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Strohschein FJ, Qi S, Davidson S, Link C, Watson L. A Retrospective Age Analysis of the Ambulatory Oncology Patient Satisfaction Survey: Differences in Satisfaction across Dimensions of Person-Centred Care and Unmet Needs among Older Adults Receiving Cancer Treatment. Curr Oncol 2024; 31:1483-1503. [PMID: 38534946 PMCID: PMC10969488 DOI: 10.3390/curroncol31030113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 03/02/2024] [Accepted: 03/05/2024] [Indexed: 05/26/2024] Open
Abstract
Over half of all new cancer cases in Alberta are diagnosed among people aged 65+ years, a group that encompasses vast variation. Patient-reported experience measures are routinely collected within Cancer Care Alberta; however, the specific consideration of the needs and concerns of older Albertans with cancer is lacking. In 2021, 2204 adults who had received treatment at a cancer centre in Alberta completed the Ambulatory Oncology Patient Satisfaction Survey (AOPSS). In this study, we explored the age differences in satisfaction across six dimensions of person-centred care and in the proportions of unmet needs across eight types of issues, with specific attention to older adults. Using three age groups (18-39, 40-64, 65+), only the physical comfort dimension showed significantly lower satisfaction among those aged 65+ years. Using five age groups (18-39, 40-64, 65-74, 75-84, 85+), significantly lower levels of satisfaction were found related to 'physical comfort' for those aged 65-74 and 75-84, 'coordination and continuity of care' for those aged 75-84 and 85+, and 'information, communication, and education' for those aged 85+. Therefore, grouping together all older adults aged 65+ years obscured lower levels of satisfaction with some dimensions of person-centred care among those aged 75-84 and 85+ years. Unmet needs generally increased with age for all types of issues, with significant differences across age groups for emotional, financial, social/family, and sexual health issues. The lower levels of satisfaction and higher proportions of unmet needs call for tailored interventions to promote optimal care experiences and outcomes among older adults receiving cancer care in Alberta and their families.
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Affiliation(s)
- Fay J. Strohschein
- Faculty of Nursing, University of Calgary, Calgary, AB T2N 1N4, Canada
- Cancer Strategic Clinical Network, Alberta Health Services, Edmonton, AB T5J 3E4, Canada
| | - Siwei Qi
- Applied Research & Patient Experience, Cancer Care Alberta, Alberta Health Services, Calgary, AB T2S 3C3, Canada
| | - Sandra Davidson
- Faculty of Nursing, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Claire Link
- Applied Research & Patient Experience, Cancer Care Alberta, Alberta Health Services, Calgary, AB T2S 3C3, Canada
| | - Linda Watson
- Faculty of Nursing, University of Calgary, Calgary, AB T2N 1N4, Canada
- Applied Research & Patient Experience, Cancer Care Alberta, Alberta Health Services, Calgary, AB T2S 3C3, Canada
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Galiano A, Feltrin A, Pambuku A, Lo Mauro L, De Toni C, Murgioni S, Soldà C, Maruzzo M, Bergamo F, Brunello A, Zagonel V. What do cancer patients experience of the simultaneous care clinic? Results of a cross-sectional study on patient care satisfaction. Cancer Med 2024; 13:e7000. [PMID: 38400662 PMCID: PMC10891442 DOI: 10.1002/cam4.7000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/28/2024] [Accepted: 01/31/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Veneto Institute of Oncology has activated a simultaneous care outpatient clinic (SCOC) in which cancer patients with advanced-stage cancer are evaluated by oncologist and palliative care specialists. This cross-sectional study investigated patients' perceptions of the quality of this service. MATERIALS AND METHODS An ad-hoc self-administered questionnaire, developed by SCOC team, was used to assess the satisfaction of patients admitted at SCOC consultation. The questionnaire, in addition to the socio-demographic questions, contains eight questions with the Likert scale: time dedicated, feel listened to, feel understood, feel free to speak openly and to express doubts and concerns, feeling about information and indication received, level of empathy of health care and quality of the relationship, level of professional/quality of performance and utility of consultation, and one open-ended question. The questionnaire has been proposed to all 174 consecutively admitted patients at SCOC. RESULTS One hundred and sixty-two patients filled in the questionnaire: 66.7% were male, median age was 71 years, 88.3% had metastatic disease. The time dedicated to SCOC consultation was judged more than adequate (55%) or adequate (35%) by 90% of subjects. Patients completely satisfied about being listened to were 92.5%, with 80.9% being completely satisfied with understanding of their issues and 92% with the freedom to speak and express doubts. Usefulness of the SCOC was rated as excellent by 40% and good by 54.4% of patients. No statistically significant differences were observed in the responses to the questions by gender, age (< or ≥70 years old) and type of tumor. CONCLUSION Our study shows high levels of satisfactions after SCOC consultation in advanced cancer subjects. Patients' feedback confirmed that SCOC model was effective in helping them during their treatment journey and decision at the end of life. This study encouraged us to enhance our practice of SCOC consultation. IMPLICATIONS FOR PRACTICE A joint evaluation of patients living with cancer by oncologist and palliative care team (SCOC-embedded model), has shown to enhance patients' experience/satisfaction with care-such as listening, understanding, receiving information, symptom control, and decision about future, independently of age, gender, and kind of tumor.
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Affiliation(s)
- Antonella Galiano
- Department of Oncology, Oncology Unit 1Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | | | - Ardi Pambuku
- Pain Therapy and Palliative Care UnitVeneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | - Leda Lo Mauro
- Clinical Nutrition Unit, Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | - Chiara De Toni
- Department of Oncology, Oncology Unit 1Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | - Sabina Murgioni
- Department of Oncology, Oncology Unit 1Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | - Caterina Soldà
- Department of Oncology, Oncology Unit 1Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | - Marco Maruzzo
- Department of Oncology, Oncology Unit 1Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | - Francesca Bergamo
- Department of Oncology, Oncology Unit 1Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | - Antonella Brunello
- Department of Oncology, Oncology Unit 1Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | - Vittorina Zagonel
- Department of Oncology, Oncology Unit 1Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
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de Vries FE, Mah K, Malfitano C, Shapiro GK, Zimmermann C, Hales S, Rodin G. Clinical evaluation questionnaire in advanced cancer: a psychometric study of a novel measure of healthcare provider interactions. BMJ Support Palliat Care 2024; 13:e1093-e1102. [PMID: 35172981 DOI: 10.1136/bmjspcare-2021-003408] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/30/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The Clinical Evaluation Questionnaire (CEQ) is a patient-reported experience measure (PREM) that assesses the perceived benefit of therapeutic interactions of patients with advanced cancer with their healthcare providers concerning issues relevant to their illness. It was developed for a randomised controlled trial of Managing Cancer and Living Meaningfully (CALM), a brief supportive-expressive therapy for patients with advanced cancer. The present study evaluates the preliminary psychometric properties of the CEQ. METHOD Patients in the CALM and usual care groups completed the CEQ 3 (n=195) and 6 (n=186) months after randomisation. The CEQ's internal consistency, factor structure and concurrent validity were evaluated, and CEQ scores in the treatment groups were compared. RESULTS The CEQ demonstrated high internal consistency for both treatment arms (Cronbach's α=0.94 to 0.95), and a single factor was consistently found in exploratory factor analyses. CEQ scores correlated significantly with satisfaction with the relationship with healthcare providers (r=0.23 to 0.61, p≤0.02) and life completion (r=0.24 to 0.37, p≤0.02) in both groups and with spiritual well-being in the CALM group (meaning: r=0.23 to 0.24, p=0.01 to 0.02; faith: r=0.24 to 0.34, p=0.001 to 0.02). The CALM group showed higher CEQ total scores than usual care at 6 months (CALM: 18.19±6.59; usual care: 14.36±7.67, p<0.001). CONCLUSIONS The CEQ is a reliable and valid PREM of the benefit perceived by patients with advanced cancer from their interactions with healthcare providers. Further study is needed to establish its value as a measure of perceived intervention benefit across different clinical and research settings.
