Does routine psychological screening of newly diagnosed rural cancer patients lead to better patient outcomes? Results of a pilot study

Patient-Reported Outcome Measures in Cancer Care: An Updated Systematic Review and Meta-Analysis

Importance

Patient-reported outcome measures (PROMs) come directly from the patient, without clinician interpretation, to provide a patient-centered perspective.

Objective

To understand the association of PROM integration into cancer care with patient-related, therapy-related, and health care utilization outcomes.

Data Sources

Searches included MEDLINE and MEDLINE Epub ahead of print, in-process, and other nonindexed citations; Embase databases (OvidSP); PsychINFO; CENTRAL; and CINAHL from January 1, 2012 to September 26, 2022.

Study Selection

Randomized clinical trials (RCTs) that enrolled adult patients (ages 18 years and older) with active cancer receiving anticancer therapy using a PROM as an intervention.

Data Extraction and Synthesis

Pairs of review authors, using prepiloted forms, independently extracted trial characteristics, disease characteristics, and intervention details. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guideline was followed. Random-effects analyses were conducted.

Main Outcomes and Measures

Overall mortality, health-related quality of life (HRQoL) measures, and hospital utilization outcomes.

Results

From 1996 to 2022, 45 RCTs including 13 661 participants addressed the association of PROMs with outcomes considered important to patients. The addition of a PROM likely reduced the risk of overall mortality (HR, 0.84; 95% CI, 0.72-0.98; moderate certainty), improved HRQoL (range 0-100) at 12 weeks (mean difference [MD], 2.45; 95% CI, 0.42-4.48; moderate certainty). Improvements of HRQoL at 24 weeks were not significant (MD, 1.87; 95% CI, -1.21 to 4.96; low certainty). There was no association between the addition of a PROM and HRQoL at 48 weeks. The addition of a PROM was not associated with reduced ED visits (OR, 0.74; 95% CI, 0.54-1.02; low certainty) or hospital admissions (OR, 0.86; 95% CI, 0.73-1.02; low certainty).

Conclusion and Relevance

The findings of this study suggest that the integration of PROMs into cancer care may improve overall survival and quality of life.

The Clinical Utility of the Adolescent and Young Adult Psycho-Oncology Screening Tool (AYA-POST): Perspectives of AYA Cancer Patients and Healthcare Professionals

Objective

Routine psychosocial screening and assessment of people diagnosed with cancer are crucial to the timely detection of distress and provision of tailored supportive care; however, appropriate screening tools have been lacking for adolescents and young adults (AYAs), who have unique needs and experiences. One exception is the recently validated AYA Psycho-Oncology Screening Tool (AYA-POST) for use with young people aged 15–29 years, which comprises a distress thermometer and age-specific needs assessment. This study investigates the clinical utility of this measure, as well as the subsequent service responsiveness within the Australian Youth Cancer Services.

Method

In total, 118 AYAs and 29 healthcare professionals: (HCPs) completed surveys about the clinical utility of the AYA-POST; a subset of 30 AYAs completed a 3-month follow-up survey assessing service responsiveness. Descriptive statistics (frequencies/means) were computed for all items, with chi-square analyses used to explore whether perceived clinical utility varied with AYA age, AYA sex, HCP discipline or HCP length of time using the AYA-POST.

Results

Participants’ responses demonstrate high levels of satisfaction with the tool, evidencing its appropriateness, practicability and acceptability. Moreover, the AYA-POST was reported to facilitate communication about psychosocial needs and prompt referrals, indicating good service responsiveness. Ratings of clinical utility did not differ significantly between AYA and HCP groups.

Conclusion

This study demonstrates that the AYA-POST is an appropriate tool in the psychosocial screening of AYAs with cancer, facilitating the identification of distress and unique concerns in this population and valuable in triaging and tailoring care for young cancer patients.

Implementing patient-reported outcomes in routine clinical care for diverse and underrepresented patients in the United States

BACKGROUND

Patient-reported outcomes (PROs) are used increasingly in routine clinical care and inform policies, reimbursements, and quality improvement. Less is known regarding PRO implementation in routine clinical care for diverse and underrepresented patient populations.

OBJECTIVE

This review aims to identify studies of PRO implementation in diverse and underrepresented patient populations, elucidate representation of clinical specialties, assess implementation outcomes, and synthesize patient needs, concerns, and preferences.

METHODS

MEDLINE, Embase, Web of Science, CINAHL, and PsycINFO were searched September 2021 for studies aiming to study PRO implementation in diverse and underrepresented patient populations within the United States. Studies were screened and data extracted by three independent reviewers. Implementation outcomes were assessed according to Proctor et al. taxonomy. A descriptive analysis of data was conducted.

RESULTS

The search yielded 8,687 records, and 28 studies met inclusion criteria. The majority were observational cohort studies (n = 21, 75%) and conducted in primary care (n = 10, 36%). Most studies included majority female (n = 19, 68%) and non-White populations (n = 15, 54%), while fewer reported socioeconomic (n = 11, 39%) or insurance status (n = 9, 32.1%). Most studies assessed implementation outcomes of feasibility (n = 27, 96%) and acceptability (n = 19, 68%); costs (n = 3, 11%), penetration (n = 1, 4%), and sustainability (n = 1, 4%) were infrequently assessed.

CONCLUSION

PRO implementation in routine clinical care for diverse and underrepresented patient populations is generally feasible and acceptable. Research is lacking in key clinical specialties. Further work is needed to understand how health disparities drive PRO implementation outcomes.

The nurse-patient interaction during rehabilitation consultations in patients surgically treated for head and neck cancer- a qualitative study

PURPOSE

Patients treated surgically for head and neck cancer may experience detrimental early and late effects of their treatment and are in need of rehabilitation post treatment to alleviate symptoms and effects. This study aimed to explore nurse-patient interactions during rehabilitation consultations assessing needs of patients in order to understand how nurses and patients experienced the consultation, the extent to which patients experienced being involved in the needs assessment and how patients experienced the information delivered.

METHODS

Findings in this study drew on three data sources: 15 observations of nurse-patient interactions during rehabilitation consultations; 15 individual patient interviews and a focus group interview with nurses. Observations and individual patient interviews took place at three different time points during the patient trajectory. The method and analysis applied Interpretive Description and Systematic Text Condensation. Analysis was performed across all three data sources and three time points.

