Using incentives in surveys of cancer patients: do "best practices" apply?

How to implement routine electronic patient-reported outcome monitoring in oncology rehabilitation

BACKGROUND

Implemenation of patient-reported outcomes (PRO) like quality of life can add the patient's perspective to traditional clinical outcomes of cancer rehabilitation in a structured and standardized way.

AIM

To present useful steps for a successful implementation of routine electronic patient-reported outcomes (ePRO) monitoring. The presented steps are exemplified by describing the procedure applied in an Austrian inpatient cancer rehabilitation centre.

METHODS

The suggested implementation steps are presented based on the structure of the replicating effective programmes framework, which was used for developing a pragmatic implementation strategy.

RESULTS

We scheduled alternating trainings and process evaluations for audit and enhancement of procedures. In this way, the ePRO participation rates could be improved. Stakeholder involvement led to initiatives that included the integration of ePRO data into the medical discharge letter and the implementation of follow-up assessments.

DISCUSSION

Tailored changes in assessment procedures enabled the successful implementation of ePRO, which has been shown to be feasible before and after cancer rehabilitation. The continuous involvement of stakeholders paved the way for further projects initiated by medical staff as users themselves (inclusion of PRO data in the discharge letter and a comprehensive ePRO follow-up using a versatile online patient portal).

Electronic Patient Reporting of Adverse Events and Quality of Life: A Prospective Feasibility Study in General Oncology

PURPOSE

Adverse event (AE) reporting is essential in clinical trials. Clinician interpretation can result in under-reporting; therefore, the value of patient self-reporting has been recognized. The National Cancer Institute has developed a Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) for direct patient AE reporting. A nonrandomized prospective cohort feasibility study aimed to explore the compliance and acceptability of an electronic (Internet or telephone) system for collecting patient self-reported AEs and quality of life (QOL).

METHODS

Oncology patients undergoing treatment (chemotherapy, targeted agents, hormone therapy, radiotherapy, and/or surgery) at 2 hospitals were sent automated weekly reminders to complete PRO-CTCAE once a week and QOL (for a maximum of 12 weeks). Patients had to speak/understand English and have access to the Internet or a touch-tone telephone. Primary outcome was compliance (proportion of expected questionnaires), and recruitment rate, attrition, and patient/staff feedback were also explored.

RESULTS

Of 520 patients, 249 consented (47.9%)-mean age was 62 years, 51% were male, and 70% were married-and 230 remained on the study at week 12. PRO-CTCAE was completed at 2,301 (74.9%) of 3,074 timepoints and QOL at 749 (79.1%) of 947 timepoints. Individual weekly/once every 4 weeks compliance reduced over time but was more than 60% throughout. Of 230 patients, 106 (46.1%) completed 13 or more PRO-CTCAE, and 136 (59.1%) of 230 patients completed 4 QOL questionnaires. Most were completed on the Internet (82.3%; mean age, 60.8 years), which was quicker, but older patients preferred the telephone option (mean age, 70.0 years). Positive feedback was received from patients and staff.

CONCLUSION

Self-reporting of AEs and QOL using an electronic home-based system is feasible and acceptable. Implementation of this approach in cancer clinical trials may improve the precision and accuracy of AE reporting.

Population-Based Survey Methods for Reaching Adolescent and Young Adult Survivors of Pediatric Cancer and Their Parents

PURPOSE

Contacting childhood cancer survivors (CCS) to assess reasons for declining receipt of follow-up care after treatment is difficult and participation in surveys may be low, resulting in biased results. We sought to demonstrate effective recruitment and population-based sampling methods to improve response and minimize bias.

METHODS

Four hundred and seventy CCS diagnosed between 2000 and 2007 at two hospitals in Los Angeles County were selected from the California Cancer Registry and were 15-25 years of age at the time of interview. Surveys of survivors and their parents were completed by multiple methods including mail, online, and telephone. Effectiveness of "plain" versus "designer" formatting of study materials was tested. Variables associated with response were analyzed using univariate and multivariable methods. Effort required for recruitment was quantified.

RESULTS

Fifty percent of survivors (n = 235) and 36.5% of parents (n = 171) responded, and there were 160 parent-child dyads among them. Among located survivors, 61% participated. Response was higher for women, parents of younger survivors, and those from higher socioeconomic status areas. Among Hispanics, no variables were related to response. More effort was required to reach men and older survivors, but efforts beyond 15 calls and 7 remailings were unproductive. Formatting (i.e., plain vs. designer) did not affect response.

CONCLUSION

Efforts to reach survivors must include multiple methods to be successful. Use of an intensive recruitment strategy and population-based sample resulted in a largely representative sample of CCS, especially for Hispanics. Expensive design efforts had little effect on recruitment, suggesting that plainer materials are sufficient. This example may inform similar studies.

