Physical activity and pain in people with and without cancer

BACKGROUND

Performing physical activity may provide analgesic benefit, although this effect is more established for noncancer pain rather than cancer pain. The relationship between physical activity and pain outcomes in adults with and without a history of cancer was examined.

METHODS

Totals of 51,439 adults without a cancer history and 10,651 adults with a cancer history from the Cancer Prevention Study II Nutrition Cohort were included. Exposures included self-reported moderate to vigorous physical activity (MVPA) as well as 2-year change in MVPA. Pain outcomes included pain intensity (primary outcome) and analgesic use (secondary outcome).

RESULTS

MVPA was inversely associated with pain intensity for adults with (odds ratio [OR], 0.84 [≥15 metabolic equivalent of task (MET) h/week vs. <7.5 MET h/week]; 95% confidence interval [CI], 0.76-0.93) and without (OR, 0.79; 95% CI, 0.75-0.82) a history of cancer. Compared to remaining inactive, participants who became sufficiently active (cancer: OR, 0.76; 95% CI, 0.68-0.86; no cancer: OR, 0.73; 95% CI, 0.69-0.77), became inactive (cancer: OR, 0.79; 95% CI, 0.71-0.88; no cancer: OR, 0.84; 95% CI, 0.80-0.89), or remained sufficiently active (cancer: OR, 0.66; 95% CI, 0.60-0.72; no cancer: OR, 0.62; 95% CI, 0.60-0.65) also reported less pain. Physical activity was not related to analgesic use.

CONCLUSIONS

The relationship between physical activity and pain intensity was not substantially different between people with and without a history of cancer. Cancer survivors who perform more activity, or who increase their activity, may experience less pain than cancer survivors who consistently perform less.

PLAIN LANGUAGE SUMMARY

People who have had cancer often experience ongoing pain. Being physically active may help reduce the intensity of the pain they experience.

Adapting a Clinical Practice Guideline for Management of Patients with Knee and Hip Osteoarthritis by Hong Kong Physiotherapists

Knee and hip osteoarthritis are common disabling conditions globally. Although numerous international clinical practice guidelines exist to guide physiotherapy management, not all recommendations issued from these guidelines can be translated to other contexts without considering the cultural acceptability and clinical implementability of targeted countries. Because the ADAPTE framework provides a robust methodology to adapt guidelines to the local context, this study used its methodology to adapt high-quality guideline recommendations to promote optimal physiotherapy care for knee and hip osteoarthritis in Hong Kong. The ADAPTE framework was used and modified to complete the adaptation process. International clinical practice guidelines were identified from eight guideline clearinghouses and six electronic databases. Two independent reviewers critically appraised the eligible guidelines using the AGREE II tool. We extracted and tabulated recommendations from high-quality guidelines. A voting-based consensus among interdisciplinary experts was conducted to decide on suitable recommendations for the Hong Kong context and whether there was a need to modify them. Pertinent recommendations were then translated into the traditional Chinese language. Our team members suggested modifying four tools and adding one to explore the patient's feedback on the recommendations, to the ADAPTE framework. The adaptation was performed on three high-quality guidelines. We adapted 28 and 20 recommendations for treating knee and hip osteoarthritis, respectively. We recommend a multimodal treatment for managing knee and hip osteoarthritis. Land- and aquatic-based exercises, patient education, and self-management were strongly recommended for patients with knee osteoarthritis. Land- and aquatic-based exercises were strongly recommended for patients with hip osteoarthritis. This is the first adaptation study in Hong Kong. It provides guidance to local physiotherapists on managing patients with knee and hip osteoarthritis. Future studies should test the effectiveness of implementing this adapted guideline to improve local physiotherapy care in Hong Kong.

Clinical practice guideline for end-of-life care in patients with cancer: a modified ADAPTE process

PURPOSE

This study seeks to adapt a guideline for end-of-life care in patients with cancer to be used by healthcare teams.