RESULTS

Four interrelated themes were identified, showing that conducting rehabilitation nursing consultations and actively involving patients is a complex process. The themes revealed the complexity: expectations for nurse-patient interaction differ; challenges of building rapport; barriers to adequately identifying rehabilitation needs; and factors inhibiting communication of advice and recommendations. Uncovering emotional needs were especially challenging. Patient further experienced an information overload, especially just prior to discharge.

CONCLUSION

Nurse-patient interaction in the rehabilitation consultation is complex and involves many different interrelated aspects that require the nurse to have the necessary interpersonal and professional skills to support the patient to enhance their involvement in the encounter.

Brief psychological distress screening on a cancer helpline: How nurses introduce, and callers respond to, the Distress Thermometer

PURPOSE

Helplines are increasingly used to provide information and support for people affected by cancer, and the distress routinely associated with diagnosis and treatment is a major focus for those providing such care. Little is known, however, about how the Distress Thermometer (DT), a widely used tool for the assessment of patient/carer distress on cancer-support telephone helplines, is introduced and used in such settings.

METHOD

Using the method of conversation analysis, we present a qualitative analysis of DT use in actual telephone interactions by looking closely at how particular practices shape interaction on a cancer helpline. Specifically, we examine how oncology-trained nurse call-takers used the DT, in situ, as a tool for assessing callers, as well as examining how callers responded to this brief screening tool.

RESULTS

Our findings show how particular positioning of the DT in the call, and particular forms of its delivery, tend to generate brief responses from callers that avoid topicalization of distress, and tend not to be associated with referral to support services.

CONCLUSIONS

Implications for successful integration of the DT as a screening tool in cancer- and other health-helpline interactions, as well as for effective training of users, are discussed.

[Individual financial burden following a cancer diagnosis from the perspective of social services in Germany]

BACKGROUND

In addition to physical, psychological and social effects, economic effects and the associated financial burden of a cancer diagnosis may also gain in importance during prolonged disease progression. Counselling by social services is an important factor in coping with this burden.

METHODS

People employed in social work in oncology were invited to participate in a survey. The survey comprises 16 items on the perception of financial burdens, changes in the relevance of the topic, risk factors and current counselling practice.

RESULTS

81% of the respondents reported that the financial burden arising from a cancer diagnosis is a relevant topic of consultation for at least half of the patients. For 55%, this topic has become more important in recent years, which is due to higher survival rates, an increased number of younger patients, and poorer social security and working conditions.

DISCUSSION AND CONCLUSION

Despite comprehensive insurance coverage, the financial burden of cancer patients has also gained in importance in Germany and must be increasingly taken into account in everyday social service counselling. Due to numerous risk factors and complex reasons, further measures are required to enable the early identification of risk constellations and to improve the situation of those affected.

Cancer-Related Distress: Revisiting the Utility of the National Comprehensive Cancer Network Distress Thermometer Problem List in Women With Gynecologic Cancers

PURPOSE

The Distress Thermometer (DT) includes a measure of cancer-related distress and a list of self-reported problems. This study evaluated the utility of the DT problem list in identifying concerns most associated with distress and poorer quality of life (QOL) in survivors of gynecologic cancer.

METHODS

Demographic, clinical, psychosocial functioning, and DT data were described among 355 women participating in a gynecologic cancer cohort. Problems from the DT list were ranked by prevalence, distress, and QOL. Logistic regression models explored factors associated with problems that were common (≥ 25% prevalence) and associated with distress and QOL.

RESULTS

The average age of participants was 59.9 years (standard deviation [SD], 10.8 years). Most participants were non-Hispanic white (97%) and had ovarian (44%) or uterine (42%) cancer. The mean DT score was 2.7 (SD, 2.7); participants reported a mean of 7.3 problems (SD, 5.9 problems). The most common problems were fatigue (53.6%), worry (49.9%), and tingling (46.3%); least common problems were childcare (2.1%), fevers (2.1%), and substance abuse (1.1%). Report of some common problems, including tingling, sleep, memory, skin issues, and appearance, was not associated with large differences in distress or QOL. In contrast, some rarer problems such as childcare, treatment decisions, eating, housing, nausea, and bathing/dressing were associated with worse distress or QOL. Younger age, lower income, and chemotherapy were risk factors across common problems that were associated with worse distress or QOL (fatigue, nervousness, sadness, fears, and pain).

CONCLUSION

The DT problem list did not easily identify concerns most associated with distress and low QOL in patients with gynecologic cancer. Adaptations that enable patients to report their most distressing concerns would enhance clinical utility of this commonly used tool.

Implementing Patient-Reported Outcome Measures in Clinical Breast Cancer Care: A Systematic Review

BACKGROUND

Patient-reported outcome measures (PROMs) are increasingly being used to improve care delivery and are becoming part of routine clinical practice.

OBJECTIVE

This systematic review aims to give an overview of PROM administration methods and their facilitators and barriers in breast cancer clinical practice.

METHODS

A systematic literature search was conducted in Embase, MEDLINE, PsycINFO, Cochrane Central, CINAHL, and Web of Science for potentially relevant articles from study inception to November 2017. Reference lists of screened reviews were also checked. After inclusion of relevant articles, data were extracted and appraised by 2 investigators.

RESULTS

A total of 2311 articles were screened, of which 34 eligible articles were ultimately included. Method and frequency of PROM collection varied between studies. The majority of studies described a promising effect of PROM collection on patients (adherence, symptom distress, quality of life, acceptability, and satisfaction), providers (willingness to comply, clinical decision making, symptom management), and care process or system outcomes (referrals, patient-provider communication, hospital visits). A limited number of facilitators and barriers were identified, primarily of a technical and behavioral nature.

CONCLUSION

Although interpreting the impact of PROM collection in breast cancer care is challenging owing to considerations of synergistic (multicomponent) interventions and generalizability issues, this review found that systematic PROM collection has a promising impact on patients, providers, and care processes/ systems. Further standardization and reporting on method and frequency of PROM collection might help increase the effectiveness of PROM interventions and is warranted to enhance their overall impact.