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Affiliation(s)
- Froukje E de Vries
- Department of Psychiatry, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Supportive Care, Princess Margaret Cancer Centre (University Health Network), Toronto, Ontario, Canada
| | - Kenneth Mah
- Department of Supportive Care, Princess Margaret Cancer Centre (University Health Network), Toronto, Ontario, Canada
| | - Carmine Malfitano
- Department of Supportive Care, Princess Margaret Cancer Centre (University Health Network), Toronto, Ontario, Canada
- Global Institute of Psychosocial, Palliative and End-of-Life Care (GIPPEC), Princess Margaret Cancer Centre (University Health Network) and University of Toronto, Toronto, Ontario, Canada
| | - Gilla K Shapiro
- Department of Supportive Care, Princess Margaret Cancer Centre (University Health Network), Toronto, Ontario, Canada
- Global Institute of Psychosocial, Palliative and End-of-Life Care (GIPPEC), Princess Margaret Cancer Centre (University Health Network) and University of Toronto, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre (University Health Network), Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Research Institute, Princess Margaret Cancer Centre (University Health Network), Toronto, Ontario, Canada
| | - Sarah Hales
- Department of Supportive Care, Princess Margaret Cancer Centre (University Health Network), Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Gary Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre (University Health Network), Toronto, Ontario, Canada
- Global Institute of Psychosocial, Palliative and End-of-Life Care (GIPPEC), Princess Margaret Cancer Centre (University Health Network) and University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Research Institute, Princess Margaret Cancer Centre (University Health Network), Toronto, Ontario, Canada
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Shield T, Bayliss K, Hodkinson A, Panagioti M, Wearden A, Flynn J, Rowland C, Bee P, Farquhar M, Harris D, Grande G. What factors are associated with informal carers' psychological morbidity during end-of-life home care? A systematic review and thematic synthesis of observational quantitative studies. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023:1-58. [PMID: 37991230 DOI: 10.3310/htjy8442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
Background Family carers are central in supporting patients nearing end of life. As a consequence, they often suffer detrimental impacts on their own mental health. Understanding what factors may affect carers' mental health is important in developing strategies to maintain their psychological well-being during caregiving. Aim To conduct a systematic review and thematic evidence synthesis of factors related to carers' mental health during end-of-life caregiving. Method Searches of MEDLINE, CINAHL, PsychINFO, Social Sciences Citation Index, EMBASE, Cochrane Central Register of Controlled Trials and Database of Abstracts of Reviews of Effects 1 January 2009-24 November 2019. We included observational quantitative studies focusing on adult informal/family carers for adult patients at end of life cared for at home considering any factor related to carer mental health (anxiety, depression, distress and quality of life) pre-bereavement. Newcastle-Ottawa Quality Assessment Scale was used. Thematic analysis with box score presentation, and meta-analysis were done where data permitted. Results Findings from 63 included studies underpinned seven emergent themes. Patient condition (31 studies): worse patient psychological symptoms and quality of life were generally associated with worse carer mental health. Patient depression was associated with higher depression in carers (standardised mean difference = 0.59, 95% confidence interval 0.32 to 0.87, I2 = 77%). Patients' other symptoms and functional impairment may relate to carer mental health, but findings were unclear. Impact of caring responsibilities (14 studies): impact on carers' lives, task difficulty and general burden had clear associations with worse carer mental health. Relationships (8 studies): family dynamics and the quality of the carer-patient relationship may be important for carer mental health and are worthy of further investigation. Finance (6 studies): insufficient resources may relate to carers' mental health and warrant further study. Carers' psychological processes (13 studies): self-efficacy and preparedness were related to better mental health. However, findings regarding coping strategies were mixed. Support (18 studies): informal support given by family and friends may relate to better carer mental health, but evidence on formal support is limited. Having unmet needs was related to worse mental health, while satisfaction with care was related to better mental health. Contextual factors (16 studies): older age was generally associated with better carer mental health and being female was associated with worse mental health. Limitations Studies were mainly cross-sectional (56) rather than longitudinal (7) which raises questions about the likely causal direction of relationships. One-third of studies had samples < 100, so many had limited statistical power to identify existing relationships. Conclusions and future work Future work must adopt a comprehensive approach to improving carers' mental health because factors relating to carer mental health cover a broad spectrum. The literature on this topic is diverse and difficult to summarise, and the field would benefit from a clearer direction of enquiry guided by explanatory models. Future research should (1) further investigate quality of relationships and finances; (2) better define factors under investigation; (3) establish, through quantitative causal analyses, why factors might relate to mental health; and (4) utilise longitudinal designs more to aid understanding of likely causal direction of associations. Study registration This study is registered as PROSPERO registration 2019 CRD42019130279 at https://www.crd.york.ac.uk/prospero/. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme HSDR 18/01/01 and is published in full in Health and Social Care Delivery Research. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Tracey Shield
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, UK
| | - Kerin Bayliss
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, UK
| | - Alexander Hodkinson
- NIHR Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
| | - Maria Panagioti
- NIHR Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
| | - Alison Wearden
- Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Manchester, UK
| | - Jackie Flynn
- Public and Community Involvement and Engagement (PCIE) Panel, NIHR Applied Research Collaboration (ARC) Greater Manchester, Manchester, UK
| | - Christine Rowland
- Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Manchester, UK
| | - Penny Bee
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, UK
| | - Morag Farquhar
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Danielle Harris
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, UK
- NIHR Applied Research Collaboration (ARC) Greater Manchester, Manchester, UK
| | - Gunn Grande
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, UK
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Quality of care and quality of life as experienced by patients with advanced cancer of a rare tumour type: results of the multicentre observational eQuiPe study. J Cancer Surviv 2023:10.1007/s11764-022-01323-8. [PMID: 36595186 DOI: 10.1007/s11764-022-01323-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 12/15/2022] [Indexed: 01/04/2023]
Abstract
PURPOSE Patients with a rare cancer face difficulties during their disease trajectory, such as delayed diagnosis and lack of expert care. However, little is known about their perceived quality of care (QoC) and quality of life (QoL) in the advanced disease stage. We aimed to assess the QoC and QoL as experienced by patients with advanced rare cancers compared to patients with advanced common cancers. METHODS In this cross-sectional study, baseline data of patients with advanced cancer from the multicentre, longitudinal, observational eQuipe study were analysed. Multivariable linear regression analyses were conducted to assess differences in experienced QoC (continuity of care, continuity of information, and satisfaction with care) and QoL (functioning, symptoms, overall QoL, and social wellbeing) between advanced rare and common cancer patients. RESULTS Of the 1087 included patients, 106 (9.8%) had a rare cancer type. In comparison to patients with advanced common cancers, patients with advanced rare cancers experienced significantly lower continuity of care (77.8 vs. 71.1 respectively, p = 0.011) and social functioning (78.8 vs. 72.6 respectively, p = 0.012). No differences were found regarding continuity of information, satisfaction with care, overall QoL, and social wellbeing. CONCLUSIONS Patients with advanced rare cancers experience less continuity of care, and the impact of the disease on social and family life seems higher compared to patients with advanced common cancers. IMPLICATIONS FOR CANCER SURVIVORS To enhance the QoC and QoL of patients with advanced rare cancers, supportive care should mainly focus on improving continuity of care and patients' social functioning.
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Morishita-Kawahara M, Koike K, Kawahara T, Kamibeppu K. The relationship between satisfaction with care and quality of life among family caregivers of of patients living with terminal cancer in general wards: a cross-sectional study. Int J Palliat Nurs 2022; 28:575-582. [DOI: 10.12968/ijpn.2022.28.12.575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background: Family caregivers of terminal cancer patients have reported experiencing low quality of life (QOL). Satisfaction with care has gained attention as a factor that correlates with QOL. Aim: To examine the relationship between ‘satisfaction with care’ and QOL of family caregivers of patients with terminal cancer. Methods: The study used a cross-sectional design and included family caregivers of patients with terminal cancer in general wards. The authors assessed family caregivers’ QOL using the caregiver quality of life index-cancer; a multivariable regression analysis was conducted to identify the factors associated with QOL. Findings: A total of 51 family caregivers enrolled in the study. Their satisfaction with care and the months since their initial diagnosis were positively associated with a more positive QOL. Conclusion: Satisfaction with care is correlated with QOL among family caregivers of patients with terminal cancer in general wards. Enhancing family caregivers’ satisfaction with care may contribute to improving their QOL.
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Affiliation(s)
- Miki Morishita-Kawahara
- Assistant Professor, Department of Gerontological Nursing, Tokyo Women's Medical University; Visiting Researcher, School of Health Sciences and Nursing, The University of Tokyo, Japan
| | - Kazuhiko Koike
- Professor, Graduate School of Medicine, The University of Tokyo, Japan
| | - Takuya Kawahara
- Assistant Professor, Clinical Research Promotion Center, The University of Tokyo Hospital, Japan
| | - Kiyoko Kamibeppu
- Professor, International University of Health and Welfare Graduate School; Professor, School of Health Sciences and Nursing, The University of Tokyo, Japan
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Lou Z, Vivas-Valencia C, Shields CG, Kong N. Examining how physician factors influence patient satisfaction during clinical consultations about cancer prognosis and pain. PEC INNOVATION 2022; 1:100017. [PMID: 37213781 PMCID: PMC10194410 DOI: 10.1016/j.pecinn.2022.100017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 12/07/2021] [Accepted: 01/03/2022] [Indexed: 05/23/2023]
Abstract
Objective Patient-physician communication affects cancer patients' satisfaction, health outcomes, and reimbursement for physician services. Our objective is to use machine learning to comprehensively examine the association between patient satisfaction and physician factors in clinical consultations about cancer prognosis and pain. Methods We used data from audio-recorded, transcribed communications between physicians and standardized patients (SPs). We analyzed the data using logistic regression (LR) and random forests (RF). Results The LR models suggested that lower patient satisfaction was associated with more in-depth prognosis discussion; and higher patient satisfaction was associated with a greater extent of shared decision making, patient being black, and doctor being young. Conversely, the RF models suggested the opposite association with the same set of variables. Conclusion Somewhat contradicting results from distinct machine learning models suggested possible confounding factors (hidden variables) in prognosis discussion, shared decision-making, and doctor age, on the modeling of patient satisfaction. Practitioners should not make inferences with one single data-modeling method and enlarge the study cohort to help deal with population heterogeneity. Innovation Comparing diverse machine learning models (both parametric and non-parametric types) and carefully applying variable selection methods prior to regression modeling, can enrich the examination of physician factors in characterizing patient-physician communication outcomes.
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Affiliation(s)
- Zhouyang Lou
- School of Industrial Engineering, Purdue University, West Lafayette, IN, USA
| | | | - Cleveland G. Shields
- Human Development and Family Studies, Purdue University, West Lafayette, IN, USA
| | - Nan Kong
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, USA
- Corresponding author at: Nan Kong 206 S. Martin Jischke Dr., West Lafayette, IN 47907, USA.
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Zomerdijk N, Panozzo S, Mileshkin L, Yoong J, Nowak AK, Stockler MR, Philip J. Palliative care facilitates the preparedness of caregivers for thoracic cancer patients. Eur J Cancer Care (Engl) 2022; 31:e13716. [PMID: 36169179 PMCID: PMC9786261 DOI: 10.1111/ecc.13716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 09/01/2022] [Accepted: 09/14/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Palliative care improves outcomes for patients with thoracic cancer; however, limited evidence exists for the benefits of this approach for caregivers. This study aimed to advance understanding of the experiences of palliative care described by bereaved caregivers. METHODS Fifteen adult caregivers completed semi-structured interviews following prior participation in a randomised controlled trial of early referral to palliative care versus discretionary referral to palliative care. Interviews explored caregiver experiences of palliative care delivery. Interview transcripts were thematically analysed. RESULTS Four related themes about the experiences of palliative care were identified, each of which required sufficient time between palliative care first contact and death: 'relationship building'; 'clear communication and information'; 'access to practical support'; and 'access to psychosocial support'. The core category underpinning these themes was palliative care facilitates caregiver preparedness. Caregivers noted that palliative care played a critical role in preparing them for the future and described a sense of practical and emotional 'relief' associated with the support services made available to them. CONCLUSION Our findings emphasise that palliative care can have a positive impact on caregivers' preparedness for providing the care needed by thoracic cancer patients and that this can improve the experiences of both caregivers and patients.
