Feasibility of a randomized controlled trial of symptom screening and feedback to healthcare providers compared with standard of care using the SPARK platform

Validation of Patient-Reported Outcome Measure in Pediatric CKD (PRO-Kid)

Key Points

PRO-Kid is a patient-reported outcome measure of the frequency and burden of symptoms. Higher PRO-Kid scores are associated with lower Pediatric Quality of Life Inventory scores.

Background

Measuring the burden of symptoms that matter most to children and adolescents with CKD is essential for optimizing patient-centered care. We developed a novel CKD-specific patient-reported outcome measure (PRO-Kid) to assess both frequency and impact of symptoms in children. In this study, we further assessed the validity and internal consistency of PRO-Kid.

Methods

In this multicenter study, children age 8–18 years with stages 3–5 CKD, including those on dialysis, were recruited from five pediatric centers. Children completed the 14-item PRO-Kid questionnaire and the validated Pediatric Quality of Life Inventory (PedsQL 4.0). We explored the dimensionality of the PRO-kid scale using exploratory and confirmatory factor analysis, to either establish that it is a unidimensional construct or identify evidence of subfactors. We then assessed internal consistency (Cronbach alpha) and construct validity (Pearson correlations).

Results

In total, 100 children were included. The median eGFR was 27.4 ml/min per 1.73 m2 (7.43–63.4), and 26 children (26%) were on dialysis. Both the PRO-Kid frequency and the impact scales were unidimensional. Cronbach alpha was high for both the PRO-Kid frequency and impact scales, 0.83 (95% confidence interval [CI], 0.78 to 0.88) and 0.84 (95% CI, 0.80 to 0.89), respectively, showing strong internal consistency. Pearson correlations between PRO-Kid and PedsQL scores were also strong: −0.78 (95% CI, −0.85 to −0.70) for the frequency score and −0.69 (95% CI, −0.78 to −0.56) for the impact score, reflecting the association between poorer quality of life and higher symptom burden.

Conclusions

PRO-Kid is a novel patient-reported symptom burden tool for children age 8–18 years with CKD that correlates strongly in the expected direction with PedsQL, supporting its validity. Future work will evaluate changes in PRO-Kid score with progression of CKD and implementation of the tool into clinical care.

High Symptom Burden Predicts Poorer Quality of Life Among Children and Adolescents Receiving Hematopoietic Stem Cell Transplantation or Chimeric Antigen Receptor T-Cell Therapy

BACKGROUND

Children with cancer and other serious illnesses experience symptom burden during hematopoietic stem cell transplantation and chimeric antigen receptor T-cell therapy, yet limited research has characterized how these symptoms interact with overall quality of life over time.

OBJECTIVE

The aim of this study was to examine the longitudinal relationship between symptoms and quality of life in children receiving hematopoietic stem cell transplantation or chimeric antigen receptor T-cell therapy.

METHODS

A multisite study design was used to collect symptom and quality of life information at pre-cell infusion and days +30, +60, and +90 from children (N = 140) receiving hematopoietic stem cell transplantation and chimeric antigen receptor T-cell therapy. A longitudinal parallel process model was used to characterize the relationship between symptoms and quality of life.

RESULTS

Children (mean age, 8.4 years) received allogeneic transplant (57.9%), autologous transplant (25.7%), or chimeric antigen receptor T-cell therapy (16.4%). Symptom prevalence was highest at baseline (>50%) for pain, fatigue, nausea, vomiting, and low appetite. Quality of life scores were worse at baseline (mean [SD], 69.5 [15.8]) and improved by 10 points by day +90. The longitudinal model indicated high symptom prevalence at baseline predicted worse quality of life at both baseline and day +90.

CONCLUSIONS

Children felt worse early in the treatment trajectory and improved by day +90. The level of symptom burden predicted the overall quality of life at all time points.

IMPLICATIONS FOR PRACTICE

Children experiencing high symptom burden should receive frequent assessment and enhanced symptom management throughout the treatment trajectory to mitigate negative impacts on quality of life.

Patient-Reported Outcomes in Pediatric Patients With Cancer

Patient-reported outcomes (PROs) are reported directly by the patients about their own health. The objective of this article was to provide an overview of PROs in pediatric cancer, to describe how PROs can be incorporated into pediatric cancer clinical trials, and to discuss how PROs can guide symptom management treatment choices in pediatric oncology. Pediatric patient self-report provides a distinct voice in describing their experience compared with family caregiver or clinician report. Thus, every effort should be made to allow children to self-report symptoms, functioning, and other quality-of-life impacts and to use that data to inform treatment decision making. In addition to its incorporation into routine clinical care, it is also important to incorporate PROs into clinical trials to understand the patient experience of treatment toxicities and their impact on quality of life. Key considerations include clearly articulated PRO aims, selection of outcomes, choice of PRO measures, and frequency of PRO assessments. Once PROs are integrated into routine clinical care, it will be important to enable evidence-based symptom management. Strategies should be based on clinical practice guidelines (CPGs). Development and adaptation of care pathways on the basis of CPGs is one approach to standardize evidence-based symptom management at individual institutions. PROs are important to pediatric patients with cancer and their families. Self-report should be emphasized wherever possible. Approaches to enable PRO reporting into routine clinical care and enable preventative and therapeutic actions for symptom management are important. These efforts will optimize quality of life for pediatric patients with cancer.