METHODS

This methodological study was conducted by modifying the ADAPTE process and adding to it a qualitative study and consensus ratings by a multidisciplinary panel of experts. A qualitative study was thus performed to identify the end-of-life needs of patients with cancer. Then, the source guidelines and the results of the qualitative study were used to draft the initial version of the guideline, with 85 adaptation recommendations. A multidisciplinary panel of healthcare experts performed the external review of the recommendations based on the four criteria of relatedness, comprehensibility, usefulness, and feasibility and scored them on a scale of 1-9. The mean score of each recommendation was calculated, and the recommendations were classified into three categories: appropriate (mean score of 7-9), uncertain (mean score of 4-6.99), and inappropriate (mean score of 1-3.99).

RESULTS

All the recommendations were approved, as they all had a mean score of 7 or higher, and were then categorized into 11 dimensions: communication management; participatory and evidence-based decision-making management; pain management; dyspnea management; nausea and vomiting management; anorexia and cachexia management; constipation management; death rattle management; management of delirium, anxiety, and restlessness; hydration management; and pharmacological considerations.

CONCLUSION

The adaptation of the guideline for end-of-life care in patients with cancer in Iran was performed by modifying the ADAPTE process with the participation of multidisciplinary stakeholders and based on the local needs.

Patterns of oxycodone controlled release use in older people with cancer following public subsidy of oxycodone/naloxone formulations: An Australian population-based study

AIM

Public subsidy of the oxycodone/naloxone controlled release (CR) combination in December 2011 expanded the overall market for oxycodone CR in the general public in Australia; we evaluate its impact in people with cancer.

METHODS

We used Repatriation Pharmaceutical Benefits dispensing data linked with the NSW Cancer Registry for Department of Veterans' Affairs (DVA) healthcare card holders 65 years and older residing in NSW between 2004 and 2013 to identify clients with cancer and their opioid dispensings. We used interrupted time series analysis to model changes in monthly rates of oxycodone CR tablets dispensed and initiations. We performed a retrospective cohort study to examine changes in client characteristics and opioid utilization over time by comparing clients initiating oxycodone CR before and after subsidy.

RESULTS

The rate of oxycodone CR tablets dispensed/month increased by 20% from December 2011, due to uptake of the oxycodone/naloxone CR combination; monthly initiations increased immediately by 17%. Initiations of buprenorphine, fentanyl, and morphine declined from December 2011. DVA healthcare card holders were significantly more likely to initiate the 5 mg oxycodone CR formulation; more likely to use immediate release oxycodone in the 90 days following initiation; and less likely to use a weak opioid in the 90 days preceding oxycodone CR initiation following December 2011 than they were prior to that time.

CONCLUSIONS

The public subsidy of the oxycodone/naloxone CR formulation expanded the overall oxycodone CR market for DVA healthcare card holders with cancer. Our findings highlight the need for updated guidelines around risk management for opioid treatment in patients with cancer.

Effectiveness of High-Fidelity Simulation in Nursing Education for End-of-Life Care: A Quasi-experimental Design

BACKGROUND

Providing end of life (EOL) care is a component of palliative care but dealing with dying patients and their family members is stressful for the healthcare providers. To prepare them for providing EOL care, the high-fidelity simulation could be used as a pedagogy in which real-life scenarios are used on the computerized manikins mimicking the real patients.

AIMS

The aim of this study was to measure the effectiveness of high-fidelity simulation to teach EOL care in the palliative nursing course in the undergraduate nursing education program at the School of Nursing and Midwifery at Aga Khan University which is private university in Karachi, Pakistan.

METHODS

This study was approved by the ethics review committee of Aga Khan University. It was hypothesized that exposure to high-fidelity simulation will lead to an increased positive attitude in participants towards the care of dying. A quasi-experimental design was used. In line with the design, there was no control group. The same group of students (n = 42) were assessed through Frommelt Attitudes Toward Care of the Dying (FATCOD) Part B assessment tool. Permission for using this tool was obtained from Dr. Katherine Frommelt, the author of this tool. Research participants filled this tool before and after the intervention, i.e., providing EOL care to a patient in a high-fidelity simulation lab.