Quality improvement of neuro-oncology services: integrating the routine collection of patient-reported, health-related quality-of-life measures

BACKGROUND

Brain cancer has a strong impact on health-related quality of life (HRQoL), and its evaluation in clinical practice can improve the quality of care provided. The aim of this project was to integrate routine collection of HRQoL information from patients with brain tumor or metastasis in 2 specialized United Kingdom tertiary centers, and to evaluate the implementation process.

METHODS

Since October 2016, routine collection of electronic self-reported HRQoL information has been progressively embedded in the participating centers using standard questionnaires. During the first year, the project was implemented, and the process evaluated, through regular cycles of process evaluation followed by an action plan, monitoring of questionnaire completion rates, and assessment of patient views.

RESULTS

Main challenges encountered included reluctance to change usual practice and limited resources. Key measures for success included strong leadership of senior staff, involvement of stakeholders in project design and evaluation, and continuous strategic support to professionals. Final project workflow included 6 process steps, 1 decision step, and 4 outputs. Questionnaires were mostly self-completed (75.1%), and completion took 6-9 minutes. Most patients agreed that the questionnaire items were easy to understand (97.0%), important for them (93.0%), and helped them think what they wanted to discuss in their clinical consultation (75.4%).

CONCLUSIONS

Integrating HRQoL information as a routine part of clinical assessments has the potential to enhance individually tailored patient care in our institutions. Challenges involved in innovations of this nature can be overcome through a systematic approach involving strong leadership, wide stakeholder engagement, and strategic planning.

Systematic screening and assessment of psychosocial well-being and care needs of people with cancer

BACKGROUND

Receiving a diagnosis of cancer and the subsequent related treatments can have a significant impact on an individual's physical and psychosocial well-being. To ensure that cancer care addresses all aspects of well-being, systematic screening for distress and supportive care needs is recommended. Appropriate screening could help support the integration of psychosocial approaches in daily routines in order to achieve holistic cancer care and ensure that the specific care needs of people with cancer are met and that the organisation of such care is optimised.

OBJECTIVES

To examine the effectiveness and safety of screening of psychosocial well-being and care needs of people with cancer. To explore the intervention characteristics that contribute to the effectiveness of these screening interventions.

SEARCH METHODS

We searched five electronic databases in January 2018: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO, and CINAHL. We also searched five trial registers and screened the contents of relevant journals, citations, and references to find published and unpublished trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and non-randomised controlled trials (NRCTs) that studied the effect of screening interventions addressing the psychosocial well-being and care needs of people with cancer compared to usual care. These screening interventions could involve self-reporting of people with a patient-reported outcome measures (PROMs) or a semi-structured interview with a screening interventionist, and comprise a solitary screening intervention or screening with guided actions. We excluded studies that evaluated screening integrated as an element in more complex interventions (e.g. therapy, coaching, full care pathways, or care programmes).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and assessed methodological quality for each included study using the Cochrane tool for RCTs and the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool for NRCTs. Due to the high level of heterogeneity in the included studies, only three were included in meta-analysis. Results of the remaining 23 studies were analysed narratively.

MAIN RESULTS

We included 26 studies (18 RCTs and 8 NRCTs) with sample sizes of 41 to 1012 participants, involving a total of 7654 adults with cancer. Two studies included only men or women; all other studies included both sexes. For most studies people with breast, lung, head and neck, colorectal, prostate cancer, or several of these diagnoses were included; some studies included people with a broader range of cancer diagnosis. Ten studies focused on a solitary screening intervention, while the remaining 16 studies evaluated a screening intervention combined with guided actions. A broad range of intervention instruments was used, and were described by study authors as a screening of health-related quality of life (HRQoL), distress screening, needs assessment, or assessment of biopsychosocial symptoms or overall well-being. In 13 studies, the screening was a self-reported questionnaire, while in the remaining 13 studies an interventionist conducted the screening by interview or paper-pencil assessment. The interventional screenings in the studies were applied 1 to 12 times, without follow-up or from 4 weeks to 18 months after the first interventional screening. We assessed risk of bias as high for eight RCTs, low for five RCTs, and unclear for the five remaining RCTs. There were further concerns about the NRCTs (1 = critical risk study; 6 = serious risk studies; 1 = risk unclear).Due to considerable heterogeneity in several intervention and study characteristics, we have reported the results narratively for the majority of the evidence.In the narrative synthesis of all included studies, we found very low-certainty evidence for the effect of screening on HRQoL (20 studies). Of these studies, eight found beneficial effects of screening for several subdomains of HRQoL, and 10 found no effects of screening. One study found adverse effects, and the last study did not report quantitative results. We found very low-certainty evidence for the effect of screening on distress (16 studies). Of these studies, two found beneficial effects of screening, and 14 found no effects of screening. We judged the overall certainty of the evidence for the effect of screening on HRQoL to be very low. We found very low-certainty evidence for the effect of screening on care needs (seven studies). Of these studies, three found beneficial effects of screening for several subdomains of care needs, and two found no effects of screening. One study found adverse effects, and the last study did not report quantitative results. We judged the overall level of evidence for the effect of screening on HRQoL to be very low. None of the studies specifically evaluated or reported adverse effects of screening. However, three studies reported unfavourable effects of screening, including lower QoL, more unmet needs, and lower satisfaction.Three studies could be included in a meta-analysis. The meta-analysis revealed no beneficial effect of the screening intervention on people with cancer HRQoL (mean difference (MD) 1.65, 95% confidence interval (CI) -4.83 to 8.12, 2 RCTs, 6 months follow-up); distress (MD 0.0, 95% CI -0.36 to 0.36, 1 RCT, 3 months follow-up); or care needs (MD 2.32, 95% CI -7.49 to 12.14, 2 RCTs, 3 months follow-up). However, these studies all evaluated one specific screening intervention (CONNECT) in people with colorectal cancer.In the studies where some effects could be identified, no recurring relationships were found between intervention characteristics and the effectiveness of screening interventions.

AUTHORS' CONCLUSIONS

We found low-certainty evidence that does not support the effectiveness of screening of psychosocial well-being and care needs in people with cancer. Studies were heterogeneous in population, intervention, and outcome assessment.The results of this review suggest a need for more uniformity in outcomes and reporting; for the use of intervention description guidelines; for further improvement of methodological certainty in studies and for combining subjective patient-reported outcomes with objective outcomes.

