Validating automated screening for psychological distress by means of computer touchscreens for use in routine oncology practice

A Framework for Automating Psychiatric Distress Screening in Ophthalmology Clinics Using an EHR-Derived AI Algorithm

Purpose

In patients with ophthalmic disorders, psychosocial risk factors play an important role in morbidity and mortality. Proper and early psychiatric screening can result in prompt intervention and mitigate its impact. Because screening is resource intensive, we developed a framework for automating screening using an electronic health record (EHR)-derived artificial intelligence (AI) algorithm.

Methods

Subjects came from the Duke Ophthalmic Registry, a retrospective EHR database for the Duke Eye Center. Inclusion criteria included at least two encounters and a minimum of 1 year of follow-up. Presence of distress was defined at the encounter level using a computable phenotype. Risk factors included available EHR history. At each encounter, risk factors were used to discriminate psychiatric status. Model performance was evaluated using area under the receiver operating characteristic (ROC) curve and area under the precision-recall curve (PR AUC). Variable importance was presented using odds ratios (ORs).

Results

Our cohort included 358,135 encounters from 40,326 patients with an average of nine encounters per patient over 4 years. The ROC and PR AUC were 0.91 and 0.55, respectively. Of the top 25 predictors, the majority were related to existing distress, but some indicated stressful conditions, including chemotherapy (OR = 1.36), esophageal disorders (OR = 1.31), central pain syndrome (OR = 1.25), and headaches (OR = 1.24).

Conclusions

Psychiatric distress in ophthalmology patients can be monitored passively using an AI algorithm trained on existing EHR data.

Translational Relevance

When paired with an effective referral and treatment program, such algorithms may improve health outcomes in ophthalmology.

Assessing Emotional Functioning with Increased Power: Relative Validity of a Customized EORTC Short Form in the International ACTION Trial

OBJECTIVES

There is a need to improve the assessment of emotional functioning (EF). In the international Advance Care Planning: an Innovative Palliative Care Intervention to Improve Quality of Life in Cancer Patients - a Multi-Centre Cluster Randomized Clinical Trial (ACTION) trial involving patients with advanced cancer, EF was assessed by a customized 10-item short form (EF10). The EF10 is based on the European Organisation for Research and Treatment of Cancer (EORTC) EF item bank and has the potential for greater precision than the common EORTC Quality of Life Questionnaire Core 30 four-item scale (EF4). We assessed the relative validity (RV) of EF10 compared with EF4.

METHODS

Patients from Belgium, Denmark, Italy, the Netherlands, Slovenia, and the United Kingdom completed EF10 and EF4, and provided data on generic quality of life, coping, self-efficacy, and personal characteristics. Based on clinical and sociodemographic variables and questionnaire responses, 53 "known groups" that were expected to differ were formed, for example, females versus males. The EF10 and EF4 were first independently compared within this known group, for example, the EF10 score of females vs the EF10 score of males. When these differences were significant, the RV was calculated for the comparison of the EF10 with the EF4.

RESULTS

A total of 1028 patients (57% lung, 43% colorectal cancer) participated. Forty-five of the 53 known-groups comparisons were significantly different and were used for calculating the RV. In 41 of 45 (91%) comparisons, the RV was more than 1, meaning that EF10 had a higher RV than EF4. The mean RV of EF10 compared with that of EF4 was 1.41, indicating superior statistical power of EF10 to detect differences in EF.

CONCLUSIONS

Compared with EF4, EF10 shows superior power, allowing a 20% to 34% smaller sample size without reducing power, when used as a primary outcome measure.

Acceptability of a Touch Screen Tablet Psychosocial Survey Administered to Radiation Therapy Patients in Japan

BACKGROUND

Studies in western clinical settings suggest that touch screen computer surveys are an acceptable mode of collecting information about cancer patients' wellbeing

PURPOSE

We examined the acceptability of a touch screen tablet survey among cancer patients in Japan.

METHODS

Eligible patients (n = 262) attending a university hospital radiation therapy (RT) department were invited to complete a touch screen tablet survey about psychosocial communication and care. Survey consent and completion rates, the proportion and characteristics of patients who completed the touch screen survey unassisted, and patient-reported acceptability were assessed.

RESULTS

Of 158 consenting patients (consent rate 60 % [95 % CI 54, 66 %] of eligible patients), 152 completed the touch screen computer survey (completion rate 58 % [95 % CI 52, 64 %] of eligible patients). The survey was completed without assistance by 74 % (n = 113; 95 % CI 67, 81 %) of respondents. Older age was associated with higher odds of having assistance with survey completion (OR 1.09; 95 % CI 1.04, 1.14 %). Ninety-two percent of patients (95 % CI 86, 96 %) felt that the touch screen survey was easy to use and 95 % (95 % CI 90, 98 %) agreed or strongly agreed that they were comfortable answering the questions. Overall, 65 % (95 % CI 57, 73 %) of respondents would be willing to complete such a survey more than once while waiting for RT treatment.

CONCLUSIONS

Although patient self-reported acceptability of the touch screen survey was high, self-administered touch screen tablet surveys may not be entirely appropriate for older cancer patients or possibly for patients with lower educational attainment.

The EORTC emotional functioning computerized adaptive test: phases I-III of a cross-cultural item bank development

Background

The European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Group is currently developing computerized adaptive testing measures for the Quality of Life Questionnaire Core-30 (QLQ-C30) scales. The work presented here describes the development of an EORTC item bank for emotional functioning (EF), which is one of the core domains of the QLQ-C30.

Methods

According to the EORTC guidelines on module development, the development of the EF item bank comprised four phases, of which the phases I–III are reported in the present paper.