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Affiliation(s)
- Nienke Zomerdijk
- Melbourne School of Psychological SciencesUniversity of MelbourneParkvilleVictoriaAustralia,Victorian Comprehensive Cancer Centre AllianceParkvilleVictoriaAustralia
| | - Stacey Panozzo
- Peter MacCallum Cancer CentreParkvilleVictoriaAustralia,Department of MedicineUniversity of MelbourneParkvilleVictoriaAustralia,St Vincent's HospitalMelbourneVictoriaAustralia
| | | | - Jaclyn Yoong
- Monash UniversityMelbourneVictoriaAustralia,Monash HealthMelbourneVictoriaAustralia,Northern HealthMelbourneVictoriaAustralia,NHMRC Clinical Trials CentreUniversity of SydneyCamperdownNew South WalesAustralia
| | - Anna K. Nowak
- Medical SchoolThe University of Western AustraliaPerthWestern AustraliaAustralia,Department of Medical OncologySir Charles Gairdner HospitalNedlandsWestern AustraliaAustralia,National Centre for Asbestos Related DiseasesInstitute for Respiratory HealthPerthWestern AustraliaAustralia
| | - Martin R. Stockler
- NHMRC Clinical Trials CentreUniversity of SydneyCamperdownNew South WalesAustralia,Department of Medical OncologyChris O'Brien LifehouseSydneyNew South WalesAustralia
| | - Jennifer Philip
- Peter MacCallum Cancer CentreParkvilleVictoriaAustralia,Department of MedicineUniversity of MelbourneParkvilleVictoriaAustralia,St Vincent's HospitalMelbourneVictoriaAustralia,Royal Melbourne HospitalMelbourneVictoriaAustralia
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Kynoch K, Ameen M, Ramis MA, Khalil H. Use of Patient-Reported Data within the Acute Healthcare Context: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11160. [PMID: 36141433 PMCID: PMC9517657 DOI: 10.3390/ijerph191811160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/24/2022] [Accepted: 09/01/2022] [Indexed: 06/16/2023]
Abstract
Patient-reported outcome measures (PROMs), patient-reported experience measures (PREMs) and patient satisfaction surveys provide important information on how care can be improved. However, data collection does not always translate to changes in practice or service delivery. This scoping review aimed to collect, map and report on the use of collected patient-reported data used within acute healthcare contexts for improvement to care or processes. Using JBI methods, an extensive search was undertaken of multiple health databases and trial registries for published and unpublished studies. The concepts of interest included the types and characteristics of published patient experience and PROMs research, with a specific focus on the ways in which data have been applied to clinical practice. Barriers and facilitators to the use of collected data were also explored. From 4057 records, 86 papers were included. Most research was undertaken in North America, Canada or the UK. The Hospital Consumer Assessment of Healthcare Providers and Systems tool (HCAHPS) was used most frequently for measuring patient satisfaction. Where reported, data were applied to improve patient-centred care and utilization of health resources. Gaps in the use of patient data within hospital services are noticeable. Engaging management and improving staff capability are needed to overcome barriers to implementation.
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Affiliation(s)
- Kathryn Kynoch
- Mater Health and Queensland Centre for Evidence Based Nursing and Midwifery, A JBI Centre of Excellence, Brisbane 4006, Australia
| | - Mary Ameen
- Faculty of Medicine, Nursing and Health Sciences, Monash Rural Health Churchill, Monash University, Churchill 3842, Australia
| | - Mary-Anne Ramis
- Mater Health and Queensland Centre for Evidence Based Nursing and Midwifery, A JBI Centre of Excellence, Brisbane 4006, Australia
| | - Hanan Khalil
- School of Psychology and Public Health, La Trobe University, Melbourne 3086, Australia
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Qian CL, Kaslow-Zieve ER, Azoba CC, Horick N, Wang I, Van Seventer E, Newcomb R, Cashavelly BJ, Jackson VA, Ryan DP, Greer JA, El-Jawahri A, Temel JS, Nipp RD. Associations of patient-reported care satisfaction with symptom burden and healthcare use in hospitalized patients with cancer. Support Care Cancer 2022; 30:4527-4536. [PMID: 35112210 DOI: 10.1007/s00520-021-06764-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 12/14/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND Hospitalized patients with cancer often experience a high symptom burden, which may impact care satisfaction and healthcare utilization. METHODS We prospectively enrolled patients with cancer and unplanned hospitalizations from September 2014 to April 2017. Upon admission, we assessed patients' care satisfaction (FAMCARE items: satisfaction with care coordination and speed with which symptoms are treated) and physical (Edmonton Symptom Assessment System [ESAS]) and psychological (Patient Health Questionnaire-4 [PHQ-4]) symptoms. We used regression models to identify factors associated with care satisfaction and associations of satisfaction with symptom burden and hospital length of stay (LOS). RESULTS Among 1,576 participants, most reported being "satisfied"/ "very satisfied" with care coordination (90%) and speed with which symptoms are treated (89%). Older age (coordination: B < 0.01, P = 0.02, speed: B = 0.01, P < 0.01) and admission to a dedicated oncology service (B = 0.20, P < 0.01 for each) were associated with higher satisfaction. Higher satisfaction with care coordination was associated with lower ESAS-physical (B = - 1.28, P < 0.01), ESAS-total (B = - 2.73, P < 0.01), PHQ4-depression (B = - 0.14, P = 0.02), and PHQ4-anxiety (B = - 0.16, P < 0.01) symptoms. Higher satisfaction with speed with which symptoms are treated was associated with lower ESAS-physical (B = - 1.32, P < 0.01), ESAS-total (B = - 2.46, P < 0.01), PHQ4-depression (B = - 0.14, P = 0.01), and PHQ4-anxiety (B = - 0.17, P < 0.01) symptoms. Satisfaction with care coordination (B = - 0.48, P = 0.04) and speed with which symptoms are treated (B = - 0.44, P = 0.04) correlated with shorter LOS. CONCLUSIONS Hospitalized patients with cancer report high care satisfaction, which correlates with older age and admission to a dedicated oncology service. Significant associations among higher care satisfaction, lower symptom burden, and shorter hospital LOS highlight the importance of improving symptom management and care coordination in this population.
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Affiliation(s)
- Carolyn L Qian
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital Cancer Center & Harvard Medical School, 55 Fruit St., Yawkey 7B, Boston, MA, USA
| | - Emilia R Kaslow-Zieve
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital Cancer Center & Harvard Medical School, 55 Fruit St., Yawkey 7B, Boston, MA, USA
| | - Chinenye C Azoba
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital Cancer Center & Harvard Medical School, 55 Fruit St., Yawkey 7B, Boston, MA, USA
| | - Nora Horick
- Department of Statistics, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA
| | - Irene Wang
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital Cancer Center & Harvard Medical School, 55 Fruit St., Yawkey 7B, Boston, MA, USA
| | - Emily Van Seventer
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital Cancer Center & Harvard Medical School, 55 Fruit St., Yawkey 7B, Boston, MA, USA
| | - Richard Newcomb
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital Cancer Center & Harvard Medical School, 55 Fruit St., Yawkey 7B, Boston, MA, USA
| | - Barbara J Cashavelly
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital Cancer Center & Harvard Medical School, 55 Fruit St., Yawkey 7B, Boston, MA, USA
| | - Vicki A Jackson
- Department of Medicine, Division of Palliative Care, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA
| | - David P Ryan
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital Cancer Center & Harvard Medical School, 55 Fruit St., Yawkey 7B, Boston, MA, USA
| | - Joseph A Greer
- Department of Psychiatry, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA
| | - Areej El-Jawahri
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital Cancer Center & Harvard Medical School, 55 Fruit St., Yawkey 7B, Boston, MA, USA
| | - Jennifer S Temel
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital Cancer Center & Harvard Medical School, 55 Fruit St., Yawkey 7B, Boston, MA, USA
| | - Ryan D Nipp
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital Cancer Center & Harvard Medical School, 55 Fruit St., Yawkey 7B, Boston, MA, USA.
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11
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Kruuse-Jensen K, Madsen KS, Bruun DM, Pilegaard M. Do outpatients with cancer and their relatives want to use an online booking system to book the appointment and radiographer for their CT examination? A small-scale study in Denmark. Radiography (Lond) 2021; 28:174-179. [PMID: 34702667 DOI: 10.1016/j.radi.2021.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 07/09/2021] [Accepted: 10/07/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Previous studies have found that online booking systems may be the preferred scheduling tool when booking appointments with healthcare providers. The aim of this study was to examine I) if outpatients with cancer and relatives of cancer patients wanted to use an online booking system to book appointments for the CT examinations, and II) if they wanted to book specific radiographers for the CT examinations. METHODS An online questionnaire was distributed to outpatients with cancer and relatives of cancer patients registered in the user panel of the Danish Cancer Society. The questionnaires consisted of 13 questions for patients and eight questions for relatives. The study applied statistical analysis and qualitative content analysis with an inductive approach. RESULTS In total, 555 patients out of 760 (73%) and 115 out of 341 (34%) relatives were included in the present study and 54% of the patients and 65% of the relatives responded that they wanted, "To a high degree" or "To some degree", to use an online system for booking the appointment of the CT examination. Furthermore, 49% of the patients and 60% of the relatives found it important, "To a high degree" or "To some degree", that the appointment of the CT examination also suited their relatives. Only 37% of the patients, in contrast to 56% of the relatives, were interested in the opportunity to book specific radiographers. Approximately half of the patients (48%) and relatives (58%) were interested in being scanned by the same radiographers. CONCLUSION In this study, a majority of patients and relatives were interested in using an online booking system to book their CT examinations. Furthermore, while a majority of the relatives were more interested in booking specific radiographers for the CT examinations, only a few patients were interested in this function. IMPLICATIONS FOR PRACTICE Using an online booking system to book the appointment could benefit the overall experience for cancer patients and relatives when attending a CT examination to ensure that the appointment also suits the relatives.
