Evaluating the quality of life of cancer patients: assessments by patients, significant others, physicians and nurses

Cancer symptoms: do patients, family caregivers and professionals agree?

OBJECTIVES

To assess the level of agreement among patients, their family caregivers and health professionals regarding the symptoms presented by patients with cancer.

METHODS

This is a cross-sectional study carried out in patients with cancer admitted to a hospital in Brazil from December 2019 to July 2020. One family caregiver for each patient was included in the study. In addition, nurses and physicians involved in patient care were included. Patients, family caregivers and health professionals responded to the Palliative Outcome Scale (POS).

RESULTS

Sixty-one patients with their family caregivers, 18 nurses and 8 physicians were included. Physicians reported a lower mean POS score than patients (p=0.008). In general, physicians and nurses underestimated the anxiety of the patient and the anxiety of the family caregivers and how much the patient feels that his or her life is worthwhile. Intraclass correlation coefficient showed moderate and good levels of agreement between patients' and family caregivers' responses (0.61). Agreement between patient and nurse (0.02) and physician (0.21) responses was poor.

CONCLUSIONS

The level of agreement between patients and healthcare professionals was very poor regarding patients' symptoms. However, the caregiver's perception of the patient's symptoms can be a reliable source of information.

Reliability and validity of the Turkish voice handicap index-partner (VHI-P-TR)

OBJECTIVE

This study examines the Turkish validity, reliability and diagnostic performance of the Voice Handicap Index-Partner (VHI-P-TR), which is used to obtain the perceptions of communication partners of individuals with dysphonia about the functional, physical and emotional handicap resulting from the patient experiencing dysphonia.

METHOD

The study included 160 individuals with dysphonia and their communication partners. First, translation, back translation, expert validity and pilot study were performed in the scale adaptation process. Then, a confirmatory factor analysis (CFA) was conducted to assess the construct validity of the VHI-P-TR. Correlations between the VHI-P-TR and Voice Handicap Index (VHI-TR) scores of dysphonic individuals were examined to evaluate the concurrent validity of the VHI-P-TR. To assess the reliability of the VHI-P-TR, a test-retest analysis was performed, and internal consistency coefficients (α) were calculated. A receiver operating characteristic (ROC) analysis was conducted to determine the cut-off point for the VHI-P scores.

RESULTS

A high positive correlation was found between the participants' VHI-P-TR and VHI-TR total and subscales mean scores (r's > 0.782; p < 0.01). The VHI-P-TR had high internal consistency regarding for its subscales and total score (α's > 0.94; p < 0.01). Factor loadings of all VHI-P-TR items were higher than 0.30 and their error variances were lower than 0.90. In addition, factor loadings were statistically significant for all the items (p < 0.05). The data fit the model well according to all CFA indices except for GFI (scale = 0.69). An adequate sensitivity and specificity were achieved for the VHI-P-TR, and the cut-off point was found as 11.50 for the total score and ranged from 2.50 to 5.50 for the subscales.

CONCLUSION

The VHI-P-TR is a valid and reliable measurement tool with high diagnostic performance in all subscales and total score, and has high levels of agreement with the VHI-TR.

Palliative clinical trials in advanced chronic liver disease: Challenges and opportunities

Patients with advanced chronic liver disease have a complex symptom burden and many are not candidates for curative therapy. Despite this, provision of palliative interventions remains woefully inadequate, with an insufficient evidence base being a contributory factor. Designing and conducting palliative interventional trials in advanced chronic liver disease remains challenging for a multitude of reasons. In this manuscript we review past and ongoing palliative interventional trials. We identify barriers and facilitators and offer guidance on addressing these challenges. We hope that this will reduce the inequity in palliative care provision in advanced chronic liver disease.

Measuring the reliability of proxy respondents in behavioural assessments: an open question

BACKGROUND

In behavioural assessment, information can be gathered from internally referenced self-reports or from proxy informants.

AIMS

This study aimed to fine-tune a brief but reliable method for evaluating the proxy accuracy in cases where responses obtained from adult and older adults' patient cannot be considered reliable.

METHODS

We generated a set of items reflecting both overt and covert behaviours related to the basic instrumental activities of daily living. The psychometric properties of the content, factorial, and criterium validity of these items were then checked. The Proxy Reliability Questionnaire-ProRe was created. We tested the frequency of "I don't know" responses as a measure of proxy reliability in a sample of healthy older adults and their proxies, and in a second sample of proxy respondents who answered questions about their parents.

RESULTS

As expected, response precision was lower for items characterizing covert behaviours; items about covert compared to overt behaviours generated more "I don't know" answers. Proxies provided less "I don't know" responses when evaluating the parent, they claimed they knew better. Moreover, we tried to validate our approach using response confidence. Encouragingly, these results also showed differences in the expected direction in confidence between overt and covert behaviours.

CONCLUSIONS

The present study encourages clinicians/researchers to how well the proxy the patient know each other, the tendency of proxies to exhibit, for example, response bias when responding to questions about patients' covert behaviours, and more importantly, the reliability of informants in providing a clinical assessment of neurocognitive diseases associated with aging.

Health-Related Quality of Life in Adolescents With Chronic Illness in Jamaica: Adolescent and Parent Reports

PURPOSE

The aim of this study is to assess the level of agreement between adolescents' self-assessment and parent-proxy reports on health-related quality of life (HRQOL) in Jamaican adolescents with chronic illness.

METHODS

A cross-sectional study was conducted, recruiting adolescents living with a chronic illness (ALCIs)-asthma, human immunodeficiency virus, insulin-dependent diabetes mellitus, or sickle cell disease and age/sex-matched healthy adolescents. Data were collected on HRQOL from adolescents and parents using the Pediatric Quality of Life Scale. Parent-adolescent agreement was determined at group level (Wilcoxon signed-rank test) and individual level (intraclass correlation coefficient).

RESULTS

Two hundred twenty-six (226) parent/adolescent pairs participated: 130 ALCIs and 96 healthy peers; mean age 14.9 ± 2.8 years; 58% females. Adolescents with and without chronic illness reported similar HRQOL; parent-proxies reported better HRQOL for healthy adolescents compared to ALCIs. Intraclass correlation demonstrated higher levels of parent-adolescent correlation for ALCIs than healthy adolescents (ALCIs: 0.11-0.34; healthy adolescents: 0.01-0.10). At group level, analyses demonstrated better parent-proxy rating of QOL in all of the scores with the exception of the general health score. Parent-proxies overestimated QOL for asthma and insulin-dependent diabetes mellitus but not for sickle cell disease and human immunodeficiency virus. Linear regression modeling revealed that female sex and living with chronic illness were significant predictors of agreement.

DISCUSSION

Parent-proxies overestimated adolescents' QOL compared to adolescents' report regardless of whether the adolescent was living with a chronic illness or not. As such, health care providers should elicit feedback from the adolescent wherever possible and proxy reports should be used as complementary information rather than primary source.

Communication in Oncology Outpatient Clinic Settings: Congruence of Quality of Life Assessment between Patient-Physician and Patient-Caregiver Dyads

Objectives

The aims of this study were to investigate the congruence of HRQOL reports between patient-physician and patient-caregiver dyads and to determine the association of variables, if any, with the congruence between dyads.

Methods

This correlational study with a cross-sectional design first approached physicians who provided care for patients with advanced cancer at the participating institution. Then, participating physicians' patients and their caregivers were recruited. All participants were required to independently fill out an HRQOL questionnaire during their outpatient visits. Descriptive statistics, weighted kappa, Wilcoxon signed-rank test, and linear regression were employed for data analysis.

Results

A total of 52 patient-physician and 27 patient-caregiver dyads were examined. Patients suffered from considerable problems in all three HRQOL domains: symptom, functioning, and overall HRQOL. The patients' level of agreement was moderate with the caregivers and fair with the physicians. A significant relationship was found between several patient-related variables and disagreement.

Conclusion

These patients with advanced cancer experienced a compromised HRQOL, warranting immediate attention. When there are barriers to obtaining a patient's self-report, clinicians may consider caregivers as a reasonable source. Patients with special characteristics need additional attention because their problems may be at a greater risk of being overlooked.