Phase I involved defining the theoretical framework for the EF item bank and a literature search. Phase II included pre-defined item selection steps and a multi-stage expert review process. In phase III, feedback from cancer patients from different countries was obtained.

Results

On the basis of literature search in phase I, a list of 1750 items was generated. These were reviewed and further developed in phase II with a focus on relevance, redundancy, clarity, and difficulty. The development and selection steps led to a preliminary list of 41 items. In phase III, patient interviews (N = 41; Austria, Denmark, Italy, and the UK) were conducted with the preliminary item list, resulting in some minor changes to item wording. The final list comprised 38 items.

Discussion

The phases I–III of the developmental process have resulted in an EF item list that was well accepted by patients in several countries. The items will be subjected to larger-scale field testing in order to establish their psychometric characteristics and their fit to an item response theory model.

Does routine psychosocial screening improve referral to psychosocial care providers and patient-radiotherapist communication? A cluster randomized controlled trial

OBJECTIVE

This study tests whether using a screening instrument improves referral to psychosocial care providers (e.g. psychologist) and facilitates patient-radiotherapist communication.

METHODS

A cluster randomized controlled trial was used. Fourteen radiotherapists were randomly allocated to the experimental or control group and 568 of their patients received care in accordance with the group to which their radiotherapist was allocated. Patients in the experimental group were asked to complete a screening instrument before and at the end of the radiation treatment period. All patients were requested to complete questionnaires concerning patient-physician communication after the first consultation and concerning psychosocial care 3 and 12 months post-intervention.

RESULTS

Patients who completed the screening instrument were referred to social workers at an earlier stage than patients who did not (P<0.01). No effects were observed for numbers of referred patients, or for improved patient-radiotherapist communication.

CONCLUSIONS

Our results suggest that a simple screening procedure can be valuable for the timely treatment of psychosocial problems in patients. Future efforts should be directed at appropriate timing of screening and enhancing physicians' awareness regarding the importance of identifying, discussing and treating psychosocial problems in cancer patients.

PRACTICE IMPLICATIONS

Psychosocial screening can be enhanced by effective radiotherapist-patient communication.

No personalization without participation: on the active contribution of psychiatric patients to the development of a mobile application for mental health

Background

Despite the increasing pervasiveness of mobile computational technologies, knowledge about psychiatric patients’ preferences regarding the design and utility of mobile applications is very poor. This paper reports on a pilot-study that involved 120 psychiatric patients in the development of a mobile application (app) that is being used for data entry into the Signature Project data bank at the Institut universitaire en santé mentale de Montréal (IUSMM), Canada. Participants were invited to comment on the ‘look and feel’ of the Signature App. Their input also extended the procedures for data collection. These suggestions may contribute to increased mental health literacy and empowerment of persons with mental illness receiving services at the IUSMM.

Methods

Participants were recruited to fill out a questionnaire on a tablet computer while waiting at the Emergency Room (ER, n = 40), Psychotic Disorders outpatient clinic (n = 40) or Anxiety and Mood Disorders outpatient clinic (n = 40) of IUSMM. Nine patients from each of these sub-groups participated in a focus group to review the results and to discuss how the design and use of the Signature App could be improved to better meet the needs of patients.

Results

This study (n = 120) indicated that psychiatric patients are clearly capable of using a tablet computer to fill out questionnaires for quantitative data entry, and that they enjoyed this experience. Results from the focus groups (n = 27) highlight that the app could also be used by patients to communicate some personal and contextual qualitative information. This would support a holistic and person-centered approach, especially at the ER where people acutely need to describe their recent history and receive emotional support.

Conclusions

This pilot-study has confirmed the necessity of involving patients not only in the testing of a new mobile application, but also as active contributors in the entire research and development process of a person-centered information and communication technology infrastructure. The input of participants was essential in designing the Signature Project computational procedure and making use of the app a positive and empowering experience. Participants also gave critical feedback remarks that went beyond the initial scope of the pilot-study, for example they suggested the addition of a client-clinician component.

Randomized controlled trial to test a computerized psychosocial cancer assessment and referral program: methods and research design

The National Cancer Coalition Network, National Cancer Institute, and American College of Surgeons all emphasize the need for oncology providers to identify, address, and monitor psychosocial needs of their patients. The Mental Health Assessment and Dynamic Referral for Oncology (MHADRO) is a patient-driven, computerized, psychosocial assessment that identifies, addresses, and monitors physical, psychological, and social issues faced by oncology patients. This paper presents the methodology of a randomized controlled trial (RCT) that tested the impact of the MHADRO on patient outcomes at 2, 6, and 12 months. Patient outcomes including overall psychological distress, depression, anxiety, functional disability, and use of psychosocial resources will be presented in future publications after all follow-up data is gathered. Eight hundred and thirty six cancer patients with heterogeneous diagnoses, across three comprehensive cancer centers in different parts of the United States, were randomized to the MHADRO (intervention) or an assessment-only control group. Patients in the intervention group were provided detailed, personalized reports and, when needed, referrals to mental health services; their oncology provider received detailed reports designed to foster clinical decision making. Those patients who demonstrated high levels of psychosocial problems were given the option to authorize that a copy of their report be sent electronically to a "best match" mental health professional. Demographic and patient cancer-related data as well as comparisons between patients who were enrolled and those who declined enrollment are presented. Challenges encountered during the RCT and strategies used to address them are discussed.

Longitudinal comparison of three depression measures in adult cancer patients

CONTEXT

Although a number of depression measures have been used with cancer patients, longitudinal comparisons of several measures in the same patient population have been infrequently reported.

OBJECTIVES

To compare the Hopkins Symptom Checklist 20-item depression scale, Short-Form 36 Mental Health Inventory five-item distress scale, and Patient Health Questionnaire nine-item depression scale in adults with cancer.