RESULTS

Out of 30-FATCOD items, significant attitude change was detected on 11-items of which 8 were positively worded statements and 3 were negatively worded statements. As per the hypothesis, it was expected for the positively worded statements that the mean score for the posttest would be significantly greater than the pretest mean score (pretest score < posttest score). The hypothesis was proved for items 1, 4, 10, 18, 22, 25, 27, and 30 as their t-value was significant at 0.05 alpha value (one-tailed). For the negatively worded statements, it was expected that the mean score for the posttest would be significantly lower than the pretest (pretest score > posttest score). The hypothesis was proved for items 5, 6, and 11 as their t-value was significant at 0.05 alpha value (one-tailed).

CONCLUSION

In this research teaching, EOL care through high-fidelity simulation had improved the attitudes of students toward providing care. This pedagogy also provided the participants with a learning opportunity to deal with their own emotions. These findings provide a way forward for teaching EOL and other complex skills of clinical practice.

Development of a cancer pain self-management resource to address patient, provider, and health system barriers to care

OBJECTIVE

The majority of self-management interventions are designed with a narrow focus on patient skills and fail to consider their potential as "catalysts" for improving care delivery. A project was undertaken to develop a patient self-management resource to support evidence-based, person-centered care for cancer pain and overcome barriers at the levels of the patient, provider, and health system.

METHOD

The project used a mixed-method design with concurrent triangulation, including the following: a national online survey of current practice; two systematic reviews of cancer pain needs and education; a desktop review of online patient pain diaries and other related resources; consultation with stakeholders; and interviews with patients regarding acceptability and usefulness of a draft resource.

RESULT

Findings suggested that an optimal self-management resource should encourage pain reporting, build patients' sense of control, and support communication with providers and coordination between services. Each of these characteristics was identified as important in overcoming established barriers to cancer pain care. A pain self-management resource was developed to include: (1) a template for setting specific, measureable, achievable, relevant and time-bound goals of care, as well as identifying potential obstacles and ways to overcome these; and (2) a pain management plan detailing exacerbating and alleviating factors, current strategies for management, and contacts for support.

SIGNIFICANCE OF RESULTS

Self-management resources have the potential for addressing barriers not only at the patient level, but also at provider and health system levels. A cluster randomized controlled trial is under way to test effectiveness of the resource designed in this project in combination with pain screening, audit and feedback, and provider education. More research of this kind is needed to understand how interventions at different levels can be optimally combined to overcome barriers and improve care.

Screening and Audit as Service-Level Strategies to Support Implementation of Australian Guidelines for Cancer Pain Management in Adults: A Feasibility Study

BACKGROUND

Pain in people with cancer is common but often under-recognized and under-treated. Guidelines can improve the quality of pain care, but need targeted strategies to support implementation.

AIM

To test the feasibility of two service-level strategies for supporting guideline implementation: a screening system and medical record audit.

DESIGN

Multimethods.

SETTING

One oncology outpatient service, and one palliative care outpatient and inpatient service.

PARTICIPANTS

Patients with advanced cancer.

METHODS

Patients were screened in the waiting room with a modified version of the Edmonton Symptom Assessment System-revised either electronically or in paper-based format. Feasibility indicated the percentage of patients successfully screened from the total number attending the services. An audit assessed adherence to key indicators of pain assessment and management. Feasibility thresholds were set at 75% incidence for screening and a median of 30 minutes per patient for audit.

RESULTS

Of 452 patient visits, 95% (n = 429) were successfully screened, 34% (n = 155) electronically and 61% (n = 274) paper-based. Electronic pain screening was technically challenging and time-intensive for nurses. Thirty-one patients consented to have their records audited. The median audit time was 37.5 minutes (range 10-120 minutes). Variability arose from the number and type of record (outpatient or inpatient). Adherence to indicators varied from 63% (pain assessment at first presentation) to 94% (regular pain assessment and medication prescribed at regular intervals).

CONCLUSIONS

This study confirmed the need to implement evidence-based guidelines for cancer pain and generated useful insights into the feasibility of pain screening and audit.