Do neurocognitive impairments explain the differences between brain tumour patients and their proxies when assessing the patient’s IADL?

Background

Neurocognitive impairments are common among brain tumour patients, and may impact patient’s awareness of performance in instrumental activities in daily life (IADL). We examined differences between patient- and proxy-reported assessments of the patient’s IADL, and whether the level of (dis)agreement is associated with neurocognitive impairments.

Methods

Brain tumour patients and their proxies completed the phase 3 version of the EORTC IADL-BN32 questionnaire measuring IADL, and patients completed six neurocognitive measures. Patient-proxy difference scores in IADL were compared between patients who were defined as neurocognitively impaired (≥2 neurocognitive measures ≥2.0 standard deviations below healthy controls) and non-neurocognitively impaired. With multinomial logistic regression analyses we examined if neurocognitive variables were independently associated with patient-proxy disagreement in IADL ratings.

Results

Patients (n=81) did not systematically (p&lt;0.01) rate IADL outcomes different than their proxies. Proxies did report more problems on 19/32 individual items and all five scales. This effect was more apparent in dyads with a neurocognitively impaired patient (n=37), compared to dyads with non-neurocognitively impaired patients (n=44). Multinomial logistic regression analyses showed that several neurocognitive variables (e.g., cognitive flexibility and verbal fluency) were independently associated with disagreement between patients and proxies on different scales.

Conclusion

Neurocognitive deficits seem to play a role in the discrepancies between brain tumour patients and their proxies assessment of patient’s level of IADL . Although replication of our results is needed, our findings suggests that caution is warranted in interpreting self-reported IADL by patients with neurocognitive impairment, and that such self-reports should be supplemented with proxy ratings.

Proxy responses regarding quality of life of patients with terminal lung cancer: preliminary results from a prospective observational study

OBJECTIVE

This prospective study used the EQ-5D utility and Visual Analogue Scale (VAS) scores to analyse the potential usefulness of proxy responses in quality of life assessments of Japanese patients with terminal lung cancer sufficiently healthy to communicate and reply by themselves. We did not investigate the potential usefulness of using proxy responses for patients who could not respond by themselves.

DESIGN

A prospective observational study.

SETTING

Single centre.

PARTICIPANTS

The EQ-5D and VAS responses were gathered from 30 in-hospital patients with lung cancer for a total of three observation points. At nearly the same time, two nurses responded by providing proxy responses.

PRIMARY AND SECONDARY OUTCOME MEASURES

EQ-5D and VAS responses.

RESULTS

There were no significant differences between the patients' and nurses' responses for EQ-5D utility and VAS scores. For the five dimensions of the EQ-5D, significant differences were found between the patients' and nurses' responses for usual activities (patients' response 1.64±0.07, nurses' response 1.41±0.05, p=0.03) and anxiety/depression (patients' response: 1.40±0.05, nurses' response: 1.19±0.03, p=0.02). There was a significant weak positive correlation between patients' and nurses' responses regarding changes in responses from the first to the third observation point (Spearman's rank correlation coefficient ρ=0.228; p<0.01).

CONCLUSION

The results suggest that proxy responses are useful because there were no significant differences between the patients' and nurses' responses for EQ-5D utility and VAS scores at the three observation points. These findings should, however, be verified in future large-scale trials.

Impact of chronic GVHD on QOL assessed by visual analogue scale in pediatric HSCT survivors and differences between raters: a cross-sectional observational study in Japan

A nationwide cross-sectional survey was conducted in long-term survivors of allogeneic hematopoietic stem cell transplantation (HSCT) in childhood to investigate the effect of chronic graft-versus-host disease (cGVHD) on quality of life (QOL) and differences in QOL assessments between raters. QOL was evaluated by a visual analogue scale (VAS). Assessments were compared between the survivor, guardian, and attending pediatrician for those aged 15 years or younger, and between the survivor and attending pediatrician for those aged 16 years or older. For cGVHD, severity scores were obtained by organ and their association with the VAS score was analyzed. The average pediatrician-rated VAS score was higher than that of other raters for both patient age groups (< 15 years and > 16 years). By organ, involvement of the skin, digestive organs, and joints in GVHD affected the VAS scores. A high joint score was associated with a low VAS score, and conversely, a high lung score was associated with a low pediatrician-rated VAS score. Our results indicate that differences between raters must be considered when evaluating QOL of HSCT survivors, because patients appeared to experience grater inconvenience and difficulties due to joint GVHD than their pediatricians perceived.

Expected Versus Experienced Health-Related Quality of Life Among Patients Recovering From Cancer Surgery: A Prospective Cohort Study

Patient expectations of the impact of surgery on postoperative health-related quality of life (HRQL) may reflect the effectiveness of patient-provider communication. We sought to compare expected versus experienced HRQL among patients undergoing cancer surgery.

METHODS

Adults undergoing cancer surgery were eligible for inclusion (2017-2019). Preoperatively, patients completed a smartphone-based survey assessing expectations for HRQL 1 week and 1, 3, and 6 months postoperatively based on the 8 short-form 36 (SF36) domains (physical functioning, physical role limitations, pain, general health, vitality, social functioning, emotional role limitations, and mental health). Experienced HRQL was then assessed through smartphone-based SF36 surveys 1, 3, and 6 months postoperatively. Correlations between 1- and 6-month trends in expected versus experienced HRQL were determined.

RESULTS

Among 101 consenting patients, 74 completed preoperative expectations and SF36 surveys (73%). The mean age was 54 years (SD 14), 49 (66%) were female, and the most common operations were for breast (34%) and abdominal (31%) tumors. Patients expected HRQL to worsen 1 week after surgery and improve toward minimal disability over 6 months. There was poor correlation (≤±0.4) between 1- and 6-month trends in expected versus experienced HRQL in all SF36 domains except for moderate correlation in physical functioning (0.50, 95% confidence interval [0.22-0.78], P < 0.001) and physical role limitations (0.41, 95% confidence interval [0.05-0.77], P = 0.024). Patients expected better HRQL than they experienced.

CONCLUSIONS

Preoperative expectations of postoperative HRQL correlated poorly with lived experiences except in physical health domains. Surgeons should evaluate factors which inform expectations around physical and psychosocial health and use these data to enhance shared decision-making.

Do Cohabitants Reliably Complete Questionnaires for Patients in a Terminal Cancer Stage when Assessing Quality of Life, Pain, Depression, and Anxiety?

BACKGROUND

Patients with bone metastases often are unable to complete quality of life (QoL) questionnaires, and cohabitants (such as spouses, domestic partners, offspring older than 18 years, or other people who live with the patient) could be a reliable alternative. However, the extent of reliability in this complicated patient population remains undefined, and the influence of the cohabitant's condition on their assessment of the patient's QoL is unknown.

QUESTIONS/PURPOSES

(1) Do QoL scores, measured by the 5-level EuroQol-5D (EQ-5D-5L) version and the Patient-reported Outcomes Measurement Information System (PROMIS) version 1.0 in three domains (anxiety, pain interference, and depression), reported by patients differ markedly from scores as assessed by their cohabitants? (2) Do cohabitants' PROMIS-Depression scores correlate with differences in measured QoL results?

METHODS

This cross-sectional study included patients and cohabitants older than 18 years of age. Patients included those with presence of histologically confirmed bone metastases (including lymphoma and multiple myeloma), and cohabitants must have been present at the clinic visit. Patients were eligible for inclusion in the study regardless of comorbidities, prognosis, prior surgery, or current treatment. Between June 1, 2016 and March 1, 2017 and between October 1, 2017 and February 26, 2018, all 96 eligible patients were approached, of whom 49% (47) met the selection criteria and were willing to participate. The included 47 patient-cohabitant pairs independently completed the EQ-5D-5L and the eight-item PROMIS for three domains (anxiety, pain, and depression) with respect to the patients' symptoms. The cohabitants also completed the four-item PROMIS-Depression survey with respect to their own symptoms.