Head and Neck Cancer: Improving Patient-Reported Outcome Measures for Clinical Practice

OPINION STATEMENT

Head and neck cancer includes a wide range of tumors that occur in several areas of the upper aerodigestive tract. Most head and neck cancer patients report treatment-related late effects (both physical and psycho-social). High-quality and patient-centered care in head and neck cancer depend on the understanding of the continuum patient's experience-the disease pathway. Healthcare has been improved by involving patients more actively in the disease process, and a few reports support that patient-reported outcomes-built around the patient's experience-given in a timely manner to oncologists are extremely valuable in oncology clinical care. Implementation and clinical use of patient-reported outcomes requires some procedures involving head and neck cancer patients, clinicians, researchers, and institutional leaders The unified and integrated vision is still absent and some current concerns are being discussed to optimize benefits of patient-reported outcomes use in clinical practice. The inclusion of all first-line caregivers, team formation and training, continuous monitoring improvement, and analysis are critical success factors to consider. Our team developed a broader and inclusive understanding of patient-reported outcomes. Patient-reported outcome (Health-Related Quality of Life) assessment is implemented as a systematic and routine process in Head and Neck Unit. Head and neck cancer patients consider the questionnaire administration as part of the clinical approach. We are currently working in a program (PROimp) using mathematical models to identify common head and neck cancer patterns and building prognostic predictive models, to predict future outcomes, to appraise risk/benefit of treatments (standard or new), and to estimate patient's risk of future disease development. It is our aim to better comprehend the singular and unexpected perceptions to really provide directed and personalized cancer care defining the patient pathway. The future holds promising for PROs that are ascending as a nuclear outcome in head and neck oncology.

Interventions to improve screening and appropriate referral of patients with cancer for psychosocial distress: systematic review

OBJECTIVES

The primary aim of the review was to determine the effectiveness of strategies to improve clinician provision of psychosocial distress screening and referral of patients with cancer.

DESIGN

Systematic review.

DATA SOURCES

Electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PsycINFO and Cumulative Index to Nursing and Allied Health Literature (CINAHL)) were searched until July 2016.

INCLUSION CRITERIA

Population: adult patients with cancer and clinical staff members.

INTERVENTION

any strategy that aimed to improve the rate of routine screening and referral for detected distress of patients with cancer. Comparison: no intervention controls, 'usual' practice or alternative interventions.

OUTCOME

(primary) any measure of provision of screening and/or referral for distress, (secondary) psychosocial distress, unintended adverse effects.

DESIGN

trials with or without a temporal comparison group, including randomised and non-randomised trials, and uncontrolled pre-post studies.

DATA EXTRACTION AND ANALYSIS

Two review authors independently extracted data. Heterogeneity across studies precluded quantitative assessment via meta-analysis and so a narrative synthesis of the results is presented.

RESULTS

Five studies met the inclusion criteria. All studies were set in oncology clinics or departments and used multiple implementation strategies. Using the Grades of Recommendation, Assessment, Development and Evaluation, the overall rating of the certainty of the body of evidence reported in this review was assessed as very low. Three studies received a methodological quality rating of weak and two studies received a rating of moderate. Only one of the five studies reported a significant improvement in referrals.

CONCLUSIONS

The review identified five studies of predominantly poor quality examining the effectiveness of strategies to improve the routine implementation of distress screening and referral for patients with cancer. Future research using robust research designs, including randomised assignment, are needed to identify effective support strategies to maximise the potential for successful implementation of distress screening and referral for patients with cancer.

PROSPERO REGISTRATION NUMBER

CRD42015017518.

A controlled study of use of patient-reported outcomes to improve assessment of late effects after treatment for head-and-neck cancer

BACKGROUND AND PURPOSE

To test the effect of longitudinal feedback on late effects reported by survivors of head-and-neck cancer (HNC) to clinicians during regular follow-up.

MATERIAL AND METHODS

A total of 266 participants were sequentially assigned to either control or intervention group and filled in electronic versions of the EORTC QLQ C-30, H&N35, HADS and a study-specific list of symptoms at up to two consecutive follow-up visits. Participants' symptoms displayed according to severity were provided to the clinician for the intervention group but not for the control group. Linear mixed-effects models were used to examine the number of symptoms assessed by clinicians (primary outcome). Multivariate linear regression models examined participants' long-term symptom control and QoL (secondary outcome).

RESULTS

More symptoms were assessed by clinicians in the intervention group at all three visits (P<0.001, <0.001, and P=0.04). No effect was observed on most patient outcomes. When prompted by patient-reported outcomes at consultations, clinicians and patients were in better agreement about the occurrence of severe symptoms at all three visits.

CONCLUSION

Timely patient-reported outcomes to clinicians in routine follow-up of HNC survivors enhanced clinicians' rates of assessment of late symptoms. Giving reports of patient-reported outcome to clinicians had limited impact on participants' QoL or symptom burden.

What happens after distress screening? Patterns of supportive care service utilization among oncology patients identified through a systematic screening protocol

PURPOSE

While distress screening is important for identifying unmet needs of cancer patients, less is known about referral and uptake of supportive care services among distressed patients. The current analysis examined screen-based rates of referral to supportive care and explored demographic and clinical correlates of referral uptake.

METHODS

We tracked distress screens completed by a varied group of cancer patients receiving outpatient care at a National Cancer Institute (NCI)-designated cancer center during a 1-month period. Electronic medical record review was used to examine the rates of supportive care referral and uptake among distressed patients.

RESULTS

Out of 644 unique screens, 195 (30 %) patients reported significant distress; distressed patients were more likely to be non-white (odds ratio (OR) = 1.71, p < 0.01), prescribed psychiatric medication (OR = 1.92, p < 0.00), and have no previous contact with the cancer center's supportive care staff (OR = 1.62, p = 0.01). Thirty-four of these patients pre-emptively declined supportive care contact; thus, 161 were referred for supportive care. Among the 99 patients who received initial assessments by a team member, only 19 (19 %) requested and completed at least one follow-up appointment.

