found among the questionnaires. One hundred percent completion rates ranged from 88.6% for the SDS to 78.5% for the SF-36, and 80% completion rates ranged from 98.7% for the SDS to 94.9% for the SF-36. Administration of standardized HR-QOL questionnaires is feasible in the clinical setting.