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Affiliation(s)
- K Kruuse-Jensen
- Radiography, Department of Technology, University College Copenhagen, Sigurdsgade 26, 2200 Copenhagen N, Denmark; Centre of Diagnostic Investigation, Department of Diagnostic Radiology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark.
| | - K S Madsen
- Radiography, Department of Technology, University College Copenhagen, Sigurdsgade 26, 2200 Copenhagen N, Denmark; Danish Research Centre for Magnetic Resonance, Center for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager and Hvidovre, Kettegaard Allé 30, 2650 Hvidovre, Denmark.
| | - D M Bruun
- Danish Cancer Society, Strandboulevarden 49, 2100 Copenhagen Ø, Denmark.
| | - M Pilegaard
- Radiography, Department of Technology, University College Copenhagen, Sigurdsgade 26, 2200 Copenhagen N, Denmark.
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12
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Malhotra C, Chaudhry I, Ozdemir S, Teo I, Kanesvaran R. Experiences with health care practitioners among advanced cancer patients and their family caregivers: A longitudinal dyadic study. Cancer 2021; 127:3002-3009. [PMID: 33878215 DOI: 10.1002/cncr.33592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 03/23/2021] [Accepted: 03/23/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND Assessing patient and caregiver experiences with care is central to improving care quality. The authors assessed variations in the experiences of advanced cancer patients and their caregivers with physician communication and care coordination by patient and caregiver factors. METHODS The authors surveyed 600 patients with a stage IV solid malignancy and 346 caregivers every 3 months for more than 2 years. Patients entered the cohort any time during their stage IV trajectory. The analytic sample was restricted to patient-caregiver dyads (n = 299). Each survey assessed patients' experiences with physician communication and care coordination; patients' symptom burden; caregivers' quality of life; and patients' and caregivers' anxiety, financial difficulties, and perceptions of treatment goals. An actor-partner interdependence framework was used for analysis. RESULTS Patients reported better physician communication (average marginal effect [AME], 6.04; 95% confidence interval [CI], 3.82 to 8.26) and care coordination (AME, 8.96; 95% CI, 6.94 to 10.97) than their caregivers. Patients reported worse care coordination when they (AME, -0.56; 95% CI, -1.07 to -0.05) or their caregivers (AME, -0.58; 95% CI, -0.97 to -0.19) were more anxious. Caregivers reported worse care coordination when they were anxious (AME, -1.62; 95% CI, -2.02 to -1.23) and experienced financial difficulties (AME, -2.31; 95% CI, -3.77 to -0.86). Correct understanding of the treatment goal (vs being uncertain) was associated with caregivers reporting physician communication as better (AME, 3.67; 95% CI, 0.49 to 6.86) but with patients reporting it as worse (AME, -3.29; 95% CI, -6.45 to -0.14). CONCLUSIONS Patients' and caregivers' reports of physician communication and care coordination vary with aspects of their own and each other's well-being and with their perceptions of treatment goals. These findings may have implications for improving patients' and caregivers' reported experiences with health care practitioners.
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Affiliation(s)
- Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore, Singapore.,Health Services and System Research, Duke-NUS Medical School, Singapore, Singapore
| | - Isha Chaudhry
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore, Singapore.,Health Services and System Research, Duke-NUS Medical School, Singapore, Singapore
| | - Semra Ozdemir
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore, Singapore.,Health Services and System Research, Duke-NUS Medical School, Singapore, Singapore
| | - Irene Teo
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore, Singapore.,Health Services and System Research, Duke-NUS Medical School, Singapore, Singapore.,National Cancer Centre, Singapore, Singapore
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13
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Mah K, Swami N, O'Connor B, Hannon B, Rodin G, Zimmermann C. Early palliative intervention: effects on patient care satisfaction in advanced cancer. BMJ Support Palliat Care 2021; 12:218-225. [PMID: 33419858 DOI: 10.1136/bmjspcare-2020-002710] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 12/01/2020] [Accepted: 12/09/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE In a cluster-randomised controlled trial of early palliative care (EPC) in advanced cancer, EPC was robustly associated with increased patient satisfaction with care. The present study evaluated mediational mechanisms underlying this EPC effect, including improved physical and psychological symptoms and quality of life, as well as relationships with healthcare providers and preparation for end of life. METHOD Participants with advanced cancer (n=461) completed measures at baseline and then monthly to 4 months. Mediational analyses, using a robust bootstrapping approach, focused on 3-month and 4-month follow-up data. RESULTS At 3 months, EPC decreased psychological symptoms, which resulted in greater satisfaction either directly (βindirect effect=0.05) or through greater quality of life (βindirect effect=0.02). At 4 months, EPC increased satisfaction through improved quality of life (βindirect effect=0.08). Physical symptom management showed no significant mediational effects at either time point. Better relationships with healthcare providers consistently mediated the EPC effect on patient satisfaction at 3 and 4 months, directly (βindirect effect=0.13-0.16) and through reduced psychological symptoms and/or improved quality of life (βindirect effect=0.00-0.02). At 4 months, improved preparation for end-of-life mediated EPC effects on satisfaction by enhancing quality of life (βindirect effect=0.01) or by reducing psychological symptoms and thereby increasing quality of life (βindirect effect=0.02). CONCLUSION EPC increases satisfaction with care in advanced cancer by attending effectively to patients' emotional distress and quality of life, enhancing collaborative relationships with healthcare providers, and addressing concerns about preparation for end-of-life. TRIAL REGISTRATION NUMBER NCT01248624.
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Affiliation(s)
- Kenneth Mah
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Nadia Swami
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Brenda O'Connor
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Breffni Hannon
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Gary Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Princess Margaret Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada .,Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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14
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Bergerød IJ, Dalen I, Braut GS, Gilje B, Wiig S. Measuring next of kin satisfaction with hospital cancer care: Using a mixed-method approach as basis for improving quality and safety. J Adv Nurs 2020; 76:1232-1246. [PMID: 32026486 DOI: 10.1111/jan.14315] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 01/02/2020] [Accepted: 01/23/2020] [Indexed: 12/16/2022]
Abstract
AIM/S To explore next of kin satisfaction with cancer care, map next of kin suggestions for involvement and combine this information to create a basis for improving quality and safety in hospitals. DESIGN Convergent parallel mixed-methods design applying the 20-item FAMCARE Scale survey instrument for quantitative measurement of satisfaction with care and with an open-ended question used for qualitative analysis. DATA SOURCES Responses from 238 next of kin (November 2016-November 2017). METHODS Exploratory factor analysis, regression analysis and qualitative content analysis were combined. RESULTS Both hospitals scored better in medical treatment (median, interquartile range: 1.5, 1.1-2.0), than in satisfaction with information and involvement of next of kin (1.9, 1.3-2.4), p < .001 (Wilcoxon signed ranks test). After adjusting for differences in demographical and clinical variables, the total FAMCARE scores were 13% higher (95% confidence interval: 1%-27%, Wald p = .029) at one of the hospitals. Qualitative findings support that the hospitals are not providing an equal offer to next of kin involvement in hospital cancer care that includes a proactive approach. CONCLUSION As a basis for quality and safety improvement, next of kin satisfaction and involvement in cancer care should be addressed in a two-sided perspective, balancing the next of kin's need for involvement in cancer treatment with the patient's perspective. IMPACT There is limited knowledge of next of kin satisfaction with hospital cancer care and how next of kin would like to be involved in this trajectory. Several aspects of satisfaction with cancer care can prompt change to improve service quality and safety (e.g. information, involvement, practical care), but this is an underused source of information. Next of kin are key in cancer care and our study demonstrates a potential large impact on future practical ways of improving cancer care service provision in an integrative perspective including next of kin.
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Affiliation(s)
- Inger J Bergerød
- Department of Hematology and Oncology, Stavanger University Hospital, Stavanger, Norway.,SHARE - Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | | | - Geir S Braut
- Stavanger University Hospital, Stavanger, Norway
| | - Bjørnar Gilje
- Department of Hematology and Oncology, Stavanger University Hospital, Stavanger, Norway
| | - Siri Wiig
- SHARE - Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
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15
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Abstract
Family caregivers provide substantial care for patients with advanced cancer, while suffering from hidden morbidity and unmet needs. The objectives of this review were to examine risk factors associated with caregiving for patients with advanced cancer, evaluate the evidence for pertinent interventions, and provide a practical framework for palliative care of caregivers in oncology settings. We reviewed studies examining the association of factors at the level of the caregiver, patient, caregiver-patient relationship, and caregiving itself, with adverse outcomes. In addition, we reviewed randomized controlled trials of interventions targeting the caregiver, the caregiver-patient dyad, or the patient and their family. Risk factors for adverse mental health outcomes included those related to the patient's declining status, symptom distress, and poor prognostic understanding; risk factors for adverse bereavement outcomes included unfavorable circumstances of the patient's death. Among the 16 randomized trials, the most promising results showed improvement of depression resulting from early palliative care interventions; results for quality of life were generally nonsignificant or showed an effect only on some subscales. Caregiving outcomes included burden, appraisal, and competence, among others, and showed mixed findings. Only three trials measured bereavement outcomes, with mostly nonsignificant results. On the basis of existent literature and our clinical experience, we propose the CARES framework to guide care for caregivers in oncology settings: Considering caregivers as part of the unit of care, Assessing the caregiver's situation and needs, Referring to appropriate services and resources, Educating about practical aspects of caregiving, and Supporting caregivers through bereavement. Additional trials are needed that are powered specifically for caregiver outcomes, use measures validated for advanced cancer caregivers, and test real-world interventions.