CONCLUSIONS

Findings from this analysis support earlier work demonstrating significant supportive care needs in cancer patients. However, it challenges the assumption that screening will result in increased uptake of supportive care services beyond initial assessment. Further work should focus on facilitating engagement and reducing barriers for patients with continuing post-assessment supportive care needs.

Translating research on the distress thermometer into practice

Distress is commonly experienced by people with cancer. The National Comprehensive Cancer Network (NCCN) developed a guideline for screening and managing distress in 1999 and has updated the guideline on an annual basis ever since. Using the five-phase framework for translational research, this article summarizes research findings related to the guideline and associated distress thermometer for each phase of translational research. The NCCN Distress Management Guideline is a useful tool to screen for and manage distress. However, additional research is needed, particularly in the areas of impact on outcomes of importance to patients.

A systematic review of barriers to optimal outpatient specialist services for individuals with prevalent chronic diseases: what are the unique and common barriers experienced by patients in high income countries?

Health utilization and need assessment data suggest there is considerable variation in access to outpatient specialist care. However, it is unclear if the types of barriers experienced are specific to chronic disease groups or experienced universally. This systematic review provides a detailed summary of common and unique barriers experienced by chronic disease groups when accessing and receiving care, and a synthesized list of possible health service initiatives to improve equitable delivery of optimal care in high-income countries. Quantitative articles describing barriers to specialist outpatient services were retrieved from CINAHL, MEDLINE, Embase, and PyscINFO. To be eligible for review, studies: were published from 2002 to May 2014; included samples with cancer, diabetes mellitus, osteoporosis, arthritis, ischaemic heart disease, stroke, asthma, chronic pulmonary disorder (COPD) or depression; and, were conducted in high-income countries. Using a previously validated model of access (Penchansky and Thomas' model of fit), barriers were grouped according to five overarching domains and defined in more detail using 33 medical subject headings. Results from reviewed articles, including the scope and frequency of reported barriers, are conceptualized using thematic analysis and framed as possible health service initiatives. A total of 3181 unique records were screened for eligibility, of which 74 studies were included in final analysis. The largest proportion of studies reported acceptability barriers (75.7 %), of which demographic disparities (44.6 %) were reported across all diseases. Other frequently reported barriers included inadequate need assessment (25.7 %), information provision (32.4 %), or health communication (20 %). Unique barriers were identified for oncology, mental health, and COPD samples. Based on the scope, frequency and measurement of reported barriers, eight key themes with associated implications for health services are presented. Examples include: common accommodation and accessibility barriers caused on service organization or physical structure, such as parking and appointment scheduling; common barriers created by poor coordination of care within the healthcare team; and unique barriers resulting from inadequate need assessment and referral practices. Consideration of barriers, across and within chronic diseases, suggests a number of specific initiatives are likely to improve the delivery of patient-centered care and increase equity in access to high-quality health services.

Cancer patient and clinician acceptability and feasibility of a supportive care screening and referral process

BACKGROUND

Incorporating supportive care into routine cancer care is an increasing priority for the multi-disciplinary team with growing evidence of its importance to patient-centred care. How to design and deliver a process which is appropriate for patients, clinicians and health services in rural areas needs further investigation.

OBJECTIVE

To (i) examine the patient and clinician acceptability and feasibility of incorporating a supportive care screening and referral process into routine cancer care in a rural setting, and (ii) explore any potential influences of patient variables on the acceptability of the process.

METHODS

A total of 154 cancer patients and 36 cancer clinicians across two rural areas of Victoria, Australia participated. During treatment visits, patients and clinicians participated in a supportive care process involving screening, discussion of problems, and provision of information and referrals. Structured questionnaires with open and closed questions were used to measure patient and clinician acceptability and feasibility.

RESULTS

Patients and clinicians found the supportive care process highly acceptable. Screening identified relevant patient problems (90%) and problems that may not have otherwise been identified (83%). The patient-clinician discussion helped patients realize help was available (87%) and enhanced clinician-patient rapport (72%). Patients received useful referrals to services (76%). Feasibility issues included timing of screening for newly diagnosed patients, privacy in discussing problems, clinician time and availability of referral options. No patient demographic or disease factors influenced acceptability or feasibility.

CONCLUSIONS

Patients and clinicians reported high acceptability for the supportive care process, although mechanisms for incorporating the process into health care need to be further developed.

Indigenous cancer patient and staff attitudes towards unmet needs screening using the SCNAT-IP

INTRODUCTION

Indigenous Australians have a higher cancer incidence, worse mortality and are less likely to receive optimal cancer treatment compared with non-Indigenous Australians. Culturally appropriate supportive care helps ensure that Indigenous patients engage in and receive optimal care. However, many existing supportive care needs tools lack cultural relevance for Indigenous people, and their feasibility with Indigenous people has not been demonstrated. The Supportive Care Needs Assessment Tool for Indigenous People (SCNAT-IP) assesses the unmet supportive care needs of Indigenous cancer patients.

PURPOSE

This descriptive study evaluates the clinical implementation of the SCNAT-IP in routine care.

METHODS

Two large tertiary cancer treatment centres and two regional oncology clinics participated. Participants included 10 clinical staff and 36 adult Indigenous cancer patients (mean age 54 years). Patients and clinicians completed brief, purpose-designed questionnaires and interviews.

RESULTS

Patients reported high ratings (means >8/10) for acceptability, helpfulness and timing items. The majority (≥80%) of staff agreed that the SCNAT-IP was useful to clinical practice, should be used in routine care and was acceptable to their patients.

CONCLUSIONS

The study provides empirical support for the feasibility and acceptability of the SCNAT-IP in routine cancer care with Indigenous Australians. Routine screening with the SCNAT-IP has the potential to improve cancer care for Indigenous people with cancer.

Brief Distress Screening in Clinical Practice: Does it Help to Effectively Allocate Psycho-Oncological Support to Female Cancer Inpatients?

BACKGROUND

The usefulness of distress screening in cancer inpatient settings has rarely been investigated. This study evaluated a brief distress screening of inpatients in a breast cancer centre and a gynaecological cancer centre.

PATIENTS AND METHODS

Hospitalised patients with breast or gynaecological cancers were screened with the Distress Thermometer. Patients who scored above the cut-off, were referred by the medical staff, or self-referred were offered bedside psycho-oncological counselling.