The Effect of Technology-Based Interventions on Child and Parent Outcomes in Pediatric Oncology: A of Experimental Evidence

Objective

In recent years, childhood cancers have become an increasingly important health problem worldwide. Evidence shows that technology-based interventions in pediatric oncology are effective, feasible, and acceptable. However, studies in this field are limited. This systematic review was planned to examine the available evidence for the impact of technology-based interventions on children, adolescents with cancer patients, and their parents.

Methods

In the systematic review, studies published between 2014 and 2023 from The Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus with Full Text, Cochrane Library, PsycINFO, ProQuest PubMed, Science Direct, Scopus, and Web of Science databases were identified using a search strategy. Six studies by the criteria were examined in terms of the technology-based intervention, the intervention's duration, the follow-up period, significant findings, and the theory used in the intervention. The Joanna Briggs Institute (JBI) critical appraisal tools were used to evaluate the quality of the studies. In this systematic review, preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were followed.

Results

A total of six studies met the inclusion criteria: five randomized controlled trials and one quasi-experimental study. In studies for children with cancer, it was determined that the children were between the ages of 6 and 18. It has been determined that technology-based interventions mostly consist of electronic health interventions such as web-based interventions, virtual reality, and digital and mobile health interventions such as messaging, phone contact, and smartphone applications. In the studies, the intervention period ranged from 1 to 1.5 ​h and 10 weeks, and the follow-up periods ranged from 12 weeks to 6 months. In studies for parents, it was observed that the intervention durations ranged from 8 to 12 weeks, and the follow-up periods varied between 3 and 12 months. In most of the studies, technology-based applications have positive effects on the physical and psychological (symptom management, anxiety, stress, coping, and quality of life) problems of children and adolescents. Technology-based interventions affect parents' knowledge levels and coping skills, psychosocial symptoms (anxiety, post-traumatic stress disorder, depression, and caregiver burden), resilience, social support, and self-efficacy.

Conclusions

Technology-based interventions have been effective in improving physical and psychological symptoms in children with cancer, and parents' coping and psychosocial symptoms. These results should be interpreted with caution due to the limited number of studies, small sample sizes, and high heterogeneity. Comprehensive and high-quality randomized controlled trials are needed to obtain the best evidence for the effectiveness of technology-based interventions in pediatric oncology.

Systematic review registration

PROSPERO registration number was CRD42022297664.

Feasibility of three times weekly symptom screening in pediatric cancer patients

OBJECTIVE

Primary objective was to determine the feasibility of three times weekly symptom reporting by pediatric cancer patients for eight weeks.

METHODS

We included English-speaking patients 8-18 years of age with cancer. Patients were sent reminders by text or email to complete Symptom Screening in Pediatrics Tool (SSPedi) three times weekly for eight weeks. When patients reported at least one severely bothersome symptom, the symptom report was emailed to the primary healthcare team. Patient-reported outcomes were obtained at baseline, week 4 ± 1 and week 8 ± 1. Symptom documentation, intervention provision for symptoms and unplanned healthcare encounters were determined by chart review at weeks 4 and 8. The primary endpoint was feasibility, defined as at least 75% patients achieving adherence with at least 60% of SSPedi evaluations. We planned to enroll successive cohorts until this threshold was met.

RESULTS

Two cohorts consisting of 30 patients (cohort 1 (n = 20) and cohort 2 (n = 10)) were required to meet the feasibility threshold. In cohort 1, 11/20 (55%) met the SSPedi completion threshold. Interventions applied after cohort 1 included engaging parents to facilitate pediatric patient self-report, offering mechanisms to remember username and password and highlighting potential benefits of symptom feedback to clinicians. In cohort 2, 9/10 (90%) met the SSPedi completion threshold and thus feasibility was met. Patient-reported outcomes and chart review outcomes were obtained for all participants in cohort 2.

CONCLUSIONS

Three times weekly symptom reporting by pediatric patients with cancer for eight weeks was feasible. Mechanisms to enhance three times weekly symptom reporting were identified and implemented. Future studies of longitudinal symptom screening can now be planned.