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Affiliation(s)
- Sorayya Alam
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Breffni Hannon
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
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16
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Okado I, Cassel K, Pagano I, Holcombe RF. Development and psychometric evaluation of a questionnaire to measure cancer patients' perception of care coordination. BMC Health Serv Res 2020; 20:52. [PMID: 31964391 PMCID: PMC6975072 DOI: 10.1186/s12913-020-4905-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 01/13/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Although the importance of care coordination (CC) is well-recognized, cancer patients often receive poorly coordinated care across varied care settings and different oncology providers. Efforts to improve cancer care are hampered by lack of adequate measures. In this two-part, mixed-method study, we describe the development, refinement, and validation of a new care coordination instrument (CCI) designed to assess cancer patients' perception of CC. METHODS In Study 1, an initial CCI was developed incorporating questions based on literature review. The items were then modified following four field tests conducted in a large academic hospital with oncology nurses (n = 20) and cancer patients (n = 120). This modified instrument was used to determine whether the CCI was able to distinguish CC between two practices (30 GI and 30 myeloma patients) within the same hospital setting. In Study 2, 68 patients receiving community-based care participated in seven focus groups. Based on these discussions, the CCI items were again refined, and psychometric evaluation was conducted to assess the quality of the instrument. RESULTS Based on field tests, 3 domains of the CCI, Communication, Navigation, and Operational, were defined as critical components of CC. The Operational domain evaluates efficiency of care and is unique to this CCI. The field test demonstrated that GI patients reported significantly better CC Overall and for the Communication and Navigation domains (all p < .05). In Study 2, patients expressed concordance with the CCI items and their CC experiences, establishing validity of the CCI. Qualitative analysis of the focus group discussions indicated that the items with the highest frequencies of participants' comments were related to the concepts of Navigator, Team, Survey, and Communication. Quantitative analysis identified items with a limited response range or high rates of "neutral" responses; accordingly, those items were removed. The final CCI survey is a 29 item, multiple-choice questionnaire with excellent reliability, Cronbach's α = .922. CONCLUSIONS We developed a novel, patient-centered tool with excellent psychometric properties that can be utilized across varied practice settings to assess patients' perception of cancer care coordination. TRIAL REGISTRATION Not required; retrospectively registered ClinicalTrials.gov NCT03594006 20 July 2018.
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Affiliation(s)
- Izumi Okado
- University of Hawai'i Cancer Center, 701 Ilalo St. 6th Floor, Honolulu, HI, 96813, USA.
| | - Kevin Cassel
- University of Hawai'i Cancer Center, 701 Ilalo St. 6th Floor, Honolulu, HI, 96813, USA
| | - Ian Pagano
- University of Hawai'i Cancer Center, 701 Ilalo St. 6th Floor, Honolulu, HI, 96813, USA
| | - Randall F Holcombe
- University of Hawai'i Cancer Center, 701 Ilalo St. 6th Floor, Honolulu, HI, 96813, USA
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17
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Havyer RD, van Ryn M, Wilson PM, Bangerter LR, Griffin JM. Concordance of Patient and Caregiver Reports on the Quality of Colorectal Cancer Care. J Oncol Pract 2019; 15:e979-e988. [PMID: 31430216 PMCID: PMC6851791 DOI: 10.1200/jop.19.00136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2019] [Indexed: 11/20/2022] Open
Abstract
PURPOSE We aimed to better understand how similarly patients with colorectal cancer and caregivers view care quality and to assess factors that may influence concordance. MATERIALS AND METHODS We conducted a secondary analysis of paired patient and caregiver quality ratings of colorectal cancer care in three specific domains: surgery, chemotherapy overall, and chemotherapy nursing. Agreement was assessed with difference scores, concordance with Gwet second-order agreement statistics (AC2), and variation in agreement with stratified analyses. We examined whether the care experiences of patients and caregivers were associated with top-box (most-positive) ratings and examined variations in concordance on the basis of the presence of a top-box score. RESULTS Four hundred seventeen patient-caregiver dyads completed the surveys. Quality-of-care ratings were positively skewed, with most dyads indicating top-box ratings. Patient and caregiver care experiences were highly associated with top-box ratings. Overall patient-caregiver concordance was very high for all three care domains (surgery: AC2, 0.87 [95% CI, 0.83 to 0.90]; chemotherapy overall: AC2, 0.84 [95% CI, 0.79 to 0.88]; chemotherapy nursing: AC2, 0.91 [95% CI, 0.87 to 0.94]). Stratified analyses of patient and caregiver characteristics did not identify any patterns that consistently affected concordance. The concordance statistic significantly decreased for all three outcomes (P < .001), however, when the patient or caregiver assessed quality as anything other than top box. CONCLUSION Caregiver and patient reports on care quality were highly concordant for top-box care and did not vary with patient or caregiver factors. Additional exploration is needed to identify reasons for increased variability when the quality scores were less than a top-box response.
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18
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Teresi JA, Ocepek-Welikson K, Ramirez M, Ornstein KA, Bakken S, Siu A, Luchsinger JA. Psychometric Properties of a Spanish-Language Version of a Short-Form FAMCARE: Applications to Caregivers of Patients With Alzheimer's Disease and Related Dementias. JOURNAL OF FAMILY NURSING 2019; 25:557-589. [PMID: 31423925 PMCID: PMC6891123 DOI: 10.1177/1074840719867345] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Although family satisfaction is recognized as a critical indicator of quality care for persons with serious illness, Spanish-language measures are limited. The study aims were to develop a Spanish translation of the short-form Family Satisfaction With End-of-Life Care (FAMCARE), investigate its psychometric properties in Hispanic caregivers to patients with Alzheimer's disease and related dementias (ADRD; N = 317; 209 interviewed in Spanish), and add parameters to an existing item bank. Based on factor analyses, the measure was found to be essentially unidimensional. Reliabilities from a graded item response theory model were high; the average estimate was 0.93 for the total and Spanish-language subsample. Discrimination parameters were high, and the model fit adequate. This is the first study to examine the performance of the short-form FAMCARE measure among Hispanics and caregivers to patients with ADRD. The short-form measure can be recommended for Hispanics and caregivers to patients with ADRD.
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Affiliation(s)
- Jeanne A. Teresi
- Hebrew Home at Riverdale Research Division, Bronx, NY, USA
- Stroud Center, New York, NY, USA
- New York State Psychiatric Institute, New York, NY, USA
- Weill Cornell Medical Center, New York, NY, USA
| | | | - Mildred Ramirez
- Hebrew Home at Riverdale Research Division, Bronx, NY, USA
- Weill Cornell Medical Center, New York, NY, USA
| | | | - Suzanne Bakken
- Columbia University School of Nursing, New York, NY, USA
| | - Albert Siu
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- James J. Peters VA Medical Center, Bronx, NY, USA
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19
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Røen I, Stifoss-Hanssen H, Grande G, Kaasa S, Sand K, Knudsen AK. Supporting carers: health care professionals in need of system improvements and education - a qualitative study. BMC Palliat Care 2019; 18:58. [PMID: 31311536 PMCID: PMC6636145 DOI: 10.1186/s12904-019-0444-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 07/04/2019] [Indexed: 11/23/2022] Open
Abstract
Background Health care professionals should prevent and relieve suffering in carers of patients with advanced cancer. Despite known positive effects of systematic carer support, carers still do not receive sufficient support. Carers have reported to be less satisfied with coordination of care and involvement of the family in treatment and care decisions than patients. In a rural district of Mid-Norway, cancer palliative care services across specialist and community care were developed. Participants’ experiences and opinions were investigated as part of this development process. Methods The aim of this qualitative study was to explore and describe health care professionals’ experiences with carer support from their own perspective. Data were collected in focus groups. Purposeful sampling guided the inclusion. Six groups were formed with 21 professionals. The discussions were audio-recorded, transcribed, and analyzed using systematic text condensation. Results In the analyzis of the focus group discussions, ten categories emerged from the exploration of health care professionals’ carer support, assessment of needs, and factors hampering carer support: 1) dependent on profession, role, and context, 2) personal relationship, 3) personal skills and competence, 4) adjusted to the stage of the disease, 5) informal assessment of carers’ needs, 6) lack of education 7) lack of systems for carer consultations, 8) lack of systems for documentation, 9) lack of systems for involving GPs, and 10) lack of systematic spiritual care. Conclusions Health care professionals built a personal relationship with the carers as early as possible, to facilitate carer support throughout the disease trajectory. Systematic carer support was hampered by lack of education and system insufficiencies. Organizational changes were needed, including 1) education in carer support, communication, and spiritual care, 2) use of standardized care pathways, including systematic carer needs assessment, 3) systematic involvement of general practitioners, and 4) a system for documentation of clinical work with carers.