METHODS

Of the 309 cancer patients enrolled in a telecare management trial for depression, 247 completed the three depression measures at both baseline and at three months and a retrospective assessment of global rating of change in depression at three months. Internal consistency and construct validity of each measure were evaluated. Responsiveness was compared by calculating standardized response means and receiver operating characteristic area under the curve, using global rating of change as the external comparator measure. Differences between intervention and control groups in depression change scores were compared by calculating standardized effect sizes (SESs).

RESULTS

Internal reliability coefficients for the three measures were ≥0.77 at baseline and ≥0.84 at three months. Construct validity was supported with strong correlations of the depression measures among themselves, moderately strong correlations with other measures of mental health, and moderate correlations with vitality and disability. In terms of responsiveness, standardized response means for all measures significantly differentiated between three groups (improved, unchanged, and worse) as classified by patient-reported global rating of change in depression at three months. The three measures were able to detect a modest treatment effect in the intervention group compared with the control group (SES ranging from 0.21 to 0.43) in the full sample, whereas detecting a greater treatment effect in depressed participants with comorbid pain (SES ranging from 0.30 to 0.58). Finally, the three measures performed similarly in detecting patients with improvement.

CONCLUSION

The Hopkins Symptom Checklist 20-item depression scale, Mental Health Inventory five-item distress scale, and Patient Health Questionnaire nine-item depression scale were established as reliable, valid, and responsive depression measures in adults with cancer. Given the current recommendations for measurement-based care, our study shows that clinicians treating depressed cancer patients have several measures from which to choose.

Using patient-reported outcomes in clinical oncology practice: benefits, challenges and next steps

Measuring patient outcomes such as health-related quality-of-life in clinical practice can provide opportunities for patient monitoring and management. Well-validated instruments are available and studies have shown that such information is acceptable to - even valued by - patients and their clinicians. However, despite such general acceptance of the idea and, as demonstrated in feasibility studies, such systematic reporting occurs rarely in oncology practice in the USA and many challenges to widespread adoption exist. These challenges include limitations in knowledge about how best to interpret individual patient-reported outcomes and clinician, patient-related and health system issues. The way forward does not lie simply in urging clinicians to add patient-reported measurement to other tasks that are part of everyday practice. Rather, new information infrastructures and technologies, combined with redesign of care, are more likely to embed the routine use of patient-reported outcomes. In addition to taking vital signs and performing laboratory tests, such information can better provide a timely response to patient needs.

Improvements in measuring the health-related quality of life of cancer patients

There have been considerable improvements in the collection of health-related quality of life (HRQOL) data in oncology over the past 20 years. The facility with which HRQOL information can now be collected from patients has also been associated with an improved understanding of the meaning of HRQOL and the association between HRQOL and patients' treatment and care plans. Therefore the role that HRQOL data can play in routine clinical practice is increasingly being recognized. The appearance of computer-adaptive tests will herald a new era in HRQOL where questionnaires will be individually tailored to each patient utilizing details unique to that person and linked to clinical management systems to allow a comprehensive assessment of HRQOL status.

Meta-analysis of screening and case finding tools for depression in cancer: evidence based recommendations for clinical practice on behalf of the Depression in Cancer Care consensus group

BACKGROUND

To examine the validity of screening and case-finding tools used in the identification of depression as defined by an ICD10/DSM-IV criterion standard.

METHODS

We identified 63 studies involving 19 tools (in 33 publications) designed to help clinicians identify depression in cancer settings. We used a standardized rating system. We excluded 11 tools without at least two independent studies, leaving 8 tools for comparison.

RESULTS

Across all cancer stages there were 56 diagnostic validity studies (n=10,009). For case-finding, one stem question, two stem questions and the BDI-II all had level 2 evidence (2a, 2b and 2c respectively) and given their better acceptability we gave the stem questions a grade B recommendation. For screening, two stem questions had level 1b evidence (with high acceptability) and the BDI-II had level 2c evidence. For every 100 people screened in advanced cancer, the two questions would accurately detect 18 cases, while missing only 1 and correctly reassure 74 with 7 falsely identified. For every 100 people screened in non-palliative settings the BDI-II would accurately detect 17 cases, missing 2 and correctly re-assure 70, with 11 falsely identified as cases. The main cautions are the reliance on DSM-IV definitions of major depression, the large number of small studies and the paucity of data for many tools in specific settings.

CONCLUSIONS

Although no single tool could be offered unqualified support, several tools are likely to improve upon unassisted clinical recognition. In clinical practice, all tools should form part of an integrated approach involving further follow-up, clinical assessment and evidence based therapy.

Psychological distress in cancer survivors: the further development of an item bank

OBJECTIVE

Assessment of psychological distress by patient report is necessary to meet patients' needs throughout the cancer journey. We have previously developed an item bank to assess psychological distress but not evaluated it for cancer survivors. Our first aim in this study was to test whether we could extend our item bank to include cancer survivors. The second aim was to examine whether the item bank could assess positive affect as a single construct alongside negative psychological symptoms.

METHODS

Responses from 1315 cancer survivors to the Hospital Anxiety and Depression Scale (HADS) and the Positive and Negative Affect Scale (PANAS) were considered for inclusion in a pre-existing item bank created from a heterogeneous sample of 4914 cancer patients. Differential item functioning (DIF) was used to assess whether HADS responses drawn from the two samples were equivalent. Common-item equating was used to anchor the shared (HADS) items, whilst the PANAS items were added. Item fit was evaluated at each stage, and misfitting items were removed. Unidimensionality was assessed with a principal components factor analysis.

RESULTS

The DIF analysis did not reveal any differences between the HADS item locations from the two samples. Three misfitting PANAS items were removed, resulting in a final unidimensional bank of 80 items with good internal reliability (α = 0.85).