RESULTS

There were no clinically important differences between the scores of patients and their cohabitants for all questionnaires, and the agreement between patient and cohabitant scores was moderate to strong (Spearman correlation coefficients ranging from 0.52 to 0.72 on the four questionnaires; all p values < 0.05). However, despite the good agreement in QoL scores, an increased cohabitant's depression score was correlated with an overestimation of the patient's symptom burden for the anxiety and depression domains (weak Spearman correlation coefficient of 0.33 [95% confidence interval 0.08 to 0.58]; p = 0.01 and moderate Spearman correlation coefficient of 0.52 [95% CI 0.29 to 0.74]; p < 0.01, respectively).

CONCLUSION

The present findings support that cohabitants might be reliable raters of the QoL of patients with bone metastases. However, if a patient's cohabitant has depression, the cohabitant may overestimate a patient's symptoms in emotional domains such as anxiety and depression, warranting further research that includes cohabitants with and without depression to elucidate the effect of depression on the level of agreement. For now, clinicians may want to reconsider using the cohabitant's judgement if depression is suspected.

CLINICAL RELEVANCE

These findings suggest that a cohabitant's impressions of a patient's quality of life are, in most instances, accurate; this is potentially helpful in situations where the patient cannot weigh in. Future studies should employ longitudinal designs to see how or whether our findings change over time and with disease progression, and how specific interventions-like different chemotherapeutic regimens or surgery-may factor in.

Decreased costs and retained QoL due to the 'PACE Steps to Success' intervention in LTCFs: cost-effectiveness analysis of a randomized controlled trial

BACKGROUND

The number of residents in long-term care facilities (LTCFs) in need of palliative care is growing in the Western world. Therefore, it is foreseen that significantly higher percentages of budgets will be spent on palliative care. However, cost-effectiveness analyses of palliative care interventions in these settings are lacking. Therefore, the objective of this paper was to assess the cost-effectiveness of the 'PACE Steps to Success' intervention. PACE (Palliative Care for Older People) is a 1-year palliative care programme aiming at integrating general palliative care into day-to-day routines in LTCFs, throughout seven EU countries.

METHODS

A cluster RCT was conducted. LTCFs were randomly assigned to intervention or usual care. LTCFs reported deaths of residents, about whom questionnaires were filled in retrospectively about resource use and quality of the last month of life. A health care perspective was adopted. Direct medical costs, QALYs based on the EQ-5D-5L and costs per quality increase measured with the QOD-LTC were outcome measures.

RESULTS

Although outcomes on the EQ-5D-5L remained the same, a significant increase on the QOD-LTC (3.19 points, p value 0.00) and significant cost-savings were achieved in the intervention group (€983.28, p value 0.020). The cost reduction mainly resulted from decreased hospitalization-related costs (€919.51, p value 0.018).

CONCLUSIONS

Costs decreased and QoL was retained due to the PACE Steps to Success intervention. Significant cost savings and improvement in quality of end of life (care) as measured with the QOD-LTC were achieved. A clinically relevant difference of almost 3 nights shorter hospitalizations in favour of the intervention group was found. This indicates that timely palliative care in the LTCF setting can prevent lengthy hospitalizations while retaining QoL. In line with earlier findings, we conclude that integrating general palliative care into daily routine in LTCFs can be cost-effective.

TRIAL REGISTRATION

ISRCTN14741671 .

Is Inpatient Hospice Care Clinically Effective? Using Phase of Illness to Evaluate Care Outcomes for Patients Admitted to a Specialist Palliative Care Unit in Ireland

Background: In health care, clinical effectiveness involves evaluating the degree to which clinical interventions achieve beneficial patient and caregiver outcomes. Objective: To evaluate the clinical effectiveness of care in a specialist palliative care unit (SPCU) in Ireland, including an analysis of the temporal relationship among admission, Phase of Illness and patient and family distress. Design/Measurements: A consecutive case series with prospectively collected admission data (n = 400). Using a casemix tool (Phase of Illness), pain, other symptoms, psychological and family distress, and performance status were documented on admission and then daily by medical staff. Results: Three hundred forty-two (85%) patients had complete data recorded on day 1. After admission, there were linear correlations between days since admission and progressive improvements in pain (Cramer's V = 0.131, p < 0.001), other symptoms (V = 0.206, p < 0.001), psychological distress (V = 0.101, p < 0.001), and family distress (V = 0.124, p < 0.001). Forty-three percent were in an unstable phase on admission. Nearly two thirds (60.7%) of these unstable patients converted to a stable phase within 48 hours of admission. Over the first 72 hours, 70.7% of unstable patients converted to a stable phase. There was also a significant correlation between phase stabilization and pain and symptom control (p = 0.007). Stable phase over the first 4 days and first 14 days was associated with significantly higher performance status. Conclusion: This study demonstrates the significant clinical effectiveness of SPCU admission across the different aspects of patient and family care.

HDQLIFE and neuro-QoL physical function measures: Responsiveness in persons with huntington's disease

BACKGROUND

Huntington's disease (HD) is a neurological disorder that causes severe motor symptoms that adversely impact health-related quality of life. Patient-reported physical function outcome measures in HD have shown cross-sectional evidence of validity, but responsiveness has not yet been assessed.

OBJECTIVES

This study evaluates the responsiveness of the Huntington Disease Health-Related Quality of Life (HDQLIFE) and the Quality of Life in Neurological Disorders (Neuro-QoL) physical function measures in persons with HD.

METHODS

A total of 347 participants completed baseline and at least 1 follow-up (12-month and 24-month) measure (HDQLIFE Chorea, HDQLIFE Swallowing Difficulties, HDQLIFE Speech Difficulties, Neuro-QoL Upper Extremity Function, and/or Neuro-QoL Lower Extremity Function). Of the participants that completed the baseline assessment, 338 (90.9%) completed the 12-month assessment, and 293 (78.8%) completed the 24-month assessment. Standardized response means and general linear models evaluated whether the physical function measures were responsive to self-reported and clinician-rated change over time.

RESULTS

Small to moderate effect sizes for the standardized response means supported 12-month and 24-month responsiveness of the HDQLIFE and Neuro-QoL measures for those with either self-reported or clinician-rated declines in function. General linear models supported 12-month and 24-month responsiveness for all HRQOL measures relative to self-reported declines in health, but generally only 24-month responsiveness was supported relative to clinician-rated declines in function.

CONCLUSIONS

Longitudinal analyses indicate that the HDQLIFE and the Neuro-QoL physical function measures are sensitive to change over time in individuals with HD. Thus, these scales exhibit evidence of responsiveness and may be useful outcome measures in future clinical trials. © 2019 International Parkinson and Movement Disorder Society.

Quality of care reported by proxies – Does resident cognition count?

Resident self-reports are considered the primary source of quality of care information, but proxy reports by family or staff can also be used to supplement or substitute resident reports. This study analyses how the results of proxy reports vary according to residents’ cognition level. The data set used covers proxy reports of family ( n = 558) and staff ( n = 801), divided by the availability of resident self-reports (family yes n = 289, no n = 269; staff yes 393, no = 408). Family and staff proxies assessed residents’ quality of care as better when resident self-reports were also available, and quality of care tended to be assessed as poorer among those with higher cognitive decline. The results of this methodological study indicate the importance of using several proxy evaluations; however, these can only supplement resident self-reports, not replace them. The interpretation rules acknowledging dependency between residents’ cognition and proxy assessments could be used as a basis for future comparisons of quality improvement in long-term care and for painting a more comprehensive picture of service quality.

Dying in acute hospitals: voices of bereaved relatives

Background

Internationally there is an increasing concern about the quality of end-of-life care (EoLC) provided in acute hospitals. More people are cared for at end of life and die in acute hospitals than in any other healthcare setting. This paper reports the views of bereaved relatives on the experience of care they and the person that died received during their last admission in two university adult acute tertiary hospitals.

Methods

Relatives of patients who died were invited to participate in a post-bereavement postal survey. An adapted version of VOICES (Views of Informal Carers - Evaluation of Services) questionnaire was used. VOICES MaJam has 36 closed questions and four open-ended questions. Data were gathered in three waves and analysed using SPSS and NVivo. 356 respondents completed the survey (46% response rate).