RESULTS

Of 125 patients, 68 (54.4%) received an offer of counselling, and 62 patients (49.6%) accepted. Most of the counselling was induced by distress screening. Only 4 (3.2%) patients self-referred to the counselling service. Of the counselled patients, 65.8% stated that they had substantially benefited from psycho-oncological support; only 5.6% of the non-counselled patients indicated that they might have benefited from psycho-oncological support.

CONCLUSION

Almost all patients who will accept and benefit from psycho-oncological counselling can be identified if distress screening is used in conjunction with referrals by physicians and nurses. Distress screening is a worthwhile component in a framework of psycho-oncological support in a cancer inpatient setting. It paves the way to counselling for cancer inpatients who need it and are willing to accept it but hesitate to self-refer to psycho-oncological services.

What is the value of the routine use of patient-reported outcome measures toward improvement of patient outcomes, processes of care, and health service outcomes in cancer care? A systematic review of controlled trials

PURPOSE

The systematic use of patient-reported outcome measures (PROMs) has been advocated as an effective way to standardize cancer practice. Yet, the question of whether PROMs can lead to actual improvements in the quality of patient care remains under debate. This review examined whether inclusion of PROM in routine clinical practice is associated with improvements in patient outcomes, processes of care, and health service outcomes during active anticancer treatment.

METHODS

A systematic review of five electronic databases (Medline, EMBASE, CINAHL [Cumulative Index to Nursing and Allied Health Literature], PsycINFO, and Psychology and Behavioral Sciences Collection [PBSC]) was conducted from database inception to May 2012 to locate randomized and nonrandomized controlled trials of patients receiving active anticancer treatment or supportive care irrespective of type of cancer.

RESULTS

Based on prespecified eligibility criteria, we included 26 articles that reported on 24 unique controlled trials. Wide variability in the design and use of interventions delivered, outcomes evaluated, and cancer- and modality-specific context was apparent. Health service outcomes were only scarcely included as end points. Overall, the number of statistically significant findings were limited and PROMs' intervention effect sizes were predominantly small-to-moderate.

CONCLUSION

The routine use of PROMs increases the frequency of discussion of patient outcomes during consultations. In some studies, PROMs are associated with improved symptom control, increased supportive care measures, and patient satisfaction. Additional effort is required to ensure patient adherence, as well as additional support to clinicians who will respond to patient concerns and issues, with clear system guidelines in place to guide their responses. More research is required to support PROM cost-benefit in terms of patient safety, clinician burden, and health services usage.

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.

Psychosocial screening effects on health-related outcomes in patients receiving radiotherapy. A cluster randomised controlled trial

OBJECTIVE

This study examined the short-term and long-term effects of using a screening instrument on psychological distress and health-related quality of life (HRQoL) among cancer patients receiving radiotherapy. In addition, we investigated the effect of early psychosocial treatment on patients' overall health-related outcomes as previous research showed that patients in the screening condition were referred to a psychosocial caregiver at an earlier stage.

METHODS

A cluster randomised controlled trial with a randomisation at the levels of 14 radiotherapists, 568 patients was conducted. Patients were asked to complete questionnaires at 3 and 12 months follow-up.

RESULTS

Mixed models analyses showed no significant intervention effects on patients' overall extent of psychosocial distress and HRQoL, both on the short and long terms. Post-hoc analyses revealed significant interactions of the intervention with early referral and improved HRQoL and anxiety, suggesting that earlier referral might influence short-term HRQoL and experienced anxiety in patients.

CONCLUSIONS

Our results suggest that the use of a psychosocial screening instrument among patients receiving radiotherapy in itself does not sufficiently improve patients' health-related outcome. The effective delivery of psychosocial care depends upon several components such as identification of distress and successful implementation of screening procedures. One of the challenges is to get insight in the effects of early referral of cancer patients for psychosocial support because early referral might have a favourable effect on some of the patients' health-related outcomes.

Effects of screening for psychological distress on patient outcomes in cancer: a systematic review

OBJECTIVE

Several practice guidelines recommend routine screening for psychological distress in cancer care. The objective was to evaluate the effect of screening cancer patients for psychological distress by assessing the (1) effectiveness of interventions to reduce distress among patients identified as distressed; and (2) effects of screening for distress on distress outcomes.

METHODS

CINAHL, Cochrane, EMBASE, ISI, MEDLINE, PsycINFO, and SCOPUS databases were searched through April 6, 2011 with manual searches of 45 relevant journals, reference list review, citation tracking of included articles, and trial registry reviews through June 30, 2012. Articles in any language on cancer patients were included if they (1) compared treatment for patients with psychological distress to placebo or usual care in a randomized controlled trial (RCT); or (2) assessed the effect of screening on psychological distress in a RCT.

RESULTS

There were 14 eligible RCTs for treatment of distress, and 1 RCT on the effects of screening on patient distress. Pharmacological, psychotherapy and collaborative care interventions generally reduced distress with small to moderate effects. One study investigated effects of screening for distress on psychological outcomes, and it found no improvement.

CONCLUSION

Treatment studies reported modest improvement in distress symptoms, but only a single eligible study was found on the effects of screening cancer patients for distress, and distress did not improve in screened patients versus those receiving usual care. Because of the lack of evidence of beneficial effects of screening cancer patients for distress, it is premature to recommend or mandate implementation of routine screening.

Psychosocial service use: a qualitative exploration from the perspective of rural Australian cancer patients

PURPOSE

This study aims to identify key issues associated with the provision of psychosocial care from the perspective of rural Australian cancer patients and determine culturally appropriate methods that may reduce barriers to service use.

METHOD

Seventeen purposively sampled adult South Australians who lived outside metropolitan Adelaide, had a diagnosis of cancer and various demographic and medical histories participated in semi-structured, face-to-face interviews. Participants also completed a demographic questionnaire. Qualitative data were analysed using thematic analysis.

RESULTS

Five key themes were identified: (1) psychosocial support is highly valued by those who have accessed it, (2) having access to both lay and professional psychosocial support is vitally important, (3) accessing psychosocial services is made difficult by several barriers (lack of information about services, initial beliefs they are unnecessary, feeling overwhelmed and concerns about stigma and dual relationships), (4) medical staff located in metropolitan treatment centres are not sufficiently aware of the unique needs of rural patients and (5) patients require better access to psychosocial services post-treatment. Methods through which rural patients believe access to psychosocial services could be improved include: (1) providing more rural-specific information on psychosocial care, (2) improving communication between health care providers and referral to psychosocial services and (3) making psychosocial services a standard part of care.