CONCLUSION

The new item bank is valid for use across the cancer journey, including cancer survivors, and modestly improves the assessment of all levels of psychological distress and positive psychological function.

Accuracy of the Hospital Anxiety and Depression Scale as a screening tool in cancer patients: a systematic review and meta-analysis

PURPOSE

The Hospital Anxiety and Depression Scale (HADS) is the most extensively validated scale for screening emotional distress in cancer patients. However, thresholds for clinical decision making vary widely across studies. A meta-analysis was conducted with the aim of identifying optimal, empirically derived cut-offs.

METHODS

PubMed, Embase, and PsycINFO databases were searched for studies that compared the HADS total and its subscale scores against a semi-structured or structured clinical interview as a reference standard with regard to its screening efficacy for any mental disorders and depressive disorders alone. Separate pooled analyses were conducted for single or two adjacent thresholds. A total of 28 studies (inter-rater agreement, κ = 0.86) were included.

RESULTS

The best thresholds for screening for mental disorders were 10 or 11 on the HADS total (sensitivity 0.80; specificity 0.74), 5 on the HADS depression subscale (sensitivity 0.84; specificity 0.50), and 7 or 8 on the HADS anxiety subscale (sensitivity 0.73; specificity 0.65). Respective thresholds for depression screening were 15 for the HADS total (sensitivity 0.87; specificity 0.88), 7 for the HADS depression subscale (sensitivity 0.86; specificity 0.81), and 10 or 11 for the HADS anxiety subscale (sensitivity 0.63; specificity 0.83).

CONCLUSIONS

The HADS anxiety subscale performed worse than the total and the depression subscales for both indicators. Diagnostic accuracy varied widely by threshold but was consistently superior for depression screening than for screening of any mental disorder.

Clinical study on the efficacy of fluvoxamine for psychological distress in gynecologic cancer patients

BACKGROUND

Diagnosis of cancer causes psychological distress. The present study investigated the safety and efficacy of fluvoxamine therapy in gynecologic cancer patients with either adjustment disorder or major depression after cancer was diagnosed.

METHODS

Screening with the Hospital Anxiety and Depression Scale (HADS) was conducted at least 2 weeks after notification of the diagnosis of cancer in 214 gynecologic cancer patients hospitalized between January 2007 and December 2008. The HADS cutoff score was set at 11 points or greater. Informed consent to the study was obtained from 10 patients, and fluvoxamine was administered for 8 weeks. As primary end points, the safety and efficacy of fluvoxamine were evaluated using the HADS and the SF-36. As a secondary end point, the Clinical Global Impression was determined.

RESULTS

The total HADS score, the anxiety score, and the depression score were significantly reduced after 6, 4, and 6 weeks of treatment, respectively. The SF-36 revealed significant improvement in vitality, mental health, and role (emotional) after 8 weeks of treatment. In the 5 patients with adjustment disorder, only the HADS anxiety score was significantly reduced after 4 weeks. In the 5 patients with major depression, the total HADS score, the anxiety score, and the depression score were significantly reduced after 6, 8, and 6 weeks, respectively. According to the SF-36, the adjustment-disorder groups showed significant improvement in mental health after 8 weeks of treatment, whereas the major-depression group showed significant improvement in vitality and role (emotional) after 8 weeks. No adverse events occurred in any subject. Assessment of the Clinical Global Impression suggested that fluvoxamine improved psychological distress in all 10 subjects.

CONCLUSIONS

The present findings suggest that fluvoxamine is useful for alleviating psychological distress, including adjustment disorder and major depression, in gynecologic cancer patients. Management of psychological distress after diagnosis of cancer is important.

Identifying psychological distress at key stages of the cancer illness trajectory: a systematic review of validated self-report measures

CONTEXT

To enable study of psychological distress along the cancer journey, we need to be able to select and map validated measures through the cancer trajectory.

OBJECTIVES

To examine the performance of self-report measures for identifying clinically significant levels of psychological distress across the cancer patient trajectory.

METHODS

Electronic searches of Medline, PsychInfo, CINAHL, EmBase, The Cochrane Library, AMED, BNI, ASSIA, and Web of Science were undertaken. Only studies of self-report measures that used validated diagnostic tools for psychiatric diagnosis as the criterion measure were included. We then further limited our focus to those papers that specified a trajectory stage.

RESULTS

Forty-eight different self-report measures were reported in the 85 papers identified. The Hospital Anxiety and Depression Scale (HADS) was the most frequently reported measure (23 times). Several other measures were reported between two and four times, but most (37) measures were reported only once. Twenty-two of the 85 included papers reported measure performance by trajectory stage. Best performing measures based on validation data available could be identified for each trajectory stage: for pretreatment, the HADS for identifying depression; during treatment, the HADS and Mental Health Inventory-5 (MHI-5) together for identifying clinically significant distress; post-treatment, the HADS for identifying depression; and at recurrence and during the palliative phase, the Brief Edinburgh Depression Scale (BEDS) for identifying depression.

CONCLUSION

No single measure had evidence to support use throughout the illness trajectory in a longitudinal study, but the HADS, in combination with the MHI-5, was supported during the cancer treatment phase, and BEDS in the palliative care phase.

The sequelae of anxiety in breast cancer: a human response to illness model

PURPOSE/OBJECTIVES

To provide a critical review of the empirical literature on anxiety in women with breast cancer using the physiologic, pathophysiologic, behavior, and experiential perspectives of the Human Response to Illness (HRTI) Model.

DATA SOURCES

Research articles, clinical articles, and Internet sources on breast cancer and anxiety. Literature sources included CINAHL, PubMed, and PsycINFO, incorporating English language reports through March 2009.