Results

The majority of respondents (87%: n = 303) rated the quality of care as outstanding, excellent or good during the last admission to hospital. The quality of care by nurses, doctors and other staff was highly rated. Overall, care needs were well met; however, findings identified areas of care which could be improved, including communication and the provision of emotional and spiritual support. In addition, relatives strongly endorsed the provision of EoLC in single occupancy rooms, the availability of family rooms on acute hospital wards and the provision of bereavement support.

Conclusions

This research provides a powerful snapshot in time into what works well and what could be improved in EoLC in acute hospitals. Findings are reported under several themes, including the overall quality of care, meeting care needs, communication, the hospital environment and support for relatives. Results indicate that improvements can be made that build on existing good practice that will enhance the experience of care for dying persons and their relatives. The study adds insights in relation to relative’s priorities for EoLC in acute hospitals and can advance care providers’, policy makers’ and educationalists’ priorities for service improvement.

Provider Perceptions of Quality of Life, Neurocognition, Physical Well-being, and Psychosocial Health in Patients with Primary Immunodeficiency/Immune Dysregulation Conditions

PURPOSE

Both pediatric and adult patients with a primary immunodeficiency/immune dysregulation (PID/PIDR) diagnosis report inferior quality of life (QOL) and patient-reported outcomes (PROs) as compared with their healthy peers. Recognition of the negative impact on QOL and PROs provides an opportunity for clinicians to intervene with supportive measures. However, provider perceptions of PID/PIDR patients' quality of life, physical well-being, psychosocial health and neurocognition, and access to supportive resources have yet to be systematically evaluated.

METHODS

We report specialty providers' perception of the QOL and psychosocial and physical well-being of their pediatric and adult patients with PID/PIDR through the utilization of an online survey assessing QOL and the impact of disease or its associated treatment on their physical well-being, mental health, social relationships, neurocognition, and work/school performance.

RESULTS

Clinicians trended towards believing adult PID/PIDR patients had worse overall QOL than children with PID/PIDR. Providers additionally identified their adult patients' QOL to be more deleteriously affected by co-morbidities than their pediatric patients. Clinicians distinguished anxiety and social relationships as the psychosocial aspects most often affected by a complex immunological diagnosis in all patients. Of physical health considerations, energy, rather than mobility or pain, was perceived to be more negatively influenced by PID/PIDR in both adult and pediatric patients.

CONCLUSIONS

Knowledge of these clinician perceptions can affect communication of findings with patients, as well as ongoing management, and thus, it is important to understand these fully to improve healthcare delivery to, and clinical management of, these patients.

Comparing Physician and Nurse Eastern Cooperative Oncology Group Performance Status (ECOG-PS) Ratings as Predictors of Clinical Outcomes in Patients with Cancer

BACKGROUND

The Eastern Cooperative Oncology Group Performance Status (ECOG-PS) scale is commonly used by physicians and nurses in oncology, as it correlates with cancer morbidity, mortality, and complications from chemotherapy and can help direct clinical decisions and prognostication. This retrospective cohort study aimed to identify whether ECOG-PS scores rated by oncologist versus nurses differ in their ability to predict clinical outcomes.

MATERIALS AND METHODS

Over 19 months, 32 oncologists and 41 chemotherapy nurses from a single academic comprehensive cancer center independently scored ECOG-PS (range: 0-5) for a random sample of 311 patients with cancer receiving chemotherapy. Logistic regression models were fit to evaluate the ability of nurse and physician ECOG-PS scores, as well as the nurse-physician ECOG-PS score difference (nurse minus physician), to predict the occurrence of chemotherapy toxicity (CTCAE v4, grade ≥3) and hospitalizations within 1 month from ECOG-PS ratings, as well as 6-month mortality or hospice referrals.

RESULTS

Physician/nurse ECOG-PS agreement was 71% (Cohen's κ = 0.486, p < .0001). Nurse ECOG-PS scores had stronger odds ratio for 6-month mortality or hospice (odds ratio [OR], 3.29, p < .0001) than physician ECOG-PS scores (OR, 2.71, p = .001). Furthermore, ECOG-PS ratings by nurses, but not physicians, correlated with 1-month chemotherapy toxicity (OR, 1.44, p = .021) and 1-month hospitalizations (OR, 1.57, p = .041). Nurse-physician disagreement, but only when physicians gave "healthier" (lower) ratings, was also associated with worse outcomes (chemotherapy toxicity OR = 1.51, p = .045; 1-month hospitalization OR, 1.86, p = .037; 6-month mortality or hospice OR, 2.99, p < .0001).

CONCLUSION

Nurse ECOG-PS ratings seem more predictive of important outcomes than those of physicians, and physician-nurse disagreement in ECOG-PS ratings predicts worse outcomes; scoring by nurses may result in additional clinical benefit.

IMPLICATIONS FOR PRACTICE

Nurse-rated Eastern Cooperative Oncology Group Performance Status (ECOG-PS) scores, compared with those rated by oncologists, better predicted hospitalizations and severe chemotherapy toxicity within 1 month from ECOG-PS assessment, as well as mortality or hospice referrals within 6 months. Physician-nurse disagreement in ECOG-PS scoring was associated with worse hospitalization, chemotherapy toxicity, and mortality and hospice referral rates. Rating performance statuses of patients with cancer by nurses instead or in addition to oncologists can result in additional clinical benefits, such as improved prognostication, as well as better informed clinical decision making regarding whether or not to administer chemotherapy, the need for additional supportive care, and goals of care discussions.

Voices that matter: end-of-life care in two acute hospitals from the perspective of bereaved relatives

Background

End-of-life care (EoLC) is an experience that touches the lives of everyone. Dying in an acute hospital is a common occurrence in developed countries across the world. Previous studies have shown that there is wide variation in EoLC and at times is experienced as being of poor quality. Assessing and measuring the quality of care provided is a key component of all healthcare systems. This paper reports on the qualitative analysis of open-ended free text questions that were asked as part of a post-bereavement survey conducted in two adult acute hospitals in Ireland.

Methods

This was a quantitative descriptive post-bereavement postal survey, gathering data retrospectively from relatives or friends of patients who died, utilising an adapted version of the VOICES (Views of Informal Carers - Evaluation of Services) questionnaire. VOICES MaJam has 29 core questions, seven questions requesting personal demographic information and four open-ended questions gathering descriptive data about the care experience during the patient’s last admission to hospital. A total of 356 valid questionnaires were returned. Qualitative data were managed, coded and analysed with NVivo 10, using a template analysis framework approach.

Results

Three quarters (75%: n = 268) responded to at least one of the open-ended questions. Several key themes emerged, indicating areas that require particular attention in EoLC. Two themes relate to how care needs are met and how the hospital environment has a critical influence on EoLC experiences. The remaining three themes relate more to the interpersonal context including whether patients are treated with dignity and respect, the psychological, emotional and spiritual needs of patients and their family members and communication.

Conclusions

Acute hospitals need to ensure that patients and their relatives receive high quality EoLC. Seeking the views of bereaved relatives should be considered by all hospitals and healthcare settings to ascertain the quality of care at end of life. This study contributes to our understanding and knowledge of what good EoLC looks like and where care can be improved, thus enabling hospitals to direct and inform quality improvement.

Physical Impairment and Social Life, Goals among Adult Long-term Survivors of Childhood Cancer: A Population-based Study from the Childhood Cancer Registry of Piedmont, Italy

Aims and Background

The study describes the health status and the attainment of life goals in the adult survivors of childhood cancer recorded at the Childhood Cancer Registry of Piedmont.

Methods and Study Design

A postal questionnaire was sent to the general practitioner of the 690 cases born before 1976 and alive in 1991 after at least 5 years from diagnosis. The answer was received for 485 (72.9%) included in the analyses. Items in the questionnaire were: sequelae related to cancer and its treatment, health-related quality of life (according to Bloom's criteria), educational level attained, and employment status.