CONCLUSIONS

Rural cancer patients want their unique needs to be recognised and to be treated differently to their urban counterparts. There is a need for more targeted and rurally relevant information for rural cancer patients, both to inform them of, and change their attitudes towards, psychosocial services. Other practical recommendations are also discussed.

Use of psychosocial services increases after a social worker-mediated intervention in gynecology oncology patients

The purpose of this study was to determine whether the introduction of psychosocial services to gynecologic oncology outpatients by a social worker increases service use. During the initial six weeks (phase I), patients were referred for psychosocial services by clinic staff. During the second six weeks (phase II), a nurse introduced available services to each patient with a brochure. During the final 12 weeks (phase III), a social worker introduced services to each patient. The authors then compared psychosocial service referral rates. The sample included 196 patients. During phase III, the probability of a patient-initiated referral increased 3.4-fold (95 percent confidence interval [CI] [1.1, 10.4], p = .04) compared with baseline; the probability of any referral rose 2.7-fold (95 percent CI [1.1, 6.3], p = .03). The mean time to referral decreased from 79.4 days at baseline to 3.9 days during phase III (p < .001). The phase III intervention was accomplished only in 34 patients (39 percent) because of scheduling conflicts. Of these, eight requested referral, resulting in a 24 percent patient-initiated referral rate after meeting with a social worker. The introduction of psychosocial services by a social worker to gynecologic oncology outpatients increases referral rates and expedites evaluation.

Effects of integrated psychosocial care for distress in cancer patients

BACKGROUND

Despite some clinical guidelines for incorporating integrated psychosocial care (combining psychological screening and psychological intervention, including adequate collaboration with mental health specialists) into routine oncology practice, definitive empirical evidence regarding the effectiveness of such care remains unavailable. Here the findings of recent experimental studies are reviewed to provide guidance regarding this issue.

METHODS

Comparative studies examining integrated psychosocial care were reviewed.

RESULTS

Studies examining interventions that include both screening and psychological care have produced contradictory results regarding effectiveness, but all the studies that have examined the effect of psychological care after the identification of distress using systematic screening have shown positive results.

CONCLUSIONS

Integrated psychosocial care may affect patients with significant distress, but the adequacy of introducing such care into routine oncology practice remains debatable.

Screening for cancer-related distress: when is implementation successful and when is it unsuccessful?

OBJECTIVE

Screening for distress is controversial with many advocates and detractors. Previously it was reasonable to assert that there was a lack of evidence but this position is no longer tenable. The question is now: what does the evidence show and, in particular, when is screening successful and when is screening unsuccessful? The aim of this paper is to review the most up-to-date recent findings from randomized and non-randomized trials regarding the merits of screening for distress in cancer settings.

METHODS

A search was made of the Embase/Medline and Web of knowledge abstract databases from inception to December 2012. Online theses and experts were contacted. Inclusion criteria were interventional (randomized and non-randomized) trials concerning screening for psychological distress and related disorders. Studies screening for quality of life were included.

RESULTS

Twenty-four valid interventional studies of distress/QoL screening were identified, 14 being randomized controlled trials (RCTs). Six of 14 screening RCTs reported benefits on patient well-being and an additional three showed benefits on secondary outcomes such as communication between clinicians and patients. Five randomized screening trials failed to show any benefits. Only two of 10 non-randomized sequential cohort screening studies reported benefits on patient well-being but an additional six showed secondary benefits on quality of care (such as receipt of psychosocial referral). Two non-randomized screening trials failed to show benefits. Of 24 studies, there were 17 that reported some significant benefits of screening on primary or secondary outcomes, six that reported no effect and one that reported a non-significantly deleterious effect upon communication. Across all studies, barriers to screening success were significant. The most significant barrier was receipt of appropriate aftercare. The proportion of cancer patients who received psychosocial care after a positive distress screen was only one in three. Screening was more effective when it was linked with mandatory intervention or referral.

CONCLUSIONS

Screening for distress/QoL is likely to benefit communication and referral for psychosocial help. Screening for distress has the potential to influence patient well-being but only if barriers are addressed. Quality of care barriers often act as a rate limiting step. Key barriers are lack of training and support, low acceptability and failure to link treatment to the screening results.

Screening for Distress and Unmet Needs in Patients With Cancer: Review and Recommendations

Purpose

This review summarizes the need for and process of screening for distress and assessing unmet needs of patients with cancer as well as the possible benefits of implementing screening.

Methods

Three areas of the relevant literature were reviewed and summarized using structured literature searches: psychometric properties of commonly used distress screening tools, psychometric properties of relevant unmet needs assessment tools, and implementation of distress screening programs that assessed patient-reported outcomes (PROs).

Results

Distress and unmet needs are common problems in cancer settings, and programs that routinely screen for and treat distress are feasible, particularly when staff are supported and links with specialist psychosocial services exist. Many distress screening and unmet need tools have been subject to preliminary validation, but few have been compared head to head in independent centers and in different stages of cancer. Research investigating the overall effectiveness of screening for distress in terms of improved recognition and treatment of distress and associated problems is not yet conclusive, but screening seems to improve communication between patients and clinicians and may enhance psychosocial referrals. Direct effects on quality of life are uncertain, but screening may help improve discussion of quality-of-life issues.

Conclusion

Involving all stakeholders and frontline clinicians when planning screening for distress programs is recommended. Training frontline staff to deliver screening programs is crucial, and continuing to rigorously evaluate outcomes, including PROs, process of care, referrals, and economic costs and benefits is essential.

The usefulness and feasibility of a screening instrument to identify psychosocial problems in patients receiving curative radiotherapy: a process evaluation

Background

Psychosocial problems in cancer patients are often unrecognized and untreated due to the low awareness of the existence of these problems or pressures of time. The awareness of the need to identify psychosocial problems in cancer patients is growing and has affected the development of screening instruments. This study explored the usefulness and feasibility of using a screening instrument (SIPP: Screening Inventory of Psychosocial Problems) to identify psychosocial problems in cancer patients receiving curative radiotherapy treatment (RT).