DATA SYNTHESIS

Patients with breast cancer experience fluctuating levels of anxiety throughout their diagnosis and treatment trajectory. Anxiety may influence an individual's response to treatment, treatment decision making, and overall quality of life.

CONCLUSIONS

Research consistently demonstrates that anxiety in patients with breast cancer can have a negative effect on patient outcomes.

IMPLICATIONS FOR NURSING

The insight gained from exploring anxiety within the context of the four interrelated perspectives of the HRTI model fosters the provision of optimal care for patients suffering with anxiety throughout their breast cancer illness trajectory.

Use of electronic quality of life applications in cancer research and clinical practice

Outcome measures of cancer treatment should include measures of quality of life, in addition to survival and objective response. Electronic administration of quality of life measures has made regular monitoring of the quality of life of individual cancer patients possible and feasible. Electronic questionnaires were well accepted by patients, had good test-retest reliability and were comparable with traditional paper-and-pen methods. Several randomized studies have shown that using quality of life screening in clinical practice can facilitate patient-doctor communication, without increasing consultation time. In one study, the regular assessment of quality of life resulted in benefits for some patients, who had better well-being and emotional functioning. Research is ongoing in developing computer-adaptive questionnaires to reduce patient burden and provide a more precise measurement. Further research using randomized controlled studies is necessary before the monitoring of individual patients' quality of life is recommended for routine practice. Special attention should be paid to training physicians in using the quality of life scores.

Quality of life in breast cancer patients: measurement issues in cancer clinical trials

Quality of life is becoming a significant issue to measure in breast cancer patients. Increasingly, in breast cancer clinical trials we see quality of life as a secondary end-point and we are understanding more about the needs of these women. However, as yet, there is no gold standard regarding which tool is the most appropriate to use. This article reviews quality of life measures that have been used in cancer clinical trials with breast cancer patients and evaluates their reliability, validity and cultural relevance. We propose suggestions for selecting future measures for use in a breast cancer population of patients.

Implementation of computer-based quality-of-life monitoring in brain tumor outpatients in routine clinical practice

CONTEXT

Computerized assessment of quality of life (QOL) in patients with brain tumors can be an essential part of quality assurance with regard to evidence-based medicine in neuro-oncology.

OBJECTIVES

The aim of this project was the implementation of a computer-based QOL monitoring tool in a neurooncology outpatient unit. A further aim was to derive reference values for QOL scores from the collected data to improve interpretability.

METHODS

Since August 2005, patients with brain tumors treated at the neuro-oncology outpatient unit of the Innsbruck Medical University were consecutively included in the study. QOL assessment (European Organisation for Research and Treatment of Cancer [EORTC] Quality of Life Questionnaire [QLQ-C30] plus the EORTC QLQ-brain cancer module [BN20]) was computer-based, using a software tool called the Computer-based Health Evaluation System.

RESULTS

A total of 110 patients with primary brain tumors (49% female; mean [standard deviation] age 47.9 [12.6] years; main diagnoses: 30.9% astrocytoma, 17.3% oligodendroglioma, 17.3% glioblastoma, 13.6% meningioma) was included in the study. On average, QOL was assessed 4.74 times per patient, 521 times in total. The user-friendly software was successfully implemented and tested. The routine QOL assessment was found to be feasible and was well accepted by both physicians and patients.

CONCLUSION

The software-generated graphic QOL profiles were found to be an important tool for screening patients for clinically relevant problems. Thus, computer-based QOL monitoring can contribute to an optimization of treatment (e.g., symptom management, psychosocial interventions) and facilitate data collection for research purposes.

Extending computer technology to hospice research: interactive pentablet measurement of symptoms by hospice cancer patients in their homes

We aimed to determine the acceptability and feasibility of a pentablet-based software program, PAINReportIt-Plus, as a means for patients with cancer in home hospice to report their symptoms and differences in acceptability by demographic variables. Of the 131 participants (mean age = 59 +/- 13, 58% women, 48.1% African American), 44% had never used a computer, but all participants easily used the computerized tool and reported an average computer acceptability score of 10.3 +/- 1.8, indicating high acceptability. Participants required an average of 19.1 +/- 9.5 minutes to complete the pain section, 9.8 +/- 6.5 minutes for the medication section, and 4.8 +/- 2.3 minutes for the symptom section. The acceptability scores were not statistically different by demographic variables but time to complete the tool differed by racial/ethnic groups. Our findings demonstrate that terminally ill patients with cancer are willing and able to utilize computer pentablet technology to record and describe their pain and other symptoms. Visibility of pain and distress is the first step necessary for the hospice team to develop a care plan for improving control of noxious symptoms.

Screening for emotional distress in cancer patients: a systematic review of assessment instruments

Screening for emotional distress is becoming increasingly common in cancer care. This systematic review examines the psychometric properties of the existing tools used to screen patients for emotional distress, with the goal of encouraging screening programs to use standardized tools that have strong psychometrics. Systematic searches of MEDLINE and PsycINFO databases for English-language studies in cancer patients were performed using a uniform set of key words (eg, depression, anxiety, screening, validation, and scale), and the retrieved studies were independently evaluated by two reviewers. Evaluation criteria included the number of validation studies, the number of participants, generalizability, reliability, the quality of the criterion measure, sensitivity, and specificity. The literature search yielded 106 validation studies that described a total of 33 screening measures. Many generic and cancer-specific scales satisfied a fairly high threshold of quality in terms of their psychometric properties and generalizability. Among the ultrashort measures (ie, those containing one to four items), the Combined Depression Questions performed best in patients receiving palliative care. Among the short measures (ie, those containing five to 20 items), the Center for Epidemiologic Studies–Depression Scale and the Hospital Anxiety and Depression Scale demonstrated adequate psychometric properties. Among the long measures (ie, those containing 21–50 items), the Beck Depression Inventory and the General Health Questionaire–28 met all evaluation criteria. The PsychoSocial Screen for Cancer, the Questionnaire on Stress in Cancer Patients–Revised, and the Rotterdam Symptom Checklist are long measures that can also be recommended for routine screening. In addition, other measures may be considered for specific indications or disease types. Some measures, particularly newly developed cancer-specific scales, require further validation against structured clinical interviews (the criterion standard for validation measures) before they can be recommended.