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Affiliation(s)
- Ingebrigt Røen
- European Palliative Care Research Centre (PRC), Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), 4. etg. Kunnskapssenteret vest, St. Olavs hospital, 7006, Trondheim, Norway. .,St. Olavs hospital HF, Trondheim University Hospital, 4. etg. Kunnskapssenteret vest, St. Olavs hospital, 7006, Trondheim, Norway.
| | - Hans Stifoss-Hanssen
- Center of diakonia and professional practice, VID Specialized University, Oslo, Norway
| | - Gunn Grande
- Division of Nursing, Midwifery and Social Work, The University of Manchester, Manchester, England
| | - Stein Kaasa
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Oncology, Oslo University Hospital, Oslo, Norway.,University of Oslo, Oslo, Norway
| | - Kari Sand
- European Palliative Care Research Centre (PRC), Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), 4. etg. Kunnskapssenteret vest, St. Olavs hospital, 7006, Trondheim, Norway
| | - Anne Kari Knudsen
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Oncology, Oslo University Hospital, Oslo, Norway
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20
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Conlon MSC, Caswell JM, Knight A, Ballantyne B, Santi SA, Meigs ML, Earle CC, Hartman M. Impact of comprehensive hospice palliative care on end-of-life care: a propensity-score-matched retrospective observational study. CMAJ Open 2019; 7:E197-E202. [PMID: 30948648 PMCID: PMC6450796 DOI: 10.9778/cmajo.20180148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Access to hospice palliative care may improve quality of life, reduce the use of potentially aggressive end-of-life care and allow for death to occur outside of an acute care hospital. The aim of this study was to examine the impact of an ambulatory hospice palliative care program on end-of-life care compared to care received by a matched control group of deceased patients. METHODS This retrospective study included patients who received hospice palliative care through the Symptom Management Program in Sudbury, Ontario, during 2012-2015. Using linked administrative health records, we defined a propensity-matched control group and derived 4 previously defined variables associated with aggressive end-of-life care (chemotherapy received in the last 2 wk of life, > 1 emergency department visit within 30 d of death, > 1 hospital admission within 30 d of death and at least 1 intensive care unit admission within 30 d of death). We also examined place of death. We measured family/caregiver satisfaction with care 3 months after the patient's death using the FAMCARE questionnaire. RESULTS Of 914 eligible decedents enrolled in the Symptom Management Program, 754 (82.5%) were matched. Receiving care through the program was protective for most measures of aggressive end-of-life care (absolute risk reduction [ARR] 12.73, 95% confidence interval [CI] 12.65-12.81 for any end-of-life care outcome) and death in an acute care setting (ARR 19.89, 95% CI 19.78-20.00). Of the 450 family caregivers invited to complete the FAMCARE questionnaire, 190 (42.2%) returned completed surveys; following data linkage and matching, 96 (21.3%) were available for analysis. Satisfaction with care received within the program appeared high (mean total score 85.72/100). INTERPRETATION Provision of hospice palliative care through this ambulatory program was associated with lower use of aggressive end-of-life care and death outside of an acute care hospital. Improving access could be expected to provide positive benefits at the individual and system level.
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Affiliation(s)
- Michael S C Conlon
- Epidemiology, Outcomes and Evaluation Research (Conlon, Caswell, Santi, Meigs), Health Sciences North Research Institute; ICES North Satellite Site (Conlon, Caswell), Health Sciences North Research Institute; Northeast Cancer Centre (Knight, Ballantyne, Hartman), Health Sciences North, Sudbury, Ont.; Cancer Care Ontario (Hartman); Ontario Palliative Care Network (Knight, Ballantyne); Canadian Partnership Against Cancer (Earle), Toronto, Ont.
| | - Joseph M Caswell
- Epidemiology, Outcomes and Evaluation Research (Conlon, Caswell, Santi, Meigs), Health Sciences North Research Institute; ICES North Satellite Site (Conlon, Caswell), Health Sciences North Research Institute; Northeast Cancer Centre (Knight, Ballantyne, Hartman), Health Sciences North, Sudbury, Ont.; Cancer Care Ontario (Hartman); Ontario Palliative Care Network (Knight, Ballantyne); Canadian Partnership Against Cancer (Earle), Toronto, Ont
| | - Andrew Knight
- Epidemiology, Outcomes and Evaluation Research (Conlon, Caswell, Santi, Meigs), Health Sciences North Research Institute; ICES North Satellite Site (Conlon, Caswell), Health Sciences North Research Institute; Northeast Cancer Centre (Knight, Ballantyne, Hartman), Health Sciences North, Sudbury, Ont.; Cancer Care Ontario (Hartman); Ontario Palliative Care Network (Knight, Ballantyne); Canadian Partnership Against Cancer (Earle), Toronto, Ont
| | - Barbara Ballantyne
- Epidemiology, Outcomes and Evaluation Research (Conlon, Caswell, Santi, Meigs), Health Sciences North Research Institute; ICES North Satellite Site (Conlon, Caswell), Health Sciences North Research Institute; Northeast Cancer Centre (Knight, Ballantyne, Hartman), Health Sciences North, Sudbury, Ont.; Cancer Care Ontario (Hartman); Ontario Palliative Care Network (Knight, Ballantyne); Canadian Partnership Against Cancer (Earle), Toronto, Ont
| | - Stacey A Santi
- Epidemiology, Outcomes and Evaluation Research (Conlon, Caswell, Santi, Meigs), Health Sciences North Research Institute; ICES North Satellite Site (Conlon, Caswell), Health Sciences North Research Institute; Northeast Cancer Centre (Knight, Ballantyne, Hartman), Health Sciences North, Sudbury, Ont.; Cancer Care Ontario (Hartman); Ontario Palliative Care Network (Knight, Ballantyne); Canadian Partnership Against Cancer (Earle), Toronto, Ont
| | - Margaret L Meigs
- Epidemiology, Outcomes and Evaluation Research (Conlon, Caswell, Santi, Meigs), Health Sciences North Research Institute; ICES North Satellite Site (Conlon, Caswell), Health Sciences North Research Institute; Northeast Cancer Centre (Knight, Ballantyne, Hartman), Health Sciences North, Sudbury, Ont.; Cancer Care Ontario (Hartman); Ontario Palliative Care Network (Knight, Ballantyne); Canadian Partnership Against Cancer (Earle), Toronto, Ont
| | - Craig C Earle
- Epidemiology, Outcomes and Evaluation Research (Conlon, Caswell, Santi, Meigs), Health Sciences North Research Institute; ICES North Satellite Site (Conlon, Caswell), Health Sciences North Research Institute; Northeast Cancer Centre (Knight, Ballantyne, Hartman), Health Sciences North, Sudbury, Ont.; Cancer Care Ontario (Hartman); Ontario Palliative Care Network (Knight, Ballantyne); Canadian Partnership Against Cancer (Earle), Toronto, Ont
| | - Mark Hartman
- Epidemiology, Outcomes and Evaluation Research (Conlon, Caswell, Santi, Meigs), Health Sciences North Research Institute; ICES North Satellite Site (Conlon, Caswell), Health Sciences North Research Institute; Northeast Cancer Centre (Knight, Ballantyne, Hartman), Health Sciences North, Sudbury, Ont.; Cancer Care Ontario (Hartman); Ontario Palliative Care Network (Knight, Ballantyne); Canadian Partnership Against Cancer (Earle), Toronto, Ont
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21
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Geessink NH, Ofstad EH, Olde Rikkert MGM, van Goor H, Kasper J, Schoon Y. Shared decision-making in older patients with colorectal or pancreatic cancer: Determinants of patients' and observers' perceptions. PATIENT EDUCATION AND COUNSELING 2018; 101:1767-1774. [PMID: 29933924 DOI: 10.1016/j.pec.2018.06.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 06/10/2018] [Accepted: 06/12/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To identify determinants of older patients' perceptions of involvement in decision-making on colorectal (CRC) or pancreatic cancer (PC) treatment, and to compare these with determinants of observers' perceptions. METHODS Patients' perceptions of involvement were constructed by the 9-item SDM questionnaire (SDM-Q-9) and a Visual Analogue Scale for Involvement (VAS-I). Observers' perceptions were constructed by the OPTION5, OPTION12, and MAPPIN'SDM. Convergent validities were calculated between the patient-sided and observer instruments using Spearman's correlation coefficient. Linear regression was used to identify determinants per criterion. RESULTS 58 CRC and 22 PC patients were included (mean age: 71.8 ± 5.2 years, 45.0% female). No significant correlations were found between the patient-sided and observer instruments. Patients' impression of involvement was influenced by patient characteristics such as quality of life and satisfaction, while observers' perceptions mainly referred to encounter characteristics such as the mean duration of consultations and general communication skills. CONCLUSION Due to evident differences in determinants, older CRC/PC patients' and observers' perceptions of involvement should both be collected in evaluating the quality of medical decision-making. PRACTICE IMPLICATIONS General communication skills should be integrated in SDM training interventions. New SDM measurement tools for patients are needed to sufficiently discriminate between the constructs of involvement and satisfaction.
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Affiliation(s)
- Noralie H Geessink
- Department of Geriatric Medicine, Radboud university medical center, Nijmegen, the Netherlands
| | - Eirik H Ofstad
- Department of Internal Medicine, Nordland Hospital Trust, Bodø, Norway
| | - Marcel G M Olde Rikkert
- Department of Geriatric Medicine, Radboud university medical center, Nijmegen, the Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud university medical center, Nijmegen, the Netherlands
| | - Jürgen Kasper
- Faculty of Health Sciences, Department Health and Caring Sciences, The Arctic University of Norway, Tromsø, Norway; Medical Clinics, University Medical Center, Tromsø, Norway
| | - Yvonne Schoon
- Department of Geriatric Medicine, Radboud university medical center, Nijmegen, the Netherlands; Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, the Netherlands.
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22
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Engel M, Brinkman-Stoppelenburg A, Nieboer D, van der Heide A. Satisfaction with care of hospitalised patients with advanced cancer in the Netherlands. Eur J Cancer Care (Engl) 2018; 27:e12874. [DOI: 10.1111/ecc.12874] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 04/13/2018] [Accepted: 05/17/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Marijanne Engel
- Department of Public Health; Erasmus Medical Center; Rotterdam the Netherlands
| | | | - Daan Nieboer
- Department of Public Health; Erasmus Medical Center; Rotterdam the Netherlands
| | - Agnes van der Heide
- Department of Public Health; Erasmus Medical Center; Rotterdam the Netherlands
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23
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Luth EA, Prigerson HG. Associations between Race and Dementia Status and the Quality of End-of-Life Care. J Palliat Med 2018; 21:970-977. [PMID: 29620949 PMCID: PMC6034391 DOI: 10.1089/jpm.2017.0638] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2018] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Non-Hispanic black and dementia patients receive more invasive and futile treatment at end of life (EOL) relative to others. Little is known about the relationship between race/ethnicity, dementia, and EOL care quality. OBJECTIVE Identify the relationship between race/ethnicity, dementia, and proxy reporters' evaluation of EOL care quality in older adults. DESIGN Latent class analysis (LCA) of national survey data. SETTING 1588 deceased Medicare beneficiaries age 65 and older from the National Health and Aging Trends Study (2011-2016). MEASUREMENTS LCA identified three types of quality EOL care using nine measures of symptom management, quality of healthcare encounters, and dignified treatment. Race and dementia were primary predictors of EOL care quality type. Adjusted models controlled for decedent education, sex, marital status, age, number of illnesses, number of hospitalizations, self-rated health, place of death, hospice involvement, and proxy relationship to decedent and familiarity with care. RESULTS Over 20% of proxies report that dying individuals experienced suboptimal EOL care quality, characterized by pain, sadness, poor communication, and inattention to personal care needs. In adjusted analyses, proxies for non-Hispanic black decedents were less likely to provide negative care assessments than proxies for non-Hispanic white decedents (adjusted odds ratio [AOR]: 0.58; 95% confidence interval [CI]: 0.40-0.86). Proxies for decedents with dementia were less likely to provide negative assessments than proxies for decedents without dementia (AOR: 0.70; 95% CI: 0.51-0.97). IMPLICATIONS Efforts to improve EOL care quality are needed. More positive EOL care quality assessments for non-Hispanic Black and dementia decedents appear counterintuitive given research demonstrating that these groups of individuals are likely to have received suboptimal EOL care. Because caregiver expectations for care may differ by decedent race and dementia status, research is needed to explore the role of caregiver expectations for EOL care to explain these paradoxical findings.