Results

Vital and marital status were obtained for all 690 cases at the offices of the town of residence. No medical condition was reported for 309 cases (63.7%). The overall proportion with a high school or university education was compared to corresponding figures for Piedmont in 1991, adjusted by age, and was as high as in the general population. Similar results are observed for occupation. Patients of both genders were married less than expected. Patients with leukemia (112 cases), non-Hodgkin's lymphoma (34) or Hodgkin's lymphoma (52) were reported to have the highest quality of life. In contrast, patients with tumors of the central nervous system (151) had the highest frequency of sequelae and the lowest score for health-related quality of life. They also presented the lowest educational achievement, the lowest proportion of employment and, among males, the lowest frequency of marriage.

Conclusions

Our study shows a good social adjustment of adult survivors from childhood cancer, with the exception of central nervous system tumors. From the methodologic point of view, the present study shows the feasibility of surveillance surveys on health-related quality of life with the contribution of general practitioners.

Everyday memory problems in alcohol abuse and dependence: Frequency, patterns and patient-proxy agreement

Using self-report to assess everyday memory in alcoholics presents challenges given the presence of both memory and metamemory deficits. Accordingly, evaluation of the reliability and validity of proxy ratings as well as the frequency of these memory lapses are of clinical importance. In the present study, 180 patient-proxy dyads completed the Prospective and Retrospective Memory Questionnaire (PRMQ). 31.7% of proxy-rated versus 2.8% of patient-rated prospective memory scores fell in the impaired to below average range. 15% of proxy-rated retrospective memory scores were below average, whereas none of the patients reported problems in this regard. Longer delays between intention formation and action yielded better prospective memory performance, while the opposite was true for retrospective memory. Agreement between patients and proxies was generally poor to fair across severity levels and the magnitude of observed differences was large (standardized response mean > 0.8). For all PRMQ items, exact agreement occurred in 45.3% of the cases. Larger patient-proxy discrepancy was associated with older age, less education and greater disease severity. Proxy ratings were internally consistent, significantly correlated with objective memory performance, and were sensitive to differences in overall PRMQ performance between severity groups. Caution should be used in the interpretations of patients' reports.

Physical and Psychological Effects of a 12-Session Cancer Rehabilitation Exercise Program

BACKGROUND

The positive effects of regular exercise for cancer survivors are becoming increasingly apparent. However, comprehensive examination of the benefits of modest levels of physical activity is somewhat lacking.

OBJECTIVES

This study aimed to test the hypothesis that participating in a 12-session exercise program will improve depression, fatigue, aerobic endurance, muscular strength, and quality of life (QOL) in patients with cancer.

METHODS

A group of 20 older adult women with a prior cancer diagnosis were evaluated during a 6- to 10-week exercise program that occurred twice weekly. The majority of patients had breast cancer (n = 14), but treatment status varied (11 were currently undergoing treatment, and 9 were post-treatment). Each patient completed initial and exit assessments, which consisted of three physical function tests and three psychosocial questionnaires. Patient charts contained the initial and final assessment scores and personal demographics.

FINDINGS

Analyses of pre- and postprogram data using paired t tests revealed that 12 exercise sessions (each lasting about an hour) significantly improved six-minute walk test, 30-second sit-and-stand test, hand grip strength test (dominant and nondominant hand), and overall QOL scores in patients. As a result, moderate levels of exercise have a beneficial effect in this population.

Systematic review of caregiver responses for patient health-related quality of life in adult cancer care

PURPOSE

In surveys and in research, proxies such as family members may be used to assess patient health-related quality of life. The aim of this research is to help cancer researchers select a validated health-related quality of life tool if they anticipate using proxy-reported data.

METHODS

Systematic review and methodological appraisal of studies examining the concordance of paired adult cancer patient and proxy responses for multidimensional, validated HRQOL tools. We searched PubMed, CINAHL, PsycINFO and perused bibliographies of reviewed papers. We reviewed concordance assessment methods, results, and associated factors for each validated tool.

RESULTS

A total of 32 papers reporting on 29 study populations were included. Most papers were cross-sectional (N = 20) and used disease-specific tools (N = 19), primarily the FACT and EORTC. Patient and proxy mean scores were similar on average for tools and scales, with most mean differences <10 points but large standard deviations. Average ICCs for the FACT and EORTC ranged from 0.35 to 0.62, depending on the scale. Few papers (N = 15) evaluated factors associated with concordance, and results and measurement approaches were inconsistent. The EORTC was the most commonly evaluated disease-specific tool (N = 5 papers). For generic tools, both concordance and associated factor information was most commonly available for the COOP/WONCA (N = 3 papers). The MQOL was the most frequently evaluated end-of-life tool (N = 3 papers).

CONCLUSIONS

Proxy and patient scores are similar on average, but there is large, clinically important residual variability. The evidence base is strongest for the EORTC (disease-specific tools), COOP/WONCA (generic tools), and MQOL (end-of-life-specific tools).

How well do we currently care for our dying patients in acute hospitals: the views of the bereaved relatives?

Background

The National Care of the Dying Audit—Hospitals (NCDAH) is used as a method to evaluate care for dying patients in England. An additional component to the 2013/2014 audit was the Local Survey of Bereaved Relatives Views using the ‘Care Of the Dying Evaluation’ (CODE) questionnaire.

Aim

Within the context of the NCDAH audit, to evaluate quality of care provided to dying patients and their families in acute hospitals from the perspective of bereaved relatives.

Design

Postbereavement survey to bereaved relatives.

Setting/participants

For acute hospitals wishing to participate, consecutive ‘expected’ adult deaths occurring between 1 May and 30 June 2013 were identified and the CODE questionnaire was sent to the next-of-kin.

Results

From 3414 eligible next-of-kin, 95 (2.8%) were excluded due to being involved in a complaint procedure and 1006 (29.5%) due to insufficient next-of-kin details. From the remaining 2313 potential participants, 858 returned a completed CODE questionnaire (37.1% response rate). Generally, symptoms were perceived to be well controlled with 769 (91%) participants reporting that either no pain was present or only there ‘some of the time’. Unmet information needs, however, was a recognised area for improvement, for example, 230 (29%) reporting having a discussion about hydration would have been beneficial.

Conclusions

Adopting a postbereavement survey to NCDAH appears to be feasible, acceptable and a valuable addition. On the whole, the majority of participants reported good or excellent care. A small but significant minority, however, perceived poor quality of patient care with clear and timely communication urgently needed.

Reliability of health-related quality-of-life assessments made by older adults and significant others for health states of increasing cognitive impairment

Background

Older adults are encouraged by many organizations to engage in advance care planning in the event of decisional incapacity. Planning for future health care often involves anticipating health-related quality of life (HRQoL) in states of reduced cognitive functioning. No study has yet examined whether anticipated HRQoL is stable over time. The accuracy with which significant others can predict how an older adult envisions HRQoL in a future state of cognitive impairment is also unknown. We investigated the extent to which health-related quality-of-life ratings made by older adults and designated proxies for health states of increasing cognitive impairment are consistent over time and agree with each other.

Methods

Results are based on HRQoL ratings made on a 5-point Likert scale by 235 community-based elder-proxy dyads on three occasions. Ratings were obtained for the older adult’s current health state as well as under the assumption that he/she had a mild to moderate stroke, incurable brain cancer or severe dementia. Data were analyzed using both traditional approaches (e.g., intraclass correlation coefficients, Bland-Altman plots) and the theory of generalizability.

Results

We found ratings to be reasonably consistent over time and in good agreement within dyads, even more so as implied cognitive functioning worsened. Across health states, ratings over time or within elder-proxy dyads were no more than one category apart in over 87% of cases. Using the theory of generalizability, we further found that, of the two facets investigated, rater had a greater influence on score variability than occasion.

Conclusions

These findings underscore the importance of discussing health-related quality-of-life issues during advance care planning and involving designated proxies in the discussion to enhance their understanding of the role that HRQoL should play in actual decision-making situations. Medical decision-making may be influenced by healthcare providers’ and family members’ assessments of an incapacitated patient’s health-related quality of life, in addition to that of the designated proxy. Future studies should investigate whether these two groups of individuals share the views of the patient and the designated proxy on anticipated HRQoL.