Methods

The study was conducted in a radiation oncology department in the Netherlands. Several methods were used to document the usefulness and feasibility of the SIPP. Data were collected using self-report questionnaires completed by seven radiotherapists and 268 cancer patients.

Results

Regarding the screening procedure 33 patients were offered to consult a psychosocial care provider (e.g. social worker, psychologist) during the first consultation with their radiotherapist. Of these patients, 31 patients suffered from at least sub-clinical symptoms and two patients hardly suffered from any symptoms. Patients' acceptance rate 63.6% (21/33) was high. Patients were positive about the content of the SIPP (mean scores vary from 8.00 to 8.88, out of a range between 0 and 10) and about the importance of discussing items of the SIPP with their radiotherapist (mean score = 7.42). Radiotherapists' perspectives about the contribution of the SIPP to discuss the different psychosocial problems were mixed (mean scores varied from 3.17 to 4.67). Patients were more positive about discussing items of the SIPP if the radiotherapists had positive attitudes towards screening and discussing psychosocial problems.

Conclusions

The screening procedure appeared to be feasible in a radiotherapy department. In general, patients' perspectives were at least moderate. Radiotherapists considered the usefulness and feasibility of the SIPP generally to be lower, but their evaluations were mixed. A positive attitude to using screening instruments like the SIPP needs to be encouraged among radiotherapists, as this may not only improve the usefulness of a screening instrument, but also patients' satisfaction with care.

Trial Registration

ClinicalTrials.gov: NCT00859768

Association of psychosocial risk screening in pediatric cancer with psychosocial services provided

OBJECTIVE

How screening for psychosocial risk in pediatric oncology may relate to the number and type of psychosocial services provided is a critical step in linking screening with treatment. We predicted that screening at diagnosis would be associated with the delivery of more psychosocial services over 8 weeks and that these services would be consistent with Universal, Targeted, or Clinical psychosocial risk level based on the Pediatric Psychosocial Preventative Health Model (PPPHM).

METHODS

Parents of children newly diagnosed with cancer received either the Psychosocial Assessment Tool (PAT; n = 49) or psychosocial care as usual (PAU; n = 47), based on their date of diagnosis and an alternating monthly schedule. Medical record review and surveys completed by social workers and child life specialists were used to determine psychosocial services provided to patients and their families over the first eight weeks of treatment.

RESULTS

As predicted, families in the PAT condition received more services than those in PAU based on social worker and child life specialist report and medical record review. Within the PAT group, families at the Targeted and Clinical levels of risk received more intensive services than those at the Universal level.

CONCLUSIONS

This initial report shows how psychosocial risk screening may impact psychosocial care in pediatric cancer, supporting the importance of screening as well as matching services to risk level.

Screening for distress and depression in cancer settings: 10 lessons from 40 years of primary-care research

OBJECTIVE

There has been at least 40 years of active research on screening for depression and distress in primary care. Both successes and failures have been documented. The purpose of this focussed narrative review was to summarise this research and present the key lessons for clinicians and researchers working in psychosocial oncology.

METHODS

We searched for studies assessing the utility of screening in primary care in seven electronic bibliographic databases (CENTRAL, CINAHL, Embase, HMIC, Medline, PsycINFO, Web of Knowledge) from inception to December 2010. Results were reviewed and summarised into key areas.

RESULTS

We found that research could be distilled into the following key learning points. (1) Primary care is an important partner in psychosocial care. (2) Both over and under detection are problematic. (3) Barriers to identification involve patient and clinician factors. (4) Acceptability of screening is critical to implementation. (5) Underserved groups need special attention in screening. (6) Patient-clinician trust is an important modifiable variable. (7) Greater contact influences detection. (8) Clinician confidence/skills influence screening success and subsequent action. (9) Training may improve confidence but effects upon long-term outcomes are modest. (10) Screening is generally ineffective without aftercare.

CONCLUSIONS

Primary care has shown largely what does not work in relation to screening. Namely relying on clinicians' unassisted judgement without infrastructural support, using over-complex scales with low acceptability, looking for depression alone, using screening without linked treatment, treating in the absence of follow-up and failing to engage patients in their own care. These pitfalls can and should be avoided in psychosocial oncology.

Examining the introduction of a supportive care screening and referral process for cancer patients: how does practice compare with protocols?

PURPOSE

The aim of this study was to examine the introduction of a supportive care screening and referral process into clinical practice for patients with cancer, and to determine how clinicians' actions compared to evidence-based protocols contained within the Supportive Care Resource Kit.

METHODS

A Supportive Care Resource Kit was developed as a resource for clinicians to enable a systematic process of screening cancer patients for unmet supportive care needs and addressing these needs by using evidence-based protocols. Clinicians were recruited and trained in supportive care and the use of the kit. Patients were recruited and screened for their supportive care needs. Patients and clinicians undertook a problem solving discussion, which was documented and analysed using content analysis.

RESULTS

In applying the screening process, clinicians undertook discussion, referral and information provision with patients. Comparison to evidence-based protocols revealed that practice was predominantly in line with protocols. Overall, clinicians' practice matched well with guidance from the protocols on discussion and referral, but less so in providing information to patients. Actions taken between supportive care domains differed with clinician preference evident for dealing with physical problems compared with practical, emotional and family problems.

CONCLUSIONS

Implications for practice and research include, exploring strategies for broadening clinician confidence in dealing with all areas of supportive care needs; undertaking further research into the use of protocols in health care and incorporating strategic, multidisciplinary planning in protocol implementation schemes.

Adolescents with diabetes and their parents' perceptions of mental health screening, assessment, and feedback

This study examined adolescents with diabetes and their parents' reactions to mental health screenings, assessments, and feedback. Most parents and adolescents did not report negative affect, but 15- and 16-year olds and referred adolescents showed greater levels of concern with assessment outcomes. Among those referred to mental health services, parents anticipated barriers in costs, insurance, and lack of qualified providers. Adolescents reported scheduling conflicts, time, and confidentiality concerns. Respondents perceived feedback as an important component of the clinical process and findings indicated a need for clinicians to incorporate psychosocial screenings and feedback in healthcare visits for adolescents with diabetes.