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Affiliation(s)
- Elizabeth A Luth
- Department of Medicine, Weill Cornell Medicine , New York, New York
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24
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Sandsdalen T, Høye S, Rystedt I, Grøndahl VA, Hov R, Wilde-Larsson B. The relationships between the combination of person- and organization-related conditions and patients' perceptions of palliative care quality. BMC Palliat Care 2017; 16:66. [PMID: 29212539 PMCID: PMC5719731 DOI: 10.1186/s12904-017-0240-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 11/14/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Little is known about the combination of person- and organization- related conditions and the relationships with patients' perspectives of care quality. Such a combination could contribute knowledge reflecting the complexity of clinical practice, and enhance individualized care. The aim was to investigate the relationships between the combination of person- and organization-related conditions and patients' perceptions of palliative care quality. METHODS A cross-sectional study, including 191 patients in the late palliative phase (73% response rate) admitted to hospice inpatient care (n = 72), hospice day care (n = 51), palliative units in nursing homes (n = 30) and home care (n = 38), was conducted between November 2013 and December 2014, using the instrument Quality from the Patients' Perspective specific to palliative care (QPP-PC). Data were analysed, using analysis of covariance, to explore the amount of the variance in the dependent variables (QPP-PC) that could be explained by combination of the independent variables - Person- and organization-related conditions, - while controlling for differences in covariates. RESULTS Patients scored the care received and the subjective importance as moderate to high. The combination of person- and organization - related conditions revealed that patients with a high sense of coherence, lower age (person - related conditions) and being in a ward with access to and availability of physicians (organization-related condition) might be associated with significantly higher scores for the quality of care received. Gender (women), daily contact with family and friends, and low health-related quality of life (person-related conditions) might be associated with higher scores for subjective importance of the aspects of care quality. CONCLUSION Healthcare personnel, leaders and policy makers need to pay attention to person- and organization-related conditions in order to provide person-centered palliative care of high quality. Further studies from palliative care contexts are needed to confirm the findings and to investigate additional organizational factors that might influence patients' perceptions of care quality.
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Affiliation(s)
- Tuva Sandsdalen
- Department of Health Studies, Faculty of Public Health, Inland Norway University of Applied Sciences, Post box 400, 2418 Elverum, Norway
- Department of Health Science, Faculty of Health, Science and Technology, Discipline of Nursing Science, Karlstad University, 651 88 Karlstad, Sweden
| | - Sevald Høye
- Department of Health Studies, Faculty of Public Health, Inland Norway University of Applied Sciences, Post box 400, 2418 Elverum, Norway
| | - Ingrid Rystedt
- Department of Health Science, Faculty of Health, Science and Technology, Discipline of Nursing Science, Karlstad University, 651 88 Karlstad, Sweden
| | | | - Reidun Hov
- Department of Health Studies, Faculty of Public Health, Inland Norway University of Applied Sciences, Post box 400, 2418 Elverum, Norway
| | - Bodil Wilde-Larsson
- Department of Health Studies, Faculty of Public Health, Inland Norway University of Applied Sciences, Post box 400, 2418 Elverum, Norway
- Department of Health Science, Faculty of Health, Science and Technology, Discipline of Nursing Science, Karlstad University, 651 88 Karlstad, Sweden
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25
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Galatsch M, Li J, Sayn-Wittgenstein FZ, Schnepp W. FAMILY CAREGIVER SATISFACTION WITH HOME-BASED PALLIATIVE CARE SERVICES IN NORTH RHINE-WESTPHALIA, GERMANY. CENTRAL EUROPEAN JOURNAL OF NURSING AND MIDWIFERY 2017. [DOI: 10.15452/cejnm.2017.08.0025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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26
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Danacı E, Koç Z. Caregiving Burden and Life Satisfaction Among Caregivers of Cancer Patients Admitted to the Emergency Department. Clin Nurs Res 2017. [PMID: 28621150 DOI: 10.1177/1054773817708083] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
This descriptive and cross-sectional study aimed to determine caregiving burden and life satisfaction among caregivers of cancer patients admitted to the emergency department. The study included 272 caregivers. Data were collected using an information form, the Zarit Burden Interview (ZBI), and the Satisfaction With Life Scale (SWLS). Among the patients, 19.1% were diagnosed with lung cancer; 44.1% were in the fourth stage of their disease; and 52% had metastasis. The mean ZBI total score was 41.2 ± 9.7, while the mean SWLS total score of caregivers was 17.6 ± 4.0. It was concluded that the mean ZBI and SWLS scores of patients' caregivers were moderately and negatively correlated ( p < .001, r = -.485). There was a negative and significant relationship between caregiving burden and quality of life.
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Affiliation(s)
- Esra Danacı
- 1 Ondokuz Mayıs University Hospital, Samsun, Turkey
| | - Zeliha Koç
- 2 Ondokuz Mayıs University, Samsun, Turkey
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27
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Feldstain A, MacDonald N, Bhargava R, Chasen M. Reported distress in patients living with advanced cancer: changes pre-post interdisciplinary palliative rehabilitation. Support Care Cancer 2017; 25:3191-3197. [DOI: 10.1007/s00520-017-3728-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 04/17/2017] [Indexed: 11/29/2022]
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28
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McDonald J, Swami N, Hannon B, Lo C, Pope A, Oza A, Leighl N, Krzyzanowska MK, Rodin G, Le LW, Zimmermann C. Impact of early palliative care on caregivers of patients with advanced cancer: cluster randomised trial. Ann Oncol 2017; 28:163-168. [PMID: 27687308 DOI: 10.1093/annonc/mdw438] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background Early palliative care improves the quality of life (QoL) and satisfaction with care of patients with advanced cancer, but little is known about its effect on caregivers. Here, we report outcomes of caregiver satisfaction with care and QoL from a trial of early palliative care. Patients and methods Twenty-four medical oncology clinics were cluster-randomised, stratified by tumour site (lung, gastrointestinal, genitourinary, breast and gynaecological), to early palliative care team referral, or to standard oncology care with palliative care only as needed. Caregivers of patients with advanced cancer (clinical prognosis of 6-24 months, Eastern Cooperative Oncology Group 0-2) in both trial arms completed validated measures assessing satisfaction with care (FAMCARE-19) and QoL [SF-36v2 Health Survey; Caregiver QoL-Cancer (CQoL-C)], at baseline and monthly for 4 months. We used a multilevel linear random-intercept mixed-effect model to test whether there was improvement in the intervention group relative to the control group over 3 and 4 months. Results A total of 182 caregivers completed baseline measures (94 intervention, 88 control); 151 caregivers (77 intervention, 74 control) completed at least one follow-up assessment. Satisfaction with care improved in the palliative intervention group compared with controls over 3 months (P = 0.007) and 4 months (P = 0.02). There was no significant improvement in the intervention group compared with controls for CQoL-C (3 months: P = 0.92, 4 months: P = 0.51), Physical Component Summary of the SF-36v2 Health Survey (3 months: P = 0.83, 4 months: P = 0.20), or Mental Component Summary of the SF-36v2 Health Survey (3 months: P = 0.87, 4 months: P = 0.60). Conclusion Early palliative care increased satisfaction with care in caregivers of patients with advanced cancer. ClinicalTrials.gov identifier NCT01248624.
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Affiliation(s)
- J McDonald
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada
| | - N Swami
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - B Hannon
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada
| | - C Lo
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada
| | - A Pope
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - A Oza
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada.,Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - N Leighl
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada.,Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - M K Krzyzanowska
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada.,Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - G Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada.,Campbell Family Research Institute, Toronto, Canada
| | - L W Le
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - C Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada.,Campbell Family Research Institute, Toronto, Canada
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29
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Burton-Chase AM, Parker WM, Polivka KM, Gritz ER, Amos CI, Lu KH, Lynch PM, Rodriguez-Bigas MA, Nancy You Y, Peterson SK. A comparison between Lynch syndrome and sporadic colorectal cancer survivors' satisfaction with their healthcare providers. Cancer Med 2017; 6:698-707. [PMID: 28211618 PMCID: PMC5345658 DOI: 10.1002/cam4.1033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 01/13/2017] [Accepted: 01/16/2017] [Indexed: 12/28/2022] Open
Abstract
This study evaluated provider satisfaction in a sample of colorectal cancer (CRC) survivors with and without Lynch syndrome (LS). Participants were case–case‐matched CRC survivors with (n = 75) or without (n = 75) LS (mean age of 55; range: 27–93). Participants completed a mailed questionnaire assessing demographics, clinical characteristics, healthcare utilization, psychosocial variables, and provider satisfaction. LS CRC survivors reported lower provider satisfaction scores on three subscales of the Primary Care Assessment Survey: communication (78.14 vs. 83.96; P < 0.05), interpersonal treatment (78.58 vs. 85.30; P < 0.05), and knowledge of the patient (60.34 vs. 69.86; P < 0.01). Among LS CRC survivors, predictors for mean communication and trust subscale scores were location of treatment and socioeconomic status. Higher mean depression scores also were associated with trust, while social support predicted higher satisfaction with communication. Sporadic CRC survivor satisfaction is driven largely by age (communication, interpersonal treatment) and patient anxiety (communication), while seeing a provider more often was associated with increased satisfaction with knowledge of the patient. LS CRC survivors reported lower levels of provider satisfaction than sporadic CRC survivors. LS survivors who received care at The University of Texas MD Anderson Cancer Center, a comprehensive cancer center (CCC), reported higher satisfaction than those receiving care at other institutions. Depressive symptoms and socioeconomic status may impact provider satisfaction ratings. Exploration of other potential predictors of provider satisfaction should be examined in this population. Additionally, further research is needed to examine the potential impact of provider satisfaction on adherence to medical recommendations in LS CRC survivors, particularly those being treated outside of CCCs.