Electronic supplementary material

The online version of this article (doi:10.1186/s12955-016-0579-3) contains supplementary material, which is available to authorized users.

Patient, family, nurse perspectives on Chinese elders' quality of life

BACKGROUND

Families and nurses are important care-providers and proxies of older people. Their ability to assess the quality of life of elders in ways that align with how older people assess themselves has policy implications for allocating services and resources to older persons.

AIM

To investigate the alignment of perspectives of the quality of life held by older people, their families and nurses in China.

METHODS

Employing a survey design using concurrent EQ-5D-3L and WHOQOL-BREF surveys, responses from 72 matched stakeholder groups were compared and agreement tested using weighted kappa/one-way random intra-class correlations and paired Student's t-test.

RESULTS

On the more observable dimensions families and nurses were in close agreement with the older person in relation to quality of life reports. However, in the more subjective domains, family and especially nurses tended to estimate that the older person's suffering as more severe than they themselves thought.

CONCLUSION

The perspectives of older patients and their family are more closely aligned regarding the older person's quality of life than that of nurses caring for them, a finding inconsistent with international research.

IMPLICATION FOR NURSING AND HEALTH POLICY

The evidence suggests that nursing work assignment processes could influence the accuracy of nurses' perceptions of their patient's quality of life.

Disparities Between Clinician and Patient Perception of Breakthrough Pain Control

CONTEXT

There are disparities in the level of symptom severity as perceived by patients and health professionals. There is limited information about patients' and clinicians' global assessment of breakthrough pain control, the need to change analgesics, and change in breakthrough pain over time.

OBJECTIVES

To establish whether patients and clinicians independently agree on adequacy of breakthrough pain control, management strategy, and impression of change over time.

METHODS

One hundred patients with breakthrough cancer pain were assessed and followed up one week later by a palliative medicine specialist. The patient and clinician independently answered the same questions about the adequacy of the patient's breakthrough pain control and breakthrough pain management. The results were compared with items on the Breakthrough Pain Assessment Tool (BAT).

RESULTS

At initial consultation, 35% of patients rated their breakthrough cancer pain as inadequately controlled compared with 72% of clinicians. Breakthrough pain analgesics were changed in 68% of cases. At one-week follow-up consultation, 62% of patients considered their breakthrough cancer pain to be better, and in 57% of cases, the clinicians also categorized the pain this way.

CONCLUSION

There are significant differences in global impressions of breakthrough pain between patients and pain clinicians that become less disparate as a therapeutic relationship evolves. Therapeutic decisions were based on clinical rather than patient perceptions.

Comparison of informal caregiver and named nurse assessment of symptoms in elderly patients dying in hospital using the palliative outcome scale

Objectives

A prospective study of symptom assessments made by a healthcare professional (HCP; named nurse) and an informal caregiver (ICG) compared with that of the patient with a terminal diagnosis. To look at the validity of HCP and ICG as proxies, which symptoms they can reliably assess, and to determine who is the better proxy between HCP and ICG.

Methods

A total of 50 triads of patient (>65 years) in the terminal phase, ICG and named nurse on medical wards of an acute general hospital. Assessments were made using the patient and caregiver versions of the palliative outcome scale (POS), all taken within a 24 h period. Agreement between patient-rated, ICG-rated and HCP-rated POS and POS for symptoms (POS-S) was measured using weighted-κ statistics. Demographic and clinical data on each group of participants were collected.

Results

ICG assessments have higher agreement with those of the patient than HCP. Better agreement in both groups was found for physical symptoms, and best agreement was for pain. The worst agreements were for psychological symptoms, such as anxiety and depression, and for satisfaction with information given. Psychological symptoms are overestimated by both ICG and HCP.

Conclusions

ICGs are more reliable proxies than HCPs. A trend for overestimation of symptoms was found in both groups which may lead to undervaluation of the quality of life by proxy and overtreatment of symptoms. This highlights the need to always use the patient report when possible, and to be aware of the potential flaws in proxy assessment. Reasons for overestimation by proxies deserve further research.

Evaluation of patient quality of life and satisfaction with home enteral feeding and oral nutrition support services: a cross-sectional study

Objective The aims of the present study, in home enteral nutrition (HEN) patients, were to assess patient satisfaction with the service and quality of life (QOL) scores, and to compare QOL scores in HEN patients with general Australian population values. Methods Self-administered voluntary questionnaires for the present cross-sectional study were mailed out to 322 eligible participants registered with HEN for >5 months. The questionnaires used included a patient satisfaction survey and a validated QOL questionnaire. Data analysis consisted of cross-tabulation, Chi-squared tests and t-tests. Results There were 112 participants. Patients reported satisfaction with information received before discharge (86%), support received after discharge (74%), expertise of the health professional (87%), access to health professionals experienced with HEN (74%), communication between health professionals (74%), costs of HEN supplies (52%) and delivery of HEN supplies (88%). QOL scores related to physical, psychological, social and environment domains were significantly lower in HEN patients than in the Australian reference population (P < 0.001). There was no significant difference in QOL and health satisfaction across different clinical areas (0.737 and 0.316, respectively). Conclusion Overall, participants were satisfied with HEN services. Participants had lower QOL scores compared with the Australian general population. Improvements to the HEN service were suggested, including sooner follow-up after hospital discharge; more frequent reviews for long-term patients; and the availability of a multidisciplinary team to manage HEN patients. What is known about the topic? Malnutrition is a common problem in Australian hospitals. Many patients require nutrition support to maintain or improve their nutrition status because of inadequate oral intake, malabsorption of nutrients or because of a disease process. Nutrition support is commonly started in the in-patient setting and, because of faster patient discharge from hospital, HEN is a cost-effective and reliable way of treating patients who continue to need nutrition support after hospital discharge. Inconsistencies exist in service provision of HEN because there is no national or state-wide standardisation of services. Australian studies that have evaluated patient satisfaction with HEN services are lacking. This is of particular importance because HEN service use is increasing. What does this paper add? This study reveals that patients receiving HEN therapy are mostly satisfied with the service provided. Patients surveyed have expressed important aspects of the HEN service include follow-up and advice from health care professionals, low price and home delivery of supplies, emphasising the importance of adequate clinical services, supply and delivery of HEN. QOL is poorer in the HEN patient population compared with the general Australian population. What are the implications for practitioners? Standardisation of HEN services is important to ensure uniformity in service provision to HEN patients. Health services adhering to best practice guidelines for HEN will result in the provision of adequate quality of care, and subsequently improved patient satisfaction and adherence to HEN therapy. Adequate service provision and appropriate monitoring and review of HEN patients in the community may also contribute to better health outcomes and better QOL for patients.

A Cross-Sectional Investigation of Fatigue, Mucositis, Hand-Foot Syndrome and Dysgeusia in Advanced Renal Cell Carcinoma Treatment: Final Results From the FAMOUS Study

Treatment of metastatic renal cell carcinoma can be associated with adverse symptoms. The perception of fatigue, mucositis, hand-foot syndrome, and dysgeusia, and quality of life (QOL) was assessed in 63 oncologists and their patients receiving first-line treatment. Physicians underestimated the severity of the symptoms and the severity correlated with a lower QOL. A consistent assessment of symptoms in routine practice might improve QOL, adherence to treatment, and outcome.

BACKGROUND

The management of symptoms associated with treatment of metastatic renal cell carcinoma (mRCC) is crucial to ensure treatment adherence and outcome. The perception of symptoms can vary between the treating physician and patient, leading to assumptions and subsequent changes in treatment, potentially affecting treatment effectiveness. The aim of the present cross-sectional study was to evaluate the perception of the common symptoms of fatigue, mucositis, hand-foot syndrome, and dysgeusia in patients with mRCC receiving systemic therapies in routine practice.