Concurrent validity of the PSYCH-6, a very short scale for detecting anxiety and depression, among oncology outpatients

OBJECTIVE

To improve the acceptability of screening for depression and anxiety among patients with cancer there is a need for scales that are both very short and accurate. To date no very short questionnaire has been found to provide optimal performance for screening in oncology populations and other candidates must be examined. This study examined the concurrent validity of a relatively new, very short scale, the six item PSYCH-6 subscale of the Somatic and Psychological Health Report (SPHERE-12), in an oncology outpatient population.

METHODS

Cross-sectional survey of 340 oncology outpatients attending a regional hospital in Newcastle, Australia. The performance of the PSYCH-6 against the Hospital Anxiety and Depression Scale (HADS) was evaluated using correlation, Cohen's kappa, positive agreement and negative agreement.

RESULTS

The PSYCH-6 subscale of the SPHERE-12, at a cut-off point of 3, had substantial agreement with the total score of the HADS (HADS-T; kappa = 0.73, p < 0.001). Negative agreement (0.92) was marginally higher than positive agreement (0.80).

CONCLUSIONS

The PSYCH-6 scale of the SPHERE-12 at a cut-off point of 3 is an equivalent instrument to the HADS-T for detecting cases and excluding non-cases of anxiety and depression and is suitable for deployment in oncology populations.

The role of health kiosks in 2009: literature and informant review

Kiosks can provide patients with access to health systems in public locations, but with increasing home Internet access their usefulness is questioned. A literature and informant review identified kiosks used for taking medical histories, health promotion, self assessment, consumer feedback, patient registration, patient access to records, and remote consultations. Sited correctly with good interfaces, kiosks can be used by all demographics but many ‘projects’ have failed to become routine practice. A role remains for: (a) integrated kiosks as part of patient ‘flow’, (b) opportunistic kiosks to catch people’s attention. Both require clear ‘ownership’ to succeed.

Depression screening using the Patient Health Questionnaire-9 administered on a touch screen computer

OBJECTIVE

To (1) evaluate the feasibility of touch screen depression screening in cancer patients using the Patient Health Questionnaire-9 (PHQ-9), (2) evaluate the construct validity of the PHQ-9 using the touch screen modality, and (3) examine the prevalence and severity of depression using this screening modality.

METHODS

The PHQ-9 was placed in a web-based survey within a study of the clinical impact of computerized symptom and quality of life screening. Patients in medical oncology, radiation oncology, and hematopoietic stem cell transplantation (HSCT) clinics used the program on a touch screen computer in waiting rooms prior to therapy (T1) and during therapy (T2). Responses of depressed mood or anhedonia (PHQ-2 cardinal depression symptoms) triggered additional items. PHQ-9 scores were provided to the oncology team in real time.

RESULTS

Among 342 patients enrolled, 33 (9.6%) at T1 and 69 (20.2%) at T2 triggered the full PHQ-9 by endorsing at least one cardinal symptom. Feasibility was high, with at least 97% completing the PHQ-2 and at least 96% completing the PHQ-9 when triggered and a mean completion time of about 2 min. The PHQ-9 had good construct validity. Medical oncology patients had the highest percent of positive screens (12.9%) at T1, while HSCT patients had the highest percent (30.5%) at T2. Using this method, 21 (6.1%) at T1 and 54 (15.8%) at T2 of the total sample had moderate to severe depression.

CONCLUSIONS

The PHQ-9 administered on a touch screen computer is feasible and provides valid depression data in a diverse cancer population.

Taking PROs and patient-centered care seriously: incremental and disruptive ideas for incorporating PROs in oncology practice

Using patient-reported outcomes (PROs) in clinical practice poses challenges for health care teams and organizations to respond to individual patient needs in a timely fashion. Well-validated tools and feasibility studies are available, but successful spread will require knowledge of effective technology dissemination in complex health delivery systems. Given what has been learned about effective implementation, it is reasonable to ask whether the broad adoption of PROs can occur incrementally using current models of care to apply PRO technology. Another approach is to start with patient needs and focus on how to meet those needs most effectively using PROs in new ways of organizing health care.

Use of Patient-Reported Outcomes in Clinical Oncology Practice

The Institute of Medicine report, Crossing the Quality Chasm, suggested some new ways of thinking about organizing care. This article describes how practices might create continuous healing relationships using methods that are independent of patient visits to monitor and address problems that may occur during cancer care. Such a system would be based on patient report, timely and useful, sensitive to change, and low burden for patients, clinicians, and administrative staff. Furthermore, it would be built into the delivery of care and be integrated with other data systems such as patient records, decision support, and community or other resources. Using reports for patients that are presented in a format that is easily understandable, patients should be able to monitor their own progress.

Issues in the design of Internet-based systems for collecting patient-reported outcomes

BACKGROUND AND OBJECTIVES

Although there is a growing interest in using patient-reported outcomes (PRO) to monitor disease progression and/or therapeutic response, to improve care, and to screen for physical or psychosocial problems in routine clinical practice, PRO instruments can be difficult to administer, score, and interpret in this setting. Internet-based approaches to PRO collection may help overcome these obstacles. This paper discusses the rationale for using the Internet for routine PRO collection, summarizes relevant literature and ongoing projects, and raises several key design and development issues that should guide further efforts in this area.