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Affiliation(s)
- Allison M Burton-Chase
- Department of Population Health Sciences, Albany College of Pharmacy and Health Sciences, Albany, New York
| | - Wendy M Parker
- Department of Population Health Sciences, Albany College of Pharmacy and Health Sciences, Albany, New York
| | - Katrina M Polivka
- Division of Health Promotion & Behavioral Science, University of Texas Health Science Center-Houston School of Public Health, Houston, Texas
| | - Ellen R Gritz
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Christopher I Amos
- Department of Community and Family Medicine, Dartmouth College, Hanover, New Hampshire
| | - Karen H Lu
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Patrick M Lynch
- Department of Gastroenterology, Hepatology, & Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Miguel A Rodriguez-Bigas
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Y Nancy You
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan K Peterson
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, Texas
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30
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Sikavi D, Weseley AJ. The relationship between psychosocial factors in the patient-oncologist relationship and quality of care: A study of breast cancer patients. J Psychosoc Oncol 2016; 35:32-46. [PMID: 27918875 DOI: 10.1080/07347332.2016.1247406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
This study examined the relationship between psychosocial factors in the patient-oncologist relationship and aspects of care among women with breast cancer. Breast cancer patients (N = 118) completed a questionnaire about their relationship with their oncologist, their treatment, and their health. While trust was related to several positive outcomes, physician supportiveness was most strongly related to satisfaction with care, and health care access was most strongly associated with general health. The results suggest that the addition of supportiveness and healthcare access to trust provide a more complete picture of patients' health outcomes.
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Affiliation(s)
- Daniel Sikavi
- a Department of Ecology and Evolutionary Biology , Princeton University , Princeton , NJ , USA
| | - Allyson J Weseley
- b Behavioral Science Program , Roslyn High School , Roslyn Heights , NY , USA
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31
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Michels CTJ, Boulton M, Adams A, Wee B, Peters M. Psychometric properties of carer-reported outcome measures in palliative care: A systematic review. Palliat Med 2016; 30:23-44. [PMID: 26407683 PMCID: PMC4708617 DOI: 10.1177/0269216315601930] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Informal carers face many challenges in caring for patients with palliative care needs. Selecting suitable valid and reliable outcome measures to determine the impact of caring and carers' outcomes is a common problem. AIM To identify outcome measures used for informal carers looking after patients with palliative care needs, and to evaluate the measures' psychometric properties. DESIGN A systematic review was conducted. The studies identified were evaluated by independent reviewers (C.T.J.M., M.B., M.P.). Data regarding study characteristics and psychometric properties of the measures were extracted and evaluated. Good psychometric properties indicate a high-quality measure. DATA SOURCES The search was conducted, unrestricted to publication year, in the following electronic databases: Applied Social Sciences Index and Abstracts, Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library, EMBASE, PubMed, PsycINFO, Social Sciences Citation Index and Sociological Abstracts. RESULTS Our systematic search revealed 4505 potential relevant studies, of which 112 studies met the inclusion criteria using 38 carer measures for informal carers of patients with palliative care needs. Psychometric properties were reported in only 46% (n = 52) of the studies, in relation to 24 measures. Where psychometric data were reported, the focus was mainly on internal consistency (n = 45, 87%), construct validity (n = 27, 52%) and/or reliability (n = 14, 27%). Of these, 24 measures, only four (17%) had been formally validated in informal carers in palliative care. CONCLUSION A broad range of outcome measures have been used for informal carers of patients with palliative care needs. Little formal psychometric testing has been undertaken. Furthermore, development and refinement of measures in this field is required.
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Affiliation(s)
- Charlotte T J Michels
- Health Services Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Mary Boulton
- Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK
| | - Astrid Adams
- Sir Michael Sobell House, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Bee Wee
- Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK Sir Michael Sobell House, Oxford University Hospitals NHS Trust, Oxford, UK Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Michele Peters
- Health Services Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Tzelepis F, Sanson-Fisher RW, Zucca AC, Fradgley EA. Measuring the quality of patient-centered care: why patient-reported measures are critical to reliable assessment. Patient Prefer Adherence 2015; 9:831-5. [PMID: 26150703 PMCID: PMC4484696 DOI: 10.2147/ppa.s81975] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
PURPOSE The Institute of Medicine (IOM) identified patient-centeredness as crucial to quality health care. The IOM endorsed six patient-centeredness dimensions that stipulated that care must be: respectful to patients' values, preferences, and expressed needs; coordinated and integrated; provide information, communication, and education; ensure physical comfort; provide emotional support; and involve family and friends. Patient-reported measures examine the patient's perspective and are essential to the accurate assessment of patient-centered care. This article's objectives are to: 1) use the six IOM-endorsed patient-centeredness dimensions as a framework to outline why patient-reported measures are crucial to the reliable measurement of patient-centered care; and 2) to identify existing patient-reported measures that assess each patient-centered care dimension. METHODS For each IOM-endorsed patient-centeredness dimension, the published literature was searched to highlight the essential role of patients in assessing patient-centered care and informing quality improvement efforts. Existing literature was also searched to identify examples of patient-reported measures that assess each patient-centeredness dimension. CONCLUSION Patient-reported measures are arguably the best way to measure patient-centeredness. For instance, patients are best positioned to determine whether care aligns with patient values, preferences, and needs and the Measure of Patient Preferences is an example of a patient-reported measure that does so. Furthermore, only the patient knows whether they received the level of information desired, and if information was understood and can be recalled. Patient-reported measures that examine information provision include the Lung Information Needs Questionnaire and the EORTC QLQ-INFO25. In relation to physical comfort, only patients can report the severity of physical symptoms and whether medications provide adequate relief. Patient-reported measures that investigate physical comfort include the Pain Care Quality Survey and the Brief Pain Inventory. Using patient-reported measures to regularly measure patient-centered care is critical to identifying areas of health care where improvements are needed.
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Affiliation(s)
- Flora Tzelepis
- Priority Research Centre for Health Behaviour, University of Newcastle and Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Robert W Sanson-Fisher
- Priority Research Centre for Health Behaviour, University of Newcastle and Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Alison C Zucca
- Priority Research Centre for Health Behaviour, University of Newcastle and Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Elizabeth A Fradgley
- Priority Research Centre for Health Behaviour, University of Newcastle and Hunter Medical Research Institute, Newcastle, NSW, Australia
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Park EM, Check DK, Yopp JM, Deal AM, Edwards TP, Rosenstein DL. An exploratory study of end-of-life prognostic communication needs as reported by widowed fathers due to cancer. Psychooncology 2015; 24:1471-6. [PMID: 25655038 DOI: 10.1002/pon.3757] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Revised: 12/05/2014] [Accepted: 12/18/2014] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Effective physician communication about prognosis is a critical aspect of quality care for families affected by terminal illness. This is particularly important for spousal caregivers of terminally ill parents of dependent children, who may have unique needs for communication about anticipated death. The objective of this study was to explore end-of-life prognostic communication experiences reported by bereaved fathers whose wives died from cancer. METHODS From October 2012 to November 2013 we surveyed widowed fathers whose wives died from cancer through an open-access educational website. The survey included the following open-ended questions regarding prognostic communication: 'What is the most important thing you would like us to know about whether/how your wife's doctors communicated with you about her anticipated death? What do you wish had been different, if anything?' We performed traditional content analysis of responses. Two researchers coded and categorized the data. RESULTS Two hundred forty-four men responded to the survey questions on prognostic communication. Major themes addressed by respondents were the importance of clear and honest communication and physician bedside manner. They also identified unmet information needs, including wanting to know prognosis sooner. Relevant sub-themes included death coming as a surprise, avoidance, and caregiver regret. CONCLUSIONS Surviving spouses due to cancer can provide important insights for health care providers about optimum prognostic communication at the end of life. Increased physician attention to the communication preferences of both patients and their partners may improve bereavement outcomes for family members.
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Affiliation(s)
- Eliza M Park
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Devon K Check
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Justin M Yopp
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Teresa P Edwards
- H. W. Odum Institute for Research in Social Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Donald L Rosenstein
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Wittenberg-Lyles E, Demiris G, Oliver DP, Burchett M. Exploring aging-related stress among older spousal caregivers. J Gerontol Nurs 2014; 40:13-6. [PMID: 24840766 DOI: 10.3928/00989134-20140506-01] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Accepted: 04/30/2014] [Indexed: 11/20/2022]
Abstract
The goal of this study was to explore aging-related stress among older spousal caregivers providing hospice care for an older adult with cancer. Cases were selected from an ongoing randomized controlled trial that involved audiorecorded visits with caregivers over four different time points. Recordings consisted of caregivers discussing caregiving problems and ways they attempted to cope. Four caregiver cases comprising 16 audiorecordings were qualitatively analyzed for aging-related stress during caregiving. Caregiving stress primarily involved the patients' cognitive deficits. The caregiving experience also made older caregivers aware of their own aging and physical limitations, heightened self-imposed expectations to fulfill their role as spouse, and led them to consider their own mortality. This study informs development of caregiver interventions aimed at addressing the reciprocal challenge of caregiving and aging.
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