PATIENTS AND METHODS

German patients receiving first-line systemic treatment for mRCC and their physicians were independently queried about the incidence and severity of fatigue, mucositis, hand-foot syndrome, and dysgeusia. Patients also completed the Functional Assessment of Cancer Therapy-General questionnaire to assess their quality of life (QOL). The effect of the 4 symptoms on QOL was analyzed using linear regression modeling.

RESULTS

A total of 63 matching questionnaires were completed by both physicians and patients with first-line treatment. The incidence and severity of symptoms differed between the patients and physicians. Patients rated the severity of symptoms significantly higher than did the physicians. A greater severity of symptoms correlated with a lower QOL. In multivariate regression analysis, fatigue adversely affected overall QOL.

CONCLUSION

Physicians underestimated the severity of common symptoms in patients with mRCC. The incorporation of patient-reported outcome measures into routine practice might increase awareness of patients' overall QOL and thereby potentially improve treatment adherence. A thorough evaluation of fatigue, its potential underlying causes, and active measures to manage fatigue could potentially improve patients' QOL.

Healthcare providers' accuracy in assessing patients' pain: A systematic review

OBJECTIVE

Healthcare providers satisfy an important role in providing appropriate care in the prevention and management of acute and chronic pain, highlighting the importance of providers' abilities to accurately assess patients' pain. We systematically reviewed the literature on healthcare providers' pain assessment accuracy.

METHODS

A systematic literature search was conducted in PubMed and PsycINFO to identify studies addressing providers' pain assessment accuracy, or studies that compared patients' self-report of pain with providers' assessment of pain.

RESULTS

60 studies met the inclusion criteria. Healthcare providers had moderate to good pain assessment accuracy. Physicians and nurses showed similar pain assessment accuracy. Differences in pain assessment accuracy were found according to providers' clinical experience, the timing of the pain assessment, vulnerable patient populations and patients' pain intensity.

CONCLUSION

Education and training aimed at improving providers with poor pain assessment accuracy is discussed especially in relation to those with limited clinical experience (<4 years) or a great deal of clinical experience (>10 years) and those providing care for vulnerable patient populations.

PRACTICE IMPLICATIONS

More research on characteristics that influence providers' pain assessment accuracy and trainings to improve pain assessment accuracy in medical and continuing education may improve pain treatment for patients.

Assessing Health-Related Quality of Life in the Greek Home Health Care Setting

The study’s aim was to evaluate the agreement between patients’ and nurses’ ratings of patients’ health-related quality of life (HRQoL) and to identify factors that affect their level of agreement. A total of 150 home health care cancer patients from Greece and all nurses ( N = 5) who worked in the home health care units completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire–Core 30 (EORTC QLQ-C30). Intraclass correlation coefficients varied between .45 and .87, indicating a moderate to excellent agreement. Median absolute difference on QLQ-C30 scores ranged from 0.00 to 16.66 points on the 0 to 100 scale. Cohen’s d varied between −0.15 and 0.59. Nurses’ higher educational level was associated with greater agreement ( p = .05). Nurses assessed lower the QoL of patients who were completely disabled than the patients themselves did ( p = .005). Our findings suggest that Greek home health care nurses estimate patients’ QoL in a reliable and valid way.

Concordance of patient and caregiver reports in evaluating quality of life in patients with malignant gliomas and an assessment of caregiver burden

BACKGROUND

Given the neurocognitive impairment experienced by many patients with malignant gliomas, caregiver reports can be critical in assessing the quality of life (QOL) of these patients. In this study, we explored whether assessment of patient QOL by the primary caregiver shows concordance with the patient's self-reported QOL, and we quantified the burden faced by caregivers.

METHODS

QOL of 45 patients was evaluated by both the patient and primary caregiver on 3 or more separate occasions using the Functional Assessment of Cancer Therapy-Brain (FACT-Br) instrument, and concordance between the 2 reports was evaluated. Caregiver burden was measured using the Caregiver Quality of Life Index-Cancer (CQOL-C) instrument.

RESULTS

Overall, good concordance was observed between the patient and caregiver FACT-Br reports (intraclass correlation coefficient = 0.74). Patient-reported FACT-Br scores were 4.75 (95% CI, 1.44-8.05) points higher than paired caregiver reports on the 200-point scale (P = .008); however, this difference did not achieve clinical significance. Caregiver burden, as measured by the CQOL-C, was significantly greater among caregivers in this study than those previously reported for caregivers of patients with lung, breast, or prostate cancer (P < .001).

CONCLUSIONS

Despite minor discrepancies in caregiver assessments of patient QOL relative to patient self-reports, our results suggest that the caregiver assessments can serve as adequate proxies for patient reports. Our results also illustrate the particularly heavy burden faced by caregivers of patients with malignant glioma. Further research into both of these areas is warranted.

Measures for improving treatment outcomes for patients with epilepsy--results from a large multinational patient-physician survey

In this large-scale, multinational, descriptive survey, we sought to identify measures for improving treatment outcomes for individuals with epilepsy. As a framework, questions relating specifically to each of the five steps of the 'patient-physician journey', namely, patient identification (omitted in this survey), diagnosis, choice of drug, disease and drug information, and patient monitoring were asked. Overall, 337 physicians and 1150 patients across France, Germany, and the United States returned questionnaires. Results indicated that 16% of the patients were initially misdiagnosed. Treatment choice was driven by efficacy, safety, experience with a drug (physician only), and convenience (patient only). Physicians were identified as the primary source of information for patients, and, as expected, better informed patients were found to adhere better to their therapy than those who were less well informed. Approximately 50% of the patients had not seen their specialist in the last year, which indicates poor follow-up; furthermore, important topics such as seizures, treatment, and its side effects were not discussed at every visit. Specialists, but not primary care practitioners (PCPs), consistently reported discussing all topics more frequently than their patients, suggesting that specialists may overestimate the clarity of their questions. There was also substantial disparity in the reasons cited for nonadherence - patients overwhelmingly cited forgetfulness, while both PCPs and specialists cited complacency, forgetfulness, and tolerability. We also noted a disparity between physicians and their patients, as well as between PCPs and specialists, in their views on the impact of epilepsy on patients' lives. Our results indicate multiple opportunities to intervene at all stages of the patient-physician journey to improve treatment outcomes. We provide practical suggestions to achieve the most from these opportunities.

Home parenteral nutrition improves quality of life and nutritional status in patients with cancer: a French observational multicentre study

PURPOSE

Malnutrition is a predictor of poor outcomes in patients with cancer. Little is known about the benefit of nutritional support in these patients. The purpose of this study was to assess the impact of home parenteral nutrition (HPN) on quality of life (Qol) in cancer patients.

METHODS

We performed an observational prospective study to determine the impact of HPN on Qol in a population of patients with heterogeneous cancer. Physicians, patients and family members had to complete a questionnaire before HPN administration and 28 days after the course of HPN. Qol was evaluated using the self-administered questionnaire FACT-G.

RESULTS

We included 767 patients with cancer of whom 437 ended the study. Mean patient age was 63±11.4 years and 60.5% were men. Primary gastrointestinal cancer was reported in 50% of patients and 65.3% were presenting metastases. Malnutrition was reported in 98.3%. After 28 days of HPN intake, significant improvement was observed in the Qol (49.95±5.82 vs. 48.35±5.01 at baseline, p<0.0001). The mean weight, serum albumin and the nutrition risk index had also improved significantly. Most patients (78%) had perceived a positive impact of the HPN. A significant improvement in patient's well-being was perceived also by family members and physicians.

CONCLUSIONS

Our data suggest that preventing and correcting malnutrition using HPN in patients with cancer might have a significant benefit on their well-being. Randomized controlled studies are required to confirm this finding.

Quality of life in dementia: a study on proxy bias

BACKGROUND

Measurement of health-related quality of life (HRQoL) in dementia is difficult. At some point people with dementia become unable to meaningfully assess their own HRQoL. At such a point in time researchers need to rely on other types of information such as observation or assessments from informal caregivers (proxies). However, caregiver assessments may be biased by several mechanisms. The current study explores whether caregivers project part of their own HRQoL in their assessments of patient HRQoL.