The predictive trifecta? Fatigue, pain, and anxiety severity forecast the suffering profile of children with cancer

BACKGROUND

Fatigue, pain, and anxiety, symptoms commonly experienced by children with cancer, may predict pediatric symptom suffering profile membership that is amenable to treatment.

METHODS

Three latent profiles (Low, Medium, and High symptom suffering) from 436 pediatric patients undergoing cancer care were assessed for association with three single-item symptoms and socio-demographic variables.

RESULTS

Pediatric-PRO-CTCAE fatigue, pain, and anxiety severity scores at baseline were highly and significantly associated with the Medium and High Suffering profiles comprised of PROMIS pediatric symptom and function measures. The likelihood of membership in the Medium Suffering group was 11.37 times higher for patients who experienced fatigue severity than those with did not, while experience of pain severity increased the likelihood of the child's membership in the Medium Suffering profile by 2.59 times and anxiety by 3.67 times. The severity of fatigue increased the likelihood of presence in the High Suffering group by 2.99 times while pain severity increased the likelihood of the child's membership in the High Suffering profile by 6.36 times and anxiety by 16.75 times. Controlling for experience of symptom severity, older patients were more likely to be in the Higher or Medium Suffering profile than in the Low Suffering profile; no other socio-demographic or clinical variables had a significant effect on the latent profile classification.

CONCLUSION

Clinician knowledge of the strong association between fatigue, pain, and anxiety severity and suffering profiles may help focus supportive care to improve the cancer experience for children most at risk from time of diagnosis through treatment.

Barriers to symptom management care pathway implementation in pediatric Cancer

BACKGROUND

Objectives were to describe barriers to pediatric cancer symptom management care pathway implementation and the impact of the COVID-19 pandemic on clinical research evaluating their implementation.

METHODS

We included 25 pediatric oncology hospitals in the United States that supported a grant submission to perform a cluster randomized trial in which the intervention encompassed care pathways for symptom management. A survey was distributed to site principal investigators prior to randomization to measure contextual elements related to care pathway implementation. Questions included the inner setting measures of the Consolidated Framework for Implementation Research (CFIR), study-specific potential barriers and the impact of the COVID-19 pandemic on clinical research. The Wilcoxon rank sum test was used to compare characteristics of institutions that agreed that their department supported the implementation of symptom management care pathways vs. institutions that did not agree.

RESULTS

Of the 25 sites, one withdrew because of resource constraints and one did not respond, leaving 23 institutions. Among the seven CFIR constructs, the least supported was implementation climate; 57% agreed there was support, 39% agreed there was recognition and 39% agreed there was prioritization for symptom management care pathway implementation at their institution. Most common barriers were lack of person-time to create care pathways and champion their use (35%), lack of interest from physicians (30%) and lack of information technology resources (26%). Most sites reported no negative impact of the COVID-19 pandemic across research activities. Sites with fewer pediatric cancer patients were more likely to agree that staff are supported to implement symptom management care pathways (P = 0.003).

CONCLUSIONS

The most commonly reported barriers to implementation were lack of support, recognition and prioritization. The COVID-19 pandemic may not be a major barrier to clinical research activities in pediatric oncology.

Readiness to Implement Symptom Management Care Pathways in Pediatric Cancer

Background: To describe barriers to pediatric cancer symptom management care pathway implementation and the impact of the COVID-19 pandemic on clinical research evaluating their implementation. Methods: We included 25 pediatric oncology hospitals in the United States that supported a grant submission to perform a cluster randomized trial in which the intervention encompassed care pathways for symptom management. A survey was distributed to site principal investigators to measure contextual elements related to care pathway implementation. Questions included the inner setting measures of the Consolidated Framework for Implementation Research (CFIR), study-specific potential barriers and the impact of the COVID-19 pandemic on clinical research. The Wilcoxon rank sum test was used to compare characteristics of institutions that agreed that their department supported the implementation of symptom management care pathways vs. institutions that did not agree. Results: Of the 25 sites, one withdrew because of resource constraints and one did not respond, leaving 23 institutions. Among the seven CFIR constructs, the least supported was implementation climate; 57% agreed there was support, 39% agreed there was recognition and 39% agreed there was prioritization for symptom management care pathway implementation at their institution. Most common barriers were lack of person-time to create care pathways and champion their use (35%), lack of interest from physicians (30%) and lack of information technology resources (26%). Most sites reported no negative impact of the COVID-19 pandemic across research activities. Sites with fewer pediatric cancer patients were more likely to agree that staff are supported to implement symptom management care pathways (P=0.003). Conclusions: The most commonly reported barriers to implementation were lack of support, recognition and prioritization. The COVID-19 pandemic was not a major barrier to clinical research activities in pediatric oncology. Clinical Trial Registration: NCT04614662.