Protocol for a phase III pragmatic stepped wedge cluster randomised controlled trial comparing the effectiveness and cost-effectiveness of screening and guidelines with, versus without, implementation strategies for improving pain in adults with cancer attending outpatient oncology and palliative care services: the Stop Cancer PAIN trial

BACKGROUND

Pain is a common and distressing symptom in people with cancer, but is under-recognised and under-treated. Australian guidelines for 'Cancer Pain Management in Adults' are available on the Cancer Council Australia Cancer Guideline Wiki. This study aims to evaluate the effectiveness and cost-effectiveness of a suite of guideline implementation strategies for improving pain outcomes in adults with cancer in oncology and palliative care outpatient settings.

METHODS

The study will use a stepped-wedge cluster randomised controlled design, with oncology and palliative care outpatient services as the clusters. Patients will be eligible if they are adults with cancer and pain presenting to participating services during the study period. During an initial control arm, services will routinely screen patients for average and worst pain over the past 24 h using a 0-10 numerical rating scale (NRS) and have unfettered access to online guidelines. During the intervention arm, staff at each service will be encouraged to use: 1) a patient education booklet and self-management resource; 2) an online spaced learning cancer pain education module for clinicians from different disciplines; and 3) audit and feedback of service performance on key indices of cancer pain screening, assessment and management. Service-based clinical change champions will lead implementation of these strategies. The trial's primary outcome will be the probability that patients initially screened as having moderate-severe (≥5/10 NRS) worst pain experience a clinically important improvement one week later, defined as  ≥ 30% reduction. Secondary outcomes will include patient empowerment and quality of life, carer experience, and cost-effectiveness. For the main analysis, linear mixed models will be used, accounting for clustering and the longitudinal design. Eighty-two patients per service at six services (N = 492) will provide > 90% power. A qualitative sub-study and analyses of structural and process factors will explore opportunities for further refinement and tailoring of the intervention.

DISCUSSION

This pragmatic trial will inform implementation of guidelines across a range of oncology and palliative care outpatient service contexts. If found effective, the implementation strategies will be made freely available on the Wiki alongside the guidelines.

TRIAL REGISTRATION

Registered 23/01/2015 on the Australian New Zealand Clinical Trials Registry ( ACTRN12615000064505 ).

Adaptation of evidence-based guideline recommendations to address urinary incontinence in nursing home residents according to the ADAPTE-process

AIMS AND OBJECTIVES

To adapt international guideline recommendations for the conservative management of urinary incontinence (UI), defined as any involuntary loss of urine, in Austrian nursing home residents following the ADAPTE-process.

BACKGROUND

Many international guidelines for managing UI are available. Nevertheless, the international recommendations have not yet been adapted to address the Austrian nursing home context. This crucial adaptation process will enhance the acceptance and applicability of the recommendations as well as encourage adherence among Austrian nurses and nursing home residents.

DESIGN

This study is a methodological study based on the ADAPTE-process, including a systematic search, quality appraisal of the guidelines using the Appraisal of Clinical Guidelines for REsearch & Evaluation II (AGREE II) instrument as well as an external review by means of a Delphi technique. The guidelines had to be topic-relevant, published within the last 3 years and achieve a rigor of development score of 80% using the AGREE II instrument.

METHODS

We searched international guideline databases to identify adequate guidelines. Two raters assessed the quality of each guideline, ascertaining that it fulfilled the inclusion criteria using the AGREE II instrument. We translated the identified recommendations into German and externally reviewed for their applicability in the Austrian context.

RESULTS

We identified 1,612 hits in 10 databases. After applying inclusion and exclusion criteria, we assessed five international clinical guidelines for quality using the AGREE II instrument. One clinical guideline fulfilled the inclusion criteria. This clinical guideline contains 116 recommendations, of which 29 were applicable in the Austrian nursing home setting.

CONCLUSION

We identified only one suitable guideline, possibly due to the stringent nature of the inclusion criteria. However, following low-quality guidelines may result in the use of recommendations that are not based on evidence and, therefore, may lead to suboptimal nursing care and outcomes.

Exploring guideline adaptation strategy for Turkey: Is "ADAPTE" feasible or does it need adaptation as well?