MAJOR FINDINGS

A small number of Internet-based PRO collection applications have been or are currently being developed. The major characteristics of several of these projects are reviewed and summarized. Successful Internet-based PRO collection applications must address patient and clinician-specific needs related to workflow and to the way in which results are presented. A growing number of instruments have been adapted for and evaluated in a web-based format.

CONCLUSIONS

Collecting PROs via the Internet has the potential to overcome many of the challenges associated with efforts to routinely use PROs in the clinical encounter.

Daily health status registration (patient diary) in patients with rheumatoid arthritis: a comparison between personal digital assistant and paper-pencil format

OBJECTIVE

The patient perspective workshops at the Outcome Measures in Rheumatology Clinical Trials have included daily measures of health status (patient diary) and use of electronic tools for data collection in the research agenda. The objective of this study was to compare daily and weekly registrations of self-reported health status measures between personal digital assistant (PDA) and paper-pencil (PP) format regarding scores, variation, and feasibility.

METHODS

Thirty-eight patients with stable rheumatoid arthritis recorded their health status during 84 days in a repeated crossover design, using PDA or PP format during four 21-day periods. Visual analog scales (VAS) for pain, fatigue, and global disease and the Rheumatoid Arthritis Disease Activity Index were scored daily; the Short Form 36 and Modified Health Assessment Questionnaire were scored weekly.

RESULTS

The average scores and measures of variation of the 4 daily health status measures over 21 days did not differ significantly between PDA and PP formats in either of the 2 crossover periods. The values for the average range between the maximum and minimum values for daily measures were similar between the 2 formats, but showed considerable variation (e.g., range for pain VAS was 19-28 mm over each 21-day period). The time to complete the instruments was similar between the 2 formats. Missing daily data entries were generally low for both periods and somewhat higher for PDA. The majority of patients (82.9%) preferred using PDA.

CONCLUSION

Daily assessments with PDA may be efficiently used for frequent data collection because this format performs similarly to the traditional PP format.

The initial development of an item bank to assess and screen for psychological distress in cancer patients

Psychological distress is a common problem among cancer patients. Despite the large number of instruments that have been developed to assess distress, their utility remains disappointing. This study aimed to use Rasch models to develop an item-bank which would provide the basis for better means of assessing psychological distress in cancer patients.An item bank was developed from eight psychological distress questionnaires using Rasch analysis to link common items. Items from the questionnaires were added iteratively with common items as anchor points and misfitting items (infit mean square >1.3) removed, and unidimensionality assessed.A total of 4914 patients completed the questionnaires providing an initial pool of 83 items. Twenty items were removed resulting in a final pool of 63 items. Good fit was demonstrated and no additional factor structure was evident from the residuals. However, there was little overlap between item locations and person measures, since items mainly targeted higher levels of distress. The Rasch analysis allowed items to be pooled and generated a unidimensional instrument for measuring psychological distress in cancer patients. Additional items are required to more accurately assess patients across the whole continuum of psychological distress.

Rasch analysis of the dimensional structure of the Hospital Anxiety and Depression Scale

The Hospital Anxiety and Depression Scale (HADS) has been used extensively in cancer patients to identify psychological distress. Reports of the factor structure and screening performance of the instrument vary. Rasch models allow an assessment of the structure of a questionnaire by identifying item fit. Removal of misfitting items may improve both the dimensionality and efficacy of screening questionnaires. A Rasch analysis of the HADS-T and subscales was used to explore the factor structure, dimensionality and screening efficacy. A total of 1855 patients completed a touchscreen version of the HADS, including 381 patients who had received a psychiatric interview (SCAN/PSE). These data were analysed using Rasch models, and the screening efficacy at identifying cases of psychological distress and anxiety and depression evaluated. The results demonstrated that the structure of the HADS-T and subscales was unidimensional. Three items from the HADS-T, and one from each of the subscales demonstrated misfit. Screening efficacy for the HADS-T and subscales was modest. However, removal of misfitting items had little impact on screening, demonstrating that items could potentially be omitted, if required. The item range covered a narrow spectrum of psychological distress, predominantly higher levels of distress. Additional items have to be added if screening for moderate to mild distress is to be improved for cancer patients.

Development of a Smiling Touchscreen multimedia program for HRQoL assessment in subjects with varying levels of literacy

OBJECTIVE

As low literacy affects the assessment of health-related quality of life (HRQoL) in several ways (e.g., subject eligibility and cost of administration), better approaches to HRQoL assessment in subjects with varying literacy levels are needed.

METHODS

We developed a multimedia touchscreen program (the Smiling Touchscreen, ST) to administer HRQoL instruments to subjects with varying levels of Chinese language and computer literacy, using an iterative process where patients' input on design, clarity of instructions, and user-friendliness were repeatedly gathered and incorporated in development. The ST thus has several user-friendly features for low-literacy subjects (e.g., presentation of individual items using visual and auditory stimuli, voice-text synchronization, and visual analog scale with a touch and drag function), which we evaluated using qualitative and quantitative methods.

RESULTS

The ST was well accepted by subjects (n = 66, 76% female, median [interquartile] age: 49.0 [40.0, 56.0]) with high (n = 43) or low (n = 23) literacy, 98% of whom found it easy or very easy to use, and 85% found the voice-text synchronization feature useful. In low-literacy subjects without computer experience (30%), none reported any difficulties using the ST. The median (interquartile) time spent to complete the ST (four Instruction and Practice screens, 24 questions, one visual analog scale) for high- and low-literacy groups was 13.9 (9.6, 23.9) and 23.2 (15.8, 26.5) minutes, respectively. Among subjects expressing a preference (n = 47), 21 (47%) favored the ST over interviewer- or self-administration.