The Effect of Financial Compensation on Willingness to Supply a Child's Blood Sample: A Randomized Controlled Trial

Medical researchers frequently need to collect blood samples from study participants. The determination of whether and how much compensation to provide to the participants is challenging. Institutional review boards typically allow researchers to provide a compensation that reimburses participants for their time and effort but is not so large as to be coercive. Using a randomized controlled trial, we estimate parents' responsiveness to financial compensation in terms of their willingness to provide their child's blood sample. We find that an additional dollar of compensation raises the willingness to provide a child's blood sample by about 0.5 percentage point at a base of 65%. This corresponds to an elasticity of .33. Using the findings, we provide general guidance on how compensation can be structured to strike a balance between appropriate compensation for participation and coercion.

Lottery ticket was more effective than a prize draw in increasing questionnaire response among cancer survivors

OBJECTIVES

Compare the effect of financial incentives on response to a cancer survivors' postal questionnaire.

STUDY DESIGN AND SETTING

Prostate cancer survivors in Ireland, 1.5-18 years after diagnosis, were randomized to the (1) "lottery" arm [a € 1 lottery scratch card sent with the questionnaire (n = 2,413)] or (2) "prize" arm [entry into a draw on return of a completed questionnaire (n = 2,407)]. Impact of interventions on response overall and by survival period ("short term": < 5 years after diagnosis; "long term": ≥ 5 years after diagnosis) was compared as was cost-effectiveness.

RESULTS

Adjusted response rate was 54.4%. Response was higher among younger men (P < 0.001) and those with earlier stage disease (P = 0.002). A modest 2.6% higher response rate was observed in the lottery compared with the prize arm [multivariate relative risk (RR) = 1.06; 95% confidence interval (CI): 1.00, 1.11]. When stratified by survival period, higher response in the lottery arm was only observed among long-term survivors (multivariate RR = 1.10; 95% CI: 1.02, 1.19; short-term survivors: RR = 1.01; 95% CI: 0.94, 1.09). Costs per completed questionnaire were € 4.54 and € 3.57 for the lottery and prize arms, respectively. Compared with the prize arm, cost per additional questionnaire returned in the lottery arm was € 25.65.

CONCLUSION

Although more expensive, to optimize response to postal questionnaires among cancer survivors, researchers might consider inclusion of a lottery scratch card.

Integrating patient reported outcomes with clinical cancer registry data: a feasibility study of the electronic Patient-Reported Outcomes From Cancer Survivors (ePOCS) system

Background

Routine measurement of Patient Reported Outcomes (PROs) linked with clinical data across the patient pathway is increasingly important for informing future care planning. The innovative electronic Patient-reported Outcomes from Cancer Survivors (ePOCS) system was developed to integrate PROs, collected online at specified post-diagnostic time-points, with clinical and treatment data in cancer registries.

Objective

This study tested the technical and clinical feasibility of ePOCS by running the system with a sample of potentially curable breast, colorectal, and prostate cancer patients in their first 15 months post diagnosis.

Methods

Patients completed questionnaires comprising multiple Patient Reported Outcome Measures (PROMs) via ePOCS within 6 months (T1), and at 9 (T2) and 15 (T3) months, post diagnosis. Feasibility outcomes included system informatics performance, patient recruitment, retention, representativeness and questionnaire completion (response rate), patient feedback, and administration burden involved in running the system.

Results

ePOCS ran efficiently with few technical problems. Patient participation was 55.21% (636/1152) overall, although varied by approach mode, and was considerably higher among patients approached face-to-face (61.4%, 490/798) than by telephone (48.8%, 21/43) or letter (41.0%, 125/305). Older and less affluent patients were less likely to join (both P<.001). Most non-consenters (71.1%, 234/329) cited information technology reasons (ie, difficulty using a computer). Questionnaires were fully or partially completed by 85.1% (541/636) of invited participants at T1 (80 questions total), 70.0% (442/631) at T2 (102-108 questions), and 66.3% (414/624) at T3 (148-154 questions), and fully completed at all three time-points by 57.6% (344/597) of participants. Reminders (mainly via email) effectively prompted responses. The PROs were successfully linked with cancer registry data for 100% of patients (N=636). Participant feedback was encouraging and positive, with most patients reporting that they found ePOCS easy to use and that, if asked, they would continue using the system long-term (86.2%, 361/419). ePOCS was not administratively burdensome to run day-to-day, and patient-initiated inquiries averaged just 11 inquiries per month.

Conclusions

The informatics underlying the ePOCS system demonstrated successful proof-of-concept – the system successfully linked PROs with registry data for 100% of the patients. The majority of patients were keen to engage. Participation rates are likely to improve as the Internet becomes more universally adopted. ePOCS can help overcome the challenges of routinely collecting PROs and linking with clinical data, which is integral for treatment and supportive care planning and for targeting service provision.