METHODS

The participants in the current study were 175 pairs, consisting of community-dwelling persons with dementia and their caregivers. The EQ-5D, the EQ-VAS and the QoL-AD were administered to collect HRQoL measurements from patients and caregivers at baseline, 6 months and 12 months. Two linear mixed models were used to investigate factors that bias proxy ratings, one with the EQ-VAS as dependent variable, and one with the EQ-5D utility as dependent variable. The independent variables were caregiver age, caregiver sex and caregiver QoL-AD items.

RESULTS

The linear mixed model with EQ-VAS as dependent variable indicated that 3 caregiver characteristics, namely caregiver age, money (caregiver's financial situation) and valuation of life as a whole were significant predictors of the patient-by-proxy VAS scores. The linear mixed model with utility value as the dependent variable showed that caregiver age and valuation of the ability to do things for fun were significant predictors of the patient-by-proxy EQ-5D utility values.

CONCLUSIONS

The current study was a first step in identifying factors that bias patient-by-proxy HRQoL assessments. It was discovered that caregivers project part of their own HRQoL onto patients when assessing patient HRQoL. This implies that patient-by-proxy HRQoL values should be interpreted with caution and not be used as a direct substitute for patient self-assessment, even when patients are no longer able meaningfully assess themselves.

Anxiety and depression in caregivers of terminally ill cancer patients: impact on their perspective of the patients' symptom burden

BACKGROUND AND OBJECTIVE

Given the important role caregivers play in palliative care planning and decision making, anxiety and depression in caregivers of terminally ill cancer patients and their impact on the caregivers' evaluation of the patients' physical and psychological symptom burden were analyzed.

DESIGN AND SUBJECTS

Thirty-three patients and their caregivers were recruited through the University Medical Center palliative care inpatient ward <24 h after admission.

MEASUREMENTS

Patients completed the Memorial Symptom Assessment Scale (MSAS). Caregivers were instructed to evaluate the symptom burden of the patient. Anxiety and depression were measured in caregivers using the PHQ-9 and the GAD-7.

RESULTS

Fifty-five percent of male caregivers and 36% of female caregivers showed moderate or severe anxiety; 36% of male caregivers compared to 14% of female caregivers had moderate or severe depression. Caregivers' anxiety was associated with a discrepancy in the patients' symptom evaluation for shortness of breath (p<0.05); nausea (p<0.05); and frequency, intensity, and distress due to anxiety (p<0.01). Depression was associated with a discrepancy in the patients' evaluation of distress due to constipation (p<0.05), as well as intensity and distress due to anxiety (p<0.05). Both the caregivers' anxiety and depression were not significantly associated with an underestimation of symptoms. There was a trend towards a higher risk of overestimation in caregivers with higher levels of anxiety (r=0.32) (p=0.07) and depression (r=0.33) (p=0.06).

CONCLUSION

Integrative palliative care should offer psychooncological care for the caregivers on a routine basis to avoid misleading perspectives possibly influencing end-of-life treatment decisions.

Expanding Assessment of Fear of Falling among Older Adults with an Intellectual Disability: A Pilot Study to Assess the Value of Proxy Responses

Introduction. Fear of falling (FOF) has emerged as an important health concern in older adults, yet it has rarely been investigated in people with intellectual disabilities (ID). Valid and reliable measurement approaches are a particular challenge. Scales that have been developed to measure FOF have not been validated for use with older people with ID and are not routinely used with proxy respondents. Method. 63 people comprised purposeful samples of 3 groups, people with ID , their nominated key workers , and additional support workers . Test-retest reliability and interrater reliability were assessed for using a dichotomous, single-item FOF screening measure. The degree of FOF and activity restriction due to FOF were also investigated. Results. Inter-rater reliability was found to be moderate to excellent with Kappa = 0.77 on ratings of the FOF item. Test-retest reliability for each group of reviewers for the FOF item were also found to be excellent (0.95). Conclusion. The global item is a suitable screening measure for FOF in older adults with ID and can assist in identification of individuals requiring further assessment. Proxies, if carefully selected, can provide consistent and reliable reports of the presence of FOF in people with ID.

Challenge of assessing symptoms in seriously ill intensive care unit patients: can proxy reporters help?

OBJECTIVE

Determine levels of agreement among intensive care unit patients and their family members, nurses, and physicians (proxies) regarding patients' symptoms and compare levels of mean intensity (i.e., the magnitude of a symptom sensation) and distress (i.e., the degree of emotionality that a symptom engenders) of symptoms among patients and proxy reporters.

DESIGN

Prospective study of proxy reporters of symptoms in seriously ill patients.

SETTINGS

Two intensive care units in a tertiary medical center in the Western United States.

PATIENTS

Two hundred and forty-five intensive care unit patients, 243 family members, 103 nurses, and 92 physicians.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

On the basis of the magnitude of intraclass correlation coefficients, where coefficients from .35 to .78 are considered to be appropriately robust, correlation coefficients between patients' and family members' ratings met this criterion (≥.35) for intensity in six of ten symptoms. No intensity ratings between patients and nurses had intraclass correlation coefficients >.32. Three symptoms had intensity correlation coefficients of ≥.36 between patients' and physicians' ratings. Correlation coefficients between patients and family members were >.40 for five symptom-distress ratings. No symptoms had distress correlation coefficients of ≥.28 between patients' and nurses' ratings. Two symptoms had symptom-distress correlation coefficients between patients' and physicians' ratings at >.39. Family members, nurses, and physicians reported higher symptom-intensity scores than patients did for 80%, 60%, and 60% of the symptoms, respectively. Family members, nurses, and physicians reported higher symptom-distress scores than patients did for 90%, 70%, and 80% of the symptoms, respectively.

CONCLUSIONS

Patient-family intraclass correlation coefficients were sufficiently close for us to consider using family members to help assess intensive care unit patients' symptoms. Relatively low intraclass correlation coefficients between intensive care unit clinicians' and patients' symptom ratings indicate that some proxy raters overestimate whereas others underestimate patients' symptoms. Proxy overestimation of patients' symptom scores warrants further study because this may influence decisions about treating patients' symptoms.

Correlations in health status between estimates of families of people with amyotrophic lateral sclerosis and estimates of staff

OBJECTIVE

The aim of this study was to compare self-estimates of the physical, psychological, and general well-being of patients with amyotrophic lateral sclerosis (ALS) and their next of kin with the assessment of the nurses and physician of these participants.

METHOD

The well-being of 35 pairs of patients and their next of kin was rated by themselves, and by a physician and nurses. The well-being was examined over time, using a visual analogue scale (VAS). Patients' physical function was estimated at the same time with the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised and the Norris scale.

RESULTS

The correlations between the staff's estimates of the well-being of patients and next of kin were similar to their own estimates, even though staff to a higher degree estimated a decrease in well-being over time among the patients. The estimates by the nurses correlated better to that of the patients and next of kin in psychological and general well-being than the physicians' estimates did.

SIGNIFICANCE OF RESULTS

Even though the staff's estimates of participants were roughly equivalent to their self-estimates, there were some differences. This result calls attention to the importance of working in teams in which different professional roles are combined and integrated, making it possible to form a holistic view of the situation of each family. A concern overlooked by one member of staff might be covered by another, and different focuses on the family may give a better composite picture of their life situation, which could lead to better support to the family.

Rationale and clinical benefits of an intensive long-term pulmonary rehabilitation program after oesophagectomy: preliminary report

Patients who undergo oesophagectomy for oesophagealcancer (OC) usually have an overall poor prognosis and, still more preoccupying, an unsatisfactory quality of life (QoL). Considering that, as already noted, post-operative pulmonary function has a strong correlation with the long-term outcome and QoL after surgery, we have assumed and speculated on the clinical benefits of an intensive long-term pulmonary post-operative rehabilitation program in this particular subset of patients.

Herein, we report the preliminary results of a comparative retrospective analysis in a series of 58 patients who underwent radical oesophagectomy and post-operative chest physical therapy (CPT) under two different protocols, from October 2006 to January 2011.

Finally, we discuss on the time-trend analysis of pulmonary function and the potential role of post-operative pulmonary rehabilitation.