CONCLUSION

The ST is well accepted by subjects with varying literacy levels, including those without computer experience. It is thus a promising new approach for HRQoL assessment among subjects with varying literacy levels.

The clinical significance of quality of life assessments in oncology: a summary for clinicians

BACKGROUND

A series of six manuscripts with an introduction appeared in the Mayo Clinic Proceedings, based upon the collective effort of 30 individuals with an interest and expertise in assessing the clinical significance of quality of life (QOL) assessments. The series of manuscripts described the state of the science of QOL assessments in oncology clinical research and practice and included extensive literature and theoretical justification for the continued inclusion of QOL in oncology clinical research and practice.

OBJECTIVES

The purpose of this paper is to produce a summary of these articles and to supplement these works with additional information that was gleaned from subsequent meetings and discussions of this material. The primary aim of this paper is to present a cogent and concise description for clinicians to facilitate the incorporation of QOL assessments into oncology clinical research and practice. The theoretical discussion is supplemented with an example of how the various ideas can be operationalized in an oncology clinical trial.

A feasibility study of computer-assisted health-related quality of life data collection in patients with oral and oropharyngeal cancer

Touchscreen technology (TST) has been widely used in the field of medicine. The purpose of this study was to pilot a standard TST system to administer the University of Washington Quality of Life Questionnaire (UWQOL) in a routine head and neck oncology clinic. The UWQOLv4 was completed using TST and a semi-structured interview was used to evaluate patients' experience of the data collection process. Forty-one of 44 consecutive cancer patients agreed to participate in the study. Although over three-quarters of patients reported never having used a computer, all but one found the UWQOLv4 'easy' or 'very easy' to complete using the TST. They preferred the TST method to paper copy and the vast majority completed the TST in 10min or less. TST provides a very suitable mechanism for routine health-related quality of life data collection. The system is easy to programme and relatively inexpensive.

Psychosocial difficulties, deprivation and cancer: three questionnaire studies involving 609 cancer patients

The aim of the study is to investigate associations between deprivation and self-reported social difficulties and psychological distress in cancer patients. A total of 304 men and 305 women (age range 18-88 years) with a range of cancer diagnoses and living in a socially diverse region (Carstairs and Morris index) completed the Hospital Anxiety and Depression Scale and the Social Difficulties Inventory. Univariate analyses of variance revealed statistically significant differences in reported social difficulties between groups (F (67, 576)=2.4, P<0.0001) with stage of disease (F (5, 576)=7.6, P<0.0001), age (F (2, 576)=4.8, P=0.009) and to a lesser extent deprivation (F (1, 576)=4.0, P=0.048) making significant contributions. Significantly more social difficulties were reported by less affluent patients with locally recurrent disease or 'survivors'. No other interactions were found. Significant differences in levels of reported psychological distress were found between groups (F (67, 575)=1.723, P=0.001) for stage of disease, sex and deprivation but no interactions observed. In conclusion, deprivation is associated with reported psychological distress and, to a lesser extent, social difficulties. Patients at particular risk cannot be identified with confidence by socio-demographic and clinical means supporting the recommendation from National Institute for Clinical Excellence for provision of psychosocial assessment for individual cancer patients.

Web-based Touch-Screen Computer Assessment of Chronic Low Back Pain

The objective of this study was to evaluate the acceptability and feasibility of a Web-based touch-screen computer questionnaire as a data collection method for patients experiencing chronic low back pain in a tertiary spine clinic. Participants completed the Oswestry Low Back Pain Disability Index, SF-36, and Beck Depression Inventory using a touch-screen computer. The time taken to complete the questionnaire was recorded electronically (M = 27.4 minutes; SD = 13.8). Prior computer experience and perceptions of computer use were also assessed. Low back pain was evaluated before and after completing the touch-screen computer questionnaire. Observations of sitting and standing tolerances were made. Participants completed a nine-item paper-and-pencil satisfaction survey after completing the computer questionnaire. Overall satisfaction level with this mode of data collection was high, supporting a larger study using touch-screen technology in patients with chronic low back pain. Important factors influencing satisfaction were the computer environment, ease of use, security, and the ability to interrupt the questionnaire process to allow for changes in sitting or standing posture.

Development and evaluation of an instrument to assess social difficulties in routine oncology practice

PURPOSE

To develop and preliminarily evaluate a Social Difficulties Inventory (SDI) for use in oncology practice.

METHODS

Item generation from patients (n = 96), staff (n = 49) and the literature. Questions constructed and pre-tested (n = 42) resulting in a 22-item questionnaire. Psychometric evaluation (n = 271) assessed frequency of endorsement, factor structure, summated scales and construct validity followed by randomisation to criterion validity or test-retest arms.

RESULTS

Items met preset frequency of endorsement criteria. Factor analysis revealed a four-factor structure, three clearly definable, (1) Physical ability, (2) Providing for the family and (3) Contact with others, explaining 45.8% variance. Summated scales developed from these demonstrated good reliability (Cronbach's alpha > 0.7) and were used to test and confirmed construct validity. Several comparators from the Life Events and Difficulties Schedule (LEDS) and Cancer Rehabilitation Evaluation System Short Form (CARES-SF) tested criterion validity and majority agreements were moderate to good. Test-retest reliability was good with most kappa values > 0.6. One item was eliminated resulting in a 21-item questionnaire.

CONCLUSION

The SDI is relevant and easy to understand. Initial psychometric evaluation was encouraging. Ongoing work to evaluate the clinical meaning and utility of the instrument and to examine the relationships between SDI scores and clinical outcomes will provide guidance about its usefulness as an assessment tool in routine oncology practice.