RATIONALE, AIMS, OBJECTIVES

Clinical Practice Guidelines are mostly developed by 3 methods; namely, de novo, adoption, and adaptation. Nonpublished studies and authors experience shows that most guidelines in Turkey are either by adoption or by adaptation. There is no available local tool for adaptation, so the process is not standardized and most of the time not explicitly defined. The objective of this study is to search for international guideline adaptation tools and test their feasibility in Turkish context, to serve a final goal of developing a unique local strategic tool for guideline adaptation.

METHODS

The methodological design of this study includes selection of an international tool for Clinical Practice Guideline adaptation, piloting this tool with selected Turkish guidelines, identifying the feasibility of this tool and exploring the needs for adaptation of the tool, drawing recommendations for adaptation of the strategies, and validation of the process by local experts.

RESULTS

The study from planning phase to finalizing the guidance, including pilot studies and panel but excluding translation of ADAPTE, lasted 18 months. Nine researchers were involved in the adaptation process and 15 more experts were involved in the validation panel. Following the suggestions of the research team on modifications and validation through the expert panel; 2 steps of the ADAPTE toolkit were rejected, 2 steps were accepted by modification, 7 steps were accepted by additional recommendations. In addition, 2 tools were suggested to be added to the toolkit.

CONCLUSION

This is the first study on adaptation of guidelines in Turkey. Pilot adaptation of 2 guidelines with ADAPTE revealed that ADAPTE is a useful and feasible tool in Turkish setting, but might require certain changes in recommendations and revision of tools.

Canadian Schizophrenia Guidelines: Introduction and Guideline Development Process

INTRODUCTION

The aim of the Canadian Schizophrenia Guidelines is to provide evidence-based recommendations for the treatment of schizophrenia and schizophrenia spectrum disorders. The target users are health care professionals. Recommendations are provided as guidance to physicians and patients, with the goal of improving the overall standard of care of individuals with schizophrenia.

METHODS

The guidelines were developed using the ADAPTE process, a systematic approach and alternative to de novo guideline development, in which an existing guideline is customised to suit the local context. We assembled a multidisciplinary team of experts, patients, and family carers from across Canada with the goal of involving individuals with diverse areas of expertise and offering different perspectives.

RESULTS

We identified 6 guidelines that were suitable for adaptation. Recommendations from each guideline were extracted and, based on content, were reviewed by the relevant working group. Each working group examined the evidence from which the recommendation was derived and the acceptability and applicability of the recommendation to the Canadian context. Working groups also made decisions on modifications to recommendations when language or terms differed between the source guideline and the Canadian context. Each working group presented selected recommendations to the guideline panel at an in-person consensus meeting. Once the consensus process was completed, each working group created a manuscript with the recommendations adapted from the included guidelines, with the rationale for each recommendation.

CONCLUSIONS

The process yielded an up-to-date list of evidence-based recommendations that are relevant and applicable in Canada.

Clinical pathway for the screening, assessment and management of anxiety and depression in adult cancer patients: Australian guidelines

PURPOSE

A clinical pathway for anxiety and depression in adult cancer patients was developed to guide best practice in Australia.

METHODS

The pathway was based on a rapid review of existing guidelines, systematic reviews and meta-analyses, stakeholder interviews, a Delphi process with 87 multidisciplinary stakeholders and input from a multidisciplinary advisory panel.

RESULTS

The pathway recommends formalized routine screening for anxiety and depression in patients with cancer at key points in the patient's journey. The Edmonton Symptom Assessment System or distress thermometer with problem checklist is recommended as brief screening tools, combined with a more detailed tool, such as the Hospital Anxiety and Depression Scale, to identify possible cases. A structured clinical interview will be required to confirm diagnosis. When anxiety or depression is identified, it is recommended that one person in a treating team takes responsibility for coordinating appropriate assessment, referral and follow-up (not necessarily carrying these out themselves). A stepped care model of intervention is proposed, beginning with the least intensive available that is still likely to provide significant health gain. The exact intervention, treatment length and follow-up timelines, as well as professionals involved, are provided as a guide only. Each service should identify their own referral network based on local resources and current service structure, as well as patient preference.

DISCUSSION

This clinical pathway will assist cancer services to design their own systems to detect and manage anxiety and depression in their patients, to improve the quality of care.